Discussion-Nursing Leadership and the Future of Nursing

What We Know › Leadership is a broad term that is often used to describe an individual’s ability to define

a vision in a specific competency. Leadership in nursing is a complex and multifaceted role, and visionary nursing leaders are needed to improve the future of the nursing profession and to effectively deliver quality patient care.(1,4,5,7,8) (For more information, see Nursing Practice & Skill … Effective Nursing Leadership: Performing and the series of Evidence-Based Care Sheets regarding nursing leadership) • The Institute of Medicine’s Future of Nursing report identifies the clinical nurse leader

as an innovative new role for meeting higher health-care quality standards. (2)

–Nursing leaders must constantly adapt to complex changes related to government policy, regulatory requirements, benchmark standards, economic forces, technology, and social challenges in the resource-constrained healthcare delivery system(8,9)

› Leadership development requires a change process of moving from a current state of high variability to a future state of high reliability and sustainability. High reliability and sustainability contribute to achieving optimal patient outcomes, supporting a healthy work environment, and promoting excellence in nursing practice(1,4,5)

• Effective nursing leadership guides staff members in developing a shared vision, values, and strategic goals for a specific setting (e.g., a unit or the department of nursing). Nursing leaders are responsible for mentoring other nurses to reach their full leadership and professional potential as well as creating supportive professional practice environments linking nurses’ perceptions of patient care, quality, and job satisfaction (5,6)

–The future of the nursing profession necessitates having nursing leaders who demonstrate effective communication, strengthening intra and interprofessional relationships, building and sustaining teams, mutual trust and respect, and collaboration with others(2,5)

–The momentum for development of nurse leaders that are equipped to manage a complex healthcare system must include readiness by the organization at all levels to support growth and development that results in change and growth of the organizations members (e.g., staffing adjustments, fostering relationships, providing resources, identifying and addressing issues that impact learning)(9)

› The aging of the nursing workforce, the current nursing shortage, and healthcare reform are the driving forces for changing the healthcare delivery system in the United States(1,3,5)

• Anticipated mass retirements of older nurses, including experienced nurse leaders, makes fostering the development of current nurses into nurse leaders vital to promote patient care and maintain cost containment(11)

–Nurse leader recruitment costs can range from 8–15% of the positon’s salary for current employees of the organization to 15–30% of the position’s salary when recruiting outside of the organization and using recruiters(11)

–The investment of today’s nurse leaders in developing nurse leaders of tomorrow is vital to avoid care disruptions due to staff turnover and to prepare nurses to lead in the complex healthcare system of today and the future(11)

–Nursing schools must promote leadership and organizations must provide opportunities for leadership development (11)

– Reported barriers to effective implementation of programs and development of nurse leaders include a lack of support for organization executives, lack of interest in the programs, inadequate fit of the program for the workplace, and an overall lack of programs(11)

– A small quality improvement project implementing a structured nurse leadership development program identified that use of a web-based leadership program combined with mentoring by nurse executives increased perceived confidence in leadership skills of nurses(11)

› The Robert Wood Johnson Foundation (RWJF) partnered with the Institute of Medicine (IOM) in a 2-year study to identify barriers to nursing practice and approaches to transforming the nursing profession. The landmark 2011 report, The Future of Nursing: Leading Change, Advancing Health, recognizes nursing leadership as a key component to transforming the nursing profession and meeting the challenges of healthcare reform(5)

• In the report, the IOM calls for comprehensive healthcare reform and actions to provide all patients with evidence-based, high-quality,safe, patient-centered healthcare by implementing the following four broad recommendations: –Enabling nurses to practice to the full extent of their education and training. Outdated policies and regulations must be

reviewed and revised to eliminate scope-of-practicelimitations. Nurses must be supported by legislation and healthcare reform in meeting the challenges of an aging population and providing high quality, safe health care for all patients(5)

– Congress must expand and amend Medicare and Medicaid programs to extend reimbursement rates and include coverage for services provided by advanced practice registered nurses (APRNs)

– State legislatures must reform scope-of-practiceregulations with the National Council of State Boards of Nursing Model Practice Act and Model Nursing Administrative Rules and require third-partypayers to provide direct reimbursement to APRNs who provide patient care within their scope-of-practiceaccording to state law

–Improving nursing education at all levels to promote professional experience in quality improvement methods, leadership opportunities, and effective collaboration with all healthcare professionals in a variety of settings. Nursing education should provide lifelong learning opportunities and a seamless transition to achieving higher level degrees(5)

– The IOM recommends doubling the number of nurses with a doctorate level degree by 2020 with support from private and public funders (e.g., Health Resources and Services Administration, the Department of Labor), accrediting organizations, and academic administrators and university trustees

–Preparing and supporting nurses to lead change and becoming full partners with other healthcare professionals in redesigning the U.S. healthcare delivery system. The IOM states, “Although the public is not used to viewing nurses as leaders, and not all nurses begin their career with thoughts of becoming a leader, all nurses must be leaders in the design, implementation, and evaluation of, as well as advocacy for, the ongoing reforms to the system that will be needed”(5)

– Nurses must take full responsibility for identifying resources (and wasted resources) and areas for improvement, implementing and serially tracking improvement methods, and making necessary changes to meet established goals

–Improving workforce data collection systems and analysis. This strategy involves identifying the numbers and types of healthcare professionals who are currently employed, the location where they are employed, and the roles in which they are employed(5)

– Improved data collection and analysis can provide for a comprehensive evaluation of cost-effectiveness and the financial impact in all areas of health care in order to effectively balance the skills among all healthcare professionals and identify demographic variations (e.g., increased need for healthcare providers to practice in rural settings)

• Researchers who conducted a multiyear study in 2011 and 2013 of nurse leaders who were members of the American Organization of Nurse Executives, the National Nursing Centers Consortium or the Visiting Nurses Association of America reported progress toward implementing the IOM’s recommendations, with an increasing proportion of practicing registered nurses holding bachelor’s degrees, an increasing proportion of healthcare institutions with nurse residency programs, and an increasing proportion of healthcare organizations offering opportunities for continuing nurse education(10)

› There are more than 3 million nurses working in the U.S.,and nursing comprises the largest part of the U.S. healthcare workforce.(5)

• Members of the nursing profession must become actively involved in healthcare policy in order to establish full partnership with other healthcare professionals.

• Nursing expertise is needed on advisory committees, commissions, task forces, and boards that are responsible for making policy decisions in order to strengthen the influence of the nursing profession and leadership regarding health policy and reform(5)

• National professional nursing organizations must unite regarding important health policy decisions and increased government spending on nursing education(5)

• Nurses can become actively involved in the political arena by meeting with local and state representatives and building partnerships with elected officials, business owners, and philanthropists in order to provide data, knowledge, and expertise to influence healthcare legislation(5)

• Nurses can redesign the future of healthcare in the U.S. by running for local, state, and national political office(5)

• Nurses are responsible for educating healthcare providers regarding the scope of nursing practice and competency; it is important that APRNs convey that they are not trying to replace physicians, but to work with them in a collaborative practice(5)

› Nurses are expected to practice leadership in all settings and be involved in the healthcare delivery process to improve patient outcomes.(5) Healthcare reform offers opportunities for advancing nursing leadership roles in the following specific areas: • Nursing-led reform in birth practices to lower costs and improve accessibility, patient satisfaction, and quality of care(5)

• School clinics to manage childhood obesity and polypharmacy and to promote screening, prevention, and improved health practices (e.g., regular exercise to achieve fitness)(5)

• Community clinics can formulate updated practice models to integrate nurses as leaders who serve patients in primary care(5)

• Transition of care practices can be improved to decrease adverse events during patient transitions; more research is required to promote collaboration of healthcare organizations to improve patient outcomes during transitions of care(5)

• Healthy aging and wellness programs can be led by nurses to develop and implement evidence-based practice and payment models(5)

• Management of chronic health conditions in the community can be led by nurses with expertise in home healthcare; this area is closely aligned with the focus of needs by programs in healthy aging and wellness and by community clinics(5)

• The area of palliative and end-of-life care require nursing expertise in clinical management, patient care delivery, updated practice models, and policy advocacy(5)

› Members of the nursing profession must collaborate with healthcare organizations;local, state, and federal governments; professional associations; certifying organizations (e.g., nursing licensing boards); education organizations; and the insurance industry to transform the nursing profession and provide affordable, accessible, patient-centered, and quality care to all patients(5)

What We Can Do › Become knowledgeable about nursing leadership and the future of nursing so you can promote evidence-based and

patient-centered healthcare practices in your facility; share this information with your colleagues › Support the four key recommendations of IOM to transform the nursing profession by

• becoming politically active in healthcare policy; for more information, see http://campaignforaction.org/ • identifying specific areas in your facility that would benefit from nursing expertise and leadership • working collaboratively with all healthcare professionals in your facility • designing, implementing, and evaluating healthcare reform and related practices in your facility • collaborating with members of your facility to improve workforce data collection systems and analysis • reviewing and revising outdated policies and regulations in your facility • endorsing and participating in continuing nursing education • mentoring other nurses

Coding Matrix References are rated using the following codes, listed in order of strength:

M Published meta-analysis

SR Published systematic or integrative literature review

RCT Published research (randomized controlled trial)

R Published research (not randomized controlled trial)

C Case histories, case studies

G Published guidelines

RV Published review of the literature

RU Published research utilization report

QI Published quality improvement report

L Legislation

PGR Published government report

PFR Published funded report

PP Policies, procedures, protocols

X Practice exemplars, stories, opinions

GI General or background information/texts/reports

U Unpublished research, reviews, poster presentations or other such materials

CP Conference proceedings, abstracts, presentation

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