Aug 02, 2021
The National Academy of Medicine’s Future of Nursing 2020-2030 Charting a Path to Achieve Health Equity Recommendations at a Glance
Recommendations at a Glance was developed for the Center to Champion Nursing America, an initiative of AARP Foundation, AARP and the Robert Wood Johnson Foundation, by InnovationPoint, LLC, under the leadership of Soren Kaplan, PhD, InnovationPoint founder. It is anchored in the nine overarching recommendations (54 sub-recommendations) within the new Future of Nursing Report.
Nine Recommendations and 54 Associated Action Items
In 2021, all national nursing organizations should initiate work to develop a shared agenda for addressing social determinants of health and achieving health equity. This agenda should include explicit priorities across nursing practice, education, leadership, and health policy engagement. The Tri-Council for Nursing and the Council of Public Health Nursing Organizations, with their associated member organizations, should work collaboratively and leverage their respective expertise in leading this agenda-setting process. Relevant expertise should be identified and shared across national nursing organizations, including the Federal Nursing Service Council and the National Coalition of Ethnic Minority Nurse Associations. With support from the government, payers, health and health care organizations, and foundations, the implementation of this agenda should include associated timelines and metrics for measuring impact.
1.1 Within nursing organizations: Assess & eliminate racist & discriminatory policies.
Assess diversity, equity, and inclusion, and eliminate policies, regulations, and systems that perpetuate structural racism, cultural racism, and discrimination with respect to identity (e.g., sexual orientation, gender), place (e.g., rural, inner city), and circumstances (e.g., disabilities, depression).
1.2 Across nursing organizations: Leverage expertise of public health nursing.
Develop mechanisms for leveraging the expertise of public health nursing (e.g., in population health, SDOH, community-level assessment) as a resource for the broader nursing.
1.3 Across nursing organizations: Leverage expertise in care coordination and care management.
Develop mechanisms for leveraging the expertise of relevant nursing organizations in care coordination and care management. Care coordination and care management principles, approaches, and evidence should be used to create new cross-sector models for meeting social needs and addressing SDOH.
1.4 Across nursing organizations: Develop mechanisms for nurses’ health, well- being, resiliency, and self-care.
Develop mechanisms for prioritizing and sharing continuing education and skill-training resources focused on nurses’ health, well-being, resiliency, and self-care to ensure a healthy nursing workforce. These resources should be used by nurses and others in leadership
1.5 External to nursing organizations: Use communication strategies to amplify health-equity related issues.
Develop and use communication strategies, including social media, to amplify for the public, policy makers, and the media nursing research and expertise on health equity–related issues.
1.6 External to nursing organizations: Increase the number and diversity of nurses.
Increase the number and diversity of nurses, especially those with expertise in health equity, population health, and SDOH, on boards and in other leadership positions within and outside of health care (e.g., community boards, housing authorities, school boards, technology- related positions).
1.7 External to nursing organizations: Establish awards recognizing contributions in achieving health equity.
Establish a joint annual award or series of awards recognizing the measurable and scalable contributions of nurses and their partners to achieving health equity through policy, education, research, and practice. Priority should be given to interprofessional and multisector collaboration.
By 2023, state and federal government agencies, health care and public health organizations, payers, and foundations should initiate substantive actions to enable the nursing workforce to address social determinants of health and health equity more comprehensively, regardless of practice setting.
2.1 Rapidly increase number of nurses with expertise in health equity and in specialty areas with current shortages.
Rapidly increase both the number of nurses with expertise in health equity and the number of nurses in specialties with significant shortages, including public and community health, behavioral health, primary care, long-term care, geriatrics, school health, and maternal health. The Health Resources and Services Administration (HRSA), the Substance Abuse and Mental Health Services Administration (SAMHSA), the Centers for Disease Control and Prevention (CDC), and state governments should support this effort through workforce planning and funding.
2.2 Invest in nursing education and traineeships in public health.
Provide major investments for nursing education and traineeships in public health, including through state-level workforce programs; foundations; and the U.S. Department of Health and Human Services’ (HHS’s) HRSA (including nursing workforce programs and Maternal and Child Health Bureau programs), CDC (including the National Center for Environmental Health), and the Office of Minority Health.
2.3 Direct funds to nurses and nursing schools to sustain and increase diversity.
State governments, foundations, employers, and HRSA should direct funds to nurses and nursing schools to sustain and increase the gender, geographic, and racial diversity of the licensed practical nurse (LPN), registered nurse (RN), and advanced practice registered nurse (APRN) workforce.
2.4 Invest in nurse loan and scholarship programs.
HRSA and the Indian Health Service (IHS) should make substantial investments in nurse loan and scholarship programs to address nurse shortages, including in public health, in health professional shortage areas (HPSAs) for HRSA, and in IHS designated sites; and invest in technical assistance that focuses on nurse retention.
2.5 Prioritize longitudinal community-based learning opportunities in all relevant Title 8 programs.
In all relevant Title 8 programs, HRSA should prioritize longitudinal community-based learning opportunities that address social needs, population health, SDOH, and health equity. These experiences should be established through academic–community-based partnerships.
2.6 Support the academic progression of socioeconomically disadvantaged students.
Foundations, state government workforce programs, and the federal government should support the academic progression of socioeconomically disadvantaged students by encouraging partnerships among baccalaureate and higher-degree nursing programs and community colleges; tribal colleges; historically Black colleges and universities; Hispanic- serving colleges and universities; and nursing programs that serve a high percentage of Asian, Native Hawaiian, and Pacific Islander students.
2.7 Establish a National Nursing Workforce Commission or significantly invest in and enhance the current capacity of HRSA’s National Advisory Council on Nurse Education and Practice.
HHS should establish a National Nursing Workforce Commission or alternatively, significantly invest in and enhance the current capacity of HRSA’s National Advisory Council on Nurse Education and Practice. The membership of this body should comprise public and private health care payers, employers, government agencies, nurses, representatives of other health professions, and consumers, all from diverse backgrounds and sectors. This entity would:
- Report on and propose actions to fill critical gaps in the current nursing workforce and prepare the future workforce to address health equity.
- Use findings, including those from workforce centers, on the diversity, capacity, supply, and distribution of nurses; associated competencies; and organizational support for the nursing workforce in addressing social needs, SDOH, and health equity. Recommend actions to ensure nurses’ continued engagement in these areas.
- Further develop recommendations for nursing education and practice with respect to addressing social needs, SDOH, and health equity, and assess the implications of these changes for nurse credentialing and regulatory actions.
- Identify and address gaps in evidence-based nursing and interprofessional and multisectoral approaches for addressing social needs, SDOH, and health equity.
- Provide information to the secretary of HHS regarding activities of federal agencies that relate to the nursing workforce and its impact on health equity.
2.8 Quantify nursing expenditures related to health equity and SDOH.
Public health and health care systems should quantify nursing expenditures related to health equity and SDOH. This includes providing support for nurses in activities that explicitly target social needs, SDOH, and health equity through health care organization policies, governance and related advisory structures, and collective bargaining agreements.
2.9 Include nursing expertise when health-related multisector policy reform is being advanced.
Representatives of social sectors, consumer organizations, and government entities should include nursing expertise when health-related multisector policy reform is being advanced.
2.10 Provide sustainable state and federal funding to prepare nurses to address SDOH and advance health equity.
State and federal governments should provide sustainable funding to prepare sufficient numbers of baccalaureate, APRN, and PhD-level nurses to address SDOH, advance health equity, and increase access to primary care.
2.11 Employers support nurses to help them play a leading role in achieving health equity.
Employers should support nurses at all levels in all settings with the financial, technical, educational, and staffing resources to help them play a leading role in achieving health equity.
By 2021, nursing education programs, employers, nursing leaders, licensing boards, and nursing organizations should initiate the implementation of structures, systems, and evidence- based interventions to promote nurses’ health and well-being, especially as they take on new roles to advance health equity.
3.1 Nursing education programs: Integrate content on nurses’ health and well-being into their programs.
Nursing education programs should integrate content on nurses’ health and well-being into their programs to raise nursing students’ awareness of the importance of these concerns and provide them with associated skill training and support that can be used as they transition to practice.
3.2 Nursing education programs: Create mechanisms to protect students most at risk for behavioral health challenges.
Nursing education programs should create mechanisms, including organizational policy and regulations, to protect students most at risk for behavioral health challenges, including those students who may be experiencing economic hardships or feel that they are unsafe; isolated; or targets of bias, discrimination, and injustice.
3.3 Employers: Provide sufficient human and material resources to enable nurses to provide high-quality care effectively and safely.
Employers, including nurse leaders, should provide sufficient human and material resources (including personal protective equipment) to enable nurses to provide high-quality person-, family-, and community-centered care effectively and safely. This effort should include redesigning processes and increasing staff capacity to improve workflow, promote transdisciplinary collaboration, reduce modifiable burden, and distribute responsibilities to reflect nurses’ expertise and scope of practice.
3.4 Employers: Establish a culture of physical and psychological safety.
Employers, including nurse leaders, should establish a culture of physical and psychological safety and ethical practice in the workplace, including dismantling structural racism; addressing bullying and incivility; using evidenced-informed approaches; investing in organizational infrastructure, such as resilience engineering; and creating accountability for nurses’ health and well-being outcomes.
3.5 Employers: Create mechanisms to protect nurses from retaliation.
Employers, including nurse leaders, should create mechanisms, including organizational policy and regulations, to protect nurses from retaliation when advocating on behalf of themselves and their patients and when reporting unsafe working conditions, biases, discrimination, and injustice.
3.6 Employers: Support diversity, equity, and inclusion across the nursing workforce.
Employers, including nurse leaders, should support diversity, equity, and inclusion across the nursing workforce, and identify and eliminate policies and systems that perpetuate structural racism, cultural racism, and discrimination in the nursing profession, recognizing that nurses are accountable for building an antiracist culture, and employers are responsible for establishing an antiracist, inclusive work environment.
3.7 Employers: Prioritize and invest in health interventions for nurses, including reward programs.
Employers, including nurse leaders, should prioritize and invest in evidence-based mental, physical, behavioral, social, and moral health interventions, including reward programs meaningful to nurses in diverse roles and specialties, to promote nurses’ health, well-being, and resilience within work teams and organizations.
3.8 Employers: Establish and standardize processes that strengthen nurses’ contribution to improving design and delivery of care and decision making.
Employers, including nurse leaders, should establish and standardize institutional processes that strengthen nurses’ contribution to improving the design and delivery of care and decision making, including the setting of institutional policies and benchmarks in health care organizations and in educational, public health, and other settings.
3.9 Employers: Reduce stigma associated with mental and behavioral health treatment for nurses.
Employers, including nurse leaders, should evaluate and strengthen policies, programs, and structures within employing organizations and licensing boards to reduce stigma associated with mental and behavioral health treatment for nurses.
3.10 Employers: Collect systematic data to better understand the health and well- being of the nursing workforce.
Employers, including nurse leaders, should collect systematic data at the employer, state (including state work- force centers and state nursing associations), and national levels to better understand the health and well-being of the nursing workforce. This enhanced understanding should be used to inform the development of evidence-based interventions for mitigating burnout; fatigue; turnover; and the development of physical, behavioral, and mental health problems.
All organizations, including state and federal entities and employing organizations, should enable nurses to practice to the full extent of their education and training by removing barriers that prevent them from more fully addressing social needs and social determinants of health and improving health care access, quality, and value. These barriers include regulatory and public and private payment limitations; restrictive policies and practices; and other legal, professional, and commercial impediments.
4.1 Changes to institutional policies and laws adopted in response to the COVID-19 pandemic should be made permanent.
By 2022, all changes to institutional policies and state and federal laws adopted in response to the COVID-19 pandemic that expand scope of practice, telehealth eligibility, insurance coverage, and payment parity for services provided by APRNs and RNs should be made permanent.
4.2 Federal authority should be used where available to supersede restrictive state laws.
Federal authority (e.g., Veterans Health Administration regulations, Centers for Medicare & Medicaid Services [CMS]) should be used where available to supersede restrictive state laws, including those addressing scope of practice, telehealth, and insurance coverage and payment, that decrease access to care and burden nursing practice, and to encourage nationwide adoption of the Nurse Licensure Compact.
4.3 Health Care Regulator Collaborative should work to advance interstate compacts and the adoption of model legislation.
The Health Care Regulator Collaborative should work to advance interstate compacts and the adoption of model legislation to improve access, standardize care quality, and build interprofessional collaboration and interstate cooperation.
Federal, tribal, state, local, and private payers and public health agencies should establish sustainable and flexible payment mechanisms to support nurses in both health care and public health, including school nurses, in addressing social needs, social determinants of health, and health equity.
5.1 Reform fee-for-service payment models.
Reform fee-for-service payment models by:
- Ensuring that the Current Procedure Terminology (CPT) code set includes appropriate codes to describe and reimburse for such nurse- led services as case management, care coordination, and team-based care to address behavioral health, addiction, SDOH, and health equity, and that the relative value units (RVUs) attached to the CPT codes result in adequate and direct reimbursement for this work; reimbursing for school nursing; and
- Reimbursing for school nursing; and
- Enabling nurses to bill for telehealth services.
5.2 Reform value-based payment models.
Reform value-based payment by:
- Using clinical performance measures stratified by such risk factors as race, ethnicity, and socioeconomic status;
- Supporting nursing interventions through clinical performance measures that incentivize reductions in health disparities between more and less advantaged populations, improvements in measures for at-risk populations, and attainment of absolute target levels of high-quality performance for at-risk populations; and
- Incorporating disparities-sensitive measures that support and incentivize nursing interventions that advance health equity (e.g., process measures such as care management and team-based care for chronic conditions; outcomes such as prevention of hospitalizations for ambulatory care–sensitive conditions).
5.3 Reform alternative payment models.
Reform alternative payment models by:
- Providing flexible funding (capitated payments, global budgets, shared savings, per member per month payments, accountable health communities models) for nursing and infrastructure that address SDOH; and
- Incorporating value-based payment (VBP) metrics that enable nurses to address SDOH and advance health equity.
5.4 Create a National Nurse Identifier.
Create a National Nurse Identifier to facilitate recognition and measurement of the value of services provided by RNs.
5.5 Ensure adequate funding for public health nursing.
Ensure adequate funding for school and public health nursing by:
- Implementing state policies that allow school nurses to bill Medicaid and supporting schools, particularly rural schools, in meeting documentation requirements;
- Reimbursing school nursing services that include collaboration with clinical and community health care providers;
- Promoting new ways of financing public health to address SDOH in the community (e.g., having federal, state, and local leaders, along with public health departments and organizations, partner with payers, health systems, and accountable health communities, and blend or braid multiple funding sources);
- Creating funding mechanisms and joint accountability metrics for the efforts of the health, public health, and social sectors to address SDOH and advance health equity that align incentives and behavior across the various stakeholders, including school health;
- Leveraging nonprofit hospital community benefit requirements to create partnerships with and among school and public health nursing, primary care organizations and other social sectors; and
Using pay scales for public health nurses that are competitive with those for nursing positions in other health care organizations and sectors, and that provide equal pay when the services provided (e.g., immunizations) are the same.
All public and private health care systems should incorporate nursing expertise in designing, generating, analyzing and applying data to support initiatives focused on social determinants of health and health equity using diverse digital platforms, artificial intelligence, and other innovative technologies.
6.1 Integrate data on SDOH and build a nationwide infrastructure.
With leadership from CMS and The Office of the National Coordinator for Health Information Technology, accelerate interoperability projects that integrate data on SDOH from public health, social service organizations, and other community partners into electronic health records, and build a nationwide infrastructure to capture and share community-held knowledge, facilitate referrals for care (including by decreasing the “digital divide”), and facilitate coordination and connectivity among health care settings and the public and nonprofit sectors.
6.2 Ensure that health equity data collaboratives improve visualization of data on SDOH.
Ensure that existing public/private health equity data collaboratives (e.g., the Gravity Project8) encompass nursing-specific care processes that improve visualization of data on SDOH and associated decision making by nurses.
6.3 Employ nurses with expertise in informatics to improve individual and population health.
Employ nurses with requisite expertise in informatics to improve individual and population health through large-scale integration of data on SDOH into nursing practice, as well as expertise in the use of telehealth and advanced digital technologies.
6.4 Give nurses in clinical settings responsibility and associated resources to innovate and use technology.
To personalize care based on person- and family-centered preferences and individual needs, give nurses in clinical settings responsibility and associated resources to innovate and use technology, including in the use of data on SDOH as context for planning and evaluating care; in the design of personal and mobile health tools; in coordination of community and public health portals across care settings; in methods for effective communication using technology; in evaluation of datasets and artificial intelligence algorithms (e.g., for racial bias); and in partnerships with corporate settings outside of health care delivery (e.g., large technology organizations, private insurers) that are addressing health equity in the nonclinical setting.
6.5 Provide resources to facilitate telehealth by nurses.
Provide supportive resources to facilitate the provision of telehealth by nurses by:
- Expanding the national strategy for a broadband/5G infrastructure to enable comprehensive community access to these services; and
- Increasing the availability of the necessary hardware, including smartphones, computers, and webcams, for high-risk populations.
Nursing education programs, including continuing education, and accreditors and the National Council of State Boards of Nursing should ensure that nurses are prepared to address social determinants of health and achieve health equity.
7.1 Actions for deans, administrative faculty leaders, faculty, course directors, and staff of nursing education programs.
- Integrate social needs, SDOH, population health, environmental health, trauma- informed care, and health equity as core concepts and competencies throughout coursework and clinical and experiential learning. These core concepts and competencies should be commensurate and seamless with academic level and included in continuing education.
- By the 2022–2023 school year, initiate an assessment of individual student access to technology, and ensure that all students can engage in virtual learning, including such opportunities as multisector simulation. Access to nursing education for geographically and socioeconomically disadvantaged students should be ensured through the development and expansion of the use of remote and virtual instructional capabilities. For rural areas, emphasis should be on baccalaureate preparation given the lower proportion of nurses educated at this level.
- To promote equity, inclusivity, and diversity grounded in social justice, identify and eliminate policies, procedures, curricular content, and clinical experiences that perpetuate structural racism, cultural racism, and discrimination among faculty, staff, and students.
- Increase academic progression for geographically and socioeconomically disadvantaged students through academic partnerships that include community and tribal colleges located in rural and urban underserved areas.
- Recruit diverse faculty with expertise in SDOH, population health (including environmental health), and health equity and associated policy expertise, and, through evidence-based and other training, develop the skills of current faculty with the objective of ensuring that students have access across the curriculum to expertise in these areas. Faculty should also have the technical competencies for online teaching.
- Ensure that students have learning opportunities with care coordination experiences that include working with health care teams to address individual and family social needs, as well as learning opportunities with multisector stakeholders that include a focus on health in all policies and SDOH. Learning experiences should include working with under- served populations in such settings as federally qualified health centers (FQHCs), rural health clinics, and IHS designated sites.
- Incorporate in all nurse doctoral education content related to SDOH, population health, environmental health, trauma-informed care, health equity, and social justice. All graduates of doctoral programs should have competencies in the use of data on SDOH as context for planning, implementing, and evaluating care and for improving population health through the large-scale application of these data.
- Ensure that PhD nursing graduates are competent to design and implement research that addresses issues of social justice and equity in education and/or health and health care and informs relevant policies. Increase the capacity of these graduates to apply research and scale interventions to address and improve social needs, SDOH, population health, environmental health, trauma-informed care, health equity, the well- being of nurses, and disaster preparedness and to inform relevant policies.
- Prepare all nursing students to advocate for health equity through civic engagement, including engagement in health and health-related public policy and communication through traditional and nontraditional methods, including social media and multisector
7.2 Actions for accreditors.
- Incorporate standards and competencies for curriculum that reflect the application of knowledge and skills to improve social needs, SDOH, population health, environmental health, trauma-informed care, and health equity.
- Incorporate standards for increasing student and faculty diversity.
- Require nursing education programs to initiate curricular assessments in 2022–2023 and phase in curricular changes that integrate social needs, SDOH, population health, environmental health, trauma-informed care, and health equity throughout the curriculum and are assessed in subsequent midterm and accreditation reporting. These curricular changes and their impact should be subject to continuous accreditation review processes.
- Include standards for nurses’ well-being and ethical practice in accreditation guidelines and include such content on nurse licensing and certification exams.
7.3 Action for the National Council of State Boards of Nursing and specialty certification organizations.
The National Council of State Boards of Nursing and specialty certification should take the following action: Incorporate test questions on meeting social needs through care coordination and on meeting population health needs, including addressing SDOH, through multisector coordination.
7.4 Action for continuing education providers.
Continuing education providers should take the following action: Evaluate each offering for the inclusion of social needs, SDOH, population health, environmental health, trauma- informed care, and health equity and strategies for associated public- and private-sector policy engagement.
To enable nurses to address inequities within communities, federal agencies and other key stakeholders within and outside the nursing profession should strengthen and protect the nursing workforce during the response to such public health emergencies as the COVID-19 pandemic and natural disasters, including those related to climate change.
8.1 Actions for the CDC.
- CDC should fund a National Center for Disaster Nursing and Public Health Emergency Response, along with additional strategically placed regional centers, to serve as the “hub” for providing leadership in education, training, and career development that will ensure a national nursing workforce prepared to respond to such events.
- CDC, in collaboration with the proposed National Center for Disaster Nursing and Public Health Emergency Response, should rapidly articulate a national action plan for addressing gaps in nursing education, support, and protection that have contributed to the lack of nurse preparedness and disparities during such events.
8.2 Develop and support emergency preparedness and response knowledge base of the nursing workforce.
The Office of the Assistant Secretary for Preparedness and Response (ASPR), CDC, HRSA, the Agency for Healthcare Research and Quality (AHRQ), CMS, the National Institute of Nursing Research (NINR), and other funders should develop and support the emergency preparedness and response knowledge base of the nursing workforce through regulations, programs, research, and sustainable funding targeted specifically to disaster and public health emergency nursing.
8.3 Lead transformational change in nursing education to address workforce development in disaster nursing and public health preparedness.
The American Association of Colleges of Nursing (AACN), the National League for Nursing (NLN), and the Organization for Associate Degree Nursing (OADN) should lead transformational change in nursing education to address workforce development in disaster nursing and public health preparedness. NCSBN should expand content in licensing examinations to cover actual responsibilities of nurses in disaster and public health emergency response.
8.4 Employer emergency response plans.
Employers should incorporate the expertise of nurses to proactively develop and implement an emergency response plan for natural disasters and public health emergencies in coordination with local, state, national, and federal partners. They should also provide additional services throughout a disaster or public health emergency, such as support for families and behavioral health, to support and protect nurses’ health and well-being.
The National Institutes of Health, the Centers for Medicare & Medicaid Services, the Centers for Disease Control and Prevention, the Health Resources and Services Administration, the Agency for Healthcare Research and Quality, the Administration for Children and Families, the Administration for Community Living, and private associations and foundations should convene representatives from nursing, public health, and health care to develop and support a research agenda and evidence base describing the impact of nursing interventions, including multisector collaboration, on social determinants of health, environmental health, health equity, and nurses’ health and well-being.
9.1 Develop mechanisms for proposing, evaluating, and scaling evidence-based practice models that leverage collaboration.
Develop mechanisms for proposing, evaluating, and scaling evidence-based practice models that leverage collaboration among public health, social sectors, and health systems to advance health equity, including co-designing innovations with individuals and community representatives and responding to community health needs assessments. This effort should emphasize rapidly translating evidence-based interventions into real-world clinical practice and community-based settings to improve health equity and population health outcomes, and applying implementation science strategies in the process of scaling these interventions and strategies.
9.2 Identify effective multisector team approaches to improving health equity and addressing social needs and SDOH.
Identify effective multisector team approaches to improving health equity and addressing social needs and SDOH, including clearly defining roles and assessing the value of nurses in these models. Specifically, performance and outcome measures should be delineated, and evaluation strategies for community-based models and multisector team functioning should be developed and implemented.
9.3 Use evidence-based approaches to increase number and diversity of students from disadvantaged groups.
Review and adapt evidenced-based approaches to increasing the number and diversity of students and faculty from disadvantaged and traditionally underrepresented groups to promote a diverse, inclusive learning environment and prepare a culturally competent workforce.
9.4 Determine evidence-based education strategies for preparing nurses to eliminate structural racism and implicit bias to strengthen culturally competent care.
Determine evidence-based education strategies for preparing nurses at all levels, including through continuing education, to eliminate structural racism and implicit bias and strengthen the delivery of culturally competent care.
9.5 Use technology to identify and integrate health and social data to improve nurses’ capacity for support.
Augment the use of advanced information technology infrastructure, including virtual services and artificial intelligence, to identify and integrate health and social data, including data on SDOH, so as to improve nurses’ capacity to support individuals, families, and communities, including through care coordination.
Source: National Academies of Sciences, Engineering, and Medicine. 2021. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington, DC: The National Academies Press. https://doi.org/10.17226/25982.