The IOM, an autonomous nonprofit organization established in 1970, is the health arm of the Academy of Sciences that works outside of the government and gives an independent viewpoint on health care issues. An IOM brochure, intended for a general audience, succinctly describes the IOM mission as one which “asks and answers the nation’s most pressing questions about health and health care” (IOM, n.d., p. 3). The IOM (2006) charter further elaborates the scope of its work as identifying important human health issues and convening interested parties to prepare expert statements and reports on these issues; responding to requests for health or medical advice from the federal government and others; dissemination of findings; and maintaining liaisons with professional societies. In recent history, the IOM (1999, 2001, 2003) has issued several landmark reports related to quality, medical errors, and health disparities that have changed the way health care policy makers and providers approach these issues.
The Future of Nursing Report
Keeping with its charter, the IOM (2011) report was the result of a collaborative effort between the IOM and the RWJF. In 2008, the RWJF approached the IOM to work on an initiative to transform nursing. Thus, an ad hoc committee was convened with the intent of providing a blueprint for change. After the initial phase of issuing the report, the RWJF was to assist in implementing an action plan. Dr. Donna Shalala, a current university president and former U.S. Health and Human Services Secretary, as chair, and Dr. Linda Burnes Bolton, a nurse executive, as vice chair led the committee. The expert member panel included six nurses, four physicians, one dentist, and seven other workforce specialists (e.g., economists). Representing both nursing and older adult health concerns was Jennie Chen Hansen, RN, MSN, the current chief executive officer of the American Geriatrics Society. The committee’s broad charge encompassed providing guidance for the delivery of nursing services, as well as increasing the capacity of the nursing education system, all within a shortage environment (IOM, 2011).
The need to transform nursing in the United States is connected with the need to transform the health care system. This collective need is associated with changes in U.S. demography related to aging, increasing diversity, health disparities for certain groups, and a rise in the prevalence of chronic conditions, as well as driving concerns for decreasing health care costs while increasing or maintaining quality and access to care (IOM, 2011). In 2008, the IOM issued a report calling for “retooling” of the geriatric health care workforce that included increasing geriatric care competence, new models of caring for older adults, and recruitment and retention issues (see Houde & Melillo, 2009, for a review). Indeed, this summative work on changes needed for the entire geriatric workforce foreshadows many of the fundamental themes found in the IOM (2011) report. In addition, the IOM (2011) focuses on the key leadership roles nurses may assume in delivering new innovative models of care.
The details of the methods used by the IOM Expert Committee are fully documented within the report. Information was gathered from an extensive literature review, coordination with the RWJF Nursing Research Network, workshops on selected topics, committee meetings and conference calls, public forums, site visits, and commissioned papers from nursing and other health care workforce experts (IOM, 2011). After considerable study, the Committee found that a transformation of practice, education, and leadership in nursing with a directive to collect better workforce data for policy making was needed. The four main findings of the Committee were (IOM, 2011, p. 33):
- Nurses should practice to the full extent of their education and training.
- Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression.
- Nurses should be full partners, with physicians and other health professionals, in redesigning health care in the United States.
- Effective workforce planning and policy making require better data collection and an improved information infrastructure.
Using these four main findings, the Committee proposed eight major recommendations. Policy changes within each recommendation were directed at many different spheres of political influence including relevant national, state, and local governments; payers; nurses; educational institutions; and consumer groups. All of the recommendations have either direct implications for the future of gerontological nursing, as some address Medicare or the Centers of Medicare & Medicaid (CMS), or indirect implications, as some are generic to all of nursing. To exemplify the scope and depth of the IOM (2011) consensus report, all of the recommendations will be highlighted with suggested policy changes and current case studies where relevant.
Recommendation 1: “Remove scope-of-practice barriers. Advanced practice registered nurses should be able to practice to the full extent of their education and training” (IOM, 2011, p. 278). Several suggested policy changes that will directly influence gerontological advanced practice RNs (APRNs) relate to Medicare and are directed at Congress or the CMS. These include expanding APRN Medicare services to those services allowable under state laws comparable to physician services and amending Medicare to authorize APRNs to perform admission assessments, hospice and skilled nursing facility admissions, and certification for home health services. In addition, it is recommended that the CMS clarify that hospitals participating in Medicare also permit APRNs to be eligible for medical staff privileges, including clinical and admitting privileges. This would ensure that gerontological APRNs could follow and manage their Medicare patients longitudinally, regardless of setting.
Other indirect influences on gerontological nursing practice would be policy changes at the state level that would require third-party payers to provide direct reimbursement to APRNs. This change would permit older adults with private insurance to access APRN services. The variation and inconsistencies in state laws that set APRN practice (e.g., scope of practice, prescriptive authority) have been widely reported and influence APRNs’ ability to practice to the full extent of their role (Naylor & Kurtzman, 2010; Stanley, 2009). The IOM (2011) report suggests that all states conform to the National Council of State Boards of Nursing Model Nursing Practice Act and Model Nursing Administrative Rules (Article XVIII, Chapter 18). In addition, the Federal Trade Commission, Antitrust Division, should review state laws and regulations for APRNs to detect any anti-competitive clauses (IOM, 2011). The last two suggestions will ensure that patients in different states will have similar access to APRN care.
Recommendation 2: “Expand opportunities for nurses to lead and diffuse collaborative improvement efforts” (IOM, 2011, p. 279). Innovative payment and care delivery collaborative models that position nurses in expanded capacities to improve outcomes and decrease health care costs should be supported by the Center for Medicare and Medicaid Innovation ( http://innovations.cms.gov). This recommendation clearly articulates that not only government-initiated policy changes, but private sector funders and organizations as well as nursing education, have a role in assisting nurses to assume a leadership role (IOM, 2011). The Arkansas Aging Initiative (RWJF, 2010b) is cited as a current example of a gerontological nurse-led interdisciplinary collaborative model. The program increases access for older adults living in rural Arkansas and improves patient outcomes for these individuals.
Recommendation 3: “Implement nurse residency programs” (IOM, 2011, p. 280). A number of health care entities including the Health Resources and Services Administration (HRSA) and CMS should fund, develop, and implement nurse residency programs across all practice settings. These programs will include the novice RN, as well as the novice APRN, and certainly will include settings with high proportions of older adults. A current example of a gerontological nursing residency program is the MGH AgeWISE™ program, which trains nurses in geropalliative care. In addition to the Boston site, this 6-month program is currently being disseminated and evaluated in six hospitals across the country (Lee, 2011).
Recommendation 4: “Increase the proportion of nurses with a baccalaureate degree to 80 percent by 2020” (IOM, 2011, p. 281). Six policy changes are outlined that delineate a collaborative effort that calls for a vertical trajectory to recruit and educate nurses, including those from underrepresented populations. Program strategies may start as early as primary and secondary schools. Some suggestions for financial incentives to assist associate-degree nurses to continue their education include expanding loan repayment and scholarships and the continuation of financial incentives for baccalaureate-degree nurses in the form of salary differentials and enhanced promotion opportunities. This recommendation aims to address the nursing shortage with an emphasis on more highly educated and more diverse nurses who can care for more complex patients, including older patients who match the diversity of the entire population.
Recommendation 5: “Double the number of nurses with a doctorate by 2020” (IOM, 2011, p. 281). Three policy initiatives include the Commission on Collegiate Nursing Education and the National League for Nursing Accrediting Commission setting a benchmark of 10% for all baccalaureate students to pursue doctorate (both PhD and practice doctorate) education, increased funding for doctorate education, and creating salary structures to provide incentives for nurses to pursue this level of education. This recommendation has a similar intent as Recommendation 4, which seeks to create a more diverse and skilled workforce. Increasing the pool of doctorally prepared nurses will increase the number of nurses who can assume leadership roles in policy and research, including those nurses interested in improving the quality of gerontological nursing through research and educating nurses to care for older adults.
Recommendation 6: “Ensure that nurses engage in lifelong learning” (IOM, 2011, p. 282). The six policies recommended to meet this recommendation are directed at policy changes at the local level, including partnerships between health care organizations and nursing education programs. This recommendation ensures that members of the nursing workforce will keep current with changes in skills needed for changes in health care and changes in characteristics of the populations needing nursing care. As nurses continue to learn over their lifetime, they may seize opportunities to learn different skills needed to care for older adults. These job situations may not have been appealing or available earlier in their career. For this recommendation, the RWJF provides a case study of an older nurse who, through retraining, decides to pursue a position in a retirement community (RWJF, 2010c).
Recommendation 7: “Prepare and enable nurses to lead change to advance health” (IOM, 2011, p. 282). The four policy changes encourage nurses to take responsibility for developing leadership skills, suggest that professional organizations offer mentoring opportunities, and suggest that education programs incorporate more leadership content into their curricula. Those organizations at private, public, and government levels seeking input should consider appointing nurses to boards and advisory committees. The Transitional Care Model is a nurse-led evidence- based initiative that oversees the care of older adults with chronic conditions as they shift from inpatient to community living. Although Medicare has not reimbursed for this model in the past, the PPACA has set aside funding for demonstration projects (Transitional Care Model, n.d.)
Recommendation 8: “Build an infrastructure for the collection and analysis of interprofessional health care workforce data” (IOM, 2011, p. 283). The National Health Care Workforce Commission, the Government Accountability Office, and the HRSA will coordinate efforts at the state and national level to collect a standardized minimum data set for all licensed health professionals so that workforce characteristics (e.g., skill mix, demographics) of these groups are known. Although not explicitly stated in the report, the skills of the nursing workforce to care for older adults need to be assessed.