Prior to the forum in Houston, a variety of stakeholders and the public were invited to submit written testimony to the committee in three areas relevant to nursing education: what to teach, how to teach, and where to teach. Those submitting written testimony were asked to describe innovative models in these three areas: funding strategies and financial incentives that could be used in nursing education; barriers to implementing or expanding innovative models and programs being used in nursing education; and how nursing education could be improved to better meet the current and future needs of Americans. Those submitting testimony were also asked to share their overall vision of the future of nursing.
Twelve individuals at the forum provided prepared oral testimony for the Initiative on the Future of Nursing; in most cases, these individuals or the organizations they represented had also submitted written testimony for the committee’s consideration. Many important ideas and suggestions for the initiative emerged from this testimony and are summarized below. A number of other individuals attending the forum offered ad hoc observations and opinions on what was discussed at the forum during an open-microphone session that closed the forum. These comments are summarized at the end of this chapter. Like the comments made by the discussants during the armchair discussions, the testimony, observations, and opinions in this chapter should not be interpreted as positions or recommendations of the committee, the Robert Wood Johnson Foundation (RWJF), or the Institute of Medicine (IOM). The testimony and comments made at the forum only represent the perspectives of those who attended and spoke at the forum and are not inclusive of all facets of nursing education.
James Walker, President
American Association of Nurse Anesthetists
Nurses need to develop an evidence-based perspective during their education to improve health care, control its costs, and extend patient access to care, said James Walker, president of the 40,000-member American Association of Nurse Anesthetists and director of Nursing Anesthesia for Baylor College of Medicine.
To become a certified registered nurse anesthetist (C.R.N.A.), a nurse must earn a bachelor’s degree, become a licensed registered nurse, and practice in acute care for at least 1 year. Today, C.R.N.A.s are prepared at the master’s level and take classes in pharmacology, anatomy, physiology, pathophysiology, and principles of anesthesia practice; they also gain extensive clinical experience. Nurse anesthetist graduates must pass a comprehensive certification exam to become a C.R.N.A., with recertification required every 2 years. By 2025, C.R.N.A.s will graduate from doctoral programs. Curricular content to be added in the future will focus on advancing clinical practice and research and improving the systems that shape anesthesia practice and care.
The outcome of the current educational system for nurse anesthetists is four-fold, Walker said:
It produces skilled nurse anesthetists to provide the full range of anesthesia and interventional pain management services.
It ensures patient access to care.
It creates access to surgical, trauma, interventional, diagnostic, and labor and delivery services everywhere in the country, particularly in rural and underserved areas of America.
It contributes to improving the quality of anesthesia care, which, according to the IOM, is approximately 50 times safer today than it was 20 years ago (IOM, 2000). This nurse-provided care is also a fraction of the cost associated with anesthesia provided by physician counterparts.
Given these outcomes, “there is now no place for restrictive federal barriers to nursing education practice,” Walker said. “What the patients in our country need is for nurses to continue leading the way by example.”
Diane Sosne, President
Service Employee International Union (SEIU) Healthcare 1199NW
To prepare nurses for leadership roles in tomorrow’s health care system and to educate enough nurses to meet the nation’s health care needs, nursing education must change, said Diane Sosne, president of SEIU Healthcare 1199NW in Washington state. Nursing education must emphasize safety, chronic disease management, preventive care, care coordination, the use of new technology, and multidisciplinary care delivery for diverse populations in multiple settings, including nontraditional ones. Providing such an education to nurses will create an important opportunity to increase the number and diversity of people in the nursing pipeline. “We need a tremendous number of nurses in all roles,” Sosne said. Partnerships between labor and management can inform the design of programs and curriculums and build in support systems to help prospective nurses succeed.
Moving health care workers along a nursing career ladder enables them to build on prior learning and engage in continuous learning. Articulation between programs and the development of shared curriculums that connect various nursing programs and levels of education can provide financial efficiencies in education, Sosne said. It is very effective, for instance, to introduce nursing concepts in prerequisite courses and to contextualize these concepts in health care settings.
Sosne cited an example of a labor–management partnership in Seattle that involves SEIU Healthcare, Northwest Hospital, and North Seattle Community College. A biology prerequisite class is being supplemented with a simulation that integrates nursing processes and critical thinking into the class. Such innovations can be supported through public–private partnerships and can be “very successful,” Sosne said, in leveraging the dollars invested in prerequisite and nursing education classes.
Phyllis Kritek, Conflict Engagement Consultant Trainer and Coach
Nursing education should build competencies in conflict engagement, said Phyllis Kritek, an independent conflict engagement consultant, trainer, and coach. Extensive research on patient safety has documented that the health care community has a cultural practice of avoiding, denying, and suppressing conflict, a practice that is often exacerbated by the abuse of power, she said. “Conflict competency is essential to challenge and change this culture,” she added.
Professional nursing has a strong and proud tradition of advocating collaboration. The IOM reports To Err Is Human (2000) and Keeping Patients Safe (2004) were part of a process that helped demonstrate that the failure to collaborate is a key factor in adverse events and catalyzed the patient safety movement. Furthermore, conflict competency shifted from being an aspiration to a requirement when the Joint Commission specifically included wording on disruptive behaviors and conflict resolution in its 2009 Leadership Standards (Joint Commission, 2008).
All nursing curriculums should include conflict competency training, Kritek asserted. This training should move beyond oversimplifications and formulaic superficiality and emphasize relationship-based conflict engagement, which is the only approach that can ensure collaboration in the challenging situations nurses confront. “Our students need practical skills, not platitudes,” she concluded.
Betty Young, President
Coleman College for Health Sciences, Houston Community College
Sergio Valdez was homeless in 2006 when he became an A.D.N. student at the Houston Community College Coleman College for Health Sciences. Today he is a registered nurse working at the Texas Medical Center. “This is just one person’s story,” said Betty Young, president of the Coleman College for Health Sciences at Houston Community College. “However, it is repeated day after day across the country in all of our community colleges.” Students in community colleges earn not just their degrees, but also the confidence that they will be able to continue their education and be successful, contributing members of the community.
The average age of students at Coleman College is 32, which means that the average student has many things to think about that 18-, 19-, or
20-year-old students probably do not, Young said. Older students and their families may have to make many sacrifices to attend college. If these students are not given the chance to attend 2-year community college nursing programs and enter into practice, they may never attend college at all.
Young recommended that the A.D.N. program be maintained as the entry point for practice. “This contributes to the diverse population of nurse practice,” Young said. Also, nurses should have an opportunity for continuing education, including earning a bachelor’s degree, while also meeting the needs of their current employer and their personal goals, she concluded.
George Boggs, President and Chief Executive Officer (CEO)
American Association of Community Colleges (AACC)
Community colleges are the primary educators of the nation’s new registered nurses, including the majority of underrepresented and returning nursing students, said AACC President and CEO George Boggs. A growing number of community colleges are offering B.S.N. programs, but the majority of nursing programs are taught at the associate degree level. The AACC favors more partnerships with university programs that are fully articulated, designed to facilitate life-long learning, and facilitate further education of associate degree nurses to help them earn advanced degrees and certifications. Especially important, said Boggs, are the R.N. to M.S.N. degree programs that can ease the persistent faculty shortages currently constraining nursing education.
Policies and regulations that encourage advanced degrees should not have the punitive effect of removing nurses from the workforce through the loss of their licenses, Boggs said. Options should be affordable; should recognize and give credit for education and experiences that nurses already have; and should be accessible even in remote and rural areas, where more than two-thirds of nurses are prepared in A.D.N. programs.
One option to consider is a 3-year B.S.N. program that is offered in other countries, Boggs said. This alternative to traditional 4-year programs could significantly increase the number of new B.S.N.s using the same available faculty and clinical site resources. Accreditation organizations may be reluctant to make such a dramatic change, but shared examinations could protect quality. “I urge the committee to focus on the
quality of the outcome of the programs rather than recommending a limitation on how nurses are taught to one standard program type,” Boggs said.
Cathleen Shultz, President
National League for Nursing (NLN)
Four values characterize the NLN’s vision for the future of nursing—caring, integrity, diversity, and excellence—said NLN President Cathleen Shultz. She highlighted a number of specific areas where the nursing workforce will need additional expertise to meet the future needs of the population.
In the area of diversity, nursing education must establish a workforce of faculty, researchers, and scholars that moves beyond tolerance of differences to engagement and celebration of differences. “We must institutionalize a commitment to diversity,” Shultz said. “Safe, quality care cannot be achieved without education inclusive of all.”
The need is urgent to build a science of nursing and to prepare a technologically savvy workforce. Toward that goal, the NLN has created an innovative simulation and resource center that helps educators develop expertise in education methodologies specific to simulation. Additionally, with an aging population, nursing faculty must gain expertise in gerontology. Faculty development programs in geriatrics must be funded and gerontology must be integrated into the nursing curriculum, she said.
These complex areas make it abundantly clear that nursing education is an advanced specialty in its own right. The Academic Nurse Educator Certification Program has certified more than 2,000 certified nurse educators since its inception. This certification validates the knowledge educators need to practice the science of nursing education, Shultz explained.
Workforce issues are not going to go away soon, Shultz said. Nursing education must sidestep the argument over whether all nurses need bachelor’s degrees and embrace the diversity offered by having multiple points of entry. All nurses should be encouraged and enabled to continue their education, she said. Problems in the work environment, such as inadequate compensation for nursing faculty, need to be confronted and creative solutions should be explored to recruit and retain faculty, Shultz concluded.
National Association of Pediatric Nurse Practitioners
As the nursing community looks to the future, it needs to consider three major issues, according to Tomika Harris, a faculty member at the University of Texas representing the National Association of Pediatric Nurse Practitioners.
First, the traditional nursing curriculum needs to be refocused to address the IOM’s recommendation for shared health care competencies, such as patient-centered care, interdisciplinary teamwork, evidence-based practice, quality improvements, and informatics (IOM, 2003). Furthermore, it is imperative to evaluate shared competencies in terms of measurable outcomes, Harris said. “Nurses need to be prepared with the skills and competencies to provide safe, quality care,” she said.
Second, nursing students at all levels need to have opportunities to integrate evidence-based research into their coursework and to engage in comparative effectiveness research that evaluates strategies to improve health, said Harris. The outcomes of this research provide essential information for clinicians and patients to decide on the best treatment. This research also provides criteria to improve the health of communities and to improve the health care system.
Third, nursing educators need to partner with funding organizations to provide seamless educational trajectories for all nursing specialties aimed at specific populations, said Harris. For example, geriatric nurses have successfully established a model partnership with the Hartford Foundation to support geriatric fellowships and innovative academic initiatives to revitalize interest in caring for the nation’s elderly population in new and effective ways. Similar partnerships could encourage the establishment of consortiums of nursing schools, shared resources, and expertise aimed at developing shared skills and competencies in other areas, such as pediatrics, Harris said.
Alexia Green, Professor
Texas Tech University Health Sciences Center
Texas is the fastest growing state in the nation, adding nearly half a million new residents in 2009, surpassing California by nearly 100,000 new residents (U.S. Census Bureau, 2009), said Alexia Green, professor at the Texas Tech University Health Sciences Center and co-team leader
of the Texas Team Addressing Nursing Education Capacity. Texas is also among the states with the largest uninsured and under-insured populations (Cunningham, 2010; Kaiser Family Foundation, statehealthfacts.org, 2010). To counter these tensions, the Texas Team developed a strategic plan that is supported by schools of nursing throughout the state, Green said.
The first goal is to focus on strategic growth and accountability, Green explained. Goals for enrollment growth in nursing education across the state have been set. Across the country, thousands of nurses are turned away from nursing programs, while thousands more enter nursing schools, but never graduate. “We need to address the [issue of] accountability,” she said, “and we are attempting to do that within our state by making sure those nurses are successful.”
The second goal is to establish regional collaboration among nursing schools across the state. Regional problems need to be identified and addressed in a collaborative manner, said Green. For example, one area of focus is clinical simulations to meet the learning needs of students in effective and efficient ways.
Mary Anne Dumas, President
National Organization of Nurse Practitioner Faculties
Educators of nurse practitioners (N.P.s) are highly innovative and adapt to working with limited resources to meet the needs of today’s N.P. students, said Mary Anne Dumas, president of the National Organization of Nurse Practitioner Faculties. For example, as a result of the nursing faculty shortage and an increased faculty workload, N.P. educators are using technology to provide Web-based and distance learning to students and to other N.P. faculty. They are delivering curriculums to rural and international students 24 hours a day, 7 days a week. “Many students cannot go to school full-time and have to work to support their families and educational costs,” Dumas said, and they “rely heavily on the flexibility of technology.”
To accommodate different student learning styles and needs, faculty are using podcasts and streaming video to record lectures and entire courses, so that students can download and listen to or view them at any time. Blogs and Web-based discussions groups balance the convenience of technology with the interpersonal components of N.P. education, Dumas said.
Simulation labs are a “great learning tool” that enable students to develop skill sets that they may not experience in a clinical rotation, but simulations do not replace direct clinical experiences, Dumas said. However, making clinical sites available for student to achieve competence is a significant challenge for N.P. programs. “Competition for preceptors is fierce in areas with multiple programs,” Dumas observed.
The challenge of access to clinical education sites could be reduced through dedicated funding for N.P. education that comes through academic institutions or community-based practice sites, Dumas said. Funding initiatives could provide reimbursement for N.P. education and increased support for nurse-managed health care centers, which are “ideal sites for exposing N.P. students to working with underserved populations,” according to Dumas. Increased funds also could support the development of guidelines for practice, mentoring, leadership development, and other valuable experiences.
Fay Raines, President
American Association of Colleges of Nursing (AACN)
Education has a direct impact on the quality of care provided by nurses and on patient outcomes, said AACN President Fay Raines. “A more highly educated nursing workforce is essential for reforming health care, addressing quality failures, and meeting needs for primary care, geriatric care, and chronic care,” she said.
Multiple studies demonstrate that outcomes improve when care is provided by nurses prepared at the baccalaureate level, and many national organizations, such as the Carnegie Foundation for the Advancement of Teaching, the National Advisory Council on Nurse Education and Practice, and the American Organization of Nurse Executives, have called for increasing the number of B.S.N.-prepared nurses. Raines also urged the committee to make recommendations for a more highly educated nursing workforce, which could be achieved by raising the educational level of nurses and reenvisioning traditional roles. As one step toward this goal, AACN is working with practice colleagues to implement the Clinical Nurse Leader Initiative. Partners in this effort include health care organizations, the Department of Veterans Affairs, and the nursing services of the Armed Forces.
The ability to prepare a well-educated nursing workforce depends on having large numbers of doctorally prepared nurses as educators, scien-
tists, and expert clinicians. A stronger focus is needed on producing more entry-level nurses at the baccalaureate level, Raines said, because data show that nurses entering the profession with a bachelor’s degree are almost four times more likely to pursue graduate studies (HRSA, 2006).
The education of advanced practice nurses also must be transformed. The growing number of nurses with doctorates of nursing practice (D.N.P.s) and recognition of the D.N.P. as the preferred preparation for specialty roles is a step in this direction, said Raines. More advanced practice nurses will be essential to meet the nation’s primary health care needs. “If we are to safely care for patients and effectively prepare future clinicians, we must make raising the educational level of nurses a national priority,” she concluded.
Patricia Hinton Walker, Vice President for Nursing Policy and Professor of Nursing Uniformed Services
University of the Health Sciences
Discussions of the future of nursing need to focus on where technology will take health care in the future, not where technology is today, said Patricia Hinton Walker, vice president for nursing policy and professor of nursing at the Uniformed Services University of the Health Sciences. Speaking as chair of the Technology Informatics Guiding Education Reform (TIGER) Initiative, Hinton Walker noted that innovative technologies from companies such as Microsoft and CVS are already moving patients forward in a socially disruptive way. “We need to talk not only about the community as a partner, but patients as partners in a very different way,” said Hinton Walker. She noted that the president of the National Committee for Quality Assurance recently referred to the “activated patient.” In this respect, nursing education needs to view patients not as the objects of care, but as partners in practice.
The increased use of technologies, such as electronic health records, will have a profound effect on practice, education, and policy, said Hinton Walker. For example, electronic health records will play a vital role in comparative effectiveness research, which will “change how we define evidence in the future.” Evidence-based medicine will still be based on randomized controlled trials, she said, but it will also be based on broader measures of the effects of the health care delivery system. To take another example, regional health information centers will influence nursing curriculums, assessments of education, the integration of ethics
and policy into teaching, and the approaches taken to personalizing medicine. Data will be “the new knowledge of the future,” Hinton Walker said.
The new capabilities that will be created by technology have not been a prominent part of the ongoing dialogue about nursing or interdisciplinary interactions in health care, Hinton Walker said. The TIGER Initiative urges the committee to consider how nurses need to be prepared for a technologically evolving future, she concluded.
David Longanecker, President
Western Interstate Commission for Higher Education
Retaining the associate’s degree in nursing is crucial, said David Longanecker, president of the Western Interstate Commission for Higher Education (WICHE). “It is possible that the bachelor’s degree for all entering nurses would be the perfect solution. But this is the best example I have seen in a long time where the perfect would be the enemy of the good,” Longanecker pointed out.
The A.D.N. should not be eliminated for three reasons, Longanecker said. First, requiring a bachelor’s degree for entry into practice is not affordable. For the 2007–2008 cohort of A.D.N. recipients, WICHE estimates that the cost of continuing on to a bachelor’s degree would be $800 million in tuition, along with other costs of attending college, and would cost the states an additional $600 million in appropriations to take those students through an additional 2 years. “Neither the students nor the states can afford that,” said Longanecker.
Second, retention of the A.D.N. is essential to diversify the nursing workforce. In Colorado, 20 percent of the population is Hispanic (U.S. Census Bureau, 2010), and that percentage will grow to 33 percent by 2025, according to estimates from the National Center for Higher Education Management Systems. However, just 3 percent of the nursing workforce is Hispanic, said Longanecker (HRSA, 2009). According to data from the National Center for Education Statistics, students of color have a greater representation in community colleges than in 4-year institutions—in 2008, 42 percent of community college students were from communities of color, compared with 32 percent of students at 4-year institutions, “and it appears likely that this will become even more skewed in years to come,” Longanecker predicted.
Third, the resources are not available to increase the capacity of bachelor’s programs in nursing. Especially in rural areas, the A.D.N. is crucial, and calculations by WICHE reveal that 20 percent of all A.D.N.s are conferred by rural institutions, compared with just 4 percent of bachelor’s degrees in nursing, Longanecker noted.
More B.S.N.s are absolutely necessary, and the capacity of 4-year institutions should be increased to expand the number of nurses with bachelor’s degrees. However, nursing also needs much stronger articulation programs and consortiums like the one in Oregon, said Longanecker. These programs provide professional tracks for more nurses to enter the field and then advance in the profession through work and learning.
At the end of the forum, Donna E. Shalala, committee chair, invited members of the audience to share their concluding remarks with the committee. Many people offered their perspectives and insight on ideas that were heard during the event or anecdotal experiences in nursing education. This final open-microphone session yielded many observations from the audience on a variety of topics relevant to the committee’s work and the future of nursing education. Like the testimony summarized above, these comments should not be interpreted as positions or recommendations of the committee, RWJF, or the IOM. The section below includes a summary of the remarks that were offered by members of the audience at the forum:
Several participants described the importance of taking steps to improve the quality of education that students receive. One participant said that to ensure the best possible educational outcomes, quality improvement processes should be applied to nursing education just as they are being applied to the health care system. Another said that nursing education should be evidence-based just as nursing practice should be, and one participant called for federal funding, with more rapid funding cycles, to launch large-scale demonstration projects that can be used to test new educational models. Other participants described a variety of innovative models currently being used that incorporate simulation, technology, residency programs, leadership training, and
interdisciplinary education—all of which are designed to better educate nurses.
One participant highlighted a variety of innovative approaches to education that are being used locally to improve education at the University of Texas Health Science Center at Houston. For example, one model features a bachelor’s degree program with clinical immersion; another model includes a regional partnership program with schools and hospitals that use a 100 percent preceptor model. The participant also highlighted a program that features retired physicians who work with nursing students; the participant said that physicians retired from clinical practice have much to teach students about not only clinical skills, but also communicating with physicians.
A number of participants offered their perspectives on the certification and accreditation of nursing education programs. One participant said that nationwide certification for nursing programs could establish quality expectations, consistency markers, and consumer protections. Another said that nationwide certification for D.N.P. programs could help standardize curriculums, while another said that nursing students at every level should graduate from accredited programs.
Several audience members offered their opinions on associate degree nursing programs and the importance of opportunities for nurses to move into higher degree programs to ensure a well-educated workforce. One person said the A.D.N. should be a starting point for nursing education, and not an end point; another concurred, highlighting the importance of academic progression to baccalaureate degrees and beyond to master’s and doctoral degrees. Another person said that surveys show that most A.D.N.s would like to continue their education. However, a number of barriers, financial and otherwise, keep them from continuing; the participant said these barriers need to be studied so they can be overcome.
A few participants commented on the importance of partnerships in advancing nursing education. One person said the business community and employers of nurses should be partners in establishing strategic plans for nursing education. Another said that regional partnerships among schools of nursing are required to establish seamless transitions for moving students to higher degree programs, create life-long learners, and help fill nursing
shortages. Another participant described sustained learning communities of students and faculty in partnership with health care agencies and institutes as an example of a seamless learning system that would better represent the real world, while facilitating student movement across care settings.
One member of the audience highlighted accelerated Ph.D. programs as a possible solution to help alleviate faculty shortages.
One participant emphasized the need for additional nursing research and funding to support this research. The participant said faculty development and educational processes need to be enhanced at the hundreds of universities that are not academic health centers (where much of the research funding is currently focused) because the majority of nurses and other health care providers are educated at these non-academic health center institutions.
One participant said the nursing community should be broadly defined to include licensed practical nurses, licensed vocational nurses, and other individuals who deliver care in homes and communities.
As prompted by the committee’s call for testimony that described visions for the future of nursing prior to the forum, a number of people shared their specific visions, which included
Students learning multicultural perspectives and receiving education in the area of geriatrics, as the U.S. population continues to grow older and diversify.
Using nurse-managed clinics to provide sites for the integration of discovery, learning, and engagement and to allow for the design of new, cost-effective, safe, high-quality, and efficient models of care.
Establishing national, evidence-based core competencies in pediatric nursing to ensure that children have a competent pediatric nurse no matter where they are treated.
Meeting the needs of nursing graduates from other countries who need to be integrated into U.S. health care settings.