new research on nursing

• Research article
• Open access
• Published: 14 June 2021

Nurses in the lead: a qualitative study on the development of distinct nursing roles in daily nursing practice

• Jannine van Schothorst–van Roekel 1 ,
• Anne Marie J.W.M. Weggelaar-Jansen 1 ,
• Carina C.G.J.M. Hilders 1 ,
• Antoinette A. De Bont 1 &
• Iris Wallenburg 1  

BMC Nursing volume  20 , Article number:  97 ( 2021 ) Cite this article

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Transitions in healthcare delivery, such as the rapidly growing numbers of older people and increasing social and healthcare needs, combined with nursing shortages has sparked renewed interest in differentiations in nursing staff and skill mix. Policy attempts to implement new competency frameworks and job profiles often fails for not serving existing nursing practices. This study is aimed to understand how licensed vocational nurses (VNs) and nurses with a Bachelor of Science degree (BNs) shape distinct nursing roles in daily practice.

A qualitative study was conducted in four wards (neurology, oncology, pneumatology and surgery) of a Dutch teaching hospital. Various ethnographic methods were used: shadowing nurses in daily practice (65h), observations and participation in relevant meetings (n=56), informal conversations (up to 15 h), 22 semi-structured interviews and member-checking with four focus groups (19 nurses in total). Data was analyzed using thematic analysis.

Hospital nurses developed new role distinctions in a series of small-change experiments, based on action and appraisal. Our findings show that: (1) this developmental approach incorporated the nurses’ invisible work; (2) nurses’ roles evolved through the accumulation of small changes that included embedding the new routines in organizational structures; (3) the experimental approach supported the professionalization of nurses, enabling them to translate national legislation into hospital policies and supporting the nurses’ (bottom-up) evolution of practices. The new roles required the special knowledge and skills of Bachelor-trained nurses to support healthcare quality improvement and connect the patients’ needs to organizational capacity.

Conclusions

Conducting small-change experiments, anchored by action and appraisal rather than by design , clarified the distinctions between vocational and Bachelor-trained nurses. The process stimulated personal leadership and boosted the responsibility nurses feel for their own development and the nursing profession in general. This study indicates that experimental nursing role development provides opportunities for nursing professionalization and gives nurses, managers and policymakers the opportunity of a ‘two-way-window’ in nursing role development, aligning policy initiatives with daily nursing practices.

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The aging population and mounting social and healthcare needs are challenging both healthcare delivery and the financial sustainability of healthcare systems [ 1 , 2 ]. Nurses play an important role in facing these contemporary challenges [ 3 , 4 ]. However, nursing shortages increase the workload which, in turn, boosts resignation numbers of nurses [ 5 , 6 ]. Research shows that nurses resign because they feel undervalued and have insufficient control over their professional practice and organization [ 7 , 8 ]. This issue has sparked renewed interest in nursing role development [ 9 , 10 , 11 ]. A role can be defined by the activities assumed by one person, based on knowledge, modulated by professional norms, a legislative framework, the scope of practice and a social system [ 12 , 9 ].

New nursing roles usually arise through task specialization [ 13 , 14 ] and the development of advanced nursing roles [ 15 , 16 ]. Increasing attention is drawn to role distinction within nursing teams by differentiating the staff and skill mix to meet the challenges of nursing shortages, quality of care and low job satisfaction [ 17 , 18 ]. The staff and skill mix include the roles of enrolled nurses, registered nurses, and nurse assistants [ 19 , 20 ]. Studies on differentiation in staff and skill mix reveal that several countries struggle with the composition of nursing teams [ 21 , 22 , 23 ].

Role distinctions between licensed vocational-trained nurses (VNs) and Bachelor of Science-trained nurses (BNs) has been heavily debated since the introduction of the higher nurse education in the early 1970s, not only in the Netherlands [ 24 , 25 ] but also in Australia [ 26 , 27 ], Singapore [ 20 ] and the United States of America [ 28 , 29 ]. Current debates have focused on the difficulty of designing distinct nursing roles. For example, Gardner et al., revealed that registered nursing roles are not well defined and that job profiles focus on direct patient care [ 30 ]. Even when distinct nursing roles are described, there are no proper guidelines on how these roles should be differentiated and integrated into daily practice. Although the value of differentiating nursing roles has been recognized, it is still not clear how this should be done or how new nursing roles should be embedded in daily nursing practice. Furthermore, the consequences of these roles on nursing work has been insufficiently investigated [ 31 ].

This study reports on a study of nursing teams developing new roles in daily nursing hospital practice. In 2010, the Dutch Ministry of Health announced a law amendment (the Individual Health Care Professions Act) to formalize the distinction between VNs and BNs. The law amendment made a distinction in responsibilities regarding complexity of care, coordination of care, and quality improvement. Professional roles are usually developed top-down at policy level, through competency frameworks and job profiles that are subsequently implemented in nursing practice. In the Dutch case, a national expert committee made two distinct job profiles [ 32 ]. Instead of prescribing role implementation, however, healthcare organizations were granted the opportunity to develop these new nursing roles in practice, aiming for a more practice-based approach to reforming the nursing workforce. This study investigates a Dutch teaching hospital that used an experimental development process in which the nurses developed role distinctions by ‘doing and appraising’. This iterative process evolved in small changes [ 33 , 34 , 35 , 36 ], based on nurses’ thorough knowledge of professional practices [ 37 ] and leadership role [ 38 , 39 , 40 ].

According to Abbott, the constitution of a new role is a competitive action, as it always leads to negotiation of new openings for one profession and/or degradation of adjacent professions [ 41 ]. Additionally, role differentiation requires negotiation between different professionals, which always takes place in the background of historical professionalization processes and vested interests resulting in power-related issues [ 42 , 43 , 44 ]. Recent studies have described the differentiation of nursing roles to other professionals, such as nurse practitioners and nurse assistants, but have focused on evaluating shifts in nursing tasks and roles [ 31 ]. Limited research has been conducted on differentiating between the different roles of registered nurses and the involvement of nurses themselves in developing new nursing roles. An ethnographic study was conducted to shed light on the nurses’ work of seeking openings and negotiating roles and responsibilities and the consequences of role distinctions, against a background of historically shaped relationships and patterns.

The study aimed to understand the formulation of nursing role distinctions between different educational levels in a development process involving experimental action (doing) and appraisal.

We conducted an ethnographic case study. This design was commonly used in nursing studies in researching changing professional practices [ 45 , 46 ]. The researchers gained detailed insights into the nurses’ actions and into the finetuning of their new roles in daily practice, including the meanings, beliefs and values nurses give to their roles [ 47 , 48 ]. This study complied with the consolidated criteria for reporting qualitative research (COREQ) checklist.

Setting and participants

Our study took place in a purposefully selected Dutch teaching hospital (481 beds, 2,600 employees including 800 nurses). Historically, nurses in Dutch hospitals have vocational training. The introduction of higher nursing education in 1972 prompted debates about distinguishing between vocational-trained nurses (VNs) and bachelor-trained nurses (BNs). For a long time, VNs resisted a role distinction, arguing that their work experience rendered them equally capable to take care of patients and deal with complex needs. As a result, VNs and BNs carry out the same duties and bear equal responsibility. To experiment with role distinctions in daily practice, the hospital management and project team selected a convenience but representative sample of wards. Two general (neurology and surgery) and two specific care (oncology and pneumatology) wards were selected as they represent the different compositions of nursing educational levels (VN, BN and additional specialized training). The demographic profile for the nursing teams is shown in Table  1 . The project team, comprising nursing policy staff, coaches and HR staff ( N  = 7), supported the four (nursing) teams of the wards in their experimental development process (131 nurses; 32 % BNs and 68 % VNs, including seven senior nurses with an organizational role). We also studied the interactions between nurses and team managers ( N  = 4), and the CEO ( N  = 1) in the meetings.

Data collection

Data was collected between July 2017 and January 2019. A broad selection of respondents was made based on the different roles they performed. Respondents were personally approached by the first author, after close consultation with the team managers. Four qualitative research methods were used iteratively combining collection and analysis, as is common in ethnographic studies [ 45 ] (see Table  2 ).

Shadowing nurses (i.e. observations and questioning nurses about their work) on shift (65 h in total) was conducted to observe behavior in detail in the nurses’ organizational and social setting [ 49 , 50 ], both in existing practices and in the messy fragmented process of developing distinct nursing roles. The notes taken during shadowing were worked up in thick descriptions [ 46 ].

Observation and participation in four types of meetings. The first and second authors attended: (1) kick-off meetings for the nursing teams ( n  = 2); (2) bi-monthly meetings ( n  = 10) between BNs and the project team to share experiences and reflect on the challenges, successes and failures; and (3) project group meetings at which the nursing role developmental processes was discussed ( n  = 20). Additionally, the first author observed nurses in ward meetings discussing the nursing role distinctions in daily practice ( n  = 15). Minutes and detailed notes also produced thick descriptions [ 51 ]. This fieldwork provided a clear understanding of the experimental development process and how the respondents made sense of the challenges/problems, the chosen solutions and the changes to their work routines and organizational structures. During the fieldwork, informal conversations took place with nurses, nursing managers, project group members and the CEO (app. 15 h), which enabled us to reflect on the daily experiences and thus gain in-depth insights into practices and their meanings. The notes taken during the conversations were also written up in the thick description reports, shortly after, to ensure data validity [ 52 ]. These were completed with organizational documents, such as policy documents, activity plans, communication bulletins, formal minutes and in-house presentations.

Semi-structured interviews lasting 60–90 min were held by the first author with 22 respondents: the CEO ( n  = 1), middle managers ( n  = 4), VNs ( n  = 6), BNs ( n  = 9, including four senior nurses), paramedics ( n  = 2) using a predefined topic list based on the shadowing, observations and informal conversations findings. In the interviews, questions were asked about task distinctions, different stakeholder roles (i.e., nurses, managers, project group), experimental approach, and added value of the different roles and how they influence other roles. General open questions were asked, including: “How do you distinguish between tasks in daily practice?”. As the conversation proceeded, the researcher asked more specific questions about what role differentiation meant to the respondent and their opinions and feelings. For example: “what does differentiation mean for you as a professional?”, and “what does it mean for you daily work?”, and “what does role distinction mean for collaboration in your team?” The interviews were tape-recorded (with permission), transcribed verbatim and anonymized.

The fieldwork period ended with four focus groups held by the first author on each of the four nursing wards ( N  = 19 nurses in total: nine BNs, eight VNs, and two senior nurses). The groups discussed the findings, such as (nurses’ perceptions on) the emergence of role distinctions, the consequences of these role distinctions for nursing, experimenting as a strategy, the elements of a supportive environment and leadership. Questions were discussed like: “which distinctions are made between VN and BN roles?”, and “what does it mean for VNs, BNs and senior nurses?”. During these meetings, statements were also used to provoke opinions and discussion, e.g., “The role of the manager in developing distinct nursing roles is…”. With permission, all focus groups were audio recorded and the recordings were transcribed verbatim. The focus groups also served for member-checking and enriched data collection, together with the reflection meetings, in which the researchers reflected with the leader and a member of the project group members on program, progress, roles of actors and project outcomes. Finally, the researchers shared a report of the findings with all participants to check the credibility of the analysis.

Data analysis

Data collection and inductive thematic analysis took place iteratively [ 45 , 53 ]. The first author coded the data (i.e. observation reports, interview and focus group transcripts), basing the codes on the research question and theoretical notions on nursing role development and distinctions. In the next step, the research team discussed the codes until consensus was reached. Next, the first author did the thematic coding, based on actions and interactions in the nursing teams, the organizational consequences of their experimental development process, and relevant opinions that steered the development of nurse role distinctions (see Additional file ). Iteratively, the research team developed preliminary findings, which were fed back to the respondents to validate our analysis and deepen our insights [ 54 ]. After the analysis of the additional data gained in these validating discussions, codes were organized and re-organized until we had a coherent view.

Ethnography acknowledges the influence of the researcher, whose own (expert) knowledge, beliefs and values form part of the research process [ 48 ]. The first author was involved in the teams and meetings as an observer-as-participant, to gain in-depth insight, but remained research-oriented [ 55 ]. The focus was on the study of nursing actions, routines and accounts, asking questions to obtain insights into underlying assumptions, which the whole research group discussed to prevent ‘going native’ [ 56 , 57 ]. Rigor was further ensured by triangulating the various data resources (i.e. participants and research methods), purposefully gathered over time to secure consistency of findings and until saturation on a specific topic was reached [ 54 ]. The meetings in which the researchers shared the preliminary findings enabled nurses to make explicit their understanding of what works and why, how they perceived the nursing role distinctions and their views on experimental development processes.

Ethical considerations

All participants received verbal and written information, ensuring that they understood the study goals and role of the researcher [ 48 ]. Participants were informed about their voluntary participation and their right to end their contribution to the study. All gave informed consent. The study was performed in accordance with the Declaration of Helsinki and was approved by the Erasmus Medical Ethical Assessment Committee in Rotterdam (MEC-2019-0215), which also assessed the compliance with GDPR.

Our findings reveal how nurses gradually shaped new nursing role distinctions in an experimental process of action and appraisal and how the new BN nursing roles became embedded in new nursing routines, organizational routines and structures. Three empirical appeared from the systematic coding: (1) distinction based on complexity of care; (2) organizing hospital care; and (3) evidence-based practices (EBP) in quality improvement work.

Distinction based on complexity of care

Initially, nurses distinguished the VN and BN roles based on the complexity of patient care, as stated in national job profiles [ 32 ]. BNs were supposed to take care of clinically complex patients, rather than VNs, although both VNs and BNs had been equally taking care of every patient category. To distinguish between highly and less complex patient care, nurses developed a complexity measurement tool. This tool enabled classification of the predictability of care, patient’s degree of self-reliance, care intensity, technical nursing procedures and involvement of other disciplines. However, in practice, BNs questioned the validity of assessing a patient’s care complexity, because the assessments of different nurses often led to different outcomes. Furthermore, allocating complex patient care to BNs impacted negatively on the nurses’ job satisfaction, organizational routines and ultimately the quality of care. VNs experienced the shift of complex patient care to BNs as a diminution of their professional expertise. They continuously stressed their competencies and questioned the assigned levels of complexity, aiming to prevent losses to their professional tasks:

‘Now we’re only allowed to take care of COPD patients and people with pneumonia, so no more young boys with a pneumothorax drain. Suddenly we are not allowed to do that. (…) So, your [professional] world is getting smaller. We don’t like that at all. So, we said: We used to be competent, so why aren’t we anymore?’ (Interview VN1, in-service trained nurse).

In discussing complexity of care, both VNs and BNs (re)discovered the competencies VNs possess in providing complex daily care. BNs acknowledged the contestability of the distinction between VN and BN roles related to patient care complexity, as the next quote shows:

‘Complexity, they always make such a fuss about it. (…) At a given moment you’re an expert in just one certain area; try then to stand out on your ward. (…) When I go to GE [gastroenterology] I think how complex care is in here! (…) But it’s also the other way around, when I’m the expert and know what to expect after an angioplasty, or a bypass, or a laparoscopic cholecystectomy (…) When I’ve mastered it, then I no longer think it’s complex, because I know what to expect!’ (Interview BN1, 19-07-2017).

This quote illustrates how complexity was shaped through clinical experience. What complex care is , is influenced by the years of doing nursing work and hence is individual and remains invisible. It is not formally valued [ 58 ] because it is not included in the BN-VN competency model. This caused dissatisfaction and feelings of demotion among VNs. The distinction in complexities of care was also problematic for BNs. Following the complexity tool, recently graduated BNs were supposed to look after highly complex patients. However, they often felt insecure and needed the support of more experienced (VN) colleagues – which the VNs perceived as a recognition of their added value and evidence of the failure of the complexity tool to guide division of tasks. Also, mundane issues like holidays, sickness or pregnancy leave further complicated the use of the complexity tool as a way of allocating patients, as it decreased flexibility in taking over and swapping shifts, causing dissatisfaction with the work schedule and leading to problems in the continuity of care during evening, night and weekend shifts. Hence, the complexity tool disturbed the flexibility in organizing the ward and held possible consequences for the quality and safety of care (e.g. inexperienced BNs providing complex care), Ultimately, the complexity tool upset traditional teamwork, in which nurses more implicitly complemented each other’s competencies and ability to ‘get the work done’ [ 59 ]. As a result, role distinction based on ‘quantifiable’ complexity of care was abolished. Attention shifted to the development of an organizational and quality-enhancing role, seeking to highlight the added value of BNs – which we will elaborate on in the next section.

Organizing hospital care

Nurses increasingly fulfill a coordinating role in healthcare, making connections across occupational, departmental and organizational boundaries, and ‘mediating’ individual patient needs, which Allen describes as organizing work [ 49 ]. Attempting to make a valuable distinction between nursing roles, BNs adopted coordinating management tasks at the ward level, taking over this task from senior nurses and team managers. BNs sought to connect the coordinating management tasks with their clinical role and expertise. An example is bed management, which involves comparing a ward’s bed capacity with nursing staff capacity [ 1 , 60 ]. At first, BNs accompanied middle managers to the hospital bed review meeting to discuss and assess patient transfers. On the wards where this coordination task used to be assigned to senior nurses, the process of transferring this task to BNs was complicated. Senior nurses were reluctant to hand over coordinating tasks as this might undermine their position in the near future. Initially, BNs were hesitant to take over this task, but found a strategy to overcome their uncertainty. This is reflected in the next excerpt from fieldnotes:

Senior nurse: ‘First we have to figure out if it will work, don’t we? I mean, all three of us [middle manager, senior nurse, BN] can’t just turn up at the bed review meeting, can we? The BN has to know what to do first, otherwise she won’t be able to coordinate properly. We can’t just do it.’ BN: ‘I think we should keep things small, just start doing it, step by step. (…) If we don’t try it out, we don’t know if it works.’ (Field notes, 24-05-2018).

This excerpt shows that nurses gradually developed new roles as a series of matching tasks. Trying out and evaluating each step of development in the process overcame the uncertainty and discomfort all parties held [ 61 ]. Moreover, carrying out the new tasks made the role distinctions become apparent. The coordinating role in bed management, for instance, became increasingly embedded in the new BN nursing role. Experimenting with coordination allowed BNs prove their added value [ 62 ] and contributed to overall hospital performance as it combined daily working routines with their ability to manage bed occupancy, patient flow, staffing issues and workload. This was not an easy task. The next quote shows the complexity of creating room for this organizing role:

The BNs decide to let the VNs help coordinate the daily care, as some VNs want to do this task. One BN explains: ‘It’s very hard to say, you’re not allowed.’ The middle manager looks surprised and says that daily coordination is a chance to draw a clear distinction and further shape the role of BNs. The project group leader replies: ‘Being a BN means that you dare to make a difference [in distinctive roles]. We’re all newbies in this field, but we can use our shared knowledge. You can derive support from this task for your new role.’ (Field notes, 09-01-2018).

This excerpt reveals the BNs’ thinking on crafting their organizational role, turning down the VNs wishes to bear equal responsibility for coordinating tasks. Taking up this role touched on nurse identity as BNs had to overcome the delicate issue of equity [ 63 ], which has long been a core element of the Dutch nursing profession. Taking over an organization role caused discomfort among BNs, but at the same time provided legitimation for a role distinction.

Legitimation for this task was also gained from external sources, as the law amendment and the expert committee’s job descriptions both mentioned coordinating tasks. However, taking over coordinating tasks and having an organizing role in hospital care was not done as an ‘implementation’; rather it required a process of actively crafting and carving out this new role. We observed BNs choosing not to disclose that they were experimenting with taking over the coordinating tasks as they anticipated a lack of support from VNs:

BN: ‘We shouldn’t tell the VNs everything. We just need this time to give shape to our new role. And we all know who [of the colleagues] won’t agree with it. In my opinion, we’d be better off hinting at it at lunchtime, for example, to figure out what colleagues think about it. And then go on as usual.’ (Field notes, 12-06-2018).

BNs stayed ‘under the radar’, not talking explicitly about their fragile new role to protect the small coordination tasks they had already gained. By deliberately keeping the evaluation of their new task to themselves, they protected the transition they had set into motion. Thus, nurses collected small changes in their daily routines, developing a new role distinction step by step. Changes to single tasks accumulated in a new role distinction between BNs, VNs and senior nurses, and gave BNs a more hybrid nursing management role.

Evidence-based practices in quality improvement work

Quality improvement appeared to be another key concern in the development of the new BN role. Quality improvement work used to be carried out by groups of senior nurses, middle managers and quality advisory staff. Not involved in daily routines, the working group focused on nursing procedures (e.g. changing infusion system and wound treatment protocols). In taking on this new role BNs tried different ways of incorporating EBP in their routines, an aspect that had long been neglected in the Netherlands. As a first step, BNs rearranged the routines of the working group. For example, a team of BNs conducted a quality improvement investigation of a patient’s formal’s complaint:

Twenty-two patients registered a pain score of seven or higher and were still discharged. The question for BNs was: how and why did this bad care happen? The BNs used electronic patient record to study data on the relations between pain, medication and treatment. Their investigation concluded: nurses do not always follow the protocols for high pain scores. Their improvement plan covered standard medication policy, clinical lessons on pain management and revisions to the patient information folder. One BN said: ‘I really loved investigating this improvement.’ (Field notes, 28-05-2018).

This fieldnote shows the joy quality improvement work can bring. During interviews, nurses said that it had given them a better grip on the outcome of nursing work. BNs felt the need to enhance their quality improvement tasks with their EBP skills, e.g. using clinical reasoning in bedside teaching, formulating and answering research questions in clinical lessons and in multi-disciplinary patient rounds to render nursing work more evidence based. The BNs blended EBP-related education into shift handovers and ward meetings, to show VNs the value of doing EBP [ 64 ]. In doing so, they integrated and fostered an EBP infrastructure of care provision, reflecting a new sense of professionalism and responsibility for quality of care.

However, learning how to blend EPB quality work in daily routines – ‘learning in practice’ –requires attention and steering. Although the BNs had a Bachelor’s degree, they had no experience of a quality-enhancing role in hospital practice [ 65 ]. In our case, the interplay between team members’ previous education and experienced shortcomings in knowledge and skills uncovered the need for further EBP training. This training established the BNs’ role as quality improvers in daily work and at the same time supported the further professionalization of both BNs and VNs. Although introducing the EBP approach was initially restricted to the BNs, it was soon realized that VNs should be involved as well, as nursing is a collaborative endeavor [ 1 ], as one team member (the trainer) put it:

‘I think that collaboration between BNs and VNs would add lots of value, because both add something different to quality work. I’d suggest that BNs could introduce the process-oriented, theoretical scope, while VNs could maybe focus on the patients’ interest.’ (Fieldnote, informal conversation, 11-06-2018).

During reflection sessions on the ward level and in the project team meetings BNs, informed by their previous experience with the complexity tool, revealed that they found it a struggle to do justice to everyone’s competencies. They wanted to use everyone’s expertise to improve the quality of patient care. They were for VNs being involved in the quality work, e.g. in preparing a clinical lesson, conducting small surveys, asking VNs to pose EBP questions and encourage VNs to write down their thoughts on flip over charts as means of engaging all team members.

These findings show that applying EPB in quality improvement is a relational practice driven by mutual recognition of one another’s competencies. This relational practice blended the BNs’ theoretical competence in EBP [ 66 ] with the VNs’ practical approach to the improvement work they did together. As a result, the blend enhanced the quality of daily nursing work and thus improved the quality of patient care and the further professionalization of the whole nursing team.

This study aimed to understand how an experimental approach enables differently educated nurses to develop new, distinct professional roles. Our findings show that roles cannot be distinguished by complexity of care; VNs and BNs are both able to provide care to patients with complex healthcare needs based on their knowledge and experience. However, role distinctions can be made on organizing care and quality improvement. BNs have an important role organizing care, for example arranging the patient flow on and across wards at bed management meetings, while VNs contribute more to organizing at the individual patient level. BNs play a key role in starting and steering quality improvement work, especially blending EBP in with daily nursing tasks, while VNs are involved but not in the lead. Working together on quality improvement boosts nursing professionalization and team development.

Our findings also show that the role development process is greatly supported by a series of small-change experiments, based on action and appraisal. This experimental approach supported role development in three ways. First, it incorporates both formal tasks and the invisible, unconscious elements of nursing work [ 49 ]. Usually, invisible work gets no formal recognition, for example in policy documents [ 55 ], whereas it is crucial in daily routines and organizational structures [ 49 , 60 ]. Second, experimenting triggers an accumulation of small changes [ 33 , 35 ] leading to the embeddedness of role distinctions in new nursing routines, allowing nurses to influence the organization of care. This finding confirms the observations of Reay et al. that nurses can create small changes in daily activities to craft a new nursing role, based on their thorough knowledge of their own practice and that of the other involved professional groups [ 37 ]. Although these changes are accompanied by tension and uncertainty, the process of developing roles generates a certain joy. Third, experimenting stimulated nursing professionalization, enabling the nurses to translate national legislation into hospital policy and supporting the nurses’ own (bottom-up) evolution of practices. Historically, nursing professionalization is strongly influenced by gender and education level [ 43 ] resulting in a subordinate position, power inequity and lack of autonomy [ 44 ]. Giving nurses the lead in developing distinct roles enables them to ‘engage in acts of power’ and obtain more control over their work. Fourth, experimenting contributes to role definition and clarification. In line with Poitras et al. [ 12 ] we showed that identifying and differentiating daily nursing tasks led to the development of two distinct and complementary roles. We have also shown that the knowledge base of roles and tasks includes both previous and additional education, as well as nursing experience.

Our study contributes to the literature on the development of distinct nursing roles [ 9 , 10 , 11 ] by showing that delineating new roles in formal job descriptions is not enough. Evidence shows that this formal distinction led particularly to the non-recognition, non-use and degradation [ 41 ] of VN competencies and discomforted recently graduated BNs. The workplace-based experimental approach in the hospital includes negotiation between professionals, the adoption process of distinct roles and the way nurses handle formal policy boundaries stipulated by legislation, national job profiles, and hospital documents, leading to clear role distinctions. In addition to Hughes [ 42 ] and Abbott [ 67 ] who showed that the delineation of formal work boundaries does not fit the blurred professional practices or individual differences in the profession, we show how the experimental approach leads to the clarification and shape of distinct professional practices.

Thus, an important implication of our study is that the professionals concerned should be given a key role in creating change [ 37 , 39 , 40 ]. Adding to Mannix et al. [ 38 ], our study showed that BNs fulfill a leadership role, which allows them to build on their professional role and identity. Through the experiments, BNs and VNs filled the gap between what they had learned in formal education, and what they do in daily practice [ 64 , 65 ]. Experimenting integrates learning, appraising and doing much like going on ‘a journey with no fixed routes’ [ 34 , 68 ] and no fixed job description, resulting in the enlargement of their roles.

Our study suggests that role development should involve professionalization at different educational levels, highlighting and valuing specific roles rather than distinguishing higher and lower level skills and competencies. Further research is needed to investigate what experimenting can yield for nurses trained at different educational levels in the context of changing healthcare practices, and which interventions (e.g., in process planning, leadership, or ownership) are needed to keep the development of nursing roles moving ahead. Furthermore, more attention should be paid to how role distinction and role differentiation influence nurse capacity, quality of care (e.g., patient-centered care and patient satisfaction), and nurses’ job satisfaction.

Limitations

Our study was conducted on four wards of one teaching hospital in the Netherlands. This might limit the potential of generalizing our findings to other contexts. However, the ethnographic nature of our study gave us unique understanding and in-depth knowledge of nurses’ role development and distinctions, both of which have broader relevance. As always in ethnographic studies, the chances of ‘going native’ were apparent, and we tried to prevent this with ongoing reflection in the research team. Also, the interpretation of research findings within the Dutch context of nurse professionalization contributed to a more in-depth understanding of how nursing roles develop, as well as the importance of involving nurses themselves in the development of these roles to foster and support professional development.

We focused on role distinctions between VNs and BNs and paid less attention to (the collaboration with) other professionals or management. Further research is needed to investigate how nursing role development takes place in a broader professional and managerial constellation and what the consequences are on role development and healthcare delivery.

This paper described how nurses crafted and shaped new roles with an experimental process. It revealed the implications of developing a distinct VN role and the possibility to enhance the BN role in coordination tasks and in steering and supporting EBP quality improvement work. Embedding the new roles in daily practice occurred through an accumulation of small changes. Anchored by action and appraisal rather than by design , the changes fostered by experiments have led to a distinction between BNs and VNs in the Netherlands. Furthermore, experimenting with nursing role development has also fostered the professionalization of nurses, encouraging nurses to translate knowledge into practice, educating the team and stimulating collaborative quality improvement activities.

This paper addressed the enduring challenge of developing distinct nursing roles at both the vocational and Bachelor’s educational level. It shows the importance of experimental nursing role development as it provides opportunities for the professionalization of nurses at different educational levels, valuing specific roles and tasks rather than distinguishing between higher and lower levels of skills and competencies. Besides, nurses, managers and policymakers can embrace the opportunity of a ‘two-way window’ in (nursing) role development, whereby distinct roles are outlined in general at policy levels, and finetuned in daily practice in a process of small experiments to determine the best way to collaborate in diverse contexts.

Availability of data and materials

The data generated and analyzed during the current study is not publicly available to ensure data confidentiality but is available from the corresponding author on reasonable request and with the consent of the research participants.

Abbreviations

Bachelor-trained nurse

Vocational-trained nurse

Evidence-based Practices

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The authors would like to thank all participants for their contribution to this study.

The Reinier de Graaf hospital in Delft, who was central to this study provided financial support for this research.

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Jannine van Schothorst–van Roekel, Anne Marie J.W.M. Weggelaar-Jansen, Carina C.G.J.M. Hilders, Antoinette A. De Bont & Iris Wallenburg

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van Schothorst–van Roekel, J., Weggelaar-Jansen, A.M.J., Hilders, C.C. et al. Nurses in the lead: a qualitative study on the development of distinct nursing roles in daily nursing practice. BMC Nurs 20 , 97 (2021). https://doi.org/10.1186/s12912-021-00613-3

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National Academies of Sciences, Engineering, and Medicine; National Academy of Medicine; Committee on the Future of Nursing 2020–2030; Flaubert JL, Le Menestrel S, Williams DR, et al., editors. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington (DC): National Academies Press (US); 2021 May 11.

The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity.

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11 The Future of Nursing: Recommendations and Research Priorities

The next 10 years will test the nation’s nearly 4 million nurses in new and complex ways. Nurses live and work at the intersection of health, education, and communities. In the decade since the prior The Future of Nursing report was published ( IOM, 2011 ), the world has come to understand the critical importance of health to all aspects of life, particularly the relationship among social determinants of health (SDOH), health equity, and health outcomes. Consistent with this broader understanding, the National Advisory Council on Nurse Education and Practice (NACNEP) (2020) advanced an important set of recommendations that the committee endorses. The NACNEP report Integration of Social Determinants of Health in Nursing Education, Practice, and Research conveys the importance of investing in SDOH and research to strengthen the nursing workforce and help nurses provide more effective care, as well as design, implement, and assess new care models.

In a year that was designated to honor and uplift nursing (the International Year of the Nurse and the Midwife 2020 1 ), nurses have been placed in unimaginable circumstances by the COVID-19 pandemic. The decade ahead will demand a stronger, more diversified workforce that is prepared to provide care; promote health and well-being among nurses, individuals, and communities; and address the systemic inequities that have fueled wide and persistent health disparities.

The COVID-19 pandemic has revealed in the starkest terms that illness and access to quality health care are unequally distributed across groups and communities, and has spotlighted the reality that much of what affects health happens outside of medical care. The pandemic and continued calls for racial justice have illuminated the extent to which structural racism—from decades of neglect and disinvestment in neighborhoods, schools, communities, and health care to discrimination and bias—has placed communities of color at much higher risk for poor health and well-being.

The committee’s recommendations call for change at both the individual and system levels, constituting a call for action to the nation’s largest health care workforce, including nurses in all settings and at all levels, to listen, engage, deeply examine practices, collect evidence, and act to move the country toward greater health equity for all. The committee’s recommendations also are targeted to the actions required of policy makers, educators, health care system leaders, and payers to enable these crucial changes, supported by the research agenda with which this chapter concludes. With implementation of this report’s recommendations, the committee envisions 10 outcomes that position the nursing profession to contribute meaningfully to achieving health equity (see Box 11-1 ).

Achieving Health Equity Through Nursing: Desired Outcomes.

In this chapter, the committee provides its recommendations for charting a 10-year path forward to enable and support today’s and the next generation of nurses to create fair and just opportunities for health and well-being for everyone. These recommendations are aimed at all nurses, including those working in hospitals, schools, and health departments; policy makers; educators; health care system leaders; and payers. The chapter concludes with a research agenda to fill current and critical gaps that would support this future-oriented path.

• CREATING A SHARED AGENDA

In order for nurses to engage fully in efforts to achieve health equity, it will be necessary for nursing organizations to work together to identify priorities for education, practice, and policy, and to develop mechanisms for leveraging existing nursing expertise and resources. Creating a shared agenda will focus efforts and ensure that all nurses—no matter where they are educated or where they practice—are prepared, supported, and empowered to address SDOH and eliminate inequities in health and health care.

Recommendation 1: In 2021, all national nursing organizations should initiate work to develop a shared agenda for addressing social determinants of health and achieving health equity. This agenda should include explicit priorities across nursing practice, education, leadership, and health policy engagement. The Tri-Council for Nursing 2 and the Council of Public Health Nursing Organizations, 3 with their associated member organizations, should work collaboratively and leverage their respective expertise in leading this agenda-setting process. Relevant expertise should be identified and shared across national nursing organizations, including the Federal Nursing Service Council 4 and the National Coalition of Ethnic Minority Nurse Associations. With support from the government, payers, health and health care organizations, and foundations, the implementation of this agenda should include associated timelines and metrics for measuring impact.

Specific actions should include the following:

• Assess diversity, equity, and inclusion, and eliminate policies, regulations, and systems that perpetuate structural racism, cultural racism, and discrimination with respect to identity (e.g., sexual orientation, gender), place (e.g., rural, inner city), and circumstances (e.g., disabilities, depression).
• Develop mechanisms for leveraging the expertise of public health nursing (e.g., in population health, SDOH, community-level assessment) as a resource for the broader nursing community, health plans, and health systems, as well as public policy makers.
• Develop mechanisms for leveraging the expertise of relevant nursing organizations in care coordination and care management. Care coordination and care management principles, approaches, and evidence should be used to create new cross-sector models for meeting social needs and addressing SDOH.
• Develop mechanisms for prioritizing and sharing continuing education and skill-training resources focused on nurses’ health, well-being, resilience, and self-care to ensure a healthy nursing workforce. These resources should be used by nurses and others in leadership positions.
• Develop and use communication strategies, including social media, to amplify for the public, policy makers, and the media nursing research and expertise on health equity–related issues.
• Increase the number and diversity of nurses, especially those with expertise in health equity, population health, and SDOH, on boards and in other leadership positions within and outside of health care (e.g., community boards, housing authorities, school boards, technology-related positions).
• Establish a joint annual award or series of awards recognizing the measurable and scalable contributions of nurses and their partners to achieving health equity through policy, education, research, and practice. Priority should be given to interprofessional and multisector collaboration.
• SUPPORTING NURSES TO ADVANCE HEALTH EQUITY

Promoting health and well-being for all should be a national priority, and a collective and sustained commitment is needed to achieve this priority. To chart this path, nurses should be fully supported with robust education, resources, and autonomy. Key stakeholders should commit to investing fully in strengthening and diversifying the nursing workforce so that it is sufficiently prepared to promote health and appropriately reflects the people and communities it serves. Nursing schools, health care institutions, and public health and community health organizations can do significantly more to empower nurses to raise their voices and use their considerable expertise to improve people’s lives, health, and well-being.

Recommendation 2: By 2023, state and federal government agencies, health care and public health organizations, payers, and foundations should initiate substantive actions to enable the nursing workforce to address social determinants of health and health equity more comprehensively, regardless of practice setting.

This can be accomplished through the following actions:

• Rapidly increase both the number of nurses with expertise in health equity and the number of nurses in specialties with significant shortages, including public and community health, behavioral health, primary care, long-term care, geriatrics, school health, and maternal health. The Health Resources and Services Administration (HRSA), the Substance Abuse and Mental Health Services Administration, the Centers for Disease Control and Prevention (CDC), and state governments should support this effort through workforce planning and funding.
• Provide major investments for nursing education and traineeships in public health, including through state-level workforce programs; foundations; and the U.S. Department of Health and Human Services’ (HHS’s) HRSA (including nursing workforce programs and Maternal and Child Health Bureau programs), CDC (including the National Center for Environmental Health), and the Office of Minority Health.
• State governments, foundations, employers, and HRSA should direct funds to nurses and nursing schools to sustain and increase the gender, geographic, and racial diversity of the licensed practical nurse (LPN), registered nurse (RN), and advanced practice registered nurse (APRN) workforce.
• HRSA and the Indian Health Service (IHS) should make substantial investments in nurse loan and scholarship programs to address nurse shortages, including in public health, in health professional shortage areas for HRSA, and in IHS designated sites; and invest in technical assistance that focuses on nurse retention.
• In all relevant Title 8 programs, HRSA should prioritize longitudinal community-based learning opportunities that address social needs, population health, SDOH, and health equity. These experiences should be established through academic–community-based partnerships.
• Foundations, state government workforce programs, and the federal government should support the academic progression of socioeconomically disadvantaged students by encouraging partnerships among baccalaureate and higher-degree nursing programs and community colleges; tribal colleges; historically Black colleges and universities; Hispanic-serving colleges and universities; and nursing programs that serve a high percentage of Asian, Native Hawaiian, and Pacific Islander students.
• Report on and propose actions to fill critical gaps in the current nursing workforce and prepare the future workforce to address health equity.
• Use findings, including those from workforce centers, on the ° diversity, capacity, supply, and distribution of nurses; associated competencies; and organizational support for the nursing workforce in addressing social needs, SDOH, and health equity. Recommend actions to ensure nurses’ continued engagement in these areas.
• Further develop recommendations for nursing education and prac- ° tice with respect to addressing social needs, SDOH, and health equity, and assess the implications of these changes for nurse credentialing and regulatory actions.
• Identify and address gaps in evidence-based nursing and interpro- ° fessional and multisectoral approaches for addressing social needs, SDOH, and health equity.
• Provide information to the secretary of HHS regarding activities of ° federal agencies that relate to the nursing workforce and its impact on health equity.
• Public health and health care systems should quantify nursing expenditures related to health equity and SDOH. This includes providing support for nurses in activities that explicitly target social needs, SDOH, and health equity through health care organization policies, governance and related advisory structures, and collective bargaining agreements.
• Representatives of social sectors, consumer organizations, and government entities should include nursing expertise when health-related multisector policy reform is being advanced.
• State and federal governments should provide sustainable funding to prepare sufficient numbers of baccalaureate, APRN, and PhD-level nurses to address SDOH, advance health equity, and increase access to primary care.
• Employers should support nurses at all levels in all settings with the financial, technical, educational, and staffing resources to help them play a leading role in achieving health equity.

PROMOTING NURSES’ HEALTH AND WELL-BEING

During the course of their work, nurses encounter physical, mental, emotional, and ethical challenges, and burnout is an increasingly prevalent problem. The COVID-19 pandemic has only exacerbated these issues. In order for nurses to help others be healthy and well, they must be healthy and well themselves; a lack of nurse well-being has consequences for nurses, patients, employers, and communities. As nurses are asked to take a more prominent role in advancing health equity, it will become even more imperative that all stakeholders—including educators, employers, leaders, and nurses themselves—take steps to ensure nurse well-being.

Recommendation 3: By 2021, nursing education programs, employers, nursing leaders, licensing boards, and nursing organizations should initiate the implementation of structures, systems, and evidence-based interventions to promote nurses’ health and well-being, especially as they take on new roles to advance health equity.

This can be accomplished by taking the following steps:

• Integrate content on nurses’ health and well-being into their programs to raise nursing students’ awareness of the importance of these concerns and provide them with associated skill training and support that can be used as they transition to practice.
• Create mechanisms, including organizational policy and regulations, to protect students most at risk for behavioral health challenges, including those students who may be experiencing economic hardships or feel that they are unsafe; isolated; or targets of bias, discrimination, and injustice.
• Provide sufficient human and material resources (including personal protective equipment) to enable nurses to provide high-quality person-, family-, and community-centered care effectively and safely. This effort should include redesigning processes and increasing staff capacity to improve workflow, promote transdisciplinary collaboration, reduce modifiable burden, and distribute responsibilities to reflect nurses’ expertise and scope of practice.
• Establish a culture of physical and psychological safety and ethical practice in the workplace, including dismantling structural racism; addressing bullying and incivility; using evidence-informed approaches; investing in organizational infrastructure, such as resilience engineering; 5 and creating accountability for nurses’ health and well-being outcomes.
• Create mechanisms, including organizational policy and regulations, to protect nurses from retaliation when advocating on behalf of themselves and their patients and when reporting unsafe working conditions, biases, discrimination, and injustice.
• Support diversity, equity, and inclusion across the nursing workforce, and identify and eliminate policies and systems that perpetuate structural racism, cultural racism, and discrimination in the nursing profession, recognizing that nurses are accountable for building an antiracist culture, and employers are responsible for establishing an antiracist, inclusive work environment.
• Prioritize and invest in evidence-based mental, physical, behavioral, social, and moral health interventions, including reward programs meaningful to nurses in diverse roles and specialties, to promote nurses’ health, well-being, and resilience within work teams and organizations.
• Establish and standardize institutional processes that strengthen nurses’ contributions to improving the design and delivery of care and decision making, including the setting of institutional policies and benchmarks in health care organizations and in educational, public health, and other settings.
• Evaluate and strengthen policies, programs, and structures within employing organizations and licensing boards to reduce stigma associated with mental and behavioral health treatment for nurses.
• Collect systematic data at the employer, state (including state workforce centers and state nursing associations), and national levels to better understand the health and well-being of the nursing workforce. This enhanced understanding should be used to inform the development of evidence-based interventions for mitigating burnout; fatigue; turnover; and the development of physical, behavioral, and mental health problems.

CAPITALIZING ON NURSES’ POTENTIAL

Nurses often have untapped potential to help people live their healthiest lives because their education and experience are grounded in caring for the whole person and whole family in a community context. However, this potential is too often underutilized. Nurses, particularly RNs, need environments that facilitate their ability to fully leverage their skills and expertise across all practice settings—in hospitals, primary care settings, rural and underserved areas, homes, community organizations, long-term care facilities, and schools. To engage fully in advancing health equity, all nurses need the autonomy to practice to the full extent of their education and training, even as they work collaboratively with other health professionals. They are, however, frequently hindered in this regard by restrictive laws and institutional policies. Policy makers and health care systems need to lift permanently all barriers that stand in the way of nurses in their efforts to address the root causes of poor health, expand access to care, and create more equitable communities.

Recommendation 4: All organizations, including state and federal entities and employing organizations, should enable nurses to practice to the full extent of their education and training by removing barriers that prevent them from more fully addressing social needs and social determinants of health and improving health care access, quality, and value. These barriers include regulatory and public and private payment limitations; restrictive policies and practices; and other legal, professional, and commercial 6 impediments.

To this end, the following specific actions should be prioritized:

• By 2022, all changes to institutional policies and state and federal laws adopted in response to the COVID-19 pandemic that expand scope of practice, telehealth eligibility, insurance coverage, and payment parity for services provided by APRNs and RNs should be made permanent.
• Federal authority (e.g., Veterans Health Administration regulations, Centers for Medicare & Medicaid Services [CMS]) should be used where available to supersede restrictive state laws, including those addressing scope of practice, telehealth, and insurance coverage and payment, that decrease access to care and burden nursing practice, and to encourage nationwide adoption of the Nurse Licensure Compact. 7
• The Health Care Regulator Collaborative should work to advance interstate compacts and the adoption of model legislation to improve access, standardize care quality, and build interprofessional collaboration and interstate cooperation.
• PAYING FOR NURSING CARE

Nurses are bridge builders, engaging and connecting with individuals, communities, public health and health care, and social services organizations to improve health for all. Without strong financial and institutional support, however, their reach and impact are limited. How care is paid for can determine one’s access to and the quality of care. Thus, it is important to improve and strengthen the design of public and private payment models so nurses are supported, encouraged, and incentivized to bridge health and social needs for people, families, and communities. Nurses also can play a key role in helping to design those models. Also important is for local, state, and federal governments to place more value on the vital role of school and public health nurses in advancing health equity by adequately funding and deploying these nurses where they are needed to promote health in communities.

Recommendation 5: Federal, tribal, state, local, and private payers and public health agencies should establish sustainable and flexible payment mechanisms to support nurses in both health care and public health, including school nurses, in addressing social needs, social determinants of health, and health equity.

Specific payment reforms should include the following:

• ensuring that the Current Procedure Terminology (CPT) code set includes appropriate codes to describe and reimburse for such nurse-led services as case management, care coordination, and team-based care to address behavioral health, addiction, SDOH, and health equity, and that the relative value units attached to the CPT codes result in adequate and direct reimbursement for this work;
• reimbursing for school nursing; and
• enabling nurses to bill for telehealth services.
• using clinical performance measures stratified by such risk factors as race, ethnicity, and socioeconomic status;
• supporting nursing interventions through clinical performance measures that incentivize reductions in health disparities between more and less advantaged populations, improvements in measures for at-risk populations, and attainment of absolute target levels of high-quality performance for at-risk populations; and
• incorporating disparities-sensitive measures that support and incentivize nursing interventions that advance health equity (e.g., process measures such as care management and team-based care for chronic conditions; outcomes such as prevention of hospitalizations for ambulatory care–sensitive conditions).
• providing flexible funding (capitated payments, global budgets, shared savings, per member per month payments, accountable health communities models) for nursing and infrastructure that address SDOH; and
• incorporating value-based payment metrics that enable nurses to address SDOH and advance health equity.
• Create a National Nurse Identifier to facilitate recognition and measurement of the value of services provided by RNs.
• implementing state policies that allow school nurses to bill Medicaid and supporting schools, particularly rural schools, in meeting documentation requirements;
• reimbursing school nursing services that include collaboration with clinical and community health care providers;
• promoting new ways of financing public health to address SDOH in the community (e.g., having federal, state, and local leaders, along with public health departments and organizations, partner with payers, health systems, and accountable health communities, and blend or braid multiple funding sources);
• creating funding mechanisms and joint accountability metrics for the efforts of the health, public health, and social sectors to address SDOH and advance health equity that align incentives and behavior across the various stakeholders, including school health;
• leveraging nonprofit hospital community benefit requirements to create partnerships with and among school and public health nursing, primary care organizations, and other social sectors; and
• using pay scales for public health nurses that are competitive with those for nursing positions in other health care organizations and sectors, and that provide equal pay when the services provided (e.g., immunizations) are the same.
• USING TECHNOLOGY TO INTEGRATE DATA ON SOCIAL DETERMINANTS OF HEALTH INTO NURSING PRACTICE

The advent and adoption of new technologies have dramatically changed nursing practice over the past several decades, and will continue to do so into the future. Given the rapid acceleration of technical advances, nurses practicing in the coming decade will need to be adept at and comfortable with using emerging technology and have the skills to support others in doing the same. Nurses are well positioned to design, adopt, and adapt new technologies in practice and leverage data on SDOH to identify and address the needs of populations, individualize care, and reduce health disparities. With care expanding beyond the walls of traditional health care settings, including hospitals and clinics, the deployment of such advanced technologies as artificial intelligence and telehealth can assist nurses in connecting to health care networks, reaching individuals in their homes and other settings, and promoting health and well-being within communities. As key stakeholders in the design, adoption, and evaluation of new care tools, nurses also need to understand how to use new technologies to reduce rather than exacerbate inequities.

Recommendation 6: All public and private health care systems should incorporate nursing expertise in designing, generating, analyzing, and applying data to support initiatives focused on social determinants of health and health equity using diverse digital platforms, artificial intelligence, and other innovative technologies.

• With leadership from CMS and The Office of the National Coordinator for Health Information Technology, accelerate interoperability projects that integrate data on SDOH from public health, social services organizations, and other community partners into electronic health records, and build a nationwide infrastructure to capture and share community-held knowledge, facilitate referrals for care (including by decreasing the “digital divide”), and facilitate coordination and connectivity among health care settings and the public and nonprofit sectors.
• Ensure that existing public/private health equity data collaboratives (e.g., the Gravity Project 8 ) encompass nursing-specific care processes that improve visualization of data on SDOH and associated decision making by nurses.
• Employ nurses with requisite expertise in informatics to improve individual and population health through large-scale integration of data on SDOH into nursing practice, as well as expertise in the use of telehealth and advanced digital technologies.
• To personalize care based on person- and family-centered preferences and individual needs, give nurses in clinical settings responsibility and associated resources to innovate and use technology, including in the use of data on SDOH as context for planning and evaluating care; in the design of personal and mobile health tools; in coordination of community and public health portals across care settings; in methods for effective communication using technology; in evaluation of datasets and artificial intelligence algorithms (e.g., for racial bias); and in partnerships with corporate settings outside of health care delivery (e.g., large technology organizations, private insurers) that are addressing health equity in the nonclinical setting.
• expanding the national strategy for a broadband/5G infrastructure to enable comprehensive community access to these services; and
• increasing the availability of the necessary hardware, including smartphones, computers, and webcams, for high-risk populations.
• STRENGTHENING NURSING EDUCATION

Regardless of the setting in which they work or their level of education, nurses of the future will be expected to have a sophisticated understanding of social needs, SDOH, and health equity and to be capable of applying this knowledge in their practice. The World Health Organization has emphasized the importance of monitoring equitable service coverage across wealth and education gradients as part of achieving universal health coverage. Similarly, leading public health researchers have advocated for using markers of health equity to monitor health and health care as a first step in confronting inequities. Recognizing and meeting social needs could both lower health care spending and improve health outcomes.

Nursing schools need to prepare nurses to understand and identify the social, economic, and environmental factors that influence health by embedding content on SDOH throughout their curricula. Schools need to ensure that nurses have substantive, enduring, relevant community-based experiences and that they value diverse perspectives and cultures in order to help all people and families thrive. Nurses should have this content updated and reinforced throughout their careers through continuing education.

Recommendation 7: Nursing education programs, including continuing education, and accreditors and the National Council of State Boards of Nursing should ensure that nurses are prepared to address social determinants of health and achieve health equity.

To implement this recommendation, deans, administrative faculty leaders, faculty, course directors, and staff of nursing education programs should take the following steps:

• Integrate social needs, SDOH, population health, environmental health, trauma-informed care, and health equity as core concepts and competencies throughout coursework and clinical and experiential learning. These core concepts and competencies should be commensurate and seamless with academic level and included in continuing education.
• By the 2022–2023 school year, initiate an assessment of individual student access to technology, and ensure that all students can engage in virtual learning, including such opportunities as multisector simulation. Access to nursing education for geographically and socioeconomically disadvantaged students should be ensured through the development and expansion of the use of remote and virtual instructional capabilities. For rural areas, emphasis should be on baccalaureate preparation given the lower proportion of nurses educated at this level.
• To promote equity, inclusivity, and diversity grounded in social justice, identify and eliminate policies, procedures, curricular content, and clinical experiences that perpetuate structural racism, cultural racism, and discrimination among faculty, staff, and students.
• Increase academic progression for geographically and socioeconomically disadvantaged students through academic partnerships that include community and tribal colleges located in rural and urban underserved areas.
• Recruit diverse faculty with expertise in SDOH, population health (including environmental health), and health equity and associated policy expertise, and, through evidence-based and other training, develop the skills of current faculty with the objective of ensuring that students have access across the curriculum to expertise in these areas. Faculty should also have the technical competencies for online teaching.
• Ensure that students have learning opportunities with care coordination experiences that include working with health care teams to address individual and family social needs, as well as learning opportunities with multisector stakeholders that include a focus on health in all policies and SDOH. Learning experiences should include working with underserved populations in such settings as federally qualified health centers, rural health clinics, and IHS designated sites.
• Incorporate in all nurse doctoral education content related to SDOH, population health, environmental health, trauma-informed care, health equity, and social justice. All graduates of doctoral programs should have competencies in the use of data on SDOH as context for planning, implementing, and evaluating care and for improving population health through the large-scale application of these data.
• Ensure that PhD nursing graduates are competent to design and implement research that addresses issues of social justice and equity in education and/or health and health care and informs relevant policies. Increase the capacity of these graduates to apply research and scale interventions to address and improve social needs, SDOH, population health, environmental health, trauma-informed care, health equity, the well-being of nurses, and disaster preparedness and to inform relevant policies.
• Prepare all nursing students to advocate for health equity through civic engagement, including engagement in health and health-related public policy and communication through traditional and nontraditional methods, including social media and multisector coalitions.

Accreditors should take the following actions:

• Incorporate standards and competencies for curriculum that reflect the application of knowledge and skills to improve social needs, SDOH, population health, environmental health, trauma-informed care, and health equity.
• Incorporate standards for increasing student and faculty diversity.
• Require nursing education programs to initiate curricular assessments in 2022–2023 and phase in curricular changes that integrate social needs, SDOH, population health, environmental health, trauma-informed care, and health equity throughout the curriculum and are assessed in subsequent midterm and accreditation reporting. These curricular changes and their impact should be subject to continuous accreditation review processes.
• Include standards for nurses’ well-being and ethical practice in accreditation guidelines, and include such content on nurse licensing and certification exams.

The National Council of State Boards of Nursing and specialty certification organizations should take the following action:

• Incorporate test questions on meeting social needs through care coordination and on meeting population health needs, including addressing SDOH, through multisector coordination.

Continuing education providers should take the following action:

• Evaluate each offering for the inclusion of social needs, SDOH, population health, environmental health, trauma-informed care, and health equity and strategies for associated public- and private-sector policy engagement.
• PREPARING NURSES TO RESPOND TO DISASTERS AND PUBLIC HEALTH EMERGENCIES

The COVID-19 pandemic has magnified the vital role of nurses on the front lines of crises—whether in the hospital intensive care unit, a community testing site, or an emergency shelter—in keeping communities safe and healthy and helping people and families cope. They are reliable, trusted, experienced, and proven responders during both public health emergencies and natural disasters, such as hurricanes and wildfires. But fundamental reforms and a stronger disaster preparedness infrastructure are needed to improve nursing education, practice, and policy so nurses are fully protected during such events and can better protect and care for recovering populations.

Recommendation 8: To enable nurses to address inequities within communities, federal agencies and other key stakeholders within and outside the nursing profession should strengthen and protect the nursing workforce during the response to such public health emergencies as the COVID-19 pandemic and natural disasters, including those related to climate change.

To this end, the following steps should be taken:

• CDC should fund a National Center for Disaster Nursing and Public Health Emergency Response, along with additional strategically placed regional centers, to serve as the “hub” for providing leadership in education, training, and career development that will ensure a national nursing workforce prepared to respond to such events.
• CDC, in collaboration with the proposed National Center for Disaster Nursing and Public Health Emergency Response, should rapidly articulate a national action plan for addressing gaps in nursing education, support, and protection that have contributed to the lack of nurse preparedness and disparities during such events.
• The Office of the Assistant Secretary for Preparedness and Response, CDC, HRSA, the Agency for Healthcare Research and Quality, CMS, the National Institute of Nursing Research (NINR), and other funders should develop and support the emergency preparedness and response knowledge base of the nursing workforce through regulations, programs, research, and sustainable funding targeted specifically to disaster and public health emergency nursing.
• The American Association of Colleges of Nursing, the National League for Nursing, and the Organization for Associate Degree Nursing should lead transformational change in nursing education to address workforce development in disaster nursing and public health preparedness. NCSBN should expand content in licensing examinations to cover actual responsibilities of nurses in disaster and public health emergency response.
• Employers should incorporate the expertise of nurses to proactively develop and implement an emergency response plan for natural disasters and public health emergencies in coordination with local, state, national, and federal partners. They should also provide additional services throughout a disaster or public health emergency, such as support for families and behavioral health, to support and protect nurses’ health and well-being.
• BUILDING THE EVIDENCE BASE

Strengthening and diversifying the nursing workforce of the future, fostering nurse well-being, and developing strong and impactful nurse leaders so that nurses can fully address the wide and persistent health disparities in the United States will require a robust and rigorous evidence base. Below, the committee prioritizes the research needs and identifies gaps in the knowledge base that, if filled, would substantially move the nursing profession forward in the future.

Recommendation 9: The National Institutes of Health, the Centers for Medicare & Medicaid Services, the Centers for Disease Control and Prevention, the Health Resources and Services Administration, the Agency for Healthcare Research and Quality, the Administration for Children and Families, the Administration for Community Living, and private associations and foundations should convene representatives from nursing, public health, and health care to develop and support a research agenda and evidence base describing the impact of nursing interventions, including multisector collaboration, on social determinants of health, environmental health, health equity, and nurses’ health and well-being.

These efforts should be focused on the following actions:

• Develop mechanisms for proposing, evaluating, and scaling evidence-based practice models that leverage collaboration among public health, social sectors, and health systems to advance health equity, including codesigning innovations with individuals and community representatives and responding to community health needs assessments. This effort should emphasize rapidly translating evidence-based interventions into real-world clinical practice and community-based settings to improve health equity and population health outcomes, and applying implementation science strategies in the process of scaling these interventions and strategies.
• Identify effective multisector team approaches to improving health equity and addressing social needs and SDOH, including clearly defining roles and assessing the value of nurses in these models. Specifically, performance and outcome measures should be delineated, and evaluation strategies for community-based models and multisector team functioning should be developed and implemented.
• Review and adapt evidence-based approaches to increasing the number and diversity of students and faculty from disadvantaged and traditionally underrepresented groups to promote a diverse, inclusive learning environment and prepare a culturally competent workforce.
• Determine evidence-based education strategies for preparing nurses at all levels, including through continuing education, to eliminate structural racism and implicit bias and strengthen the delivery of culturally competent care.
• Augment the use of advanced information technology infrastructure, including virtual services and artificial intelligence, to identify and integrate health and social data, including data on SDOH, so as to improve nurses’ capacity to support individuals, families, and communities, including through care coordination.

Across all of these efforts, nurses should partner with key community stakeholders in research design; identification of the characteristics of new health models; and the development of related institutional and public policies at the health system, public health, and community levels. To expand the cohort of nurse researchers engaged in this research agenda, NINR should offer continuous summer intensive seminars to build expertise in population health, SDOH, and health equity. Table 11-1 summarizes gaps in the current research base that have been identified throughout this report.

Research Topics for the Future of Nursing, 2020–2030.

• FINAL THOUGHTS

The nursing profession is vital to the nation’s creation of a culture of health, reduction of health disparities, and improvement in the health and well-being of the population. The committee’s nine recommendations provide a comprehensive path forward for policy makers, practicing nurses, educators, health care system leaders, researchers, and payers to enable and support the nurses of today and the future in creating fair and just opportunities for health and well-being for everyone. The social, political, and health care trends discussed in this report, while replete with myriad challenges, also offer nurses new opportunities for practice and collaboration. Nurses will need to continue to adapt and respond to new and developing health problems at both the individual and community levels, and to deepen their understanding of how social, economic, and environmental issues and systemic barriers affect the health and well-being of the people and communities they serve. The rapidly deployed changes in community-based and clinical care, nursing education, nursing leadership, and nursing–community partnerships resulting from the COVID-19 pandemic have amplified those challenges. The deployment of all levels of nurses across the care continuum, including in collaborative practice models, will be necessary to address the challenges of building a more equitable and accessible health care system.

The United States is at an inflection point with respect to addressing disparities in health and well-being that have adversely impacted too many people for too long. The nation’s health care system is also at an inflection point in terms of meeting consumers’ health needs in ways and in places commensurate with their preferences. It is imperative that the nursing profession focus on the training and competency development needed to prepare nurses, including advanced practice nurses, to work competently in home and community-based as well as acute care settings and to lead efforts to build a culture of health and health equity. There is no time to waste. Over the next 10 years, nurses will assume even greater responsibility for helping to build an accessible, equitable, high-quality public health and health care system that works for everyone. The recommendations in this report are aimed at ensuring that nurses are inspired, supported, valued, and empowered in pursuing that goal so that by 2030, all individuals and communities will have the opportunities they need to live healthy lives.

• Anderson JE, Ross AJ, Back J, Duncan M, Snell P, Walsh K, Jaye P. Implementing resilience engineering for healthcare quality improvement using the CARE model: A feasibility study protocol. Pilot and Feasibility Studies. 2016; 2 (61) doi: 10.1186/s40814-016-0103-x. [ PMC free article : PMC5154109 ] [ PubMed : 27965876 ]
• NACNEP (National Advisory Council on Nurse Education and Practice). Integration of social determinants of health in nursing education, practice, and research. 16th Report to the Secretary of the U.S. Department of Health and Human Services and the U.S. Congress. Washington, DC: Health Resources and Services Administration; 2020.

See https://www ​.who.int/campaigns ​/annual-theme ​/year-of-the-nurse-and-the-midwife-2020 (accessed April 12, 2021).

The Tri-Council for Nursing includes the following organizations as members: the American Association of Colleges of Nursing, the American Nurses Association, the American Organization for Nursing Leadership, the National Council of State Boards of Nursing, and the National League for Nursing.

The Council of Public Health Nursing Organizations includes the following organizations as members: the Alliance of Nurses for Healthy Environments, the American Nurses Association, the American Public Health Association—Public Health Nursing Section, the Association of Community Health Nursing Educators, the Association of Public Health Nurses, and the Rural Nurse Organization.

The Federal Nursing Service Council is a united federal nursing leadership team representing the U.S. Army, Air Force, Navy, National Guard and Reserves, Public Health Service Commissioned Corps, American Red Cross, U.S. Department of Veteran Affairs, and the Uniformed Services University of the Health Sciences Graduate School of Nursing.

Resilience engineering is focused on “understanding the nature of adaptations, learning from success and increasing adaptive capacity” ( Anderson et al., 2016 , p. 1).

The term “commercial” refers to contractual agreements and customary practices that make antiquated or unjustifiable assumptions about nursing.

Under the Nurse Licensure Compact (NLC), “nurses can practice in other NLC states without having to obtain additional licenses. The current NLC allows for RNs and LPNs/licensed vocational nurses (LVNs) to have one multistate license in any one of the 35 member states” (see https://www ​.ncsbn.org/nlcmemberstates ​.pdf ). According to the National Council of State Boards of Nursing (NCSBN), “An APRN must hold an individual state license in each state of APRN practice” (see https://www ​.ncsbn.org/2018_eNLC_FAQs.pdf ). There is a movement, organized by the National Council of State Boards of Nursing, to have an APRN Compact (see https://aprncompact ​.com/about.htm ) (all accessed April 12, 2021).

See https://sirenetwork ​.ucsf ​.edu/TheGravityProject (accessed April 12, 2021).

• Cite this Page National Academies of Sciences, Engineering, and Medicine; National Academy of Medicine; Committee on the Future of Nursing 2020–2030; Flaubert JL, Le Menestrel S, Williams DR, et al., editors. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington (DC): National Academies Press (US); 2021 May 11. 11, The Future of Nursing: Recommendations and Research Priorities.
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