Viewpoint: Why nurses will require a stronger back in 2012: Six key challenges facing the nursing community

Editor’s note: Viewpoint highlights the thoughts, opinions, and expertise of well-known nurse leaders. We welcome your comments about these thought-provoking articles.

My grandmother always told me to never pray for a lighter load, but to ask, instead, for a stronger back. Nurses may want to keep this philosophy in mind in 2012 given the long list of challenges facing our profession.

Nurses, perhaps more than any other single occupation, stand at the forefront of major changes in the healthcare industry. But we are not just standing still waiting for changes to happen to us. We are moving toward change as never before, redefining and expanding our roles to be the champions of quality care improvements, research innovations and patient rights, and advancing our skills as leaders to assure our spot at the table with policy makers, hospital executives and other industry leaders.

If ever we were going to, collectively, need that stronger back, now is the time.

As the dean of a major university nursing school, I know first-hand that there is much at stake for us all, both individually and for nursing as a profession. Here are six of the greatest challenges that my colleagues and I will be focused on in 2012. I hope you will join us in advancing these causes.

1. Facilitating advanced education and a culture of learning

Not so long ago, earning a Licensed Practical Nurse (LPN) certificate was considered adequate training for most nurses. But today, with medical knowledge and medical technology increasing exponentially year after year, it is no longer adequate. According to the National Advisory Council on Nurse Education and Practice’s 2010 report to the U.S. Department of Health and Human Services, the medical knowledge base that had previously been doubling every five to eight years is expected to begin doubling every year. Nurses simply will not be able to keep up without advanced education and a system supporting lifelong learning.


Today’s advanced degree programs offer many opportunities for nurses, from master’s and PhD programs to specialized clinician training in fields as diverse as oncology nursing, cardiac nursing and genetics. These programs not only provide a deeper foundational understanding of clinical work and the issues affecting healthcare delivery, but they offer broader career paths, the chance to practice more independently and obtain better salaries. Yet in 2010, only 41% of nurses had bachelor’s degrees and far fewer – 12% – had master’s degrees.

Attracting more nurses to advanced degrees is a profoundly important goal and one that all academic institutions should work toward. We can do this by —

  • fostering a culture of lifelong learning through nursing organizations, schools of nursing, health care organizations and healthcare media.
  • promoting the benefits of advanced degrees to nursing students, including better choices of jobs, higher salaries, broader career path opportunities, and better patient outcomes.
  • expanding the available number of slots for students in advanced degree programs. Many schools are hampered by too few slots for too many eligible and eager students.
  • facilitating access to advanced degree learning through online RN to BSN education modules or evening, after-hours programs.
  • facilitating access to advanced degree funding through scholarships, tuition reimbursement programs, nurse association grants and Federal grants.
  • establishing a firm timeline by which a bachelor’s degree will be the new minimum required to practice nursing. The Future of Nursing Campaign has designated that we try to reach a goal of 80% of nurses having a baccalaureate degree by 2020. I believe that horizon is too far off, and that we must exceed the goal before 2020 in order to meet the demands on our field. The American Association of Colleges of Nursing (AACN) will, by 2015, require a mandatory doctoral degree for those who wish to become advance practice nurses. I believe that we must challenge ourselves to likewise step up our deadline for a bachelor’s degree requirement.

By implementing these changes, we can be sure that the nurses of tomorrow are properly trained with the broad knowledge and skills they will need to best serve their patients and achieve the best outcomes.

2. Development of a National Nurse Residency (Transition-to-Practice) Program

With healthcare reform, hospitals and other health providers are being asked to meet extraordinary demands for better care at a lower cost. In the new regulatory environment, hospitals will be expected to take on more accountability, improve outcomes and better address costly critical and acute care. In many cases, reimbursement will shift to a fee-for-performance model and a hospital’s financial success will depend, at least in part, on its ability to prevent hospital-acquired conditions, reduce unnecessary readmissions and meet rigorous pre-determined metrics. In this environment, hospitals will be demanding the highest caliber nurse professionals with in-depth clinical practice experience, specialization in key areas such as oncology and geriatrics, proficiency with new technology, and the ability to work effectively with colleagues in case management and across all departments.

To keep pace, nursing programs have established accelerated nursing programs to quickly get nurses into practice. But we must do more than simply get nurses out on the floor. We must ensure that they are properly prepared to perform the complex, fast-paced and often overwhelming tasks found in the actual hospital setting. We must assure the safety of every patient by establishing universal nurse residency programs, to begin immediately after the completion of a nursing degree or before transitioning into a new area of clinical practice. This is not a new idea. Schools of nursing and hospitals have been working for years to get such programs into place, but they are costly, and many have been abandoned due to lack of funding and an absence of advocacy by opinion leaders and policy makers. Nurse leaders must continue to rally schools of nursing, nursing coalitions, state boards of nursing, appropriate credentialing organizations and the Federal government to determine a clear path for the development, funding and implementation of these programs.

3. Increased diversity and transcultural/transgenerational training

As our population shifts to include more minorities and as the number of seniors and centenarians doubles and triples, nurses must be better prepared to communicate in more languages, and to better understand a range of cultural and aging issues. At universities like UCLA School of Nursing, not only do we continue to diversify our faculty, students and staff to ensure a true transcultural nursing school, but we also send our students and faculty researchers to other areas of the world to broaden their depth of understanding of culturally sensitive care and to collaborate on key health issues in developing nations. Through an international exchange of ideas and research collaborations, nurses are addressing important health challenges and pushing the scientific and medical boundaries as never before. The results include research collaboration on everything from smoking cessation to HIV/AIDs, the establishment of new international scientific conferences and expanded opportunities for Federal and international grants. Ultimately, the true winners are our patients, as our increasingly global perspective translates to better care for all.

4. Removal of scope of practice barriers

All the advanced degrees and residency training in the world won’t change nursing much or help us meet the growing demands for care unless we eliminate the regulatory obstacles that currently hinder nurses from practicing fully according to their educational capabilities. Do you know of any other profession where professionals are not allowed to practice to the full extent of their skills, abilities and education? Advanced practice nurses must be allowed to act as full partners in health assessment, treatment and care of patients. This is the top recommendation of the Institute of Medicine Report on the Future of Nursing, and should be supported fully by all schools of nursing, nursing organizations, nursing students and other coalitions. States must reform scope of practice regulations to ensure that advanced practice nurses are defined as primary care providers and are thus eligible for clinical and admitting privileges, are accessible to patients through the new state health insurance exchanges (launching in 2014) and are eligible for payment with private health plans as well as Medicare and Medicaid. Now is the time for this to happen, as physician shortages, an aging population and demand for more and better services strain our healthcare system. Nurse practitioners and other specialty care nurses are the answer to this growing concern, but only if they are freed of existing scope of practice limitations and able to act in accordance with the demand and their capabilities.

5. Putting science into practice

Evidence-based practice has been recognized as the “gold standard” of care by the healthcare community, as it attempts to combine the best available evidentiary research with the most appropriate care for the patient’s individual needs. However, nurses have been challenged to implement such practice by barriers due to lack of time, lack of access to the most appropriate research, failure of organizations to adopt a culture conducive to evidence-based care, and lack of nursing autonomy. Hospitals and schools of nursing must find paths to overcome these barriers and put easy-to-follow steps in place which support evidence-based practice.

At UCLA, for example, the School of Nursing and the Ronald Reagan UCLA Medical Center have collaborated to establish a director of evidence-based practice position, designed to institute a structure to engage staff nurses and other clinicians in the constant process of examining their practices to ensure they are backed by the best available scientific evidence. This includes supporting nurses in original research, bringing the findings of relevant studies to the attention of nurses, and helping nurses institute important research-based practice changes at the hospital. This program has facilitated any number of improvements. For example, based on findings that thoracic surgery patients were not consistently prepared for their post-operative experience, one nurse developed a DVD for patients and their families, greatly relieving post-op anxieties and reducing unnecessary readmissions. Tools like this not only improve patient care, but reduce healthcare costs for everyone and further demonstrate the critical role that nurses can play in our evolving healthcare system.

6. Shortage of nursing school faculty

Faculty shortages at nursing schools are limiting student capacity at a time when the demand for nurses is skyrocketing. U.S. nursing schools turned away more than 67,000 qualified applicants from baccalaureate and graduate nursing programs in 2010 due to an insufficient number of faculty, clinical sites, classroom space and budgetary and other constraints. While the American Association of Colleges of Nursing is leveraging its resources to address this issue through focused media attention, data collection and the procurement of federal funding for faculty training programs, we must all focus attention on this crisis by making sure our nurse faculties have the appropriate support and resources they need to not only prevent job burnout, but to encourage potential retirees to stay on the job longer. And, we must continue lobbying policy makers and the Federal government to act swiftly to help fund new faculty recruitment and training.

These challenges nurses face are not for the faint-of-heart, or for those without conviction. But, I know of no other profession more capable of meeting tough challenges than nursing. Our specialty was built by individuals who have broad shoulders, a strong back and perseverance. Nurses will, as they have done always, continue to transform healthcare in ways that will have an immeasurable impact on the nation’s health.

Courtney H. Lyder is dean and professor of the UCLA School of Nursing, professor of Medicine and Public Health as well as Executive Director of the UCLA Health System Patient Safety Institute and Assistant Director of the UCLA Health System.

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40 thoughts on “Viewpoint: Why nurses will require a stronger back in 2012: Six key challenges facing the nursing community”

  1. Anonymous says:

    In the ’70s the Canadian Nurses Association put out a ‘position paper’ to inform stakeholders the Canadian nurses would be Bachelor prepared by the year 2000. The ANA was discussing the same proposal, but but it didn’t happen. here. NOW U.S. nurses are obtaining crucial nursing knowledge with on-line coursesand entering the work force lacking basic skills. Nurse education has diminished rather than gone forward for the majority of nurses.Too many on-line courses.

  2. ivlady says:

    I too have heard these same arguments since the early 80’s. Getting financial aid to get a BSN is the only way it would be worth going back to school for the majority of RN’s without a BSN. Somebody wants us to have BSN’s without giving us the financial incentive to do so.

  3. JoH says:

    JK has it right – as long as nurses are part of the room charge what we do won’t be valued. The room charge is easier allowing the variety of activities that are carried out for our patients every shift to be ignored (and therefore uncompensated).

  4. Anonymous says:

    Agree with the other posts. This is the same language almost word for word that I have been reading and hearing since 1988. As long as nursing has no authority at the table these problems will never change. They will just be passed on to a new generation of nurses. We have to have degrees to be nurses but just strong backs with no back bone in the workplace.

  5. roni says:

    While the necessity to pursue a higher degree is pushed by the majority of those who hold higher degrees is a wonderful idea many of those who work at the bedside have no financial means or see a reason to pursue a higher degree. There are no differences in salaries for those degrees that cost thousands of dollars to pursue just as there is no difference in the NCLEX that they take to obtain that degree.
    While I obtaing my BSN there is only personal satisfaction that will be obtained no other

  6. vicki says:

    It is appalling to me that as a profession we cannot realize and appreciate that there is a need for each level of care giver. As an educator I am honored to provide training for an entry level that can use their education as a “stepping stone” to progress and add to their knowledge. Not everyone can be an Advanced Practice Nurse!

  7. jplahn says:

    First of all, I’ve been hearing this entry level battle since I graduated from my ADN program in 1985! My question??? Why are we still offering AD Nursing Programs? If we want the change WE have to make it. Seems like we as a profession are not willing to “bite the bullett” and “Just Do It”.
    But FIRST!
    We must change nursing curricula to meet the needs of the profession! I orient new nurses and find no difference in orientation needs of ADN vs BSN in acute care.

  8. Christy says:

    Nursing has been talking about most of these issues since 1965 – with little to no action taken. If nursing is serious this time then lets start: first, close ALL remaining diploma schools – it is professionally embarrassing that they remain open; second, as of 2015, ALL ADN junior college programs must affiliate with a BSN program to remain open – any ADN thereafter will be a Technical RN, until they meet the BSN standard; third, pay nursing faculty a comparable wage to other professors.

  9. sharon olson says:

    Two areas I feel need more dialogue and emphasis. First,the wellness of nurses holistically as they face the challenges of an increasingly hi-tech environment. How do they reclaim their healing presence at the bedside rather than just being present for tasks. Second, the validation of men’s contribution in nursing is critical to the profession’s future growth.Caring is gender neutral as is healing presence. S.O. author- The Ecology of Wellness-a personal and professional resource for nurses.

  10. K says:

    When I graduated with my ADN in 1978 I understood that this was only the first step. I went on to work full-time and pursue the BSN and MSN. It saddens me that we are still no closer to resolving the entry level into practice issue now than we were then. I agree wholeheartedly with the comments of the other posters. Enough talking already -do something.

  11. lb says:

    I work worldwide in nursing and there are not enough PhD prepared faculty anywhere, including the US; problem is incentives for further study are few, and having recently retired from a prestigious US university along with 6 other of my PhD faculty, no attempt has been made to continue to engage us..what a waste.

  12. Anonymous says:

    In regard to the nursing faculty shortage: I am a PMHCNS board certified through the ANCC. I was told I could not teach at UCLA or in the community college system in Los Angeles because I do not have INPATIENT nursing experience in the PAST 5 years. This supposedly has something to do with the BRN regulations. I had 17 years of inpatient experience in addition to my 20 years of outpatient experience as a CNS in Geriatric Psychaitry. No wonder there is a faculty shortage.

  13. Anonymous says:

    I have been an RN for 45 years.
    I retired as a Dean of Health Education which included nursing and several other health programs. If I had $1 for each hour I have spent in meetings dis-cuss-ing these issues locally, state and nationally I would be wealthy! Now I am just frustrated to have spent all those hours and nursing is STILL talking. When will we ACT???

  14. KDV says:

    I am a diploma school grad who was around when the position paper came out in the mid 60s. What’s amazing to me is we are STILL discussing this. Instead of getting a BSN IN 10, how about on level of entry only by 2022. A wise woman I met years ago convinced me when she sai “it’s many parent’s dream to have their child graduate from college. Why is it not the dream of the nursing profession. Wise woman, Marilyn Prouty.

  15. jk says:

    Mandating BSN within 10 years of entering practice is unrealistic These elitist ideas do not consider the human factor.The best approach to empowering nurses is for hospitals to start billing for nursing services so we can show we are revenue producers. Then we can sit at the table with equal power in decisions.

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