The Future of Nursing 2020–2030: Charting a path to achieve health equity

Abstract

•The National Academy of Medicine report, The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity calls for a series of policy reforms to unleash the potential of nurses to play greater roles in advancing health equity.•The report recommends that the systems that educate, pay and employ nurses: 1) permanently remove barriers to care; 2) value their contributions; 3) prepare nurses to tackle health equity; and 4) diversify the workforce. The need to fully support nurses is interwoven throughout the report.•All nurses should work in partnership with others to advance the nine major report recommendations. The National Academy of Medicine's long-anticipated report, The Future of Nursing 2020–2030: Charting a Path to Achieve Health Equity, offers an aspirational vision: the achievement of health equity in the United States built on strengthened nursing capacity, diversity, and expertise (Wakefield, 2021Wakefield M. Federally qualified health centers and related primary care workforce issues.Jama. 2021; 325: 1145-1146Crossref PubMed Scopus (10) Google Scholar). Released in May 2021, the report arrives at a critical moment for the profession. Many nurses are burned out, exhausted, and have experienced moral injury from caring for an unrelenting stream of patients with COVID-19. The pandemic has laid bare and further exacerbated long-existing health inequities. School closings during the pandemic similarly exacerbated educational disparities, and poor treatment of Black, Indigenous, and other people of color by police spotlighted inequities in law enforcement. Collectively, these inequities have resulted in renewed calls to dismantle structural, cultural, and interpersonal racism, including within nursing. This new report provides a roadmap for how the nursing profession can contribute its expertise to create a fairer, more just and healthier world. The report is the second collaboration between the Robert Wood Johnson Foundation (RWJF) and the National Academy of Medicine (NAM) on the future of nursing. The first report, released in 2010, re-conceptualized the role of nurses in transforming the healthcare system (Shalala et al., 2011Shalala D. Bolton L.B. Bleich M.R. Brennan T. Campbell R. Devlin L. The future of nursing: Leading change, advancing health. 10. The National Academy Press, Washington DC2011: 12956https://www.nap.edu/catalog/12956/the-future-of-nursing-leading-change-advancing-healthGoogle Scholar). RWJF and AARP formed The Future of Nursing: Campaign for Action, a nationwide initiative to advance the report recommendations. Over the past decade, the nursing field strengthened nursing education, advanced practice, promoted leadership, and increased workforce diversity. In doing so, the nursing field has built – and is continuing to build – its capacity to provide high-quality care to more Americans. As nursing built its capacity and as the evidence increasingly linked inequities to poorer health status, it became clear that nurses could do more to build healthier communities and advance equity. Nurses are the most trusted profession and the first point of contact for most people seeking health care. They are bridge builders and collaborators who engage and connect with people, communities, and organizations to promote health and well-being (Pittman, 2019Pittman, P. (2019,. March 12). Activating nursing to address the unmet needs of the 21st century: Background paper for the NAM Committee on Nursing 2030.Robert Wood Johnson Foundation. Available at: https://publichealth.gwu.edu/sites/default/files/downloads/HPM/Activating%20Nursing %20To%20Address%20Unmet%20Needs%20In%20The %2021st%20Century.pdfGoogle Scholar). Their expertise could be better used to combat the many shortcomings of the U.S. health system. The United States spends $3.5 trillion each year on health care (CMS, 2020) more than any other country in the world but ranks last compared with other high-income countries on equity, access to care, health care outcomes, and administrative efficiency (Schneider et al., 2021Schneider, E. et al.,(2021, August)) Mirror, Mirror 2021 — Reflecting Poorly: Health Care in the U.S. compared to other high-income countries (Commonwealth Fund). https://doi.org/10.26099/01dv-h208.Google Scholar). Life expectancy, infant mortality and maternal mortality are worse in the United States compared with other high-income nations. Disparities in health care access and outcomes related to race, income, geography and other social and environmental factors are also common. RWJF has long believed that nurses have enormous potential for tackling the shortcomings of health and health care in the United States and in 2019 asked the NAM to form a committee tasked with charting a path for the nursing profession to create a culture of health, reduce health disparities, and improve the health and well-being of the nation. As the committee was well into the process of reviewing evidence and preparing to write the report, the pandemic took hold across the country and shined a light on the nation's rampant health inequities. The committee delayed the report to incorporate the major lessons from the pandemic: its disproportionate and devastating toll on poor and marginalized populations that could largely be attributed to persistent health disparities; the need to fully support nurses; and better prepare the workforce for future disasters. Released in May 2021, the report called for a series of policy reforms to unleash the potential of nurses to play greater roles in advancing health equity. The report recommends that the systems that educate, pay, and employ nurses: (1) permanently remove barriers to care; (2) value their contributions; (3) prepare nurses to tackle health equity; and (4) diversify the workforce. The report underscores that prioritizing nurse well-being is paramount to advancing the recommendations. In addition, the report calls on national nursing organizations to develop a shared agenda for addressing the social determinants of health and achieving health equity. Finally, the committee prioritized research needs to build the evidence base to support nurses in advancing health equity. Each of these areas is discussed below. Far too often in the United States, people do not see a health care provider when they need one. Nearly 30 million people are uninsured in the United States, and roughly 40 million have health plans that leave them potentially underinsured (Collins et al., August 2020Collins, Sara R., Gunja, Munira Z., & Aboulafia, Gabriella N. (2020). U.S. Health insurance coverage in 2020: A looming crisis in affordability — findings from the Commonwealth Fund Biennial Health Insurance Survey, 2020.Commonwealth Fund. https://doi.org/10.26099/6aj3-n655.Google Scholar). In addition, timely access to health care is undermined due to the inability to pay; geographic inaccessibility to services and providers, particularly in rural and underserved urban areas; lack of health literacy; and fundamental mistrust of the health care system and providers. Research demonstrates that delays in obtaining care can lead people to experience worse symptoms and disease progression (Man et al., 2018Man R.X.G. Lack D.A. Wyatt C.E. Murray V. The effect of natural disasters on cancer care: A systematic review.The Lancet Oncology. 2018; 19: e482-e499https://doi.org/10.1016/S1470-2045(18)30412-1Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar). Nurses can help to explicitly address these gaps in access to care. For example, about 70% to 80% of advanced-practice nurses work in primary care, including in pediatrics, adult practice, gerontology, and nurse midwifery. While the primary care nurse practitioner field has grown, the number of physicians entering primary care has stagnated or declined (Barnes et al., 2018Barnes H. Richards M.R. McHugh M.D. Martsolf G. Rural and nonrural primary care physician practices increasingly rely on nurse practitioners.Health Affairs. 2018; 37: 908-914https://doi.org/10.1377/hlthaff.2017.1158Crossref PubMed Scopus (127) Google Scholar; Barnes et al., 2018Xue Y. Ye Y. Brewer C. Spetz J. Impact of state nurse practitioner scope-of-practice regulation on health care delivery: Systematic review.Nursing outlook. 2016; 64: 71-85https://doi.org/10.1377/hlthaff.2017.1158Crossref PubMed Scopus (117) Google Scholar). Care provided by nurse practitioners has been found to be comparable to the care provided by physicians, according to numerous studies (Perloff et al., 2019Perloff J. Clarke S. DesRoches C.M. O'Reilly-Jacob M. Buerhaus P. Association of state-level restrictions in nurse practitioner scope of practice with the quality of primary care provided to Medicare beneficiaries.Medical Care Research and Review. 2019; 76: 597-626Crossref PubMed Scopus (24) Google Scholar; Yang et al., 2020Yang B.K. Johantgen M.E. Trinkoff A.M. Idzik S.R. Wince J. Tomlinson C. State Nurse Practitioner practice regulations and US health care delivery outcomes: A systematic review.Medical Care Research and Review. 2021; 78: 183-196https://doi.org/10.1177/1077558719901216Crossref PubMed Scopus (32) Google Scholar). They are less expensive to employ than physicians and are more likely to care for vulnerable populations, including those in rural areas (Perloff et al., 2016Perloff J. DesRoches C.M. Buerhaus P. Comparing the cost of care provided to Medicare beneficiaries assigned to primary care nurse practitioners and physicians.Health Services Research. 2016; 51: 1407-1423Crossref PubMed Scopus (83) Google Scholar). However, the ability of nurses to expand access to care is limited by state and federal laws, institutional barriers, and restrictive health systems policies that prohibit them from working to the full extent of their education and training (Wakefield et al., 2021Wakefield M.K. Williams D.R. Le Menestrel S. Flaubert J.L. The future of nursing 2020-2030: Charting a path to achieve health equity. National Academies Press, Washington, D.C.2021https://www.nationalacademies.org/our-work/the-future-of-nursing-2020-2030Crossref Google Scholar). The report calls for all public and private organizations to remove these regulatory and payment limitations as well as restrictive policies and practices. In fact, during the pandemic, seven states (Kansas, Louisiana, Massachusetts, New Jersey, New York, Virginia, and Wisconsin) temporarily provided full practice authority to nurse practitioners. Evidence is just becoming available about the effect of the temporary waivers to expand scope of practice during the pandemic (Kleinpell et al., 2021Kleinpell R. Myers C.R. Schorn M.N. Likes W. Impact of COVID-19 pandemic on APRN practice: Results from a national survey.Nursing Outlook. 2021; 69: 783-792https://doi.org/10.1016/j.outlook.2021.05.002Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar; Stucky et al., 2021Stucky C.H. Brown W.J. Stucky M.G. COVID 19: An unprecedented opportunity for nurse practitioners to reform healthcare and advocate for permanent full practice authority.Nursing Forum. 2021; 56: 222-227https://doi.org/10.1111/nuf.12515Crossref PubMed Scopus (24) Google Scholar); one study in the Midwest found that states with waivers were able to decrease death rates from COVID-19 (Chung, 2020Chung B.W. The impact of relaxing nurse practitioner licensing to reduce COVID mortality: Evidence from the midwest.Illinois Labor and Employment Relations. 2020; (Retrieved from:) (. pp. 7–11)http://publish.illinois.edu/projectformiddleclassrenewal/files/2020/06/The-Impact-of-RelaxingNurse-Practioner-Licensing8413.pdfGoogle Scholar). The report calls for these temporary restrictions on scope of practice to be made permanent. This recommendation to remove practice barriers continues the work of the first report, but it discusses in more detail the need to lift barriers that prevent RNs and licensed-practical nurses from practicing to the top of their education and training to increase access to care and help to reduce health care inequities for populations struggling to see a provider when they need one. Barriers that limit the care that RNs and licensed practical nurses provide include restrictions on providing telehealth services and workplace policies that prevent nurses from providing care. Allowing nurses to practice to the full extent of their education and training is an important policy solution to eliminating preventable gaps in access to care. As the report notes, the public and private payment systems do little to reduce health inequities. This shortcoming has recently been underscored by the Biden Administration, which has indicated its intent to make health equity a priority consideration in payment policy (Brooks-LaSure, Fowler, Seshamani, & Tsai, 2021Brooks-LaSure Chiquita Fowler E. Seshamani M. Tsai D. et al.Brooks-LaSure, ChiquitaInnovation at the Centers for Medicare and Medicaid Services: a vision for the next 10 years.Health Affairs Blog. 2021; https://doi.org/10.1377/hblog20210812.211558Crossref Google Scholar). Because payment drives health care parameters, actions that prioritize health equity can make a profound impact in creating change. The current U.S. payment systems undervalue the care that nurses provide and underestimate the critical role that they can play in addressing obstacles to health equity. For example, acute care nurses can screen patients at discharge to help identify and address social needs like food insecurity. Similarly, community-based nurses can work to advance city or state policies that address the need for accessible housing and safe neighborhoods. But payment systems often only reimburse for physicians’ services while including the services of nurses and other team-based care providers under generic facility charges. With financial support, nurses can markedly expand efforts to advance health equity through their roles in care management and team-based care; preventative care; community nursing, including school nurses; and providing telehealth services. School nurses, for example, are a lifeline for 56 million students, particularly children from low-income families, but they are undervalued for the services they provide. They detect illnesses early, help manage chronic conditions, and contact trace outbreaks of infectious disease, including COVID-19. They also provide mental health care. About one-third of student health visits to school nurses before the pandemic were related to mental health (Foster et al., 2005Foster S. Rollefson M. Doksum T. Noonan D. Robinson G. Teich J. School Mental Health Services in the United States, 2002-2003.Substance Abuse and Mental Health Services Administration. 2005; Google Scholar), a need that has grown tremendously during the pandemic. Students of color face more barriers to accessing mental health treatment than others, and structural racism can exacerbate these conditions (Lipson et al., 2018Lipson S.K. Kern A. Eisenberg D. Breland-Noble A.M. Mental health disparities among college students of color.Journal of Adolescent Health. 2018; 63: 348-356Abstract Full Text Full Text PDF PubMed Scopus (143) Google Scholar). But 25% of schools do not employ a school nurse, and 35% employ one part-time (Willgerodt et al., 2018Willgerodt M.A. Brock D.M. Maughan E.D. Public school nursing practice in the United States.The Journal of School Nursing. 2018; 34: 232-244Crossref PubMed Scopus (99) Google Scholar). School nurses are able to bill Medicaid for services that they provide, but the process is so cumbersome that few schools do so (Ollove, 2019Ollove M. Pew Charitable Trusts. Available at.2019Google Scholar). Investments that expand, strengthen, and diversify the nursing workforce will help to advance health equity. Specific to the nursing profession, the report calls for public and private payers to provide reimbursement for nursing interventions that address social needs and the social determinants of health in nursing practice and education. Payment systems can enable nurses to make essential contributions to improving care and outcomes for all patients by delivering proven interventions and strategies that can reduce health inequities. Furthermore, the widespread adoption of successful, evidence-based nursing innovations to improve care will remain limited if the organizations that employ nurses are not adequately compensated for these care improvements (Chin and Bisognano, 2021Chin Marshall Bisognano Maureen Payment reform for nursing to advance health equity: The future of nursing 2020-2030 NAM report.Health Affairs Blog. 2021; (Available at:)https://www.healthaffairs.org/do/10.1377/hblog20210511.490956/full/Google Scholar). The report recommends that public and private payment systems be intentionally designed to support and incentivize health care and public health organizations to enable nurses to perform these vital roles. Simply put, the United States spends tremendous amounts of money for health care services, with health outcomes that pale in comparison to countries that spend far less. Recognizing this incongruity, public and private sector efforts are underway to recast payment policy that produces better health outcomes. Nursing input in these payment discussions is critically important, as is payment policy that values the contributions nurses can make to advancing health equity. The next generation of nurses needs to be well prepared to promote health equity and improve the health and well-being of everyone. All nurses will need to understand and identify the complex social and environmental factors that affect health, effectively care for an aging and more diverse population, engage in new professional roles, use new technology, collaborate with other professions and sectors around health equity issues, and adapt to a changing policy environment. Meaningful, deep and broad collaboration with partners across the health care and public health systems as well as outside of health care with organizations focused on housing, transportation, social isolation, and food insecurity will be paramount during the next decade. Yet, the nursing field will face an extraordinary challenge in preparing the next generation as an estimated 1.2 million nurses born during the baby boom generation retire by 2030. This tectonic shift will result in an unprecedented knowledge gap (Buerhaus, May 3, 2017Buerhaus, Auerbach (2017).& Staiger, http://healthaffairs.org/blog/2017/05/03/how-should-we-prepare-for-the-wave-of-retiring-baby-boomer-nursesGoogle Scholar), even as nursing education strives to produce nurses well prepared to take on contemporary and futures roles and takes action to advance the NAM report recommendations. Specific recommendations to prepare nurses to tackle health equity include: Too often, content related to the social determinants of health, health inequities, and population health are not well-integrated into undergraduate and graduate nursing education. Academic programs must ensure that nurses are prepared to address the social determinants of health and advance health and healthcare equity. Associated content and competencies should be well-integrated throughout coursework, including through expanded community learning opportunities. Schools need to evaluate the extent to which they provide substantive education in locations that provide important direct engagement with individuals and families from diverse backgrounds who present with an array of social needs as well as with communities facing challenges associated with the social determinants of health (Wakefield et al., 2021Wakefield M.K. Williams D.R. Le Menestrel S. Flaubert J.L. The future of nursing 2020-2030: Charting a path to achieve health equity. National Academies Press, Washington, D.C.2021https://www.nationalacademies.org/our-work/the-future-of-nursing-2020-2030Crossref Google Scholar). Creating learning opportunities across the curriculum, including in public policy venues, accompanied by meaningful reflection on challenging topics such as biases are essential. Much of this learning can occur through active, sustained learning opportunities provided through public health environments such as schools, workplaces, home health care, federally qualified health centers, public health clinics, homeless shelters, public housing sites, public libraries, residential addiction programs, and telework settings. These student experiences, calibrated for educational level, should incorporate opportunities to deeply observe and work collaboratively with other health and non-health professionals to address the social determinants of health. Ultimately, students need active engagement in experiences that prepare them to act on a strong foundation in health equity, care for diverse populations with competence and empathy, and allow them to build the necessary skills and competencies to advance health equity. Nurse educators can find inspiration from exceptional examples of nursing schools that emphasize content and robust engagement around the social determinants of health, population health and community experiential placements. For example, graduate students at the University of Washington spend a year immersed in grassroots work in the community followed by a year immersed in policy. Washburn University in Topeka, Kansas, integrated its DNP academic program with a community clinic that reflects interdisciplinary practice and commitment to ongoing academic improvement informed by both students and faculty. More doctorally prepared nurses will be necessary to teach the next generation of nurses and systematically build the evidence base around concepts and issues that connect the social determinants of health, health equity, and health status as well as associated nursing interventions. PhD nursing graduates will need to be able to design and implement research that addresses issues of social justice and equity in education and healthcare, including a focus on informing institutional and public policies. Increasing the number of nurses with PhDs requires financial resources, including scholarship and loan repayment opportunities; sufficient numbers of expert available faculty, including for mentorship; and curriculum revisions that focus on equity. All PhD graduates should have competencies in the use of data on the social determinants of health as context for planning, implementing, and evaluating care and for improving population health through large-scale data application. In addition to developing and fielding new knowledge to advance health and healthcare equity, developing a more diverse nursing workforce will be critical. The new report calls on the nursing field to address systemic racism and bias within nursing education and practice, and to prioritize diversity and cultural humility – defined by flexibility, a lifelong approach to learning about diversity, and recognition of the role of individual bias and systemic power in health care interactions (Agner, 2020Agner J. Moving from cultural competence to cultural humility in occupational therapy: A paradigm shift.American Journal of Occupational Therapy. 2020; 74 (7404347010p1–7404347010p7)Crossref PubMed Scopus (20) Google Scholar). Nursing needs to identify and address structural racism within the profession to address systemic barriers that contribute to the nursing profession remaining overwhelmingly white and female. Despite periodic calls to increase diversity, the nursing field is still roughly 80% white, even though white individuals comprise 60% of the U.S. population. The gap widens further for nurses in leadership positions, including in academia and practice. American Association of Colleges of Nursing and American Organization of Nurse Leaders, 2021American Association of Colleges of Nursing and American Organization of Nurse Leaders. (2021). Unpublished data as report to The Future of Nursing: Campaign for Action.Google Scholar that 10% of nursing faculty and 4% of deans were people of color, while the American Organization of Nurse Leaders said that just under 10 percent of chief nursing officers were people of color (AACN and AONL, 2021). Nurses of color repeatedly report experiencing discrimination and bias within their work settings (Cottingham et al., 2018Cottingham M.D. Johnson A.H. Erickson R.J. I can never be too comfortable”: Race, gender, and emotion at the hospital bedside.Qualitative Health Research. 2018; 28: 145-158Crossref PubMed Scopus (44) Google Scholar; Ghazal et al., 2020Ghazal L.V. Ma C. Djukic M. Squires A. Transition-to-US practice experiences of internationally educated nurses: An integrative review.Western Journal of Nursing Research. 2020; 42: 373-392Crossref PubMed Scopus (19) Google Scholar). Fragmented efforts, while important locally, are wholly insufficient to achieving a nationally diverse workforce. Prioritized support should be directed toward the development of substantive, evidence-based and ultimately scaled efforts to achieve nursing workforce diversity across practice settings, academic institutions and in leadership positions. Within nursing academic and practice environments, everyone should feel included and welcomed. To achieve this relatively simple-sounding aim, however, requires meaningful and sustained efforts to make sure that nursing students and faculty reflect the diversity of the population and that barriers of structural racism are removed from nursing education, including in the curricula, institutional polices and structures, and the formal and informal distribution of resources and power (Iheduru-Anderson, 2021Iheduru-Anderson K.C. The White/Black hierarchy institutionalizes White supremacy in nursing and nursing leadership in the United States.Journal of Professional Nursing. 2021; 37: 411-421Crossref PubMed Scopus (25) Google Scholar). Across practice environments, all nurses need to be able to effectively communicate and connect with people of different backgrounds and be capable of self-reflection regarding how their own beliefs and biases may affect their caregiving. Achieving these aims is predicated on a diversified and strengthened academic and practice environment that is inclusive, which requires recruiting and admitting or hiring people from diverse backgrounds, races and ethnicities. Schools of nursing should offer students support and address barriers to their success throughout their academic career and into practice. Implicit and explicit bias training coupled with learning about structural discrimination will be critical for nurses in practice settings. Workplaces should recruit, retain, mentor, and promote nurses from underrepresented backgrounds. The report includes several recommendations that prioritize actions for nursing educators and academic administrators and that will lead to increased workforce diversity, equity and inclusion. Among the recommendations are to (1) identify and eliminate policies, procedures, curricular content, and clinical experiences that perpetuate structural racism and discrimination among faculty, staff and students; (2) increase academic progression for geographically and socioeconomically disadvantaged students through academic partnerships that include community and tribal colleges located in underserved areas; and (3) recruit diverse faculty with expertise in health equity and use evidence-based and other trainings to develop the health equity skills of faculty. Disasters and other public health emergencies disproportionately affect people of color, those with low incomes, those experiencing housing insecurity, and those with limited access to health care and transportation (Davis et al., 2010Davis J.R. Wilson S. Brock-Martin A. Glover S. Svendsen E.R. The impact of disasters on populations with health and health care disparities.Disaster Medicine and Public Health Preparedness. 2010; 4: 30-38Crossref PubMed Scopus (76) Google Scholar). Although nurses serve on the frontlines of emergencies and help people and communities to cope and recover, nursing curricula does not consistently and thoroughly teach students about health care emergency preparedness. The report recommends that nursing schools and employers expand disaster preparedness educational and training opportunities for nurses in all sectors and at all levels with particular attention to vulnerable populations. To unleash the potential of nurses to advance health equity, our country needs to prioritize nurse well-being. The nursing profession has been lauded for its selflessness and caring in delivering care under extremely challenging circumstances during the COVID-19 pandemic. However, this professional engagement, often accompanied by physical and emotional risk to themselves and their families, came with a cost. Even prior to the pandemic, studies showed stress impacting the nursing community, catalyzed by an array of factors ranging from working in understaffed settings, to experiencing bullying and violence in the workplace, to the added pressures of caring for children or elderly relatives outside of work hours (Robert Wood Johnson Foundation, 2019Robert Wood Johnson Foundation. (2019). Unpublished research.Google Scholar; Sauer and McCoy, 2017Sauer P.A. McCoy T.P. Nurse bullying: Impact on nurses’ health.Western Journal of Nursing Research. 2017; 39 (Available at:): 1533-1546https://journals.sagepub.com/doi/full/10.1177/0193945916681278?casa_token=biN4hjrWD4MAAAAA%3AIY5SuolSiNSxhnqGXvThsD5YbTHq-u2JWCXgWydb9oFlDtt9jaQi51zqYaXoDCQIRsNAq5ckUZ8Crossref PubMed Scopus (61) Google Scholar). Levels of stress and burnout increased during the pandemic, resulting in moral injury and post-traumatic stress disorder for many nurses (Le Bleu Lucchesi, 2021Le Bleu Lucchesi Emile The Ignored History of Nurse PTSD.Discover Magazine. 2021; (Available at:)https://www.discovermagazine.com/health