Abstract

Delivery of health care services in the United States is becoming ever more challenging as the health care system grows more complex and the demand for services escalates.  Factors underlying the mounting challenges include: an aging population that is demanding increasing amounts of health care services; cost pressures that are creating economic challenges; consumers who are demanding greater focus on the quality of health care; innovations in patient care such as new medications and new technologies that require new skills and knowledge; and an increasingly diverse population for whom the most effective care requires increased cultural competence and sensitivity.

The nursing workforce plays a critical role in addressing such challenges.  Nurses are the single largest component of the health care workforce.  However, projections show a shortage of registered nurses (RNs) expanding to potentially insurmountable levels over the next decade and a half.  In addition, both newly educated nurses and those already in the workforce need educational and practice opportunities that will provide new capabilities that are attuned to the increasingly complex health care environment.  Necessary new capabilities include: the critical thinking skills to rapidly acquire and assimilate new information to make appropriate patient care decisions; the skills and knowledge required to adopt innovations in patient care; and increased cultural competence that corresponds to the cultural diversity of the population. 

Thus, it must be the objective of policymakers to produce greater numbers of nurses to meet growing demand; and build a nurse workforce with the skills and abilities required to work competently in a changing and increasingly complex health care environment.

The National Advisory Council on Nurse Education and Practice (NACNEP) reviewed these challenges at its November 2005 and April 2006 meetings and developed a set of recommendations that are put forward in this report.  The recommendations described herein address the objectives by supporting policy initiatives that will:

• Prioritize funding for initiatives to increase the proportion of BSNs in the nursing workforce;
• Prepare RNs for future challenges through increased support for improving nursing education;
• Increase the diversity of nursing students and the cultural competence of RNs; and
• Support initiatives to optimize the nursing work environment.

Executive Summary

More Nurses are Needed, but More is Not Enough

The organization and delivery of health care in the United States is continually changing in order to meet new economic challenges and to adopt improvements and innovations in patient care.  Delivery of health care services in the United States is becoming more demanding as the health care system is becoming more complex and the expectation for services is growing.  Factors underlying the increased challenges include: an aging population that is demanding increasing amounts of health care services; cost pressures; consumers who are demanding greater focus on the quality of health care; innovations in patient care such as new medications and new technologies that require new skills and knowledge; and an increasingly diverse population for whom the most effective care requires increased cultural competence and sensitivity.

The nurse workforce plays a critical role in addressing such challenges.  Nurses are the single largest component of the health care workforce.  However, projections show a shortage of registered nurses (RNs) expanding to potentially insurmountable levels over the next decade and a half.  In addition, both newly educated nurses and those already in the workforce need educational and practice opportunities that will provide new capabilities that are attuned to the increasingly complex health care environment.  Necessary new capabilities include: the critical thinking skills to rapidly acquire and assimilate new information to make appropriate patient care decisions; the skills and knowledge required to adopt innovations in patient care; and increased cultural competence that corresponds to the cultural diversity of the population. 

Thus, it should be the objective of policy makers to: produce greater numbers of nurses to meet growing demand; and build a nurse workforce with the skills and abilities required to work competently in a changing and increasingly complex and diverse health care environment. 

Enhancing Education

There are different avenues for entry-level RN education.  These include associate degree programs, diploma programs, and baccalaureate degree programs.  At present there are more nurses in the workforce with associate degrees or diplomas than with baccalaureate degrees or higher.  RN-to-BSN programs exist to facilitate RNs with diplomas or associate degrees to obtain baccalaureate nursing degrees and augment their existing skills.  These programs build on previous learning to enhance critical thinking skills; provide further professional development; prepare RNs for a broader scope of practice; and expand their understanding of complex issues affecting patients and health care delivery.  It takes one to two years to complete the RN-to-BSN program, depending on the RN’s past academic achievement, type of program, and the school’s requirements.  This time frame could be shortened by increasing the number of accelerated RN-to-BSN programs.  Such programs currently exist and are preferred by prospective diploma or associate degree RNs who have families and also hold full-time employment. 

The current nursing shortage is made worse as qualified applicants continue to be turned away from nursing schools because of insufficient faculty and facilities.  The capacity for nursing education programs can be expanded through collaborative linkages and partnerships including more articulation agreements between Associate Degree in Nursing (ADN) programs and four-year institutions offering the Bachelor of Science in Nursing (BSN) programs, and through greater deployment of funding.  Accelerated baccalaureate and master’s degrees in nursing programs for non-nursing graduates provide a way for individuals with undergraduate degrees in other disciplines to build on prior learning experiences and to transition into the field of nursing. 

Because a major impediment to expanded student enrollment capacity involves nurse faculty shortages, approaches for addressing this shortage also need to be implemented.  Such approaches include stimulating interest in academic careers, combining clinical experience with training in academic disciplines, and distance learning.

Nursing and the Work Environment: Improving Outcomes

The increased complexity in health care delivery systems requires changes in the nursing work environment.  Identifying approaches for accommodating the increased complexity is a key step in improving the quality of patient care as well as in retaining nurses in the workforce.  Improving the work environment may involve increasing staffing ratios, making better use of technology, and developing, expanding, and enhancing processes.  Dysfunctional work environments are a significant contributor to stress and burnout.  Any issue that contributes to nurse dissatisfaction is particularly problematic at a time when a shortage in the supply of nurses makes retention so important. 

Recommendations

The National Advisory Council on Nurse Education and Practice (NACNEP) reviewed these challenges at its November 2005 and April 2006 meetings and developed a set of recommendations that are put forward in this report.  The recommendations are outlined below:

1. Prioritize funding for initiatives to increase the proportion of BSNs in the nursing workforce.  Fund programs, demonstration projects, evaluations, and/or research efforts that:

• Prepare nursing faculty to meet the increased demand for BSN-level and higher degree graduates through expansion in number and capacity of PhD programs and provide incentives to encourage practicing nurses to become clinical faculty.  Increase the number of MS-to-PhD programs in nursing.
• Give funding preference to pre-baccalaureate (associate degree/diploma) education programs that demonstrate a plan to foster baccalaureate preparation with partnerships between baccalaureate and pre-baccalaureate programs.
• Employ and integrate technology (e.g., distance learning, simulation) into the educational process and curriculum content.
• Facilitate partnerships between health care systems and nursing programs to matriculate existing nursing personnel into baccalaureate degree programs.

2. Prepare RNs for future challenges by increasing support for efforts to improve nursing education. Fund programs, demonstration projects, evaluations, and/or research efforts that:

• Create shared regional clinical simulation centers, technology centers, and virtual skills labs to complement clinical rotation and provide access to evidence-based practices.
• Prepare students and faculty to deal with surge demands (e.g., sudden increases in the need for nursing services), in order to more effectively address health crises, such as natural or man-made disasters.
• Continue to examine the relationships between the level of nursing education of Registered Nurses in various practice settings and patient outcomes.
• Support partnerships between hospitals and academic nursing institutions to assist hospitals in achieving evidence-based status.
• Identify and disseminate evidence-based practice curriculum models.

3. Increase the diversity of nursing students and the cultural competence and sensitivity of RNs.  Fund programs, demonstration projects, evaluations, and/or research efforts that:

• Prioritize funding for schools and colleges of nursing that identify and implement plans for recruiting, retaining, and graduating more diverse students, and for recruiting and retaining more diverse faculty.
• Apply evidence-based curricular models that prepare existing and future nurses to provide culturally competent care.
• Evaluate and disseminate best-practice models that increase nursing school graduation rates for those groups with lower completion rates.

4. Support initiatives to optimize the nursing work environment. Fund programs, demonstration projects, evaluations, and/or research efforts that:

• Support nursing outcomes research to identify effective nursing practices such as studies of patient-centered care delivery models, the impact of nurse-to-patient ratios, and the use of nursing-sensitive performance measurement.
• Evaluate and improve the nursing work environment and work-flow processes to enhance nurse retention, safety, satisfaction, productivity, and patient outcomes (e.g., via “Enhancing Patient Care” grants that address the aging workforce, decrease job burnout, reduce latent errors, lessen burdensome paperwork, and facilitate technological solutions).
• Improve non-mortality incident (e.g., falls, pressure ulcers) outcome measures and associated data collection in Federally mandated datasets (e.g., Center for Medicare and Medicaid Services data reporting requirements).
• Implement evidence-based RN retention models across the health care system.