Q&A with Dr. Susan Hassmiller, Ph.D., R.N., F.A.A.N., the Robert Wood Johnson Foundation Senior Adviser for Nursing

By JJ Horning, HWIC Information Specialist

The Future of Nursing: Campaign for Action is a collaboration between the Robert Wood Johnson Foundation (RWJF) and AARP. The RWJF web site states, “The Committee of the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine was tasked with creating a blueprint on the role of nurses in the design and improvement of public and institutional policies at the national, state and local levels.” This blueprint is the recently released Institute of Medicine’s (IOM) report “The Future of Nursing: Leading Change, Advancing Health,” which examines the nursing workforce. Sue Hassmiller was the project’s Study Director.

What is the goal/vision of the Initiative on the Future of Nursing?

What we want to do is to make sure that all Americans have access to high quality patient-centered care in a health care system, where nurses contribute as essential partners in achieving success. That’s really our vision. We’re taking the broad view, the 30,000-foot view, but this time the foundation is very involved in and committed to improving the health and health care for all Americans. With this campaign we want to make sure we’re doing it using nurses as effective partners with other health professionals and of course using the IOM report and its recommendations as our blueprint to how to get there.

The IOM report, your blueprint, is over 500 pages long. One of the four key messages to come out of the report is the need to increase the number of nurses achieving higher levels of education and training – 80% of nurses achieving the baccalaureate degree, up from 50%, by 2020, and twice the current number of nurses completing a doctorate by 2020. Could you explain what the impact would be on the field of nursing as a result of achieving these levels of education and some of the potential challenges to reaching these goals?

The first one’s easier; the challenges are many. So here’s the problem: we have an undereducated workforce. The majority of nurses in this country come from community colleges and I do too. However, I went on to get a doctorate. The vast majority of nurses in this country only have community college degrees. The Affordable Care Act talks about how more and more care is moving to the community. This means that if we’re talking about the future of nursing, we’re talking about nursing and health care in particular moving to the community. Nurses who are graduates of community college programs learn how to be an acute care nurse – in other words, how to work in a hospital. If we want to move more care to the community – home health, school health, public health – that means that that kind of education, the concepts, learning, and experience, you only begin to get in a baccalaureate education.

There also is research evidence, done by Linda Aiken, that care is safer if you have a predominantly baccalaureate educated nursing staff in hospitals. There are two other issues that are really, really critical with an undereducated workforce. We have two very severe shortages going on in our country right now. Fortunately we’re not in a particular nursing shortage because of the recession and people holding onto their jobs, working double time and going back to work into nursing. So we don’t have a clinical nursing shortage at this time, but it’s coming. The shortages we do have are in two critical areas: the faculty and primary care. We could educate many more nurses than we are right now. Thousands and thousands and thousands of students are looking to get into nursing school and they can’t get in because there’s just not enough faculty. You can’t get to a masters and a PhD to become faculty without first having a baccalaureate degree.

We also have an enormous primary care shortage in this country and it will only increase. The Affordable Care Act says that we have at least 32 million more people that will be coming onto our rolls by 2014, so we need more providers at the primary care level to take care of all these people. Where are they going to come from? Physicians are not going into primary care as much as they used to, so we need to fill those gaps with nurse practitioners. You cannot get to be a nurse practitioner at the minimum masters level, and now they’re saying doctor in nursing practice, without having first a baccalaureate degree.

The challenges to reaching these goals are enormous! In this country we have a little over 50% of the nurses with a baccalaureate or higher degree and we want to get to 80%. That’s a big enough hoop in and of itself. In New Mexico, only 37% of nurses have a baccalaureate degree. How in the world do you get to 80%? It is like the biggest hurdle ever! But if you don’t draw your line in the sand, you’re never going to get there.

The reason the challenges are enormous is because there are not a lot of incentives to continue one’s education. You have people obtaining their community college degree and it’s fabulous! All of the sudden you’re an RN, you start going to work, you start collecting a paycheck, nobody’s paying you a differential so you’re getting the same amount of pay that a baccalaureate nurse would get. I’m happy. I’m a nurse. I’m a Registered Nurse. I’m getting a good pay. Why in the world would I ever go back to school? I’d have to stop my job. That means I’d have to stop my paycheck. I’d have to pay for more schooling…for what??? The disincentives are enormous and the steps to overcoming the incentives are there. We lay all of that out in the report.

This is also a societal issue. If you want people to take care of you when you’re ill, in the hospital, or in the nursing home, the federal government needs to step up to the plate, which they always have, to help with scholarships. To get nurses to go back to school for a baccalaureate, you need very, very generous stipends from employers, tuitions, and scholarships from federal government, states, and foundations like us. It needs to be as easy as possible. You need the local university to come onto your employer’s site so that when you’re done with your shift you can go to a class and you don’t have to leave. There needs to be online education. There are just not enough universities.

So what do you do? You do what Florida did. Florida said we have a shortage of nurses and we want them to be baccalaureate educated. They turned several of their community colleges into four-year degree granting institutions so that students who were there already getting a community college degree never have to leave. They can go to the same classrooms, the same setting in the same part of their rural environment or inner city – wherever their community college is, and they can be comfortable. They never have to go to a big university and their community college will give them a baccalaureate degree. This is something that the state legislatures have to fix, which has been solved in Florida, but other states have to take it up.

Then there are cultural attitudes that have to be overcome. There are faculty at the community college level and presidents and administrators who don’t say to these students, “Hey, this is great! You’ve got a community college degree now keep on going.” Everybody has to be in this together – community colleges working with universities. So it creates an attitude that you’re bettering yourself, that patients’ lives are in your hands and you owe it to patients to improve your education and keep on moving – academic progression we call it.

The Future of Nursing Campaign for Action has created Regional Action Coalitions (RACs) throughout the U.S. Five pilot RACs were formed in October 2010 and just recently 10 more were announced. What exactly is a RAC team?

We’re not ever going to get these recommendations adopted with just nurses. So if this a societal issue, then more than just nurses should be involved in this campaign. Besides, nurses are not really the big decision-makers at the table. They don’t make financial decisions and big policy decisions, so you need a lot of people at the table to help move these recommendations along. So who’s involved in these Regional Action Coalitions? It can be a nursing organization, but there have to be two co-leads such as a nursing organization and then another lead organization in the state that has nothing to do with nursing per se.

We now have 15 states involved and the co-leads are very diverse. Two of our states are co-led by Blue Cross Blue Shield Foundation, one is a physician-led area health education center, in Mississippi it’s the State Department of Administration and Finance, in California it’s a state legislator who just stepped down, there are a couple of state AARP affiliates, and in Utah it’s an organization called Health Insight which is an umbrella organization overseeing several health care organizations in their state. So it’s very diverse and we’re trying to get as many different partners as possible.

What are these teams doing? What IOM objectives are they specifically working on?

They are encouraged to look at the report recommendations and do an analysis of their state as to what they have been working on, what their resources are because they have to resource their own regional action coalition, where their passions lie, what their needs are, and what their challenges are. Then they can make decisions on what their priorities are and what recommendations they’re going to work on.

So it’s really up to the state as to what they work on, but I can tell you that the vast majority of them are really highly energized around the 80/20 recommendation. That’s the recommendation to getting the 80% baccalaureate educated staff or nurses by 2020. Also, a lot of them are working on the scope of practice to change their state laws so that more nurses and nurse practitioners can practice to the top of their education and training.

What are the challenges for these RAC teams in implementing the IOM report recommendations?

Well, that really depends on what they’re working on. I’ve already spelled out the challenges for working on the 80/20 recommendation. If they’re working on getting their state laws changed, those are enormous challenges because there’s a lot of pushback by state medical societies. Because divisions are at the table and they are the decision makers in organizations and in states, then even if there is a need in a particular state around getting more primary care, if a state medical society doesn’t want it, they put pressure on their legislators to fight against the nurse practitioners in the state. That’s an enormous challenge.

One of our recommendations has to do with the Federal Trade Commission (FTC) and unfair trade between physicians and what they’re stopping nurses from doing. Florida petitioned the FTC that they have a predominance of elderly people in the state, but they don’t have enough primary care doctors or enough providers to take care of their elderly and the chronically ill. The FTC ruled in their favor, but that hasn’t changed the state laws. The legislators have the FTC ruling that said that physicians in Florida are unfairly and unduly fighting against laws that would help the citizens of the state. Now they have to really do it and they’re afraid of the state medical society.

What is the future of the RAC teams and how do they imbed inside this RWJF initiative?

This is our field strategy. We’re doing a lot of other things in the campaign at the national level. We have stakeholders that we’re reaching out to, both nursing and non-nursing, to support the campaign and different research efforts. We have a whole research agenda. We have a communications strategy. We’re doing messaging and publications and interviews like I’m doing now. And then we have a whole evaluation and tracking and monitoring of strategy. The Regional Action Coalitions are just one part of our strategy – our field strategy. But I would say they’re the heart of this campaign. They’re the ones that are really out there doing the hard work. So we are working in partnership with AARP who is providing technical assistance to our state partnerships and to whatever they need, whether it’s help with grant writers, facilitators, messaging, communications or connecting around best practices. Whatever technical assistance we think a state needs, we’ll give it to them.

Is there anything else you would like to add to this conversation?

The main point I really want to leave you with is that this is a campaign to improve health and health care in this country. It is not a campaign just about nurses for nurses with nurses. This is about how to improve health and health care by using the largest segment of the workforce effectively. To not use nurses to the top of their education and training is a wasted resource, which is true for all health professionals. If all health professionals were used to the top of their education and training, then the whole system, we think, would be run more effectively. Not just health care workforce, of course there’s a lot of systems issues to worry about too.

Now we have a blueprint that has a great amount of evidence to guide us in our work and that’s important. So this is not a campaign based on feelings, or emotions, or what nurses think is right, it’s really based on what a group of high-level, well-experienced, multi-sector committee members have determined would improve our health and health care system based on all the available evidence.

The last thing I would leave you with is that this is a very inclusive campaign. It is not about who can join and who can’t join. We want all 50 states to be involved. We don’t want to over-promise and under-perform with our technical assistance, so that’s why we’re taking it a little slow. But by next year, 2012, we hope that we’re working with all 50 states in regional action coalition teams. We would just really encourage people to visit our website because that is where they can find out about a lot of information. Our website is simply TheFutureOfNursing.org.

Please note that the views expressed in this article are the opinions of the interviewee and do not reflect the official policies, positions, or opinions of the Health Workforce Information Center or its funder.