ISSUE 1: The Future of Nursing
The IOM Report in Review
Welcome to Nursing in the 21st Century, a new mobile journal designed to stimulate conversation around the rapidly changing roles of nurses in America.
Our first issue is a response to the Institute of Medicine (IOM) and Robert Wood Johnson Foundation’s (RWJF) report The Future of Nursing: Leading Change, Advancing Health. Since its release in 2010, the report has generated widespread discussion and interest and has proposed a vision for a transition that will affect nurses practicing at all levels.
Examining the report and its philosophical goals after two years, we see the report as a sort of fulcrum, balancing the higher intellectual aims of education and care delivery on the one hand, with the reality of degree attainment and workforce challenges on the other.
Follow-up reviews on the progress toward meeting the philosophical aims of the report are encouraging (as described in our first article, “The Future of Nursing,” by Dr. Julie Fairman). However, further examination of the day-to-day delivery of care – particularly in rural environments, educational requirements for nurse preparation, and current market trends surrounding financing and care management, brings our awareness to the gaps between vision and workable applications.
The perfect storm looms large: the population is aging, health reform legislation is providing financial access to care that is stimulating an increased demand for services, and the public and the profession alike have concerns about workforce shortages. Can the visionary precepts of the IOM report be reconciled with reality? How can we come to well-designed solutions?
It is generally not disputed that under current conditions, a shortfall of registered nurses cannot be averted. Graduation rates, as reported by all schools preparing nurses for licensure, are already proving insufficient to meet demand. And, any significant influx of students, estimated to be needed in the hundreds of thousands by 2025, will strain the limited number of qualified faculty. The United States is projected to have a nursing shortage that is expected to intensify as baby boomers age and the need for health care grows. Compounding the problem is the fact that nursing colleges and universities across the country are struggling to expand enrollment levels to meet the rising demand for nursing care.
Luckily, these realities are now compelling nurse educators and employers into collaborative relationships, to take a hard look at where we are and to create new paths that will lead to where we need to be.
It is clear that a change in care delivery models necessitates a change in the skills, education, and techniques required to provide health care. In addition, the rapid changes in the financing of care will (and are) forcing nurses, graduates, employers and educators to respond just as quickly by adopting new methods to prepare nurses for practice.
Is it possible to preserve and improve the current workforce pipeline while simultaneously applying resources more efficiently to achieve evidence-based and competency-based practice? Our first issue considers this question, and looks at the profession post-IOM from a range of contributors, in the hopes of providing answers, posing questions, and offering possible solutions.
Our first piece is a conversation between two authors of the report, Julie Fairman and Susan Hassmiller.
From there, we turn toward efforts to find newer models of collaborative practice and education.
Diane Huber, in her piece titled “Rural Health Care and the Future of Nursing: Can We Get There from Here?” offers insight into the burdens faced by rural areas, caught between keeping up with care demands while making progress in meeting the IOM report’s educational recommendations.
Patty Jones' article, “A Shifting Care Continuum and Its Nursing Workforce Implications” provides a look at some of the new health care financing and delivery models, and the expectations those models place on nurses to comprehend and contribute to them in evolving practice settings.
Milena Staykova's piece on associate degree education looks at how two-year nursing degree programs fit the evolving marketplace.
"The Future of Nursing: Leading Change, Advancing Health" is the first major, broad study on the nursing profession since 1983 and is serving as a blueprint for a national campaign to improve the nation’s health through a transformation of the nursing profession.
Since 2010, three organizations have come together to form “The Future of Nursing” campaign : The Center to Champion Nursing in America (CCNA), American Association of Retired People (AARP) and The Robert Wood Johnson Foundation (RWJF). The campaign focuses on implementing the report's four key recommendations:
Nurses should practice to the full extent of their education and training.
Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression.
Nurses should be full partners, with physicians and other health care professionals, in redesigning health care in the United States.
Effective workforce planning and policy making require better data collection and information infrastructure.
Guided by the energy and vision of Susan C. Reinhardand Susan B. Hassmiller the campaign will transform the recommendations of the IOM report into direct and measurable actions, across all levels of stakeholders.
The IOM report was clear that the health care system could not be reformed without nurses, but also that nurses should not have to make those changes by themselves. Stakeholders outside the profession - including philanthropists, government officials, and others who recognize the value of including nurses in leadership roles - have been called upon to assist these state coalitions, creating collaborative relationships in areas such as fund raising, strategizing, and making connections in the media and among legislators.
In less than two years, progress has been impressive.
To date, most state coalitions have chosen to specifically examine and address Recommendation 2 - education requirements. The report has set a very clear goal of increasing the proportion of baccalaureate prepared nurses from 36% in 2008 to 80% by 2020 (referred to as “80/20”), and doubling the number of doctoral prepared nurses from 13% in 2008 to 26% by 2020.
Already, the coalitions are developing innovative educational models including shared curriculum (Connecticut), shared faculty (Arizona), competency-based education programs (New Jersey), allowing community colleges to grant baccalaureate degrees (Florida), and accelerated RN to MSN programs (widespread).
In terms of addressing other tenets of the report, leadership - as referenced in Recommendation 3 - is being examined by the North Carolina Action Coalition, which is strategizing to get more nurses on hospital boards. A variety of states are working to remove scope-of-practice barriers.
In just this past year, CCNA has convened stakeholders through its Champion Nursing Coalition and Champion Nursing Council to develop strategies to implement IOM recommendations. Work is paying off in the form of resources, consultation, and legislative movement. For example, in Vermont, the Champion Nursing Council has made connections with Governor Peter Shumlin, who has formed a state commission to implement recommendations. In Connecticut, the Champion Nursing Council has raised funds to develop innovative, collaborative education models that include simulation. Spokespersons for the Campaign for Action have presented at over 120 meetings in more than twenty states.
I recently interviewed Sue Hassmiller, a principal author of the report, about its scope, goals and progress. Listen to our conversation here.
Rural health care delivery systems are plagued with a number of serious, ongoing challenges. These challenges stem from a range of factors, some as basic as traditional difficulties with workforce recruitment and retention. Others have to do with shifting reimbursement streams and technological requirements such as the need to digitize records in order to comply with the 2010 Affordable Care Act (ACA).
Adding to these challenges is the pressing list of recommendations from the 2010 IOM/RWJF "Future of Nursing" report, which calls for changes in the way nurses are educated, how and where they practice, and in what capacity.
This article looks at factors that have historically challenged rural health care and views them through the lens of the recommendations of the IOM/RWJF report and the implementation timeline of the ACA. Can nurses who provide care in rural settings meet the call for additional educational preparation while simultaneously meeting the special needs of rural residents and complying with the federal guidelines directing how care is administered and paid for? Can the existing educational pipeline be adapted to quickly and efficiently support the growing need for greater numbers of nurses to care for rural residents? Will rural states with primary care shortages recognize nurses can and should practice to the full extent of their training? How do we get there from here?
Rural Health Challenges: An Overview
Issues surrounding workforce have always been a serious factor in the delivery of care to rural residents. For decades, rural employers have struggled to attract and retain a sufficient supply of well-qualified nurses and other health care practitioners, and have often found themselves unable to compete with the benefits and salaries offered by major urban centers.
Instructive on this point is the information found in the 2008 National Sample Survey of Registered Nurses (NSSRN), a survey conducted every four years by the U.S. Department of Health and Human Services Health Resources and Services Administration (HRSA) to identify trends in the workforce. NSSRN reports a significant geographic variation in nursing employment across the country. Some rural areas experienced as much as a twofold difference in the employed-nurse-to-population ratio as compared to urban centers. In fact, rural counties with designated health professions shortage areas outnumber urban counties with shortage areas by a ratio of 2 to 1.
Because there are fewer numbers of nurses and health care professionals available in general in rural communities and therefore fewer professionals in the rural communities available for back-up and coverage, ground-level challenges surrounding volume (How many nurses do we need? How many do we have?) and how to recruit (How do we tap into the educational programs graduating the nursing workforce we need?) are expected to continue (Ricketts, 2005).
Challenges associated with sustaining a rural nursing workforce have recently become magnified. This is particularly true in light of all the reasons mentioned: an aging population, insufficient numbers of new nurses and other care providers who are willing to work in rural communities, and the near-retirement age of the existing workforce.
Needs of Rural Residents
The demographics of rural residents vary from urban residents in a variety of ways. Recent census data shows close to a fifth of the nation’s population lives in rural communities, and about a third of those households receive government assistance in the form of food stamps. Many rural areas also reflect lower income and higher poverty rates than elsewhere in the United States. In addition, a greater proportion of rural residents are uninsured or covered through public sources, such as Medicaid, CHIP or Medicare. Data indicate that underinsured or uninsured Americans seek health care less often and may therefore be in need of more extensive (and expensive) treatment when at last they are seen by a health care provider.
This variation is especially true with regard to shortages of primary care providers whether advanced practice nurses or primary care physicians (MacDowell et al., 2010). According to MacDowell et al. (2010) overall physician shortages were reported by 75% of the responding CEOs in rural hospitals. Nationally 53.1% of respondents indicated a shortage of Internal Medicine physicians (considered by the medical profession to be primary care physicians). A pending primary care shortage is widely acknowledged.
It is clear that rural America has fewer providers per population, the population is often poorer and therefore may have less financial access to care, and episodes of care may be less frequent and therefore more intense when an intervention does occur.
Infrastructure of Rural Hospitals
Administrative and financial infrastructure, records management, and reimbursement under special designations for rural institutions such as “sole community provider” (SCP) and “Critical Access Hospitals” (CAH), are all under scrutiny and in a state of flux. As a result, rural hospitals are scrambling to continue to meet the qualifying requirements for special designations as established by the Federal Government so important to rural health care survival. Now, however, federal funds are tight. New payment systems will likely alter how hospitals are reimbursed for care, particularly care delivered to Medicare patients, many of whom live in rural America, jeopardizing a key revenue stream for CAHs and SCPs. In addition, CAHs operate on a “cost-based” system of payment, meaning they are paid based on claims submitted for services rendered. In order to comply with new federal mandates, however, the reimbursement system is already moving toward a “value-based” system, or rewarding value over volume, with payment tied to patient care outcomes. Meeting the standards for verifying value may be more difficult for rural providers as the matrix was developed with urban systems and urban resources in mind.
Is the CAH designation safe? Will it continue to be available to provide much-needed financial support and relief to rural health care providers in the face of growing federal cuts? What happens when the funding stream for Medicare reimbursement, which sometimes makes up as much as 70% of rural hospital revenue, shifts? How will changes in funding affect nurses who are already practicing in rural areas, as well as those in school now? How will rural hospitals afford to hire staff, replace equipment, and buy into new informatics and other technology with less reimbursement?
In the fall of 2012, Minnesota Public Radio compiled an extensive and useful report on Minnesota’s rural health care initiatives and examined how some of these questions are being answered in Minnesota and how potential solutions are being received and integrated in the health care delivery system in that state. It is feasible that examples such as this one have lessons for other rural delivery systems that can help with workforce redesign and delivery of rural care despite the many challenges.
Viewed in concert, these changes can certainly be perceived as a major source of threat and uncertainty to the sustainability of the rural health care delivery system and the rural workforce itself. The convergence of factors associated with reimbursement trends, federal health care legislation and the recommendations of the IOM/RWJF report to change nursing practice and nursing education illustrates the reality that rural areas 1- count more heavily than urban areas on Medicare funding and special federal designations, and 2- are under the same pressure as urban hospitals to meet the federal legislation (ACA) and the workforce education mandates of the IOM/RWJF report with fewer available staff and smaller pools of capital reserves.
Rural providers have been tasked to come up with solutions. And quickly.
The IOM Report and the Changing Roles of Nurses
Following the release of the IOM/RWJF report in 2010, it was noted within the nursing community that there was a significant response to what was considered a national mandate to: reconfigure health care workforce roles, emphasize team-based collaboration, provide professional care coordination and to pursue evidence-based management of transitions of care. To do this, the report called for a transformation of the profession of nursing, both in scope of practice and in educational preparation. The report identified the nursing profession, with 2.6 million members (Kaiser Health News, 2011), as the largest segment of the U.S. health care delivery workforce on the front lines of patient care.
Primary Care and Scope-of-Practice Barriers
Primary among major messages in the report, but not the only message to have impact on rural America, was one that called for removal of barriers that “prevent nurses from being able to respond effectively to rapidly changing health care settings and an evolving health care system” (IOM, 2010a, p.1). Rural America is proving an ample testing ground for this tenet.
As shown, statistics surrounding shortfalls in primary care providers in rural areas are startling. It seems logical — and has been suggested for years — that some of the primary care shortages might be resolved through the use of advanced practice nurses (APRN). For example, nurse practitioners are prepared to deliver primary care and are considered professional members of the nursing workforce who can increase access to primary care. Studies demonstrate quality of care and effective patient outcomes, as well as more cost effective delivery of care when provided by nurse practitioners or advanced practice nurses. Nonetheless, there have been fundamental problems with expanding their roles. Such barriers are especially difficult in rural communities.
To begin, there is an uneven supply of nurse practitioners. In addition, consistent identification of activities allowable within the scope of an expanded nursing practice are difficult to establish across state lines. States have distinct licensing requirements and definitions for allowable practice. A nurse may be able to deliver care in one state that is prohibited in another. Variations in state insurance laws also impact the ability (or inability) to capture reimbursement for services provided.
In summary, in spite of the growing need for access to primary care, especially in rural America, nurse practitioners have consistently been prevented from delivering a full scope of primary and advanced nursing care, making role implementation inconsistent (Ricketts, 2005). Thus, we have a barrier to one of the explicit recommendations of the IOM/RWJF Report: allowing nurses to practice to the full extent of their education, and, as a result, we are missing an opportunity to address a prominent problem — access to care — in rural areas.
Has progress been made toward removing scope-of-practice barriers? Articles and headlines from newspapers and magazines show mixed results.
In 2011, many states — including California, Texas and New York — did not allow nurse practitioners to diagnose illnesses or prescribe medications without the direct supervision of a physician. In other states — like Michigan and Oklahoma — nurse practitioners were allowed to diagnose, but not to prescribe. On the other hand, in fourteen states — including Oregon, New Mexico and New Hampshire — nurse practitioners were allowed to do both without physician supervision. Additionally, restrictions sometimes vary regionally within a state, with nurse practitioners practicing independently in rural areas and under the supervision of a physician in cities.
In 2012, laws in Lubbock, Texas still prevented nurses from ordering even basic supplies without a physician signature. In Louisiana, a bill was introduced in May 2012 that would have allowed advance practice nurses to practice without any affiliation with a physician, if the nurse was working in a medically underserved area. It failed later that same month. In West Virginia, an article in The State Journal reported the Legislature re-wrote the definition of a nurse practitioner and also expanded prescription rules in a recent legislative session so nurse practitioners could prescribe drugs for chronic conditions.
And, in spring 2012, an article, "Why Nurses Need More Authority," written by physician and professor John W. Rowe and published in The Atlantic calls for expanding the role of the APRN: “…34 states that restrict APRN's scope of practice will eventually have to come to terms with a growing shortage of physicians and increasing demands to save money and restructure how we receive and pay for health care.”
Workforce Needs and the Education Pipeline
At the other end of the nursing workforce spectrum, opposite advanced practice, is the issue of what the pre-licensure educational preparation of nurses should be in a changing environment. A critical issue in rural areas (and nationally) is the urgent need to review and revise the skills and roles of the nursing workforce to keep up with new approaches and systems of care.
IOM Goals vs. Ground-Level Realities
Chief among present day realities is the health status of the American population.
It is undisputed that more Americans are living longer and will need to receive care more often and most likely that care will be delivered in the community rather than in the hospital. As the population ages there will also be an increased demand for care of chronic conditions as well as heightened requirements for providing care augmented by highly sophisticated technology. These facts are magnified in rural areas where care providers are fewer and distances between health facilities are significant.
The IOM/RWJF report states: “Nurses must achieve higher levels of education and training to respond to these increasing demands” (2010a, p.2). Given the rapid advances in the treatment of disease and the increased numbers of patients who seek care within ever more complex delivery models, the recommendation that nurses attain additional education to address safe, patient-centered care across settings seems fitting. It is also logical to assume that increasing the percentage of BSN-prepared nurses in the workforce would create a more educated workforce. Indeed, the IOM encourages this approach by stating (2010b, p.4): “The committee recommends that the proportion of nurses with baccalaureate degrees be increased to 80 percent by 2020.”
How to accomplish this IOM recommendation is not entirely clear. It is most likely not as easy as requiring all nurses to have a BSN degree. This is most certainly true in rural areas where the majority of the nursing workforce is ADN graduates who are needed in their facilities and who may not have the time or financial resources to commit to more years of education. There is also not enough evidence to simply eliminate ADNs who have been successfully working with patients since the 1950s. These issues need discussion to include forward thinking planning to account for how it might be possible for the nursing workforce across the country, in all communities, to be populated with only BSN nurses.
How can these issues be addressed? The changing face of health care delivery brought about by new policy and payment structures calls for a proper re-assessment of the nursing curricula and basic nursing skill sets that are the current standard. Surely it will be necessary to apply energy and attention to the preparation of a new type of nursing graduate for engagement in a new practice environment. It is reasonable to connect the changes in the practice field to changes needed in the preparation of the nursing workforce and to describe that work as educational reform. However, reform in nursing education may mean different things to different people. Most definitely reform, given such rapid change in the environment, should be necessary as a sooner rather than a later professional activity. This is so much so that the IOM (2010b) issued a further report: The Future of Nursing: Focus on Education.
However, implementation of actual curricular changes in basic nursing education programs that address the form and function of nursing practice in the twenty-first century are still in beginning phases of thoughtful discussion and planning, but are moving rapidly in some areas.
Some Points to Ponder
Given the length of time it takes to attain degrees in nursing (two years minimum for the ADN and four years minimum for a Baccalaureate degree in nursing, with advanced practice and nurse practitioner preparation an additional two to four years), is it reasonable to limit entry to nursing practice to BSN preparation? This is a controversial recommendation for the following reasons:
According to National League for Nursing (NLN) numbers, in 2008, associate degree and diploma nurses accounted for nearly 50% of the RN workforce, with about 36% holding an associate degree (ADN) as the highest preparation. According to data in the 2008 National Sample Survey of Registered Nurses (NSSRN), RNs whose initial education was in an ADN program have a higher rate of full-time employment than do those who entered the profession with a bachelor’s or master’s degree, underscoring again the need for a plan to preserve the resources of the ADN workforce in the delivery of care while better integrating nursing educational preparation.
The escalation of the need for nurses continues, and the well-documented evidence of continued shortfalls in numbers of nursing graduates prevails. The message of the IOM/RWJF report calling for the proportion of nurses with baccalaureate degrees be increased to 80% (from the current 45% of the workforce) by 2020 is viewed by some as part of a worthy movement to transform health care delivery. The controversy contained in this recommendation, however, is underscored by the absence of practical discussion to guide a reconfiguration of one half of the current workforce with hospital certificates or Associate Degrees in nursing. Especially at risk are rural communities who already struggle to employ enough nurses and other health care providers to care for rural populations.
Current dilemmas, including workforce challenges, shortages in primary care, and barriers to nursing practice as described in this article must also be addressed, and the question remains: Can we realistically get there from here? As demonstrated in this article, this question is especially apropos for rural America.
Transitions of Care
All is not lost. For example, in some rural areas, hospital leaders and nursing program leaders are coming together in serious discussion to plan and develop a seamless transition that will sustain and transform the workforce, as well as fit new models of care and practice. If barriers to implementing the IOM recommendations can be addressed and resolved, the twin foci for transformation in both rural and urban communities then become: 1- the reform of the nursing education system and 2- fundamental changes to roles for nurses in primary care.
The IOM, as mentioned, does touch on the need for reform in nursing education and includes mention of curriculum and program articulation and nurse residency programs as vehicles for change. Not fully addressed is the means whereby nurses evolve their roles in primary care to encompass care coordination and the management of transitions of care, as these are the new models for care. Especially important in managing transitions in care will be development of best practice models of nursing care for rural health care delivery systems, as facilities and resources are often based in locations that are distant from one another.
The Future of Nursing report and the American Nurses Association (ANA) have identified care coordination and transitions of care as core nursing roles. The ANA position statement says “Care coordination promotes greater quality, safety, and efficiency in care, resulting in improved health care outcomes and is consistent with nursing’s holistic, patient-centered framework of care” (ANA, 2012a, p.3). Care coordination, according to the ANA, is a professional competency of all registered nurses, and the value nurses add to the role of care coordinator has been documented in reports and studies from a wide variety of settings and diverse populations (ANA, 2012b). Models that work include the primary care-based nurse-managed health clinic model defined in the Affordable Care Act (ACA), which has a strong care coordination component as its hallmark (American Academy of Nursing, 2012).
Indeed, models of team-based collaboration and coordinated care are in development across the country as an outgrowth of the Affordable Care Act. As nursing education progresses in teaching new nursing skills and roles, nurses could become well prepared to participate in the development of collaborative coordinated models of care. Nurses so educated would be present at the team-based table not just because their holistic-style of education, but also because as a result of their preparation they bring knowledge, skills and abilities that match care coordination requirements. As care coordination roles evolve, nurses can actively participate in shaping roles and redefining job descriptions and scope of practice, particularly in advanced primary care practice where they have valuable patient assessment and care planning skills to add to the delivery model. Moving from the traditional silo-based specialty and hospital focused medical model of care to a coordinated team approach may be difficult to conceptualize and execute. However, it must be done. Such models should be especially effective in rural communities where collaborative, coordinated care models are, of necessity, already important to the delivery systems.
In the education of nursing students, value is added by teaching nursing case management and population health management models and principles such as disease-specific, evidence-based protocol management of specialty populations. Care coordination with effective management of transitions in care results in desired patient and organizational outcomes and will be the heart of the new delivery system. Nurses can achieve these outcomes with preparation focused on these approaches to care.
The health challenges facing Americans and the nation have dramatically shifted (IOM, 2010b), and traditional approaches to care are being pushed into different configurations by market forces. For example, the changes in reimbursement created by the Affordable Care Act create momentum for massive changes in payment structures as well as the design of the health care delivery systems. In rural America where shortfalls in resources and workforce already exist, there will be even greater cause for concern as well as an exponential need for careful planning to maintain a positive edge to the ability of rural communities to have the care providers and care systems they need.
The synergy from the IOM/RWJF reports sparks an additional drive for change to nursing education and the regulation of nursing practice that should be filtered through the requirements for nurses needed in rural areas. All these factors are converging simultaneously. Nurses, because of their role with patients, are key to transformative models of care, and must be prepared in educational programs that include training for new roles emerging in the environment. The nursing education system must change quickly to prepare greater numbers of nurses with knowledge, skills and abilities for very different roles and functions, which include care coordination and expanded nursing practice in the role of primary care provider. This requires all avenues for preparing nurses to remain open and better connected. More graduates, not fewer, are required. It is also required that the specific workforce needs of both urban and rural communities be considered in preparing a new nursing workforce. As illustrated in this article, the resources available to urban vs. rural communities are often widely divergent and cannot be ignored.
The financial burden associated with additional educational preparation for nurses, especially in rural areas, is significant. However, if the premise is accepted that nurses must be educated at more advanced levels in order to fully participate in the new models of care, then models of education and preparation that are fundamentally different from what has been offered in the past, in associate- as well as baccalaureate-nursing programs, must be the mandate. The current environment creates an opportunity for nurses to come together as colleagues in practice and in education, to discuss and plan for the transformation of health care and future of nursing in a manner that has not previously existed. There are equal stakes in the outcome for both Associate Degree and Baccalaureate degree programs and for employers of nurses. Each segment works in the new environment to prepare nurses for practice and looks to hire qualified nurses in sufficient numbers to meet the public’s expectations for care.
The IOM itself has said (IOM, 2011, p.403): “The future of health care rests solidly with the strength nursing brings in holistic care, ability to collaborate and innovate from the bedside to the community and the ability to adapt to the changing environment.” Nurses, through their professional experiences have access to information about patient care and nursing outcomes that can leverage and actively construct the new care coordination and care management models. Of all the health care professions, nurses have the best-matched skills and the greatest opportunity for preparing to work with patients in the new models of care.
There is a tremendous amount of work to do to get ready to participate in the new care environments in both urban and rural communities. Nursing leaders are aware that when nurses do not proactively participate, the system fills the gap without them.
To paraphrase the IOM, in order to fully participate, nursing must adapt practice, education and curriculum to the new century, promote access to higher education, advocate for innovative models of care and practice and advocate for policies in health care and education to support those innovations. Nursing leaders in their transformative work must also address the realities associated with differences in practice settings between urban and rural communities and find solutions to move the nursing workforce forward, while leaving no resource behind.
American Academy of Nursing. (2012). The imperative for patient, family, and population centered interprofessional approaches to care coordination and transitional care. Retrieved from: http://www.aannet.org/assets/docs/PolicyResources/aan_care%20coordination_3.7.12_email.pdf
American Nurses Association (ANA). (2012a). Care coordination and registered nurses’ essential role. Position statement. Retrieved from:http://nursingworld.org/DocumentVault/Position-Statements/Practice/Care-Coordination-and-Registered-Nurses-Essential-Role.pdf
American Nurses Association (ANA. (2012b). The value of nursing care coordination: A white paper of the American Nurses Association. Retrieved from: http://www.nursingworld.org/carecoordinationwhitepaper
Health Resources and Services Administration (HRSA), U.S. Department of Health and Human Services. (2010). The registered nurse population: Findings from the 2008 National Sample Survey of Registered Nurses. Washington, DC: Author
Institute of Medicine (IOM). (2010a). The future of nursing: Leading change, advancing health: Report brief. Washington, DC: The National Academies Press. Retrieved from: http://www.iom.edu/~/media/Files/Report%20Files/2010/The-Future-of-Nursing/Future%20of%20Nursing%202010%20Report%20Brief.pdf
Institute of Medicine (IOM). (2010b). The future of nursing: Focus on education. Washington, DC: The National Academies Press.
Institute of Medicine (IOM). 2011. The future of nursing: Leading change, advancing health. Washington, DC: The National Academies Press.
Kaiser Health News, 2011 Retrieved from: http://www.statehealthfacts.org/comparetable.jsp?ind=438&cat=8&sub=103&yr=200&typ=1&sort=a
MacDowell, M., Glasser, M., Fitts, M., Nielsen, K., & Hunsaker, M. (2010). A national view of rural health workforce issues in the USA. Rural and Remote Health, 10, 1-12. Retrieved from: http://www.rrh.org.au/articles/subviewnthamer.asp?ArticleID=1531
Morrison, I. (2012). Reinventing rural care. Trustee, 3, 29-31.
Ricketts, T. C (2005). Workforce issues in rural areas: A focus on policy equity. American Journal of Public Health, 95(1), 42-48.
Health care reform, notably authorized by the Affordable Care Act (ACA), has already started to trigger changes in national health care coverage.
The reform effort is also funding research initiatives intended to identify approaches to health care delivery and financing that will completely transform current models of care. The goal is to discover and develop new approaches that will foster long-term improvements in both cost and quality. The federally issued “Triple Aim” objectives central to reform legislation are: improving the experience of health care, improving the health status of populations, and reducing the cost per capita of health care.
In spite of whether or not one agrees with the framework for reform, changes underway have undeniable implications for nursing leadership, workforce development, and skills training. Viewed as challenges, opportunities, or a mix of the two, the nursing profession has a choice: to participate by leading or to participate by reacting.
Leading, which provides the greatest opportunity for positive gain and engagement within the profession, is the more difficult path. Leading requires setting aside the traditional views and guidelines that structure nursing education programs, rethinking the familiar levels of nursing practice and the customary hierarchies in education and training so that new, still-unnamed professional roles and career paths can develop.
This article will consider the impact of health reform on the financing of care and on current standards of nursing practice. It will look at a revised set of standards for a nursing workforce whose skills will need to align with a continuum of care that is moving toward community and outpatient resources and away from hospitals. To this end, The Robert Wood Johnson Foundation (RWJF) Initiative on the Future of Nursing, at the Institute of Medicine (IOM) entitled “The Future of Nursing: Leading Change, Advancing Health” makes recommendations in their report that do address leadership. The recommendations, however, do not describe the evolving realities of the work environment, some of which will be examined here.
The IOM/RWJF Charge to Nurses to Lead
The IOM-appointed committee on the RWJF initiative “The Future of Nursing” resulted in eight recommendations, which were then synthesized into four key messages. The purpose of the committee’s work was to produce a report that would make recommendations for an action-oriented blueprint for the future of nursing.
One of the initial eight recommendations, “Prepare and enable nurses to lead change to advance health” is especially key in this post- Affordable Care Act era. It states:
Nurses, nursing education programs, and nursing associations should prepare the nursing workforce to assume leadership positions across all levels, while public, private, and governmental health care decision makers should ensure that leadership positions are available to and filled by nurses.
• Nurses should take responsibility for their personal and professional growth by continuing their education and seeking opportunities to develop and exercise their leadership skills.
• Nursing associations should provide leadership development, mentoring programs, and opportunities to lead for all their members.
• Nursing education programs should integrate leadership theory and business practices across the curriculum, including clinical practice.
• Public, private, and governmental health care decision makers at every level should include representation from nursing on boards, on executive management teams, and in other key leadership positions.
This recommendation and its related points encourage the nursing profession to step back and consider the core concept, “advancing health,” and its possible interpretations.
Advancing health can be understood as advancing the clinical health of the individual who may be in a stable state or having an acute episode, or who may need management of a chronic condition. Advancing health can be leading change at the national, community and/or population health level while supporting the health needs of the individual. Or, an even more comprehensive interpretation would include advancing resource stability and workforce training in tandem with advancing the health of the individual.
This combined approach is one in which a nursing presence has the potential to effectively and successfully contribute to the goals of health improvement. However, if nursing education and subsequent practice continue to follow the traditional disease-based medical approach to health care, practitioners will surely find themselves unprepared to participate, much less lead, in a health care environment geared toward health management and health promotion. If nursing classrooms, coursework, and licensure exams continue to reflect a disease-based medical model to providing care, students may not be exposed to the workings of health care financing and will lack the basic yet critical foundation for understanding how financial access to care directly influences outcomes of care given and received. This is an important omission because in the very near future, the standard of practice for health care will rest on those very outcomes.
As hospitals become less of an epicenter of care, and community-based services become the norm, gaps in the nursing workforce’s preparation for practice at the community level will soon be evident. At this moment, broadly considered, nursing education curricula do not provide sufficient preparation for nurses to participate in designing the community-based services that include such new features as medical homes and accountable care organizations, or in structures such as Insurance Exchanges. Nonetheless, it is still essential for nursing students and nursing practitioners to understand the economic climate and the new methods for financing care-delivery systems, systems that are driving the new models of care.
New Models Bring Opportunities for a Range of Participation
At this moment, educated, influential professionals and national organizations are at work describing and implementing new models to improve health care delivery systems. For example, money from federal and private foundation sources is flowing toward community-based initiatives, such as Accountable Care Organizations (ACOs), intended to transform health care into delivery systems that improve the health of the population. ACOs are being promoted by the federal government as community-based initiatives that support information transparency and coordinated care for patients using “medical homes,” with payments to providers based on results.
While new forms of delivering and coordinating care are rich with opportunities to test the emerging ideas rooted in changes to national health policy, current projects under discussion, such as ACOs and Patient Centered Medical Home (PCMH), are nearly devoid of nursing participation. This is striking considering the possibility that the success of coordinated care delivered in community settings depends on effective nurse involvement.
Let’s take a closer look at some of these new models being tested. The first two, Health Insurance Exchanges and Chartered Value Exchanges (CVEs), address new types of insurance and quality improvement structures for health care. The second two, Affordable Care Organizations (ACOs) and Patient Centered Medical Home (PCMH), address new types of care delivery systems for health care.
Health Insurance Exchanges
One of the components of Health Reform is the establishment of Health Insurance Exchanges, intended to provide “one-stop” online access to state-by-state information and options for purchasing private or public health insurance. On September 30, 2010, the United States Department of Health and Human Services (HHS), announced $49 million dollars in grants to help 48 states and the District of Columbia plan for the establishment of Health Insurance Exchanges These grants, of up to $1 million each, provide states with resources to conduct the research and perform the planning needed to build a better health insurance marketplace online and determine how a state’s Exchange will be operated and governed. Future funding will support the actual development and implementation of Exchanges that states will undertake through 2014.
The Exchanges are expected to provide established standards for the benefits offered, as well as the names of health plans that participate on the Exchange. Health plans will be required to meet quality and reporting standards. Quality requirements include accreditation, consumer satisfaction, and population health measurement elements.
Nursing leaders should be taking an active role in participating in the design of the Health Insurance Exchanges based on their understanding of population health and the demographics of the communities in which they work and live. As nursing care will be defined by patient outcomes in the near future, nursing education programs should encompass information on measuring population health, as well as measuring consumer quality as it relates to health care.
As stated earlier, nurses, particularly those moving into primary care roles, must have an understanding of the financial provisions of the health insurance exchanges. The payment for all services in health care will be affected by the proposed plans to provide coverage to more people through use of the exchanges.
Chartered Value Exchanges
At the local level, in cities, towns, and villages, Community Quality Collaboratives are now the key drivers of health care reform. The Learning Network for Chartered Value Exchanges (CVEs) is a relatively new national program supported by the U.S. Agency for Healthcare Research and Quality (AHRQ). Formed in 2007, the Learning Network brings together 24 CVEs, or community quality collaboratives, from across the country. In aggregate, these collaboratives involve more than 550 health care leaders and represent more than 124 million lives, more than one-third of the U.S. population. The collaboratives are multistakeholder initiatives with a mission of quality improvement and transparency. These Collaboratives, Chartered Value Exchanges, (CVEs), are implementing a bold vision for health care reform built on four cornerstones:
Measuring and publishing quality information to enable consumers to make better decisions about their care.
Measuring and publishing price information to give consumers information they need to make decisions on purchasing health care.
Promoting quality and efficiency of care.
Adopting interoperable health information technology.
Accountable Care Organizations (ACOs):
As described in the earlier Affordable Care Act video, the Affordable Care Act includes provisions for a new administrative system for care providers to serve Medicare patients, called Shared Savings Programs. A Shared Savings Program is a voluntary program designed to encourage physicians, hospitals, and other providers of Medicare-covered services and supplies to join together and develop accountability standards and outcomes while reducing costs. These tenets form the foundation of what are referred to as Accountable Care Organization (ACOs), and are, at their root, driven by a need to find better ways to serve Medicare patients. In theory, an ACO agrees to improve the health and quality of care for individuals and improve the health of populations while reducing the rate of health care spending growth without restricting access to care providers. Medicare beneficiaries served through an ACO, for example, would continue to have free choice regarding when and from whom they receive care.
When an ACO succeeds in coordinating care for its targeted population, thus meeting the (four) ACO health improvement program objectives as described above, the federal payer, the Centers for Medicare and Medicaid Services (CMS), shares the Medicare savings with the ACO. As of July 1, 2012, CMS had authorized 154 ACOs.
One specific ACO, the Pioneer ACO, was announced in January 2012 and is comprised of 32 medical-care treatment organizations that were selected by The Center for Medicare and Medicaid Innovation, created to aggregate early adopters of coordinated care that already had a demonstrated record of success. This model allows these provider groups to move to a population-based payment model on a track consistent with other models of Medicare Shared Savings Programs.
As described, accountable care in which collaborative work results in shared savings will change how and by whom services are delivered. Perhaps the greatest challenge for nurses will be to work in collaborative models of care that require nurses to share accountability with a team of practitioners. Many nurses accustomed to carrying heavy workloads may have difficulty integrating their work with contributions from other providers. This is a requirement for successful care delivery in the ACO model. Emphasis on sharpening skills conducive to practice in these systems will be important aspects of nursing curricula.
Patient Centered Medical Homes
The PCMH isn’t a home, per se, or a physical structure, but occurs in a health care setting that facilitates partnerships between individual patients, their personal physicians, and, when appropriate, the patient’s family. Care is facilitated by registries, information technology, health information exchange, patient involvement and other means to assure that patients get care when and where they need and want it in a culturally and linguistically appropriate manner.
Several accreditors, such as the National Committee for Quality Assurance (NCQA) and URAC along with professional societies, employers and health insurers have encouraged the development of PCMH models. These efforts have included implementing pilots, providing financial incentives and developing standards for PCMHs.
Originally limited to physician-led practices, the National Committee for Quality Assurance (NCQA) opened this program to nurse-led practices in 2010 in states that allow these clinicians to provide the full range of primary care and practice independently. Physician Assistants and Nurse Practitioners are also eligible to be listed as part of a recognized practice if they manage their own panel of patients. Thus, for states this model permits a full scope of practice for nursing.
According to NCQA, as of November 2012, there are more than 4,937 practices that have been recognized as meeting PCMH standards.
Preparation of the Nursing Workforce through Changes to Nursing Curricula
The IOM report recommends that nurses be full partners in redesigning health care in the United States. It is still unclear how nursing education can redesign the curricula to add the knowledge base and skills needed for practice in a reformed health care delivery system. The nursing shortfall, widely reported, will require a re-examination of the preparation of Associate as well as Baccalaureate degree nurses in order to maintain required levels of care delivery in new areas of community health practice. The literature illustrates that demands for care increase as the population ages and more people have insurance. Comprehensive discussion among nursing leaders and practitioners to completely understand skill level and preparation requirements for nursing practice along a changed continuum of care is a necessary first step. This an opportunity for nursing leadership to be much more out of the box in their thinking as they lead by example as well as with expertise and work more collaboratively in a multidisciplinary environment.
At the core of the models described in this paper, and in other models which are emerging as structures in the transformative direction of health reform, are key principles and activities which include:
Population-based analysis and interventions that are prioritized based on the characteristics of health care gaps
Patient-centered care design
Education and engagement strategies that directly involve the patient and family in achieving better health and preventing exacerbation of chronic care.
Medical homes and medical ‘neighborhoods’ that integrate primary care, psycho-social needs, specialty care and community programs in a manner that provides better resource use and easier access.
Care coordination that assists patients as they maneuver the complexities of the health care delivery system.
Proactive outreach that encourages timely preventive care and supports care compliance.
Transparent discussions and thoughtful choices made based on evidence-based options and costs of alternatives.
Activities that support these approaches are best delivered by interventions that are driven by data that identifies the specific need to be addressed by a team-based care plan to include advanced practice nurses working in teams with technically trained nurses and other levels of staff who support stated patient care outcomes. All levels of nurses are most likely needed to fill the continuum of care and care delivery. No level of preparation, from LPN to ADN to BSN to Master’s preparation, is discounted.
The Nursing Disconnect – Are We Prepared?
What do the new models of care delivery and financing require of nursing, and what will it take to be fully prepared? Let’s examine a few of the overarching trends:
Population-based Needs Assessment Balanced with Member-centric Approaches.
The new models described here, as well as in other papers, promote assessment of population-based care to include:
Financial risk sharing
Effective patient engagement in changing patterns and outcomes
Understanding the big picture – financing and benefits design, and
Clinical decision making, assessment and teaching
Skills Needed by Nursing Professionals
Most likely these skills should be included in nursing curricula at all levels of nursing education, perhaps at different levels of concentration:
Analytic skills for understanding data, for reading and applying research, and for conducting research and analysis
Clinical skills in patient assessment and care planning adapted to the new coordinated and collaborative models of care along the continuum from hospital to local community
Team collaboration – leading and being part of a collaborative effort to meet the care needs of the demographic served by the care facility, organization or system
Financial acumen –to understand resource allocation and economic impact of decision making and improvements to health status
Organization – resource, operations and personnel management and leadership
Patient teaching, coaching engagement, outreach, follow-up, and self-care techniques
How do nurses become prepared to lead in the new environment? Perhaps national nursing leadership will need to reach out beyond interests specific to nursing and extend outward to encompass other key providers of care including technicians, information technology experts, allied health professionals, physicians, pharmacists and others.
As the current nursing workforce and educational scene are surveyed, the question is “Does nursing have what it takes, or not, to be a full participant in the changed and changing health care environment? Maybe the answer is not a yes or a no; maybe the answer is simply: Not yet.
Large numbers of baby boomers are headed toward retirement. The Affordable Healthcare Act led by President Obama provides health care coverage to millions of Americans and simultaneously opens the door to a new level of demand for services. Health care leaders are aware of an increased need for health care professionals to serve the public. (Bradley, 2011). And, there is growing recognition that a looming workforce shortage threatens to overwhelm the entire scene.
Nursing as a front line in the health care workforce will have a significant role in the future health care delivery system of American society. However, the current gap between an increased demand for care and a decreased supply of nurses will deepen into the next decades. We cannot graduate enough nurses to meet the current, let alone future, demand. In addition, the nursing workforce grows older, “an estimated 900,000 nurses — more than a third of the total workforce — are in their 50s and will eventually have to retire” (Bradley, 2011, p. 7).
Associate degree nursing (ADN) education, primarily offered at the community college level, offers a practical and economically suitable solution to resolve the imbalance between nurses available and nurses needed for the health care industry. This is a timely and important option for those seeking jobs and for an industry needing to increase the available workforce. Nurses can be ready for licensure in two to three years (as opposed to the minimum four years of education required for a baccalaureate degree) at a lower cost to the student in both time and money. Putting resources into expanding associate degree nursing education programs throughout the country deserves attention and consideration for several reasons which will be discussed in this article.
Mission of Community Colleges
The mission of the community college education is rooted in an historical purpose to serve the needs of the community and to offer educational opportunities to diverse student populations. These populations include traditional newly graduated high school seniors and non-traditional adult and second career students, minority learners, immigrants, and the economically disadvantaged (Clapps, 2008). According to Bundy and Smith (2004) and Nicholas (2008), nontraditional students are also frequently defined as adults working full- or part-time, first generation college attendees, minorities, and those with dependents. Non-traditional students either pay tuition out of pocket or depend on loans and spouse’s financial support. The source of payment for education and the student’s other obligations are important factors in deciding to invest in higher education along with considerations regarding debt and time commitments. A shorter course of educational preparation leading to a job, such as an associate degree in nursing, could be preferable, especially since the competency based assessment of the graduates’ job performance is equivalent to those completing longer courses of study in the same field.
Nursing students at the community college level frequently reflect the demographic of a non-traditional college population. Kaufman (2010) concluded that 49% of ADN students were over 30 years old, compared to the rest of the U.S. two-year college student population, “where only about one in four students are 30 or over” (p. 196). According to the American Association of Community Colleges (AACC, 2012a), more minority nurses receive training from associate than baccalaureate degree programs (12,907 in ADN programs versus 9,377 in BSN programs). This information seems to indicate that these ADN nursing students are adult learners, probably already in the job market and in need of a specific educational track to advance or secure their job choices.
Also of interest is the fact that according to the Bureau of Labor and Statistics “at least 57% of job openings in the United States between 2006 and 2016 will require some postsecondary education” (p. 2) most likely leading more students to enroll in community colleges especially during an economic recession. Currently the high national unemployment rates draw to community colleges increasing numbers of applicants who are seeking to train for a second career or to learn new skills marketable in the contemporary workplace. As previously stated, many individuals cannot afford the substantially higher tuition of four year academic institutions. The reasonably priced tuition and fees at community colleges have become an attractive solution for many students and their families. Especially attractive to those considering a career in nursing is the fact that approximately 98% of ADN students find employment within six months of graduation (AACC, 2012a).
Contemporary Issues Affecting the ADN Practitioners
In 1950 as in 2010, health care delivery in the U. S. underwent structural changes that impacted the education of health care professionals. After World War II, the education and professional training at community colleges offered income potential for war veterans, the female population, and immigrants. Dr. Millfried Montag’s proposal for a two-year nursing education program at community colleges, along with the demands for skilled professionals, nurtured the development of an associate degree nursing education at community colleges (Orsolini-Hain, & Waters, 2009). This initiative was evaluated in the 1970s and found to be an effective educational path which led to resolution of the prior serious nursing shortage.
Not much has changed in the intervening decades. Nurses are still necessary and still in demand. However, in 2010, the Institute of Medicine (IOM) and the Robert Wood Johnson Foundation (RWJF) issued a report called The Future of Nursing: Leading Change, Advancing Health. It describes an action-oriented blueprint for the future of nursing with several major recommendations. One recommendation is to increase the number of nurses with baccalaureate-degree preparation from 35% to 80% of the nursing workforce by 2020. The implication is that the RN workforce should become primarily composed of nurses prepared at the baccalaureate level. Scott and Brinson (2011) noted several major challenges to this recommendation. For example:
Numerous studies on the educational progression of ADN-level nurses demonstrate common challenges facing students, including role strain, cost, access, and lack of rewards. (Scott & Brinson, 2011, p. 301).
This observation underscores the difficulty many nurses prepared at the associate degree level would have to overcome in order to meet a requirement to attain baccalaureate degrees to practice nursing.
Many associate degree nurses provide service in large sectors of the work environment, such as hospitals. If the standard for practice becomes exclusively a baccalaureate degree, thus eliminating or limiting opportunities for associate degree preparation and practice, the already strained supply of nurses will diminish further and the workforce will decrease dramatically. In addition, as in other segments of society, many ADN nurses will retire in the next decade and their replacements in the workforce cannot be filled solely by the pool of baccalaureate graduates. Thus, achievement of the above mentioned IOM/RWJF recommendation is made even more complex. To meet the IOM/RWJF goal, the report urges professional organizations and those employing nurses to encourage nurses with ADN preparation to continue their education by offering them tuition reimbursement, salary differential, and career advancement opportunities. Staykova (2012) highlighted the importance of community college education as a platform for further education, professional training and retraining, and frequently successful employment. To be exclusive in the reform of nursing by accepting only one avenue for nursing preparation and practice is to ignore the current realities of the existing inadequacy in the supply of nurses (the majority of whom are ADN prepared), the inability of the present day nursing programs to graduate enough nurses to meet the need, the expected reduction in workforce due to retirements, and the ever-growing gap between demand for service and nurses available to provide it.
Advancing the education of nurses holding an associate degree may be a desirable goal, but the goal itself does not address the confirmed need to increase the supply of professional nurses as is supported by all the points mentioned in this article. Nurses with associate degree preparation make up the majority of the contemporary workforce. Community colleges in the U. S. provide education and training to 57% of new nurses, and these hold an associate degree and are also a major source of other health care workers (AACC, 2012b). For example, “42% of nurse clinicians, 29% of clinical nurse specialists, 47% of head nurses, and 62% of supervisors” hold an associate degree (AACC, 2012a, para. 1). Limiting or discouraging the continued availability of associate degree nursing education programs and ADN nurses will close the door on a leading source of new nurses at national and local levels in a time of critical need.
Community colleges have proven that graduates are competent professionals (Bradley, 2011). Perin (2006) noted that 61% of the students taking the national certification nursing exam for registered nurses graduated from associate degree program preparation, whereas only 35% held a baccalaureate degree. ADN practitioners with at least five years of clinical experience indicated higher confidence in delegating skills compared to BSN-prepared nurses (Saccomano & Pinto-Zipp, 2011).
An interesting finding from the annual survey of schools of nursing for academic year 2008-2009, (Kaufman, 2010), stated that 45% of the qualified students applying for associate degree nursing education were declined admission, compared to 28% of qualified applicants for baccalaureate and 23% of qualified applicants for diploma programs. This point illustrates the fact that there is a market for increasing the number of students enrolled in associate degree education programs which is not being met. At a time when the need for nurses is growing, it is discouraging to see the major supplier of the nursing workforce deny admission to qualified students. Undeniably, shortages in faculty, clinical training sites, and financial constraints in the academic world contribute to the forced rejection of qualified students. These factors must also be addressed when considering solutions to the nursing workforce shortfall.
Professional organizations such as the American Association of Colleges of Nursing (AACN) and nursing leaders in academia and practice should focus efforts on revitalizing the shortest and most cost-effective pathway to nursing education, then encourage graduates to further their professional education by actively working to establish pathways for students to do so (educational ladders, financial assistance, web based programs). Attention should be directed toward increasing capacity at associate degree nursing programs and toward further attracting students from underserved populations. According to the American Association of Community Colleges (AACC, 2012a), currently more minority nurses receive training from associate than baccalaureate degree programs (12,907 in ADN programs versus 9,377 in BSN programs). [*See Graphic 3: AACC Brief - Distribution of RN by Race/Ethnicity]. Tapping under-represented minorities as potential candidates for nursing education can increase numbers of graduates and help speed up the effort to close the gap between supply and demand for health care professionals. Continuing to enrich the nursing workforce by supporting access to education for under-represented minorities is also an added bonus in that it increases the possibility that the demographic will become more representative of the community served.
Education and Licensure Examination
Entry into nursing practice for the Registered Nurse (RN) is based on formal nursing education and passing the National Council Licensure Examination-Registered Nurse (NCLEX) administered by state authorities (Kozier et al., 2008; NCSBN, 2007; Potter & Perry, 2009. According to AACC (2012a), “All RNs—whether they hold an associate or bachelor's degree or a diploma—pass the RN licensure exam at the same rate and are authorized to provide the same scope of practice” (para.1). All educational programs prepare students to practice within the accepted legal and ethical scope of nursing and students from all types of program are accountable for their actions or failures to act.
That being said, ADN programs do face the challenge of preparing successful students who will pass the licensure examination after a shorter course of study. These programs accomplish just that. This is good news. Community colleges offer the shortest path to prepare nurses for the licensure exam and practice making these programs essential for meeting the need for more nurses.
It is also helpful that associate degree nursing competencies can and do serve as a foundation for advancing to baccalaureate preparation (AACN, 1998). BSN competencies build on ADN competencies and support the professional nurse’s ability to handle responsibilities in diverse health care settings. This is an advantage that should be leveraged further by developing greater synchronicity in both curricula. Community college ADN programs contribute significantly to increasing the numbers of nurses in the workforce, attract students from several demographics, especially in times of economic recession, and also serve as a bridge to baccalaureate education.
The growing demand for skilled professionals has affected the supply. Economic fluctuations constrain prospective students from seeking education and new careers at four year academic institutions. Community colleges provide a pathway to professional training and a bridge to further education that is cost-effective, practical, and time-sensitive, making education at these institutions the most appealing investment. Two-year associate degree nursing preparation increases the likelihood of narrowing the health care professional gap in the near future. But, instead of rejuvenating the possibilities of this educational path at a time when health care workforce challenges are escalating, recent reforms by national and professional nursing organizations have muddied the future of ADN education without giving consideration to the consequences and without pushing to incorporate innovative ways to preserve ADN education as a resource to enhance health care benefits to the public. This limiting approach should be reconsidered in favor of augmenting successful, available ADN programs in order to sustain, maintain and uphold the current and future nursing workforce.
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Retired former CEO of CGFNS International, an organization recognized globally for its expertise in credentials assessment of foreign-educated health professionals and currently President and CEO of Barbara Nichols Consulting.
PhD, RN, FAAN, a Professor and Senior Faculty Associate, Hartford Institute for Geriatric Nursing both at the College of
Nursing, New York University. She is a Nurse Attending at New York University Langone Medical Center. Her work focuses on the organization and delivery of nursing care.
DIANE L. HUBER
PhD, RN, NE-BC, FAAN, and a nationally recognized nursing administration expert, researcher, academic, speaker, and consultant. She specializes in leadership and nursing care management, emphasizing case and population health management.
Compass Clinical Consulting Managing Director, RN, and PhD, with more than 30 years of experience in senior health care leadership roles in university, regional, state and national organizations. She is a regular keynote speaker throughout the country and has authored a leading college text on law and ethics in healthcare.
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