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Nursing’s Growing Role

Rebecca Hendren, for HealthLeaders Media, July 13, 2010
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Hassmiller notes that nursing as a whole is disadvantaged in the healthcare setting by having less formal education than other professions. "Nurses are the ones who coordinate care—they lead—and they only have a community college degree," she says.

"But the fact of the matter is that 60% to 70% of all nurses have ADN degrees," says Hassmiller. "How do you close the door on community colleges, especially in rural areas? How do you tell them they are not really RNs? There's a real discrepancy between reality and what the ideal should be. At the very least, we should make it much easier for community college graduates to go right on for their baccalaureate degrees. As more and more care is delivered in the community, nurses will need that extra community-based education provided by the baccalaureate degree. And to ease the growing faculty shortage, nurses will have to have a minimum of a master's degree, which is most easily attained if a nurse already has a BSN."

Although the work of the Initiative on the Future of Nursing will make recommendations on how to reform nursing education, nothing is likely to change immediately. In the meantime, organizations have their work cut out, bridging the gap from school to practice. Most hospitals already have preceptorships to provide extended orientations to new graduates and help them learn through the mentorship of more experienced RNs, but often these last for only a few weeks and then RNs are on their own. One way to provide more long-term support is through residency programs. Nurse residency structures have been shown to increase new graduate retention and help nurses become competent practitioners more quickly.

"I think this can make an enormous difference in this country," says Hassmiller. "Every physician has a residency program before [being] deemed fit for practice. But for some reason, someone goes to nursing school and the day they pass their boards all of a sudden they are responsible for practicing as a full-fledged practitioner."

Hassmiller suggests residency programs based on mentoring, training, and helping new graduates transition to practice will prepare nurses for the demands of future healthcare needs.

"I think it would help with errors; it would help with the psychological and sociological transition to becoming a healthcare leader," says Hassmiller. "I think we lose nurses who worry whether nursing is 'right for me.' We are facing too big of a shortage to have to worry about losing people we spent so much money getting through school."

Organizations that institute such measures set new graduates on the road to being successful leaders, which can be continued through support at various levels.

"We have some staff with associate degrees," says Zastocki. "But I'm happy to say we started this articulation program and we have great success with people going from associate degrees ... to baccalaureate and then master's programs. Many staff are in master's programs and all our nursing leadership team is committed to master's preparation."

"It's a part of the culture and philosophy we have within the organization," says Zastocki.

Importance of clinical leadership
Nurses with higher degrees are providing ever more leadership in hospitals and are shaping the way care is provided. As the physician shortage worsens, nurses are poised to accept greater responsibility for care coordination and even primary care.

"We have to start looking at our health workforce differently," says Cheryl Peterson, MSN, RN, director of nursing practice and policy for the American Nurses Association. "Physicians, APNs, nurses, nurses aides, and techs. We've got to make better use of all of our skills, knowledge, and ability, and deploy more efficiently and be able to work as a team so we're providing care not just in hospitals but in communities and to families and to populations, and we all have a role to play in that."

Prairie Lakes has achieved its vision of nurse leaders at the bedside with no advanced practice nurses. "I would have a hard time recruiting them," notes Fuller of her small community hospital.

Other organizations are turning to APNs and nurses with specialty certifications to fulfill leadership needs, including Chilton Memorial Hospital, which has above-the-national-average numbers of nurses with certification. The 260-licensed-bed hospital is actively looking to grow its numbers of nurses with certification and with advanced degrees to better prepare them to be clinical nurse leaders.

"It is something we're going to have to pursue," says Zastocki. "One of the things we expect to see is the exodus of Baby Boomer nurses; we will need to think about different, nontraditional care delivery models. During this transition, we want to ensure all aspects of care are coordinated as we work through how we provide nursing care. Ensuring a well-educated workforce with a sound body of knowledge, as evidenced by certification, is one strategy that we are employing. CNLs are another potential model that could help us with new payment reform, assist us to educate new nursing staff, and coordinate other care providers."

Clinical nurse leader role
The clinical nurse leader role is relatively new, and 2009 data showed there are 1,000 in the country who have passed certification exams. But many more are enrolled in master's degree programs and applications to programs are soaring. The CNL is not officially defined as one of the four advanced practice roles in nursing (i.e., clinical nurse specialists, nurse practitioners, certified nurse midwives, and certified registered nurse anesthetists). Advanced practice nurses are prepared with specialist education in a defined area of practice.

Robert Rosseter, chief communications officer for the American Association of Colleges of Nursing, defines CNLs as advanced generalists who serve as "air traffic controllers" on nursing units. "These clinicians are lateral integrators who provide centralized care coordination and put evidence-based practice into action," says Rosseter. "A CNL evaluates outcomes, performs risk analysis, and implements changes in care plans, with the goal of reinforcing patient safety."

Units that employ CNLs have been shown to have shorter lengths of stay and readmission rates, improvements in quality and patient safety such as decreased fall and infection rates, and lower RN turnover.

The CNL role complements nurse managers. The clinical expert can be responsible for a unit's patient outcomes by supervising the application of evidence-based practice; by designing, implementing, and evaluating patient care; and by supervising the care. That allows nurse managers to devote their time to management issues.

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