The Future of Nursing: Leading Change, Advancing Health report compiled by the  Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing at the Institute of Medicine (IOM) was released in October 2010.  The report has generated lively discussions from multiple disciplines about scope of practice, educational preparation and training, and leadership roles of nurses at all levels.  Eight recommendations are included in the report:

1.     Remove scope-of-practice barriers.

2.     Expand opportunities for nurses to lead and diffuse collabora¬tive improvement efforts.

3.     Implement nurse residency programs.

4.     Increase the proportion of nurses with a baccalaureate degree to 80 percent by 2020.

5.     Double the number of nurses with a doctorate by 2020.

6.     Ensure that nurses engage in lifelong learning.

7.     Prepare and enable nurses to lead change to advance health.

8.     Build an infrastructure for the collection and analysis of inter¬professional health care workforce data. (http://iom.edu/~/media/Files/Report%20Files/2010/The-Future-of-Nursing/Future%20of%20Nursing%202010%20Recommendations.pdf)

I will comment on Number 5 which addresses doubling the number of nurses with a doctorate by 2020 – the research PhD and the clinical Doctor of Nursing Practice (DNP).  Questions that are commonly asked about DNP preparation include: (1) Why should there be a shift to doctoral preparation for advanced practice nurses (APNs)? (2) Will master’s prepared nurses no longer be qualified to continue to provide services as APNs? (3) If the goal is to address the primary care shortage, how does extending training achieve that? (4) Will increasing the debt load of potential providers but not the income generate the same specialization migration that has plagued physicians?  Quick responses are: (1) The time has come; (2) No, this change will not disenfranchise currently licensed and certified APNs; (3) APNs will have a value-added skill set to help improve quality of care and health outcomes; (4) Specialization will not become the norm.

The DNP degree is designed to prepare advanced practice nurses with increased value-added skills in leadership, systems thinking, evidence-based practice, health care policy, health information technology, and population health.  Current master’s curricula are already overloaded with trying to provide all of these essential inputs to creating the optimal nursing workforce.  Adding more credits to include mandatory content in basic curricula is not realistic.  Graduates are expected to demonstrate competencies in broad areas reflecting the increasing complexity of care delivery.  Many master’s programs are beyond 60 credits now; on average, students take 2 years full-time and 3-5 years part time to earn a master’s degree.  The DNP is 2 years post-masters and 3 years post baccalaureate for full-time study.  The trade off of a few more months in school for a more highly prepared APN should not even be a point for discussion.  APNs will still be prepared at the master’s level unless the DNP becomes entry level to practice by 2015, as recommended by the American Association of Colleges of Nursing (AACN).

Many nurses have not entered doctoral studies because they were not interested in pursuing research careers; the DNP degree provides an option for those who want to earn a final degree in nursing.  The investment of time and money does pose challenges for nurses who are working full-time and have multiple other life responsibilities.  Personal motivation is a major driving force for APNs who do enroll in DNP programs.  DNP programs have been attractive to nurses from diverse backgrounds – primary care and specialty care, rural and urban settings, and the experienced and the novice.  A number of APNs already work in specialty practices and emerging changes in APN educational preparation through the Consensus agreement (http://www.aacn.nche.edu/Education/pdf/APRNReport.pdf) creates more standardized curricula, education and training, for all APNs.  The number of APN graduates who might opt for specialties instead of primary care probably will not increase in most areas of practice.  Opportunities for clinical faculty positions in academic institutions secondary to the nursing faculty shortage is another driving force encouraging enrollments in DNP programs.  As the DNP role becomes more defined, the value of their added skills will be recognized, and compensation will follow accordingly.

The IOM report offers strategies for achieving greater numbers of nurses with doctoral degrees.  Two main actions required from schools of nursing are to review current curricula and revise to make progression from basic preparation to more advanced degrees a more seamless process and to obtain increased levels of financial assistance from private and government sources.  Without addressing these two areas, especially in tough economic times, preparing nurses at any level becomes increasingly difficult.

Downloadable free copy of full report: http://www.iom.edu/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health.aspx.

Burman et al. (2005): http://ajcc.aacnjournals.org/content/14/6/463.full.pdf+html

Newland (2011): http://journals.lww.com/tnpj/Fulltext/2011/04000/The_Doctor_of_Nursing_Practice__What_are_your.1.aspx

Miller (2008): http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2605113/

American Association of Colleges of Nursing (2009): http://www.aacn.nche.edu/DNP/DNPFAQ.htm

Clinton & Sperhac (2009): http://www.con.ohio-state.edu/attachments/Doctoral_programs/DNP_Issues_and_Consequences_article.pdf

Barry (2009): http://www.nursingcenter.com/library/JournalArticle.asp?Article_ID=856423

Nova Scotia Premier Darrell Dexter has announced in a speech earlier this month plans for a $16-million collaborative primary care clinic in Queens County. The overarching goal is to bring Better Care Sooner to Nova Scotia residents by reshaping how emergency care is delivered.

The collaborative care clinic will have space for five  family  physicians, a nurse practitioner, family practice nurses and  other  health professionals.The new plans also call for an upgraded 22-bed  inpatient unit.

Additionally the Better Care Sooner is poised to:

-improve access to primary care, especially in smaller communities.

-make emergency care more patient-centered and streamlined.

-provide care that is better tailored to those whose needs are more complex (i.e. seniors).

-increase public awareness of 911 and the healthlink nurse line 811.

-make changes to the way health care is funded (reward better, patient-centered care).

The government states that roughly 84 percent of ER visits at the hospital would be better addressed by primary care.

Dexter says the province is committing $2.5 million to the project while the Region of Queens Municipality has committed $1 million.

About $11 million comes from the Queens Foundation and private donors, and another $1.5 million still needs to be raised.

Check out the whole story at http://www.canadaviews.ca/2010/12/23/improvements-will-ease-er-overcrowding-access-to-care/

On December 15, 2009, Hope Street Group brought together an impressive group of major stakeholders in health care reform to continue discussing some of the most pressing issues in health care reform. Over the last 18 months, the Bipartisan Working Group has tackled some of the toughest and most important issues in health care reform such as cost, quality, and access. This last dinner shifted gears a bit and focused issues regarding current legislation and implementation as well as issues outside of legislation, such as revitalizing primary care.

You can find the full executive summary of the dinner here, however here are some key points from the primary care discussion for you all to ponder:

• The notion that physicians are not going into primary care due to high levels of medical school debt is a fallacy. Since physicians training at military medical schools without any medical school debt still don’t go into primary care.

• The primary care issue focuses on improving the supply of primary care physicians and does not place a strong enough focus on increasing quality care for patients. This needs to be turned around and thought in terms of how to best address the needs of primary care patients.

• Primary care is not just about the physician shortage. We need to look at expanding the role of nurses, especially in chronic disease management. There is a real opportunity here to improve efficiency and quality.

• Medical schools need to stop basing all of their residency training in tertiary centers (specialty hospitals) which biases students toward specialties over primary care since primary care seems less intellectually satisfying.

Do you agree with any of these comments? Disagree?  Log in or register to post comments!