Nurses tapped for more training, bigger role in health care

The Institute of Medicine says nurses' roles, responsibilities and education should change significantly to meet the increased demand for care expected from health care reform.

Further, nurses should train alongside other health professionals and assume leadership roles in redesigning care, stated the report. Nurses should undergo residencies, increase their ranks of those with bachelor's degrees from 50% to 80% by 2020, ensure that at least 10% of their baccalaureates enter a master's or doctoral program within five years, and double the number of doctoral candidates.

There are more than 3 million nurses in the U.S., and because of their direct patient contact and the proportion of time the profession spends in direct patient care, “Nurses should be full partners, with physicians and other health professionals, in redesigning health care in the United States,” the report said.

Once nurses are trained, scope of practice limits should be lifted, the report stated, as should insurance and regulatory hurdles, so that the health system can reap the full benefit. Scope of practice barriers are particularly problematic for advanced practice registered nurses (APRNs), the report found.

Studies of advanced practice nurses and the experiences of health care organizations, such as the Veterans Health Administration, Geisinger Health System, and Kaiser Permanente, that have increased the roles and responsibilities of nurses in patient care show that these nurses deliver safe, high-quality primary care.

In one example, the VA had been transforming itself since the 1990s in anticipation of an aging veteran population. The results of the VA's initiatives using both front-line RNs and APRNs showed that patients received significantly better health care based on various quality-of-care indicators such as mammography, flu and pneumococcal vaccination, cancer screening and other conditions than patients enrolled in Medicare's fee-for-service program. In some cases, the study showed, between 93% and 98% of VA patients received appropriate care in 2000; the highest score for comparable Medicare patients was 84%. Meanwhile, spending per enrollee rose much more slowly than in Medicare, by 30% from 1999 to 2007 compared with 80% for Medicare over the same period.

The report is the product of a study convened by the Robert Wood Johnson Foundation Initiative on the Future of Nursing, which will organize a national conference at the end of November to discuss implementation.

The conclusions aren't without detractors. The American Medical Association responded, “Nurses are critical to the health care team, but there is no substitute for education and training. Physicians have seven or more years of postgraduate education and more than 10,000 hours of clinical experience; most nurse practitioners have just two-to-three years of postgraduate education and less clinical experience than is obtained in the first year of a three year medical residency. These additional years of physician education and training are vital to optimal patient care, especially in the event of a complication or medical emergency, and patients agree.”