In addition to changes in nursing practice and education, discussed in Chapters 3 and 4, respectively, strong leadership will be required to realize the vision of a transformed health care system. 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. Additionally, nurses will need leadership skills and competencies to act as full partners with physicians and other health professionals in redesign and
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The Future of Nursing: Leading Change, Advancing Health 5 Transforming Leadership Key Message #3: Nurses should be full partners, with physicians and other health professionals, in redesigning health care in the United States. Strong leadership is critical if the vision of a transformed health care system is to be realized. Yet not all nurses begin their career with thoughts of becoming a leader. The nursing profession must produce leaders throughout the health care system, from the bedside to the boardroom, who can serve as full partners with other health professionals and be accountable for their own contributions to delivering high-quality care while working collaboratively with leaders from other health professions. In addition to changes in nursing practice and education, discussed in Chapters 3 and 4, respectively, strong leadership will be required to realize the vision of a transformed health care system. 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. Additionally, nurses will need leadership skills and competencies to act as full partners with physicians and other health professionals in redesign and
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The Future of Nursing: Leading Change, Advancing Health reform efforts across the health care system. Nursing research and practice must continue to identify and develop evidence-based improvements to care, and these improvements must be tested and adopted through policy changes across the health care system. Nursing leaders must translate new research findings to the practice environment and into nursing education and from nursing education into practice and policy. Being a full partner transcends all levels of the nursing profession and requires leadership skills and competencies that must be applied both within the profession and in collaboration with other health professionals. In care environments, being a full partner involves taking responsibility for identifying problems and areas of waste, devising and implementing a plan for improvement, tracking improvement over time, and making necessary adjustments to realize established goals. Serving as strong patient advocates, nurses must be involved in decision making about how to improve the delivery of care. Being a full partner translates more broadly to the health policy arena. To be effective in reconceptualized roles and to be seen and accepted as leaders, nurses must see policy as something they can shape and develop rather than something that happens to them, whether at the local organizational level or the national level. They must speak the language of policy and engage in the political process effectively, and work cohesively as a profession. Nurses should have a voice in health policy decision making, as well as being engaged in implementation efforts related to health care reform. Nurses also should serve actively on advisory committees, commissions, and boards where policy decisions are made to advance health systems to improve patient care. Nurses must build new partnerships with other clinicians, business owners, philanthropists, elected officials, and the public to help realize these improvements. This chapter focuses on key message #3 set forth in Chapter 1: Nurses should be full partners, with physicians and other health professionals, in redesigning health care in the United States. The chapter begins by considering the new style of leadership that is needed. It then issues a call to nurses to respond to the challenge. The third section describes three avenues—leadership programs for nurses, mentorship, and involvement in the policy-making process—through which that call can be answered. The chapter then issues a call for new partnerships to tap the full potential of nurses to serve as leaders in the health care system. The final section presents the committee’s conclusions regarding the need to transform leadership in the nursing profession. A NEW STYLE OF LEADERSHIP Those involved in the health care system—nurses, physicians, patients, and others—play increasingly interdependent roles. Problems arise every day that do not have easy or singular solutions. Leaders who merely give directions and expect them to be followed will not succeed in this environment. What is needed is
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The Future of Nursing: Leading Change, Advancing Health a style of leadership that involves working with others as full partners in a context of mutual respect and collaboration. This leadership style has been associated with improved patient outcomes, a reduction in medical errors, and less staff turnover (Gardner, 2005; Joint Commission, 2008; Pearson et al., 2007). It may also reduce the amount of workplace bullying and disruptive behavior, which remains a problem in the health care field (Joint Commission, 2008; Olender-Russo, 2009; Rosenstein and O’Daniel, 2008). Yet while the benefits of collaboration among health professionals have repeatedly been documented with respect to improved patient outcomes, reduced lengths of hospital stay, cost savings, increased job satisfaction and retention among nurses, and improved teamwork, interprofessional collaboration frequently is not the norm in the health care field. Changing this culture will not be easy. The new style of leadership that is needed flows in all directions at all levels. Everyone from the bedside to the boardroom must engage colleagues, subordinates, and executives so that together they can identify and achieve common goals (Bradford and Cohen, 1998). All members of the health care team must share in the collaborative management of their practice. Physicians, nurses, and other health professionals must work together to break down the walls of hierarchal silos and hold each other accountable for improving quality and decreasing preventable adverse events and medication errors. All must display the capacity to adapt to the continually evolving dynamics of the health care system. Leadership Competencies Nurses at all levels need strong leadership skills to contribute to patient safety and quality of care. Yet their history as a profession dominated by females can make it easier for policy makers, other health professionals, and the public to view nurses as “functional doers”—those who carry out the instructions of others—rather than “thoughtful strategists”—those who are informed decision makers and whose independent actions are based on education, evidence, and experience. A 2009 Gallup poll of more than 1,500 national opinion leaders,1 “Nursing Leadership from Bedside to Boardroom: Opinion Leaders’ Perceptions,” identified nurses as “one of the most trusted sources of health information” (see Box 5-1) (RWJF, 2010a). The Gallup poll also identified nurses as the health professionals that should have greater influence than they currently do in the critical areas of quality of patient care and safety. The leaders surveyed believed that major obstacles prevent nurses from being more influential in health policy decision making. These findings have crucial implications for front-line nurses, 1 Gallup research staff—Richard Blizzard, Christopher Khoury, and Coleen McMurray—conducted telephone surveys with 1,504 individuals, including university faculty, insurance executives, corporate executives, health services leaders, government leaders, and industry thought leaders.
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The Future of Nursing: Leading Change, Advancing Health BOX 5-1 Results of Gallup Poll “Nursing Leadership from Bedside to Boardroom: Opinion Leaders’ Perceptions” Opinion leaders rate doctors and nurses first and second among a list of options for trusted information about health and health care. Opinion leaders perceive patients and nurses as having the least amount of influence on health care reform in the next 5–1 years. Reducing medical errors, increasing quality of care, and promoting wellness top the list of areas in which large majorities of opinion leaders would like nurses to have more influence. Relatively few opinion leaders say nurses currently have a great deal of influence on increasing access to care, including primary care. Opinion leaders identified top barriers to nurses’ increased influence and leadership as not being perceived as important decision makers or revenue generators compared with doctors, having a focus on acute rather than preventive care, and not having a single voice on national issues. Opinion leaders’ suggestions for nurses to take on more of a leadership role were making their voices heard and having higher expectations. SOURCE: RWJF, 2010a. who possess critical knowledge and awareness of the patient, family, and community but do not speak up as often as they should. To be more effective leaders and full partners, nurses need to possess two critical sets of competencies: a common set that can serve as the foundation for any leadership opportunity and a more specific set tailored to a particular context, time, and place. The former set includes, among others, knowledge of the care delivery system, how to work in teams, how to collaborate effectively within and across disciplines, the basic tenets of ethical care, how to be an effective patient advocate, theories of innovation, and the foundations for quality and safety improvement. These competencies also are recommended by the American Association of Colleges of Nursing as essential for baccalaureate programs (AACN, 2008). Leadership competencies recommended by the National League for Nursing and National League for Nursing Accrediting Commission are being revised to reflect similar principles. More specific competencies might include learning how to be a full partner in a health team in which members from various professions hold each other accountable for improving quality and decreasing preventable adverse events and medication errors. Additionally, nurses who are interested in pursuing entrepreneurial and business development opportunities need competencies in such areas as economics and market forces, regulatory frameworks, and financing policy.
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The Future of Nursing: Leading Change, Advancing Health Leadership in a Collaborative Environment As noted in Chapter 1, a growing body of research has begun to highlight the potential for collaboration among teams of diverse individuals from different professions (Paulus and Nijstad, 2003; Pisano and Verganti, 2008; Singh and Fleming, 2010; Wuchty et al., 2007). Practitioners and organizational leaders alike have declared that collaboration is a key strategy for improving problem solving and achieving innovation in health care. Two nursing researchers who have studied collaboration among health professionals define it as a communication process that fosters innovation and advanced problem solving among people who are of different disciplines, organizational ranks, or institutional settings [and who] band together for advanced problem solving [in order to] discern innovative solutions without regard to discipline, rank, or institutional affiliation [and to] enact change based on a higher standard of care or organizational outcomes. (Kinnaman and Bleich, 2004) Much of what is called collaboration is more likely cooperation or coordination of care. Katzenbach and Smith (1993) argue that truly collaborative teams differ from high-functioning groups that have a defined leader and a set direction, but in which the dynamics of true teamwork are absent. The case study presented in Box 5-2 illustrates just how important it is for health professionals to work in teams to ensure that care is accessible and patient centered. Leadership at Every Level Leadership from nurses is needed at every level and across all settings. Although collaboration is generally a laudable goal, there are many times when nurses, for the sake of delivering exceptional patient and family care, must step into an advocate role with a singular voice. At the same time, effective leadership also requires recognition of situations in which it is more important to mediate, collaborate, or follow others who are acting in leadership roles. Nurses must understand that their leadership is as important to providing quality care as is their technical ability to deliver care at the bedside in a safe and effective manner. They must lead in improving work processes on the front lines; creating new integrated practice models; working with others, from organizational policy makers to state legislators, to craft practice policy and legislation that allows nurses to work to their fullest capacity; leading curriculum changes to prepare the nursing workforce to meet community and patient needs; translating and applying research findings into practice and developing functional models of care; and serving on institutional and policy-making boards where critical decisions affecting patients are made. Leadership in care delivery is particularly important in community and
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The Future of Nursing: Leading Change, Advancing Health BOX 5-2 Case Study: Arkansas Aging Initiative A Statewide Program Uses Interprofessional Teams to Improve Access to Care for Older Arkansans Bonnie Sturgeon was an independent 80-year-old in 2005 when shortness of breath began to slow her down. She had been living on her own for decades, driving herself to church and singing in the choir. She went to the Christus St. Michael Health System in Texarkana, Texas, her home town, for a diagnostic workup. There she met Amyleigh Overton-McCoy, PhD, GNP-BC, RN, a geriatrics nurse practitioner with the Arkansas Aging Initiative (AAI). “When I first went to see Amyleigh, I was there an hour or more,” Ms. Sturgeon said. “She asked me every question she could think of, and I wondered how many questions could be asked?” But the intensive interviewing and testing revealed that she had three blocked arteries and had experienced a heart attack. Ms. Sturgeon was scheduled for a triple coronary artery bypass grafting procedure. Five years later, she credits Ms. Overton-McCoy with saving her life. “I’ve not ever been in her office that she hasn’t gone over the past visit, what progress I made, and if I’ve had any new problems, even the smallest thing.” Patient centeredness, meticulous diagnostics, and wise counsel represent the kind of nursing that might provide a textbook definition of holistic care. This is the kind of care older Arkansans have been receiving since state voters passed the Tobacco Settlement Proceeds Act of 2000, which ordered that state monies from the Tobacco Master Settlement Agreement go toward health care initiatives, including the AAI. This is not about making somebody live to be 100 or 110. This is about quality of life. You can make the end [of life] as great as the beginning. That’s my job. —Amyleigh Overton-McCoy, PhD, GNP-BC, RN, geriatrics nurse practitioner and education director, Texarkana Regional Center on Aging, Texarkana, Texas Affiliated with the Donald W. Reynolds Institute on Aging at the University of Arkansas for Medical Sciences (UAMS) in Little Rock, the AAI has two direct service components. First, a team consisting of a geriatrician, an advanced practice registered nurse (APRN), and a social worker provides care at each of eight satellite centers on aging owned and managed by local hospitals (and financially self-supporting through Medicare). The team follows its patients across settings—hospital, clinic, home, and nursing home—as needed. Second, an education component supported by the tobacco settlement funds targets health professionals and students, older adults and their families, and the community at large.
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The Future of Nursing: Leading Change, Advancing Health The AAI’s director, Claudia J. Beverly, PhD, RN, FAAN, said that these two components are funded separately but go hand in hand in practice. New patients usually see a physician for an initial examination. APRNs are responsible for health promotion and disease prevention—mammograms and flu shots, for example—as well as analyses of current drug regimens. For patients with complex conditions, social workers make referrals and work with families on nursing home placement. Almost all older Arkansans can now access interprofessional geriatric care within an hour’s drive of their home. Patients are quite satisfied with their care and with the team approach (Beverly et al., 2007). Unpublished analyses of the areas around the centers show lower rates of emergency room use and hospitalization and higher rates of health care knowledge among elderly patients. Physicians at the eight sites report to Dr. Beverly, who is also director of UAMS’s Hartford Center of Geriatric Nursing Excellence, which provides some funding to the AAI. She has hired a nurse with a doctorate and a geriatrician to act as associate directors. Developing teamwork has been a priority. “This is such a beautiful case study in how nursing and medicine can work together,” she said, “and how, together, we can do good things.” There have been some obstacles: primary care services are dependent upon Medicare funding, and with an annual budget of $2 million to divide among eight sites, additional revenue is needed. There also may not be enough clinicians trained in geriatrics available. And although Dr. Beverly believes that APRNs “should have their own panel of patients,” they see only returning patients at the centers. She said funding has been secured to further evaluate how best to use team members. The model has continued to evolve from the first center in Northwest Arkansas that Dr. Beverly started as a Robert Wood Johnson Executive Nurse Fellow. That site is developing a program for the training of in-home caregivers, including home health aides and family members. And a new telehealth project will allow patients and clinicians to “see” a specialist electronically. “Economically, this is going to provide a huge benefit to patients,” Ms. Overton-McCoy said. Nurse Amyleigh Overton-McCoy explains to Bonnie Sturgeon how to manage the common health concerns associated with aging.
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The Future of Nursing: Leading Change, Advancing Health home settings where nurses work more autonomously with patients and families than they do in the acute care setting. In community and home settings, nurses provide a direct link connecting patients, their caregivers, and other members of the health care team. Other members of the health care team may not have the time, expertise, or first-hand experience with the patient’s home environment and circumstances to understand and respond to patient and family needs. For example, a neurologist may not be able to help a caregiver of an Alzheimer’s patient understand or curtail excessive spending habits, or a surgeon may not be able to offer advice to a caregiver on ostomy care—roles that nurses are perfectly positioned to assume. Leadership in these situations sometimes requires nurses to be assertive and to have a strong voice in advocating for patients and their families to ensure that their needs are communicated and adequately met. Box 5-3 describes a nurse who evolved over the course of her career from thinking that being an effective nurse was all about honing her nursing skills and competencies to realize that becoming an agent of change was an equally important part of her job. A CALL FOR NURSES TO LEAD Leadership does not occur in a social or political vacuum. As Bennis and Nanus (2003) note, the fast pace of change can be managed only if it is accompanied by leaders who can track the context of the “social architecture” to sustain and implement innovative ideas. Creating innovative care models at the bedside and in the community or taking the opportunity to fill a seat in a policy-making body or boardroom requires nurse leaders to develop ideas; approach management; and courageously make decisions within the political, economic, and social context that will make their solutions real and sustainable. A shift must take place in how nurses view their responsibility to those they care for; they must see themselves as full partners with other health professionals, and practice and education environments must socialize and educate them accordingly. An important aspect of this socialization is mentoring others along the way. More experienced nurses must take the time to show those who are new and less experienced the most effective ways of being an exceptional nurse at the bedside, in the boardroom, and everywhere between. Technology such as chat rooms, Facebook, and even blogs can be used to support the mentoring role. A crucial part of working within the social architecture is understanding how leadership and practice produce change over time. The nursing profession’s history includes many examples of the effect of nursing leadership on changes in systems and improvements in patient care. In the late 1940s and early 1950s, nurse Elizabeth Carnegie led the fight for the racial integration of nursing in Florida by example and through her extraordinary character and organizational skills. Her efforts to integrate the nursing profession were based in her sense of social justice not just for the profession, but also for the care of African American
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The Future of Nursing: Leading Change, Advancing Health citizens who had little access to a workforce that was highly skilled or provided adequate access to health care services. Also in Florida, in the late 1950s, Dorothy Smith, the first dean of the new University of Florida College of Nursing, developed nursing practice models that brought nursing faculty into the hospital in a joint nursing service. Students thereby had role models in their learning experiences, and staff nurses had the authority to improve patient care. From this system came the patient kardex and the unit manager system that freed nurses from the constant search for supplies that took them away from the bedside. In the 1980s, nursing research by Neville Strumpf and Lois Evans highlighted the danger of using restraints on frail elders (Evans and Strumpf, 1989; Strumpf and Evans, 1988). Their efforts to translate their findings into practice revolutionized nursing practice in nursing homes, hospitals, and other facilities by focusing nursing care on preventing falls and other injuries related to restraint use, and led to state and federal legislation that resulted in reducing the use of restraints on frail elders. Nurses also have also led efforts to improve health and access to care through entrepreneurial endeavors. For example, Ruth Lubic founded the first free-standing birth center in the country in 1975 in New York City. In 2000, she opened the Family Health and Birth Center in Washington, DC, which provides care to underserved communities (see Box 2-2 in Chapter 2). Her efforts have improved the care of thousands of women over the years. There are many other examples of nurse entrepreneurs, and a nurse entrepreneur network2 exists that provides networking, education and training, and coaching for nurses seeking to enter the marketplace and business. Will Student Nurses Hear the Call? Leadership skills must be learned and mastered over time. Nonetheless, it is important to obtain a basic grasp of those skills as early as possible—starting in school (see Chapter 4). Nursing educators must give their students the most relevant knowledge and practice opportunities to equip them for their profession, while instilling in them a desire and expectation for new learning in the years to come. Regardless of the basic degree with which a nurse enters the profession, faculty should feel obligated to show students the way to their first or next career placement, as well as to their next degree and continuous learning opportunities. Moreover, students should not wait for graduation to exercise their potential for leadership. In Georgia, for example, health students came together in 2001 under the banner “Lead or Be Led” to create a student-led, interprofessional nonprofit organization that “seeks to make being active in the health community a professional habit.” Named Health Students Taking Action Together (Health-STAT), the group continues to offer workshops in political advocacy, media 2 See http://www.nurse-entrepreneur-network.com/public/main.cfm.
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The Future of Nursing: Leading Change, Advancing Health BOX 5-3 Nurse Profile: Connie Hill A Nurse Leader Extends Acute Care Nursing Beyond the Hospital Walls It was at a 2002 meeting at Children’s Memorial Hospital in Chicago that Connie Hill, MSN, RN, reviewed the chart of a child who had been on a ventilator in her unit for 2 years. She asked her colleagues why the child had not been discharged. “It wasn’t because she was not medically stable,” Ms. Hill said recently, “but because there was a lack of community resources to support her.” Inadequate community services existed for a child with special needs in Chicago, the third-largest city in the nation? “I was dumbfounded,” she recalled. “And I said, ‘We need to start a consortium. We need to invite policy makers, state agencies, community leaders.’ And people just looked at me, like, ‘Okay, Connie. How are we going to get that started?’” As director of 9 West, the 30-bed Allergy/Pulmonary/Transitional Care Unit, Ms. Hill persisted, and in 2004 the Consortium for Children with Complex Medical Needs was formed. The 75-member coalition of parents, clinicians, advocates, and representatives of government agencies and insurance companies meets quarterly, with the goal of “networking, education, and advocacy” on behalf of the city’s special-needs children, some of whom may be on ventilators indefinitely. For example, the group identified poor reimbursement of home health care as a serious obstacle, and the hospital established ties to agencies able to tackle the reimbursement issue. Now, some children can go home to receive care. Connie Hill, MSN, RN Ms. Hill never intended to be a leader. She was working as a staff nurse at the hospital in the mid-1990s when colleagues encouraged training, networking, and fundraising. Its annual leadership symposium convenes medical, nursing, public health, and other students statewide to learn about health issues facing the state and work together on developing potential solutions (HealthSTAT, 2010). The National Student Nurses Association (NSNA), initiated in 1998, offers an online Leadership University that allows students to enhance
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The Future of Nursing: Leading Change, Advancing Health her to apply for a clinical manager position in 9 West. She followed their advice, and in late 2000 when her supervisor failed to return from maternity leave, she proposed a “shared leadership model.” After a year or so during which she and two other nurses shared the directorship, Ms. Hill was asked to become sole director (some staff were uncomfortable with the decentralized authority, despite good clinical outcomes). She did so, with a modest goal: “I wanted to provide a venue for all nurses to have a voice.” With this goal in mind, Ms. Hill decided in 2008 that 9 West would be a good fit for Transforming Care at the Bedside (TCAB), a national initiative of The Robert Wood Johnson Foundation with the Institute for Healthcare Improvement. Communication between nurses and rotating medical residents was targeted in the hospital’s quest to improve the coordination of care (Quisling, 2009). As Ms. Hill said, “It’s disheartening when you receive a patient survey and a family says, ‘The doctor said this, but then the nurse told me that.’” A procedure was created for staff nurses to provide orientations to residents, who rotate monthly among units, to foster better team communication. Residents are now more likely to confer with 9 West nurses during rounds, Ms. Hill said, increasing satisfaction among nurses, residents, patients, and families. As a doctoral student at the University of Wisconsin-Milwaukee College of Nursing, Ms. Hill is examining an often neglected population: teens born with HIV, a majority of whom are African American and Hispanic. Now that many HIV-positive children survive into adulthood, they mature sexually and face the stigma attached to the infection. Ms. Hill’s study uses PhotoVoice, which involves putting cameras into the hands of HIV-positive teens and asking them for a visual answer to the question, “Where do you see yourself in five years?” “They’re writing their own story” in photographs, she said, a story they can use to raise awareness in others and to remind themselves of their own strengths. I wanted to make the environment for the child and parents a place where they could feel safe, even though there was a lot of scary stuff going on around them. —Connie Hill, MSN, RN, director of a 30-bed unit at Children’s Memorial Hospital, Chicago Ms. Hill has quite a story herself. As a mother of a grown son, a pediatric nurse who endured many hospitalizations as a child, a researcher whose study is an outgrowth of her advocacy work, and an African American who strives to enhance access to health care for all, she is a woman of both practical ideas and lofty ideals. So when she saw that a child capable of living at home had been in her unit for 2 years, her natural response was to assemble a consortium. Today, that child is doing well at home. their capacity for leadership through several avenues, such as earning academic credit for participating in the university’s leadership activities and discussing leadership issues with faculty. Students work in cooperative relationships with other students from various disciplines, faculty, community organizations, and the public (Janetti, 2003). Box 5-4 profiles two student leaders, one of whom eventu-
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The Future of Nursing: Leading Change, Advancing Health the quality of policies enacted. Investigators are funded to complete innovative studies of topics relevant to current and future health policy. Participants in both programs receive intensive training to improve the content and delivery of messages intended to improve health policy and practice. This training is critical, as investigators are often called upon to testify to Congress about the issues they have explored. The health policy fellows bring their more detailed understanding of how policies are formed back to their home organizations. In this way, they are more effective leaders as they strive to bring about policy changes that lead to improvements in patient care. American Nurses Credentialing Center Magnet Recognition Program Although not an individual leadership program, the American Nurses Credentialing Center (ANCC) Magnet Recognition Program11 recognizes health care organizations that advance nursing excellence and leadership. In this regard, achieving Magnet status indicates that the nursing workforce within the institution has attained a number of high standards relating to quality and standards of nursing practice. These standards, as designated by the Magnet process, are called “Forces of Magnetism.” According to ANCC, “the full expression of the Forces embodies a professional environment guided by a strong visionary nursing leader who advocates and supports development and excellence in nursing practice. As a natural outcome of this, the program elevates the reputation and standards of the nursing profession” (ANCC, 2010). Some of these Forces include quality of nursing leadership, management style, quality of care, autonomous nursing care, nurses as teachers, interprofessional relationships, and professional development. Mentorship12 Leadership is also fostered through effective mentorship opportunities with leaders in nursing, other health professions, policy, and business. All nurses have a responsibility to mentor those who come after them, whether by helping a new nurse become oriented or by taking on more formal responsibilities as a teacher of nursing students or a preceptor. Nursing organizations (membership associations) also have a responsibility to provide mentoring and leadership guidance, as well as opportunities to share expertise and best practices, for those who join. Fortunately, a number of nursing associations have organized networks to support their membership and facilitate such opportunities: 11 See http://www.nursecredentialing.org/Magnet/ProgramOverview.aspx. 12 This section draws on personal communication in 2010 with Susan Gergely, Director of Operations, American Organization of Nurse Executives; Beverly Malone, CEO, National League for Nursing; Robert Rosseter, Chief Communications Officer, American Association of Colleges of Nursing; and Pat Ford Roegner, CEO, American Academy of Nursing.
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The Future of Nursing: Leading Change, Advancing Health The American Association of Colleges of Nursing (AACN) conducts an expertise survey that is used to identify subject matter experts across topic areas within its membership; it also maintains a list of nursing education experts. Names of these experts are shared with members on request. These resources also are used to identify experts to serve on boards, respond to media requests, and serve in other capacities. In addition, AACN offers an annual executive leadership development program and a new deans mentoring program to further promote and foster leadership. The National League for Nursing (NLN) has established an Academy of Nurse Educators whose members are available to serve as mentors for NLN members. NLN engages these educators in a variety of mentoring programs, from a National Scholarly Writing Retreat to the Johnson & Johnson mentoring program for new faculty. While AONE does not have a formal mentoring program, it has developed online learning communities where members are encouraged to interact, post questions, and learn from each other. These online communities facilitate collaboration; encourage the sharing of knowledge, best practices, and resources; and help members discover solutions to day-to-day challenges in their work. The American Academy of Nursing keeps a detailed list of nurse “Edge Runners”13 that describes the programs nursing leaders have developed and the outcomes of those programs. Edge Runner names and contact information are prominently displayed so that learning and mentoring can take place freely.14 The American Nurses Association just passed a resolution at its 2010 House of Delegates to develop a mentoring program for novice nurses. The program has yet to be developed. Over the years, the National Coalition of Ethnic Minority Nurse Associations (NCEMNA) has offered numerous workshops, webinars, and educational materials to develop its members’ competencies in leadership, policy, and communications. NCEMNA’s highly regarded Scholars program15 promotes the academic and professional development of ethnic minority investigators, in part through a mentoring program. It serves as a model worth emulating throughout the nursing profession. 13 The Edge Runner program is a component of the American Academy of Nursing’s Raise the Voice campaign, funded by the Robert Wood Johnson Foundation. The Edge Runner designation recognizes nurses who have developed innovative, successful models of care and interventions to address problems in the health care delivery system or unmet health needs in a population. 14 See AAN’s Edge Runner Directory, http://www.aannet.org/custom/edgeRunner/index.cfm?pageid=3303&showTitle=1. 15 See http://www.ncemna.org/scholarships.asp.
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The Future of Nursing: Leading Change, Advancing Health Involvement in Policy Making Nurses may articulate what they want to happen in health care to make it more truly patient centered and to improve quality, access, and value. They may even have the evidence to support their conclusions. As with any worthy cause, however, they must engage in the policy-making process to ensure that the changes they believe in are realized. To this end, they must be able to envision themselves as leaders in that process and seek out new partners who share their goals. The challenge now is to motivate all nurses to pursue leadership roles in the policy-making process. Political engagement is one avenue they can take to that end. As Bethany Hall-Long, a nurse who was elected to the Delaware State House of Representatives in 2002 and is now a state senator, writes, “political actions may be as simple as voting in local school board elections or sharing research findings with state officials, or as complex as running for elected office” (Hall-Long, 2009). For example, engaging school board candidates about the fundamental role of school nurses in the management of chronic conditions among students can make a difference at budget time. And if the goal is broader, perhaps to locate more community health clinics within schools, achieving buy-in from the local school board is absolutely vital. As Hall-Long writes, however, “since nurses do not regularly communicate with their elected officials, the elected officials listen to non-nursing individuals” (Hall-Long, 2009). Political engagement can be a natural outgrowth of nursing experience. When Marilyn Tavenner first started working in an intensive care unit in Virginia, she thought, “If I were the head nurse or the nurse manager, I would make changes. I would try to influence that unit and that unit’s quality and staffing.” After she became a nurse manager, she thought, “I wouldn’t mind doing this for the entire hospital.” After succeeding for several years as a director of nursing, she was encouraged by a group of physicians to apply for the CEO position of her hospital when it became available. Eventually, Timothy Kaine, governor of Virginia from 2006 to 2010, recruited her to be the state’s secretary of health and human resources. In February 2010, Ms. Tavenner was named deputy administrator for the federal Centers for Medicare and Medicaid Services. Like many nurses, she had never envisioned working in government. But she realized that she wanted to have an impact on health care and health care reform. She wanted to help the uninsured find resources and access to care. For her, that meant building on relationships and finding opportunities to work in government.16 Other notable nurses who have answered the call to serve in government include Sheila Burke, who served as chief of staff to former Senate Majority Leader Robert Dole, has been a member of the Medicare Payment Advisory Commission, 16 This paragraph draws on personal communication with Marilyn Tavenner, principal deputy administrator and chief operating officer, Centers for Medicare and Medicaid Services, May 11, 2010.
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The Future of Nursing: Leading Change, Advancing Health and now teaches at Georgetown and Harvard Universities; and Mary Wakefield, who was named administrator of HRSA in 2009 and is the highest-ranking nurse in the Obama Administration. Speaker of the House Nancy Pelosi’s office has had back-to-back nurses from The Robert Wood Johnson Foundation Health Policy Fellows Program as staffers since 2007, providing a significant entry point for the development of new health policy leaders. Additionally, in 1989 Senator Daniel Inouye established the Military Nurse Detailee fellowship program. This 1-year fellowship provides an opportunity for a high-ranking military nurse, who holds a minimum of a master’s degree, to gain health policy leadership experience in Senator Inouye’s office. The fellowship rotates among three branches of service (Army, Navy, and Air Force) annually.17 During the Clinton Administration, Beverly Malone served as deputy assistant secretary for health in the Department of Health and Human Services (HHS). In 2002, Richard Carmona, who began his education with an associate’s degree in nursing from the Bronx Community College in New York, was appointed surgeon general by President George W. Bush. Shirley Chater led the reorganization of the Social Security Administration in the 1990s. Carolyne Davis served as head of the Health Care Finance Administration (predecessor of the Centers for Medicare and Medicaid Services) in the 1980s during the implementation of a new coding system that classifies hospital cases into diagnosis-related groups. From 1979 to 1981, Rhetaugh Dumas was the first nurse, the first woman, and the first African American to serve as a deputy director of the National Institute of Mental Health (Sullivan, 2007). Nurses also have served as regional directors of HHS and as senior advisors on health policy to HHS. As for elected office, there were three nurse members of the 111th Congress—Eddie Bernice Johnson (D-TX), Lois Capps (D-CA), and Carolyn McCarthy (D-NY)—all of whom had a hand in sponsoring and supporting health care–focused legislation, from AIDS research to gun control. Lois Capps organized and co-chairs the Congressional Nursing Caucus (which also includes members who are not nurses). The group focuses on mobilizing congressional support for health-related issues. Additionally, 105 nurses have served in state legislatures, including Paula Hollinger of Maryland, who sponsored one of the nation’s first stem cell research bills. None of these nurses waited to be asked; they pursued their positions, both elected and appointed, because they knew they had the expertise and experience to make changes in health care. Very little in politics is accomplished without preparation or allies. Health professionals point with pride to multiple aspects of the Prescription for Pennsylvania initiative, a state health care reform initiative that preceded the ACA and is also described in Box 5-6. As is clear from a detailed 2009 review, success was not achieved overnight; smaller legislative and regulatory victories set the stage 17 Personal communication, Corina Barrow, Lieutenant Colonel, Army Nurse Corps, Nurse Corps Detailee, Office of Senator Daniel Inouye (D-HI), August 25, 2010.
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The Future of Nursing: Leading Change, Advancing Health BOX 5-6 Case Study: Prescription for Pennsylvania A Governor’s Leadership Improves Access to Care for Residents of a Rural State When Pennsylvania Governor Edward Rendell took office in 2003, one-twelfth of the state’s 12 million residents had no access to health care, 80 percent of health care expenditures went to treating chronic illnesses, and $3 billion was spent annually on avoidable hospitalizations of chronically ill patients. Pennsylvanians were 11 percent more likely than all other Americans to use the emergency room (ER). If we look at the workforce and the health care needs of an aging population, we’re insane if we don’t try to figure out how we can make sure that we have an adequate number of [clinicians] with the skill and knowledge to work together. —Ann S. Torregrossa, Esq., director, Governor’s Office of Health Care Reform for the Commonwealth of Pennsylvania On his first day in office, Governor Rendell established the Office of Health Care Reform to begin to address residents’ access to affordable, high-quality health care. In January 2007 he announced a major new blueprint for that reform, Prescription for Pennsylvania (known as Rx for PA, www.rxforpa.com), which would promote access to care for all Pennsylvanians and reduce the state’s skyrocketing health care expenses. In the 3-plus years since, many initiatives have been undertaken, including expanding health insurance coverage for the uninsured; improving access to electronic health information through the Pennsylvania Health Information Exchange; establishing a chronic illness commission, which in 2008 recommended, among other proposals, the patient-centered medical home; addressing workforce shortages through the Pennsylvania Center for Health Careers; establishing seven “learning collaboratives” that involve about 800 providers and 1 million patients and teach a variety of providers to collaborate on primary care teams; and expanding the legal scope of practice for physician assistants, advanced practice registered nurses (APRNs), clinical nurse specialists, certified nurse midwives, and dental hygienists (although legislation is still needed to allow APRNs to prescribe medications independently).
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The Future of Nursing: Leading Change, Advancing Health This last strategy has had an impact on access to care, particularly for the uninsured and underinsured. There are now 51 retail clinics that use APRNs in urban, suburban, and rural areas, and they provide care to 60 percent of the state’s uninsured, said Ann S. Torregrossa, Esq., who in 2005 was named deputy director and in 2009 director of the Office of Health Care Reform. Ms. Torregrossa said that of 300,000 visits to such clinics, about half would have been ER visits. Retail clinics have been shown to reduce costs and improve access to care (Mehrotra et al., 2009). Other outcome data after the first year of Rx for PA show an increase in the number of people with diabetes receiving eye and foot examinations and a doubling of the number of children with asthma who have a plan in place for controlling exacerbations (Pennsylvania Governor’s Office, 2009). There are about 250 nurse-managed health centers nationwide and 27 in Pennsylvania; many are affiliated with schools of nursing and provide care at a 10 percent lower cost than other models—including a 15 percent reduction in ER use and a 25 percent reduction in prescription drug costs (according to unpublished data from the National Nursing Centers Consortium [NNCC]). Tine Hansen-Turton, MGA, JD, CEO of the NNCC and vice president of the Public Health Management Corporation, a nonprofit institute, said that nurses involved in Rx for PA have a great deal to teach clinicians and leaders in other states as they grapple with health care reform (Hansen-Turton et al., 2009). The nurse-managed health centers in particular offer a preventive care model that improves access to care. And Pennsylvanians have given high marks to the care they have received from APRNs, Ms. Hansen-Turton said, adding, “It’s all about access.” Governor Edward Rendell speaks about the important role of nurses in improving access to health care in Pennsylvania.
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The Future of Nursing: Leading Change, Advancing Health starting in the late 1990s. Even some apparent legislative failures built the foundation for future successes because they caused nurses to spend more time meeting face to face with physicians who had organized opposition to various measures. As a result, nursing leaders developed a better sense of where they could achieve compromises with their opponents. They also found a new ally in the Chamber of Commerce to counter opposition from some sections of organized medicine (Hansen-Turton et al., 2009). Hansen-Turton and colleagues draw three major lessons from this experience. First, nurses must build strong alliances within their own professional community, an important lesson alluded to earlier in this chapter. Pennsylvania’s nurses were able to speak with a unified voice because they first worked out among themselves which issues mattered most to them. Second, nurses must build relationships with key policy makers. Pennsylvania’s nurses developed strong relationships with several legislators from both major political parties and earned the support of two successive sitting governors: Thomas Ridge (Republican) and Edward Rendell (Democrat). Third, nurses must find allies outside the nursing profession, particularly in business and other influential communities. Pennsylvania’s nurses gained a strong ally in the Chamber of Commerce when they were able to demonstrate how expanding regulations to allow nurses to do all they were educated and demonstrably capable of doing would help lower health care costs (Hansen-Turton et al., 2009). Perhaps the most important lesson to draw from the Pennsylvania experience lies in the way the campaign was framed. The focus of attention was on achieving quality care and cost reductions. A closer examination of the issues showed that achieving those goals required, among other things, expanding the roles and responsibilities of nurses. What drew the greatest amount of political support for the Prescription for Pennsylvania campaign was the shared goal of getting more value out of the health care system—quality care at a sustainable price. The fact that the campaign also expanded nursing practice was secondary. Those expansions are likely to continue as long as the emphasis is on quality care and cost reduction. Similarly, the committee believes that the goal in any transformation of the health care system should be achieving innovative, patient-centered, highvalue care. If all stakeholders—from legislators, to regulators, to hospital executives, to insurance companies—act from a patient-centered point of reference, they will see that many of the solutions they are seeking require a transformation of the nursing profession. A CALL FOR NEW PARTNERSHIPS Having enough nurses and having nurses with the right skills and competencies to care for the population is an important societal issue. Having allies
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The Future of Nursing: Leading Change, Advancing Health from outside the profession is important to achieving this goal. More nurses need to reach out to new partners in arenas ranging from business, government, and philanthropy to state and national medical associations to consumer groups. Additionally, nurses need to fortify alliances that are made through personal connections and relationships. Just as important, society needs to understand its stake in ensuring that nurses are effective full partners and leaders in the quest to deliver quality, high-value care that is accessible to diverse populations. The full potential of the nursing profession in care, leadership, and research must be tapped to deal with the wide range of health care challenges the nation will face in the coming years. Eventually, to transform the way health care is delivered in the United States, nurses will have to move not just out of the hospital, but also out of health care organizations entirely. For example, nurses are underrepresented on the boards of private nonprofit and philanthropic organizations, which do not provide health care services but often have a large impact on health care decisions. The Commonwealth Fund and the Kaiser Family Foundation, for instance, have no nurses on their boards, although they do have physicians. Without nurses, vital ground-level perspectives on quality improvement, care coordination, and health promotion are likely missing. On the other hand, AARP provides a positive example. At least two nurses at AARP have served in the top leadership and governance roles (president and chair) in the past 3 years. Nurses serve on the health and long-term services policy committee, and the senior vice president of the Public Policy Institute is also a nurse. AARP’s commitment to nursing is clear through its sponsorship, along with the Robert Wood Johnson Foundation, of the Center to Champion Nursing. CONCLUSION Enactment of the ACA will provide unprecedented opportunities for change in the U.S. health care system for the foreseeable future. Strong leadership on the part of nurses, physicians, and others will be required to devise and implement the changes necessary to increase quality, access, and value and deliver patient-centered care. If these efforts are to be successful, all nurses, from students, to bedside and community nurses, to CNOs and members of nursing organizations, to researchers, must develop leadership competencies and serve as full partners with physicians and other health professionals in efforts to improve the health care system and the delivery of care. Nurses must exercise these competencies in a collaborative environment in all settings, including hospitals, communities, schools, boards, and political and business arenas. In doing so, they must not only mentor others along the way, but develop partnerships and gain allies both within and beyond the health care environment.
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