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IOM Report Offers Glimpse of Nursing's Future

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   October 12, 2010

An Institute of Medicine report emphasizes the importance of nurse education in healthcare reform and suggests a timeline. The report calls for 80% of RNs to have BSNs by 2020 and for the number of nurses with doctorate degrees to have doubled in the same timeframe. Here is what's in store for bridging the gap between education and practice.

The report says that to handle the increasing complexity of care and greater responsibilities they must assume in the future healthcare world, nurses will need higher levels of education and training, starting with the baccalaureate.

Last week saw the release of the long-awaited report from the Institute of Medicine, in collaboration with the Robert Wood Johnson Foundation, about the future of nursing in America. The report's recommendations are broad, sweeping, and more than a little controversial.

The report is a culmination of a two-year project involving unprecedented engagement with healthcare professionals across the country. In addition to its scientific review of literature, the committee listened to the testimony of experts at three major national forums on acute care, care in the community, and nursing education.

A few months ago, while research was still being collated, I spoke with Susan Hassmiller, the RWJF senior adviser for nursing, who is also the director of the RWJF Initiative on the Future of Nursing at the IOM.

Hassmiller told me that one of RWJF's aims was in being involved with the project was to engage the public in the creation of the report.

"We believe, with our experience at RWJF, that if you engage people ahead of time with a process and let them participate in the process, then when the recommendations come out, they will be much more willing—because have participated in the process—to take those recommendations and help implement them," says Hassmiller.

One of the dangers of expensive reports is that once they are done, they sit on the shelf. But RWJF has committed to ensuring this does not happen.

"The thing that makes this [report] very unique is that my foundation has agreed to a two-year implementation plan," says Hassmiller. "My foundation has supported a plan to take those recommendations and work with groups across the country to do whatever we can with everyone."

And the report will need every ounce of that support for its sweeping recommendations to actually take shape and for it to serve, as its authors intend, as a blueprint for nursing and healthcare as a whole in the age of reform.

The report's 500-plus pages can be boiled down to four key messages, which are:

  • 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 healthcare professionals, in redesigning healthcare in the United States
  • Effective workforce planning and policy making require better data collection and information infrastructure

Some of these findings are nothing new and have been recommended by thought leaders for decades, such as increasing the number of RNs with baccalaureate degrees. This report gives new credence to the call and suggests a timeline: It calls for 80% of RNs to have BSNs by 2020 and for the number of nurses with doctorate degrees to have doubled in the same timeframe.

The report says that to handle the increasing complexity of care and greater responsibilities they must assume in the future healthcare world, nurses will need higher levels of education and training, starting with the baccalaureate.


The link between nurses' educational preparation and patient outcomes has been demonstrated in numerous studies. Assorted professional organizations and scholarly reports have made this call before, so is there anything that will make this occasion different? A lot of organizations already offer tuition reimbursement for associate degree nurses to obtain baccalaureates, and yet we still hover at around 50%. It remains to be seen what strategies the committee will eventually recommend, but the report does says that public and private organizations should provide resources to help nurses with associate degrees pursue a Bachelor of Science in Nursing within five years of graduation and to help nursing schools ensure that at least 10% of their baccalaureate graduates enter a master's or doctoral program within five years.

Along the same topic, the report acknowledges the difficulty new nurses have in transitioning from education to practice and its recommendation that the profession institute residency training will shine a lot more attention on this important issue. Residency programs help new nurses bridge the gap from education to practice and, when done correctly, help set them on the course for lifelong learning.

The most controversial side of the report so far has been the call for nurses to practice to the full scope of their practice. The committee acknowledges that to meet the increasing demands for healthcare at a time of significant demographic and health system changes in this country, we need to tap the capabilities of advanced practice registered nurses (APRN).

It is this role of APRNs in primary care that is most controversial and received a swift response from the American Medical Association.

"With a shortage of both physicians and nurses and millions more insured Americans, healthcare professionals will need to continue working together to meet the surge in demand for healthcare," said Rebecca J. Patchin, MD, board member of the AMA. "A physician-led team approach to care—with each member of the team playing the role they are educated and trained to play—helps ensure patients get high-quality care and value for their healthcare spending.

"Nurses are critical to the healthcare team, but there is no substitute for education and training. Physicians have seven or more years of postgraduate education and more than 10,000 hours of clinical experience, most nurse practitioners have just two-to-three years of postgraduate education and less clinical experience than is obtained in the first year of a three-year medical residency. These additional years of physician education and training are vital to optimal patient care, especially in the event of a complication or medical emergency, and patients agree," said Patchin.

Most nurses would argue that nurses are not trying to replace physicians, simply to practice alongside them as distinct but equal professions engaged in the provision of care to patients.

The president of the IOM, Harvey Fineberg, MD, MPP, PhD, said "The report aims at empowering nurses to be even more effective and making long-lasting improvement to quality, access, and the value of healthcare for all Americans."

This report has the potential to usher in a new era of change and empower the profession. For years, nursing's ability to affect change has been hindered by the lack of a single voice to decide a direction and priorities. Most nurses don't belong to the American Nurses Association, which is the big national nursing association one might think represents nursing. They are more likely to belong to associations that represent their specialty, e.g., Emergency Nurses Association or the Association of Critical Care Nurses. Then there are the state-level associations, which also push their own agendas. I've heard before that the reason nurses can't get things done on Capitol Hill is that they don't come with one voice on one issue.

Perhaps this report can be a unifying voice we can all get behind.


Rebecca Hendren is a senior managing editor at HCPro, Inc. in Danvers, MA. She edits and manages The Leaders' Lounge blog for nurse managers. Email her at

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