Since the last edition of this book, much has occurred related to advanced practice nursing and the need for leadership skills and expertise. The Institute of Medicine's The Future of Nursing report (IOM, 2010) has begun to move the needle on educational progression, leadership, interprofessional collaboration, and expansion of the scope of practice; we now have almost 300 doctorate of nursing practice (DNP) programs across the nation, and the percentage of nurses with bachelor of science in nursing (BSN) degrees is slowly increasing. The Patient Protection and Affordable Care Act (ACA) has been rolled out with many challenges and opportunities. Accountable care organizations, as a result of the ACA, have evolved with some successes and some very hard lessons about the risk and complexity of keeping communities healthy. The term population health is no longer a concept; it is shifting the way we need to educate, practice, and lead. More than 80% of nurse practitioners, one segment of advanced practice registered nurses (APRNs), are prepared in primary care, whereas less than 15% of physicians entered a primary care residency and less than 4% of senior medical school students identified interest in primary care. Currently more than two thirds of all Americans have seen an APRN for their primary health care needs, with more than 916 million visits to APRNs each year (American Association of Nurse Practitioners [AANP], 2014). The Federal Trade Commission (2014) has provided an analysis of barriers to fair trade health care practices and identified recommendations concerning state scope of practice legislation.

APRNs can make the difference between chaos and quality in today's complex health care system if and only if they develop leadership competencies needed for the current environment. The changes identified here, as well as revolutionary advances in technology pharmaceutical research, and surgical innovations, coupled with the organizational complexities and fierce competition for resources, have created unprecedented challenges as well as opportunities for the APRN. In the midst of these awe-inspiring advances, it is clear that the sobering unintended consequences of a complex, highly regulated, and yet fragmented system, first identified by the IOM more than 15 years ago (IOM, 1999, 2001, 2004), have not yet been solved. At a time when the cloning of a human is possible, ensuring the basics, such as hand washing for all providers and preventing falls, remains, at times, elusive. In addition, the incentive structure of the reimbursement system is finally holding providers accountable to keep communities healthy by preventing illness and supporting wellness, creating both intended and unintended consequences. APRNs have incredible opportunities but still face obstacles related to the hierarchy of the health care system that have plagued nurses for decades. O'Neil, Morjickian, Cherner, Hirschkorn, and West (2008) postulated that without a deep commitment to an investment in leadership development for those instrumental in health care outcomes, the future of health care is at risk.

This chapter highlights the opportunity APRNs have in this new world if they embrace this moment with strong leadership competencies and skills to shape the future. We emphasize the importance of leadership competencies for APRNs who have major responsibilities for delivery of quality care, evidence-based practice, patient safety, innovations in nursing practice, and leadership in systems. Different leadership development models and curricula related to leadership in DNP programs are explored. Application of leadership competencies to specific scenarios common to APRNs are presented.

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