1. Salmond, Susan S. EdD, RN

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In 1999, the Institute of Medicine (IOM) jolted healthcare and the American public with their report, To Err is Human. We were reminded that the healthcare system can be hazardous to your health, that medical error was the 8th leading cause of death in the United States and that the total cost from the fallout of this medical error was about $37.6 billion a year. The goal of the report was to break the cycle of inaction that had persisted across healthcare and demand accountability for addressing the multifaceted factors contributing to patient safety risks (IOM, 2000, p. 1).

Figure. Susan S. Sal... - Click to enlarge in new windowFigure. Susan S. Salmond, EdD, RN

Shortly after, a second IOM report, Crossing the Quality Chasm: A New Health System for the 21st Century, articulated concern over the disturbing absence of real progress toward restructuring healthcare systems to address both quality and cost concerns. They emphatically called for fundamental change to the American healthcare delivery system as well as for systems to align payment methods with quality improvement goals and a restructuring of clinical education to be consistent with the principles of the 21st century health system (IOM, 2001, p. 17).


Crossing the Quality Chasm effectively described the last quarter of the 20th century as an "era of Brownian motion in healthcare" (IOM, 2001, p. 3) with plenty of turmoil and little change. It concluded that current care systems cannot do the job and that there was a need for transformational change.


The seismic waves created by these reports have shaken up healthcare and academic education for healthcare providers. As we are confronted with the complexity of the healthcare system and the patients for whom we care for, it is time to challenge the way we have always done things and begin to solve our problems with new ways of thinking. The new generic masters' program/role, the Clinical Nurse Leader (CNL) and the Doctor of Nursing Practice (DNP) are avenues to preparing for the new demands in leadership and practice.


The DNP is a practice degree (as compared to a research degree) targeting nurses in both direct clinical care roles (nurse practitioners, clinical nurse specialists) and indirect care roles (nurse administrators, quality directors) and prepares them as leaders and policy experts who will direct quality patient outcomes. Many of the students in DNP programs today have wanted to pursue a terminal doctoral degree but did not find the PhD to be value added to their career goals. The DNP offers an alternative that is likely to make a significant difference to practice and patient outcomes.


Graduates are prepared to assume full leadership roles in clinical practice, clinical teaching, and as experts in evidence based practice. The DNP prepared nurse is expected to make major contributions to evidence-based practice in the workplace, the community, and the academic arena. This is accomplished through evidence translation, evidence syntheses and the generation of new knowledge through the collaboration with PhD nurse researchers. A cadre of DNPs in the practice setting will have the advanced knowledge and skills to better propose alternative models of care and solutions to ongoing and emerging problems with attention to cultural values, best evidence, clinical outcome data, policy, finance, and interdisciplinary collaboration.


The Clinical Nurse Leader (CNL) was a true joint venture between academia and practice in response to a recognized need for advanced skill at the bedside/point of care. Considered a generalist masters, The CNL contributes to improvement in patient safety, quality of care, fiscal outcomes and implementation of evidence-based care at the unit level. The CNL is prepared to create an environment of clinical excellence by supporting professional nursing care and coordinating the management of complex conditions and patient situations through review of the effectiveness of practice modifications in collaboration with the clinical team. The CNL is able to manage information and integrate it with clinical practice and communicate research findings and other forms of evidence and assist the clinical team to incorporate this material into practice.


I believe that these new programs will enhance clinical leadership in nursing and health care and will assure that the voice of nursing is heard as decisions are made within the organization and in the larger health care system. Open to the changing demands of the times, these new programs will change practice, just as changing practice has changed education.




Institute of Medicine. (2001). Crossing the Quality Chasm: A New Health System for the 21st Century. National Academy Press, Washington, D.C. [Context Link]


Free Executive Summary available at


Institute of Medicine. (2000). To Err is Human. National Academy Press, Washington, D.C. Free Executive Summary available at[Context Link]