Nursing Leaders Call for Reforms Relating to Scope of Practice and Nursing Education

NEJM articles by Hassmiller, Aiken and Fairman embrace findings from IOM Nursing Report.

    • January 27, 2011

In a pair of articles in the December 15, 2010, issue of the New England Journal of Medicine, key nursing leaders argue that the profession has a critical role to play in implementing the Affordable Care Act, but that critical reforms to the education of nurses and the scope of their practice are needed.

“Broadening the Scope of Nursing Practice” is a joint article by Julie A. Fairman, Ph.D., R.N., F.A.A.N., a 2006 recipient of a Robert Wood Johnson Foundation (RWJF) Investigator Award in Health Policy Research (2006); John W. Rowe, M.D.; Susan Hassmiller, Ph.D., R.N., F.A.A.N., the RWJF senior adviser for nursing; and Donna E. Shalala, Ph.D. The authors were all participants in the Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine (IOM), with Shalala the chair, Rowe a member of the committee, Hassmiller the staff study director and Fairman a member of the study staff. In the article, they write that, for health care reform to succeed, “all health care providers must be permitted to practice to the fullest extent of their knowledge and competence. This will require establishing a standardized and broadened scope of practice for advanced-practice registered nurses — in particular, nurse practitioners — for all states.”

Writing in a medical journal with a target audience of physicians, the authors note that some physicians’ organizations have expressed concerns that nurse practitioners cannot deliver primary care services “that are as high-quality or safe as those of physicians.” However, they write, “Evidence from many studies indicates that primary care services, such as wellness and prevention services, diagnosis and management of many common uncomplicated acute illnesses, and management of chronic diseases such as diabetes can be provided by nurse practitioners at least as safely and effectively as by physicians.” Moreover, they note, “physicians’ additional training has not been shown to result in a measurable difference from that of nurse practitioners in the quality of basic primary care services. We are not arguing that nurse practitioners are substitutes for these physicians, but rather that we should consider how primary care services can be more effectively provided to more people with the use of the full primary care workforce.”

State laws are the chief barrier to nurses practicing to the full extent of their training. Sixteen states and the District of Columbia allow nurse practitioners to practice and prescribe independently, the authors note, and other states are moving in that direction.

The authors write that in states that do not yet allow nurses to practice to the extent of their training, the development of such cost-effective approaches as retail clinics and medical homes has been hindered. “Research in Massachusetts shows that using nurse practitioners or physician assistants to their full capacity could save the state $4.2 billion to $8.4 billion over 10 years and that greater use of retail clinics staffed primarily by nurse practitioners could save an additional $6 billion,” they say.

They also observe that nurse practitioners’ training is faster and considerably cheaper than physicians’. “Between three and 12 practitioners can be educated for the price of educating one physician, and more quickly,” they write.

“This is a critical time to support an expanded, standardized scope of practice for nurses,” they conclude. “Economic forces, demographics, the gap between supply and demand and the promised expansion of care necessitate changes in primary care delivery. A growing shortage of primary care providers seems to ensure that nurses will ultimately be required to practice to their fullest capacity. Fighting the expansion of nurse practitioners' scope of practice is no longer a defensible strategy. The challenge will be for all health care professionals to embrace these changes and come together to improve U.S. health care.”

Reforming Nurse Education

In the same issue of the New England Journal of Medicine, Linda Aiken, Ph.D., F.A.A.N., F.R.C.N., R.N., a 1988 recipient of a RWJF Investigator Award in Health Policy Research and a former vice president at RWJF, addresses the need to increase the proportion of nurses who hold at least a bachelor’s degree.

In her article, “Nurses for the Future,” Aiken notes that “Within the next 10 years, half of nursing-school faculty members will reach retirement age; the anticipated attrition represents a crisis in the making, with potentially far-reaching consequences for the replenishment of the nurse workforce, which is itself on the verge of losing some 500,000 nurses to retirement.” The core of the problem is that the current graduation rates for nurses with master’s degrees or higher—potential nursing school faculty members—are too low to maintain current faculty sizes as those retirements begin.

The solution Aiken embraces is to increase the proportion of nurses who enter the workforce with a bachelor’s degree or higher, because those nurses are considerably more likely to go on to receive the advanced degrees that would allow them to teach subsequent generations of nurses. She writes that the most promising strategy for accomplishing that transition “is for all pre-licensure nurse-education programs to confer bachelor's degrees. Because of licensure requirements, there is no longer a substantial difference in the time to completion of associate's and bachelor's degrees in nursing: both take about three years of full-time study.”

Aiken observes that the IOM’s “Future of Nursing” report calls for discontinuing hospital diploma programs entirely, and a doubling of the number of doctoral nurses by 2020. She goes on to call for increased federal funding for baccalaureate education.

“It will be extremely difficult, if not impossible,” she concludes, “to generate enough nursing faculty, [advanced practice registered nurses) and nurses to fill leadership and executive roles requiring graduate-level education if entry-level nursing education does not shift entirely to the baccalaureate level. The stakeholders (educational institutions and students) will respond to financial incentives—which are, after all, the tried-and-true American way of bringing about change.”