APRNs have an essential leadership role that starts in the practice setting.
This leadership role is multifaceted and is critical to the achievement of healthcare redesign and the achievement of the Quadruple AIM. The latter is an expansion of the more often recognized Triple Aim set forth by the Institute for Healthcare Improvement’s (IHI), by adding the improvement
of the work life of healthcare providers to the aims of quality and safety, improved health, and reduced costs ( Bodenheimer & Sinsky, 2014 ). No one is more equipped to lead this charge in the work setting than nurses who have the education and knowledge of the policies, regulations, culture, and their own work environment.
APRNs can make the difference in accomplishing these aims where they work if and only if they develop leadership competencies needed for the current environment. The changes in healthcare restructuring, as well as revolutionary advances in technology, pharmaceutical research, and surgical innovations, coupled with the organizational complexities and fierce competition for resources, have created unprecedented challenges as well as opportunities for the APRN. In the midst of these awe- inspiring advances, it is clear that the sobering unintended consequences of a com- plex, highly regulated, and yet fragmented system, first identified by the Institute of Medicine (IOM, now the National Academy of Medicine [NAM]) more than 15 years ago (IOM, 1999 , 2001 , 2004 ), have not yet been solved. At a time when the cloning of a human is possible, ensuring the basics, such as hand washing for all providers and preventing falls, re- mains, at times, elusive. In addition, the incentive structure of the re- imbursement system is finally holding providers accountable to keep communities healthy by preventing illness and supporting wellness, cre- ating both intended and unintended consequences. Lack of leadership has been shown to be an instrumental influence in the occurrence of sentinel events ( Joint Commission, 2017 ). APRNs have incredible opportunities but still face obstacles related to the hierarchy of the healthcare system that has plagued nurses for decades.
Pursuing your graduate education and APRN specialty is foundational to your growth as a nurse leader. Becoming a leader is process and can build on the leadership experiences you have had. Conduct a self- assessment for your current leadership in practice and school. Consider taking an in- ventory of leadership projects that you may have already experienced, for example: committee/council work; managing a unit; leading a team;
implementing a change process; carrying out research, evidence- based or research project; and or coaching, precepting, or mentoring others such as students or new RNs. These experiences can be appointed, elected, or volunteer.
Preparation and action are required to cultivate your role as a leader in anticipation of your new work role. Self- awareness is basic to planning and taking action steps. Krejci and Malin (2001 , 2006 ) developed a model based on more than 20 years of teaching and consulting in the area of leadership development with nurses in a variety of roles ( Krejci & Malin, 1997 ). The model encompasses leadership development for all nurses, not just those in formal leadership positions. The foundation of the model is self- awareness, which the literature on leadership has consistently identified as being a prerequisite for successful leadership. The components in this model are congruent with the master’s and DNP essentials documents (AACN, 2006 , 2011 ; see Figure 7.1 ). Self- awareness, self- efficacy, and mission occupy the
center of the model, surrounded by supporting competencies of systems thinking, circle of influence (personal power), interpersonal communica- tion, building teams, negotiating conflict, moving vision to action, coaching and developing others, and implementing change.
Although there seems to be much agreement that leadership competen- cies are a prerequisite for success as an APRN. As basic APRN education moves more fully to DNP programs, nursing education has a stunning op- portunity to build a strong foundational curriculum that seeds stronger leaders.
The development of future APRN leaders is double- pronged and requires both leadership in everyday practice and a plan to take on formal leader- ship roles. In fact, the IOM report ( 2011 ) sets the expectation that all nurses develop as leaders “from bedside to boardroom” (IOM, 2011 ). However, as we look forward to the roles nurses have in leadership in healthcare today, those with advanced education, like APRNs, will be more critical than ever.
The many strides that have come in the exponential growth of APRNs will not be sustained without strong leadership, given the ever- changing health, demographic, and political landscape.
The challenge for APRNs, those who educate them, and those executives to whom they report, is understanding the leadership implications of the APRN role in their day- to- day work practice . Given the primacy of lead- ership in the APRN role, across practice and even countries, much more work is needed to understand APRN leadership ( Elliott, Begley, Sheaf, &
Higgins, 2016 ).
Systems thinking
Commitment Experience
Moving vision to
action
Coaching and developing
others
Implementing change successfully
Negotiating conflict
Leveraging circle of influence/Personal
power Interpersonal communication Self-awareness,
self-efficacy, mission
Building teams
Self as leader
Self as leader
FIGURE 7.1 Krejci and Malin’s leadership model of competencies.
Much as the barriers to APRN practice have been discussed throughout the book and your education, there are numerous barriers that exist to fully embrace and develop APRN leadership. In a scoping review, Elliott et al. (2016 ) identified not only 13 barriers to practice, but they catego- rized 11 enablers to leadership practice. The latter is a critical step to examining the ways to build on existing strengths. This study is impor- tant as leadership is discussed as a concept across types of advanced practice nursing. Both the barriers and enablers were categorized into four broad levels: healthcare system, organization, team, and advanced practitioner. Most barriers and enablers are found at the organizational level, showing how structural empowerment is essential to APRN lead- ership as noted by Steward et al. (2014). Interestingly at the APRN level, several barriers are noted specifically to leadership, the very focus of this chapter. Issues related to the healthcare system are discussed in Chapter 10 .
Thus, within the APRN everyday work role, there are many opportuni- ties as well as obstacles to being a leader. While you may have an APRN role that focuses on executive leadership or advancement of evidence like research or quality improvement, most entry APRN roles are in direct clin- ical care. Clinical leadership at the front lines is equally needed for solving everyday problems of care related to a variety of seemingly disparate topics ranging from adopting new practice guidelines to reducing readmission rates. Many thousands of articles are found in the literature that highlight specific clinical projects like EBP, quality that was carried out under the lead- ership of CNMs, CNPs, CRNAs, or CNSs individually, in groups, or across categories of APRNs like CNSs and NPs. The projects evolve from everyday practice like common health problems (e.g., heart failure), deficiencies iden- tified from root cause analyses (e.g., work- arounds or hand- off failures), and high- profile national problems (e.g., hospital- acquired complications).
One example can be seen in the work to decrease readmissions, costs, and adverse events by an interdisciplinary team led by CNSs in a small com- munity hospital. The team developed the program called the At Risk Care Plan (ARCP) as a partial result of safety analyses. High- end users of care were often patients who were repeatedly readmitted and experiencing ad- verse events like falls while hospitalized. The ARCP is a care coordination tool that is incorporated into the patient’s chart and details a tailored care plan for each patient designated at risk. Written and verbal communica- tion both in person and electronically are essential to the ARCP ( Bahle, Majercik, Ludwick, Bukosky, & Frase, 2014 ). Often a small project, espe- cially when disseminated, will lead to the expansion of efforts beyond the work setting.