The Future of Nursing: A Midwifery Perspective


In October 2010, the Institute of Medicine released the report The Future of Nursing: Leading Change, Advancing Health,1 which was developed in partnership with the Robert Wood Johnson Foundation. The impetus for the report was the crossroads created by the passage of the Affordable Care Act and anticipated resulting overhaul of the US health care system. As the largest profession in the health care workforce, nurses are essential in redesigning the health care system and thus were chosen as the focus of the report. An interdisciplinary committee representing a wide range of expertise, including nursing, midwifery, medicine, dentistry, research, health policy, public health, law, social work, and economics, developed the report, which contains 4 key messages (Box 1) and 8 recommendations (Box 2).

Table Box 1. . The Future of Nursing Key Messages
1. Nurses should practice to the full extent of their education and training.
2. Nurses should achieve higher levels of education and training through an improved education system that promotes seamless
 academic progression.
3. Nurses should be full partners, with physicians and other health care professionals, in redesigning health care in the United States.
4. Effective workforce planning and policy making require better data collection and information infrastructure.
Table Box 2. . The Future of Nursing Recommendations
1. Remove scope-of-practice barriers.
2. Expand opportunities for nurses to lead and diffuse collaborative improvement efforts.
3. Implement nurse residency programs.
4. Increase the proportion of nurses with a baccalaureate degree to 80 percent by 2020.
5. Double the number of nurses with a doctorate by 2020.
6. Ensure that nurses engage in lifelong learning.
7. Prepare and enable nurses to lead change to advance health.
8. Build an infrastructure for the collection and analysis of interprofessional health care workforce data.

As one of the 4 types of advanced practice registered nurses (APRNs), certified nurse-midwives (CNMs) are specifically discussed in the report. In fact, one of the report's case studies, which describe innovative nursing models that directly affect health care, focuses on the midwifery model of care provided by CNMs in birth centers. The case study features the Family Health and Birth Center in Washington, DC, and its founder, Ruth Watson Lubic, CNM, EdD, FACNM, FAAN. The inclusion of CNMs in recommendations about APRNs makes it reasonable to use midwife in addition to nurse when discussing many aspects of the report.

As I have listened to dialogue about The Future of Nursing, 3 key points have emerged as significant to me with regard to claiming scope of practice, focusing on patients, and using this report as an actionable agenda to promote change. First, the key message that nurses and midwives should practice to the full extent of our education and training does not mean we are trying to expand our practice. Instead, we are laying claim to what is rightfully ours based upon what we are already educated and trained to do. In many cases, the needed consistent state legislation, payor authorization and coverage of midwifery services, and medical staff privileges reflect what is already a reality for some midwives rather than unprecedented change.

Second, while the report focuses on the nursing profession, our efforts to implement the report's recommendations must be centered on patients and quality of care. Fortunately, this is an area in which there is a large body of evidence about midwifery practice. A recent systematic review compared outcomes of APRN and physician care.2 The outcomes for CNMs are reported in more detail in a separate publication3 and include lower use of interventions (eg, labor induction, episiotomy), lower incidence of perineal lacerations, and higher breastfeeding rates with CNM care compared to physician care. Infant outcomes (eg, low Apgar score, neonatal intensive care unit admission) were comparable for CNMs and physicians. This review is an invaluable resource as we secure the role of midwifery in the evolving health care system. We must make clear that our goal is improving the health of women and families, rather than our objective being advancement of the midwifery profession.

Third, while The Future of Nursing is groundbreaking and inspiring, the report cannot transform the nursing and midwifery professions. However, it does provide a wealth of information and clear, specific actions we can take to bring about transformation. The report ends with a blueprint for action and was followed by the launch of the Campaign for Action, which strives to advance comprehensive health care change and turn the recommendations of The Future of Nursing into actions at the national, state, and local levels. Box 3 provides the link to the Campaign for Action Web site, which contains many valuable resources and highlights accomplishments to date, as well as links to The Future of Nursing and the International Academy of Nursing Editors’ collection of articles and editorials related to the report.

Table Box 3. . The Future of Nursing Online Resources
The Future of Nursing: Leading Change, Advancing Health
Download a PDF copy of the report for free or order a hard copy
The Future of Nursing: Campaign for Action
Learn more about this initiative to implement the recommendations of The Future of Nursing
The International Academy of Nursing Editors (INANE) Future of Nursing Initiative
Locate articles and editorials about The Future of Nursing that have appeared in nursing journals

We have reached an unprecedented time of opportunity for nursing and midwifery. This is our moment. Now we must seize it and maximize the contributions of our professions, positively transform the health care system, and ultimately, and most importantly, provide the best care possible to the women and families we serve.


Thank you to Carole R. Myers, PhD, RN, and the International Academy of Nursing Editors for presentations and discussions about The Future of Nursing that were essential to this editorial.