The Future of Nursing 2020–2030 Charting a Path to Achieve Health Equity report, issued by the National Academy of Medicine Committee on the Future of Nursing 2020-2030, is addressing topics that will impact the nursing industry in the coming years. Sponsored by the Robert Wood Johnson Foundation, the report examined issues and topics foremost on the minds of those in the industry and brought forward recommendations to help guide important changes including scope of practice regulations, health and well-being of nurses, and better payment models.
Currently, 27 states restrict the autonomous practice of nurse practitioners, despite the nurses having the education and training to practice in such a manner. With advocates working to remove these remaining restrictions, Cunningham says the progress is happening, but slow. “Each state has regulations that govern advanced practice registered nurse scope of practice,” she says. “When we say APRN, there are really four groups of nurses we are talking about. Most commonly it is nurse practitioners, but also includes certified nurse midwives, certified registered nurse anesthetists, and clinical nurse specialists.” The report also looks at the institutional barriers for other nurses, including registered nurses (RNs) and licensed practical nurses (LPNs), to allow them to practice to the top of their education and training.
The restrictions have been loosening ever so slowly. “There has been considerable progress in this area, I will says that,” says Cunningham, “but it has taken a couple of decades. There are 27 states that don’t allow APRNs in those states to do things they are educationally prepared to do. Examples include prescribing medicine, diagnosing a patient, and providing treatment independent of a physician. Even when it is allowed, there are administrative burdens. It’s not a very nimble system.”
Increasing Access to High-quality Care
The Future of Nursing report did a lot of research on the elements and regulations that limit access to care in general and to the high-quality care offered by APRNs, says Cunningham. And while opponents say that non-physician providers are less likely to provide high-quality care because they don’t have the same training or clinical experience, Cunningham disagrees saying the data doesn’t show that quality of patient care is reduced. “Arguments are made against scope of practice being relaxed really are not keeping the patient at the center of the discussion and it should be at the center of the discussion,” she says. “APRNs bring specific skills and knowledge. In states with restrictions, patients have less access to primary care.”
What autonomous practice does, she says, is significantly increase access to care, especially in rural and underserved communities where physician care may be scarce or difficult to access. APRNs aren’t looking to practice brain surgery, says Cunningham. What they will do, and are trained to do, is provide high-quality primary care services.
At various times, changes to these rules have proven to be especially effective. Interestingly, Cunningham says the COVID-19 pandemic inspired eight states to suspend scope of practice restrictions as a key strategy to manage the pandemic care in the interests of the public and when the health of the nation was at risk. The strategy worked so well, some of those states have moved to make those changes permanent, she says. In 2016 APRNs also saw expanded practice regulations when the Comprehensive Addiction and Recovery Act allowed nurse practitioners to prescribe buprenorphine, a drug used to manage addiction, says Cunningham. The bill increased access to care in rural areas and helped keep patients with substance use disorder safe. When federal authority supersedes state regulations (such as this instance), says Cunningham, that should be looked at more closely as it gives evidence of how loosening regulations can protect public health.
Reducing Administrative Burden
Granting nurses autonomy also helps organizations stay nimble, says Cunningham. It allows them to move nurses where they are needed during times of crisis like COVID, without the extensive forms and processes typically required. COVID, says Cunningham, showed how being able to move nurses to different areas to treat patients or to cover for nurses who were called to a different area, was essential to patient health.
And while the immediate outcomes look positive, Cunningham says the data that emerges from the pandemic will tell a more complete story. “Reductions in mortality especially will be the kind of outcomes data that will be compelling to make this permanent,” she says. “The current recommendation is that all changes that were adopted in response to COVID should be made permanent by 2022. That’s a strong recommendation coming out of the report, but there’s good data to show this is a strong direction.”
Improving Care Access Through the Workforce
And the sheer number of working APRNs would offer a significant boost to primary care efforts where they are especially needed such as in rural or low-income areas. “For counties that are deficient in the number of primary care providers, meeting the needs of the population is important,” says Cunningham. “It creates more equitable communities.”
To remain focused on the patient, the report’s findings show many ways APRNs are trained and educated to improve patient outcomes. “We should be focused on the health of the nation,” says Cunningham. “The current situation is antiquated given the health concerns of the nation. It is not focused on the patient. We need to ask, ‘How do we improve the health of the nation?'”
The report finds removing restrictions also has other benefits. “The clinical piece of this,” says Cunningham, “is that it would be extremely empowering for nurses to do all the things they are prepared to do.”
Henderson, who specializes in psychiatric nursing and nursing in the community, says looking at nursing through the lens of community health competencies is a critical component of comprehensive nursing education.
Community Health in Nursing Education
Although Henderson says community health is covered in nursing education, the standards in place don’t reveal how often or how well community health and public health nursing competencies are covered in individual programs. Sometimes it’s just as one course or an elective course.
“We argue in the report that these areas of community health, public health, social determinants, and population health need to be comprehensively threaded throughout the curriculum,” Henderson says, “so it’s not an add-on. It’s baked in fundamentally into everything we do in our nursing practice.” As nursing education changes, schools and students will begin to collaborate more across disciplines.
Changing how nursing is taught and how students gain experience means more nursing students need to spend time working in various community settings. Nurses learn best through experiential learning, says Henderson, especially with community-based social issues. “Put students in the community and put students in settings where they are finding experts,” he says. And when students find the specialty that appeals to them, letting nurses deviate from the typical path will get them started quickly. “Telling nurses they need one to two years of med-surge under their belts is unnecessary,” says Henderson, “and we have to stop perpetuating that.”
Experience in the Right Settings
For nurses who know they aren’t interested in a med-surge path, those two years could be better spent gaining targeted skills. Immersing themselves with on-site community health work strengthens their commitment to the role.
“Without that kind of immersion, you are reinforcing stereotypes because what you read is not contextualized by what happens,” says Henderson. For instance, he says, nurses may read that “because you’re African American, you’re more at risk for ‘A'” or “because you live in this community, you’re more at risk for ‘Y.'” It’s not contextualized as to why any health impacts are happening, he says.
Nursing education depends on nurses understanding the socioeconomic influences of disease. Henderson says nurses who are immersed in a community may see that patients lack access to green spaces to exercise or may not feel safe in their neighborhood. They may see patients don’t have easy and affordable access to healthy foods.
“The context is the patients don’t live in a community that sets them up to eat healthy, exercise, and take care of themselves to reduce the risk for something like diabetes,” he says. “It has nothing to do with them being African American and has to do more with community conditions. You have to see that and experience it.” Henderson, whose own career was deeply influenced by his early work in community health, says nurses can’t address the health needs in a community without addressing the social needs. “The community is the teacher,” he says. “We go into a community with preconceived notions. But patient-centered care is community-centered care.”
Reading something in a book gives nursing students a theoretical background, but going out into the community, often sparks a passion about uncovering a solution to the root causes of some of the issues patients are facing. “There are downstream effects of that,” says Henderson.
Shift in Nursing Education
As nursing education changes to a community focus, nursing students will need faculty leaders who can talk to them about how to change approaches to tasks like screenings.
“One of the biggest hurdles is getting students out of the mindset of I have to get out to do a specific task,” he says. “It’s about what kinds of conversations are you having during the screening when you’re checking someone’s eyes. Are you learning about their home life? In community public health, you’re exploring the issues that are surrounding their lives and the issues that impact their wellness so you can focus on intervention and prevention.” Nursing students have to be taught about it in their classroom work so they can merge their knowledge and hands-on experience to examine the root causes of illness differently.
Workforce Preparation and Qualification
People want to work in the settings they are exposed to, says Henderson, so nursing students should work in settings that let them see a nurse’s role in schools, correctional facilities, public libraries, preschools, community health centers, homeless shelters, and public housing, and learn from the experts who work in those settings.
Sometimes, says Henderson, the best professional to explain those topics are the ones on the front lines, like the social workers or school counselors who see people for issues that might not be related to an immediate health concern, but that most certainly impact health. With a chronic nursing faculty shortage, allowing educators who don’t have a nursing degree might help fill some gaps in staffing and course content, he says.
Henderson says the Future of Nursing Report calls for including curriculum topics around nursing policy, structural racism, and health equity to help nurses over their entire careers.
And, Henderson says, the report also advocates for nursing schools to address racism in society and within its own professional structures. “Nursing as a profession for a long time hasn’t addressed how racism has impacted our own profession,” says Henderson. “We say in this report we want to go out and do all this good and improve health equity, but we still have to clean our own house a little bit and examine how nurses of color are still discriminated against within our own schools and our own workplaces. And we talk about that in this report and that’s crucial.”
Higher education also must take a new look at its environment. “Schools of nursing need to acknowledge the impact of structural racism has within their own institution and how that disadvantages nursing students and faculty of color,” says Henderson. “That means critical examination of curriculum policy practices, curriculum strategies, and how they allocate resources. Who has the power and what do those dynamics look like?”
Diversity and Equity
A diverse, inclusive, and equitable nursing environment needs to be clearly defined. “Many people say diversity and think just by being diverse, we are equitable,” Henderson says. “But that’s not the case. You can be diverse but not equitable. You can have diverse people at the table, but it’s not equitable if they aren’t valued and their voices aren’t heard.” Lots of groups are recognizing that, says Henderson, but now they have to decide how to act on it and raise awareness about it.
Continually advocating for change in nursing and working to keep uncomfortable conversations ongoing and productive encompasses topics both new and historic, says Henderson, and is the focus of the next decades of nursing education. “It’s about who is having these conversations,” he says. “If we keep having the same people at the table, we won’t get far.”
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