On the Future of Nursing Practice

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Focus on Scope of Practice

[By Staff Reporters]

Transforming the health care system to meet the demand for safe, quality, and affordable care will require a fundamental rethinking of the roles of many health care professionals, including nurses. The 2010 Affordable Care Act represents the broadest health care overhaul since the 1965 creation of the Medicare and Medicaid programs, but nurses are unable to fully participate in the resulting evolution of the U.S. health care system. This is true for nurses at all levels, whether they practice in schools or community and public health centers or acute care settings. A variety of historical, cultural, regulatory, and policy barriers limit nurses’ ability to contribute to widespread and meaningful change.

In 2008, the Robert Wood Johnson Foundation (RWJF) and the Institute of Medicine (IOM) launched a two-year initiative to respond to the need to assess and transform the nursing profession. The IOM appointed the Committee on the RWJF Initiative on the Future of Nursing, at the IOM, with the purpose of producing a report that would make recommendations for an action-oriented blueprint for the future of nursing.

As part of its report, the committee considered the obstacles all nurses encounter as they take on new roles in the transformation of health care in the United States. While challenges face nurses at all levels, the committee took particular note of the legal barriers in many states that prohibit advance practice registered nurses (APRNs) from practicing to their full education and training. The committee determined that such constraints will have to be lifted in order for nurses to assume the responsibilities they can and should be taking during this time of great need.




The Changing Health Care System

In the 21st century, the health challenges facing the nation have shifted dramatically. The health care system is in the midst of great change as care providers discover new ways to provide patient-centered care; to deliver more primary care as opposed to specialty care; and to deliver more care in the community rather than the acute care setting. Nurses are well poised to meet these needs by virtue of their numbers, scientific knowledge, and adaptive capacity, and health care organizations would benefit from taking advantage of the contributions nurses can make.


As the health care system has expanded over the past 40 years, the education and roles of APRNs, in particular, have evolved in such a way that nurses now enter the workplace qualified to provide more services than had been the case previously. Yet while APRNs are educated and trained to do more, some physicians challenge expanding scopes of practice for nurses. The committee stresses that physicians are highly trained and skilled providers and that some services clearly should be provided by physicians, who have received more extensive and specialized education and training than APRNs. However, given the great need for more affordable health care, nurses should be playing a larger role in the health care system, both in delivering care and in decision making about care.

The committee argues that APRNs are not acting as physician extenders or substitutes. They work throughout the entirety of health care, from health promotion and disease prevention to early diagnosis to prevent or limit disability. APRNs sometimes provide services that many people associate with physicians, such as assessing patient conditions or ordering and evaluating tests, but they also incorporate a range of services from other disciplines, including social work, nutrition, and physical therapy.


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