1. Porter-O'Grady, Tim DM, EdD, ScD(h), FAAN

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It isn't accidental that the IOM began its report "The Future of Nursing: Leading Change, Advancing Health" with the heading "A Vision for Health Care." Equally important is the emphasis in the report on the need for leadership necessary to transform this vision into reality. In fact, Key Message 3 specifically challenges nurses to demonstrate full partnership with physicians and other health professionals in redesigning U.S. healthcare. Further, on the same page, the IOM specifically enumerates nursing's positioning, and its adaptive capacity provides the profession with a unique opportunity for leading health transformation.1

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The IOM specifically recognizes the need for strong and capable leadership if the vision for transforming healthcare is to ever be realized. The report suggests that the nursing profession must produce leaders at every level of the system and accept key leadership positions in policy, politics, organizations, and practice. As the requisites of transformation and implementation of health reform demand, nurses must exhibit leadership capacity and high-level collaborative skills at every place in the system and in every way that affects advancing the potential for contemporary high-quality patient care.


Full partnership in the leadership of collaboration requires a unique set of skills. Because of nursing's pivotal position in the patient care arena, it's naturally disposed to coordinating, integrating, and facilitating the team practices necessary to create mutual commitment between the disciplines. Nurse leaders are charged with facilitating action to devise and implement the appropriate change strategies necessary to increase quality, access, and value in a patient-centered care environment.2 Indeed, the IOM emphasized that the development of these leadership capacities is fundamental to advancing the profession. The requisite of the profession, therefore, is to ensure that the potential for leadership capacity is advanced through incorporation of leadership development at every level of nursing education and practice in both the academic and clinical environments.


The report challenges our profession to take responsibility for individual and professional growth in developing appropriate leadership competencies. In fact, the report suggests that neither the profession nor patient care can advance through the complexities of contemporary change and transformation without developing a renewed focus on leadership capacities at every level of practice.3



The Future of Nursing report makes specific recommendations related to the advancement of nursing leadership. Recommendation 2 emphasizes the need for nurses to "lead in diffuse collaborative improvement efforts."4 Here, the report emphasizes the need for nurses to lead:


-the development and evaluation of payment models affecting the delivery of nursing care.


-the collaboration and pooling of funds to advance research on models of care and innovative solutions to patient-care problems.


-the creation and adoption of innovative patient-centered care models.


-improvements in innovation in medical and health devices and information technology.


-entrepreneurial opportunities for nurses to initiate programs and businesses directed to improving health and healthcare.


The report clearly calls for nurses to assume primary responsibility for personal and professional growth through efforts that continue individual education and opportunities that develop and advance the exercise of leadership skills. The recommendation further identifies the need for a wide variety of nursing bodies to accelerate their attention in providing leadership development, mentoring programs, and opportunities for nurses. Further emphasis on integrating leadership theory and sound business practices across the curriculum and in the arena of clinical practice is identified by the report as vital. The final challenge of the recommendation is that public-private and governmental healthcare decision-making bodies at every level should include representation from the nursing profession on their boards, executive management teams, and in key leadership positions.5



The report also devotes considerable attention to the IOM's call for transformative nursing leadership. Specifically, it targets the development of those leadership capacities that demonstrate nursing's ability to act as a full partner with other disciplines and key players in the arena of healthcare decision making. In these interdisciplinary care environments, real partnership requires the assumption of full responsibility for leading and coordinating efforts that identify problems related to waste, care improvement, tracking quality improvement, and achieving established goals. The obligation of nursing advocacy for high-quality patient care creates a requisite that nurses provide leadership and be fully involved in decisions related to improving and advancing care delivery.


Full partnership creates an increasing demand for nurses to play a stronger role in the health policy arena, the report suggests. Nurses at every level of practice must see policy as something they're obligated to shape rather than something that happens to them over which they have no control. To adequately address the demand for policy involvement, the education of the nurse must include political dynamics and the management of complex multifocal relationships. This challenge for leadership involvement is twofold: (1) contemporary policy leaders must now see nurses as essential and equal partners in policy decisions at the national, regional, local, institutional, and practice levels; and (2) nurses must see themselves as essential policy leaders responsible for identifying roles and opportunities for policy leadership in their own commitment to be personally engaged in policy decisions at the national, regional, local, institutional, and practice levels.


A new style

In the contemporary healthcare environment, nurses, physicians, patients, and other health professionals are increasingly interdependent. Singular solutions don't adequately address the kinds of complex problems presented to patient-care decision makers. A new kind of partnership-based leadership will be necessary to improve patient outcomes, reduce errors, and impact staff engagement and satisfaction. The repeated evidence of the benefits of collaboration hasn't yet been well articulated into the activities of health professionals across the health system. Changing this culture, although not easy, will be essential to advancing quality healthcare.6


The need for collaborative engagement strategies is now essential to good practice at every level of leadership. The priority need in adjusting the historic culture represented by silo behaviors is the development of collaborative management structures and strategies. Nurses, physicians, and all health professions now must work diligently to demolish hierarchical silos and develop a mutual accountability for advancing quality and reducing error. In addition, nurses must refine their inherent adaptive capacity in advancing their ability to embrace the continually evolving healthcare dynamic and successfully engaging others in transforming care.


Nurses have an additional burden of historic preconceptions, gender references and biases, and inaccurate perceptions driven by historic views of nurses as "functional doers," as those who carry out the instruction of others.7 Nurses are often not seen as thoughtful strategists whose decisions are informed and whose actions are based on a body of knowledge, education, evidence, and experience. Although the report suggests that nurses are almost universally perceived as needing to have greater influence on health decision making, the common perceptions also indicate that they generally don't.


Two sets of competencies are specifically noted in the IOM report as requisites for more effective leadership on the part of nurses; a critical set of competencies that form the foundation for any level of effective leadership and a narrower specific set of competencies that reflect a more particular time and place.8 Leadership competencies that emphasize the development of collaborative skills in the leadership of diverse teams from different disciplines are emphasized as an essential skill set for future nursing leaders.


A call to lead

The report recognizes that leadership must unfold at every level of nursing practice and across every practice setting.9 Establishing a disciplinary locus of control is an essential point of reference from which to value the nursing discipline and translate its key role in coordinating, integrating, and facilitating essential interprofessional roles and relationships around patient care. Each setting, of course, provides different demands, requiring more specific and detailed leadership applications relevant to the needs of the setting and the kinds of service relationships expressed there.


Further emphasis in the report recognizes the value of innovation in the expression of the leadership role. Creating innovative care models in the patient's setting and throughout the healthcare community is an essential requisite of contemporary practice. Innovation must operate at every level of leadership, recognizing the need to transform practice, practitioners, health systems, and health service models using multimodal methodologies and a wide variety of emergent innovation tool-sets necessary to advance creative and high-utility solutions.


The need for innovation and creative solutions with regard to contemporary nursing and patient-care issues can be evidenced in the demand for new service structures, education models, practice models, interdisciplinary practice processes, and the advancement of newer entrepreneurial approaches to advancing quality healthcare. Opportunities for innovation and leadership need to be expressed across the full range of nursing: student, practitioner, clinical leader, manager, executive, and board member. Each of these roles provides a range of opportunities to make essential changes that affect the growth, development, and utility of nursing roles from nursing student to nurse researcher and executive. The report emphasizes the need for nurses in each of these capacities to hear a specific call to leadership from within the role in a way that commits to making a significant and particular difference in advancing the role of the profession, its relationships, and the people nurses serve.


The report makes a specific plea to the nursing profession and nursing organizations with regard to their relationships and interactions within. When nurses can't achieve internal agreement, essential decisions depending on agreement simply aren't made and the critical issues requiring collective action remain unaddressed. Although interdisciplinary consensus and collaboration are essential to advancing quality health service, advocacy within the discipline is vitally important when interdisciplinary decision making must be informed by discipline-specific advocacy that positively advances quality patient care.


Good leadership implies discipline-specific strategies for dispute resolution and consensus seeking, thus creating an internal disciplinary dynamic for mediating diversities of views and/or positions to arrive at the interdisciplinary table having achieved a level of consensus and a well-articulated position that contributes to interdisciplinary dialogue and decision making.


Finally, the leadership call for the profession represents the need for nurses to play a central role in mechanisms of patient quality and safety. Nurses and nursing organizations must see themselves as critical purveyors representing the professional mission directed to advancing the quality, safety, and value of patient-centered healthcare for individuals, families, and communities. Working with other disciplines and the profession's own Nursing Alliance for Quality Care, a unique opportunity presents itself for nurses to speak with a more unified voice in establishing nursing policy that can advance dramatic achievements in quality and safety and strongly inform broader health policy, which advances the quality and safety agenda of health service for the American public.10


Our response

The Future of Nursing report recommends the need to use existing nursing organizations and leadership bodies in developing curricula and programs that can advance the leadership capacity of the profession to respond to the challenges presented in transforming the health system. The report urges all professional nursing organizations to incorporate in their role increasing capacity for leadership development as a fundamental part of their service to the profession and to the community. The report enumerates specific programs of individual professional organizations offering potentially effective leadership development programs, including the American Nurses Association, the American Association of Colleges of Nursing, the National League for Nursing, the American Organization of Nurse Executives, the American Academy of Nursing, and the National Coalition of Ethnic Minority Nurse Associations.11


Policy making, political partnerships

After building the evidence to support what nurses need to make healthcare more patient centered and to improve quality, access, and value, translating it into policy and practice is the next critical step. To this end nurses must be able to establish the political and practice partnerships necessary to influence both political action and policy formation. Political engagement is identified in the report as an essential skill set, still it's one that nurses haven't yet refined. Examples of institutional and legislative nurse leaders who demonstrated the capacity to manage politics and influence policy provided exemplars of effectiveness in the report.12 After the creation and demonstration of effective models has unfolded, it becomes imperative for those successes to be idealized and generalized broadly to other institutions, services, and clinical partners. Suggesting policy and practice approaches that have evidenced effectiveness and can be replicated provides a firm foundation upon which to propose political action and policy change across the healthcare landscape.


Establishing policy requires the capacity to engage stakeholders and to construct effective partnerships with them to form the necessary critical mass of coalitions sufficient to sustain necessary change. Nurses, working through significant institutional, organizational, and professional partnerships, in collective coalitions or through membership on board and governance bodies, are a strong predictor of successful alliances that advance policy. The IOM report emphasizes that nurses can advance the interest of quality and effective healthcare by perceiving themselves as effective and powerful collaborators who hold key positions in organizations and partnerships in places and ways that advance meaningful public health policy. The IOM suggests that nurses playing such leadership roles are essential to advance a meaningful, effective, and sustainable quality health system.13


Implications for managers

The IOM Future of Nursing report reaffirms much of what has been said previously in a number of historic documents and forums addressing the profession of nursing. Through use of contemporary language and examples, the report reemphasizes the central value of nursing and nurses in advancing a quality-based and effective healthcare system. This report again challenges nurses to better address issues of education and competence, advanced practice, leadership and innovation, and impact on health policy and practices. Additionally, the report challenges nursing leadership to develop specific competencies for advancing collaboration, engaging in interdisciplinary decisions and clinical processes, and facilitating the formation of evidence-based policy affecting quality care and health service delivery.


Throughout the report, the IOM suggests that nursing is positioned to have a significant impact on the healthcare system. The extent of that impact is entirely dependent on the willingness of the profession to develop the role capacities and leadership essential to make a difference in ensuring quality, accessible healthcare in a reformed and transforming health system. However, there's no doubt that it's up to the profession and its leaders to demonstrate the political and professional maturity to negotiate the complex landscape of interdisciplinary collaboration; resolution of disparate advocacy positions; positioning of nurses on key organizational, legislative, and policy boards; and asserting nursing's legitimate role in decisions and actions, which advance effective quality healthcare.


Although some of the lingering gender and role issues remained unaddressed, the report serves as a strong call to action on the part of the nursing profession to play its full and proper role as an equal partner in a broad interdisciplinary convergence of effort to create, advance, and sustain an American healthcare system that works at every level to ensure the health of Americans in a truly cost-effective, accessible, safe, high-quality manner. As always, the question remains: Will nurses answer the call?




1. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC; 2010:S-3. [Context Link]


2. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC; 2010;2(S-6, paragraph 4). [Context Link]


3. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC; 2010:3(S-7). [Context Link]


4. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC; 2010:(S-9). [Context Link]


5. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC; 2010:(S-12). [Context Link]


6. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC; 2010:(5-2). [Context Link]


7. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC; 2010:(5-3). [Context Link]


8. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC; 2010:(5-4). [Context Link]


9. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC; 2010:(5-6 to 5-16). [Context Link]


10. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC; 2010:(5-16). [Context Link]


11. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC; 2010:(5-19, 20). [Context Link]


12. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC; 2010:(5-20 to 5-22). [Context Link]


13. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC; 2010:(5-24). [Context Link]