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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25982.
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Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

Mary K. Wakefield, David R. Williams, Suzanne Le Menestrel, and Jennifer L. Flaubert, Editors Committee on the Future of Nursing 2020–2030 NATIONAL ACADEMY OF MEDICINE PREPUBLICATION COPY—Uncorrected Proofs

THE NATIONAL ACADEMIES PRESS  500 Fifth Street, NW  Washington, DC 20001 This activity was supported by a contract between the National Academy of Sciences and the Robert Wood Johnson Foundation (Grant Number 76081). Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project. International Standard Book Number-13: 978-0-309-XXXXX-X International Standard Book Number-10: 0-309-XXXXX-X Digital Object Identifier: https://doi.org/10.17226/25982 Library of Congress Control Number: Additional copies of this publication are available from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu. Copyright 2021 by the National Academy of Sciences. All rights reserved. Printed in the United States of America Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2021. The future of nursing 2020–2030: Charting a path to achieve health equity. Washington, DC: The National Academies Press. https://doi.org/10.17226/25982. PREPUBLICATION COPY—Uncorrected Proofs

The National Academy of Sciences was established in 1863 by an Act of Congress, signed by President Lincoln, as a private, nongovernmental institution to advise the nation on issues related to science and technology. Members are elected by their peers for outstanding contributions to research. Dr. Marcia McNutt is president. The National Academy of Engineering was established in 1964 under the charter of the National Academy of Sciences to bring the practices of engineering to advising the nation. Members are elected by their peers for extraordinary contributions to engineering. Dr. John L. Anderson is president. The National Academy of Medicine (formerly the Institute of Medicine) was established in 1970 under the charter of the National Academy of Sciences to advise the nation on medical and health issues. Members are elected by their peers for distinguished contributions to medicine and health. Dr. Victor J. Dzau is president. The three Academies work together as the National Academies of Sciences, Engineering, and Medicine to provide independent, objec- tive analysis and advice to the nation and conduct other activities to solve complex problems and inform public policy decisions. The National Academies also encourage education and research, recognize outstand- ing contributions to knowledge, and increase public understanding in matters of science, engineering, and medicine. Learn more about the National Academies of Sciences, Engineering, and Medicine at www.nationalacademies.org. PREPUBLICATION COPY—Uncorrected Proofs

Consensus Study Reports published by the National Academies of Sciences, Engineering, and Medicine document the evidence- based consensus on the study’s statement of task by an authoring committee of experts.  Reports typically include findings, conclusions, and recommendations based on information gathered by the committee and the committee’s deliberations. Each report has been subjected to a rigorous and independent peer-review process and it represents the position of the National Academies on the statement of task. Proceedings published by the National Academies of Sciences, Engineering, and Medicine chronicle the presentations and discussions at a workshop, symposium, or other event convened by the National Academies. The statements and opinions contained in proceedings are those of the participants and are not endorsed by other participants, the planning committee, or the National Academies. For information about other products and activities of the National Academies, please visit www.nationalacademies.org/about/whatwedo. PREPUBLICATION COPY—Uncorrected Proofs

COMMITTEE ON THE FUTURE OF NURSING 2020–2030 MARY K. WAKEFIELD (Co-Chair), Visiting Professor, The University of Texas at Austin DAVID R. WILLIAMS (Co-Chair), Florence and Laura Norman Professor of Public Health and Chair, Department of Social and Behavioral Sciences, T.H. Chan School of Public Health, and Professor, Department of African and African American Studies, Harvard University MAUREEN BISOGNANO, President Emerita and Senior Fellow, Institute for Healthcare Improvement JEFFREY BRENNER, Co-Founder and Chief Medical Officer, JunaCare PETER I. BUERHAUS, Professor of Nursing, College of Nursing, and Director, Center for Interdisciplinary Health Workforce Studies, Montana State University MARSHALL H. CHIN, Richard Parrillo Family Professor of Healthcare Ethics, Department of Medicine, University of Chicago REGINA S. CUNNINGHAM, Chief Executive Officer, Hospital of the University of Pennsylvania; Adjunct Professor and Assistant Dean, School of Nursing, University of Pennsylvania JOSÉ J. ESCARCE, Distinguished Professor of Medicine, David Geffen School of Medicine, and Distinguished Professor of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles GREER GLAZER, Schmidlapp Professor of Nursing and Dean, College of Nursing, University of Cincinnati MARCUS HENDERSON, Charge Nurse, Adolescent Services, Fairmount Behavioral Health System; Lecturer, School of Nursing, University of Pennsylvania ANGELICA MILLAN, Former Children’s Medical Services Nursing Director, County of Los Angeles Department of Public Health JOHN W. ROWE, Julius B. Richmond Professor of Health Policy and Aging, Mailman School of Public Health, Columbia University WILLIAM M. SAGE, James R. Dougherty Chair for Faculty Excellence, School of Law, and Professor of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin VICTORIA L. TIASE, Director of Research Science and Informatics Strategy, NewYork-Presbyterian Hospital WINSTON WONG, Scholar in Residence, University of California, Los Angeles, Kaiser Permanente Center for Health Equity v PREPUBLICATION COPY—Uncorrected Proofs

Study Staff SUZANNE LE MENESTREL, Study Director (from June 2020) SUSAN B. HASSMILLER, Senior Scholar in Residence and Advisor to the President on Nursing, National Academy of Medicine JENNIFER LALITHA FLAUBERT, Program Officer ADRIENNE FORMENTOS, Research Associate TOCHI OGBU-MBADIUGHA, Senior Program Assistant (from October 2020) CARY HAVER, Study Director (until June 2020) LORI BRENIG, Senior Program Assistant (until May 2020) CAROL SANDOVAL, Senior Program Assistant (until September 2020) ASHLEY DARCY-MAHONEY, National Academy of Medicine Distinguished Nurse Scholar-in-Residence (August 2020 to August 2021) ALLISON SQUIRES, National Academy of Medicine Distinguished Nurse Scholar-in-Residence (March 2019 to August 2020) SHARYL NASS, Senior Board Director, Board on Health Care Services vi PREPUBLICATION COPY—Uncorrected Proofs

Reviewers This Consensus Study Report was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published report as sound as possible and to ensure that it meets the institu- tional standards for quality, objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We thank the following individuals for their review of this report: FRANK BAEZ, New York University Langone Health KENYA V. BEARD, Chamberlain University PATRICIA FLATLEY BRENNAN, National Library of Medicine SALLY S. COHEN, New York University MARY PAT COUIG, The University of New Mexico FRANCIS J. CROSSON, Kaiser Permanente Bernard J. Tyson School of Medicine WILLIAM A. DARITY, JR., Duke University MARGARET FLINTER, Community Health Center, Inc. BIANCA K. FROGNER, University of Washington EMILY A. HAOZOUS, The University of New Mexico BERNADETTE MAZUREK MELNYK, The Ohio State University TERI A. MURRAY, Saint Louis University DANIEL J. PESUT, University of Minnesota KRISTINE QURESHI, University of Hawai’i at Mānoa vii PREPUBLICATION COPY—Uncorrected Proofs

viii REVIEWERS ROBERT D. REISCHAUER, The Urban Institute CAROL A. ROMANO, Uniformed Services University of the Health Sciences SUSAN E. STONE, Frontier Nursing University and American College of Nurse-Midwives DANIEL WEBERG, The Ohio State University Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommenda- tions of this report, nor did they see the final draft before its release. The review of this report was overseen by BOBBIE BERKOWITZ, Columbia University, and MAXINE HAYES, University of Washington. They were responsible for making certain that an independent examination of this report was carried out in accordance with the standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the authoring committee and the National Academies. PREPUBLICATION COPY—Uncorrected Proofs

Foreword The year 2020, the bicentennial of Florence Nightingale’s birth, was desig- nated by the World Health Organization (WHO) as the International Year of the Nurse and the Midwife. According to WHO, “Nurses and midwives play a vital role in providing health services. These are the people who devote their lives to caring for mothers and children; giving lifesaving immunizations and health ad- vice; looking after older people and generally meeting everyday essential health needs. They are often, the first and only point of care in their communities.” As president of the National Academy of Medicine (NAM) and as a physi- cian who has worked closely with nurses over the decades, I know the central role of nursing in achieving the high-quality, accessible, and compassionate care that individuals, families, and communities richly deserve. I am proud that we can help commemorate this occasion through the release of our latest report, The Future of Nursing 2020–2030: Charting a Path to Achieve Health Equity. This report is the third in a series on the future of nursing that we at the NAM (formerly known as the Institute of Medicine [IOM]) have been privileged to create with the sponsorship of the Robert Wood Johnson Foundation. The first of these reports, The Future of Nursing: Leading Change, Advancing Health, published in 2011, presented a set of bold recommendations to strengthen the capacity, education, and critical role of the nursing workforce.  It emboldened nurses to play a central role in improving health care for people, families, and communities around the world. That report, which has served as a blueprint for the nursing profession, is the National Academies’ second most downloaded health and medicine report since its release and continues to reach thousands of nurses and other important stakeholders around the world. ix PREPUBLICATION COPY—Uncorrected Proofs

x FOREWORD The second nursing report, released in 2016, Assessing Progress on the Insti- tute of Medicine Report The Future of Nursing, highlighted promising progress made since the 2011 report while noting that much more needed to be done. It outlined three themes central to the future success of the Robert Wood Johnson Foundation/AARP Future of Nursing Campaign for Action (the Campaign): the need to build a broader coalition to increase awareness of nurses’ ability to play a full role in health professions practice, education, collaboration, and leadership; the need to continue to make promoting diversity in the nursing workforce a priority; and the need for better data with which to assess and drive progress. Alongside these two reports have been the exemplary and steadfast efforts of the innovative change initiative, the Campaign, in continuing to implement the recommendations from the first report while working to take on the recom- mendations of the second in a more robust way. Of note, efforts to create a more diverse workforce and to expand ways of working with others in and outside of the health system have served to foreshadow the importance of nurses as key players in achieving health equity in the United States and globally. No one profession or group will achieve the health equity needed in this nation without all health professions, working within and across disciplines, aspiring to advance the culture required. Working across sectors with steadfast vigilance will be a necessary ingredient not only in understanding but also in taking real action to achieve health equity. With this third report, The Future of Nursing 2020–2030: Charting a Path to Achieve Health Equity, the NAM and the Robert Wood Johnson Foundation continue their steadfast collaboration toward promoting a culture of health for all. Both organizations believe that uneven access to conditions needed for good health across the United States has been well documented, as have the poor ef- fects on health that result. The growing visibility of the impacts of systemic rac- ism in almost every aspect of people’s lives—policing, health care, the economy, education—is evident. Now more than ever, the nation sees clearly the need for an equitable, just, and fair society—one that promotes racial equity, as well as equity across circumstances, communities, and abilities. The good news is that so many of us are asking, “How can we do better? How can I do better?” In a time marked by COVID-19’s unprecedented global health challenges, nurses have stepped up—many times at great personal cost to themselves. Nurses have seen firsthand this disease’s inequitable impact on those they serve. They have also experienced firsthand COVID-19’s inequitable impact on the profession. Nurses are more likely to die than are other health care profes- sionals, and nurses of color are far more likely to die. As this report points out with compelling evidence, nurses can play a central role in addressing these in- equities across the entire spectrum. The nation cannot achieve true health equity PREPUBLICATION COPY—Uncorrected Proofs

FOREWORD xi without nurses, which means it must do better for nurses. They must be supported in charting a path for themselves while they work to serve others. This report is intended to do just that. I am very grateful to the committee for their consensus on the important recommendations in this report—especially the co-chairs, Mary Wakefield and David Williams—and to the National Academies staff, including Suzanne Le Menestrel, Jennifer Flaubert, Adrienne Formentos, and Tochi Ogbu-Mbadiugha, as well as Susan Hassmiller, who served as senior scholar in residence and who provided continuity between the first and third reports. This report calls on many within and around the nursing community to take more definitive action on eliminating systemic racism, whether in schools, institu- tions, or the profession and its associations. Nurses are powerful in number and in voice and the world needs their actions now more than ever on how individuals, families, and communities might best be served in a more equitable fashion. And in asking nurses to play a central leadership role, I am reminded of the importance of nurse well-being. Nurses have been called on to do so much in this last year throughout the COVID-19 pandemic, and the nation must support them, includ- ing by giving them all the necessary tools and equipment to do their job in the best way possible. I am confident that the nursing community and other important stakeholders will use the recommendations in this report and their evidence base to lead the way to a more equitable and healthy society. Victor J. Dzau, M.D. President, National Academy of Medicine PREPUBLICATION COPY—Uncorrected Proofs

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Preface In 2019, the Robert Wood Johnson Foundation (RWJF) sponsored this study to explore the important contributions of nursing to addressing social determi- nants of health (SDOH) and health equity in the United States. This was to serve as a parallel effort to other National Academy of Medicine reports and initiatives sponsored by RWJF around efforts to create a more robust culture of health in the United States. The work of this committee began in 2019 after years of evidence documenting the relationship between SDOH and health outcomes, as well as broader challenges associated with health and health care equity. By the end of 2020, this report was to be released in a year that was being commemorated by the World Health Organization as the International Year of the Nurse and the Midwife.1 Throughout the year, the committee participated in three major town hall meetings; a series of site visits in and around Seattle, Chicago, and Philadelphia; and two other public sessions, recordings and materials from which are available online.2 We heard time and again how the highly complex health and social needs of people were critical in defining their overall health and well-being, and that of their families and populations at large. The committee’s work continued in 2020 with the goal of launching this report at the end of the year. In March, however, the COVID-19 pandemic hit the 1  See https://www.who.int/campaigns/annual-theme/year-of-the-nurse-and-the-midwife-2020 (ac- cessed April 13, 2021). 2  Town hall recordings and materials can be accessed at https://nam.edu/publications/the-future-of- nursing-2020-2030 (accessed April 13, 2021). xiii PREPUBLICATION COPY—Uncorrected Proofs

xiv PREFACE United States, and throughout the year it was evident that the challenges outlined in this report were vastly magnified by the most devastating health care event in more than a century. The pandemic, which has since killed nearly 3 million peo- ple globally and sickened more than 135 million more,3 laid bare the depth and breadth of inequity and its impacts on the health and well-being of large swaths of the nation’s population, disproportionately impacting people of color, those with low income, and those living in rural areas. Simultaneously, 2020 taxed the nation’s nursing workforce in ways that had never been fully anticipated and planned for. Overcrowded hospitals, countless deaths, and lack of personal protective equipment to secure their safety, in addi- tion to falling sick themselves, pushed nurses to their limits. Many called nurses heroes, but nurses time and again shunned that title and responded by saying they were doing the work they were called to do as nurses, albeit without the equip- ment, including respirators and personal protective gear, they needed to deliver care safely. Caring for highly infectious patients with dire needs had sweeping adverse impacts on the physical and mental health of scores of thousands of the nation’s nurses. In addition to the crises created by the pandemic and the trauma it caused for society at large and nurses, years of racial injustice culminated in tragic events that also shone a light on inequities for people of color. The tragic deaths of George Floyd, Breonna Taylor, and countless others unleashed decades of pent-up emotion and widespread protests regarding the state of equity in the United States and around the world. These deaths highlighted the reality that serious challenges were being faced, especially by people of color. This report’s release in 2021 comes as the United States and the world have suffered great loss, but also are buoyed by the promise of lessons learned, including witnessing the nursing profession’s commitment to health, nursing innovations that improved health care in real time for patients and families im- pacted by COVID-19, and nurse-driven adaptations in education and practice that will likely drive lasting changes in both. There is now deeper evidence and understanding of the differential impact of generations of inequity associated with racism and bias, socioeconomic status, disabilities, financial poverty, and living in areas with decreased health care access that has fueled compromised health status for many of our fellow Americans. It is against this backdrop that the committee strove to produce a report that would anticipate the needs of the population and the nursing profession for the next decade while advancing a set of recommended actions that can make a meaningful impact on deploying the profession more robustly, so that nurses will be both prepared for disasters in the 3  The figures as of April 13, 2021, were 135.1 million global cases and more than 2.9 million COVID-related deaths. Nearly 600,000 of these deaths were in the United States. See https://www. who.int/publications/m/item/weekly-epidemiological-update-on-covid-19---13-april-2021 (accessed April 13, 2021). PREPUBLICATION COPY—Uncorrected Proofs

PREFACE xv future and prepared to engage in the complex but essential work of advancing health equity, addressing SDOH, and meeting social needs of individuals and families. While the 2011 The Future of Nursing report was about building the capacity of the nursing workforce, this report clearly answers the question of to what end. Nursing capacity must be brought to bear on the above complex health and social issues and inequities. By virtue of its history, its focus, and its presence across sectors and popula- tions, the nursing profession is well positioned to bring its expertise to working in partnership with other disciplines and sectors to leverage contemporary oppor- tunities and address deep-seated health and social challenges. And the committee believes that all nurses, at all levels, and no matter the setting in which they work, have a duty and responsibility to work with other health professionals and sectors to address SDOH and help achieve health equity. As was noted in the preface of the 2011 report, “What nursing brings to the future is a steadfast commitment to patient care, improved safety and qual- ity, and better outcomes.”4 The present report expands that report’s focus on outcomes by clearly incorporating and leveraging the profession’s own ethics, values, and knowledge assets to address the upstream and midstream work of applying evidence linking health and health care equity to health outcomes for individuals, families, communities, and populations, as well as further building out evidence-based models, health system policies and health-related public policies, and educational approaches. Nurses in particular are well prepared to create, partner in, and lead the complex work of integrating the social and health sectors in support of the health and well-being of individuals, families, and communities. Nurses, working with social service sectors in and across commu- nity-based ambulatory care and public health settings to implement health system and point-of-care interventions can help advance continuous care models that are individual- and population-centered. In addition to addressing social needs, nurses are called upon to inform and implement policies that will ultimately affect the greatest numbers of people in the most profound ways. For decades, the International Council of Nurses (ICN) has explicitly supported nurses around the world in contributing their expertise to informing health-related public policy. The ICN has also called for policy maker receptivity to nurses’ expertise. Nurses recognize that poorly informed public policy, like poor health care and compromised SDOH, can undermine the health of patients, families and communities. And upstream ac- tions to address social determinants are often rooted in long-standing policies that contribute to inequity in housing, employment, education, and other key precursors to health. 4  IOM (Institute of Medicine). 2011. The future of nursing: Leading change, advancing health. Washington, DC: The National Academies Press. PREPUBLICATION COPY—Uncorrected Proofs

xvi PREFACE We are grateful to a very committed expert group of committee members who spent countless hours discussing, debating, and then reaching consensus around some very difficult topics. In any consensus-building process, not every individual will agree with every statement in a report such as this, as reflected in a supplemental statement written by one committee member, provided in Ap- pendix E; the response of the rest of the committee to this statement appears in Appendix F. The discussion and ultimate set of recommendations in this report were enhanced by the breadth of expertise brought to bear, expertise that went far beyond the nursing profession. We are also grateful to the talented staff of the National Academies of Sciences, Engineering, and Medicine who worked tire- lessly with us to create this report. Finally, we appreciate the foresight of RWJF in valuing the contributions and leadership of nursing in addressing SDOH and health equity and their sponsorship of this report. Mary K. Wakefield and David R. Williams, Co-Chairs Committee on the Future of Nursing 2020–2030 PREPUBLICATION COPY—Uncorrected Proofs

Dedication This report is dedicated to the nurses around the world who paid the ultimate price of caring for people during the COVID-19 crisis of 2020–2021. Hundreds lost their lives, and many thousands became sick themselves. And those who escaped the physical symptoms of the illness did not necessarily escape the phys- ical and mental toll of working long hours in grueling circumstances, sometimes without proper personal protective equipment. Their dedication and persistence in the face of adversity saved countless lives. They were also there to ease the suffering of the dying with a hand held, a song sung, or a video call to loved ones. For them, we look to the future of nursing to help ensure that what happened to the nursing profession this year and those in their care, especially the disad- vantaged and people of color, becomes an event of the past. xvii PREPUBLICATION COPY—Uncorrected Proofs

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Acknowledgments To begin, the committee would like to thank the sponsor of this study. Funds for the committee’s work were provided by the Robert Wood Johnson Foundation (RWJF). Numerous individuals and organizations made important contributions to the study process and this report. The committee wishes to express its gratitude for each of these contributions, although space does not permit identifying all of them here. Appendix A lists the individuals who provided valuable information at the committee’s open workshops and its three town halls on the future of nursing. The committee thanks the members of the staff of the National Academies of Sciences, Engineering, and Medicine for their significant contributions to the re- port: Suzanne Le Menestrel, Susan B. Hassmiller, Jennifer L. Flaubert, Adrienne Formentos, Tochi Ogbu-Mbadiugha, Ashley Darcy-Mahoney, Carol Sandoval, Lori Brenig, Cary Haver, and Allison Squires. The committee would also like to thank Rona Briere, Allison Boman, Diana Mason, Dalia Sofer, Paul Selker, and Maya Thomas for their writing, editorial, and fact-checking assistance. The committee would like to especially acknowl- edge Erin Hammers Forstag for her writing and editing contributions. We would like to thank National Academies staff members who provided invaluable sup- port throughout the project: Micah Winograd, business financial partner; Daniel Bearss and Anne Marie Houppert, research librarians, for assistance with litera- ture searches; and staff that contributed additional writing and research, including Alix Beatty, Bernice Chu, Carolyn Fulco, and Adrienne Stith-Butler. Thank you to Laura DeStefano, Greta Gorman, Andrew Grafton, Talia Lewis, Devona Over- ton, Esther Pak, and Olivia Ramirez for their communications expertise; Annalee Espinosa Gonzales and Joe Goodman for logistical support in Philadelphia and xix PREPUBLICATION COPY—Uncorrected Proofs

xx ACKNOWLEDGMENTS Seattle; and Sharyl Nass, Tina Seliber, and Lauren Shern for guidance throughout the study process. The committee appreciates the contributions of Molly Ellison and Janet Firshein, who provided strategic communications support for this report through the communications firm Burness. The committee would also like to thank Dave McClinton from African American Graphic Designers for the report cover design and Elena Ovaitt for designing figures and models for the report. In conjunction with each of its town halls, the committee also visited several clinical and community sites to observe clinics and programs that are nurse-led or where nurses acted as important members of multidisciplinary teams in con- tributing to health equity and addressing social determinants of health in various settings. The committee greatly appreciates the time and information provided by all of these individuals, especially those who helped to coordinate those visits, including Sue Birch and Azita Emami in Seattle; Kathleen Noonan and Roberta Waite in Camden, New Jersey, and Philadelphia; and Janice Phillips and Sue Swider in Chicago. The committee also gratefully acknowledges the contributions of the individ- uals who provided data and research support. Margo Edmunds and Raj Sabharwal of AcademyHealth with a team of research managers, Karen Johnson, Kent Key, Polly Pittman, and Joanne Spetz, who created research products that synthesized, translated, and disseminated information to inform the committee’s deliberations. The committee also acknowledges and greatly appreciates the time and effort of David Auerbach and Timothy Bates in analyzing workforce data. The committee would like to thank as well the authors whose commissioned papers added to the evidence base for the study: Amy J. Barton, University of Colorado College of Nursing; Barbara Brandt and Carla J. Dieter, University of Minnesota; Jack Needleman, Fielding School of Public Health, University of California, Los Angeles; Tener Veenema, Johns Hopkins University School of Nursing; and Shanita D. Williams, Health Resources and Services Administra- tion, with research assistance from Emily Clifford, Johns Hopkins University. Finally, the committee acknowledges the following individuals who provided additional data, reports, and support to the committee: Michelle Adymec, Mavis Asiedu-Frimpong, Sheila Brown, Laura Buckley, Jess Cordero, Dayna Fondell, Ebony Haley, Lauran Hardan, Mark Humowiecki, Stephanie Jean-Louis, An- drew Katz, Renee Murray, Victor Murray, Jeneen Skinner, Aaron Truchil, and Katie Wood, Camden Coalition of Healthcare Providers; Min An, Kline Galland House; Kate Baber, Downtown Emergency Services Center; Teresita Batayola, Dante Batingan, Rattana Chaokhote, Asqual Getaneh, Sherryl Grey, DoQuyen Huynh, Rachel Koh, Rayburn Lewis, Ian Munar, Jackqui Sinatra, Eric Ric Troyer, and Mayumi Willgerodt, International Community Health Services; Rebecca Bixby, Laniece Coleman, Joan Gray, Mary Katherine Green, Diana Hartley-Kim, Lidyvez Sawyer, Mary Thornton-Bowmer, Stephen and Sandra Sheller 11th Street Family Health Services, Drexel University; Michelle Cleary, Jesse Dean, Robin Fleming, Tamarra Henshaw, and Suzanne Swadener, Washington State PREPUBLICATION COPY—Uncorrected Proofs

ACKNOWLEDGMENTS xxi Health Care Authority; Rebecca Darmoc, Marquis Forman, Mariela Hernandez, and Angelique Richard, Rush University College of Nursing; Candice Douglass, Panome Ratsavong, and Nolan Ryan, University of Washington School of Nurs- ing; Kathy Eaton, Deb Gumbardo, Elizabeth Masse, Erika Miller, Mady Murray, and Debra Ridling, Seattle Children’s Hospital; Yolanda Fong, Kitsap Public Health; Theresa Gallagher and Angela Moss, Sue Gin Health Center; Joan Gray, Tarun Kapoor, and Jubril Oyeyemi, Virtua Health System; Jennifer Grenier and Nicole Wynn, The Surplus Project; Patty Hayes and Doreen Hersh, Public Health Seattle & King County; Ayesha Jaco, Westside United and Rush University Med- ical Center; Jennifer Johnson Joefield, Peninsula Community Health Services; Sally Lemke, Simpson School Based Health Center; Janice Mason, Malcolm X Community College; Brenda Montgomery, Harrison Hospital (CHI Franciscan); Julie Morita, Chicago Department of Public Health; Donna Nickitas, Rutgers School of Nursing–Camden; William Reedy, Thresholds Community Mental Health Center; James Rice, City Colleges of Chicago School of Nursing; Cynda Rushton, Johns Hopkins University School of Nursing; Kelsey Stedman and Jayme Stuntz, Kitsap Connect; and Janet Tomcavage, University of Pennsylvania School of Nursing. We would also like to thank the staff of the Seattle Indian Health Board, Era Living, Ida Culver House, and Salvation Army (Seattle) and everyone at the Port Gamble S’Klallam Health Center. PREPUBLICATION COPY—Uncorrected Proofs

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Contents ACRONYMS AND ABBREVIATIONS xxix SUMMARY 1 1 INTRODUCTION 17 2 SOCIAL DETERMINANTS OF HEALTH AND HEALTH EQUITY 31 3 THE NURSING WORKFORCE 59 4 THE ROLE OF NURSES IN IMPROVING HEALTH CARE ACCESS AND QUALITY 99 5 THE ROLE OF NURSES IN IMPROVING HEALTH EQUITY 127 6 PAYING FOR EQUITY IN HEALTH AND HEALTH CARE 147 7 EDUCATING NURSES FOR THE FUTURE 189 8 NURSES IN DISASTER PREPAREDNESS AND PUBLIC HEALTH EMERGENCY RESPONSE 247 9 NURSES LEADING CHANGE 275 xxiii PREPUBLICATION COPY—Uncorrected Proofs

xxiv CONTENTS 10 SUPPORTING THE HEALTH AND PROFESSIONAL WELL-BEING OF NURSES 301 11 THE FUTURE OF NURSING: RECOMMENDATIONS AND RESEARCH PRIORITIES 355 APPENDIXES A BIOGRAPHICAL SKETCHES OF COMMITTEE MEMBERS AND PROJECT STAFF 377 B DATA COLLECTION AND INFORMATION SOURCES 391 C DATA SOURCES, DEFINITIONS, AND METHODS 405 D GLOSSARY 415 E THE FUTURE OF NURSING 2020–2030: MEETING AMERICA WHERE WE ARE 423 F COMMITTEE RESPONSE TO SUPPLEMENTAL STATEMENT 429 G PROFILES OF NURSING PROGRAMS AND ORGANIZATIONS 433 PREPUBLICATION COPY—Uncorrected Proofs

Boxes, Figures, and Tables BOXES S-1 Achieving Health Equity Through Nursing: Desired Outcomes, 2 S-2 The Committee’s Recommendations, 13 1-1 Types of Nursing Care Providers, 19 1-2 Statement of Task, 24 2-1 Social Determinants of Health, 33 2-2 Intersectionality, 39 3-1 Internationally Educated Nurses, 65 3-2 COVID-19 and Nurse Staffing in Nursing Homes, 70 3-3 Health Disparities Among American Indians/Alaska Natives, 85 3-4 Agenda for Nursing Health Services Research, 92 4-1 Innovative In-Home Care Programs, 107 4-2 Transitional Care Model, 113 4-3 Culturally and Linguistically Appropriate Services, 115 5-1 Shortcomings of Evaluations of Health Equity Interventions, 130 5-2 Examples of Edge Runner Programs, 138 5-3 Delaware Cancer Consortium, 140 xxv PREPUBLICATION COPY—Uncorrected Proofs

xxvi BOXES, FIGURES, AND TABLES 7-1 National League for Nursing’s (NLN’s) Vision for Integration of the Social Determinants of Health into Nursing Education Curricula, 194 7-2 Domains for Nursing Education, 203 7-3 Competencies for Nursing Education, Depending on Preparation Level, 203 7-4 Discussing Difficult Topics, 205 7-5 Highlights from the Seattle Townhall on Technology and Health Equity and Implications for Nursing Education, 210 7-6 Pine Ridge Family Health Center, 215 7-7 The Community Action Poverty Simulation, 216 7-8 Examples of Supports for Nursing Students, 226 8-1 Pulse Nightclub Shooting, 254 8-2 COVID-19 in Hidalgo County, Texas, 256 8-3 Lessons Learned from Nurses’ Role in Evacuation During Hurricane Sandy, 258 10-1 Technological Factors Impacting Nurses’ Well-Being, 305 10-2 A Snapshot of the Physical Health of American Nurses, 307 10-3 COVID-19 and Nurses’ Health and Well-Being, 309 10-4 Mobile Technology and Mental Health Interventions, 323 10-5 Examples of Nursing Schools’ Well-Being Initiatives, 330 10-6 Psychological Personal Protective Equipment (PPE), 332 11-1 Achieving Health Equity Through Nursing: Desired Outcomes, 356 FIGURES S-1 A framework for understanding nurses’ role in addressing the equity of health and health care, 5 1-1 A framework for understanding the nurse’s role in addressing the equity of health and health care, 27 2-1 Conceptual framework of the Commission on the Social Determinants of Health, 35 2-2 Social Determinants of Health and Social Needs Model, 37 2-3 Expected age at death among 40-year-old men and women, by household income percentile, 43 3-1 Number of nursing doctoral graduates by race/ethnicity, 66 3-2 Nurse practitioners by race and ethnicity, 2018, 73 3-3 Scope of practice for nurse practitioners by state, 87 PREPUBLICATION COPY—Uncorrected Proofs

BOXES, FIGURES, AND TABLES xxvii 4-1 Licensure staffing patterns (paid and unpaid volunteer) by geography, 110 5-1 Areas of activity that strengthen integration of social care into health care, 129 7-1 Training topics that would have helped registered nurses (RNs) do their jobs better, by type of work performed and graduation from their nursing program, 2018, 196 7-2 Training topics that would have helped nurse practitioners do their jobs better, by type of work performed and graduation from their nursing education program, 2018, 197 8-1 Disaster nursing timeline, 250 10-1 Systems model of burnout and well-being, 304 TABLES 3-1 Demographic Characteristics of Full-Time Equivalent (FTE) Registered Nurses (RNs), 2000–2018, 63 3-2 Number and Percentage of Nurses with Various Levels of Nursing Education by Race, 2018, 64 3-3 Number of Registered Nurses (RNs) by Employment Setting, Average Annual Earnings, and Age, 2018, 66 3-4 Number of Employed Advanced Practice Registered Nurses (APRNs), 2008 and 2018, 72 3-5 Nurse Practitioner Employment Settings, 2018, 74 3-6 Nurse Practitioner Employment by Clinical Specialty Area, 2018, 76 5-1 Definitions of Areas of Activities That Strengthen Integration of Social Care into Health Care, 129 7-1 Pathways in Nursing Education, 192 7-2 Number of Graduates from Nursing Programs in the United States and Territories, 2019, 193 7-3 Nursing Program Graduates by Degree Type and by Race/Ethnicity, 2019, 218 7-4 Nursing Program Graduates by Degree Type and Gender, 2019, 219 7-5 Diversity and Inclusion in Accreditation Standards, 220 PREPUBLICATION COPY—Uncorrected Proofs

xxviii BOXES, FIGURES, AND TABLES 9-1 A Framework for Nurse Leadership, 279 11-1 Research Topics for the Future of Nursing, 2020–2030, 373 C-1 Demographic Characteristics of Full-Time Equivalent (FTE) Registered Nurses, 2001–2018, 406 C-2 Number of Registered Nurses by Employment Settings, Average Annual Earnings, and Age, 2018, 411 C-3 Nurse Practitioner Employment Settings, 2018, 413 PREPUBLICATION COPY—Uncorrected Proofs

Acronyms and Abbreviations AACN American Association of Colleges of Nursing ACA Patient Protection and Affordable Care Act ACE adverse childhood experience ACEN Accreditation Commission for Education in Nursing ACS American Community Survey AD associate’s degree AHA American Hospital Association AHRQ Agency for Healthcare Research and Quality AMA American Medical Association ANA American Nurses Association APHA American Public Health Association APM alternative payment model APRN advanced practice registered nurse ASMN Academy of Medical-Surgical Nurses BWH Bureau of Workforce CAPABLE Community Aging in Place: Advancing Better Living for Elders CCNA Center to Champion Nursing in America CCNE Commission on Collegiate Nursing Education CDC Centers for Disease Control and Prevention CMMI Center for Medicare & Medicaid Innovation CMS Center for Medicare & Medicaid Services CNM certified nurse midwife CNS certified nurse specialist xxix PREPUBLICATION COPY—Uncorrected Proofs

xxx ACRONYMS AND ABBREVIATIONS COVID-19 coronavirus disease 2019 CPT Current Procedural Terminology CRNA certified registered nurse anesthetist DNP doctor of nursing practice EHR electronic health record FEMA Federal Emergency Management Agency FNS Frontier Nursing Service FQHC federally qualified health center HBR Healthy Baton Rouge HHS U.S. Department of Health and Human Services HIV human immunodeficiency virus HPSA health professional shortage area HRSA Health Resources and Services Administration ICD International Classification of Diseases IHI Institute for Healthcare Improvement IHS Indian Health Service IOM Institute of Medicine LVN/LPN licensed vocational nurse/licensed practical nurse MACPAC  Medicaid and CHIP (Children’s Health Insurance Plan) Payment and Access Commission MedPAC Medicare Payment Advisory Commission NA nursing assistant NACCHO National Association of County and City Health Officials NACNEP National Advisory Council on Nurse Education and Practice NASN National Association of School Nurses NCLEX-RN National Council Licensure Examination for Registered Nurses NCSBN National Council of State Boards of Nursing NFP Nurse-Family Partnership NIH National Institutes of Health NINR National Institute of Nursing Research NLN National League for Nursing NRC National Research Council NSSRN National Sample Survey of Registered Nurses PREPUBLICATION COPY—Uncorrected Proofs

ACRONYMS AND ABBREVIATIONS xxxi OADN Organization of Associate Degree Nurses OECD Organisation for Economic Co-operation and Development PACE Program of All-Inclusive Care for the Elderly PCMH patient-centered medical home PHIN Public Health Information Network PHN public health nurse PPE personal protective equipment RBRVS resource-based relative value scale RCT randomized controlled trial RHC rural health clinic RN registered nurse RUC RVS Update Committee RWJF Robert Wood Johnson Foundation SAMHSA Substance Abuse and Mental Health Services Administration SBHC school-based health center SDOH social determinants of health SNAP Supplemental Nutrition Assistance Program SONSIEL Society of Nurse Scientists, Innovators, Entrepreneurs and Leaders SOP scope of practice VA U.S. Department of Veterans Affairs VBP value-based payment VHA Veterans Health Administration WHO World Health Organization PREPUBLICATION COPY—Uncorrected Proofs

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The decade ahead will test the nation’s nearly 4 million nurses in new and complex ways. Nurses live and work at the intersection of health, education, and communities. Nurses work in a wide array of settings and practice at a range of professional levels. They are often the first and most frequent line of contact with people of all backgrounds and experiences seeking care and they represent the largest of the health care professions.

A nation cannot fully thrive until everyone - no matter who they are, where they live, or how much money they make - can live their healthiest possible life, and helping people live their healthiest life is and has always been the essential role of nurses. Nurses have a critical role to play in achieving the goal of health equity, but they need robust education, supportive work environments, and autonomy. Accordingly, at the request of the Robert Wood Johnson Foundation, on behalf of the National Academy of Medicine, an ad hoc committee under the auspices of the National Academies of Sciences, Engineering, and Medicine conducted a study aimed at envisioning and charting a path forward for the nursing profession to help reduce inequities in people's ability to achieve their full health potential. The ultimate goal is the achievement of health equity in the United States built on strengthened nursing capacity and expertise. By leveraging these attributes, nursing will help to create and contribute comprehensively to equitable public health and health care systems that are designed to work for everyone.

The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity explores how nurses can work to reduce health disparities and promote equity, while keeping costs at bay, utilizing technology, and maintaining patient and family-focused care into 2030. This work builds on the foundation set out by The Future of Nursing: Leading Change, Advancing Health (2011) report.

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