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May 18, 2021

Expand Nurses’ Scope of Practice, Strengthen Nursing Education to Advance Health Equity, Report Advises

Author Affiliations
  • 1Consulting Editor, JAMA Health Forum and JAMA
JAMA Health Forum. 2021;2(5):e211527. doi:10.1001/jamahealthforum.2021.1527

A new report from the National Academy of Medicine says that strengthening the nursing profession in several areas over the next decade—including lifting scope-of-practice barriers and expanding nursing education—is needed to promote health equity, develop a skilled and diverse nursing workforce, and protect nurses’ health and well-being.

As a group, the nearly 4 million nurses in the United States comprise the largest component of the nation’s health care workforce. Meeting the demands that nurses will increasingly face, such as caring for an aging population, helping to shape policies aimed at breaking down structural racism and addressing social determinants of health, and responding to an increase in mental and behavioral health conditions, will require significant increases in the number, types, and distribution of nurses across not only geographic areas, but also across specialties and care settings, the report notes.

“This is a transformational time for the field of nursing. While the pandemic has changed nearly every aspect of health care, the impacts on nursing may be the most profound, as demand for their skills is at an all-time high,” said Mary Wakefield, PhD, RN, visiting professor at Georgetown University and at the University of Texas at Austin and co-chair of the committee that wrote the report, in a statement.

During the COVID-19 pandemic, increased demands on health care systems prompted some states to waive or ease restrictions on the care nurses can deliver under their licenses. One of the report’s chief recommendations is to lift scope-of-practice barriers and make these changes permanent.

As of January 2021, 23 states and the District of Columbia allow full practice authority for nurse practitioners, which permits them to prescribe medication, diagnose patients, and provide treatment without a physician present. However, physician oversight is required in 16 states for prescribing medication and in 11 states for all aspects of practice.

The committee that developed the report recommends that 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 [advanced practice registered nurses (APRNs)] and RNs should be made permanent.”

The group also urges state and local governments to provide more funding for school and public health nurses, noting that although a school nurse may be the only health professional some students see regularly, about 25% of schools lack a school nurse and that school nursing is inadequately funded, especially in schools attended by children in low-income homes.

National nursing organizations, led by the Tri-Council for Nursing and the Council of Public Health Nursing Organizations, should work to develop a shared agenda for addressing social determinants of health and achieving health equity by the end of 2021, the committee advises. Upon the development of such an agenda, government agencies, health care and public health organizations, payers, and foundations should take action to ensure that nurses have the resources and support “to address social determinants of health and health equity more comprehensively, regardless of practice setting.”

Strengthening nursing education is essential to equip future nurses to address these challenges, the report says, noting that nursing education programs have historically emphasized training for care in hospitals rather than in other settings in the community, including schools, workplaces, and home health care. To train future nurses, schools of nursing should provide substantive education in community and primary care settings, as well as in rural health clinics and Indian Health Service sites—and also provide nursing students with training that will help them adapt to use of technologies such as telehealth, digital health tools, and data analytics, the report says.

Noting that current nursing program faculty are overwhelmingly white and female, the committee emphasizes that building a diverse nursing workforce is a critical element in preparing nurses to address social determinants of health and health equity. Although the nursing workforce has steadily grown more diverse, the group urges nursing schools “to continue and expand their efforts to recruit, support, and mentor diverse students.”

Increasing the number of nurses with bachelor’s and doctoral degrees is another priority cited in the report, with PhD-prepared nurses needed to conduct research aimed at improving clinical and community health, as well as to educate the next generation of nurses. Boosting the number of nurses with a focus on social determinants of health and in certain specialties with existing shortages, including behavioral health, geriatrics, long-term care, maternal health, primary care, and public and community health, is also essential to build the workforce needed in the years ahead.

The COVID-19 pandemic has intensified the demands on nurses, and reports of burnout and mental health stresses among front-line health workers during the COVID-19 pandemic underscore the need to protect nurses’ health and well-being, the committee says. Although nurses “have experienced roadblocks to well-being before—from burnout, to compassion fatigue, to injuries and infection—COVID-19 has intensified their stress and left them feeling unprotected and unsupported,” the report notes.

If nurses are to take on the emotionally taxing work of helping to address the many social determinants of health and advancing health equity, the systems that educate and employ nurses have an obligation to fully support them as they take on these new roles, the committee says.

“Policy makers, nurse employers, nursing schools, nurse leaders, and nursing associations all have a role in achieving this goal,” the report says. “Ultimately, the health and well-being of nurses influence the quality, safety, and cost of the care they provide, as well as organizations and systems of care.”

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Article Information

Published: May 18, 2021. doi:10.1001/jamahealthforum.2021.1527

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Stephenson J. JAMA Health Forum.

Corresponding Author: Joan Stephenson, PhD, Consulting Editor, JAMA Health Forum (Joan.Stephenson@jamanetwork.org).

Conflict of Interest Disclosures: None reported.

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    1 Comment for this article
    Nursing Educators Pay is an Area in Need of Improvement
    Francis Holt, PhD, BSN |
    If we are to strengthen nursing education, then we need to address the long-standing issue of exceptionally poor pay for nurse educators. I know of several clinically excellent nurses who would like to teach but cannot afford to. You cannot strengthen education without strengthening the educators.
    CONFLICT OF INTEREST: None Reported
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