Leadership Development in Educational programs
Formal Nursing Education (BSN and MSN)
Leadership development in nursing became more formally recognized and integrated into education with the advent of BSN programs in nursing. The inclusion of leadership content in the curriculum was indeed one of the hallmarks that distinguished a BSN education. The Essentials for Baccalaureate Education (AACN, 2008) emphasizes the importance of leadership and identifies "Basic Organizational and Systems Leadership for Quality and Patient Safety" as the second essential for baccalaureate education. Subsequently, BSN programs all have some type of leadership and management course that students take before graduating. However, most of these courses are traditional leadership courses that focus more on content related to delegation, nurse practice acts, magnet hospital designation, evidence-based practice, quality improvement endeavors, and some management content on staffing, productivity, and budgeting. These courses are content driven rather than developing individuals as leaders.
All these concepts are important but insufficient for true leadership development. For nurses, the one senior leadership course may be the only course they get on leadership before being responsible for advocating for clients in a system that renders most clients confused about their bills, their disease, the many providers they encounter, and the technology that they may be dependent on upon discharge.
Traditionally in MSN programs, except for those pursuing the nursing leadership or administrative tracks, graduate students may take only one course addressing health care systems and some leadership content. Given necessities and the knowledge explosion, a majority of the curricula for those pursuing clinical degrees focused on nursing theory, pathophysiology, pharmacology, technology, research, education, professional issues, and management of conditions. In reality however, once practicing, APRNs are expected to be exquisite agents of change, skilled negotiators, astute group leaders, incisive systems thinkers, innovators of practice, and flexible collaborators with a variety of other leaders. Adding complexity to their role, APRNs operate from a basis of expert power, usually in staff roles, while many of the administrative and physician leaders APRNs negotiate with on a day-to-day basis are often those who hold line positions of authority within the organization. In 2011, the AACN published The Essentials of Master's Education in Nursing, which explicitly focuses on leadership competencies for all MSN prepared nurses. Essential II, titled "Organizational and Systems Leadership," identifies that any MSN program "recognizes that organizational and systems leadership are critical to the promotion of high quality and safe patient care. Leadership skills are needed that emphasize ethical and critical decision making, effective working relationships, and a systems-perspective" (p. 4). It will be interesting to identify how leadership competencies change as programs begin to realign with the essentials. Although this development will certainly advance the focus on leadership, reading about, writing about, and discussing leadership often fall short of developing new competencies. Given the findings from Burgess and Curry (2014) that lack of leadership was an instrumental influence in sentinel events, we can no longer avoid this.
Outside of Nursing
Industries outside of health care have long understood that leadership development, not just cognitive understanding, is crucial to productivity, satisfaction, profitability, and retention (Buckingham & Coffman, 1999). There have been prestigious fellowships such as the Kellogg Fellowship and in-depth training of business leaders through centers such as the Center for Creative Leadership (CCL, 2008). Interestingly enough, 65% of the leaders trained in the CCL, one of the top-ranked executive education providers worldwide, were men. Many industries have also invested in consultants to provide leadership development for leaders throughout the organization.
However, it is not common for nurse leaders to participate in these leadership fellowships in the same numbers that other leaders do, including leaders of health care systems. As a case in point, the American Council on Education (ACE) has a very well regarded leadership fellowship for leaders in academic settings (acenet.edu/leadership/programs/Pages/ACE-Fellows-Program.aspx). This fellowship has launched many presidents and provosts in their careers, but from reviewing credentials from ACE fellows in the past 40 years, fewer than 20 academic nurse leaders have participated in this fellowship, a very small percentage.
Physician leadership development is also alive and well. An Internet search using the words physician leadership development turned up leadership development and leadership fellowship programs focused exclusively on physicians at Harvard, Stanford, Johns Hopkins, Duke, and others. The American Association of Medical Colleges (AAMC) created a standard set of competencies called the Physician Competency Reference Set (PCRS) and is tracking competencies across accredited medical schools (aamc. org). The PCRS delineates the difference between objectives and competencies and has comprehensive and very specific competencies relevant to effective leadership. For example, under the category of Personal and Professional Development, the competencies include the following: self-awareness, healthy coping, managing conflict, trustworthiness, leadership skills that enhance team functioning, and self-confidence that puts patients, families, and members of health care teams at ease.
The AAMC offers a host of leadership seminars, courses, and institutes and in 2012 reported that the number of medical schools creating "leadership academies" within their schools has grown significantly over a 10-year period.
It is clear to the AAMC and many academic health centers that it is crucial to provide in-depth leadership development for physicians to gain leverage in today's health care system. Crites, Ebert, and Schuster (2008) have recommended a curriculum revision to incorporate in-depth leadership competencies throughout every year of medical school; they believe these skills are crucial to the future success of the profession. They also believe it is imperative to develop physicians as leaders early in their careers to make the biggest difference. They agree with Goleman (2001) that leadership competencies are easier to develop and longer lasting when professionals are just beginning their careers rather than as midcareer development.
Although nursing leadership development programs are not as extensive or as numerous as the physician and traditional chief executive officer (CEO) programs, several significant and influential programs exist. These programs elucidate the competencies needed for nurses who are agents of change and leaders in the health care system today. One of the most prestigious leadership development programs in nursing has been the Robert Wood Johnson Foundation, Executive Nurse Fellowship (RWJFENF) program (Bellack & Morjikian, 2005). This program developed nurse leaders from practice, public health, and educational environments to have an effect on health policy and patient outcomes. The RWJFENF program identified five main competencies needed for nurses to make a difference in today's health care environment. These competencies include self-awareness, interpersonal and communication effectiveness, risk taking and creativity, strategic visioning, and inspiring and leading change. Since the publication of the last edition, the Robert Wood Johnson Foundation has redirected funds for the Nurse Executive Fellowship and beginning in 2015 will begin to support interprofessional leadership development to align with the IOM The Future of Nursing report, which encourages interdisciplinary collaboration.
The University of South Carolina created a Center for Nursing Leadership in 1994. The center focuses on the competencies of organizational communication, self-awareness, resolution and negotiation of conflict, impact of globalization and complexity of organizations (or "circles of influence"), leadership and management of complex systems, and strategic thinking. The center offers the Amy C. Cockcroft fellowship program, developing nurses in all roles in many different settings to become stronger leaders and affect health care throughout the southeastern United States (University of South Carolina, College of Nursing, Center for Nursing Leadership, n.d.).
Recently O'Neil et al. (2008) canvassed the leadership development programs available to nurse leaders. They found that most of the activity for leadership development has occurred since 2000, although leadership development in other industries began strong development in the 1970s (CLC, 2008). They surveyed nursing and nonnursing leaders to ascertain the competencies needed in nursing leaders. They found that both nursing and nonnursing leaders valued building effective teams first and foremost, followed by communicating vision, managing conflict, translating vision into strategy, and maintaining focus on patient and consumer. The authors reported that leaders of health care had a clear preference for developing leadership competencies in nurses but that leadership development of nurses was undercapitalized compared with other industries.
Although these leadership development programs are a great resource for nurses in all roles, it is incumbent upon both nursing practice and education to ensure that APRNs have the sufficient leadership competencies to leverage their clinical contributions and influence health care as we move forward with a new political and economic climate. Although the AACN highlights leadership as one of the main essentials of the DNP curriculum, many programs have yet to integrate leadership development to the depth of the efforts occurring in medical schools.
Within DNP Curriculum
The current explosion of DNP programs provides good evidence of the belief within the nursing community that the health care system, the profession, and the public need nurses who are prepared to be practice leaders. In 2013 almost 15,000 students were enrolled in DNP programs across the country (AACN, 2014a).
The AACN developed the Essentials for Doctoral Education for Advanced-Nursing Practice in 2006 (AACN, 2006), identifying eight main essentials for curriculum in any DNP program. The DNP essentials document delineates the importance of leadership knowledge and skills throughout the document and specifically addresses leadership in Essentials II, VI, and VIII. Essential II is focused on organizational and systems leadership for quality improvement and systems thinking. Graduates must have advanced communication skills to lead quality improvement and patient safety initiatives. Essential VI is focused on interprofessional collaboration for improving patient and population health outcomes. To be successful, graduates must demonstrate the ability to employ effective communication and collaborative skills, lead interprofessional teams, and employ consultative and leadership skills with intraprofessional and interprofessional teams to create change in health care and complex health care delivery systems. Essential VIII is focused on advanced practice nursing. Among other requirements, DNP graduates must be able to develop and sustain therapeutic relationships and partnerships with patients and other professionals; demonstrate advanced levels of systems thinking; and guide, mentor, and support other nurses to achieve excellence in nursing practice (AACN, 2006).
A review of the AACN website reveals 243 schools currently offer DNP degrees, an increase of almost 300% since the last edition of this book was published. A 2014 study conducted by the RAND Corporation for AACN describes the current state of DNP programs in the United States (AACN, 2014b). Findings suggest almost universal agreement among those surveyed that the content added with DNP programs is highly valuable. While the masters degree continues to be the primary pathway for APRN entry into practice education, the number of DNP degree programs continue to expand steadily. The report provides a detailed analysis of facilitators and barriers to transitioning master's level APRN programs to the DNP and recommends AACN continue with efforts to assist schools facing challenges in offering a BSN to DNP program, particularly programs existing within larger universities.
A search of APRN professional organization's websites resulted in finding readily available resource materials on the website for the National Organization of Nurse Practitioner Faculties (nonpf.org) related to leadership core competencies. The website provides access to the "DNP NP Toolkit: Process and Approach to DNP Competency Based Evaluation," as well as sample curriculum "Templates for Doctorate of Nursing Practice (DNP) NP Education." The organization states these are made available to promote quality education for nurse practitioners at the doctoral level and in an effort to ensure national standards are incorporated into DNP programs nationally.
The website of the National Association of Clinical Nurse Specialists (nacns.org) includes a statement of neutrality with regard to DNP preparation and a comprehensive set of CNS core competencies (National Association of Clinical Nurse Specialists [NACNS], 2012). Neiminen, Mannevaara, and Fagerstrom (2011) identified five major themes for APRN competencies with leadership in a caring culture as one.
These two APRN roles and relevant competencies, along with the AACN Essentials for DNP Education competencies, were compared with the model and framework the authors developed for their leadership development and research work (Krejci & Malin, 2001, 2006). The model is based on more than 20 years of teaching and consulting in the area of leadership development with nurses in a variety of roles (Krejci & Malin, 1997). The model encompasses leadership development for all nurses, not just those in formal leadership positions. The foundation of the model is self-awareness, which the literature on leadership has consistently identified as being a prerequisite for successful leadership (Covey, 2004; Goleman & Boyatzis, 2008; Guthrie & Kelly-Radford, 1998; O'Neil et al., 2008; Senge, 1990). The components in this model are congruent with the essentials document (AACN, 2006) (Figure 7.1). Self-awareness, self-efficacy, and mission occupy the center of the model, surrounded by supporting competencies of systems thinking, circle of influence (personal power), interpersonal communication, building teams, negotiating conflict, moving vision to action, coaching and developing others, and implementing change.