IOM Nursing Reports
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REPORT IN BRIEF Institute of Medicine
DECEMBER 2015
Assessing Progress on the
Institute of Medicine Report
The Future of Nursing
In 2010, the Institute of Medicine (IOM) released a landmark report, The Future of Nursing: Leading Change, Advancing Health, that addressed the crucial role of nurses in a rapidly evolving health care landscape. Shortly after the release of this
report, the Robert Wood Johnson Foundation (RWJF), in partnership with AARP,
launched the Future of Nursing: Campaign for Action (the Campaign). The Cam-
paign has since worked at the national and state levels to shepherd the report’s
recommendations.
RWJF asked the IOM to convene a committee to examine changes in the fi eld of nurs-
ing since the release of The Future of Nursing report and to assess progress made in
implementing the report’s recommendations. The resulting report, Assessing Progress
on the Institute of Medicine Report The Future of Nursing, offers recommendations
that provide a blueprint for the Campaign and other stakeholders to accelerate
implementation of The Future of Nursing recommendations.
CONTEXT
The more than 3 million registered U.S. nurses make up the largest segment of the
nation’s health care system. Nurses work in a wide variety of settings, including
hospitals, public health centers, schools, and homes, and they provide a continuum
of services including direct patient care, health promotion, patient education, and
coordination of care.
The Affordable Care Act created new health care delivery and payment models that
emphasize teamwork, care coordination, value, and prevention: models in which
nurses can contribute a great deal of knowledge and skill. Indeed, the nursing pro-
fession is making a wide-reaching impact by providing quality, patient-centered, ac-
cessible, and affordable care. The 2010 report issued a number of recommendations
aimed at helping to ensure that nurses are prepared to help fi ll the need for quality
health care in a fundamentally shifting care delivery system.
The Campaign and many other stakeholders have worked to prepare nurses for new
and vital roles. The current committee fi nds that the Campaign has made signifi cant
The nursing profession is
making a wide-reaching
impact by providing
quality, patient-centered,
accessible, and aff ordable
care.
2
progress in many aspects of its work in a short period of
time. For continued progress, work in specifi c areas, as
outlined below, requires more focus and attention.
AREAS OF RECOMMENDATION
In a changing health care culture and landscape, with
increasing importance placed on interprofessional
collaboration, the Campaign, the fi eld of nursing, and
stakeholders in other professions working to improve
health care delivery can continue to make signifi cant
contributions by addressing challenges in the areas of
health care delivery and scope of practice, education,
collaboration, leadership, diversity in the nursing profes-
sion, and workforce data.
Removing Barriers to Practice and Care
The 2010 report proposed that Advanced Practice Reg-
istered Nurses (APRNs), if permitted to practice to the
full extent of their education and training, could help
build the workforce necessary to satisfy the health care
needs of an increasing number of people with access to
health insurance and contribute their unique skills to the
delivery of patient-centered health care. Steps have been
taken at both the federal and state levels, but barriers to
expanding APRN scope of practice remain.
Collaborative models of practice, in which all health
professionals practice to the full extent of their education
and training, optimize the effi ciency and quality of care
for patients and enhance the satisfaction of health care
providers. The committee recommends that the Cam-
paign work with other health professions groups, policy
makers, and the nursing community to build common
ground around removing scope of practice restrictions
and increasing interprofessional collaboration to improve
health care practice in the interest of patients.
Transforming Education
Transformation in the health care system and practice
environments requires a corresponding transformation
of nursing education. For nurses to be prepared to meet
increasingly complex patient needs, function as leaders,
and advance science, they should achieve higher levels
of education, at the time they enter into the profession
and throughout their careers. For this reason, the com-
mittee recommends expanding educational opportuni-
ties, including efforts to: (1) support academic pathways
toward the baccalaureate degree; (2) explore ways to
create and fund transition-to-practice residency pro-
grams; (3) promote the pursuit of doctoral degrees, with
an emphasis on the Ph.D.; and (4) promote interprofes-
sional and lifelong learning.
Collaborating and Leading
Nurses are needed to lead and participate in ongoing
reforms to the health care system, to direct research
on evidence-based improvements to care, to translate
research fi ndings into practice, to be full partners on the
health care team, and to advocate for policy change.
Nurses in leadership positions contribute their unique
perspective and expertise on issues such as health care
delivery, quality, and safety. The committee recommends
that the Campaign work to expand efforts and opportu-
nities for interprofessional collaboration and leadership
development. The Campaign also should encourage
nurses to serve in executive and leadership positions—in-
cluding those at health care systems, insurance compa-
nies, government agencies, and advisory committees—
such that they may be involved in the redesign of health
care delivery and payment systems.
Promoting Diversity
The 2010 report identifi ed lack of diversity as a challenge
for the profession and indicated that a more diverse
3
workforce would help better meet current and future
health care needs and provide more culturally relevant
care. The Campaign has made diversity one of its pil-
lars, and nationwide, many stakeholder organizations
in health care, education, and government have taken
steps to increase the diversity of the nursing workforce
and that of the health professions more broadly. The
committee recommends that the Campaign continue to
prioritize diversity and implement a series of actions to
promote it.
Improving Data
There are major gaps in understanding numbers and
types of health professionals, where they are employed,
and what roles they fi ll. Yet this knowledge is critical to
support new models of health care delivery and im-
prove patient care. The committee recommends that
the Campaign use its strong brand and partnerships
to help improve data collection. The Campaign should
play a role in convening, supporting, and promoting
collaboration among organizations and associations to
consider how they might create more robust data sets
and how certain data sets can be organized and made
available to researchers, policy makers, and planners. The
federal government and states also should play a role
by expanding existing data collection activities to better
measure and monitor the role of nurses in the health
care workforce.
CONCLUSION
No single profession, working alone, can meet the
complex needs of patients and communities. Nurses
should continue to develop skills and competencies in
leadership and innovation and collaborate with other
professionals in health care delivery and health system
redesign. To continue progress on the implementation
of The Future of Nursing recommendations and to effect
change in an evolving health care landscape, the nursing
community, including the Campaign, must build and
strengthen coalitions with stakeholders both within and
outside of nursing. The committee hopes that its recom-
mendations will help the Campaign and other organiza-
tions as they work to improve access to quality health
care for all. ♦ ♦ ♦
No single profession, working alone, can
meet the complex needs of patients and
communities. Nurses should continue to
develop skills and competencies in leader-
ship and innovation and collaborate with
other professionals in health care delivery
and health system redesign.
Committee for Assessing Progress on Implementing the
Recommendations of the Institute of Medicine Report
The Future of Nursing: Leading Change, Advancing Health
Stuart H. Altman (Chair)
Brandeis University
Carmen Alvarez
Johns Hopkins University
Cynthia C. Barginere
Rush University Hospital
Richard A. Berman
University of South Florida
Karen Donelan
Massachusetts General Hospital
and Harvard Medical School
Suzanne Ffolkes
Research!America
Paula Gubrud
Oregon Health & Science
University
Jack Needleman
University of California, Los
Angeles
Michele J. Orza
Patient-Centered Outcomes
Research Institute
Robert L. Phillips
American Board of Family
Medicine
Edward Salsberg
George Washington University
George E. Thibault
Josiah Macy, Jr. Foundation
Study Staff
Adrienne Stith Butler
Study Director
Lauren Shern
Program Offi cer
Thelma L. Cox
Administrative Assistant
Lora K. Taylor
Financial Associate
Andrew M. Pope
Director, Board on Health
Sciences Policy
Study Sponsor
Robert Wood Johnson
Foundation
iom.nationalacademies.org
Copyright 2015 by the National Academy of Sciences.
All rights reserved.
The Future of Nursing
Leading Change, Advancing Health
Advising the nation/Improving health
For more information visit
www.iom.edu
/nursing
Report Recommendations
1 RepoRT ReCommeNdATIoNs
Key messages
Nurses should practice to the full extent of their education and training.•
Nurses should achieve higher levels of education and training through an •
improved education system that promotes seamless academic progression.
Nurses should be full partners, with physicians and other health care professionals, •
in redesigning health care in the United States.
Effective workforce planning and policy making require better data collection •
and an improved information infrastructure.
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 applicable 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 programs in states that
have adopted the National Council of State Boards of Nursing Model Nursing Practice Act
and Model Nursing Administrative Rules (Article XVIII, Chapter 18).
For state legislatures:
• Reform scope-of-practice regulations to conform to the National Council 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 pro-
vide direct reimbursement to advanced practice registered nurses who are practicing within
their scope of practice under state law.
2 THe FuTuRe oF NuRsINg
For the Centers for Medicare and Medicaid Services:
• Amend or clarify the requirements for hospital participation in the Medicare 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 effects 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 circum-
stances in which they are qualified to do so.
Recommendation 2: expand opportunities for nurses to lead and diffuse collabora-
tive improvement efforts. Private and public funders, health care organizations, nursing educa-
tion 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 lead-
ership capacity to improve health outcomes 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.
3 RepoRT ReCommeNdATIoNs
• Nursing education programs and nursing associations should provide entrepreneurial pro-
fessional development that will enable nurses to initiate 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 organizations should take actions to sup-
port nurses’ completion of a transition-to-practice program (nurse residency) after they have com-
pleted 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 Commis-
sion and the Community Health Accreditation Program, 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 graduate medical education
funding from diploma nursing programs to support the implementation of nurse residency
programs in rural and critical access areas.
• Health care organizations, the Health Resources and Services Administration and Centers
for Medicare and Medicaid Services, and philanthropic organizations should fund the devel-
opment and implementation of nurse residency programs across all practice settings.
• Health care organizations that offer nurse residency programs and foundations should evalu-
ate the effectiveness of the residency programs in improving the retention of nurses, expand-
ing competencies, and improving 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 baccalaureate degree from 50 to 80 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 create a workforce prepared
to meet the demands of diverse populations across the lifespan.
• The Commission on Collegiate Nursing Education, working in collaboration 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 reim-
bursement, creating a culture that fosters continuing education, and providing a salary dif-
ferential and promotion.
4 THe FuTuRe oF NuRsINg
• Private and public funders should collaborate, and when possible pool funds, to expand bac-
calaureate programs to enroll more students by offering scholarships and loan forgiveness,
hiring more faculty, expanding clinical instruction through new clinical partnerships, and
using technology to augment instruction. These efforts should take into consideration strate-
gies 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 interprofessional collaboration through joint class-
room and clinical training opportunities.
• Academic nurse leaders should partner with health care organizations, leaders from primary
and secondary school systems, and other community 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 administrators 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 progress 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.
5 RepoRT ReCommeNdATIoNs
Recommendation 6: ensure that nurses engage in lifelong learning. Accrediting bod-
ies, schools of nursing, health care organizations, and continuing competency 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 competen-
cies 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 compre-
hensive set of clinical performance 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 profes-
sional 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 learn-
ing and provide resources for interprofessional continuing competency programs.
• Health care organizations and other organizations that offer continuing competency pro-
grams 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 ensure 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 develop 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 business 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.
6 THe FuTuRe oF NuRsINg
Recommendation 8: Build an infrastructure for the collection and analysis of inter-
professional health care workforce data. The National Health Care Workforce 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
professions that can be used to assess health care workforce needs by demographics, num-
bers, skill mix, and geographic distribution.
• The Workforce Commission and the Health Resources and 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.
• The Workforce Commission and the Health Resources and 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.
• The Workforce Commission and the Health Resources and 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 require-
ments by role, skill mix, region, and demographics.
• The Workforce Commission and the Health Resources and Services Administration should
coordinate workforce research efforts with the Department of Labor, state and regional edu-
cators, employers, and state nursing workforce centers to identify regional health care work-
force needs, and establish regional targets and plans for appropriately increasing the supply
of health professionals.
• The Government Accountability Office should ensure that the Workforce Commission mem-
bership includes adequate nursing expertise.
7 CommITTee LIsT
Committee on the Robert Wood Johnson Foundation Initiative on
the Future of Nursing, at the Institute of medicine
Donna E. Shalala (Chair)
President, University of Miami, Coral Gables, FL
Linda Burnes Bolton (Vice Chair)
Vice President and Chief Nursing Officer, Cedars-Sinai Health System and Research Institute, Los
Angeles, CA
Michael R. Bleich
Dean and Dr. Carol A. Lindeman Distinguished Professor, Vice Provost for Inter-professional Edu-
cation and Development, Oregon Health & Science University School of Nursing, Portland
Troyen A. Brennan
Executive Vice President, Chief Medical Officer, CVS Caremark, Woonsocket, RI
Robert E. Campbell
Vice Chairman (retired), Johnson & Johnson, New Brunswick, NJ
Leah Devlin
Professor of the Practice, University of North Carolina at Chapel Hill School of Public Health,
Raleigh
Catherine Dower
Associate Director of Research, Center for the Health Professions, University of California, San
Francisco
Rosa Gonzalez-Guarda
Assistant Professor, School of Nursing and Health Studies, University of Miami, Coral Gables, FL
David C. Goodman
Professor of Pediatrics and of Health Policy, and Director, Center for Health Policy Research, The
Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH
Jennie Chin Hansen
Chief Executive Officer, American Geriatrics Society, New York
C. Martin Harris
Chief Information Officer, Cleveland Clinic, OH
8 THe FuTuRe oF NuRsINg
Anjli Aurora Hinman
Certified Nurse-Midwife, Intown Midwifery, Atlanta, GA
William D. Novelli
Distinguished Professor, McDonough School of Business, Georgetown University, Washington,
DC
Liana Orsolini-Hain
Nursing Instructor, City College of San Francisco, CA
Yolanda Partida
Director, National Center, Hablamos Juntos, and Assistant Adjunct Professor, Center for Medical
Education and Research, University of California, San Francisco, Fresno
Robert D. Reischauer
President, The Urban Institute, Washington, DC
John W. Rowe
Professor, Mailman School of Public Health, Department of Health Policy and Management,
Columbia University, New York
Bruce C. Vladeck
Senior Advisor, Nexera Consulting, New York
The Institute of medicine serves as adviser to the nation to improve health.
Established in 1970 as the health arm of the National Academy of Sciences,
the Institute of Medicine is a nonprofit organization that works outside of government
to provide unbiased and authoritative advice to decision makers and the public.
Advising the nation / Improving health
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Washington, DC 20001
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