When the Institute of Medicine (IOM) and the Robert Wood Johnson Foundation (RWJF) released their Future of Nursing: Leading Change, Advancing Health report in 2010, the nursing profession and the entire healthcare industry were challenged. This report introduced 43 sweeping recommendations for reform that cut across nursing practice, medical education, workforce planning, policy making, technology, quality improvement, and patient safety.1,2 According to Susan Hassmiller, the RWJF Senior Adviser for Nursing who directed the RWJF Initiative on the Future of Nursing and is currently leading the report's implementation, the campaign isn't focused exclusively on nursing. Hasmiller stated, "We're saying it's really about the healthcare system providing high-quality care to all Americans in this country. We backed into nursing from that; how can nurses be used more effectively as part of the solution to the bigger issue of getting quality healthcare to all Americans?"3
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The culmination of 2 years of research and consensus building has framed the Future of Nursing's recommendations as an urgent call to action. If answered, this call would significantly alter healthcare delivery and the entire nursing profession. The IOM expects the report to usher in "the golden age" of nursing.4 When fully implemented, the Campaign for Action is expected to position more than 3 million nurses not only as trusted caregivers at the bedside, but as front-line activists, change agents, and leaders in the healthcare reform movement.
It isn't surprising that the national response to the Future of Nursing report has been so intense and predictable across professional disciplines. The TriCouncil for Nursing (the American Association of Colleges of Nursing, American Nurses Association, American Organization of Nurse Executives, and National League for Nursing) strongly endorsed the report, which acknowledges the central role of nurses in healthcare reform, and calls for collaboration among stakeholders to advance the report's recommendations.5
In contrast, the American Medical Association responded to the report by highlighting the difference in educational requirements of nurses versus physicians, emphasizing the importance of physician-led care teams, and stating that more responsibility for nurses wasn't the answer to the physician shortage in the United States.6 In addition, the Council of Medical Specialty Societies, which represents 34 medical societies and more than 650,000 physicians, expressed concern that the IOM report failed to justify the proposed expansion of practice for advanced practice nurses (APRNs), and urged that the focus be redirected to increasing the number of working nurses.7
Hassmiller hasn't been surprised at the different reactions to the report. "All the stakeholders have different priorities. I'm telling people they should take the report-whether they're government, a hospital, a school, a single nurse-see what makes sense to them, and determine what they might want to take a lead on, be a co-lead on, or generally support."3 Phrased differently, in a recent series on the IOM report, the report proposes "a blueprint that leaders can use to formulate implementation strategies," the success of which hinges on nurse leaders assimilating the four key recommendations within their own organizations and work settings.8
The Robert Wood Johnson University Hospital (RWJUH) is the principal teaching hospital of the University of Medicine and Dentistry of New Jersey's Robert Wood Johnson Medical School. We describe our Division of Nursing's response to the IOM Future of Nursing report. This process involved creating opportunities within our hospital and our professional networks for honest conversation about the report and its implications, and then using strategic planning to design our action strategies.
Key message 1: Nursing practice
The first key message from the IOM report stated that "advanced practice registered nurses should be able to practice to the full extent of their education and training." This statement included a long list of proposed legislative initiatives for Congress, state legislatures, the Federal Trade Commission, the Antitrust Division of the Department of Justice, the Centers for Medicare and Medicaid Services, and the Office of Personnel Management.2 The focus sounds deceptively simple; however, this is a highly politicized issue in healthcare today as it imposes national and local regulations on APRNs' scope of practice. This issue is a minefield: it's confusing to the public, it's a major source of disagreement in the healthcare industry, and, within the ranks of APRNs, it's a hotbed of discontent that stems from practice standards that vary from state to state.8 The discontent arises from not only regulatory restrictions to expanding the scope of practice, but also professional resistance to expanded roles, fragmentation of the entire healthcare system, and outdated insurance policies and regulations.9 All of these factors prevent APRNs from working up to their full education and training. Without intervention, the barriers threaten to derail the overall transformation strategy of the healthcare system.9
At RWJUH, we crafted a two-pronged strategy to address this recommendation. In the legislative arena, we've made a commitment to work closely with the New Jersey Nurses Association, the Organization of Nurse Executives of New Jersey, the New Jersey Hospital Association, the New Jersey League for Nursing, the Philippine Nurses Association of New Jersey, and our state legislators to ensure that the New Jersey Nurse Practice Act includes full practice parameters for APRNs.
Within RWJUH, we reviewed and adjusted position descriptions, roles, and responsibilities (in all hospital areas where our nurses practice), and we're expanding our current clinical nurse specialist cohort to practice to fullest extent of APRN licensure enabled by the New Jersey Nurse Practice Act. We're establishing a student summer residency program, a graduate nurse residency program, and a nursing academy in partnership with area universities. We're continuing to advance our efficiency efforts by embedding Lean principles in all RWJUH departments where RNs work, beginning with our ED and perioperative environment.10 Both are well on their way to achieving permanent process flow improvements and streamlined operations that will enhance the work experience and efficiency of our nurses, physicians, technicians, and ancillary personnel. We continue advancing our work on nursing-sensitive quality measure improvements, cross-training all our nurses, achieving and sustaining nationally benchmarked productivity targets, and advancing our nurse scientist program, which promotes IRB nursing research at the point of service.
Key message 2: Nursing education
"Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression." This key statement included a number of substantial recommendations, such as increasing the proportion of nurses with a bachelor's of science in nursing (BSN) degree to 80% and doubling the number of nurses with doctorates by 2020; providing competency-based education and interprofessional education on teamwork and collaboration; and increasing the diversity of the nursing workforce in terms of race, ethnicity, and gender.2
We've spent far too long debating the entry-level educational requirements for nurses. This ongoing debate has eroded our ability to assume leadership in healthcare policy and reform; we have to reach a consensus that a BSN must be the entry-level requirement for professional nursing practice.11 Nursing education in this era of reform must go beyond the traditional curricula to include learning how to manage political dynamics and complex relationships.12 In interdisciplinary care environments, nurses must be prepared to lead efforts that identify problems related to waste, improving care, tracking quality improvement, and achieving established goals.12
At RWJUH, we took these recommendations seriously and established new educational criteria for our nursing staff. These include a BSN as the entry-level educational requirement for our nurses; a BSN requirement for all current nurse managers by 2016; a master's of science in nursing (MSN) degree for all current nurse educators by 2013; APRN as the preferred minimum entry level for our nurse educators; national certification encouraged for all eligible Magnet(R) RNs; and a doctoral degree for all our nursing associate vice presidents and vice presidents by 2016. We also established an educational gateway for our nurses who've graduated from a non-BSN RN program and are employed in non-RN positions. If accepted, they must complete their BSN within 5 years of hire. To facilitate this rising educational bar at our hospital, we're working in partnership with our area universities to bring BSN, MSN, and doctoral programs to our campus. Although challenging, we've also initiated crucial conversations with our university-based BSN academic partners to secure tuition reductions.
In total, these efforts provide tangible evidence of our hospital's commitment to nursing education and our belief that lifelong learning is an absolute, not an option, for all nurses.8,13 Educational expectations such as these at RWJUH are necessary on a national scale to move nursing from the least formally educated of all the healthcare professions to a higher level of educational preparation.8
Key message 3: Partnership for progress
This key message brings laser-like focus to the central importance of collaboration and innovation in healthcare reform. "Nurses should be full partners, with physicians and other healthcare professionals, in redesigning healthcare in the United States."2 This message calls for nurses to develop a more robust portfolio of leadership skills that match the demands required for systemic healthcare reform, and to overcome the burdens of past perceptions and biases that associated nurses with lesser, more "assistive" roles-employees who carried out the instructions of others.12 Such perceptions were reaffirmed in a recent survey of opinion leaders and supported by the RWJF that nurses were unlikely to have significant impact on redesigning the healthcare system.14 The report suggests that the transformation of our healthcare system depends upon a renewed focus on leadership capacities at every level of practice.14
At RWJUH, we've embraced this call to action by integrating engagement strategies (shared experience, connecting relationships, and creating communities for action) with classic principles of innovation.15,16 Both approaches are necessary because professionals who work in today's healthcare environment are interdependent, and the complex challenges they face can't be remedied with singular solutions from the past.12
We believe that we've met the classic prerequisites for positioning ourselves as innovators:
* control of financial resources
* ability to understand and apply complex knowledge
* ability to cope with a high degree of uncertainty
* willingness to accept occasional setbacks
* "venturesomeness" based on our interest in new ideas.16
We're considering transforming an inpatient unit in our hospital as a "future care delivery innovation" test site. This unit will serve as an incubator for new delivery models, product trials, collaborative practice models, and approaches for improving patient safety.17 In addition, we're creating new organizational structures that will support our commitment to innovation.
Key message 4: Technology
In this cyber age, there's no transformation without technology. The final key message "effective workforce planning and policy making require better data collection and information infrastructure" confirms the central role of information technology in healthcare reform and the transformation of nursing.2 The critical importance of using real-time data to inform and predict changes in the nursing workforce, nursing education, and nursing practice across diverse settings was recently emphasized.18 In addition, as caregivers at the bedside, nurses must be positioned as front-line decision makers who design, develop, purchase, implement, and evaluate information technology that supports nursing decisions and care delivery. The IOM report cites the Technology Informatics Guiding Education Reform Initiative as an innovative example of nurse-directed technology development.19 This group of more than 1,400 nurses is using technology to create patient-centered care that's more safe, more efficient and accessible, and less burdensome to nurses. This type of involvement places nurses in a position to truly shape decision and policy, rather than reverting to a more passive role with limited or no control.
At RWJUH, we use technology enhancements for data-based decision making that keeps us current on workforce requirements in light of baby boomer retirement projections, entry-into-practice targets, and our available workforce pool. We're very aware of the statistics on the aging of our profession and appreciate that developing creative retention programs may be well worth the energy and resources.20 These nurses represent a "treasure chest of talent that can benefit us all as many will redefine retirement as a stage of moving on to newer, different ways of working."21 In the practice arena, our hospital is proceeding with full implementation of electronic medical records (EMRs), radio frequency identification technology for inventory control, and bar coding for medication and laboratory services. Ultimately, we're looking to our EMR system to streamline all the clinical care processes and documentation within RWJUH.
As we look ahead to the nursing of the future, we might quote Charles Dickens in A Tale of Two Cities: "It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness."23 Authors of a five-part editorial series, which examined the IOM report, spoke eloquently of the great opportunity that lies ahead for our profession: the chance to assume a major leadership role in the most significant transformation of our healthcare system in modern times.8,9,11,12,18 All spoke with hope about the nursing profession rising to the occasion and taking its rightful place in the leadership of this reform movement. Yet, the authors recognized the real barriers that we face-a shortage of nurses and nursing faculty, an aging profession, legislative and political barriers to full practice, dissention within our own ranks, and less than ideal expectations of our own potential as leaders and change agents. All authors ended their articles with a similar query: Will nurses heed the call to action?
There's encouraging news. Since the release of the IOM Future of Nursing report in October 2010, the Campaign for Action recently reported that action coalitions are now operating in 49 states.24 These coalitions of nursing, healthcare, business, and consumer leaders are the driving force behind change at the local and state levels. The coalitions capture best practice, assess research needs, document lessons learned, and identify models that can be replicated.
There are other encouraging signs of progress. RWJF's president recently cited a number of educational institutions that are using creative ways to help their nurses progress to BSN and advanced degrees.25 Success, she says, depends on such changes becoming the national norm rather than the exception. Overcoming barriers to educational progression requires more than any single solution and the commitment of many.25 It's a commitment to act, both individually and collectively, through nursing organizations and other avenues for change.26
Our experiences at RWJUH during the time since the release of the IOM report prove it's possible to take heed and help transform healthcare. We wasted no time widening our circle of involvement by creating a new future for nurses at our hospital. We've participated in difficult conversations with our colleagues, partners, and stakeholders and we've stepped out of our comfort zone into the unsettling neutral zone-a place between the old ways of being and the new.15,22 Most important, we've organized our Division of Nursing into a real community of action; we're committed to positioning nursing at RWJUH to lead the fundamental shift in the delivery of American healthcare.
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