- Email: [email protected]
The Value Proposition for Graduate Education of Emerging Nurse Leaders: Immediate Benefit to Organizations
The Value Proposition for Graduate Education of Emerging Nurse Leaders: Immediate Benefit to Organizations Bonnie Pilon, PhD, RN-BC, FAAN,Terri D. Crutcher, DNP, Susie Leming-Lee, DNP, Richard Watters, PhD, Kelly A.Wolgast, DNP, FACHE, and Debra Arnow, DNP, RN, NE-BC
T
he economic impact of higher education on the individual has been
widely documented, with benefits measured in terms of lifetime earning power, accumulation of household wealth, lower unemployment, access to healthcare coverage, and overall better health across all ages and income levels.1–6 The economic impact within the workplace, to the employer, is less precisely defined.
Overall benefits include a better
prepared workforce, which can lead to increased economic benefit to the employer and to society as a whole. Specific benefits related to investing in the education of current and future health systems nurse leaders may have an early, as well as a sustained, impact on the organization. Using case studies, this report explores the beneficial economic and quality impact on healthcare agencies and institutions during, as well as after, the completion of degree requirements when emerging nurse leaders pursue graduate education in health systems management.
BACKGROUND Nurse leaders oversee the work of more than 3 million registered nurses as well as 752,000 licensed practical nurses and assistive personnel at all levels of patient care delivery.7 The magnitude of their influence on patient safety, quality, and financial outcomes within the institution is substantial. Registered nurses (RNs) with graduate degrees comprised only 13.2% of all licensed RNs in 2008.8 Within the cohort, 375,794 held master’s degrees (12.2%) and 28,369 were doctorally prepared. Of those with master’s degrees, 77.2% held a master of science in nursing (MSN) (290,084). www.nurseleader.com
Within the total master’s degree–prepared cohort, 19.2% of those RNs had graduate degrees with a focus on administration, business, or management. Data were not available to discern which of these RNs pursued their degrees within schools of nursing or in related disciplines. From these data, it is apparent that there are only 72,000 nurses prepared at the graduate level for leadership and management within the US health system. This system is complex and vast— made up of 5,724 hospitals with just under 37 million admissions per year,9 14,500 home care agencies10 serving 1.5 million patients,11 and 16,100 skilled nursing facilities
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with 1.5 million residents.12 The paucity of well-prepared nurse leaders yields a ratio of 555:1 patients to master’s degree–prepared nurse leader—not a desirable situation given the patient safety, quality, and financial challenges inherent throughout the US health system. Accredited graduate nursing programs offering MS/MSNs in nursing administration, health systems management, or leadership/management are available in both traditional classroom programs as well as online; however, there is some variation in credit hour requirements and curriculum. This article explores the value proposition for graduate education of current and emerging nurse leaders as a key component for leveraging positive changes in patient safety, quality, and financial results within organized healthcare settings, based on data from the Health Systems Management program at Vanderbilt University School of Nursing.
BACKGROUND There is an abundance of literature on leadership education in nursing; however, there is no consensus on the best preparation methods or models.13 This brief review describes some contemporary perspectives on the value of leadership education at the graduate level in nursing and uses the Institute of Medicine report The Future of Nursing as the guiding direction on this issue.14 The Future of Nursing report discusses the need to ensure that nurses are educated to assume leadership roles across the system in order to tackle the challenges ahead in redesigning the facets of healthcare delivery. Specifically, the report states: Strong leadership is critical if the vision of a transformed healthcare system is to be realized.... The nursing profession must produce leaders throughout the healthcare system, from the bedside to the boardroom, who can serve as full partners with other health professionals and be accountable for their own contributions to delivering high-quality care while working collaboratively with leaders from other health professions.14(p. 7,8) Scott and Yoder-Wise15 support this perspective and add the need to educate more nurse leaders beyond the baccalaureate level in order to continue progress in advancing patient safety and quality, as well as promoting innovative models of care delivery. In addition, they present the challenges related to advancing the education of nurses in management and leadership positions as this is often neglected in favor of advancing education of nurses in clinical specialties. Aiken16 illustrates this challenge further with data that demonstrate that without significant shifts upward in nursing education-level standards, the current production of nurses at the associate degree level will preclude the generation of enough nurses to accommodate the numbers of leadership and executive roles that require graduate-level education. The continued complexities of healthcare demand nursing leaders to be prepared with advanced skills in leadership, management, and business competencies through well-designed academic programs in order to successfully influence and lead future directions in nursing.17,18
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PROGRAM DESCRIPTION Vanderbilt School of Nursing opened its nursing administration master’s degree program in 1987. The original curriculum was offered until 1996. As more nurses began assuming leadership roles across a variety of healthcare organizations, the title of the program changed to Health Systems Management (HSM) to reflect the shift in focus as it pertained to the role of the nurse leader. Course content and program requirements were expanded as well to reflect the broader focus on the healthcare industry. Since 1987, 333 nurses have graduated from these programs. Graduates of the nursing administration/HSM program have served/are serving as nurse managers, program directors, chief nursing officers, hospital administrators, uniformed services officers, consultants, nursing faculty, and one graduate was the first nurse to serve as the commissioner of health in her state. The HSM program of study prepares graduates for the advanced role of nursing and healthcare management. This program is designed to prepare nurses at the graduate level to manage the delivery of nursing and healthcare services across the spectrum of healthcare settings. Graduates acquire the breadth of management knowledge and skills to perform effectively and assume leadership positions in healthcare delivery organizations, government, and the broader healthcare industry. As part of this program, students learn to implement processes and programs to achieve continual improvement in care delivery as well as meet financial targets and maintain fiscal accountability; collaborate effectively across disciplines and healthcare settings to enhance integration of services and care delivery; facilitate clear communication of expectations and accountabilities to assigned staff; innovate, implement, and manage change; balance strategic, financial, operational, quality, and interpersonal responsibilities; and participate in research. The curriculum consists of 11 courses of 3 credits each, 1 course of 2 credits, and 1 course of 4 credits, for a total of 39 credits. All courses are offered in an online learning environment. The e-learning format is designed to support flexibility, connection, interaction, and access to state-of-the-art resources and computer support. As part of their learning experience, students are assigned to small groups and participate in a variety of online activities such as discussion boards, blogs, and web-based conference calls. Case studies, based on current and relevant nursing practice, challenge students to critically analyze, evaluate, and develop solutions to issues in nursing and management practice and healthcare. These online learning experiences provide students with the opportunity to interact with one another and share their understanding of the course materials, as well as apply what they have learned to their practice. The program links technology with learning while embracing cultural and academic diversity. The Vanderbilt HSM curriculum includes a variety of topics to prepare emerging nurse leaders to manage the delivery of nursing and healthcare services in multiple settings and specialties. Topics include leadership, financial management, continuous quality improvement, nursing theory, organizational dynamics, health informatics, and healthcare
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management of populations. The program includes a mixture of didactic work and practice opportunities that enhance the educational experience. In the last semesters of the program, students complete 2 practicum courses. The practicum experience provides students with an opportunity to work closely with a manager or administrator in one of a variety of healthcare settings including nurse-managed clinics, community-based clinics, ambulatory care centers, industry, insurance companies, public sector sites, and hospitals. Students also have the opportunity to observe and practice management and leadership skills in these healthcare environments. In addition, students work on agency-designated projects, and present their process and results to the agency as well as to their peer student group.
APPLIED LEARNING: REAL-WORLD CASES Nurse leaders who seek personal learning through evidence-based health systems management programs add value to their organizations. These leaders are critical in the building of the workforce capability and capacity conducive to high performance by engaging, managing, and developing the workforce to utilize its full potential in aligning the organization’s overall mission, vision, and action plans. They can capitalize on the organization’s core competencies, build the organization’s knowledge assets, and improve the environment for innovations while understanding success in today’s ever-changing, globally competitive environment demands agility.19 Applied or action learning20 is focused on the “real-world” healthcare system, providing the student with the ability to build and sustain relationships with customers/patients; to understand intelligent risk; to innovate and transition to new technology; to develop new products and services; to improve work processes; and to meet changing business, market, and regulatory demands.19 This instructional approach allows both the student and the organization to gain the capability, capacity, and sustainability to experience high performance success. The following applied learning cases provide examples of how graduate HSM students have applied evidence and skills acquired during their academic work in their healthcare agencies and settings. These cases illustrate how the use of applied learning opportunities adds measureable value to the organization. Case One The HSM graduate student performed a cost analysis utilizing a financial model of care for elective coronary artery bypass graft surgery to determine possible opportunities for cost reduction. The results included: 1. Identification of proficiencies around financial and clinical models of care for application across populationbased management systems, specifically coronary artery bypass graft surgeries 2. Comparison of the evidence-based clinical model of care with the financial model to determine opportunities for cost savings in comparative surgeries 3. Total cost savings per patient of $1,249.82. www.nurseleader.com
There were a total of 151 cases performed during the second 6-month time frame for a total costs savings during those 6 months of $188,723.42 and annualized savings of $377,446.84. Case Two A new formal work process and associated report was developed by the HSM graduate student to track RN vacancies and number of positions required to meet budgeted staffing models, and to record and track full-time equivalent (FTE) availability on a weekly basis. Data were tracked that included: 1. Information from the staffing models 2. Current filled and vacant positions from human resource reports 3. Recruiting information on pending new hires 4. Current staff available each week 5. Family Medical Leave Act (FMLA) status 6. Other leave types, staff hired and on orientation 7. The number of FTEs needed each shift Results included a process that could predict the number of staff required for patient care while new staff complete orientation and before new staff are fully available on the time schedule. The new process and the associated report clearly reflect available and nonavailable FTEs that provided managers with a consistent, reliable data tracking tool to make timely staffing decisions that resulted in savings to the organization by reducing variability in staffing levels through the use of predictive modeling. Case Three The HSM graduate student along with a perioperative healthcare team created and implemented a work process to consistently identify the patient’s legal guardian in order to decrease the surgical case delays of the daily first-case start times in pediatric cases. The process improvement outcome resulted in a zero delay in first-case starts over a 4-month tracking period with no loss of revenue as a result of case delay. Case Four The HSM graduate student created a system redesign along with recommendations to reduce the number of low-acuity visits to the emergency department (ED) in a Veteran's Administration hospital. Prior to the implementation of the new process in fiscal year 2011, 6,462 veterans were seen in the ED at an average cost of $441.00 per visit, for a total annual cost of $2,849,742. With the redesigned process, those veterans who were not having a true emergency were seen by the urgent care service. This improvement initiative resulted in reducing the average cost of the visit to $100 per case, generating $2,203,542 in cost reduction at this facility. Case Five A process analysis was conducted by the HSM graduate student to determine the effectiveness of the current use of humidified oxygen for every patient admitted to the postanesthesia care unit. The results of the analysis showed there was no evidence to support the current practice. Using
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change theory and effective leadership skills, the student planned and initiated a change in the process that resulted in a savings of approximately $80,000. Case Six The HSM graduate student developed a comprehensive nurse retention strategy designed to retain nursing talent for a large healthcare organization, improve nursing satisfaction, and leverage a high-performing workforce, ultimately saving onboarding and attrition costs for the organization. Program components included a formalized residency program, externship program, preceptor program, and mentor program, and a process to develop nurse leaders as chief retention officers— onboarding, monitoring, coaching/development, and team building. The overall goal was to reduce attrition numbers by 10% with a stretch goal of 20% by the third quarter of 2014. With an average of 500 nurses in the organization, this translates to 7 to 14 nurses (medical-surgical and critical care) retained, with a projected savings ranging from $361,000 to $732,000 in 1 year. These applied learning cases are evidence of the valueadded results that organizations can expect from students completing graduate education in healthcare leadership and management. Applied learning also allows the student to gain a realistic approximation of what will be encountered in the workplace.21 Through this learning approach, students gain the knowledge to support the organization’s mission, vision, and strategic plans, leading to a more sustainable, successful, high-performing organization.
CONCLUSION There is a compelling need for more sophisticated nursing management and leadership to respond to the clinical, organizational, and fiscal challenges faced by the healthcare industry to address the future of healthcare. As Heller et al.22 wrote in “The Future of Nursing Education”: Nurse managers and executives require clinical experience and strong communication skills, as well as business acumen and knowledge of financial and personnel management, organizational theory, and negotiation. With the nursing labor budget constituting a significant proportion of total spending, and cost overruns in acute care hospitals, long-term care facilities, and home care agencies, nursing management is too often found to be lacking in fundamental decision science and fiscal knowledge. A great need exists for educational support for experienced nurses to be developed into nurse executives, prepared to work competently alongside their business colleagues. Nursing schools are called on to expand their core and continuing education programs to address these needs.22 Through the application of powerful and effective teaching strategies, employers reap the benefits from their nurse leaders and emerging leaders pursuing graduate education in healthcare leadership and management. These real-world projects provide the learner with the opportunity to focus on why and how to apply a skill or concept while effecting real, sustainable, and positive change in their work settings,
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and builds the nurse leader’s problem-solving skills. Applied learning also provides a team-building opportunity for the learner that is an essential competency in healthcare. Healthcare educators and providers face a rapidly changing healthcare landscape, shifting student and patient demographics, an explosion of technology, and the globalization of healthcare, in addition to a myriad of challenges in everyday operations. As institutional leaders position their organizations to meet today’s challenges and tomorrow’s, it is imperative that healthcare educators and healthcare organizations focus their resources on the development of competent nurse leaders in order to meet those challenges. NL References 1. Baum S, Ma J. Education Pays: The Benefits of Higher Education for Individuals and Society. Washington, DC: College Board; 2007. 2. Gouskova E, Strafford F. Trends in Household Wealth Dynamics, 2001-2003. Ann Arbor, MI: Institute for Social Research, University of Michigan; 2005. 3. Bureau of Labor Statistics. Labor Force Statistics From the Current Population Survey. US Department of Labor. http://www.bls.gov/cps/earnings. htm#education. Accessed September 2, 2013. 4. Kaiser Family Foundation. The Uninsured: A Primer—Key Facts about Health Insurance on the Eve of Coverage Expansions. October 2013. http://www.kaiseredu.org/issue-modules/the-uninsured/backgroundbrief.aspx?p⫽1. Accessed September 2, 2013. 5. Muenning P. Health returns to education interventions, executive summary. Paper presented at: the 2005 Symposium on the Social Costs of Inadequate Education; October 24, 2005; New York, NY. http://www.tc.columbia.edu/ centers/EquitySymposium/symposium/resourceDetails.asp?PresId⫽5. Accessed September 2, 2013. 6. Wong M, Shapiro M, Boscardin W, Ettner S. Contribution of major diseases to disparities in mortality. N Engl J Med. 2002;347:1565-1592. 7. Bureau of Labor Statistics. Licensed Practical and Licensed Vocational Nurses. In: Occupational Outlook Handbook, 2012-13 Edition. Washington, DC: US Department of Labor. http://www.bls.gov/ooh/healthcare/licensedpractical-and-licensed-vocational-nurses.htm. Accessed September 2, 2013. 8. Health Resources and Services Administration, US Department of Health and Human Services. Findings From the 2008 National Sample of Registered Nurses. Washington, DC: HRSA; 2010. 9. American Hospital Association. Fast Facts on US Hospitals. http://www.aha.org/ research/rc/stat-studies/fast-facts.shtml. Accessed September 13, 2013. 10. Caffrey C, Sengupta M, Moss A, Harris-Kojetin L, Valverde R. Home Healthcare and Discharged Hospice Care Patients: United States, 2000 and 2007. National Health Statistics Reports: No 38. Hyattsville, MD: National Center for Health Statistics; 2011. 11. Jones AL, Dwyer LL, Bercovitz AR, Strahan GW. The National Nursing Home Survey: 2004 overview. National Center for Health Statistics. Vital Health Stat. 2009;13:1-155. 12. Centers for Disease Control and Prevention. FastStats: Nursing Home Care. http://www.cdc.gov/nchs/fastats/nursingh.htm. Accessed September 13, 2013. 13. Androwich IM, Watson CA, Belcher JVR, et al. Graduate practicums in nursing administration programs: current approaches and recommendations. J Nurs Adm. 2012;42:454-457. 14. Institute of Medicine. The Future Of Nursing: Leading Change, Advancing Health. Washington, DC: National Academies Press; 2010. http://www.iom.edu/ Reports/2010/The-future-of-nursing-leading-change-advancing-health.aspx. Accessed May 29, 2013. 15. Scott ES, Yoder-Wise PS. Increasing the intensity of nursing leadership. J Nurs Adm. 2013;42:1-3. 16. Aiken LH. Nurses for the future. N Engl J Med. 2011;364:196-198. 17. Kleinman CS. Leadership roles, competencies and education: how prepared are our nurse managers? J Nurs Adm. 2003;33:451-455. 18. Aduddell KA, Dorman GE. The development of the next generation of nurse leaders. J Nurs Educ. 2010;49:168-171. 19. Baldrige Performance Excellence Program. 2013-2014 Health Care Criteria for Performance Excellence. Gaithersburg, MD: U.S. Department of Commerce, National Institute of Standards and Technology. http://www.nist.gov/baldrige. . Accessed August 30, 2013. 20. McGill I, Beaty L. Action Learning: A Guide for Professional, Management and Educational Development. 2nd ed. London, UK: Kogan Page; 1995.
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21. Bechert U, Cronk BC. Applied learning at the graduate level—professional science master’s programs lead the way. J Appl Learn High Educ. 2012;4:23-33. http://www.missouriwestern.edu/appliedlearning/ volume3.asp. Accessed September 1, 2013. 22. Heller BR, Oros MT, Durney-Crowley J. The Future of Nursing Education: Ten Trends to Watch. National League of Nurses website. http://www.nln.org/ nlnjournal/infotrends.htm. 2013. Accessed September 2, 2013.
Bonnie Pilon, PhD, RN-BC, FAAN, is a professor and senior associate dean at Vanderbilt University School of Nursing in Nashville,Tennessee. She can be reached at [email protected]. Terri D. Crutcher, DNP, is a an assistant professor at Vanderbilt University School of Nursing in Nashville,Tennessee. Susie Leming-Lee, DNP, is a
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an assistant professor at Vanderbilt University School of Nursing in Nashville,Tennessee. Richard Watters, PhD, is a an associate professor at Vanderbilt University School of Nursing in Nashville,Tennessee. Kelly A.Wolgast, DNP, FACHE, is an assistant professor at Vanderbilt University School of Nursing in Nashville,Tennessee. Debra Arnow, DNP, RN, NE-BC, is a chief nursing officer at Omaha Children’s Hospital & Medical Center in Omaha, Nebraska. 1541-4612/2014 Copyright 2014 by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.mnl.2013.11.004
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T
he economic impact of higher education on the individual has been
widely documented, with benefits measured in terms of lifetime earning power, accumulation of household wealth, lower unemployment, access to healthcare coverage, and overall better health across all ages and income levels.1–6 The economic impact within the workplace, to the employer, is less precisely defined.
Overall benefits include a better
prepared workforce, which can lead to increased economic benefit to the employer and to society as a whole. Specific benefits related to investing in the education of current and future health systems nurse leaders may have an early, as well as a sustained, impact on the organization. Using case studies, this report explores the beneficial economic and quality impact on healthcare agencies and institutions during, as well as after, the completion of degree requirements when emerging nurse leaders pursue graduate education in health systems management.
BACKGROUND Nurse leaders oversee the work of more than 3 million registered nurses as well as 752,000 licensed practical nurses and assistive personnel at all levels of patient care delivery.7 The magnitude of their influence on patient safety, quality, and financial outcomes within the institution is substantial. Registered nurses (RNs) with graduate degrees comprised only 13.2% of all licensed RNs in 2008.8 Within the cohort, 375,794 held master’s degrees (12.2%) and 28,369 were doctorally prepared. Of those with master’s degrees, 77.2% held a master of science in nursing (MSN) (290,084). www.nurseleader.com
Within the total master’s degree–prepared cohort, 19.2% of those RNs had graduate degrees with a focus on administration, business, or management. Data were not available to discern which of these RNs pursued their degrees within schools of nursing or in related disciplines. From these data, it is apparent that there are only 72,000 nurses prepared at the graduate level for leadership and management within the US health system. This system is complex and vast— made up of 5,724 hospitals with just under 37 million admissions per year,9 14,500 home care agencies10 serving 1.5 million patients,11 and 16,100 skilled nursing facilities
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with 1.5 million residents.12 The paucity of well-prepared nurse leaders yields a ratio of 555:1 patients to master’s degree–prepared nurse leader—not a desirable situation given the patient safety, quality, and financial challenges inherent throughout the US health system. Accredited graduate nursing programs offering MS/MSNs in nursing administration, health systems management, or leadership/management are available in both traditional classroom programs as well as online; however, there is some variation in credit hour requirements and curriculum. This article explores the value proposition for graduate education of current and emerging nurse leaders as a key component for leveraging positive changes in patient safety, quality, and financial results within organized healthcare settings, based on data from the Health Systems Management program at Vanderbilt University School of Nursing.
BACKGROUND There is an abundance of literature on leadership education in nursing; however, there is no consensus on the best preparation methods or models.13 This brief review describes some contemporary perspectives on the value of leadership education at the graduate level in nursing and uses the Institute of Medicine report The Future of Nursing as the guiding direction on this issue.14 The Future of Nursing report discusses the need to ensure that nurses are educated to assume leadership roles across the system in order to tackle the challenges ahead in redesigning the facets of healthcare delivery. Specifically, the report states: Strong leadership is critical if the vision of a transformed healthcare system is to be realized.... The nursing profession must produce leaders throughout the healthcare system, from the bedside to the boardroom, who can serve as full partners with other health professionals and be accountable for their own contributions to delivering high-quality care while working collaboratively with leaders from other health professions.14(p. 7,8) Scott and Yoder-Wise15 support this perspective and add the need to educate more nurse leaders beyond the baccalaureate level in order to continue progress in advancing patient safety and quality, as well as promoting innovative models of care delivery. In addition, they present the challenges related to advancing the education of nurses in management and leadership positions as this is often neglected in favor of advancing education of nurses in clinical specialties. Aiken16 illustrates this challenge further with data that demonstrate that without significant shifts upward in nursing education-level standards, the current production of nurses at the associate degree level will preclude the generation of enough nurses to accommodate the numbers of leadership and executive roles that require graduate-level education. The continued complexities of healthcare demand nursing leaders to be prepared with advanced skills in leadership, management, and business competencies through well-designed academic programs in order to successfully influence and lead future directions in nursing.17,18
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PROGRAM DESCRIPTION Vanderbilt School of Nursing opened its nursing administration master’s degree program in 1987. The original curriculum was offered until 1996. As more nurses began assuming leadership roles across a variety of healthcare organizations, the title of the program changed to Health Systems Management (HSM) to reflect the shift in focus as it pertained to the role of the nurse leader. Course content and program requirements were expanded as well to reflect the broader focus on the healthcare industry. Since 1987, 333 nurses have graduated from these programs. Graduates of the nursing administration/HSM program have served/are serving as nurse managers, program directors, chief nursing officers, hospital administrators, uniformed services officers, consultants, nursing faculty, and one graduate was the first nurse to serve as the commissioner of health in her state. The HSM program of study prepares graduates for the advanced role of nursing and healthcare management. This program is designed to prepare nurses at the graduate level to manage the delivery of nursing and healthcare services across the spectrum of healthcare settings. Graduates acquire the breadth of management knowledge and skills to perform effectively and assume leadership positions in healthcare delivery organizations, government, and the broader healthcare industry. As part of this program, students learn to implement processes and programs to achieve continual improvement in care delivery as well as meet financial targets and maintain fiscal accountability; collaborate effectively across disciplines and healthcare settings to enhance integration of services and care delivery; facilitate clear communication of expectations and accountabilities to assigned staff; innovate, implement, and manage change; balance strategic, financial, operational, quality, and interpersonal responsibilities; and participate in research. The curriculum consists of 11 courses of 3 credits each, 1 course of 2 credits, and 1 course of 4 credits, for a total of 39 credits. All courses are offered in an online learning environment. The e-learning format is designed to support flexibility, connection, interaction, and access to state-of-the-art resources and computer support. As part of their learning experience, students are assigned to small groups and participate in a variety of online activities such as discussion boards, blogs, and web-based conference calls. Case studies, based on current and relevant nursing practice, challenge students to critically analyze, evaluate, and develop solutions to issues in nursing and management practice and healthcare. These online learning experiences provide students with the opportunity to interact with one another and share their understanding of the course materials, as well as apply what they have learned to their practice. The program links technology with learning while embracing cultural and academic diversity. The Vanderbilt HSM curriculum includes a variety of topics to prepare emerging nurse leaders to manage the delivery of nursing and healthcare services in multiple settings and specialties. Topics include leadership, financial management, continuous quality improvement, nursing theory, organizational dynamics, health informatics, and healthcare
June 2014
management of populations. The program includes a mixture of didactic work and practice opportunities that enhance the educational experience. In the last semesters of the program, students complete 2 practicum courses. The practicum experience provides students with an opportunity to work closely with a manager or administrator in one of a variety of healthcare settings including nurse-managed clinics, community-based clinics, ambulatory care centers, industry, insurance companies, public sector sites, and hospitals. Students also have the opportunity to observe and practice management and leadership skills in these healthcare environments. In addition, students work on agency-designated projects, and present their process and results to the agency as well as to their peer student group.
APPLIED LEARNING: REAL-WORLD CASES Nurse leaders who seek personal learning through evidence-based health systems management programs add value to their organizations. These leaders are critical in the building of the workforce capability and capacity conducive to high performance by engaging, managing, and developing the workforce to utilize its full potential in aligning the organization’s overall mission, vision, and action plans. They can capitalize on the organization’s core competencies, build the organization’s knowledge assets, and improve the environment for innovations while understanding success in today’s ever-changing, globally competitive environment demands agility.19 Applied or action learning20 is focused on the “real-world” healthcare system, providing the student with the ability to build and sustain relationships with customers/patients; to understand intelligent risk; to innovate and transition to new technology; to develop new products and services; to improve work processes; and to meet changing business, market, and regulatory demands.19 This instructional approach allows both the student and the organization to gain the capability, capacity, and sustainability to experience high performance success. The following applied learning cases provide examples of how graduate HSM students have applied evidence and skills acquired during their academic work in their healthcare agencies and settings. These cases illustrate how the use of applied learning opportunities adds measureable value to the organization. Case One The HSM graduate student performed a cost analysis utilizing a financial model of care for elective coronary artery bypass graft surgery to determine possible opportunities for cost reduction. The results included: 1. Identification of proficiencies around financial and clinical models of care for application across populationbased management systems, specifically coronary artery bypass graft surgeries 2. Comparison of the evidence-based clinical model of care with the financial model to determine opportunities for cost savings in comparative surgeries 3. Total cost savings per patient of $1,249.82. www.nurseleader.com
There were a total of 151 cases performed during the second 6-month time frame for a total costs savings during those 6 months of $188,723.42 and annualized savings of $377,446.84. Case Two A new formal work process and associated report was developed by the HSM graduate student to track RN vacancies and number of positions required to meet budgeted staffing models, and to record and track full-time equivalent (FTE) availability on a weekly basis. Data were tracked that included: 1. Information from the staffing models 2. Current filled and vacant positions from human resource reports 3. Recruiting information on pending new hires 4. Current staff available each week 5. Family Medical Leave Act (FMLA) status 6. Other leave types, staff hired and on orientation 7. The number of FTEs needed each shift Results included a process that could predict the number of staff required for patient care while new staff complete orientation and before new staff are fully available on the time schedule. The new process and the associated report clearly reflect available and nonavailable FTEs that provided managers with a consistent, reliable data tracking tool to make timely staffing decisions that resulted in savings to the organization by reducing variability in staffing levels through the use of predictive modeling. Case Three The HSM graduate student along with a perioperative healthcare team created and implemented a work process to consistently identify the patient’s legal guardian in order to decrease the surgical case delays of the daily first-case start times in pediatric cases. The process improvement outcome resulted in a zero delay in first-case starts over a 4-month tracking period with no loss of revenue as a result of case delay. Case Four The HSM graduate student created a system redesign along with recommendations to reduce the number of low-acuity visits to the emergency department (ED) in a Veteran's Administration hospital. Prior to the implementation of the new process in fiscal year 2011, 6,462 veterans were seen in the ED at an average cost of $441.00 per visit, for a total annual cost of $2,849,742. With the redesigned process, those veterans who were not having a true emergency were seen by the urgent care service. This improvement initiative resulted in reducing the average cost of the visit to $100 per case, generating $2,203,542 in cost reduction at this facility. Case Five A process analysis was conducted by the HSM graduate student to determine the effectiveness of the current use of humidified oxygen for every patient admitted to the postanesthesia care unit. The results of the analysis showed there was no evidence to support the current practice. Using
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change theory and effective leadership skills, the student planned and initiated a change in the process that resulted in a savings of approximately $80,000. Case Six The HSM graduate student developed a comprehensive nurse retention strategy designed to retain nursing talent for a large healthcare organization, improve nursing satisfaction, and leverage a high-performing workforce, ultimately saving onboarding and attrition costs for the organization. Program components included a formalized residency program, externship program, preceptor program, and mentor program, and a process to develop nurse leaders as chief retention officers— onboarding, monitoring, coaching/development, and team building. The overall goal was to reduce attrition numbers by 10% with a stretch goal of 20% by the third quarter of 2014. With an average of 500 nurses in the organization, this translates to 7 to 14 nurses (medical-surgical and critical care) retained, with a projected savings ranging from $361,000 to $732,000 in 1 year. These applied learning cases are evidence of the valueadded results that organizations can expect from students completing graduate education in healthcare leadership and management. Applied learning also allows the student to gain a realistic approximation of what will be encountered in the workplace.21 Through this learning approach, students gain the knowledge to support the organization’s mission, vision, and strategic plans, leading to a more sustainable, successful, high-performing organization.
CONCLUSION There is a compelling need for more sophisticated nursing management and leadership to respond to the clinical, organizational, and fiscal challenges faced by the healthcare industry to address the future of healthcare. As Heller et al.22 wrote in “The Future of Nursing Education”: Nurse managers and executives require clinical experience and strong communication skills, as well as business acumen and knowledge of financial and personnel management, organizational theory, and negotiation. With the nursing labor budget constituting a significant proportion of total spending, and cost overruns in acute care hospitals, long-term care facilities, and home care agencies, nursing management is too often found to be lacking in fundamental decision science and fiscal knowledge. A great need exists for educational support for experienced nurses to be developed into nurse executives, prepared to work competently alongside their business colleagues. Nursing schools are called on to expand their core and continuing education programs to address these needs.22 Through the application of powerful and effective teaching strategies, employers reap the benefits from their nurse leaders and emerging leaders pursuing graduate education in healthcare leadership and management. These real-world projects provide the learner with the opportunity to focus on why and how to apply a skill or concept while effecting real, sustainable, and positive change in their work settings,
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and builds the nurse leader’s problem-solving skills. Applied learning also provides a team-building opportunity for the learner that is an essential competency in healthcare. Healthcare educators and providers face a rapidly changing healthcare landscape, shifting student and patient demographics, an explosion of technology, and the globalization of healthcare, in addition to a myriad of challenges in everyday operations. As institutional leaders position their organizations to meet today’s challenges and tomorrow’s, it is imperative that healthcare educators and healthcare organizations focus their resources on the development of competent nurse leaders in order to meet those challenges. NL References 1. Baum S, Ma J. Education Pays: The Benefits of Higher Education for Individuals and Society. Washington, DC: College Board; 2007. 2. Gouskova E, Strafford F. Trends in Household Wealth Dynamics, 2001-2003. Ann Arbor, MI: Institute for Social Research, University of Michigan; 2005. 3. Bureau of Labor Statistics. Labor Force Statistics From the Current Population Survey. US Department of Labor. http://www.bls.gov/cps/earnings. htm#education. Accessed September 2, 2013. 4. Kaiser Family Foundation. The Uninsured: A Primer—Key Facts about Health Insurance on the Eve of Coverage Expansions. October 2013. http://www.kaiseredu.org/issue-modules/the-uninsured/backgroundbrief.aspx?p⫽1. Accessed September 2, 2013. 5. Muenning P. Health returns to education interventions, executive summary. Paper presented at: the 2005 Symposium on the Social Costs of Inadequate Education; October 24, 2005; New York, NY. http://www.tc.columbia.edu/ centers/EquitySymposium/symposium/resourceDetails.asp?PresId⫽5. Accessed September 2, 2013. 6. Wong M, Shapiro M, Boscardin W, Ettner S. Contribution of major diseases to disparities in mortality. N Engl J Med. 2002;347:1565-1592. 7. Bureau of Labor Statistics. Licensed Practical and Licensed Vocational Nurses. In: Occupational Outlook Handbook, 2012-13 Edition. Washington, DC: US Department of Labor. http://www.bls.gov/ooh/healthcare/licensedpractical-and-licensed-vocational-nurses.htm. Accessed September 2, 2013. 8. Health Resources and Services Administration, US Department of Health and Human Services. Findings From the 2008 National Sample of Registered Nurses. Washington, DC: HRSA; 2010. 9. American Hospital Association. Fast Facts on US Hospitals. http://www.aha.org/ research/rc/stat-studies/fast-facts.shtml. Accessed September 13, 2013. 10. Caffrey C, Sengupta M, Moss A, Harris-Kojetin L, Valverde R. Home Healthcare and Discharged Hospice Care Patients: United States, 2000 and 2007. National Health Statistics Reports: No 38. Hyattsville, MD: National Center for Health Statistics; 2011. 11. Jones AL, Dwyer LL, Bercovitz AR, Strahan GW. The National Nursing Home Survey: 2004 overview. National Center for Health Statistics. Vital Health Stat. 2009;13:1-155. 12. Centers for Disease Control and Prevention. FastStats: Nursing Home Care. http://www.cdc.gov/nchs/fastats/nursingh.htm. Accessed September 13, 2013. 13. Androwich IM, Watson CA, Belcher JVR, et al. Graduate practicums in nursing administration programs: current approaches and recommendations. J Nurs Adm. 2012;42:454-457. 14. Institute of Medicine. The Future Of Nursing: Leading Change, Advancing Health. Washington, DC: National Academies Press; 2010. http://www.iom.edu/ Reports/2010/The-future-of-nursing-leading-change-advancing-health.aspx. Accessed May 29, 2013. 15. Scott ES, Yoder-Wise PS. Increasing the intensity of nursing leadership. J Nurs Adm. 2013;42:1-3. 16. Aiken LH. Nurses for the future. N Engl J Med. 2011;364:196-198. 17. Kleinman CS. Leadership roles, competencies and education: how prepared are our nurse managers? J Nurs Adm. 2003;33:451-455. 18. Aduddell KA, Dorman GE. The development of the next generation of nurse leaders. J Nurs Educ. 2010;49:168-171. 19. Baldrige Performance Excellence Program. 2013-2014 Health Care Criteria for Performance Excellence. Gaithersburg, MD: U.S. Department of Commerce, National Institute of Standards and Technology. http://www.nist.gov/baldrige. . Accessed August 30, 2013. 20. McGill I, Beaty L. Action Learning: A Guide for Professional, Management and Educational Development. 2nd ed. London, UK: Kogan Page; 1995.
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21. Bechert U, Cronk BC. Applied learning at the graduate level—professional science master’s programs lead the way. J Appl Learn High Educ. 2012;4:23-33. http://www.missouriwestern.edu/appliedlearning/ volume3.asp. Accessed September 1, 2013. 22. Heller BR, Oros MT, Durney-Crowley J. The Future of Nursing Education: Ten Trends to Watch. National League of Nurses website. http://www.nln.org/ nlnjournal/infotrends.htm. 2013. Accessed September 2, 2013.
Bonnie Pilon, PhD, RN-BC, FAAN, is a professor and senior associate dean at Vanderbilt University School of Nursing in Nashville,Tennessee. She can be reached at [email protected]. Terri D. Crutcher, DNP, is a an assistant professor at Vanderbilt University School of Nursing in Nashville,Tennessee. Susie Leming-Lee, DNP, is a
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an assistant professor at Vanderbilt University School of Nursing in Nashville,Tennessee. Richard Watters, PhD, is a an associate professor at Vanderbilt University School of Nursing in Nashville,Tennessee. Kelly A.Wolgast, DNP, FACHE, is an assistant professor at Vanderbilt University School of Nursing in Nashville,Tennessee. Debra Arnow, DNP, RN, NE-BC, is a chief nursing officer at Omaha Children’s Hospital & Medical Center in Omaha, Nebraska. 1541-4612/2014 Copyright 2014 by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.mnl.2013.11.004
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