function of nursing education

In concert with its mission, NCSBN develops cutting edge resources, initiatives and programs for nursing regulatory bodies in their roles of regulating nursing education programs. Further, NCSBN collaborates with nursing education organizations, nurse educators and other stakeholders and participates in national nursing education meetings and initiatives.

NCSBN keeps nurse educators updated on the latest news, research, and resources in nursing education through the biannual  Leader to Leader magazine.  Sign up here  to receive future issues of Leader to Leader. NCSBN also has  resources for new nurses .

State Requirements for Licensure

The U.S. Department of Education (USDE) implemented new regulations on July 1, 2024, for professional nursing programs (PN, RN and APRN). Learn more about the professional licensure requirements in each state/jurisdiction .

National Simulation Guidelines

How much simulation should be used in nursing programs and what are best practices?

NCSBN recently conducted a  landmark study of simulation use in prelicensure ADN and BSN nursing programs across the country.

Fraud Detection Guidance for Employers and Educators

While the majority of nurses are honest, competent and caring individuals, there are occasional opportunists who fraudulently cover up their backgrounds to advance their education or seek employment. This paper provides nurse educators and employers with recommendations for identifying fraud when they review nurse applications and transcripts for advanced study, employment, certification or other uses.

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NCSBN's Annual Report Program

In NCSBN's Annual Report Program we collect data from the participating NRBs to provide them with an annual report of their programs, but also to create a national database of nursing education data.

Nurse Licensure Guidance

Need guidance on applying for a nursing license in the U.S. as a registered nurse (RN) or licensed practical/vocational nurse (LPN/VN)? Use this tool for state-specific details, based on where you will be living and where you want to practice . This tool was created for both internationally and domestically educated nurses.

Distance Education Requirements

For the first time, every requirement that US Nursing Regulatory Bodies (NRBs) have for out-of-state distance education programs is available in one convenient location. You can search by location to learn specific NRB distance education rules and regulations , and how to comply with them.

The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity (2021)

Chapter: 7 educating nurses for the future, 7 educating nurses for the future.

You cannot transmit wisdom and insight to another person. The seed is already there. A good teacher touches the seed, allowing it to wake up, to sprout, and to grow.

—Thich Nhat Hanh, global spiritual leader and peace activist

Throughout the coming decade, it will be essential for nursing education to evolve rapidly in order to prepare nurses who can meet the challenges articulated in this report with respect to addressing social determinants of health (SDOH), improving population health, and promoting health equity. Nurses will need to be educated to care for a population that is both aging, with declining mental and physical health, and becoming increasingly diverse; to engage in new professional roles; to adapt to new technologies; to function in a changing policy environment;

and to lead and collaborate with professionals from other sectors and professions. As part of their education, aspiring nurses will need new competencies and different types of learning experiences to be prepared for these new and expanded roles. Also essential will be recruiting and supporting diverse students and faculty to create a workforce that more closely resembles the population it serves. Given the growing focus on SDOH, population health, and health equity within the public health and health care systems, the need to make these changes to nursing education is clear. Nurses’ close connection with patients and communities, their role as advocates for well-being, and their placement across multiple types of settings make them well positioned to address SDOH and health equity. For future nurses to capitalize on this potential, however, SDOH and equity must be integrated throughout their educational experience to build the competencies and skills they will need.

The committee’s charge included examining whether nursing education provides the competencies and skills nurses will need—the capacity to acquire new competencies, to work outside of acute care settings, and to lead efforts to build a culture of health and health equity—as they enter the workforce and throughout their careers. A thorough review of the current status and future needs of nursing education in the United States was beyond the scope of this study, but in this chapter, the committee identifies priorities for the content and nature of the education nurses will need to meet the challenge of addressing SDOH, advancing health equity, and improving population health. Nursing education is a lifelong pursuit; nurses gain knowledge and skills in the classroom, at work, through continuing professional development, and through other formal and informal mechanisms ( IOM, 2016b ). While the scope of this study precluded a thorough discussion of learning outside of nursing education programs, readers can find further discussion of lifelong learning in A Framework for Educating Health Professionals to Address the Social Determinants of Health ( IOM, 2016b ), Redesigning Continuing Education in the Health Professions ( IOM, 2010 ), and Exploring a Business Case for High-Value Continuing Professional Development: Proceedings of a Workshop ( NASEM, 2018a ).

To change nursing education meaningfully so as to produce nurses who are prepared to meet the above challenges in the decade ahead will require changes in four areas: what is taught, how it is taught, who the students are, and who teaches them. This chapter opens with a description of the nursing education system and the need for integrating equity into education, and then examines each of these four areas in turn:

• domains and competencies for equity,
• expanded learning opportunities,
• recruitment of and support for diverse prospective nurses, and
• strengthening and diversification of the nursing faculty.

In addition to changes in these specific areas, there is a need for a fundamental shift in the idea of what constitutes a “quality” nursing education. Currently, National Council Licensure Examination (NCLEX) pass rates are used as the primary indicator of quality, along with graduation and employment rates ( NCSBN, 2020a ; O’Lynn, 2017 ). This narrow focus on pass rates has been criticized for diverting time and attention away from other goals, such as developing student competencies, investing in faculty, and implementing innovative curricula ( Giddens, 2009 ; O’Lynn, 2017 ; Taylor et al., 2014 ). In addition, the NCLEX is heavily focused on acute care rather than on such areas of nursing as primary care, disease prevention, SDOH, and health equity ( NCSBN, 2019 ). In response to such concerns about the NCLEX, the National Council of State Boards of Nursing (NCSBN) conducted a study to identify additional quality indicators for nursing education programs; indicators were identified in the areas of administration, program director, faculty, students, curriculum and clinical experiences, and teaching and learning resources ( Spector et al., 2020 ). To realize the committee’s vision for nursing education, it will be necessary for nursing schools, accreditors, employers, and students to look beyond NCLEX pass rates and include these types of indicators in the assessment of a quality nursing education.

OVERVIEW OF NURSING EDUCATION

Nurses are educated at universities, colleges, hospitals, and community colleges and can follow a number of educational pathways. Table 7-1 identifies the various degrees that nurses can hold, and describes the programs that lead to each degree and the usual amount of time required to complete them. In 2019, there were more than 200,000 graduates from baccalaureate, master’s, and doctoral nursing programs in the United States and its territories, including 144,659 who received a baccalaureate degree ( AACN, 2020a ) (see Table 7-2 ).

Nursing programs are nationally accredited by the Accreditation Commission for Education in Nursing (ACEN); the Commission on Collegiate Nursing Education (CCNE); the Commission for Nursing Education and Accreditation (CNEA); and other bodies focused on specialty areas of nursing, such as midwifery. Graduating registered nurses (RNs) seek licensure as nurses through state boards, and take examinations administered by the NCSBN as graduates with their first professional degree and then as specialists with certification exams offered through specialty organizations. These bodies set minimum standards for nursing programs and establish criteria for certification and licensing, faculty qualifications, course offerings, and other features of nursing programs ( Gaines, n.d. ).

TABLE 7-1 Pathways in Nursing Education

SOURCES: Adapted from IOM, 2011 ( AARP, 2010 . Courtesy of AARP. All rights reserved).

The Need for Nursing Education on Social Determinants of Health and Health Equity

A report of the Institute of Medicine (IOM) from nearly two decades ago asserts that all health professionals, including nurses, need to “understand determinants of health, the link between medical care and healthy populations, and professional responsibilities” ( IOM, 2003 , p. 209). The literature is replete with calls for all nurses to understand concepts associated with health equity, such as disparities, culturally competent care, equity, and social justice. For example, Morton and colleagues (2019) identify essential content to prepare nurses for

TABLE 7-2 Number of Graduates from Nursing Programs in the United States and Territories, 2019

a Number of first-time NCLEX test takers, which is proxy for new graduates ( NCSBN, 2020a ).

SOURCE: AACN, 2020a .

community-based practice, including SDOH, health disparities/health equity, cultural competency, epidemiology, community leadership, and the development of enhanced skills in community-based settings. O’Connor and colleagues (2019) call for an inclusive educational environment that prepares nurses to care for diverse patient populations, including the study of racism’s impacts on health from the genetic to the societal level, systems of marginalization and oppression, critical self-reflection, and preparation for lifelong learning in these areas. And Thornton and Persaud (2018) state that the content of nursing education should include instruction in cultural sensitivity and culturally competent care, trauma-informed care and motivational interviewing, screening for social needs, and referring for services. These calls align with the Health Resources and Services Administration’s (HRSA’s) most recent strategic plan, which prioritizes the development of a health care workforce that is able to address current and emerging needs for improving equity and access ( HRSA, 2019 ). Additionally, recommendations of the National Advisory Council on Nurse Education and Practice (NACNEP) (2016) include that population health concepts be incorporated into nursing curriculum and that undergraduate programs create partnerships with HRSA, the U.S. Department of Veterans Affairs (VA), and the Indian Health Service (IHS), agencies that serve rural and frontier areas, to increase students’ exposure to different competencies, experiences, and environments.

In concert with these perspectives and recommendations, nursing organizations have developed guidelines for how nursing education should prepare nurses to work on health equity issues and address SDOH. In 2019, the National League for Nursing (NLN) issued a Vision for Integration of the Social Determinants of Health into Nursing Education Curricula , which describes the importance of SDOH to the mission of nursing and makes recommendations for how SDOH should be integrated into nursing education (see Box 7-1 ).

As described in Chapter 9 , the American Association of Colleges of Nursing’s (AACN’s) Essentials 1 provides an outline for the necessary curriculum content and expected competencies for graduates of baccalaureate, master’s, and doctor of nursing practice (DNP) programs. Essentials identifies “Clinical Prevention and Population Health” as one of the nine essential areas of baccalaureate nursing education. Among other areas of focus, Essentials calls for baccalaureate programs to prepare nurses to

• collaborate with other health care professionals and patients to provide spiritually and culturally appropriate health promotion and disease and injury prevention interventions;
• assess the health, health care, and emergency preparedness needs of a defined population;
• collaborate with others to develop an intervention plan that takes into account determinants of health, available resources, and the range of activities that contribute to health and the prevention of illness, injury, disability, and premature death;
• participate in clinical prevention and population-focused interventions with attention to effectiveness, efficiency, cost-effectiveness, and equity; and
• advocate for social justice, including a commitment to the health of vulnerable populations and the elimination of health disparities.

Curriculum content and expected competencies laid out in Essentials for master’s- and DNP-level nursing education also address SDOH, disparities, equity, and social justice ( AACN, 2006 , 2011 ). While Essentials only guides baccalaureate, master’s, and DNP programs, the document’s emphasis on health equity and SDOH demonstrates the importance of these topics to the nursing profession as a whole.

As of 2020, AACN has been shifting toward a competency-based curriculum. As part of this effort, AACN published a draft update to Essentials that identifies 10 domains for nursing education: knowledge for nursing practice; person-centered care; population health; scholarship for nursing discipline; quality and safety; interprofessional partnerships; systems-based practice; informatics and health care technologies; professionalism; and personal, professional, and leadership development. Within these 10 domains are specific competencies that AACN believes are essential for nursing practice ( AACN, 2020b ), including

• engage in effective partnerships,
• advance equitable population health policy,
• demonstrate advocacy strategies,

___________________

1 See https://www.aacnnursing.org/Education-Resources/AACN-Essentials (accessed April 13, 2021).

• use information and communication technologies and informatics processes to deliver safe nursing care to diverse populations in a variety of settings, and
• use knowledge of nursing and other professions to address the health care needs of patients and populations.

Nurses themselves have also indicated the need for more education and training on these topics. The 2018 National Sample Survey of Registered Nurses (NSSRN) asked the question, “As of December 31, 2017, what training topics would have helped you do your job better?” Figure 7-1 shows the percentage of six different training topics that RNs said would help them do their job better. Overall, RNs working in schools, public health, community health, and emergency and urgent care were more likely than RNs working in all other employment settings listed in Figure 7-1 to indicate that they could have done their job better if they had received training in SDOH, population health, working in underserved communities, caring for individuals with complex health and social needs, and especially mental health. These results could reflect RNs encountering increasingly complex individuals and populations, rising numbers of visits and caseloads, the fact that the RNs working in these settings frequently provide

care for people facing multiple social risk factors that harm their health and well-being, or inadequacy of the training in these areas that RNs had received. RNs—particularly those working in informatics, health care management and administration, and education—also indicated that training in value-based care would have been helpful. Additionally, RNs who had graduated after 2010 were more likely than those who had graduated before then to indicate that they could have done their job better with training across all of these topics.

Nurse practitioners (NPs) have also indicated the need for more training in SDOH. In response to the 2018 NSSRN question described above, NPs working in public health and community health, emergency and urgent care, education, and long-term care reported that they could have done their job better if they had received training in SDOH, mental health, working in underserved communities, and providing care for medically complex/special needs. Across all types of practice settings, one-third felt that training in mental health issues would have helped them do their job better, while very few NPs indicated that training in value-based care would have been helpful. Additionally, NPs who had graduated since 2010 were more likely than those who had graduated before then to indicate that they would have benefited from training in these topics. Figure 7-2 shows the percentage of six different training topics that NPs mentioned would have helped them do their job better.

The Need for Integration of Social Determinants of Health and Health Equity into Nursing Education

Despite guidelines from both the American Association of Colleges of Nursing (AACN) and the National League for Nursing (NLN) and numerous calls for including equity, population health, and SDOH in nursing education, SDOH and related concepts are not currently well integrated into undergraduate and graduate nursing education. Nor has the degree to which nurses are prepared and educated in these areas been studied systematically ( NACNEP, 2019 ; Tilden et al., 2018 ). The committee was unable to locate a central repository of information about the coursework and other educational experiences available to nursing students across types of programs and institutions, or any other source of systematic analysis of nursing curricula. This lack of information about nursing preparation programs limits the conclusions that can be drawn about them. Thus, the discussion in this chapter is based on the assumption that some nursing programs are likely already pursuing many of the goals identified herein, but that this critically important content is not yet standard practice throughout nursing education.

One way to explore whether and how health equity and related concepts are currently integrated into nursing education is to look at accreditation standards. While the standards do not detail every specific topic to be covered in nursing curricula, they do set expectations, convey priorities, and identify important areas of study. For example, the accreditation standards of the CCNE state that advanced practice registered nurse (APRN) programs must include study of advanced physiology, advanced health assessment, and advanced pharmacology ( CCNE, 2018 ). Accreditation standards could be used to prioritize the inclusion of health equity and SDOH in nursing curriculum; however, this is not currently the case. The CCNE standards state that accredited programs must incorporate the AACN Essentials into their curricula, and while these standards do not specifically mention equity, SDOH, or other relevant concepts ( CCNE, 2018 ), that is expected to change to correspond with the updates to the Essentials described previously (see Box 7-1 ). CNEA’s accreditation standards likewise include no mention of population health, SDOH, or health equity ( NLN, 2016 ), although a more recent document from NLN makes a strong case for the integration of SDOH into nursing education curricula ( NLN, 2019 ). ACEN’s associate’s and baccalaureate standards call for inclusion of “cultural, ethnic, and socially diverse concepts” in the curriculum; the master’s and doctoral standards require that curriculum be “designed so that graduates of the program are able to practice in a culturally and ethnically diverse global society,” but do not address health equity, population health, or SDOH.

Another approach for examining the inclusion of these concepts in nursing education is to look at exemplar programs. As part of the Future of Nursing: Campaign for Action, the Robert Wood Johnson Foundation commissioned a study of best practices in nursing education to support population health ( Campaign for

Action, 2019b ). That report notes that although many nursing programs reported including population health content in their curriculum, few incorporated the topic substantially. However, the report also identifies exemplars of programs with promising population health models. These exemplars include Oregon Health & Science University, which incorporates population health throughout the curriculum as a key competency; Rush University, which incorporates cultural competence throughout the curriculum; and Thomas Jefferson University, which offers courses in health promotion, population health, health disparities, and SDOH. NACNEP has also examined exemplars of nursing programs that incorporate health equity and SDOH into their curricula ( NACNEP, 2019 ). The programs highlighted include the University of Pennsylvania School of Nursing, which has a course called Case Study—Addressing the Social Determinants of Health: Community Engagement Immersion ( Schroeder et al., 2019 ). This course offers experiential learning opportunities that focus on SDOH in vulnerable and underserved populations and helps students design health promotion programs for these communities. The school also offers faculty education in SDOH.

As far as the committee was able to determine, most programs include content on SDOH in community or public health nursing courses. However, this material does not appear to be integrated thoroughly into the curriculum in the majority of programs, nor could the committee identify well-established designs for curricula that address this content outside of community health rotations ( Campaign for Action, 2019b ; Storfjell et al., 2017 ; Thornton and Persaud, 2018 ). In the committee’s view, a single course in community and/or public health nursing is insufficient preparation for creating a foundational understanding of health equity and for preparing nurses to work in the wide variety of settings and roles envisioned in this report. Ideally, education in these concepts would be integrated throughout the curriculum to give nurses a comprehensive understanding of the social determinants that contribute to health inequities ( NACNEP, 2019 ; NLN, 2019 ; Siegel et al., 2018 ). Moreover, academic content alone is insufficient to provide students with the knowledge, skills, and abilities they need to advance health equity; rather, expanded opportunities for experiential and community learning are critical for building the necessary competencies ( Buhler-Wilkerson, 1993 ; Fee and Bu, 2010 ; NACNEP, 2016 ; Sharma et al., 2018 ). All those involved in nursing education—administrators, faculty, accreditors, and students—need to understand that health equity is a core component of nursing, no less important than alleviating pain or caring for individuals with acute illness. Graduating students need to understand and apply knowledge of the impact of such issues as classism, racism, sexism, ageism, and discrimination and to be empowered to advocate on these issues for people who they care for and communities.

As currently constituted, then, nursing education programs fall short of conveying this information sufficiently in the curriculum or through experiential learning opportunities. Yet, the existing evidence on what nursing education programs offer is scant. Research is therefore needed to assess whether and how

many nursing programs are offering sufficient coursework and learning opportunities related to SDOH and health equity and to examine the extent to which graduating nurses have the competencies necessary to address these issues in practice.

The Need for BSN-Prepared Nurses

The 2011 The Future of Nursing report includes the recommendation that the percentage of nurses who hold a baccalaureate degree or higher be increased to 80 percent by 2020. The report gives several reasons for this goal, including that baccalaureate-prepared nurses are exposed to competencies including health policy, leadership, and systems thinking; they have skills in research, teamwork, and collaboration; and they are better equipped to meet the increasingly complex demands of care both inside and outside the hospital ( IOM, 2011 , p. 170). In 2011, 50 percent of employed nurses held a baccalaureate degree or higher; as of 2019, that proportion had increased to 59 percent ( Campaign for Action, 2020 ). Both the number of baccalaureate programs and program enrollment have increased substantially since 2011 2 ( AACN, 2019a ), and the number of RNs who went on to receive BSNs in RN-to-BSN programs increased 236 percent between 2009 and 2019 ( Campaign for Action, n.d. ). However, the goal of 80 percent of nurses holding a BSN was still not achieved by 2020, for a number of reasons. Although the proportion of new graduates with a BSN is higher than the proportion of existing nurses with a BSN, the percentage of new graduates joining the nursing workforce each year is small. Given this ratio, it would have been “extraordinarily difficult” to achieve the goal of 80 percent by 2020 ( IOM, 2016a ; McMenamin, 2015 ). Nurses already in the workforce face barriers to pursuing a BSN, including time, money, work–life balance, and a perception that additional postlicense education is not worth the effort ( Duffy et al., 2014 ; Spetz, 2018 ). Moreover, schools and programs have limited capacity for first-time nursing students and ADN, LPN nurses, or RNs without BSN degrees ( Spetz, 2018 ).

Nonetheless, the goal of achieving a nursing workforce in which 80 percent of nurses hold a baccalaureate degree or higher remains relevant, and continuing efforts to increase the number of nurses with a BSN are needed. Across the globe, the proportion of BSN-educated nurses is correlated with better health outcomes ( Aiken et al., 2017 ; Baker et al., 2020 ), and there are clear differences as well as similarities between associate’s degree in nursing (ADN) programs and BSN programs. In particular, BSN programs are more likely to cover topics relevant to liberal education, organizational and systems leadership, evidence-based practice, health care policy, finance and regulatory environments, interprofessional collaboration, and population health ( Kumm et al., 2014 ). Accelerated, nontraditional, and other pathways to the BSN degree are discussed later in this chapter.

2 See Chapter 3 for demographic information on employed nurses in the United States.

The Need for PhD-Prepared Nurses

There are two types of doctoral degrees in nursing: the PhD and the DNP. The former is designed to prepare nurse scientists to conduct research, whereas the latter is a clinically focused doctoral degree designed to prepare graduates with advanced competencies in leadership and management, quality improvement, evidence-based practice, and a variety of specialties. PhD-prepared nurses are essential to the development of the research base required to support evidence-based practice and add to the body of nursing knowledge, and DNP-educated nurses play a key role in translating evidence into practice and in educating nursing students in practice fundamentals ( Tyczkowski and Reilly, 2017 ) (see Chapter 3 for further discussion of the role of DNPs).

The number of nurses with doctoral degrees has grown rapidly since the 2011 The Future of Nursing report was published ( IOM, 2011 ). As a proportion of doctorally educated nurses, however, the number of PhD graduates has remained nearly flat. In 2010, there were 1,282 graduates from DNP programs and 532 graduates receiving a PhD in nursing. By 2019, the number of DNP graduates had grown more than 500 percent to 7,944, while the number of PhD graduates had grown about 50 percent to 804 ( AACN, 2011 , 2020a ).

The slow growth in PhD-prepared nurses is a major concern for the profession and for the nation, because it is these nurses who serve as faculty at many universities and who systematically study issues related to health and health care, including the impact of SDOH on health outcomes, health disparities, and health equity. PhD-prepared nurses conduct research on a wide variety of issues relating to SDOH, including the effect of class on children’s health; linguistic, cultural, and educational barriers to care; models of care for older adults aging in place; and gun violence ( Richmond and Foman, 2018 ; RWJF, 2020 ; Szanton et al., 2014 ). Nurse-led research provided evidence-based solutions in the early days of the COVID-19 pandemic for such challenges as the shift to telehealth care, expanding demand for health care workers, and increased moral distress ( Lake, 2020 ). However, Castro-Sánchez and colleagues (2021) note a dearth of nurse-led research specifically related to COVID-19; they posit that this gap can be attributed to workforce shortages, a lack of investment in clinical academic leadership, and the redeployment of nurses into clinical roles. More PhD-prepared nurses are needed to conduct research aimed at improving clinical and community health, as well as to serve as faculty to educate the next generation of nurses ( Broome and Fairman, 2018 ; Fairman et al., 2020 ; Greene et al., 2017 ).

Nursing practice is dependent on a robust pipeline of research to advance evidence-based care, inform policy, and address the health needs of people and communities ( Bednash et al., 2014 ). The creation of the BSN-to-PhD direct entry option has helped produce more research-oriented nurse faculty ( Greene et al., 2017 ), but time, adequate faculty mentorship, mental health issues, and financial hardships, including the cost of tuition, are barriers for nurses pursuing these

advanced degrees ( Broome and Fairman, 2018 ; Fairman et al., 2020 ; Squires et al., 2013 ). One approach for increasing the number of PhD-prepared nurses is the Future of Nursing Scholars program, which successfully graduated approximately 200 PhD students through an innovative accelerated 3-year program ( RWJF, 2021 ). Similar programs have been funded by such foundations as the Hillman Foundation and Jonas Philanthropies to help stimulate the pipeline, build capacity (especially in health policy) among graduates, and model innovative curricular approaches ( Broome and Fairman, 2018 ; Fairman et al., 2020 ).

DOMAINS AND COMPETENCIES FOR EQUITY

As noted earlier, a number of existing recommendations specify what nurses need to know to address SDOH and health inequity in a meaningful way. In addition, the Future of Nursing: Campaign for Action surveyed and interviewed faculty and leaders in nursing and public health, asking about core content and competencies for all nurses ( Campaign for Action, 2019b ). Respondents specifically recommended that nursing education cover seven areas:

• policy and its impact on health outcomes;
• epidemiology and biostatistics;
• a basic understanding of SDOH and illness across populations and how to assess and intervene to improve health and well-being;
• health equity as an overall goal of health care;
• interprofessional team building as a key mechanism for improving population health;
• the economics of health care, including an understanding of basic payment models and their impact on services delivered and outcomes achieved; and
• systems thinking, including the ability to understand complex demands, develop solutions, and manage change at the micro and macro system levels.

Drawing on all of these recommendations, guidelines, and perspectives, as well as looking at the anticipated roles and responsibilities outlined in other chapters of this report, the committee identified the core concepts pertaining to SDOH, health equity, and population health that need to be covered in nursing school and the core knowledge and skills that nurses need to have upon graduation. For consistency with the language used by the AACN, these are referred to, respectively, as “domains” (see Box 7-2 ) and “competencies” (see Box 7-3 ). The domains in Box 7-2 are fundamental content that the committee believes can no longer be covered in public health courses alone, but need to be incorporated and applied by nursing students throughout nursing curricula. All nurses, regardless of setting or type of nursing, need to understand and be prepared to address the underlying barriers to better health in their practice.

The committee believes that incorporation of these domains and competencies can guide expeditious and meaningful changes in nursing education. The committee acknowledges that making room for these concepts will inevitably require eliminating some existing material in nursing education. The committee does not believe that it is the appropriate entity to identify what specific curriculum changes should be made; a nationwide evaluation will be needed to ensure that nursing curricula are preparing the future workforce with the skills and competencies they will need. The committee also acknowledges that nursing programs differ in length, and that an ADN program cannot cover SDOH equity to the same extent as a BSN program. The specific knowledge and skills a nurse will need will vary depending on her or his level of nursing education. For example, a nurse with a BSN may need to understand and be able to use the technologies that are relevant to his or her area of work (e.g., telehealth applications, electronic health records [EHRs], home monitors), while an APRN may need a deeper understanding of how to analyze health records in order to provide care and monitor health status for populations outside clinical settings.

Nonetheless, nursing education at all levels—from licensed practical nurse (LPN) to ADN to BSN and beyond—needs to incorporate and integrate the domains and competencies in Boxes 7-2 and 7-3 to the extent possible so as to develop knowledge and skills that will be relevant and useful to nurses and essential to achieving equity in health and health care. Given the relationship among SDOH, social needs, and health outcomes and the increasing focus of health care systems on addressing these community and individual needs, the domains and competencies identified here are essential to ensure that all nurses understand and can apply concepts related to these issues; work effectively with people, families, and communities across the spectrum of SDOH; promote physical, mental, and social health; and assume leadership and entrepreneurial roles to create solutions, such as by fostering partnerships in the health and social sectors, scaling successful interventions, and engaging in policy development. While none of the domains listed in Box 7-2 are new to nursing, the health inequities that have become increasingly visible—especially as a result of the COVID-19 pandemic—demand that these domains now be substantively integrated into the fabric of nursing education and practice.

Many sources highlight both the challenges faced by front-line graduates when confronted with these issues, and the reality that many nursing schools lack faculty members with the knowledge and competencies to educate nurses effectively on these issues ( Befus et al., 2019 ; Effland et al., 2020 ; Hermer et al., 2020 ; Levine et al., 2020 ; Porter et al., 2020 ; Rosa et al., 2019 ; Valderama-Wallace and Apesoa-Varano, 2019 ). To remedy the latter gap, educators need to have a clear understanding of these issues and their links to both educational and patient outcomes (see the section below on strengthening and diversifying the nursing faculty). It is important to note as well that some of these topics, including the connections among implicit biases, structural racism, and health equity, may be difficult for educators and students to discuss (see Box 7-4 ).

Given the limited scope of this report, the committee has chosen to highlight three of the competencies from Box 7-3 in this section. 3 The first is delivering person-centered care to diverse populations. As the United States becomes increasingly diverse, nurses will need to be aware of their own implicit biases and be able to interact with diverse patients, families, and communities with empathy and humility. The second is learning to collaborate across professions, disciplines, and sectors. As discussed previously in this report, addressing SDOH is necessarily a multisectoral endeavor given that these determinants go beyond health to include such issues as housing, education, justice, and the environment. The third is continually adapting to new technologies. Advances in technology are reshaping both health care and education, and making it possible for both to

3 For further discussion of domains and competencies, see AACN, 2020b ; Campaign for Action, 2019b ; IOM, 2016b ; NACNEP, 2019 ; NLN, 2019 ; Thornton and Persaud, 2018 .

be delivered in nontraditional settings and nontraditional ways. In the present context, technology can expand access to underserved populations of patients and students—for example, telehealth and online platforms can be used to connect with those living in rural areas—but it can also exacerbate existing disparities and inequities. Nurses need to understand both the promises and perils of technology, and be able to adapt their practice and learning accordingly.

Delivering Person-Centered Care and Education to Diverse Populations

As discussed in Chapter 2 , people’s family and cultural background, community, and other experiences may have profound impacts on their health. Given the increasing diversity of the U.S. population, it is critical that nurses understand the impact of these factors on health, can communicate and connect with people of different backgrounds, and can be self-reflective about how their own beliefs and biases may affect the care they provide. To this end, the committee believes it is essential that nursing education include the concepts of cultural humility and implicit bias as a thread throughout the curriculum.

An integral part of learning about these concepts is an opportunity to reflect on what one is learning and to draw connections with past learning and experiences. Researchers have established that instruction that guides students in reflection helps reinforce skills and competencies (see, e.g., NASEM, 2018c ). This idea has been explored in the context of education in health professions and has been identified as a valuable way to foster understanding of health equity and SDOH ( IOM, 2016b ; Mann et al., 2007 ). While the strategies, goals, and structure of such reflection may vary, the process in general helps learners in health care settings examine their own values, assumptions, and beliefs ( El-Sayed and El-Sayed, 2014 ; Scheel et al., 2017 ). In the course of structured reflection, for example, students might consider how such issues as racism, implicit bias, trauma, and policy affect the care people receive and create conditions for poor health, or how their own experiences and identities influence the care they provide.

Cultural Humility

In recent years, the focus in discussions of patient care has shifted from cultural competency to cultural humility ( Barton et al., 2020 ; Brennan et al., 2012 ; Kamau-Small et al., 2015 ; Periyakoil, 2019 ; Purnell et al., 2018 ; Walker et al., 2016 ). The concept of cultural competency has been interpreted by some as limited for a number of reasons. First, it implies that “culture” is a technical skill in which clinicians can develop expertise, and it can become a series of static dos and don’ts ( Kleinman and Benson, 2006 ). Second, the concept of cultural competency tends to promote a colorblind mentality that ignores the role of power, privilege, and racism in health care ( Waite and Nardi, 2017 ). Third,

cultural competency is not actively antiracist but instead leaves institutionalized structures of White privilege and racism intact ( Schroeder and DiAngelo, 2010 ).

In contrast, cultural humility is defined by flexibility, a lifelong approach to learning about diversity, and a recognition of the role of individual bias and systemic power in health care interactions ( Agner, 2020 ). Cultural humility is considered a self-evaluating process that recognizes the self within the context of culture ( Campinha-Bacote, 2018 ). The concept of cultural humility can be woven into most aspects of nursing and interprofessional education. For example, case studies in which students learn about the experience of a particular disease or strategies for disease prevention can be designed to model culturally humble approaches in the provision of nursing care and the avoidance of stereotypical thinking ( Foronda et al., 2016 ; Mosher et al., 2017 ). One effective approach to cultivating cultural humility is to accompany experiential learning opportunities or case studies with reflection that expands learning beyond skills and knowledge. This includes questioning current practices and proposing changes to improve the efficiency and quality of care, equality, and social justice ( Barton et al., 2020 ; Foronda et al., 2013 ). Programs designed to develop nurses’ cultural sensitivity and humility, as well as cultural immersion programs, have been developed, and research suggests that such programs can effectively develop skills that strengthen nurses’ confidence in treating diverse populations, improve patient and provider relationships, and increase nurses’ compassion ( Allen, 2010 ; Gallagher and Polanin, 2015 ; Sanner et al., 2010 ).

Implicit Bias

Implicit bias is an unconscious or automatic mental association made between members of a group and an attribute or evaluation ( FitzGerald and Hurst, 2017 ). For example, a clinician may unconsciously view White patients as more medically compliant than Black patients ( Sabin et al., 2008 ). These types of biases not only can have consequences for individual health outcomes ( Aaberg, 2012 ; Linden and Redpath, 2011 ) but also may play a role in maintaining or exacerbating health disparities ( Blair et al., 2011 ). There are many resources available for implicit bias awareness and training; for example, Harvard University offers a number of Implicit Association Tests (IATs), the Institute for Healthcare Improvement offers free online resources to address implicit bias, and the AACN offers implicit bias workshops for nurses ( AACN, n.d. ; Foronda et al., 2018 ).

Evidence on the use of implicit bias training is limited. One review of the use of an IAT in health professions education found that the test had contrasting uses, with some curricula using it as a measure of implicit bias and others using it to initiate discussions and reflection. The review found a dearth of research on the use of IATs; the authors note that the nature of implicit bias is highly complex and cannot necessarily be reduced to the “time-limited” use of an IAT ( Sukhera et al., 2019 ). A systematic review of interventions designed to reduce implicit bias

found that many such interventions are ineffective, and some may even increase implicit biases. The authors note that while there is no clear path for reducing biases, the lack of evidence does not weaken the case for “implementing widespread structural and institutional changes that are likely to reduce implicit biases” ( FitzGerald et al., 2019 ). One promising model is an intervention that helps participants break the “prejudice habit” ( Devine et al., 2012 ). This multifaceted intervention, which includes situational awareness of bias, education about the consequences of bias, strategies for reducing bias, and self-reflection, has been shown to reduce implicit racial bias for at least 2 months ( Devine et al., 2012 ). Clearly, more research is needed in this area.

Learning to Collaborate Across Professions, Disciplines, and Sectors

As discussed in Chapter 9 , eliminating health disparities will require the active engagement and advocacy of a broad range of stakeholders working in partnership to address the drivers of structural inequities in health and health care ( NASEM, 2017 ). In these efforts, nurses may lead or work with people from a variety of professions, disciplines, and sectors, including, for example, physicians, social workers, educators, policy makers, lawyers, faith leaders, government employees, community advocates, and community members. Working across sectors, especially as they relate to SDOH (food insecurity, transportation barriers, housing, etc.), is a critical competence. Collaboration among these types of stakeholders has multiple benefits, including broader expertise and perspective, the capacity to address wide-ranging social needs, the ability to reach underserved populations, and sustainability and alignment of efforts (see Chapter 9 for further discussion). A traditional nursing education, which focuses on what is taught rather than on building competencies, is unlikely to give students the understanding of broader social, political, and environmental contexts that is necessary for working in these types of strategic partnerships ( IOM, 2016b ). If nursing students are to be prepared to practice interprofessionally after graduation, they must be given opportunities to collaborate with others before graduation ( IOM, 2013 ) and to build the competencies they will need for collaborative practice. The Interprofessional Education Collaborative (IPEC) identified four core competencies for interprofessional collaborative practice ( IPEC, 2016 ). While these competencies were developed specifically to prepare students for interprofessional practice within health care, they are also applicable to broader collaborations among other professions, disciplines, and sectors both within and outside of health care:

• Work with individuals of other professions to maintain a climate of mutual respect and shared values.
• Use the knowledge of one’s own role and those of other professionals to appropriately assess and address the health care needs of patients and to promote and advance the health of populations.
• Communicate with patients, families, communities, and professionals in health and other fields in a responsive and responsible manner that supports a team approach to the promotion and maintenance of health and the prevention and treatment of disease.
• Apply relationship-building values and the principles of team dynamics to perform effectively in different team roles in planning, delivering, and evaluating patient/population-centered care and population health programs and policies that are safe, timely, efficient, effective, and equitable.

There are opportunities for nursing students to gain interprofessional and multisector collaborative competencies through both experiential learning in the community (discussed in detail below) and classroom work. Increasingly, nursing schools are working with other institutions to offer students classes in which they learn with or from students and professionals in other disciplines. For example, the University of Michigan Center for Interprofessional Education offers courses in such topics as health care delivery in low- and middle-income countries, social justice, trauma-informed practice, interprofessional communication, and teamwork. Courses are open to students from the schools of social work, pharmacy, medicine, nursing, dentistry, physical therapy, public health, and business. 4

Despite the benefits of interprofessional education, however, there are barriers that affect the implementation of such programs in health professions education, including different schedules, lack of meeting space, incongruent curricula plans, faculty not trained to teach interprofessionally, faculty overload, and the challenge of providing adequate opportunities for all levels of students ( NLN, 2015a ). The use of simulation has been proposed as a vehicle for overcoming such barriers to impart interprofessional collaborative competencies ( NLN, 2013 ); a systematic review of the evidence found that this approach can be effective ( Marion-Martins and Pinho, 2020 ). Nurses can also gain interprofessional experience by pursuing dual degrees. For example, the University of Pennsylvania offers dual degrees that combine nursing with health care management, bioethics, public health, law, or business administration.

Continually Adapting to New Technologies

Nurses can use a wide variety of existing and emerging technologies and tools to address SDOH and provide high-quality care to all patients (see Box 7-5 ). Broadly speaking, these technologies and tools fall into three categories: patient-facing, clinician-facing, and data analytics. Patient- and clinician-facing tools collect data and help providers and patients connect and make decisions

4 Not all courses are open to students from all schools.

about care. Data analytics uses data, collected from patients or other sources, to analyze trends, identify disparities, and guide policy decisions. Beginning as students, all nurses need to be familiar with these technologies, be able to engage with patients or other professionals around their appropriate use, and understand how their use has the potential to exacerbate inequalities.

Patient-facing technologies include apps and software, such as mobile and wearable health devices, as well as telehealth and virtual visit technologies ( FDA, 2020 ). These tools allow nurses and other health care providers to expand their reach to those who might otherwise not have access because of geography, transportation, social support, or other challenges. For example, telehealth and mobile apps allow providers to see people in their homes, mitigating such barriers to care as transportation while also helping providers understand people in the context of their everyday lives. Essential skills for nurses using these new tools will include

the ability to project a caring relationship through technology ( Massachusetts Department of Higher Nursing Education Initiative, 2016 ) and to use technology to personalize care based on patient preferences, technology access, and individual needs ( NLN, 2015b ). The role of telehealth and the importance of training nurses in this technology have been recognized for several years ( NONPF, 2018 ; Rutledge et al., 2017 ), but the urgent need for telehealth services during the COVID-19 pandemic has made it “imperative” to include telehealth training in nursing curricula ( Love and Carrington, 2020 ). Moreover, it is anticipated that the shift to telehealth for some types of care will become a permanent feature of the health care system in the future ( Bestsennyy et al., 2020 ).

Clinician-facing technologies include EHRs, clinical decision support tools, mobile apps, and screening and referral tools ( Bresnick, 2017 ; CDC, 2018 ; Heath, 2019 ). A number of available digital technologies can facilitate the collection and integration of data on social needs and SDOH and help clinicians hold compassionate and empathetic conversations about those needs ( AHA, 2019 ; Giovenco and Spillane, 2019 ). In 2019, for example, Kaiser Permanente launched its Thrive Local network ( Kaiser Permanente, 2019 ), which can be used to screen for social needs and connect people with community resources that can meet these needs. The system is integrated with the EHR, and it is capable of tracking referrals and outcomes to measure whether needs are being met; these data can then be used to continuously improve the network.

Nurses will need to understand how and when to use these types of tools, and can leverage their unique understanding of patient and community needs to improve and expand them. As described in Chapter 10 , such technologies as EHRs and clinical alarms can burden nurses and contribute to workplace stress. However, nurses have largely been left out of conversations about how to design and use these systems. For example, although nurses are one of the primary users of EHR systems, little research has been conducted to understand their experiences with and perceptions of these systems, which may be different from those of other health care professionals ( Cho et al., 2016 ; Higgins et al., 2017 ). Out of 346 usability studies on health care technologies conducted between 2003 and 2009, only 2 examined use by nurses ( Yen and Bakken, 2012 ). Educating nurses to understand and assess the benefits and drawbacks of health care technologies and have the capacity to help shape and revamp them can ultimately improve patient care and the well-being of health professionals.

Tools for data analytics are increasingly important for improving patient care and the health of populations ( Ibrahim et al., 2020 ; NEJM Catalyst, 2018 ). Analysis of large amounts of data from such sources as EHRs, wearable monitors, and surveys can help in detecting and tracking disease trends, identifying disparities, and finding patterns of correlation ( Breen et al., 2019 ; NASEM, 2016a ; Shiffrin, 2016 ). The North Carolina Institute for Public Health, for example, collaborated with a local health system in analyzing data to inform a community health improvement plan ( Wallace et al., 2019 ). Data on 12 SDOH indicators were sourced

from the American Community Survey and mapped by census tract. The mapping provided a visualization of the disparities in the community and allowed the health system to focus its efforts strategically to improve community health. The North Carolina Department of Health and Human Services later replicated this strategy across the entire state ( NCDHHS, 2020 ).

There are opportunities for nurses to specialize in this type of work. For example, nursing informatics is a specialized area of practice in which nurses with expertise in such disciplines as information science, management, and analytical sciences use their skills to assess patient care and organizational procedures and identify ways to improve the quality and efficiency of care. In the context of SDOH, nursing informaticists will be needed to leverage artificial intelligence and advanced visualization methods to summarize and contextualize SDOH data in a way that provides actionable insights while also eliminating bias and not overwhelming nurses with extraneous information. Big data are increasingly prevalent in health care, and nurses need the skills and competencies to capitalize on its potential ( Topaz and Pruinelli, 2017 ). Even nurses who do not specialize in informatics will need to understand how the analysis of massive datasets can impact health ( Forman et al., 2020 ; NLN, 2015b ). Investments in expanding program offerings, certifications, and student enrollment will be needed to meet the demand for nurses with such skills.

As noted, however, despite its promise for improving patient care and community health, technology can also exacerbate existing disparities ( Ibrahim et al., 2020 ). For example, people who lack access to broadband Internet and/or devices are unable to take advantage of such technologies as remote monitoring and telehealth appointments ( Wise, 2012 ). Older adults, people with limited formal education, those living in rural and remote areas, and the poor are less likely to have access to the Internet. As health care becomes more reliant on technology, these groups are likely to fall behind ( Arcaya and Figueroa, 2017 ). In addition, such technologies as artificial intelligence and algorithmic decision-making tools may exacerbate inequities by reflecting existing biases ( Ibrahim et al., 2020 ). Nursing education needs to prepare nurses to understand these potential downsides of technology in order to prevent and mitigate them. This has become a particularly critical issue during the COVID-19 pandemic, with the rapid shift to telehealth potentially having consequences for those with low digital literacy, limited English proficiency, and a lack of access to the Internet ( Velasquez and Mehrotra, 2020 ).

Not all nurses will need to acquire all of the key technological competencies; curricula can be developed according to the likely needs of nurses working at different levels. For example, most nurses will need the knowledge and skills to use telehealth, digital health tools, and data-driven clinical decision-making skills in practice, whereas nurse informaticians and some doctoral-level nurses will need to be versed in device design, bias assessment in algorithms, and big data analysis.

EXPANDING LEARNING OPPORTUNITIES

As stated previously, the domains and competencies enumerated above cannot be conveyed to nursing students through traditional lectures alone. Building the competencies to address population health, SDOH, and health inequities will require substantive experiential learning, collaborative learning, an integrated curriculum, and continuing professional development throughout nurses’ careers ( IOM, 2016b ). The 2019 Campaign for Action survey of nursing educators and leaders found that a majority of respondents identified “innovative community clinical experiences” and “interprofessional education experiences” as the top methods for teaching population health ( Campaign for Action, 2019b ). A recurrent theme in interviews with respondents was the importance of active and experiential learning, with opportunities for partnering with nontraditional agencies ( Campaign for Action, 2019b ). These types of community-based educational opportunities, particularly when they involve partnerships with others, are critical for nursing education for multiple reasons.

First, experience in the community is essential to understanding SDOH and gaining the competencies necessary to advance health equity ( IOM, 2016b ). In fact, restricting education in SDOH to the classroom may even be harmful, given the finding of a 2016 study that medical students who learned about SDOH in the classroom rather than through experiential learning demonstrated an increase in negative attitudes toward medically underserved populations ( Schmidt et al., 2016 ).

Second, community-based education offers opportunities for students to engage with community partners from other sectors, such as government offices of housing and transportation or community organizations, preparing them for the essential work of participating in and leading partnerships to address SDOH. An example is a pilot interdisciplinary partnership between a school of nursing and a city fire department in the Pacific Northwest that allows students to practice such skills as motivational interviewing to identify the range of problems (e.g., transportation issues, difficulty accessing insurance or providers, lack of caregiving support) faced by people calling emergency services ( Yoder and Pesch, 2020 ).

Third, nursing is increasingly practiced in community settings, such as schools and workplaces, as well as through home health care ( WHO, 2015 ). Nursing students are prepared to practice in hospitals, but do not necessarily receive the same training and preparation for these other environments ( Bjørk et al., 2014 ). Education in the community allows nursing students to learn about the broad range of care environments and to work collaboratively with other professionals who work in these environments. For example, students may work in a team with community health workers, social workers, and those from other sectors (e.g., housing and transportation), work that both enriches the experience of student nurses and creates bridges between nursing and other fields ( Zandee et

al., 2010 ). Nurses who have these experiences during school may then be more prepared to lead and participate in multisector efforts to address SDOH—the importance of which is emphasized throughout this report—once they enter practice. Evidence suggests that graduating students are more likely to seek work in areas that are familiar to them from their education, clinical experience, and theoretical training ( Jamshidi et al., 2016 ); thus, these nontraditional educational experiences may increase the number of nurses interested in working in the community. Moreover, while training in acute care settings has often been regarded as more valuable than that provided in community settings, evidence indicates that the two offer comparable opportunities for learning clinical skills ( Morton et al., 2019 ). In fact, clinical care in community-based settings can present greater complexity relative to that in the hospital, and some technical skills (e.g., epidemiologic disease tracking, tuberculosis assessment and management, immunizations) are more available in community than in acute care settings ( Morton et al., 2019 ).

Some nursing programs have incorporated community-based experiential learning into their programs. At community colleges and universities, schools have implemented nurse-managed clinics that serve the local population and their own students while also giving students technical skills and experience in interacting with the community. Lewis and Clark Community College, for example, operates a mobile health unit that brings health and dental care to six counties in southern Illinois ( Lewis and Clark, n.d. ), while nursing students at Alleghany College of Maryland can gain experience in the Nurse Managed Wellness Clinic, which offers such services as immunizations, screenings, and physicals ( Alleghany College, 2020 ). At the baccalaureate and master’s level, a number of schools offer longitudinal, integrated experiences in settings as varied as federally qualified health centers (FQHCs), public health departments, homeless shelters, public housing sites, public libraries, and residential addiction programs ( AACN, 2020c ). Students and faculty at the University of Washington School of Nursing, for example, support community-oriented projects in partnership with three underserved communities in the Seattle area. Graduate students work for 1 year on grassroots projects (e.g., food banks, school health) and then reinforce this experience with 1 year of work at the policy level ( AACN, 2020c ). At the doctoral level, Washburn University transformed its DNP curriculum to incorporate SDOH and reinforce that instruction through experiential learning in the community (see Box 7-6 ). In addition to clinical education, nursing students can participate in nontraditional clinical community engagement and service learning opportunities, such as volunteering at a homeless shelter or working in a service internship for a community organization. These opportunities get students into the community, help them build relationships with people from health care and other sectors, and promote understanding of and engagement with SDOH ( Bandy, 2011 ).

Simulation-Based Education

Simulation-based education is another useful tool for teaching nursing concepts and developing competencies and skills ( Kononowicz et al., 2019 ; Poore et al., 2014 ; Shin et al., 2015 ). It can range from very low-tech (e.g., using oranges to practice injections) to very high-tech (e.g., a virtual reality emergency room “game”), but all simulations share the ability to bridge the gap between education and practice by imparting skills in a low-risk environment ( SSIH, n.d. ).

Simulations give students an opportunity to make real-time decisions and interact with virtual patients without having to face many of the challenges of traditional clinical education ( Hayden et al., 2014 ). They can be used to enhance many types of skills, including communication ( NASEM, 2018b ), cultural sensi-

tivity ( Lau et al., 2016 ), and screening for SDOH ( Thornton and Persaud, 2018 ). Several simulation-based tools are available for learning about the realities of poverty, such as the Community Action Poverty Simulation (see Box 7-7 ) and the Cost of Poverty Experience ( ThinkTank, n.d. ). Such tools can help nurses identify ways in which their practice could directly mitigate the effects of poverty on individuals, families, and communities. Evaluations of poverty simulations have found that they can positively impact attitudes toward poverty and empathy among nurses and nursing students ( Phillips et al., 2020 ; Turk and Colbert, 2018 ), although one study noted that the simulations should be accompanied by the inclusion of social justice concepts throughout the curriculum to achieve lasting change ( Menzel et al., 2014 ).

Individual schools may or may not have the resources or faculty to support some types of simulation activities. For those that do not, simulation centers shared by schools of multiple professions and hospitals can provide access ( Marken et al., 2010 ). For example, the New York Simulation (NYSIM) Center was created through a public–private partnership to manage interprofessional, simulation-based education for students and hospital employees across multiple sites ( NYSIM, 2017 ). The opportunity to take part in simulation experiences with students from other health professions can also improve collaboration and teamwork and prepare nurses for practicing interprofessionally in the workplace ( von Wendt and Niemi-Murola, 2018 ).

Limitations on in-person clinical training during the COVID-19 pandemic conditions have demonstrated the promise of simulation-based education as

a way to supplement traditional nursing education, allowing students to complete their education and sustaining the nursing workforce pipeline ( Horn, 2020 ; Jiménez-Rodríguez et al., 2020 ; Yale, 2020 ). Before the pandemic, the NCSBN conducted a longitudinal, randomized controlled trial of the use of simulation and concluded that substituting simulation-based education for up to half of a nursing student’s clinical hours produces comparable educational outcomes and students who are ready to practice ( Hayden et al., 2014 ). The COVID-19 pandemic has necessitated and accelerated the use of simulation to replace direct care experience in nursing schools, and state boards of nursing have loosened previous restrictions on its use ( NCSBN, 2020b ). Evaluation of this expanded use of simulation and other virtual experiences during the pandemic is needed, both in preparation for future emergencies and for use in nursing education generally.

RECRUITING AND SUPPORTING DIVERSE PROSPECTIVE NURSES

The composition of the population of prospective nurses and the ways they are supported throughout their education are important factors in how prepared the future nursing workforce will be to address SDOH and health equity. As discussed in prior chapters, developing a more diverse nursing workforce will be key to achieving the goals of reducing health disparities, providing culturally relevant care for all populations, and fostering health equity ( Center for Health Affairs, 2018 ; IOM, 2011 , 2016 ; Williams et al., 2014 ). A diverse workforce is one that reflects the variations in the nation’s population in such characteristics as socioeconomic status, religion, sexual orientation, gender, race, ethnicity, and geographic origin.

The nursing workforce has historically been overwhelmingly White and female, although it is steadily becoming more diverse (see Chapter 3 ). The 2016 IOM report assessing progress on the 2011 The Future of Nursing report notes that shifting the demographics of the overall workforce is inevitably a slow process since only a small percentage of the workforce leaves and enters each year ( IOM, 2016a ). The pipeline of students entering the field, on the other hand, can respond much more rapidly to efforts to increase diversity ( IOM, 2016a ). Since the 2011 report was published, significant gains have been realized in the diversity of nursing students. The number of graduates from historically underrepresented ethnic and racial groups more than doubled for BSN programs, more than tripled for entry-level master’s programs, and more than doubled for PhD programs ( AACN, 2020a ). The number of underrepresented students graduating from DNP programs grew by more than 1,000 percent, although this gain was due in large part to rapid growth in these programs generally. Yet, despite these gains, nursing students remain largely female and White: in 2019, 85–90 percent of students were female, and around 60 percent were White. The percentages of ADN, BSN, entry-level master’s, PhD, and DNP graduates in 2019 by race/ethnicity and gender are shown in Tables 7-3 and 7-4 , respectively. For example, the

proportion of Hispanic or Latino nurses is highest among ADN graduates (12.8 percent) and lowest among PhD (5.5 percent) and DNP (6 percent) graduates, while the proportion of Asian nurses is highest among MSN graduates (11.2 percent) and lower among graduates with all other degrees. The proportion of PhD graduates who are male (9.9 percent) is significantly lower than the proportion of graduates with other degrees who are male.

Diversifying and strengthening the nursing student body—and eventually, the nursing workforce—requires cultivating an inclusive environment, recruiting and admitting a diverse group of students, and providing students with support and addressing barriers to their success throughout their academic career and into practice. In addition, it is essential to make available information that will enable prospective students to make informed decisions about their education and give them multiple pathways for completing their education (e.g., distance learning, accelerated programs). Accrediting bodies can play a role in advancing diversity and inclusion in nursing schools by requiring certain policies, practices, or systems. For example, the accreditation standards for medical schools of the Liaison Committee on Medical Education (LCME) include the following expectation ( LCME, 2018 ):

TABLE 7-3 Nursing Program Graduates by Degree Type a and by Race/Ethnicity, 2019

NOTE: ADN = associate degree in nursing; BSN = bachelor of science in nursing; DNP = doctor of nursing practice; LPN/LVN = licensed practical/vocational nurse; MSN = master of science in nursing.

a Data not available for LPN/LVN.

b ADN data are from 2018.

c Entry-level master’s degree.

SOURCE: American Association of Colleges of Nursing, Enrollment & Graduations in Baccalaureate and Graduate Programs in Nursing (series); Integrated Postsecondary Education Data System (IPEDS), Completions Survey (series) for ADN data.

TABLE 7-4 Nursing Program Graduates by Degree Type a and Gender, 2019

A medical school has effective policies and practices in place, and engages in ongoing, systematic, and focused recruitment and retention activities, to achieve mission appropriate diversity outcomes among its students, faculty, senior administrative staff, and other relevant members of its academic community. These activities include the use of programs and/or partnerships aimed at achieving diversity among qualified applicants for medical school admission and the evaluation of program and partnership outcomes.

Currently, none of the major nursing accreditors (ACEN, CCNE, CNEA) includes similar language in its accreditation standards. As shown in Table 7-5 , of six possible areas for standards on diversity and inclusion, ACEN and CCEN have standards only for student training, while CNEA has standards for student training and faculty diversity. No nursing accreditors have standards for student diversity; in comparison, accrediting bodies for pharmacy, physician assistant, medical, and dental schools all have such standards.

Cultivating an Inclusive Environment

Efforts to recruit and educate prospective nurses to serve a diverse population and advance health equity will be fruitless unless accompanied by efforts to acknowledge and dismantle racism within nursing education and nursing practice ( Burnett et al., 2020 ; Schroeder and DiAngelo, 2010 ; Villaruel and Broome, 2020 ; Waite and Nardi, 2019 ). The structural, individual, and ideological racism that exists in nursing is rarely called out, and this silence further entrenches the idea of Whiteness as the norm within nursing while marginalizing and silencing other groups and their perspectives ( Burnett et al., 2020 ; Iheduru-Anderson, 2020 ; Schroeder and DiAngelo, 2010 ). Non-White students report a wide variety of negative experiences in nursing school, including unsupportive faculty, discrim-

TABLE 7-5 Diversity and Inclusion in Accreditation Standards

SOURCE: Batra and Orban, 2020 .

ination and microaggressions 5 on the part of faculty and peers, bias in grading, loneliness and social isolation, feeling unwelcome and excluded, being viewed as a homogeneous population despite being from varying racial/ethnic groups, lack of support for career choices, and a lack of mentors ( Ackerman-Barger et al., 2020 ; Graham et al., 2016 ; Johansson et al., 2011 ; Loftin et al., 2012 ; Metzger et al., 2020 ). These experiences are associated with adverse outcomes that include disengagement from education, loss of “self,” negative perceptions of inclusivity and diversity at the institution, and institutions’ inability to recruit and retain a diversity of students ( Metzger et al., 2020 ). By contrast, when students characterize the learning environment as inclusive, they are more satisfied and confident in their learning and rate themselves higher on clinical self-efficacy and clinical belongingness ( Metzger and Taggart, 2020 ).

Notably, however, underrepresented and majority students describe inclusive environments differently. In a study of fourth-year baccalaureate nursing students, both groups described an inclusive classroom as one where they felt comfortable and respected and had a sense of belonging, but underrepresented minority students also noted the importance of feeling safe, feeling free from hostility, and being seen as themselves and not a representative of their group ( Metzger and Taggart, 2020 ). Both groups agreed that inclusivity requires a top-down approach, and that faculty are particularly influential in creating an inclusive environment, yet underrepresented students shared many experiences in which faculty either disrupted the sense of belonging or did not intervene when someone else did ( Metzger and Taggart, 2020 ).

While increased attention has recently been focused on increasing diversity in nursing education, the pervasiveness of racism requires more open acknowledgment and discussion and a systematic and intentional approach that may, as discussed earlier, be uncomfortable for some ( Ackerman-Barger et al., 2020 ; Villaruel and Broome, 2020 ). Cultivating an inclusive environment requires acknowledging and challenging racism in all aspects of the educational experience, including curricula, institutional policies and structures, pedagogical strategies, and the formal and informal distribution of resources and power ( Iheduru-Anderson, 2020 ; Koschmann et al., 2020 ; Metzger and Taggart, 2020 ; Schroeder and DiAngelo, 2010 ; Villaruel and Broome, 2020 ; Waite and Nardi, 2019 ). Nursing school curricula have historically focused on the contributions of White and female nurses ( Waite and Nardi, 2019 ). The weight given to this curricular content sends a message to students—both White students and students of color—about what faculty consider important ( Villaruel and Broome, 2020 ). Moving forward, curricula need to include a critical examination of the history of racism within nursing and an acknowledgment and celebration of the contribution of nurses of color ( Waite and Nardi, 2019 ). Such efforts need to be led by a broad group of individuals from all levels within an institution; racism in institutional practices

5 Brief and commonplace daily indignities (see Chapter 10 ).

can be so ingrained that it is difficult for those with power to recognize ( Villaruel and Broome, 2020 ). Faculty often understand the importance of an inclusive learning environment, but struggle with moving from intention to action (Beard, 2013, 2014 ; Metzger et al., 2020 ).

While institutional efforts to change organizational culture are thoroughly described in the literature, they remain too rare to address the problems described above effectively ( Breslin et al., 2018 ). In the early 2000s, the University of Washington School of Nursing implemented a project designed to change the “climate of whiteness” at the school ( Schroeder and DiAngelo, 2010 ). The project involved many facets, including year-long antiracist workshops; a comprehensive and institutionalized diversity statement; and action plans for addressing admission barriers, encouraging ongoing education for faculty, and disseminating antiracist information to the entire campus. The authors of an evaluation of the project note that while initial feedback was positive, changing the sociopolitical climate of a school is a long-term process that requires institutional commitment, innovative leadership, long- and short-term strategies, and patience ( Schroeder and DiAngelo, 2010 ). Unfortunately, many administrators and leaders may hesitate to initiate dialogues about these issues or may lack knowledge of how to address the challenges, and in many institutions, faculty and administrators from underserved groups have been expected to carry this burden, which can allow their colleagues to remain passive ( Lim et al., 2015 ). The committee stresses that addressing racism and discrimination within the nursing profession requires more than mere programs or statements; it requires developing action-oriented strategies, holding difficult conversations about privilege, dismantling long-standing structures and traditions, conducting curricular reviews to detect biases and correct as necessary, and exploring how interpersonal and structural racism shapes the student experience both consciously and unconsciously ( Burnett et al., 2020 ; Iheduru-Anderson, 2020 ; Waite and Nardi, 2019 ).

Recruitment and Admissions

Many social and structural barriers impede the entry of underrepresented students into the nursing profession ( NACNEP, 2019 ). Several approaches can be taken to improve access for prospective underrepresented students and, by extension, increase the diversity of the nursing workforce. Recruitment of underrepresented students can start years before nursing school through such approaches as improved K–12 science education ( AAPCHO, 2009 ) and outreach to junior high and high school students, such as through summer pipeline programs ( Katz et al., 2016 ) or health career clubs ( Murray et al., 2016 ). K–12 education is particularly important for sparking students’ interest in the health professions, as well as for giving them the foundational knowledge necessary for success ( NASEM, 2016b ). One innovative approach to preparing young people for a career in nursing is the Rhode Island Nurses Institute Middle College Charter High School (RINIMC).

RINIMC offers a free, 4-year, nursing-focused, high school education open to any student in Rhode Island; students graduate with experience in health care as well as up to 20 college credits. Nearly half of the program’s students are Latinx, and more than one-third are Black ( RINIMC, n.d. ). Establishing a pathway to nursing education for diverse students well before undergraduate school is important, particularly for first-generation students ( Katz et al., 2016 ; McCue, 2017 ). Some states offer dual enrollment programs. An example is Ohio’s College Credit Plus program, in which students in grades 7 to 12 have the opportunity to earn college and high school credits simultaneously, thus preparing them for postsecondary success. 6

Once students have applied to nursing school, a system of holistic admissions can improve the diversity of the incoming class ( Glazer et al., 2016 , 2020). A holistic admissions system involves evaluating an applicant based not only on academic achievement but also on experiences, attributes, potential contributions, and the fit between the applicant and the institutional mission ( DeWitty, 2018 ; NACNEP, 2019 ). Schools that have implemented such a system have seen an increase in the diversity of their student body ( Glazer et al., 2016 , 2018 ). Academic measures (e.g., graduation and exam pass rates) have remained unchanged or improved, and schools have reported increases in such measures as student engagement, cooperation and teamwork, and openness to different perspectives ( Artinian et al., 2017 ; Glazer et al., 2016 , 2020). In a recent paper published by AACN (2020d) , the following promising practices in holistic admissions were identified: (1) review institutional mission, vision, and values statements to ensure that they value diversity and inclusion; (2) create an “experience, attributes, and metrics (E-A-M) model” (p. 16) that connects back to the institution’s mission statement; (3) identify recruitment practices that align with the E-A-M model; (4) design rubrics to be used by admissions committees that are reflective of the E-A-M model; (5) engage faculty and staff in the holistic admissions review process; (6) use technology resources such as a centralized application system to maintain efficiencies; (7) develop tailored support services for underrepresented students; and (8) engage in a review and assessment of the entire process.

Addressing Barriers to Success

Part of cultivating an inclusive educational environment is acknowledging and addressing barriers that may prevent students from achieving their potential. As noted previously, some students—particularly those from underrepresented groups—may need support in a number of areas, including economic, social and emotional, and academic and career progression. Attention to the barriers faced by students is essential at each step along the pathway from high school preparation; to recruitment, admission, retention, and academic success in nurs-

6 See https://www.ohiohighered.org/collegecreditplus (accessed April 13, 2021).

ing school; to graduation and placement in a job; to retention and advancement within a nursing career ( IOM, 2016b ).

Providing Economic Supports

Cost is a key factor in decisions about nursing education for most students, and is particularly salient for those from underrepresented groups, who come disproportionately from families with comparatively low incomes and levels of wealth ( Diefenbeck et al., 2016 ; Graham et al., 2016 ; Sullivan, 2004 ). Sabio and Petges (2020) interviewed associate’s degree nursing students in a Midwestern state and found that the total cost of a baccalaureate degree and student debt was the greatest barrier to pursuing a degree, followed by family and personal, such as head-of-household, responsibilities. This challenge is pervasive in higher education, and there are indications that the problem is growing ( Advisory Committee on Student Financial Assistance, 2013 ). Students need to have the financial resources not only for tuition but also for an array of education-related expenses, including housing, food, work attire, books, and supplies.

Providing clear information about the costs of nursing education and available financial supports early in the recruitment and admission process is key to identifying those who need help and encouraging them to enroll ( Pritchard et al., 2016 ). Recruitment and admission practices need to take into account student finances and how future salaries affect choices, particularly for certain groups of students. Most health care systems provide some level of tuition reimbursement for baccalaureate and higher education, and this support may lead students toward certain settings (e.g., acute care) and away from others (e.g., public health, primary care) ( Larsen, 2012 ). Other financial support options are available, including the Public Service Loan Forgiveness program, which offers full forgiveness after 10 years for employees of nonprofit or government organizations ( U.S. Department of Education, n.d.b ), and programs through HRSA that award loan repayment to RNs and advanced practice nurses who work in health professions shortage areas for at least 2 years ( HRSA, 2021 ).

State policy reform can help remove some of the structural barriers to education. For example, New York State has implemented a program that allows New York households earning less than $125,000 annually to qualify for free instate tuition at state public universities ( New York State, n.d. ). New nurses who complete an associate’s degree in New York are required to complete a bachelor’s degree within 10 years of graduation; free in-state tuition could make a considerable difference for these nurses in pursuing their next degree. While it is too early to assess the effects on the composition of the nursing workforce, this approach bears further evaluation. Certainly it is critical for state policies to facilitate the financing of nursing education using models other than additional student loans. There are demonstrated disparities in the burden of student debt between Black and White students ( Brookings Institution, 2016 ), and the risk of assuming large

amounts of debt for students from disadvantaged backgrounds may be one they cannot afford to take. Therefore, innovative financing models are necessary to ensure that all nurses can pursue educational opportunities.

It is also important to note that as they progress in their education, students of many backgrounds may experience food insecurity, struggles with housing, or issues with transportation that affect their ability to perform ( AAC&U, 2019 ; Laterman, 2019 ; Strauss, 2020 ). Institutions need to ensure that students’ basic needs are met during their studies through sustained, multiyear funding and resources to support students facing financial emergencies.

Social and Academic Supports

Once students have been admitted, some nursing schools offer programs, such as summer programs that bridge high school and college, designed to prepare them academically and socially for the rigors of nursing education. Some of these programs are designed specifically for underrepresented and/or first-generation college students ( Pritchard et al., 2016 ), who may lack adequate family, emotional, and moral support; mentorship opportunities; professional socialization; and academic support ( Banister et al., 2014 ; Loftin et al., 2012 ). A study at the University of Cincinnati College of Nursing found that the impact of its summer bridge program lasted throughout the first year of school, and that grade point averages and retention were similar between underrepresented and majority students ( Pritchard et al., 2016 ). The Recruitment & Retention of American Indians into Nursing (RAIN) program at the University of North Dakota conducts a “No Excuses Orientation” workshop to give incoming American Indian students an opportunity to create connections and become acquainted with people and resources at the university ( UND, 2020 ). Tribal leaders are included in the orientation, along with discussions of cultural and family values and issues.

Another approach for supporting students is through mentoring programs. As discussed in Chapter 9 , these programs create supportive environments by providing peer and faculty role modeling, academic guidance, and support ( Wilson et al., 2010 ). Evidence indicates that mentoring programs for students from underrepresented groups are more effective when they include nurses and faculty from those groups, who have firsthand understanding of the unique challenges these students and nurses regularly confront ( Banister et al., 2014 ). This observation underscores the need for diverse faculty, mentors, and preceptors with the availability and willingness to guide these students and teach them leadership. For example, the RAIN program provides mentoring to American Indian students; staff and leaders are heavily involved in the local American Indian communities, and many are tribal members themselves ( Minority Nurse, 2013 ).

Students who represent the first generation in their families to enter a postsecondary institution may face challenges other students do not, and are more

likely to graduate if they receive support ( Costello et al., 2018 ). Parents and significant others can be a crucial source of support ( Pritchard et al., 2020 ); socializing and educating family members about the rigors of nursing programs may facilitate their support for students. A variety of programs around the country have succeeded in increasing graduation rates among first-generation students, including pipeline programs that have successfully increased the diversity of candidates entering nursing. These programs include HRSA pipeline programs; HOSA-Future Health Professionals; and university-based programs such as the Niganawenimaanaanig program at Bemidji State University in Minnesota, created to support American Indian nursing students ( HOSA, 2012 ; HRSA, 2017 ; Wilkie, 2020 ). Federal funding is available for these types of programs from sources that include HRSA’s Health Careers Opportunity Program and Nursing Workforce Diversity Grant program. However, the need for such programs exceeds the available funding. Box 7-8 lists some of the ways in which nursing programs can support their students’ success.

Data on Quality

One important tool for recruiting a more diverse student population is providing relevant data to prospective students so they can make informed decisions about where to study. These data could include NCLEX pass rates; however, these rates alone are insufficient to determine whether a school is likely to have the resources to support a student through to graduation. Data on student reten-

tion, graduation by demographic, full cost to attend, tuition, and other quality indicators can signal to both consumers and funders whether a nursing education program has the necessary infrastructure and support to retain students from diverse backgrounds. Pass rates can be reported by race, ethnicity, socioeconomic status, first-time college/university attendees, adult learners with children living at home, and status as an English as a second language (ESL) learner to help students choose a program that best suits their needs. It is also important for schools to provide on their websites demographic information about their current enrollees. As discussed above, NCSBN identified additional quality indicators for nursing education; as these indicators begin to be measured and reported, the data can help prospective students make more informed choices.

Educational Pathways and Options

As nursing education programs adapt their curricula and other learning experiences to better address SDOH and health equity, it will be important to consider the educational pathways students may follow, both in their initial preparation and as they progress in their careers. A key way of strengthening the nursing workforce will be to encourage nurses to pursue the next level of education and certification available to them and to improve access to these educational opportunities, especially for those from underrepresented communities ( Jones et al., 2018 ; Phillips and Malone, 2014 ).

One way to improve access and encourage nurses to take the next step in their education is by offering expedited programs that allow them to complete their degree in less time. For example, there are articulation agreements, either among educational institutions or at the state or regional level, that align the content and requirements of programs. These types of agreements accelerate the RN-to-BSN and RN-to-MSN pathways and allow students to easily transfer credits between community colleges and universities ( AACN, 2019b ). There are also bridge programs available for LPNs who wish to pursue the ADN or BSN degree. Investments in articulation programs have been responsible in part for an increase in the number of employed nurses with a baccalaureate degree, from 49 percent in 2010 to 59 percent in 2019 ( Campaign for Action, n.d. ). Further progress in this area is needed, however, particularly for partnerships between baccalaureate nursing programs and academic institutions that serve underrepresented populations (e.g., tribal colleges, historically Black colleges and universities). A model of this type of partnership can be found in the New Mexico Nursing Education Consortium, 7 which coordinates prelicensure nursing curricula in 16 locations at state, tribal, and community colleges.

Nursing education can also be expedited through the use of a competency-based curriculum that allows students to progress by demonstrating the required

7 See https://www.nmnec.org (accessed April 13, 2021).

competencies rather than meeting specific hour requirements ( U.S. Department of Education, n.d.a ). With this approach, which is currently used, for example, by Western Governors University, students can self-pace their education and potentially save time and money by learning the material quickly or tapping previous knowledge ( WGU, 2020 ). This type of educational approach may be particularly useful for nontraditional students who are entering nursing with other experiences and education. For example, a person with a background as a nursing or medical assistant may find that he or she can quickly master some of the required material for a nursing degree, particularly at the beginning. Workers from other sectors may also be able to pivot to nursing. During the COVID-19 pandemic, a study identified health care jobs, such as nursing assistant, that out-of-work hospitality workers could quickly transition to pursue ( Miller and Haley, 2020 ). While the study did not include jobs that required further education or certification, the shared skill sets that the authors identified include many skills that are central to nursing.

Another approach for increasing access to nursing education is to expand the use of distance learning opportunities. Distance learning gives students flexibility, and may be particularly beneficial for those from rural areas or other areas without a nursing school in the vicinity ( NCSBN, 2020b ). Rural areas face multiple challenges: rural populations have high rates of chronic disease and have difficulty accessing care because of provider shortages in these areas (see Chapter 2 ). Relative to their urban counterparts, rural nurses are less likely to hold a BSN ( Merrell et al., 2020 ). Distance learning has been used for many years to reach rural populations, but there are challenges with respect to regulation and ensuring the quality of education ( NCSBN, 2020a ). Efforts have been made to assess and improve the quality of distance learning; Quality Matters, for example, is an organization that provides peer-reviewed evaluation of distance or hybrid programs using a set of quality standards. 8 While many nursing programs are adhering to these standards ( Quality Matters, 2020 ), many are not, and the quality of distance learning remains uneven. The rapid rollout of distance learning during the COVID-19 pandemic has provided a unique opportunity to evaluate the effectiveness of different strategies for distance learning and to leverage this experience to expand and improve distance learning opportunities in the future.

STRENGTHENING AND DIVERSIFYING THE NURSING FACULTY

A system of nursing education that can prepare students from diverse backgrounds to address SDOH and health equity requires a diverse faculty ( NACNEP, 2019 ; Thornton and Persaud, 2018 ). Unfortunately, the faculty currently teaching in nursing programs is overwhelmingly White and female: as of 2018, full-time faculty in nursing schools were about 93 percent female, and only 17.3 percent were from underrepresented groups, up from 11.5 percent in 2009 ( AACN, 2020c ).

8 See https://www.qualitymatters.org (accessed April 13, 2021).

In addition to this lack of diversity, the number of faculty may be inadequate to prepare the next generation of nurses: not only were there 1,637 faculty vacancies in 2019 across 892 nursing schools, but the schools surveyed hoped to create 134 new faculty positions in that year ( AACN, 2020c ). These shortages contributed to decisions to turn away more than 80,000 qualified applicants, although other insufficiencies also played a part. The AACN report cites several key reasons for faculty shortages: increasing average age of faculty members and associated increasing retirement rates, high compensation in other settings that attracts current and potential nurse educators, and an insufficient pool of graduates from master’s and doctoral programs ( AACN, 2020c ; Fang and Bednash, 2017 ). A 2020 NACNEP report calls the faculty shortage a “long-standing crisis threatening the supply, education, and training of registered nurses” and recommends federal efforts as well as a coordinated private–public response to address the shortage ( NACNEP, 2020 ).

Finally, faculty must have the knowledge, skills, and competencies to prepare their students for the challenges of advancing health equity and fully understanding the implications of SDOH for their daily practice ( NACNEP, 2019 ). If health equity and SDOH are to be integrated throughout the curriculum (as discussed earlier in this chapter), all faculty, including tenure-track faculty, clinical instructors, mentors, and preceptors, must have these competencies ( Thornton and Persaud, 2018 ). To develop these competencies, nursing schools must commit resources and support to faculty development ( Thornton and Persaud, 2018 ).

Diversifying the Faculty

As noted, diverse faculty are needed to broaden the perspectives and experiences to which nursing students are exposed and to serve as mentors and role models for diverse students ( Phillips and Malone, 2014 ). Unfortunately, minority faculty members often face barriers similar to those faced by students, including an unwelcoming environment; feeling marginalized, underappreciated, and invisible; a lack of support; feelings of tokenism; and the inability to integrate into existing faculty structures ( Beard and Julion, 2016 ; Hamilton and Haozous, 2017 ; Iheduru-Anderson, 2020 ; Kolade, 2016 ; Salvucci and Lawless, 2016 ; Whitfield-Harris and Lockhart, 2016 ). Faculty from underrepresented groups report feeling isolated, lacking in mentorship and collegial support, and burdened by having to represent the entire underrepresented community ( Kolade, 2016 ; Whitfield-Harris et al., 2017 ). In addition, as discussed in Chapter 9 , faculty from underrepresented racial and ethnic groups face a “diversity tax,” in which they are asked to be part of efforts to improve diversity and inclusion to serve on committees; mentor underrepresented students; and participate in other activities that are uncompensated, unacknowledged, and unrewarded ( Gewin, 2020 ). These demands on underrepresented faculty can lead to frustration, burnout, and a feeling that they have been given responsibility for institutional diversity ( Gewin, 2020 ).

These experiences of minority faculty can result in high attrition and low satisfaction ( Whitfield-Harris et al., 2017 ), and further research is needed on specific ways in which institutions can recruit and support a diverse faculty ( Whitfield-Harris et al., 2017 ). Proposed approaches include cultivating an inclusive educational environment ( Hamilton and Haozous, 2017 ), taking intentional action and holding open discourse to strengthen the institutional commitment to diversity ( Beard and Julion, 2016 ), improving financial assistance and mentorship opportunities for faculty ( Salvucci and Lawless, 2016 ), and conducting climate surveys to better understand the feelings and experiences of underrepresented faculty and using these data to improve the institutional culture ( DeWitty and Murray, 2020 ). The challenges these faculty face and the opportunities to address these challenges highlight the importance of efforts by schools of nursing to recruit, support, and retain diverse faculty.

Faculty Development

Collectively, nursing school faculty need to be prepared to teach their students about the complex linkages among population health, SDOH, and health outcomes ( NLN, 2019 ; Thornton and Persaud, 2018 ). To do so, as discussed above, nurse educators need to move beyond teaching abstract principles to integrating the core concepts and competencies related to these linkages into the entire learning experience across nursing education programs. They also need to create a truly inclusive and safe educational environment and prepare nurses to care for a diverse population, which, as discussed above, requires that they understand issues of racism and systems of marginalization and engage in critical self-reflection ( O’Connor et al., 2019 , Peek et al., 2020 ). Yet, many faculty in nursing schools lack the knowledge and experience needed to develop curricula and strategies for incorporating SDOH into all areas of nursing education ( NACNEP, 2019 ; Valderama-Wallace and Apesoa-Varano, 2019 ).

Several approaches are available for preparing nursing school faculty to teach content related to SDOH and health equity. One approach, discussed above, is to actively recruit more diverse faculty who reflect the nation’s population and provide different perspectives and role models for students ( The Macy Foundation, 2020 ). Another approach is to encourage the development and dissemination of evidence-based methods for teaching nursing students how they can incorporate these core concepts into nursing practice. For example, educators involved in developing innovative models of classroom and experiential learning could focus on disseminating these models with the assistance of nursing associations and organizations, including through publication, continuing education programs, or faculty-to-faculty education and mentoring. Finally, institutions can provide in-depth and sustained learning opportunities for faculty, staff, and preceptors focused on how they can support their students in learning about SDOH and health equity both within and outside of the classroom ( IOM, 2016b ). While some fund-

ing sources are available for these types of efforts, including support from private foundations and HRSA grants for faculty development, the critical importance of this content to health outcomes argues for providing more such resources.

IMPLICATIONS OF COVID-19 FOR NURSING EDUCATION

It has been 100 years since a global event has had an impact on nursing education in the United States and around the world equal to that of the COVID-19 pandemic. Both World War I and the influenza pandemic of 1918 to 1920 led to transformations in nursing education, including standardization of training and professionalization of the field. The COVID-19 pandemic has already led to innovations that are likely to shape the future of nursing education. Faculty have adopted new teaching strategies, demonstrating creativity and adaptability, within a span of days or weeks, while such technologies as simulation-based education have quickly been adapted to replace in-person clinical hours ( Jiménez-Rodríguez et al., 2020 ). In one example of a rapid pivot, educators at the University of Pennsylvania School of Nursing transitioned a community immersion course from in-person to virtual form when all in-person classes were canceled. While they faced challenges, the educators found that students were able to remain dedicated to their community partnerships and to think creatively about how to meet their learning objectives ( Flores et al., 2020 ). These and similar innovations may ultimately guide the way to expanding and improving nursing education.

At the same time, however, the pandemic has highlighted challenges and inequities in nursing education. Simulated clinical experiences are practical only if a school and its students have access to computers with enough power to run the software, for example. While online learning has been in use for more than a decade, not all schools or faculty are prepared to deliver content in this way, nor are all students capable of accessing the necessary technology. Moreover, as practice settings have been emptied of non-COVID patients, programs have been facing multiple challenges in providing students with sufficient hours of instruction, training, and clinical practice. These challenges have underscored the limitations of traditional ways of educating nurses even as they have presented unique opportunities for innovation. To translate these short-term challenges into long-term improvements in nursing education will require

• evaluation of such practices as distance learning and virtual experiential learning to identify and disseminate best practices;
• a sense of urgency in the development of substantial changes, such as modifications of curriculum and the adoption of new technologies; and
• partnership with public- and private-sector organizations, associations, and researchers that can bring both resources and expertise to the tasks of strengthening nursing education.

CONCLUSIONS

Currently, most nursing schools tend to cover the topics of SDOH, health equity, and population health in isolated, stand-alone courses. This approach is insufficient for creating a foundational understanding of these critical issues and for preparing nurses to work in a wide variety of settings. This content needs to be integrated and sustained throughout nursing school curricula and paired with community-based experiential opportunities whereby students can apply their knowledge, build their skills, and reflect on their experiences.

Conclusion 7-1: A curriculum embedded in coursework and experiential learning that effectively prepares students to promote health equity, reduce health disparities, and improve the health and well-being of the population will build the capacity of the nursing workforce.

Preparing nursing students to address SDOH and improve health equity will require more than didactic learning and traditional clinical experiences. It will require that students engage actively in experiences that will expand and diversify their understanding of nursing practice, prepare them to care for diverse populations with empathy, and allow them to build the necessary skills and competencies for the nursing practice of tomorrow.

Conclusion 7-2: Increasing the number of nurses with PhD degrees who focus on the connections among social determinants of health, health disparities, health equity, and overall health and well-being will build the evidence base in this area. Building capacity in schools of nursing will require financial resources, including scholarship/loan repayment opportunities; adequate numbers of expert faculty available to mentor; and curriculum revisions to focus more attention on social determinants of health and health equity.

Having more nurses prepared at the PhD level will help build the knowledge base in the nursing profession for other nurses to translate (DNPs) and use in practice settings (LPNs, RNs, APRNs).

• develop such technical competencies as use of telehealth, digital health tools, and data analytics; and
• gain substantive experience with delivering care in diverse community settings, such as public health departments, schools, libraries, workplaces, and neighborhood clinics.

Building a diverse nursing workforce is a critical component of the effort to prepare nurses to address SDOH and health equity. While the nursing workforce has steadily grown more diverse, nursing schools need to continue and expand their efforts to recruit, support, and mentor diverse students.

Conclusion 7-4: Successfully diversifying the nursing workforce will depend on holistic efforts to support and mentor/sponsor students and faculty from a wide range of backgrounds, including cultivating an inclusive environment; providing economic, social, professional, and academic supports; ensuring access to information on school quality; and minimizing inequities.

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The decade ahead will test the nation's nearly 4 million nurses in new and complex ways. Nurses live and work at the intersection of health, education, and communities. Nurses work in a wide array of settings and practice at a range of professional levels. They are often the first and most frequent line of contact with people of all backgrounds and experiences seeking care and they represent the largest of the health care professions.

A nation cannot fully thrive until everyone - no matter who they are, where they live, or how much money they make - can live their healthiest possible life, and helping people live their healthiest life is and has always been the essential role of nurses. Nurses have a critical role to play in achieving the goal of health equity, but they need robust education, supportive work environments, and autonomy. Accordingly, at the request of the Robert Wood Johnson Foundation, on behalf of the National Academy of Medicine, an ad hoc committee under the auspices of the National Academies of Sciences, Engineering, and Medicine conducted a study aimed at envisioning and charting a path forward for the nursing profession to help reduce inequities in people's ability to achieve their full health potential. The ultimate goal is the achievement of health equity in the United States built on strengthened nursing capacity and expertise. By leveraging these attributes, nursing will help to create and contribute comprehensively to equitable public health and health care systems that are designed to work for everyone.

The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity explores how nurses can work to reduce health disparities and promote equity, while keeping costs at bay, utilizing technology, and maintaining patient and family-focused care into 2030. This work builds on the foundation set out by The Future of Nursing: Leading Change, Advancing Health (2011) report.

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What is Nursing?

_____________________________________________________________________________

DEFINITION OF NURSING

Nursing integrates the art and science of caring and focuses on the protection, promotion, and optimization of health and human functioning; prevention of illness and injury; facilitation of healing; and alleviation of suffering through compassionate presence. Nursing is the diagnosis and treatment of human responses and advocacy in the care of individuals, families, groups, communities, and populations in recognition of the connection of all humanity.

ANA (2021). Nursing: Scope and Standards of Practice, Fourth Edition, p. 1.

21 st Century nursing is the glue that holds a patient’s health care journey together. Across the entire patient experience, and wherever there is someone in need of care, nurses work tirelessly to identify and protect the needs of the individual.  

Beyond the time-honored reputation for compassion and dedication lies a highly specialized profession, which is constantly evolving to address the needs of society. From ensuring the most accurate diagnoses to the ongoing education of the public about critical health issues; nurses are indispensable in safeguarding public health.

Nursing can be described as both an art and a science; a heart and a mind. At its heart, lies a fundamental respect for human dignity and an intuition for a patient’s needs. This is supported by the mind, in the form of rigorous core learning. Due to the vast range of specialisms and complex skills in the nursing profession, each nurse will have specific strengths, passions, and expertise.

However, nursing has a unifying ethos:  In assessing a patient, nurses do not just consider test results. Through the critical thinking exemplified in the nursing process (see below), nurses use their judgment to integrate objective data with subjective experience of a patient’s biological, physical and behavioral needs. This ensures that every patient, from city hospital to community health center; state prison to summer camp, receives the best possible care regardless of who they are, or where they may be.

What exactly do nurses do?

In a field as varied as nursing, there is no typical answer. Responsibilities can range from making acute treatment decisions to providing inoculations in schools. The key unifying characteristic in every role is the skill and drive that it takes to be a nurse. Through long-term monitoring of patients’ behavior and knowledge-based expertise, nurses are best placed to take an all-encompassing view of a patient’s wellbeing.

What types of nurses are there?

All nurses complete a rigorous program of extensive education and study, and work directly with patients, families, and communities using the core values of the nursing process. In the United States today, nursing roles can be divided into three categories by the specific responsibilities they undertake.

Registered Nurses

Registered nurses (RN) form the backbone of health care provision in the United States. RNs provide critical health care to the public wherever it is needed.

Key Responsibilities

• Perform physical exams and health histories before making critical decisions
• Provide health promotion, counseling and education
• Administer medications and other personalized interventions
• Coordinate care, in collaboration with a wide array of health care professionals

Advanced Practice Registered Nurses

Advance Practice Registered Nurses (APRN) hold at least a Master’s degree, in addition to the initial nursing education and licensing required for all RNs. The responsibilities of an APRN include, but are not limited to, providing invaluable primary and preventative health care to the public. APRNs treat and diagnose illnesses, advise the public on health issues, manage chronic disease and engage in continuous education to remain at the very forefront of any technological, methodological, or other developments in the field.

APRNs Practice Specialist Roles

• Nurse Practitioners prescribe medication, diagnose and treat minor illnesses and injuries
• Certified Nurse-Midwives provide gynecological and low-risk obstetrical care
• Clinical Nurse Specialists handle a wide range of physical and mental health problems
• Certified Registered Nurse Anesthetists administer more than 65 percent of all anesthetics

Licensed Practical Nurses

Licensed Practical Nurses (LPN), also known as Licensed Vocational Nurses (LVNs), support the core health care team and work under the supervision of an RN, APRN or MD. By providing basic and routine care, they ensure the wellbeing of patients throughout the whole of the health care journey

• Check vital signs and look for signs that health is deteriorating or improving
• Perform basic nursing functions such as changing bandages and wound dressings
• Ensure patients are comfortable, well-fed and hydrated
• May administer medications in some settings

What is the nursing process?

No matter what their field or specialty, all nurses utilize the same nursing process; a scientific method designed to deliver the very best in patient care, through five simple steps.

• Assessment – Nurses assess patients on an in-depth physiological, economic, social and lifestyle basis.
• Diagnosis – Through careful consideration of both physical symptoms and patient behavior, the nurse forms a diagnosis.
• Outcomes / Planning – The nurse uses their expertise to set realistic goals for the patient’s recovery. These objectives are then closely monitored.
• Implementation – By accurately implementing the care plan, nurses guarantee consistency of care for the patient whilst meticulously documenting their progress.
• Evaluation – By closely analyzing the effectiveness of the care plan and studying patient response, the nurse hones the plan to achieve the very best patient outcomes. 

Nurses are Key to the Health of the Nation

• There are over 4 million registered nurses in the United States today.
• That means that one in every 100 people is a registered nurse.
• Nurses are in every community – large and small – providing expert care from birth to the end of life.
• According to the January 2012 “United States Registered Nurse Workforce Report Card and Shortage Forecast” in the American Journal of Medical Quality, a shortage of registered nurses is projected to spread across the country between 2009 and 2030. In this state-by-state analysis, the authors forecast the RN shortage to be most intense in the South and the West
• Nurses' roles range from direct patient care and case management to establishing nursing practice standards, developing quality assurance procedures, and directing complex nursing care systems.

ANF "Nurses as Leaders"

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The nursing profession was founded to protect, promote, and improve health for all ages.

ANA has been helping American nurses improve our nation's health since 1896.

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Nursing definitions

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Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings. Nursing includes the promotion of health, prevention of illness, and the care of ill, disabled and dying people.

Advocacy, promotion of a safe environment, research, participation in shaping health policy and in patient and health systems management, and education are also key nursing roles. (ICN, 2002)

Long definition

Nursing, as an integral part of the health care system, encompasses the promotion of health, prevention of illness, and care of physically ill, mentally ill, and disabled people of all ages, in all health care and other community settings. Within this broad spectrum of health care, the phenomena of particular concern to nurses are individual, family, and group "responses to actual or potential health problems" (ANA, 1980, P.9).

These human responses range broadly from health restoring reactions to an individual episode of illness to the development of policy in promoting the long-term health of a population.

The unique function of nurses in caring for individuals, sick or well, is to assess their responses to their health status and to assist them in the performance of those activities contributing to health or recovery or to dignified death that they would perform unaided if they had the necessary strength, will, or knowledge and to do this in such a way as to help them gain full of partial independence as rapidly as possible (Henderson, 1977, p.4).

Within the total health care environment, nurses share with other health professionals and those in other sectors of public service the functions of planning, implementation, and evaluation to ensure the adequacy of the health system for promoting health, preventing illness, and caring for ill and disabled people. (ICN, 1987)

Definition of a Nurse

The nurse is a person who has completed a program of basic, generalized nursing education and is authorized by the appropriate regulatory authority to practice nursing in his/her country. Basic nursing education is a formally recognised programme of study providing a broad and sound foundation in the behavioural, life, and nursing sciences for the general practice of nursing, for a leadership role, and for post-basic education for specialty or advanced nursing practice. The nurse is prepared and authorized :

• (1) To engage in the general scope of nursing practice, including the promotion of health, prevention of illness, and care of physically ill, mentally ill, and disabled people of all ages and in all health care and other community settings
• (2) To carry out health care teaching
• (3) To participate fully as a member of the health care team
• (4) To supervise and train nursing and health care auxiliaries
• (5) To be involved in research

(ICN, 1987)

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News & Data

Launch of 2024-2025 nursingcas application cycle.

August 13, 2024

Tri-Council for Nursing Releases Statement: When Nurses Vote, Health Care Policy Changes for the Better

August 12, 2024

AACN Recognizes Loyola University Chicago with an Inclusive Excellence, Belonging, and Sustainability in Nursing Education Award

August 08, 2024

The Essential Update

Current initiatives.

As the collective voice for academic nursing, AACN serves as the catalyst for excellence and innovation in nursing education, research, and practice. 

Well-being Initiatives

AACN actively promotes best practices and exemplars related to faculty and student wellness in our programming.

Partnerships & Leadership Engagement

Announced in January 2022, AACN is leading a two-year project, titled A Competency-Based Approach to Leadership Development and Resilience for Student Nurses, with funding from the Johnson & Johnson Foundation in partnership with the Center for Health Worker Innovation. 

Competency-Based Education for Practice-Ready Nurse Graduates

With funding through the  American Nurses Foundation’s Reimagining Nursing Initiative , AACN launched a three-year initiative earlier this year, titled  Competency-Based Education for Practice-Ready Nurse Graduates , to accelerate the move to competency-based education and the rapid adoption of the 2021 Essentials.

Diversity, Equity, & Inclusion

The American Association of Colleges of Nursing is a leading advocate for diversity, equity, and inclusion in nursing. AACN offers programs and resources to help nursing schools develop, promote, and advance DEI initiatives.

Conferences & Webinars

The Succession Plan: Developing a New Generation of Nurse Leaders

August 15 at 2:00 pm (ET)

Graduate Nursing Essentials: Utilizing the GNSA on Your Academic Journey

August 27 at 2:00 pm (ET)

Teaching Planetary Health During the Anthropocene Epoch

September 26 at 2:00 pm (ET)

Essentializing Your Curriculum: Moving Forward with Competency-Based Education Workshop

September 27, 2024 | St. Louis, MO

Unifying Caring Science and the AACN Essentials

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January 16-18, 2025 | Coronado, CA

Executive Development Series (ED) for Deans

March 28-29, 2025 | Washington DC

Deans Annual Meeting & Pre-Conference

March 29-31, 2025 | Washington, DC

Student Policy Summit

March 30-31, 2025 | Washington DC

Graduate Nursing Admissions Professionals (GNAP) Conference

April 7-9, 2025 | Seattle, WA

Business Officers of Nursing Schools (BONUS) Annual Meeting

April 23-25, 2025 | Nashville, TN

Access Connection Engagement (ACE) Symposium

June 4-6, 2025 | Indianapolis, IN

Our Mission

The American Association of Colleges of Nursing (AACN) is the national voice for academic nursing. AACN works to establish quality standards for nursing education; assists schools in implementing those standards; influences the nursing profession to improve health care; and promotes public support for professional nursing education, research, and practice.

“AACN is the only place that I can come and truly be among peers.”

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Join the Graduate Nursing Student Academy (GNSA) and access valuable programs, services, and resources tailored for graduate nursing students at AACN member schools. 

Nursing Theories & Theorists Explained

What is nursing theory.

• Nursing Theory Users
• Metaparadigms

Nursing Theorists

Nursing theory in practice.

Nursing theory is "a creative and rigorous structuring of ideas that project a tentative, purposeful, and systematic view of phenomena," per the book  Integrated Theory and Knowledge Development in Nursing.

Nursing theory provides the foundational knowledge that enables nurses to care for their patients and guides their actions. Theories are in place, regardless of nursing specialization, to establish guidelines for both broad and specific nursing practices.

Nursing theory is heavily influenced by Florence Nightingale's pioneering work, which significantly influenced the modern  nursing definition . Nightingale's Environmental Theory stated that nursing “ought to signify the proper use of fresh air, light, warmth, cleanliness, quiet, and the proper selection and administration of diet – all at the least expense of vital power to the patient.” 

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By identifying potential risk factors for illness or conditions that would exacerbate an illness and potentially lead to death, Nightingale saw the importance of a patient’s environment to their overall health and well-being. As a result, healthcare professionals, including nurses, began to treat patients differently and the start of population health and public health is seen. 

In Florence Nightingale’s Environmental Theory, she identified five environmental factors: 

• Efficient drainage 
• Cleanliness or sanitation
• Light or direct sunlight

These factors were essential to decrease the spread of contagious diseases and decreasing mortality and morbidity. 

While Florence Nightingale may have introduced the first nursing theory in 1860, it is still extremely relevant today. In countries where fresh air, pure water, efficient drainage, cleanliness or sanitation, and light or direct sunlight are not present, morbidity and mortality are increased. 

What are Nursing Theories Used For?

Nursing theories provide the foundation for nursing practice and are essential to the care of patients. Academic hospitals and Magnet hospitals will consistently ensure that nursing theories are incorporated into their policies and procedures to ensure best practice is being used. 

Most nurses and institutions will employ a variety of nursing theories within their everyday practice versus just one theory. Most do it unknowingly. 

Nursing theories help bedside nurses evaluate patient care and base nursing interventions on the evaluation of the findings. 

The theories can also provide nurses with the rationale to make certain decisions. An example of a nursing theory in use is seen in the care of a Jehovah’s Witnesses patient that does not believe in blood transfusions. While the patient may need a blood transfusion, Dorothea Orem’s Self-Care theory provides nurses with a solid basis for assisting their patients and giving them the opportunity to express independence and control in caring for themselves. While the nurse may not agree with the patient’s decision to not receive a blood transfusion, Orem’s theory suggests the importance of allowing the patient to make the decision and respecting it as their own choice. 

Oftentimes, the integration of nursing theory is not as obvious as in the aforementioned example. However, it is important for nurses and nursing students to understand and respect the importance of nursing theories and their impact on modern-day nursing and healthcare. 

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Who are Nursing Theories Used By?

While all nurses, regardless of position and specialty, utilize nursing theories in their practice, not all nurses are aware of their implications. Generally speaking, most nursing theories are used by nurse educators and nurse researchers. 

Nurse educators will utilize nursing theories in designing course curriculums based on educational principles, research, and theories to provide nursing students with the knowledge and skills needed to provide care to their patients. 

Nurse researchers will conduct theory-guided research in order to create best practices and to predict potential clinical problems or explain existing knowledge. 

Nursing Metaparadigms

There have been countless nursing theories introduced since Florence Nightingale's Environmental Theory, including Imogene King‘s Theory of Goal and Dorothy Johnson’s Behavioral System Model. What they all have in common is they center around the nursing metaparadigm.

A metaparadigm is a set of theories or ideas that provide structure for how a discipline should function. Nursing metaparadigms were first classified by Fawcett into four specific categories, 

• Environment

These four concepts are fundamental to all nursing theories and without identification of them and their relevance to the theory, it is incomplete.

Furthermore, these four basic nursing metaparadigms point to the holistic care of a patient and their medical health is interconnected to the four concepts. 

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The Four Main Concepts of Nursing Theory

Fawcett’s four specific concepts help define nursing and set it apart from other disciplines and professions. These four concepts have been used to define the context and content of the nursing profession. The person is the most important concept in nursing theory, but each theorist's interpretation of the other concepts is how to differentiate between them. 

Person (also referred to as Client or Human Being) is the recipient of nursing care and may include individuals, patients, groups, families, and communities.

2. Environment

Environment or situation is defined as the internal and external surroundings that affect the patient. It includes all positive or negative conditions that affect the patient, the physical environment, such as families, friends, and significant others, and the setting for where they go for their healthcare.

Health is defined as the degree of wellness or well-being that the client experiences. It may have different meanings for each patient, the clinical setting, and the health care provider.

The attributes, characteristics, and actions of the nurse providing care on behalf of or in conjunction with, the client. 

Levels of Nursing Theory

Nursing theories are categorized into three levels including, 

• Grand Nursing Theories
• Mid-range Nursing Theories
• Nursing Practice Theories

Grand Nursing Theories 

These are theories based on broad, abstract, and complex concepts. They provide the general framework for nursing ideas pertaining to components such as people and health. These theories typically stem from a nurse theorist’s own experience.

Mid-Range Nursing Theories 

These are theories that drill down into specific areas of nursing rather than deal with sweeping concepts. They can emerge from nursing practice, research, or from the theories of similar disciplines.

Nursing Practice Theories 

These are theories that narrow their focus even further, specifically focusing on concepts concerning a defined patient population. These theories tend to directly affect patients more than the other two types of theories. Bedside nurses will often use these theories in their everyday practice. 

We talked about Nightingale and Orems' role as nursing theorists and reviewed their respective theories. Let's explore the work of some other notable nursing theorists and how their work helps nurses and other healthcare providers give better patient care.

Virginia Henderson: Nursing Need Theory

Virginia Henderson's Nursing Need Theory centers around the concept of basic human needs. Henderson believed that the role of a nurse is to assist individuals in meeting their fundamental needs and help them increase their independence. 

Her theory emphasizes the nurse's role in supporting patients in activities such as:

Maintaining desired postures

Dress and undress

Cleanliness

Communicating fears, opinions, and needs, and

Worshiping according to their faith

Jean Watson:  Theory of Human Caring

Jean Watson is a contemporary nursing theorist renowned for her Theory of Human Caring . Watson emphasizes the importance of creating a caring and compassionate relationship between the nurse and the patient. 

Her theory focuses on  ten factors:

Upholding humanistic-altruistic values by practicing kindness and compassion

Being genuinely present and fostering faith, hope, and belief systems while respecting the subjective experiences of oneself and others

Cultivating self-awareness and spiritual practices, transcending ego-centeredness to achieve a transpersonal presence.

Developing and nurturing loving, trusting, and caring relationships

Encouraging the expression of both positive and negative emotions, actively listening to others' stories without judgment

Applying creative problem-solving through the caring-healing process

Engaging in transpersonal teaching and learning within a caring relationship, adapting to the individual's perspective and transitioning towards a coaching approach for enhanced health

Creating a healing environment on various levels, fostering an atmosphere of authentic caring presence at an energetic and subtle level.

Acknowledging the interconnectedness of mind, body, and spirit while upholding human dignity

Embracing the spiritual, mysterious, and unknown aspects of life

Madeleine Leininger: Transcultural Nursing Theory

Leininger's Transcultural Nursing Theory , also called Culture Care Theory, focuses on providing culturally congruent care by understanding and respecting the values, beliefs, and practices of diverse individuals and groups.

Hildegard Peplau: Interpersonal Relations Theory

Peplau's Interpersonal Theory of Interpersonal Relations emphasizes that the journey of nurse-patient relationships involves three pivotal stages that are essential for their success: 

The initial orientation

A dynamic working phase, and

A  thoughtful termination process

According to Peplau, the nurse's role is to facilitate the patient's growth and development by utilizing therapeutic communication, empathy, and understanding.

Betty Neuman: Neuman Systems Model

The Neuman Systems Model focuses on identifying stressors that have the potential to negatively impact an individual's health and overall well-being. It incorporates various factors such as physiological, psychological, sociocultural, and developmental aspects. 

The theory also provides a flexible structure for assessment, intervention, and evaluation in nursing practice. 

Sister Callista Roy: Adaptation Model

The Roy Adaptation Model is based on the belief that individuals are adaptive systems, constantly interacting with their environment to maintain their physiological and psychosocial integrity. It views the person as a holistic being, consisting of four interconnected adaptive modes:

Physiological Mode: Deals with physical and biological aspects of adaptation, including the body's response to stressors, maintaining homeostasis, and meeting basic physiological needs.

Self-Concept Mode: Focuses on individuals' perception of themselves, including self-esteem and self-image.

Role Function Mode: Considers the roles people have in their lives, such as spouse, parent, employee, or student. 

Interdependence Mode: Emphasizes the importance of social relationships and how individuals interact with others, such as support from social networks.

Martha Rogers: Science of Unitary Human Being

Rogers' Science of Unitary Human Beings believed that nursing should focus on promoting harmony and balance within the individual and their environment. 

Her theory emphasizes the interconnectedness of human beings with their surroundings and the importance of energy fields in health and healing. Spoken another way, patients cannot be considered as “separate” from their environment.

Patricia Benner: Novice to Expert Theory

Benner's Novice to Expert Theory describes the stages of nursing skill from novice to advanced beginner, and finally, to competent. 

She emphasizes the importance of practical experience and clinical judgment in nursing practice and highlights that expertise develops over time through practice and reflection.

Imogene King: Theory of Goal Attainment

King's Theory of Goal Attainment focuses on the nurse-patient relationship and the mutual goal-setting process. Her theory emphasizes that nurses and patients should collaborate to establish goals that promote the patient's well-being and health.

Katharine Kolcaba: Comfort Theory

Kolcaba's Comfort Theory highlights the significance of providing comfort to patients as a central goal of nursing care. 

Her theory defines comfort as the immediate experience of being strengthened in physical, psychospiritual, environmental, and sociocultural dimensions.

Kolcalba’s framework proposes that healthcare providers:

Assess if patient’s comfort needs are not being met

Create interventions to meet those needs

Measure comfort prior to and after the interventions

Nursing theories are used every day in practice even if nurses aren’t aware of their use. Theories help guide evidence-based research which then leads to best practices and policies. These policies and procedures keep patients safe, while providing the best care possible. 

Nursing theories also allow nurses to positively influence the health and well-being of their patients beyond taking care of them at the bedside. Nursing theory-guided practice helps improve the quality of care delivered and helps continue to move the nursing profession forward into the 21st century. 

Most bedside nurses will not necessarily know the theories behind their practice so their usefulness is often dismissed. Advanced practice nurses, nurse scholars, nurse educators, and nurse researchers are most likely going to be up to date on current nursing theories and their impact on the nursing profession. 

Nursing theories should continue to guide nursing practice both in academia and at the bedside. It allows nurses to provide current best-practice care to their patients while also impacting them beyond the bedside. Florence Nightingale’s Environmental Theory was groundbreaking during the 1860s and helped change the course of nursing and healthcare while changing the outcomes of patients through the identification of environmental factors that may hinder their health and well-being. 

Nursing Theory FAQs

What are the major nursing theories .

• All nursing theories encompass person, environment, health, and the nurse and are categorized into three hierarchies: grand nursing theories, middle-range nursing theories, and practice level nursing theories.  

What are examples of nursing theory? 

• Some examples of nursing theories include the Environmental Theory, the Casey Model of Nursing, the Martha Rogers Theory, the Tidal Model, and the Cultural Care Theory. 

What is the Casey model of nursing?

• The Casey Model of Nursing is a model of nursing designed to encompass the child-health relationship with five focuses: child, family, health, environment, and the nurse. 

What is Martha Roger's Theory?

• The Martha Rogers Theory of nursing looks at people as “unitary” human beings that can’t be divided into parts and nursing as a blend of both art and science. 

What is a partnership model in nursing?

• It’s a patient and family-centered care system that focuses on partnership between the two, along with education, support, communication, and collaborative practice.

What are the principles of the tidal model? 

• The tidal model of nursing has 6 principles: curiosity, virtue, mystery investigation, respect of the person, crisis as an opportunity, possessing goals, and pursuit of elegance.

Kathleen Gaines (nee Colduvell) is a nationally published writer turned Pediatric ICU nurse from Philadelphia with over 13 years of ICU experience. She has an extensive ICU background having formerly worked in the CICU and NICU at several major hospitals in the Philadelphia region. After earning her MSN in Education from Loyola University of New Orleans, she currently also teaches for several prominent Universities making sure the next generation is ready for the bedside. As a certified breastfeeding counselor and trauma certified nurse, she is always ready for the next nursing challenge.

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• The Importance of Nursing Interventions in Patient Care Plans

Aug 14, 2024 | RN to BSN

Nursing interventions play a critical role in healthcare, often serving as the backbone of effective patient care while optimizing patient health and comfort. Of course, nursing interventions can also be complex, especially when you consider the collaborative nature of care plans and the vital role that nurses play in their implementation.

Understanding the importance of nursing interventions helps bridge the gap between assessment and patient outcomes. This knowledge prepares both current and aspiring nurses for this critical job component.

What Are Nursing Interventions? Actions That Drive Healing

When answering the question, “What are nursing interventions?” this typically refers to purposeful actions designed to address specific patient needs and achieve desired patient outcomes. It is important to look at nursing interventions not just as “tasks,” but as important components of a comprehensive patient care plan that must be decided upon carefully. In addition to centering around patient health and well-being, nursing interventions should also help maintain a safe and clean environment for other members of a healthcare facility, including staff.

Types of Nursing Interventions

There are three main types of nursing interventions, with each type being initiated by different healthcare professionals. These include:

• Independent  – These are actions that nurses initiate on their own without direct physician orders. Some examples of independent interventions include providing patients with basic education and repositioning patients for comfort as needed.
• Dependent  – These are actions initiated based on physician orders, where nurses typically follow the directive but can question and recommend alternatives if they believe better options exist for the patient. Examples of dependent interventions include administering medication or inserting a catheter.
• Collaborative  – This refers to actions that require coordination and input from other healthcare team members, which can include nurses, doctors/physicians, and specialists. For example, a doctor might consult with nursing teams, physical therapy physicians, and even dietary specialists to ensure that interventions align with the patient’s specific needs.

The Importance of Understanding Nursing Classifications

In addition to understanding the different types of nursing interventions, nurses must also have an in-depth knowledge and awareness of nursing classification systems. Specifically, the most widely used taxonomy for organizing and categorizing nursing interventions is known as the  Nursing Interventions Classification (NIC) system .

Under the NIC system, interventions are organized into a four-level hierarchy. This system is critical for standardizing terminology, enhancing communication among healthcare professionals, and facilitating research and evidence-based practice among healthcare providers.

The Purpose of Nursing Interventions: Turning Plans Into Progress

Ultimately, the primary purpose of nursing interventions is to effectively carry out care plans while achieving the best possible outcome for the patient. There are numerous ways in which the right interventions and care plans can improve patient outcomes by addressing specific needs. This then helps reduce the risk of complications, promoting health and wellness, and restoring a sense of function and independence.

Addressing Patient Needs

At a very basic level, nurse interventions directly address the complex physical, emotional, and psychological needs of the patient. For instance, if a patient is feeling restless and uncomfortable, a nurse may take independent action to reposition the patient for greater comfort.

Meanwhile, nurses may provide compassionate care and basic education to patients as a means of mitigating emotional stress and empowering them regarding their own care. In this sense, nursing interventions can directly contribute to the overall well-being of patients.

Preventing Complications

When used properly, nursing interventions may also proactively prevent complications. A nurse taking care to reposition a bed-ridden patient on a regular basis, for example, may help prevent pressure ulcers. In the interim, regular changing and cleaning of wounds may reduce the risk of infections. Other interventions, such as using a fall risk assessment tool and providing proper patient education, can reduce the risk of a fall and lead to improved patient outcomes.

Promoting Health and Wellness

In many ways, nursing interventions can also be used to promote a greater sense of health and wellness within patient populations. Nurses have a great deal of information at their disposal, and they also tend to spend the most direct time interacting with patients. Nurses can use this to their advantage by using independent interventions to inform, educate, and empower patients to take charge of their own health. This can foster self-care and healthy behaviors that can lead to improved health and wellness down the road.

Restoring Function and Independence

Patients who have lost their sense of independence can suffer from a declining quality of life, which can have a negative impact on physical and psychological health. Fortunately, the right nursing interventions can help patients regain lost function and independence, resulting in an improved quality of life and better outlook overall.

For example, nurses can help patients with pain by administering medication that has been approved by a physician. In the meantime, nurses can demonstrate mobility exercises to patients to help improve their range of motion and facilitate recovery following an injury. These seemingly small interventions, when part of a coordinated care plan, can make all the difference in patient outcomes.

Nursing Intervention Examples: A Diverse Toolkit for Care

To better understand nursing interventions and how they can align with care plans, it can be helpful to consider some specific nursing interventions examples. Below, you’ll find examples of nursing interventions for a wide range of issues, ranging from acute pain and COPD to pneumonia, anxiety, and even fall risk.

Nursing Interventions for Acute Pain

Patients suffering from acute pain may be in a great deal of distress, especially if pain is severe. Ultimately, the goal of a patient care plan for acute pain should be to pinpoint and treat the root cause of the pain. However, there are interventions nurses may follow to relieve acute pain for patients in distress. Some examples may include:

• Administering pain medications.
• Applying hot or cold packs.
• Guiding meditation or other relaxation techniques.
• Distracting with music or other stimuli.
• Acupuncture or acupressure techniques.

Nursing Interventions for COPD

Chronic obstructive pulmonary disease (COPD) is a serious condition caused by damage to the airways. Patients with this condition may have a hard time breathing due to blocked airflow, which can have a serious impact on the patient’s quality of life.

Nursing interventions for patients with COPD  will vary depending on the severity of the condition and other factors. Typically, interventions for this condition are collaborative in nature, relying on expertise from many healthcare professionals and specialists. Examples of potential interventions for COPD patients may include:

• Assessment of symptoms and lung function, such as listening to the lungs and measuring oxygen saturation.
• Administering oxygen therapy.
• Use of specialized breathing devices.
• Patient education, such as learning how to use an inhaler.
• Pulmonary rehabilitation.

Nursing Interventions for Pneumonia

Pneumonia is a serious infection of the lungs characterized by inflammation of the alveoli (air sacs) and tissue surrounding the lungs. This infection can be caused by viruses, bacteria, or even fungi, and the complications can be life-threatening. With this in mind, nurses and healthcare professionals must be prepared to react promptly to patients presenting with pneumonia, using interventions such as:

• Carefully monitoring oxygen levels and other vital signs.
• Administering antibiotics or other medication to address the infection.
• Ensuring that patients receive plenty of fluids to prevent dehydration and worsening of symptoms.
• Administering oxygen as needed.
• Performing other respiratory care techniques, such as chest percussion and incentive spirometry.

Nursing Interventions for Anxiety

Patients presenting with signs of anxiety or an anxiety attack must also be cared for promptly and compassionately. Interventions for anxiety should be highly specific to the patient’s unique needs and symptoms, but some common examples include:

• Patient education in the form of explaining coping strategies, such as deep breathing and meditation).
• Creating a calm environment with minimal noise or distractions.
• Administering of anti-anxiety medications as prescribed by a physician.
• Referral to mental health counseling, support groups, or other resources.

Nursing Interventions for Fall Risk

Some patients, such as the elderly, may be at a greater risk of falls that could result in injuries or additional complications. With this in mind, nurses are often tasked with conducting fall risk assessments of patients and following common interventions as needed, such as:

• Keeping hospital beds at the lowest possible position.
• Ensuring that call lights and patients’ personal items are within easy reach.
• Ensuring that the area around a patient’s bed is free from obstructions or tripping hazards.
• Educating patients on safe movement.

The Role of Nursing Interventions in Patient Care Plans

Overall, nursing interventions are an essential component of the overarching nursing process that includes assessment, diagnosis, planning, implementation, and evaluation. In many ways, interventions serve as the “action” phase of the nursing process, where a care plan is put into practice and desired results can be achieved. Without practical nursing interventions, it would be impossible in most cases to achieve patient objectives while providing the highest standard of care.

When nurses and other healthcare professionals have a solid understanding of which interventions should be used in different scenarios, it is possible to carry out care plans effectively and with the best interests of the patient in mind.

Advance Your Nursing Education at Nevada State University

As you can see, nursing interventions often play a critical role in the implementation of patient care plans. That said, determining the right interventions for each patient is a complicated process full of nuances and must be done with the patient’s best interests in mind. At the end of the day, when nurses and other healthcare professionals collaborate with the best patient outcomes in mind, it is possible to address patient needs while minimizing complications and promoting wellness.

Looking to advance your own nursing education and better serve your patients? It may be time to explore Nevada State University’s  RN to BSN online program , which is available in both a part-time and full-time track to suit your needs and schedule. This program is specifically designed for busy nursing professionals who want to pursue their bachelor’s degrees in nursing while working at their own pace, so  get in touch  to learn more or start your online  application  today!

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National Academies of Sciences, Engineering, and Medicine; National Academy of Medicine; Committee on the Future of Nursing 2020–2030; Flaubert JL, Le Menestrel S, Williams DR, et al., editors. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington (DC): National Academies Press (US); 2021 May 11.

The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity.

• Hardcopy Version at National Academies Press

4 The Role of Nurses in Improving Health Care Access and Quality

Of all the forms of inequality, injustice in health care is the most shocking and inhumane. —Dr. Martin Luther King, civil rights activist

Nurses can be key contributors to making substantial progress toward health care equity in the United States in the decade ahead by taking on expanded roles, working in new settings in innovative ways, and partnering with communities and other sectors. But the potential for nurses to help people and communities live healthier lives can be realized only if the barriers to their working to the full extent of their education and training are removed. To this end, it will be necessary to revise scope-of-practice laws, public health and health system policies, state laws regarding the use of standing orders, and reimbursement rules for Medicare and other payers. Major shifts occurring both within society at large and within health care will transform the environment in which the next generation of nurses will practice and lead. If health care equity is to be fully achieved, nursing schools will need to focus on ensuring that all nurses, regardless of their practice setting, can address the social factors that influence health and provide care that meets people where they are.

Health care equity focuses on ensuring that everyone has access to high-quality health care. As shown in the Social Determinants of Health and Social Needs Model of Castrucci and Auerbach (2019) (see Chapter 2 ), health care is a downstream determinant of health, but disparities in health care access and quality can widen and exacerbate disparities produced by upstream and midstream determinants of health outcomes.

According to Healthy People 2020, access to quality health care encompasses the ability to gain entry into the health care system through health insurance, geographic availability, and access to a health care provider. Health care quality has been defined as “the degree to which health care services for individuals and populations increase the likelihood of desired outcomes and are consistent with current professional knowledge” ( IOM, 1990 , p. 4). The Agency for Healthcare Research and Quality (AHRQ) defines quality health care “as doing the right thing for the right patient, at the right time, in the right way to achieve the best possible results” ( Sofaer and Hibbard, 2010 ). Nurses deliver high-quality care by providing care that is safe, effective, person-centered, timely, efficient, and equitable ( IOM, 2001 ).

As noted, frameworks for social determinants of health (SDOH) place the health care system downstream, often operating in response to illness, rather than upstream, impacting the underlying causes of health outcomes ( Castrucci and Auerbach, 2019 ). Therefore, health care itself does not address most of the upstream factors, or root causes of illness, that affect health equity; such upstream social factors as economic and housing instability, discrimination and other forms of racism, educational disparities, and inadequate nutrition can affect an individual’s health before the health care system is ever involved ( Castrucci and Auerbach, 2019 ). Health equity is discussed in detail in Chapter 5 . Some estimates indicate that a small portion of health outcomes is related to health care, while equity in health care is an important contributing factor to health equity ( Hood et al., 2016 ; Remington et al., 2015 ).

Major shifts occurring both within society at large and within health care will transform the environment in which the next generation of nurses will practice and lead. These shifts encompass changing demographics, including declining physical and mental health; increased attention to racism and equity issues; the development and adoption of new technologies; and changing patterns of health care delivery. The widespread movement for racial justice, along with the stark racial disparities in the impacts of COVID-19, has reinforced the nursing profession’s ethical mandate to advocate for racial justice and to help combat the inequities embedded in the current health care system. The commitment to social justice is reflected in provision 9 of the Code of Ethics of the American Nurses Association ( ANA, 2015 ), and its priority has been elevated by the increased demand for social justice within communities and society at large.

Changing health outcomes will require action at all levels—upstream, midstream, and downstream—and nurses have a major role at all levels in reducing gaps in clinical outcomes and improving health care equity. Nurses can strengthen their commitment to diversity, equity, and inclusion by leading large-scale efforts to dismantle systemic contributors to inequality and create new norms and competencies within health care. In that process, nurses will need to meet the complex ethical challenges that will arise as health care reorients to respond to the rapidly changing landscape ( ANA, 2020 ; Beard and Julion, 2016 ; Koschmann et al., 2020 ; Villarruel and Broome, 2020 ). To ensure nursing’s robust engagement with these major shifts in health care and society, investments in the well-being of nurses will be essential ( ANA, 2015 ) (see Chapter 10 ).

This chapter examines ways in which nurses today work to improve health care equity, as well as their potential future roles and responsibilities in improving equity through efforts to expand access to and improve the quality of health care. Existing exemplars are also described, as well as implications of COVID-19 for health care access and quality.

NURSES’ ROLES IN EXPANDING ACCESS TO QUALITY HEALTH CARE

The United States spends more than $3.5 trillion per year on health care, 25 percent more per capita than the next highest-spending country, and under-performs on nearly every metric ( Emanuel et al., 2020 ). Life expectancy, infant mortality, and maternal mortality are all worse in the United States than in most developed countries. In the United States, moreover, disparities in health care access and health outcomes are seen across racial lines; however, being able to use social and financial capital to buy the best health care is not necessarily associated with the world’s best health outcomes. Even among White U.S. citizens and those of higher socioeconomic status (SES), U.S. health indicators still lag behind those in many other countries ( Emanuel, 2020 ). The U.S. population will not fully thrive unless all individuals can live their healthiest lives, regardless of their income, their race or ethnicity, or where they live. As discussed in Chapter 2 , however, race and ethnicity, income, gender, and geographic location all play substantial roles in a person’s ability to access high-quality, equitable, and affordable health care. A variety of professionals from within and outside of health care settings participate in efforts to ensure equitable access to care. But the role of nurses in these efforts is key, given their interactions with individuals and families in providing and coordinating person-centered care for preventive, acute, and chronic health needs within health settings, collaborating with social services to meet the social needs of individuals, and engaging in broader population and community health through roles in public health and community-based settings.

Both in the United States and globally, the rapid growth in the number of older people in the population will likely lead to increased demand for services and programs to meet their health and social care needs ( Donelan et al., 2019 ; Spetz et al., 2015 ), including care for chronic conditions, which account for approximately 75 percent of all primary care visits ( Zamosky, 2013 ). The aging population will also bring change in the kinds of care the patient population will need. Older people tend to require more expensive care, and to need increasing support in managing multiple conditions and retaining strength and resilience as they age (Pohl et al., 2018). These realities underscore the importance of designing, testing, and adopting chronic care models, in which teams are essential to managing chronic disease, and registered nurses (RNs) play a key role as chronic disease care managers ( Bodenheimer and Mason, 2016 ). Studies of exemplary primary care practices ( Bodenheimer et al., 2015 ; Smolowitz et al., 2015 ) define key domains of RN practice in primary care, including preventive care, chronic illness management, practice operations, care management, and transition care.

Since the passage of the Patient Protection and Affordable Care Act, substantial changes have occurred in the organization and delivery of primary care, emphasizing greater team involvement in care and expansion of the roles of each team member, including RNs ( Flinter et al., 2017 ). Including RNs as team members can increase access to care, improve care quality and coordination for chronic conditions, and reduce burnout among primary care practitioners by expanding primary care capacity ( Fraher et al., 2015 ; Ghorob and Bodenheimer, 2012 ; Lamb et al., 2015 ).

In primary care, RNs can assume

at least four responsibilities: 1) Engaging patients with chronic conditions in behavior change and adjusting medications according to practitioner-written protocols; 2) Leading teams to improve the care and reduce the costs of high-need, high-cost patients; 3) Coordinating the care of chronically ill patients between the primary care home and the surrounding healthcare neighborhood; and 4) Promoting population health, including working with communities to create healthier spaces for people to live, work, learn, and play. ( Bodenheimer and Mason, 2016 , pp. 11–12)

Findings from a 2013 study of The Primary Care Team: Learning from Effective Ambulatory Practices (LEAP) suggest that a large majority of LEAP primary care practices, regardless of practice type or corporate structure, use RNs as a key part of their care team model ( Ladden et al., 2013 ). This contrasts with a study of 496 practices in the Centers for Medicare & Medicaid Services (CMS) Comprehensive Primary Care initiative ( Peikes et al., 2014 ) that found that only 36 percent of practices had RNs on staff, compared with 77 percent of LEAP sites ( Flinter et al., 2017 ).

The health needs of individuals exist across a spectrum, ranging from healthy people, for whom health promotion and disease prevention efforts are most appropriate, to people who have limited functional capacity as a result of disabilities, severe or multiple chronic conditions, or unmet social needs or are nearing the end of life. Access to quality health care services is an important SDOH, and equitable access to care is needed for “promoting and maintaining health, preventing and managing disease, reducing unnecessary disability and premature death, and achieving health equity” ( ODPHP, 2020 ). Likewise, “strengthening the core of primary care service delivery is key to achieving the Triple Aim of improved patient care experiences, better population health outcomes, and lower health care costs” ( Bodenheimer and Mason, 2016 , p. 23). The 2011 The Future of Nursing report echoes these themes:

while changes in the healthcare system will have profound effects on all providers, this will be undoubtedly true for nurses. Traditional nursing competencies, such as care management and coordination, patient education, public health intervention, and transitional care, are likely to dominate in a reformed healthcare system as it inevitably moves toward an emphasis on prevention and management rather than acute [hospital] care. ( IOM, 2011 , p. 24)

Given the increased evidence supporting the focus on addressing social needs and SDOH to improve health outcomes, these competencies are even more important a decade later. While progress has been made, there is still work to be done, and leveraging and expanding the roles and responsibilities of nurses can help improve access to care ( Campaign for Action, n.d. ).

For people who have difficulty accessing health care because of distance, lack of providers, lack of insurance, or other reasons, nurses are a lifeline to care that meets them where they are. Nurses work in areas that are underserved by other health care providers and serve the uninsured and underinsured. They often engage with and provide care to people in their homes, they work in a variety of clinics, they use telehealth to connect with people, and they establish partnerships and create relationships in schools and communities. In addition to expanding the capacity of primary care, nurses serve in vital roles during natural disasters and public health emergencies, helping to meet the surge in the need for care (see Chapter 8 ). Yet, the potential for nurses to advance health equity through expanded access to care is limited by state and federal laws and regulations that restrict nurses’ ability to provide care to the full extent of their education and training (see Chapter 3 ). Ways in which nurses can fulfill this potential to increase access to care for populations with complex health and social needs are discussed below.

• INCREASING ACCESS FOR POPULATIONS WITH COMPLEX HEALTH AND SOCIAL NEEDS

Many individuals cannot access health care because of lack of insurance, inability to pay, and lack of clinics or providers in their geographic area. To bridge this gap, access to care is expanded through a variety of settings where nurses work, including federally qualified health centers (FQHCs), retail clinics, home health and home visiting, telehealth, school nursing, and school-based health centers, as well as nurse-managed health centers. Across all of these settings, nurses are present and facilitate access to health services for individuals and families, often serving as a bridge to social services as well.

Federally Qualified Health Centers

Through FQHCs—outpatient facilities located in a federally designated medically underserved area or serving a medically underserved population—nurses expand access to services for individuals regardless of ability to pay by helping to provide comprehensive primary health care services, referrals, and services that facilitate access to care. The role of advanced practice registered nurses (APRNs) in FQHCs has grown over time ( NACHC, 2019 ). The emerging role of RNs in FQHCs is seen in increased interactions with patients, involvement in care management, and autonomy in the delivery of care. Nurses also work to address key social factors in partnership with care coordinators, health coaches, and social workers to improve health outcomes ( Flinter et al., 2017 ).

Retail Clinics

Health care delivery in the United States has been undergoing transformation, and these changes provide new opportunities for more patients and greater access to nurses as new policies are implemented, new payment models take hold, resources are focused on SDOH, and consumerism shapes care choices. One change in particular since the prior The Future of Nursing report ( IOM, 2011 ) has been and will continue to be impactful for nursing: the emergence of nontraditional health care entities, such as retail clinics. The evolution and rapid growth of these established retail clinics provide increased accessibility of basic care, health screenings, vaccines, and other services for some populations ( Gaur et al., 2019 ). The number of such is growing rapidly, from around 1,800 in 2015 to 2,700 operating in 44 states and the District of Columbia by 2018.

Retail clinics provide more accessible primary care for some populations. In 2016, 58 percent of retail clinic visits represented new utilization instead of substitution for more costly primary care or emergency department visits ( Bachrach and Frohlich, 2016 ). Many individuals and families use retail clinics for their convenience, which includes long hours of operation, accessible location, and walk-in policies, as well as low-cost visits. These attributes are important for those with lower income or without insurance who may not have a regular source of care or be able to access a primary care provider ( Bachrach and Frohlich, 2016 ). However, research shows retail clinics are typically placed in higher-income, urban, and suburban settings with higher concentrations of White and fewer Black and Hispanic residents ( RAND Corporation, 2016 ). The RAND Corporation (2016) study found that while 21 percent of the U.S. population lived in medically underserved areas, only 12.5 percent of retail clinics were located in these areas. RAND concluded that “overall, retail clinics are not improving access to care for the medically underserved.” Thus, while these new models of care have the potential to advance health care equity and population-level health, the available data do not indicate that this potential has been realized ( RAND Corporation, 2016 ). The equity impact of these retail clincs depends in large part on who utilizes the services, and whether the utilization patterns are similar to or different from those of traditional health care.

Retail clinics are staffed largely by nurse practitioners (NPs) ( Carthon et al., 2017 ). These clinics in pharmacies and grocery stores often have been constrained by restrictive scope-of-practice laws. In 2016, a study by the University of Pennsylvania School of Nursing’s Center for Health Outcomes and Policy Research investigated scope-of-practice regulatory environments and retail-based clinic growth. Looking at three states with varying levels of scope-of-practice restrictions, the study found an association between relaxation of practice regulations and retail clinic growth. Evidence suggests that optimization of innovative health care sites such as retail clinics will require moving toward the adoption of policies that standardize the scope of practice for NPs, the providers who largely staff retail clinics ( Carthon et al., 2017 ).

Home Health and Home Visiting

Visiting people in their homes can advance equitable access to quality health care. Home health care has increased access to care for many Americans, from older individuals to medically fragile children. Yao and colleagues (2021) recently explored trends in the U.S. workforce providing home-based medical care and found that less than 1 percent of physicians participating in traditional Medicare provide more than 50 home visits each year (a rate unchanged between 2012 and 2016). By contrast, the number of NPs providing home visits nearly doubled during that same period. Home health nurses address a fragmented system by coordinating care for patients transitioning from a tertiary care facility to ongoing health care within their own homes. Since the onset of the COVID-19 pandemic, these nurses have increasingly provided families with respite for caregivers and offered mental health services in many forms, but certainly in decreasing social isolation for elderly people. Delivering care at home has offered a window for physicians and NPs to see where patients live, to engage in telehealth video calls with family members present, and to see the features of neighborhoods that impact health (e.g., sidewalks, playgrounds, stairs).

With the expansion in the home health care industry driven by an aging population, home visiting nurses are essential to providing care and enhancing health care equity ( Walker, 2019 ). Prior to 2020, Medicare rules allowed only physicians to order home health services for Medicare beneficiaries. However, the Coronavirus Aid, Relief, and Economic Security (CARES) Act permanently authorizes physician assistants and NPs to order home health care services for Medicare patients. In addition, CMS has instituted new policies outlining comprehensive temporary measures for increasing the capacity of the U.S. health care system to provide care to patients outside a traditional hospital setting amid the rising number of COVID-19-related hospitalizations nationwide. These measures include both the Hospital Without Walls and Acute Hospital Care At Home programs, both initiated during the pandemic. Under previous federal requirements, hospitals had to provide services within their own buildings, raising concerns about capacity for treating COVID-19 patients, especially those requiring ventilator and intensive care. Under CMS’s temporary new rules, hospitals can transfer patients to outside facilities, such as ambulatory surgery centers, inpatient rehabilitation hospitals, hotels, and dormitories, while still receiving hospital payments under Medicare. Provision for at-home care, which is often preferred by patients, is especially important during a crisis such as the pandemic, when hospital care means family and/or caregivers cannot be present. Moreover, some research has shown home care to be less costly and to result in fewer readmissions relative to hospital care ( Levine et al., 2020 ). These programs also will create new demand for nurses to work in the community and are the types of adaptations that occurred as a result of the COVID-19 pandemic that should remain permanent to expand high-quality access to care.

The locus of care delivery will continue to follow personal preferences of individuals and families. To improve health care access, nurses will need to be intentional about meeting patients where they are in the most literal sense, and to serve as advocates with and within public health, retail clinics, and health systems to ensure that patients can access the care they need in their homes and neighborhoods. Box 4-1 describes several innovative nurse-led, in-home care programs.

Innovative In-Home Care Programs.

In addition to home health, nurse home visiting programs often include such services as health check-ups, screenings, referrals, and guidance in navigating other programs and services in the community ( Child and Family Research Partnership, 2015 ). Growing evidence suggests that home visits by nurses during pregnancy and in the first years of a child’s life can improve the health and well-being of both child and family, including by promoting maternal and child health, prevention of child abuse and neglect, positive parenting, child development, and school readiness. This positive impact has been found to continue into adolescence and early adulthood ( NASEM, 2019 ).

The proliferation of mobile devices and applications offers an opportunity for nurses to use telehealth more broadly to connect with individuals. Telehealth, including video visits, email, and distance education, serves as a tool to connect with people on an ongoing basis without their having to leave their homes, workplaces, or other settings, and allows for long-distance patient and clinician contact for purposes of clinical interventions, health promotion, education, assessment, and monitoring. The use of telehealth is especially helpful for those who have difficulty traveling to obtain care and those who reside in rural or remote areas. Vulnerable populations with multiple chronic illnesses, poor health literacy, and lack of supportive resources may benefit the most from telehealth use. However, use of telehealth or virtual health tools is limited by access to reliable Internet connections and the availability of the necessary hardware, including smartphones, computers, or webcams. A recent report in the Journal of the American Medical Association looks at 41 FQHCs serving 1.7 million patients. Prior to the COVID-19 pandemic, there was minimal telehealth use at these facilities. During March 2020, FQHCs rapidly substituted in-person visits with telephone and video visits. For primary care, however, 48.5 percent of telehealth visits occured by telephone and 3.4 percent by video. In addition, CMS estimated that 30 percent of telehealth visits were audio-only during the pandemic. These numbers indicate that telehealth appointments for lower-income Americans were in large part audio-only, raising questions about the quality of care ( Uscher-Pines et al., 2021 ).

There have been examples of telehealth activities that have demonstrated great success. The Mississippi Diabetes Telehealth Network, for example, implemented a program that uses telehealth in the home as a viable way to bring a care team to patients to assist them as they manage their illnesses. NPs provide daily health sessions and remote monitoring for individuals with diabetes ( Davis et al., 2020 ; Henderson et al., 2014 ). A prospective, longitudinal cohort study design evaluated the relationship between using telehealth for chronic care management and diabetes outcomes over a 12-month period, finding a significant difference in HbA1c values from baseline to 3-, 6-, 9-, and 12-month values ( Davis et al., 2020 ). In another example, Mercy Hospital, a virtual care center, delivers telehealth services to rural communities in Arkansas, Kansas, Missouri, and Oklahoma. One of its many services is Nurse on Call, which provides timely clinical advice and is available around the clock. In still another example, Banner Health’s skilled nursing model delivers home care combined with telehealth services to people at home instead of their having to move to a nursing home facility ( Roth, 2018 ).

School Nursing

School nurses are front-line health care providers, serving as a bridge between the health care and education systems. Hired by school districts, health departments, or hospitals, school nurses attend to the physical and mental health of students in school. As public health sentinels, they engage school communities, parents, and health care providers to promote wellness and improve health outcomes for children. School nurses are essential to expanding access to quality health care for students, especially in light of the increasing number of students with complex health and social needs. Access to school nurses helps increase health care equity for students. For many children living in or near poverty, the school nurse may be the only health care professional they regularly access.

School nurses treat and help students manage chronic health conditions and disabilities; address injuries and urgent care needs; provide preventive and screening services, health education, immunizations, and psychosocial support; conduct behavioral assessments; and collaborate with health care providers, school staff, and the community to facilitate the holistic care each child needs ( Council on School Health, 2008 ; Holmes et al., 2016 ; HRSA, 2017 ; Lineberry and Ickes, 2015 ; Maughan, 2018 ). By helping students get and stay healthy, school health programs can contribute to closing the achievement gap ( Basch, 2011 ; Maughan, 2018 ). According to Johnson (2017) ,

Healthy children learn better; educated children grow to raise healthier families advancing a stronger, more productive nation for generations to come. School nurses work to assure that children have access to educational opportunities regardless of their state of health. (p. 1)

Meeting the mental health needs of children can be particularly challenging. Researchers estimate that about a quarter of all school-age children and adolescents struggle with mental health issues, such as anxiety and depression. Approximately 30 percent of student health visits to the school nurse are for mental health concerns, often disguised by complaints of headaches and stomachaches ( Foster et al., 2005 ). School nurses have experience with screening students at risk for a variety of such concerns and can assist students in addressing them ( NASN, 2020a ). However, most youth—nearly 80 percent—who need mental health services will not receive them ( Kataoka et al., 2005 ); schools are not always equipped to deal with students’ emotional needs, and parents often lack the awareness or resources to get help for their children. Additionally, a recent study found disparities in access to mental health treatment for students along racial and ethnic lines ( Lipson et al., 2018 ), and structural racism undergirds many risk factors for mental illness (see Chapter 2 ). The COVID-19 pandemic has revealed—and exacerbated—inequities among children of different incomes and races/ethnicities. School closures and social isolation have affected all students, but especially those living in poverty. In addition to the damage to student learning, the loss of access to mental health services that were offered by schools has resulted in the emergence of a mental health crisis ( Leeb et al., 2020 ; Patrick et al., 2020 ; Singh et al., 2020 ).

Schools are increasingly being recognized not just as core educational institutions but also as community-based assets that can be a central component of building healthy and vibrant communities ( NASEM, 2017 ). Accordingly, schools and, by extension, school nurses are being incorporated into strategies for improving health care access, serving as hubs of health promotion and providers of population-based care ( Maughan, 2018 ). Yet, while there have been calls for every school to have access to a nurse ( Council on School Health, 2016 ; NASN, 2020b ), only 39.9 percent of schools employed a full-time nurse in 2017. The remainder of schools (39.3 percent) employed a part-time nurse or did not employ a nurse at all (25.2 percent) ( Willgerodt, 2018 ). The availability and staffing levels of school nurses vary greatly by geography ( Willgerodt, 2018 ) (see Figure 4-1 ).

Licensure staffing patterns (paid and unpaid volunteer) by geography. SOURCE: Data from Willgerodt, 2018.

To address the lack of health care resources in rural school settings, telehealth programs have been implemented with success ( RHI, 2019 ). An example is Health-e-Schools, in which onsite school nurses connect sick students with health care providers. The program employs a full-time, off-site family NP who uses telehealth to evaluate and diagnose patients with such health issues as earaches, sore throats, colds, and rashes, as well as to provide sports physicals, medication, chronic disease management, and behavioral health care. It began as a telehealth program implemented by only 3 schools in 2011 and has since expanded to more than 80 schools serving more than 25,000 students. Health-e-Schools has helped increase classroom attendance and decrease the amount of time parents or guardians must take off from work to bring their children to appointments. This model relies heavily on the school nurses employed within each school district to serve as primary telehealth providers, thus requiring that funding be allocated to provide a school nurse in each school.

School-Based Health Centers

School-based health centers (SBHCs) also make care accessible to students in the school setting. In 2017, 2,584 SBHCs were operating in the United States ( Love et al., 2019 ). SBHCs often operate as a partnership between the school and a community health organization, such as a community health center, hospital, or local health department; more than half are supported by or are an extension of FQHCs ( SBHA, n.d. ). SBHC services include primary care, mental health care, social services, dentistry, and health education, but vary based on community needs and resources as determined through collaborations among the community, the school district, and health care providers ( CPSTF, 2015 ; HRSA, 2017 ). Services are provided by interprofessional teams of health care professionals that include nurses, mental health care providers, physicians, nutritionists, and others. As of 2017, NPs provided primary care services onsite and through telehealth services at 85 percent of SBHCs ( Love et al., 2019 ; SBHA, 2018 ).

One example of an SBHC is the nurse-run Vine School Health Center (VSHC) located at the Vine Middle Magnet School in Knoxville, Tennessee, a Title I school where 100 percent of the students qualify for free lunch. VSHC provides onsite and telehealth services to anyone up to 21 years of age who lives in the county. It also serves 10 other Title I schools through direct health care or telehealth services. The clinic is a partnership between the University of Tennessee College of Nursing and Knox County Schools and is staffed by nurses, nursing students, social workers, and special education professionals. Staff assist families with social needs, including food, housing, clothing, linkages to health insurance, and financial support for rent and utilities ( AAN, 2015 ; Pittman, 2019 ). Services rendered during the 2016–2017 school year included 1,110 early and periodic screening, diagnostic and treatment (EPSDT) exams; 1,896 immunizations; 4,455 physical health visits; and 1,796 mental health clinic visits. VSHC estimates that its services enabled the avoidance of more than 2,500 potential emergency room visits per academic year, associated with savings of about $375,000 per year ( AAN, 2015 ).

• IMPROVING THE QUALITY OF HEALTH CARE

Access to comprehensive health care services is a precursor to equitable, quality health care. Nurses are uniquely qualified to help improve the quality of health care by helping people navigate the health care system, providing close monitoring and follow-up across the care continuum, focusing care on the whole person, and providing care that is culturally respectful and appropriate. Nurses can help overcome barriers to quality care, including structural inequities and implicit bias, through care management, person-centered care, and cultural humility.

Care Management

In the current health care system, care is often disjointed, with processes varying between primary and specialty care and between traditional and emerging care sites. People may not understand the processes of the health care system, such as where they will receive care, how to make appointments, or the various providers with whom they may come into contact. Perhaps most important, patients may not understand why all the providers across settings where they receive care should be knowledgeable about the services they receive and the problems that have been identified to ensure seamless, continuous high-quality care. Social factors affecting people with complex health needs may also adversely affect their ability to receive optimal care. Care management, care coordination, and transitional care are activities that nurses perform as members of a health care team to decrease fragmentation, bolster communication, and improve care quality and safety. A care management approach is particularly important for people with complex health and social needs, who may require care from multiple providers, medical follow-up, medication management, and help in addressing their social needs.

Care management—a set of activities designed to “enhance coordination of care, eliminate duplication of services, reduce the need for expensive medical services, and increase patient engagement in self-care”—helps ensure seamless care ( CHCS, 2007 ; Goodell et al., 2009 ). The components of care management include care coordination, transitional care, and social care.

Care coordination is defined as the “deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient’s care to facilitate the appropriate delivery of healthcare services.” It is needed both to overcome obstacles of the health care system, such as fragmentation, communication, and billing/cost, and to increase access ( McDonald et al., 2007 , p. 4).

Transitional care entails coordinating care for people moving between various locations or levels of care, providing navigation, coordination, medication reconciliation, and education services ( Storfjell et al., 2017 ). The Transitional Care Model, developed by Mary Naylor (see Box 4-2 ), and the Care Transitions Intervention, developed by Eric Coleman, are prominent nurse-centered care models focused on the often disjointed transition from an inpatient hospital stay to follow-up ambulatory care. Both models engage people with chronic illness from hospitalization to postdischarge, and employ a nursing coach or team “to manage clinical, psychosocial, rehabilitative, nutritional and pharmacy needs; teach or coach people about medications, self-care and symptom recognition and management; and encourage physician appointments” ( Storfjell et al., 2017 , p. 27). Both reduce readmissions and costs ( Storfjell et al., 2017 ).

Transitional Care Model.

Health care delivery models that incorporate social care have created critical roles for nurses in coordinating care across providers and settings and collaborating with other professionals and community resources to improve the health of individuals with complex health and social needs. Chapter 5 provides examples of nurse-centered programs incorporating social care. Nurses are vital to carrying out these functions of care management. Common to nurses’ roles are functions including providing care coordination, developing care plans based on a person’s needs and preferences, educating people and families within care settings and during discharge, and facilitating continuity of care for people across settings and providers ( ANA, n.d. ).

Person-Centered Care

The person-centered care model embraces personal choice and autonomy and customizes care to an individual’s abilities, needs, and preferences ( Kogan et al., 2016 ; Van Haitsma et al., 2014 ). Through person-centered care, nurses collaborate with people, including the patient and other care team members, to deliver personalized quality care that addresses physical, mental, and social needs ( CMS, 2012 ; Terada et al., 2013 ). Features of person-centered care include an emphasis on codesign of interventions, services, and policies that focus on what the person and community want and need; respect for the beliefs and values of people; promotion of antidiscriminatory care; and attention to such issues as race, ethnicity, gender, sexual identity, religion, age, socioeconomic status, and differing ability status ( Santana et al., 2018 ). And person-centered care focuses not only on the individual but also on families and caregivers, as well as prevention and health promotion. Integrating person-centered care that improves patient health literacy is necessary to ensure patient empowerment and engagement and maximize health outcomes. Health literacy ensures that “patients know what they must do after all health care encounters to self-manage their health” ( Loan et al., 2018 , p. 98).

Research has demonstrated the efficacy of person-centered care, for example, in reducing agitation, neuropsychiatric symptoms, and depression, as well as improving quality of life, for individuals with dementia ( Kim and Park, 2017 ). In another example, people with acute coronary syndrome receiving person-centered care reported significantly higher self-efficacy ( Pirhonen et al., 2017 ). Person-centered care is person-directed, such that people are provided with sufficient information to help them in making decisions about their care and increase their level of engagement in care ( Pelzang, 2010 ; Scherger, 2009 ), and nurses who engage people in their care are less likely to make mistakes ( Leiter and Laschinger, 2006 ; Prins et al., 2010 ; Shiparski, 2005 ). Person-centered care leads to better communication between patients and caregivers and improves quality of care, thereby increasing patient satisfaction, care adherence, and care outcomes ( Hochman, 2017 ).

Cultural Humility

As discussed in Chapter 2 , implicit bias can lead to discrimination against others. In particular, structural racism in health care compromises the ability to deliver culturally competent care ( Evans et al., 2020 ).

Historically, nursing has been at the forefront of advocacy, and there are many examples of how nurses have addressed, and are addressing, inequities in many aspects of our teaching, research, scholarship, and practice. Yet, there remain too many examples of structural racism throughout nursing and we must be open to continuing to examine, identify, and change these within our own profession. ( Villaruel and Broome, 2020 , p. 375)

Nurses may contribute to structural inequities in how they facilitate or hamper access to quality health care services since they are frequently the first point of contact for many individuals who need care. Cultural humility—“defined by flexibility; awareness of bias; a lifelong, learning-oriented approach to working with diversity; and a recognition of the role of power in health care interactions” ( Agner, 2020 , p. 1)—is therefore essential for nurses.

Cultural humility enables nurses to participate in more respectful partnerships with patients in order to advance health care equity. According to Foronda and colleagues (2016) , cultural humility has been found to result in effective treatment, decision making, communication, and understanding; better quality of life; and improved care. In contrast, clinicians with implicit bias may show less compassion toward and spend less time and effort with certain patients, leading to adverse assessment and care ( Narayan, 2019 ). Because implicit bias can negatively affect patient interactions and health outcomes, it is important for nurses to be aware of their bias and how it may directly or indirectly impact patient interactions and the quality of care they provide ( Hall et al., 2015 ).

Multiple strategies exist to help nurses achieve cultural humility and manage implicit bias to ensure that they provide high-quality, equitable care. Chapter 7 details the importance of incorporating cultural humility in nursing education. Instead of focusing broadly on the general population, quality improvement interventions characterized by cultural humility focus on needs that are unique to people of color (POC) and tailor care to overcome cultural and linguistic barriers that cause disparities in care (Green et al., 2010). With this approach, data on disparities are used to assess an intervention, with an emphasis on addressing barriers that are specific to underrepresented groups ( ANA, 2018 ; Green et al., 2010; Villarruel and Broome, 2020 ). Box 4-3 describes culturally and linguistically appropriate services, designed to equip nurses with the knowledge, skills, and awareness to provide high-quality care for all patients regardless of cultural or linguistic background.

Culturally and Linguistically Appropriate Services.

When nurses are educated and empowered to act at multiple levels—upstream, midstream, and downstream—they help reduce the effects of structural inequities generated by the health care system. This includes education about how structural inequities may affect their practice environments (as well as research and policy) and, by association, the people with whom they work in clinical and community-based settings (see the detailed discussion of nursing education in Chapter 7 ).

• IMPLICATIONS OF COVID-19 FOR HEALTH CARE EQUITY

The COVID-19 pandemic has highlighted the pivotal role of nurses in addressing health care equity. During public health emergencies, nurses in hospitals and in public health and other community settings need to function collaboratively and seamlessly. The pandemic has heightened the need for team-based care, infection control, person-centered care, and other skills that capitalize on the strengths of nurses ( LaFave, 2020 ). Broadening of scope-of-practice regulations and expansion of telehealth services during the COVID-19 pandemic have allowed nurses to practice to the full extent of their education and training, providing equitable care and increasing access to care.

The surge of critically ill people due to the pandemic created the need to rapidly increase the capacity of the health care workforce, especially to replenish workforce members who needed to quarantine or take time to care for sick family members or friends ( Fraher et al., 2020 ). In response, multiple governors issued executive orders expanding the scope of practice for NPs. As of April 10, 2020, five states (Kentucky, Louisiana, New Jersey, New York, and Wisconsin) had temporarily suspended all practice agreement requirements, providing NPs with full practice authority ( AANP, 2020 ). Thirteen states (Alabama, Arkansas, Indiana, Massachusetts, Michigan, Mississippi, Missouri, Oklahoma, Pennsylvania, South Carolina, Tennessee, Texas, and West Virginia) had enacted a temporary waiver of selected practice agreement requirements. By December 7, 2020, executive orders had expired for Kansas, Michigan, and Tennessee, and all practice agreement requirements had been temporarily suspended for Kentucky, Louisiana, New Jersey, New York, Virginia, and Wisconsin ( AANP, 2020 ). Maintaining these broadened scopes of practice for nurses after the pandemic has ended would increase NPs’ opportunities to increase access to quality health care for individuals with complex health and social needs.

Hospitals are also redeploying health care workers—physicians, NPs, nurses, and others—from areas with decreasing patient volumes (resulting from, for example, limitations on elective procedures) to higher-need intensive care unit (ICU), acute care, and emergency service areas. For example, nurse anesthetists have been redeployed from operating rooms to ICUs to intubate and place central lines for patients in the surge response to COVID-19 ( Brickman et al., 2020 ). As of December 2020, CMS was finalizing changes that allow NPs to “supervise the performance of diagnostic tests within their scope of practice and state law, as they maintain required statutory relationships with supervising or collaborating physicians” ( CMS, 2020a ). These changes will help make permanent some of the workforce flexibilities that were allowed during the pandemic.

Although much attention has been paid to the dire need for health care supplies and hospital beds to treat patients with severe cases of COVID-19, less attention has been directed at impacts of the pandemic on communities; their ability to weather the crisis; and individuals’ physical, mental, and social health. Nurses, including public health nurses, working in and with communities continue to be critical to efforts to contain the COVID-19 pandemic, as well as other pandemics that may occur in the future.

Older Adults

Older adults have been disproportionately affected by COVID-19, and older POC are even more likely to experience disproportionate morbidity and mortality. CMS data show that Black Medicare beneficiaries were hospitalized four times as often and contracted the virus nearly three times as often compared with Whites of similar age ( CMS, 2020b ; Godoy, 2020 ). According to the Centers for Disease Control and Prevention (CDC), 8 of 10 deaths from COVID-19 in the United States have been among adults 65 and older ( Freed et al., 2020 ). Nursing homes have been particularly hard hit and faced multiple unique challenges in serving those most vulnerable to the virus.

The pandemic has had significant emotional, social, and mental health effects on older adults and their caregivers, and nurses and nursing assistants in nursing homes have borne a great burden in carrying out the front-line work of trying to keep residents healthy, care for recovered patients, and help mitigate isolation and its detrimental effects on residents. These tasks in many cases have been performed in the absence of residents’ family members and friends, who have not been allowed to visit as part of efforts to prevent the spread of infection. Inside nursing homes, the nursing staff have had to act as both caregivers and confidants, carrying out their usual tasks while also supporting many residents through confusion, depression, and suicidal ideation. In multigenerational homes, additional steps have been required to mitigate COVID-19 risk for older adults, such as using separate bathrooms, wearing masks within the household if someone is sick, or avoiding visitors. Demand for home health nursing services, inclusive of following strict public health measures (masks, handwashing, quarantining), has increased during the pandemic.

Changes in Medicare policy during the COVID-19 pandemic have given older adults greater access to a variety of mental health services, including those provided in their homes. Access to telehealth has also been expanded to meet the urgent need to provide safe access to care. Medicare payment for telehealth visits in nursing homes was previously restricted to rural areas, but under the 1135 waiver and the Coronavirus Preparedness and Response Supplemental Appropriations Act, CMS temporarily broadened access to telehealth services to ensure that Medicare beneficiaries could access services from the safety of their homes ( CMS, 2020b ). Accordingly, NPs and other health care professionals have used telehealth to screen people for COVID-19 and treat noncritical illnesses that can be managed at home.

Telehealth also has helped address concerns about workforce capacity for adult health care due to the surging numbers of COVID-19 cases and reports of exposure among health care workers: “as many as 100 health care workers at a single institution have to be quarantined at home because of COVID-19” ( Hollander and Carr, 2020 ). NPs who are quarantined because of exposure can provide telehealth services. It is important to note that the barriers discussed earlier due to restrictive scope-of-practice regulations may include limitations on providing telehealth services across state lines. Recognition of clinical licenses across states, such as through interstate agreements, could ease these barriers ( NQF, 2020 ).

Although CDC has reported that COVID-19 poses a relatively low risk for children, research on natural disasters has shown that, compared with adults, children are more vulnerable to the emotional impact of traumatic events that disrupt their daily lives. The pandemic has required that children make significant adjustments to their routines (e.g., because of school and child care closures and the need for social distancing and home confinement), disruptions that may interfere with a child’s sense of structure, predictability, and security. Young people—even infants and toddlers—are keen observers of people and environments, and they notice and react to stress in their parents and other caregivers, peers, and community members ( Bartlett et al., 2020 ). While most children eventually return to their typical functioning when they receive consistent support from sensitive and responsive caregivers, others are at risk of developing significant mental health problems, including trauma-related stress, anxiety, and depression. Children with prior trauma or preexisting mental, physical, or developmental problems, as well as those whose parents struggle with mental health disorders, substance misuse, or economic instability, are at especially high risk for emotional disturbance. Thus, in addition to keeping children physically safe during a public health emergency such as the COVID-19 pandemic, it is important to care for their emotional health ( Bartlett et al., 2020 ).

Barriers to mental health care result in serious immediate and long-term disadvantages for young people, especially students of color. Mental health—a key component of children’s healthy development—was already a growing concern prior to the pandemic and the concurrent nationwide protests in response to racial injustice and anti-Black racism, with the demand for mental health services among U.S. adolescents increasing in the past decade ( Mojtabai et al., 2020 ). This concern has been fueled by increases in the incidence of anxiety and depression, as well as a trend in which victims of suicide have been younger. As noted earlier, programs such as Nurse-Family Partnership (see Box 4-1 ), as well as school nurses and school-based health centers, represent channels through which nurses can assist children and families with health care access to address mental health needs.

The health care system is being transformed by an increased focus on community-based coordinated care and the use of technology to improve communication so as to achieve better population health outcomes at lower cost. At the local level, providers in public health and school settings can collaborate strategically to increase their community’s capacity to address the root causes of illness and improve overall population health by implementing broad social, cultural, and economic reforms that address SDOH. Such collaboration can benefit the entire health care system by leading to seamless care, reducing duplicative services, and lowering the costs of care.

• CONCLUSIONS

Whether in an elementary school, a hospital, or a community health clinic, nurses work to address the root causes of poor health. As the largest and consistently most trusted members of the health care workforce, nurses practice in a wide range of settings. They have the ability to manage as well as collaborate within teams and connect clinical care, public health, and social services while building trust with communities. However, nurses are limited in realizing this potential by state and federal laws that prohibit them from working to the full extent of their education and training. The COVID-19 pandemic in particular has revealed that the United States needs to do a much better job of linking health and health care to social and economic needs, and nurses are well positioned to build that bridge.

Conclusion 4-1: Nurses have substantial and often untapped expertise to help individuals and communities access high-quality health care, particularly in providing care for people in underserved rural and urban areas. Improved telehealth technology and payment systems have the potential to increase access, allowing patients to obtain their care in their homes and neighborhoods. However, the ability of nurses to practice fully in these and other settings is limited by state and federal laws that prohibit them from working to the full extent of their education and training. Conclusion 4-2: Nurses are uniquely qualified to improve the quality of health care by helping people navigate the health care system; providing close monitoring, coordination, and follow-up across the care continuum; focusing care on the whole person; and providing care that is culturally respectful and appropriate. Through a team-based approach, nurses can partner with professionals and community members to lead and manage teams and connect clinical care, public health, and social services while building trust with communities and individuals.

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