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I The Future of Nursing Education1 Edited by Linda R. Cronenwett, Ph.D, R.N., FAAN University of North Carolina at Chapel Hill School of Nursing SUMMARY AND CONCLUSIONS “Learn the past, watch the present, and create the future.” In October 2009, Don Berwick and I were out of the country when we re- ceived invitations from Susan Hassmiller to co-author a background paper on the future of nursing education for the Robert Wood Johnson Foundation/Institute of Medicine (RWJF/IOM) Committee on the Future of Nursing. Initial conversa- tions led to long lists of potential topics to be covered. Inevitably, we kept coming back to the question: What would be useful to committee members who deserved a base for their deliberations that was focused and helpful? In the end, we decided that detailed descriptions of the current challenges and recommendations for the future of nursing education from two people were not the answer. Instead, we requested and received permission to challenge five leaders, in addition to our- selves, to write short papers focused on recommendations addressing the most important three issues from each of their perspectives. With input from the RWJF/IOM Committee members and staff, we chose five esteemed (and busy) leaders and asked them to rise to this challenge within 10 weeks. Each person agreed, and each met the deadline. There were no group discussions, and, since each of us submitted our papers at the same time (no one finished early!), no one altered his or her content based on reading someone else’s contributions. 1 The responsibility for the content of this article rests with the authors and does not necessarily represent the views of the Institute of Medicine or its committees and convening bodies. 4

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4 THE FUTURE OF NURSING The seven papers are reprinted below, followed by a summary of the themes that emerged across papers. How does it match what you would have written? SUMMARY The authors of the preceding papers came from the Northeast, South, Mid- west, and Western parts of the country. One is a distinguished physician col- league, and the nursing educators are comprised of three professors (one a dean emeritus) and three current deans. Each has exerted leadership—in science, teaching, practice, and policy—for multiple decades. Each leads initiatives that extend beyond the boundaries of their places of employment. One is the current president of the American Academy of Nursing. What can we learn across the issues each chose to raise? The style of the papers differed, so what was called a recommendation, con- clusion, or issue varies. I extracted each major point, regardless of label. These major points from all authors are included in the categories below. Following each theme, authors for whom this was a major point are listed in regular font. Some additional authors mentioned the same point but not at the level of recom- mendations, conclusions, or major issues, and their names are listed in italics. Finally, I organized themes using categories that the RWJF/IOM committee chose for panel presentations at their upcoming meeting (what to teach, how to teach, where to teach), adding a few remaining categories so that all major points were included. What to Teach (or What Students Should Learn) • Competencies necessary for continuous improvement of the quality and safety of health care systems—patient-centered care, teamwork and col- laboration, evidence-based practice, quality improvement, safety, and informatics (Berwick, Cronenwett, Tanner) − Mastery of knowledge of systems, interpretations of variation, human psychology in complex systems, and approaches to gaining knowl- edge in real-world, local contexts (Berwick) − Skills and methods for leadership and management of continual im - provement, for nurse-teachers and nurse-executives (Berwick) • Competencies needed in new care delivery models − Population health and population-based care management (Tanner) − Care coordination (Tilden) • Knowledge based on standardized science prerequisites (Dracup, Tanner) • Health policy knowledge, skills, and attitudes (Tilden) • C ompetencies related to emerging health needs—e.g., geriatrics (Tanner)

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4 APPENDIX I How to Teach • Guide students in integrating knowledge from clinical, social, and be - havioral sciences with the practice of nursing to enhance development of clinical reasoning skills (Cronenwett, Dracup, Tanner, Tilden) • Enhance opportunities for interprofessional education (Cronenwett, Dracup, Gilliss, Tilden, Tanner) − Evaluate and test models of interprofessional education, including timing, determination of what levels of students should learn together, and what content is most effectively delivered with interprofessional learners (Tilden) • Develop and test new approaches to pre-licensure clinical education, including use of simulation (Dracup, Tanner) • Involve students in interprofessional quality improvement projects (Berwick, Gilliss, Cronenwett) • Develop model pre-licensure curricula that incorporate best practices in teaching and learning and can be used as a framework for community college–university partnerships (Tanner) Where to Teach • In baccalaureate and higher degree programs (Aiken, Cronenwett, Dracup, Gilliss, Tanner, Tilden) − Significantly increase the number and proportion of new registered nurses who graduate from basic pre-licensure education with a bac- calaureate or higher degree in nursing (Aiken, Cronenwett) − Require the BSN for entry into practice (Dracup, Tilden) − Support community college/university partnerships that increase the number of associate degree graduates that complete the baccalaureate degree (Dracup, Tanner) − A llow community colleges to provide baccalaureate degrees (Dracup) • In post-graduate residency programs − Develop and test clinical education models that include post-graduate residency programs (Tanner) − Implement requirement of post-graduate residency for initial re- licensure (Cronenwett, Tanner) • In health care settings that foster day-to-day change and improvement (Berwick) • In programs built on strong academic–practice setting partnerships (Cronenwett, Gilliss) − At Academic Health Centers, promote governance structures that combine the strategic, rather than operational, oversight for nursing (Gilliss)

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40 THE FUTURE OF NURSING • In settings that are models of integrated care where care coordination skills can be developed (Tilden) Who Teaches (Characteristics of Desired Faculty Members of the Future) Increase the number of faculty members: • Whose criteria for appointment and advancement include recognition of practice-based accomplishments, including engagement in the work of improving health care (Berwick, Gilliss, Dracup, Cronenwett) • Who can move easily during careers between practice and academe (Gilliss) • Who shorten their career paths from BSN to doctoral degree (Aiken, Dracup) • Who maintain professional certification and/or clinical competence (Gilliss) • Who build alliances with faculty in other disciplines (medicine, engi- neering, business, public health, law) (Gilliss) • Who are capable of leading efforts to advance interprofessional educa- tion (Dracup, Tilden) Recommendations: To Nursing Organizations • Ensure that schools produce ever-increasing numbers of nurse practi- tioners for primary care roles at a time when expanded access to health care will increase society’s need for primary care providers (Cronenwett, Gilliss) − Challenge current credit-heavy requirements and test teaching in- novations that improve competence while reducing program credits (Gilliss) • Support the faculty development necessary to bring about the magnitude of reforms in nursing education recommended in the Carnegie study, necessitated by advances in nursing science and practice and guided by advances in the science of learning (Tanner) • Advance post-master’s DNP education, maintaining specialist prepara- tion at the master’s program level (Cronenwett, Gilliss) − Fund initiative to facilitate professional consensus that DNP programs should be launched as post-master’s program for the foreseeable fu- ture (Cronenwett) − Clarify the expectations for nurse scientists interested in translational research—will both the DNP and the PhD be required? Will the DNP alone be sufficient for tenure-track positions in research-intensive universities? (Dracup)

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41 APPENDIX I • Include as accreditation criteria for nursing education programs: − Substantive nursing education–service partnerships, e.g., in shared teaching and clinical problem solving (Cronenwett, Gilliss) − Interprofessional education (Cronenwett, Dracup, Gilliss, Tilden) − Development of competencies in health policy (Tilden) − Student/faculty participation in or leadership of teams that work to improve health care (Berwick, Cronenwett) − Student competency development related to health policy (Tilden) • Identify top ten areas of needed faculty development and provide public recognition for success (Gilliss) • Support a learning collaborative of state boards of nursing willing to implement regulatory requirements for transition to practice residency programs as a prerequisite for initial re-licensure (Cronenwett) • Require proof of a nurse’s participation in or leadership of teams that work to continuously improve the health care system for renewal of certification (Berwick) • Urge testing of interprofessional teamwork and collaboration and health policy competencies in licensure exams (Tilden) Recommendations: To Government and Other Organizations • Increase scholarships, loan forgiveness, and institutional capacity awards to increase the number and proportion of newly licensed nurses graduating from baccalaureate and higher degree programs (Aiken, Cronenwett) • Increase scholarships, loan forgiveness, and institutional capacity awards for graduate nurse education at master’s and doctoral levels (Aiken, Dracup) • Redirect Medicare GME nursing education funds to support graduate nurse education (Aiken, Dracup, Tanner) • Redirect Medicare GME nursing education funds from hospital-based pre-licensure programs to postgraduate residency programs (Cronenwett, Tanner) • Promote innovation and evaluation of novel approaches to improving preparation for the practice of nursing through expanded Title VIII fund- ing (Cronenwett, Tanner) • Invest in nursing education research, related particularly to the evalua - tion of multiple pathways to licensure (Tanner) • Use CTSA or other research facilitation structures to promote knowledge development at the point of care, translation of knowledge into prac- tice, practice improvements, and interprofessional education (Dracup, Gilliss)

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42 THE FUTURE OF NURSING • Create a federal health professions workforce planning and policy capac- ity in the Executive Branch (Aiken) • Expand authorities for Title VII/VIII funds to support development and evaluation of interprofessional education innovations (Gilliss) • Expand Nurse Faculty Loan Programs and other loan forgiveness/ scholarship programs that produce more faculty (Aiken, Dracup) • Encourage public and private resource investments that incentivize stu- dents and nursing programs to expedite production of qualified nurse faculty by shortening the trajectory from entry into basic nursing pro- grams through doctoral and post-doctoral study (Aiken, Dracup) • Use Perkins funds to incentivize community college nursing programs to increase the proportion of their nursing students who complete their initial education with a BSN (Aiken) • Increase programs that support greater production of nurse practitioners for primary care (and remove legal barriers to interprofessional educa- tion and practice) (Aiken, Cronenwett) • Fund a longitudinal study to track state-based data on number and proportion of new nurse graduates from ADN vs. BSN/higher degree programs (Cronenwett) − Advance media attention to states that exemplify “best practices” in the distribution of new nurse graduates from ADN vs. BSN programs (Cronenwett) • Include health services research (in addition to drug and treatment in - tervention trials) in initiatives to enhance comparative effectiveness research (Aiken) • Require universities and colleges (presidents, provosts, deans) to support infrastructures and mandates for interprofessional education (Tilden) CONCLUSION The recommendations of seven leaders committed to the development of future generations of health professionals included some expected diversity of views. Nonetheless, given the long list of issues that would have been covered had we chosen to write one comprehensive paper, a remarkably small number of themes emerged. Hopefully, these rich ideas and themes can be used to inform the deliberations of the RWJF/IOM Committee on the Future of Nursing. Even more hopefully, a collective national response to these important issues will create a future that meets nursing’s obligations to the society it serves.

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43 APPENDIX I NURSING EDUCATION POLICY PRIORITIES Linda H. Aiken, Ph.D., FAAN, FRCN, R.N. University of Pennsylvania Nursing is one of the most versatile occupations within the health care workforce. In the 150 some years since Nightingale developed and promoted the concept of an educated workforce of caregivers for the sick, modern nursing has reinvented itself a number of times as health care has advanced and changed (Lynaugh, 2008). As a result of nursing’s versatility, new career pathways for nurses have evolved attracting a larger and more diverse applicant pool and a broader scope of practice and responsibilities. Nursing, because of its versatil- ity, has been an enabling force for change in health care along many dimensions including but not limited to the evolution of the high-technology hospital, the pos- sibility for physicians to combine office and hospital practice, length of hospital stay among the shortest in the world, reductions in the work hours of resident physicians to improve patient safety, extending national primary care capacity, improving access to care for the poor and rural residents, and contributing to much needed care coordination for the chronically ill and frail (Aiken et al., 2009). Indeed, with every passing decade, nursing has become a more integral part of health care services to the extent that a future without large numbers of nurses is impossible to envision. A POLICY CHALLENGE From a policy perspective, nursing’s versatility is important to note for the simple reason that nursing has evolved faster than public policies affecting the profession. The result is that nursing’s forward progress to better serve the public is hampered by the constraints of outdated public policies involving govern- ment education subsidies, workforce priorities, scope of practice limitations and regulations, and payment policies. An important priority in national health care reform is achieving better value for the expenditures made on health services. Since health care is labor intensive, getting more value will depend in large part on enhancing productivity and effectiveness of the workforce. Nurses represent a large and unexploited opportunity to achieve greater value. The purpose of this paper is to identify and discuss several key changes in nursing education policy that are critically needed to shape the nurse workforce to best serve the health care needs of the American public in the years ahead. It is written with the assumption that nurse scope of practice and payment policy reforms will take place over the near term to remove some of the existing barri- ers to nurses practicing to the full extent of their education and expertise. This assumption is based on steady progress in removing barriers to nursing practice at the state level and language in current national health reform legislation show-

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44 THE FUTURE OF NURSING ing greater neutrality in the designation of types of health professionals who can participate in and lead new initiatives in primary care and chronic care coordina- tion. Changes in nursing education policies are needed to ensure that the nurse workforce of the future is appropriately educated for anticipated role expansions and changing population needs. Five priority recommendations regarding the future of nursing education are advanced for consideration by the RWJF Committee on the Future of Nursing at the IOM: • Increase and target new federal and state subsidies in the form of schol- arships, loan forgiveness, and institutional capacity awards to signifi- cantly increase the number and proportion of new registered nurses who graduate from basic pre-licensure education with a baccalaureate or higher degree in nursing. • Increase federal and state subsidies for graduate nurse education at the master’s and doctoral levels in the form of scholarships, loan forgive- ness, and institutional capacity with a priority on producing more nurse faculty. • Encourage public and private resource investments to incentivize students and nursing programs to expedite production of qualified nurse faculty by shortening the trajectory from entry into basic nursing education through doctoral and post-doctoral study by expedited bachelor of science in nursing (BSN) to PhD programs and comparable innovations. • Create a federal health professions workforce planning and policy capac- ity in the Executive Branch with authority to recommend to the President and the Congress health workforce policy priorities across federal agen- cies and departments. • Recommend the inclusion of health services research on various forms of nursing investments in improving care outcomes including comparisons of the cost effectiveness of improving hospital nurse-to-patient ratios, increasing nurse education, and improving the nurse work environment. At present comparative effectiveness research is more focused on drug and treatment intervention trials than on innovations in care delivery including workforce interventions. PRIORITY FUNDING TO INCREASE INITIAL BSN GRADUATES Every year the percent of new registered nurses graduating from associate degree programs increases, and it is now over 66 percent of all new nurse gradu- ates. Multiple blue ribbon panels on nursing education, including the just released Carnegie Foundation Report on Nursing Education (Benner et al., 2010) as well as health workforce reports to Congress for two decades, have concluded that there is a substantial shortage of nurses with BSN and higher education to meet

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4 APPENDIX I current and future national health care needs. Advances in medical science and technology, the changing practice boundaries between medicine and nursing, and the increase in the share of the population with multiple chronic health conditions create a level of complexity in health care that requires a more educated health care workforce. Nursing is the least well educated health profession by far but the one experiencing the greatest expansion in scope of practice and responsibilities. The National Advisory Council on Nurse Education and Practice (NACNEP) (1996), policy advisors to the Congress and the U.S. Secretary of Health and Human Services on nursing issues, urged almost 15 years ago that policy actions be taken to ensure that at least 66 percent of nurses would hold a baccalaureate or higher in nursing by 2010; the actual result is closer to 45 percent. As described in the sections below, growing evidence suggests that the shortage of nurses with BSN and higher education is adversely affecting a number of dimensions of health care delivery now and these problems will only become exaggerated in the future. Quality of Hospital Care A growing body of research documents that hospitals with a larger propor- tion of bedside care nurses with BSNs or higher qualifications is associated with lower risk of patient mortality. Aiken and colleagues (2003) in a paper published in the Journal of the American Medical Association (JAMA) showed that in 1999, each 10 percent increase in the proportion of a hospital’s bedside nurse workforce with BSN qualification was associated with a 5 percent decline in mortality fol- lowing common surgical procedures. A similar finding was published by Friese and associates for cancer surgical outcomes (Friese et al., 2008). Aiken’s team has replicated this finding in a larger study of hospitals in 2006. Similar results have been published for medical as well as surgical patients in at least three large studies in Canada and Belgium (Estabrooks et al., 2005; Tourangeau et al., 2007; Van den Heede et al., 2009). This research has motivated the American Association of Nurse Executives, the major professional organization representing hospital nurse chief executive officers who employ 56 percent of the nation’s nurses, to establish the BSN as the desired credential for nurses. Many hospitals, particularly teaching hospitals and children’s hospitals, are acting on the evidence base by requiring the BSN for employment. Nurse executives in teaching hospitals have a goal of 90 percent BSN nurses, and community hospital nurse executives aim for at least 50 percent BSN-prepared nurses (Goode et al., 2001). Since only 45 percent of bedside care nurses have a BSN, many executives cannot reach their goals. Access and Costs There is some research evidence that the cost effectiveness of nursing im- proves with a more educated workforce. In Aiken’s JAMA paper, evidence was

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4 THE FUTURE OF NURSING presented to show that the mortality rates were the same for hospitals in which nurses cared for 8 patients each, on average, and 60 percent had a BSN and for hospitals in which nurses cared for only 4 patients each but only 20 percent had a BSN (Aiken, 2008; Aiken et al., 2003). More research is needed to assess the comparative value of investing in different nursing strategies that evaluate the relative cost and outcomes of increasing nurse staffing, educational levels, and improving the organizational context and culture of the nurse work environment. At this point the evidence is encouraging that a more educated hospital nurse workforce might allow for a smaller nurse workforce without adversely affect- ing patient outcomes. If confirmed in future research, this finding could have important implications for both cost of hospital care and for the number of nurses actually needed in the future to staff hospitals. In the ambulatory sector, there is a strong research base documenting that nurses with advanced clinical training, usually master’s degrees in advanced clinical practice, provide primary care with outcomes comparable to, and in some domains like symptom control and satisfaction better than, those of physicians and with lower costs (Griffiths et al., 2010; Horrocks et al., 2002). Rand research- ers estimated, for example, that the state of Massachusetts could save up to $8 billion over a decade by attracting more advanced practice nurses and removing barriers that prevent them from practicing at the full level of their education and expertise (Eibner et al., 2009). Increased use of advanced practice nurses is one of the very few practice innovations currently underconsidered in national health reform, including medical homes and chronic care coordination, that would yield net cost savings nationally according to Rand researchers (Hussey et al., 2009). How the Shortage of BSN Nurses Impacts Future Nurse Supply As argued above, the shortage of BSN nurses has implications for health care quality and safety, access, and costs of care. A less well recognized consequence of the shortage of BSN nurses is a shortage of faculty which could have a long- term impact on national production capacity of nurses for the future. The Department of Labor estimates that 600,000 new jobs will be created for nurses over the next 10 years, the highest rate of new job production for any profession (Bureau of Labor Statistics, 2009). In addition, over a half million nurses in the current workforce, which has an average age of around 48, will reach retirement age over the same period, resulting in the need for over a mil- lion nurses to be added to the national workforce. The good news is that there is tremendous interest in nursing as a career in the United States after a century of difficulty attracting the best and brightest to nursing. The reasons for this unprec- edented interest are multifaceted, having to do with attractive incomes, averaging nationally $65,000 a year and higher in some locations, better job prospects than in other employment sectors, and perceptions of personally satisfying work help- ing others. If we can take advantage of this unprecedented interest and expand nursing school production, future nursing shortages could be greatly attenuated.

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4 APPENDIX I The bad news is that nursing schools do not have the capacity to absorb the great windfall in applicants. Estimates suggest that at least 40,000 qualified applicants to nursing schools are being turned away each year (AACN, 2009). There are several reasons why nursing schools are unable to accept the influx of applicants. Nursing schools have expanded enrollments steadily for more than a decade with graduations increasing from about 75,000 in 1994 to 110,000 in 2008. Resources of all kinds are now stretched and schools are having difficulty expanding further. Institutions of higher education in general are experiencing serious budget constraints and as a result are slowing enrollment growth. Addi- tionally the shortage of nursing faculty has become a major constraining factor. A strategy for ameliorating the nurse faculty shortage that has received little attention to date is to increase entry-level education of nurses to produce a larger pool of nurses likely to obtain graduate education. In a recent paper in Health Affairs Aiken and colleagues provided a cohort analysis to determine the highest education achieved by nurses receiving their basic or initial nursing education between 1974 and 1994 (Aiken et al., 2009). We found that choice of initial nursing education program—associate degree or baccalaureate—was the major predictor of final educational attainment. Close to 20 percent of nurses ir- respective of initial nursing education obtain a higher degree. However, of the 20 percent of associate degree nurses who obtain an additional degree, 80 percent stop at the baccalaureate degree. Of the 20 percent of nurses with a baccalaureate degree who go on for additional education, almost 100 percent obtain at least a master’s degree. This is an important finding for the design of policy interventions since investments in encouraging BSN education have not distinguished between RN-to-BSN programs and basic BSN programs. The yield for teachers is entirely different between the two types of programs. If the current scenario of distribu- tion of nurses by type of basic education had been reversed since 1974 and 66 percent of nurses had graduated from BSN programs instead of 33 percent, we estimate that there would be over 50,000 more nurses with master’s and higher degrees today. We concluded in our Health Affairs paper that it was a mathematical im- probability that the nurse faculty shortage could be solved without changing the distribution of nurses by type of basic education. There are simply not enough nurses who obtain a master’s or higher degree to meet the dramatic increase in demand for clinicians, administrators, teachers, and leaders who require a gradu- ate degree. What would be the expected yield in terms of nursing faculty that would be likely to obtain by increasing basic BSN education? To answer this we undertook an analysis of the National Sample Surveys of Registered Nurses over time to ex- plore whether career trajectories of nurses with graduate education had changed over time. The answer is yes—significantly. For example, in 1982, 17 percent of nurses with master’s degrees and 62 percent of nurses with doctorates were in faculty positions compared to only 7 percent of master’s and 41 percent of nurses with PhDs in 2004. Nurses with graduate degrees are selecting positions in

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4 THE FUTURE OF NURSING students’ greater familiarity with each others’ roles, competencies, nomenclatures, and scopes of practice will result in more collaborative graduates. Graduates from programs with IPE training will be ready to work effectively in patient-centered teams where miscommunication and undermining behaviors are minimized or eliminated, resulting in safer, more effective care and greater clinician and patient satisfaction. Specifically, IPE is thought to achieve collaboration in implementing policies and improving services, prepare students to solve problems that exceed the capacity of any one profession, improve future job satisfaction, create a more flexible workforce, modify negative attitudes and perceptions, and remedy fail- ures in trust and communication (Barr, 2002). Efforts have been made to evaluate the effectiveness of IPE in improving outcomes, typically including increased student satisfaction, modified negative stereotypes of other disciplines, increased collaborative behavior, and improved patient outcomes. However, IPE’s effect is not easily verified since control group designs are expensive, reliable measures are few, and time lapses can be long between IPE and the behaviors of graduates. Barr and colleagues reviewed 107 evaluations of IPE in published reports, judged to be of sufficient quality for in- clusion according to Cochrane review standards (www.cochrane.org), and found support for three outcomes: IPE creates positive interaction among students and faculty; encourages collaboration between professions; and improves aspects of patient care, such as more targeted health promotion advice, higher immunization rates, and reduced blood pressure for patients with chronic heart disease (Barr et al., 2005). In further work, Reeves et al. (2009) reviewed six later studies that met methodology inclusion criteria as randomized controlled trials, controlled before-and-after studies, and interrupted time series design studies. Four of the studies found that IPE improved aspects of how clinicians worked together, such as an improved working culture and decreased errors in an emergency depart- ment, improved care management for domestic violence victims, and improved knowledge and skills of clinicians caring for mental health patients. The remain- ing two studies found that IPE had no effect at all. Although empirical evidence is mixed, there is widespread theoretical agreement and anecdotal evidence that students who demonstrate teamwork skills in the simulation lab or at the bed- or chair-side with patients will apply them beyond the walls of their academic pro- grams, particularly if valued and reinforced by the care environments in which they later work. In the early days of IPE, students graduated into patient care environments in which siloed and hierarchical systems predominated, thus creating a significant disconnect between their college-based learning and post-graduation experi- ence. Now, 10 years into the widespread reforms triggered by the IOM’s searing Quality Chasm reports, the practice environments students enter tend to reinforce rather than discourage cooperative behaviors and attitudes. This shift suggests a readiness for IPE and fuels the momentum among health science universities toward a growing acceptance of IPE in curricula.

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 APPENDIX I IPE goes well beyond classroom-type courses comprised largely of didactic lectures, considered ineffective in cultivating team-based behaviors. Sitting side- by-side in lecture halls produces little student engagement with either the faculty or other students. From a pedagogical perspective, IPE learning comes from conjoint reflection, problem solving, and experience. Effective IPE training pro- duces much more than the sum of its parts, rather, it generates interprofessional discourse that shapes collaborative thinking and behavior. IPE typically takes one or more of three approaches: (1) clinical skills lab simulation activities using manikins or standardized patients in case scenarios often videotaped to facilitate review and reflection, (2) service learning projects that enhance students’ civic engagement often with diverse communities, and (3) specific patient group clinics such as in the care of geriatric or HIV/AIDS patients. Barriers to IPE exist (Gilbert, 2005) but are surmountable. Jurisdictions of faculty and professional organizations abound. Different accrediting bodies are loath to yield control over traditional curricula and standards. Space in curricula, with their emphasis on factual content over synthesis, integration, and coopera- tion, is limited. Relatively rigid academic calendars control course schedules. Other barriers pertain to motivating faculty. How to reward and give faculty credit for IPE when the traditional reward systems such as promotion, tenure, and merit raises are governed within, not across, professions. Resources of the various deans to support IPE likely differ. Typically schools of nursing have smaller over- all budgets than schools of medicine but a higher percent of funding that supports the education mission. Medical school faculty typically are expected to generate a larger proportion of their salaries through clinical practice and/or research. When done well IPE can be expensive for many reasons, e.g., small groups with stability over time to allow for reflection and the development of trust, and/or expensive equipment for simulations. These budgetary issues can contribute to different levels of willingness of deans to support IPE. Recommendations 1. Students at all levels of nursing education—baccalaureate, master’s, and doctoral—must have exposure to IPE training and demonstrate competence in interprofessional collaboration. 2. Since academic curricula tend to resist change unless pressured by external forces such as accreditation requirements and licensure/certifying exam con- tent, major education and standard-setting organizations must cooperate to bring about IPE. In addition, endorsement of IPE must come from the highest levels within academic settings, including presidents, provosts, and deans. 3. Nursing faculty need development in IPE teaching, which requires structure and funding. The traditional notion of “teacher as expert” urgently needs replacement with teacher as coach and facilitator. Faculty, whose average age nationally is in the mid-50s, need the tools to make this transition. In

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 THE FUTURE OF NURSING addition, since most nursing faculty are not active in practice, their own clinical experience is often dated and sometimes based on past unsatisfying interprofessional relationships, making them poor champions for IPE. 4. The level and timing of bringing various students together requires analysis and pilot testing because of students’ varying educational pathways and readiness for IPE. For example, evaluate pairing senior medical students with graduate nursing and allied health students, in an effort to have students bring relatively comparable amounts of university education and clinical exposure to the experiences. 5. IPE should be structured around knowledge, skills, and competencies to in - clude: interpersonal and listening skills; techniques for constructive dialogue and disagreements; how “evidence” in evidence-based practice is weighted; systems thinking and problem solving; engaging patients and families as active participants in care; verbal and nonverbal communication within the care team; effective data reports and displays; stereotypes and prejudices; and appreciating alternative conceptual frameworks and points of view. EDUCATION IN CARE COORDINATION Both the health professions literature and the popular press note that fail- ures in patient care coordination are widespread in the United States. Indeed, fragmented care, lost records, hand-offs without full information, poor return of information from specialty care after referral, unnecessary and redundant proce- dures and services—and the attendant patient fatigue, frustration, and costs—are the very heart of the quality chasm. This problem is particularly acute for the 125 million people with chronic illness, disability, or functional limitations, and for the elderly whose numbers will swell in the decades ahead. Short hospital stays have exacerbated the problem. Historically, primary care physicians coordinated their own patients’ care within and across settings, but this function has all but been lost for myriad reasons, including the growth in hospitalist care, patient self-referrals to special- ists, the breakdown in communication between primary care and specialty care, financing constraints on physician time, and overall uncoordinated systems of in- formation technology. Failures in care coordination also can be traced to curricula where the competencies required are assumed to be intuitive and thus minimized or overlooked altogether. Serious consequences result from poor care coordination. Especially wor- risome is the post-hospital fate of patients. One study of care transitions found that 19 percent of patients experienced adverse events following discharge from a U.S. teaching hospital, most of which were avoidable and typically related to poor communication (Forster et al., 2003). In another survey, 48 percent of newly discharged patients reported not receiving information about side effects of new prescriptions ordered at discharge (Schoen et al., 2005). In a study of urgent care

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 APPENDIX I patients, in 33 percent of cases information such as medical history and labora - tory results was absent. In half the cases, the information was essential to patient care (Gandhi, 2005). As defined by the National Quality Forum (2006), care coordination should meet patients’ needs and preferences for information and services across settings over time. This facilitates beneficial, efficient, safe, and high-quality patient ex- periences and improved health care outcomes. Qualities and principles of care coordination include an enduring patient relationship and an established and up-to-date care plan that anticipates routine needs, manages acute, episodic, and chronic care needs and tracks progress toward goals that are jointly set by the health care team and the patient/family. Care coordination ensures information flow to and from referrals to specialty care or community services; ensures that all team members, including the patient, are apprised of tests and services with results readily available; reconciles medication orders and educates patients and families about side effects and medication management; and reduces opportuni- ties for error. Care coordination requires linguistically and culturally competent communication with the patient and family, and seeks and responds to patient/ family questions and feedback. Yawning gaps in care coordination are rallying many health professions or- ganizations to search for solutions. For example, the American Board of Internal Medicine Foundation structured its annual Forum on this topic in 2007, and later spearheaded a consortium, referred to as the SUTTP Alliance (Stepping Up to the Plate for Managing Transitions in Care) comprised of 10 medical specialty societies, including the American College of Physicians, the American Academy of Family Physicians, and the Society of Hospital Medicine. Nurses are the logi- cal and ideal clinicians to fill the role of care coordinator, yet a similar alliance among nursing organizations is absent. Germane to this paper, curricula in care coordination in nursing education are underdeveloped. Nursing research has produced important findings about advance practice nurses as care coordinators. Brooten’s early work on care of low-birth-weight infants (Brooten et al., 1986) showed significant cost and quality improvement for early discharge and follow up home care by advance practice nurses (APNs). Naylor and colleague’s (1999, 2004) studies of a transitional care model by APNs for older cardiac patients post-hospitalization also demonstrated positive effects of nurse-managed transitional care. In these models, APNs tailored post- discharge services to each patient’s situation and followed patients by telephone and home visits. The intervention emphasized patients’ and caregivers’ goals, individualized plans of care developed and implemented in collaboration with patients’ physicians, educational and behavioral strategies to address needs, and coordination and continuity of care across settings. Overall outcomes were positive across a series of studies, showing lower rehospitalization rates, fewer hospital days when readmitted, substantial cost savings, and greater patient satisfaction with care.

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 THE FUTURE OF NURSING Another superlative example of care coordination is On Lok Senior Health Services for older adults living in San Francisco. For over 30 years, On Lok has used multidisciplinary teams, electronic medical records, capitated pay- ment, and a full range of services (including transportation, housing, meals, adult day health services, and geriatric aides who make frequent home visits) to provide seamless transitions for nursing home-eligible frail elders at lower cost than usual care. On Lok became the model for similar institutions around the Unitd States through the Program of All-Inclusive Care for the Elderly (PACE) (Bodenheimer, 1999). Another care coordination model is Tom Bodenheimer’s “teamlet” (Bodenheimer and Laing, 2007), dyads that are a subset of the larger health care team and comprised of a physician and, ideally, an experienced nurse or an APN. Patients enter “an expanded encounter,” in which pre-, post-, and between- visit care is continually monitored and coordinated by the nurse. Ingredients for success include making sure the patient understands advice and direction and agrees with the plan of care; communicating and interpreting laboratory and other diagnostic tests, and continually looping information between the patient and family, the physician, other care providers such as clinical pharmacists and allied health. Bodenheimer notes that ideally the coach would be an RN or an advanced practice nurse, but in their absence, a medical assistant could be trained for the role. Thus, the role of care coordinator as patient advocate, communicator, as- sessor, and intervener, ideally suited to what nurses do best, presents a huge opportunity for nursing education. But, as implied by Bodenheimer, the nursing profession will be bypassed if nurses fail to seize the opportunity. To do so, how- ever, requires that nursing school curricula incorporate not just the knowledge underlying the competencies of the role but convey the importance of the role to students by threading the concept and competencies of care coordination through- out the curricula. As already mentioned, most nursing curricula currently teach compartmentally, not across systems. Courses, particularly in the baccalaureate program where attitudes about nursing and nursing care are first formed, focus on content and skills in specific discrete clinical settings. Faculty generally teach within, not across, settings of care. Often the master’s level Clinical Nurse Spe- cialist program is the only track with a course or parts of courses that address care transitions and care coordination, and this content may be confused with case management, the latter being a more limited concept usually applied to contain- ing costs within reimbursement systems. Interprofessional education discussed above will by itself, improve gradu- ates’ competence in care coordination because many of the competencies students learn in IPE are relevant. However, there is a body of knowledge and sets of skills, attitudes, and role-related behaviors specific to care coordination that should be integrated throughout the levels of nursing education rather than confined to episodic IPE training.

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 APPENDIX I Recommendations 1. BSN students should be placed for clinical training in new models of inte - grated care that require care coordination, such as accountable care organiza- tions within universities or medical homes. 2. MSN students should study the research cited above that shows the effective- ness of APN transitional care. Components of MSN clinical training should include the care coordination role. 3. Across education levels of nursing education, care coordination should be structured around knowledge, skills and competencies to include: advanced assessment skills appropriate for senior baccalaureate and master’s/DNP students; interpersonal and communication skills necessary for the ability to communicate with patients and families with a high degree of sensitiv- ity and cultural competence, as well as the science-based skills necessary to communicate effectively with physicians and others on the health care team; competencies in care planning that integrate the biological, social, and psychological needs of patients; understanding of and ability to seek and ap- ply evidence-based protocols and national standards for patient conditions; and payment and social services systems to better address the full range of patients’ and families’ needs. HEALTH POLICY EDUCATION In large measure nursing education must remain patient focused. This makes sense for an applied discipline whose goal is the prevention or amelioration of illness and the improvement in the wellbeing of patients, families, and communi- ties. However, a major lesson of the past 20 years is the degree to which health systems and policy shape the health both of populations and individual patients. Yet nursing students gain only a glimmer that health policy at multiple levels, from the hospital unit to the federal government, affects not only their practice but ultimately the fate of patients. Few educational programs include more than a token course on health policy, typically only at the graduate level. Since nurs- ing education curricula generally treat health policy as extra rather than core, the naiveté of graduates, is no surprise. With few exceptions, nurses generally view themselves as being shaped by, not shaping, policy. Since nurses largely take a back seat to policy processes, the profession’s in- put has been relatively invisible, certainly compared to that of medicine (Mechanic and Reinhard, 2002). Few nurses, when asked “What is nursing?” include health policy as a component of what nurses do (Gebbie et al., 2000). Missed opportu- nities for nursing to shape legislation or wade into legislative debates are all too common. One example is the recent Centers for Medicare and Medicaid Services (CMS) rule that restricts reimbursement for such “never events” as pressure ulcers, certain catheter-related infections and injuries, and certain surgical site

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0 THE FUTURE OF NURSING infections. The majority of these conditions can be prevented by excellent nursing care, yet the nursing profession has not effectively convinced the Congress or the American public that nursing care is the key ingredient safeguarding the public from these problems (Leavitt, 2009). Another example is the “killing grandma” and “death panel” controversy, sparked by wording in the August 2009 congressional health care reform bills. Thousands of nurses across the country have daily, intimate contact with patients and families in the throes of decision making about DNR orders, advance direc- tives, and other end-of-life issues. Nurses have close personal knowledge about how they and other clinicians facilitate discussions and considerations about palli- ative care and life-extending treatments. Despite this, nurses were largely silent in the face of widespread public misunderstanding and resulting acrimonious outcry over what is intended in counseling patients facing such decisions. This silence is surely an outgrowth of the inattention of nursing curricula to health policy. The Healthy People Curriculum Task Force, convened by the Association of Academic Health Centers and the Association of Teachers of Preventive Medi- cine, with representatives from medicine, nursing, pharmacy, and physician as- sistants, as well as their educational associations recommended the following four domains fundamental to health professions curricula on health policy (http:// www.atpm.org/CPPH_Framework/index.html): • Organization of clinical and public health systems (connecting the pieces of the system; connecting clinical care to public health structures) • Health services financing (underlying determinants of cost and options for payment and cost containment; comparison to health systems of other countries) • Health workforce (understanding the roles and responsibilities of other health professionals) • Health policy process (introduction to the impact of policy on health and clinical care, the processes involved in developing policies, and opportunities to participate in those processes, whether within a local institution or state or federal legislation) Medicine has advocated the inclusion of these domains in all medical school curricula (Riegelman, 2006). Nursing curricula should do no less. As emphasized above, health policy curricula are needed at the baccalaure- ate, master’s, and doctoral levels of nursing education, with increasing scope and complexity as the student advances. Political competence requires continuing skill development that begins early in students’ education, thus setting the course toward the graduate’s life-long engagement. Baccalaureate students need to understand the role of policies at the unit level that shape the environment in which they will eventually work. Workplace policies (e.g., mandatory overtime, nurses’ authority to close beds to new admis-

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1 APPENDIX I sions based on professional judgment of adequate staffing, school nurses’ author- ity to teach reproductive information) lend themselves for students’ analysis and can help students clarify their own biases and potential ethical conflicts. Another example of the type of policy work ideal for analysis by baccalau- reate, and even graduate, nursing students pertains to the Robert Wood Johnson Foundation and the Institute for Healthcare Improvement project, Transforming Care at the Bedside (www.ihi.org/IHI/Programs/TransformingCareAtTheBed- side/). TCAB is an excellent teaching–learning vehicle for students to gain un- derstanding of local policy and how it is shaped. Originally designed as a way to improve hospital work environments so that more nurses would seek (and stay) in positions on medical–surgical units, TCAB also addresses care improvement processes, such as rapid PDSA (plan-do-study-act) cycles for gathering data to influence patient care policies. Faculty should engage baccalaureate students in this TCAB literature, with application in clinical assignments and an emphasis on policy implications and processes. In addition, baccalaureate students need an understanding of the important role that nursing organizations can play so as to encourage their involvement both as students and as graduates. Graduate education in nursing, both at the master’s and doctoral levels, should be infused with multiple learning experiences in health policy, including both explication and hands-on experience. Building on the foundation from the health policy curriculum at the baccalaureate level, APN students need to be ac- tively involved in political processes that affect the care they will deliver in the future. At this stage of their education, they should be expected to understand the link between evidence and policy, i.e., the role that data can play in illuminating problems and capturing the attention of policy makers. IPE can provide collab- orative efficiencies so that interprofessional student groups engage together in policy projects. AACN’s DNP Essentials (www.aacn.nche/DNP/pdf/Essentials.pdf) includes “Health Care Policy for Advocacy in Health Care” (Essential V), which expects DNP graduates to engage in the health policy process, whether through institu- tional decision-making, influencing organizational standards, or governmental actions. It is expected that students will be oriented to the principles of social justice, particularly in advocating for the underserved. Examples of hands-on assignments include preparing and presenting a policy brief analyzing a state or national health policy issue or problem related to access, utilization, cost, or quality; writing a letter (not to be sent) to an editor or an elected official on a health issue; and educating the lay public through speaking at local Rotary or other civic organization. At the PhD level, student understanding of how to impact health policy moves specifically to the role of research. The focus at this level should be on advanced knowledge of political processes within the state and federal govern- ment and on the competencies needed to articulate research findings persuasively. Students should understand how to plan their doctoral studies and related work,

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2 THE FUTURE OF NURSING such as scholarly projects and the dissertation, toward the end goal of becom - ing influential. Many authorities (e.g., McBride et al., 2008) urge researchers to engage end users when framing research since those in position to make policy frequently complain that the research they need is rarely available. A useful ex- ercise for PhD students early in their program is to meet with a state or federal elected member to discuss topics of mutual interest in improving health or health care and determining what evidence may be useful in future policy agenda. Linking research findings to health policy formulation requires a set of specific skills which should be core to PhD education. These range from the con- crete, for example, selecting a title for a policy brief or media report that reflects the key take-away message (since busy policy makers will overlook material that does not draw them in quickly), to the more conceptual, e.g., learning the separate perspectives of legislators who make policy and researchers who study health problems, which Hinshaw refers to as “moving between two cultures” (Hinshaw, 2008). Recommendations 1. In addition to health policy courses at baccalaureate, master’s, and doctoral levels, health policy objectives should be threaded throughout the curricu- lum, ideally embedded in every course and reflected in course assignments. Using probing questions that invite student reflection, synthesis, integration, and deduction, faculty should lead students to articulate the policy implica- tions in everything they study. 2. Accreditation and licensure/certifying examinations must ramp up their ex - pectations for student competencies related to health policy. 3. Health policy education should be structured around knowledge, skills and competencies to include: policy-related relationship building skills; tech- niques for crafting testimony and writing effective white papers and posi- tion statements; effective use of numeric and narrative data to emphasize evidence-based information; working with the media; critiquing the ethical aspects of health policy in terms of vulnerable populations; mastering health policy terminology; understanding legislators’ perspectives; techniques for policy analysis; legislative processes in policy development; roles of stake- holders and special interest groups; and advocacy and strategies to influence policy. EPILOGUE The RWJF/IOM Initiative on the Future of Nursing will yield transforma- tional recommendations for the nursing profession at a critical time in history for nursing and for America’s health care system. There is much to reform in nursing education, from agreement about the minimum degree for entry into practice to

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3 APPENDIX I producing graduates with the requisite knowledge, skills, and interprofessional competencies they will need. This paper has reviewed the rationale for and cur- ricular implications of three target areas—interprofessional education, education for care coordination, and education for health policy—around which to restruc- ture education at the baccalaureate, master’s, and doctoral levels. The author ac- knowledges the difficulties in changing entrenched curricula and habits of faculty educated in past eras. But one remains optimistic, given the many examples of progress already made (Benner et al., 2010) that an enlightened profession with a will for change can bring about a refreshing new future for nursing education. REFERENCES Barr, H. (2002). Interprofessional education today, yesterday and tomorrow: A review, LTSN Hs&P, London, England. Barr, H., Koppel, I., Reeves, S., Hammick, M. and Freeth, D. (2005). Effective interprofessional education: Argument, assumption & evidence. Blackwell Publishing Ltd., Oxford, England. Benner, P., Sutphen, M., Leonard, V., and Day, L. (2010). Educating nurses: A call for radical transformation. The Carnegie Foundation for the Advancement of Teaching, Jossey-Bass, San Francisco. Bodenheimer, T. (1999). Long-term care for frail elderly people—the On Lok model. New England Journal of Medicine, 341, 1324-1328. Bodenheimer, T., and Laing, B.Y. (2007). The “teamlet” model of primary care. Annals of Family Medicine, 5, 457-461. Brooten, D., Kumar, S., Brown, L. P., Butts, P., Finkler, S. A., Bakewell-Sachs, S., Gibbons, A., and Delivoria-Papadopoulos, M. (1986). A randomized clinical trial of early hospital discharge and home follow-up of very-low-birth-weight infants. New England Journal of Medicine, 315(15), 934-939. Committee on Quality of Health Care in America. (2001). Crossing the quality chasm. Institute of Medicine, National Academy Press, Washington, DC. Evanoff, B., Potter, P., Wolf, L., Grayson, D., Dunagan, C., and Boxerman, S. (2005). Can we talk? Priorities for patient care differed among health care providers. Advances in Patient Safety, Volume 1. Rockville, MD, AHRQ. Forster, A., Murff, H. J., Peterson, J. F., Gandhi, T. K., and Bastes, D. W. (2003). The incidence and severity of adverse events affecting patients after discharge from the hospital. Annals of Internal Medicine, 138, 161-167. Gandhi, T. K. (2005). Fumbled handoffs: One dropped ball after another. Annals of Internal Medicine, 142, 352-358. Gebbie, K. M., Wakefield, M., and Kerfoot, K. (2000). Nursing and health policy. Journal of Nursing Scholarship, 32(3), 307-315. Gilbert, J. H. V. (2005). Interprofessional learning and higher education structural barriers. Journal of Interprofessional Care, Supplement 1, 87-106. Greiner, A. C., and Knebel, E. (2003). Health professions education: A bridge to quality. Institute of Medicine, the National Academies Press, Washington, DC. Hinshaw, A. S. (2008) Nursing research shaping health policy. Paper presented at the University of Nebraska Medical Center College of Nursing, March 25, 2008. Leavitt, J. K. (2009). Leaders in health policy: A critical role for nursing. Nursing Outlook, 57, 3-77.

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