Assignment On Futuristic Nursing
1College of Nursing, Washington State University, Spokane, WA 99210-1495, USA
2Family and Child Nursing, University of Washington, Seattle, WA 98195, USA
3College of Nursing, Seattle University, Seattle, WA 98122, USA
Copyright © 2012 Cynthia Fitzgerald et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Nursing education programs may face significant difficulty as they struggle to prepare sufficient numbers of advanced practice registered nurses to fulfill the vision of helping to design an improved US healthcare system as described in the Institute of Medicine's “Future of nursing” report. This paper describes specific challenges and provides strategies to improve advanced practice nursing clinical education in order to ensure that a sufficient number of APRNs are available to work in educational, practice, and research settings. Best practices are identified through a review of classic and current nursing literature. Strategies include intensive interprofessional collaborations and radical curriculum revisions such as increased use of simulation and domestic and international service work. Nurse educators must work with all stakeholders to create effective and lasting change.
National and international reports, including one published recently by the Institute of Medicine , describe the potential for advanced practice registered nurses (APRNs) to contribute to the provision of high-quality healthcare as part of comprehensive healthcare reform [2, 3]. Preparing APRNs for practice and fostering the role of APRNs in a variety of educational, clinical, and research settings are necessary steps toward achieving this vision. Given the current economic and political climate in the United States, however, success may be elusive. At present, a shrinking number of nurse educators carry an increasingly large responsibility for educating a declining number of APRNs [4, 5]. In many settings, outdated regulations, policies, and biases prevent APRNs from practicing to the fullest extent of their education, skills, and competencies [6–8]. Some US-based physician organizations have mounted campaigns aimed at discrediting APRN education and practice and decrying the potential of APRNs to provide cost-effective and clinically efficient care [9, 10].
While barriers to practice are significant, innovative approaches to clinical education and curricular transformation offer promise to nursing administrators, nursing educators, and practicing APRNs who are committed to preparing a highly qualified APRN workforce that will serve future generations of Americans. The rapid development and establishment of the practice doctorate has generated cautious enthusiasm among many nurse educators who are eager to help APRNs achieve their fullest potential in clinical practice. The purpose of this paper is to describe challenges in providing APRN clinical education and to propose achievable strategies for educating future APRNs to participate fully in transforming the United States healthcare system. We argue that the time is right to identify and implement educational practices that will lead to the optimal development of clinical skills, knowledge, and practice acumen and help meet the goals endorsed by national nursing organizations and set forth in the “Future of nursing” report published in 2011 . While the IOM report is extraordinarily thorough, its scope does not include suggestions for specific strategies for improving APRN clinical education, a gap this paper seeks to fill.
Advanced practice registered nurses include nurse practitioners (NPs), certified nurse-midwives (CNMs), certified registered nurse anesthetists (CRNAs), and clinical nurse specialists (CNSs). APRNs represent an underutilized source of quality health care providers . Only 3.8% of the 2.4 million US registered nurses (RNs) are NPs, 0.3% are CNMs, 1.1% are CRNAs, and 0.9% (down from 1.2% in 2004) are CNSs . While the nurse anesthetist was the first advanced practice role to emerge in the late 19th century, formal APRNs education programs did not start until the 20th century. The first nurse-midwifery program began in 1932 at the Maternity Care Association in New York, and in 1954, Rutgers University offered the first CNS graduate program with a specialty in psychiatric and mental health. The role of the nurse practitioner then developed in the 1960s with the increase in federal funding for advanced nursing education in order to fill the need for primary care providers . Since the various roles have emerged, APRNs consistently provide high-quality, cost-effective patient care in a variety of healthcare settings . Today, the majority of APRNs are employed in primary care settings, with most providing women’s health, obstetrics, and mental health services . One hallmark of APRN practice is the provision of care directed at illness prevention, health promotion, and improved patient care outcomes . APRN practice represents one aspect of the nursing profession’s ongoing efforts to provide high-quality healthcare to diverse populations. Overcoming barriers to APRN practice in today’s healthcare environment will lead to improvements in health care for many, especially among traditionally underserved populations.
We define many challenges associated with providing effective APRN clinical education, particularly in clinical practice settings. Our analysis of the challenges in Table 1 led us to identify innovative educational and programmatic strategies with potential to improve APRN education. The strategies we present include both internal (those related to educational institutions) and external (those related to social, political, and interprofessional practice issues) factors.
Table 1: Challenges to effective APRN clinical education.
3. Internal Challenges
For the purpose of this paper, we defined internal challenges as those existing within the profession and/or within educational organizations responsible for preparing APRNs for practice. When considering these internal challenges, we discovered, not surprisingly, that the literature was dominated by information about the critical role of the growing nursing and nursing faculty shortages. Clearly, not enough qualified nursing faculty are available to meet the nation’s need for increased numbers of APRNs, and the projections describing future shortfalls are bleak [15, 16]. While the nursing faculty shortage has been well described in the literature, some aspects of it are germane in a discussion about APRN education, especially given the relatively large numbers of potential students unable to gain admission because of limited faculty resources .
Educational organizations find it increasingly difficult to attract qualified APRNs willing to serve in faculty roles. The demand for APRNs in both educational institutions and in a variety of practice settings has increased simultaneously, but educational institutions are disadvantaged by their inability to offer competitive compensation packages. Constrained budgets result in compressed salaries throughout higher education systems, increasing the gap between salaries available in practice and those offered for teaching positions.
When APRNs do pursue education at the PhD level, they often graduate only to face the reality of the tenure process in research-driven educational institutions. Emphasis on the role of faculty in conducting research and generating research-related revenue limits the availability of PhD-prepared APRN faculty to participate in direct clinical supervision of APRN students. One result is that the primary responsibility for APRN clinical education falls to faculty not eligible for tenure  and whose salaries are typically lower than those available for APRNs in clinical practice . Educational institutions without established faculty practice plans face additional barriers for supporting and retaining faculty who need to practice to maintain certification and licensure, in addition to teaching and meeting tenure criteria.
As many schools of nursing transition to the Doctorate of Nursing Practice (DNP), existing advanced practitioner faculty without a doctorate may find that they are underqualified . Institutional requirements for supervisory committees of doctoral students may require faculty to hold equivalent doctorates, and supervision of DNP students may increase faculty workloads. PhD-prepared nursing faculty may lack the advanced practice qualifications to teach specialty content in APRN programs. Smaller educational institutions may not have the institutional structures or additional faculty necessary to support the development of DNP programs . While the development of DNP preparation and practice offers much promise for preparing the future workforce, the transition process may temporarily exacerbate the shortage of available clinical faculty and result in decreased numbers of APRN graduates. It is too soon to tell whether these transitional challenges will affect the quality of APRN clinical education. The net result may be additional reductions in the available supply of APRNs at precisely the time when they are most needed to address the challenges of healthcare reform in the US .
The number of annual graduates from APRN programs has fallen from a peak in 1998 . This decline is multifaceted, relating to a variety of barriers facing nurses who might otherwise pursue graduate education. Admission to APRN educational programs can be difficult. As many as 17% of graduate nursing programs are highly selective, and there are insufficient openings for qualified applicants . Program costs present challenges to potential applicants whose educational plans are altered by the recent economic downturn in the US as well as by declines in available employer tuition-reimbursement programs; in 2009, 15% of masters of nursing programs cited affordability as a commonly stated reason for students not enrolling . Program location can be a deterrent to nurses who are place bound by responsibilities to support family and provide income. Although the need for more APRNs in rural communities is critical, APRN programs are less accessible to nurses in rural areas, where there are fewer nurses, and nurses must contend with lower salaries and longer commutes . In some areas, there are vacancies in some nursing programs, while others may turn away qualified applicants. Additionally, there are significant shortages of Hispanic, Native American, and men in nursing and in APRN programs. White, non-Hispanic women make up over 83% of APRN nurses . The result is a professional nursing community that does not reflect the diversity of the US population .
Since World War II, educational programs offering Associate Degrees have proliferated and graduates of those programs have become Registered Nurses (ADNs) in increasing numbers. In turn, this internal challenge has influenced the shortage of APRNs, given that nurses prepared in ADN programs are less likely than bachelor’s prepared nurses to obtain graduate degrees . If ADNs do pursue graduate education, time to completion of an APRN program expands, given the requirement for ADNs to complete bachelor’s education before entering a graduate nursing program. Such problems clearly bring the APRN supply needs back to nurse educators and leaders at all levels.
4. External Challenges
The primary challenge facing APRN education from outside educational institutions is the limited number of available clinical sites and preceptors . To increase the number of APRNs prepared to practice independently and to the fullest extent of their scope of practice, nursing education programs must increase both the number and quality of available preceptors and sites. Since many existing faculty practice settings are inadequate to meet this need, educational institutions must rely on cooperative, volunteer community preceptors. There is a shortage of APRN preceptors, particularly in acute care or hospital-based specialties (i.e., CNMs, neonatal nurse practitioners (NNPs), and acute care nurse practitioners). Often, APRN specialties require that preceptors hold the same specialty certification. For example, certified nurse-midwives (CNMs) must provide education to CNM students . While there is a great need for APRN graduates to serve rural areas, there are even fewer preceptors and role models available in these underserved locations.
The limited supply of potential preceptors and clinical sites is exacerbated by competitive forces. Medical resident preparation dominates the use of available clinical sites in hospitals. Federal funding through the Medicare program supports resident education, but not APRN preparation. In many academic medical centers, APRNs are employed for medical student and resident education, further reducing the field of potential preceptors for APRN students . Nursing educational institutions are concentrated in large urban areas near hospitals and may compete with other nursing educational institutions for clinical sites and preceptors.
State regulations and specialty certification agencies place additional requirements on educational institutions that further limit the capacity to prepare APRN students. Direct supervision of students limits the number of students individual preceptors may have at any given time. The requirement for low student-faculty ratios in clinical courses makes APRN education expensive. For example, the National Task Force on Quality Nurse Practitioner Education recommends faculty-to-student ratios of 1 : 6 in situations where there is indirect clinical supervision . Requirements for supervised student clinical practice in most APRN programs are typically established at a minimum of 500 hours, and the DNP requires at least 1000 hours of clinical practice . This increase in DNP student practice hours will increase the need for qualified and willing preceptors.
The limited availability of national funding poses a significant external challenge to successful APRN education. Increasing the capacity of educational institutions to educate APRNs requires additional funding. The current prioritization for medical education and residency training through federal support makes increasing funding for nursing education difficult. Furthermore, current research funding priorities by the National Institute of Nursing Research do not support the investigation of nursing education issues, nor do they support research about the implementation of innovative practice education models at the graduate level. In many research organizations, nursing faculty pursuing academic careers and tenure are discouraged from pursuing clinical education research as a funded line of inquiry. Among potential APRN preceptors, there may be a lack of willingness to precept APRN students due to a lack of incentives beyond the ideals of serving the profession. Most educational institutions are unable to compensate preceptors financially for their teaching roles and are limited in the nonfinancial benefits they may provide preceptors such as faculty titles and access to educational resources. Potential preceptors may see the challenges to practitioner productivity or the additional time commitments of being a preceptor as disincentives to assuming the role. The lack of formal preparation and support for the teaching role may further discourage APRNs from being a preceptor. While direct or graduate entry training is increasingly used as a mechanism for increasing the supply of APRN graduates, potential preceptors may be resistant to training students with little or no health care experience.
The final challenge to increasing the preparation of APRNs is closely tied to the profession’s relationship with the citizens who are served. Nursing continues to be a profession dominated by Caucasian women, a limitation that affects the profession’s negotiation of relationships with other more male-dominated professions. In addition to the chronic underrepresentation of men, diverse populations, and rural inhabitants in the nursing workforce, advanced practice nursing continues to contend with an identity crisis among the US population as a whole, who suffer from a knowledge deficit regarding the skills and abilities of APRNs. Historically, nurses work at the direction of physicians, and cultural and occupational patterns that reinforce this dependent relationship are slow to change. While it is not clear the American Medical Association’s efforts to counter the IOM’s Future of Nursing Report will be entirely successful , the lack of support for full-scope APRN practice from this influential organization is disappointing to those with a vision for the provision of collaborative care in an efficient and effective interprofessional model. Negotiating a new position in health care for nurses and APRNs will continue to be complicated by gender politics as well as power positioning.
5. Strategies and Solutions
The IOM report presents an unparalleled challenge to nursing educators, that is, to foster the development of an “improved education system that promotes seamless academic progression” [1, page 164]. Significant innovation and change are needed to accomplish this vision and to increase the number of APRN graduates. While some of what is required must be implemented on a nation-wide scale, there is strong potential for nursing education programs to implement local and regional strategies that will increase the numbers of APRN graduates prepared to practice at the fullest extent of their education and licensure.
In preparing this discussion of strategies and solutions described in Table 2, we considered our own experience as educators in graduate nursing programs and explored recommendations from multiple authors describing approaches that have been successful in enhancing the education of APRNs. Taken individually, each of these strategies has the potential to help programs make incremental improvements in the recruitment, retention, and preparation of graduate nursing students. In combination, these strategies offer the promise of helping nursing education affect transformation in the preparation and practice of APRNs.
Table 2: Solutions and strategies.
For the purposes of this paper, internal strategies are those that can be undertaken within nursing education programs and the universities that house them, while external are those that reflect some level of engagement with other organizations including other nursing education programs and healthcare organizations.
5.1. Internal Strategies
As noted above and in the IOM report, the expansion of advanced nursing education programs is hampered by a faculty shortage that represents the convergence of multiple factors. These include supply-side problems related to the nursing shortage itself as well as to competitive factors that reflect, among other things, the relatively high cost of graduate nursing education when compared to the earning potential of nurse educators. Like prelicensure nursing education, advanced practice nursing education is resource intensive, requiring sophisticated laboratory settings, computer equipment, and high faculty-to-student ratios.
One approach with potential to aid in the nursing faculty shortage and to make more clinical resources available for APRN education involves internal efforts by educational institutions to develop and strengthen collaborative partnerships. The American Association of Colleges of Nursing  and the Robert Wood Johnson Foundation  recommend that educational organizations work with one another as well as with hospitals and healthcare organizations to develop innovative capacity expanding approaches for preparing nurses and nurse educators and to foster the expansion of nursing education programs. These programs are likely to be costly, but if the benefits can be well-described, educational institutions, hospitals, and healthcare organizations may be willing to invest in their success. As one example of innovative collaboration between university programs, Siewert and her colleagues from the University of Iowa College of Nursing report on collaborative efforts with the University of Missouri at Kansas City that allows for dual enrollment of neonatal nurse practitioner students and helps to optimize faculty resources and enhance student learning opportunities at both institutions . An innovative array of academic and service partnerships linking Bassett Medical Center in Cooperstown, New York, with educational programs at the State University of New York Institute for Technology in Utica, New York now offers tuition support for advanced practice nursing preparation with an emphasis on improving care in a large rural community . These programs and others like them offer much promise in addressing faculty shortages and other challenges while offering innovative contemporary APRN education to place-bound students.
In almost every aspect, curriculum, teaching, and learning must undergo radical transformation, as Benner and her colleagues asserted in 2010 . Nursing programs have traditionally been content driven, but the needs of students and faculty are changing along with those of the workplace . At the core of these new and revised curricula is an emphasis on integrating established educational and professional competencies with educational strategies that encourage problem solving and that enhance students’ critical thinking abilities. Such curricula will encourage the simultaneous development of innovative learning activities, ensure effective student evaluations, and provide clinical experiences that emphasize the optimization of student practice outcomes . Competency-based education may have additional advantages including the development of more learner competence, confidence, and compassion [34, 35].
Problem-based learning can be integrated within a competency-based framework or as a stand-alone strategy to enhance the development of critical thinking and hypothesis-testing skills [36, 37]. Problem-based learning (also known by other terms with slightly different applications, including case-, practice-, or concept-based learning) helps students ground learning in relevant clinical experiences [38, 39]. As students engage closely with faculty in exploring new concepts and identifying new solutions, the process of discovery can lead to the development of improved clinical judgment .
The use of simulation in nursing education is becoming increasingly popular for its ability to enhance the critical thinking of advanced practice nursing students and because it provides a useful evaluative tool for faculty . Through the use of high-fidelity computerized simulation models, APRN students safely develop new knowledge and skills about high-risk, low-volume practices . Other simulation activities involving scripted patients or rotation through skill-based practice stations in laboratory settings also offer enhanced opportunity for student learning and faculty participation. Clinical simulation activities can add greater value by linking APRN students with medicine, pharmacy, and rehabilitation students across the health sciences .
Interprofessional education offers the potential to enhance efficiency in the provision of clinical education for all students  and fosters collaborative practice beyond the educational period. Success has been demonstrated when APRN education has been integrated with specialty and generalist physician practice in a mental health practice setting, as described by Roberts and her colleagues  and likely has much potential to improve education and patient care in a variety of other settings. While mistrust by physicians of the APRN role threatens to constrain the development of collaborative educational models, the promise of interprofessional education also has the potential to unite APRN and physician practice. Such efforts to integrate education and training hold much promise for the US healthcare system as a whole.
Distance education helps create opportunities for otherwise place-bound nurses to pursue graduate studies to become APRNs by extending the reach of nursing education programs beyond traditional boundaries. Improvements in online course management software and evidence-based distance teaching pedagogical approaches provide a foundation for the asynchronous delivery of high-quality and engaging course content. The use of streaming media and a wide range of unified communication technologies (e.g., video cameras, instant messaging, web-connected whiteboards, etc.) enhance faculty-student and student-student engagement. Despite the obvious challenges of providing adequate supervision for APRN students who may be completing coursework from remote areas and with little direct faculty contact, the rewards of accessing optimal professional education using distance education technologies can be great for place-bound students living in underserved communities. To help these programs and students to succeed, educational programs can develop innovative faculty hiring agreements, hiring APRNs who live in the students’ home communities to provide supervision for didactic learning experiences as well as for clinical practice and evaluation. The education and support these faculty members may require can be provided in part by professional development or continuing education programming.
5.2. External Strategies
Not all responsibility for enhancing advanced practice nursing lies with classroom or faculty-driven learning activities. As the number of available clinical sites and preceptors has declined, the need to consider effective alternatives for APRN clinical education has increased. Nursing education programs must “aggressively pursue alternative clinical learning sites and experiences” if they want to assure that students participate in appropriate patient-centered learning activities .
The development of partnerships with a broad range of community organizations and providers can create mutual benefits and provide additional learning opportunities for APRN students. While faculty may believe that an ideal clinical placement would pair students with preceptors in one-to-one relationships with clients arriving at set appointment times, there may be great value in developing partnerships with agencies and individuals who provide care in different models and settings . The development of community partnerships with a service-learning framework can provide APRN students with innovative opportunities to engage in health promotion, physical and mental health assessments, and intervention with individuals who might not otherwise receive healthcare services in a given setting. For example, assignment of students to a correctional facility could offer students the opportunity to engage with individuals in need of health assessment or behavioral intervention , even in the absence of a formally organized on-site health clinic. Assigning students to work with clients through a variety of community agencies can enhance learning opportunities for APRN students and improve care for individuals seeking nonhealthcare services such as meal delivery or day care . Facilitating student engagement in homeless centers can provide a variety of learning opportunities while serving to increase student understanding of social conditions and mental illness . These innovative learning opportunities can provide students with opportunities to build personally meaningful collateral skills even when the emphasis is on accomplishing practice-related learning objectives [50, 51].
In 2004, Connolly and her colleagues described the innovative creation of a collaborative approach to nursing education . Although writing about associate degree nursing education, key concepts have the potential for application in advanced practice education. These include the introduction of interprofessional collaboration that links nursing, medicine, and allied health personnel education within single community health settings, allowing the development of knowledge and skills that are essential to advanced practice nursing.
Academic health centers that integrate faculty practice opportunities with clinical education experience opportunities may well provide ideal environments for APRN education. Not all graduate nursing programs are situated on campuses that house such centers, however. Heller and Goldwater suggest that the development of innovative patient-driven programs, designed to improve access, may also offer enhanced clinical education opportunities for advanced practice students . Their experience with the development of a mobile clinic offering primary care services by APRNs and their supervising faculty, dubbed the “Wellmobile,” illustrates a comprehensive and innovative approach to clinical care. In addition to providing a structured environment that places emphasis on the clinical education of APRN students, the “Wellmobile” also offered students the opportunity to develop strong business and management skills .
Although they can be costly and somewhat difficult to coordinate and offer, domestic and international healthcare missions do offer APRN students and faculty innovative opportunities to provide care to the underserved. While many available international opportunities are useful for student enrichment alone, with secure funding, careful planning, and rigorous attention to the management of learning and evaluation, successful programs can extend clinical education beyond local limits . Participation in mission-driven clinical experiences offers students opportunities to provide care for vulnerable populations and can serve as cultural immersion experiences, enriching students’ cultural competence. They may also provide opportunities for students to develop skills in leadership and practice inquiry, cornerstones of DNP practice.
Finally, funding must be made available to support the vision that advanced practice nurses will assume a large measure of responsibility for the success of healthcare reform in the United States. Improvement in the healthcare system requires the collaborative effort of many disciplines. At present, the current “system of medical education and graduate training… is not aligned with the delivery system reforms essential for increasing the value of health care in the United States.” [54, page 103] The current system of funding graduate medical education does not provide sufficient resources to support the education of nurses in clinical practice settings. While it is typical for medical residents to be supported with salaries, stipends, living allowances, and even resources such as equipment and textbooks, responsibility for APRN clinical education rests solely with the students themselves. Educating an effective nursing workforce is a responsibility that must be shared by nursing programs, academic institutions, and government agencies with support from policy makers who will stand firm in sponsoring a coherent and appropriate approach to the education of a collaborative workforce . It will not be sufficient to simply provide increases in available loans or to improve loan repayment programs; for APRN clinical education to be on par with medical education, nursing classroom and clinical education must receive full financial support. Further, there must be improvements in Medicare compensation for services provided by APRNs, including those related to performance as clinical preceptors and research mentors. Funding for improved and financially supported residency programs for APRNs could come from federal programs that accept a mandate to provide healthcare services to all citizens or that compensate physicians at greater rates than APRNs for the provision of equal services .
The Institute of Medicine Report on The Future of Nursing  calls for increasing the supply of highly educated and clinically skilled APRNs who can practice to the fullest possible extent of their scope of practice. Clearly, APRNs have the potential to contribute to the provision of high-quality healthcare as part of comprehensive healthcare reform in the United States. If this vision is to be accomplished, however, numerous challenges inherent in the current APRN educational process and barriers in the practice environment must be overcome. This paper has identified challenges that specifically hinder the clinical education of APRNs and proposed strategies and solutions to help educational institutions address them. In preparing this paper, we considered our personal experience and explored the literature describing innovative approaches and strategies that have been successful for others. These approaches to APRN clinical education can affect a radical transformation in the preparation of APRNs and help ensure the healthcare needs of US citizens are met by a diverse and collaborative workforce of professionals united in a vision to optimize the practice potential of all practitioners. It is imperative that nurse educators work with all stakeholders to improve the education of APRNs through the identification and implementation of best practice clinical education strategies designed to overcome the current barriers to the provision of high-quality clinical experiences.
The authors would like to thank Dr. Ruth Bindler for her support.
Edited by Linda R. Cronenwett, Ph.D, R.N., FAAN
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 nursing’s 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 versatility, 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 possibility 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, nursing’s versatility is important to note for the simple reason that nursing has evolved faster than public policies affecting the profession. The result is that nursing’s forward progress to better serve the public is hampered by the constraints of outdated public policies involving government 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 barriers 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 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 coordination. 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 scholarships, loan forgiveness, and institutional capacity awards to significantly 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 master’s and doctoral levels in the form of scholarships, loan forgiveness, 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 capacity in the Executive Branch with authority to recommend to the President and the Congress health workforce policy priorities across federal agencies 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 graduates. 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 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 proportion 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 hospital’s bedside nurse workforce with BSN qualification was associated with a 5 percent decline in mortality following common surgical procedures. A similar finding was published by Friese and associates for cancer surgical outcomes (Friese et al., 2008). Aiken’s 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 nation’s nurses, to establish the BSN as the desired credential for nurses. Many hospitals, particularly teaching hospitals and children’s 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 improves with a more educated workforce. In Aiken’s JAMA paper, evidence was 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 affecting 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 master’s 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 researchers 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 million 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 unprecedented 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 helping others. If we can take advantage of this unprecedented interest and expand nursing school production, future nursing shortages could be greatly attenuated.
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. Additionally 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 program—associate degree or baccalaureate—was the major predictor of final educational attainment. Close to 20 percent of nurses irrespective 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 master’s 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 distribution 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 master’s and higher degrees today.
We concluded in our Health Affairs paper that it was a mathematical improbability that the nurse faculty shortage could be solved without changing the distribution of nurses by type of basic education. There are simply not enough nurses who obtain a master’s or higher degree to meet the dramatic increase in demand for clinicians, administrators, teachers, and leaders who require a graduate degree.
What would be the expected yield in terms of nursing faculty that would be likely to obtain by increasing basic BSN education? To answer this we undertook an analysis of the National Sample Surveys of Registered Nurses over time to explore whether career trajectories of nurses with graduate education had changed over time. The answer is yes—significantly. For example, in 1982, 17 percent of nurses with master’s degrees and 62 percent of nurses with doctorates were in faculty positions compared to only 7 percent of master’s and 41 percent of nurses with PhDs in 2004. Nurses with graduate degrees are selecting positions in clinical care and administration in ever larger numbers. The yield for teachers is clearly greater for those who earn doctoral degrees which argues for policies that aggressively recruit BSN nurses into expedited doctoral education thus bypassing the master’s, which has a very clinical curriculum and a different end objective focused on producing clinicians. Probably for historical reasons, many schools build their curricula sequentially from BSN to MSN to doctoral degree. However, the clinical master’s in specialty practice has little to do with learning to teach or to conduct research. The clinical masters is not a building block for doctoral study but a terminal degree like the MBA or the Masters in Engineering. In order to address the faculty shortage two things would have to happen simultaneously. More nurses would need to initiate basic nursing education at the baccalaureate level AND expedited BSN to PhD programs would need to be expanded to interest students in teaching careers earlier and expedited to bypass the clinical masters that emphasize career trajectories in clinical care. The clinical master’s is not a building block for doctoral education but a different career pathway.
Tying educational loan forgiveness to teaching is a reasonable supplemental strategy along with a focus on BSN to PhD education to help offset lower incomes in faculty positions. Actually closing the gap between practice and academic salaries is not feasible. The gap exists in every practice discipline including medicine, law, business, and engineering. University faculty salaries vary for different fields depending upon market factors but not enough to close the gap between teaching and practice within disciplines. Combining clinical and academic responsibilities for nurse faculty is a potential strategy for enhancing faculty incomes. However, in only a few nursing specialties like nurse anesthesia or executive positions are rates of remuneration for clinical nursing care high enough to offset lower academic salaries for teachers with joint clinical appointments.
Articulation programs aimed at facilitating additional education for RNs with less than a baccalaureate degree have been tried for decades and do little to produce more teachers. Once nurses qualify for licensure, 80 percent do not seek further education. Oregon has the most innovative approach to improving articulation between associate degree and baccalaureate programs by standardizing requirement; the Oregon program has twice the success rate of the national average with 40 percent of associate degree nurses obtaining the BSN. However, the Oregon articulation initiative would not solve the shortage of teachers because most of those who get the BSN will not go for a second additional degree. RN-to-MSN programs would have a somewhat higher yield for teachers than RN-to-BSN completion courses but not nearly as high a yield as BSN-to-PhD programs.
Associate degree education is appealing to policy makers because it seems to offer upward mobility and it is less expensive and more geographically accessible. However, data suggest in the case of registered nurses that initial qualification for licensure at the associate degree level actually constrains educational and career mobility compared to those who initially qualify at the bachelor’s degree level. The advantages of associate degree education, lower out-of-pocket costs and geographic proximity, can be offset in the case of nursing by public subsidies for educational costs and distance learning. The length of associate degree and baccalaureate programs are not significantly different because of licensure requirements. Maintaining three (including diploma) educational pathways for nurses that at least on the surface do not seem radically different have a dramatic impact on the upward educational mobility of nurses thus contributing to the shortage of faculty and other nurses requiring graduate-level education.
The majority of countries with health care comparable to the United States have moved to standardize nursing education at the baccalaureate entry level including the European Union. States have the authority in the United States to set licensure requirements for nursing. Prospects for standardizing education of nurses through licensure changes across 50 states are not good. However, financial incentives imbedded in public subsidies for nursing education could have a significant effect on changing patterns of education just as payment incentives change medical practice patterns.
The IOM Committee should recommend increasing public subsidies for basic nursing education—federal and state—and tying these funds to the production of baccalaureate graduates. Policies should be neutral on types of institutions—community colleges or 4-year colleges and universities—that could benefit from funding. Capitation funding on the basis of BSN graduates from basic education programs could be effective in shifting the proportion of graduates toward more with BSN qualifications. Coupled with increased funding for graduate nurse education, this could be an effective strategy for addressing the faculty shortage along with shortages of advanced practice nurse clinicians and administrators.
IOM committee members in a previous discussion of this option asked what the yield would be for faculty positions in increasing baccalaureate graduates. Additional research is needed to answer this important question directly. However, we know from existing research that BSN initial graduates are three times more likely to get a master’s degree and twice as likely to get a doctoral degree than associate degree nurses (Aiken et al., 2009), which would likely produce more teachers. Because the current yield of teachers is relatively low overall among nurses with graduate degrees—only 7 percent of master’s graduates and 41 percent of doctoral graduates electing faculty positions—policies to increase baccalaureate initial education would have to be accompanied by efforts to increase the teacher yield. Promising strategies to increase the teacher yield among those with graduate credentials include scholarship and educational loan repayment for those in teaching roles and funds to expand BSN-to-PhD expedited programs. And investments in more baccalaureate nurse graduates would also likely return additional benefits in the form of better quality, improved access, and efficiency for those electing clinical practice roles, an outcome in the public’s interest.
INCREASED FEDERAL AND STATE FUNDING FOR GRADUATE NURSE EDUCATION
The evidence is strong that the growth of advanced nurse practice has contributed to improved access to general care (Aiken et al., 2009). Over the past decade advanced practice nurses have largely staffed the new retail clinics that currently provide about 3 million ambulatory visits a year at an estimated per visit cost of below the average cost to a physician office. Additionally, advanced practice nurses have enabled the largest expansion of Community Health Centers (CHCs) since the Great Society Program; CHCs currently provide over 16 million visits in 7,300 sites to largely underserved people. In total, advanced practice nurses are estimated to provide up to 600 million ambulatory patient visits a year, a national primary care capacity enhancement that will become increasingly critical to access in a context of primary care physician shortage.
The rate of production of new advanced practice nurses (APNs) which had been growing steadily since the 1970s has been flat in recent years. Interest among nurses in advanced practice roles appears strong but the shortage of student financial aid for graduate nurse education has a chilling effect on enrollment growth. It is difficult for many nurses to forego employment income to attend graduate programs full time without scholarships or loans which are in short supply. The major source of funding for graduate nurse education is Title VIII annual appropriations which currently total about $60 million (estimate for graduate education only, not all of Title VIII funding), compared to $2.4 billion for direct graduate medical education for physicians. A large proportion of APN students pursue graduate education on a part-time basis which slows the production of new graduates. Employer tuition benefits, an important source of educational assistance for practicing nurses, have been reduced during the economic downturn, eroding available financial support for graduate nurse education, particularly at the master’s level which is generally required for advanced nurse clinical practice.
Medicare, since its inception, has paid for a share of graduate medical education. It has also reimbursed some hospitals for a portion of their nursing education costs. An analysis we conducted of 2006 HCRIS data from the Centers for Medicare and Medicaid Services (CMS) suggested that Medicare funding for nursing education was slightly less than $160 million annually, a small amount compared to medical education investments, but almost as much as all of Title VIII funding for nursing in that year. CMS has a larger estimate of $300 million in Medicare payments for nursing education but we cannot verify that estimate with publicly available data. But whether Medicare funding is $160 million or $300 million annually, policies governing expenditures are very different from how the funds are spent in support of medical education, the amount is large relative to other sources of federal support for nursing education, and the funding does not materially affect the supply of nurses or the quality of nursing care for the elderly (Aiken and Gwyther, 1995). Most of the funds are limited to hospital-sponsored diploma nursing schools which currently prepare less than 5 percent of new RNs annually. Also five or six states account for almost half of Medicare nursing education funding because of the location of the relatively few surviving diploma nursing schools.
A number of workforce studies and commissions, including a 1997 IOM committee, have called for the realignment of Medicare funding for nursing education to graduate nursing education (IOM, 1997). The health reform bill passed by the Senate proposes a small demonstration of up to five hospitals to test Medicare payments for graduate nursing education. While better than no progress at all, the proposed demonstration is too small to significantly advance a change in Medicare policy that is long overdue.
There is sufficient information available now as suggested by the Institute of Medicine in 1997 to realign Medicare nursing education funding to graduate nursing education. This could be a budget-neutral programmatic shift which would more than double current federal funding levels for graduate nursing education and serve as a significant stimulus for increased production of advanced practice nurses to meet the multitude of existing and emerging needs resulting from the continuously changing boundaries between nursing and medicine.
FEDERAL AUTHORITY ON HEALTH WORKFORCE POLICIES
There is little effective health workforce policy-making at the federal level. The modest nursing policy capacity is located within the Health Resources and Services Administration, an agency within the Department of Health and Human Services (HHS) with little of its own funding and no authority to engage CMS which controls Medicare nursing education funding or the Department of Education, where the largest funding for nursing education resides in the form of Carl Perkins Act funding for community colleges.
Patterns of basic pre-licensure education for nurses have changed dramatically in the 45 years since the nation’s last major health reform—Medicare and Medicaid. In 1965, over 85 percent of nurses received their basic education in hospital-sponsored diploma programs; now less than 5 percent do. The percentage of registered nurses receiving training in associate degree programs was less than 2 percent in 1965 but is over 66 percent today. Baccalaureate nursing programs produced about 10 percent of new nurses in 1965, which increased to about a third of new nurses by 1980 and has been stable there for 30 years (Aiken and Gwyther, 1995). Current Medicare policies for support of nursing education as implemented by CMS are still based on nursing education patterns that existed when Medicare was passed but that are practically irrelevant today. CMS has been resistant to proposals to realign existing Medicare support for nursing education to graduate nursing education through multiple different administrations in Washington.
The single largest source of federal support for nursing education is the Department of Education’s funding for community colleges through the Carl Perkins Act. Perkins funds exceed $8 billion annually. A high priority should be set on examining whether and how Perkins funds could be targeted to incentivize community college nursing programs to increase the proportion of their nursing students who complete their initial education with a BSN. There are numerous feasible strategies to do this including having community colleges offer the BSN as in Florida and other states as well as innovative partnerships with 4-year colleges and universities perhaps using state-of-the-art distance learning technologies supported by Perkins funding.
The most influential of the many commissions on nursing over the decades was the 1982 IOM study Nursing and Nursing Education: Public Policies and Private Actions. That study made a recommendation involving an organizational change within HHS that dramatically altered national nurse leadership and nursing education. The recommendation was to move the responsibility and budget authority for nursing research from HRSA to NIH where research was highly visible and influential. The establishment of the National Institute of Nursing Research within two decades fundamentally transformed the engagement of nursing in evidence-based innovations to improve health outcomes, helped create new and important interdisciplinary research and research training collaborations, and improved the relevance and quality of nursing education in universities. The proposal to establish a nursing workforce authority at a higher level of the federal government could have an equally influential impact on the adequacy of the national nurse workforce.
The Commission on the Future of Nursing has considered many important aspects of the education and practice of nursing. Of the many types of recommendations the committee might consider, recommendations regarding federal (and state) funding of nursing education are among the most actionable and potentially influential in creating a future for nursing that serves the public’s interests in patient-centered accessible health services at affordable costs. What is good for the public is genuinely good for nursing. Using public nursing education policy as a vehicle for achieving a better balance between the qualifications of nurses and national health care needs could result in great return on investment now and in the years ahead.
AACN (American Association of Colleges of Nursing). 2009. “Nursing Faculty Shortage Fact Sheet,”http://www.aacn.nche.edu/Media/pdf/FacultyShortageFS.pdf (accessed 5 May 2008); and Geraldine Bednash, executive director, AACN, personal communication, 9 February 2009.
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PREPARING NURSES FOR PARTICIPATION IN AND LEADERSHIP OF CONTINUAL IMPROVEMENT
Donald M. Berwick, M.D.
Institute for Healthcare Improvement
“I see.” said the nurse,
“You’re saying that I have two jobs: doing my job, and making my job better.”
In the 20 years since I first heard that comment from my colleague, Paul Batalden, MD (retold January 2010), who was quoting a participant in a course he was teaching on health care improvement, I have never heard a more succinct summary of the modern view of the pursuit of quality in a complex system. It is a deceptively simple idea, replete with implications for the preparation, self-image, support, and daily life of the professional. It represents a comprehensive goal for the modern nurse and for those who wish to prepare people for that role.
The capacity to “make my job better” is not inborn. Nor is it usually taught in professional education. What professional education, including nursing education, has more reliably focused on is the content of the job—the subject-matter knowledge and cognitive and manipulative skills to care for patients in existing processes and institutions. Standards exist for how one ought to perform tasks, including dynamic tasks like problem-solving; professional preparation instills mastery of those tasks, and professional licensure and certification allege to assure achievement of that mastery.
W. Edwards Deming, one of the great theorists and teachers of improvement in systems contexts, distinguished this discipline-specific and subject-matter knowledge, which tells one, in effect, “how to be a nurse,” from what he called “Knowledge for Improvement” (or, less felicitously, “Profound Knowledge”) (Deming, 1994), which would tell one “how to improve nursing” or, more accurately, “how to help improve the system of which nursing is a component.” Mastery of the first—subject-matter mastery—does not confer mastery of the second—knowledge for improvement. This form of knowledge invites attention to the system in which professional work is conducted.
In some ways it is surprising how little our pedagogy promotes appreciation of systems of care. Arguably, most graduates of most health professional educational programs suffer from considerable “functional illiteracy” about the systems in which they work. Few emerge from their studies with a well-developed sense of responsibility for the performance of these systems, even though they work in those systems and depend on them every day.
The evidence of serious deficiencies in the performance of health care as a system is overwhelming and incontrovertible. It fueled the findings and recommendations of the landmark Institute of Medicine report, Crossing the Quality Chasm, in the year 2001, which claimed: “Between the health care we have and the care we could have lies not just a gap but a chasm” (IOM, 2001, p. 1). Its diagnosis—incapable systems of care: “In its current form, habits, and environment, American health care is incapable of providing the public with the quality health care it expects and deserves” (IOM, 2001, p. 43). The Chasm report established six “Aims for Improvement” of care, which now compose a canonical list:
safety (reducing harm from care);
effectiveness (increasing the reliability of alignment between scientific evidence and practice, reducing both underuse of effective practices and overuse of ineffective ones);
patient-centeredness (offering patients and their loved ones more control, choice, self-efficacy, and individualization of care);
timeliness (reducing delays that are not instrumental, intended, and informative);
efficiency (reducing waste in all its forms); and
equity (closing racial and socioeconomic gaps in quality, access, and health outcomes).
In the decade since the Chasm report, the social imperative for all six of these improvements has increased, with perhaps special emphasis lately on “efficiency” as the costs of American health care have come to appear less and less sustainable. Activities in health care policy, management, and payment have increased, with more or less coherence, in pursuit of those goals. Yet the response from health professionals (and the faculties who train them) to shoulder accountability for health system performance has been limited, and in many places virtually absent.
If, as the Chasm report alleges, the current system of care is “incapable” of the needed improvement, then, logically, pursuit of the IOM Aims for Improvement requires that the system change. Nursing, like any health care profession, can become an object of change, or an agent of change. The latter role will require a new form of professionalism with new skills in system redesign.2
Nursing is positioned well to be a change agent. One recent national project to reduce patient injuries, the Institute for Healthcare Improvement’s 100,000 Lives Campaign (McCannon et al., 2006) translated the IOM aims of “safety” and “effectiveness” into operational form as “bundles” of evidence-based care procedures, such as the “Central Line Bundle” to prevent catheter-associated bloodstream infections, the “Ventilator Bundle” to present respirator-associated pneumonias, and Rapid Response Teams to intercept patient deterioration with early warning, diagnosis, and treatment. Hundreds of hospitals reported success in improved patient outcomes, and a recurrent pattern included activated nurses, supported to standardize their own processes of care according to the Institute for Healthcare Improvement (IHI) “bundles,” and empowered and supported to monitor and enforce those standards across disciplines, including with their physician colleagues (Berwick et al., 2006). Present steadily at the point of care, committed to excellence and reliability, equipped to measure locally, biased toward teamwork, and, crucially, encouraged to innovate locally to adapt changes to local contexts, nurses proved the ideal leaders for changing care systems and raising the bar on results.
Some relevant education innovation are well under way. The pioneering work of the Quality and Safety Education for Nurses (QSEN) project (Cronenwett et al., 2007) and the adoption by the American Association of Colleges of Nursing of the QSEN quality improvement competencies in The Essentials of Baccalaureate Education for undergraduate nursing education is heartening and opens the possibility that students across the professions will develop similar competencies for the improvement of care. Further, QSEN’s work on faculty development (Cronenwett et al., 2009a) and graduate nursing education (Cronenwett et al., 2009b) to extend these ideas into all of nursing professional development is exciting. IHI’s Open School for the Health Professions is an interprofessional educational community that helps students from all the health professions to acquire the skills to become change agents for health care improvement.
From the viewpoint of nursing education, the capacity to help improve systems of care has two big elements: (a) personal skills and (b) a context of leadership and management that allows those skills to thrive in action. Nursing education fit for the needs of the 21st century will attend to both.
PERSONAL SKILLS: THE CATEGORIES OF KNOWLEDGE FOR IMPROVEMENT
Deming’s four “profound knowledge” categories offer a useful framework for education goals and achievements for nurses capable of helping to improve systems:
Knowledge of Systems
Knowledge of Variation
Knowledge of Psychology
Knowledge of How to Gain Knowledge
Let us explore each.
Knowledge of Systems
“Knowledge of Systems” refers to understanding the technical characteristics of complex systems, in which factors like interdependency, feedback loops and other nonlinear dynamics, uncertainty, and sensitivity to small changes constantly operate. Without systems knowledge, one approaches work (or life in general) as a series of lists, with a mentality of checking off tasks, with assumptions of direct and linear cause-and-effect dynamics. The world, or the organization, is modeled like a machine, and simplification seems helpful. In health care, of course, things rarely work that way. In clinical work, medications can have remote, delayed, and confusing side effects; organs interact in complex and powerful ways; patient status can be unstable, with feedback loops that spiral into sudden disasters and unwelcome surprises. Well-trained nurses are familiar with system dynamics of that sort: they understand the pituitary-adrenal-hypothalamic axis; they have studied family systems; and they are alert always to medication interactions and the effects of organ failure on physiology. Each of these requires “knowledge of systems,” that is, knowledge of the body as a system, for appropriate diagnosis and response.
Where “knowledge of systems” is less robust in the preparation of nurses (as well as most other health professionals) is in understanding the work of health care as a system. This ignorance is the harvest less of intent than of historical accidents. In effect, modern health care is an assemblage of component roles, disciplines, and institutions built up more or less independently, and often without much regard for their interactions. Nurses and doctors who will work together for their entire professional lives rarely train together for even a single day. Tasks are compartmentalized. In many medical records “nursing notes” remain separate from “physicians’ notes,” and in many hospital wards the “Nurses’ Conference Room” and “Nursing Rounds” are separate from the “Doctors’ Conference Room” and “Medical Rounds.” The fragmentation runs deep, as reflected in language, oaths, uniforms, schedules, and prerogatives.
In addition, the processes of care themselves, by which I mean the flows and steps through which patients, specimens, information, and ideas pass, are often unclear and designed, if at all, only unconsciously. No one is really sure what all the steps are that a patient traverses from admission to diagnosis to treatment to discharge, and no one is in charge of the entire flow. In Paul Batalden’s words, health care lacks the “catwalks” that make processes visible, and therefore analyzable, in manufacturing. It is very hard to manage and improve what one cannot see or understand, and “process illiteracy” confounds health care redesign often.
This is not inevitable. “How do we do that?” is a perfectly reasonable and tractable question for almost any set of interdependent deeds in health care, just as long as someone is in a position to ask and to mobilize the information to find the answer. The answer may prove embarrassing—there may be no stable process at all, or the one that does exist can look, upon inspection, absurdly wasteful or unscientific; but, the ability to examine and study processes opens the door to changing processes, which is on the road to improving them.
I am not a nurse, but my guess is that nursing educators will have no difficulty at all recognizing some educational goals in which “knowledge of systems” is already a high priority. For example, I suspect that nursing training for some specialist roles, such as for participation in an open heart surgery team, is full of attention to system dynamics of all sorts. No patient has ever gotten successfully onto and off of a heart–lung machine without exquisite attention by an entire team to process steps, interdependencies, and interactions, likely very consciously designed and monitored.
The task in modernization of nursing education is to generalize the pursuit of system knowledge into all that nursing is and does. Topics of relevance may include (a) health care as a system, (b) general systems theory, (c) queuing theory and flow in care systems, (d) reliability and reliability engineering, (e) lean production, and (f) resilience (Spear, 2008). In the important and special arena of safety, system topics include (g) human factors science (Reason, 1990), (h) team communications and collaboration, (i) failure mode and effect analysis, and (j) properties of high-reliability organizations (Weick and Sutcliffe, 2007), to name a few.
Knowledge of Variation
Professor George Box has said, “All systems produce information on the basis of which they can be understood.” The new professional capable of leading and participating in improvement knows how to hear and use that information.
Measurement is abundant in health care, as nurses well know. Nurses spend an inordinate proportion of their time documenting and recording things; they measure all the time. However, measuring is not at all the same task as using measurement, especially using measurement to improve. When measuring for improvement (as opposed to measuring for judgment or measuring for selection), one is either (a) observing variation to extract ideas or (b) introducing variation to study the consequences.
Observing variation is what nurses do every day in recording a patient’s vital signs, for example. The aim is inference: either that the patient is stable, or that a systematic or sudden change in status is under way. In effect, every blood pressure or temperature measurement is a test of a hypothesis that either “something special is going on” or “nothing special is going on.” Nurses in that role are like other scientists—continually measuring and making repeated inferences (Berwick, 1991).
How well they do that helps to determine patients’ outcomes. “Is the antibiotic working as expected?” “Is the blood pressure coming under control?” “Is the patient entering, or staying in, proper fluid balance?” Upon the answers to those questions, based on proper interpretation of variation, rest crucial decisions about maintaining or changing theories and therapies. The challenges of proper interpretation are significant, and neither physicians nor nurses yet today receive sufficient instruction in how to understand variation correctly. The consequence of failure are what Dr. Deming referred to technically as two forms of “tampering.” The first form is to react to a random change in a measurement—such as a temporary rising temperature or a temporarily falling blood pressure—as if it were informative (“the antibiotic is not working,” or “this patient needs more pressor”) when, in fact, the observed fluctuation is only random, and would revert if nothing new were done. The converse form of tampering is to classify a change as characteristic of a system when, in actual fact, it is not at all likely to be representative of the general system from which it comes. This misinterpretation can lead one to make a wholesale change in response to a special event, as when our transportation security system radically alters inspection regimes in response to a single, unlikely-to-be-repeated threat.3
As modern medical care and monitoring multiply the volume of information and the number of measurements flooding the nurse at the front line, the demand for technical sophistication in interpreting physiological and biochemical variation rises steadily. The modern nurse should be equipped as never before with the knowledge to interpret variation correctly, to avoid tampering, and to increase agility in appropriate response.
What applies to patients applies to systems of care, as well. The “vital signs” of health care as a system are numerous and, like measurements of patients, increasing in availability daily. System characteristics include, for example, waiting times and delays, rates of complication and outcomes of surgery and other interventions, infection, and mortality, patient satisfaction, costs and levels of waste and efficiency, safety levels and adverse events, and levels of variation in approaches to diagnosis and treatment. Many such measurements are appearing in new forms of accountability of health care organizations and professionals to payers, regulators, accreditation agencies, consumer groups, and licensing bodies. The psychology of such external measurement can be quite negative, inducing fear, anger, and sometimes deceptive practices even among the most committed professionals, but this negative cycle ought not to obscure a basic fact: that the improvement of health care systems requires very much the same type of measurement, used internally, that scrutiny bodies demand and use for other purposes externally (James et al., 2003). Ideally, even if no one else required measurement of infection rates or surgical outcomes, clinicians, themselves, ought to seek them avidly as a crucial resource for making care better.
Modern nurses will, of necessity, have to learn the tasks involved in measurement for scrutiny and compliance—that’s the hard fact. But, modernized nursing education will emphasize far more the role and use of system metrics as a support to the continual improvement of health care along all six of the IOM dimensions. Individual nursing practice will, in that mode, include avid measurement and sophisticated interpretation to answer questions of the form: “How is our system doing at X, and what can the variation tell us about how to do better?”
Measurement for improvement goes far beyond mere observation. It includes systematic, local interventions—making changes in processes of care and assessing and learning from the consequences of those changes. An important boundary exists between formal scientific investigations—experiments that ought to invoke the whole apparatus of planning and human subjects protection that are now required in some settings—and the daily practice of continual improvement through the introduction and assessment of better local processes—the “Plan-Do-Study-Act” approach that is at the core of modern improvement methods, and about which we will have more to say below. That said, the modern nurse ought to be equipped to participate in and often to lead systematic changes in work processes, and to assess their effects on the outcomes desired (Langley et al., 2009).
Knowledge of Psychology
Largely because interdependency, especially interdependency among people, is so much a characteristic of complex systems like health care, human nature and psychology play a strong role in the success or failure of improvement efforts. Dr. Deming had in mind a rather long list of the components of “psychology” whose understanding and mastery underpin successful improvement work. One short subset of relevant skills is this:
Conflict resolution and negotiation;
Group process and meeting management;
Forging and maintaining cooperation and coalitions;
Understanding motivation, especially intrinsic motivation;
Communication and signaling; and
Maintaining a culture of safety.
The unifying concept among these topics is “managing and improving interpersonal relationships,” which can be daunting in a context of high pressures on production, historical boundaries among disciplines and subsystems, hierarchy, and high risk. Scholars of so-called high reliability organizations (HROs) (Weick and Sutcliffe, 2007) nonetheless find that it is exactly under conditions of stress, risk, and complexity that relationships matter the most in determining success. It may be impossible for nurses unilaterally to effect better relationships unless other professionals aim to do the same, but nurses are so central to health care processes that they may well be able to take the lead.
Knowledge of How to Gain Knowledge
Learning in complex systems is, itself, complex. Nonlinear systems confound attempts to develop and enforce simple models of cause and effect, and so traditional, hypothetico-deductive methods to explore cause and effect often fail. We know that in the daily life of parenting, marital relationships, and team sports, where “continual learning and improvement” replaces “planned experiment” as an approach for gaining knowledge.
Even where firm, cause-and-effect knowledge exists in science-based health care—the knowledge, for example, that antibiotic A will almost always kill bacterium B—the application of that knowledge runs straightaway into the messy world of complex systems. That is, reliably getting the antibiotic safely into the body of a patient with that germ turns out to be a constant challenge as systems fail (the order got lost), unpredicted side effects occur (the patient is on an incompatible other drug), local circumstances become highly relevant (the drug is unfamiliar to the new doctor), and errors multiply (the bacteriological report was on the wrong patient). The fact is frustrating and inescapable: in health care, as in any complex enterprise, the simple, scientific facts lie fallow without continual adaptation to local contexts.
The consequence for improvement is this: almost all effective improvements require continual, local experimentation—local growth in knowledge. All improvement requires change (although not all changes are improvements), and proper change requires continual learning. A modern workforce, including modern nurses, is fully equipped to act as “scientists at work.” When the nurse quoted at the top of this essay said, “I have two jobs: my job and improving my job,” she was entering a world of continual trial and learning for both of those roles.
We might call the subject, scarily, “epistemology,” for it involves, after all, a theory of knowledge, itself: the idea that human beings in complex systems best acquire new knowledge by making changes and studying the effects of those changes. But, it is in fact not so arcane at all. This is the form of learning that all healthy people use in almost all the common endeavors of their daily lives—the endeavors that they care about and are in some degree of control over: sports, hobbies, loving relationships, cooking, dieting, and getting a good night’s sleep. In every single case, the individual who wishes to get better finds ways continually to test new approaches, knowing that, as we all know: “If you continue to do what you’ve always done, you’ll always get what you’ve always gotten.” That’s not good enough for your tennis game or your gardening, and it’s not good enough for the work of health care, either.
The jargon of modern improvement is “PDSA”—“Plan-Do-Study-Act.” This describes a simple, iconic cycle of aim-setting, testing, reflection, and change based on reflection. The modern nurse who intends to “improve the job” effectively needs to be a master of the “PDSA Cycle” at work. Unlike in gardening or tennis, PDSA at work is not a solo enterprise. Almost all forms of organized quality improvement activity today involve teams; groups, not soloists, carry out the tasks of will building, measurement, idea generation, design and conduct of small-scale tests of change, reflection, and guidance to further action. These compose quality improvement projects. For a modern nurse, participation and leadership in such project work is the form taken of action based on “knowledge about how to gain knowledge.”
LEADERSHIP AND MANAGEMENT SKILLS
The four areas of skill and knowledge explored above—systems, variation, psychology, and epistemology—compose a strong set of goals for modernized nursing education on behalf of quality improvement. One key element is missing, however—the context of leadership and management that allows those skills to thrive. Not all nurses will become formal system leaders during their careers, but those who do will more effectively nurture system improvement if they understand how to lead improvement.
A full exploration of “leadership for improvement” is beyond the scope of this essay, and numerous resources are readily available attempting to describe what leaders need to know in order to foster improvement in the systems they lead (Reinertsen et al., 2008). However, a few leadership-dependent elements deserve special mention because they interact so strongly with the topics addressed above:
Setting Aims and Building Will to Improve
Measurement and Transparency
Finding Better Systems
Supporting PDSA Activities, Risk, and Change
When leaders, including nursing leaders, establish these and other preconditions in the work setting, they can effectively liberate the energy and wisdom of the front-line staff and middle managers to incorporate continuous improvement into their daily work, and they stand a better chance of ensuring that these good-hearted, local improvement efforts align with and support the most important strategic goals of the organization and system as a whole. Just as good teachers in a classroom make it possible for students to become active learners, so do good managers make it possible for nurses and all health professionals to become active, curious, effective, and, ideally, joyous improvers.
Modern health care demands continual system improvement to better meet social needs for safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity. Nurses, like all other health professionals, need skills and support to participate effectively in that endeavor, and, often, to lead it. Nursing education is poised to accelerate progress by embedding health care improvement skills in all phases of professional formation.
Following are recommendations intended to support this vision:
Preparation of nurses should include mastery of knowledge of systems, interpretation of variation, human psychology in complex systems, and approaches to gaining knowledge in real-world contexts.
During professional preparation, nurses-in-training should experience and reflect upon active involvement in multidisciplinary quality improvement projects and work settings that foster day-to-day change and improvement.
During professional preparation, nurses-in-training should experience, reflect upon, and develop the knowledge, skills, and attitudes that create competence in patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics.
Preparation of nurse-teachers and nurse-executives should include acquiring and practicing skills and methods for the leadership and management of continual improvement.
Organizations that license and certify nurses or accredit nursing education programs should require evidence of nurses’ preparation for participation in or leadership of teams that work to continuously improve health care systems and individual and population health.
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NURSING EDUCATION PRIORITIES FOR IMPROVING HEALTH AND HEALTH CARE
Linda R. Cronenwett, Ph.D., R.N., FAAN
University of North Carolina at Chapel Hill School of Nursing