Online Discussion

Hi,

Assignment is as follows:

Synthesize and briefly (no more than 2-3 paragraphs) describe a theory

from another discipline and discuss how you could use this theory in

your current practice.

I am attaching several articles that were given for this week.

Available online at www.sciencedirect.com
Nurs Outlook 63 (2015) 41e47
www.nursingoutlook.org
Advancing Health Through Nursing: Progress of the Campaign for Action
A bold new vision for America’s health care system
The Future of Nursing report becomes a catalyst for change.
Susan B. Hassmiller, PhD, RN, FAAN*, Susan C. Reinhard, PhD, RN, FAAN
The 2010 Institute of Medicine (IOM) report, The Future
of Nursing: Leading Change, Advancing Health (IOM, 2011),
offers a bold vision for a new kind of health care system
in America. The report redefines the field of nursing
and asserts that nurses should be full partners in
reforming health care. It recognizes the invaluable
contributions nurses make as both acute care and
primary care providers and envisions pivotal roles for
nurses in public health, education, research, business,
governance, and public policy. The report challenges
the nation’s 3 million nurses, the largest segment of
the professional health care workforce, to learn more
and lead moredand it urges decision makers to create
circumstances that will help nurses to succeed in all of
these roles.
Issued at a time when the United States was reinventing its health care system through unprecedented national reform, the IOM report generated both
broad and deep interest. It quickly became the primary
reason people visited the IOM website, and it has been
the IOM’s most-read report. Since its release, it has
generated conversation among a wide array of stakeholders, including policymakers, and has set in motion
not just incremental changes but significant momentum toward a new U.S. health care delivery
systemdone that offers the promise of improving access and quality while lowering costs.
Less than two months after the report’s release in
early October 2010, the Robert Wood Johnson Foundation (RWJF) and AARP teamed up to launch the farreaching, multifaceted Future of Nursing: Campaign
for Action to implement the IOM’s recommendations.
Risa Lavizzo-Mourey, MD, the president and chief executive officer of the RWJF, noted the importance of the
campaign, which was announced during the National
Summit on Advancing Health Through Nursing in
Washington, DC, by declaring it “the first day of a new
future for nursing.”
The IOM report asserted that a transformed nursing
profession would lead to an improved health care
systemdone that was more accessible, affordable, and
patient- and family-centered, and, at the same time,
safe, effective, and efficient. The joint initiative between the RWJF, the nation’s largest philanthropy
devoted to health, and AARP, one of the nation’s largest
Risa Lavizzo-Mourey, president and chief executive
officer of the Robert Wood Johnson Foundation
(RWJF), center, and Susan B. Hassmiller, director of
the Future of Nursing: Campaign for Action and
senior adviser for nursing at the (RWJF), center right,
meet with members of the District of Columbia and
New Jersey action coalitions during the Campaign
for Action’s Summit 2013: Transforming Health Care
Through Nursing, in Washington, DC. Photo by Greg
Gibson from Greg Gibson Photography, on behalf of
AARP.
Reprinted with permission from the American Journal of Nursing. Hassmiller, SB, Reinhard, SC. A bold new vision for America’s health
care system. Am J Nurse 2015 Feb; 115(2):65-71.
* Corresponding author: Dr. Susan B. Hassmiller, Robert Wood Johnson Foundation, Senior Adviser for Nursing, P.O. Box 2316, Route 1,
Princeton, N.J. 08543, United States.
E-mail address: shassmi@rwjf.org (S.B. Hassmiller).
0029-6554/$ – see front matter Copyright Lippincott Williams & Wilkins. All rights reserved.
http://dx.doi.org/10.1016/j.outlook.2014.11.017
42
Nurs Outlook 63 (2015) 41e47
consumer organizations, was intended to help make
this vision a reality.
In the four years since, the Campaign for Action has
helped to make the Future of Nursing report a genuine
catalyst for change. From the start, it was envisioned
that the work of the campaign would take place at the
state level, carried out by Action Coalitions. These state
coalitions quickly multiplieddfrom just a handful at
the time of the campaign’s launch to 51 today. They
have had a nationwide impact.
This article, which is also reprinted in AJN and freely
available online, examines the progress, barriers, and
not inconsiderable work still needed to implement the
IOM’s recommendations. Subsequent articles, which
will be published in AJN and Nursing Outlook, examine
the IOM report’s recommendations and detail the
progress that has been madedoffering an in-depth
look at the achievements of the Campaign for Action
as well as a roadmap for the work that lies ahead.
Promoting Lasting Change
The Campaign for Action was intended to transform
and diversify the nursing profession. Because building
awareness of this work is essential, those involved in
the campaign began educating the public by speaking to
groups across the country, often using one of their
greatest assets: the members of the IOM committee that
produced the Future of Nursing report. Former U.S.
Health and Human Services Secretary Donna E. Shalala,
PhD, president of the University of Miami and chair of
the IOM committee, and Linda Burnes Bolton, DrPH, RN,
FAAN, vice president and chief nursing officer of
Cedars-Sinai Medical Center and IOM committee vice
chair, both devoted considerable time to ensuring that
leaders in nursing, health care, education, business, and
other fields recognized the importance of implementing
the IOM recommendations.
Other high-profile leaders, too, have spoken out in
support of the campaign’s work, almost from the start.
Former Pennsylvania governor Ed Rendell, a Democrat,
was an early supporter and advocated to expand
nurses’ scope of practice; more recently, New Mexico
governor Susana Martinez, a Republican, advocated for
the education and scope of practice recommendations.
The campaign has also sought to use social media to
engage key communities, generated thousands of news
stories, and contributed articles and commentaries to
prestigious journals, including AJN, the Journal of Professional Nursing, AARP International: The Journal, BoardRoom Press, Frontiers of Health Services Management, Health
Affairs, the Journal of Change, and the Journal of Healthcare
Management, among others (Hassmiller, 2013;
Hassmiller & Combes, 2012; Hassmiller & Truelove,
2014; Lumpkin, 2013; Reinhard & Hassmiller, 2009,
2012; Shalala, in press; “Six Sites Meet”, 2013).
Awareness was critical, but the campaign aimed
even higher: it wanted to inspire nurses, other health
care workers, and educational leaders to help implement the IOM’s recommendations and bring about
lasting change. Although elaborate plans were made to
advance each IOM recommendation, it was clear from
the start that only a sustained commitment and a shift
in attitude about nurses and nursing could secure the
progress the campaign envisioned.
To begin addressing this challenge, the campaign
brought in powerful partners. It created a strategic
advisory committee led by Sheila Burke, MPA, RN,
FAAN, of the Harvard School of Public Health, and
including leaders in business, health care, and education to guide the national implementation of the IOM
recommendations and to serve as campaign ambassadors (Future of Nursing, n.d.).
The campaign also engaged two entities created
by the Center to Champion Nursing in America
(CCNA), a joint initiative of the RWJF and AARP
created in 2007 to strengthen the nursing workforce,
in the effort to advance the IOM report’s recommendations: the Champion Nursing Council (Future
of Nursing, n.d.), which brought together 23 leading
nursing associations, and the Champion Nursing
Coalition (Future of Nursing, n.d.), which engaged
national business, consumer, and health professional organizations.
These efforts generated significant national momentum. For example, in 2011 the Leapfrog Group, a
nonprofit organization made up of large purchasers of
health care, began considering Magnet status when
scoring hospital safety. Additional action, however,
was needed at the state level through the passage of
state laws and regulations. Therefore, the campaign
began to establish Action Coalitions in each state that
were modeled after similar entities created for the
CCNA. Within two years, each state and the District of
Columbia had an Action Coalition working to advance
the goals of the Future of Nursing report.
These state coalitions were deliberately structured
to ensure a variety of perspectives, and each was coled by a nurse and a non-nurse. Leaders of the Indiana Action Coalition, for example, are Kimberly J.
Harper, MS, RN, chief executive officer of the Indiana
Center for Nursing, and Richard Kiovsky, MD, director
of the state’s Area Health Education Centers network.
All Action Coalitions include nurses, other health care
providers, consumers, educators, businesses, and
other stakeholders.
With grants from the RWJF totaling nearly $18
million to datedand supplemented by more than $11
million in additional funding raised within the
statesdthese 51 Action Coalitions have formed a
powerful community that tests strategies, shares
lessons learned, and achieves goals. The RWJF has
also provided substantial financial resources to the
CCNA to give Action Coalitions technical assistance in
addition to communications and research and evaluation support. Finally, generous in-kind resources
have been devoted to the campaign by the states and
AARP.
Nurs Outlook 63 (2015) 41e47
Progress on IOM Recommendations
The Campaign for Action is making progress implementing the recommendations in the Future of Nursing
report (see Table 1), particularly in regard to education,
scope of practice, workforce diversity, nurse leadership, and workforce data collection.
Education
The campaign is focusing on three IOM education
recommendations: to increase the number of nurses
with baccalaureates, to double the number of nurses
with doctoral degrees, and to encourage interprofessional education, in which students from different
health specialties are educated together, at least some
of the time, in classrooms or during academic
activities.
Baccalaureate-Prepared Nurses
The IOM report noted that the United States needs
many more highly educated nurses. This is because
Americans are living longer and with more chronic
conditions; there is a fast-growing need to provide
preventive and primary care at home, in schools, and
in the community; and there is a debilitating nurse
faculty shortage. And although the report recognized
the enormous contributions of nurses with an associate’s degree in nursing (ADN), the IOM issued a call to
make it easier for nurses to obtain bachelor of science
in nursing (BSN) and more advanced degrees (IOM,
2011).
When the Campaign for Action launched in 2010,
49% of employed nurses in the United States had BSNs
(according to figures compiled from the U.S. Census
Bureau’s American Community Survey Public Use
Microdata Sample). The IOM report recommends that
80% of RNs have a bachelor’s or more advanced degree
by 2020 (IOM, 2011).
The Action Coalitions set out to advance this
recommendation by encouraging strong partnerships
between community colleges and universities to
make it easier for nurses to transition to programs
that confer higher degrees. Every Action Coalition is
working to advance the IOM’s education recommendations. However, nine of thesedTexas, California,
Washington, Hawaii, North Carolina, New York,
Montana, Massachusetts, and New Mexicodwere
chosen to be part of the RWJF’s Academic Progression
in Nursing program, which is helping to lead this
work.
The campaign has established measurable goals
that are tracked through the use of “dashboard indicators” to assess progress (Future of Nursing, n.d.).
These focus on nurse education, barriers to practice
and care, interprofessional collaboration, RN leadership, and the collection of workforce data. The
campaign collects information from various data
43
sources and uses this to measure progress regarding
these indictors.
In 2014, for instance, the campaign was able to
show that the percentage of employed nurses with a
baccalaureate is on the rise: in 2013, 51% of the nation’s employed nurses had a BSN, and there was a
10% rise in the number of RNs with bachelor’s degrees between 2010 and 2012, from 1.37 million to
1.52 million (according to figures compiled from the
U.S. Census Bureau’s American Community Survey
Public Use Microdata Sample). More nurses are
enrolling in baccalaureate programs, according to
the American Association of Colleges of Nursing
(AACN, 2014a), and the number of enrollees in RNto-BSN programs is ballooning, rising 57% from
2010 to 2014.
Doctoral Degrees
A second IOM education recommendation is to double
the number of nurses with doctoral degrees by 2020
(IOM, 2011). The IOM report notes that only 1% of the
nation’s 3 million nurses had doctoral degrees in 2010.
It recommends that this number double, because
nurses with doctorates are needed to conduct scientific research, provide advanced care, assume leadership roles in health care, end the critical shortage of
nursing faculty, and educate the next generation of
nurses.
The dashboard indicators revealed significant
progress toward this goal. From 2010 to 2013, the
number of nurses enrolled in doctoral programs rose
70%, from 11,645 to 19,828. Much of this growth was
in doctor of nursing practice (DNP) programs: the
number of students enrolled in these practiceoriented programs jumped from 7,304 in 2010 to
14,688 in 2013. Enrollment in research-oriented PhD
programs has also grown: in 2013, 5,140 students
were enrolled in these programs, up from 4,611
in 2010.
To accelerate the progress, the RWJF has created
the Future of Nursing Scholars program, which is
supported by the Independence Blue Cross Foundation, UnitedHealth Group, the Rhode Island Foundation, North Shore-LIJ Health System, the Johnson and
Johnson Campaign for Nursing’s Future, Cedars- Sinai
Medical Center, and Ascension Health and is
providing grants to schools of nursing to support a
growing number of nurse PhD candidates each school
year.
Interprofessional Education
The IOM also called for an end to “educational silos,” in
which students of one health profession are isolated
from those in other fields (IOM, 2011). According to the
dashboard indicators, in the 2013-2014 academic
school year, of the 10 nursing schools at universities
with graduate health professional schools that were
surveyed, nine required at least one interprofessional
clinical course or activitydup from four during the
2010-2011 academic year.
44
Nurs Outlook 63 (2015) 41e47
Table 1 e Recommendations of the IOM’s Future of Nursing Report
Recommendation
1. Remove scope-of-practice barriers.
2. Expand opportunities for nurses to lead and diffuse
collaborative improvement efforts.
3. Implement nurse residency programs.
4. Increase the proportion of nurses with a baccalaureate to
80% 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
interprofessional health care workforce data.
Details
Advanced practice RNs should be able to practice to the full
extent of their education and training.
Private and public funders, health care organizations,
nursing education 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.
State boards of nursing, accrediting bodies, the federal
government, and health care organizations should take
action to support nurses’ completion of a transition-topractice program (nurse residency) after they have
completed a prelicensure or advanced practice degree
program or when they are transitioning into new clinical
practice areas.
Academic nurse leaders across all schools of nursing
should work together to increase the proportion of
nurses with a baccalaureate from 50% to 80% 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.
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.
Accrediting bodies, 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.
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.
The National Health Care Workforce Commission, with
oversight from the Government Accountability Office
and the Health Resources and Services Administration
(HRSA), 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 HRSA should collaborate with state
licensing boards, state nursing workforce centers, and
the U.S. Department of Labor in this effort to ensure that
the data are timely and publicly accessible.
Source: Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine, 2011.
Scope of Practice
Advanced practice RNs (APRNs) provide highly skilled
care to an increasingly complex population of patients.
The IOM report said that the United States needs more
APRNs, but in many states, overly restrictive laws and
regulations prevent APRNs from practicing to the full
extent of their education and training. This has led to
what an appendix to the IOM report calls a “crazy quilt of
widely varied, often inconsistent, sometimes contradictory licensure and payment laws” (IOM, 2011).
Opponents of lifting restrictions on APRN practice
sometimes claim that doing so will compromise the
quality and safety of care. However, the IOM report
Nurs Outlook 63 (2015) 41e47
notes that there is no evidence that care is better in
states with more restrictive scope-of-practice laws or
that APRNs are any less able than physicians to provide
safe, effective, and efficient care. The National Conference of State Legislatures has noted that removing
APRN restrictions benefits patients by improving access to care, especially in regions in which there are
shortages of primary care providers (Ewing & Hinkley,
2013). In many states, the local AARP offices are
bringing consumers’ voices to these debates, as staff
write letters and visit state legislatures to emphasize
the need for access to nursing care.
Since 2010, seven stateseConnecticut, Kentucky,
Minnesota, Nevada, North Dakota, Rhode Island, and
Vermont have removed statutory barriers that prevented NPs from providing care to the full extent of
their education and training. Other states have passed
laws toward guaranteeing full practice authority for
NPs. Texas, for example, has removed a restriction
requiring on-site physician supervision of nurse-led
retail health clinics, and Utah has allowed NPs to be
reimbursed by Medicaid for services they provide to
beneficiaries.
Diversify the Nursing Workforce
The nursing workforce has historically been, and remains, predominantly white and female. A more diverse
workforce is needed to provide culturally and linguistically appropriate health care services to an increasingly
diverse population. Racial and ethnic diversity among
nurses can also strengthen the relationship between
nurses and minority communities and is an important
step toward reducing disparities in health and health
care, according to the IOM, which also notes that greater
gender diversity among nurses would be beneficial (IOM,
2011). Currently, men make up less than 10% of the
nursing workforce (U.S. Census Bureau, 2013).
The number of minorities in the nursing workforce
is gradually rising, as is the share of the nursing
workforce they represent, according to the Campaign
for Action. In 2010, approximately 24% of the nation’s
RNs identified themselves as minorities (AACN, 2014b);
that percentage inched up closer to 25% in 2012. Data
collection is improving, too. In 2011, 34 states collected
race and ethnicity data regarding their nursing workforces; in 2013, that number jumped to 45.
Nurse Leadership
Nursing is consistently ranked as the nation’s most
trusted profession (Gallup, 2014). Nurses represent the
largest group of health care professionals, and they are
the providers who spend the most time with patients.
As such, they have unique and valuable insights into
health and health care. Nevertheless, the IOM report
pointed out that nurses are often overlooked during
discussions and decisions about health care reform,
even though patients, providers, and payers would
benefit from their input.
45
One principal reason for this is that relatively few
nurses occupy positions of influence in the health care
system or society. The nursing profession, the IOM
report argues, must do its part to correct this. It calls on
the profession to “produce leaders throughout the health
care system, from bedside to boardroom, who can serve
as full partners with other health professionals and be
accountable for their own contributions to delivering
high-quality care while working collaboratively with
leaders from other health professions” (IOM, 2011).
Action coalitions around the country are working to
do just that, putting in place programs that train nurses
to serve on a variety of health and health care boards,
and keeping track of board openings and encouraging
nurses to apply. Progress toward this goal is difficult to
measure because the American Hospital Association
last issued survey results in 2011, when it found that 6%
of the nation’s hospital boards included nurse members
(Van Dyke et al., 2011). A new study has confirmed that
the number is probably even lower, with about 2% of
nurses included as voting members on hospital, health
system, and academic medical center boards (Szekendi
& et al., 2014). The Campaign for Action, with the support of Action Coalitions, is working with nursing associations nationwide to meet its ambitious goal of
putting 10,000 new nurses on boards by 2020.
Workforce Data Collection
Policymakers need comprehensive data on the health
care workforce to make informed decisions about
policies that can influence the supply of and demand
for nurses and other health professionals. At present,
such analysis is hampered by gaps in data on the
numbers and types of health professionals currently
employed, where they are employed, and in what role.
To address this lack of consistent data, the IOM report
calls for the creation of a national health care workforce commission, state and regional workforce centers, and funding for workforce data collection and
studies. This was authorized under the Affordable Care
Act but remains an unfunded mandate.
Action Coalitions are helping to ensure that this
recommendation is realized by working with state
boards of nursing to increase the number of data items
collected when nurses are licensed or renew their
licenses. From 2010 to 2014, 24 states increased the
number of data items collected about the nursing
workforce, including information about race and
ethnicity, entry-level education, and employment
setting. This is helping to build the national infrastructure for the collection and analysis of interprofessional health care workforce data.
More Work Ahead
Although the progress made during these first four
years of the Campaign for Action has been
46
Nurs Outlook 63 (2015) 41e47
TEN WAYS YOU CAN HELP
Implementing the Recommendations of the IOM’s
Future of Nursing Report.
1. Read the Future of Nursing report and encourage
colleagues to do the same.
2. Follow the Future of Nursing: Campaign for Action on
Twitter and “like” it on Facebook.
3. Learn what your state Action Coalition is doing and
get involved by visiting www.campaignforaction.org.
4. Invite your state Action Coalition to send a speaker to
an upcoming forum at your place of employment or to the
local chapter of a nursing or other association to which you
belong.
5. Seek out a mentor who will help you to develop as a
nurse.
6. Dedicate yourself to mentoring and supporting a nurse
in the next generation.
7. Contact the dean at the school(s) where you studied
nursing and ask if the school has integrated the IOM report
into its curricula. Ask if there is an opportunity to speak to
students about how the IOM report is shaping their future.
8. Consider obtaining a more advanced degreeda BSN,
MSN, PhD, or DNPdor encourage a colleague to do so.
9. Seek an appointment to a board of directorsdof a
community group, nonprofit organization, health clinic, or
similar entitydin your local community, or encourage
another nurse to do so.
10. Blog about Future of Nursing: Campaign for Action
activities and goals. Submit a letter to the editor of your
local newspaper about the IOM’s Future of Nursing report.
impressive, it has been predictably uneven, and
considerable work remains. To fully realize the
IOM’s vision for the future of nursing, the campaign
must expand its leadership, strengthen its Action
Coalitions, increase and stabilize its resources, and
win the hearts and minds of many more stakeholders.
Even among nurses, campaign leaders know there is
more work to do. The community of highly educated
nurses has embraced the IOM vision and many nursing
students are engaged, but some staff-level nurses
remain unaware of the report. Further, the recommendation that 80% of nurses have BSNs by 2020 has
been polarizing, alienating some nurses who have
ADNs.
To more fully engage the nursing community and
create a sustained force for change, campaign
leaders are appealing to nurses’ social mandate to
contribute to the good of society. Many nurses take
the Florence Nightingale pledge in recognition of
their mission to contribute to society through
research and evidence-based practice and to do all
they can to elevate professional nursing standards.
The IOM report outlined a way to fulfill this oath. The
campaign is thus asking all nurses, “How are you
going to implement the IOM report in your institution and state?” The goal is to inspire each nurse to
become an active participant in implementing the
IOM recommendations.
Another priority is to strengthen the Action Coalitions across the country. Somedincluding those
in California, New Jersey, North Carolina, and
Texasdhave been extremely successful, bringing in
diverse and powerful stakeholders and large grants
to support their work. They have set up active
workgroups that are advancing a range of IOM
recommendations.
Other Action Coalitions have started more slowly,
encountered more barriers, and made more modest
progress. Some are raising money through bake sales
and other small events, still building their infrastructure and seeking to engage stakeholders. Most
continue to rely on in-kind support.
The campaign is using a model of evidence-based
indicators of success (Raynor, 2011) to identify
effective coalitions. The goal is to share lessons
learned about the most effective ways to strengthen
the infrastructure of Action Coalitions across the
country.
To learn how you can implement the IOM recommendations, see Ten Ways You Can Help.
Conclusion
The IOM’s groundbreaking Future of Nursing report
called for a radical overhaul of the nursing profession
as a way to transform U.S. health and health care. Five
years after its release, it is clear that the IOM did much
more than chronicle an ongoing conversation about
expanding the role of nurses. It imagined a world in
which all nurses could become lifelong learners, practice to the extent of their education and training, and
serve as full partners in providing care and promoting
health on the front lines as well as in boardrooms.
The IOM did not simply suggest that nurses
contribute to changing our health care systemdit
warned that change would not succeed unless nurses
helped shape and lead it. It said that a highly educated,
skilled, diverse nursing workforce is a prerequisite for a
high-quality health care system poised to meet current
and emerging needs.
In doing so, one of the nation’s most prestigious
institutions launched a new era for health care in the
United States. But the promise of that era will only be
fully realized if the progress to implement the Future of
Nursing recommendations continues.
Susan B. Hassmiller is director of the Future of Nursing:
Campaign for Action and senior adviser for nursing at the
Nurs Outlook 63 (2015) 41e47
Robert Wood Johnson Foundation, Princeton, NJ. Susan C.
Reinhard is senior vice president of the AARP Public Policy
Institute and chief strategist at the Center to Champion
Nursing in America, Washington, DC. Contact author: Susan
B. Hassmiller, shassmi@rwjf.org. The authors have disclosed
no potential conflicts of interest, financial or otherwise.
references
American Association of Colleges of Nursing. (2014a). AACN Finds
Slow Enrollment Growth at Schools of Nursing [press release].
Retrieved from http://www.aacn.nche.edu/news/articles/
2014/slow-enrollment.
American Association of Colleges of Nursing. (2014b). Fact sheet:
enhancing diversity in the workforce. Retrieved from http://www.
aacn.nche.edu/media-relations/diversityFS.pdf.
Committee on the Robert Wood Johnson Foundation Initiative on
the Future of Nursing, at the Institute of Medicine. (2011). The
Future of Nursing: Leading Change, Advancing Health.
Washington, DC: National Academies Press. Retrieved from
http://www.nap.edu/catalog.php?record_id¼12956.
Ewing, J., & Hinkley, K. N. (2013, April). Meeting the primary care
needs of rural America: Examining the role of non-physician
providers. Denver: The Rural Health Connection. http://www.ncsl.
org/documents/health/RuralBrief313.pdf.
Future of Nursing. (n.d.) Campaign for action: campaign
progressd dashboard indicators. Center to Champion Nursing in
America. Retrieved from http://campaignforaction.org/
dashboard.
Future of Nursing (n.d.). Campaign for action: who’s involvedd
strategic advisory committee. Center to Champion Nursing in
America. Retrieved from http://campaignforaction.org/whosinvolved/strategic-advisory-committee.
Future of Nursing (n.d.). Campaign for action: who’s involvedd
champion nursing council. Center to Champion Nursing in
America. Retrieved from http://campaignforaction.org/whosinvolved/champion-nursing-council.
Future of Nursing (n.d.). Campaign for action: who’s involvedd
champion nursing coalition. Center to Champion Nursing in
America. Retrieved from http://campaignforaction.org/whosinvolved/champion-nursing-coalition.
47
Gallup. (2014). Americans rate nurses highest on honesty, ethical
standards. Retrieved from http://www.gallup.com/poll/180260/
americans-rate-nurses-highest-honesty-ethical-standards.
aspx
Hassmiller, S., & Combes, J. (2012). Nurse leaders in the
boardroom: a fitting choice. Journal of Healthcare Management,
57(1), 8e11.
Hassmiller, S. B. (2013). The RWJF’s investment in nursing to
strengthen the health of individuals, families, and
communities. Health Aff (millwood), 32(11), 2051e2055.
Hassmiller, S. B., & Truelove, J. (2014). Are you the best leader you
can be? Am J Nurs, 114(1), 61e67.
Lumpkin, J. (2013). The missing voices. Boardroom Press,
24(6), 1e2. Retrieved from http://library.
governanceinstitute.com/Research- Publications/
ResourceLibrary/tabid/185/CategoryID/34/List/1/Level/a/
ProductID/1427/Default.aspx?SortField¼DateCreated
þDESC%2cDateCreatedþDESC.
Looking ahead: trends and challenges in the future of nursing.
(2013). Journal of Change, 2(1), 8e9. Retrieved from http://
webversion.staywellcustom.com/ibc/2013/spring.
Raynor, J. (2011). What Makes an Effective Coalition? Evidence-based
Indicators of success. Philadelphia PA: TCC Group. Retrieved
from http://www.mcf.org/system/article_resources/0000/
1297/What_Makes_an_Effective_Coalition.pdf.
Reinhard, S., & Hassmiller, S. (2012). The future of nursing:
transforming health care. AARP Int J54e60. Retrieved from
http://journal.aarpinternational.org/a/b/2012/02/the- futureof-nursing-transforming-health-care.
Reinhard, S. C., & Hassmiller, S. B. (2009). Partners in solutions to
the nurse faculty shortage. J Prof Nurs, 25(6), 335e339.
Shalala, D. (in press). Nursing leaders can deliver a new model of
care. Front Health Serv Management.
Szekendi, M., Prybil, L., Cohen, D. L., Godsey, B., Fardo, D. W., &
Cerese, J. (2014). Governance practices and performance in US
academic medical centers. American Journal of Medical Quality.
Advance online publication. http://dx.doi.org/10.1177/
1062860614547260.
U.S. Census Bureau. (2013). Male Nurses Becoming More
Commonplace, Census Bureau Reports. [press release]. Retrieved
from http://www.census.gov/newsroom/press-releases/2013/
cb13-32.html.
Van Dyke, K., Combes, J., & Joshi, M. (2011). 2011 AHA Health Care
Governance Survey Report. Chicago: American Hospital
Association.
How Nurse Leaders Can Fix
Our Healthcare System
Susan B. Hassmiller, PhD, RN, FAAN, and Winifred V. Quinn, PhD
W
hen Sarah Simmons* moved 2 hours
unable to find a provider who was accepting new
outside of New York City, she never
patients. Even with a reputable insurance plan, it
imagined that finding a primary care physician in
was a struggle to find care. Unfortunately, Sarah is
her new hometown would be a problem. Yet she was
not alone.
www.nurseleader.com
Nurse Leader
31
I
n the United States today, we have a growing number of
people who need healthcare, have more chronic illness, but
simply can’t find healthcare providers to serve them. With the
Affordable Care Act, millions more people are insured and
seeking care. So how can we provide the healthcare that they
need? And how can we do this in a way that will support
improved health, reduce chronic illness, and contain costs?
The nation’s largest philanthropy devoted exclusively to
health and healthcare, the Robert Wood Johnson Foundation
(RWJF), has been exploring this question. With a mission to
improve health and healthcare, RWJF is determined to create
a “Culture of Health” where Americans live longer, healthier
lives, and everyone has access to affordable, quality care. In an
effort to achieve this goal, RWJF has invested nearly $600
million in nursing-related causes over the past decade.1
At the same time, AARP, the largest consumer organization in the nation, knew that our healthcare system was
falling short when it came to the growing needs of increasing
numbers of older adults and their family caregivers. AARP
had been hearing from its members about how restrictions
on nurse practitioners were hampering access to care and
creating problems in obtaining a full range of services in the
community. Such barriers cause older adults to seek health
services using more expensive options such as hospitalizations
or nursing home care. AARP recognized that to serve the
needs of its 37 million members, it had to ensure that they
could get the care they need, when and where they need it.
The 2 organizations came to the conclusion that nurses
held the key to health system improvements and that nursing
needed a greater voice in healthcare transformation. It also
became clear that nurses needed to engage directly with
consumers about their healthcare needs—as well as how the
healthcare system could meet these needs.
CENTER TO CHAMPION NURSING IN AMERICA
Nurses are the single largest segment of the healthcare workforce.2 They work at the frontlines of care, in the boardroom,
and as consumer advocates. In survey after survey, nurses are
named the most trusted of the healthcare professions.3 Their
perspective on how things should work and how to improve
quality has led to reductions in medical errors, patient
injuries, and hospital readmissions.
In 2007, RWJF and AARP launched the Center to
Champion Nursing in America (CCNA) to examine and promote how nursing policy issues influence consumers’ access to
quality care. CCNA’s initial mission was to help solve the pending nursing shortage—a problem that was becoming worse due
to the steady increase in the number of aging people with
chronic conditions at the same time that a generation of nurses
was retiring.4-6 The capacity of nursing schools to accept more
nursing students needed to be expanded, because a bottleneck
caused by a lack of nursing faculty was preventing tens of thousands of prospective students from entering nursing schools.7,8
Something had to be done if there were going to be enough
nurses to provide care for a growing population needing care.
*Name changed to protect privacy.
32
Nurse Leader
AARP collaborated with more than a dozen national nursing organizations to support legislation to direct Medicare to
further fund graduate nursing education. A provision to support
more graduate nursing education was inserted in the Patient
Protection and Affordable Care Act (ACA), which was signed
into law in March 2010; this helped to ramp up the training of
more registered nurses and advanced practice registered nurses
(APRNs). The nursing organizations that AARP brought
together continue to collaborate on efforts to remove outdated
restrictions on APRNs that exist at the federal level and in
more than half of the states.
As AARP’s then-chief executive officer (CEO) Bill Novelli
said at CCNA’s launch, “Nurses are critical to ensuring that
patients get the best care possible—not just in hospitals, but in
the delivery of home health care, in assisted-living facilities and
in nursing homes.”7 It wasn’t long, however, before CCNA’s
efforts expanded to improve both access to and quality of care.
INSTITUTE OF MEDICINE’S FUTURE OF NURSING
REPORT
Soon after the launch of the CCNA, RWJF funded the
Institute of Medicine (IOM) to convene a committee of
experts to develop recommendations on how nurses could
help to improve health care. The committee was chaired by
Donna Shalala, PhD, the longest-serving secretary for Health
and Human Services under the Clinton administration. Dr.
Shalala is currently president of the University of Miami,
which boasts one of the largest nursing schools in the country. Committee members included nurse leaders, payers,
physicians, and healthcare, policy, and quality experts.
In 2010, the IOM released “The Future of Nursing: Leading
Change, Advancing Health” report,9 which provided a blueprint
for improving healthcare through nursing. The report was a
game-changer. It quickly became the most widely read report
in the IOM’s history, and for 4 consecutive years, the Future of
Nursing report has been the number 1 reason people visit the
IOM website.
The report made 5 recommendations:
1. Remove practice barriers that prevent nurse practitioners from providing the care they are trained to provide
2. Encourage nurse leadership in board rooms and policy
discussions on the future of healthcare
3. Strengthen nursing education and training and streamline
pathways for nurses to obtain more advanced degrees
4. Improve workforce data collection to help predict
healthcare workforce needs
5. Expand diversity in nursing to better reflect the general
population and meet workforce demand
A wide variety of healthcare stakeholders took notice of
the report. Healthcare executives, payers, policymakers, and of
course, nurses started to discuss what these recommendations
meant, not only for the future of nursing, but also for the
future of healthcare.
CAMPAIGN FOR ACTION
RWJF’s president and CEO, Risa Lavizzo-Mourey, decided
that the IOM Future of Nursing report was too important to
April 2015
sit on a shelf. She directed RWJF to partner with AARP to
launch the Future of Nursing: Campaign for Action to
implement the IOM’s recommendations across the country.
Directed by CCNA, the Campaign launched action coalitions in all 50 states and the District of Columbia. Each is
made up of volunteer nursing and non-nursing leaders who
work together to leverage nursing leadership, strengthen
nursing education, diversify the nursing workforce, improve
workforce data collection, and remove barriers to practice
and care.
The campaign has been tracking progress on each of the
IOM goals; headway is being made on all fronts. For example,
since the release of the IOM report, nearly every state is
pursuing an effort to streamline nursing education, making it
easier for associate degree nursing students to move onto
pursuing baccalaureate nursing degrees. Registered nurses
with associate degrees have strong clinical skills; however, the
IOM argued that baccalaureate-prepared nurses, or BSNs, are
equipped with strong clinical skills as well as systems knowledge, leadership and community training, and experience.
This difference is fundamental to changing and improving
healthcare systems over the continuum of care. Easing matriculation for associate- and diploma-educated nurses is a major
step toward the IOM’s recommendation that 80% of nurses
hold 4-year degrees by 202010(p.173) and that more nurses with
advanced degrees be available to fill faculty positions at nursing schools.
Perhaps the most seminal recommendation in the IOM
Future of Nursing report is based on the premise that our
healthcare system cannot possibly meet growing demand if it
is functioning at partial capacity. In more than half of states in
the United States, advanced practice registered nurses
(APRNs) and physician assistants are restricted by outdated
regulations that limit their ability to expand access to care.
Meanwhile, in 19 states and the District of Columbia,
APRNs can practice to the full extent of their license and
training, providing primary and preventive care at retail clinics, physician offices, urgent care centers, and more.11
REMOVING OUTDATED BARRIERS TO CARE BY
APRNS
Since the Campaign for Action began, 7 states Nebraska (in
2015), Connecticut (in 2014), Minnesota (in 2014), Nevada
(in 2013), North Dakota (in 2011), Rhode Island (in 2013),
and Vermont (in 2011)— have removed barriers that prevented nurse practitioners from providing care to the full extent
of their education and training. In 2014, 4 more states,
Massachusetts, Michigan, New Jersey, and Pennsylvania, have
legislation pending to remove barriers; progress has been
made in one form or another in 5 other states. Other states
have incrementally modernized their scope of practice laws.
For example, in New York and Maryland, the requirement for
nurse practitioners to have one type of oversight by physicians was replaced with a less stringent contract called an
“attestation agreement.” Kentucky and Utah also made
incremental improvements, allowing nurse practitioners to
provide almost all of their care without physician oversight—
www.nurseleader.com
except for prescribing controlled substances. Therefore, in
rural areas of those states, people who only have access to
nurse practitioners for their care need to travel long distances
to obtain prescriptions for pain and other medications.
Although unleashing the skills of nurse practitioners is
clearly a common sense solution to expand access to care and
healthcare system capacity, it is not without controversy.
Some physicians groups are adamantly opposed, arguing that
such an approach would reduce the quality of care. Claims
about a potential loss of quality run counter to the experience of more than a dozen states that have benefited from
APRNs practicing to the full extent of their knowledge and
training for decades.12 These false claims stymied recent
efforts to remove barriers in California and Florida, which,
ironically, have a growing number of older and more ethnically diverse consumers who could greatly benefit from
greater access to care.
AARP has been supporting nursing organizations and
representatives from nearly 30 states to strategize about how
to modernize practice laws. The organization provides technical support such as messaging, media outreach, public policy
education, and stakeholder engagement to states as they work
to unleash the scope of practice for nurse practitioners. For
example, AARP engaged its grassroots network in California
in the summer of 2013 to support legislation that would
modernize practice laws. Although the effort failed, a coalition emerged that will support nurse practitioners in the
future. This coalition includes businesses, insurers, the
California Hospital Association, and a physician group. We
expect greater success in the next round.
States that embraced greater use of nurse practitioners
early tended to be those with more remote and underserved
areas. Nurse practitioners willing to stay or move to these
locations to provide care, created a body of evidence to support expanding the use of APRNs across the country. Studies
have shown that nurse practitioners can provide anywhere
from 70% to 90% of what primary care physicians provide.13
A growing body of research also shows that nurse practitioners provide quality care and are highly effective in helping
people to control chronic disease and promote wellness,14,15
thereby controlling healthcare costs.
This is undoubtedly a major reason why the number of
nurse practitioners is growing, and the number of consumers
who are cared for by nurse practitioners is skyrocketing. For
example, the number of Medicare beneficiaries receiving care
from nurse practitioners increased 15-fold between 1998 and
2010.16 Researchers found a link between states with the
least restrictive regulations and those with the largest increase
in consumers seen by nurse practitioners. Clearly, modifying
state regulations for the APRN’s practice is one path to
expanding primary care access.
APRNS—EXPANDING ACCESS TO CARE IN RETAIL
CLINICS, COMMUNITY HEALTH CENTERS
Before regulators and policymakers realized that nurse practitioners could help solve the access-to-care problem, the marketplace saw the value in this approach. Nurse leaders have
Nurse Leader
33
worked closely with CVS Minute Clinic, Target, and other
retailers to establish easy access points for people to receive
care. Since the year 2000, 1400 retail clinics have been established, most of which are staffed by APRNs.17-19 A Rand
study found that these clinics provide 6 million clinical visits
annually, mostly by nurse practitioners.20-22
Nurse practitioners also play a vital role in improving
healthcare access through their work caring for consumers
in community health centers and in the Veterans Health
Administration (VHA). In 2014 community health centers
are expected to serve more than 25 million people,23 the
overwhelming majority of whom are low income and live
in underserved areas. Federally qualified community health
centers are the backbone of our nation’s healthcare safety
net; they rely on APRNs to provide this much-needed
primary care. The VHA, which is the single largest healthcare system in the country, has been relying on nurse practitioners to not only reduce wait times, but to provide
research and recommendations on how to improve access
to care.
IMPROVING PROVIDER AND CONSUMER
EXPERIENCE
Removing barriers that restrict nurse practitioners from providing care they are trained and capable of providing does
more than improve access. It can also help to improve both
the provider and consumer experience. For example, economists Tracynski and Udalova24 have estimated that practice
barriers waste 10% of providers’ time, filling out burdensome
paperwork. This time would be better spent on clinical care.
In addition, nearly half (47%) of respondents in a 2012 public
opinion poll by National Public Radio, RWJF, and Harvard
School of Public Health said that “Doctors or nurses not
spending enough time with patients was a major reason for
problems with quality of health care.”25
Therefore, changing our healthcare system to embrace
APRNs as the first line of primary and preventive care is a
potential win–win: It enables primary care physicians to
spend more time with complex cases, and it provides consumers more time with their providers—whether they are
nurses, physicians, or both.
Retooling our system to embrace the skills of nurse
practitioners can also help us build a society where being
healthy and staying healthy is a fundamental and guiding
social value. This is RWJF’s vision for a Culture of Health.
For too long, our healthcare system has focused on treating
disease rather than promoting wellness. To achieve a culture
of health where people of all incomes, races, and ethnicities
have an equal opportunity to achieve good health, we must
do a better job educating consumers about the benefits of
managing chronic illness and maintaining a healthy lifestyle.
To do that, our health care system needs to be able to reach
more people and healthcare providers need the time and
capacity to connect with consumers in ways they can
understand. That means we must insure nurse leaders guide
healthcare management to better balance the business of
healthcare with consumer needs.
34
Nurse Leader
THE FEDERAL TRADE COMMISSION STEPS IN
The Federal Trade Commission (FTC) recognized the importance of unleashing the power and capacity of nurse practitioners to solve our access problems when it released a
national report urging states to modernize laws and regulations related to APRNs. Prior to this, the FTC issued letters
of warning to 11 states—Alabama, Connecticut, Florida,
Illinois, Kentucky, Louisiana, Massachusetts, Missouri,
Tennessee, Texas, and West Virginia—because it found these
states’ practice restrictions potentially violate consumer
choice and are not in their best interest.26
The FTC’s intervention on this issue was prodded by
Senator Jay Rockefeller and the late Senator Daniel Inoyoue,
who, soon after the IOM Future of Nursing report’s release,
wrote a letter to the FTC asking for a review and ruling on
the restraints on nurse practitioners at the state level. Not
everyone was supportive, however. The American Medical
Association also wrote a letter to the FTC, rebuffing the
IOM’s Future of Nursing report recommendation to remove
practice barriers on APRNs. Four years later, in 2014, the
FTC made its position clear: outdated barriers to the practice
of APRNs are a direct assault on consumer freedom and are
stymying the ability of people to access healthcare.
NURSES LEADING THE WAY
If we are going to create a new era in healthcare with the
consumer at the center, then nurses must be prepared to serve
as full partners with physicians and others in re-designing this
new system. That is one of the most important goals of the
Future of Nursing: Campaign for Action: to embolden nurses to
take their rightful place in healthcare decision making. When
nurses contribute fully as leaders, the results are impressive.
For example, research shows that nurse-led initiatives have:
• Reduced falls with harm
• Reduced “code blue” calls
• Reduced 30-day re-admissions
• Improved care transitions27,28
Despite this, the American Hospital Association reports
that only 4% of hospital board seats are occupied by nurses.29
This must change; many of the Future of Nursing Campaign
state action coalitions are recruiting nurses for hospital and
health system board appointments as well as state and national
leadership positions. The progress is in the numbers reported
to the CCNA, with 268 appointed to leadership boards; state
action coalitions in North Carolina and Wyoming have
helped to launch leadership institutes; the Texas Action
Coalition has prepared 400 nurses for board positions; the
New Jersey Action Coalition has set a goal to place a nurse
leader in every hospital boardroom; and the Leapfrog Group
requires nurses to be integrated into governance for hospitals
to attain Magnet® status.
Nurses are a trusted voice of experience with a unique
perspective on consumer and family needs. For our system to
work at its best, we must be sure that our nurses are using all
capabilities and working to the full extent of their education
and training. To do anything less robs consumers of the healthcare they need, when and where they need it. Fortunately, we
April 2015
are well on our way to expanded access to care through nurses
who are well prepared and ready for the task. NL
References
1. Hassmiller S. The RWJF’s investment in nursing to strengthen the health of
individuals, families, and communities. Health Aff (Millwood).
2013;32:2051-2055.
2. American Association Colleges of Nursing. Nursing Fact Sheet. Updated
April 2011. http://www.aacn.nche.edu/media-relations/fact-sheets/nursingfact-sheet. Accessed July 28, 2014.
3. Swift A. Honesty and Ethics Rating of Clergy Slides to New Low. Nurses
Again Top List; Lobbyists Are Worst. 2013. Gallup.
http://www.gallup.com/poll/166298/honesty-ethics-rating-clergy-slides-newlow.aspx. Accessed July 28, 2014.
4. Buerhaus PI, Staiger DO, Auerbach DI. Implications of an Aging Registered
Nurse Workforce. JAMA. 2000;283:2948 -2954.
5. Buerhaus PI, Auerbach DI, Staiger DO. The Recent Surge In Nurse
Employment: Causes And Implications. Health Aff. 2009;28:w657 -w668.
6. Institute of Medicine. Retooling for an Aging America: Building the Health
Care Workforce. 2008. https://www.iom.edu:443/Reports/2008/Retooling-foran-Aging-America-Building-the-Health-Care-Workforce.aspx. Accessed
February 17, 2015.
7. Kuehn BM. No end in sight to nursing shortage: bottleneck at nursing
schools a key factor. JAMA. 2007;298:1623-1625.
8. The American Association of Colleges of Nursing. Nursing Shortage. Updated
April 24, 2014. http://www.aacn.nche.edu/media-relations/fact-sheets/nursing-shortage. Accessed July 16, 2014.
AARP. AARP CEO Bill Novelli Delivers Remarks on Creation of Center to
Champion Nursing. December 6, 2007. [Press Release]. http://www.aarp.org/
about-aarp/press-center/info-2007/aarp_ceo_bill_novelli_delivers_remarks_on_
creation.html. Accessed February 16, 2015.
9. Institute of Medicine. The Future of Nursing: Leading Change, Advancing
Health. Washington, DC: The National Academies Press; 2011.
10. The American Association of Nurse Practitioners. 2014 Nurse Practitioner
State Practice Environment. http://www.aanp.org/images/documents/stateleg-reg/stateregulatorymap.pdf. Accessed July 28, 2014.
11. The Robert Wood Johnson Foundation Nursing Research Network. Evidence
Brief: Quality of Care Provided by Advanced Practice Registered Nurses
(APRNs). May 2011. http://thefutureofnursing.org/sites/default/files/Quality
%20of%20Care%20Provided%20by%20Advanced%20Practice%20Registered
%20Nurses_0.pdf. Accessed July 28, 2014.
12. Sullivan-Marx EM. Lessons learned from advanced practice nursing payment.
Policy Polit Nurs Pract. 2008;9:121-126.
13. Mundinger MO, Kane RL, Lenz ER, et al. Primary Care Outcomes in
Patients Treated by Nurse Practitioners or Physicians: A Randomized Trial.
JAMA. 2000; 283:59-68.
14. Bauer JC. Nurse practitioners as an underutilized resource for health reform:
Evidence-based demonstrations of cost-effectiveness. JAANP. 2010;22:228
-231.
15. Naylor MD, Kurtzman ET. The Role Of Nurse Practitioners In Reinventing
Primary Care. Health Affairs. 2010;29:893-899.
16. Kuo YF, Loresto FL Jr., Rounds LR, Goodwin JS. States with the least restrictive regulations experienced the largest increase in patients seen by nurse
practitioners. Health Aff (Millwood). 2013;32:1236-1243.
17. Cassel CK. Retail clinics and drugstore medicine. JAMA. 2012;307:2151–
2152.
18. Rudavsky R, Pollack CE, Mehrotra A. The geographic distribution, ownership, prices, and scope of practice at retail clinics. Ann Intern Med.
2009;151:315–320.
19. CCA Clinics. Fact Sheet: Convenient Care Clinics: Increasing Access.
http://ccaclinics.org/images/stories/downloads/factsheets/ccafactsheet_
increasing_access.pdf. Accessed July 28, 2014.
20. Spetz J, Parente ST, Town RJ, Bazarko D. Scope-of-practice laws for nurse
practitioners limit cost savings that can be achieved in retail clinics. Health
Aff (Millwood). 2013;32:1977-1984.
21. Mehrotra A, Lave JR. Visits to retail clinics grew fourfold from 2007 to
2009, although their share of overall outpatient visits remains low. Health
Aff (Millwood). 2012;31:2123-2129.
22. Mehrotra A, Lave J. Visits to Retail Clinics Grew Four Fold from 2007 to 2009,
Although Their Share of Overall Outpatient Visits Remains Low. Health Affairs,
2012;31:2123-2129..
23. Uniform Data System. Health Center Impact. 2012. http://bphc.hrsa.gov/
healthcenterdatastatistics/. Accessed July 28, 2014.
24. Traczynski J, Udalova V. Nurse practitioner independence, health care
utilization, and health outcomes. In Fourth Annual Midwest Health
www.nurseleader.com
Economics Conference. http://www2.hawaii.edu/~jtraczyn/paperdraft_
050414_ASHE.pdf. Accessed February 18, 2015.
http://www.lafollette.wisc.edu/research/health_economics/Traczynski.pdf.
Accessed July 28, 2014.
25. National Public Radio, the Robert Wood Johnson Foundation, and Harvard
School of Public Health. 2013. Sick in America. http://www.npr.org/documents/
2012/may/poll/topline.pdf. Accessed July 28, 2014.
26. Federal Trade Commission. Policy Perspectives: Competition and the
Regulation of Advanced Practice Nurses. March 2014. http://www.ftc.gov/
reports/policy-perspectives-competition-regulation-advanced-practice-nurses.
Accessed July 28, 2014.
27. Needleman J and Hassmiller S. The Role of Nurses in Improving Hospital
Quality and Efficiency: Real World Results 2009.
28. Naylor MD, Brooten D, Campbell R, et al. Transitional Care of Older Adults
Hospitalized with Heart Failure: A Randomized Controlled Trial. J Am Geriatr
Soc. 2004.
29. American Hospital Association. AHA Hospital Statistics, 2011 Edition.
Chicago, IL: American Hospital Association; 2011.
Susan B. Hassmiller, PhD, RN, FAAN, is senior program officer at
the Robert Wood Johnson Foundation and director, Future of
Nursing: Campaign for Action She can be reached at
shassmiller@rwjf.org. Winifred V. Quinn, PhD, is director,
Advocacy & Consumer Affairs, Center to Champion Nursing in
America, a joint initiative of AARP, the AARP Foundation, and
the Robert Wood Johnson Foundation, in Washington, DC.
Note: The authors acknowledge the expert assistance of Susan
Lamontagne, Health Care Communications Consultant, IQ
Solutions, Inc., in the writing of this paper.
1541-4612/2014/ $ See front matter
Copyright 2015 by Elsevier Inc.
All rights reserved.
http://dx.doi.org/10.1016/j.mnl.2015.01.008
Nurse Leader
35
Chapter 18:
Ethical Theories and Principles
Theory in the Humanities and Philosophy
❖“Theory” in the humanities usually refers to any one
of a combination of ideas, hypotheses, or
propositions derived from a range of the humanities
fields such as literary theory, postmodern theory in
sociology, and structuralism or poststructuralism in
cultural anthropology.
❖Philosophers generally regard something termed
theory with indifference and consider that those
inclined to examine “theory” will have little
background in philosophy.
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Ethics Versus Morality
❖“Morality” is an accepted set of cultural beliefs about
what is right and wrong behavior.
❖The ANA (2015a) expanded on the distinctions by
observing that morality refers to “personal values,
character, or conduct of individuals or groups,”
whereas ethics is “the formal study of that morality
from a wide range of perspectives including
semantic, logical, analytics, epistemological and
normative” (p. xi). Furthermore, one might
describe ethics as evidence-based or critically
assessed morality.
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Question #1
❖Tell whether the following statement is true or false:
❖Ethics refers to personal values, character, or
conduct of individuals or groups.
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Answer to Question #1
❖False
❖Rationale: The ANA (2015a) expanded on the
distinctions by observing that morality refers to
“personal values, character, or conduct of
individuals or groups,” whereas ethics is “the formal
study of that morality from a wide range of
perspectives including semantic, logical, analytics,
epistemological and normative” (p. xi).
Furthermore, one might describe ethics as evidencebased or critically assessed morality.
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Applying the Essentials—Ethics
❖“Ethics” is one of the core concepts for nursing
practice as identified in the new AACN “Essentials”
(AACN, 2021). The Essentials explain that ethics
refers to the principles that guide behaviors and
note that “ethics is closely tied to moral philosophy
involving the study of or examination of morality
through a variety of different approaches” (p. 13).
The principles of autonomy, beneficence,
nonmaleficence, and justice are highlighted in the
document.
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Philosophical Theories of Ethics
❖Virtue Ethics, or Virtue Theory, is the term used to
describe Aristotle’s views on ethics as well as newer
approaches based on his writings.
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Modern Ethical Theories
❖Utilitarianism is a posteriori (knowledge dependent
on experience or evidence; personal knowledge),
like the social sciences, whereas the other—
Deontology—is a priori (knowledge independent of
experience), like math and logic.
❖Deontology and utilitarianism perspectives agree on
what is the right thing to do. The difference between
them—the philosophically irreconcilable difference—
is in the justification.
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Bioethical Principles
❖The Belmont Report resulted from the infamous
Tuskegee Study. The outcome was the Guidelines
for Protection of Human Subjects of Research.
❖Subsequently a system of bioethical principles has
been proposed consisting of four main ideologies:
autonomy, beneficence, nonmaleficence, and
justice. Each of the four principles can be justified
using either deontologic or utilitarian reasoning, and
they have found much acceptance among health
professionals, including nurses (ANA, 2015a).
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Autonomy
❖The principle of autonomy, or respect for persons,
focuses on the rights of individuals to make
informed choices about their health care.
o Focus is patient autonomy—not professional
autonomy
o It’s based on a patient’s rights to control health
care decisions
o Informed consent is one aspect—therein a
patient has to be told about their health issues
and possible treatments in a manner that
promotes comprehension
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Beneficence
❖The principle of beneficence refers to doing what is
in the patient’s best interest and involves balancing
benefits and burdens.
o Health care providers have an obligation to act
for the benefit of the patient.
o There may be a tension between beneficence
and paternalism.
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Question #2
❖Tell whether the following statement is true or false:
❖The principle of beneficence refers to doing what is
in the patient’s best interest and involves balancing
benefits and burdens.
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Answer to Question #2
❖True
❖Rationale: The principle of beneficence refers to
doing what is in the patient’s best interest and
involves balancing benefits and burdens.
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Nonmaleficence
❖The principle of nonmaleficence relates to the
Hippocratic principle of “first, do no harm.”
❖Health care professionals have an obligation to avoid
causing bodily harm and death to patients and to
minimize pain and suffering.
❖There may be tension between beneficence and
nonmaleficence
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Justice
❖Justice is often described in terms of fairness in both
treatment and research.
❖Justice obligates health care professionals to provide
necessary treatment for all members of society.
o Focus on vulnerable populations
o Questions about justice arise because of
inequality in resources and inequity in risks
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Ethical Decision Making
❖The first step in the process of ethical decision
making is to recognize when an ethical issue or
dilemma exists.
❖The second step in ethical decision making is to
determine as many of the responses as possible to
the issues or dilemma that might arise.
❖An analysis of how the principles and philosophical
theories relate to these possible responses should
follow and should be used by both patients and
clinicians in ethical decision making.
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Chapter 17:
Learning Theories
What Is Learning?
❖Learning—a change in behavior (knowledge,
attitudes, and/or skills) that can be measured.
❖Learning occurs as individuals interact with their
environment, incorporating new information into
what they already know.
❖Learning is a relatively permanent change in
behavior or in behavioral potential as a result of
experience.
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Learning
❖Learning is the means by which skills, values,
knowledge, attitudes, and emotions are acquired.
❖Learning creates a change within the individual.
❖Learning can describe a process, a product, or a
function.
Copyright © 2022 Wolters Kluwer · All Rights Reserved
What Is Teaching?
❖Teaching is one of the most important roles of
nurses.
❖Teaching is the intentional act of communicating
information; facilitation of learning.
o Must be aware and attend to how people learn
o Must be aware of the importance of the material
to the person or family
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Applying the Essentials—Learning
Theories
❖Key competencies of the “Essentials” (AACN, 2021)
include: “Employ individualized educational
strategies based on learning theories,
methodologies, and health literacy” and to work to
“Educate individuals and families regarding self-care
for health promotion, illness prevention, and illness
management” (p. 32). These competencies will
apply in situations where nurses engage in patient
education, staff development, or academic learning.
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Learning Theories
❖Learning theories describe processes used to bring
about changes in how we understand information
and/or change in how we perform tasks or skills.
❖Many theories of learning can be useful for nurses.
❖Main categories
o Behavioral learning theories
o Cognitive learning theories
o Adult learning theory
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Types of Learning Theories
❖ Three basic types of categories of learning
o Affective learning (change in feelings, values,
beliefs)
o Cognitive leaning (acquiring information)
o Psychomotor learning (skills, physical abilities)
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Behavioral Learning Theories #1
❖Among the first and most widely used
❖Focus on what is directly observable in learners
❖Based on the works of Pavlov and Thorndike
o Behavior (response) is the result of a stimulus.
o Stimulus–Response (S–R) Models of Learning
❖Thorndike—original S–R framework
❖Pavlov—classical conditioning
❖Skinner—operant conditioning
❖Hull—S–R + reinforcement
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Behavioral Learning Theories #2
❖Behavioral theories are concerned with observable
and measurable aspects of behavior.
❖Behaviors can be controlled through rewarding
desirable behavior and ignoring or punishing
undesirable behavior.
❖Reinforcing the desired behavior increases its
recurrence in the future.
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Question #1
❖Use of behavioral theory in learning does which of
the following?
A. Reinforces learning
B. Rewards positive responses
C. Conditions responses
D. All of the above
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Answer to Question #1
❖D. All of the above
❖Rationale: In behavioral learning theories, behavior
or response is viewed as the result of stimulus to
certain conditions. The response is the learned
behavior, which becomes conditioned and can be
reinforced in multiple ways.
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Cognitive Learning Theories #1
❖Behavioral learning theories fail to consider
thoughts, feelings, and cognitive processes of the
learner.
❖Cognitive theories consider the learner’s own goals,
thoughts, expectations, motivations, and abilities.
❖Became popular in the 1960s; focus on how people
learn and how to change behaviors
❖Problem: the behavior that is reinforced may not be
the behavior intended.
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Cognitive Learning Theories #2
❖Cognitive-field (Gestalt) theories
o Learning is closely related to perception.
o Learning is reorganization of the learner’s
perceptual or psychological world (i.e., their
field).
o Learning is the process of discovering and
understanding relationships among people,
things, and ideas in the field.
o Self-actualization is a driving force that
motivates human behavior.
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Cognitive Learning Theories #3
❖Cognitive-field (Gestalt) theories—(cont.)
o Perceptions of reality and experience are unique
to each individual.
o Thoughts influence actions.
o Kurt Lewin was a major gestalt theorist.
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Cognitive Development/Interaction
Theories
❖Behavior, mental processes, and the environment
are interrelated.
❖Assumes learning is a sequential process and takes
place over time.
❖Stresses the importance of experiential interaction
with the environment.
❖Focus on conditions that promote learning.
❖Support student understanding of the whole rather
than its separate parts.
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Cognitive Development/Interaction
Theories: Piaget
❖Cognitive development occurs in stages:
sensorimotor, preoperational, concrete operational,
and formal operational.
❖Stages are universal to persons everywhere.
❖Must be able to assimilate new information into
existing cognitive structures to learn.
❖Assimilation and accommodation processes are
critical to development and learning.
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Cognitive Development/Interaction
Theories: Gagne
❖To be successful, learning requires varying
conditions.
❖Learning outcomes are divided into five categories:
intellectual skills, verbal information, cognitive
strategies, motor skills, and attitudes.
❖Also believed there are eight types of learning that
are sequential and hierarchical (e.g., involuntary
responses to problem solving).
❖Teaching involves arranging conditions external to
the learner to enhance learning.
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Question #2
❖Gagne categorizes learning outcomes as intellectual
skills, verbal information, cognitive strategies,
attitudes, and:
A. Accommodation
B. Behavioral intention
C. Learning needs
D. Motor skills
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Answer to Question #2
❖D. Motor skills
❖Rationale: Motor skills are one of the learning
outcomes needed in many circumstances.
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Cognitive Development/Interaction
Theories: Bandura #1
❖Bandura—Social Learning Theory
o Concerned with social influences that affect
learning (culture, ethnicity)
o Environment, cognitive factors, and behavior
interact reciprocally
o Emphasis on self-efficacy
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Cognitive Development/Interaction
Theories: Bandura #2
❖ Focus is on how people learn from one another.
❖ Concepts of observational learning, imitation,
and modeling (vicarious learning).
❖ Cognition plays a role in learning.
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Cognitive Development/Interaction
Theories: Bandura #3
❖ Self-efficacy is the competence to perform a
specific task or range of tasks.
❖ People are more likely to engage in behaviors
they can perform successfully—those with high
self-efficacy.
❖ Teaching efforts should focus on developing selfefficacy.
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Cognitive Development/Interaction
Theories: Bandura #4
❖Bandura Social Learning Theory—Implications
o Learners learn by observing others.
o Modeling can help teach new behavior(s).
o Teachers must model appropriate behaviors.
o Students must believe they are capable of
learning—self-efficacy.
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Cognitive Development/Interaction
Theories: Bandura #5
❖ Bandura’s work is widely used in nursing.
❖ Many citations relate to research.
o Self-efficacy of nursing students using simulations.
o Education program for patients who receive an
implantable cardioverter defibrillator.
o Effects of peer mentoring on stress and anxiety of nursing
students.
o Efforts to promote self-efficacy in midwifery students.
o Development and testing tool to measure implementation
of evidence-based practice among RN’s Among many
other studies.
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Humanistic Learning Theory
❖Humanistic theory is the foundation for many
successful wellness programs, self-help groups, and
palliative care (Braungart et al., 2019) and can be
effectively applied in nursing education in strategies
such as problem-based learning, service learning,
and the flipped classroom.
❖For Rogers (1983), the learner is in the process of
becoming, the goal of education is to develop a
“fully functioning person,” and the teacher’s role is
to facilitate the process. The learner has both the
freedom to learn and to be self-directed.
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Information-Processing Models
❖Information-processing theories propose an
elaborate set of internal processes to account for
how learning and retention occur (Ormrod, 2020).
❖In information-processing theories, human memory
is thought to be composed of three stores: sensory
store, short-term store, and long-term store.
Information from the environment passes
sequentially through the stores (Braungart et al.,
2019).
❖In information-processing models, learning consists
of transferring information from sort-term memory
to long-term memory.
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Cognitive Load Theory
❖Cognitive Load Theory (CLT) is an example of an
information processing theory based on the work of
John Sweller, who began studying the idea in the
1980s.
❖The major components of CLT include schemas:
classifications of the material that the mind of the
learner makes.
❖A basic tenet of the theory is recognition that
working memory can deal with only a few novel
pieces of information at a time, but long-term
memory allows the knowledge to be grouped
together with already existing schemas to develop a
huge amount of knowledge of specific fields.
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Adult Learning Theory (Andragogy) #1
❖Malcolm Knowles initially presented his work on
adult learning principles in the 1970s.
❖Coined the term “andragogy” as a process model to
describe how adults learn.
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Adult Learning Theory (Andragogy) #2
❖Knowles believed that adult learning did not follow
the principles of traditional pedagogy in which
teachers are responsible for deciding what, where,
when, and how information will be learned.
❖Believed that because adults are more self-directed,
they should control their own learning.
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Adult Learning Theory—Assumptions #1
❖Need to know: Adults need to know why they need
to learn something.
❖Self-concept: Maturity moves self-concept from
dependence to being self-directed.
❖Experience: Maturity increases experience that can
be helpful in learning.
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Adult Learning Theory—Assumptions #2
❖Readiness to learn: Life problems or situations
create a readiness to learn.
❖Orientation to learning: need to recognize
application of information (need to relate what they
are learning to personal/professional experiences)
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Adult Learning Theory—Assumptions #3
❖Motivation: Adults are primarily motivated by a
desire to solve immediate and practical problems.
❖Motivation is often internal rather than external.
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Adult Learning Theory—Implications #1
❖Learners should be motivated and ready to learn.
❖Learners should be involved in planning and
evaluation of instruction.
❖Instruction should be problem-centered rather than
content-oriented.
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Adult Learning Theory—Implications #2
❖Learners should be explained why they are studying
something.
❖Instruction should be task-oriented and should
consider range of background of learners.
❖Learners should be able to relate subject to
personal/professional experiences.
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Adult Learning Theory—Application
❖ Knowles’s work has been used by nurses in
o Practice (patient education)
▪ Model of andragogy for osteoporosis education
▪ Approach to cardiac in-patient education
▪ Facilitating self-management in diabetes education
o Education
▪ Graduate education curriculum design
▪ Use of journaling in an RN-BSN program
▪ Continuing education—computer learning needs
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Learning Styles
❖Most individuals have a preferred style of learning—
how they interact with instructional circumstances to
enhance learning.
o Visual
o Auditory
o Tactile/kinesthetic
❖May prefer “global” or analytic view.
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Question #3
❖Tell whether the following statement is true or false:
❖All information should be presented in the same
method to patients.
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Answer to Question #3
❖False
❖Rationale: Every learner is different; this includes
patients. The APN or RN providing education should
assess the individual for best learning style and use
the method of learning to suit the learner.
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Basic Principles of Learning #1
❖Learning may be emotional as well as intellectual.
❖Learning is highly unique: People learn in different
ways.
❖Learning can be painful.
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Basic Principles of Learning #2
❖ Learning is facilitated when
o Moving from simple to complex, concrete to
abstract, and known to unknown.
o Information is personal and individualized.
o Relevant to learners’ needs and problems
o The individual is attentive.
o Feedback is provided promptly.
Copyright © 2022 Wolters Kluwer · All Rights Reserved