AS WE ENTERED 2020, it was unknown that across the world a viral pandemic was brewing. The coronavirus-2019 (COVID-19) pandemic has cost thousands of lives and is testing the health care system to stretch to unimagined capacity. In addition, populations with health disparities suffered disproportionate mortality. Nurse leaders, critical to influencing all aspects of the nursing and health care environment, are navigating a new uncharted landscape that was not previously imagined. Before the pandemic, health care environments were growing increasing more complex with mega mergers resulting in network-driven health systems and new reimbursement paradigms focused on attainment of value-based health outcomes. The National Academy of Medicine initiated the process in 2019 for creating a vision for the nursing profession from 2020 to 2030 to meet future anticipated health and social care demands.1 The convened committee led a consensus study to define a course for the nursing profession to lead and support a culture of health, reduce health disparities, and improve the health and well-being of the US population in the 21st century.1 In addition to describing the role of nurses in achieving the vision of a healthy national population, the report draws attention to the health and well-being needs of nurses.1 The COVID-19 pandemic has drawn laser focus on the health and well-being of nurses. As we respond and adapt during these turbulent times, the American Organization for Nursing Leadership (AONL) and the Association for Leadership Science in Nursing (ALSN) would like to offer insights into the competencies nursing leaders need to navigate these current and future challenges.
The ALSN began 50 years ago as the Council for Graduate Education for Administrative Nursing. We changed our name in 2019 to reflect the evolution of the organization's mission to unite nursing leadership practice, education, and research. We advance the science that informs nursing leadership education and practice.
The AONL, previously known as the American Organization of Nurse Executives (AONE), has regarded nursing leadership as a specialty for over 50 years and provided innovative professional development, advocacy, and research to advance the nursing leadership specialty nationwide. The official name change occurred in 2019 to represent the diverse network of nurse leaders, working at all levels across the continuum of care.2
In 2005, the AONE first published the Nurse Executive Competencies, a competency model for nurse executive practice. The competency model framework is based on 5 critical domains: (1) communication and relationship management, (2) professionalism, (3) leadership, (4) knowledge of the health care environment, and (5) business skills and knowledge. The AONE Board understood its role as a professional organization in compiling input from experts and environmental scans to develop standards guiding the field of nurse executive practice.3,4
The AONL Nurse Executive Competencies have been modified over the years to stay ahead of evolving trends in nurse executive practice. AONL's leaders have continued to address the needs of nurse leaders across the continuum of care with the development of AONL Nurse Executive Competencies: System Chief Nurse Executive, and AONL Nurse Executive Competencies: Post-Acute Care (AONL, 2020). These competencies have been used to guide nurse executive practice and education. They have served as an instrument for nurse leaders to use for assessment of skills in critical areas of nursing leadership.5
Another nurse leader role, the nurse manager, provides the vital link between the administrative strategic plan and the point of care, along with leading the frontline nursing workforce. Many nurse managers are frequently promoted based on clinical experience and lack leadership and management competence. A collaboration between the AONL and the American Association of Critical-Care Nurses (AACN) developed the Nurse Manager Leadership Partnership Learning Domain Framework, an evidence-based framework that consists of 3 domains: (1) development of the leader within, (2) the science of managing the business, and (3) the art of leading people.6
Nurse managers are critical to organizational performance and it is important they too are competent. They frequently learn from “on the job experience” and may take 7 years to become proficient in the role.7 Nurse managers, based on a national study, would benefit from structured competency development programs and graduate education.7,8 Although these competency models continue to be relevant, how do they need to be adapted or modified to provide today's nursing leader the tools to excel in practice and education.
As recently as last year, Sanford and Janney9 proposed updates to nurse leader competencies. They identified the need for leaders to develop stronger competencies around strategic thinking, executive presence, innovation, governance, business skills, and use of big data.9 Updates to the Future of Nursing Report and recent events of COVID-19 provide a backdrop for revisiting our established nurse leader competencies.
CRISIS RESPONSE AND MANAGEMENT
The COVID-19 pandemic is teaching us an important lesson about crisis response and management. Leading during this pandemic is different from traditional disaster response and recovery. A traditional disaster has been a more time-limited phenomenon such as a hurricane or explosion. There may be planning leading up to the event, the event occurs, and then recovery ensues. The impact of the pandemic is a more protracted and variable event. Leaders experiencing more immediate impact needed to rapidly build capacity to respond to the outbreak. The initial response included developing action plans to increase bed capacity and match staff and supplies. A traditional incident command model is useful yet insufficient, as the pandemic will likely wax and wane over an indeterminate time. Matching capacity to need will shift as the country reopens for business. Will we ever return to business as usual? Only time will tell to what degree, but the United States will likely adapt to a new normal, and nurse leaders will need to respond accordingly. Now more than ever, innovation and agility will be a nurse leader's greatest assets.10
In the last decade, the need for nursing leaders to be equipped with informatics competence as health care organizations are acquiring and implementing electronic health information systems to support the work of nurses has become evident. Without informatics knowledge and skills, nurse leaders may not appreciate the implications of an absent nursing voice at the decision-making table.9,11 Collaborative work with the International Medical Informatics Association and the AONL has helped to gain consensus on competencies for nurse leaders.12 Many nurse leaders may not appreciate the need for informatics nurse competence. A self-assessment tool, Nursing Informatics Competency Assessment for the Nurse Leader, can provide information on specific gaps and guide the nurse leader in learning opportunities.13
The COVID-19 pandemic has accelerated the use of telemedicine as primary care practices attempted to limit personal exposure to the coronavirus.14 Telemedicine was even used in the in-patient settings in some instances.15 The progress made in implementing this innovative technology will likely remain once the crisis passes. Nurse leaders need to expand technology competencies. Telemedicine is only one such technology competency. Artificial intelligence and virtual reality are gaining prominence in nursing education. At a minimum, nurse leaders need to understand the technology to remove barriers and support the adoption of innovations that have the potential to improve practice and patient care while balancing quality and resources.11
Prior to COVID-19, the health care system experienced greater demands due to the increased complexity of the patients: they are living longer and experiencing more comorbidities requiring specialized care.16 To effectively care for this population, health care systems need to provide the right level of care in the right setting by the right provider. This means that providers from across the continuum of care must be engaged. Nurse leaders are positioned to participate in the design of these care delivery systems and determine the competencies needed by the interprofessional team. Nurse leaders need to broaden their scope of influence beyond nursing.
The addition of COVID-19 has added the burden of providing care for higher volumes of higher-acuity patients being admitted without their usual family support systems. This imposes greater burden on the nursing staff since there are insufficient resources to assist in personal care and providing critically important emotional support. The shortage of nurses with critical care expertise required that nurse leaders develop strategies to assist those nurses with the necessary critical care expertise. Innovative models of care included pairing medical-surgical or procedural nurses with critical care nurses who worked in teams to care for a number of patients. Definitely not ideal, but in the moment, the best alternative. An insufficient supply of adequately trained nurses and personal protective equipment is leading to burnout and posttraumatic stress among our nurses.17 Attrition may follow if not actively managed by nurse leaders. Having the competencies to lead through crisis and actively manage negative effects on nurses is critical for our workforce.
We are at a critical point in health care. We are experiencing rationing of care and services in a way that the United States has never experienced.18 Leaders who anticipated the ethical burdens engaged in advanced decision-making and developed guidelines for the frontline team. These guidelines are intended to relieve the moral distress burden from the individual in crisis moments. The pandemic has also uncovered disparities in outcomes based on race.19 Being competent in social determinants of health and population health is important, as we embrace a new vision for health care.
EVIDENCE-BASED MANAGEMENT (OR FOCUS SPECIFICALLY ON DATA)
Sanford and Janney9 noted that nurse leaders need to be able to understand big data. Big data are used to generate business intelligence. Business intelligence is a process of analyzing and displaying data in a way that helps leaders make better decisions. It requires leaders to be able to evaluate the quality and sources of the data; a fundamental step in the evidence-based management process.20 As a consumer of data, nurse leaders first need to know how to evaluate the strength of data. In other words, what is the validity, reliability, generalizability, and relevance of the data to the problem being solved. The next step in the evidence-based management process is identifying evidence-based strategies to improve the organizational problem. Getting evidence into practice has been one of nursing's biggest challenges.21 Thus, developing competencies in translational and implementation science will help nurse leaders effect change in their organizations.
The American Association of Colleges of Nursing (AACN) has historically established the expected outcomes for both baccalaureate and graduate education, termed the Essentials. The master's and Doctor of Nursing Practice (DNP) essentials provide guidance to educational programs of the competencies needed at these educational levels. The ALSN has long advocated for graduate education for nurse leaders at all levels.22 Nurse managers benefit from graduate preparation at the master's level and executive nurse leaders benefit from preparation at the DNP level. In October 2019, the AACN established a new task force to re-envision the current Essentials. The task force is charged with designing standards based on trends and projected changes in higher education, health care systems, characteristics of learners, technological realities related to teaching/learning practices, and competency-based education.23 A possible outcome of the re-envisioning of the AACN Essentials is the elimination of the MSN degree option with a health care system or leadership focus.23 Given the value of master's education to nurse managers, an unintended consequence may be that nurse leaders chose graduate education outside of nursing.
AONL leadership competencies are used as frameworks across the United States in competency development courses, graduate education at the master's and doctoral level, and many leadership textbooks.5,24 The AACN and the AONL have committed to work together to identify ways to modify the standards to prepare contemporary nurse leaders.
Investment in the development of competent nursing leaders is critical to achieve a culture of health, reduce health disparities, and improve the health and well-being of the US population. Evidence supports that many nurses move to leadership roles without formal education and development. Although experiential learning is common, development programs and formal graduate education, either masters or DNP, may be a more effective and efficient approach to achieve aggressive health care goals.
The AACN task force has adopted the definition of competencies as “observable and measurable behaviors that are demonstrated at multiple times across a program of study. The competencies apply across both entry into professional nursing education as well as advanced professional nursing education.” 23 AACN's approach of aligning common competencies across baccalaureate, master's, and DNP education may be a model for nursing leadership practice to consider for advancing safe and high-quality nursing practice across the health care system and continuum of care.
The high-impact event of the coronavirus or COVID-19 pandemic has highlighted the nurses' vital role in caring for patients, families, and protection of the health of communities. During these unprecedented times, nurse leaders' knowledge and skills are tested. In addition, this crisis has provided opportunities to explore creative and innovative approaches to solve previously unimaginable challenges. As we move into recovery and rebuilding of the health care system post COVID-19 pandemic, nurse leaders have an opportunity to examine current standards and explore new opportunities for the nursing leaders' role in reconsidering how we can better use technology, to improve access to care to care, and reimagining health care in the post COVID-19 pandemic world.
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