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ACP's response to the IOM's report the future of nursing: Leading change, advancing health

The Institute of Medicine (IOM) recently released a study, The Future of Nursing: Leading Change, Advancing Health. The report calls for new and expanded roles for nurses in a redesigned health care system. It recommends improving education for all nurses and allowing nurses to practice to the full extent of their license and ability. It advocates overhauling state scope of practice acts and suggests that advanced practice registered nurses (APRNs) -- certified registered nurse anesthetists, certified nurse-midwives, clinical nurse specialists, and certified nurse practitioners should be allowed to practice independently.

Although many of the recommendations of the IOM report are consistent with positions advocated by the American College of Physicians (ACP), other elements are of concern:

  • The College agrees that the nursing and medical professions together have critical roles and responsibilities in providing comprehensive, team-based and patient-centered care that takes full advantage of the training and experiences of each profession. As trained health care professionals, physicians and nurses share a commitment to providing high-quality care.

  • Recommendation #1 of the IOM report seeks to remove scope-of-practice barriers. It includes calls upon state legislatures to reform scope-of-practice regulations to conform to the National Council of State Boards of Nursing advanced practice registered nurse model rules and regulations that would allow APRNs to practice independently. The IOM's emphasis on independent practice is at odds with the goal of ensuring that patients receive comprehensive and patient-centered care within the context of a health care team.

    • Today, no one clinician should practice independently of other clinicians. Instead, the goal should be to develop collaborative and team-based models that allow every member of the team to contribute to the best possible outcomes to the full level of their training and skills while recognizing differences in their training and skills.

  • Physicians and nurses complete training with different levels of knowledge, skills, and abilities that are complementary but not equivalent:

    • Physicians must complete four years of medical school with two years of clinical rotations during the third and fourth years of medical school (3200 hours of general clinical education) and a minimum of three years of full-time clinical postgraduate residency training (minimum 7800 hours) in their specialty.

    • Licensed Practical /Licensed Vocational Nurses (LPN/LVNs) complete a 12 to 18 month educational program at a vocational/technical school or community college. They work under the supervision of a physician or registered nurse.

    • Registered Nurses (RNs) may complete a two-three year Associate Degree (ASN) program of study at a community college, diploma school of nursing or a four-year college or university; however, a four-year Baccalaureate Degree in Nursing (BSN) is the standard for a registered nurse and Recommendation 4 of the IOM calls for increasing the proportion of nurses with a baccalaureate degree to 80 percent by 2020. Many registered nurses receive additional training and specialize in areas such as critical care, public health, or oncology.

    • Advanced Practice Registered Nurses (APRNs) generally receive a Master's degree and/or post Master's Certificate. Increasingly, APRNs go on to obtain degrees as Doctor of Nursing Practice (DNP) or Doctor of Philosophy in Nursing (PhD). There are also post-baccalaureate programs that combine the Master's and Doctorate programs and take approximately three years to complete on a fulltime schedule.

    • The IOM report acknowledges that "the nursing profession itself must undergo a fundamental transformation if the committee's vision for health care is to be realized." It also recognizes that physicians receive more extensive and specialized education and training than nurses. The IOM report concludes, "Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression."

  • Internists are particularly well suited to provide long-term, comprehensive care in the office and the hospital, managing both common and complex illnesses of adolescents, adults, and the elderly:

    • Internists receive in-depth training in the diagnosis and treatment of conditions affecting all organ systems.

    • Internists have a strong grounding in the scientific basis of clinical medicine and in disease pathophysiology, providing them with the background to effectively integrate current and evolving scientific knowledge with the delivery of clinical care.

    • Internists are specially trained to solve puzzling diagnostic problems and can handle severe, complex chronic illnesses and situations where several different illnesses may strike at the same time.

    • Internists' training is solely directed to care of adult patients; consequently, internists are especially focused on care of adult and aged patients with multiple complex chronic diseases.

    • Internists are trained in the essentials of primary care internal medicine, which incorporates an understanding of disease prevention, wellness, substance abuse, and mental health.

    • Because of the differences in years and content of training, patients with complex problems, multiple diagnoses, or difficult management challenges will typically be best served by internists and other physician specialists working with a team of health care professionals that may include nurse practitioners, physician assistants (PAs), and other non-physician clinicians.

    • A personal physician, working collaboratively with teams of other qualified health professionals, plays an essential role in delivering high quality, patient-centered, and coordinated care to patients. Advanced practice nursing cannot substitute for nor replace primary care medical practice as provided by general internists, family physicians, pediatricians and other physicians.

  • Whenever possible, the needs and preferences of every patient should be met by the health care professional with the most appropriate skills and training to provide the necessary care:

    • Patients rely on a health care clinician's professional designation as an indication of the level of training, skills, and knowledge of those providing their care. The use of the prefix "Dr." or "Doctor" by nurses who have obtained the DNP degree could lead to confusion and misconceptions by patients.

    • Patients have the right to be informed of the credentials and qualifications of health care professionals involved in their care to better enable them to understand the background and orientation of their care givers. Consequently, information should be available to patients to help them distinguish among the different health care professionals involved in their care

  • Workforce policies should recognize that training more nurse practitioners or physician assistants does not eliminate the need or substitute for increasing the numbers of general internists and other physicians trained to provide primary care. A recent study projects a shortage of tens of thousands of primary care physicians for adult patients, even after the contributions of the nursing profession, physician assistants, and other non-physician health professionals are taken into account.

  • In addition to nursing, the contributions of physician assistants, working together with physicians, nurses and other health professionals in a team-oriented practice, such as the patient-centered medical home, should be supported as a proven model for delivering high-quality, cost-effective patient care.

  • Physicians, nurses, APRNs, and physician assistants need to be trained to know when they should refer or hand-off a patient to a clinician with a different level of skill and training. This applies not only to non-physicians, but also to primary care physicians and subspecialists who need to engage the skills of another physician-specialist.

  • The IOM recommends that the FTC and the Antitrust Division of the Department of Justice should review state regulations concerning APRNs to identify those that have anti-competitive effects without contributing to the health and safety of the public. It further recommends that "States with unduly restrictive regulations should be urged to amend them to allow advanced practice registered nurses to provide care to patients in all circumstances in which they are qualified to do so."

    • State licensing laws and regulations are intended to protect the public by ensuring that all licensed health clinicians and health professionals have the skills, training and experience required to provide a defined level of service to patients.

    • In this era of transformation of health care delivery, review of state licensing laws would be better served by looking at those areas where APRNs are not allowed to perform functions within the patient-centered medical home that evidence suggests their knowledge, skills, and abilities should allow them to perform. Delivery models such as the VA could be looked to for guidance. Data from patient-centered medical homes can provide additional evidence-based guidance over time as to the specific functions best filled by different health care professionals.

    • Review of state licensing laws should not lead to changes that could harm patient care by allowing any group of health care professionals to provide care for which that profession does not have the requisite training, experience and skills. Such laws should, however, allow all health care professionals to practice to the full level of their training, experience and skills working in a collaborative, team-based environment.

ACP believes that the future of health care delivery will require multidisciplinary teams of health care professionals that collaborate to provide patient-centered care. The key to high performance in multidisciplinary teams is an understanding of the distinctive roles, skills, and values of all team members primary care physicians, medical and surgical specialists, nurses (including APRNs, RNs and NPs), physician assistants, and other health professionals working together to delivery high quality, effective, coordinated and team-based care.

Recognizing and building on the common ground between the physicians, nurses, physician assistants, and other health professionals is vital to improving collaboration to meet the complex health care needs of the population.


Contact: David Kinsman
American College of Physicians

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