Influence and leadership in advanced nursing practice roles

Rethinking the Concept of Influence in Relation to Nursing Pracitce

The objective of this study is to examine the concept of influence in relation to the nursing practice. Towards this end. This study will review material that is academic and peer-reviewed in nature as well a professionally published documents in this area of inquiry.

Nursing practice has the power to influence the concept of healthcare and the outcomes for patients in this realm. This study intends to show this capacity in the field of professional nursing. The work of Roussell (nd) states that safety of patients as well as quality initiatives contain six objective for improvement that includes the following: (1) Safety lf health care; (2) effectiveness of health care; (3) timely healthcare; (4) waste reduction in health care and (5) equity in healthcare. (Rousell, nd, p. 20) Nurse directed healthcare is new in the field of healthcare. This study will first examine the role of the nursing professional in order to conduct a thorough review of the areas in which the nursing professional is able to use the concept of influence in their nursing practice. Secondly, this study will examine nursing leadership concepts which will add to the knowledge of the ability of the nursing professional to utilize the concept of influence in their nursing practice.

I. Nurse Practitioners and Nursing Professional Education, Training and Roles

The nurse practitioner is reported as a registered nurse (RN) that has "additional training, usually at the master's level. The graduate training builds on nursing roles in patient advocacy and education, and incorporates physical assessment and diagnostic skills, along with management of acute, chronic and episodic diseases. This includes taking a patient history, performing a physical exam, ordering and interpreting laboratory tests, providing medication, referring to specialists and promoting healthy lifestyles." (Wessell, 2005, p. 2) Wessell (2005) reports that the first NP program began in 1965 in the state of Colorado and involved training of nurses in the provision of pediatric care to populations that were underserved. It is reported that there are an estimated 40,000 nurse practitioner and that by the year 2000 that the number had risen to more than 62,000 nurse practitioners. By 2004, it is reported that more than 100,000 nurse practitioner were practicing. (Wessell, 2005, p. 2) Nurse practitioners are reported to practice in areas that include "women's health, pediatrics, school health, psychiatry, neonatology, and oncology, while others seeks a broader focus in family medicine." (Wessell, 2005, p. 2) Nurse practitioners are state regulated and are required to adhere to laws set by states and this involves "certification with national credentialing organizations." (Wessell, 2005, p. 2) It is reported that some states "allow NPs to practice completely independently, others require a collaborative agreement with an MD that defines the scope of practice for that work site, while others do not recognize practice by NPs at all. While the level of prescriptive authority also varies by state, NPs have prescriptive authority in most states, including the opportunity to apply for a Drug Enforcement Agency (DEA) number, allowing them to prescribe controlled substances. One of the many policy issues NP organizations are focusing on is that of allowing managed care patients to choose an NP as their primary care provider." (Wessell, 2005, p.3) It is reported that nurse practitioners in addition to Physician's Assistants (PAs) and Certified Nurse Midwives (CNMs), "are often referred to as midlevel providers or physician extenders. Some NPs and PAs object to these terms, arguing that they imply the NP, PA or CNM occupies a lower position than a physician. However one resolves such concerns, few would disagree that there is a role for every person in the complex health system, including physicians, nurses, social workers, pastoral care ministers, and NPs and Pas." (Wessell, 2005, p. 3)

It is reported in a recent journal published in the Wall Street Journal and written by Ann O'Sullivan, an NP at University of Pennsylvania that NPs and doctors working in collaboration result in the best possible results. O'Sullivan is reported as stating that in one case that a patient who needed to stop smoking involved the explanation by the physician of the "physiological problems with smoking while the NP looks at the psychological factors in smoking and the personal barriers to smoking cessation." (Wessell, 2005, p. 4)

Wessell (2005) reports that studies on satisfaction of patients have demonstrated that HPs are rated with "high favorability. The most effective role of the NP in the primary care setting is that of a provider who combines medical knowledge, diagnostic ability, and prescriptive authority with education regarding disease management and lifestyle modifications, and works in a team with others. Nurse Practitioners are in a favorable position to develop an ongoing relationship and to build on patient strengths, taking into account real life demands of the patient." (p. 4)

The focus of medical training while being on such as diagnosis and treatment is differentiated from NP training which has as its focus the care and prevention in health care. In the area of chronic disease, it is reported that "on-going education and reinforcement in the management of the disease is important. By empowering patients to take care of themselves, make lifestyle changes, and prevent acute exacerbations of disease, NPs help in the prevention of expensive hospital visits which will be financially beneficial to the medical system and personally beneficial to the patient." (Wessell, 2005, p. 5)

II. Nursing Leadership and Influence

It is reported in the work of Curtis, de Vries, and Sheerin (2011) that the importance of "effective leadership in health care has been emphasized" in a great deal of the literature. Dunham and Fisher (1990) emphasized the importance of leadership as did Hewison and Griffiths (2004) and Roussel et al. (2009). Specifically stated is that research in the area of leadership "has demonstrated a positive relationship with improved patient safety outcomes." (Tregunnoet al, 2009 cited in Curtis, de Vries and Sheerin, 2011, p. 306) In addition, effective leadership results in work environments that are healthy according to Shirey (2009) as well as in worker satisfaction (Heller, et al., 2004) and lower rates of turnover (Gelinas and Bohen, 2000) and finally patient outcomes that are better (Wong and Cummings, 2007).

There are many challenges that nursing professionals face in the present including such as "new roles, new technology, financial constraints, greater emphasis on participation, cultural diversity and education" however, it is held that it is not possible for nursing professionals to consider leadership to be "an optional role or function…Leadership must exist in every healthcare facility where effecting change and achieving high standards of patient care are stipulated in job titles, such as Director of Nursing, Nurse Consultant, or Modern Matron" (Sullivan and Garland, 2010 cited in Curtis de Vries and Sheerin, 2011, p. 306). It is critical however, for the nursing professional to understand that as stated by Curtis de Vries and Sheerin (2011) that "the taking on of a leadership role by itself is not sufficient for ensuring effectiveness. The leader must be knowledgeable about leadership and be able to apply leadership skills in all aspects of work." (p. 306)

According to Heller et al. (2004) overall, today's nursing professionals are ill-prepared for leadership roles during their educational programs and it is this "gap between adequate educational preparation and the demands of the clinical setting [which] can result in ineffective leadership in nursing." (Curtis, de Vries, and Sheerin, 2011, p. 306) Leadership is such that results in various images and ideas and may be inclusive of such as "power, influence, followership, dynamic personality, charisma, goals, autocratic behavior, innovation, cleverness, warmth and kindness." (Curtis, de Vries, and Sheerin, 2011, p. 307)

Researchers have examined the various ideas concerning leadership and have described as "The process by which an agent induces a subordinate to behave in a desired manner" as noted in the work of Bennis (1959) and cited in the work of Curtis, de Vries and Sheerin (2011, p. 307) In addition, leadership has been stated to be the "ability to influence people toward attainment of goals.' (Daft, 2000 cited in Curtis, de Vries and Sheerin, 2011, p. 307) Leadership is reported in the work of Weihrich and Koontz (2005) as influence of the "art or process of influencing people so that they will strive willingly and enthusiastically toward the achievement of group goals." (Curtis de Vries and Sheerin, 2011, p. 307)

According to Sullivan and Garland (2010) leadership relates to skills on an interpersonal level that may exert influence over others to reach specific achievement of goals. It is reported that a theme that is common and one that appears to "run through many definitions" is that leadership is relative to the influence of the "attitudes, beliefs, behaviors and feelings of other people." (Spector, 2006, cited in Curtis, de Vries and Sheerin, 2011, p. 307)

III. Various Theories of Leadership

The various theories concerning leadership are set out in the work of Spector (2006) as follows:

(1) the trait approach, which is concerned with personal traits that contribute to effective leadership; Curtis, de Vries, and Sheerin, 2011, p. 307)

(2) The behavior approach, which, like trait theory, explores leadership from the perspective of the leader and focuses on leader behaviors; Curtis, de Vries, and Sheerin, 2011, p. 307)

(3) The contingency approach (Fielder's contingency theory and path-goal theory) suggests that leadership is about the interaction between a person (leader), his/her behavior and the situation; Curtis, de Vries, and Sheerin, 2011, p. 307)

(4) The leader -- member exchange approach (charismatic or transformational leadership) is concerned with the relationships between subordinate and supervisor. (Curtis, de Vries, and Sheerin, 2011, p. 307)

IV. Research Findings on Nursing Leadership

A study conducted and reported in the work of Bowles and Bowles (2000) was such that sought to compare the "transformational leadership behaviors of firstline managers working in Nurse Development Units (NDUs) and those working in non-NDUs." (Curtis, de Vries and Sheerin, 2011, p. 307) It is reported that the "NDU scheme was established in the UK to explore innovative nursing practice and increase the quantity and quality of nurse leaders." (Curtis, de Vries and Sheerin, 2011, p. 307) Stated in the findings are indications that the self-evaluations of leaders were "similar for both groups. However, leadership of leaders working in NDUs was rated more highly by the observer evaluations than was that of leaders from non-NDUs. Furthermore, leaders from the NDUs demonstrated more transformational leadership behaviors than did their colleagues in non-NDUs." (Curtis, de Vries and Sheerin, 2011, p. 308) Also reported in the findings in this study was that "leaders from NDUs were not regarded as 'more credible role models or as being more active in promoting the capability and confidence of their staff' (Bowles and Bowles, 2000 cited in Curtis, de Vries and Sheerin, 2011, p. 308).

Another study is reported in the work of Dunham and Fisher (1990) who sought to identify the characteristics that comprise nursing leadership that is excellent in nature and the following description arose from this study "...administrative competence, adequate education, business skills, clinical expertise and an understanding of leadership principles." (Curtis, de Vries and Sheerin, 2011, p. 308) Stated to be interesting about these findings include that nursing leadership "as perceived by nurse executives, differed from general leadership because of its emphasis on nurses assuming responsibility for influencing and improving the practice environment." (Curtis, de Vries and Sheerin, 2011, p. 308) These findings are similar to those reported in the work of Antrobus and Kitson (1999) which indicated that "leaders in whatever position they were in combined their sphere of influence with clinical practice. In other words, nursing knowledge derived from nursing practice was instrumental in influencing their leadership." (Curtis, de Vries and Sheerin, 2011, p. 308)

Noted as other terms that have been used to describe leadership in the profession of nursing include:

(1) Empowering others

(2) Facilitating learning

(3) Developing nursing knowledge

(4) Working with and through others to achieve success (Antrobus and Kitson, 1999 cited in: Curtis, de Vries and Sheerin, 2011, p. 308)

The work of Marquis and Huston (2009) notes that leadership and management must be differentiated one from the other and state that leadership skill requirements "are more complex than those needed for management." (Curtis, de Vries and Sheerin, 2011, p. 309) The difference between leaders and managers is set out in the work of Hughes et al. (2006) as follows:

(1) Managers administer, leaders innovate;

(2) Managers maintain, leaders develop;

(3) Managers control, leaders inspire;

(4) Managers have a short-term view; leaders have a long-term view;

(5) Managers ask how and when, leaders ask what and why;

(6) Managers initiate, leaders originate;

(7) Managers accept the status quo, leaders challenge it. (Curtis, de Vries and Sheerin, 2011, p. 309)

The work of Reed and Dennison (2011) examines the role of the Clinical Nurse Leader (CNL) and reports "Contemporary healthcare delivery systems entered the new millennium fraught with challenges to the provision of safe environments for those entrusted to their care. Over the last two decades, healthcare's quality-safety-performance-improvement infrastructure has burgeoned, but providing quality and safe care for patients and families remains challenging. Quality and safety-improvement activities no longer occur at the place where care is actually delivered. Often the offices and desks of quality and safety-improvement staff are located in back hallways, administrative areas, or even in separate buildings. .This results in a disconnect between care providers and the valuable safety and quality data that can be used to guide efforts and achieve sustainable results. The CNL is a clinician who brings the locus of control for safe and quality care from the administrative areas straight to the unit's providers who deliver the services. The role of the Clinical Nurse Leader (CNL) restores this vital connection. The CNL is a clinician who brings the locus of control for safe and quality care from the administrative areas straight to the unit's providers who deliver the services. The CNL answers the call to rise above the staccato pace of fragmented and complex healthcare delivery and lead others to ensure that patient care is safe and effective." (p. 1) The Clinical Nurse Leader is able to influence the staff and the entire unit in the provision of care through working administratively and in a position of leadership to bring about a higher level and quality of care for patients.

Reed and Dennison (2011) report that the Clinical Nurse Leader (CNL) role was envisioned due to the vast concerns linked to care for individuals who receive inpatient care. Specifically stated is "Current nursing and healthcare literature most often describes the CNL role in tertiary care environments. Additionally, tertiary care hospitals include systems in which the quality of nursing care is most directly guided by nurse-sensitive-indicator measurements, trending, and improvement efforts. However, CNLs are also prepared to provide and coordinate care for individuals, families, groups, and communities in varied settings." (p. 1) Over the years to come and as the "number of CNL graduates increases and this new role continues to mature, CNLs will bring their unique educational preparation and skills to increasingly diverse settings, including home health, rehabilitation, long-term, community, and ambulatory care. In addition, increasing emphasis on globalization and global healthcare will provide another important opportunity to apply the unique skill sets of the Clinical Nurse Leader." (Reed and Dennison, 2011, p. 1) The work of Barnett, Stanton and Blakney (2010) are reported to have made identification of the "CNL role components that are of particular interest to diverse healthcare professionals, such as clinical leaders, care coordinators within and across healthcare settings, outcomes managers, staff education, and mentors." (Reed and Dennison, 2011, p. 1) In these diverse roles, the nursing professional has the potential to influence the health care excellence and quality of care provided to patients.

In regards to leadership "within a global healthcare context is a core competency of CNL practice" it is reported that Clinical Nurse Leaders (CNLs) "learn about the global environment in which healthcare is provided and are prepared to adapt care in response to global environmental factors. To meet the global health knowledge and competencies delineated in the vision of the CNL role. CNL graduate students at the University of Virginia have engaged in interdisciplinary clinical and leadership experiences in many settings around the world, including Denmark, South Africa, Guatemala, the Bahamas, and India. The number and breadth of these experiences varies based on student interest and experience. However, students generally focus on community health needs related to health promotion, nutrition, sanitation, and hygiene. The student discovered through these pictures and stories that the community equated clean water with affluence, but did not equate clean water with health. Although these global health experiences are not explicitly focused on learning to develop a culture of safety, skills acquisition in areas of leadership, teamwork, evidence-based care, communication, learning, justice, and patient-centeredness are infused within the experiences. An interdisciplinary water improvement project in a community in rural South Africa illustrates these skills on the part of a CNL student. While engineering students and other professionals were repeatedly challenged to help a community sustain a clean water delivery system, it was the CNL student's assessment of a gap in the community understanding of relationships between water and health that enabled this project to finally succeed." (Reed and Dennison, 2011, p. 1)