Six months after Congress passed the health reform law last year, the Institute of Medicine of the National Academy of Sciences issued a landmark report on nursing. Although seemingly separate events at the time, it’s clear now that they are integrally linked: Never has quality care been more dependent on the total engagement of nurses as well as other health professionals.
At its core, the Affordable Care Act is about providing care. It will enable about 32 million uninsured Americans to get coverage for services and treatment that they previously couldn’t afford, at times with devastating consequences. Yet the nation’s acute shortage of primary care physicians means that many patients still could find themselves going without. Health reform will be a hollow promise if we give people health insurance without giving them access to health care providers.
That’s the crucial point of intersection between the law and the Institute’s report on The Future of Nursing: Leading Change, Advancing Health.
The report identifies the actions needed for the nation’s more than 3 million nurses—the largest segment of U.S. health care ranks—to be able to contribute as essential partners from a patient’s bedside to a hospital boardroom. It calls for an end to barriers that prevent nurses from working to the full extent of their education, training and competency. Such barriers exist in two-thirds of the states and keep advanced-practice nurses from diagnosing and treating routine illnesses, ordering basic tests or prescribing medications without a physician’s oversight.
In the wake of the report’s publication, a nationwide initiative to implement its recommendations launched. Supported by the Robert Wood Johnson Foundation in collaboration with AARP, the Future of Nursing: Campaign for Action is moving forward through coalitions and organizations in almost every state. These groups include nurses and other health professionals, business and association executives, nonprofit and academic leaders, policy-makers and consumer advocates.
In Vermont, the governor is forming a blue-ribbon commission to consider key recommendations from the report. Montana is implementing a rural nurse residency program, and Georgia has begun offering online doctoral programs to speed expansion of nursing faculty—whose shortage has repercussions throughout nursing education.
The 671-page report has drawn attention at the federal level, too. Sen. Daniel Inouye of Hawaii and several of his Senate and House colleagues urged the Federal Trade Commission in April to review state regulations that restrict advanced-practice nurses’ work. In addition, Inouye asked the commission to monitor the regulations for their anticompetitive influence.
Removing scope-of-practice limitations is unquestionably the report’s most controversial section. It need not be. Sixteen states and the District of Columbia allow advanced-practice nurses to see primary care patients independent of a physician, and studies have consistently shown no compromise of patient safety. The expert committee that authored the report conducted a robust evaluation of all the scientific evidence before giving its endorsement.
There is also other support. In an article in the New England Journal of Medicine early this year, Linda H. Aiken of the University of Pennsylvania Center for Health Outcomes and Policy Research noted that advanced-practice nurses have permitted the biggest expansion of services at community health centers in a quarter century. And these days, Aiken calculated, advanced-practice nurses provide care at retail clinics to more than 3 million families annually. Those numbers convey real impact that we hope will increase as the Campaign for Action accelerates.
The Future of Nursing continues to rank as one of the most visited reports on the Institute’s website, which bodes well for its staying power and the campaign’s progress during its second year. Although the challenges remain considerable, just as they do with the Affordable Care Act itself, the real promise of this work is a transformed health system and accessible quality care for all.
Harvey V. Fineberg is president of the Institute of Medicine. John W. Rowe, who served on the Institute committee on the future of nursing, is a professor of health policy and management at the Columbia University Mailman School of Public Health.
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