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.
( 2015a ), the AACN Essentials documents (AACN, 2006 , 2011), the IOM Future of Nursing : Leading Change, Advancing Health Report (2011) as well as in the competencies for each of the APRN roles. The need for APRNs to as- sume a leadership role in healthcare is further exemplified by the National Organization of Nurse Practitioner Faculties (NONPF) recommendation to move NP education to the DNP level by 2025 so that all NP students achieve doctoral- level core and population- focused competencies (NONPF, 2018 ). APRNs can exert leadership in the healthcare environment to im- prove outcomes in each of the domains of the Quadruple Aim through inspiration, innovation, and influence.
Operationalizing leadership for each of the APRN roles within the healthcare environment does not have clear definition nor are there spe- cific competencies. This is in part due to the fact that the primary focus of CNMs, NPs, and CRNAs is in the direct provision of care related to their specialization. For CNSs, while they include the three spheres of patient, nurse, and system, their daily work often focuses on supporting system efforts to improve patient outcomes at the organizational level. These roles do not often translate into direct formal and visible leadership roles. Not having direct leadership responsibility limits the vision of a preferred fu- ture for nursing, and specifically, APRN roles in leading and advancing change in the healthcare system.
The need for APRNs to assume visible leadership roles within the healthcare environment is critical, given the rapidly increasing number of APRNs, the need for APRN services, and the complexity of healthcare.
Formal leadership roles within one’s organization may include direct man- agement responsibility, advancement of research and quality improve- ment, interprofessional collaboration, and mentoring. Within the larger healthcare environment, these arenas include being a citizen leader to foster interdisciplinary collaboration and partnerships with consumers to achieve common healthcare objectives and the advancement of health for the public.
The landmark Future of Nursing : Leading Change, Advancing Health re- port (IOM, 2011 ) indicates that nurses along with physicians need to be leaders in reforming the healthcare system, which directly aligns with the Quadruple Aim of healthcare. It requires thinking more strategi- cally about APRNs' leadership roles. The 5- year report on the Future of Nursing (Altman, Butler, & Shern, 2016 ) outcomes indicates that a major means of accomplishing this objective is for nurses to serve on boards, commissions, and advisory panels. The Nurses on Boards Coalition (NOBC) is one tangible initiative to increase nursing’s influence at high policy levels in the healthcare environment.
The NOBC was formed by nurses from across the nation and other or- ganizations with support from the Robert Wood Johnson Foundation and the AARP as part of the implementation of the Future of Nursing report under the aegis of the Future of Nursing: Campaign for Action. The goal is to increase nurse representation on corporate, health- related and other boards, panels, and coalitions by having 10,000 nurses on such boards and
groups by 2020 (NOBC, 2017 ). As of this writing, only one APRN associa- tion, the National Association of Pediatric Nurse Practitioners (NAPNAP), is a member of this group indicating that this a potential area of growth and need for APRN organizational leadership commitment.
The NOBC philosophy is that nurses have the qualifications to serve as integral members of healthcare decision- making groups including skills in communication, finance, quality improvement, strategic planning, and management (NOBC, 2017 ). Nurses bring the “nursing lens,” which includes their perspective on the intricacies and complexities of the human condition acquired during their nursing careers (Disch, 2019). APRNs bring their clinical focus and expertise to board service. Hospital boards that have a greater emphasis on the use of clinical quality metrics are perceived as having higher performance ( Tsai et al., 2015 ). Dramatically increasing the number of nurses on boards has the potential to turn around the findings of a Gallup poll finding that only 14% of American opinion leaders thought that nurses were likely to exert a great deal of in- fluence on healthcare reform and eliminate some of the barriers to nurses exerting a greater influence in the healthcare system ( Khoury, Blizzard, Wright Moore, & Hassmiller, 2011 ). Board service provides opportunities for nurses to influence healthcare, enhance care at the local or regional level, enhance the public’s trust in nursing, and provide opportunities for nurses to fulfill their societal obligations ( Sundean, Polifroni, Libal,
& McGrath, 2017 , 2018 ). These high- level decision- making opportunities position APRNs to fully participate in the redesign of the healthcare system.
The NOBC created a database of nurses serving on boards to track pro- gress. However, the most recently available data indicates that in 2014 only 5% of hospital boards had registered nurse (RN) members (American Hospital Association Center for Healthcare Governance, 2014 ). Although hospitals and large healthcare systems are one arena for board service, there are numerous other healthcare and community boards that would benefit from the expertise of APRNs. Resources for nurses serving on boards are available on the NOBC ( https://www.nursesonboardscoalition.org/ ) and Campaign for Action websites ( https://campaignforaction.org/ ).
APRNs can also provide leadership in achieving the Quadruple AIM through clinical processes related to their practice to improve quality.
Today’s healthcare environment requires the generation of new research, the evaluation of evidence, and efforts to put evidence into practice through quality improvement. APRN leadership in this arena is a two- pronged ap- proach. It has been conceptualized as a continuum between production of research and the production and implementation of EBP ( Hølge- Hazleton, Kjerholt, Berthelsen, & Thomsen, 2016 ). APRNs, regardless of their educa- tional preparation and because of their extensive practice expertise, should be engaged in thoughtful analysis of the need for research in an area in which APRNs can partner with researchers, provide leadership in the re- search enterprise of a healthcare system, or evaluate proposed research within their organizational setting. Many practice groups have joined
practice- based research networks (PBRNs) to address specific healthcare re- search questions and translate evidence into practice (Agency for Research and Healthcare Quality [AHRQ], n.d.). APRNs have the potential to take on a leadership role in evaluating the feasibility of joining such a network and managing the oversight in applying the information obtained through participation in a PBRN.
Leadership in quality improvement and EBP is inextricably intertwined.
Although each of the APRN roles may be at different stages of development with regard to overall leadership in this arena, there is ample opportunity for APRNs to become thought leaders and experts in improving patient outcomes contributing to the achievement of the Quadruple Aim. APRNs can provide EBP and quality improvement leadership at the micro and macro levels ( Finkelman, 2013 ). At the micro level, these activities may in- clude identification of problems, proposing quality improvement and EBP projects working with members of interdisciplinary teams to achieve spe- cific goals; at the macro level, it may include participation in these initiatives at the state and national levels ( Finkelman, 2013 ).
Improving quality on a broader basis requires a focus on population health; the health of a population is intertwined with health inequities. One cannot achieve population health goals when large segments of the popu- lation do not have access to healthcare. Achieving population health goals will involve efforts to address the underlying health inequities with local engagement and commitment (Williams & Phillips, 2019). Access to health- care means addressing the needs of vulnerable populations.
APRNs have traditionally served vulnerable populations ( Xue &
Intrator, 2016 ). APRNs may often be the only healthcare providers in their communities, in nursing homes, and other settings serving low- income patients; federally qualified community health centers are twice as likely to employ NPs, CNMs, and physicians’ assistants as other settings (National Association of Community Health Centers, 2014). The Comprehensive Addiction and Recovery Act (CARA) of 2016, which expands substance use treatment services, also provides additional prescribing privileges to NPs ( Substance Abuse and Mental Health Services Administration, 2018 ), thus facilitating access to care.
Although many APRNs are in settings that serve vulnerable populations, every day they may face challenges in subtle biases hindering access to care and impacting the experience of care which in turn impacts quality and safety. Fitzgerald, Myers, and Clark (2017 ) propose using Bardaracco’s model of quiet leadership (2002) to address the needs of vulnerable populations such as immigrants by taking action to stop injustice, being persistent in solving a problem, and using an incremental approach to work a problem through the organizational hierarchy. APRNs can address the needs of vul- nerable populations not only by the type of work settings and their location (e.g., rural), but also by exerting leadership and taking action to ensure that their patients receive the care that is intended.
With care shifting to outpatient and community settings, organizations at the state and national levels are setting policy, and creating standards
and guidelines. Advancement of this leadership role includes engaging staff in these processes and providing guidance to enhance the develop- ment of collective EBP and quality improvement expertise within health- care systems, thus directly impacting overall quality of care. Including cost analyses for the implementation of new practices and/or new ways of utilizing healthcare personnel has the potential to reduce the cost of healthcare.
Nursing has a long history of demonstrating the overall benefit of APRNs for the quality of care, as well as real and potential cost savings ( Newhouse et al., 2011 ; Rantz, Birtlely, Flesner, Crecelius, & Murray, 2017 ).
For example, the Family Health and Birth Center in Washington, DC, addresses the needs of a vulnerable population by using a midwifery/
NP model to provide low- income women with access to care. This has resulted in a reduction of preterm births and cesarean section rates with more than $1.6 million in savings annually for the Washington, DC health- care system ( American Academy of Nursing, 2015 ). These types of efforts need to be expanded to all areas of practice with the inclusion of financial analyses. There are considerable challenges in conducting economic ana- lyses for NPs and CNSs: the use of standard guidelines has the potential to enhance the comprehensiveness of such economic evaluations ( Lopatine et al., 2017 ).
As the utilization of APRNs becomes more widespread, it is also im- portant for APRNs to take on leadership roles in fostering positive work environments and responsibilities commensurate with their education to contribute to the fourth aim of healthcare. This can involve a variety of formal leadership roles as well as participation in shared governance at the direct care level. An extensive body of research indicates that a positive work environment, job satisfaction, and autonomy for nurses are critical to improve outcomes for hospitalized patients. When NPs serve as primary care providers with their own patient panels, they have more positive perceptions of their work environment, and NP job satisfaction is linked with being less likely to report intention to leave and organizational sup- port of NP practice ( Poghosyan, Liu, & Norful, 2017 ; Poghosyan, Liu, Shang,
& D’Aunno, 2017 ). This research is being expanded to the nurse anesthetist arena as well ( Boyd & Poghosyan, 2017 ).
APRNs can also provide expertise in the credentialing process as well as in the regulatory and legislative environment to enhance more effec- tive utilization of APRNs ( Anen & McElroy, 2017 ). APRNs should examine their work responsibilities to ensure that they are practicing at the top of the license and not engaging in work that is more appropriately carried out by other healthcare professionals. Nurses transitioning to their APRN role may have traditionally carried out non- nursing activities as staff nurses, and thus, may not realize the implications of continuing that practice in their new realm by engaging in traditional nursing responsibilities when functioning as an APRN. This will allow for greater efficiencies, thereby enhancing access to care while allowing APRNs to focus on improving outcomes directly related to their care.