State Data_1986-2015YearGross state product per capitaEducation sp.docx

State Data_1986-2015YearGross state product per
capitaEducation spending per studentUnemployment ratesHigh
school graduation
rate198614,0402,565.009.168.50198715,0902,573.007.673.9019
8816,2612,717.666.975.00198916,8423,197.006.672.10199017,
5523,327.186.369.50199118,3683,626.566.969.80199219,3673,
615.986.970.40199319,8033,761.136.666.10199420,7934,036.5
35.464.30199521,8824,404.775.264.80199622,6134,716.174.56
2.70199723,4744,903.294.462.40199824,2145,165.563.964.401
99925,2645,511.624.361.30200025,7345,758.434.164.10200126
,5716,052.014.763.70200227,6506,327.235.462.10200328,9676,
642.065.464.70200431,3686,812.245.065.00200533,2747,308.9
33.865.90200634,9147,979.703.566.20200732,4048,390.623.56
7.10200833,6439,103.365.269.00200933,0968,870.0010.169.90
201033,9459,001.009.188.00201134,6509,224.009.772.0020123
5,6258,705.008.075.00201336,5018,755.007.280.00201437,593
8,821.006.886.30201536,7509,611.026.189.30201637,4029,642.
136.087.10
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The Future of Nursing: Leading Change, Advancing Health
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7
Recommendations and Research Priorities
Reflecting the charge to the committee, the purpose of this
report is to con-
sider reconceptualized roles for nurses, ways in which nursing
education system
can be designed to educate nurses who can meet evolving health
care demands,
the role of nurses in creating innovative solutions for health
care delivery, and
ways to attract and retain well-prepared nurses in a variety of
settings. The report
comes at a time of opportunity in health care resulting from the

passage of the
Affordable Care Act (ACA), which will provide access to care
for an additional
32 million Americans. In the preceding chapters, the committee
has described
both barriers and opportunities in nursing practice, education,
and leadership.
It has also discussed the workforce data needed to guide policy
and workforce
planning with respect to the numbers, types, and mix of
professionals that will
be required in an evolving health care environment.
The primary objective of the committee in fulfilling its charge
was to de-
fine a blueprint for action that includes recommendations for
changes in public
and institutional policies at the national, state, and local levels.
This concluding
chapter presents the results of that effort. The committee’s
recommendations are
focused on maximizing the full potential and vital role of nurses
in designing and
implementing a more effective and efficient health care system,
as envisioned by
the committee in Chapter 1. The changes recommended by the
committee are
intended to advance the nursing profession in ways that will
ensure that nurses
are educated and prepared to meet the current and future
demands of the health
care system and those it serves.
This chapter first provides some context for the development of
the com-
mittee’s recommendations. It details what the committee

considered to be its
scope and focus, the nature of the evidence that supports its
recommendations,
2��
2�0 THE FUTURE OF NURSING
cost considerations associated with the recommendations, and
how the recom-
mendations might be implemented. The chapter then presents
recommendations
for nursing practice, education, and leadership, as well as
improved collection
and analysis of interprofessional health care workforce data,
that resulted from
the committee’s review of the evidence.
CONSIDERATIONS THAT INFORMED THE
COMMITTEE’S RECOMMENDATIONS
As discussed throughout this report, the challenges facing the
health care
system and the nursing profession are complex and numerous.
Challenges to
nursing practice include regulatory barriers, professional
resistance to expanded
scopes of practice, health system fragmentation, insurance
company policies,
high turnover among nurses, and a lack of diversity in the

nursing workforce.
With regard to nursing education, there is a need for greater
numbers, better
preparation, and more diversity in the student body and faculty,
the workforce,
and the cadre of researchers. Also needed are new and relevant
competencies,
lifelong learning, and interprofessional education. Challenges
with regard to
nursing leadership include the need for leadership competencies
among nurses,
collaborative environments in which nurses can learn and
practice, and engage-
ment of nurses at all levels—from students to front-line nurses
to nursing execu-
tives and researchers—in leadership roles. Finally,
comprehensive, sufficiently
granular workforce data are needed to ascertain the necessary
balance of skills
among nurses, physicians, and other health professionals for a
transformed health
care system and practice environment.
Solution
s to some of these challenges are well within the purview of the
nursing profession, while solutions to others are not. A number
of constraints
affect the profession and the health care system more broadly.
While legal and

regulatory constraints affect scopes of practice for advanced
practice registered
nurses, the major cross-cutting constraints originate in
limitations of available
resources—both financial and human. These constraints are not
new, nor are they
unique to the nursing profession. The current economic
landscape has magnified
some of the challenges associated with these constraints while
also reinforcing
the need for change. To overcome these challenges, the nursing
workforce needs
to be well educated, team oriented, adaptable, and able to apply
competencies
such as those highlighted throughout this report, especially
those relevant to
leadership.
The nursing workforce may never have the optimum numbers to
meet the
needs of patients, nursing students, and the health care system.
To maximize the
available resources in care environments, providers need to
work effectively
and efficiently with a team approach. Teams need to include

patients and their
families, as well as a variety of health professionals, including
nurses, physicians,
pharmacists, physical and occupational therapists, medical
assistants, and social
RECOMMENDATIONS AND RESEARCH PRIORITIES 2�1
workers, among others. Care teams need to make the best use of
each member’s
education, skill, and expertise, and health professionals need to
practice to the
full extent of their license and education. Just as physicians
delegate to registered
nurses, then, registered nurses should delegate to front-line
caregivers such as
nursing assistants and community health workers. Moreover,
technology needs
to facilitate seamless care that is centered on the patient, rather

than taking time
away from patient care. In terms of education, efforts must be
made to expand
the number of nurses who are qualified to serve as faculty.
Meanwhile, curricula
need to be evaluated, and streamlined and technologies such as
high-fidelity
simulation and online education need to be utilized to maximize
available fac-
ulty. Academic−practice partnerships should also be used to
make efficient use
of resources and expand clinical education sites.
In conducting its work and evaluating the challenges that face
the nursing
profession, the committee took into account a number of
considerations that
informed its recommendations and the content of this report.
The committee care-
fully considered the scope and focus of the report in light of its
charge (see Box
P-1 in the preface to the report), the evidence that was
available, costs associated
with its recommendations, and implementation issues. Overall,
the committee’s

recommendations are geared toward advancing the nursing
profession as a whole,
and are focused on actions required to best meet long-term
future needs rather
than needs in the short term.
Scope and Focus of the Report
Many of the topics covered in this report could have been the
focus of the
entire report. As indicated in Chapter 4, for example, the report
could have fo-
cused entirely on nursing education. Given the nature of the
committee’s charge
and the time allotted for the study, however, the committee had
to cover each
topic at a high level and formulate relatively broad
recommendations. This report
could not be an exhaustive compendium of the challenges faced
by the nursing
workforce, nor was it meant to serve as a step-by-step guide
detailing solutions
to all of those challenges.
Accordingly, the committee limited its recommendations to

those it believed
had the potential for greatest impact and could be accomplished
within the next
decade. Taken together, the recommendations are meant to
provide a strong
foundation for the development of a nursing workforce whose
members are well
educated and well prepared to practice to the full extent of their
education, to
meet the current and future health needs of patients, and to act
as full partners in
leading change and advancing health. Implementation of these
recommendations
will take time, resources, and a significant commitment from
nurses and other
health professionals; nurse educators; researchers; policy
makers and govern-
ment leaders at the federal, state, and local levels; foundations;
and other key
stakeholders.

An emphasis of the committee’s deliberations and this report is
nurses’ role
in advancing care in the community, with a particular focus on
primary care.
While the majority of nurses currently practice in acute care
settings, and much
of nursing education is directed toward those settings, the
committee sees primary
care and prevention as central drivers in a transformed health
care system, and
therefore chose to focus on opportunities for nurses across
community settings.
The committee believes nurses have the potential to play a vital
role in improv-
ing the quality, accessibility, and value of health care, and
ultimately health in
the community, beyond their critical contributions to acute care.
The current
landscape also directed the committee’s focus on primary care;
concern over an
adequate supply of primary care providers has been expressed

and demand for
primary care is expected to grow as millions more Americans
gain insurance
coverage through implementation of the ACA (see Chapters 1
and 2). Addition-
ally, many provisions of the ACA focus on improving access to
primary care,
offering further opportunities for nurses to play a role in
transforming the health
care system and improving patient care.
The committee recognizes that improved primary care is not a
panacea and
that acute care services will always be needed. However, the
committee sees
primary care in community settings as an opportunity to
improve health by
reaching people where they live, work, and play. Nurses serving
in primary care
roles could expand access to care, educate people about health
risks, promote
healthy lifestyles and behaviors to prevent disease, manage
chronic diseases, and
coordinate care.

The committee also focused on advanced practice registered
nurses in its
discussion of some topics, most notably scope of practice.
Recognizing the im-
portance of primary care as discussed above, the committee
viewed the potential
contributions of these nurses to meeting the great need for
primary care services if
they could practice uniformly to the full extent of their
education and training.
Available Evidence
The charge to the committee called for the formulation of a set
of bold
national-level recommendations—a considerable task. To
develop its recom-
mendations, the committee examined the available published
evidence, drew on
committee members’ expert judgment and experience, consulted
experts engaged
in the Robert Wood Johnson Foundation Nursing Research
Network, and com-
missioned the papers that appear in Appendixes F through J on
the CD-ROM in

the back of this report. The committee also called on foremost
experts in nursing,
nursing research, and health policy to provide input,
perspective, and expertise
during its public workshops and forums (described in Appendix
C).
In addition to the peer-reviewed literature and newly
commissioned research,
the committee considered anecdotal evidence and self-
evaluations for emerging
models of care being implemented across the country. Evidence
to support the
diffusion of a variety of promising innovative models informed
the committee’s
deliberations and recommendations. Many of these innovations

are highlighted
as case studies throughout the report, and others are discussed
in the appendixes.
These case studies offer real-life examples of successful
innovations that were
developed by nurses or feature nurses in a leadership role, and
are meant to
complement the peer-reviewed evidence presented in the text.
The committee be-
lieves these case studies contribute to the evidence base on how
nurses can serve
in reconceptualized roles to directly affect the quality,
accessibility, and value of
care. Cumulatively, the case studies and nurse profiles
demonstrate what is pos-
sible and what the future of nursing could look like under ideal
circumstances in
which nurses would be highly educated and well prepared by an
education system
that would promote seamless academic progression, in which
nurses would be
practicing to the full extent of their education and training, and
in which they
would be acting as full partners in efforts to redesign the health
care system.

The committee drew on a wealth of sources of evidence to
support its rec-
ommendations. The recommendations presented are based on
the best evidence
available. There is a need, however, to continue building the
evidence base in
a variety of areas. The committee identified several research
priorities to build
upon its recommendations. For example, data are lacking on the
work of nurses
and the nursing workforce in general, primarily because of a
dearth of large and
well-designed studies explicitly exploring these issues.
Accordingly, the commit-
tee calls for research in a number of areas that would yield
evidence related to the
future of nursing to address some of the shortcomings in the
data it encountered.
Boxes 7-1 through 7-3 list research questions that are directly
connected to the
recommendations and the discussion in Chapters 3 through 5.
The committee
believes that answers to these research questions are needed to
help advance the

profession.
Costs Associated with the Recommendations
The current state of the U.S. economy and its effects on federal,
state, and
local budgets pose significant challenges to transforming the
health care system.
These fiscal challenges also will heavily influence the
implementation of the
committee’s recommendations. While providing cost estimates
for each recom-
mendation was beyond the scope of this study, the committee
does not deny that
there will be costs—in some cases sizable—associated with
implementing its
recommendations. These costs must be carefully weighed
against the potential
for long-term benefit. Expanding the roles and capacity of the
nursing profession
will require significant up-front financial resources, but this
investment, in the
committee’s view, will help secure a strong foundation for a
future health care
system that can provide high-quality, accessible, patient-

centered care. Based on
its expert opinion and the available evidence, the committee
believes that, de-
spite the fiscal challenges, implementation of its
recommendations is necessary
BOX 7-1
Research Priorities for Transforming Nursing Practice
Scope of Practice
•
Comparisonofcosts,qualityoutcomes,andaccessassociatedwithara
ngeof
primarycaredeliverymodels.
•

Examinationoftheimpactofexpandingtherangeofprovidersallowed
tocertify
patientsforhomehealthservicesandforadmissiontohospiceoraskill
ednurs-
ingfacility.
•
toper-
forminitialhospitaladmittingassessments.
•
Captureofintendedandunintendedconsequencesofalternativereim
bursement
mechanismsforadvancedpracticeregisterednurses(APRNs),physic
ians,and
otherprovidersofprimarycare.
•
Explorationoftheimpactofalternativepaymentreformpoliciesonth
eorganiza-
tionandeffectivenessofcareteamsandontheroleplayedbyregistered
nurses
(RNs),physicianassistants,andAPRNsoncareteams.

•
CaptureoftheimpactofhealthinsuranceexchangesontheroleofAPR
Nsin
theprovisionofprimarycareintheUnitedStates.
Residencies
• Identificationof thekey featuresof residencies that result
innursesacquiring
confidenceandcompetencyatareasonablecost.
• Analysis of the possible unintended consequences of
reallocating federal,
state, and/or facility budgets to support residencies and other
nurse training
opportunities.
Teamwork
• Identification of the main barriers to collaboration between
nurses and other
healthcarestaffinarangeofsettings.
•
Identificationandtestingofneworexistingmodelsofcareteamsthath

avethe
potentialtoaddvaluetothehealthcaresystemifwidelyimplemented.
• Identificationand testingofeducational innovations thathave
thepotential to
increasehealthcareprofessionals’abilitytoserveasproductive,colla
borative
careteammembers.
Technology
•
Identificationandtestingofnewandexistingtechnologiesintendedto
support
nurses’decisionmakingandcaredelivery.
•
Captureofthecostsandbenefitsofarangeofcaretechnologiesintende
dto
supportnurses’decisionmakingandcaredelivery.
• Identificationof
thecontributionsofvarioushealthprofessionalstothedesign
and development, purchase, implementation, and evaluation of
devices and

informationtechnologyproducts.
• Development of a measure of “meaningful use” of
information technology by
nurses.
Value
•
Captureoftheimpactofchangesmadetothesystemofcaredeliveryon
costs
andqualityoverthenext5−10years.
•
Captureofthecostsofimplementingtherecommendationsinthisrepo
rt.
• Captureof the impactof implementingtherecommendations in
thisreporton
thecostandqualityofhealthcareprovidedintheUnitedStates.
•
Analysisoftheintendedandunintendedeffectsofincreasingpayment
forpri-
marycareprovidedbyphysiciansandotherproviders.

to increase the quality, accessibility, and value of care through
the contributions
of nurses.
Implementation of the Recommendations
Each of the recommendations presented in this report is
supported by a
level of evidence necessary to warrant its implementation. This
does not mean,
however, that the evidence currently available to support the
committee’s recom-
mendations is sufficient to guide or motivate their
implementation. The research
priorities presented in Boxes 7-1 through 7-3 constitute key
evidence gaps that
need to be filled to convince key stakeholders that each
recommendation is fun-
damental to the transformation of care delivered by nurses. For
example, to be
convinced to purchase equipment necessary to expand the
number of nurses that
can be educated using expensive new teaching technologies,
such as high-fidelity

RECOMMENDATIONS AND RESEARCH PRIORITIES 2��
BOX 7-1
Research Priorities for Transforming Nursing Practice
Scope of Practice
•
Comparisonofcosts,qualityoutcomes,andaccessassociatedwithara
ngeof
primarycaredeliverymodels.
•
tocertify
patientsforhomehealthservicesandforadmissiontohospiceoraskill
ednurs-
ingfacility.

•
toper-
forminitialhospitaladmittingassessments.
•
Captureofintendedandunintendedconsequencesofalternativereim
bursement
mechanismsforadvancedpracticeregisterednurses(APRNs),physic
ians,and
otherprovidersofprimarycare.
•
Explorationoftheimpactofalternativepaymentreformpoliciesonth
eorganiza-
tionandeffectivenessofcareteamsandontheroleplayedbyregistered
nurses
(RNs),physicianassistants,andAPRNsoncareteams.
•
CaptureoftheimpactofhealthinsuranceexchangesontheroleofAPR
Nsin
theprovisionofprimarycareintheUnitedStates.

Residencies
• Identificationof thekey featuresof residencies that result
innursesacquiring
confidenceandcompetencyatareasonablecost.
• Analysis of the possible unintended consequences of
reallocating federal,
state, and/or facility budgets to support residencies and other
nurse training
opportunities.
Teamwork
• Identification of the main barriers to collaboration between
nurses and other
healthcarestaffinarangeofsettings.
•
Identificationandtestingofneworexistingmodelsofcareteamsthath
avethe
potentialtoaddvaluetothehealthcaresystemifwidelyimplemented.
• Identificationand testingofeducational innovations thathave
thepotential to

increasehealthcareprofessionals’abilitytoserveasproductive,colla
borative
careteammembers.
Technology
•
Identificationandtestingofnewandexistingtechnologiesintendedto
support
nurses’decisionmakingandcaredelivery.
•
Captureofthecostsandbenefitsofarangeofcaretechnologiesintende
dto
supportnurses’decisionmakingandcaredelivery.
• Identificationof
thecontributionsofvarioushealthprofessionalstothedesign
and development, purchase, implementation, and evaluation of
devices and
informationtechnologyproducts.
• Development of a measure of “meaningful use” of
information technology by
nurses.

Value
•
Captureoftheimpactofchangesmadetothesystemofcaredeliveryon
costs
andqualityoverthenext5−10years.
•
Captureofthecostsofimplementingtherecommendationsinthisrepo
rt.
• Captureof the impactof implementingtherecommendations in
thisreporton
thecostandqualityofhealthcareprovidedintheUnitedStates.
•
Analysisoftheintendedandunintendedeffectsofincreasingpayment
forpri-
marycareprovidedbyphysiciansandotherproviders.
simulation, distance learning, and online education modalities,
decision makers
in nursing schools will likely need evidence for the impact of
these technologies

on increasing the capacity of the nursing education system, as
well as assurance
that these technologies are an effective way to educate students.
Likewise, before
agreeing to reorganize care and training in a way that supports
nursing residen-
cies, hospitals will likely want to understand the true costs of
such programs, as
well as the key ingredients for their success. And before state
political leaders can
be persuaded to enact legislation to expand and standardize the
scope of practice
for advanced practice registered nurses, they will need messages
to convey to
their constituents about what these changes will mean for
acquiring timely access
to high-quality primary care services.
The committee urges the health services research community to
embark on
research agendas that can produce the evidence needed to guide
the implementa-
tion of its recommendations. At the same time, the committee
recognizes, from

2�� THE FUTURE OF NURSING
BOX 7-2
Research Priorities for Transforming Nursing Education
•
Identificationofthecombinationofsalary,benefits,andjobattributes
thatre-
sultsinthemosthighlyqualifiednursesbeingrecruitedandretainedin
faculty
positions.
• Analysisofhowalternativenursefaculty/studentratiosaffect
instructionand
theacquisitionofknowledge.
•
Captureofhowoptimalnursefaculty/studentratiosvarywiththeimpl
ementa-

tionofneworexistingteachingtechnologies,includingdistancelearn
ing.
•
Identificationofthefeaturesofonline,simulation,andtelehealthnurs
ingedu-
cationthatmostcost-effectivelyexpandnursingeducationcapacity.
• Capture of the experience in nursing schools that include new
curriculum
relatedtoexpandedclinicalsettings,evidence-
basedpractice,andinterprofes-
sionalandpatient-centeredcare.
•
Identificationandevaluationofnewandexistingmodelsofnursinged
ucation
implementedtoensurethatnursesacquirefundamentalcompetencies
needed
toleadandengageincontinuousqualityimprovementinitiatives.
• Identification or development of an assessment tool to ensure
that nurses
have acquired the full range of competence required to practice
nursing in

undergraduate,postgraduate,andcontinuingeducation.
• Analysis of the impact of a range of strategies for increasing
the number
of nurses with a doctorate on the supply of nurse faculty,
scientists, and
researchers.
•
Identificationofthestaffandenvironmentalcharacteristicsthatbests
upport
thesuccessofdiversenursesworkingtoacquiredoctoraldegrees.
•
Identificationandtestingofnewandexistingmodelsofeducationtosu
pport
nurses’engagementinteam-based,patient-
centeredcaretodiversepopula-
tions,acrossthelifespan,inarangeofsettings.
• Development ofworkforcedemandmodels that canpredict
regional faculty
shortages.
the work of Mary Naylor and colleagues (2009), that a strong

evidence base, even
if supported by the results of multiple randomized clinical trials
funded by the
National Institutes of Health, will not be sufficient to propel a
new model, policy,
or practice to a position of widespread acceptance and
implementation. “Health
care is rich in evidence-based innovations, yet even when such
innovations are
implemented successfully in one location, they often
disseminate slowly—if at
all. Diffusion of innovations is a major challenge in all
industries including health
care” (Berwick, 2003).
Experience with the Transitional Care Model (TCM), described
in Chapter
2, illustrates this point. In this case, barriers intrinsic to the way
care is currently
organized, regulated, reimbursed, and delivered have delayed
the ability of a
cost-effective, quality-enhancing model to improve the lives of
the chronically

BOX 7-3
Research Priorities for Transforming Nursing Leadership
•
Identificationofthepersonalandprofessionalcharacteristicsmostcr
itical to
leadershipofhealthcareorganizations,suchasaccountablecareorga
niza-
tions,healthcarehomes,medicalhomes,andclinics.
•
Identificationoftheskillsandknowledgemostcriticaltoleadersofhe
althcare
organizations, such as accountable care organizations, health
care homes,
medicalhomes,andclinics.
•

Identificationofthepersonalandprofessionalcharacteristicsmostim
portant
toleadersofqualityimprovementinitiativesinhospitalsandothersett
ings.
• Identificationof thecharacteristicsofmentors thathavebeen (or
couldbe)
mostsuccessfulinrecruitingandtrainingdiversenursesandnursefac
ulty.
•
Identificationoftheinfluenceofnursingonimportanthealthcaredeci
sionsat
alllevels.
•
Identificationoftheuniquecontributionsofnursestohealthcarecom
mittees
orboards.
ill. Learning from barriers to diffuse evidence-based health care
interventions
within health systems, Naylor and colleagues identified several
ingredients cru-
cial to successful diffusion. First, the model or innovation

should be a good fit in
response to a critical need, either within an organization or
nationwide. Second,
without strong champions, especially those with decision-
making power, there is
very little chance of widespread adoption. The researchers
learned the hard way
the cost of failure to engage all stakeholders in a project—early,
continually, and
throughout. Engagement with the media is especially important.
An understand-
ing of the landscape is necessary as well and should guide
efforts to market the
innovation to others. Milestones and measures of success are
important to all
team members and throughout the entire diffusion process.
Finally, flexibility, or
the willingness to adapt the model or innovation to meet
environmental or orga-
nizational demands, increases the probability of success (Naylor
et al., 2009).
Planning for the implementation of the committee’s
recommendations is
beyond the scope of this report. However, the committee urges

health care pro-
viders, organizations, and policy makers to carry out the eight
recommendations
presented below to enable nurses to lead in the transformation
of the health
care system and advance the health of patients and communities
throughout the
nation.
CONCLUSION
The committee believes the implementation of its
recommendations will
help establish the needed groundwork in the nursing profession
to further the
2�� THE FUTURE OF NURSING
work of nurses in innovating and improving patient care. The

committee sees its
recommendations as the building blocks required to expand
innovative models of
care, as well as to improve the quality, accessibility, and value
of care, through
nursing. The committee emphasizes that the synergistic
implementation of all of
its recommendations as a whole will be necessary to truly
transform the nurs-
ing profession into one that is capable of leading change to
advance the nation’s
health.
RECOMMENDATIONS
Recommendation 1: Remove scope-of-practice barriers.
Advanced practice
registered nurses should be able to practice to the full extent of
their education
and training. To achieve this goal, the committee recommends
the following
actions.
For the Congress:

• Expand the Medicare program to include coverage of advanced
practice
registered nurse services that are within the scope of practice
under ap-
plicable state law, just as physician services are now covered.
• Amend the Medicare program to authorize advanced practice
registered
nurses to perform admission assessments, as well as
certification of
patients for home health care services and for admission to
hospice and
skilled nursing facilities.
• Extend the increase in Medicaid reimbursement rates for
primary care
physicians included in the ACA to advanced practice registered
nurses
providing similar primary care services.
• Limit federal funding for nursing education programs to only
those pro-
grams in states that have adopted the National Council of State
Boards
of Nursing Model Nursing Practice Act and Model Nursing

Administra-
tive Rules (Article XVIII, Chapter 18).
For state legislatures:
• Reform scope-of-practice regulations to conform to the
National Coun-
cil of State Boards of Nursing Model Nursing Practice Act and
Model
Nursing Administrative Rules (Article XVIII, Chapter 18).
• Require third-party payers that participate in fee-for-service
payment
arrangements to provide direct reimbursement to advanced
practice
registered nurses who are practicing within their scope of
practice under
state law.

For the Centers for Medicare and Medicaid Services:
• Amend or clarify the requirements for hospital participation in
the Medi-
care program to ensure that advanced practice registered nurses
are
eligible for clinical privileges, admitting privileges, and
membership on
medical staff.
For the Office of Personnel Management:
• Require insurers participating in the Federal Employees
Health Benefits
Program to include coverage of those services of advanced
practice
registered nurses that are within their scope of practice under
applicable
state law.
For the Federal Trade Commission and the Antitrust Division of
the Department
of Justice:

• Review existing and proposed state regulations concerning
advanced
practice registered nurses to identify those that have
anticompetitive ef-
fects without contributing to the health and safety of the public.
States
with unduly restrictive regulations should be urged to amend
them to
allow advanced practice registered nurses to provide care to
patients in
all circumstances in which they are qualified to do so.
Recommendation 2: Expand opportunities for nurses to lead and
diffuse col-
laborative improvement efforts. Private and public funders,
health care orga-
nizations, nursing education programs, and nursing associations
should expand
opportunities for nurses to lead and manage collaborative
efforts with physicians
and other members of the health care team to conduct research
and to redesign
and improve practice environments and health systems. These
entities should also

provide opportunities for nurses to diffuse successful practices.
To this end:
• The Center for Medicare and Medicaid Innovation should
support the
development and evaluation of models of payment and care
delivery that
use nurses in an expanded and leadership capacity to improve
health out-
comes and reduce costs. Performance measures should be
developed and
implemented expeditiously where best practices are evident to
reflect the
contributions of nurses and ensure better-quality care.
• Private and public funders should collaborate, and when
possible pool
funds, to advance research on models of care and innovative
solutions,

including technology, that will enable nurses to contribute to
improved
health and health care.
• Health care organizations should support and help nurses in
taking
the lead in developing and adopting innovative, patient-centered
care
models.
• Health care organizations should engage nurses and other
front-line staff
to work with developers and manufacturers in the design,
development,
purchase, implementation, and evaluation of medical and health
devices
and health information technology products.
• Nursing education programs and nursing associations should
provide
entrepreneurial professional development that will enable

nurses to initi-
ate programs and businesses that will contribute to improved
health and
health care.
Recommendation 3: Implement nurse residency programs. State
boards of
nursing, accrediting bodies, the federal government, and health
care organiza-
tions should take actions to support nurses’ completion of a
transition-to-practice
program (nurse residency) after they have completed a
prelicensure or advanced
practice degree program or when they are transitioning into new
clinical practice
areas.
The following actions should be taken to implement and support
nurse residency
programs:
• State boards of nursing, in collaboration with accrediting
bodies such
as the Joint Commission and the Community Health
Accreditation Pro-

gram, should support nurses’ completion of a residency program
after
they have completed a prelicensure or advanced practice degree
program
or when they are transitioning into new clinical practice areas.
• The Secretary of Health and Human Services should redirect
all gradu-
ate medical education funding from diploma nursing programs
to sup-
port the implementation of nurse residency programs in rural
and critical
access areas.
• Health care organizations, the Health Resources and Services
Admin-
istration and Centers for Medicare and Medicaid Services, and
philan-
thropic organizations should fund the development and
implementation
of nurse residency programs across all practice settings.
• Health care organizations that offer nurse residency programs
and foun-
dations should evaluate the effectiveness of the residency

programs in
improving the retention of nurses, expanding competencies, and
improv-
ing patient outcomes.
Recommendation 4: Increase the proportion of nurses with a
baccalaureate
degree to 80 percent by 2020. Academic nurse leaders across all
schools of
nursing should work together to increase the proportion of
nurses with a bac-
calaureate degree from �0 to �0 percent by 2020. These leaders
should partner
with education accrediting bodies, private and public funders,
and employers to
ensure funding, monitor progress, and increase the diversity of
students to cre-

ate a workforce prepared to meet the demands of diverse
populations across the
lifespan.
• The Commission on Collegiate Nursing Education, working in
collabo-
ration with the National League for Nursing Accrediting
Commission,
should require all nursing schools to offer defined academic
pathways,
beyond articulation agreements, that promote seamless access
for nurses
to higher levels of education.
• Health care organizations should encourage nurses with
associate’s and
diploma degrees to enter baccalaureate nursing programs within
5 years
of graduation by offering tuition reimbursement, creating a
culture that
fosters continuing education, and providing a salary differential
and
promotion.
• Private and public funders should collaborate, and when

possible pool
funds, to expand baccalaureate programs to enroll more students
by of-
fering scholarships and loan forgiveness, hiring more faculty,
expanding
clinical instruction through new clinical partnerships, and using
technol-
ogy to augment instruction. These efforts should take into
consideration
strategies to increase the diversity of the nursing workforce in
terms of
race/ethnicity, gender, and geographic distribution.
• The U.S. Secretary of Education, other federal agencies
including the
Health Resources and Services Administration, and state and
private
funders should expand loans and grants for second-degree
nursing
students.
• Schools of nursing, in collaboration with other health
professional
schools, should design and implement early and continuous
interpro-

fessional collaboration through joint classroom and clinical
training
opportunities.
• Academic nurse leaders should partner with health care
organizations,
leaders from primary and secondary school systems, and other
commu-
nity organizations to recruit and advance diverse nursing
students.
Recommendation 5: Double the number of nurses with a
doctorate by 2020.
Schools of nursing, with support from private and public
funders, academic ad-
ministrators and university trustees, and accrediting bodies,
should double the
number of nurses with a doctorate by 2020 to add to the cadre
of nurse faculty
and researchers, with attention to increasing diversity.

• The Commission on Collegiate Nursing Education and the
National
League for Nursing Accrediting Commission should monitor the
prog-
ress of each accredited nursing school to ensure that at least 10
percent
of all baccalaureate graduates matriculate into a master’s or
doctoral
program within 5 years of graduation.
• Private and public funders, including the Health Resources
and Services
Administration and the Department of Labor, should expand
funding for
programs offering accelerated graduate degrees for nurses to
increase
the production of master’s and doctoral nurse graduates and to
increase
the diversity of nurse faculty and researchers.
• Academic administrators and university trustees should create

salary and
benefit packages that are market competitive to recruit and
retain highly
qualified academic and clinical nurse faculty.
Recommendation 6: Ensure that nurses engage in lifelong
learning. Accredit-
ing bodies, schools of nursing, health care organizations, and
continuing com-
petency educators from multiple health professions should
collaborate to ensure
that nurses and nursing students and faculty continue their
education and engage
in lifelong learning to gain the competencies needed to provide
care for diverse
populations across the lifespan.
• Faculty should partner with health care organizations to
develop and
prioritize competencies so curricula can be updated regularly to
ensure
that graduates at all levels are prepared to meet the current and
future
health needs of the population.

• The Commission on Collegiate Nursing Education and the
National
League for Nursing Accrediting Commission should require that
all
nursing students demonstrate a comprehensive set of clinical
perfor-
mance competencies that encompass the knowledge and skills
needed
to provide care across settings and the lifespan.
• Academic administrators should require all faculty to
participate in
continuing professional development and to perform with
cutting-edge
competence in practice, teaching, and research.
• All health care organizations and schools of nursing should
foster a
culture of lifelong learning and provide resources for
interprofessional
continuing competency programs.
• Health care organizations and other organizations that offer
continu-
ing competency programs should regularly evaluate their

programs for
adaptability, flexibility, accessibility, and impact on clinical
outcomes
and update the programs accordingly.
Recommendation 7: Prepare and enable nurses to lead change to
advance
health. Nurses, nursing education programs, and nursing
associations should
prepare the nursing workforce to assume leadership positions
across all levels,
while public, private, and governmental health care decision
makers should en-
sure that leadership positions are available to and filled by
nurses.

• Nurses should take responsibility for their personal and
professional
growth by continuing their education and seeking opportunities
to de-
velop and exercise their leadership skills.
• Nursing associations should provide leadership development,
mentoring
programs, and opportunities to lead for all their members.
• Nursing education programs should integrate leadership theory
and busi-
ness practices across the curriculum, including clinical practice.
• Public, private, and governmental health care decision makers
at every
level should include representation from nursing on boards, on
executive
management teams, and in other key leadership positions.
Recommendation 8: Build an infrastructure for the collection
and analysis of
interprofessional health care workforce data. The National
Health Care Work-
force Commission, with oversight from the Government

Accountability Office and
the Health Resources and Services Administration, should lead
a collaborative
effort to improve research and the collection and analysis of
data on health care
workforce requirements. The Workforce Commission and the
Health Resources
and Services Administration should collaborate with state
licensing boards, state
nursing workforce centers, and the Department of Labor in this
effort to ensure
that the data are timely and publicly accessible.
• The Workforce Commission and the Health Resources and
Services
Administration should coordinate with state licensing boards,
including
those for nursing, medicine, dentistry, and pharmacy, to develop
and
promulgate a standardized minimum data set across states and
profes-
sions that can be used to assess health care workforce needs by
demo-
graphics, numbers, skill mix, and geographic distribution.

Services
Administration should set standards for the collection of the
minimum
data set by state licensing boards; oversee, coordinate, and
house the
data; and make the data publicly accessible.
Services
Administration should retain, but bolster, the Health Resources
and
Services Administration’s registered nurse sample survey by
increasing
the sample size, fielding the survey every other year, expanding
the data
collected on advanced practice registered nurses, and releasing
survey
results more quickly.
Services
Administration should establish a monitoring system that uses
the most

current analytic approaches and data from the minimum data set
to
systematically measure and project nursing workforce
requirements by
role, skill mix, region, and demographics.
Services
Administration should coordinate workforce research efforts
with the
Department of Labor, state and regional educators, employers,
and state
nursing workforce centers to identify regional health care
workforce
needs, and establish regional targets and plans for appropriately
increas-
ing the supply of health professionals.

• The Government Accountability Office should ensure that the
Workforce
Commission membership includes adequate nursing expertise.
REFERENCES
Berwick, D. M. 2003. Disseminating innovations in health care.
JAMA 289(15):1969-1975.
Naylor, M. D., P. H. Feldman, S. Keating, M. J. Koren, E. T.
Kurtzman, M. C. Maccoy, and R.
Krakauer. 2009. Translating research into practice: Transitional
care for older adults. Journal
of Evaluation in Clinical Practice 15(6):1164-1170.

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