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A reflection on the complexity of the career in nursing

Editor who approved publication: With the implementation of the Affordable Care Act, elevated roles for nurses of care coordinator, clinical nurse leader, and advanced practice registered nurse have come to the forefront. Because change occurs so fast, matching development and education to job requirements is a challenging forecasting endeavor.

The Complex Work of RNs: Implications for Healthy Work Environments

The purpose of this article is to envision clinical leadership development and education opportunities for three emerging roles. The adoption of a common framework for intentional leadership development is proposed for clinical leadership development across the continuum of care. Solutions of innovation and interdependency are framed as core concepts that serve as an opportunity to better inform clinical leadership development and education.

Additionally, strategies are proposed to advance knowledge, skills, and abilities for crucial implementation of improvements and new solutions at the point of care. Although the future may be difficult to predict exactly, history has taught us that it is crucial to prepare nurses for key roles in the health care delivery system, both for present jobs and for potential future opportunities.

The challenge for clinical leadership is how to structure the knowledge, skills, and abilities required so that nurses are positioned to step into roles that are needed, yet, for which there may not yet be formal jobs. One example is expanding and elevating the registered nurse RN role from traditional care delivery to integrating care, where they are working with autonomy, authority, and accountability in managing and coordinating care across disciplines and a reflection on the complexity of the career in nursing.

They noted that there is a compelling need to expand the contributions and optimize the scope of practice of RNs in primary health care for leadership in interprofessional teams. The purpose of this article is to envision clinical leadership opportunities for three nursing roles: Subsequent implementation has contributed to reconfiguration in health care delivery, accelerated the demand for health care along with a shortage of key health care professionals, and opened up new and expanded roles for nurses under new care delivery models.

Aimed at extending health insurance coverage, there are many provisions of the ACA, including those designed to emphasize prevention and wellness, improve quality and system performance, and curb costs. Notable among these aspects are the creation of health homes and integration of care for persons with chronic illnesses, improvements in care coordination, emphasis on prevention and primary care, investment in health information technology, and testing of new delivery and payment systems.

The goal is to link payment to a value-based system that improves quality of care and is not just based on volume of services.

Nurses hold the central ground for quality, safety, and improving the patient experience. For example, having quick care clinics affiliated with a hospital can decrease nonemergent patients seeking health care on weekends and nights in the emergency department and increase patient satisfaction with not having to wait.

What is clinical leadership in nursing? Leadership in nursing is highly valued. The Institute of Medicine 3 noted that nurses need to be prepared to lead in all aspects of health care. Clinical leadership is defined here as the process of influencing point-of-care innovation and improvement in both organizational processes and individual care practices to achieve quality and a reflection on the complexity of the career in nursing of care outcomes.

McCausland 5 noted that new interdisciplinary models of care that cross traditional boundaries of ambulatory, inpatient, and community settings need credible clinical leaders. Thomas and Roussel 6 noted that clinical leadership is about clinicians augmenting care for safety and quality by using innovation and improvement. This places the opportunity for health care leadership at the clinical level within the realm of each direct provider of care, especially nurses who are at the direct care level.

Clinical leadership uses the skills of the RN and adds components of general leadership skills, skills in management of care delivery at the point of care, and focused skills in using evidence-based practice for problem solving and outcomes management.

How has nursing changed and what does the future hold?

There is clearly a need for clinical leadership in nursing because of the many and varied point-of-care implementation problems that arise. For example, patient safety may be compromised if there is poor team communication. When nurses are busy or short-staffed, hand-off communications may be compromised, creating gaps in care Huber et al, unpublished data, 2015.

Discharge transitions may not be smooth if both sending and receiving areas do not communicate well. Medication administration may be less than smooth when multiple disciplines caring for a patient do not coordinate prescribing and transcribing practices. This is true in acute care and across the continuum.

Resolving ongoing care gaps requires energetic actions based on best practices, teamwork, care coordination, and clinical leadership competencies at the point of care. Evidence base for clinical leadership There is a body of evidence demonstrating the relationship between nursing leadership and patient outcomes. Their systematic review of 20 studies from 2005 to 2012 on the relationship of nursing leadership practices and patient outcomes demonstrated a positive relationship between relational leadership and multiple patient outcomes.

A connection between supportive leadership styles and positive patient safety outcomes was noted.

  • Having experienced multiple hospitalizations in the past, he explained that his most recent episode was due to a mixup between short acting and long acting insulins;
  • What follows with each new observation and receipt of information from minute to minute is a continuous re-ordering of the priorities of the activities in the list;
  • The emergence of care coordination, CNL, and APRN roles has occurred in part because of the need for continuity of care and management of care transitions that were not well addressed in an acute care focused, episodic delivery system;
  • All states regulate advanced practice nurses in some manner;
  • It may be that much of the nurse dissatisfaction with work environments is due to the amount of time spent having to make trade-offs between equally important care decisions that affect safety and quality of care;
  • The relationship between work and nonwork domains:

Among the 20 studies reviewed, transformational leadership was the most frequently used leadership theory. Transformational leadership is an evidence-based theory used as a strategy and manifested as a style for working within the complexity of care and the use of interdisciplinary teams. Transformational leadership directly addresses some of the competencies in the first category of leadership.

There is a solid body of evidence that transformational leadership is related to effectiveness, 9 — 12 which is especially important for working with interprofessional teams, managing the coordination of care, and innovating roles and functions as structures are changing.

Clinical leadership roles Clinical leadership roles are often thought of as targeted to the development of nurse managers and executives. Given the need for clinical leadership development at all levels, the focus here is on the development and education of nurses as leaders who are prepared to lead at the unit, program, or microsystem level and across the continuum of care.

Nurses in direct care roles deliver care to and coordinate the care of patients and clients. Yet, there are organizational and systems imperatives for quality and safety initiatives and innovations designed and executed by nurses. Thus, to fully enact the direct care role, nurses must be prepared to address all situations that arise at the intersection of clinical practice provider with patient and family with the context and environment of care organizations and groups of multiple care providers and disciplines.

This is the imperative of clinical leadership. For example, the leadership and management of care transitions, both within and across settings and sites of care, is a crucial function under implementation of the ACA and its VBP financial aspects. The traditional preparation of nurses has not emphasized these roles and functions, but rather mastery of the psychomotor and conceptual skills needed to deliver entry-level care as an RN.

The US health care system has been predominantly acute care driven. Thus, there has been heavy emphasis on learning directed to acute care practice and disease-specific knowledge rather than management of populations, chronic conditions management, care integration, and care coordination among multiple disciplines and in multidisciplinary team care delivery models.

In studying new and elevated roles for nurses as care integrators, Joynt and Kimball 1 identified the following examples: Since these emerging roles support the ACA, we will discuss the preparation and developmental opportunities for these roles.

Nursing Research and Practice

Care coordinator role As the health care environment has been changing and care is shifting to population management and outpatient settings, the care coordinator role has emerged as a new twist on case management and a new model of professional nursing practice.

Nurses are often responsible for coordinating care for a group or population of patients. For example, nurses may manage populations of patients with diabetes or cardiovascular disease in acute care. In the new and emerging models, nurses are and will be managing many types of carved out populations with chronic illnesses or behavioral health conditions across settings and sites and for long time frames. New roles and jobs have been the natural result.

Contemporary names are care coordinators, health coaches, navigators, or care managers. Case managers have a long and distinguished history of service delivery in nursing and social work.

Education for the care coordinator role arises from education within the discipline eg, nursing or social work and often includes specialty knowledge and experience in case or population health management. There is no generally acknowledged curriculum for education and training of care coordinators or case managers, but there is a text that is a core curriculum for addressing the case manager certification exam.

It issues standards of practice and links with transitions of care organizations.

Complexity and Health Coaching: Synergies in Nursing

Case managers practice within a variety of professional disciplines. The top two work settings for case managers are health plans 28. They use field-tested role and function studies as the basis of their certification, qualifications, and test plan.

CCMC has identified eight essential activities of case management: The six core components of case management are: They can be used to guide studying for the exam. In addition, CCMC offers many other resources for case management practice, such as a code of ethics called the code of professional conduct. These authors call for new settings and contexts for experiential learning activities for care coordinators to enable collaboration and skill development across the continuum of care versus traditional settings and approaches.

Figure 1 Framework for intentional clinical leadership development.

Clinical leadership development and education for nurses: prospects and opportunities

The CNL has been described as a front-line innovator. CNL education helps prepare nurses for opportunities to make improvements in systems at the point of care, where changes closely impact patients and families. CNL education prepares nurses to focus on transforming care at the point of care. CNLs have advanced knowledge, skills, and abilities in quality improvement, outcomes measurement and management, systems management, and changing leadership to bring to bear on transforming care.

According to Binder, 22 little is known about structures and processes that influence successful integration, and components that influence or hinder effectiveness and sustainability of the CNL role. Therefore, the intentional framework serves to provide enabling education to influence role effectiveness Figure 1.

APRNs are prepared, by education and certification, to assess, diagnose, and manage patient problems, to order diagnostic tests, and to prescribe medications. State licensing laws define the permissible scope of practice for RNs, as promulgated by state Boards of Nursing. All states regulate advanced practice nurses in some manner. Some license nurse practitioners; some grant authority to practice through certificates, recognition, or registration.

These include graduation from approved educational programs and certification examinations. Many states rely on national certification programs to measure competency. APRNs typically are educated at the graduate level with in-depth preparation for a specialty practice, then take a certification exam, then comply with individual state licensing requirements. However, considerable variation remains from state to state. Under the consensus model, all APRNs must pass a national certification exam.

APRN practice is seen as building on the competencies of RNs, demonstrating a greater depth and breadth of knowledge, greater synthesis of data, increased complexity of skills and interventions, and having greater role autonomy. APRNs have found jobs in acute care hospitals, managing care for specialty populations. They are also embedded in primary care as primary care providers.

For example, rural health clinics in Iowa rely on senior clinical personnel such as physicians, physician assistants, and nurse practitioners to provide care coordination, care and case management, and identification of high-risk patients.

Team effectiveness was a major focus. There has been considerable research done to compare patient outcomes of care provided by APRNs and physicians. The conclusion is that outcomes of care by APRNs in collaboration with physicians are a reflection on the complexity of the career in nursing, and in some instances better, than care by a physician alone.

A systematic review concluded that APRN care is safe, cost-effective, and results in similar clinical outcomes and patient satisfaction as compared to care by physicians alone for the populations and in the settings of the reviewed studies. That being said, intentional leadership development will be required for current and future APRNs Figure 1.

Clinical leadership opportunities Health care systems and organizations must constantly gauge environmental forces and trends in patient care delivery to determine competency gaps within the workforce. Strategic and intentional development of clinical leaders can occur through education and training. The evidence base from business management research proves that leadership knowledge, skill, and abilities can be taught.

Now it is clear that they should be taught in health care.