Health Care Reform and Increased Patient Needs Require Transformation of Nursing Profession

Oct. 5, 2010 -- Nurses' roles, responsibilities, and education should change significantly to meet the increased demand for care that will be created by health care reform and to advance improvements in America's increasingly complex health system, says a new report from the Institute of Medicine. (Read Full Report).

Nurses should be fully engaged with other health professionals and assume leadership roles in redesigning care in the United States, said the committee that wrote the report.  To ensure its members are well-prepared, the profession should institute residency training for nurses, increase the percentage of nurses who attain a bachelor's degree to 80 percent by 2020, and double the number who pursue doctorates.  And regulatory and institutional obstacles -- including limits on nurses' scope of practice -- should be removed so that the health system can reap the full benefit of nurses' training, skills, and knowledge in patient care.

"The report's recommendations provide a strong foundation for the development of a nursing work force whose members are well-educated and prepared to practice to the fullest extent of their training, meet the current and future needs of patients, and act as full partners in leading advances in the nation's health care system," said committee chair Donna E. Shalala, president, University of Miami, Miami.  "Transforming the nursing profession is a crucial element to achieving the nation's vision of an effective, affordable health care system that is accessible and responsive to all," added committee vice chair Linda Burnes Bolten, vice president for nursing, chief nursing officer, and director of nursing research, Cedars-Sinai Medical Center, Los Angeles.

At more than 3 million in number, nurses make up the single largest segment of the health care work force.  They also spend the greatest amount of time in delivering patient care as a profession.  Nurses therefore have valuable insights and unique abilities to contribute as partners with other health care professionals in improving the quality and safety of care as envisioned in the Affordable Care Act (ACA) enacted this year, the committee said.

States, federal agencies, and health care organizations should remove scope of practice barriers that hinder nurses from practicing to the full extent of their education and training, the report says.  Scope of practice barriers are particularly problematic for advanced practice registered nurses (APRNs).  With millions more patients expected to have access to health coverage through the ACA, the health care system needs to tap the capabilities of APRNs to meet the increased demand for primary care, the committee said.  Data from studies of APRNs and the experiences of health care organizations that have increased the roles and responsibilities of nurses in patient care, such as the Veterans Health Administration, Geisinger Health System, and Kaiser Permanente, show that these nursing professionals deliver safe, high-quality primary care.

To handle greater responsibilities and the increasing complexity of health care, nurses should achieve higher levels of education and training through an improved education system that includes creation of a residency program to help nurses transition from education to practice and additional opportunities for lifelong learning, the report says.  Nursing is unique among health professions in that there are multiple tracks by which individuals can attain undergraduate education -- through diploma, associate degree, or bachelor's degree programs.  The health care system does not provide sufficient incentives for nurses to pursue higher degrees and additional training, the report says.  Lack of academic progression has prevented more nurses from working in faculty and advanced practice roles at a time when there is a significant shortage in both areas, it adds.  Public and private organizations should provide resources to help nurses with associate degrees and diplomas pursue a Bachelor of Science in Nursing within five years of graduation and to help nursing schools ensure that at least 10 percent of their baccalaureate graduates enter a master's or doctoral program within five years. 

Health care organizations, including nursing associations and nursing schools, should also provide nurses greater opportunities to gain leadership skills and put them into practice, the report adds. Nurses in turn need to recognize their responsibility and capability to contribute on management teams, boards, and other groups shaping health care.  To that end, all health professionals should have opportunities to be educated and trained with other health professionals, which would facilitate the kind of interprofessional practice that is called for by many to promote more effective patient care. 

Transforming the health care system and the practice environment will require a balance of skills and perspectives among physicians, nurses, and other health care professionals.  Shaping the work force needed to achieve this balance will necessitate better data on the numbers and types of health care professionals currently employed, where they are employed, and what types of activities they perform, the report says.

The report is the product of a study convened under the auspices of the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine, and is the result of the committee’s review of scientific literature on the nursing profession and a series of public forums to gather insights and evidence from a range of experts.  The Initiative on the Future of Nursing will organize a national conference Nov. 30 through Dec. 1 to discuss ways to implement the report's recommendations.


The report and the Initiative on the Future of Nursing are sponsored by the Robert Wood Johnson Foundation.  Established in 1970 under the charter of the National Academy of Sciences, the Institute of Medicine provides independent, objective, evidence-based advice to policymakers, health professionals, the private sector, and the public.  The National Academy of Sciences, National Academy of Engineering, Institute of Medicine, and National Research Council make up the National Academies.  A committee roster follows. 

Contacts:  Christine Stencel, Senior Media Relations Officer

Christopher White, Media Relations Assistant

Office of News and Public Information

202-334-2138; e-mail <[email protected]>

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[ This news release and report are available at ]




Committee on Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine      

Donna E. Shalala, Ph.D., FAAN (chair)

President and Professor of Political


University of Miami



Linda Burnes Bolton, Ph.D., R.N. (vice chair)
Vice President for Nursing

Cedars-Sinai Medical Center

Los Angeles


Michael Bleich, Ph.D., M.P.H., R.N., FAAN
Carol A. Lindeman Distinguished Professor and Dean
School of Nursing
Health and Science University


Troyen A. Brennan, J.D., M.D., M.P.H.
Executive Vice President and
Chief Medical Officer
CVS Caremark
Woonsocket, R.I.

Robert E. Campbell, M.B.A.
Vice Chairman
Johnson & Johnson (retired)
New Brunswick, N.J.


Leah M. Devlin, D.D.S., M.P.H.
State Health Director
North Carolina Department of Health and Human Services


Catherine Dower, J.D.

Associate Director, Health Law and

Center for Health Professions
University of San Francisco

San Francisco


Rosa Gonzalez-Guarda,Ph.D., M.S.N, M.P.H., R.N., M.P.H.

Assistant Professor
School of Nursing and Health Studies
University of Miami



David C. Goodman, M.D., M.S.
Professor of Pediatrics and Health Policy
The Dartmouth Institute for Health Policy and Clinical Practice
Dartmouth Medical School
, N.H.


Jennie C. Hansen, R.N., M.S.,RAAN
Board President
Washington, D.C.

C. Martin Harris, M.D., M.B.A.
Chief Information Officer
Department of General Internal Medicine
Cleveland Clinic Foundation


Anjli A. Hinman, M.P.H., C.N.M., F.N.P.-B.C.
Certified Nurse Midwife and Family Nurse Practitioner
Intown Midwifery
Atlanta, Ga.

William D. Novelli, M.A.
Former Chief Executive Officer
Washington, D.C.

Liana M. Orsolini-Hain, Ph.D., R.N., CCRN
Nursing Instructor
City College of San Francisco
San Francisco


Yolanda Partida, D.P.A., M.S.W.
Hablamos Juntos
Fresno, Calif.

Robert D. Reischauer, Ph.D.
The Urban Institute
Washington, D.C. 

John W. Rowe, M.D.
Department of Health Policy and Management
Columbia University Mailman School of Public Health
New York City

Bruce C. Vladeck, Ph.D.
Senior Adviser
Nexera Consulting
New York City



Susan Hassmiller

Study Director