Journal of Nursing Education

Editorial Free

The Nursing Workforce and Health Reform: Implications for Nursing Education

Amy J. Barton, PhD, RN, FAAN

In June 2017, the National Forum of State Nursing Workforce Centers hosted their annual conference in Denver, Colorado. The purpose of this editorial is to describe the themes of the discussions that occurred, along with their influence on nursing education. The themes of the conference paralleled the recommendations from “Assessing Progress on the IOM Report: The Future of Nursing” (National Academies of Sciences, Engineering, and Medicine, 2015). The themes are Collaborating and Leading in Care Delivery and Redesign, Removing Barriers to Practice and Care, Achieving Higher Levels of Education, Promoting Diversity, and Improving Workforce Data Infrastructure (National Academies of Sciences, 2015).

Within the theme of Collaborating and Leading in Care Delivery and Redesign, Wilensky (2017) indicated that the U.S. health care system is changing rapidly, with the importance of nursing continuing to increase. Although the specific policy direction is unclear, an emphasis on value will remain. Since the passage of the Medicare Access and CHIP Reauthorization Act of 2015, the Centers for Medicare and Medicaid Services has been implementing their quality program so payment for Medicare Part B services is based more on value than on volume. Providers (including advanced practice nurses [APNs]) can opt to participate in either the Merit-Based Incentive Payment System (MIPS) or the Alternative Payment Models (APMs). MIPS is based on quality metrics, improvement activities, advancing care information (effective use of information technology), and cost. APMs are a payment strategy that focus on high-quality and efficient care provided to a specific clinical condition, a care episode, or a population. Although the details of these programs are beyond the scope of this article, it's important that nursing faculty understand them and the implications for the future workforce. Curriculum for nursing students must include policy and financing content to provide context for operations within the health care environment. It's important that nursing students have accurate information concerning value-based reimbursement and the move away from fee-for-service payments.

From a leadership perspective, the key message is that the expanding role and importance of nurses in health care delivery will continue. It's important that leaders within the profession decide on both short-term and long-term goals and map a strategy to attain those. Nurses must take an active role in discussions about health care reform. The views and positions of the nursing community must be known and clear to engage in effective dialogue. This provides an opportunity for faculty to shape learning activities focused on clarity and effective articulation of an argument.

The second theme was Removing Barriers to Practice and Care. Several presentations concerned the advanced practice workforce and the influence of scope of practice on access to care across states. Additional focus was on maximizing the role of RNs. Mason (2017) presented the reality of the current costly and poor performing health system, with its emphasis on acute care. An emphasis on health will facilitate redesign of the role of the RN as it pertains to health and primary care. RNs should be prepared to function in an integrated behavioral health model and provide care coordination for patients who experience multiple chronic illnesses and psychosocial problems. RNs should be prepared in techniques such as motivational interviewing to promote health and wellness and provide effective coaching for self-care management. Further, it will become increasingly important for RNs to structure their care beyond the patient to families and communities (Josiah Macy Jr. Foundation, 2016). Mason (2017) raised several key questions to facilitate developing primary care capacity within the role of the RN that are pertinent for nurse educators:

  • What do you know about your community's primary care capacity, including the use of RNs and APNs in primary care?
  • Where are model primary care practices?
  • What can you do to showcase model practices and obtain clinical placements for your students?
  • How does your school of nursing integrate primary care into the didactic and clinical portions of the curriculum?
  • Can you be a leader in facilitating partnerships between education and practice to build high-performing primary care practices and changing curriculums?

The third theme of the report that resonated at the conference was Achieving Higher Levels of Education. Several state workforce centers presented about how effectively they have moved the dial on the baccalaureate education of RNs. Although it was acknowledged that the goal of 80% of the nursing workforce being prepared minimally at the baccalaureate level will unlikely be met by 2020, progress toward the goal must continue in order to foster quality care and patient safety. Nationally, the proportion of U.S.-educated first-time NCLEX takers prepared at the baccalaureate level increased from 39.3% in 2010 to 44.9% in 2015 (Campaign for Action, 2016a). Of note, the numbers of baccalaureate graduates increased 28% from 55,407 to 70,889 in that same time frame. Regarding doctoral preparation, the proliferation of Doctor of Nursing Practice (DNP) programs enabled more than doubling the number of doctorally prepared nurses, with the number of DNPs increasing by more than 200%. However, there will be renewed emphasis on nurses pursuing the PhD (growth rate of 33%) to facilitate an adequate faculty pipeline for the future (Campaign for Action, 2016b).

The fourth theme is Promoting Diversity. Several state coalitions reported on creative projects that have facilitated attracting diverse students into nursing. These have helped increase the representation of racial and ethnic minorities, but nationally, the numbers do not yet reflect the population. In addition, the proportion of male nurses still hovers at 12%. Of interest to nurse educators was the creation of programs that increase exposure about the profession to students in the 5th grade. Further, emphasis on holistic admission policies at the collegiate level, as well as creative community college partnerships, was promoted to further diversify the workforce. Faculty play a key role in the admissions process and have the capacity to engage in creative solutions to meet this goal.

The final theme, and the emphasis of the conference, was Improving Workforce Data Infrastructure. Fraher (2017) indicated that models that predict workforce supply are difficult because they consider variables such as epidemiology, demography, socioeconomic and risk factors, and disease prevalence. Demand models are even more challenging as they require consideration of patient expectations, payment, models of care, and insurance and income. Buerhaus (2017) indicated that nurses from the Baby Boomer generation are retiring in increasing numbers. Projections indicate that the workforce should be able to replace Baby Boomers on a national, aggregate basis. There will likely be a distribution problem, versus a supply problem, in the future. A significant variable in supply, however, will be the work habits of the Millennial generation, which will dominate the workforce in the mid 2020s and beyond. Unfortunately, at this point in time, work habits have not been available for a sufficient period of time to assist in modeling the workforce of the future.

The National Forum of State Nursing Workforce Centers demonstrated the progress that has been made since the publication of the Future of Nursing report (Institute of Medicine, 2010). It also provided evidence that consolidating around common goals can facilitate a new reality in which nurses can lead the way to a healthy nation. Nurse educators should take leadership roles to further advance schools of nursing in preparing the dynamic workforce of the future.

Amy J. Barton, PhD, RN, FAAN

Associate Editor


  • Buerhaus, P. (2017, June7). Projections of decelerating growth in the size of the RN workforce: A generational perspective. Speech presented at The Nursing Workforce & Health Reform: Trends and Opportunities in a New Political Era. , Denver, CO. .
  • Campaign for Action. (2016a). Number and percent of U.S.-educated, first-time NCLEX-takers with BSN. Retrieved from
  • Campaign for Action. (2016b). Number of people receiving nursing doctoral degrees annually. Retrieved from
  • Fraher, E. (2017, June8). The state of nursing workforce models: Lessons learned from state and national efforts. Speech presented at The Nursing Workforce & Health Reform: Trends and Opportunities in a New Political Era. . Denver, CO. .
  • Institute of Medicine. (2010). The future of nursing: Leading change, advancing health. Washington, DC: The National Academies Press.
  • Josiah Macy Jr. Foundation. (2016). Registered nurses: Partners in transforming primary care. Recommendations from the Macy Foundation Conference on preparing registered nurses for enhanced roles in primary care. New York, NY: Author.
  • Mason, D. (2017, June7). Building the nation's primary care capacity: Nursing's mandate for leadership. Speech presented at The Nursing Workforce & Health Reform: Trends and Opportunities in a New Political Era. , Denver, CO. .
  • National Academies of Sciences, Engineering and Medicine. (2015). Assessing progress on the Institute of Medicine report The Future of Nursing. Washington, DC: The National Academies Press.
  • Wilensky, G. (2017, June7). Reforming health care reform. Speech presented at The Nursing Workforce & Health Reform: Trends and Opportunities in a New Political Era. , Denver, CO. .

The author has disclosed no potential conflicts of interest, financial or otherwise.


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