PAST, PRESENT, AND FUTURE TRENDS OF MASTER'S EDUCATION IN NURSING SALLY O. GERARD, DNP, RN, CNL, CDE*, MEREDITH W. KAZER, PHD, CNL, A/GNP-BC†, LYNN BABINGTON, PHD, RN‡, AND THERESA T. QUELL, PHD, RN§ Nurses interested in pursuing careers in advanced practice are now being educated at the doctoral level through new doctorate of nursing practice degree programs. In light of this shift, master's programs for advanced practice nurses are in a tenuous position, and it is questionable whether the remaining master's level educational programs are meeting the needs of consumers, health care institutions, and students. Given the great need for clinical leadership in health care, it is essential to reexamine master's nursing education to ensure that educational institutions are meeting the needs of graduate nursing students, consumers, and health care systems. Research supports that the master's-prepared nurse of the future must be proficient in the development and management of accountable care systems using state-of-the-art technology. In addition, interprofessional models show improvement in health care delivery and health outcomes. The current demands in health care that impact nursing education will be discussed, including the movement toward interprofessional education and the broadened expertise, required of master's-prepared nurses working in an era of health care reform. While academic medical centers are actively advancing toward an interprofessional model, the majority of nurses in this country are educated in private and community settings. This article will examine the move toward interprofessional education at a private university, utilizing clinical partnerships to revise the master's program. The goal of this revision is to empower students with the expertise required in today's health care environment to improve the delivery of care. (Index words: Master's nursing education; Educational innovation; Trends of nursing education) J Prof Nurs 30:326–332, 2014. © 2014 Elsevier Inc. All rights reserved.
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HE RECENT INSTITUTE of Medicine (IOM) report on the Future of Nursing states that nurses must achieve higher levels of education and training in response to…“increasing [healthcare] demands” (IOM, 2010, p. 2). This statement comes at a pivotal time in nursing education. Nurses interested in pursuing careers in advanced practice are now being educated at the doctoral level through new doctorate of nursing practice (DNP) degree programs. In light of this shift, master's programs in nursing are in a tenuous position, and it is questionable whether the remaining master's level educational programs (health care management, nursing education, and clinical nurse leader [CNL]) are meeting the needs of consumers, health care institutions, and students. The 2008 registered nurse (RN) Survey *Assistant Professor, †Professor and Associate Dean, ‡Dean and Professor, §Assistant Dean, Fairfield University, Fairfield, CT. Address correspondence to Sally O. Gerard: DNP, RN, CNL,CDE, Assistant Professor, Fairfield University, Fairfield, CT. E-mail: sgerard@ fairfield.edu 8755-7223 326 http://dx.doi.org/10.1016/j.profnurs.2014.01.005
conducted by the Bureau of Health Professions indicated that 19.2% of RNs who earned a master's degree enrolled in programs with a focus in administration, business, or management, 13.3% focused on education, and 5.9% earned public health degrees (Bureau of Health Professions, 2010; The Registered Nurse Population: Findings from the 2008 National Sample Survey of Registered Nurses. September 2010. Rockville, MD: U.S. Department of Health and Human Services.). Dr. Patricia S. YoderWise, President of the Council on Graduate Education for Administration of Nursing, summarized the situation by stating, “The absence of a nursing master's option could have unintended consequences of moving nurses in leadership roles to other fields to secure a master's degree. This further dilutes the knowledge needed to be highly effective in leading and managing the nursing team.” She further states that “eliminating the master's in nursing as part of the education progression could be counterproductive to patients and the profession” (Yoder-Wise, 2011, p. 258). Given the great need for clinical leadership in health care, it is essential to reexamine master's nursing education to ensure that educational institutions are
Journal of Professional Nursing, Vol 30, No. 4 (July/August), 2014: pp 326–332 © 2014 Elsevier Inc. All rights reserved.
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meeting the needs of graduate nursing students, consumers, and health care systems. Globally, there is a strong call for developing models of interprofessional education (IPE) and practice. Research supports that interprofessional models will lead to improvements in health care delivery and health outcomes (IPEC, 2011). The purpose of this article is to review master's education in nursing from the past to present to enhance understanding of the various types of educational programs that have developed over time and how society has influenced this development. The current demands in health care with potential to impact nursing education will be discussed, including the movement toward IPE and the broadened expertise expected of master'sprepared nurses working in an era of health care reform. Based on the educational history and the current needs of nurses in the present health care environment, the future of master's nursing education will be envisioned. The article concludes by presenting one curricular model for a master's in nursing program that meets the need for highly skilled nurse leaders in the 21st century.
History of Master's in Nursing Programs The education of master's-prepared nurses has a long and interesting history. Responding to new knowledge and growing technology in the early part of the twentieth century, nurses struggled to find answers to improve patient care through advanced education. A dearth of graduate nursing educational programs forced nurses to pursue advanced degrees in other disciplines such as education, business, and health care administration ( Flood, 2010). The fifties and sixties saw a great need to prepare nurse educators as the profession of nursing grew and expanded toward baccalaureate preparation. Despite the growing complexity in health care and the need for advanced clinical education, early master's programs in nursing focused more on developing nurse educators and administrators than expert clinicians. Many of the clinical specializations in nursing evolved from expanded roles in RN practice developed on the job. Certificate programs were developed for RNs interested in obtaining new knowledge and skills needed for these new and expanded roles. Eventually, the certificate programs evolved into formalized degree programs. The first clinical master's in nursing program began in the 1960s, educating nurses for roles as clinical nurse specialists (CNS). In response to the shortage of primary care physicians in the 1960s, the first nurse practitioner (NP) programs were developed. Pohl, Hanson, and Newland (2010) reported that the focus of the first NP role was to provide assessment and management of care for patients with acute and chronic health conditions with an emphasis on health promotion and wellness. The NP role has extended far beyond this original conceptualization toward the management of patients with complex medical conditions. By the early 1980s, the “advanced practice nursing” title described all advanced clinical nursing roles including CNSs, NPs, certified RN anesthetists, and certified nurse midwives.
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The later part of the 20th century witnessed a proliferation of master's degree clinical nursing programs aimed at preparing nurses for advanced practice and a decline of nonclinical master's degree programs for nurse educators and administrators. The subsequent decades continued to see increasing role definition and expansion of these advanced clinical roles culminating in the development of the advanced practice RN consensus statement in 2008 (APRN Joint Dialogue Group Report, 2008). This statement seeks to both unite and promote the continued role of advance practice nursing in the evolving health care system. As the clinical complexity of patient care continues to accelerate, along with the growth in knowledge, technology, and patient care resources, the need for clinical expertise continues to expand. In 2004, the American Association of Colleges of Nursing (AACN) called for the basic education of all Advanced Practice Registered Nurse (APRNs) to be at the doctoral level (AACN, 2004) through the attainment of DNP degrees. The Council on the Accreditation of Nurse Anesthetists states that this degree is required for the credentialing examination and licensure by 2025. While graduate nursing programs await decisions regarding minimum credentialing requirements for NP certification by the respective boards and subsequent changes in state licensing requirements, APRNs continue to be educated at both the master's and doctoral level. The movement away from nonclinical specialties at the master's level, followed by the current progress of clinical education of APRNs toward a DNP, is leaving a slow but steady decline of clinically focused master's programs available to students. Remaining clinical education at the master's level is largely the CNL, a role created in 2006 by the AACN to meet the rising complex health needs of patients within the health care system (AACN, 2006). CNL programs are distinctive in that they are developed with identified partnerships between academia and health care providers, ensuring that programs meet the needs of community employers. CNL graduates are prepared to meet the predominant health care challenges of the future, including rising technological advances in health care, needs of an aging population, chronic illness management, health disparities associated with socioeconomic dislocation, and health promotion and disease prevention (IOM, 2001). As of November 2013, the AACN Web site lists over 100 CNL programs nationwide (http://www.aacn.nche.edu/cnl/about/cnl-programs). Although CNLs continue to be essential in promoting positive patient outcomes in the health care delivery system, the integration and acceptance of this role has been limited. Keeling (2009) proposed that to predict the future of master's nursing education, one needs simply to look at the past. Each of the movements in graduate education was designed to meet a societal need. To prepare nursing educators and leaders, nurses often sought education among other disciplines until master's programs focusing on nursing education, health care management, and administration were developed. The need for nurses to
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administer anesthesia during war and deliver babies during the depression led to the development of clinical specializations in anesthesia and midwifery. Subsequent societal needs to provide primary and specialty care resulted in the growth and specialization of NP programs at both the master's and doctoral levels. The professional demands on the health care system today provide a framework for the future of nursing education and practice, as outlined in the landmark report from the IOM, The Future of Nursing: Leading Change, Advancing Health (2010). The growing emphasis on interdisciplinary health professional education will guide the evolution of new and innovative master's programs in nursing.
Current Demands of Health Care System Three elements can be viewed as substantial drivers of the rapidly changing health care landscape that support a revised blueprint for master's nursing education. The first consideration is the transformation toward a more accountable delivery system, and second is the use of technology to deliver care and engage consumers. Accountability and technology have dramatic implications on the complex processes that make up the broad spectrum of care. The third substantial driver in the current health care system is the movement toward interprofessional teams to meet the current and future health care needs of the population. This approach will be accomplished by the pooling of knowledge and skills across disciplines. Nurses are not only critical to these teams but also in the redesign of health care initiatives through planning, implementation, evaluation, and sustainability.
Accountability Never before have health care organizations been more committed to accountability, whether for the noble mission of “excellent care” or the practical mission to protect the “bottom line.” Gone are the days of accountability resting only with the top executives of an organization. Transparency of outcomes and financial incentives for achieving quality goals have forced organizations to take on a “bedside to boardroom” approach to improvement. High functioning health care organizations engage teams of direct caregivers to design process changes leading to improved outcomes. Many leaders lose sleep on a weekly, monthly, or quarterly basis awaiting the release of the most recent metrics measuring quality. No longer are these reports discussed behind closed doors with little sense of urgency. Data on quality indicators and dashboard topics are made available for all members of the health care team. Every individual involved in delivering care influences patient outcomes, and these measures have never been more scrutinized. While focus on accountability in health care today has a new set of challenges, it offers opportunities for improving processes, addressing fragmentation of care, and protecting vulnerable patients. In the past, it was
“acceptable” for organizations to have a certain percentage of unfortunate outcomes such as falls, infections, and frequent readmissions, which, essentially, had no negative financial implications. Currently, aggressive measures have been put into place by many hospitals to eliminate detrimental patient outcomes. Organizations are adapting standards from other industries to change attitudes about what is acceptable and strengthen the team approach to a culture of safety and excellence. This type of organizational transformation requires nurse leaders to possess a skill set different from years past.
Technology Another driver of change that incorporates accountability is meaningful use of health information technology, an umbrella term for rules and regulations that providers must meet to qualify for federal incentives under the American Recovery and Reinvestment Act of 2009 (www. medicity.com; Medicity.com, 2012). This legislation provides financial incentives to organizations using certified electronic health record (EHR) technology to improve the quality of care and submit quality measures to the Centers for Medicare and Medicaid Services. Adapting an EHR system and developing efficient, intuitive processes are daunting and expensive tasks for most of the organizations. Further, the skills to develop, evaluate, implement, and support these systems are substantial. Clearly, meaningful use will have a major impact on health care professionals in the next decade. Organizations across the nation have a new incentive to utilize technology with the specific aim of financial solvency. In a broader sense, every organization has challenges around the acquisition, implementation, and maintenance of all types of technology to deliver care. The expertise required in today's health care environment has included a steep upward trajectory from the complexity of EHRs to supply distribution, equipment tracking, patient monitoring, and telehealth, and communication devices. This phenomenon in health care has impacted the work of nurses and other health care providers in every setting. On the consumer side, technology has already changed how people approach their own care and gather information about providers. With easy access to information about diseases, medications, and treatments, consumers have a plethora of information available, although the quality of that information may be varied. As health care moves in to the future, continued advances will allow individuals to integrate technology and health information in unprecedented ways. Multiple approaches to patient support have become more critical because the new age of accountability impacts both providers and consumers. Health care delivery of the future calls for individuals to be accountable, adopt provider recommendations, and be fully engaged partners in their own health. This model will require new approaches to support and communication and may lead consumers to seek never-before-possible ways to interact with
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clinicians. The industry will respond with interventions that have yet to be considered. One example that illustrates the changing expectations of health care providers and consumers comes from the field of diabetes management. The American Association of Diabetes Educators recently released the 2012 revisions to their national standards of care. One significant change was the revision of the name of the standards to include the word support. The National Standards for Diabetes Self-Management Education and Support state that the rationale for this change stems from importance of support as an ongoing process of chronic illness (Fain, 2012). The new standards also place a stronger emphasis on frequent communication among team members to ensure high quality, effective education, and support for all people with diabetes and prediabetes (Fain, 2012). Technology, such as on-line education, blogs, and tailored messages on key behaviors, applications for mobile devices, on-line tracking of patient performance and goals, and opportunities to connect with providers, families, and friends for critical support, are all technology-related interventions projected to improve diabetes education and support (Kaufman, 2012). This example may be applied to the management of any chronic illness. The focus of new health care mandates, including increased accountability for conditions such as heart failure, has already been implemented; technology will no doubt be utilized as a resource for care. In any setting, the sophistication of knowledge required in the area of technology will be sizeable. Consumer expectations, coupled with the financial incentives from payers, will require a highly skilled and collaborative workforce.
Interprofessional Team Approach to Improved Care An emerging theme in health care that will demand changes for future health care providers focuses on the interprofessional health care team rather than individual disciplines. The World Health Organization (WHO, 2010, p. 7) states that “Interprofessional Education (IPE) happens when students from two or more health professions improve understanding about each other's roles to enhance effective collaboration and improve health outcomes. IPE is a necessary step in preparing a 'collaborative practice-ready' health workforce that is better prepared to respond to local health needs.” WHO (2010) reports that interprofessional learning environments improve the skills of all involved health professionals and health care outcomes for patients. In its Framework for Action on Interprofessional Education & Collaborative Practice, the organization stated, “there is now sufficient evidence to indicate that IPE enables effective collaborative practice which, in turn optimizes health-services, strengthens health systems and improves health outcomes” (WHO, 2010, p. 18). Effective collaborations among health care professionals positively impact outcomes such as length of hospital stay, readmissions, and mortality rates in both acute and primary care settings (WHO, 2010).
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Incorporation of IPE learning experiences into health professional curricula will enhance students' knowledge of, communication with, and attitudes about other health disciplines (Interprofessional Education Collaborative Expert Panel, 2011; Larson, 2012; Reeves, Goldman, Burton, and Sawatzky-Girling, 2010). According to the Interprofessional Education Collaborative Expert Panel (2011), IPE that primes health professions students to deliberately work together is a national imperative toward building a safer and better patientcentered U.S. health care system. In the most highperforming systems, a cadre of providers come together to collaborate, communicate, and partner with patients and families to provide optimal care. Health care providers must develop new skills to be effective members of teams providing the highest quality of care. Across the country, teams of practicing health care members are being educated together on topics such as teamwork, communication, safety, and quality. This culture will ensure that every member of the health care team has an ethical obligation to assume responsibility for the delivery of safe care (LifeWings, 2010). The new world of health care accountability and technology will be supported by an improved model of professional teamwork. Whether it is a primary care office, an emergency department or operative suite, teams of professionals are experiencing rapid changes in roles, skills, and demands. As a community, the team must work together running frontline care units that meet demands of the future. This expectation of “sharing the sandbox” and focusing on the patient may be the greatest challenge to developing new educational models. As outcomes become more visible and technology more sophisticated, collaborative care will become an expectation. The demands on the health care system will require highly educated and skilled clinical leaders, and nurses are positioned to meet these demands.
The Future of Master's Nursing Education The focus on accountability, technology, and interprofessional practice in health care provide a framework for master's nursing education for the next century. Moreover, health care reform will increase the number of Americans with insurance coverage to an estimated 94% of Americans (healthreformgps.org, 2012). This will require more primary care providers to care for patients, and nurses who take the leadership role in designing and managing accountable systems for the delivery of care by interprofessional teams. These pressures, along with dramatic advances in diagnostic, therapeutic, and educational technologies, will demand new consideration about master's education. The IOM report, The Future of Nursing: Leading Change, Advancing Health (2010) lays out a blueprint for how the nursing profession must adapt as it faces these challenges. The report states that “…high quality healthcare cannot be achieved without exceptional nursing care and leadership” (IOM, 2011, p. ix). The recommendations challenge educators to prepare and
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empower nurses to lead change to improve health care outcomes and expand opportunities for nurses to lead collaborative improvement efforts. It is imperative that master's nursing education be prepared to meet these challenges. Recognizing these trends, The AACN revised The Essentials of Master's Education in Nursing “to reflect the profession's continuing call for imagination, transformative thinking, and evolutional change” (AACN, 2011, p. 3). The 10 essentials form the core for all master's programs in nursing, along with the necessary curricular elements and framework. Although nursing programs throughout the country educate APRNs at both the master's and doctoral level and these practitioners begin to address the critical shortage of health care providers, there are few masters' programs focused on indirect roles for nurses. The health care system is demanding nurses that are educated at the master's level for roles focusing on health care systems that emphasize overall function of the organization. Thus, it becomes important to educate nurses for emerging roles in health care delivery and designed with the knowledge and skill sets needed to lead change, promote health, and elevate care in various roles and settings. These skills outlined in the Master's Essentials (AACN, 2011) include organizational leadership that requires systems thinking, facilitation of change, communication, finance and marketing expertise, understanding and management of information and health care technologies, and the ability to translate and integrate research into practice, particularly around the area of quality and safety. Master's graduates will be the leaders in accountable health care systems fostering the progression of interprofessional teams to meet the complex health care needs of the future. Given the current challenges, master's degree programs in nursing must be revised to meet the needs of the health care system for highly skilled clinical leaders. Nurses must be prepared at the systems level to manage accountable care organizations that make effective use of emerging technologies implemented through an interprofessional team approach. Many large academic medical centers around the country and around the world are moving forward with various elements of this model of education. However, despite these advances, the majority of nurses are educated outside of the Academic Medical Center in private and community nursing programs. These programs have a specific set of challenges related to the provision of interprofessional clinical experiences for students. Because of these logistical and possible financial challenges, innovations in the approach to education design and interprofessional partnerships are essential. To begin the development of a new model for master's nursing education in one school of nursing, we convened a focus group of area health care providers to discuss their organization's needs for master's-prepared nurses with specific knowledge and skills. Five executive nurse leaders, including chief nursing officers or their imme-
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diate designates participated, representing four large tertiary care facilities in the greater southern Connecticut area. Consistent with the literature, findings from this group revealed qualities that health care employers were looking for in nurses educated at the master's level to advance their organization in future decades. Many qualities were explored (see Text Box 1), but the overarching results supported the need for nurses prepared with the knowledge and skills to support systems redesign and utilize technology for cost efficient care. A critical component identified among focus group participants was that the ideal master's-prepared nurse leaders of the future must possess the knowledge and interpersonal skills to lead the interprofessional teams that are vital to the functioning of high-performing organizations. Following the focus group, faculty underwent a comprehensive assessment of the school of nursing's Master's of Science in Nursing (MSN) curriculum with the intent of integrating the results of the focus group along with The Essentials of Master's Education in Nursing (AACN, 2011), The Future of Nursing recommendations (IOM, 2011), and recommendations Text Box 1 Clinical Partner Focus Group Summary Employer vision of nurses as leaders in the next 10–20 years: Professionals who can identify, prioritize, implement, and evaluate system redesign Leaders of interdisciplinary care Creative seekers of systems improvements to enhance operations Financially minded health care professionals Outcome managers Transitional care specialists Knowledge and Skills needed to lead change: Fiscal knowledge to justify salary with outcomes Measurement of outcomes and basic statistics for evaluation of metrics Health promotion principles Interpretation of directives and standards Administrative skills such as staffing budgeting Succession management principles Members of the interprofessional team that students should work with: Financial specialists Health care administrators Patient safety specialists Information technology specialists Physicians System redesign specialists Allied health professionals Statisticians Nurse attorneys/risk specialists
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from the Core Competencies for Inter-professional Collaborative Practice (Interprofessional Education Collaborative Expert Panel (2011). An MSN program evaluation process was conducted whereby program outcomes and objectives were mapped against the essentials (AACN, 2011) and evaluated to ensure that graduates are prepared effectively at the master's level for practice in their chosen specialty areas. Two challenges were identified in developing effective curricula that met the AACN essentials and incorporated elements necessary for educational tracks that met the identified needs of students. While the nursing faculty possessed some of the expertise to teach the identified competencies, deficits were identified in teaching elements of accountable care. To address this challenge, school of nursing faculty met with colleagues across campus to identify graduate courses taught in other schools that help students develop these competencies. In addition, elective courses have been worked into the new master's curriculum to offer students a flexible array of courses that meet individual career objectives. Students choose from a list of courses from different disciplines or concentrations in business, marketing, informatics, biotechnology, communication, education, or special populations. A collaborative academic model allows for a richer, more selfdirected graduate experience with a great variety of coursework in the school of business, graduate education and counseling, arts and science, and the school of engineering. The second challenge identified was the need to create interprofessional learning opportunities for students in a university where the only health professional education is nursing. This is a common challenge across most of the nursing programs that exist in nonacademic medical centers. In fact, educational environments that support collaborative practice are non-existent in most of the programs that prepare health professionals. To overcome this barrier, faculty again sought guidance and support from practice partners.
In order to develop experiences that meet IPE competencies, school of nursing faculty, together with practice partners, have designed and developed clinical immersion experiences that integrate IPE for graduate nursing students. These experiences require students and faculty members, in conjunction with clinical preceptors, to collaborate in the development of innovative solutions to patient care and health care system problems to improve health care outcomes. This interprofessional work influences decision making and brings about change through graduate student leadership that can lead to improvement in the health and quality of life for all members of society. To evaluate the effectiveness of these competencies, students develop a practice portfolio that illustrates program outcomes. These interprofessional experiences will effectively prepare students for collaborative practice and, ultimately, improve the care of patients and families. The resulting curriculum (see Figure 1) provides students with opportunities to develop competencies in both clinical and nonclinical areas (e.g., business, systems management, and communication). Experiential learning opportunities and rigorous immersion experiences provide the foundation for the new master's in nursing leadership curriculum. This new model encompasses the curriculum essentials for CNL certification and expanded options for students with diverse interests that focus on supporting clinical care. It also meets the needs of partnering health care institutions and The Essentials of Master's Education in Nursing (AACN, 2011), The Future of Nursing recommendations (IOM, 2011), and the Core Competencies for Inter-professional Collaborative Practice (AACN, 2011). Most importantly, this new model exemplifies the future of health care by offering meaningful experiences with nonnursing disciplines and providing education and skills that reach beyond the nursing curriculum and are vital to the expanded role for nurse leaders in health care. Clinical experiences
Figure 1. Model of inputs and outcomes of a revised MSN curriculum.
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associated with this model have been designed with partnership health care facilities using a team-based approach to delivering quality patient care.
Summary and Conclusion To develop a model for the master's nursing education of the future, the nursing profession may simply look at the past. The health care system has undergone many changes over the past century and currently presents a number of demands on nurses to be prepared to lead health care systems and use technology to the fullest possible extend. Nursing schools must respond to the needs of the health care system by preparing graduates with the skill set to be leaders and change agents. Moving toward an interprofessional model of health professions education will lead to health care improvement and provide the foundation of curricular design. The model of master's level nursing education proposed herein has been developed collaboratively with other health professional colleagues and nonhealth professional colleagues and includes discussion with certifying and accrediting bodies that serve to guide master's nursing education. The new master's curriculum presented provides an innovative approach for nursing programs in academic settings that do not educate multiple health care professions in a common setting. The model maximizes resources by partnering with nonhealth care disciplines that are eager to work with nursing professionals. It also provides a model of IPE developed in collaborative with practice partners that supports the development of accountable, technology savvy, “collaborative practiceready” nurse leaders. The analytical outcomes, currently being collected from the first cohort of students, will add to the national conversation regarding the future of master's nursing education and international conversations on reforming education for health professionals.
References American Association of Colleges of Nursing. (2004). AACN position statement on the practice doctorate in nursing. Washington, DC: Author. American Association of Colleges of Nursing. (2006). End-ofprogram competencies & required clinical experiences for the clinical nurse leader. Washington, DC: Author. American Association of Colleges of Nursing. (2011). The essentials of master’s education in nursing. Washington, DC: Author. APRN Joint Dialogue Group Report. (2008). Consensus model for APRN regulation: Licensure, accreditation, certifica-
tion & education. Retrieved December 15, 2013 from http:// www.apna.org/files/public/JointDialogueReport.doc. Fain, J. (2012). National standards for diabetes selfmanagement and support: Updated and revised 2012. The Diabetes Educator, 38, 595. Flood, M. E. (2010). Best-laid plans: A century of nursing curricula. In S. Keating (Ed.). Curriculum Development and Evaluation in Nursing. (pp. 5–32). New York: Springer. Health Reform GPS. (2012). Reform overview, summary of health reform legislation. Retrieved December 15, 2013 from http://www.healthreformgps.org/summary-of-the-legislation/. Institute of Medicine. (2001). Crossing the quality chasm. Washington, DC: The National Academies Press. Institute of Medicine. (2011). The future of nursing: Leading change, advancing health. Washington, DC: The National Academies Press. Interprofessional Education Collaborative Expert Panel. (2011). Core competencies for interprofessional collaborative practice: Report of an expert panel. Washington, D.C.: Interprofessional Education Collaborative. Kaufman, N. (2012). The diabetes education and support revolution: A new role for diabetes educators. AADE in Practice, Summer, 2012, 4. Keeling, A. W. (2009). A brief history of advanced practice nursing in the United States. In A.B Hamric, J.A. Spross, & C.M. Hanson, (Eds.). Advanced Practice Nursing,(pp. 3-32). St. Louis: Saunders Elsevier Publishing. Larson, E. (2012). New rules for the game: Interdisciplinary education for health professional. Nursing Outlook, 60, 264–271. LifeWings. (2010). Teamwork skills workshop. Memphis TN: LifeWings Partners LLC. Medicity.com (2012). What is meaningful use? Retrieved December 15, 2012 from http://www.medicity.com/meaningfuluse-101.html. Pohl, J.M., Hanson, C., & Newland, J. (2010). Nurse practitioners as primary care providers: History, context, and opportunities. Commissioned paper by the Josiah Macy Foundation for their conference on “Primary Care: Who will provide it and how will they be trained?” Raleigh, NC. Reeves, S., Goldman, J., Burton, A., & Sawatzky-Girling, B. (2010). Synthesis of systematic review evidence of interprofessional education. Journal of Allied Health, 39, 198–203. The Registered Nurse Population: Findings from the 2008 National Sample Survey of Registered Nurses. September 2010. Rockville, MD: U.S. Department of Health and Human Services. World Health Organization (WHO). (2010). Framework for action on interprofessional education & collaborative practice. http://whqlibdoc.who.int/hq/2010/WHO_HRH_HPN_10. 3_eng.pdf. Yoder-Wise, P. S. (2011). The doctor of nursing practice: A national workforce perspective. Nursing Outlook, 59, 258.
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HE RECENT INSTITUTE of Medicine (IOM) report on the Future of Nursing states that nurses must achieve higher levels of education and training in response to…“increasing [healthcare] demands” (IOM, 2010, p. 2). This statement comes at a pivotal time in nursing education. Nurses interested in pursuing careers in advanced practice are now being educated at the doctoral level through new doctorate of nursing practice (DNP) degree programs. In light of this shift, master's programs in nursing are in a tenuous position, and it is questionable whether the remaining master's level educational programs (health care management, nursing education, and clinical nurse leader [CNL]) are meeting the needs of consumers, health care institutions, and students. The 2008 registered nurse (RN) Survey *Assistant Professor, †Professor and Associate Dean, ‡Dean and Professor, §Assistant Dean, Fairfield University, Fairfield, CT. Address correspondence to Sally O. Gerard: DNP, RN, CNL,CDE, Assistant Professor, Fairfield University, Fairfield, CT. E-mail: sgerard@ fairfield.edu 8755-7223 326 http://dx.doi.org/10.1016/j.profnurs.2014.01.005
conducted by the Bureau of Health Professions indicated that 19.2% of RNs who earned a master's degree enrolled in programs with a focus in administration, business, or management, 13.3% focused on education, and 5.9% earned public health degrees (Bureau of Health Professions, 2010; The Registered Nurse Population: Findings from the 2008 National Sample Survey of Registered Nurses. September 2010. Rockville, MD: U.S. Department of Health and Human Services.). Dr. Patricia S. YoderWise, President of the Council on Graduate Education for Administration of Nursing, summarized the situation by stating, “The absence of a nursing master's option could have unintended consequences of moving nurses in leadership roles to other fields to secure a master's degree. This further dilutes the knowledge needed to be highly effective in leading and managing the nursing team.” She further states that “eliminating the master's in nursing as part of the education progression could be counterproductive to patients and the profession” (Yoder-Wise, 2011, p. 258). Given the great need for clinical leadership in health care, it is essential to reexamine master's nursing education to ensure that educational institutions are
Journal of Professional Nursing, Vol 30, No. 4 (July/August), 2014: pp 326–332 © 2014 Elsevier Inc. All rights reserved.
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meeting the needs of graduate nursing students, consumers, and health care systems. Globally, there is a strong call for developing models of interprofessional education (IPE) and practice. Research supports that interprofessional models will lead to improvements in health care delivery and health outcomes (IPEC, 2011). The purpose of this article is to review master's education in nursing from the past to present to enhance understanding of the various types of educational programs that have developed over time and how society has influenced this development. The current demands in health care with potential to impact nursing education will be discussed, including the movement toward IPE and the broadened expertise expected of master'sprepared nurses working in an era of health care reform. Based on the educational history and the current needs of nurses in the present health care environment, the future of master's nursing education will be envisioned. The article concludes by presenting one curricular model for a master's in nursing program that meets the need for highly skilled nurse leaders in the 21st century.
History of Master's in Nursing Programs The education of master's-prepared nurses has a long and interesting history. Responding to new knowledge and growing technology in the early part of the twentieth century, nurses struggled to find answers to improve patient care through advanced education. A dearth of graduate nursing educational programs forced nurses to pursue advanced degrees in other disciplines such as education, business, and health care administration ( Flood, 2010). The fifties and sixties saw a great need to prepare nurse educators as the profession of nursing grew and expanded toward baccalaureate preparation. Despite the growing complexity in health care and the need for advanced clinical education, early master's programs in nursing focused more on developing nurse educators and administrators than expert clinicians. Many of the clinical specializations in nursing evolved from expanded roles in RN practice developed on the job. Certificate programs were developed for RNs interested in obtaining new knowledge and skills needed for these new and expanded roles. Eventually, the certificate programs evolved into formalized degree programs. The first clinical master's in nursing program began in the 1960s, educating nurses for roles as clinical nurse specialists (CNS). In response to the shortage of primary care physicians in the 1960s, the first nurse practitioner (NP) programs were developed. Pohl, Hanson, and Newland (2010) reported that the focus of the first NP role was to provide assessment and management of care for patients with acute and chronic health conditions with an emphasis on health promotion and wellness. The NP role has extended far beyond this original conceptualization toward the management of patients with complex medical conditions. By the early 1980s, the “advanced practice nursing” title described all advanced clinical nursing roles including CNSs, NPs, certified RN anesthetists, and certified nurse midwives.
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The later part of the 20th century witnessed a proliferation of master's degree clinical nursing programs aimed at preparing nurses for advanced practice and a decline of nonclinical master's degree programs for nurse educators and administrators. The subsequent decades continued to see increasing role definition and expansion of these advanced clinical roles culminating in the development of the advanced practice RN consensus statement in 2008 (APRN Joint Dialogue Group Report, 2008). This statement seeks to both unite and promote the continued role of advance practice nursing in the evolving health care system. As the clinical complexity of patient care continues to accelerate, along with the growth in knowledge, technology, and patient care resources, the need for clinical expertise continues to expand. In 2004, the American Association of Colleges of Nursing (AACN) called for the basic education of all Advanced Practice Registered Nurse (APRNs) to be at the doctoral level (AACN, 2004) through the attainment of DNP degrees. The Council on the Accreditation of Nurse Anesthetists states that this degree is required for the credentialing examination and licensure by 2025. While graduate nursing programs await decisions regarding minimum credentialing requirements for NP certification by the respective boards and subsequent changes in state licensing requirements, APRNs continue to be educated at both the master's and doctoral level. The movement away from nonclinical specialties at the master's level, followed by the current progress of clinical education of APRNs toward a DNP, is leaving a slow but steady decline of clinically focused master's programs available to students. Remaining clinical education at the master's level is largely the CNL, a role created in 2006 by the AACN to meet the rising complex health needs of patients within the health care system (AACN, 2006). CNL programs are distinctive in that they are developed with identified partnerships between academia and health care providers, ensuring that programs meet the needs of community employers. CNL graduates are prepared to meet the predominant health care challenges of the future, including rising technological advances in health care, needs of an aging population, chronic illness management, health disparities associated with socioeconomic dislocation, and health promotion and disease prevention (IOM, 2001). As of November 2013, the AACN Web site lists over 100 CNL programs nationwide (http://www.aacn.nche.edu/cnl/about/cnl-programs). Although CNLs continue to be essential in promoting positive patient outcomes in the health care delivery system, the integration and acceptance of this role has been limited. Keeling (2009) proposed that to predict the future of master's nursing education, one needs simply to look at the past. Each of the movements in graduate education was designed to meet a societal need. To prepare nursing educators and leaders, nurses often sought education among other disciplines until master's programs focusing on nursing education, health care management, and administration were developed. The need for nurses to
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administer anesthesia during war and deliver babies during the depression led to the development of clinical specializations in anesthesia and midwifery. Subsequent societal needs to provide primary and specialty care resulted in the growth and specialization of NP programs at both the master's and doctoral levels. The professional demands on the health care system today provide a framework for the future of nursing education and practice, as outlined in the landmark report from the IOM, The Future of Nursing: Leading Change, Advancing Health (2010). The growing emphasis on interdisciplinary health professional education will guide the evolution of new and innovative master's programs in nursing.
Current Demands of Health Care System Three elements can be viewed as substantial drivers of the rapidly changing health care landscape that support a revised blueprint for master's nursing education. The first consideration is the transformation toward a more accountable delivery system, and second is the use of technology to deliver care and engage consumers. Accountability and technology have dramatic implications on the complex processes that make up the broad spectrum of care. The third substantial driver in the current health care system is the movement toward interprofessional teams to meet the current and future health care needs of the population. This approach will be accomplished by the pooling of knowledge and skills across disciplines. Nurses are not only critical to these teams but also in the redesign of health care initiatives through planning, implementation, evaluation, and sustainability.
Accountability Never before have health care organizations been more committed to accountability, whether for the noble mission of “excellent care” or the practical mission to protect the “bottom line.” Gone are the days of accountability resting only with the top executives of an organization. Transparency of outcomes and financial incentives for achieving quality goals have forced organizations to take on a “bedside to boardroom” approach to improvement. High functioning health care organizations engage teams of direct caregivers to design process changes leading to improved outcomes. Many leaders lose sleep on a weekly, monthly, or quarterly basis awaiting the release of the most recent metrics measuring quality. No longer are these reports discussed behind closed doors with little sense of urgency. Data on quality indicators and dashboard topics are made available for all members of the health care team. Every individual involved in delivering care influences patient outcomes, and these measures have never been more scrutinized. While focus on accountability in health care today has a new set of challenges, it offers opportunities for improving processes, addressing fragmentation of care, and protecting vulnerable patients. In the past, it was
“acceptable” for organizations to have a certain percentage of unfortunate outcomes such as falls, infections, and frequent readmissions, which, essentially, had no negative financial implications. Currently, aggressive measures have been put into place by many hospitals to eliminate detrimental patient outcomes. Organizations are adapting standards from other industries to change attitudes about what is acceptable and strengthen the team approach to a culture of safety and excellence. This type of organizational transformation requires nurse leaders to possess a skill set different from years past.
Technology Another driver of change that incorporates accountability is meaningful use of health information technology, an umbrella term for rules and regulations that providers must meet to qualify for federal incentives under the American Recovery and Reinvestment Act of 2009 (www. medicity.com; Medicity.com, 2012). This legislation provides financial incentives to organizations using certified electronic health record (EHR) technology to improve the quality of care and submit quality measures to the Centers for Medicare and Medicaid Services. Adapting an EHR system and developing efficient, intuitive processes are daunting and expensive tasks for most of the organizations. Further, the skills to develop, evaluate, implement, and support these systems are substantial. Clearly, meaningful use will have a major impact on health care professionals in the next decade. Organizations across the nation have a new incentive to utilize technology with the specific aim of financial solvency. In a broader sense, every organization has challenges around the acquisition, implementation, and maintenance of all types of technology to deliver care. The expertise required in today's health care environment has included a steep upward trajectory from the complexity of EHRs to supply distribution, equipment tracking, patient monitoring, and telehealth, and communication devices. This phenomenon in health care has impacted the work of nurses and other health care providers in every setting. On the consumer side, technology has already changed how people approach their own care and gather information about providers. With easy access to information about diseases, medications, and treatments, consumers have a plethora of information available, although the quality of that information may be varied. As health care moves in to the future, continued advances will allow individuals to integrate technology and health information in unprecedented ways. Multiple approaches to patient support have become more critical because the new age of accountability impacts both providers and consumers. Health care delivery of the future calls for individuals to be accountable, adopt provider recommendations, and be fully engaged partners in their own health. This model will require new approaches to support and communication and may lead consumers to seek never-before-possible ways to interact with
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clinicians. The industry will respond with interventions that have yet to be considered. One example that illustrates the changing expectations of health care providers and consumers comes from the field of diabetes management. The American Association of Diabetes Educators recently released the 2012 revisions to their national standards of care. One significant change was the revision of the name of the standards to include the word support. The National Standards for Diabetes Self-Management Education and Support state that the rationale for this change stems from importance of support as an ongoing process of chronic illness (Fain, 2012). The new standards also place a stronger emphasis on frequent communication among team members to ensure high quality, effective education, and support for all people with diabetes and prediabetes (Fain, 2012). Technology, such as on-line education, blogs, and tailored messages on key behaviors, applications for mobile devices, on-line tracking of patient performance and goals, and opportunities to connect with providers, families, and friends for critical support, are all technology-related interventions projected to improve diabetes education and support (Kaufman, 2012). This example may be applied to the management of any chronic illness. The focus of new health care mandates, including increased accountability for conditions such as heart failure, has already been implemented; technology will no doubt be utilized as a resource for care. In any setting, the sophistication of knowledge required in the area of technology will be sizeable. Consumer expectations, coupled with the financial incentives from payers, will require a highly skilled and collaborative workforce.
Interprofessional Team Approach to Improved Care An emerging theme in health care that will demand changes for future health care providers focuses on the interprofessional health care team rather than individual disciplines. The World Health Organization (WHO, 2010, p. 7) states that “Interprofessional Education (IPE) happens when students from two or more health professions improve understanding about each other's roles to enhance effective collaboration and improve health outcomes. IPE is a necessary step in preparing a 'collaborative practice-ready' health workforce that is better prepared to respond to local health needs.” WHO (2010) reports that interprofessional learning environments improve the skills of all involved health professionals and health care outcomes for patients. In its Framework for Action on Interprofessional Education & Collaborative Practice, the organization stated, “there is now sufficient evidence to indicate that IPE enables effective collaborative practice which, in turn optimizes health-services, strengthens health systems and improves health outcomes” (WHO, 2010, p. 18). Effective collaborations among health care professionals positively impact outcomes such as length of hospital stay, readmissions, and mortality rates in both acute and primary care settings (WHO, 2010).
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Incorporation of IPE learning experiences into health professional curricula will enhance students' knowledge of, communication with, and attitudes about other health disciplines (Interprofessional Education Collaborative Expert Panel, 2011; Larson, 2012; Reeves, Goldman, Burton, and Sawatzky-Girling, 2010). According to the Interprofessional Education Collaborative Expert Panel (2011), IPE that primes health professions students to deliberately work together is a national imperative toward building a safer and better patientcentered U.S. health care system. In the most highperforming systems, a cadre of providers come together to collaborate, communicate, and partner with patients and families to provide optimal care. Health care providers must develop new skills to be effective members of teams providing the highest quality of care. Across the country, teams of practicing health care members are being educated together on topics such as teamwork, communication, safety, and quality. This culture will ensure that every member of the health care team has an ethical obligation to assume responsibility for the delivery of safe care (LifeWings, 2010). The new world of health care accountability and technology will be supported by an improved model of professional teamwork. Whether it is a primary care office, an emergency department or operative suite, teams of professionals are experiencing rapid changes in roles, skills, and demands. As a community, the team must work together running frontline care units that meet demands of the future. This expectation of “sharing the sandbox” and focusing on the patient may be the greatest challenge to developing new educational models. As outcomes become more visible and technology more sophisticated, collaborative care will become an expectation. The demands on the health care system will require highly educated and skilled clinical leaders, and nurses are positioned to meet these demands.
The Future of Master's Nursing Education The focus on accountability, technology, and interprofessional practice in health care provide a framework for master's nursing education for the next century. Moreover, health care reform will increase the number of Americans with insurance coverage to an estimated 94% of Americans (healthreformgps.org, 2012). This will require more primary care providers to care for patients, and nurses who take the leadership role in designing and managing accountable systems for the delivery of care by interprofessional teams. These pressures, along with dramatic advances in diagnostic, therapeutic, and educational technologies, will demand new consideration about master's education. The IOM report, The Future of Nursing: Leading Change, Advancing Health (2010) lays out a blueprint for how the nursing profession must adapt as it faces these challenges. The report states that “…high quality healthcare cannot be achieved without exceptional nursing care and leadership” (IOM, 2011, p. ix). The recommendations challenge educators to prepare and
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empower nurses to lead change to improve health care outcomes and expand opportunities for nurses to lead collaborative improvement efforts. It is imperative that master's nursing education be prepared to meet these challenges. Recognizing these trends, The AACN revised The Essentials of Master's Education in Nursing “to reflect the profession's continuing call for imagination, transformative thinking, and evolutional change” (AACN, 2011, p. 3). The 10 essentials form the core for all master's programs in nursing, along with the necessary curricular elements and framework. Although nursing programs throughout the country educate APRNs at both the master's and doctoral level and these practitioners begin to address the critical shortage of health care providers, there are few masters' programs focused on indirect roles for nurses. The health care system is demanding nurses that are educated at the master's level for roles focusing on health care systems that emphasize overall function of the organization. Thus, it becomes important to educate nurses for emerging roles in health care delivery and designed with the knowledge and skill sets needed to lead change, promote health, and elevate care in various roles and settings. These skills outlined in the Master's Essentials (AACN, 2011) include organizational leadership that requires systems thinking, facilitation of change, communication, finance and marketing expertise, understanding and management of information and health care technologies, and the ability to translate and integrate research into practice, particularly around the area of quality and safety. Master's graduates will be the leaders in accountable health care systems fostering the progression of interprofessional teams to meet the complex health care needs of the future. Given the current challenges, master's degree programs in nursing must be revised to meet the needs of the health care system for highly skilled clinical leaders. Nurses must be prepared at the systems level to manage accountable care organizations that make effective use of emerging technologies implemented through an interprofessional team approach. Many large academic medical centers around the country and around the world are moving forward with various elements of this model of education. However, despite these advances, the majority of nurses are educated outside of the Academic Medical Center in private and community nursing programs. These programs have a specific set of challenges related to the provision of interprofessional clinical experiences for students. Because of these logistical and possible financial challenges, innovations in the approach to education design and interprofessional partnerships are essential. To begin the development of a new model for master's nursing education in one school of nursing, we convened a focus group of area health care providers to discuss their organization's needs for master's-prepared nurses with specific knowledge and skills. Five executive nurse leaders, including chief nursing officers or their imme-
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diate designates participated, representing four large tertiary care facilities in the greater southern Connecticut area. Consistent with the literature, findings from this group revealed qualities that health care employers were looking for in nurses educated at the master's level to advance their organization in future decades. Many qualities were explored (see Text Box 1), but the overarching results supported the need for nurses prepared with the knowledge and skills to support systems redesign and utilize technology for cost efficient care. A critical component identified among focus group participants was that the ideal master's-prepared nurse leaders of the future must possess the knowledge and interpersonal skills to lead the interprofessional teams that are vital to the functioning of high-performing organizations. Following the focus group, faculty underwent a comprehensive assessment of the school of nursing's Master's of Science in Nursing (MSN) curriculum with the intent of integrating the results of the focus group along with The Essentials of Master's Education in Nursing (AACN, 2011), The Future of Nursing recommendations (IOM, 2011), and recommendations Text Box 1 Clinical Partner Focus Group Summary Employer vision of nurses as leaders in the next 10–20 years: Professionals who can identify, prioritize, implement, and evaluate system redesign Leaders of interdisciplinary care Creative seekers of systems improvements to enhance operations Financially minded health care professionals Outcome managers Transitional care specialists Knowledge and Skills needed to lead change: Fiscal knowledge to justify salary with outcomes Measurement of outcomes and basic statistics for evaluation of metrics Health promotion principles Interpretation of directives and standards Administrative skills such as staffing budgeting Succession management principles Members of the interprofessional team that students should work with: Financial specialists Health care administrators Patient safety specialists Information technology specialists Physicians System redesign specialists Allied health professionals Statisticians Nurse attorneys/risk specialists
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from the Core Competencies for Inter-professional Collaborative Practice (Interprofessional Education Collaborative Expert Panel (2011). An MSN program evaluation process was conducted whereby program outcomes and objectives were mapped against the essentials (AACN, 2011) and evaluated to ensure that graduates are prepared effectively at the master's level for practice in their chosen specialty areas. Two challenges were identified in developing effective curricula that met the AACN essentials and incorporated elements necessary for educational tracks that met the identified needs of students. While the nursing faculty possessed some of the expertise to teach the identified competencies, deficits were identified in teaching elements of accountable care. To address this challenge, school of nursing faculty met with colleagues across campus to identify graduate courses taught in other schools that help students develop these competencies. In addition, elective courses have been worked into the new master's curriculum to offer students a flexible array of courses that meet individual career objectives. Students choose from a list of courses from different disciplines or concentrations in business, marketing, informatics, biotechnology, communication, education, or special populations. A collaborative academic model allows for a richer, more selfdirected graduate experience with a great variety of coursework in the school of business, graduate education and counseling, arts and science, and the school of engineering. The second challenge identified was the need to create interprofessional learning opportunities for students in a university where the only health professional education is nursing. This is a common challenge across most of the nursing programs that exist in nonacademic medical centers. In fact, educational environments that support collaborative practice are non-existent in most of the programs that prepare health professionals. To overcome this barrier, faculty again sought guidance and support from practice partners.
In order to develop experiences that meet IPE competencies, school of nursing faculty, together with practice partners, have designed and developed clinical immersion experiences that integrate IPE for graduate nursing students. These experiences require students and faculty members, in conjunction with clinical preceptors, to collaborate in the development of innovative solutions to patient care and health care system problems to improve health care outcomes. This interprofessional work influences decision making and brings about change through graduate student leadership that can lead to improvement in the health and quality of life for all members of society. To evaluate the effectiveness of these competencies, students develop a practice portfolio that illustrates program outcomes. These interprofessional experiences will effectively prepare students for collaborative practice and, ultimately, improve the care of patients and families. The resulting curriculum (see Figure 1) provides students with opportunities to develop competencies in both clinical and nonclinical areas (e.g., business, systems management, and communication). Experiential learning opportunities and rigorous immersion experiences provide the foundation for the new master's in nursing leadership curriculum. This new model encompasses the curriculum essentials for CNL certification and expanded options for students with diverse interests that focus on supporting clinical care. It also meets the needs of partnering health care institutions and The Essentials of Master's Education in Nursing (AACN, 2011), The Future of Nursing recommendations (IOM, 2011), and the Core Competencies for Inter-professional Collaborative Practice (AACN, 2011). Most importantly, this new model exemplifies the future of health care by offering meaningful experiences with nonnursing disciplines and providing education and skills that reach beyond the nursing curriculum and are vital to the expanded role for nurse leaders in health care. Clinical experiences
Figure 1. Model of inputs and outcomes of a revised MSN curriculum.
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associated with this model have been designed with partnership health care facilities using a team-based approach to delivering quality patient care.
Summary and Conclusion To develop a model for the master's nursing education of the future, the nursing profession may simply look at the past. The health care system has undergone many changes over the past century and currently presents a number of demands on nurses to be prepared to lead health care systems and use technology to the fullest possible extend. Nursing schools must respond to the needs of the health care system by preparing graduates with the skill set to be leaders and change agents. Moving toward an interprofessional model of health professions education will lead to health care improvement and provide the foundation of curricular design. The model of master's level nursing education proposed herein has been developed collaboratively with other health professional colleagues and nonhealth professional colleagues and includes discussion with certifying and accrediting bodies that serve to guide master's nursing education. The new master's curriculum presented provides an innovative approach for nursing programs in academic settings that do not educate multiple health care professions in a common setting. The model maximizes resources by partnering with nonhealth care disciplines that are eager to work with nursing professionals. It also provides a model of IPE developed in collaborative with practice partners that supports the development of accountable, technology savvy, “collaborative practiceready” nurse leaders. The analytical outcomes, currently being collected from the first cohort of students, will add to the national conversation regarding the future of master's nursing education and international conversations on reforming education for health professionals.
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