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.

Leadership development is an oft-overlooked issue in nursing, so it's no surprise that charge nurses rarely receive the training they need. Many organizations promote nurses into the charge position simply because they are good nurses and no one else wants to do it. But the charge nurse is crucial to the smooth operation of a patient care unit, and spending time on training and development can reap dividends in organizational efficiency.

At the basic level, charge nurses manage the operations of patient care units during a particular shift. They assign tasks, workloads, and oversee the care provided to patients. But they also provide support, mentorship, and guidance to bedside nurses. For those reasons, it's important to train charge nurses so they are up to the job.

 
Tammy Berbarie is an accreditation coordinator at Baylor Jack and Jane Hamilton Heart and Vascular Hospital in Dallas, and a former director of education, who created a charge nurse orientation program for her hospital. Berbarie believes charge nurses are an organization's untapped resource. She says these frontline leaders—the eyes and ears of the patient care operation—are vital to ensuring patient safety, quality, and satisfaction, and staff retention.

"I believe that most organizations are in an infant stage when it comes to developing their charge nurses," says Berbarie. "It is important to develop a robust orientation program to give them the confidence to manage the patient units."

Berbarie recommends organizations provide all charge nurses with an orientation program, which includes a preceptor and leadership development training.

1. Charge nurse orientation. To be effective, charge nurses must know their responsibilities. The best way to outline expectations and ensure competency is to spend time orienting them to their new role.

Orientation can be accomplished in a one day workshop or through a series of training sessions. This is the time to cover the charge nurse role, regulatory requirements, coordination and delivery of patient care, patient safety, quality improvement, and leadership topics.

2. Charge nurse preceptors. Following the workshop, new charge nurses should be assigned a preceptor. Preceptors are routine for newly hired nurses and it's a technique that works well for any new role. Preceptors not only show new charge nurses the ropes, they also serve as mentors who can support them in their new role.

Berbarie advises the precepted time should last two- to three-weeks and that senior leadership should be active participants and strive to present the preceptees with as many experiences as possible.

3. Leadership development. The third part of the orientation program as a whole is the development of leadership skills. At a minimum, Berbarie says charge nurses should receive training on:

• Leadership
• Team building
• Conflict resolution
• Communication
• Developing talent

Organizations that do not invest in leadership skills for charge nurses will not get the most from them. The best charge nurses mesh administrative, clinical, and educational expertise with the ability to solve conflicts, reduce nurse-to-nurse hostility, improve communication, and ensure the unit is a collaborative, collegial place to work.

There has been a spate of news articles in the last few months about nurse protests and threats of strikes. A frayed work environment lies at the heart of many of these confrontations, with a workforce that feels it is stretched too thin. Nurses are speaking up about overwork and short staffing and the effect they feel it has on patient care.

Nurses at a Veterans Administration hospital in Augusta, GA, last week planned a protest claiming 16-hour workdays that they said threatened patient care. Facing a budget deficit of several million dollars, the VA nurses association said the hospital was forced to slow hiring and extend nurses workdays.

The Washington State Nurses Association successfully sued two healthcare organizations over missed rest breaks. The rulings affirmed the employers' responsibility to provide uninterrupted rest breaks.

These incidents, and others, are surprising during a weak economy, when jobs are scarce—particularly for new grads—and employers in all professions find many people are simply grateful to have a job.

The complaints are even more surprising given the culture of nursing. Rarely having time for rest and meal breaks is part of the nursing folklore. New graduate initiation practically stipulates that a requirement of successful floor nurses is a gargantuan bladder.

This culture is entrenched. A 2004 study published in the Journal of Nursing Administration revealed that hospital staff nurses were completely free of patient care responsibilities during a break or meal period less than half the shifts they worked. In 10% of their shifts, nurses reported having no opportunity to sit down for a break or meal period. The rest of the time, nurses said they had time for a break, but no one was available to take over patient care.

The study found that nurses reported having only 25.7 minutes break during their entire shift. Nurses working the longest hours were least likely to receive appropriate breaks (e.g., 10 minutes every 2 hours and a 30-minute meal period free of patient care responsibilities).

Research demonstrates that overworked, tired nurses make more errors. They are more likely to make a medication error and they are less able to think critically. They may fail to catch the subtleties in a patient's case that indicate a serious problem, leading, eventually, to failure to rescue (which CMS is now tracking, incidentally).

This skewed culture can also be evidence of a deeper problem of horizontal hostility, also known as bullying, lateral violence, or nurses "eating their young." It manifests itself in a culture where nurses complain about having to watch someone's patients while they take a quick break. Or gossiping about so-and-so being a "bad nurse" because he leaves his patients to get lunch.

Instead of being viewed as a rite of passage, or a part of nursing, it should be required that nurses take breaks. Senior leadership should pay attention to whether nurses take breaks for the sake of staff and patient health.

Here are three tips leadership can implement:

1. Promote taking a break as the right thing to do for patient safety. The Washington State case found it was the hospital's responsibility to ensure nurses were receiving breaks, not the individual nurses. Leaders must step in. Ask nurse managers to pay attention to this issue and check whether staff are getting breaks. Support nurse managers to make the culture change when needed.

2. Educate nurses on the importance of breaks: Host a lunch and learn seminar on the importance of rest and the danger that fatigued nurses pose to patients. Provide strategies for busy units on how to ensure nurses are able to take breaks.

3. Implement fatigue countermeasures: It can be as simple as talking about breaks to change the culture of martyrdom too many nurses feel they must work under. Small investments can pay big dividends, particularly if you bring extra help. Consider having per diem or float pool nurses who work during meal periods. I've written before about creative scheduling for older nurses and those who want non-traditional hours. You'd be surprised at the number of people who would love to work two hours rather than a full shift. A hospital in California developed an SOS?save our staff—program to do just this. They have nurses who work 3- to 4-hours to cover lunch breaks. If a unit is stretched thin that day, they can ask the SOS nurses whether they want to stay longer.

Another option is to bring in nursing students. The hospital pays students to answer call bells or check dressings. It gives the students experience on the unit, which they want, and removes some of the burden from the RNs.

When budgets are stretched thin, it may appear the wrong time to focus on this issue. A little extra effort, however, can pay dividends in staff satisfaction and patient safety. And it just might stop those nurses ending up on the local evening news.

Summer-graduating nurses are starting their first jobs, and hospitals are beginning the arduous task of turning novices into competent, professional RNs.

The leap from nursing school to practice is tough and many hospitals complain that nursing school does not prepare students for the real world of nursing.

"The newest literature and research says we need to transform nursing education across the nation," says Jim Hansen, supervisor of new graduate and student services at Kootenai Health in Coeur d'Alene, ID. "There's a gigantic gap in the way nurses are currently prepared and how hospitals need them to practice. Thus far, the ones who have been working to bridge the gap are the hospitals."

The concept of nurse residency programs has emerged to fill the gap between school and practice. Similar to physician residency programs, the intent is to continue education, mentoring, and support to enable novices to become competent practitioners.

"There's a very high degree of turnover among new graduate nurses," says Hansen. "The literature varies widely, but it can be as high as 60% in the first year at some hospitals. They spend a lot of money onboarding, training, and orienting these nurses only to have them turn around and leave."

Hansen says a residency program helps increase retention and lower turnover, which justifies the investment in developing a program.

"It always comes down to money," he says. "We can justify the costs incurred by the money saved in reducing nurse turnover."

 
In a large hospital system with significant new graduate turnover, Hansen estimates residency programs could save $200,000-$400,000 per year. Even small organizations can save thousands, which can more than pay for the time and expense of instituting programs.

Nurse residency programs are much more involved than what happens during orientation and preceptorships. They are structured programs that last longer—typically a year, although some hospitals have shorter programs—and that support new grads with ongoing education and mentoring.

Hospitals design programs that meet their needs. A typical curriculum includes ongoing clinical education, development of skills such as critical thinking, and social networking. Many new graduates report that time spent with other new grads is the most helpful part of the program, allowing them a much-needed outlet to decompress and share stories, receiving comfort from finding others are in the same boat.

Hansen says Kootenai Health views the residency program as an investment in the professionalism of its nurses. When designing the program, he focused on the end point. "What kind of a nurse do we want to have?" he says. "We want good nurses who provide excellent care and are committed to staying working with us."

He examined the gaps that had been identified between school and practice and set out to include education in technical skills, as well as what he calls "professional comportment," including critical thinking, organizational skills, prioritization skills, professionalism, and interacting with physicians, pharmacy, and all the members of the care team.

Hansen says new graduate nurses often fall short on communication and leadership skills, "so hospitals have to pick up the slack." Residency programs can fill in the gaps by teaching new nurses how to:

• Interact with peers and other professionals
• Lead clinical conferences or rounds
• Think critically
• Grow professionally

They can also contribute to professional development by helping new nurses gain an understanding of research and evidence-based practice so they can apply it at the bedside, which is crucial for hospitals' ongoing efforts to improve clinical outcomes.