Higher learning
Practice and education: Partnering to create a pipeline of nurse leaders By Cecil Holland, PhD, EdD, MSN, APRN, FNP
A
s the nursing profession navigates the 21st century, it’s increasingly important to consider the pipeline of future nurse leaders. As the landscape of the profession changes due to a multiplicity of factors, it’s crucial for nursing practice leaders and academic institutions to engage in critical conversations and partnerships to sustain leadership capacity in the nursing profession. Paramount in these conversations and partnerships is evaluation of leadership curricula; identification of requisite leadership competencies and skills in nurse managers, RNs, and nursing students; developing leadership competencies and skills as nursing students matriculate through nursing programs; and creating opportunities for leadership mentoring. As the profession continues to face challenges directly related to the nursing workforce shortage, such as decreased enrollment in nursing schools, nursing faculty shortages, an aging nursing workforce, and expected nurse manager and leader retirement, it’s incumbent on academicians, clinicians, and practice leaders to consider the impact these variables will have on the future nurse leader workforce. Data suggest that a significant segment of the RN workforce is reaching retirement age. With over 55% of the nurse workforce age 50 and older, the healthcare landscape may be in serious trouble.1 This article shares the perspective of collaborative engagement between practice and education in addressing the critical need of increasing the pipeline of future nurse leaders. 8 January 2015 • Nursing Management
Decreased nursing school enrollments There appears to be a direct correlation between decreased enrollment in nursing programs and the availability of future nurse leaders. Data suggest that enrollment in nursing schools isn’t growing fast enough to keep up with the future demand necessary for a sustainable workforce.1 As the profession considers strategies to increase enrollment, attention to diversity and representation of underserved and underrepresented populations is imperative. The evidence suggests that patients prefer healthcare providers who “look like them.”2 The data also suggest that the quality of patient care and health outcomes increases when the healthcare provider resembles the patient for whom he or she is caring. Knowing this, nursing programs should increase efforts to connect with underserved and underrepresented populations, and healthcare administrators and nurse leaders should examine hiring strategies and the proportion of underrepresented nurses. In order for there to be a pipeline of diverse students, nursing schools must first diversify their student population. Together, practice and education can share in the marketing efforts, recruitment strategies, and admissions processes. Leveraging these types of collaborative efforts and coordinated campaigns will ensure an increase in nursing school enrollments and nursing student diversity, thus influencing a more diverse nurse leader workforce and the future of dynamic, diverse nurse leaders.2,3 Addressing the aging nursing workforce According to the Health Resources and Services Administration, the nursing profession will experience more than 1 million RNs reaching retirement age within the next 10 to 15 years. By 2020, it’s projected that over half of all RNs in the United States will reach retirement age.4 Many of these nurses are leaders in their respective specialties. This significant reduction in the nursing workforce will leave considerable gaps in nurse leader positions. To effectively address this foreseeable issue, shared responsibilities and collaborative efforts must ensue. www.nursingmanagement.com
Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Higher learning Practice and education need to examine critical factors that impact the aging nursing workforce and collaboratively create solutions or strategies for addressing this national trend. According to the Institute of Medicine report Retooling for an Aging America: Building the Health Care Workforce, more needs to be done at every level to retain older healthcare professionals, particularly within the nursing workforce.5 The report suggests that nurse leaders should provide adequate resources necessary to retain the older nurse, including creating less physically demanding jobs, the use of assistive technology, creating team-oriented work structures, and implementing alternative and flexible work schedules.5,6 Providing for and/or supporting this type of work environment is believed to have a positive impact on retaining the older, more experienced nurse, which is important because research supports the value that the experienced nurse brings to the healthcare landscape in terms of quality health services and improved health services outcomes.7,8 Value and respect experienced nurses for who they are and what they bring to the workforce. Recognize the changing healthcare landscape and nurse profile in the context of the broader labor market and capitalize on the vast talents of the older nurse.8,9 For example, Microsoft reports that older workers are needed not only because of their skills and experiences, but because there are fewer new or young workers in the pipeline.8,10 As the healthcare demands of an aging population continue to grow, retaining a sustainable, well-trained nursing workforce becomes critical in both practice and education arenas. Experts believe that experienced nurses can provide a valuable service as mentors or coaches for www.nursingmanagement.com
new and/or less experienced colleagues. As mentors or coaches, experienced nurses can assist in identifying and grooming the next cadre of nurse leaders. A retention strategy for older nurses is to prepare them (those with requisite skills and talent) for leadership positions. Investing in the experienced nurse via retooling and retraining allows healthcare organizations to maintain a viable workforce of skilled nurses who can continue to contribute to quality healthcare delivery and an organization’s bottom line in meaningful ways.4,9 Identifying future leaders Identifying the next cadre of nurse leaders is a significant first step in closing the nurse leader chasm. To find the next generation of leaders, look within the current landscape of your institution. Organizations should be intentional in terms of directing their investment toward leader development and identifying potential leader talent within that might otherwise be missed. Employing various leadership assessment tools may assist in identifying the next team of nurse leaders, as well as provide direction for leadership succession planning and development. One such tool is the Growth Factor Inventory (GFI). Although performance may be an indicator of potential leadership ability, it isn’t the “sure all” indicator. For many nurse leaders, it may be challenging to distinguish between good performance and future potential leadership capacity; thereby increasing the likelihood that some good leaders may be missed or the wrong nurse may advance to a leadership position. Using the GFI to measure characteristics from mentoring and coaching to formal leadership skills and traits, nurse leaders, nurse educators, and administrators are better able to identify
Table 1: How to identify potential leadership capabilities Nursing students and clinical nurses need to see themselves as leaders, understand the importance of their role as potential nurse leaders, and demonstrate confidence because self-confidence is a key competence for leaders. It’s also important to have the courage to take calculated risks. A nurse’s ability to lead depends on his or her ability to take risks and manage complex situations. Nurses and nursing students should also demonstrate the art of effective communication. Being able to listen and clearly articulate increases leadership capacity. Nursing students and clinical nurses with leadership potential need to identify a mentor or coach and watch and learn from that individual. They should pay particular attention to the mentor/coach’s ability to lead effectively and emulate those skills. By recognizing these attributes, nurse leaders, educators, and clinicians are poised to help develop future nurse leaders.
readiness to lead among those who have the propensity to become outstanding nurse leaders. The GFI readiness indicators include being eager to learn, demonstrating a breadth of perspective, understanding others, and displaying personal maturity.11 It’s imperative that nurse leaders, educators, and clinicians recognize the potential leadership capability in nursing students and clinical nurses and develop that potential. Nurses should also engage in selfassessments to determine their leadership potential. These assessments identify not only leadership styles, but essential skills necessary for effective leadership. (See Table 1.) Collaboratively, practice and education must engage in opportunities to invest in nursing students via internships, apprenticeships, in-service and continuing education, and so on. Collaborating in leadership curricula, utilizing nurse executives/leaders to assist in teaching leadership courses, sharing human resources, and providing mentoring and shadowing opportunities are strategies that can
Nursing Management • January 2015 9
Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Higher learning be employed to facilitate leadership skill development. It’s evident that the development of nurse leaders should start early during the nursing education phase; however, continuation beyond the formal education phase into practice is essential.4,12,13 Creating a sustainable pipeline of nurse leaders In order to effectively address the issue of sustainability, practice and education need to engage in critical conversations and actions that facilitate sustaining a viable pipeline of nurse leaders. One suggestion is joint leadership succession planning. Practice and education can confer and identify potential students who exhibit leadership skills, develop leadership and mentoring plans specifically designed to augment those skills, and jointly participate as partners in the implementation and evaluation of the leadership and mentoring plans. Providing opportunities for leadership shadowing experiences, especially for nursing students, may contribute to a sustainable pipeline because it allows a firsthand view of leadership in action and what an effective and/or perhaps an ineffective leader looks like. Leadership tracks and career ladders are means for a sustainable pipeline of nurse leaders and should be considered as potential nurse leaders are sought. To begin the conversation, practice nurse leaders should contact nurse leaders in academic institutions. Discussion regarding leadership curricula and identification and development of talents, competencies, and skills of potential leaders should ensue. Nurse leaders may want to consider serving on advisory boards of the universities and colleges that educate and train their nursing workforce. This allows opportunities to further dialog about workforce needs and other opportunities to partner. Serving as adjunct
faculty and/or a visiting professor gives the nurse leader another opportunity to identify and recruit potential future nurse leaders while participating in their development. Building and sustaining a healthy work environment is paramount in creating a sustainable pipeline. Nurse leaders can help create an inviting and warm work environment by engaging staff members and students in the development of shared values. Creating a culture of engagement is an important aspect of support and sustainability. Any opportunity that nurse leaders have to participate in the development of nursing students and clinical nurses increases the potential pipeline of future leaders.14 Closing the nurse leadership chasm Practice and education can partner to close the nurse leader chasm. Opportunities exist to collaborate regarding the development of the next generation of nurse leaders. By working together, practice and education can undertake the challenges of decreased enrollment in nursing schools, identify potential new talent, develop leadership pathways, create opportunities for mentoring and shadowing, create synergy between practice and education, retool and/ or retrain an aging nurse workforce, and create a sustainable pipeline of nurse leaders for the 21st century. When nurse leaders are active and engaged in recruiting and retaining nurse leaders, the return on investment is substantial. NM
REFERENCES 1. American Association of Colleges of Nursing. Nursing shortage fact sheet. http://www. aacn.nche.edu/media-relations/fact-sheets/ nursing-shortage. 2. American Association of Colleges of Nursing. Amid nursing shortages, schools employ strategies to boost enrollment. http://www.aacn.nche.edu/aacn-publica tions/issue-bulletin/boost-enrollment. 3. American Association of Colleges of Nursing. Effective strategies for increasing diversity in
10 January 2015 • Nursing Management
nursing programs. http://www.aacn.nche. edu/aacn-publications/issue-bulletin/effective-strategies. 4. Harrington L, Heidkamp M. The aging workforce: challenges for the health care industry workforce. http://www.dol.gov/odep/ pdf/NTAR-AgingWorkforceHealthCare.pdf. 5. Institute of Medicine. Retooling for an aging America: building the healthcare workforce. http://www.iom.edu/~/media/Files/ Report%20Files/2008/Retooling-for-anAging-America-Building-the-Health-CareWorkforce/ReportBriefRetoolingforanAging AmericaBuildingtheHealthCareWorkforce.pdf. 6. Sweet S, Pitt-Catsouphes M, Besen E, Hovhannisyan S, Pasha F. Talent pressures and the aging workforce: responsive action steps for the health care and social assistance sector. http://www.bc.edu/content/dam/ files/research_sites/agingandwork/pdf/ publications/TMISR02_HealthCare.pdf. 7. The Victorian Government Initiative. Value added: the wisdom of older nurses at work. http://www.health.vic.gov.au/__ data/assets/pdf_file/0019/507070/ web-bookmarked-version-value-added.pdf. 8. Robert Wood Johnson Foundation. Wisdom at work: the importance of the older and experienced nurse in the workplace. http:// www.rwjf.org/content/dam/supplementaryassets/2006/06/wisdomatwork.pdf. 9. Dols J, Landrum P, Wieck KL. Leading and managing an intergenerational workforce. Creat Nurs. 2010;16(2):68-74. 10. Microsoft. The changing workforce. http:// www.microsoft.com/issues/essays/2003/ 04-09aging.mspx?pf=true. 11. Hays Group. Growth factor inventory. http://www.haygroup.com/leadership andtalentondemand/ourproducts/item_ details.aspx?itemid=91&type=1&gclid=C PXS3quZucECFabm7AodpCgA_w&t=2. 12. Scoble KB, Russell G. Vision 2020, part I: profile of the future nurse leader. J Nurs Adm. 2003;33(6):324-330. 13. Curtis EA, de Vries J, Sheerin FK. Developing leadership in nursing: exploring core factors. Br J Nurs. 2011;20(5):306-309. 14. Sherman R, Pross E. Growing future nurse leaders to build and sustain healthy work environments at the unit level. The Online Journal of Issues in Nursing. 2010;15(1). Cecil Holland is an assistant dean of Admissions, Student Affairs, and Program Effectiveness at Winston-Salem State University in WinstonSalem, N.C. The author has disclosed that he has no financial relationships related to this article. DOI-10.1097/01.NUMA.0000459100.79105.1b
www.nursingmanagement.com
Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Practice and education: Partnering to create a pipeline of nurse leaders By Cecil Holland, PhD, EdD, MSN, APRN, FNP
A
s the nursing profession navigates the 21st century, it’s increasingly important to consider the pipeline of future nurse leaders. As the landscape of the profession changes due to a multiplicity of factors, it’s crucial for nursing practice leaders and academic institutions to engage in critical conversations and partnerships to sustain leadership capacity in the nursing profession. Paramount in these conversations and partnerships is evaluation of leadership curricula; identification of requisite leadership competencies and skills in nurse managers, RNs, and nursing students; developing leadership competencies and skills as nursing students matriculate through nursing programs; and creating opportunities for leadership mentoring. As the profession continues to face challenges directly related to the nursing workforce shortage, such as decreased enrollment in nursing schools, nursing faculty shortages, an aging nursing workforce, and expected nurse manager and leader retirement, it’s incumbent on academicians, clinicians, and practice leaders to consider the impact these variables will have on the future nurse leader workforce. Data suggest that a significant segment of the RN workforce is reaching retirement age. With over 55% of the nurse workforce age 50 and older, the healthcare landscape may be in serious trouble.1 This article shares the perspective of collaborative engagement between practice and education in addressing the critical need of increasing the pipeline of future nurse leaders. 8 January 2015 • Nursing Management
Decreased nursing school enrollments There appears to be a direct correlation between decreased enrollment in nursing programs and the availability of future nurse leaders. Data suggest that enrollment in nursing schools isn’t growing fast enough to keep up with the future demand necessary for a sustainable workforce.1 As the profession considers strategies to increase enrollment, attention to diversity and representation of underserved and underrepresented populations is imperative. The evidence suggests that patients prefer healthcare providers who “look like them.”2 The data also suggest that the quality of patient care and health outcomes increases when the healthcare provider resembles the patient for whom he or she is caring. Knowing this, nursing programs should increase efforts to connect with underserved and underrepresented populations, and healthcare administrators and nurse leaders should examine hiring strategies and the proportion of underrepresented nurses. In order for there to be a pipeline of diverse students, nursing schools must first diversify their student population. Together, practice and education can share in the marketing efforts, recruitment strategies, and admissions processes. Leveraging these types of collaborative efforts and coordinated campaigns will ensure an increase in nursing school enrollments and nursing student diversity, thus influencing a more diverse nurse leader workforce and the future of dynamic, diverse nurse leaders.2,3 Addressing the aging nursing workforce According to the Health Resources and Services Administration, the nursing profession will experience more than 1 million RNs reaching retirement age within the next 10 to 15 years. By 2020, it’s projected that over half of all RNs in the United States will reach retirement age.4 Many of these nurses are leaders in their respective specialties. This significant reduction in the nursing workforce will leave considerable gaps in nurse leader positions. To effectively address this foreseeable issue, shared responsibilities and collaborative efforts must ensue. www.nursingmanagement.com
Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Higher learning Practice and education need to examine critical factors that impact the aging nursing workforce and collaboratively create solutions or strategies for addressing this national trend. According to the Institute of Medicine report Retooling for an Aging America: Building the Health Care Workforce, more needs to be done at every level to retain older healthcare professionals, particularly within the nursing workforce.5 The report suggests that nurse leaders should provide adequate resources necessary to retain the older nurse, including creating less physically demanding jobs, the use of assistive technology, creating team-oriented work structures, and implementing alternative and flexible work schedules.5,6 Providing for and/or supporting this type of work environment is believed to have a positive impact on retaining the older, more experienced nurse, which is important because research supports the value that the experienced nurse brings to the healthcare landscape in terms of quality health services and improved health services outcomes.7,8 Value and respect experienced nurses for who they are and what they bring to the workforce. Recognize the changing healthcare landscape and nurse profile in the context of the broader labor market and capitalize on the vast talents of the older nurse.8,9 For example, Microsoft reports that older workers are needed not only because of their skills and experiences, but because there are fewer new or young workers in the pipeline.8,10 As the healthcare demands of an aging population continue to grow, retaining a sustainable, well-trained nursing workforce becomes critical in both practice and education arenas. Experts believe that experienced nurses can provide a valuable service as mentors or coaches for www.nursingmanagement.com
new and/or less experienced colleagues. As mentors or coaches, experienced nurses can assist in identifying and grooming the next cadre of nurse leaders. A retention strategy for older nurses is to prepare them (those with requisite skills and talent) for leadership positions. Investing in the experienced nurse via retooling and retraining allows healthcare organizations to maintain a viable workforce of skilled nurses who can continue to contribute to quality healthcare delivery and an organization’s bottom line in meaningful ways.4,9 Identifying future leaders Identifying the next cadre of nurse leaders is a significant first step in closing the nurse leader chasm. To find the next generation of leaders, look within the current landscape of your institution. Organizations should be intentional in terms of directing their investment toward leader development and identifying potential leader talent within that might otherwise be missed. Employing various leadership assessment tools may assist in identifying the next team of nurse leaders, as well as provide direction for leadership succession planning and development. One such tool is the Growth Factor Inventory (GFI). Although performance may be an indicator of potential leadership ability, it isn’t the “sure all” indicator. For many nurse leaders, it may be challenging to distinguish between good performance and future potential leadership capacity; thereby increasing the likelihood that some good leaders may be missed or the wrong nurse may advance to a leadership position. Using the GFI to measure characteristics from mentoring and coaching to formal leadership skills and traits, nurse leaders, nurse educators, and administrators are better able to identify
Table 1: How to identify potential leadership capabilities Nursing students and clinical nurses need to see themselves as leaders, understand the importance of their role as potential nurse leaders, and demonstrate confidence because self-confidence is a key competence for leaders. It’s also important to have the courage to take calculated risks. A nurse’s ability to lead depends on his or her ability to take risks and manage complex situations. Nurses and nursing students should also demonstrate the art of effective communication. Being able to listen and clearly articulate increases leadership capacity. Nursing students and clinical nurses with leadership potential need to identify a mentor or coach and watch and learn from that individual. They should pay particular attention to the mentor/coach’s ability to lead effectively and emulate those skills. By recognizing these attributes, nurse leaders, educators, and clinicians are poised to help develop future nurse leaders.
readiness to lead among those who have the propensity to become outstanding nurse leaders. The GFI readiness indicators include being eager to learn, demonstrating a breadth of perspective, understanding others, and displaying personal maturity.11 It’s imperative that nurse leaders, educators, and clinicians recognize the potential leadership capability in nursing students and clinical nurses and develop that potential. Nurses should also engage in selfassessments to determine their leadership potential. These assessments identify not only leadership styles, but essential skills necessary for effective leadership. (See Table 1.) Collaboratively, practice and education must engage in opportunities to invest in nursing students via internships, apprenticeships, in-service and continuing education, and so on. Collaborating in leadership curricula, utilizing nurse executives/leaders to assist in teaching leadership courses, sharing human resources, and providing mentoring and shadowing opportunities are strategies that can
Nursing Management • January 2015 9
Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Higher learning be employed to facilitate leadership skill development. It’s evident that the development of nurse leaders should start early during the nursing education phase; however, continuation beyond the formal education phase into practice is essential.4,12,13 Creating a sustainable pipeline of nurse leaders In order to effectively address the issue of sustainability, practice and education need to engage in critical conversations and actions that facilitate sustaining a viable pipeline of nurse leaders. One suggestion is joint leadership succession planning. Practice and education can confer and identify potential students who exhibit leadership skills, develop leadership and mentoring plans specifically designed to augment those skills, and jointly participate as partners in the implementation and evaluation of the leadership and mentoring plans. Providing opportunities for leadership shadowing experiences, especially for nursing students, may contribute to a sustainable pipeline because it allows a firsthand view of leadership in action and what an effective and/or perhaps an ineffective leader looks like. Leadership tracks and career ladders are means for a sustainable pipeline of nurse leaders and should be considered as potential nurse leaders are sought. To begin the conversation, practice nurse leaders should contact nurse leaders in academic institutions. Discussion regarding leadership curricula and identification and development of talents, competencies, and skills of potential leaders should ensue. Nurse leaders may want to consider serving on advisory boards of the universities and colleges that educate and train their nursing workforce. This allows opportunities to further dialog about workforce needs and other opportunities to partner. Serving as adjunct
faculty and/or a visiting professor gives the nurse leader another opportunity to identify and recruit potential future nurse leaders while participating in their development. Building and sustaining a healthy work environment is paramount in creating a sustainable pipeline. Nurse leaders can help create an inviting and warm work environment by engaging staff members and students in the development of shared values. Creating a culture of engagement is an important aspect of support and sustainability. Any opportunity that nurse leaders have to participate in the development of nursing students and clinical nurses increases the potential pipeline of future leaders.14 Closing the nurse leadership chasm Practice and education can partner to close the nurse leader chasm. Opportunities exist to collaborate regarding the development of the next generation of nurse leaders. By working together, practice and education can undertake the challenges of decreased enrollment in nursing schools, identify potential new talent, develop leadership pathways, create opportunities for mentoring and shadowing, create synergy between practice and education, retool and/ or retrain an aging nurse workforce, and create a sustainable pipeline of nurse leaders for the 21st century. When nurse leaders are active and engaged in recruiting and retaining nurse leaders, the return on investment is substantial. NM
REFERENCES 1. American Association of Colleges of Nursing. Nursing shortage fact sheet. http://www. aacn.nche.edu/media-relations/fact-sheets/ nursing-shortage. 2. American Association of Colleges of Nursing. Amid nursing shortages, schools employ strategies to boost enrollment. http://www.aacn.nche.edu/aacn-publica tions/issue-bulletin/boost-enrollment. 3. American Association of Colleges of Nursing. Effective strategies for increasing diversity in
10 January 2015 • Nursing Management
nursing programs. http://www.aacn.nche. edu/aacn-publications/issue-bulletin/effective-strategies. 4. Harrington L, Heidkamp M. The aging workforce: challenges for the health care industry workforce. http://www.dol.gov/odep/ pdf/NTAR-AgingWorkforceHealthCare.pdf. 5. Institute of Medicine. Retooling for an aging America: building the healthcare workforce. http://www.iom.edu/~/media/Files/ Report%20Files/2008/Retooling-for-anAging-America-Building-the-Health-CareWorkforce/ReportBriefRetoolingforanAging AmericaBuildingtheHealthCareWorkforce.pdf. 6. Sweet S, Pitt-Catsouphes M, Besen E, Hovhannisyan S, Pasha F. Talent pressures and the aging workforce: responsive action steps for the health care and social assistance sector. http://www.bc.edu/content/dam/ files/research_sites/agingandwork/pdf/ publications/TMISR02_HealthCare.pdf. 7. The Victorian Government Initiative. Value added: the wisdom of older nurses at work. http://www.health.vic.gov.au/__ data/assets/pdf_file/0019/507070/ web-bookmarked-version-value-added.pdf. 8. Robert Wood Johnson Foundation. Wisdom at work: the importance of the older and experienced nurse in the workplace. http:// www.rwjf.org/content/dam/supplementaryassets/2006/06/wisdomatwork.pdf. 9. Dols J, Landrum P, Wieck KL. Leading and managing an intergenerational workforce. Creat Nurs. 2010;16(2):68-74. 10. Microsoft. The changing workforce. http:// www.microsoft.com/issues/essays/2003/ 04-09aging.mspx?pf=true. 11. Hays Group. Growth factor inventory. http://www.haygroup.com/leadership andtalentondemand/ourproducts/item_ details.aspx?itemid=91&type=1&gclid=C PXS3quZucECFabm7AodpCgA_w&t=2. 12. Scoble KB, Russell G. Vision 2020, part I: profile of the future nurse leader. J Nurs Adm. 2003;33(6):324-330. 13. Curtis EA, de Vries J, Sheerin FK. Developing leadership in nursing: exploring core factors. Br J Nurs. 2011;20(5):306-309. 14. Sherman R, Pross E. Growing future nurse leaders to build and sustain healthy work environments at the unit level. The Online Journal of Issues in Nursing. 2010;15(1). Cecil Holland is an assistant dean of Admissions, Student Affairs, and Program Effectiveness at Winston-Salem State University in WinstonSalem, N.C. The author has disclosed that he has no financial relationships related to this article. DOI-10.1097/01.NUMA.0000459100.79105.1b
www.nursingmanagement.com
Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
