Herrin, Donna MSN, RN, CNAA-BC, CHE; Jones, Katherine PhD, RN, FAAN; Krepper, Rebecca PhD, RN, MBA, CNAA-BC; Sherman, Rose EdD, RN, CNAA-BC; Reineck, Carol PhD, CCRN, CNAA-BC, COI
Collaboration between the American Organization of Nurse Executives (AONE) and the Council on Graduate Education for Administration in Nursing (CGEAN) presented a unique opportunity for practice and education to jointly develop nursing leadership curricula for the future. The call to action described in part 1 of this 2-part series led to subsequent work developing a new foundation and new strategies. The goal of the partnership was to develop a graduate curriculum framework to support the knowledge, skills, and abilities needed by current and future nursing leaders in administrative practice. Task force members shared pertinent literature, references, and curricular documents used to guide content in nursing administration and leadership development programs.
Table 1 displays the titles and sources and gives an overview of the content of these important documents.1-9 Educators established current curricula in nursing administration based on the American Association of Colleges of Nursing's (AACN) Essentials of Master's Education for Advanced Practice Nursing,7 the American Nurses Association's (ANA) Scope and Standards of Practice for Nurse Administrators,10 the Joint AONE and AACN Position Statement on Nursing Administration Education,11 and curriculum guidance developed by CGEAN in 1995.6 Members of the CGEAN discussed a need to undertake a major revision of these curricular guidelines when the opportunity to partner with AONE presented itself. The wide range of source documents provided the partners with perspective on key competencies expected of today's nursing leaders. Task Force members used a novice-to-expert framework12 that clarified leadership content needed at different levels of nursing leadership education. In addition to the reference documents,1-9 the AONE/CGEAN Three-Dimensional Administration Curriculum Model 2006 © AONE and CGEAN presented in this article also reflects the scholarship, practice experiences, and expert opinion of the partnership members.
AONE/CGEAN Three-dimensional Administration Curriculum Model
Future nursing administration curricula may be conceptualized in a 3-dimensional framework surrounded by an omnipresent quality and safety "net" displayed in Figure 1. The first dimension is composed of the 5 requisite domains recommended by the Healthcare Leadership Alliance and AONE.1 These domains are business, leadership, environment, communication, and professionalism. The second dimension is an amalgam of 10 domain threads. Domain threads are critical considerations integrated into curriculum across all domains. Domain threads include evidence-based practice, quality improvement, ethics, effective communication, influencing behaviors, strategic management, accountability, teamwork, clinical leadership, and mentoring. The third dimension is composed of 5 competency levels.12 Competencies are recognition that, with experience, the nurse leader develops through novice, advanced beginner, competent, proficient, and expert levels12 in each domain. Academic program coordinators may want to crosswalk their current curriculum against this "netted" 3D framework. A crosswalk or review may help determine the extent to which their respective programs meet both graduate academic standards and community needs.
MSN and PhD Degrees: Essential for Long-term Survival of Nursing Administration Science
The AONE-CGEAN partnership discussed the evolution of the doctor of nursing practice (DNP) for nurse practitioners.8 In this discussion, AONE members had strong feelings about a critical need to maintain nursing administration programs at both the master's and doctoral levels. Doctoral program types should definitely include the PhD and, possibly, the DNP. In the past, nursing leaders often chose graduate programs outside the discipline of nursing, most notably programs in business (MBA) or health administration (MHA). Although many healthcare organizations encouraged their nurse executives to attend these programs, there is concern regarding the focus on business skills to the exclusion of advanced knowledge in the discipline of nursing. Programs grounded in nursing leadership provide an understanding of evidenced-based practice, development of a strong patient care perspective, and promotion of leadership of the profession, something MBA and MHA programs do not provide or emphasize.13
In the past decade, there have been periods of time when enrollment in nursing administration master's degree programs was very low. Many factors contributed to this, including a lack of strong focus by schools and faculty on the nursing administration curriculum, heavy emphasis at local and national levels placed on preparation for advanced practice clinical roles, and a certain lack of attractiveness of nursing administrative roles to potential students.13,14 A reversal in this trend may be underway. Members of the CGEAN anecdotally report that they are beginning to see increases in enrollments in nursing administration graduate programs. In fact, one member reported that enrollment has quadrupled in the past 2 years.
More recently, concerns have been expressed that a shift toward the DNP from more traditional master's degree programs could result in future nurse executives and managers choosing to attend MBA or MHA programs because of time constraints in their leadership roles. This would be unfortunate. Graduate nursing education plays an important role in both leadership development and in the generation of significant contributions to the science of nursing administrative practice. The partnership acknowledged that each level of graduate education provides a unique and critical contribution to the practice and science of nursing administration.
Nursing research provides the scientific basis for the practice of the profession. It encompasses a wide scope of scientific inquiry, including health systems and outcomes research. Nursing research on health systems and outcomes examines how the organization and delivery of healthcare influence quality, cost, and the experience of patients and their families.15 Cost containment pressures, increasing numbers of uninsured, and disparities in access and outcomes coexist with public and private sector pressures to improve the quality and safety of care. Doctorally prepared nurses in the management specialty areas conduct studies at the organizational and systems level to address these pressing issues.
As a discipline, management research is a social science that seeks to contribute to both theoretical and applied knowledge.16 The Department of Veteran's Affairs17 identified 2 overlapping themes in management research. One theme is research for managers. These projects are tailored to specific management needs, are short-term, and are conducted at the individual staff or unit level. Master's-prepared nurses are prepared to carry out this level of analysis. The emphasis is on solving specific managerial problems. The second theme is research on management and organizations. These projects are defined by the subject of the study, such as factors influencing the turnover of staff within the organization. The emphasis at this level is on building knowledge. Doctorally prepared nurses engage in this type of inquiry.
In the past 2 decades, research by nurses has dramatically increased, but much of nursing remains invisible in healthcare quality, health services research, health policy, and healthcare finance initiatives.18 There is a growing need to determine and quantify the extent to which nurses contribute to care that is safe, beneficial, patient centered, timely, efficient, and equitable.19 The National Quality Forum endorsed 15 national voluntary consensus standards for nurse-sensitive care and 11 related research and implementation recommendations.20 These standards have helped identify priority areas for research in measuring care that will lead to improved patient safety and healthcare outcomes. Several of these measures are system centered, including skill mix, nursing hours per patient day, and voluntary turnover of staff.
Recent emphasis on evidence-based practice throughout the health professions indicates that nursing, medicine, health administration, and other health service providers have accepted the need to base current clinical practice on sound evidence, particularly the evidence derived from research.21 However, evidence has not usually been the basis for developing new approaches to organizing and managing care. The Institute of Medicine22,23 pointed out that management decisions create the context for safety and quality; however, evidence-based management is not the norm. Healthcare administrators are responsible for making many nonclinical decisions that directly or indirectly affect healthcare and health, including restructuring care delivery systems and redesigning care processes.17 Managerial decisions thus have a tremendous impact on patient safety and quality, access to care, and cost of care and need to be evidence based. It is critical that nurses prepared at the doctoral level be major contributors to building this scientific basis for managerial practice.
Nurse leaders must be excellent communicators, team builders, change agents, and analytical thinkers and must have a commitment to service excellence.24 Advanced nursing education is a requirement for those nurses assuming these leadership positions, whether it is at the middle management or top executive levels. To prepare for leadership positions, innovation in graduate education is imperative.
Innovative Teaching Strategies
Over the years, evidence mounted that didactic learning experiences based on lectures and other passive learning strategies are not the ideal way to convey new knowledge. Instead, interactive educational strategies and problem-based learning provide a milieu for developing knowledge and skills that can be translated into the practice setting. A case-based approach to learning engages students in discussions of specific situations, typically real-world examples. This teaching methodology is learner centered and involves intense interaction among the students. Instructors serve as facilitators of the discussion and analysis rather than as providers of content. The students, either individually or in teams, sort through information, identify relevant facts, apply analytic tools, articulate issues, reflect on their own relevant experiences, and develop strategies for solving problems or reaching conclusions that can relate to new situations.25
The case method can assist students to develop analytical, collaborative, and communication skills.25 In nursing administration master's programs, the capstone or final didactic course in the curriculum should be based on cases that allow analysis, synthesis, and application of the content learned in previous courses. Over the course of a semester, cases can be organized to progress from short and straightforward cases addressing specific topics to complex and detailed cases that lend themselves to collaborative problem solving.
Work schedules and family responsibilities often prevent enrollment in traditional programs that require full-time attendance or weekly visits to campus. Alternatives that use Web-based learning technologies to provide high-quality educational offerings now exist. In 1999, AACN26 identified 5 issues to consider when developing standards to support these distance education programs: planning, technological infrastructure, faculty development, student support, and evaluation of learning and program outcomes. An increasing number of nursing administration master's programs have adopted an approach that combines Web-based learning with monthly campus visits for in-class meetings.
The Web-based learning strategies include posted PowerPoint presentations and lecture notes, streaming videos of guest lecturers or special programs, team assignments, Internet assignments, and threaded discussions. Students may be asked to lead specific discussion threads or to post a team presentation. Face-to-face sessions are considered by many academics to be essential to building a connection with the campus, the instructor, and classmates. Guest speakers, student presentations, quizzes and tests, and informal interactions also take place during these times. Classes are usually held on Fridays and Saturdays, with specific times determined by the students and instructors in the classes.
In place of campus visits, a newer instructional technology called Web casting is being used by some schools to deliver audio and video presentations via the Internet.27 This enables learners to participate in a live class by way of a personal computer, omitting the need to travel to the campus location.
An alternative to computer-based instruction is the use of intensives. Rather than short visits to campus several times a month, students come to the campus for a week or two during the summer months or during the break between fall and spring semesters or over spring break. Usually, classrooms are more available during these periods. Schedules must be determined in advance to allow the students sufficient time to request the time off. Between campus visits, students stay in contact by e-mail.
Innovative strategies must be well thought out and accepted by the involved faculty. Intensives are exhausting to students and instructor alike; thus, varied activities must be planned. Students must be self-disciplined when using Web-based instruction and keep up with assignments and discussions. Instructors must also be "present" on the Web site and respond to students in a timely fashion. Ground rules must be established ahead of time so that discussions do not become personal chat rooms. Instructors need to make sure that all students are participating and take turns initiating discussions. The quality and quantity of the postings to the discussion thread are important. To maintain the interest of the students, each course should have a different balance of Web-based activities. Although the threaded discussion is a mainstay of all courses, other activities may include an online debate, team assignments, accessing and analyzing databases, guest participants online, posted PowerPoint presentations or notes, homework problem sets, selected readings, and related discussion questions.
Other innovations in nursing administration programs involve creative academic/service partnerships. One crucial element of a nursing administration educational program is the selection of preceptors who can role model the various elements of the managerial or executive role. The service setting may also serve as the location for master's "change projects." Arranged with preceptors or other designated persons in the clinical setting, these projects must be seen as valuable to the institution and must meet the learning objectives. Increasingly, students are conducting integrative reviews of specific clinical problems of concern to clinicians, such as fall prevention or ventilator management. What are seen much less frequently are reviews of management practices that influence the effectiveness or efficiency of care delivery.
While discussing the development of the future nursing administration graduate curricula, some issues were placed in the "parking lot," that is, those to be considered with insights from others. Parking lot issues were named as such not because these were not important but rather they needed additional input. The following parking lot items will be covered in the future. The authors invite you, the readers, to send additional items to the corresponding author that you believe should be added to this list. The first parking lot issue relates to the competencies. Additional competencies are needed for 4 specific curricular content areas: facilities planning, project management, health promotion, and complexity science.
Facilities planning: Nurse leaders are increasingly involved in the design and implementation of new facilities. What specific competencies should the nurse leader and nurse administrator have related to facilities planning?
Project management: The ability to organize, control, and deliver a project on time and within budget is a skill needed by nurse executives today. Specific competencies that address project management need to be identified.
Health promotion/assessment of populations: An awareness of national and community-level health problems and their potential impact on the organization is a necessity for all nurse leaders. Should competencies focus on the use of epidemiological, social, and environmental data to evaluate community health deficits?
Complexity science: Healthcare delivery today occurs in a very complex, nonlinear organization. One issue is the outdated view of a world that is mechanistic; it is no longer relevant to focus on how individual parts work so one can understand the whole. What competencies does the nurse leader need to accomplish organizational outcomes within a complex adaptive system?
In addition to the issues relating to the 4 competencies above, there were some items the task force "parked" because additional discussion was needed to determine if the item should be included as a competency thread (ie, the depth of knowledge/understanding/application of a content item varied from novice to expert) or a domain thread(concept area that crosses all curricular items) or a curriculum thread. These issues and corresponding questions included team development, analysis of financial statements, information technology recover, and personal or professional issues.
Team development: Now, more than ever before, nurse leaders must work through teams to accomplish patient care goals. Should team development be a domain thread? Should the concept of teams be addressed under each of the major curricula areas?
Analysis of financial statements: Is this a competency thread? Should there be a leveling of ability to interpret and analyze financial statements? Should the difference be in the complexity of the organization?
Information technology recovery: As organizations become more sophisticated in the use of technology and data are stored electronically, it is imperative for nurse leaders to examine how data are being safeguarded. Should information technology recovery be included as a domain thread?
Personal and professional issues: Should these be domain threads? Because people process information differently, should there be competencies about information processing? Since there are now multiple generations in the workplace, should there be special acumen in handling generational diversity?
A final item in the parking lot is the idea of incorporating Bloom's28 classic taxonomy. It is the opinion of the task force that it would be beneficial to consistently use verbs that relate to the cognitive process categories of understand, apply, analyze, evaluate, and create across each of the novice-to-expert competency levels.
The Institute for Healthcare Improvement (IHI)29 recommended restructuring health professions education to be consistent with principles of the 21st century health system. The restructuring would (1) lead the continual improvement of the quality, safety, and value of healthcare; (2) help professionals identify good care derived from scientific evidence; (3) recognize gaps; and (4) identify activities necessary to close the gaps. The AONE-CGEAN Task Force has started initial steps to restructure nursing administration graduate education toward the important ends identified by IHI.29 Ongoing intentional collaboration and dialogue among nurse leaders in practice and education settings are crucial to maintain the momentum for patient care safety and quality.
The authors thank the AACN and ANA for the professional and educational foundations on which this work can build. The AONE-CGEAN Task Force members are Kathy Harris, Donna Herrin, Diane Huber, Katherine Jones, Rebecca Jones, Rebecca Krepper, Milisa Manojlovich, Carol Reineck, Rose Sherman, Pamela Thompson, and Linda Workman.
© 2006 Lippincott Williams & Wilkins, Inc.