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JULY/AUGUST 2011 :: 72(4)
Future of Nursing in North Carolina

The policy forum of this issue takes as its point of departure an April 2011 summit of North Carolina nurse leaders, who met to review and discuss recommendations from The Future of Nursing: Leading Change, Advancing Health, a report recently published by the Institute of Medicine of the National Academies. Commentaries from experts across the state affirm the importance of ensuring that an effective, educated nursing workforce is present; that nursing education involves a seamless process; that nurses can practice to the full extent of their education and training; that nurses are full partners in redesigning health care; and that an effective, comprehensive health care workforce planning system is in place. Also in this issue, original articles address the use Charlotte-area emergency departments for primary care services and the presence of defibrillators in North Carolina public schools.

INVITED COMMENTARY

Educational Preparation to Strengthen Nursing Leadership

Elaine S. Scott

N C Med J. 2011;72(4):296-299.PDF | TABLE OF CONTENTS



Two of the 8 recommendations in the Institute of Medicine of the National Academies report on the future of nursing call for increased leadership by nurses. While nurses alone cannot transform health care, they do need a stronger voice in health care systems, and they need better educational preparation as members of the health care leadership team.

Are nurses the underused resource that can improve health through prevention and reduce disparities in health through access and affordability? According to the Institute of Medicine of the National Academies (IOM) and the Institute for Healthcare Improvement, the answer is yes [1, 2]. Nursing is the largest profession in health care, and nurses have an outstanding reputation of trust with consumers, but their impact on health care redesign and innovation has been limited in the practice settings where they work. Nurses are essential safeguards in hospitals, providing 24-hour surveillance and management of patients. Nurses are the primary group of health professionals responsible for running our public health system, they are the single largest portal of care for poor and underserved individuals, and nurse practitioners provide exemplary primary care, with research confirming that the care they deliver is comparable to that provided by primary care physicians [3]. Yet, nurses continue to have a silent voice in the health care system. To a large extent, this silence is attributable to a need for stronger development of leadership within the nursing profession.

Two of the 8 recommendations in the recently published IOM report on the future of nursing call for expanded leadership and leadership preparation for nurses [1]. Specifically, nurses are needed to lead innovation at the bedside, to work collaboratively with physicians and other members of the health care team to redesign care that is affordable and effective, and to serve on public and private boards related to health care [1]. The report also calls for expanded “opportunities for nurses to lead and manage collaborative efforts to conduct research and to redesign and improve practice environments and health systems” [1pS-9]. One recommended avenue for fostering leadership abilities is to increase the number of nurses with a baccalaureate to 80% by 2020 [1]. The best place to start educational-advancement initiatives is with nurses who are in formal leadership positions. Well-educated nurses in management positions can better address the needs of patients and communities, support nursing staff in returning to school, and advocate for a better-educated nursing workforce in North Carolina.

While nurses alone cannot transform health care, they do need a stronger leadership presence in health care systems, and they need to be better prepared as collaborators and innovators on the health care team. For several years, a national survey has prioritized financial stability, health care reform implementation, government mandates, and quality and patient safety as the top 4 concerns of hospital administrators [4]. To address these concerns, the nursing perspective is essential [2]. There are significant differences between the perspectives offered by nurse leaders and those offered by chief executive officers and health care boards [5]. Chief nurse officers are more familiar with reports and research on quality and patient safety, and they have a different perspective on what needs to be done to improve quality in health care organizations [5]. Patient outcomes are influenced by nursing care and by nursing leadership that infuses the importance of quality and safety throughout the organization [6-9]. The survival of health care reform initiatives that eliminate reimbursement for hospital-associated adverse events and promote pay-for-performance standards also requires the involvement of nurses [2]. The voice of the nurse needs to be heard, particularly in the boardroom and at the executive team’s decision-making table [5]. Whereas the chief financial officer is skilled in viewing health system concerns in relationship to money, the chief executive officer ensures organizational sustainability, and the chief operating officer manages risk and operational integrity, the chief nurse officer provides the knowledge and skill to ensure patient safety, quality care, and beneficial outcomes.

Nurse leaders set the example for other nurses to follow, and they influence the policies health care organizations create to promote educational advancement, tuition reimbursement, and clinical ladder requirements. A well-educated workforce of nurse leaders not only strengthens the profession’s competency, it also improves patient outcomes. Research demonstrates that effective nurse leaders contribute to lower patient mortality [6], healthier work environments [7], and improved quality and patient safety [5]. An effective nurse leader must be well educated and well prepared. By requiring master’s level education for senior nurse leaders and baccalaureate education for frontline and midlevel nurse managers, organizations can strengthen the team that addresses health care reform initiatives and patient safety.

The American Organization of Nurse Executives (AONE) endorses the recommendation that nurse leaders need to be prepared at least at the baccalaureate or master’s level [10]. The AONE has developed competency recommendations for managers at all levels, including (1) communication and relationship building, (2) knowledge of the health care environment, (3) leadership, (4) professionalism, and (5) business skills. A more detailed description of these domains can be found in Table 1. In addition to academic degrees, another important indicator of competency for nurse leaders is national certification. The certifying examination for nurse executives, offered by the American Nurse Credentialing Center (ANCC), tests the nurse leader’s abilities in 5 domains (Table 2). The ANCC requires that all nurses pursuing certification as a nurse executive must hold a bachelor’s degree or higher in nursing, have had at least 24 months of administrative practice during the previous 5 years, and have completed 30 or more hours of continuing education in nursing administration within the past 3 years. If the candidate for certification has a master’s degree in nursing administration, the last prerequisite is waived [11].

The ANCC oversees both the certification for nurse executives and the designation of magnet status for hospitals. Magnet status is an award given to hospitals that satisfy a set of criteria designed to measure the strength and quality of their nursing services [12]. Magnet hospitals demonstrate better patient outcomes, higher levels of nursing job satisfaction, and lower turnover rates among nursing staff [13]. Hospitals with magnet status promote nurse involvement in research, data collection, and decision making related to patient care delivery. “Recognizing quality patient care, nursing excellence, and innovations in professional nursing practice, the Magnet Recognition Program provides consumers with the ultimate benchmark to measure the quality of care that they can expect to receive. When U.S. News & World Report publishes its annual showcase of ‘America’s Best Hospitals,’ being an ANCC Magnet organization contributes to the total score for quality of inpatient care” [12]. Recent data demonstrate that 51.7% of the nurse leaders in magnet facilities across the United States hold a master’s degree or higher [14].

Graduate-level education in nursing administration prepares the nurse leader to achieve certification and to be competent to address the complex issues of organizing and delivering nursing care in today’s health system. A review of 57 nursing administration master’s programs in the United States showed that content on finance, economics, organizational theory, outcomes evaluation and management, quality improvement, legal and regulatory issues, health policy, and human resource management was essential in the curriculum for nurse leaders [15]. In contrast, the curriculum for an associate’s degree in nursing (ADN) focuses on developing entry-level competency in the delivery of safe and effective clinical care to individuals. This is also true for baccalaureate-level education in nursing, although my review of the 10 largest bachelor’s of science in nursing (BSN) programs in North Carolina found that 100% of these programs also provide courses in population health, leadership, and research. When nurses with an ADN return to school to achieve a BSN, the nursing courses required focus on content in 3 main areas: leadership development, community and population health, and evidence-based practice. While BSN programs across the state include basic instruction on leadership, clinical research, and elements of wellness and population health, the degree of competence nurse leaders currently need in these areas far exceeds these rudimentary educational frameworks for practice. Although BSN education equips nurses to function as charge nurses and assistant nurse managers, it clearly is inadequate for higher levels of administrative function in health care organizations. Master’s level education is preferable if nurses are to acquire academic preparation in the areas in which the AONE and the ANCC recommend that nurse leaders must be competent and if nurse leaders are to partner in redesigning a safer, more efficient, and more effective care system for patients in North Carolina.

The East Carolina Center for Nursing Leadership was established at East Carolina University in 2006 to address the statewide need to advance leadership competency among nurses. With a mission to mobilize nurses to be effective partners and leaders in creating healthier communities in North Carolina, the center works to promote leadership development among nursing students, to advance research on nursing leadership, and to engage with community nurse leaders. One of the first workforce evaluations performed by the center was an examination of the educational levels of nurse managers in the state. A review of the 2009 North Carolina Board of Nursing database of nurses classified as administrators, supervisors, or head nurses revealed that, in contrast to nurse leaders in magnet facilities, only 11.7% of those in North Carolina held a master’s degree. The majority of nurse leaders in North Carolina are educated at less than a baccalaureate level, with 10.8% holding a diploma in nursing and 43.1% holding an ADN. Approximately 30% of North Carolina nurse managers have a BSN, and 4.3% have a baccalaureate in a field other than nursing. The center procured a number of grants aimed at providing an improved gateway toward advanced nursing degrees (ie, RN-BSN and MSN) for nurse leaders. Efforts included transitioning the master’s degree in nursing leadership concentration to an online program, developing regional cohorts of nurses who want to return to school, mentoring ADN-credentialed nurse leaders in the educational process, and offering an annual emerging-leaders institute that introduced nurse leaders to online technologies for learning and shared evidence about how higher levels of education inform administrative practice in nursing. In response to these initiatives, the online administration program has grown from 6 to 85 students, 76 nurse managers have received 30 continuing education units for leadership training, and 8 student cohorts have been established across the state in hospital environments.

To advance the contribution that the nursing workforce can make to improve patient access and safety, improve quality, and promote innovation and cost containment, nurse leaders must be well educated and well prepared. Nurses need physicians, hospital administrators, and finance officers who see value in having an informed nurse leader to partner with as health care is transformed in North Carolina. Just as quality and patient safety cannot be improved without nurses, nursing cannot be improved without a shared vision among health care professionals and boards that a well-educated nurse leader is an asset to the clinical team, to the health care leadership team, and to North Carolina communities.

Acknowledgment
Potential conflicts of interest. E.S.S. has no relevant conflicts of interest.

References
1. Institute of Medicine of the National Academies (IOM). The Future of Nursing: Leading Change, Advancing Health. Washington, DC: The National Academies Press; 2011.

2. Bisognano M. Nursing’s role in transforming health care. Healthc Exec. 2010;25(2):84-87.

3. Lenz E, Mundinger M, Kane R, Hopkins S, Lin S. Primary care outcomes in patients treated by nurse practitioners or physicians: two-year follow-up. Med Care Res Rev. 2004;61(3):332-351.

4. American College of Healthcare Executives announces top issues confronting hospitals: 2010 [press release]. Chicago, IL: American College of Healthcare Executives; January 24, 2011. American College of Healthcare Executives Web site. http://www.ache.org/Pubs/Releases/2011/topissues.cfm. Accessed May 5, 2011.

5. Mastal MF, Joshi M, Schulke K. Nursing leadership: championing quality and patient safety in the boardroom. Nurs Econ. 2007;25(6):323-330.

6. Cummings GG, Midodzi WK, Wong CA, Estabrooks CA. The contribution of hospital nursing leadership styles to 30-day patient mortality. Nurs Res. 2010;59(5):331-339.

7. Sherman R, Pross E. Growing future nurse leaders to build and sustain healthy work environments at the unit level. Online J Issues Nurs. 2010;15(1):DOI 10.3912/OJIN.Vol15No01Man01.

8. Needleman J, Buerhaus P, Pankratz VS. Nurse staffing and inpatient hospital mortality. N Engl J Med. 2011;364:1037-1045.

9. Blegen MA, Goode CJ, Spetz J, Vaughn T, Park SH. Nurse staffing effects on patient outcomes. Med Care. 2011;49(4):406-414.

10. AONE nurse executive competencies. Nurse Leader. 2005:50-56. http://www.aone.org/aone/certification/docs%20and%20pdfs/NurseExecCompetencies.pdf. Accessed January 12, 2010.

11. Nurse executive certification eligibility criteria. American Nurse Credentialing Center Web site. http://www.nursecredentialing.org/NurseExec-Eligibility.aspx. Accessed November 10, 2010.

12. Program overview. American Nurse Credentialing Center Web site. http://www.nursecredentialing.org/Magnet/ProgramOverview.aspx. Accessed May 13, 2011.

13. Armstrong KJ, Laschinger H. Structural empowerment, magnet hospital characteristics, and patient safety: making the link. J Nurs Care Qual. 2006;21(2):124-132.

14. Average magnet organization characteristics. American Nurse Credentialing Center Web site. http://www.nursecredentialing.org /CharacteristicsMagnetOrganizations.aspx. Accessed September 9, 2011.

15. Scott ES. Nursing administration graduate programs in the United States. J Nurs Adm. 2007;37(11):517-522.


Elaine S. Scott, PhD associate professor, College of Nursing, East Carolina University, Greenville, North Carolina.

Address correspondence to Dr. Elaine S. Scott, College of Nursing, East Carolina University, 3138 Health Sciences Bldg, Greenville, NC 27858 (scottel@ecu.edu).