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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.


The National Perspective on the Future of Nursing: Where We Are Going

Susan B. Hassmiller

N C Med J. 2011;72(4):324-326.PDF | TABLE OF CONTENTS

The Robert Wood Johnson Foundation and the AARP have embarked on The Future of Nursing: Campaign for Action to strengthen nursing education, enable nurses to practice to the full extent of their education and training, advance interprofessional collaboration, expand nurse leadership, and improve collection of data about the health care workforce.

The Robert Wood Johnson Foundation (RWJF), the nation’s largest health and health care philanthropy, has embarked with AARP, the nation’s largest consumer organization, on The Future of Nursing: Campaign for Action to advance comprehensive health care change. The campaign envisions a nation where all Americans have access to high-quality, patient-centered care in a health care system in which nurses contribute as essential partners in achieving success. The campaign is focusing on the nursing profession because nurses deliver the most patient care and are trained in the coordination of care across the health care spectrum. Risa Lavizzo-Mourey, RWJF president and chief executive officer, often says that our society cannot begin to address the challenges facing our health care system without first addressing the challenges facing the nursing profession. Nurses, working with other members of the health care team, can help ensure that our health care system delivers integrated, equitable, and cost-effective services. Given many health professionals’ increasingly interdependent roles, confronting some of nursing’s key challenges will have broad benefits for every member of the health care team.

The Campaign for Action builds on the recommendations in The Future of Nursing: Leading Change, Advancing Health [1], a recently published report from the Institute of Medicine of the National Academies (IOM) that provides a blueprint for transforming the nursing profession to improve health care and meet the needs of diverse populations.

The campaign’s first goal is to strengthen nursing education and training, to ensure that patients receive safe, high-quality, patient-centered care. In North Carolina and the rest of the country, patient needs have become more complex as the population has become older and sicker, and delivering high-quality care often demands competencies in evidence-based practice, leadership, health policy, research, and the latest medical technology and information management systems. Several studies support a significant association between the educational level of registered nurses and outcomes for patients in the acute care setting, including mortality rates [2-6].

Furthermore, as care moves from the hospital to medical homes and the community, nurses need to be prepared to provide community-based care. Persistent health disparities also demand a diverse workforce that provides culturally competent care. The campaign aims to strengthen nursing education by fulfilling the IOM recommendations of increasing the proportion of nurses with a baccalaureate degree to 80% by 2020, doubling the number of nurses with a doctorate by 2020, and implementing nurse residency programs and promoting lifelong learning.

The second goal is to enable nurses to practice to the full extent of their education and training. The United States faces a primary care shortage, and staffing shortages will be exacerbated during the next decade as millions of newly insured Americans seek care and the average age of the US population continues to increase. Expanding access to primary care requires all nurses to practice to the full extent of their education and training. Moreover, all providers should be able to maximize the time they spend treating patients. Decades of research show that advanced practice registered nurses (APRNs) provide basic primary care services that are as safe, effective, and efficient as those provided by physicians [7-10]. As with any other primary care professionals, APRNs refer patients to a specialty provider if the care required extends beyond the scope of their education, training, and skills.

Yet, regulations in many states, including North Carolina, prevent nurses from being able to give the care that they are trained to provide (Figure 1). North Carolina law requires nurse practitioners to practice with a physician’s supervision, whereas nurse practitioners in other states are able to prescribe medicine and see patients without a physician’s supervision. The Campaign for Action seeks to implement the IOM report recommendation to remove these scope-of-practice barriers so that all nurses can practice to the full extent of their education and training.

The third goal is to advance interprofessional collaboration. Studies demonstrate that effective coordination and communication among health professionals can improve quality and patient safety [11, 12]. Health professionals working together as integrated teams draw on individual and collective skills and experiences across disciplines, allowing each provider to practice at a higher level and deliver better patient care. With more patients having complex health needs, providers will need to work in teams to efficiently and effectively manage and coordinate comprehensive care.

However, medical students, nursing students, and students in other health professions have very little meaningful interaction with each other during their years of formal education, often leaving them ill-prepared to work together as team members. To facilitate interprofessional collaboration, nurses and other health professionals should be educated together as students and during their careers through lifelong learning opportunities. This exposure and collaboration early in educational programs and continuing through postgraduate training will lay the groundwork that is so critical to an improved health care system and culture.

To fulfill the IOM recommendation of implementing early and continuous interprofessional collaboration, the campaign is enlisting professional associations, educational institutions, health care entities, and funders integral to advancing interprofessional collaboration. The campaign will highlight medical centers, primary care settings, and long-term care facilities that successfully implement team-based care.

The fourth goal is to expand nurse leadership. As the health professionals who spend the most time with patients, nurses bring an important voice and point of view to management and policy discussions. Cultivating and promoting leaders within the nursing profession—from the front lines of care to the boardroom—are crucial if nurses are to have a role in improving health care quality, safety, access, and value. The IOM report recommends expanding opportunities for nurses to lead and diffuse collaborative improvement efforts, as well as enabling nurses to lead change to advance health. To achieve these recommendations, the campaign will promote leadership initiatives for nurses at various career stages. Educational programs need to embed relevant competencies and training across health care settings and levels. Leadership development and mentoring programs also need to be made available.

However, as the IOM report makes clear, better leadership must be developed across all of the health professions, and it must foster a culture of mutual respect, collaboration, problem solving, and accountability. Patients and the health care system will be the true beneficiaries.

The fifth goal is to improve the collection of data about the health care workforce. Planning for fundamental, wide-ranging changes in the education and deployment of the nursing workforce will demand comprehensive data about the entire health care workforce. We need better data about the numbers and types of health professionals currently available and what will be needed in the future. Once an improved infrastructure for collecting and analyzing this type of data is available, systematic assessment and projection of workforce requirements by role, skill mix, region, and demographic characteristics should inform future nursing practice and education.

RWJF and the AARP Center to Champion Nursing in America are rallying support across the health care spectrum and engaging health professionals, policymakers, consumer leaders, and prominent officials and groups from government, business, academia, and philanthropy to spur the campaign forward. More than a quarter of the states in the country are involved in official RWJF/AARP Action Coalitions, our grassroots strategy to drive implementation at the state level, and more than half of the states have brought together partnerships independently to begin to work to implement the recommendations. We anticipate that most states will be part of this campaign by the end of 2012.

North Carolina leaders held a statewide summit in April 2011 and developed an action plan to implement the IOM recommendations. To succeed, we need physicians, policymakers, academic researchers, other health professionals, and consumers to join the Campaign for Action in North Carolina. It truly will take all of us. For more information on how to get involved, go to The Future of Nursing: Campaign for Action Web site (available at: Only with your help will we succeed in transforming the health care system so that all Americans receive integrated, equitable, and cost-effective services.

Potential conflicts of interest. S.B.H. has no relevant conflicts of interest.

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

2. 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.

3. Estabrooks CA, Midodzi WK, Cummings GG, Ricker KL, Giovannetti P. The impact of hospital nursing characteristics on 30-day mortality. Nurs Res. 2005;54(2):74-84.

4. Friese CR, Lake RT, Aiken LH, Silber HH, Sochalski J. Hospital nurse practice environments and outcomes for surgical oncology patients. Health Serv Res. 2008;43(4):1145-1163.

5. Tourangeau AE, Doran DM, McGillis Hall L, et al. Impact of hospital nursing care on 30-day mortality for acute medical patients. J Adv Nurs. 2007;57(1);20-29.

6. Van den Heede K, Lesaffre E, Diya L, et al. The relationship between inpatient cardiac surgery mortality and nurse numbers and educational level: analysis of administrative data. Int J Nurs Stud. 2009;46(6):796-803.

7. Mundinger MO, Kane RL, Lenz ER, et al. Primary care outcomes in patients treated by nurse practitioners or physicians: a randomized trial. JAMA. 2000;283(1):59-68.

8. Laurant M, Reeves D, Hermens R, Braspenning J, Grol R, Sibbald B. Substitution of doctors by nurses in primary care. Cochrane Database Syst Rev. 2004;(2):CD001271.

9. Hatem M, Sandall J, Devane D, Soltani H, Gates S. Midwife-led versus other models of care for childbearing women. Cochrane Database Syst Rev. 2008;(4):CD004667.

10. Office of Technology Assessment. Health Technology Case Study 37: Nurse Practitioners, Physician Assistants and Certified Nurse Midwives: A Policy Analysis. Washington, DC: US Government Printing Office; 1986.

11. Barnsteiner JH, Disch JM, Hall L, Mayer D, Moore SM. Promoting interprofessional education. Nurs Outlook. 2007;55(3):144-150.

12. Barr H. Interprofessional Education Today, Yesterday and Tomorrow: A Review. London, United Kingdom: Higher Education Academy, Health Sciences and Practice Network; 2002.

Susan B. Hassmiller PhD, RN senior advisor for nursing, Robert Wood Johnson Foundation, and director, Future of Nursing: Campaign for Action, Princeton, New Jersey.

Address correspondence to Dr. Susan B. Hassmiller, Rte 1 and College Rd East, PO Box 2316, Princeton, NC 08543 (