Available online at www.sciencedirect.com
Nurs Outlook 63 (2015) 105e107
From the Editor
Marion E. Broome, PhD, RN, FAAN
There have never been such bright prospects for the profession of nursing to make an impact and take the lead in improving the health of the American people. We can achieve this through our contributions to knowledge generation and translation in symptom science and health promotion, interventions to enhance patients’ self-management of their chronic illness and by developing testing and implementing innovative approaches to empower and mobilize patients and their families about their health. Playing our part in widening access to health care for all citizens will require we continue to focus on expanding the number of BSN prepared entry level nurses, advanced practice nurses and doctorally prepared nurses to provide care across settings, lead systems of care, teach and conduct research. This past decade schools of nursing in the US have expanded their programs at all levels, despite caps on tuition, decreasing state appropriations and decreasing federal support for research and innovative, responsive educational programs. But as a result of converging forces, both external and internal to the profession, these very schools are facing a crisis that threatens to decrease the number of advanced practice nurses in the near future.
up we did! There is no question that the IOM recommendations about scope of practice has been a big boost to our own calls for allowing our APN graduates to practice to the full extent of their preparation. Additionally, changes in compensation for health care that require the use of interprofessional teams that could provide high quality, cost effective care for consumers, the development of business models that allow APNs to see consumers more conveniently across the country and the passage of the Affordable Care Act were major influencing factors. The dramatic increase in Doctor of Nursing Practice programs over the past decade provide some APNs with preparation in quality improvement, leadership, and evidence based practice that enable them to develop and implement innovative models of care in non traditional and traditional settings. The dramatic expansion of APN programs by schools was largely facilitated by the hiring of non-tenure track faculty who spend some of their time in practice settings. Finally, the widespread development of distance accessible and online programs expanded access to advanced education for nurses, especially those in more rural settings. All of these factors were and are facilitators of the expansion of the numbers of Advanced Practice Nurses required to meet the needs. This expansion of APN education, concurrently with expansion of programs preparing BSN graduates for entry to practice and the development and implementation of over 200 DNP programs across the country is remarkable and every nurse in education and practice settings (because it took both!) needs to be proud of how nursing as a profession ‘stepped up’. But not all appears to be clear sailing as we move forward. There are constraining forces, both internal and external to the profession, which have the potential to threaten the viability of many Advanced Practice Nurse educational programs and potential solutions lie well beyond any individual school to address.
Factors Influencing the Need for APN Workforce Expansion
Health System and Health Care Financing Forces
There were several events that set the stage for the profession to move forward this past decade- and step
Recently someone told me they believed I was unnecessarily concerned about how changes in health care
Nurs Outlook 63 (2015) 105e107
would affect primary care access for the clinical education of graduate students. This perception could stem from either a highly unusual local situation in the area in which that person resides, or on being out of touch with how fast and dramatically health care organizations are changing. There is a great deal of turmoil in the health care markets as mergers of hospitals and creation of large networked systems of physicians specialty practices, primary care clinics and hospitals occur on a weekly basis-all over the country. The impending reductions in compensation to physician providers and hospitals, which will be dramatically reduced and shifted away from procedure based and episodic care to systems of care and population health, must clearly transform nursing care models as well. And outpatient and primary care has largely moved to a 15 minute visit template that challenges even the most seasoned health care provider to provide care, much less one who has agreed to precept advanced practice, medical or physician assistant students. As a result all health profession schools find themselves fiercely competing for preceptor time. As providers are compensated less per visit and expected to see more patients they are much less likely to agree to take students without some compensation for loss in their productivity, which translates into lost income. This situation is already anecdotally reported as critical all over the country. Traditionally neither schools of nursing nor medicine have ever paid preceptors for their time. The Center for Medicare and Medicaid Services funded 5 Graduate Nursing Education pilot programs, which are over halfway through their funding cycle and which provide funding for hospitals to expand nurse practitioner student placement opportunities-yet it is uncertain if and for how long that funding will be maintained. Additionally, given the caps on tuition in most universities and the concerted attention to student debt, passing these costs on to the student is not a viable option for the future.
University Constraints Over the past decade the prescriptions for course and clinical experiences in APN curricula have increased dramatically. Some of these prescriptions have clearly led to an improved consistency across programs both within and across schools. However, in other cases in the quest to improve quality of programming, restrictions on how many hours of clinical, who can precept a student, the value (and counting-or not) of standardized patients and simulation hours have left the profession with clinical education models that will likely not survive the next 2-3 years. Often it is difficult to find evidence to support some of the prescriptions for the number of clinical hours, the type of experiences, or find studies which compare various pedagogies (e.g. simulation
and standardized patients versus precepted instruction, etc.). All options for clinical pedagogies have a price tag so the need for clear evidence supporting any recommendation or mandated educational practice is essential. As these external restraining forces continue to increase, academic programs will find themselves in the position of making difficult decisions about how many APN programs and students they can support and still meet all accreditation and credentialing criteria. Faculty within these schools must be as cognizant of the cost of their programs in order to create new approaches that will assure an adequate pipeline of APNs to meet the needs projected for the future. Fixed costs such as faculty salaries, online programming support structures, supported time for faculty practice to stay credentialed are ever increasing and must be balanced by the number of students in the program. Faculty will have to be provided time to practice but they also need to have time and interest in learning new and time efficient methods of evaluating students in clinical education experiences. Regulating bodies need to provide support for studies of graduate education to compare various new pedagogies designed to address these challenges. Faculty, accreditation and credentialing bodies, and state boards of nursing must weigh their recommendations against evidence comparing various strategies and the cost of implementing them, unless we plan to revert to restricting supply.
Moving Forward for Collective Good No one entity in nursing can solve these challenges in isolation. We, as a profession, are all in this together. If we are to meet the challenge for more APNs needed in the future we must find new ways to come together, study the issues and gain consensus on the ways forward. What will this take? In the future, organizations that thrive will continue to develop innovative approaches to external forces that threaten their continued effectiveness. These organizations must engage in creative abrasion, creative agility and creative resolution to problems and challenges they encounter trying to meet the demands for their products (Hill, Bandeau, Truelove, & Lineback, 2014). I would argue that those characteristics will also be critical for professions to thrive and meet the demand for their practitioners. I think that we, as a profession, need to engage more in ‘creative abrasion’ ediscourse, debate, and discovery driven learning, about what our graduate students really need to practice in the uncertain health settings of the future. Creative ‘Agility’ will mandate we engage in quick pursuit of curricular changes, reflection and adjustments for the future-not something we as a profession have ever appeared to be comfortable with. And finally a creative resolution to the challenges will require we engage together to solve these problems so
Nurs Outlook 63 (2015) 105e107
we can move forwardemandating we make decisions that may contain some disparate and often opposing views. One has to ask, if in the face of the multiple external, and internal forces we are facing, are we willing to come together and examine these challenges through shared dialogue, to demonstrate agility and flexibility in curricular demandseespecially clinical education, and develop some creative solutions that can be piloted across multiple schools. If we can achieve such unity of purpose, I have no doubt that nursing as a profession will survive. After all we have certainly negotiated many difficult transitions over the past hundred years. But thriving may be a different story. That is, stepping up to meet the demands for nurses who can lead in the profession across all settings will require special interest groups set mutual goals, negotiate and work together by aligning and leveraging their strengths instead of engaging in rigid positions and prescriptions that will cripple the production of APNs for the future. The American Association of Nurse Practitioners (AANP, 2015) recently released data showing that the number of nurse practitioners licensed in the United States has nearly doubled over the past ten years, rising from approximately 106,000 in 2004 to 205,000 as of December 31, 2014 (www.aanp. org). I believe that the biggest threats to continuing this level of production and realizing the profession’s dream of being a major player and contributor to improving health in our country do not lie outside of the discipline. It is no one sector’s (i.e. education, professional organizations, credentialing bodies, accreditation bodies, regulators, practice sites) problem to solve. So blaming and refusing to renegotiate treasured positions about ‘the right (and only) way’ will leave us fighting among ourselves and pave the way for other advanced practice providers to fill the vacuum of need.
To address those forces it will mean that leaders in all the various sectors of nursing come together to examine these forces together. We should do no less. I know our leaders have the strength of vision, foresight, and will to come together. There is much at stake- but much to be gained from our ‘collective genius’.
American Association of Nurse Practitioners (AANP). (2015). Nurse practitioner ranks surge to 205,000, nearly doubling over past decade. Retrieved from www.aanp.org. Hill, L., Bandeau, G., Truelove, E., & Lineback, K. (2014). Collective genius: The art and practice of leading innovation. Boston, MA: Harvard Business Review.
Author Description Marion E. Broome is the Editor-in-Chief of Nursing Outlook. Marion E. Broome, PhD, RN, FAAN Corresponding author: Dr. Marion E. Broome Dean and Vice Chancellor for Nursing Affairs Duke University School of Nursing Associate Vice President for Academic Affairs Duke University Health System School of Nursing Duke University DUMC 3322, 307 Trent Dr. Durham, NC 27710. E-mail address: [email protected]
0029-6554/$ e see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.outlook.2015.02.004