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With the implementation of the Affordable Care Act, elevated roles for nurses of care coordinator, clinical nurse leader, and advanced practice registered nurse have come to the forefront. Because change occurs so fast, matching development and education to job requirements is a challenging forecasting endeavor. The purpose of this article is to envision clinical leadership development and education opportunities for three emerging roles. Clinical Certification and Target Population Essay. The adoption of a common framework for intentional leadership development is proposed for clinical leadership development across the continuum of care. Solutions of innovation and interdependency are framed as core concepts that serve as an opportunity to better inform clinical leadership development and education. Additionally, strategies are proposed to advance knowledge, skills, and abilities for crucial implementation of improvements and new solutions at the point of care.
Complexity, chaos, high rates of change, serious safety and quality issues, and workforce shortages in health care are some of the reasons why clinical leadership is important. Although the future may be difficult to predict exactly, history has taught us that it is crucial to prepare nurses for key roles in the health care delivery system, both for present jobs and for potential future opportunities. The challenge for clinical leadership is how to structure the knowledge, skills, and abilities required so that nurses are positioned to step into roles that are needed, yet, for which there may not yet be formal jobs. One example is expanding and elevating the registered nurse (RN) role from traditional care delivery to integrating care, where they are working with autonomy, authority, and accountability in managing and coordinating care across disciplines and settings.1 Smolowitz et al2 studied 16 primary health care practices that used RNs to the full extent of their scope of practice in team-based care and found that episodic and preventive care, chronic disease management, and practice operations were the three main aspects of RN activities. They noted that there is a compelling need to expand the contributions and optimize the scope of practice of RNs in primary health care for leadership in interprofessional teams. The purpose of this article is to envision clinical leadership opportunities for three nursing roles: specifically, care coordinator, clinical nurse leader (CNL), and advanced practice RN (APRN), and discuss a common framework for leadership development and education. Clinical Certification and Target Population Essay.
The Patient Protection and Affordable Care Act (ACA) was passed and signed into law in 2010. Subsequent implementation has contributed to reconfiguration in health care delivery, accelerated the demand for health care along with a shortage of key health care professionals, and opened up new and expanded roles for nurses under new care delivery models. Aimed at extending health insurance coverage, there are many provisions of the ACA, including those designed to emphasize prevention and wellness, improve quality and system performance, and curb costs. Notable among these aspects are the creation of health homes and integration of care for persons with chronic illnesses, improvements in care coordination, emphasis on prevention and primary care, investment in health information technology, and testing of new delivery and payment systems. Authorized under the ACA for Medicare reimbursement, the Centers for Medicare and Medicaid Services (CMS) has implemented an initiative to reward acute care hospitals with quality-of-care incentive payments for the quality of care delivered to Medicare patients. Called Hospital Value-Based Purchasing (VBP), this program bases payment (or nonpayment) to hospitals on how closely they follow best clinical practices and how well they enhance patients’ experience of care. The goal is to link payment to a value-based system that improves quality of care and is not just based on volume of services.
These changes in the context of health care delivery have driven the need to supercharge RNs’ leadership knowledge, skills, and abilities and develop targeted care coordination and integration competencies for a more robust skill set that is matched to changing clinical leadership imperatives. Because of ACA and VBP, there is an urgent need for innovation and better management of reciprocal interdependence. Nurses hold the central ground for quality, safety, and improving the patient experience. For example, having quick care clinics affiliated with a hospital can decrease nonemergent patients seeking health care on weekends and nights in the emergency department and increase patient satisfaction with not having to wait. Clinical Certification and Target Population Essay. However, to run smoothly, nurse clinical leadership is needed to coordinate and integrate care with affiliated sites such as laboratories, imaging centers, and pharmacies.
Leadership in nursing is highly valued. The Institute of Medicine3 noted that nurses need to be prepared to lead in all aspects of health care. Leadership is defined as “the process of influencing people to accomplish goals. Key concepts related to leadership are influence, communication, group process, goal attainment, and motivation”.4 In order to understand clinical leadership, it needs to be defined. Clinical leadership is defined here as the process of influencing point-of-care innovation and improvement in both organizational processes and individual care practices to achieve quality and safety of care outcomes. McCausland5 noted that new interdisciplinary models of care that cross traditional boundaries of ambulatory, inpatient, and community settings need credible clinical leaders. Thomas and Roussel6 noted that clinical leadership is about clinicians augmenting care for safety and quality by using innovation and improvement. This places the opportunity for health care leadership at the clinical level within the realm of each direct provider of care, especially nurses who are at the direct care level. They stated “There is a need for a more programmatic, strategic approach to clinical leadership, because the United States’ ailing health care system is in urgent need of reform”.6 Thus, clinical leadership needs targeted preparation.
Clinical leadership uses the skills of the RN and adds components of general leadership skills, skills in management of care delivery at the point of care, and focused skills in using evidence-based practice for problem solving and outcomes management. There is clearly a need for clinical leadership in nursing because of the many and varied point-of-care implementation problems that arise. For example, patient safety may be compromised if there is poor team communication. When nurses are busy or short-staffed, hand-off communications may be compromised, creating gaps in care (Huber et al, unpublished data, 2015).Clinical Certification and Target Population Essay. Discharge transitions may not be smooth if both sending and receiving areas do not communicate well. Medication administration may be less than smooth when multiple disciplines caring for a patient do not coordinate prescribing and transcribing practices. This is true in acute care and across the continuum. Resolving ongoing care gaps requires energetic actions based on best practices, teamwork, care coordination, and clinical leadership competencies at the point of care.
There is a body of evidence demonstrating the relationship between nursing leadership and patient outcomes.7 Wong et al7 found 19 patient outcome variables were related to leadership in the 5 categories of patient satisfaction: patient mortality, patient safety outcomes, adverse events, complications, and patient health care use. Their systematic review of 20 studies from 2005 to 2012 on the relationship of nursing leadership practices and patient outcomes demonstrated a positive relationship between relational leadership and multiple patient outcomes. A connection between supportive leadership styles and positive patient safety outcomes was noted. They concluded that “the current evidence suggests a clear relationship between relational leadership styles and lower patient mortality and reduced medication errors, restraint use, and hospital-acquired infections”.7 Relational leadership styles were also positively and indirectly related to improved work environments and outcomes for nurses.8 This suggests that it is important for leaders to understand the patient care processes and the role of nurses in promoting better outcomes. Among the 20 studies reviewed, transformational leadership was the most frequently used leadership theory.
Transformational leadership is an evidence-based theory used as a strategy and manifested as a style for working within the complexity of care and the use of interdisciplinary teams.9 It is a relational leadership style and an evidence-based management practice that can form the basis of practical clinical leadership development and education. For example, the American Organization of Nurse Executives (AONE)10 has identified five core nurse executive competencies: leadership, communication and relationship-building, business skills, knowledge of the health care environment, and professionalism. Transformational leadership directly addresses some of the competencies in the first category of leadership. There is a solid body of evidence that transformational leadership is related to effectiveness,9–12 which is especially important for working with interprofessional teams, managing the coordination of care, and innovating roles and functions as structures are changing. Clinical Certification and Target Population Essay.
Clinical leadership roles are often thought of as targeted to the development of nurse managers and executives. Given the need for clinical leadership development at all levels, the focus here is on the development and education of nurses as leaders who are prepared to lead at the unit, program, or microsystem level and across the continuum of care. This is the “cutting edge” where the operations of care delivery occur. Nurses in direct care roles deliver care to and coordinate the care of patients and clients. Yet, there are organizational and systems imperatives for quality and safety initiatives and innovations designed and executed by nurses. Thus, to fully enact the direct care role, nurses must be prepared to address all situations that arise at the intersection of clinical practice (provider with patient and family) with the context and environment of care (organizations and groups of multiple care providers and disciplines). This is the imperative of clinical leadership. For example, the leadership and management of care transitions, both within and across settings and sites of care, is a crucial function under implementation of the ACA and its VBP financial aspects. The traditional preparation of nurses has not emphasized these roles and functions, but rather mastery of the psychomotor and conceptual skills needed to deliver entry-level care as an RN. The US health care system has been predominantly acute care driven. Thus, there has been heavy emphasis on learning directed to acute care practice and disease-specific knowledge rather than management of populations, chronic conditions management, care integration, and care coordination among multiple disciplines and in multidisciplinary team care delivery models. A near-term acceleration of care delivery reconfigured to outpatient and primary care will change nurses’ practice settings and job requirements, including expanding roles and levels of autonomy. These changes will impact nurses’ development and educational needs. In studying new and elevated roles for nurses as care integrators, Joynt and Kimball1 identified the following examples: serving as team leaders, CNLs serving as unit-based care managers, nurse practitioners serving as primary care providers in clinics, and nurse coaches managing transitions across settings.Clinical Certification and Target Population Essay. Three major clinical leadership roles for nurses that are positioned to enable the expectations of the ACA are care coordinator, CNL, and APRN. Since these emerging roles support the ACA, we will discuss the preparation and developmental opportunities for these roles.
As the health care environment has been changing and care is shifting to population management and outpatient settings, the care coordinator role has emerged as a new twist on case management and a new model of professional nursing practice. Nurses are often responsible for coordinating care for a group or population of patients.13 However, this has been housed within the context of acute care delivery in the past. For example, nurses may manage populations of patients with diabetes or cardiovascular disease in acute care. In the new and emerging models, nurses are and will be managing many types of carved out populations with chronic illnesses or behavioral health conditions across settings and sites and for long time frames. New roles and jobs have been the natural result. Contemporary names are care coordinators, health coaches, navigators, or care managers. These roles have arisen in conjunction with shifts to patient-centered medical homes and accountable care organizations under the ACA and reimbursement shifts that have put renewed emphasis on care coordination, care management, and prevention strategies related to VBP aspects.14 Care coordinators often serve as case managers, and care coordination is at the core of case management practice.
Case managers have a long and distinguished history of service delivery in nursing and social work. Education for the care coordinator role arises from education within the discipline (eg, nursing or social work) and often includes specialty knowledge and experience in case or population health management. There is no generally acknowledged curriculum for education and training of care coordinators or case managers, but there is a text that is a core curriculum for addressing the case manager certification exam.15 At this point, development and education for nurses in care coordination roles tend to be outside of formal graduate education. The professional organization, the Case Management Society of America (CMSA), is the major body representing case managers.Clinical Certification and Target Population Essay. It issues standards of practice and links with transitions of care organizations. CMSA’s annual conference is a key educational event.
Case managers practice within a variety of professional disciplines. The top two work settings for case managers are health plans (28.8%) and hospitals (22.8%); most case managers are RNs (88.6%).16 Certification is not universally mandatory; however, about 40% of employers require board certification.16 There are many certifications available. The Commission for Case Manager Certification (CCMC) is the oldest, largest, and most recognized of the certifications. They use field-tested role and function studies as the basis of their certification, qualifications, and test plan. CCMC has identified eight essential activities of case management: assessment, planning, implementation, coordination, monitoring, evaluation, outcomes, and general aspects. The six core components of case management are: 1) psychosocial aspects; 2) health care reimbursement; 3) rehabilitation; 4) health care management and delivery; 5) principles of practice; and 6) case management concepts.17 These six domains form the knowledge content areas for the exam’s test plan. They can be used to guide studying for the exam. In addition, CCMC offers many other resources for case management practice, such as a code of ethics called the code of professional conduct. The California Institute for Nursing and Healthcare (CINH) conducted a nurse role exploration project. These authors call for new settings and contexts for experiential learning activities for care coordinators to enable collaboration and skill development across the continuum of care versus traditional settings and approaches.18 That being said, intentional leadership development will be required for current and future care coordinators roles (Figure 1). Clinical Certification and Target Population Essay.
Specific to nursing, the CNL role was conceptualized and developed by the American Association of Colleges of Nursing (AACN) and nursing leaders in 2003.19 It was a new role in nursing, with preparation as an advanced generalist focused on transforming care at the unit of service or point of care.20 The CNL role is especially suited to collaborative work with interprofessional teams and in the coordination of care. Prepared at the Master’s level, CNLs acquire the knowledge, skills, and abilities for evidence-based practice, care coordination, teamwork, quality and safety, outcomes management, and operational management of a complex micro-system. The CNL has been described as a front-line innovator. One of the ultimate aims of the CNL is to improve patient care outcomes, costs, and satisfaction in the microsystem through the development of eight competencies, which include those of clinician, educator, advocate, outcomes manager, information manager, team manager, system analyst/risk anticipation, and member of the profession.Clinical Certification and Target Population Essay.