If you could envision a preferred future for registered nurses (RNs), what would that look like? Would you want an RN’s voice heard, honored, and considered essential at every healthcare decision-making table? Would you want every RN energized to begin work each day; to experience a continuous journey of professional growth and improvement; to be acknowledged and recognized appropriately for their optimal contribution? Have you pondered how this preferred future could be realized?
When the Institute of Medicine’s original report on the future of nursing was released (IOM, 2011), it outlined a future full of opportunity and with the challenge for all nurses to practice to the full extent of their education and scope. Over the last several decades, much has occurred to elevate the practice and value of the RN. Patient needs have become more complex and quality and patient safety are now the front and center of reimbursement and regulatory landscapes. Nurses have adapted to these changes by expanding their skill sets and knowledge of science, securing their places as linchpins to provision of improved health outcomes in the era of healthcare reform (IOM, 2011).
Still, there is much to be done. Experts agree that the ability of RNs to practice to the fullest extent of their education and scope has not yet been achieved in most healthcare settings (IOM, 2015). In response to this problem, the American Nurses Association (ANA) established a Professional Issues Panel—the Barriers to RN Scope of Practice Panel (Panel)—to explore factors that both promote and inhibit nurses ability to practice to the top of their licensure. The Panel was established as a think tank to create an environment for RNs to consider and identify some barriers to RNs’ ability to practice to the full extent of their education, experience, and scope of practice.
Five of the six introductory articles in this OJIN topic are based on the work of the ANA panel and written by members of the panel steering committee. These articles include evidence-based recommendations to address some of the barriers identified by the panel that prevent RN practice to the full extent of education and scope. The first four articles are organized in this OJIN topic based on key roles of RNs that emerged from the panel work and demonstrate RN value to the healthcare delivery system: RN as professional, RN as advocate, RN as innovator, and RN as collaborative leader. The fifth article provides an executive summary of the panel work. The sixth article discusses a research study that considered several variables important to full scope of practice, such as nurse educational level and organizational factors.
The first article, “Registered Nurses as Professionals: Accountability for Education and Practice,” focuses on several key messages. Authors Zittel, O’Sullivan, Siek and Moss write that to ensure the highest possible patient outcomes, preparation of RNs at the BSN level is essential. This can be accomplished either through initial education or through educational progression. To achieve this, individuals, organizations, policy makers, and educators must make policy decisions based on this core message. Seamless academic progression models must be developed to support nurses educational advancement (BSN or higher). This article also focuses on individual level nurse responsibility to practice at the fullest extent of scope of practice and remain accountable for their own educational progression. The article considers timing related to achieving specialty certification and recommendations for basic nursing education and continuing education content related to scope of practice, standards, and competencies, and for individual RN responsibility to obtain a BSN degree upon entrance to the nursing profession. To achieve this goal, it will be critical for academia and practice environments to provide appropriate mentoring and guidance toward that goal.
The second article, “Registered Nurses as Caregivers: Influencing the System as Patient Advocates,” outlines multiple steps at the stakeholder level to support the RN. It includes forward thinking suggestions for organizations to adopt a model of privileging and credentialing RNs and comprehensive methods to assess nurse competency. Authors Lucatorto, Thomas, and Siek also recommend that organizations maximize the use of nurse-initiated protocols in concert with specific, validated nurse competencies. The article proposes academic and practice setting collaboration to define, research, validate, and measure the evaluation of nursing care and use these data to expand comprehensive nurse quality indicators. Lastly, the article challenges nurses to engage in measuring the effectiveness of nursing care and articulate the value they add to patient care. The article challenges hospitals and healthcare systems to evaluate available data and make data-based decisions to determine and quantify the value of the RN.
The article entitled “Registered Nurses Leading Innovative Changes,” considers strategies to position nurses in all roles and settings to drive innovative changes in policy and procedures. The purpose of these changes is to advance the National Quality Strategy (U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality, 2016) and the goals of the Institute for Healthcare Improvement (n.d.) Triple Aim. Authors Thomas, Seifert, and Joyner describe the concept of innovation and examine ways that nurses are creating new knowledge through innovations in areas such as primary care, quality improvement, healthcare policy, health information technology, simulation training, and delegation. The authors describe efforts to create environments that foster innovation and consider characteristics and attributes of nurses who score higher on an innovation scale. They also discuss skillsets that may play an important role is nurse innovation, including leadership skills, self-awareness, resilience, financial management skills, and critical thinking skills. The article concludes with a series of recommendations to empower all nurses to lead innovation and encourage nurse managers and nurse leaders to create environments where innovation can thrive.
Article four, “Registered Nurses as Interprofessional Collaborative Partners: Creating Value-Based Outcomes,” describes programs to maximize RN contribution and minimize barriers to practice, including transition programs, nurse residencies, student nurse externships, preceptorship, and the creation of healthy work environments for RNs. Moss, Seifert, Lucatorto and O’Sullivan identify recommendations to advance nurse-led initiatives in culturally competent care; describe recommendations to create and foster interprofessional environments; and highlight evidence-based programs to support RN transition-to-practice environments. The authors suggest specific recommendations related to the required minimum level of education for preceptors; development and evaluation of transition programs; and partnerships for academic and practice environments for development of collaborative interdisciplinary practice models. They also highlight the importance of culturally competent care and a nursing workforce that reflects the community being served.
The fifth article related to the effort of the panel, “Registered Nurses as Professionals, Advocates, Innovators, and Collaborative Leaders: Executive Summary,” offers a synthesis of the panel work process, findings, and recommendations. Panel members, led by Williams and Baker, work together to describe their methodology, succinctly recapitulate the four role definitions and recommendations that emerged from their effort and offer recommendations for RNs at the individual level to remove barriers and practice to the full extent of their scope. The authors conclude with considerations for future work.
The final article, “Enhancing Patient Safety: Factors Influencing Medical Error Recovery among Medical-Surgical Nurses,” presents a view on RN scope of practice external to the work of the panel. Authors Gaffney, Hatcher, Milligan and Trickey have conducted research that examined the potential relationships between nurse characteristics, organizational factors, and recovery of medical errors among medical-surgical nurses in hospitals. Several variables in their study, such as educational level and organizational policy, were also found important by the members of the ANA panel. The study authors suggest that improving patient safety within the healthcare system requires nurses who are able to fully use their education, and expertise.
Acknowledging change is incredibly difficult. Because change is difficult, nurses must create a guiding vision, take incremental steps toward that vision, and not lose heart when faced with obstacles. Nurses must embrace revolutionary ideas that are implemented in an evolutionary manner. Nurses must not forget that they are part of a community of care providers and may need to help others embrace this vision and their role in actualizing it. Through that process, nurses can eliminate limits and barriers to their current practice and deliver on the promise of their potential.
If a future is created where nurses practice to the full extent of their education and scope, the entire healthcare delivery system will benefit. In the opinion of the panel members, there are many significant potential outcomes to such an effort. The healthcare delivery team will be fueled by mutual respect and an improved sense of interdisciplinary collaboration. Financial stewardship will be achieved by implementing proactive strategies to attain high-value patient outcomes as opposed to reactive mitigation of system inefficiency. Nurses will have a high level of job satisfaction that can translate to improved care of the patient at the bedside.
Recommendations set forth in these OJIN articles demonstrate that this preferred future is within our power to achieve. The journal editors invite you to share your response to this OJIN topic addressing Barriers to RN Scope of Practice either by writing a Letter to the Editor or by submitting a manuscript which will further the discussion of this topic which has been initiated by these introductory articles.
Portions of the research for this article were performed by an American Nurses Association (ANA) Professional Issues Panel entitled “Barriers to RN Scope of Practice.” The panel was composed of volunteers from a variety of nursing backgrounds who contributed through participation on the Panel’s Steering Committee and Advisory Committee. While the articles were generated by authors participating in a Professional Issues Panel convened by ANA, the conclusions and recommendations articulated by any author do not necessarily reflect those of the Association.
Kathy Baker, PhD, RN, NE-BC
Tracy E. Williams, DNP, RN, FNAP
Institute of Medicine (2011). The future of nursing leading change, advancing health. Washington, DC: National Academy Press.
Institute for Health Care Improvement. (n.d.). The Triple Aim. Retrieved from http://www.ihi.org/engage/initiatives/tripleaim/pages/default.aspx.
Institute of Medicine. (2015). Assessing progress on the Institute of Medicine report: The future of nursing. Washington, DC: National Academy Press.
U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality. (2016). 2015 national healthcare quality and disparities report and 5th anniversary update on the national quality strategy. Rockville, MD: Agency for Healthcare Research and Quality; AHRQ Pub. No. 16-0015. Retrieved from http://www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/nhqdr15/2015nhqdr.pdf