The future of nursing education and practice was outlined in a landmark report published in October 2010 by the Institute of Medicine (IOM). The report was a 2-year joint effort between the Robert Wood Johnson Foundation and the IOM entitled The Future of Nursing: Leading Change, Advancing Health.1 The committee members who proposed future recommendations were distinguished leaders in nursing, medicine, healthcare administration, and business. In the final report there were 4 key issues (Table 1) and 8 recommendations (Table 2) that reflected the need for nurses to continue their formal education and expand current roles.1 This pivotal undertaking will place nurses in strategic positions to transform our nation’s healthcare.
The business of healthcare is more complex than in years past. Nurses need to have a broader education in order to successfully care for the patient in a complete and comprehensive manner. The IOM report highlighted nursing competencies to include leadership, health policy, system improvement, research, and evidence-based practice.1 Additionally, teamwork and collaboration across the entire spectrum of healthcare are critical elements in caring for patients today in any setting. Gone are the days when a patient is discharged from the hospital to go directly home. Coordination of care and transition to interim care facilities are common and necessary in order for a patient to achieve normal activities of daily life. However, this coordination and skill in teamwork and collaboration are typically not part of nursing school curricula, even though they are an essential part of caring for patients today. As a result of the IOM report, schools of nursing will likely take a careful look at curricula and may realize that some of what is being taught today could perhaps be replaced with lessons in these important elements of care.
Communication with other members of the healthcare team is vital in the proper care of patients, whether it be in the hospital or in an outpatient setting. Polishing this useful skill and creating an environment where positive interactions take place in the context of patient care is essential. The hierarchical system that once existed is less apparent today and not relevant in 21st century patient-centered healthcare. Therefore, it is imperative that members understand how to communicate and effectively interact with each other in the most efficient way possible to achieve excellence in patient caring.
Specialties such as oncology nursing demand a great deal of unique knowledge and a special skill set. There are few schools of nursing that offer electives in oncology nursing at the baccalaureate level. Providing opportunities for nursing students to complete a preceptorship with an oncology nurse in either the hospital or outpatient setting would stimulate a larger pool of new oncology nurses who would have a basic understanding of the unique knowledge and expertise necessary for caring for the oncology population. Providing education in survivorship and end-of-life care would go a long way in helping new nurses understand how to interact with both of these special populations. Additionally, nurse residency programs are few and far between. The IOM report elaborates on this need and the advantages of such residency programs.
The allotted time for a residency allows nursing graduates to acquire special knowledge and skills necessary to providing safe quality care within an evidence-based framework. This likely would promote confidence in new graduates and better functioning once they are employed. Moreover, these types of programs may provide the impetus for the baccalaureate-prepared nurse to continue to the graduate level, keeping in line with one of the IOM recommendations. According to Aiken and colleagues, hospitals with higher proportions of nurses educated at the baccalaureate level or higher experience lower mortality and failure-to-rescue rates.2
The IOM report is the result of thousands of hours of deep discussion between highly respected individuals in many professional fields. The report concluded that nurses need to be part of the global discussion regarding the health of our nation. Specifically, advanced practice nurses (APNs) need to be able to practice fully, as compatible with their graduate education and training. APNs, particularly nurse practitioners and clinical nurse specialists in oncology, are one solution in caring for the many survivors that will make up an enormous population in the years to come. These advanced practitioners should be able to practice in a collaborative manner with (not under the supervision of) an oncologist. According to Peter Yu, MD (oral communication, November 2011), an oncologist with the Palo Alto Medical Foundation in Mountain View, California, “we are directing our NPs to genetic counseling and survivorship programs where they can develop new models [of care] that are not constrained by the past.”
Additionally, he commented on the education specifically of the oncology nurse practitioner, “Perhaps ASCO should create a training module [for the oncology nurse practitioner] from the physician perspective that could be adopted by ONS as part of the ONS certification process.” These ideas may create a more solid foundation for the collaborative practice for APNs and oncologists going forward.
In addition to the IOM recommendation that advanced practice registered nurses (APRNs) be able to practice to the full extent of their education and training, the APRN Advisory Panel met with the APRN Consensus Work Group in April 2006 to discuss APRN issues. For some time they worked in parallel, but they eventually joined forces in January 2007 to begin a dialogue for the purpose of developing a document that would become a new model for advanced practice nurses—APRN Model of Regulation (Figure).3 Advanced practice nurses are defined as certified registered nurse anesthetist (CRNA), certified nurse-midwife (CNM), clinical nurse specialist (CNS), and certified nurse practitioner (CNP).
There are 4 essential elements—licensure, accreditation, certification, and education—that create the framework for the model. Individuals are licensed as independent practitioners for practice at the level of 1 of the 4 APRN roles within at least 1 of the 6 identified population foci (Figure). Education, certification, and licensure of an individual must be congruent in terms of role and population. An example of this would be that an individual graduating from a Family Nurse Practitioner program could not practice as a psychiatric/mental health nurse practitioner. Advanced practitioners may specialize, but they cannot be licensed solely within a specialty area.
For example, a CNP working as an advanced oncology certified nurse practitioner (AOCNP) must be certified by either the American Academy of Nurse Practitioners (AANP) or the American Nurses Credentialing Center (ANCC), first within in the specific population foci in which she/he was educated and trained, and then by the Oncology Nursing Certification Corporation. Special certification, such as AOCNP or advanced oncology clinical nurse specialist (AOCNS), is an option but is often recommended because it may be a requirement for employment in a particular state. According to the APRN Consensus Model Frequently Asked Questions,4 an APRN must legally represent herself/himself as APRN plus the specific role (CRNA, CNM, CNS, CNP).
An example of this would be as follows: APRN, CNP, adult oncology. Many in nursing believe we currently have too many initials after our names that the patient population doesn’t understand. One may argue that APRNs did not have much input into this signature regulation and that having to sign both APRN and the role is redundant. Additionally, many in advanced practice roles believe that once you have been educated beyond the basic RN role, the designation of RN should not be used, but rather the new role, such as CNP. After all, an advanced practice nurse practices under a different license and different scope of practice than an RN. However, if every state adopts the Consensus Model, nursing may finally have, in part, some standardization of how we sign our names.
As it stands now, states have different practice acts with specific restrictions on practice for the advanced practice nurse. This creates a cumbersome process when an APRN wishes to move from state to state, as there may be different educational, licensure, or prescriptive requirements. Goals of the
APRN Consensus Model include improved mobility for APRNs, standardization in educational programs, and homogeneity in independent practice, assuring the public that the APRN is highly prepared and certified to provide safe quality care and better access to the APRN for all patients. The target date for implementation is 2015. Implementation will likely be staggered, and full implementation may go beyond the target date.
Healthcare systems and the manner in which we deliver care are changing and becoming increasingly more important to the consumer, healthcare provider, and institution. Nursing has always played a critical role in the implementation and delivery of care. Now, more than ever, nursing has the ppportunity to be front and center in the sharing of ideas to improve the trajectory of care for patients. The IOM report and the APRN Consensus Model both serve as road maps for now and the future in guiding the profession of nursing in its quest to make valuable contributions to the overall health and well-being of all those we serve.
- Institute of Medicine of the National Academies (IOM). The Future of Nursing: Leading Change, Advancing Health. www.iom.edu/nursing. Published October 5, 2010. Accessed November 11, 2011.
- Aiken L, Clarke SP, Cheung RB, Sloane DM, Silber JH. Educational levels of hospital nurses and surgical patient mortality. JAMA. 2003;290:1617-1623.
- APRN Consensus Work Group, National Council of State Boards of Nursing APRN Advisory Committee. Consensus Model for APRN Regulation: Licensure, Accreditation, Certification & Education. www.aacn. nche.edu/education-resources/APRNReport.pdf. Published July 7, 2008. Accessed November 13, 2011.
- APRN Consensus Frequently Asked Questions. American Nurses Association Web site. www.nursing-world.org/ConsensusModelFAQ. Updated August 19, 2010. Accessed November 27, 2011.