New Opportunities for Nurses

In New York State, nurses are now in the eye of a perfect storm.

First, the Institute of Medicine’s (IOM) landmark Future of Nursing report provides a framework for transforming education and transitioning models of care to focus on populations rather than individuals. At the same time, the Affordable Care Act (ACA) extends coverage to millions of Americans, many of whom will receive primary care from nurse practitioners (NPs). Building on this foundation, the Nurse Practitioners Modernization Act, recently passed as part of the state budget, will allow NPs to practice independently. Combined, these three events are poised to transform the nursing profession and create unprecedented opportunities for advanced practice nurses to assume leadership roles in research, clinical practice and health policy, according to Columbia Nursing Dean Bobbie Berkowitz, PhD, RN, FAAN. 

“The IOM report provided the evidence base that now serves as the backbone of the policy changes we’re beginning to see resulting from the Affordable Care Act,” Berkowitz said last month at the Center for Health Policy panel discussion on the changing health care system and the future of nursing. “On top of that, in New York, after many, many years of work we have finally achieved this major milestone with scope of practice legislation.” 

Starting next year, when the NP Modernization Act takes effect, advanced practice nurses with approximately two years of full-time work experience will be able to practice in New York without written agreements or protocols with supervising physicians. This will position NPs to play a bigger role in creating the patient-centered medical homes envisioned by the ACA – a team approach to care that is designed to increase communication among providers and enhance the quality of care while also reducing costs. “Patient-centered medical homes are going to be built with significant NP engagement,” Berkowitz said. “We are going to see an expansion of nurse-managed primary care.”

Nurses will also need to think beyond medical homes for individual patients, and instead consider the health of entire populations, Berkowitz said. This means thinking across communities, across health systems, and across clinical environments. Public health initiatives like obesity prevention, nutrition in schools, and safe housing can all benefit from a well-educated nursing workforce with an understanding of how families and individuals respond to risks and opportunities for help within communities. “We need to think beyond advanced practice nursing as managing patient encounters and instead think of this as managing populations,” she said.

Berkowitz also envisions nursing education evolving to reflect new models of care. Education will shift away from measuring time served to complete a degree to instead focus on competencies tied to specific outcomes needed for effective research and clinical practice, she said.  The IOM provides a framework for this endeavor, recommending that schools work to double the number of doctoral-prepared nurses and to establish the baccalaureate as the entry to the workforce.

In both classroom and clinical settings, nurses will need to gain a better understanding of technology and data to help create and use effective tools to measure outcomes. These tools must capture how well individual providers and entire health systems perform so that payment models can reward quality care for individuals and for entire communities, Berkowitz said. The opportunity to understand the health of a population of patients within a health system or a geopolitical environment is dependent on large data sets and the ability to access the data and make sense of it. Education about the collection and utilization of data is a must, she said. “Our nurses of the future will not only need these skills, they will need to design the measurement systems,” Berkowitz said. “As nurse leaders, we all need to look at uses of technology as an opportunity rather than a burden.”

“Post-graduate residencies for advanced practice nurses are an opportunity to extend competencies into a practice environment, and an opportunity to prepare the nurses of the future to practice to the full scope of their education and develop into the next generation of health care leaders,” Berkowitz said. “We also have to redesign the payment models that have resulted in a lack of parity for NPs and physicians who perform identical services for patients.”