Reflection Paper The IOM published report, “Future of Nursing: Leading Change, Advancing Health,” (attached) makes recommendations for lifelong learn -

Reflection Paper
The IOM published report, “Future of Nursing: Leading Change, Advancing Health,” (attached) makes recommendations for lifelong learning and achieving higher levels of education.
In 1,000 words, examine the importance of nursing education and discuss your overall educational goals.
Include the following:

Discuss your options in the job market based on your educational level.
Review the IOM Future of Nursing Recommendations for achieving higher levels of education. Describe what professional certification and advanced degrees (MSN, DNP, etc.) you want to pursue and explain your reasons for wanting to attain the education. Discuss your timeline for accomplishing these goals.
Discuss how increasing your level of education would affect how your competitiveness in the current job market and your role in the future of nursing.
Discuss the relationship of continuing nursing education to competency, attitudes, knowledge, and the ANA Scope and Standards for Practice and Code of Ethics.
Discuss whether continuing nursing education should be mandatory. Provide support for your response.

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You are required to cite to a minimum of three sources to complete this assignment. Sources must be published within the last 5 years and appropriate for the assignment criteria and relevant to nursing practice.
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The Future of Nursing: Leading Change, Advancing Health
(2011)

700 pages | 6 x 9 | HARDBACK
ISBN 978-0-309-15823-7 | DOI 10.17226/12956

Committee on the Robert Wood Johnson Foundation Initiative on the Future of
Nursing, at the Institute of Medicine; Institute of Medicine

Institute of Medicine 2011. The Future of Nursing: Leading Change, Advancing
Health. Washington, DC: The National Academies Press.
https://doi.org/10.17226/12956.

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The Future of Nursing: Leading Change, Advancing Health

The Future of Nursing Education1

Edited by Linda R. Cronenwett, Ph.D, R.N., FAAN
University of North Carolina at Chapel Hill School of Nursing

1 The responsibility for the content of this article rests with the authors and does not necessarily
represent the views of the Institute of Medicine or its committees and convening bodies.

SUMMARY AND CONCLUSIONS

Learn the past, watch the present, and create the future.

In October 2009, Don Berwick and I were out of the country when we re-
ceived invitations from Susan Hassmiller to co-author a background paper on the
future of nursing education for the Robert Wood Johnson Foundation/Institute of
Medicine (RWJF/IOM) Committee on the Future of Nursing. Initial conversa-
tions led to long lists of potential topics to be covered. Inevitably, we kept coming
back to the question: What would be useful to committee members who deserved
a base for their deliberations that was focused and helpful? In the end, we decided
that detailed descriptions of the current challenges and recommendations for the
future of nursing education from two people were not the answer. Instead, we
requested and received permission to challenge five leaders, in addition to our-
selves, to write short papers focused on recommendations addressing the most
important three issues from each of their perspectives.

With input from the RWJF/IOM Committee members and staff, we chose
five esteemed (and busy) leaders and asked them to rise to this challenge within
10 weeks. Each person agreed, and each met the deadline. There were no group
discussions, and, since each of us submitted our papers at the same time (no one
finished early!), no one altered his or her content based on reading someone elses
contributions.

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4 THE FUTURE OF NURSING

The seven papers are reprinted below, followed by a summary of the themes
that emerged across papers. How does it match what you would have written?

SUMMARY

The authors of the preceding papers came from the Northeast, South, Mid-
west, and Western parts of the country. One is a distinguished physician col-
league, and the nursing educators are comprised of three professors (one a dean
emeritus) and three current deans. Each has exerted leadershipin science,
teaching, practice, and policyfor multiple decades. Each leads initiatives that
extend beyond the boundaries of their places of employment. One is the current
president of the American Academy of Nursing. What can we learn across the
issues each chose to raise?

The style of the papers differed, so what was called a recommendation, con-
clusion, or issue varies. I extracted each major point, regardless of label. These
major points from all authors are included in the categories below. Following
each theme, authors for whom this was a major point are listed in regular font.
Some additional authors mentioned the same point but not at the level of recom-
mendations, conclusions, or major issues, and their names are listed in italics.
Finally, I organized themes using categories that the RWJF/IOM committee chose
for panel presentations at their upcoming meeting (what to teach, how to teach,
where to teach), adding a few remaining categories so that all major points were
included.

What to Teach (or What Students Should Learn)

Competencies necessary for continuous improvement of the quality and
safety of health care systemspatient-centered care, teamwork and col-
laboration, evidence-based practice, quality improvement, safety, and
informatics (Berwick, Cronenwett, Tanner)

Mastery of knowledge of systems, interpretations of variation, human
psychology in complex systems, and approaches to gaining knowl-
edge in real-world, local contexts (Berwick)

Skills and methods for leadership and management of continual im-
provement, for nurse-teachers and nurse-executives (Berwick)

Competencies needed in new care delivery models
Population health and population-based care management (Tanner)
Care coordination (Tilden)
Knowledge based on standardized science prerequisites (Dracup,

Tanner)
Health policy knowledge, skills, and attitudes (Tilden)
Competencies related to emerging health needse.g., geriatrics

(Tanner)

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APPENDIX I 4

How to Teach

Guide students in integrating knowledge from clinical, social, and be-
havioral sciences with the practice of nursing to enhance development
of clinical reasoning skills (Cronenwett, Dracup, Tanner, Tilden)

Enhance opportunities for interprofessional education (Cronenwett,
Dracup, Gilliss, Tilden, Tanner)

Evaluate and test models of interprofessional education, including
timing, determination of what levels of students should learn together,
and what content is most effectively delivered with interprofessional
learners (Tilden)

Develop and test new approaches to pre-licensure clinical education,
including use of simulation (Dracup, Tanner)

Involve students in interprofessional quality improvement projects
(Berwick, Gilliss, Cronenwett)

Develop model pre-licensure curricula that incorporate best practices in
teaching and learning and can be used as a framework for community
collegeuniversity partnerships (Tanner)

Where to Teach

In baccalaureate and higher degree programs (Aiken, Cronenwett,
Dracup, Gilliss, Tanner, Tilden)

Significantly increase the number and proportion of new registered
nurses who graduate from basic pre-licensure education with a bac-
calaureate or higher degree in nursing (Aiken, Cronenwett)

Require the BSN for entry into practice (Dracup, Tilden)
Support community college/university partnerships that increase the

number of associate degree graduates that complete the baccalaureate
degree (Dracup, Tanner)

Allow community colleges to provide baccalaureate degrees
(Dracup)

In post-graduate residency programs
Develop and test clinical education models that include post-graduate

residency programs (Tanner)
Implement requirement of post-graduate residency for initial re-

licensure (Cronenwett, Tanner)
In health care settings that foster day-to-day change and improvement

(Berwick)
In programs built on strong academicpractice setting partnerships

(Cronenwett, Gilliss)
At Academic Health Centers, promote governance structures that

combine the strategic, rather than operational, oversight for nursing
(Gilliss)

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40 THE FUTURE OF NURSING

In settings that are models of integrated care where care coordination
skills can be developed (Tilden)

Who Teaches (Characteristics of Desired Faculty Members of the Future)

Increase the number of faculty members:

Whose criteria for appointment and advancement include recognition of
practice-based accomplishments, including engagement in the work of
improving health care (Berwick, Gilliss, Dracup, Cronenwett)

Who can move easily during careers between practice and academe
(Gilliss)

Who shorten their career paths from BSN to doctoral degree (Aiken,
Dracup)

Who maintain professional certification and/or clinical competence
(Gilliss)

Who build alliances with faculty in other disciplines (medicine, engi-
neering, business, public health, law) (Gilliss)

Who are capable of leading efforts to advance interprofessional educa-
tion (Dracup, Tilden)

Recommendations: To Nursing Organizations

Ensure that schools produce ever-increasing numbers of nurse practi-
tioners for primary care roles at a time when expanded access to health
care will increase societys need for primary care providers (Cronenwett,
Gilliss)

Challenge current credit-heavy requirements and test teaching in-
novations that improve competence while reducing program credits
(Gilliss)

Support the faculty development necessary to bring about the magnitude
of reforms in nursing education recommended in the Carnegie study,
necessitated by advances in nursing science and practice and guided by
advances in the science of learning (Tanner)

Advance post-masters DNP education, maintaining specialist prepara-
tion at the masters program level (Cronenwett, Gilliss)

Fund initiative to facilitate professional consensus that DNP programs
should be launched as post-masters program for the foreseeable fu-
ture (Cronenwett)

Clarify the expectations for nurse scientists interested in translational
researchwill both the DNP and the PhD be required? Will the DNP
alone be sufficient for tenure-track positions in research-intensive
universities? (Dracup)

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The Future of Nursing: Leading Change, Advancing Health

APPENDIX I 41

Include as accreditation criteria for nursing education programs:
Substantive nursing educationservice partnerships, e.g., in shared

teaching and clinical problem solving (Cronenwett, Gilliss)
Interprofessional education (Cronenwett, Dracup, Gilliss, Tilden)
Development of competencies in health policy (Tilden)
Student/faculty participation in or leadership of teams that work to

improve health care (Berwick, Cronenwett)
Student competency development related to health policy (Tilden)
Identify top ten areas of needed faculty development and provide public

recognition for success (Gilliss)
Support a learning collaborative of state boards of nursing willing to

implement regulatory requirements for transition to practice residency
programs as a prerequisite for initial re-licensure (Cronenwett)

Require proof of a nurses participation in or leadership of teams that
work to continuously improve the health care system for renewal of
certification (Berwick)

Urge testing of interprofessional teamwork and collaboration and health
policy competencies in licensure exams (Tilden)

Recommendations: To Government and Other Organizations

Increase scholarships, loan forgiveness, and institutional capacity
awards to increase the number and proportion of newly licensed nurses
graduating from baccalaureate and higher degree programs (Aiken,
Cronenwett)

Increase scholarships, loan forgiveness, and institutional capacity awards
for graduate nurse education at masters and doctoral levels (Aiken,
Dracup)

Redirect Medicare GME nursing education funds to support graduate
nurse education (Aiken, Dracup, Tanner)

Redirect Medicare GME nursing education funds from hospital-based
pre-licensure programs to postgraduate residency programs (Cronenwett,
Tanner)

Promote innovation and evaluation of novel approaches to improving
preparation for the practice of nursing through expanded Title VIII fund-
ing (Cronenwett, Tanner)

Invest in nursing education research, related particularly to the evalua-
tion of multiple pathways to licensure (Tanner)

Use CTSA or other research facilitation structures to promote knowledge
development at the point of care, translation of knowledge into prac-
tice, practice improvements, and interprofessional education (Dracup,
Gilliss)

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42 THE FUTURE OF NURSING

Create a federal health professions workforce planning and policy capac-
ity in the Executive Branch (Aiken)

Expand authorities for Title VII/VIII funds to support development and
evaluation of interprofessional education innovations (Gilliss)

Expand Nurse Faculty Loan Programs and other loan forgiveness/
scholarship programs that produce more faculty (Aiken, Dracup)

Encourage public and private resource investments that incentivize stu-
dents and nursing programs to expedite production of qualified nurse
faculty by shortening the trajectory from entry into basic nursing pro-
grams through doctoral and post-doctoral study (Aiken, Dracup)

Use Perkins funds to incentivize community college nursing programs
to increase the proportion of their nursing students who complete their
initial education with a BSN (Aiken)

Increase programs that support greater production of nurse practitioners
for primary care (and remove legal barriers to interprofessional educa-
tion and practice) (Aiken, Cronenwett)

Fund a longitudinal study to track state-based data on number and
proportion of new nurse graduates from ADN vs. BSN/higher degree
programs (Cronenwett)

Advance media attention to states that exemplify best practices in
the distribution of new nurse graduates from ADN vs. BSN programs
(Cronenwett)

Include health services research (in addition to drug and treatment in-
tervention trials) in initiatives to enhance comparative effectiveness
research (Aiken)

Require universities and colleges (presidents, provosts, deans) to support
infrastructures and mandates for interprofessional education (Tilden)

CONCLUSION

The recommendations of seven leaders committed to the development of
future generations of health professionals included some expected diversity of
views. Nonetheless, given the long list of issues that would have been covered
had we chosen to write one comprehensive paper, a remarkably small number of
themes emerged. Hopefully, these rich ideas and themes can be used to inform the
deliberations of the RWJF/IOM Committee on the Future of Nursing. Even more
hopefully, a collective national response to these important issues will create a
future that meets nursings obligations to the society it serves.

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The Future of Nursing: Leading Change, Advancing Health

APPENDIX I 43

NURSING EDUCATION POLICY PRIORITIES

Linda H. Aiken, Ph.D., FAAN, FRCN, R.N.
University of Pennsylvania

Nursing is one of the most versatile occupations within the health care
workforce. In the 150 some years since Nightingale developed and promoted
the concept of an educated workforce of caregivers for the sick, modern nursing
has reinvented itself a number of times as health care has advanced and changed
(Lynaugh, 2008). As a result of nursings versatility, new career pathways for
nurses have evolved attracting a larger and more diverse applicant pool and a
broader scope of practice and responsibilities. Nursing, because of its versatil-
ity, has been an enabling force for change in health care along many dimensions
including but not limited to the evolution of the high-technology hospital, the pos-
sibility for physicians to combine office and hospital practice, length of hospital
stay among the shortest in the world, reductions in the work hours of resident
physicians to improve patient safety, extending national primary care capacity,
improving access to care for the poor and rural residents, and contributing to
much needed care coordination for the chronically ill and frail (Aiken et al.,
2009). Indeed, with every passing decade, nursing has become a more integral
part of health care services to the extent that a future without large numbers of
nurses is impossible to envision.

A POLICY CHALLENGE

From a policy perspective, nursings versatility is important to note for the
simple reason that nursing has evolved faster than public policies affecting the
profession. The result is that nursings forward progress to better serve the public
is hampered by the constraints of outdated public policies involving govern-
ment education subsidies, workforce priorities, scope of practice limitations and
regulations, and payment policies. An important priority in national health care
reform is achieving better value for the expenditures made on health services.
Since health care is labor intensive, getting more value will depend in large part
on enhancing productivity and effectiveness of the workforce. Nurses represent
a large and unexploited opportunity to achieve greater value.

The purpose of this paper is to identify and discuss several key changes in
nursing education policy that are critically needed to shape the nurse workforce
to best serve the health care needs of the American public in the years ahead. It
is written with the assumption that nurse scope of practice and payment policy
reforms will take place over the near term to remove some of the existing barri-
ers to nurses practicing to the full extent of their education and expertise. This
assumption is based on steady progress in removing barriers to nursing practice
at the state level and language in current national health reform legislation show-

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44 THE FUTURE OF NURSING

ing greater neutrality in the designation of types of health professionals who can
participate in and lead new initiatives in primary care and chronic care coordina-
tion. Changes in nursing education policies are needed to ensure that the nurse
workforce of the future is appropriately educated for anticipated role expansions
and changing population needs.

Five priority recommendations regarding the future of nursing education are
advanced for consideration by the RWJF Committee on the Future of Nursing
at the IOM:

Increase and target new federal and state subsidies in the form of schol-
arships, loan forgiveness, and institutional capacity awards to signifi-
cantly increase the number and proportion of new registered nurses
who graduate from basic pre-licensure education with a baccalaureate
or higher degree in nursing.

Increase federal and state subsidies for graduate nurse education at the
masters and doctoral levels in the form of scholarships, loan forgive-
ness, and institutional capacity with a priority on producing more nurse
faculty.

Encourage public and private resource investments to incentivize students
and nursing programs to expedite production of qualified nurse faculty by
shortening the trajectory from entry into basic nursing education through
doctoral and post-doctoral study by expedited bachelor of science in
nursing (BSN) to PhD programs and comparable innovations.

Create a federal health professions workforce planning and policy capac-
ity in the Executive Branch with authority to recommend to the President
and the Congress health workforce policy priorities across federal agen-
cies and departments.

Recommend the inclusion of health services research on various forms of
nursing investments in improving care outcomes including comparisons
of the cost effectiveness of improving hospital nurse-to-patient ratios,
increasing nurse education, and improving the nurse work environment.
At present comparative effectiveness research is more focused on drug
and treatment intervention trials than on innovations in care delivery
including workforce interventions.

PRIORITY FUNDING TO INCREASE INITIAL BSN GRADUATES

Every year the percent of new registered nurses graduating from associate
degree programs increases, and it is now over 66 percent of all new nurse gradu-
ates. Multiple blue ribbon panels on nursing education, including the just released
Carnegie Foundation Report on Nursing Education (Benner et al., 2010) as well
as health workforce reports to Congress for two decades, have concluded that
there is a substantial shortage of nurses with BSN and higher education to meet

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The Future of Nursing: Leading Change, Advancing Health

APPENDIX I 4

current and future national health care needs. Advances in medical science and
technology, the changing practice boundaries between medicine and nursing, and
the increase in the share of the population with multiple chronic health conditions
create a level of complexity in health care that requires a more educated health care
workforce. Nursing is the least well educated health profession by far but the one
experiencing the greatest expansion in scope of practice and responsibilities. The
National Advisory Council on Nurse Education and Practice (NACNEP) (1996),
policy advisors to the Congress and the U.S. Secretary of Health and Human
Services on nursing issues, urged almost 15 years ago that policy actions be taken
to ensure that at least 66 percent of nurses would hold a baccalaureate or higher
in nursing by 2010; the actual result is closer to 45 percent. As described in the
sections below, growing evidence suggests that the shortage of nurses with BSN
and higher education is adversely affecting a number of dimensions of health care
delivery now and these problems will only become exaggerated in the future.

Quality of Hospital Care

A growing body of research documents that hospitals with a larger propor-
tion of bedside care nurses with BSNs or higher qualifications is associated with
lower risk of patient mortality. Aiken and colleagues (2003) in a paper published
in the Journal of the American Medical Association (JAMA) showed that in 1999,
each 10 percent increase in the proportion of a hospitals bedside nurse workforce
with BSN qualification was associated with a 5 percent decline in mortality fol-
lowing common surgical procedures. A similar finding was published by Friese
and associates for cancer surgical outcomes (Friese et al., 2008). Aikens team
has replicated this finding in a larger study of hospitals in 2006. Similar results
have been published for medical as well as surgical patients in at least three large
studies in Canada and Belgium (Estabrooks et al., 2005; Tourangeau et al., 2007;
Van den Heede et al., 2009).

This research has motivated the American Association of Nurse Executives,
the major professional organization representing hospital nurse chief executive
officers who employ 56 percent of the nations nurses, to establish the BSN as
the desired credential for nurses. Many hospitals, particularly teaching hospitals
and childrens hospitals, are acting on the evidence base by requiring the BSN
for employment. Nurse executives in teaching hospitals have a goal of 90 percent
BSN nurses, and community hospital nurse executives aim for at least 50 percent
BSN-prepared nurses (Goode et al., 2001). Since only 45 percent of bedside care
nurses have a BSN, many executives cannot reach their goals.

Access and Costs

There is some research evidence that the cost effectiveness of nursing im-
proves with a more educated workforce. In Aikens JAMA paper, evidence was

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The Future of Nursing: Leading Change, Advancing Health

4 THE FUTURE OF NURSING

presented to show that the mortality rates were the same for hospitals in which
nurses cared for 8 patients each, on average, and 60 percent had a BSN and for
hospitals in which nurses cared for only 4 patients each but only 20 percent had
a BSN (Aiken, 2008; Aiken et al., 2003). More research is needed to assess the
comparative value of investing in different nursing strategies that evaluate the
relative cost and outcomes of increasing nurse staffing, educational levels, and
improving the organizational context and culture of the nurse work environment.
At this point the evidence is encouraging that a more educated hospital nurse
workforce might allow for a smaller nurse workforce without adversely affect-
ing patient outcomes. If confirmed in future research, this finding could have
important implications for both cost of hospital care and for the number of nurses
actually needed in the future to staff hospitals.

In the ambulatory sector, there is a strong research base documenting that
nurses with advanced clinical training, usually masters degrees in advanced
clinical practice, provide primary care with outcomes comparable to, and in some
domains like symptom control and satisfaction better than, those of physicians
and with lower costs (Griffiths et al., 2010; Horrocks et al., 2002). Rand research-
ers estimated, for example, that the state of Massachusetts could save up to $8
billion over a decade by attracting more advanced practice nurses and removing
barriers that prevent them from practicing at the full level of their education and
expertise (Eibner et al., 2009). Increased use of advanced practice nurses is one
of the very few practice innovations currently underconsidered in national health
reform, including medical homes and chronic care coordination, that would yield
net cost savings nationally according to Rand researchers (Hussey et al., 2009).

How the Shortage of BSN Nurses Impacts Future Nurse Supply

As argued above, the shortage of BSN nurses has implications for health care
quality and safety, access, and costs of care. A less well recognized consequence
of the shortage of BSN nurses is a shortage of faculty which could have a long-
term impact on national production capacity of nurses for the future.

The Department of Labor estimates that 600,000 new jobs will be created
for nurses over the next 10 years, the highest rate of new job production for any
profession (Bureau of Labor Statistics, 2009). In addition, over a half million
nurses in the current workforce, which has an average age of around 48, will
reach retirement age over the same period, resulting in the need for over a mil-
lion nurses to be added to the national workforce. The good news is that there is
tremendous interest in nursing as a career in the United States after a century of
difficulty attracting the best and brightest to nursing. The reasons for this unprec-
edented interest are multifaceted, having to do with attractive incomes, averaging
nationally $65,000 a year and higher in some locations, better job prospects than
in other employment sectors, and perceptions of personally satisfying work help-
ing others. If we can take advantage of this unprecedented interest and expand
nursing school production, future nursing shortages could be greatly attenuated.

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APPENDIX I 4

The bad news is that nursing schools do not have the capacity to absorb
the great windfall in applicants. Estimates suggest that at least 40,000 qualified
applicants to nursing schools are being turned away each year (AACN, 2009).
There are several reasons why nursing schools are unable to accept the influx of
applicants. Nursing schools have expanded enrollments steadily for more than
a decade with graduations increasing from about 75,000 in 1994 to 110,000 in
2008. Resources of all kinds are now stretched and schools are having difficulty
expanding further. Institutions of higher education in general are experiencing
serious budget constraints and as a result are slowing enrollment growth. Addi-
tionally the shortage of nursing faculty has become a major constraining factor.

A strategy for ameliorating the nurse faculty shortage that has received
little attention to date is to increase entry-level education of nurses to produce
a larger pool of nurses likely to obtain graduate education. In a recent paper in
Health Affairs Aiken and colleagues provided a cohort analysis to determine
the highest education achieved by nurses receiving their basic or initial nursing
education between 1974 and 1994 (Aiken et al., 2009). We found that choice of
initial nursing education programassociate degree or baccalaureatewas the
major predictor of final educational attainment. Close to 20 percent of nurses ir-
respective of initial nursing education obtain a higher degree. However, of the 20
percent of associate degree nurses who obtain an additional degree, 80 percent
stop at the baccalaureate degree. Of the 20 percent of nurses with a baccalaureate
degree who go on for additional education, almost 100 percent obtain at least a
masters degree. This is an important finding for the design of policy interventions
since investments in encouraging BSN education have not distinguished between
RN-to-BSN programs and basic BSN programs. The yield for teachers is entirely
different between the two types of programs. If the current scenario of distribu-
tion of nurses by type of basic education had been reversed since 1974 and 66
percent of nurses had graduated from BSN programs instead of 33 percent, we
estimate that there would be over 50,000 more nurses with masters and higher
degrees today.

We concluded in our Health Affairs paper th

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