The seminal Institute of Medicine report, The Future of Nursing, Leading Change, Advancing Health, was informed and driven by data, and made specific recommendations relating to the need to expand collection and use of data. A follow-up 2015 report underscored those recommendations. Data has been integral in increasing the scope and reach of practice for advanced practice nurses, and will continue to be critical to the future of the nursing profession and the delivery of healthcare as a whole.
In 2010, the Institute of Medicine (IOM) published The Future of Nursing: Leading Change, Advancing Heath.1 As of 2016, friends and followers of the Future of Nursing: Campaign for Action (Campaign for Action) number 90,000. An “Action Coalition” dedicated to implementing the recommendations of the Future of Nursing report exists in all 50 states and the District of Columbia. And, at over 130,000 downloads, the Future of Nursing report continues to be the most sought-after report in the history of the IOM.
The Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing (“committee”) relied on data to assess the state of healthcare at the outset of the Affordable Care Act. The data painted a now familiar picture of unsustainable healthcare costs, an aging and chronically ill population, and a fragmented healthcare workforce that reacted to illness instead of promoting wellness. The report served to culminate a 15-month, multi-stakeholder process that included a review of over 2,100 pieces of literature.
Data informs all of the report’s recommendations, yet the committee also identified numerous gaps in data. In fact, one of the four “key messages” and one of the eight recommendations directly call for better healthcare workforce data collection and improved infrastructure. The committee argued that effective workforce policy and planning required interprofessional data that take into account the variety of roles healthcare professionals could occupy within a given team.
Leading the way
Data on the lack of primary care providers formed much of basis for the recommendation to remove barriers to care delivered by advanced practice nurses (APNs). The committee used data and projections from Health Services and Resources Administration (HRSA) and Government Accountability Office (GAO). For example, data on Health Provider Shortage Areas (HPSAs) supported concern about disparate access to care throughout the country. Government data highlighted a failure of the healthcare system. Research on the healthcare workforce presented non-physician clinicians, especially APNs, as a possible solution. The committee reviewed the evidence on the proportion of APNs practicing in rural clinics and urban community health centers. They looked at the number of medical students entering internal medicine residency programs and the number of APNs trained in primary care.
The committee did not consider the number of primary care providers as simple arithmetic. They also reviewed the 30-plus years of evidence indicating that APNs, including nurse practitioners, deliver high-quality care. Much of the evidence the committee evaluated evolved from nurse-led health settings. Many Nurse-Managed Health Centers (NMHCs) are affiliated with schools of nursing and provide an excellent opportunity for practice and research to align with workforce development and patient-centered care.
Data collected through HRSA demonstration projects also proved informative. An issue brief included in the report’s appendix explored how five nurse-led innovations in chronic disease management controlled costs in practical ways.2 The government-funded demonstrations facilitated the body of evidence that proposed solutions to the shortages presented by government data on workforce supply and healthcare demand.
The research on cost-effectiveness emerging from nurse-led clinics was especially valuable, likely because APN data would more likely be included in the National Provider Index (NPI). Nurse practitioners working in physician-led settings, regardless of whether state law requires physician supervision or collaboration, have little incentive to bill under their NPI, because NPs received 85% of the physician reimbursement for Medicaid. NPI data, collected by the Centers for Medicare and Medicaid, has therefore been a promising but not fruitful source of government data.
In 2015, the IOM released another report, Assessing Progress on the Institute of Medicine Report The Future of Nursing.3 Among the expanded recommendations was another call for better data. Without data, a movement can lose direction. Data is simultaneously necessary to inform the agenda, track its progress, and evaluate its impact. But good data is hard to obtain, especially in a timely manner. State workforce data has constraints related to privacy, funding, and political shifts. Federal workforce data can lack the granularity necessary to direct local action. Data on quality outcomes and cost changes rapidly as the very instruments for measuring these outcomes move through public notice and comment.
The Campaign for Action tracks national progress toward the recommendations of the IOM report through a series of “dashboard indicators.”4 The metrics keep the Campaign and the state Action Coalitions aligned and moving forward. They are imperfect but essential measures of the Campaign’s work. The movement of nurses leading change and advancing health is not easily reduced to numbers. But it was numbers that spurred the movement, numbers that the movement demands, and numbers that keep driving the Future of Nursing.
Sarah Hexem, JD is the Law and Policy Director for the National Nurse-led Care Consortium. Ms. Hexem directs a range of policy initiatives including: public health law research projects in partnership with the Centers for Disease Control and Prevention; federal and state policy advocacy supporting nurse-led care; and capacity-building for nurse-led medical legal partnerships. She also functions as the Executive Director of the Pennsylvania Action Coalition, an initiative endorsed by the Robert Wood Johnson Foundation and AARP, where she builds strategic partnerships to implement the Institute of Medicine’s 2010 Future of Nursing Report.
1. “The Future of Nursing: Leading Change, Advancing Health,” Institute of Medicine (2011), accessed November 12, 2016, http://www.nationalacademies.org/hmd/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health.aspx.
2. “G Transformational Models of Nursing Across Different Care Settings." Institute of Medicine (2011). The Future of Nursing: Leading Change, Advancing Health. Washington, DC: The National Academies Press, doi: 10.17226/12956.
3. “Assessing Progress on the IOM Report The Future of Nursing,” Institute of Medicine (2015), accessed November 12, 20116, https://www.nationalacademies.org/hmd/Reports/2015/Assessing-Progress-on-the-IOM-Report-The-Future-of-Nursing.aspx.
4. “Dashboard Indicators,” Campaign for Action, accessed November 12, 2016, http://campaignforaction.org/resource/dashboard-indicators/.