Sonson, Susan L. DNP, MS, CRNA
Nurse executive, nurse administrator, CNO, nurse manager, head nurse, chief nurse, and chief nursing executive—just a few of the many titles nurse leaders have today. Along with the diversity in job title and description, the educational recommendations and requirements for these roles are also diverse. Historically, nurses have been promoted based on their clinical competency, but in today's complex healthcare systems, nurse executives need more than just good clinical judgment. They also need skills in communication, conflict management, leadership, professionalism, and business.
Nurse executives are facing challenges and being asked to develop systems to make facilities more cost-effective and efficient. In today's changing healthcare environment, advance practice registered nurses (APRNs) are a valuable solution to engage as we deal with many of our healthcare delivery challenges. It's imperative for nurse administrators to understand the various roles for APRNs and how to utilize them in healthcare delivery systems, including shared governance initiatives as a component of the Magnet® journey.
Making the transition
There are four nationally recognized categories of APRNs: certified registered nurse anesthetist, certified nurse-midwife, clinical nurse specialist (CNS), and certified nurse practitioner (CNP). The CNPs and CNSs can be further divided by specialty and certification. Each of the four categories of APRNs has their own professional associations and governing bodies. Laws governing practice can vary from state to state and by individual institutional policies. Some states give APRNs total autonomy, whereas others are very restrictive. This is such a problem that the Institute of Medicine Future of Nursing report contains a 30-page appendix addressing the issue of maximizing APRN services.1
The American Association of Colleges of Nursing (AACN) has recommended that the APRN role be transitioned to the doctor of nursing practice (DNP) degree by 2015. APRNs already have advanced training and education in their specialties and they apply this knowledge for their patients and facilities every day. So many people ask why the need to transition the APRN to a DNP degree? The answer is simple. DNP-prepared APRNs are practice leaders. Traditionally, doctoral-prepared nurses were PhDs with a focus on conducting research. The DNP was designed for nurses in direct clinical practice and areas that support clinical practice. The DNP-prepared APRN is an expert at implementing research in the clinical area. The DNP curriculum provides education on evidence-based practice, biostatistics, translational science, systems management, technology, and healthcare economics. DNP-prepared APRNs can facilitate initiatives to expand and improve healthcare outcomes in all systems.
One system-wide initiative for which the role of DNP-prepared APRN hasn't been articulated is the Magnet Recognition Program® for hospitals. When an organization initiates the journey to Magnet recognition, a part of that journey is the institution and maintenance of a shared governance structure. Shared governance is a nursing administration system structure designed to reflect the professional character of the participants in the nursing organization and promote certain positive behaviors and practice. The purpose of shared governance is the establishment of a system in which staff members participate fully in all activities that have an impact on their work and their ultimate goal of meaningful patient care.2
There are many different models of shared governance, and as many interpretations. These models can be very complex. Many of them don't articulate a role for the DNP-prepared APRN in an organization; instead, they have specialty nurses, which usually represent RNs in specific areas such as pediatrics, geriatrics, and medical-surgical. However, specific mention of the role that DNP-prepared APRNs can play in this crucial initiative is lacking.
Cost-effectiveness of shared governance
Shared governance helps contain costs by increasing job satisfaction to retain nurses.3 According to the Robert Wood Johnson Foundation, various studies have shown that the average cost of replacing an RN is currently $22,000 to $64,000.4 The estimated cost of replacing a full-time RN in 2007 averaged $37,567. Two-thirds of RN replacement costs were associated with temporarily filling vacant RN positions and the training and orientation of new nurses. The cost increases with more highly trained and specialized nurses.
In 1993, a study done at Mercy Hospital in San Diego, Calif., showed that it had a 5-year cumulative savings of $5,837,126 with the implementation of shared governance.5 Implementing shared governance requires a large financial commitment from the institution, but the payback can be significant in monetary terms and staff satisfaction. St. Mary's Hospital in Wisconsin is another stellar example of how shared governance can save money for the organization. In 2003, the hospital had never needed to hire an agency nurse, had unscheduled overtime, and never paid a signing bonus, a finder's fee, or an extra shift premium.6 At the same time, the hospital's operating margins have averaged 11% a year when the national average is 1.5% a year. The key? St. Mary's vice president attributes it all to shared governance.
The process of implementing shared governance involves the development of unit practice councils (UPCs). These councils are unit specific and report to a nurse administrator. With the transition of APRNs from master's degree preparation to the DNP, APRNs are the ideal nursing professionals to lead UPCs. Each UPC could have one DNP-prepared APRN serving as chairperson to give the institution that has achieved Magnet recognition—or is trying to achieve it—the expertise that a DNP can offer, which is one way that they can be utilized to the full extent of their education.
Nurse executive education
Curriculum development for nurse executive educational programs is as diverse as the multitude of titles given to nurse administrators. There's a large amount of literature on the subject of nurse executive education, but most of it's based on individual opinion and organizational recommendations. Before the educational requirements can be determined, the role that the nurse leader will be taking must be considered. Nursing administrative leadership is divided into two levels: manager and executive. Managers are the first and mid-level administrators responsible for a specific clinical service or unit at the microsystem level.7 Executives are the top-level nurse administrators responsible for the executive level of patient care service.7
In a recent study, approximately 50% of nurses with titles suggesting a leadership position reported having less than a bachelor's degree as their highest credential.8 The nursing discipline needs to evaluate the degree required for the educational preparation of nurse leaders and make sure that they have the same advantages and opportunities as their business executive counterparts and are prepared to lead nursing practice, including familiarity with shared governance models.
The Council on Graduate Education for Administration in Nursing (CGEAN) issued a position statement on the educational preparation of nurse executives and nurse managers.9 It states that graduate preparation in nursing management, business knowledge, and leadership skills are needed for success in the complex healthcare environment.9 The position statement expands on the opinions of the American Association of Nurse Executives (AONE) and the AACN, recommending seven different goals and expectations. The CGEAN suggests that nurse managers be prepared at the master's level and nurse executives be prepared at the doctoral level. It also supports the recommendation of the AACN to implement the DNP as a post-master's terminal degree option with an aggregate/systems/organizational focus in administration, healthcare policy, informatics, and population-based specialties.9
The AONE published an updated list of nurse executive competencies, recommending that nurse educators utilize it as a curriculum guideline for the educational preparation of nurses seeking expertise and knowledge in executive nursing practice.10 The AONE acknowledges that there are nurse executives with all levels of education, but it specifically encourages nurse executives to prepare themselves at the doctoral level.
Although there's extensive literature on leadership, shared governance, and administration, there isn't much consensus on educational requirements for nurse executives and very little on the DNP-prepared APRN's role in shared governance.11–13 Nurse executives are key stakeholders in creating the environment for shared governance initiatives. As a result, understanding the role that DNP-prepared APRNs can play in such initiatives is essential. However, after reviewing the literature and contacting several MSN program directors, there doesn't appear to be coursework designed specifically to address the role of the DNP-prepared APRN in shared governance initiatives. Curricula for programs that prepare nurse executives must educate them about shared governance and the role of DNP-prepared APRNs in shared governance initiatives.
Implications for practice
Implementing DNP-prepared APRNs as leaders in shared governance initiatives and the Magnet journey will require facilities that want to be pioneers in developing a new structure to enhance the ability to advance nursing, initiate best practices, and improve patient outcomes. Figure 1 represents a new conceptual model in shared governance and emphasizes the DNP-prepared APRN as the core in leading council initiatives. Key nurse executive competencies should include building shared governance models and the effective use of DNP-prepared nurses, specifically DNP-prepared APRNs.
Organizations are struggling to meet budgets, retain staff, and increase patient and staff satisfaction. This author believes that the key is the implementation of shared governance with UPCs being led by DNP-prepared APRNs. The DNP-prepared APRN is a practice leader who'll be able to facilitate initiatives to expand and improve outcomes in all areas.
For too many years nursing has let others determine the path of its profession; with the transition to the DNP, it's time for nursing to take charge and forge its own pathway. Shared governance is the perfect format to guide us in this development. Nurse executives represent all nurses; it's up to us to make sure they have the necessary tools and education. As nurses, we need to speak up and control our own practice and determine our own professional pathway before someone else does.
1. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: The National Academies Press; 2011.
2. Hoying C, Allen SR. Enhancing shared governance for interdisciplinary practice. Nurs Adm Q. 2011; 35:(3):252–259.
3. Relf M. Increasing job satisfaction and motivation while reducing nursing turnover through the implementation of shared governance. Crit Care Nurs Q. 1995; 18:(3):7–13.
4. Robert Wood Johnson Foundation. Assessing the Direct Cost of RN Turnover. Chicago, IL: Robert Wood Johnson Foundation; 2004.
5. DeBaca V, Jones K, Tornabeni J. A cost-benefit analysis of shared governance. J Nurs Adm. 1993; 23:(7–8):50–57.
6. Weber D. True Shared Governance: How One Hospital Flourishes While Others Flounder. Chicago, IL: Cor Health LLC; 2004; .
7. Jones RA. Preparing tomorrow's leaders: a review of the issues. J Nurs Adm. 2010; 40:(4):154–157.
10. American Organization of Nurse Executives. The AONE Nurse Executive Competencies. Chicago, IL: American Organization of Nurse Executives; 2004.
11. Cummings G, Lee H, Macgregor T, et al. Factors contributing to nursing leadership: a systematic review. J Health Serv Res Policy. 2008; 13:(4):240–248.
12. Barden AM. Shared governance and empowerment in registered nurses working in a hospital setting. Nurs Adm Q. 2011; 35:(3):212–218.
13. Adams JM. An evidence-based structure for transformative nurse executive practice: the model of the interrelationship of leadership, environments, and outcomes for nurse executives (MILE ONE). Nurs Adm Q. 2009; 33:(4):280–287.