The 2010 healthcare reform act (Patient Protection and Affordable Care Act, or PPACA) gives nurses new opportunities to deliver care and play an integral role in leading change. (See http://championnursing.org/sites/default/files/nursingandhealthreformlawtable.pdf.) Understanding these opportunities is just the first step. We need to know how we can be part of the solution to achieve better patient outcomes at a more reasonable cost. We need to do more to prevent disease; provide chronic care management to an aging, sicker, and more diverse population; and offer end-of-life care that emphasizes comfort and compassion. Across all settings—especially geriatrics—we must do more to prepare ourselves for the future.

In this article, I outline nine challenges that individual nurses and our profession must address if we are to help lead our country to a healthcare system that is more equitable and provides a higher quality of care. (For a flowchart of these challenges, see Nurse’s role in reforming healthcare by clicking on the PDF icon above.)

1. Use nurse-led innovations. Nurses know how to expand access to care and improve quality at lower cost. We’ve developed innovative care models to prove it, including nurse-managed health clinics, home visiting programs for low-income mothers, and the Transitional Care Model (TCM). By emphasizing the use of master’s-prepared nurses to oversee care from the hospital to within the home, this model has reduced rehospitalizations for elderly patients with multiple chronic conditions. Research shows that using the TCM helps patients achieve better long-term health outcomes and avoid repeat hospitalizations, all at a reduced cost. We need more nurses to develop innovations. (For good examples to follow, visit www.aannet.org/i4a/pages/index.cfm?pageid=3303.)
2. Generate evidence and engage in research. Nurses play important roles as innovators who help shape quality and safety. Successful models aren’t born, implemented, or sustained without solid effectiveness data. It’s up to all nurses to collect and track data to improve their own practice as part of broader efforts to improve care. Nursing research helps build the scientific foundation for clinical practice, prevention, and improved patient outcomes.
   We must support nurse researchers through adequate funding. The Robert Wood Johnson Foundation (RWJF) is doing this by funding the Interdisciplinary Nursing Quality Research Initiative, a program that links evidenced-based nursing care to improved patient outcomes.
3. Redesign nursing education. All nurses need to possess basic competencies to meet the demands of an aging and diverse society, with an emphasis on clinical training in multiple settings across the lifespan. The emphasis should be on quality and safety, evidence-based practice, research, and leadership. Several RWJF programs are working to incorporate these concepts into nursing education, including Quality and Safety in Nursing Education, the New Jersey Nursing Initiative, and the Nurse Faculty Scholars program. Therefore, we need to remove barriers to attaining baccalaureate and advanced degrees, such as by strengthening partnership links between community colleges and upper-division degree-granting institutions and all academic institutions and practice organizations. The RWJF-funded Center to Champion Nursing in America is providing technical assistance to help with academic progression. A standardized residency program would give nurses on-the-job learning and would better prepare them for clinical practice. Certification and continuous learning opportunities are essential to a profession that’s responsible for others’ lives.
4. Expand the scope of practice. Advanced practice nurses (APNs) must be allowed to practice to the full extent of their education and licensure. Working with physicians, they can provide cost-effective care and help address the primary care shortage. However, statutory and regulatory barriers prevent them from practicing to the full extent of their licensure. With 32 million Americans about to receive health insurance under PPACA, it’s crucial that APNs be permitted to provide the primary care they’re trained to give.
5. Diversify our workforce. Approximately 33% of our population belongs to a racial or ethnic minority group, and by 2042 minorities will account for a majority of the U.S. population. To reduce health disparities, greater efforts must be made to ensure that the nursing workforce reflects patients’ diverse backgrounds and cultural values. Furthermore, all nurses should be educated to provide culturally competent care. Finally, we need to bring more men into the profession. The goal of RWJF’s New Careers in Nursing program is to provide scholarships to students from diverse backgrounds to attain baccalaureate and masters degrees.
6. Embrace technology. We must learn to use the new­est medical technology and electronic documentation systems to improve quality. Nursing schools should use simulation labs and take advantage of online classes to educate more students. Nurses are frequent technology users; more of us need to be at the table to help make decisions about designing and purchasing the technologies that help patients the most. The RWJF Technology Drill Downs program provides a process that enables nurses to identify and apply technology solutions to improve patient care.
7. Foster interprofessional collaboration. Teamwork and collaboration are critical to seamless high-quality care. The process begins with understanding the roles and responsibilities of each healthcare discipline. Understanding—and the trust it fosters—must start in joint nursing and medical school training programs, and continue as a cultural norm in practice settings.
8. Develop leadership at every level. Nurses should have the opportunity to take on leadership activities whether they practice at the bedside or sit in the boardroom. They must believe they are capable and fully empowered to provide excellent care and make the changes necessary to improve ineffectual systems. Physicians and administrators must support nurses in their efforts. Most of all, nurses need to help each other through mentoring, educational and skills development opportunities, and support networks.
9. Be at the table. As the healthcare professionals most actively engaged in direct patient care, nurses are positioned to provide leadership in all healthcare areas, including developing systems to reduce medical errors, improving quality, providing better care coordination, increasing access to care, and averting workforce shortages. Yet clinical experience isn’t enough. To serve as successful and knowledgeable board or committee members, nurses must be familiar with governance, strategy, fundraising, financial systems, health law, and policy. Always say “yes” when asked to be at the table. If you believe you’re ready but haven’t been asked, then ask to be involved in a board or committee of interest. Nurse Leaders in the Boardroom, another RWJF program, is working to bring more nurses into leadership positions at the local, state, and national levels.

At the end of her life, Florence Nightingale said, “May we hope that when we are all dead and gone, leaders will arise who have been personally experienced in the hard, practical work, the difficulties and the joys of organizing nursing reforms, and who will lead far beyond anything we have done.” Take her words to heart and prepare yourself to contribute to the reforms that will take place in our lifetime. We have much to contribute.

Selected references

Nightingale F. Sick nursing and health nursing. In: Billings JS, Hurd HM, eds. Hospitals, Dispensaries and Nursing: Papers and Discussions in the International Congress of Charities, Correction and Philanthropy. Section III, Chicago, June 12-17, 1893. Baltimore, MD: The Johns Hopkins Press, 1894.

Transitional Care Model. http://www.nursing.upenn.edu/ncth/transitional-care-model/index.php. Accessed August 3, 2010.

U.S. Department of State, Bureau of International Information Programs. U.S. minorities will be the majority by 2042, Census Bureau says. http://www.nytimes.com/2008/08/14/world/americas/14iht-census.1.15284537.html. Accessed August 3, 2010.

Susan Hassmiller is Senior Advisor for Nursing at the Robert Wood Johnson Foundation in Princeton, New Jersey.