Introduction
The health of Americans is in serious jeopardy as the capacity of the nursing profession to care for an expanding, longer-living population continues to shrink. While nursing readily accepts the responsibility to fulfill its contract with society to maximize health, the profession’s leadership recognizes that the current system of nursing practice, education and credentialing is inadequate to meet the future health care needs and demands of consumers. Transformation that realizes discrete scopes of practice and licensure, with clearly defined educational preparation for each scope of practice, is required. Inherent to this transformation is the requirement that nursing service leaders and nurse educators collaborate with delivery system stakeholders to design, refine and implement a nursing care system: one that facilitates the work of nursing in a satisfying and rewarding manner while promoting nursing advancement in clinical practice.
Public understanding about the appropriate roles of nurses in health care delivery systems, as delineated by clear scope of practice and differentiated licensure tied to educational preparation, is essential. Americans will be better served by a diversified nursing workforce whose competencies are matched to specific roles. An adequate number of nurses, prepared with different types of knowledge and skills, is fundamental to the provision of quality, cost effective care. “This mediates against production of nurse clinicians who are all things to all people.” (AACN, AONE, N-OADN, 1995)
The challenge is to develop a comprehensive plan for nursing practice, education and credentialing that 1) distinguishes the specific sets of competencies that will be needed for the profession to meet its social mandate to improve health and provide care and 2) ensure that nursing is developed as a career that will attract a sufficient supply of new entrants necessary to meet the needs of society. The attractiveness of nursing as a career will be enhanced by Vision 2020 For Nursing.
Vision 2020 For Nursing
The Nursing Practice and Education Consortium (N-PEC) envisions a future in which nursing
will:
1. be clearly understood by society for its unique contributions to health care.
2. be viewed by the public as an intellectually challenging, economically advantageous and evolving career option with a global presence.
3. serve individuals, families and communities in the United States as health advocate/case manager.
4. be an evidence-based discipline with nurses as knowledge brokers.
5. be directly accountable to and selected by those served.
6. have a nursing education system that is based in institutions of higher education and prepares nursing clinicians for clearly differentiated roles.
7. have a practice environment in which nurses practice in distinct and clearly differentiated roles.
8. demonstrate congruence among competencies as delineated by educational preparation, licensure, employment expectations about roles and compensation.
9. have strong practice/education partnerships that recognize the contributions of expert nurses to the preparation of future nurse clinicians.
10. have a formalized period of standardized internship or residency post licensing.
11. use significant numbers of master’s prepared nurses to lead clinical care.
12. will be comprised of at least 20% doctorally prepared nurses who are prepared to practice as experts in illness care, public health, health education and faculty roles.
13. place emphasis on practice which applies cost-effective treatment of illness, health promotion, disease and illness prevention.
14. have an infrastructure for practice that is embedded in fully diversified professional corporations.
15. be innovative and entrepreneurial in improving nursing care to ensure quality, cost-effective outcomes.
16. have an active role in health care policy discussions and decision-making.
17. actively and strategically manage the supply of nurses prepared for the differentiated roles and, in conjunction with policymakers, work to ensure an appropriate supply of well-educated and competent nurse clinicians for these differentiated roles.
Consensus Statement
The overarching goal of nursing in the United States is to assist people and communities to achieve and maintain maximum health and to cope effectively with illnesses, accidents and diseases. Specifically, nursing’s social mandate is to be responsive to America’s diverse needs for enlightened health and illness care. In order to fulfill this mandate nursing must create research-based and evidence-based nursing care that ensures quality, cost-effective outcomes.
Nursing has a proud history of addressing factors associated with matters relevant to health and disease while making the distinction that disease, illness and optimal health are different phenomena. Nurses, along with multidisciplinary colleagues, maintain and maximize human well-being and functional ability by (1) preventing or alleviating individual and environmental factors that contribute to the experience of illness, and (2) enhancing factors that foster the experience of wellness.
In efforts to meet society’s needs for nursing care, the discipline has created a full range of educational programming including diploma, associate degree, baccalaureate degree, masters degree and doctoral degrees in nursing to 1) prepare nurses to meet the nursing care needs of individuals, families and communities, and 2) advance and disseminate knowledge pertinent to nursing care. Historically, the various diploma and academic degrees in nursing have not been clearly differentiated in terms of the competencies achieved in these different programs, the corresponding credentialing requirements and the practice distinctions and employment opportunities associated with different educational outcomes. This lack of differentiation has resulted in unclear expectations on the part of prospective nurses, employing agencies and the public. The lack of clarity, coupled with the turmoil accompanying the recent reorganization in health care delivery systems, has contributed to the perception by young people that nursing is a blue collar, non-intellectually demanding, financially unrewarding and insecure type of work
(JWT Specialized Communications, 2000). For the most part, the current health care environment is not supportive of nursing; and it is typically devoid of nurturing qualities. In general, nurses do not feel respected or valued for their contributions to the health care team.
To preclude an escalating crisis in the health care delivery system due to a shortage of nurses, major changes in delivery settings and in the preparation of nurses are indicated. Nursing has historically experienced cycles of perceived oversupply or diminished demand. Newer dynamics related to the aging of the nursing workforce and decreased enrollments of new entrants to the nursing workforce portend a more serious and longer term shortage in the nursing workforce (Buerhaus, Staiger & Auerbach, 2000; Bednash, 2000). To recruit and retain sufficient numbers of appropriately prepared nurses to meet consumer health care needs, the profession must design and employ practice frameworks that maximize the use of nurses’ intellectual capital and provide opportunities for career advancement.
To ensure a sufficient supply of nurses to meet society’s needs for first-rate nursing care through 2020, N-PEC member organizations agree that major transformations in nursing practice, education and regulation are required. Specifically, alignment among educational preparation, regulation, scope of practice and practice roles in all settings is required.
Therefore, the N-PEC proposes a markedly revised conceptualization of nursing roles and scopes of practice for the profession. A model depicting possible scopes of practice is presented in Figure 1 below. Each of the scopes of practice is represented by the letters A, B, C and D. Scope A is currently conceived as an unlicensed care provider, while individuals practicing in Scopes B and C would require a license. The consortium also believes that separate and distinct licensure would exist for Scope B and Scope C providers. As distinct entities, movement between Scope B and Scope C would be limited. To better bridge education and practice,
N-PEC members supported the incorporation of post-license internships for Scope B and residencies for Scope C. Graduate education would be required for practice in Scope D, and individuals would move from Scope C to Scope D through this graduate education.
N-PEC members agree that future work needs to be directed to 1) delineating scopes of practice with corresponding competencies for each type of nursing care provider, 2) identifying strategies for developing licensure, and where appropriate, credentialing mechanisms for each type of nurse provider, and 3) developing practice settings where the new scopes of practice and roles can be enacted with organizational support.
To accomplish these ends, demonstration projects, competitively sought and funded, are realistic next steps, once scopes of practice, competencies and educational preparation are identified. These projects require collaboration among educational institutions, practice settings of various types and respective state boards of nursing.
Assumptions
The following assumptions underlie the urgent need to redesign nursing education, practice and regulation to prepare and retain the nursing workforce needed now and in the future.
1. Health care delivery will continue to be a major priority for the nation; nursing is an essential component of health care delivery.
2. Nursing practice, education and regulation have not kept pace with changes in the health care delivery system.
3. The supply of nurses will become insufficient to meet the growing health care demands of diverse populations.
4. The nursing discipline must attract younger and second-career people to strengthen the future of the profession.
5. Career options for men, women and diverse ethnic groups will expand in the future and result in competition for persons interested in nursing as a career.
6. If the current trajectory of diminishing supply of nurses as a consequence of retirement exceeding new entrants continues, the public will experience an irreversible loss of needed nursing care.
7. A nursing faculty shortage will be intensified by the aging workforce and inadequate faculty salaries.
8. Nursing organizations can support the strategic plan through their political will to do so.
Strategic Plan Objective and Outcomes
Objective: To meet the health needs of Americans by assuring an adequate supply of appropriately prepared nurses. To accomplish this objective, we must create satisfying and rewarding careers in nursing that distinguish knowledge-based roles and competencies in nursing practice and specify educational preparation, career development options and supportive regulations.
Outcomes: The following outcomes will be achieved:
Outcome #1: A vision statement for the discipline of nursing that meets the needs of diverse populations is developed.
A. Develop a succinct statement, accompanied by a narrative draft.
B. Establish full N-PEC endorsement and support for the document.
C. Secure support of N-PEC organizational leadership and members.
D. Revise statement and secure feedback from internal and external stakeholders.
E. Complete widespread dissemination of final draft.
Outcome #2: The nature and scope of the competencies required to actualize the discipline’s contributions to the health of Americans in the future will be defined.
A. Prepare an assessment of present and evolving populations and health care system needs.
B. Delineate distinct scopes of nursing practice.
C. Distinguish the required roles and the competencies associated with those roles in relation to types of health care and the needs of population segments.
D. Define the educational preparation required for these roles.
Outcome #3: Consensus statement regarding scopes of practice, educational preparation and credentialing for nursing practice is achieved.
A. Convene consensus conferences with members of N-PEC organizations for dialogue about Outcomes #1 and #2.
B. Develop a grid that contains clusters of competencies matched to educational preparation, practice roles and credentialing, including appropriate licensure as discovered in conference feedback.
C. Secure broader feedback from internal and external stakeholders; revise grid.
D. Secure support of consortium member organizational leadership and members.
E. Complete and disseminate final revision of consensus statement on scopes of educational preparation and credentials for nursing practice.
Outcome #4: Creation of nursing practice frameworks characterized by nurses accountable for populations of patients.
A. Define the guiding principles for the ideal practice model, which will deliver care in the face of the nursing shortage, with particular focus on evidence of quality of care and cost effectiveness.
B. Identify the above principles for each of the various practice settings.
C. Examine pertinent findings from the field, i.e., “Colleagues in Caring” initiatives, and develop application initiatives and guidelines.
D. Identify the requirements of state and voluntary regulatory bodies, and analyze their impact on establishing national nursing practice competencies.
E. Identify the factors within nursing practice that serve as barriers or facilitators to nursing practice.
F. Articulate the economic value of implementing frameworks that match nursing competencies with the variety of health care needs.
G. Secure support from nurse managers to assist in achieving desired outcomes.
Outcome #5: A nursing education transition framework that reflects the full range of scopes of practice competencies and corresponding preparation, as identified in Outcome #2, is specified.
A. Assess resources available within existing nursing education system.
B. Analyze exemplar transition frameworks and processes used in designing major educational and practice transformations in other disciplines.
C. Draft a plan to transform and transition nursing education to reflect the desired educational framework.
D. Determine the financial viability of projected educational programs.
E. Present to N-PEC and obtain support for the document.
F. Secure support of consortium member organizational leadership.
G. Obtain feedback from internal and external stakeholders and revise education framework.
H. Complete final revision and begin widespread dissemination.
Outcome #6: A model feedback loop that promotes mutual accountabilities and collaboration between practice and education at national levels is constructed.
A. Collate and analyze information about effective national frameworks (in and out of nursing) that incorporate recognition of the mutual accountabilities between education and practice.
B. Identify the essential relationships needed between stakeholders.
C. Agree upon and implement a feedback process.
D. Identify the driving and inhibiting factors to effective collaboration between practice and education.
E. Establish a continuous feedback loop between nursing practice and education that enhances the efforts of both.
F. Include representatives of regulatory and credentialing bodies in the decision making.
Outcome #7: The regulatory and credentialing system prospectively reflects the prescribed changes in practice and education.
A. Collaborate with the appropriate regulatory and credentialing bodies.
B. Assess the state of affairs within the regulatory and credentialing arenas.
C. Identify needed changes and associated implications.
D. Create a transition plan and process for needed regulatory changes.
E. Develop a cost/benefit analysis that addresses the revised regulatory and credentialing requirements.
Outcome #8: Collaborative demonstration projects between education, practice and regulatory bodies provide evidence of strategies that can be used to bring about the desired transformation in nursing education, practice and regulation. The projects would demonstrate Outcomes #4-7.
A. Secure funding for demonstration projects.
B. Develop and disseminate an RFP for demonstration projects.
C. Competitively review and select proposals to be funded.
D. Evaluate demonstration projects containing strategies to transform nursing education, licensure and credentialing, and practice.
Outcome #9: A communications plan informing publics throughout the process is devised.
A. Contract with a public relations firm to develop the plan.
B. Develop a compelling image for the initiative.
C. Develop white papers and other explanatory documents for publication.
D. Communicate information to nursing stakeholders as the framework is developed.
E. Hold periodic regional forums to describe the framework and elicit feedback.
F. Conduct national closed-circuit broadcasts.
G. Design a web page with hotlinks to nursing organizations.
Outcome #10: Increase the number of individuals choosing nursing as a career.
A. Collaborate with the Nurses for a Healthier Tomorrow campaign.
B. Identify “best” nursing education frameworks that excel in recruitment and retention of students and promote career advancement.
C. Collaborate with HRSA: Health Careers for Kids program.
Outcome #11: A central coordinating center to manage the transformational process is established.
A. Seek external funding.
1. Design the coordinating center project with full consortium input; write the grant proposal with task force of consortium.
B. Attend to transitional activities.
1. Secure commitment from N-PEC members to financially support activities during the period preceding grant funding. (May conduct fundraising efforts.)
2. Maintain continuity of N-PEC organization leaders by conducting succession planning.
Sumber Asli: www.cna-nurses.ca/CNA/documents
