1. Changing Demographics and
Population shifts in the United States have affected health care
priorities as well as the practice of nursing. Due to advances in
public health and clinical care, the average life span is increasing
rapidly. By 2020, more than 20 percent of the population will be
65 and older, with those over 85 constituting the fastest growing
Greater life expectancy of individuals with chronic and acute conditions
will challenge the health care system's ability to provide efficient
and effective continuing care. Significant increases in the diversity
of the population affect the nature and the prevalence of illness
and disease, requiring changes in practice that reflect and respect
diverse values and beliefs. Disparities in morbidity, mortality,
and access to care among population sectors have increased, even
as socioeconomic and other factors have led to increased violence
and substance abuse. Nursing practice, education, and research must
embrace and respond to these changing demographics, and nurses must
focus on spiritual health, as well as the physical and psychosocial
health of the population.
Student demographics are also changing. Ethnic and racial diversity
of nursing schools has increased dramatically, creating a rich cultural
environment for learning. Students are entering schools of nursing
at an older age and are bringing varying college and work experiences,
as well as more sophisticated expectations for their education.
They are typically employed in full-time careers, and many are raising
families, which places constraints on their educational experiences
and necessitates greater flexibility in scheduling.
Schools of nursing must be prepared to confront the challenges associated
with today's more mature student body, and educational methods and
policies, curriculum and case materials, clinical practice settings,
and research priorities need to value and reflect the diversity
of the student body, as well as the population in general. At the
same time, schools must focus recruitment efforts on the more traditional,
2. The Technological Explosion
The rapid growth in information technology has already had a radical
impact on health care delivery and the education of nurses. Advances
in processing capacity and speed, the development of interactive
user interfaces, developments in image storage and transfer technology,
changes in telecommunications technology, and the increased affordability
of personal computers have contributed to the explosion of information
technology applications. Advances in digital technology have increased
the applications of telehealth and telemedicine, bringing together
patient and provider without physical proximity. Nanotechnology
will introduce new forms of clinical diagnosis and treatment by
means of inexpensive handheld biosensors capable of detecting a
wide range of diseases from miniscule body specimens.
Dramatic improvements in the accessibility of clinical data across
settings and time have improved both outcomes and care management.
The electronic medical record will replace traditional documentation
systems. Through the Internet, consumers will be increasingly armed
with information previously available only to clinicians. Electronic
commerce will become routine for transacting health care services
Nurses of the 21st century need to be skilled in the use of computer
technology. Already, distance learning modalities link students
and faculty from different locales and expand the potential for
accessible continuing professional education. Technically sophisticated
preclinical simulation laboratories will stimulate critical thinking
and skill acquisition in a safe and user-friendly environment. Faster
and more flexible access to data and new means of observation and
communication are having an impact on how nursing research is conducted.
3. Globalization of the World's
Economy and Society
Globalization has been brought about by many factors, including
advances in information technology and communications, international
travel and commerce, the growth of multinational corporations, the
fall of communism in Eastern Europe and the Soviet Union, and major
political changes in Africa and Asia. With the "death of distance"
in the spread of disease and the delivery of health care, there
are both extraordinary risks and extraordinary benefits. Along with
the potential for rapid disease transmission, there is potential
for dramatic improvements in health due to knowledge transfer between
cultures and health care systems.
Nursing science needs to address health care issues, such as emerging
and reemerging infections, that result from globalization. Nursing
education and research must become more internationally focused
to disseminate information and benefit from the multicultural experience.
4. The Era of the Educated Consumer,
Alternative Therapies and Genomics, and Palliative Care.
The Educated Consumer Despite some information gaps, today's patient
is a well-informed consumer who expects to participate in decisions
affecting personal and family health care. With advances in information
technology and quality measurement, previously unavailable information
is now public information, and consumers are asked to play a more
active role in health care decision making and management. The media
and the Internet have facilitated this trend.
Technological advances in the treatment of disease have led to the
need for ethical, informed decision making by patients and families.
Consumers are thus becoming more interested and knowledgeable about
health promotion as well as disease prevention, and there is increased
acceptance and demand for alternative and complementary health options.
The increased power of the consumer in the patient-provider relationship
creates a heightened demand for more sophisticated health education
techniques and greater levels of participation by patients in clinical
decisions. Nurses must be prepared to understand this changed relationship
and be skilled in helping patients and families maximize opportunities
to manage their health.
Alternative Therapies and Genomics Amazing growth is taking place
at opposing ends of the technological spectrum. The impact of the
Human Genome Project and related genetic and cloning research is
unparalleled. Gene mapping will drive rapid advances in the development
of new drugs and the treatment and prevention of disease. Technological
sophistication of the highest order is required for this research,
which has the potential to lead to unparalleled ethical questions
and conflicts while bringing about critical diagnostic and therapeutic
At the low-tech end of the spectrum, the voracious demand by consumers
for "alternative" or "complementary" therapies
to enhance health and healing has begun to influence mainstream
health care delivery. Several academic medical centers now have
offices of alternative medicine, and the National Institutes of
Health recently funded new initiatives dedicated to this field.
Increasingly, major health systems are seeking ways to provide both
traditional, Western medicine while offering the best of the alternative
therapies to their patients.
As is true for many trends, alternative medicine holds both promise
and peril. While it is thought that it may unlock behavioral and
spiritual components of health and healing heretofore resistant
to most conventional medicine, risks of consumer fraud, therapeutic
conflict, and patient noncompliance are real. Nursing research has
the potential to enhance knowledge regarding what constitutes a
"healing" therapy. Nursing education and practice must
expand to include the implications of the emerging therapies from
both genetic research and alternative medicine, while managing ethical
conflicts and questions. The inclusion of nontraditional health
care providers may augment the health care team.
Palliative and End-of-Life Care Technological advancements in the
treatment of illness and disease have created new modalities that
extend life while challenging traditional ethical and societal values
regarding death and dying. Greater recognition of the need to ensure
comfort and promote dignity is reflected in the now nearly universal
promotion of advanced directives, organ donation, and palliative
care for the terminally ill. New settings for care, such as inpatient
and home-based hospice, and new forms of care, including pain management,
spiritual practices, and support groups and bereavement counseling,
are now likely to be part of well-developed health care systems.
A significant gap in the body of scientific knowledge and clinical
education with regard to palliative and end-of-life care remains,
and nursing education must prepare graduates for a significant role
in these areas.
5. Shift to Population-Based
Care and the Increasing Complexity of Patient Care
Rising costs and an aging population have led to new settings and
systems of care across the health care continuum. Managed care and
risk-based contracting mechanisms have forced a shift from episodic
care with an acute orientation to care management with a focus on
The marriage of care with cost requires nursing professionals to
have an understanding of practice methods that improve quality,
respond to clinical complexity, and lower costs. Patients in inpatient
settings are increasingly more acutely ill; the standard ratio of
critical care/specialty beds to general use beds in hospitals today
is close to 1:1, up substantially from a decade ago. Furthermore,
expanded life expectancy has led to increases in the number, severity,
and duration of chronic conditions, thereby increasing the complexity
of the care provided and managed by clinicians. The community has
largely become the setting for chronic disease management and prevention.
Providing services for defined groups "covered" by managed
care will demand skills and knowledge in clinical epidemiology,
biostatistics, behavioral science, and their application to specific
populations. Nurses must demonstrate management skills at both the
organizational and patient care levels. These concepts must be incorporated
into the nursing curriculum.
6. The Cost of Health Care and
the Challenge of Managed Care
Cost of Health Care A concern of businesses and governments for
at least 30 years, the cost of health care in the United States
has approached 15 percent of the total gross national product. Thus,
individuals have joined the debate about health care costs. Despite
the fact that more than 40 million Americans lack health care insurance
coverage, and certain health indices lag by a wide margin behind
those of other societies, total health care spending in this country
significantly outstrips that of other developed countries. Many
reasons have been suggested, including the advanced technology available
to virtually all residents through academic medical centers, the
scientific and technologic infrastructure that has led to most of
the diagnostic and therapeutic breakthroughs in medicine, cultural
norms regarding aging and end-of-life, the cost of violence and
drug addiction, and the growing economic and health disparity between
segments of the population.
Concerns about cost have led to the popularity of managed care options,
first by corporations for their employees and now by governments,
through the Medicare and Medicaid programs. Despite recent federal
budget surpluses and proposals to expand funding and benefits in
Medicare, there is serious concern among economists, legislators,
and bureaucrats about the long-term solvency of both publicly funded
Concerns about cost are present in every form of nursing practice;
they affect how work is organized, treatment plans for patients,
and patients' perceptions of and participation in care. For example,
even individuals with health insurance are wary of increased out-of-pocket
expenses and noncovered services. And there is heightened concern
about pharmaceutical costs, fueled, in part, by the development
of sophisticated new drugs.
Managed Care and Reimbursement Challenges Within both the public
and private sectors, managed care is quickly becoming the dominant
reimbursement mechanism for health care providers, bringing both
opportunities and problems. Despite the promise for flexible financing
that managed care risk was thought to offer, provider contracts
are still based on fees for service, reducing the incentives to
truly manage care, prevent illness, and promote health. Nursing
professionals, who have historically taken the lead in health education
and health promotion, are disappointed by the lack of financing
and reimbursement available through managed care organizations for
these vital services. However, advanced practice nurses - nurse
practitioners and case managers in particular - have benefited greatly
by the managed care movement. Demand for these lower cost providers
has dramatically increased, and their competence and quality in
the primary care field have been acknowledged.
APNs still confront barriers to direct reimbursement from managed
care organizations that lack the knowledge and political will to
challenge the traditional medical model. Across the country, nurse
practitioners are deterred from being credentialed on provider panels.
More research is needed to demonstrate the value to the health care
delivery system, as well as the cost effectiveness, of health education,
health promotion, and advanced nursing practice. Nursing education
programs must prepare students at all levels for roles in case management
and employment in the managed care environment.
7. Impact of Health Policy and
The impact of federal and state health policy and regulation on
the practice of nursing cannot be ignored. Issues surrounding health
care are often complex, involving the fields of medicine and economics,
and affecting individuals' rights as well as access to health care.
Consumers are concerned about quality, and corporations and individual
providers are concerned about economic survival.
Two major trends will have a significant impact on health care delivery.
First, there will be an increase in state and federal regulation
as costs rise and managed care continues to expand. Along with regulation,
there will be attempts to shift to less expensive settings and apply
market forces to restrain costs.
Second, shared responsibility for the Medicaid program and the shift
to managed care has resulted in an increased oversight role for
the states. States must define, measure, and assess quality, and
serve as contractors for corporate entities while enforcing accountability
of managed care organizations. Both new regulation and devolution
have serious implications for health care delivery and the practice
of nursing. Historically, nursing's influence on policy and regulation
has been disproportionately low relative to the breadth of nursing
practice and its importance within the health care delivery system.
Nursing schools, scholars, executives, and professional nursing
organizations must more actively contribute to the development of
health policy and regulation. Ethical issues involved in working
in an integrated system constrained by economic incentives are being
defined more and more by government policy makers, not health care
professionals. Nursing leaders should contribute to the dialogue
that defines these issues; students must be prepared for a meaningful
role in the political arena.
8. The Growing Need for Interdisciplinary
Education for Collaborative Practice
A wide range of knowledge and skills is required to effectively
and efficiently manage the comprehensive needs of patients and populations.
The health care delivery system of the future will rely on teams
of nurses, nurse practitioners, physicians, dentists, social workers,
pharmacists, and other providers to work together. While interdisciplinary
and collaborative practice is still not the norm, there has been
a heightened awareness of the need for coordinated care and a significant
increase in the use of midlevel providers, such as APNs, as part
of the primary care team.
With care management a critical component in health care delivery,
nurses must demonstrate leadership and competence in interdisciplinary
and collaborative practice for continuous quality improvement. Team-based,
interdisciplinary approaches have been shown to be highly effective
for improving clinical outcomes and reducing cost. Teaching methods
that incorporate opportunities for interdisciplinary education and
collaborative practice are required to prepare nurses for their
unique professional role and to understand the role of other disciplines
in the care of patients.
9. The Current Nursing Shortage/Opportunities
for Lifelong Learning and Workforce Development
Nursing shortages have a negative impact on patient care and are
costly to the health care industry. A significant nursing shortage
exists today, particularly in acute and long-term care settings.
It results from many factors. For example, nurses of the "baby
boom" generation are beginning to retire; women today have
numerous career opportunities; and there is a lingering perception
of nursing as a "trade," versus a "profession,"
which contributes to the lack of new individuals entering the field.
As the age of entering students rises, the number of years of practice
decreases, also affecting supply. While the number of male and minority
students has been steadily rising, their ranks are still underrepresented.
The current shortage is judged to be deeper than past shortages
and probably more resistant to short-term economic strategies that
have worked before. However, as in the past, the current shortage
will almost certainly raise salaries and increase flexibility for
nurses. Other recent advances in the profession and the health care
industry are likely to have a positive impact on recruitment. These
include the opportunity to practice in a variety of clinical settings;
the dramatic increase in opportunities for APNs; new careers in
care management and case management; and the interest of biotechnology,
information technology, and pharmaceutical companies in hiring skilled
nursing professionals. Nursing education must partner with the health
care industry to develop innovative short- and long-term solutions
that address the nursing shortage, including aggressive student
recruitment and the initiation of an intense media/marketing campaign.
The public image of the nursing role must be revitalized to change
The need for more sophisticated nursing management and leadership
to respond to the clinical, organizational, and fiscal challenges
faced by the health care industry has not gone unrecognized. Nurse
managers and executives require clinical experience and strong communication
skills, as well as business acumen and knowledge of financial and
personnel management, organizational theory, and negotiation. With
the nursing labor budget constituting a significant proportion of
total spending, and cost overruns, in acute care hospitals, long-term
care facilities, and home care agencies, nursing management is too
often found to be lacking in fundamental decision science and fiscal
knowledge. A great need exists for educational support for experienced
nurses to be developed into nurse executives, prepared to work competently
alongside their business colleagues. Nursing schools are called
on to expand their core and continuing education programs to address
Rapidly evolving technology, increasing clinical complexity in many
patient care settings, advances in treatment, and the emergence
of new diseases are all factors contributing to the increased need
for a strong emphasis on critical thinking and lifelong learning
among professional nurses. Further, new clinical roles, the need
for managerial and executive talent, the imperative to retain nurses
in active practice over longer careers, and the desire by practicing
nurses to move up the economic ladder lead to the demand for continuing
education and career mobility and development. Schools of nursing
have many of the core resources needed to deliver continuing professional
education and can provide appropriate courses efficiently and effectively.
Affiliation with schools by nurses in active practice may lead to
an increase in enrollment for advanced degrees. Health care and
health-related organizations may serve as institutional partners
in sponsoring such program offerings, which would contribute to
their relevance, increase participation, and lower costs.
10. Significant Advances in
Nursing Science and Research
Nursing research is an integral part of the scientific enterprise
of improving the nation's health. The growing body of nursing research
provides a scientific basis for patient care and should be regularly
used by the nation's 2.5 million nurses. Most studies concern health
behaviors, symptom management, and the improvement of patients'
and families' experiences with illness, treatment, and disease prevention.
Research is conducted to improve patient outcomes and promote the
health and well-being of communities, especially of the most vulnerable
Nursing research and scholarship has received significant funding
by public and private agencies in the last decade and is increasingly
recognized as an independent body of knowledge. However, the challenges
associated with advancing the research agenda in nursing are complex
and varied. Schools of nursing are not sufficiently focused on the
scholarship and science of nursing as top priorities, and, although
graduate degrees in nursing have become more common, doctorally
prepared nursing professionals are not being produced in large enough
numbers to meet the growing need. In addition, there is a need for
enhanced mentorship for new researchers to strengthen skills and
capacity to conduct meaningful nursing research. Significant opportunities
exist for schools of nursing, especially those affiliated with academic
health centers, to address these challenges and enhance the research
contributions of nursing scholars.
At the dawn of the 21st century and the long-awaited new millennium,
nurse educators face a rapidly changing health care landscape, shifting
student and patient demographics, an explosion of technology, and
the globalization of health care, in addition to a myriad of everyday
challenges. As we position ourselves to meet today's challenges
and tomorrow's, we must understand the drivers affecting nursing.
To quote Peter Drucker in Managing for the Future, "It is not
necessary to be clairvoyant to know the future; it is only necessary
to clearly interpret what has already happened and then project
forward the likely consequences of those happenings" (Truman
Talley Books, 1992).
About the Authors Barbara R. Heller, EdD, RN, FAAN, is dean and
professor at the School of Nursing, University of Maryland, Baltimore.
She is serving her second term as a member of the National League
for Nursing Board of Governors. Marla T. Oros, MS, RN, is assistant
dean for clinical practices and services, School of Nursing, University
of Maryland. Jane Durney-Crowley, MHA, RN,.a member of the Board
of Visitors, School of Nursing, University of Maryland, is Executive
Vice President, Operations and Culture, Catholic Healthcare Partners,
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