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JULY/AUGUST 2011 :: 72(4)
Future of Nursing in North Carolina

The policy forum of this issue takes as its point of departure an April 2011 summit of North Carolina nurse leaders, who met to review and discuss recommendations from The Future of Nursing: Leading Change, Advancing Health, a report recently published by the Institute of Medicine of the National Academies. Commentaries from experts across the state affirm the importance of ensuring that an effective, educated nursing workforce is present; that nursing education involves a seamless process; that nurses can practice to the full extent of their education and training; that nurses are full partners in redesigning health care; and that an effective, comprehensive health care workforce planning system is in place. Also in this issue, original articles address the use Charlotte-area emergency departments for primary care services and the presence of defibrillators in North Carolina public schools.

ISSUE BRIEF

The Future of Nursing and the Health of North Carolinians: The North Carolina Summit

Margaret C. Wilmoth

N C Med J. 2011;72(4):278-281.PDF | TABLE OF CONTENTS



Nurse leaders in North Carolina convened the Statewide Summit for Creating the Future of Nursing and Health Care in North Carolina on April 11, 2011. This article summarizes the summit and lays out the way ahead for implementing, in North Carolina, recommendations from the report on the future of nursing recently published by the Institute of Medicine of the National Academies (IOM). A synopsis of the commentaries composing the policy forum of this issue of the NCMJ follows, linking them to the IOM report.

More than 200 thought leaders from across North Carolina convened at the McKimmon Center on the North Carolina State University campus on April 11, 2011, to discuss the future of the profession of nursing in our state. The Statewide Summit for Creating the Future of Nursing and Health Care in North Carolina was convened by nursing leaders from across the state to both review and discuss with key stakeholders The Future of Nursing: Leading Change, Advancing Health, a report recently published by the Institute of Medicine of the National Academies [1].

Attendees included former Governor James Hunt, chief executive officers of health care systems and professional organizations; physicians; state legislators; other health care professionals, such as dentists; state and local government policy advocates; business owners, and nurse leaders from across the state. Nurse attendees included practitioners, educators, and military service members assigned to posts and bases in North Carolina. Attendees were assigned to preselected seating at tables to ensure diversity of views for facilitated discussions that would take place during the day.

The day began with Donna Havens from the University of North Carolina (UNC)–Chapel Hill opening the summit and orienting attendees to the agenda. She introduced Governor Hunt, who spoke on the health challenges currently facing North Carolinians and the urgent need for nurses, who are educated to care for them. He advocated for removal of licensure limits that restrict the ability of advanced practice nurses to practice at the top of their education and of barriers to reimbursement by insurance companies. Governor Hunt linked the lifting of these impediments to practice to improving access to quality care for all. He also urged the audience to support increasing the level of education required for nurses in North Carolina to more effectively meet the health needs of our citizens. He spoke about not only increasing the numbers of nurses educated at the baccalaureate level, but also the numbers educated at the master’s and doctorate levels, for the sake of the health of North Carolinians.

Leah Devlin, visiting professor at UNC–Chapel Hill, presented an overview of the IOM report and the National Call to Action that arose from the work of the committee that authored the IOM report. She highlighted 2 unique aspects of this IOM report. The first is the report’s call for broad, multisector action to improve the nations’ public health by using nurses in a different, more diverse manner. The IOM report called for societal intervention to strengthen nursing so all will benefit. The second unique aspect of the report is the involvement of the world’s largest health foundation, the Robert Wood Johnson Foundation, in enacting the report’s findings. This IOM report differs from their other work in that the AARP is linking with the Robert Wood Johnson Foundation to move the recommendations in the report to definable action. This unique linkage of the report to an action coalition underscores the critical nature of the profession of nursing to the health of the nation and the effectiveness of the US health system.

Elaine Scott of East Carolina University followed with a review of the 4 key messages from the report and the 8 recommendations that, if all enacted, would greatly enhance the profession’s ability to impact health care access, quality, and costs. Next, a panel presented current initiatives already taking place in North Carolina that are related to the report’s recommendations. Panelists included Pam Silberman, president and chief executive officer of the North Carolina Institute of Medicine (NCIOM), who reviewed the NCIOM’s 2004 report on nursing [2]. The NCIOM report recommended that 60% of North Carolina nurses be prepared with a bachelor of science in nursing for entry into practice; the IOM report sets the bar at 80% for each state by 2020 [1]. This standard has 2 inherent challenges. One is to create new paradigms for seamless educational pathways to move nurses beyond their entry-level education. The second is to reduce the resistance toward increasing the educational preparation by both graduates and faculty in the community college system. Increased emphasis needs to be placed on the positive impact that greater levels of nursing educational preparation has on patient outcomes, while not negating the role of community colleges in the initial entry of many nurses into the health care workforce [3].

Erin Fraher from the Sheps Center for Health Services Research at UNC–Chapel Hill addressed the type of workforce that is necessary to achieve the desired health outcomes among individuals at patient-centered medical homes in the state. Brenda Causey from Asheville-Buncombe Technical Community College spoke about the efforts to increase the numbers of nurses prepared with a bachelor’s degree through the Regionally Increasing Baccalaureate Nurses (RIBN) project. The chief nursing officer at Randolph Hospital, Tremonteo Crawford, presented her hospital’s successful ”transition to practice” project that helps new graduates transition from student to practicing nurse. Finally, Gale Adcock, director of corporate health services at SAS Institute, reported on the work of the North Carolina Board of Nursing in the area of advanced practice nursing.

After the morning panel, attendees were guided through a discussion of the IOM report, its recommendations, and which of the report’s 8 priority recommendations should be emphasized for future action in North Carolina. By use of interactive technologies, each participant selected 3 IOM recommendations that they believed would advance nursing in North Carolina. The 4 recommendations with the most votes were then identified for group discussion during and immediately after lunch. Each attendee was assigned to one of 4 rooms, with each room assigned one of the top 4 recommended priorities, to develop strategies for implementing the assigned recommendation in North Carolina. The 4 recommendations that were discussed in detail and will form the basis for work following the summit were to remove barriers to practice (recommendation 1), expand opportunities for nurses to lead (recommendation 2), increase the proportion of nurses with a bachelor of science in nursing (recommendation 4), and prepare and enable nurses to lead change (recommendation 7). All groups then shared their proposed strategies to move the 4 recommendations forward in North Carolina.

Catherine Gilliss, dean of the School of Nursing at Duke University, closed the summit. She reminded attendees that reforming the health care system to achieve the goals of high-quality, cost-effective, accessible care will require leadership from every sector. All of the health professions must be at the table to reform the system; when the voice of the largest of the health professions—nursing—is absent, the system and the patients, who are at the center of the system, suffer. Gilliss shared with the audience that a coalition of organizations led by the Foundation for the Future of Nursing Education will be applying to the Robert Wood Johnson Foundation to become a “regional action coalition” to ensure a coordinated, collegial effort in moving these recommendations forward in North Carolina.

Gillis closed the summit by saying, “As we look toward addressing these issues we are reminded that we will be best served by keeping the well-being of the public in the center of our screen. Health is broadly conceived and health status is the result of many factors, including economic well-being, community resources, the environment, access to good nutritional choices and the opportunity to exercise safely. Health care services are delivered by many and most patients require a range of services during the course of their lives. Our goals should be to make the needed services accessible for them when they are needed.”

The policy forum of this issue of the NCMJ highlights current work consistent with the goals of the IOM report that is already underway in North Carolina, as well as work that remains. Susan Hassmiller [4] of the Robert Wood Johnson Foundation opens the forum by providing a national perspective on the changes coming to the nursing profession from this seminal report.

Four commentaries address the IOM recommendation of increasing the educational preparation of nurses. R. Scott Ralls [5], president of the North Carolina Community College System, discusses the role of this system in preparing nurses at the associate’s degree in nursing level, the first of many rungs on the educational ladder. Mary “Polly” Johnson, Vincent Hall, and Brenda Causey [6] highlight the RIBN model as one innovative pathway for a seamless progression between community colleges and universities among individuals who have an associate’s degree in nursing and desire baccalaureate preparation. Elaine Scott and Helen Brinson [7] discuss barriers that have precluded more nurses in the state from moving from the associate’s degree in nursing to graduate-level preparation and present some thoughts on how to move forward. Eileen Kohlenberg [8] discusses the state of nursing education in North Carolina at present and recommends 9 innovations in nursing education that are urgently needed to ensure that the citizens of our state are cared for by well-qualified nurses.

Several other articles round out challenges facing nursing education early in this century. Polly Johnson, Joyce Roth, and Pamela Jenkins [9] highlight the current work being done to provide an evidence-based transition-to-practice model for nursing. Elaine Scott [10] thoughtfully addresses the topic of preparing nurses to be leaders. Nursing must join other professionals by being intentional about developing leadership skills and in a way that builds from one level of educational preparation to the next. A recently published editorial by Cleeter [11] describes national efforts to develop leadership skills in nursing faculty. North Carolina must not lag behind these national efforts.

Advanced practice nurses have a long history of providing quality and cost-effective care but are often limited by statutes and regulatory agencies in their ability to practice to the full extent of their education and training. The first of the IOM recommendations addresses this very issue. Three commentaries in the policy forum discuss advanced practice nursing and the barriers they face in North Carolina in providing care. Bobby Lowery and Deborah Varnum [12] provide an overview of the limitations that current regulations governing supervision and insurance reimbursement place on the ability of nurse practitioners in our state to practice at the top of their license and training. An article by Eileen Kugler, Linda Burhans, and Julia George [13] discusses work being done by an advisory committee to move North Carolina nurse practitioners to more autonomous practice. Victoria Soltis-Jarrett [14] rounds out the discussion of nurse practitioners by highlighting the innovative psychiatric nurse practitioner program offered at UNC–Chapel Hill.

Leadership is critical to ensuring that nurses are prepared to partner with other health professionals in designing health care delivery systems. Without leadership development, nurses will remain in the shadows, and their physician colleagues will hire others to do nurses’ work. Connie Mullinix [15] provides a provocative view on the effects of gender and gender politics on the nursing profession. She also suggests that the quality outcomes mandated by the Affordable Care Act that affect the financial viability of hospitals is dependent on expert nursing preparation and the acceptance of nurses as full partners in working to achieve quality outcomes. Delivery of quality care is also dependent on nurses who are skilled in health information technology and knowledgeable about how to use basic statistics to analyze health outcomes of panels of patients with defined chronic diseases. In her commentary, Jane Peace [16] discusses health information technology and its role in measuring health care outcomes.

Recommendation 8 in the IOM report refers to building a workforce database that will provide for collection and analysis of interprofessional health care workforce data. Erin Fraher and Cheryl Jones [17] discuss the importance of developing such a system to ensure an adequate nursing workforce in North Carolina.

The theme of the 2011 Nurses Week was “Nurses: Trusted to Care.” Gallup polls continue to identify nursing as the highest-ranked profession valued for the integrity and high ethical standards of its workforce. Trust, in its most basic form, can be defined as the assured reliance on another individual [18]. Covey [19] takes this further and asserts that it is trust that enables one to be an influential leader. He suggests that trust is the enabling power of leadership influence. Nurses must leverage their position as members of the most trusted profession to lead the improvements in nursing and health care for the benefit of individuals who receive their care.

The Future of Nursing Coordinating Council will be leading the way in North Carolina to ensure that (1) North Carolinians will have an effective, educated nursing workforce; (2) education for nurses is accomplished through a seamless educational process; (3) nurses can practice to the full extent of their education and training; (4) nurses are full partners in redesigning health care in North Carolina; and (5) there is an effective and comprehensive health care workforce planning system in the state (Figure 1).

Acknowledgment
Potential conflicts of interest. M.C.W. has no relevant conflicts of interest.

References
1. Institute of Medicine of the National Academies. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: The National Academies Press; 2011.

2. North Carolina Institute of Medicine (NCIOM). Task Force on the North Carolina Nursing Workforce Report. Durham, NC: NCIOM; 2004. http://www.nciom.org/wp-content/uploads/2010/10/fullreport.pdf. Accessed August 8, 2011.

3. Aiken LH, Clarke SP, Cheung RB, Sloane DM, Silber JH. Educational levels of hospital nurses and surgical patient mortality. JAMA. 2003;290(12):1617-1623.

4. Hassmiller SB. The national perspective on the future of nursing: where we are going. N C Med J. 2011;72(4):324-326 (in this issue).

5. Ralls RS. The role of the North Carolina Community College System in nursing education. N C Med J. 2011;72(4):307-309 (in this issue).

6. Johnson MP, Hall VP, Causey B. Regionally increasing baccalaureate-prepared nurses in North Carolina: the RIBN project. N C Med J. 2011;72(4):304-306 (in this issue).

7. Scott ES, Brinson H. Escalating the pathway from the associate’s degree in nursing to the bachelor of science in nursing and/or the master of science in nursing: what is standing in the way? N C Med J. 2011;72(4):300-303 (in this issue).

8. Kohlenberg E. Contribution of nursing education programs to the implementation of the Affordable Care Act in North Carolina. N C Med J. 2011;72(4):289-292 (in this issue).

9. Johnson MP, Roth JW, Jenkins PR. Evidence-based transition to practice: developing a model for North Carolina. N C Med J. 2011;72(4):282-284 (in this issue).

10. Scott E. Educational preparation to strengthen nursing leadership. N C Med J. 2011;72(4):296-299 (in this issue).

11. Cleeter D. Faculty leadership development: concept or reality? Nurs Outlook. 2011;59(3):109-110.

12. Lowery B, Varnam D. Nurse practitioner practice: policy implications. N C Med J. 2011;72(4):310-313 (in this issue).

13. Kugler EC, Burhans LD, George JL. Removing legal barriers to support advanced practice registered nurses’ ability to practice to the full extent of their education and training. N C Med J. 2011;72(4):285-288 (in this issue).

14. Soltis-Jarrett V. Psych NP-NC: a benchmark graduate nurse practitioner program for meeting the mental health needs of North Carolina. N C Med J. 2011;72(4):293-295 (in this issue).

15. Mullinix C. Making nurses full partners in redesigning health care in North Carolina. N C Med J. 2011;72(4):314-316 (in this issue).

16. Peace J. Nurses and health information technology: working with and around computers. N C Med J. 2011;72(4):317-319 (in this issue).

17. Fraher EP, Jones CB. North Carolina’s nursing workforce: planning today for a reformed tomorrow. N C Med J. 2011;72(4):320-323 (in this issue).

18. Trust. Merriam-Webster Web site. http://www.merriam-webster.com/dictionary/trust. Accessed May 2, 2011.

19. Covey SR. The Speed of Trust: The One Thing That Changes Everything. New York, NY: Free Press; 2006.


Margaret C. Wilmoth, PhD, MSS, RN professor, School of Nursing, College of Health and Human Services, University of North Carolina–Charlotte, Charlotte, North Carolina.

Address correspondence to Dr. Margaret C. Wilmoth, School of Nursing, CHHS, University of North Carolina–Charlotte, 9201 University City Blvd, Charlotte, NC 28269 (mcwilmot@uncc.edu).