Although a school of nursing at a southeastern university had a successful primary care nurse practitioner program since 1996, a strategic environmental scan indicated the need for a non-nurse practitioner program designed to prepare nurses for other types of advanced practice roles. The university, located in one of the most rapidly developing areas of the nation, serves a large, diverse student body drawn principally from the metropolitan area and a few surrounding rural areas. The nurse practitioner program has maintained a strong recruitment and retention focus, with approximately 40 students admitted each fall. Graduates of the nurse practitioner program demonstrate pass rates of 98% to 100% on national certification examinations and employment placement rates of 100% as nurse practitioners. The program’s alternate-weekend class schedule and geographically convenient practicum site assignments are cited as strengths by the program’s graduates.
Through review of the evaluations of the current graduate nursing program and an assessment of its graduates and other nursing leaders in the community, faculty identified an increasing need in the local health care community for advanced practice nurses who could provide leadership and care management for populations in a variety of health care settings. These advanced practice nurses would possess the knowledge, skills, and competencies necessary to successfully navigate the ever-increasing complexity of today’s health care environment. The purpose of this article is to describe the processes used in developing a new focus for the graduate nursing program that included curriculum design and pedagogy, program implementation, and evaluation strategies.
A call continues to be issued for preparation of nurses with advanced clinical and conceptual competencies in care management, ethical and value-based decision making, and leadership. In Health Care’s Human Crisis: The American Nursing Shortage, Kimball and O’Neil (2002) reported that the current model of nursing practice requires change to address the structural nursing shortage that exists in this country. The authors called for a re-envisioning of the nursing profession, with creation of new nursing practice models. They also suggested that nursing education and health care environments be reinvented to address the needs and values of the next generation of nurses. Various authors continue to propose a new model of nursing leadership to handle the challenges and complexities of the ever-changing health care system (Barker, Sullivan, & Emery, 2006; Boyatzis & McKee, 2005; Kerfoot, 2006; McGuire & Kennerly, 2006; Nickitas, Keida, Nokes, & Neville, 2004; Porter-O’Grady & Malloch, 2003; Senge, Scharmer, Jaworski, & Flowers, 2004).
Nurse leaders need to thrive and embrace change as they effectively and efficiently guide their organizations through turbulent and chaotic times (Porter-O’Grady & Malloch, 2003). A new era of resonant leaders is emerging—leaders who inspire organizations, are mindful, and instill hope (Boyatzis & McKee, 2005). This new era of leadership requires presence, a skill process of suspending, redirecting, letting go, letting come, crystallizing, prototyping, and institutionalizing in order to create transformation (Senge et al., 2004). Competencies must be framed around complexity science and leaders must have proficiency and comfort with the ever-evolving technology and interpersonal and intrapersonal abilities, such as coaching employees, managing a team of colleagues, educating coworkers, managing conflict, and caring for self (Porter-O’Grady & Malloch, 2007).
According to Kerfoot (2006), in our 21st century world:
the successful leader and manager have two very important challenges: to scan the horizon and not be thrown into crisis by not seeing predictable surprises, and to recognize the longer, more pervasive trends that are in the distant future
Kerfoot suggested competencies in developing an annual plan that incorporates four parts:
- Review any changes in the organization’s plan.
- Determine changes required from an annual autopsy.
- Review goals already outlined in the long-range plans for the coming year.
- Alter the plan based on evidence so as to avoid predictable surprises.
The leaders of the 21st century must envision new and different realities and futures. Of critical importance is the emotional competence required as one functions in a leadership role that focuses on “facilitating the transition to a new way of living and working” in the 21st century (Porter-O’Grady & Malloch, 2003, p. 21).
Various reports and articles call for specific requirements in the development of graduate programs for nurse leaders (Bleich et al., 2003; Hanson & Hamric, 2003). Trends on the type of leader required are well documented in various publications (American College of Healthcare Executives, 2005). In preparing nurse leaders, Cardin and McNeese-Smith (2005) stated that “the goals of an effective nursing administration graduate program must be to produce graduates who can lead others, and who will make a positive difference to patients, staff, and organizations” (p. 154). The emergence of new advanced practice specialties need to be deliberately shaped to posses core competencies that are standardized and meet national certification and regulation requirements. Unfortunately, Senge et al. (2004) indicated that we often see the world through our own mental models and have a difficult time suspending these models to envision new and different realities and futures. As we plan for new realities, academic and service partnerships are essential to prepare leaders who are innovative, adapt to the changing workplace, and integrate the new set of competencies to assure nursing efficiency, patient safety, and quality of care.
In summary, the review of literature provided evidence of the need for new competencies. In light of this review, faculty conceptualized an advanced practice role that incorporates components of the various advanced practice specialties, as well as establishes a possible career-track pathway for more individuals obtaining a doctorate in nursing. The new competencies inherent in the role include the following:
- Care management and leadership.
- Information and health care technology systems.
- Research process and evidence-based practice.
- Human resource use.
- Conflict resolution and negotiation.
- Advanced assessment and disease management principles.
- Teaching-learning strategies and curricular patterns.
- Health policy and health systems thinking.
Initial Program Development
This university provides strong undergraduate and graduate education programs that prepare students for advancement in their chosen professions. This preparation includes critical thinking, effective communication and interpersonal skills, leadership development, social responsibility, and lifelong learning. Faculty inculcated these concepts through the process of program development. The Master of Science in Nursing, Advanced Care Management and Leadership program needed to be built around these concepts to contribute to the university’s mission, as well as to the enhancement of health care institutions in the community. The initial stage of program development consisted of the three phases.
The first phase involved focus surveys with surrounding health care institutions through advisory boards and meetings with nurse leaders. The findings of these surveys and meetings indicated that nurses did not have an adequate understanding of the policy, power, financial, and care management issues inherent in today’s health care environment.
A second phase involved interviews with interested faculty who had expertise in specific curricular areas. The faculty were invited to participate in exploring the possibility of a new focus in the graduate programs at the university and the design of a new curriculum. A component of this development also included analyzing and incorporating nationally recognized nursing education standards within the curricula. From the beginning, the program developers subscribed to such standards as the American Association of the Colleges of Nursing’s (AACN) The Essentials of Master’s Education for Advanced Practice Nursing (1996) and to the National Association of Clinical Nurse Specialists’ (NACNS) Statement on Clinical Nurse Specialist Practice and Education (1996).
The final phase of the program development involved a consultation and collaboration process with other university graduate programs. Because the literature review indicated the need for curricular instruction in team building, conflict management, human resource focus, and management skills, input was sought from faculty in the university’s Executive Masters in Business Administration Program and the Masters of Science in Conflict Management Program. Input from these focus groups led to the development of collaborative partnerships between the programs, as described in the curriculum design below. A second part of this phase also included consultation with a nationally recognized expert on leadership in nursing, which led to further refinement of the curriculum design.
The next stage of program development consisted of the curriculum design, which included the development of specific courses and course sequencing to achieve the overall program goal of preparing experienced professional nurses for leadership roles in advanced care management in various health care settings. The curricular design focused on three major areas that provided a framework for course development based on standards, competencies, and student needs. These three areas included:
- Core advanced practice nursing knowledge (assessment, professional role, pathophysiology, pharmacology, nursing and health care theory, research).
- Ethical leadership and health policy, with global application in health care systems.
- Principles of evidence-based practice and leadership in advanced care management.
Review of graduate curriculum requirements from AACN and NACNS resulted in the development of the following core courses: Advanced Health Assessment, Health Maintenance, and Health Promotion; Pharmacology for Advanced Practice Nursing; Pathophysiology for Advanced Practice Nursing; Professional Advanced Practice Role Development and Health Care Issue; Healthcare Theory, and Research Application and Outcome Evaluations in Advanced Practice Nursing. These courses are taught jointly to students in the Primary Care Nurse Practitioner Program and the Masters in Advanced Care Management and Leadership Program to maximize the use of resources.
A review of the American Nurses Association’s Code of Ethics for Nurses with Interpretive Statements (2001) and the Scope and Standards of Advanced Practice for Registered Nurses (1996) resulted in the development of the following courses: Ethics of Leadership for Advanced Practice Nursing, and Advanced Care Management Leadership Practicum. In addition, the literature review demonstrated the need to include a course on health policy and finance. These courses emphasized ethical leadership, health systems, and health policy in client care situations and from a global perspective.
Finally, work by Tanner (1998; 1999) and Youngblut and Brooten (2001) provided a framework for establishing a strong foundation of evidence-based practice principles. For this reason, the research, advanced care management, and leadership courses were designed to focus on evidence-based practice and outcomes linked to patient safety and quality care. These courses included Advanced Care Management Models, Research Applications and Outcome Evaluations in Advanced Practice Nursing, Analytical Business Applications and Leadership Skills for Advanced Practice Nursing, and Advanced Care Management Project.
The school of nursing uses the university’s assurance of learning model that is based on outcome evaluation strategies. The program also adheres to the requirements of the Commission on Collegiate Nursing Education and the American Nurses Credentialing Center (ANCC, 2009) for graduate programs and certification eligibility. The curriculum design provides for appropriate practicum experiences to allow students to apply for specific national certification. In addition, the program has specific outcomes based on curriculum foci and graduate competencies and skills. An example of this process relates to the curriculum focus of budgetary and fiscal knowledge. After completion of the program, students have acquired the knowledge and skills needed to oversee budgets and participate in the financial planning process. Another example concerns the curriculum focus of health systems and health policy. Upon graduation, students possess the knowledge and skills needed to analyze current health care delivery models and systems, as well as the dynamics of health policy development.
Another aspect of the evaluation process is the opportunity for students, alumni, and the graduates’ employers to provide ongoing feedback to the program. Students are given the opportunity to evaluate the program while they are enrolled and at the time of graduation. As alumni, they are asked at 1-year, 3-year, and 5-year intervals to complete program evaluations. Employers of the graduates are also asked to evaluate the program at 1-year, 3-year, and 5-year intervals. As faculty and administrators reviewed the initial program evaluation data provided by students, specific changes were implemented (i.e., the addition of a second research course and the delineation of specific curricular tracks). Documented benefits of the program from alumni and employers indicated that many of the graduates are obtaining promotions to leadership positions.
The Master of Science in Nursing in Advanced Care Management and Leadership Program incorporates several innovative strategies, as evidenced in literature and environmental scanning, to ensure the development of the next generation of nurse leaders while building on existing strengths and opportunities of an already existing graduate nursing program. The program prepares graduates to be expert clinicians and outstanding leaders equipped to manage and improve client care outcomes. Students have the opportunity to focus their studies in a particular area of interest via the practicum courses, which provide an overall value-added educational experience. They can customize their educational experiences to best meet their learning needs and overall professional goals.
Other value-added experiences include geographically diverse opportunities for practicum experiences, clinical experts, and facilities, as well as the opportunity to participate in practical experiences in the community. The delivery model of the program allows students to complete advanced practice education with a minimum of career disruption. The 40-semester hour cohort program provides the flexibility of online and alternate-weekend class delivery and is built around core graduate courses with the fluency of tracks to accommodate individuals’ educational needs. Grounded in clinical practice and guided by health care theory, policy, and research, graduates possess knowledge and competencies to assume the advanced leadership roles required in future health care systems.
- American Association of Colleges of Nursing. (1996). The essentials of master’s education for advanced practice nursing. Washington, DC: Author.
- American Hospital Association, Society for Healthcare Strategy and Market Development. (2005). Futurescan: Health trends and implications 2005–2010. Chicago: Health Administration Press.
- American Nurses Association. (1996). Scope and standards of advanced practice for registered nurses. Washington, DC: Author.
- American Nurses Association. (2001). Code of ethics for nurses with interpretive statements. Washington, DC: Author.
- American Nurses Credentialing Center. (2009). ANCC Nurse Certification Requirements. Washington, DC: ANA. Retrieved 9/14/09 from http://www.nursecredentialing.org/certification.aspx
- Barker, A.M., Sullivan, D.T. & Emery, M.J. (2006). Leadership competencies for clinical managers: The renaissance of transformational leadership. Sudbury, MA: Jones and Bartlett.
- Bleich, M.R., Hewlett, P.O., Santos, S.R., Rice, R.B., Cox, K.S. & Richmeier, S. (2003). Analysis of the nursing work-force crisis: A call to action. American Journal of Nursing, 103(4), 66–74.
- Boyatzis, R. & McKee, A. (2005). Resonant leadership: Renewing yourself and connecting with others through mindfulness, hope, and compassion. Boston: Harvard Business School Press.
- Cardin, S. & McNeese-Smith, D. (2005). A model for bridging the gap from theory to practice to reality. Nursing Administrative Quarterly, 29(2), 154–161.
- Hanson, C.M. & Hamric, A.B. (2003). Reflections on the continuing evolution of advanced practice nursing. Nursing Outlook, 51(5), 203–209. doi:10.1016/S0029-6554(03)00158-1 [CrossRef]
- Kerfoot, K. (2006). Megatrends, the annual report, possibilities (on leadership). Nursing Economic$, 24, 47–49.
- Kimball, B. & O’Neil, E. (2002). Health care’s human crisis: The American nursing shortage. Retrieved April 26, 2008, from http://www.rwjf.org/pr/product.jsp?id=15647
- McGuire, E. & Kennerly, S.M. (2006). Nurse managers as transformational and transactional leaders. Nursing Economic, 24(4), 179–185.
- National Association of Clinical Nurse Specialists. (1996). Statement on clinical nurse specialist practice and education. Harrisburg, PA: Author.
- Nickitas, D.M., Keida, R., Nokes, K.M. & Neville, S. (2004). Nurturing nursing’s future through nurse executive partnerships. Nursing Economic$, 22(5), 258–263.
- Porter-O’Grady, T. & Malloch, K. (2003). Quantum leadership: A textbook of new leadership. Sudbury, MA: Jones and Bartlett.
- Porter-O’Grady, T. & Malloch, K. (2007). Quantum leadership: A resource for health care innovation. Sudbury, MA: Jones and Bartlett.
- Senge, P., Scharmer, C.O., Jaworski, J. & Flowers, B. (2004). Presence: Human purpose and the field of the future. New York: Currency Doubleday.
- Tanner, C.A. (1998). Clinical judgment and evidence-based practice: Conclusions and controversies. Communicating Nursing Research, 31, 19–35.
- Tanner, C.A. (1999). Evidence-based practice: Research and critical thinking. Journal of Nursing Education, 38, 99.
- Youngblut, J.M. & Brooten, D. (2001). Evidence-based nursing practice: Why is it important?ACCN Clinical Issues: Advanced Practice in Acute and Critical Care, 12, 468–476. doi:10.1097/00044067-200111000-00003 [CrossRef]