Leadership in Advanced Practice Nursing: Key Roles and Strategies

Nurse Staffing Ratios and Cost-Effectiveness

Staffing is not the main issue in elevating or containing costs: the main issue is retention. High turnover rates in nursing can drive costs up, but proper staffing with an appropriate ratio of nurses to patients can actually reduce costs over the long term, so long as turnover is not an issue. The reason is that appropriate staffing leads to improvements in quality care delivery (Martin, 2015). As Rothberg, Abraham, Lindenauer, and Rose (2005) point out, improving nurse-to-patient staffing ratios is a cost-effective intervention that — far from being detrimental to cost control — reduces costs because it enables patients to receive better care and reduces the risk of nursing errors committed as a result of burnout.

Everhart, Neff, Al-Amin, Nogle, and Weech-Maldonado (2013) show that in highly competitive markets, the better the nurse-to-patient ratios, the better the reputation of the hospital. The only markets in which increases in staffing have not been found to be impactful are non-competitive rural markets. In short, the law of diminishing returns appears to apply, both cost-wise and care-wise, only in markets where nurses and facilities are not challenged to outperform their competition. In markets where hospitals and healthcare facilities must be competitive, adequate staffing does help to contain costs and increase the quality of care that patients receive.

Care Delivery Models for Changing Populations

Healthcare leaders can determine appropriate nursing and care delivery models to address rapidly changing populations by focusing on the models that will best serve the needs of the community. For instance, the transcultural model of nursing emphasizes cultural understanding and requires nurses to learn how different cultures create different expectations among populations (Maier-Lorentz & Leininger, 2008). In a rapidly changing population, there is bound to be an influx of cultures — whether because the population is aging, more ethnicities are arriving in the area, or for other reasons. These various populations must be understood as having unique needs, wants, desires, and expectations. Therefore, by exercising innovative leadership (Gliddon, 2006) and emphasizing the importance of recognizing cultural values among patients, healthcare leaders can determine the appropriate nursing and care delivery models to help their nurses address the needs of a diverse population.

It is also important to attend to the needs of healthcare providers themselves: nurses may require training and instruction and, as a result, could benefit from the implementation of specific models that provide them with the right kind of guidance. Leaders must be able to communicate with their workers, listen, and identify issues and potential barriers to change. By creating a vision of what the organization is trying to achieve and bringing all stakeholders on board, the right models will begin to fall into place as resistance to change is overcome.

The ACA, Doctoral Nursing, and the Doctor Title Debate

As Lathrop and Hodnicki (2014) point out, the Affordable Care Act (ACA) helped to bring reform to the healthcare industry by focusing on "a preventive healthcare model that emphasizes primary care, funds community health initiatives, and promotes quality care." This reform has created a demand for doctorally prepared APRNs who can deliver quality care in primary care settings as envisioned by the ACA. Doctorally prepared nurses can provide leadership, guidance for interdisciplinary teams, and advocacy for future nursing reforms.

Another issue that has emerged in recent years in state legislatures is who has the right to be called a doctor. As Zittel (2012) notes, "in January 2011, two U.S. representatives introduced H.R. 451, the Healthcare Truth and Transparency Act of 2011, designed to empower patients by increasing transparency in healthcare provider-related advertisements and marketing." The goal of this bill is to make clear to patients which care providers are medical doctors — physicians — and which are doctors of nursing. While the bill aims to reduce confusion about who is a doctor, it actually adds to that confusion. "Doctor" is an academic title, not solely a medical one. Doctors of nursing have just as much right to advertise themselves using a title traditionally associated with the concept of a medical doctor. This bill would effectively render nurses with doctoral training as appearing less equipped and knowledgeable than medical doctors. That would be disadvantageous for APRNs because, as the Institute of Medicine has pointed out, there is a pressing need for more APRNs in primary care, and doctoral nurses should be respected within the industry — not further marginalized by legislation that seeks to subvert their right to identify themselves as doctors of nursing.