The growth and development of gerontological nurse leaders in policy

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The growth and development of gerontological nurse leaders in policy G. Adriana Perez, PhD, RN, CRNP, ANP-BC, FAANa,*, Diana J. Mason, PhD, RN, FAANb, J. Taylor Harden, PhD, RN, FAANc, Tara A. Cortes, PhD, RN, FAANd a Leonard Davis Institute of Health Economics, University of Pennsylvania School of Nursing, Philadelphia, PA Center for Health Policy and Media Engagement, George Washington University School of Nursing, Washington, DC c National Hartford Center of Gerontological Nursing Excellence, University of Maryland Baltimore School of Nursing, Baltimore, MD d Hartford Institute for Geriatric Nursing, New York University Rory Meyers College of Nursing, New York, NY b

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abstract

Article history: Received 27 July 2017 Revised 11 October 2017 Accepted 19 October 2017

Background: The National Hartford Center of Gerontological Nursing Excellence (NHCGNE) Scholars/Fellows Award Program was designed to promote the growth and development of nurse scientists, educators, and leaders in aging. Purpose: McBride’s conceptual framework of the growth and development of nurse leaders was used to examine the NHCGNE impact on health and aging policy work among scholars/fellows, including barriers, facilitators, and resources. Methods: A multimethod two-phased approach included an online survey (phase I) focused on research and policy impact at local, state, or national level. Telephone interviews (phase II) were conducted to further understand the nature, depth, and focus of respondents’ policy work. Discussion: Based on our findings, we propose multilevel recommendations for advancing nurse scientists’ capacity to be leaders in shaping policy. Conclusion: Keen research skills are influential in policy advancement but not sufficient to advance policy. Preparing nurse scientists with competencies in translating research into policy can ultimately transform health and health care for older adults.

Keywords: Gerontological nursing Leadership Health policy Nursing academia Geriatric nursing workforce National Hartford Center Gerontological Nursing Excellence

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Cite this article: Perez, G. A., Mason, D. J., Harden, J. T., & Cortes, T. A. (2017, -). The growth and development of gerontological nurse leaders in policy. Nursing Outlook, -(-), 1-12. https://doi.org/ 10.1016/j.outlook.2017.10.005.

Introduction The report by the Institute of Medicine (2011), The Future of Nursing: Leading Change, Advancing Health, calls for nurses to be leaders and partners in redesigning health care and shaping health policy: To be effective in reconceptualized roles, nurses must see policy as something they can shape rather than

something that happens to them. Nurses should have a voice in health policy decision making and be engaged in Implementation efforts related to health care reform (p. 8). In addition, Nursing’s Social Policy Statement (American Nurses Association, 2010) posits that nurses have an essential role in advancing the public’s health through health policy. But is that something that nurses are prepared to do and are doing, particularly those who are leaders and experts in their fields?

* Corresponding author: G. Adriana Perez, Department of Family and Community Health, University of Pennsylvania School of Nursing, Claire M. Fagin Hall, 418 Curie Boulevard, Philadelphia, PA 19104-4217. E-mail address: [email protected] (G.A. Perez). 0029-6554/$ - see front matter Ó 2017 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.outlook.2017.10.005

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In 2000, the American Academy of Nursing (academy) received a grant from the John A. Hartford Foundation to strengthen the capacity of schools of nursing to build experts in care of older adults as researchers, educators, and leaders (Franklin et al., 2011). The initiative was known as BAGNC, or Building Academic Geriatric Nursing Capacity, and it funded predoctoral scholars and postdoctoral fellows to develop their leadership and research knowledge and skills. In 2011, the program moved to the Gerontological Society of America (GSA) as the National Hartford Center of Gerontological Nursing Excellence (NHCGNE) and was housed at New York University Rory Meyers College of Nursing for 1 year while becoming a freestanding nonprofit organization now incorporated in Washington, DC, 2017. The academy and NHCGNE partnered to examine whether and how these leaders in gerontological nursing were influencing health policy, although policy had not been an explicit part of the initial program. This article reports on the findings of our multimethod study and makes recommendations for future directions to develop nurses as leaders in health policy.

Background The current mission of the NHCGNE is to enhance and sustain the capacity and competence of all nurses to provide quality care to older adults by supporting faculty development, advancing gerontological nursing science, facilitating adoption of best practices, fostering leadership, and designing and shaping policy. The history of the NHCGNE spans nearly two decades and is closely aligned with the mission of the John A. Hartford Foundation to improve the health of older Americans. The NHCGNE, an international association of schools of nursing and like-minded organizations, is an example of the foundation’s substantive investment in health and its transformative grant making to prepare the nursing workforce to be competent to care for our aging society and world (Harden & Watman, 2015). The critical objectives of the NHCGNE are to: a. Prepare new faculty to provide academic leadership in gerontological nursing for associate and higher degree nursing programs nationally to address the dynamic and changing needs of the older adults of the future; b. Enhance the gerontological nursing expertise of current faculty at associate and higher degree nursing programs nationally; and c. Leverage funding to support activities of the NHCGNE and promote long-term sustainability. The NHCGNE Scholars/Fellows Training Award Program (Harden & Watman, 2015) officially concluded in December 2016 and the collective 15 cohorts spanning 2001 to 2015 and across 50 well-established

research-aligned schools of nursing are now known as NHCGNE Legacy Affiliates (http://www.nhcgne.org/ development). To date, there are 249 Legacy Affiliates that have received more than 280 predoctoral/postdoctoral training awards for specialization in gerontology. Some of the predoctoral NHCGNE scholars went on to become postdoctoral NHCGNE fellows. In 2016, 87% of scholars and fellows who completed an annual NHCGNE evaluation survey are now working in academic appointments, with 24% in non-tenure-track positions, 33% in tenure-track positions, and 30% already with tenure. Collectively, during and after their NHCGNE award programs, the Legacy Affiliates obtained $281,794,133 in funding from a total of 955 research grants for studies with specific relevance to the care of older adults. Methodological approaches represented among the studies included quantitative, qualitative, and mixed methods as well as pilot testing of clinical interventions. Most of the studies arose from the researchers’ interests in changing practice or policy.

Conceptual Framework For this study, we used the conceptual framework of The Growth and Development of Nurse Leaders by McBride (2011) (Figure 1). This framework is driven by the tenets of developmental psychology (Dalton, Thompson, & Price, 1977) and addresses three major views: leadership as personal, leadership as achieving organizational goals, and leadership as transformational. The framework focuses on career stage and mentoring needs as well as developmental tasks by career trajectory. The framework is inclusive of personal qualities of leaders, including strengths, limitations, and stages of a career. Building on the foundation of formal education, socialization, and the assimilation of values, beliefs, and knowledge, the second major view focuses on essential skill sets in achieving organizational effectiveness, including expectations, processes, and directions, which takes into account communication effectiveness and development of people, programs, and resources. The framework comes to completion with an emphasis on strategic vision and excellence as a change strategy. For the purpose of this article, the authors focus on leadership as personal inclusive of preparation and independent contributions.

Purpose and Aims The purpose of this research is to explore the impact of the NHCGNE scholarship program on the experiences of funded scholars and fellows in health and aging policy. Our goals were to determine the impact of the program on the scholarship and policy outcomes of the NHCGNE scholars and fellows in gerontological nursing and to examine the barriers, facilitators, and resources for engaging in policy work that impacts the health of older adults.

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Stage

Central Developmental Task

Means

Role of Mentor

Preparation

Learning – assimilating values, knowledge base, clinical/inquiry skills of chosen specialty

Analysis of strengths and limitations Formal education Socialization experiences Certification

Independent Contributions

Moving from novice to competence – Demonstrating ability to work independently and interdependently in chosen area of practice, [research, education and/or policy].

Development of “Home” Setting

Moving from competence to expertise – assuming responsibility for development of others and the setting

Development of Field/Health Policy

Shaping profession and health care – Exercising power of authority; creating a vision for the future

The Gadfly Period aka Expert

Continuing to shape profession and health care; no longer constrained by institutional obligations

Build collegial network Deal with gap b/t ideals learned and realities of work setting Demonstrate the ability to think, synthesize and act critically Mentor less experienced and less educated. Engage in strategic planning Develop tolerance for ambiguity and political savvy Build home setting’s image, infrastructure, and resources Mentor in more complex aspects of role Consult in area of expertise Serve as advisor to local, regional, national and/or international efforts and organizations Coach current generation of leaders Take on special projects that require highlevel integrative abilities Articulate strong positions that might not have been possible when constrained by institutional affiliation

Model values and practices Encourage problem-solving skills Help set career goals Guide to experiences that build skills and expand vision Help navigate inner workings of institution and profession Open doors of opportunity Direct to resources Facilitate networking Keep focus on meeting professional benchmarks of success Share successes, failures and tips Provide feedback regarding strategy Teach how to delegate Develop mentoring abilities Nominate for awards Discuss strategy and likely future scenarios Recommend for opportunities Sponsor for honors Assist in envisioning postretirement prospects Recommend for opportunities

Figure 1 e The growth and development of nurse leaders: career stages and mentoring needs.

Methodology This study was approved by the Institutional Review Board of the University of Pennsylvania and includes a mixed-methods two-phased approach. Phase 1 included an online survey of all scholars and fellows as part of an annual online survey that the NHCGNE sends to alumni via e-mail. The survey included open-ended questions about the following:
their achievements or impact of their research;
enduring changes to practice or policy related to their award;
identification and description of a public and/or private policy change that the person made at the local, state, or national level and outcomes to date;
the factors that served as barriers or challenges to their policy work;
the factors that facilitated their policy work; and
additional training or experiences in the program that would have helped them in their policy work. Phase 2 included telephone interviews using purposive sampling among respondents who had conducted policy work, either local, state, regional, or national, and would be willing to participate to elaborate on their responses (Bernard, 2002). A total of 16 respondents were invited to be interviewed who varied on the nature, depth, and focus of their policy work. The research team conducted the first interview together to ensure consensus on the approach to conducting the interviews and enhance the credibility and

trustworthiness of data (Elo et al., 2014). The remaining interviews were conducted by one assigned research team member. Interviews were recorded and transcribed. The semistructured interviews used the questions listed in Box 1.

Sample The annual online survey was e-mailed to 246 surviving scholars and fellows (note that some respondents were both a scholar and, subsequently, a fellow). For phase 1 analysis, 155 surveys were completed, reflecting a 63% response rate, although not all respondents provided information for each question. From this sample, 16 were selected for phase 2 telephone interviews. Participants in the interviews received an e-mail invitation with the study description, emphasizing the voluntary nature of participation. From these, 12 agreed to participate and completed a consent form; three did not respond and one declined, reflecting a 75% response and participation rate. The final interview sample included geographically diverse alumni scholars and fellows currently working in academia, from assistant to full professor rank.

Data Analysis Phase 1 data were transferred into a spreadsheet. Each member of the team was assigned one or two questions to analyze. A descriptive content analysis approach was used to gain a deeper understanding of the scholar/fellow experiences with health and aging policy, as a result of the NHCGNE scholarship program

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QUESTIONS USED IN PHASE 2 TELEPHONE INTERVIEWS a. We are interested in how the NHCGNE experience influenced your engagement in policy work related to the health or health care of older adults. Describe the link between your NHCGNE experience and the policy work that you subsequently did. b. Describe the policy work itself. What was the problem you were trying to address, what was the policy option you put forth or supported, and what did your engagement in this policy work entail? c. What were the greatest challenges that you confronted in doing this work? And how could subsequent NHCGNE experiences help new scholars/fellows to address these challenges?

research, acquiring grants, being published, developing a reputation as an expert, being at important decision-making tables, and influencing policy. These responses emphasize the research component of the NHCGNE scholars/fellows programs. In some cases, respondents reported that the program influenced their approach to and skill in conducting the research; as one noted, “My award allowed me to be the PI on interprofessional research study before ‘interprofessional’ was popular.” For others, the program provided them with the financial support for conducting pilot work that would lead to private or federal grants. In phase 1 of the study, only 25% (n ¼ 38) of the respondents said that they had helped to lead public and/ or private policy changes on a local (18%), state (53%), and/or national or international (29%) level, ranging from policy work in a small nursing home chain to work with Centers for Medicare and Medicaid on matters that impact dual-eligible seniors.

Enduring Policy Changes d. Share your three most important lessons learned from your policy work. e. Did the NHCGNE experience change your professional networks in ways that advanced your policy work? If so, in what ways? f. What recommendations do you have for helping new and prior scholars/fellows to enhance their influence on local, state, or national public and private policy?

(Sandelowski, 1993, 2000). The analysis entailed coding responses to a question, counting the coded responses, and deriving key themes that emerged from the responses to each question. These analyses were then validated by another member of the research team. For phase 2, transcribed interviews were first reviewed individually by each research team member. The team then discussed each interview. Common themes across interviews and quotes that exemplified these themes were identified by the team through consensus.

Findings The following themes arose from the analysis of phase 1 and phase 2 data. Where applicable, more detail from the survey is included.

Achievements Related to Award Activities Figure 1 provides data from the online survey on what respondents said was evidence of the impact of the award activities. The interviews confirmed the primary achievements as being advancing their program of

In response to a question asking participants to identify “any enduring changes to practice or policy related to their award or research activities,” 26 (16.8%) of the 155 respondents said that it was too early in their careers to determine enduring changes. The survey asked respondents to identify a specific example of the policy changes they influenced. The question did not specify that the policy work be related to their research. Most respondents did not provide an example. One respondent said he or she was too tired to do policy work, and the other said that he or she needed more help on policy. Thirty-six (23%) of the 155 respondents identified an example. Five of these were on nursing scope of practice at the state level working with The Future of Nursing: Campaign for Action state action coalitions; five addressed issues at the national level through influencing practice standards such as being involved with the Choosing Wisely campaign of the academy; nine reported working at local level on issues in their communities or their workplaces; and seven reported being engaged in advocacy activities, such as writing to legislators, authoring a letter to the editor, or working on a policy committee to promote 24-hr registered nurse care in nursing homes. For those who were involved in shaping policy related to their research, 12 respondents did so in relation to policies that had an impact on clinical practice, such as pressure ulcers, glycemic management, pulse oximetry monitoring, reducing urinary tract infections, reducing readmissions, dementia, active surveillance in men with prostate cancer, screening for pain, and using mobile technology in the home setting for older adults with cognitive impairment. Only two said that they had influenced policy at the federal level (e.g., The Joint Commission’s guidelines for home care); two at the state level (e.g., adult protective services); two in academia (e.g., developing

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undergraduate and graduate level education focused on aging and disability); and three at the international level (e.g., recommendations to the World Health Organization on global initiatives to develop innovative approaches for dementia care and prevention). Others identified health systems, in general, and the environment (e.g., aging in place and care coordination, environmental policies that promote healthy aging). Eleven said that they had engaged with a variety of organizations concerned with aging and health, such as the GSA, the academy, the Centers for Disease Control and Prevention, and the National Council on Aging. Some of this involvement occurred while they served in leadership positions.

Importance of the NHCGNE Experience Several themes arose from both the survey and interviews about the importance of the NHCGNE experience to their careers and work.

Moving Leadership to Another Level The experience enabled scholars and fellows to hone their leadership skills. Repeatedly, respondents reported that just being selected to be a scholar or fellow seemed to validate that they were worthy of this special opportunity and strengthened their selfconfidence. Those who started as scholars and later became fellows experienced exponential growth, supporting the idea that these kinds of experiences may be important for nurses who are beyond a novice or competent leadership level. As one respondent noted: . it gave me some added confidence about who I was as a doctoral student in that I wasn’t just a lowly person on the academic ladder; that I had someone standing behind me, some big group believed in me. It gave me confidence to make some local contacts and reach out to [local health-related organization with whom the respondent had not had prior contact] . I called up their executive director and introduced myself and being able to say you know, I’m a John A. Hartford Foundation scholar and I’m interested in researching [topic of her dissertation]. It just opens doors. It helps, you know. Maybe they would’ve greeted me with open arms anyway, but I don’t know if I would’ve had the confidence to call them if I hadn’t had that wind behind my sails pushing me forward. The experience also empowered participants to enter new circles with support and feedback from their mentors, who were nationally recognized gerontological researchers: Recently I attended a research-focused discussion seminar hosted by the Center for Innovative Care on Aging. After the presentations, there was an open discussion that focused on translational science. I

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enjoyed participating in that discussion and later my mentors both independently commented to me that my contributions were valuable and reflected significant growth. I reflected on their comments afterwards and it has become very clear to me how many opportunities the Award has provided to me that have facilitated that growth. Having the opportunity to interact with so many people who are passionate, committed, and dedicated to excellence in their fields has helped me to internalize many of those same attributes. Areas of knowledge that just two years ago were completely new to me are now areas that I find most invigorating and where I would like to focus my work going forward. The leadership component of the program included the importance of networking. The annual conferences and mentoring provided opportunities for the fellows and scholars to connect with leaders in their specific area of focus. In some cases, the connections and learnings have endured that, “I feel that the leadership activities were most valuable as well as the chance to be part of a team who are change agents locally and nationally. Because of those connections, I am sitting on the policy committees for two national organizations and doors have been opened for me to work with leadership teams at multiple levels.” Another respondent noted that, “Award has ensured productivity as a productive scholar. Also, having opportunities to meet outstanding researchers and leaders in gerontology nursing at conferences including GSA is very inspiring and valuable!!” The program also helped participants to be more deliberate on their path to being the next generation of national experts and leaders in their fields. Several respondents spoke of the importance of their assigned mentor, noting that, “Being mentored by [name of assigned mentor] was life changing and something I will be forever grateful for. I hope to pay it forward.” Another said, “Experience with a NHCGNE inspired me to initiate a geriatric interest group with other faculty at my next faculty position with the idea to eventually be able to qualify as a center.” Another respondent summed how the NHCGNE experience built her confidence to up this way: “As you develop this expertise in a certain area, you find yourself getting drawn into and seeking out, but also being asked to join things like taskforces and to weigh in with opinions here and there. It’s in many ways just a natural progression whether you seek it or not. You’re going to get drawn into these discussions that have ended up in more policy changes.”

Mentors are Key Mentorship emerged as perhaps the singular most influential element in the respondents’ descriptions of factors impacting their careers. There appeared to be two kinds of mentorship. A mentorship frequently mentioned by scholars was one that helped them to frame and refine their research to expand the science

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in their specific field. One respondent said that, “That skill of learning how to interact with other scientists .. you have more research expertise, you have more to say, you begin to participate.” This mentorship provided them with confidence as a scientist and with a network of other scientists in their field. And yet, one respondent stated that, “We have research mentors that help us walk through the process . I gained a tremendous amount . They do not do policy work. I think if I had a policy person that would have been useful.” This was reinforced for respondents who had the second type of mentordone who had experience in research and in moving a field of research into policy formulation. This mentorship provided the scholars with an understanding of how science could be brought to the table to inform legislators and policymakers. There was also a perception that although they were trained as nurse scientists, there were mechanisms through which they could influence others to move their work forward into policy arenas. As one respondent noted that, “I see myself as a nurse scientist . I hope my work informs policy through the advisory council I sit on.” One respondent sent published articles to a local congressman and made visits to legislators’ offices. Another said that, “. the thinking is that your research is either policy focused or disease focused. I learned from my mentor that it should be hybridddo you improve function and decrease (healthcare resources) utilization?” One respondent who had a mentor who has moved her own research into national policy stated as her important lesson learned, “Your research should influence policy . policy influences research .. there is a line between the two that you must carefully negotiate.” One respondent summed up the connection between research and policy this way: “You have to see your work through to that end. If you don’t get it out into policy you’re not going to really change practice. That’s got to go hand in hand with the publishing and all that stuff. You have to think about the policy implications. At some point you have to get at those changes, too.” The mentors opened the doors, helped to focus the scholar’s/fellow’s work, enabled the scholar/fellow to deepen their knowledge of research, affirmed that the scholar’s/fellow’s work was the right work to be doing, helped to refine scholar/fellow goals and objectives for their work, guided the scholar/fellow in critical thinking about next steps, and helped them to make the connection between research and policy. This last benefit occurred mostly when the mentor was a researcher who was engaged in policy at a national level or a state level.

Expanding Networks in Meaningful Ways Whether through their mentor opening doors for them or meeting national leaders at the annual leadership conference, respondents consistently reported on being able to expand their networks to the gerontological world; and some were able to connect in meaningful

ways with stakeholders in the policy world at the local, state, and national levels. Others highlighted the importance of expanding their involvement in professional associations (gerontological and nursing) and coalitions in ways that helped to make visible their special expertise and to shape policy. “It is 100 percent, maybe 99.8 percent because of the Hartford experience that I have the networks that I have,” said one respondent.

The Uncertain Link Between Science and Policy The NHCGNE experience gave respondents the release time and research funding they needed to complete a dissertation or postdoctoral research; as one respondent noted that: “I can’t separate out Hartford from my PhD. They feel all like they’re one.” It also helped scholars and fellows to align their research with other research and policy interests, particularly when the value of their research focus was not initially obvious to others. This seemed to be particularly so for those doing research on long-term care. However, none of the respondents saw their work as policy work. Rather, they saw their work as science; and some understood that science is important to developing sound policies. For one respondent, “the leadership conference provided me both with inspiration and practical tools for engaging in policy work . just being around national leaders in nursing that were engaged in policy work was inspiring and encouraged me to think that this was something that I could potentially be involved in as well.” Some respondents were involved in policy work before the NHCGNE experience, particularly through professional associations; and they stood out as both being engaged in policy work and understanding the importance of nurse leaders, including researchers, participating in shaping policy at local, state, and national levels. As one respondent reported: You should conduct research that has an eye to policy. That’s the major lesson is that at the end of the day that your research should be conducted in order to influence policy. On the other hand, understandingdand then second, understand that policy influences your research. Then the third is, which I’m not sure that I completely understand, but that there is a line between the two that you must carefully negotiate. Overall, the NHCGNE experience, including the annual conference, was described as transformative. As one respondent put it: The leadership conference provided me both with inspiration and practical tools for engaging in policy work. That was always a pretty strong emphasis of the leadership conference. Both the content and then simply, honestly just being around national leaders in nursing that were engaged in policy work was inspiring and encouraged me to think that this was something that I could potentially be involved

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in as well. Critically, the fellowship provided me with time to engage work that I think otherwise it would be very difficult to carve out of a busy new junior faculty workload. For another respondent, the NHCGNE experience provided “. an amazing, amazing change for me all the way around, both in my vision of who I am, as well as in what I can do now. The door is unlocked for many things for me and it would not have happened, truly, without the John A. Hartford Foundation, but also without the PhD. The thinking piece really changed because of that.” One respondent summed up her NHCGNE experience this way: I developed the overall confidence experience for someone in my circumstance to meet leaders in gerontological nursing who have made an impact on practice, the care of older adults through policy, while at the leadership conferences changed my trajectory. The Hartford experience created the conditions for me to excel and the program helped me to take myself more seriously.

Barriers to Focusing on Policy Respondents to the survey and the interviews identified a number of barriers that were synthesized into four themes.

Priorities and Time A common statement by respondents was that they did not have time to do policy work. Many (87%) of the respondents are faculty in college or university schools of nursing at the assistant or associate professor level. At research-intensive universities, research is the priority. Tenure and promotion are based on external research funding and data-based publications in highimpact journals. Policy work is seen as what a professor does once tenured with a substantial research track record. As one respondent noted:

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busy just trying to hold their head above water with all their responsibilities, and the meetings, and trying to get their head around the courses that they’re teaching. That they don’t foresee the impact.” Some of the respondents work in schools where teaching is the priority. Again, policy work was not seen as a priority and may not count for tenure and promotion. Policy work is not part of their position description. As junior faculty in either setting, the scholars are often unable to spend more time on policy if they want some semblance of a personal life outside the academia. For most, there is simply not enough time for policy work when it is not a priority within the employing institution. Several respondents noted that policy work takes time, including traveling to policymakers, and they could not afford to devote this time when it would not count toward their promotion and tenure. Thus, some respondents saw policy work as a future focus: “.the way I decided to look at it is . get your research, get your credibility, and then it’s at the associate level that you can start to put into action the skillset that I learned as a Hartford scholar.” But even for more experienced respondents, doing policy work is a time management challenge: “I’m mid-career faculty now, and I haven’t been able to figure out how can I get the time to do this? How do I fit this into my day so I have a life outside of my job? I think thatdthat’s where I’m stuck right now is how do I do this?”

Lack of Support for Policy Work The failure of academia and health care organizations to value policy work meant that there were few institutional supports for this work, unlike the supports that are available for teaching and research. This issue seemed consistent among several respondents, despite the exceptional policy implications of their research. Others pointed out that opportunities for external funding of policy work are limited, making it difficult to demonstrate the external funding expectations of some universities or to underwrite clinical/administrative time to shape health policy.

Lack of Knowledge, Skills, and Mentors in Policy One thing [my dean] explained to us is that your first years, as you’re an assistant professor, it’s about demonstrating productivity. Then as an associate professor is where you demonstrate impact. The sense that I have is that these years as an assistant professor, you really have to demonstrate that these are the focus years. Then where, then, you can start impacting policy is after you are promoted to associate professor. The issue . is that we were getting the influence from the [NHCGNE] to focus on policy and yet our institutions were saying, “No, no, you have to get the research dollars and publish, and then later you can focus on policy.” Another respondent said, “I think that we don’t make the connection between policy and what we do day-to-day. Oftentimes that’s lost in a new faculty member. They’re so

A number of respondents noted that “The policy world is incredibly complex, and it’s complex in a way that my academic training didn’t prepare me for.” Many simply did not know enough about policy and politics to be engaged in policy work and feel comfortable in policy arenas. Those who attended the NHCGNE-sponsored Health Policy Institute were more confident in their policy knowledge and skills and recommended that others have this same opportunity. Participation in this institute is through a competitive process, and it was not available to all scholars and fellows. As noted earlier, a mentor with deep policy experience was a tremendous support in learning about not only how to do policy work but also its importance. Still others noted that a lack of mentors in policy was a significant challenge to learning about how to influence policy through their research.

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Challenges of the Political Environment Some respondents reported that policy work is time consuming, and its dynamic nature requires rapid responses although changing policy is often a long-term endeavor. As one respondent said, “it can also be a very long process, which often makes one feel discouraged.” Several respondents noted that their local or state legislature was dysfunctional, making policy work discouraging and difficult. In some cases, the distance of the respondent to the state capitol and being unfamiliar with a new community’s political players and context were barriers.

great experience that was for them, because we gave them the tools .”

Specialty Expertise

Facilitators to Focusing on Policy

Several respondents noted that their specialty expertise and program of research brought them to policy tables in which they otherwise may not have participated. “I’ve been generating data in a focused way on a particular problem, using methods that you could say it’s taken me almost three years as junior faculty to begin to become recognized and invited to participate in settings where more policy or practice guidelines are debated and decided . I would not possibly have begun to see these immerging opportunities if I hadn’t been establishing myself well as a credible authority in my research area.”

There were six major facilitators for doing policy work:

Having Mentors

Working With Others A number of respondents identified the importance of professional organizations, other nurse advocates, non-nurse advocates, and stakeholders (including community stakeholders involved in advocacy work), and mentors as significant facilitators. NHCGNE alumni were singled out as particularly helpful and supportive.

As noted earlier, mentors in policy were viewed as crucial to respondents in seeing the policy relevance of their research and learning how to use their research to shape policy. Those who did not have a mentor with policy experience understood the benefit: “The NHCGNE Conference was wonderful, but I think [policy] needs to be introduced regularly and reinforced. You almost need a mentor. At least I feel I need a mentor on how to be an active contributor to informing policy.”

Training The NHCGNE program was viewed, particularly by more recent participants, as helpful in making the link between research and policy. Again, the GSA Hartford Policy Institute was viewed as a very valuable experience for both didactic and hands-on learning. Others identified the Robert Wood Johnson Foundation programs (health policy, nurse executive fellows, and nurse faculty scholars), as well as the Health and Aging Policy Fellowship (HAPF) in Washington, DC.

University/Organizational Support Although the respondents’ employing organizations were identified as barriers to policy work, many respondents noted that support from these organizations could be a facilitator.

Prior Experiences and Interest A number of respondents described policy work that was seemingly unrelated to their NHCGNE research focus. Some were involved in policy work in their communities or state or national nursing organizations, including the Future of Nursing: Campaign for Action state action coalitions. Others had been teaching policy, which reinforced their interest, knowledge, and commitment to policy work. “Early on when I did a policy course, I actually encouraged the students to reach out to our local legislatures . They had to write a Policy Brief. They had to have their Elevator Speech ready. Go and talk to those legislatures. Shocking, shocking, at how enthusiastic they were when they came back [laughter]. I never expected that to be such a hit. It was a simple thing, you know, 57 students went out in groups and talked to their legislatures . What a

Lessons Learned Those we interviewed identified the following lessons that they believe they had learned about policy work as a scholar or a fellow: a. Be confident about your expertise and potential contributions; it is essential. b. Find common ground, focusing on communications and negotiation, particularly because, as one respondent said, “policy is a negotiation.” Where do you and your work fit in or align with others? Where is the link between the research and policy? c. Be cognizant of what is happening around you. This may be in your field, the world, your community, or other arena. d. Work at the local level where you may be most likely to see an impact but connect your work to national efforts. “I think globally but act locally,” said one respondent. e. Move from a focus on your independent contributions to making a difference in the field through partnerships and collaborations. f. The squeaky wheel gets greased, so be persistent and prepared. “Be in the room and ready to seize the moment.” g. Go to scientific meetings and engage there to build collegial networks. h. Know funding sources and how to get grants. i. Be willing to serve as “the deputy instead of the sheriff” for a while to learn from others, build your experience, and establish your reputation.

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Recommendations Respondents identified the following recommendations for better preparing scholars and fellows for policy work: a. Increase the focus on policy at the regular NHCGNE conference; consider an additional day to the conference that would focus on building policy skills and possibly developing a policy internship. b. Develop advanced opportunities for learning about policy and encourage people to take advantage of it. For example, make the interprofessional GSA Hartford Policy Institute an option for more people and include follow-up experiences. These opportunities should incorporate more hands-on experiences, such as a workshop format and face time with policymakers and exposure to RNs with policy experience. Another example is providing a course in policy analysis and strategy, including how to engage the community in moving a policy forward; how to connect with local, state, and national policymakers and stakeholders; developing organizational policy briefs; and serving on boards of policy-relevant organizations. c. Provide exposure to others in geriatrics who have been influential in shaping policy, including those serving as mentors and policymakers. These should not just be nurses. d. Foster skill development in communicating, public speaking, and messaging in relation to policy and policymakers. e. Focus more on making explicit the link between research and policy, including how to find time for policy at a research-intensive university.

Discussion The NHCGNE program was begun in 2000 as a way to build a cadre of nurse researchers who would be leaders in transforming the care of older adults. The journey of preparation, proficiency and excellence involves many stages and central developmental tasks. As it evolved, the program of annual conferences and selection of mentors increasingly included a focus on policy, particularly in recent years. The purpose of our study was to determine whether a research-focused program to develop nurse leaders in geriatrics and gerontology also shaped the participants’ understanding of the link between research and policy and between leadership and policy. This multimethod study surveyed those who had served as NHCGNE scholars and fellows from 2010 to 2016 and included indepth telephone interviews of 12 respondents who had described a focus on policy in the survey. Twenty-five percent of respondents to the online survey said that they had helped to lead public or private policy changes and that the NHCGNE program was

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life changing for many of the scholars and fellows in ways that reflect the stages of career development outlined by McBride (2011) in her conceptual framework on the Growth and Development of Nurse Leaders and should position these nurses to be effective leaders in shaping health policy in the future. Scholars and fellows talked about the program changing them from an internal focus on their own growth and development (preparation stage) to a focus on their organization, the health care system, local communities, and beyond (development of the field stage). Through the confidence gained during the program, scholars were able to address policy matters from a deepening evidence-based expertise as a scientist. But they also were able to use their knowledge, skill, and science to view the bigger world, understand other perspectives, and determine ways that they could inform or impact policy. These are leadership attributes and transferable to executive positions or seats on boards. Mentorship was identified as one of the more important aspects of this program. The role of the mentor is a central component of the conceptual framework by McBride (2011) mirroring the data and themes, including modeling values and practices, opening doors of opportunity, facilitating networks, providing feedback on strategy, and recommending for opportunities. The interviewees consistently expressed the impact made by their mentors on their values, skills, research, and the direction in which their careers developed. It was evident that the scholars and fellows who were mentored by people well grounded in health policy reflected a more developed understanding of how their scholarship could inform and shape policy. This finding emphasizes the importance of the mentorementee relationship. Mentors bring their knowledge to that relationship, and those who are highly productive researchers can foster that area of development in a mentee. Ideally, research mentors would be those who could also guide mentees on how to use their research to influence policy; but where this is not possible, having a policy mentor in addition to a research mentor can help mentees develop the knowledge and skills necessary in those areas. It is important for developing professionals to seek mentorship outside, as well as in, nursing. The NHCGNE title of scholar or fellow, annual conferences, and mentors provided scholars and fellows with the confidence in themselves and their ability to operate assertively in new and influential networks of people. These networks provided the scholars and fellows with opportunities that helped them believe that they can leverage the career, choices, and actions as they move on in their chosen career path. Several scholars were able to leverage their networks and leadership attributes to gain positions on advisory and governing boards at the state and local levels. Since the Future of Nursing report (2010), state action coalitions have advocated for more nursing representation on governing boards. With the knowledge and skills gained

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through the BAGNC program, the scholars/fellows have been able to bring their voices to policy forums and influence decisions. At this stage of development, Development of the Field, the central developmental task is shaping the profession and health caredexercising power of authority and creating a vision for the future. As indicated in the data and the framework by McBride (2011), these scholars and fellows are advancing leadership as personal, as achieving organizational goals and as a major transformation. While growing and developing as leaders, nevertheless, the scholars and fellows identified a number of difficulties to be leaders in shaping health policy. Many of the scholars expressed difficulty in finding the time to work in policy arenas because of their workload, which, in academic settings, focused on teaching and research. There are two factors that drive this perception. One is the separation of policy from everything else one does, and the other is the perceived value of policy-related work in academic settings, as follows. First, if nurses are to be leaders in evidence-based policy formulation, we must start with teaching doctoral students to explore the policy implications of their research, and then actively reward them for using their research to inform policy. Population health includes policy-related interventions, and such discussions are crucial at the undergraduate, masters, or doctoral levels (Lentz, Lichtenstein, & Pollack, 2007). Nurses tend to look at policy as something other people do, and it is not linked to their work. Researchers need to think of their work as laying the groundwork for informing policy. As their research develops, their results must be tied back to practice and policies that influence health care delivery and the health of populations. Integrating policy into nursing curricula should not be optional or an add-on. It must be core content. Educators need to be providing students with the foundational understanding of how policies affect the health of populations and drive the practice of health care professionals. Practitioners are governed by policies that limit or expand their practice and help or detract from the wellness of our most vulnerable populations. It is essential that nurses not only understand how policy affects their work but also the importance of their engagement in forming and reforming policy decisions, and how to do this. Second, tenure in most universities is achieved primarily by an individual’s successful record in research funding and publication of the work in peer-reviewed journals. This is viewed as impact and can be measured or counted in journal impact factors and number of research grants. But we have not seen any tenure and promotion criteria that speak specifically to demonstrating an impact on policy through presenting testimony on a study, consulting with a department of health to shape long-term care regulations, or getting media attention to a significant problem that could be addressed through a policy response. This step, using research findings, is considered a critical first step in the policy process and can help inform effective

policymaking and resource allocation (Mason, Gardner, Outlaw, & O’Grady, 2016). Similarly, in teaching-intensive colleges and universities, teaching is valued as it contributes to students’ learning. There is very little value placed on the work faculty might be doing in educating lawmakers or writing position articles and developing coalitions for action. Therefore, the routine work of faculty is around research and teaching; and that becomes the space of comfort while the world of policy becomes more remote. It is important for universities to recognize the visibility faculty provide to both the institution and the profession through using its knowledge, skills, and voice to shape health policy as well as to provide support for faculty interested in pursuing the policy implications of their research. If criteria for tenure and promotion for assistant and associate professors do not explicitly recognize policy work as a demonstration of impact of research, opportunities for nurse scientists to lead in interprofessional spheres will be missed.

Recommendations Based on the findings of this study, we propose the following recommendations for advancing nurse scientists’ capacity to be leaders in shaping policy. These are based on our view of policy as a part of research and leadership, not a separate and an isolated entity. a. Doctoral nursing programs should include progressive opportunities to explore with students the links between research and policy, the policy implications of their research, and the knowledge and skills needed to be a competent influencer or leader in translating research into policy. We believe that every doctoral student and researcher should be able to address the question, “How will this study inform and improve policy?” Not all studies may do so, just as bench research may not be immediately relevant to practice; but the question must be asked if we are to strengthen scientists’ understanding of the linkages between research and policy. The American Association of Colleges of Nursing (AACN) has outlined essential components of Doctor of Nursing Practice programs that include a significant emphasis on policy competencies (AACN, 2006); however, the most recent document on essentials for PhD programs does not outline essential policyrelated outcomes for the future researchers and academics (AACN, 2010). The profession needs to be clear about the competencies that should be developed in research-focused doctoral programs and hope that AACN will undertake this important work. b. Doctoral and postdoctoral nursing students need strong mentors who are expert researchers and experienced at using their research to shape policy. If a research mentor does not have both skill sets, a second mentor should be assigned who has expertise in policy. In addition, midcareer nurse scientists need opportunities for advanced mentoring in policy.

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c. Doctoral-prepared nurse scientists should be encouraged to apply for the Robert Wood Johnson Foundation Health Policy Fellowship and the HAPF program as well as other opportunities at the state and national levels to obtain high-level experiences in the policy world. Other specialties in nursing should also consider developing a program modeled after the NHCGNE program and to deliberately incorporate a policy focus, in addition to building scholars’ leadership and research skills. Nurse scientists should be encouraged and funded to attend relevant organizational conferences and meetings that have a strong focus on policy, such as the GSA or the American Health Care Association (AHCA), an influential organization that focuses on both research and policy related to long-term care and assisted living facilities. Finally, the academy’s Expert Panel on Aging provides a great opportunity for fellows and those who aspire to become fellows to learn about policy related to aging. The academy’s Jonas Policy Scholars program has included doctoral or postdoctoral nurses to work with expert panels, including the Expert Panel on Aging. Given the number of nurses with expertise in aging who could benefit from development of their policy skills, additional funding should be sought to create opportunities for scholars to be assigned to the Expert Panel on Aging. Through this platform, gerontological nurse leaders may develop policy proposals, testimony, articles, policy briefs, recommendations, advocacy papers, position statements, and research agendas to advance the health of older adults. d. Universities, colleges, and health care organizations must work on redefining what impact means in a way that counts policy work. Policy, like publications and presentations, can and should be used to demonstrate continuing development and competence (Wichita State University, 2017; Woolston, 2016). Policy work needs to be reframed as a form of professional currency with a significant impact on the individual’s and school’s or workplace’s reputation. This reframing should lead to these organizations developing supports and rewards that faculty and scientists may need to be able to use their research to shape policy. The teachingintensive colleges and universities that have significant service requirements may be in the best position to lead the way in developing criteria for showing impact through policy work, perhaps counting it as service. However, research-intensive schools should redefine research impact to include demonstrating its impact on policy. e. The current NCGNE, now an independent 501(c) (3) nonprofit organization, may continue to have a significant impact in enhancing policy work and outcomes among gerontological nurse leaders, including Legacy Affiliates. For example, in partnership with the academy’s Expert Panel on Aging and Hartford Institute for Geriatric Nursing, the NHCGNE should consider initiating a policy linkage program,

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including a regular policy blog to disseminate research that may impact policy. Existing platforms, such as the annual Academy Policy Conference and NHCGNE Leadership Conference, can be leveraged to invite other potential partners, including the National Association of Directors of Nursing Administration, Inc. and AHCA members to present at these events. The AHCA is also a strong policy force that can provide nurses in long-term and postacute care, with the necessary tools, information, and resources to take action on policy work. f. Leadership development must progress from focusing on development of the individual nurse scientist to how the individual can develop their home institution and field of interest. Emerging leaders should be encouraged to work at the local level, including serving on boards of health-related organizations or policy-related advisory entities. National service should remain a goal for nurse leaders, but bringing a broad perspective to local work can provide valuable experiential learning. The academy’s Institute for Nursing Leadership has focused on gubernatorial appointments because these can be influential positions, particularly as attention on health policy is moving more to the state level. In addition, the Nurses on Boards Coalition (www.nursingonboardscoalition.org) provides resources and opportunities for appointments at local, state, and national levels.

Conclusion “I just think it’s critical that people be aware of how much government impacts every aspect of people’s lives, when it comes to being an older adult in the United States”dSo said one of the participants in this study. The NHCGNE program provided rich opportunities to prepare nurse scientists as leaders, and the program evolved with an emphasis on policy in recent years, in recognition of this statement’s truth. As the profession is challenged to step up and, in partnerships with others, lead efforts to transform health care, we must pay attention to how we are preparing the next generation of nurse leaders and scientists. Evidence is essential, although usually not sufficient, to develop or change policy. Preparing nurse scientists with competencies in translating research into policy and being able to negotiate the political world of policy can transform health and health care in the nation.

Acknowledgments This study was funded by a grant from the John A. Hartford Foundation to the American Academy of Nursing. We thank the Patricia G. Archbold Scholars

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and Claire M. Fagin Fellows who participated in the survey and interviews for this article.

references

American Association of Colleges of Nursing [AACN]. (2006). The essentials for doctoral education for advanced nursing practice. Washington, DC: American Association of Colleges of Nursing. American Association of Colleges of Nursing [AACN]. (2010). The research-focused doctoral program in nursing: Pathway to excellence. Washington, DC: American Association of Colleges of Nursing. American Nurses Association. (2010). Nursing’s social policy statement. Silver Spring, MD: American Nurses Association. Bernard, H. R. (2002). Research methods in anthropology: Qualitative and quantitative approaches (3rd ed.) Walnut Creek, CA: Alta Mira Press. Dalton, G. W., Thompson, P. H., & Price, R. L. (1977). The four stages of professional careersdA new look at performance by professionals. Organizational Dynamics, 6(1), 19e42. Elo, S., Ka¨a¨ria¨inen, M., Kanste, O., Po¨lkki, T., Utriainen, K., & Kynga¨s, H. (2014). Qualitative content analysis: A focus on trustworthiness. Sage Open, 4(1), 2158244014522633. Franklin, P. D., Archbold, P. G., Fagin, C. M., Galik, E., Siegel, E., Sofaer, S., & Firminger, K. (2011). Building academic geriatric

nursing capacity: Results after the first 10 years and implications for the future. Nursing Outlook, 59(4), 198e205. Harden, J. T., & Watman, R. (2015). The National Hartford Center of Gerontological Nursing Excellence: An evolution of a nursing initiative to improve care of older adults. The Gerontologist, 55(Suppl. 1), S1eS12. Institute of Medicine. (2011). The future of nursing: Leading change, advancing health. Washington, DC: National Academies Press. Lentz, P. M., Lichtenstein, R. L., & Pollack, H. A. (2007). Health policy approaches to population health: The limits of medicalization. Health Affairs, 26(5), 1253e1257. Mason, D. J., Gardner, D. B., Outlaw, F. H., & O’Grady, E. T. (2016). Policy and politics in nursing and health care. In (7th). Elsevier, St. Louis, MO. McBride, A. B. (2011). The growth and development of nurse leaders. New York, NY: Springer Publishing. Sandelowski, M. (1993). Rigor or rigor mortis: The problem of rigor in qualitative research revisited. Advances in Nursing Science, 16(2), 1e8. Sandelowski, M. (2000). Whatever happened to qualitative description? Research in Nursing & Health, 23, 324e340. Wichita State University (2017). Academic and professional currency. Retrieved from http://webs.wichita.edu/?u¼business1&p¼/ facultyandstaff/academicandprofessionalcurrency Woolston, C. (2016). Conference presentation: Lead the poster parade. Nature, 536, 115e117.