Jones, Rebecca A. DNSc, RN, NEA-BC
The news on television and radio, business and professional journals, and nursing professional organization literature includes briefs on the nursing shortage. This shortage of nurses also includes a shortage of nursing leaders. One major focus of academics is graduate education for tomorrow's leaders, with a new graduate degree, the doctorate of nursing practice (DNP), at the doctoral level. However, with a shortage in nursing, does an additional doctoral degree address the needs of the future healthcare system and ultimately the patient? Are we contributing to the overeducation of America without really addressing the needs? The purpose of this column is to raise some of those issues relative to undergraduate and graduate nursing administration education.
The concept for the article arose from the recent collaboration of CGEAN as an affiliate of the AONE over the course of the last 2 years. A task force composed of officers from both organizations has held quarterly phone conferences to collaborate on issues of mutual interest, one being a recent DNP roundtable discussion at the annual 2009 International Nursing Administration Research Conference and another a preconference session scheduled for April 9, 2010, at the annual AONE meeting in Indianapolis, Indiana. This session will feature members from CGEAN and AONE. The issues facing the future development of administrative leaders for clinical nursing settings, discussed here, will be explored in a panel presentation involving the audience at that session.
Before determining the education preparation of future nursing leaders, one must first consider the leadership role to be assumed. Administrative leadership roles are conceptualized as divided into 2 levels, manager and executive.1 Nursing administration roles focus on the management of fiscal and human resources. Managers are the first- and middle-level administrators responsible for a specific clinical service or unit at the micro system level. Executives are the top level of nursing administration responsible for the executive level of patient care service. Managerial competencies are geared toward the complexity and scope of the role in the healthcare setting. For example, the beginning nurse manager at the unit level would require communication skills to lead groups of nurses in committee work and interdisciplinary committee work at the unit level, whereas the nurse executive would require skills to navigate collaborative, interdisciplinary committee work at the healthcare system level and relationships with external healthcare and professional communities. A middle-level manager would need business skills to develop a budget for one or several units, whereas the nurse executive would be required to develop complex budgets for the entire nursing division coupled with budget variance analysis to achieve a balanced budget. Then, resources would be distributed and managed across the whole nursing organization. A nurse manager would be responsible for recruiting, hiring, and developing staff nurses to manage patient care on a 24-hour basis on a given unit or clinic. The middle manager would manage staffing to achieve a standard for hours of patient care per patient per day for several units or clinics. The nurse executive would be tasked with oversight for managing a balanced budget across the entire healthcare system while delivering the standard hours of patient care. Roles also involve scope of practice and areas of responsibility.
Scope of Practice and Responsibility
Another issue concerns the scope of practice, micro system versus macro system, of tomorrow's nursing administration leaders. The ANA standards define the nurse administrator as an RN who orchestrates and influences the work of others in a defined environment, most often healthcare focused, to enhance the shared vision of an organization or institution.1 The scope of practice for the nurse manager might involve individuals, families, and groups at the micro system level on an inpatient unit or clinic. Middle-level managers would be expected to manage individuals, families, groups, communities, and populations at the macro level across several units or clinics. The nurse executive would work across micro and macro systems with internal and external groups. Schaffner2 envisions a role that converges "operations, patient care, and stewardship of resources." Thus, the nurse administrator must have a knowledge base in the management of fiscal and human resources and business skills coupled with knowledge of patient care and the skills to manage patient outcomes.
Knowledge Domains and Competencies
Future nursing administration knowledge may be conceptualized in a 3-dimensional framework surrounded by an omnipresent quality and safety "net."3 The first dimension is composed of the 5 requisite domains and competencies recommended by the Health Leadership Alliance and AONE.4 Managers at all levels require competencies in the following domains:
(1) communication and relationship building,
(2) a knowledge of the healthcare environment,
(4) professionalism, and
(5) business skills.
The second dimension contains 10 domain threads integrated across the knowledge domains.3 Domain threads include the concepts of 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.5 Competencies are recognition that, with experience, the nurse leader develops through novice, advanced beginner, competent, proficient, and expert levels in each domain.5
The ANA has developed standards of practice using the nursing process as a framework around the following areas: assessment; identification of issues, problems, or trends; outcomes identification; planning; implementation; coordination; health promotion; health teaching; and education and consultation. This content is also important to the development of competencies for the nurse administrator.1 Readers are referred to the references cited above for a more complete description. Although domains, threads, and competency levels are addressed in the literature, specific competencies related to each area are not explicitly published.
Educational Level and Experience
Some of today's managers are prepared at the baccalaureate (or less) level, and the focus on being a manager does not really occur until the graduate level. Thus, what is the appropriate educational level for tomorrow's leader: bachelors, masters, or doctorate? Several states, including New York and New Jersey, have legislation in progress to support the BSN degree for the RN.6 Although the Michigan Organization of Nurse Executives and AONE are supportive of multiple approaches, which may include first obtaining an ADN or other nursing degrees, ultimately the BSN degree is deemed necessary for the future.7 These views raise the issue of the baccalaureate degree as the necessary requirement for entry into the practice of nursing again. If the baccalaureate degree is necessary for entry into practice as an RN, then is it sufficient to prepare one for the role specialty of nursing administration?
Local markets, degrees offered by local universities and colleges, and family and social demands have an impact on the degree chosen by an individual. Sometimes, the levels of degrees offered are driven by local markets and college and university mission as opposed to designing the appropriate degree for the level of knowledge, skills, and abilities required for the role. Oftentimes, the degree level chosen is purely a function of the RN's need to enter the workforce, continue to work, raise a family, and pursue career advancement. Thus, the degrees offered in the geographic area, and family and social demands, dictate choice.
The American Nurses Credentialing Center and AONE presently offer certification examinations at 2 levels with requirements for degrees, years of experience, and the nature of the position dictating the level of the examination8-11 (Table 1). With debate over the appropriate degree for entry into practice and certification examinations for basic and advanced nurse executive and nurse manager and leader, it is difficult to determine if the degree required for the nursing administration role should be at the bachelor's or master's level. Both organizations offering certification examinations have 2 levels of examinations, one requiring the minimum of the bachelor's and the other a master's, depending on the level of the role, degree, and years of experience.8-11 Several years' experience is required to take either type of certification examination. However, additional years of experience may cancel out the requirement for an advanced degree.
A new nursing doctorate, the DNP, prepares nurses at an advanced specialized level to promote and translate evidence into practice. The more traditional degree, PhD, prepares the individual to generate knowledge. The practice doctorate was instigated by the expanding number of credits in master's-level programs.12 The AACN has set a goal of moving all advanced practice degrees, which according to AACN includes the MSN administration for the nurse executive, at the master's level to the DNP level by 2015.12 Given the expanding role of the nurse executive to manage complexity in medical centers and academic health science centers, the DNP is appropriate for executive nurse leader of the future. However, controversy remains and a commitment to retaining both the master's- and doctoral-level degrees to support the entry-, middle-, and executive-level roles that nurse administrators may assume in future nursing leadership roles.
The RN leader's career trajectory, nursing versus healthcare administration, might also play a role in determining the discipline appropriate for the level of the degree. Some nurses pursue administrative roles in healthcare operations external to the department or division of nursing. These nurses may require additional knowledge in healthcare administration theory and competencies at the macro system level.13 Although domains and competencies are similar in both nursing and healthcare administration leadership models,3-5,13 it is important for future nurse leaders to consider their individual career trajectory when choosing a discipline for the graduate degree.
Another issue involves the nature of research. Nursing administration research provides the scientific basis for the practice of the profession of nursing administration. Given the scope and complexity of the role of nurse leaders, that research base encompasses a wide scope involving health systems and outcomes at the organizational and patient level. The ANA defines nursing administration research as research on health systems and outcomes that examines how the organization and delivery of healthcare influence quality, cost, and the experience of patients and their families.14 Research informs practice, the focus of the DNP role. However, this new role with a focus on evidence-based practice research may detract from research focused on generating new knowledge.15
There are many issues concerning roles, scope of practice, knowledge domains and competencies, education level and experience, and discipline. We invite you to attend the preconference session at the 2010 Annual AONE Conference and help us craft a blueprint for action moving forward. For a bibliography of references informing this discussion, visit the CGEAN Web site (http://www.cgean.org/aone.php) or see Bibliography, Supplemental Digital Content 1, http://links.lww.com/JONA/A15. If you are not attending, send your comments to me at RJones2@careered.com.
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