The committee has carefully considered Dr. Sage’s supplemental statement (see Appendix E) and believes the report’s findings and conclusions that form the basis for its recommendations are consistent with the evidence at hand. The Statement of Task for this consensus study on The Future of Nursing 2020–2030 directed the committee to chart a path for the nursing profession to help the nation create a culture of health, reduce health disparities, and improve the health and well-being of the U.S. population in the 21st century. The committee believes that an ambitious call for action associated with each component of the Statement of Task for this study is robustly addressed within the report and its recommendations even as the report content is guided by the standards for evidence-based recommendations of the National Academies of Sciences, Engineering, and Medicine. This report adheres to those requirements to present recommendations that are supported by evidence. The committee is not permitted to advance an advocacy agenda.
The committee members all agree that the report should illuminate a path for nursing that, if executed, would substantively address the serious issues of inequities in the nation that are clearly shown to adversely impact health status. Through its extensive exploration of issues and formulation of a set of recommendations that invites broad and deep engagement across multiple stakeholders, the committee believes it has developed a report that substantively addresses issues of inequities associated with health disparities. Committed to the National Academies’ requirements to ground all conclusions and recommendations in sound science, the committee has directed nine action-oriented recommendations to specific actors with a specific timeline. Dr. Sage’s recommendation that the committee formulate strong hypotheses for the post-COVID era is beyond the scope of
the committee’s Statement of Task and while interesting, would be inappropriate for this report. The remainder of this response by the committee addresses some of the specific points Dr. Sage makes in his supplemental statement.
NURSING’S ROLE IN DISASTER PREPAREDNESS
Dr. Sage states that the report does not focus sufficiently on nursing in the post-COVID period. We disagree strongly with this view. The committee has offered two recommendations related specifically to COVID-19 and future emergencies (see Recommendations 3 and 8 in Chapter 11) and devoted two chapters to the topic of disaster preparedness/public health emergencies and the well-being of the nursing workforce (see Chapters 8 and 10, respectively). Specifically, the committee has called out moral distress, stating: “Nurses in all roles and settings are confronted with ethical challenges that have the potential to cause moral suffering (ANA Code of Ethics, 2015), including moral distress or moral injury (Rushton, 2018). When nurses are unable to convert their moral choices into action because of internal or external constraints, moral distress ensues and threatens their integrity (Ulrich and Grady, 2018).” Conclusion 10-1 in Chapter 10 states: “All environments in which nurses work affect the health and well-being of the nursing workforce. Ultimately, the health and well-being of nurses influence the quality, safety, and cost of the care they provide, as well as organizations and systems of care. The COVID-19 crisis has highlighted the shortcomings of historical efforts to address nurses’ health and well-being.” Inclusion of further material regarding nursing in the post-COVID era would clearly be beyond the scope of this study and run the risk of creating an imbalance that would diminish the importance of the many other issues at the core of the committee’s charge.
PROGRESS SINCE THE 2011 THE FUTURE OF NURSING REPORT
Dr. Sage states that the report’s response to the lack of progress in some areas over the past decade is inadequate. We reject this view; the report emphasizes the need for additional progress throughout. The report addresses the important but insufficient progress in nurses achieving greater parity with physicians through an expanded scope of practice for advanced practice nurses that was recommended in the 2011 report, and includes a recommendation reiterating the need to continue this work. Recommendation 4 states: “All organizations, including state and federal entities and employing organizations, that prevent nurses from practicing to the full extent of their education and training by imposing regulatory barriers; public and private payment limitations; restrictive policies and practices within health care, public health, and other community-based organizations; and other legal, professional, and commercial impediments should remove those barriers so that nurses can fully address social needs and social determinants of health and improve health care access, quality, and value.”
Most important, this report expands on the work identified in the 2011 report as needed to increase the diversity of the nursing workforce. (See, for instance, Conclusion 3-3 in Chapter 3: “As the nation’s population becomes more diverse, sustaining efforts to diversify the racial, ethnic, and gender composition of the nursing workforce will be important.”) The committee explicitly addresses racism, social determinants of health, and health equity throughout the report. Building on the need to expand diversity, this report describes the racism that is embedded in nursing education and practice and calls for nurses to address their own biases and address structural racism. The report also identifies opportunities to deploy more fully the expertise of baccalaureate and other nurses in a wide array of settings. And the report advances a set of recommendations that, if implemented, will align resources and attention to address contemporary and emerging challenges facing both the profession and the U.S. population—fully commensurate with the scope of this study.
ALIGNMENT ACROSS NURSING
We also emphatically disagree with Dr. Sage’s remarks regarding the committee’s treatment of opportunities for increased alignment across nursing organizations. The report’s first recommendation focuses explicitly on the alignment of expertise and other resources within nursing profession associations and organizations, and this and other recommendations reflect the opportunity for partnerships with other professions and groups. Regarding the lack of sufficient recognition of the value of nursing, the report states that there must be direct public funding for both school nursing and public health. The two chapters that address this need are Chapter 4, “The Role of Nurses in Improving Health Care Access and Quality,” and Chapter 5, “The Role of Nurses in Improving Health Equity.” The committee also calls for workforce expansion (see Chapter 3) and adequate financing of the nursing workforce (see Chapter 6). In particular, the committee notes a number of ways in which public health nursing and school nursing can be bolstered in an effort to lead health equity efforts.
Taken together, the committee believes that this report and its recommendations, if implemented, will have far-reaching and meaningful impact on the education and practice of nurses at every level and specialty. Dr. Sage said that the goal of the report should be to make a compelling case for action and advocacy. The committee believes that a careful reading of the report will reveal that this has in fact been accomplished within the evidence-based tradition of the National Academies.
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