Center for the Study of the History of Nursing

196 n engl j med 364;3 january 20, 2011
From the Barbara Bates Center for the
Study of the History of Nursing, University
of Pennsylvania School of Nursing, Philadelphia (J.A.F.); the Robert Wood Johnson
Foundation Initiative on the Future of Nursing, Institute of Medicine, Washington, DC
(J.A.F., J.W.R., S.H., D.E.S.); the Department of Health Policy and Management,
Mailman School of Public Health, Columbia
University, New York (J.W.R.); and the University of Miami, Miami (D.E.S.).
See also related letters to the Editor (10.1056/
This article (10.1056/NEJMp1012121) was
published on December 15, 2010, at NEJM
1. Laurant M, Reeves D, Hermens R, Braspenning J, Grol R, Sibbald B. Substitution of
doctors by nurses in primary care. Cochrane
Database Syst Rev 2005;2:CD001271.
2. Institute of Medicine. The future of nursing: leading change, advancing health. Washington, DC: National Academies Press, 2010.
3. Eibner CE, Hussey PS, Ridgely MS, McGlynn EA. Controlling health care spending
in Massachusetts: an analysis of options.
August 2009. (
4. APRN model act/rules and regulations.
Chicago: National Council of State Boards
of Nursing, 2008. (
5. Starck PL. The cost of doing business in
nursing education. J Prof Nurs 2005;21:
Copyright © 2010 Massachusetts Medical Society.
Broadening the Scope of Nursing Practice
Nurses for the Future
Linda H. Aiken, Ph.D., R.N.
On October 5, 2010, the Institute of Medicine (IOM)
issued a report in which it recommended that the proportion
of nurses in the United States
who hold at least a bachelor’s
degree be increased from its
current level of 50% to 80% by
2020.1 The education of nurses
may seem to be a less pressing
matter than providing access to
care for millions of uninsured
Americans and making care affordable, effective, and safe for
all. Yet if we don’t alter the historical patterns of nursing education, the country’s nursing resources will be crippled for the
foreseeable future — with repercussions for all those patientfocused goals.
Nursing schools are turning
away tens of thousands of qualified applicants because of budget constraints and a worsening
faculty shortage. Within the next
10 years, half of nursing-school
faculty members will reach retirement age; the anticipated attrition
represents a crisis in the making,
with potentially far-reaching consequences for the replenishment
of the nurse workforce, which is
itself on the verge of losing some
500,000 nurses to retirement.
The number of new graduates from nurse-practitioner programs has remained flat, at
about 8000 per year, despite rapidly escalating demand. The 80-
hour workweek for resident physicians was made possible by
teaching hospitals’ hiring of
thousands of advanced-practice
registered nurses (APRNs). More
than 3 million American families annually have received care
at some 1100 new retail clinics
staffed primarily by APRNs.
APRNs have facilitated the largest expansion of community
health centers since the 1960s,
with 7354 sites throughout the
country now providing care for
more than 16 million people.
Nurse anesthetists administer an
estimated 30 million anesthetics
to patients each year. Moreover,
a number of health care reform
initiatives are predicated on
APRNs’ filling a range of new
roles in primary care, prevention,
and care coordination.
Why has the graduation rate
of APRNs stalled when there are
so many good employment opportunities for nurses, and why
is there a looming shortage of
nursing faculty? The answer is
simple, although the solution may
not be: to qualify for faculty or
APRN positions, most nurses
have to return to school after
obtaining their basic education
and licensure to acquire two or
more additional academic degrees
— a prospect that is simply not
feasible for most practicing nurses.
Approximately 60% of new
nurses graduate from associate’s
degree programs, 36% from
bachelor’s degree programs, and
3% from hospital-sponsored diploma programs. The creation
of multiple educational entry
points to nursing has been promoted by public policies designed to optimize access to
nursing education for a diverse
student body, promote wide
geographic distribution in supply, and keep costs affordable.
But a serious unintended consequence of permitting the majority of new graduates to enter
nursing practice with an associate’s degree or less is that too
few nurses advance through
multiple additional degrees to
qualify as faculty or APRNs.
The graph shows the yield of
graduate degrees according to
the type of basic nursing education received. For every 1000
nurses who initially graduated
The New England Journal of Medicine
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Copyright © 2011 Massachusetts Medical Society. All rights reserved.
n engl j med 364;3 january 20, 2011
from a bachelor’s degree program
between 1974 and 1994, almost
200 eventually obtained a master’s or higher degree. In contrast, only 58 of every 1000
nurses who initially graduated
from an associate’s degree program obtained at least a master’s degree. Moreover, twice as
many nurses with an initial
bachelor’s degree ultimately obtained a doctorate, a finding that
is relevant to the IOM’s call for a
doubling of the number of doctoral level nurses by 2020.
Of the approximately 72,000
nurses graduating from associate’s degree nursing programs
in 2010, only about 4000 are
likely to ever obtain a master’s
or higher degree — a yield that
cannot produce enough faculty
to replenish a workforce of more
than 3 million nurses. Had the
proportions of registered nurses
with initial education in bachelor’s and associate’s degree programs been reversed between
1974 and 1994, with the larger
proportion being bachelor’s graduates, there would probably have
been 50,000 more nurses today
with master’s or higher degrees.2
The IOM is recommending the
creation of more efficient pathways for nurses to obtain additional education after licensure.
Among the benefits of a more
highly educated nurse workforce
is the potential for improving
patient outcomes.3 However, unless patterns of initial education
are changed, the stream of nurses into graduate education will
not be large enough to avert
shortages of faculty and APRNs.
There is a limit to the number of
degrees nurses can reasonably be
expected to obtain after licensure.
The most promising strategy
for producing enough faculty
members and APRNs is for all
prelicensure nurse-education programs to confer bachelor’s degrees. Because of licensure requirements, there is no longer a
substantial difference in the time
to completion of associate’s and
bachelor’s degrees in nursing:
both take about 3 years of fulltime study. The IOM has called
for discontinuing hospital diploma
programs entirely. Some states
now permit community colleges
to grant bachelor’s degrees in
nursing, which is a reasonable
solution. Distance learning and
simulation technologies, partnerships between educational institutions and clinical organizations,
and more creative collaboration
between community colleges and
universities can facilitate the provision of a bachelor’s degree to
everyone who enters a prelicensure program. Students will not
pass up an opportunity to obtain
a bachelor’s degree for the same
time commitment and cost required for an associate’s degree,
and nursing schools, including
community colleges, will respond
to financial incentives that reward them for granting a bachelor’s degree as the end point of
basic nursing education.
Public funding for nursing
education must be used to steer
the change in basic nursing education, just as public funding
for patient care steers change in
health care delivery. More than
$8 billion per year in Perkins
funds from the Department of
Education (an important source
of funding for community colleges but outside the reach of
health care workforce planning)
could be used as part of a comprehensive federal strategy that
would make it possible for all
new nurses to graduate with a
bachelor’s degree. Baccalaureate
education is a stated priority for
Title 8 funds (annual appropriations administered by the Department of Health and Human
Services that support nursing education), but funding levels are
inadequate. The Nurse Training
Act of 1964 expanded university
Nurses for the Future
No. of Nurses (per 1000)
Initial BSN
Initial ADN
Highest level, doctorate
Highest level, master’s
Highest level, bachelor’s
Highest level, associate’s
803 785
18 49 9
Line Combo 4-C H/T
Figure has been redrawn and type has been reset.
Please check carefully.
1 of 1
JOB: 36403 ISSUE: 01-20-11
2 col
Highest Degree Attained by Nurses According to Initial Type of Education, per 1000
Graduates, 1974–2004.
ADN denotes associate’s degree in nursing, and BSN bachelor of science in nursing.
Figures are based on the author’s calculations using unpublished data from the 2004
National Sample Survey of Registered Nurses, Health Resources and Service Administration, Bureau of Health Professions, Division of Nursing.
The New England Journal of Medicine
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Copyright © 2011 Massachusetts Medical Society. All rights reserved.
198 n engl j med 364;3 january 20, 2011
education for nurses and laid
the groundwork for the development of APRNs.4 We need an
equivalent effort now. The approximately $160 million per year
in Medicare funding for nursing
education should be used to support clinical training of graduatelevel APRNs rather than diploma
nursing programs.5
It will be extremely difficult,
if not impossible, to generate
enough nursing faculty, APRNs,
and nurses to fill leadership and
executive roles requiring graduate-level education if entry-level
nursing education does not shift
entirely to the baccalaureate level. The stakeholders (educational institutions and students) will
respond to financial incentives
— which are, after all, the triedand-true American way of bringing about change.
Disclosure forms provided by the author
are available with the full text of this article at
From the Center for Health Outcomes and
Policy Research, School of Nursing, University of Pennsylvania, Philadelphia.
See also related letters to the Editor (10.1056/
This article (10.1056/NEJMp1011639) was published on December 15, 2010, at
1. Institute of Medicine. The future of nursing: leading change, advancing health. Washington, DC: National Academies Press, 2011.
2. Aiken LH, Cheung RB, Olds DM. Education policy initiatives to address the nurse
shortage in the United States. Health Aff
(Millwood) 2009;28:w646-w656.
3. Aiken LH, Clarke SP, Cheung RB, Sloane
DM, Silber JH. Educational levels of hospital
nurses and surgical patient mortality. JAMA
4. Lynaugh JE. Nursing the Great Society:
the impact of the Nurse Training Act of 1964.
Nurs Hist Rev 2008;16:13-28.
5. Aiken LH, Gwyther ME. Medicare funding
of nurse education: the case for policy
change. JAMA 1995;273:1528-32.
Copyright © 2010 Massachusetts Medical Society.
Nurses for the Future
Assessing an ACO Prototype — Medicare’s Physician Group
Practice Demonstration
John K. Iglehart
One of the few major provisions of the Affordable Care
Act (ACA) with solid bipartisan
support establishes a new delivery model: the accountable care
organization (ACO). Congress directed the Department of Health
and Human Services (DHHS) to
develop an ACO program to improve the quality of care provided to Medicare beneficiaries and
reduce its costs while retaining
fee-for-service payment. Under
this program, medical groups
would have to take responsibility
for achieving these goals and
would share in any savings derived by Medicare.
Despite the burst of interest
in ACOs, little attention has been
paid to the results of a demonstration project sponsored by the
Centers for Medicare and Medicaid Services (CMS) that was the
model for the reform law’s ACO
provisions. In the Medicare Physician Group Practice (PGP) demonstration, the CMS contracted with
10 large multispecialty groups
with diverse organizational structures, including free-standing physician groups, academic faculty
practices, integrated delivery systems, and a network of small
physician practices.1
As a share of total Medicare
spending, fee-for-service expenditures for physician services have
been relatively stable (13% of $491
billion in 2009). However, this
payment model has been under
attack because of its inherent incentive for increasing the quantity, but not necessarily the quality,
of physician-delivered care. But
policymakers vividly remember
the backlash against managed
care, whose capitation payments
were seen as an incentive to stint
on care, so with no new alternative to fee for service in the offing, Medicare’s physician-payment
policy has remained essentially
In 2000, Congress tasked the
DHHS with testing incentive-based
payment methods for physicians,
directing Medicare to encourage
care coordination and investment
in processes for more efficient
service delivery and to reward physicians for improving health care
outcomes. In response, the CMS
designed the PGP project to examine whether care management
initiatives could generate cost savings by reducing avoidable hospital admissions, readmissions,
and emergency department visits, while improving quality.1
The demonstration began in
April 2005, with 10 large group
practices (ranging from 232 to
1291 physicians) operating in
various regions of the country.
Participating doctors received
their regular Medicare fee-forservice payments, but the groups
were also eligible for an 80%
share of Medicare’s savings
(“performance payments”) if the
The New England Journal of Medicine
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Copyright © 2011 Massachusetts Medical Society. All rights reserved.

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