Introduction

The Third Report of the Pew Health Professions Commission, "Critical Challenges; Revitalizing the Health Professions for the Twenty-First Century" (1995), (the Report), describes a transformed U.S. health care industry characterized by systems of integrated care combining primary, specialty, and hospital services. Forecasting the success of such systems, the Report states that they will produce better management, more accountability and responsiveness, more effective use of resources, greater innovation and diversity in health delivery, more concern about education, prevention, and care management, a greater orientation towards improving the health of the entire population, and more reliance on outcomes data and evidence. While there may be differences of opinion with regard to the overall optimism of the forecast, various aspects of the Commission's predictions are already having an impact on all health professions, and a major impact on nursing.

The Pew Report highlighted four education and workforce issues of particular importance to all health professions. These were:

• Redesigning the health care workforce to make delivery systems more responsive to the demands of cost, patient satisfaction, and quality. The Commission stressed the need for health professionals to practice in community- and ambulatory- based settings and forecast the decline in dominance of the hospital as a training venue.
• Re-regulating the health education and practice environment with standardization among states, flexibility, accountability to the public, and the possibility of overlapping scopes of practice based on demonstrated competency.
• Rightsizing the professions with reductions in subsidies for education tied to care delivery rather than workforce needs, and restructuring training opportunities for foreign nationals. The latter should include changing immigration law to tighten the visa process, thereby ensuring that international [medical] students return to their native countries upon completion of training.
• Restructuring education so that educational institutions accommodate to the same dynamic, thereby altering the system of care. This means new structures of accountability and movement away from control by the professions through processes of censure and accreditation. This issue is of great concern to all the health professions (see following discussion of regulation). Several of these issues are implicit or explicit in the Commission's discipline specific recommendations.

The Pew Health Professions Commission (1995) made seven Specific Recommendations for Nursing. The Report deals with physicians, nurses, pharmacists, public health, and allied health professions. This paper focuses only on the challenges for nursing. These recommendations included:

• Educational Diversity: Recognize the value of the multiple entry points to professional practice available to nurses through preparation in associate, baccalaureate, and Master's programs; each is different, and each has important contributions to make to the changing health care system.
• Professional Titles: Consolidate the professional nomenclature so that there is a single title for each level of nursing preparation and service.
• Career Ladders: Distinguish between the practice responsibilities of different levels of nursing. Focus associate preparation on entry-level hospital setting and nursing home practice, baccalaureate on hospital-based care management and community-based practice, and Master's degree on specialty practice in the hospital and independent practice as a primary care provider. Strengthen existing career ladder programs in order to make movement through these levels of nursing as easy as possible.
• Education Programs: Reduce the size and number of nursing education programs by 10-20%. These closings should apply to associate and diploma degree programs and should pay attention to the reality that many areas have a shortage of educational programs and many more have a surplus.
• Training Programs: Encourage the expansion of the number of Master's level nurse practitioner training programs by increasing the level of federal support for students.
• Integration: Develop new models of integration between needs.

Rather than discussing these recommendations individually, I will group my comments into two categories related to nursing and four that relate to all health professions but have implications for nursing. The two categories related to nursing are manpower issues in terms of need and preparation and curriculum issues. The four categories relating to all health professions are the scientific base of educational programs, team training and cross-professional education, culturally sensitive care, and regulation issues.

Recommendations Relating to Nursing

Manpower Issues

The Report presages the loss of 200,000 to 300,000 hospital jobs in nursing with important but non-compensating gains in primary care settings. Nursing will be hardest hit by the restructuring of hospitals and subsequent substitution of non-licensed workers for nurses as care-givers. Many hospitals have brought in consulting firms who recommend downsizing the nursing population, eliminating the nursing hierarchical structure, and fostering previously failed techniques such as team nursing and hotel-like services. The Pew Report forecasts the closure of entire hospitals and perhaps as many as 60% of hospital beds, expansion of primary care, and surpluses of 100,000 to 150,000 physicians and 200,000 to 300,000 nurses. Predictions about personnel were based on closure of beds and movement of care to outpatient settings. The current restructuring and downsizing occurring are unrelated to these changes. Thus, it is difficult to attribute the chaotic situation of inpatient care today to systems of integrated care.

The Commission praised the efficiency of associate degree programs, but believed that they do not adequately address the opportunities and demands that the future holds for nursing. The Commission's recommendation about closing programs, with an emphasis on diploma and associate degree programs, is in keeping with current experience alluded to above.

Many hospitals have brought in consulting firms who recommend downsizing the nursing population, eliminating the nursing hierarchical structure, and fostering previously failed techniques such as team nursing and hotel-like services.

Should this action take place, the number of students as I stated, currently in associate degree programs would mandate an increase in baccalaureate programs. This is particularly true if there is a response to the Commission's other manpower recommendation -- i.e., an increase in Master's level practitioner programs.

As of 1994, there were 1,501 basic nursing programs. Of these, 509 were baccalaureate programs, 868 were associate degree programs, and 124 were diploma programs (National League for Nursing, 1996). Looking at the current pathways for registered nurse preparation, we can see that the Commission's recommendations will produce the same dilemmas for nursing as have previous recommendations for either closing associate degree programs or limiting their growth. The Commission's recommendation regarding closing programs is similar to others that have been largely ignored in the past. Further, market conditions in the past have been short lived; when demand dropped, student enrollment in all nursing programs was affected. In the past, there have not been careful, selective changes in nursing education programs. Now, the profession is challenged to be proactive in response to current market pressures and expected acceleration of these pressures.

The March 1996 National Sample Survey of Registered Nurses shows beginning changes in employment that match the predictions of the Commission (Division of Nursing, 1996). While there was a 3% increase in the number of RNs employed in the hospital setting between 1992 and 1996, it was restricted to outpatient and other types of services, such as labor and delivery rooms and surgical facilities, rather than inpatient bed units. Although RNs in inpatient bed units represented about half the nurses in hospitals in 1996, the number decreased 6% between 1992 and 1996. While this percentage is far short of the Commission's predictions, it is clear that marketplace changes are occurring in both numbers and modalities of work.

I have commented before that nursing's responses to short term problem trends have led to immediate solutions that have themselves created long-term problems (Fagin & Lynaugh, 1988). Proliferation of substandard schools and programs, and maintenance of such schools long beyond their necessity, are two examples of problems that contribute to the current dilemma. Again, nursing and educational institutions have an opportunity to respond to evidence supporting the movement of educational programs into the mainstream of higher education. This would mean the immediate planning for closure of all remaining hospital schools. Further, predictions of need pose implications for reducing the size of programs preparing for nursing practice at the prebaccalaureate level and increasing the capability of college and university programs. These are steps the profession can and must take. If these steps do not take place, problems for the future can be forecast now. Whenever market downturns have occurred in the past, applications to nursing programs have decreased dramatically. Given the increasing age of the working RN (more than 50% of employed RNs are over 40 years of age [Division of Nursing, 1996]), we can anticipate that such decreases would lead to a nursing shortage early in the 2000s. Further, there is no guarantee that the reduction in students will take place in the right type of schools. Should baccalaureate numbers decline, the resulting shortage will not be limited to first level positions in nursing; eventually the pool of qualified students for graduate level programs will be affected. This is clearly a challenge for the nursing profession.

The Commission's Report recommended the expansion of Master's level practitioner programs. In 1994, there were 276 Master's programs with 34,157 students enrolled; 26,181 of these students were enrolled in either nurse practitioner or advanced clinical practice programs (National League for Nursing, 1996). The Commission recommended increasing the level of federal support for students in these programs. There appears to be an increasing job market for Master's prepared nurse practitioners in managed care organizations, hospitals, and community health agencies in many specialty areas, including, but not limited to, geriatrics, family practice, women's health, pediatrics, and oncology. Clearly, the amount of support available for such students is vital in order to increase the numbers of students enrolled. Hospital benefit packages have been a major source of support for part-time study of nursing students at all levels. As these programs are reduced, there will be enormous ramifications for the Master's level student body. Further, neither baccalaureate nor Master's degree programs have ever received Medicare funding. Federal funding available for baccalaureate programs from Title VIII in 1994 totaled $10.4 million, as compared to Medicare funding of approximately $220 million for hospital-based diploma schools and a larger estimated amount for associate degree education funded by the Carl Perkins Act (Aiken & Gwyther, 1994). The Commission's recommendation for increasing the level of federal support for students is essential if we are to expand the number of advanced practice nurses.

Curriculum Issues

Next, I will comment on the specific curriculum recommendations for nursing. These recommendations include career ladders; care management, specialty practice, integration; and management role. The full recommendations appear at the beginning of this article.

Career Ladders. Schools of Nursing throughout the United States have been developing "articulation programs" for some years. RN student enrollment in basic baccalaureate programs increased by 10.7% between 1993 and 1994 (National League for Nursing, 1996). Some of these programs articulate directly between associate degree and baccalaureate levels; others have Master's programs designed specifically for associate degree graduates. Many schools started such programs when they were having difficulty recruiting more traditional students. Others started articulation programs because of pressure from states and localities. Still others started articulation programs because of strong philosophical views on the appropriateness of educational mobility.

The Commission recommended the reduction of numbers of associate degree programs for several reasons. First, these programs are preparing the largest number of RNs for an increasingly difficult market. In addition to reductions in hospital employment, there has been a reduced demand for associate degree graduates in hospitals. As the supply of nurses has become greater than the demand, hospitals are increasingly skeptical about the fit of the associate degree graduate with their needs.

Augmenting the knowledge and skills of associate degree and diploma graduates and preparing them for contemporary and future practice will require the strengthening of existing programs, and the development of new offerings. This is a major challenge.

Thus, positions that were once readily available are now scarce; recent associate degree graduates are experiencing difficulty finding the placements they desire -- or, in some localities, finding any nursing position. Those programs that have focused on partnerships with nursing homes have had considerable success, but nursing homes cannot or will not be a major employer for the large numbers being graduated from associate degree programs.

Programs for career mobility will be of increasing importance. Augmenting the knowledge and skills of associate degree and diploma graduates and preparing them for contemporary and future practice will require the strengthening of existing programs, and the development of new offerings. This is a major challenge. From the curriculum standpoint, however, the Commission's recommendation for "career ladders" should be easily met by educational programs.

Retooling the skills of current nurses so that they can respond to changes in the employment market is related to issues of manpower and curriculum. Nurses with experience and education in acute care hospital work may find themselves desiring retraining or at least reorientation to prepare them for ambulatory settings and community health. If the predictions of the Commission are correct, reduction in hospital beds will have major implications for the numbers of nurses needed for acute care. Keep in mind that there has been a cumulative real case-mix change in hospitals on the order of a 20% growth in complexity (Physicians Payment Review Commission, 1994). Unless hospital beds are markedly reduced and hospitals actually close, clinical nurse staffing may not be as reduced as the Commission prognosticates. Nonetheless, educational programs developed collaboratively by universities, nursing organizations, and employers that focus on community nursing, case management, patient/family management skills, and the like will be of great benefit to all aspects of health services. Such programs already exist in various parts of the country (Vasquez, 1997).

Care Management. The recommendation for preparing baccalaureate graduates for care management in hospitals and community health settings is a bit more complex. Baccalaureate programs have focused on community health in one way or another for decades. The curriculum strategy has changed from an integrated approach to community, in which community health is incorporated into all clinical nursing, to a curriculum focus that includes a separate course and clinical work. In 1994, the majority of basic baccalaureate programs offered both specific and integrated courses in community-based care. The pendulum appears to be swinging toward this approach, which is in keeping with the recommendations of the Commission.

The question of whether baccalaureate programs can focus on care management will depend on their definition of this term. If "care management" implies the management of care for an assigned group of patients, the role of the baccalaureate graduate is clear and should also include the direct care of many of these patients. That role can and should be encompassed and prepared for at the baccalaureate level. On the other hand, if the program planners interpret "care management" as meaning management of care without the direct care focus, both they and their students may be disappointed. Students interested in management without direct care have little reason to select nursing at the undergraduate level. Patients who have complex health problems will be more concerned abut the care expertise of the provider than their managerial competence. While hospitals and other employers may be interested in such a trend in the short term, patient care quality must prevail in the long term. Therefore, curriculum developers must approach this recommendation carefully and integrate the care management role as one aspect of the direct practice role.

Specialty Practice. Master's level programs already prepare for advanced practice in clinical specialties and in nurse practitioner roles. Fifty percent of students in Master's programs are focusing on clinical practice (Division of Nursing, 1996). Crucial factors here will be the kind and quality of faculty available for these programs and the clinical experiences of students. Faculty must themselves be expert practitioners and supervised clinical settings must be open to students. The availability of appropriate settings will be discussed further.

Integration. The recommendation for new models of integration between education and integrated systems of care will require that practice settings have intense interest in and a commitment to nursing education, even where there is some concern that adding students to the mix of providers will add costs. This is extremely important for both nursing and medicine. Some integrated systems are less interested in having students participate in their care settings then their forebears, who believed that education of health professional students added to their prestige and that quality and was their obligation. The presence of nurses in corporate roles, who are also involved in the nursing education program(s) and who believe in broad professional roles for nurses, will increase the possibility of achieving this objective. Educational programs that have reached some level of integration with practice settings -- e.g., share appointments of faculty clinicians who hold positions in both practice and education and sit on the boards of the health systems, will have greater success in working with integrated systems than will those programs whose faculty have remained separate from the practice arena.

Management Role. Given the immense changes we are seeing in health service delivery, the recommendation for recovering the clinical management role is extremely important. Indeed, while schools of nursing are rushing to add management to their curricula at all levels, many systems seem to be going in quite the opposite direction.

A recent report prepared for the Commonwealth Fund summarized past degree and continuing education initiatives to foster high level management preparation (Aiken, Gwyther, & Scalzi, 1997). In particular, the report focused on those programs that led to combined degrees in business and nursing. As of 1997, there are 54 MSN/MBA programs in the United States. Enrollment in these programs has been low, averaging 3.6 per program in 1996. Nonetheless, there is considerable interest in management courses as part of the general nursing curricula; in response to student and market pressure, many nursing programs have management content as part of their Master's, doctoral, and, in fewer cases, undergraduate curricula.

The question is how many of the programs reporting management content deal with clinical management vs. administrative management. The Commission recognizes the importance of clinical management of patient care at all levels, and considers each level to be responsible for an ever-expanding portfolio of patients and settings. Keeping the management concept clinical in the thinking of nurse educators will be crucial for the profession and will require careful planning of content and clinical experiences.

Recommendations For All Health Professionals

The recommendations relating to curricula for all health professions are as important as the specific recommendations for nursing. The Commission recommended that all health professionals increase the scientific base of their educational programs, provide opportunities for team training and cross-professional education for integrated systems, and continue commitment to diversity of the student body, as well as providing educational experiences that increase cultural sensitivity. Further, the Report highlighted four major issues that must be addressed. Three of these are inherent in the recommendations discussed above -- i.e., redesigning the health care workforce, rightsizing the professions, and restructuring education.

The Commission recommended that all health professionals increase the scientific base of their educational programs, provide opportunities for team training and cross-professional education for integrated systems, and continue commitment to diversity of the student body, as well as providing educational experiences that increase cultural sensitivity.

While it is not patently inherent in the recommendations for nursing, the issue of regulation is clearly implied and vital if professionals are to be able to practice in flexible roles.

Some of these recommendations have been pursued over the past thirty years with more or less success. While the time may be right for them now, my guess is that new strategies will have to be devised to increase success in areas where nursing has failed in the past. This applies specifically to the recommendation for team training and cross-professional education.

Scientific Base for Educational Programs

The Commission recommended that the scientific base of all health professions be increased to reflect the changing systems of care. This base should include psychosocial, population, and health management sciences.

Faculties must review this recommendation and determine whether they agree with it. If they agree with the Commission's view, curriculum planners in nursing schools will need to examine their current offerings and ascertain whether and where change is needed. Changing curricula, adding and removing courses, and meeting students" and accreditors" needs for quality are daunting tasks; changes in recent years have already put great burdens on faculty and students. Concerns about nursing competence in various areas such as pharmacology and pathophysiology have suggested the necessity of greater depth of learning in the biological sciences. It is important that curriculum change to accommodate the needs of integrated, managed systems of care do not displace other important areas.

Team Training and Cross Professional Education

Team training and cross professional training have been a part of nursing and other health professional programs for at least thirty years. This history shows episodic spurts of interest but little evidence of prolonged success. Even where funding has been made available to encourage interdisciplinary education, efforts have not been extremely successful. This recommendation also mentions the sharing of clinical training resources, an especially difficult objective. As more and more education occurs in the ambulatory setting, space and finances may dictate a diminution rather than an increase in such possibilities. Accomplishing this recommendation will require work with both educational and practice settings. Schools of nursing will need the help of their administrations and of interested private and governmental bodies to move forward successfully.

It is interesting to note that the AACN ISSUE BULLETIN (July 1997) reported that interdisciplinary education is gaining ground. Offering many examples from nursing schools across the nation, the BULLETIN pointed to a range of collaborative educational experiences, including joint faculty appointments, participation in neighborhood health projects, work in nursing homes, including architectural design and wound co-healing where nursing faculty work with faculty in Biomedical Engineering, and many examples of interdisciplinary education in both undergraduate and graduate programs. These offerings include electives and required courses. The report in this issue bodes well for the Pew Commission's recommendations.

Culturally Sensitive Care

The Commission urges all schools to continue their commitments to ensuring the diversity of student bodies. In general, nursing schools have heeded earlier recommendations dealing with cultural diversity in their student bodies. These efforts have had modest success in the past two decades, and increases in numbers continue. Between 1993 and 1994, for example, there were small increases in percentages of blacks, hispanic, and asian students enrolled in nursing programs; there has also been a steady increase in the percentage of men graduating from nursing programs. Master's programs also experienced an increase in black, hispanic, and asian students between 1993 and 1994 (National League for Nursing, 1996).

The issue of whether curriculum content deals successfully with cultural diversity is somewhat more complex. This issue has been discussed widely and a variety of initiatives have been developed and implemented -- e.g., specific courses, integration of content in existing courses, training opportunities for faculty through seminars, sensitivity training, workshops, and retreats, conferences for internal and external audiences, and cross-university classes and courses. Examination of these initiatives and of curricula that have been successful in producing graduates with the requisite content to deal successfully with the diverse American and world populations would be two ways of meeting the objectives for change or improvement. It might be useful to share such information at meetings and through accreditation materials.

Regulatory Change

The Pew Health Professions Commission did not deal directly with specifics of regulatory change. Rather, another committee studied this issue and formulated specific recommendations. The Commission discussed and debated the regulation issue and agreed on general directions. The Report highlights necessary reforms in regulations that include standardization, public accountability, flexibility, effectiveness, and efficiency.

The concerns of the Commission in the regulation area were the inhibition of consumer access to health care services, restriction of practitioners to practice, and demonstration of continued competency.

The concerns of the Commission in the regulation area were the inhibition of consumer access to health care services, restriction of practitioners to practice, and demonstration of continued competency. Further, in some disciplines, the absence of public members of regulatory bodies limits the accountability of the professional group to the public it serves -- particularly in areas of complaint and discipline.

Nursing groups' negative reactions to the recommendations for change in the regulatory area were caused by concerns about the loss of professional control (mentioned earlier as one of the Report's issues "of major importance"), the threat of "institutional licensure," and the possibility of permitting lesser prepared workers to perform nursing roles. These are legitimate concerns. The Commission members were reminded, however, that nursing is very eager to have inhibitions on its own practice removed and that, state by state, the profession has been fighting restrictive licensing rules affecting advanced nursing practice and the direct access of consumers to nurse practitioners. Thus, it is important to recognize that in our quest for expanded scopes of practice we must also be sensitive to the possible double standard of our arguments.

Summary and Conclusions

The Third Report of the Pew Health Professions Commission, "Critical Challenges: Revitalizing the Health Professions for the Twenty-First Century" (1995), describes a transformed U.S. health care industry with emerging systems of integrated care that combine primary, specialty, and hospital services. Forecasting the success of such systems, the Report states that they will produce: better management, accountability, and responsiveness; more effective use of resources; more innovation and diversity in health delivery; more inclusivity in definitions of health; more concern about education, prevention, and care management, rather than treatment; a greater orientation towards improving the health of the entire population; more reliance on outcomes data and evidence. The Report predicts that these changes will cause closure of as many as half of the nation's hospitals, expansion of primary care, surpluses in the supply of physicians, nurses, and pharmacists, consolidation of allied health professions, and demand for public health professionals. The Commission's seven recommendations for nursing call for: maximizing opportunities presented by the profession's educational diversity; consolidation of professional nomenclature; distinguishing between practice responsibilities at different levels and strengthening career ladders; downsizing nursing education programs -- particularly diploma and associate degree programs; expanding Master's level practitioner programs; developing new models of integration between education and systems of health care; "recovering" the clinical management role of nursing.

I have grouped the discussion of these recommendations into two areas -- i.e., manpower and curriculum. I have also dealt with issues highlighted by the Commission that apply to all health professionals, and have looked at their implications for nursing.

Nursing has a good record of responding to mandates for change. The current changes in health delivery should cause us to re-examine our present and future. This examination and subsequent actions must take into account the clear and central focus of the profession -- i.e., how we prepare our graduates to deliver quality patient care. Any response to the Commission's recommendations must be accompanied by having nursing educators assume leadership in the overarching scene of health care, encouraging and conducting research on effects of changing practices on patient care, publicizing the results of this research, and changing local and national policies.

Author

Claire Fagin, PhD, RN, FAAN
E-mail: Fagin@mail.med.upenn.edu

Claire Fagin PhD., R.N. served on the Third Pew Commission on the Health Professions. Presently she is the Leadership Professor Emeritus and Dean Emerita of the University of Pennsylvania School of Nursing, and is a Consultant in Organizational Leadership. She has been involved in nursing education for more than thirty years, and has taught and administered programs at baccalaureate, master's, and doctoral levels. Her interest in nursing practice stemmed from both her involvement in psychiatric nursing and primary care. She has worked on integrating education and practice as part of her educational positions. Always active in the intersection of nursing and consumer issues, Dr. Fagin is currently working on patient care issues created by the cost focus of the health care system.

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