1. Volume XX, Number X 2011 www.nursingleadership.netVolume 27, Number 2 2014 www.nursingleadership.net Canadian Journal of Nursing Leadership Nursing LeadershipLeadership in Nursing Management, Practice, Education & Research Baccalaureate Nursing Education: Has It Delivered? A Retrospective Critique 27 Commentary: Future Directions for Nursing Education 35 Boundary Spanning by Nurse Managers: Effects of Managers Characteristics and Scope of Responsibility on Teamwork 42 Commuter Migration: Work Environment Factors Influencing Nurses Decisions Regarding Choice of Employment 56 Politics Policy Theory Innovation SPECIAL FOCUS ON THE FUTURE OF NURSING p.14

2. At the heart of datawww.cihi.ca When Canadians spoke, we listened. Coming soon: A website that shows people how their health system is performing. aAccess to care? aEfficient spending? aQuality health care? aHealth outcomes? aDisease prevention? Health system performance reporting? Were about to kick it up a notch. From your friends at the Canadian Institute for Health Information. 3. EDITORIAL 1 From the Editor-in-Chief Creativity Core to the rEvolution of Education The challenge now is to transform education systems into something better suited to the real needs of the 21st century.At the heart of this transformation there has to be a radically different view of human intelligence and of creativity(Robinson 2011: p.14) Although nursing education in Canada has undergone marked changes over the last 50 years,with the advent of technology mediated approaches to teaching,learning, and healthcare delivery,it essential and of some urgency to dramatically rethink the foci and methods of undergraduate nursing education now.Whether health promo- tion,maintenance or restoration,the healthcare needs of a predominantly older Canadian demographic have shifted.Similarly the locus and modes of care delivery are continuing to devolve from the bastions of hospital care to home and community- based care supported by inter-professional teams of clinicians with ever broadening scopes of practice.Thus nurseswork and the nature of practice environments are rapidly evolving such that the requisite skills and knowledge of practitioners may be sadly lacking in our new graduates.Not to mention that the undergraduate student of today is inclined to want to learn in ways different from the predominant endur- ing methods provisioned by our academic institutions.As the rethinking of nursing education unfolds,the creativity element of leadership will be essential to our collec- tive success. 4. 2 Nursing Leadership Volume 27 Number 2 2014 In previous issues of CJNL,authors have highlighted the key recommendations arising from the CNAs National Expert Commission (Villeneuve and Mildon,2013a; 2013b). In relation to nursing education,the commission specifically underscored the impor- tance of collaboration among professional associations,educators,scientists,unions, and employers to reachconsensus on the scientific knowledge,education,competen- cies and skill sets demanded of effective 21st century registered nurses.They noted thatcurricula are out of date and out of step with the transformationsthat lay ahead in healthcare,and issued a call to make radical changes in healthcare education includ- ing new topics and teaching methods (CNA 2012: 45).Another call to action which is inextricably connected to any revamp of content and techniques is the need to escalate the use of technology in their words:Learning to take full advantage of technology should be just as important a part of education and employer orientation as learning about medications(2012: 46). Subsequent to the release of the commissions report was the constitution of a think tank to address the future of nursing education in Canada.A report of those delibera- tions has also been tabled (MacMillan 2013) and the key directives synthesized for our readership (MacMillan and Gurnham 2013).Of particular note was a clarion call for a national review of nursing education,the likes of which has not been undertaken since 1965.In this issue,Baker provides us with a synopsis of some significant mile- stones in Canadian nursing education including the outcomes of previous landmark studies.Pilj-Zeiber and colleagues provide an historical perspective on what the shift to baccalaureate education has meant for contemporary nursing practice in Canada. They posit that debates about the value of education versus service,professional versus vocational identity,and theoretical versus practical knowledge persist in the midst of concerns regarding the misalignment of education and practice. Regardless of these debates,lets be sure not to exclude the target of our intentions in the discussion.We are seeing a new kind of learner with different needs,capabilities and resources; our students are products of a technology-mediated society and as such have very different expectations.Days of thesage on the stageare no longer accept- able; being theguide on the sideis the order of the day (King 1993).In rethinking nursing education it is equally essential to challenge pedagogical techniques and traditions in order to be effective and responsive to the needs of the new generation of student nurse.Personally the experience of trying new methods in the classroom and online (e.g.,flipped classroom,wikis,MOOCs,Peer Scholar these are yours to explore) can be profoundly rewarding if not an opportunity to overturn ones entrenched views of teaching and learning.While not at all discomfited by technology, presently designing an online graduate course on leadership and administration has 5. 3 presented this academic with some interesting possibilities.While lamenting the loss ofthe classroomon the one hand,the demand for creativity in designing an online learning space that incorporates effective elements of student engagement and creates a community of learning is kind of fun.The old dog can learn new tricks. As Sir Ken Robinson (2011) wrote:the role of a creative leader is not to have all the ideas; its to create a culture where everyone can have ideas and feel that theyre valued. Lets get creative together! Lynn M. Nagle, RN, PhD Editor-in-Chief References Canadian Nurses Association (CNA), 2012. A Nursing Call to Action. Report of the National Expert Commission. Accessed June 10, 2014 at: www.cna-aiic.ca/expertcommission. King, A. 1993.Sage on the Stage to Guide on the Side. College Teaching 41: 30-35. MacMillan, K. (Ed.) 2013. Proceedings of a Think Tank on the Future of Undergraduate Nursing Education in Canada. Halifax: Dalhousie University School of Nursing. MacMillan, K. and M. Gurnham. 2013.Leaders Hold an Invitational Think Tank on Undergraduate Nursing Education. Nursing Leadership 26(2): 25-28. doi: 10.12927/cjnl.2013.23304. Robinson, Sir K. 2011. Out of our Minds: Learning to be Creative. Capstone Publishing: West Sussex, UK. Villeneuve, M. and B. Mildon. 2013a.Better Health, Better Care, Better Value: National Expert Commission, Part 1. Nursing Leadership 26(1): 20-23. doi: 10.12927/cjnl.2013.23452. Villeneuve, M. and B. Mildon. 2013b.Better Health, Better Care, Better Value: National Expert Commission, Part 2. Nursing Leadership 26(2): 19-24. doi:10.12927/cjnl.2013.23451. 6. 4 Nursing Leadership Volume 27 Number 2 2014 special focus on nursing in public health Call for Papers/Abstracts Nurses are taking on increasingly important leadership roles in the public health system. The Canadian Journal of Nursing Leadership will publish a focused issue devoted specifically to the challenges and opportunities for nurses in the public health sector. we are looking of papers that focus on: Unique leadership challenges in Public Health Demonstrations of research, case studies Advanced practice roles Innovations (e.g., the use of technology) Current and emerging policy issues Prospective authors are invited to submit a 200-word abstract in advance of their manuscripts. Abstracts should be sent to: Dianne Foster-Kent, Editorial Director: dkent@longwoods.com Canadian Journal of Nursing Leadership Nursing LeadershipLeadership in Nursing Management, Practice, Education & Research 7. Volume 27 Number 2 2014 EDITOR-IN-CHIEF Lynn M. Nagle, RN, PhD Assistant Professor Lawrence S. Bloomberg Faculty of Nursing University of Toronto EDITOR, POLICY AND INNOVATION Michael J. Villeneuve, RN, MSc Lecturer and Associate Graduate Faculty Lawrence S. Bloomberg Faculty of Nursing, University of Toronto Principal, Michael Villeneuve Associates Mountain, ON EDITOR, PRACTICE Patricia Petryshen, RN, PhD Chief Executive Officer Assessment Strategies Inc. Ottawa, ON EDITOR, RESEARCH Greta G. Cummings RN, PhD CIHR New Investigator AHFMR Population Health Investigator Professor, Faculty of Nursing, University of Alberta BOOK EDITOR Gail J. Donner, RN, PhD Partner, donnerwheeler Professor Emeritus Lawrence S. Bloomberg Faculty of Nursing, University of Toronto EDITOR EMERITUS Dorothy Pringle, OC, RN, PhD, FCAHS Professor Emeritus & Dean Emeritus Lawrence S. Bloomberg Faculty of Nursing University of Toronto Executive Lead, Health Outcomes for Better Information & Care Ontario Ministry of Health & LTC EDITORIAL ADVISORY BOARD Kirsten Krull (Chair) Vice President and Chief Nursing Executive Hamilton Health Sciences Centre Hamilton, ON Beverly Malone, PhD, RN, FAAN Chief Executive Officer National League for Nursing New York, NY Patricia OConnor, RN, MSc (A), CHE Director of Nursing and CNO, Montreal General Hospital Montreal, QC Rhonda Seidman-Carlson, RN, MN Vice President Interprofessional Practice and Chief Nursing Executive The Scarborough Hospital Scarborough, ON Joan Shaver, PhD, RN, FAAN Dean, College of Nursing University of Arizona Tucson, AZ Linda Silas, RN, BScN President Canadian Federation of Nurses Unions Ottawa, ON Carol A. Wong, RN, MScN, PhD Assistant Professor School of Nursing, Faculty of Health Sciences The University of Western Ontario London, ON EDITORIAL DIRECTOR Dianne Foster-Kent MANAGING EDITOR Ania Bogacka COPYEDITOR Francine Geraci PROOFREADER Scott Bryant PUBLISHER Anton Hart ASSOCIATE PUBLISHER Rebecca Hart ASSOCIATE PUBLISHER Susan Hale ASSOCIATE PUBLISHER Matthew Hart ASSOCIATE PUBLISHER/ADMINISTRATION Barbara Marshall DESIGN AND PRODUCTION Benedict Harris The Canadian Journal of Nursing Leadership is published four times per year by the Academy of Canadian Executive Nurses/LAcademie des Chefs de Direction en Soins Infirmiers and Longwoods Publishing Corp. The journal is refereed and published primarily for nurse administrators, managers and educators. Information contained in this publication has been compiled from sources believed to be reliable. While every effort has been made to ensure accuracy and completeness, these are not guaranteed. The views and opin- ions expressed are those of the individual contributors and do not necessarily represent an official opinion of Canadian Journal of Nursing Leadership or Longwoods Publishing Corporation. Readers are urged to consult their professional advisers prior to acting on the basis of material in this journal. The Canadian Journal of Nursing Leadership is indexed in the following: Pubmed/ Medline, CINAHL, Nursing Citation Index, Nursing Abstracts, CSA (Cambridge), Ulrichs, IndexCopernicus, Scopus ProQuest, Ebsco Discovery Service and is a partner of HINARI. No liability for this journals content shall be incurred by Longwoods Publishing Corporation, the editors, the editorial advisory board or any contributors. ISSN No. 1910-622X eISSN No. 1929-6355 Publications Mail Agreement No. 40069375 June 2014 HOW TO REACH THE EDITORS AND PUBLISHER Telephone: 416-864-9667 Fax: 416-368-4443 ADDRESSES All mail should go to: Longwoods Publishing Corporation, 260 Adelaide Street East, No. 8, Toronto, Ontario M5A 1N1, Canada. For deliveries to our studio: 54 Berkeley St., Suite 305, Toronto, Ontario M5A 2W4, Canada SUBSCRIPTIONS Individual subscription rates for one year are $95 for online only and $117 for print + online. Institutional subscription rates are $347 for online only and $494 for print + online. For subscriptions contact Barbara Marshall at 416-864-9667, ext. 100 or by e-mail at bmarshall@longwoods.com. SUBSCRIBE ONLINE Go to www.nursingleader- ship.net and click on Subscribe. Subscriptions must be paid in advance. An additional tax (GST/HST) is payable on all Canadian transactions. Rates outside of Canada are in US dollars. Our GST/HST number is R138513668. REPRINTS/SINGLE ISSUES Single print issues are available at $43. Canadian orders include shipping and handling. Reprints can be ordered in lots of 100 or more. For reprint information call Barbara Marshall at 416-864-9667 or fax 416-368-4443, or e-mail to bmarshall@longwoods.com. Return undeliverable Canadian addresses to: Circulation Department, Longwoods Publishing Corporation, 260 Adelaide Street East, No. 8, Toronto, Ontario M5A 1N1, Canada EDITORIAL To submit material or talk to our editors please contact Dianne Foster-Kent at 416-864-9667, ext. 106 or by e-mail at dkent@ longwoods.com. Author guidelines are avail- able online at http://www.longwoods.com/ pages/nl-for-authors. ADVERTISING For advertising rates and inquiries, please contact Matthew Hart at 416-864-9667, ext. 113 or by e-mail at mhart@longwoods.com. PUBLISHING To discuss supplements or other publishing issues contact Rebecca Hart at 416-864-9667, ext. 114 or by e-mail at rhart@longwoods.com. 8. In This Issue Volume 27 Number 2 2014 1 Editorial ACEN UPDATE 8 Nurses: Leading Change One Day at a Time Katherine Chubbs There has been enormous progress in nursing, and that progress did not come without change. Nurses have two choices: to be a part of developing and leading the change, or to have change happen to them. EMERGING LEADERS 10 Critical Appraisal through a New Lens L. Kathleen Stevens, E. Darlene Ricketts and Jill E.E. Bruneau Critical appraisal is a shift that nurses require. But how can they develop it? SPECIAL FOCUS ON THE FUTURE OF NURSING 14Leading the Revolution in Nursing Practice: Advancing Health in the Digital Age Tim Porter-OGrady Nursing is on the verge of a major shift in both its work and its value due to increasing pressure to move out of acute-care hospitals and into the community; and the influence of digitization in how nurses are able to provide care. 21 Commentary: Nursing Must Learn to Adapt Roger Watson When examining the qualities required to meet the future, it is clear that if nursing does not learn and adapt, it will not survive; if it does not survive and begin to shape its environment, then it will become irrelevant. 24 Commentary: Nurses Positive Impact Across the Continuum Rob Fraser Leaders need to look far ahead, setting a course that excites and engages others in improving nurses positive impact on health, throughout life and at the time of death. LEADERSHIP PERSPECTIVE 27 Baccalaureate Nursing Education: Has It Delivered? A Retrospective Critique Em M. Pijl-Zieber, Sonya Grypma and Sylvia Barton The authors challenge the current nursing system and call for a nationwide curriculum review to help the profession adapt to the changing needs of the Canadian healthcare system. 35 Commentary: Future Directions for Nursing Education Cynthia Baker Critical reflection on the introduction of baccalaureate education as the entry-to-practice require- ment in Canada is timely. Efforts to chart future directions for nursing education must take into account long-standing issues from the past. 9. In This Issue Published by the Academy of Canadian Executive Nurses/L'Acadmie des Chefs de Direction en Soins Infirmiers and Longwoods Publishing Corporation 7 Indicates Peer-review NURSING RESEARCH 42 Boundary Spanning by Nurse Managers: Effects of Managers Characteristics and Scope of Responsibility on Teamwork Raquel M. Meyer, Linda OBrien-Pallas, Diane Doran, David Streiner, Mary Ferguson- Par and Christine Duffield Increasing role complexity has intensified the work of managers in supporting healthcare teams. This study examined the influence of front-line managers characteristics and scope of responsibility in teamwork. 56 Commuter Migration: Work Environment Factors Influencing Nurses Decisions Regarding Choice of Employment D. Rajacich, M. Freeman, M. Armstrong-Stassen, S. Cameron and B. Wolfe This mixed-methods research examined factors influencing registered nurses decisions to work in their home country, Canada, or to commute daily to a nursing position in the United States. BOOK REVIEW 68Nursing Leadership from the Outside In Reviewed by Pam Hubley This book is intended to help nurses develop their leadership potential using insights, stories, lessons learned and practical tips offered up by a wide range of individuals who have worked with nurses, experienced nursing care or relied on nursing leadership to advance their goals. Perspectives from business leaders, physician CEOs, professional association directors, academic heads and politicians are shared with honesty and personal insight. 4 Special Focus on Nursing in Public Health Call for Papers/Abstracts 40 Call for Reviewers 41 Thank you to our reviewers 10. 8 Nurses: Leading Change One Day at a Time Katherine Chubbs, RN, MHS Vice President and Chief Nursing Officer, Eastern Health, NL President, Academy of Canadian Executive Nurses Chair, Canadian College of Health Leaders, NL Chapter I know that sometimes it feels as though we stay status quo day after day or year after year, but actually so much has changed in nursing as a profession. I occasionally hear a nurse say,we tried that before and it did not work, or been there, done that, but my thoughts always come back to why?Was it because the environment was not ready, the nurses were not ready, the patients or clients were not ready? There has been enormous progress in nursing, and that progress did not come without change. The way I see it, we have two choices: to be a part of develop- ing and leading the change, or to have change happen to us. I can think of many scenarios where change has happened to me in my career: changing scope of prac- tice, changing workplace, changing position, changing organization and on and on. But in my experience, which is like that of many others, it is best to participate in making that change happen. Nurses have been leading change and innovation likely for as long as the profession has existed. For example, some of you may not know that Florence Nightingale is credited with inventing the polar graph (Reference.com 2014). Not all nurses have to be inventors, but we do want our nurses to be involved in creating organizations that we can be proud to say deliver excellent evidence- based, high-quality care in safe environments. Labour is a meaningful experience. Having to work harder at something makes it more meaningful this is known as the IKEA effect (Norton 2009). The IKEA effect also demonstrates a limitation, namely, that labour leads to higher value only when the labour is fruitful (Norton 2009). Many nurses feel that they have to work harder now than ever before. Despite this, they continue to bring new ideas ACEN UPDATE 11. 9Nurses: Leading Change One Day at a Time to the forefront and be involved. We know that when nurses are involved in the creation of something, they value it more. A survey by researchers at Harvard University of nearly 600 senior execu- tives identified engagement as the third highest success factor in their business, coming just slightly behind a high level of customer service (in our world, how we service our patients, clients, residents and their significant others) and effec- tive communication (Harvard Business Review Analytic Services 2013). Business leaders recognize that an engaged workforce leads to innovation, productivity and bottom-line performance (Harvard Business Review Analytic Services 2013). There is a valuable cycle evolving here. Nurses need to be involved in decision- making and change to make their work meaningful; meaningful work creates engagement; engagement increases innovation, productivity and performance; innovation leads to change. As senior nursing leaders, we need to make this our approach. How can we help nurses to be involved? Encourage them to volunteer for any opportunities they see to improve service, and to speak up when they think change is needed. Inspire them to challenge the status quo and ask to try new things. We have to be open to new ideas and ways of doing our work. If something doesnt work, then we can try something else. As nurses, we must love our work. We will never give it our best if we dont. As nurses, we must be at the forefront of change and innovation. We each have the power to influence our environments to make them more like what we want more what we will love. In fact, I would say we all have a responsibility to do that. Lastly, as nurses, we have knowledge. We are highly educated, skilled leaders who have the power to do great things. At nearly 300,000 strong, Canadian nurses will lead our organizations to the places they need to be. In the words of John Ruskin,When love and skill work together, expect a masterpiece. References Harvard Business Review Analytic Services. 2013. The Impact of Employee Engagement on Performance. Retrieved May 13, 2014. . Norton, M.I. 2009. The IKEA Effect: When Labor Leads to Love. Retrieved May 13, 2014. . Reference.com. 2014. What Did Florence Nightingale Invent? Retrieved May 13, 2014. . 12. 10 Nursing Leadership Volume 27 Number 2 2014 Many websites, nursing education sessions and journal articles stress the impor- tance of critical appraisal of research for evidence-informed decision-making. Prior to starting our doctoral program, we assumed that because a study was published, it had strong evidence. In reading research reports we, like others, had a tendency to focus on results and sample size, taking what was presented more or less as fact or at face value. We often gave all evidence equal weight regardless of the strength of the study design or the internal validity of the methods. After all, these published articles had been peer reviewed! However, we have now learned that astute critical appraisal requires the ability to critically appraise the research methodology, the quality of the evidence, the applicability to clinical practice and the opportunities to improve patient care and outcomes. Furthermore, it is also important to be able to assess the quality of a body of evidence in addition to the quality and limitations of individual studies. So, critical appraisal is a skill that nurses require. But how can we develop it? Our Epiphany about Critical Appraisal In our undergraduate nursing education, we learned that to develop any skill, practice is required. As nurses, we understand skill development. To learn how to take a patients blood pressure (BP), we practised possibly a hundred times before transferring this knowledge and skill to the clinical setting. Based on our Critical Appraisal through a New Lens L. Kathleen Stevens, RN, MN Doctoral student, Memorial University School of Nursing, St. Johns, NL E. Darlene Ricketts, RN, MPH Doctoral student, Memorial University School of Nursing, St. Johns, NL Jill E.E. Bruneau, NP, MHSc Doctoral student, Memorial University School of Nursing, St. Johns, NL 13. 11EMERGING LEADERS assessment or appraisal of a patients BP, important clinical decisions were made for that patient. Through all these BP assessments we learned the nuances and variations of the sounds of the systolic and diastolic pressures. By practising, we developed confidence to transfer this skill to the clinical area. However, even when we arrived in the clinical setting, our instructor accompanied us to guide our assessments until we were competent to work independently. Is this what happens with the skill of critical appraisal of research evidence? Important clinical decisions, such as choice of dressings to promote optimal wound healing, are also made for clients based on the assessment and appraisal of research. However, the preparation that we received about evaluating research evidence is dissimilar to the preparation we received for learning how to do a BP. Undergraduate students are often required to find a minimum number of research articles in preparation for clinical work or for writing a paper, but usually they do not critique the methods used in these research reports. Students often do not distinguish between a literature review and a research study. Even after they have completed a research methods course, the key limitations that students identify often focus on sample size, validity and reliability of instruments, and generalizability, with equal weight given to all types of study designs and study quality. Lack of consistent use of critical appraisal tools may contribute to such superficial appraisals. As nursing students, we were taught that research is vital to nursing practice, but unlike learning to take a BP, we did not practise critical appraisal of research stud- ies a hundred times. As well, we had no opportunity to develop the confidence to transfer these skills to the clinical setting. The incongruity is that we knew evidenced-informed decision-making was vital to delivering high-quality care, but we did not fully appreciate the depth of critical appraisal required to make a thor- ough assessment. This situation would be similar to knowing that assessing a BP was vital for patient care but not being able to transfer and apply that knowledge to practice. As doctoral students in a research methods course, we had the opportunity to study critical appraisal, practise it and receive feedback. This experience led to an epiphany about the complexity of critical appraisal as a systematic skill to be developed and enhanced over time. Our intention is not to criticize undergradu- ate education, but to look at critical appraisal through a new lens and to explore the implications of this epiphany for nursing management, education and practice. 14. 12 Nursing Leadership Volume 27 Number 2 2014 Critical Appraisal Skills in the Practice Setting: Who Needs Them? It is easy to understand why researchers need to appraise research evidence criti- cally in order to develop research proposals and interpret their own research find- ings. It is less easy to understand why those in practice need good critical appraisal skills. However, we believe that they do! Nurses in practice, at all levels, need the same critical appraisal skills as researchers, although they may apply them in different contexts. For example, programs and policies need to be informed by the best evidence, and this can occur only if critical appraisal is conducted. It is therefore especially important that nurses who serve on policy and proce- dure committees be able to find, critically appraise and synthesize the available evidence to inform policy and practice recommendations. Others in practice frequently consult the literature for different reasons than policy and procedure committee members. All nurses read literature to keep up to date about their particular practice area. Managers, clinical educators and those in specialist roles also look at literature to identify new approaches to address concerns or to prepare an educational session for nurses, patients or patients families. Being able to assess the validity and value of individual research stud- ies and literature reviews will help ensure that their own recommendations are informed by evidence. Staff nurses may read fewer research reports than manag- ers and educators, and they may read them for a different purpose, but critical appraisal skills will facilitate their questioning and validation of their practice. Implications for Nursing Practice, Education and Partnerships It is crucial that those in leadership positions in nursing academia address the development of critical appraisal skills in nursing students, because this is where future nurses and nurse leaders are first introduced to research and research utili- zation. At the same time, educational initiatives in the practice setting should be undertaken to promote skill development in practising nurses, because they likely have the same understanding of critical appraisal that we had prior to starting our doctoral program. Journal clubs may help nurses on the front line feel better prepared to appraise research, participate in committee work and help translate evidence into practice, as well as stimulate them to discuss and question practice. Now is the time for nursing leaders to find opportunities to create environments that promote learning in critical appraisal, particularly in areas where nurses would most utilize these skills. For example, those who work on policy and procedure committees, or who rely heavily on the literature in their work, may need more focused education and support related to critical appraisal. 15. 13Critical Appraisal through a New Lens Collaboration among leaders in nursing education, practice and research, as well as with other health professions, would be beneficial. Using similar approaches in these different areas of nursing will result in continuity and consistency for nurses as they continue to build and apply their critical appraisal skills. Furthermore, collaborative inter-professional educational initiatives will mean that research expertise from all involved disciplines can be shared and enhanced. If nurses receive the same education as other health professionals, they will learn to use a common language in critical appraisal and in promoting evidence-informed recommendations. So Whats Next? We need to change the system so that future new nurses will have a stronger skill set and the work environment will help them strengthen and apply those skills. But we also need to play catch-up. Nurse leaders must make a special effort to address the present situation in both education and practice, and to bring criti- cal appraisal skills to the essential level required to achieve evidenced-informed decision-making and practice. Building this expertise can help improve outcomes for patients, nurses and the populations they serve. Lets get moving! Acknowledgements The authors would like to thank Dr. Donna Moralejo for triggering our epiphany about critical appraisal and for her valuable assistance with this paper. 16. 14 Leading the Revolution in Nursing Practice: Advancing Health in the Digital Age Tim Porter-OGrady, DM, EdD, APRN, FAAN Senior Partner, Health Systems, TPOG Associates, Atlanta, GA Professor of Practice, College of Nursing and Health Innovation ASU, Phoenix, AZ Clinical Professor, Leadership Scholar, College of Nursing OSU, Columbus, OH Adjunct Professor, School of Nursing, Emory University, Atlanta, GA Nursing is on the verge of a major shift in both its work and its value. Since the time of Nightingale, nurses have been caring for the sick and have developed a growing presence in the acute care environment, where the majority of nurses practise today (McDonald 2010). Yet, the very foundations of nursing are grounded in the community, and nursing is fundamentally driven by the urge to advance and maintain health and prevent illness (Dossey 2005). While many nurses practise in just such pursuits, the majority are employed by hospitals and health systems in the care of the sick. The medical model, which has dominated Western medicine for the majority of the 20th century, has consumed much of the nursing professions energies and focus (Goldsmith 1993; Haven 1869; Sarma et al. 2012). Medicines ability to advance treatment modalities and surgical interventions, and to refine drug therapies, has reinforced a predominating tertiary model of medical services and care that has ultimately focused on late- stage, late-engagement interventions and care services (Wilson et al. 2012). The problem with this approach, however, is that the net aggregate health of persons over time has not been substantially improved as a direct result of these clinical efforts alone (Smith and Institute of Medicine 2012). Indeed, the condi- tions that create the demand for many interventions have actually accelerated, with little in place to address them early and effectively before they require more intensive measures, along with their attendant costs: heart disease, diabetes, obesity and cancer, among others, keep expanding, with concomitant pressure on health and fiscal resources. Health effectiveness, sustainability, longevity and SPECIAL FOCUS ON THE FUTURE OF NURSING 17. 15 quality of life are sacrificed and are the price paid for such a system. This approach continues to strain social, political and economic capital in a way that simply cannot be sustained without risking national viability and solvency (Gortmaker et al. 2011; Porter and Teisberg 2006; Ray 1995). At the same time, the continuing and deepening impact of digitization in the contemporary age is changing everything we are and everything we do. Communication technology mobilizes us in ways that accelerate our portability and availability to one another in a virtual medium that removes almost all barri- ers to human communication and interaction (Brooks and Grotz 2010; Horn 2010). Digitization and miniaturization create engineering utility that alters our therapeutics, interventions, intensity and outcomes in almost unimaginable ways. Genomics, genetics and DNA manipulation promise a whole therapeutic milieu that foreshadows the decline of hospitals and late-stage interventions for whole populations of patients and clinical conditions (Gu 2011). All these factors, when taken together, create a synergy that shifts the social and service construct for healthcare and creates a new complexity that changes the way in which nurses practise, how they provide care and where they work. The New Social Compact The new social compact that emerges from the convergence of these forces in the contemporary age is driven by an essential need for accountability and value. In fact, the conditions of the age call for a real commitment from nursing leaders (indeed, all health leaders) to establish a direct relationship between nurses work and the impact that work has on the health of those we serve. It is imperative that the language and structures that represented a volume-based approach to service, care and resource use be eclipsed now by a more robust demonstration of impact, outcome and value (Kathy Malloch and Timothy Porter-OGrady 2010a). The question now is not so much what did you do? but more what difference did it make? The notion of whether the work was valuable insofar as it produced, changed or improved the health and healing experience is now the critical metric that validates its value and impact. The price of service now must more strongly reflect the value of that service, not simply its cost. If what we do as nurses merely feels good or right, or represents a ritual or routine that is no longer relevant, then it should not be paid for. In the digital age, the information infrastructure should now reveal just-in-time information about the veracity and validity of a specific nursing action in a way that verifies it, challenges it and ultimately changes it in real time. Patients come to the health system not so much for what it does but instead for what they get (value). If they dont get what they were promised or have a right to expect, it doesnt matter what was done for them. Nursing practice isnt inherently valuable because we do it; it is valuable because it makes a difference in the health and life Leading the Revolution in Nursing Practice: Advancing Health in the Digital Age 18. 16 Nursing Leadership Volume 27 Number 2 2014 of those we serve. In this era, we must be able to show evidence of a direct cause- and-effect relationship between what we do and what really happens for patients. In addition, the health of our populations is not driven by the action of any one discipline. The essential interface of the clinical efforts of all providers that make up the partnership of contribution affecting outcome and value is key to effective health service. The vertical and linear structures within which we have histori- cally worked are no longer effective in this digital age to successfully provide a continuum of value-defined services. The earlier we engage people and popula- tions, the more diverse our service structures must become. Further, early engage- ment systems must be more localized, decentralized and point-of-service driven (Stutz 2013). Patients must themselves be drivers and co-participants in decisions and actions that affect their care. Because most late-stage interventions reflect inadequate early-stage lifestyle choices, the ability of providers to access persons where they live will be critical to meaningful and sustainable impact. This is especially true for the sickest minority of persons who drive the majority of the costs of healthcare. The earlier we can engage these populations, the greater the economy-of-scale impact we can have on resource use and quality of life. To do so will require the best efforts and evidence-grounded approaches (Melnyk and Fineout-Overholt 2012). These will be hammered out in the necessary nego- tiations between the team of providers and the patient in a concerted effort to change habits, practices and behaviours honed by consistency, determination and congruence along the continuum of care. Such an approach creates real-time modalities that are transferable as they are tested and communicated within the linked and integrated clinical information system that informs clinical leaders also in real time of their value and affordability. What Leaders Must Do Nursing leaders have a huge obligation to broaden nursing awareness of the significance of this sea-change affecting practice over the next two decades. Nurses entering practice today will spend the majority of their careers in making these changes and writing a new script for practice. Time is of the essence, and there is little that is more relevant work for todays leaders. Leaders do not generally live solely in the present. If they do, they are not provid- ing much leadership. Leaders live in the potential somewhere between here and there. True leaders have peered over the horizon, or at least done a good job of environmental scanning, as they anticipate the future. Leaders spend a good deal of their time in translational work, helping others understand what it is about the future that they must be aware of today. In this effort, the leader sets the land- scape for staff proaction preparation for timely and relevant response (Porter- OGrady and Malloch 2008). 19. 17Leading the Revolution in Nursing Practice: Advancing Health in the Digital Age With this in mind, here are five specific leadership activities that are critical at this time: 1.Leaders must be able to anticipate and predict the trajectory of changes that will affect the future of nursing practice. It is increasingly important for leaders to be able to coalesce effort around critical factors that point towards significant differences for tomorrows healthcare. The convergence of technological, socio- political and economic changes described above creates the value-driven context for healthcare providers of the future. If leaders have kept up with the trend- ing circumstances of the time, they should not be surprised by their impacts on service and care. And neither should their staff, if the leaders have been good and faithful in translating and applying the change factors to their own clinical environments and roles. 2.Good leaders read broadly beyond their own field in order to determine what is transferable, or at least applicable. At least 10% of a leaders time should be spent in exploration and the generation of innovation. There is a need for new think- ing. The leader should be challenging staff with the questions,What difference did you make here today? What has changed as a result of what you have done today? What will you do differently tomorrow as a result of what you discovered today?While standardization enables customization, standardization is not an end; it is merely the ground of practice, the scaffolding, from which nurses reach to the innovative and the excellent. No one ever standardized themselves to excellence, but no one ever achieved excellence without having a standard upon which to construct it. 3.The leader must demonstrate an availability, even vulnerability, to the demand for growth and change. Recognizing the impact of cellular communication, for example, and the portability it implies, means the leader doesnt work to prevent the young nurse from texting the physician but finds a way to make the action useful, meaningful, safe and confidential. Staff cannot go anywhere the leader hasnt been or is not willing to go. Embracing the journey and the challenges to personal comfort, security and competence is a sign of great leadership. The leader works to set tables for creative and innovative trans-disciplinary dialogue about service, partnership, care and the continuum. Making it safe to push the walls of past practice is a role requirement for every leader today. 4.The early stages of any meaningful change involve heavy commitment from the leader and some degree of deconstruction. Innovation requires taking apart at least some of the existing reality or circumstances that reflect past practice, habit, ritual or routine. This often means confronting staff behaviours directly and engaging them in the noisy process of assuming a new way of being or doing. The natural reaction to this dramatic impact of the early change process often places leaders in a negative light, compelling them to deal with staff complaints, blame or other forms of acting out. This state is disagreeable 20. Nursing Leadership Volume 27 Number 2 201418 enough in itself to make many leaders reluctant to lead any change. Leaders must recognize such reactions as normative, incorporate them into the plan for change and give staff reaction a voice, a medium for expression. This way, the negative energy associated with change has a place to go; it becomes visible and useful in identifying various challenges to the change in a way that can be posi- tively addressed. 5.What change agents bring to thinking about change is important to the relevance and viability of the change itself. Innovation requires different patterns of think- ing. Leaders must reflect on change in the context of where it is headed, rather than from a historic or even contemporary perspective. They need to demon- strate predictive capacity in a way that can translate into the work of creating a preferred future. The good leader walks ahead into the change and travels back to the staff with the story of the journey, sufficient to inform their construc- tion of the scaffolding and substance necessary to get there. The vision of the change is the province of the leader; the substance of change is the work of the staff. The leader creates a context and commitment for a shared vision, while the staff construct the landscape of the lived vision (Malloch and Porter-OGrady 2010b). Living The Social Compact of Nursing Writing the script for a preferred health future is the obligation of nursing leader- ship. Our legacy from Florence Nightingale is our professional commitment to the advancement of peoples health (McDonald 2010). She made it clear on many occasions that ensuring the health of society was a sacred mandate for the nurse (Mowbray 2008; OMalley 1931; Williamson 1999). The profession often gets captured by its commitments to doing for and is just as frequently captured by the questions of what and how.We often forget that the fundamental question that purposes our work as nurses is why.After all, our work must be driven by meaning if it is ever to be a sustainable part of the future health landscape. We are now at a time when we must demonstrate a stronger link between cause and effect in practice in an effort to establish a sustaining value for our work (Schmidt and Brown 2012). As time moves on in the health continuum, nursing work will need to partner more intensely and fit more tightly with the work of other disciplines. The intersections between team members are becoming more critical to the seamless experience of truly effective health service. The essential effort to link information, practise, quality and affordability in contemporary health systems will require a goodness of fit among all disciplines in a way that establishes viability, best practices, and service, social and financial value. Systems will not be able to support players or partners that cannot distinguish their legiti- macy, impact and value in the relationship between them and their partners in service. This legitimacy cannot just be defined; it must instead be demonstrated. 21. 19 Effective teams will need comparability among practitioners in order to achieve the necessary equity in teams to articulate common ground, mutual contribution and shared value. Those who cannot demonstrate comparability in conceptualiza- tion, critical thinking, evidence-based practices, contribution and value will rele- gate themselves to subsequent or secondary roles in applying the script of clinical work rather than writing it. There is no doubt that this is a challenging, transformational time for all in healthcare that calls leaders to the fullest expression of their role. The ambiguity, tenuousness and uncertainty of the times bear witness to the need for vision, clar- ity and meaning. Now leaders must stay grounded in the larger and longer view of the journey, moving further into the digital age. They must be able to translate the landscape into language that excites and engages nurses and team members (including physicians and our other clinical partners) in a way that joins all in the effort to obtain a truly healthy society rather than simply take care of the sick. Those we serve have the right to expect no less from us. That, after all, is what they call us to do. Correspondence may be directed to: Tim Porter-OGrady by e-mail at: info@tpogas- sociates.com or by telephone at: 404-892-8494. References Brooks, R. and C. Grotz. 2010.Implementation of Electronic Medical Records: How Health Care Providers Are Managing the Challenges of Going Digital. Journal of Business & Economics Research 8(6): 7385. Dossey, B.M. 2005. Florence Nightingale Today: Healing, Leadership, Global Action. Silver Spring, MD: American Nurses Association. Goldsmith, J. 1993.Driving the Nitroglycerin Truck: The Relationship between the Hospital and Physician. Healthcare Forum Journal 36(2): 3640. Gortmaker, S.L., B.A. Swinburn, D. Levy, R. Carter, P.L. Mabry, D.T. Finegood et al. 2011.Changing the Future of Obesity: Science, Policy and Action. Lancet 378(9793): 83847. doi: 10.1016/S0140- 6736(11)60815-5. Gu, W. 2011. Gene Discovery for Disease Models. Hoboken, NJ: Wiley. Haven, E.O. 1869. The Medical Profession. Address delivered to the medical class at the University of Michigan, March 31, 1869. Ann Arbor, MI: Dr. Chases Steam Printing House. Horn, S. 2010.Digital Medicine: Health Care in the Internet Era. Choice 47(10): 201718. Malloch, K. and Porter-OGrady, T. 2010a. Introduction to Evidence-Based Practice in Nursing and Health Care (2nd ed.). Sudbury, MA: Jones and Bartlett. Malloch, K. and Porter-OGrady, T. 2010b. The Quantum Leader: Applications for the New World of Work. Boston: Jones & Bartlett. McDonald, L. 2010. Florence Nightingale at First Hand. Waterloo, ON: Wilfrid Laurier University Press. Melnyk, B. and E. Fineout-Overholt. 2012. Evidence-Based Practice and Nursing and Healthcare (2nd ed.). St. Louis: Lippincott Williams & Wilkins. Mowbray, P. 2008. Florence Nightingale and the Viceroys: A Campaign for the Health of the Indian People. London: Haus. Leading the Revolution in Nursing Practice: Advancing Health in the Digital Age 22. 20 Nursing Leadership Volume 27 Number 2 2014 OMalley, I.B. 1931. Florence Nightingale, 18201856: A Study of Her Life Down to the End of the Crimean War. London: T. Butterworth. Porter-OGrady, T. and K. Malloch. 2008.Beyond Myth and Magic: The Future of Evidence- Based Leadership. Nursing Administration Quarterly 32(3): 17687. doi: 10.1097/01. NAQ.0000325174.30923.b6. Porter, M. and E. Teisberg, E. 2006. Redefining Health Care: Creating a Value-Based Competition on Results. Boston: Harvard Business School Press. Ray, R. 1995.Controlling Americas Health Care Costs via Health Care Futures. Health Care Management Review 20(2): 8591. Sarma, S., R.A. Devlin, A. Thind and M.K. Chu. 2012.Canadian Family Physicians Decision to Collaborate: Age, Period and Cohort Effects. Social Science & Medicine 75(10): 181119. doi: 10.1016/j.socscimed.2012.07.028. Schmidt, N.A. and J.M. Brown. 2012. Evidence-Based Practice for Nurses: Appraisal and Application of Research (2nd ed.). Sudbury, MA: Jones & Bartlett Learning. Smith, M.D. & Institute of Medicine Committee on the Learning Health Care System in America. 2012. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Washington, DC: National Academies Press. Stutz, L. 2013.The Evolution of Banner Healths Case Management Program. Professional Case Management 18(3): 13841. doi: 10.1097/NCM.0b013e31828495b1. Williamson, L., ed. 1999. Florence Nightingale and the Birth of Professional Nursing. Bristol: Thoemmes Continuum. Wilson, A., N. Whitaker and D. Whitford. 2012.Rising to the Challenge of Health Care Reform with Entrepreneurial and Intrapreneurial Nursing Initiatives. Online Journal of Issues in Nursing 17(2): 5. 23. 21 Nursing is changing, nursing is about to change more and from my United Kingdom perspective nursing could even be said to be in crisis (Francis 2013). Crises, such as the one in the United Kingdom, require solutions, and many people are working hard on this (Council of Deans of Health 2013; Department of Health 2014; Nursing and Midwifery Council 2013); however, solving crises adheres us to the past, nudges us into it must not happen again anxiety and inevitably lowers horizons. Leadership is stultified because leaders are visionar- ies, and in the face of a crisis, vision becomes blurred blinded even by fear of trying anything new for fear that it will not work. Rather, the inevitable message is turn the clock back, back to a time when all seemed to be well, when nurses were angels and patients got better. The bureaucrats, managers and administrators live in the past. Some venture into the now, but only leaders see the future and fear not to sow the seeds of change. Dr. Porter-OGrady does not fall into the trap that I have already stumbled into: parochialism. He does not mention a country or an incident. He simply points to the future and outlines the qualities of the people we will need across the world to ensure that we make it to the future. It strikes me that if nursing does not learn and adapt, it will not survive; if it does not survive and begin to shape its environ- ment, then it will become irrelevant. Commentary: Nursing Must Learn to Adapt Roger Watson, RN, PhD Editor-in-Chief, Journal of Advanced Nursing University of Hull, UK COMMENTARY 24. 22 Nursing Leadership Volume 27 Number 2 2014 Global Citizens Without specifying it, what Dr. Porter-OGrady is pointing to is the global health agenda (Jamison et al. 2013) and the seemingly inexorable rise in non- communicable diseases (NCDs). Even the most prominent and at one time terrifying spectre of HIV/AIDS, which killed without discrimination and for which a cure seemed impossible, has been brought under control by both prevention and cure (with no room for complacency on either count and notwithstanding the global disparities in access to relevant measures). However, the list of NCDs is long, global, likely to increase with affluence and, in many cases, preventable; in most cases, it is manageable. Tertiary care is packed with the cases that went wrong, were not prevented and could not be managed where the disease occurs: at home and in the community. Nurses are complicit in this acute care medical model and, while offering lip-service to care in the community and the superiority of prevention over cure, the classic image of the nurse remains one of being uniformed, in hospital and largely waiting for orders. This model is wholly inadequate to address the global health agenda. Global health has many definitions that need not distract us. However, there is a tendency to see global health as being over there while, all the time, it is right here wher- ever you are either in your local native population or in that increasing sector of the population that also used to be over there but are now over here. I recall teaching students in Edinburgh, Scotland about sickle-cell anaemia and being told it was a waste of time; they would never encounter it in their local hospital. How many of those students now work, if not overseas, in large conurbations where the immigrant community often many generations in their adopted country harbours the genes for sickle-cell and other rare anaemias? Once again, I make the mistake that Dr. Porter-OGrady skillfully avoids of becoming parochial. Global Leadership I travel widely, normally more than 10 countries annually in Europe, North America, the Far East, Southeast Asia and the Southern Hemisphere. In terms of Dr. Porter-OGradys vision for leadership, I am heartened that everywhere I go I am inspired by the people I meet in nursing. These are people at all levels and in all manner of positions but, it has to be said, many in academic positions. They espouse and exemplify the very qualities that are required: they see round the corner and over the horizon; they are eclectic in their reading; and they are not afraid to be wrong occasionally and are certainly not afraid to be opposed. I see other qualities at a more prosaic level: they have a sense of humour and even a disarming self-deprecation; they are not the people who say I dont get Twitter or whats the point in blogging? These are the people who have embraced the new technologies, social media and the myriad platforms through which contact 25. 23 can be maintained and influence exerted. Thankfully, a great many are younger than I. I have seen such colleagues lose their jobs and be sidelined for their vision, but I have never seen them give up. Therefore, there is hope. We have the leaders and we have the vision, but these need to be amalgamated. Is now the time for more leadership programs, more conferences and more reports? We may need more leadership training, but it will not yield solutions; conferences seem almost antediluvian in these days of constant conferencing, and another report may give the reporters a sense of completion and satisfaction. But most reports are out of date long before they are published, and most focus on yesterdays problems with yesteryears answers. We need something more flexible, more alive and something that instead of report- ing continues to comment, continues to provoke and continues to question. Specifically, I was privileged to be part of the inaugural meeting of the Global Advisory Panel on the Future of Nursing (GAPFON) in March 2014. Thus far the proceedings and the agenda are not public, thus avoiding the what about? trap whereby agenda, membership and solutions are offered by national and inter- national bodies and individuals terrified that their particular interests and angles may be omitted. Some of these external interests may well be part of the solution, but many are already part of the problem. GAPFON may not be the solution, but we will try hard not to be part of the problem. References Council of Deans of Health. 2013. Healthcare Assistant Experience for Pre-Registration Nursing Students in England. London: Author. Retrieved May 3, 2014. . Department of Health. 2014. The Government Response to the House of Commons Committee Third Report of Session 2014-14: After Francis: Making a Difference. London: Author. Francis, R. 2013. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. London: The Stationery Office. Retrieved May 3, 2014. . Jamison, D.T., L.H. Summers, G. Alleyne, K.J. Arrow, S. Berkley, A. Binagwaho et al. 2013.Global Health 2035: A World Converging within a Generation. The Lancet 382(9908): 1898955. doi: 10.1016/S0140-6736(13)62105-4. Nursing and Midwifery Council. 2013. NMC Response to the Francis Report. London: Author. Retrieved May 3, 2014. . Nursing Must Learn to Adapt 26. 24 Nursing Leadership Volume 27 Number 2 2014 Tim Porter-OGradys closing paragraph hits the perfect note. Leaders need to look far ahead, setting a course that excites and engages others in improving nurses positive impact on health, throughout life and at the time of death. The only part I would reframe is his claim that now we are on the verge of change. Society, technology and knowledge are always changing the way healthcare is practised. Textbooks and journal articles dating back hundreds of years are filled with authors crying foul over new devices and methods (Hrisson 1835). Technology will always disrupt, even if disruption takes time. The digital age only accelerates the rate of change and is creating more opportunities and awareness of deficien- cies that require us to transform healthcare and nursing practice. Porter-OGrady focuses on what needs to be done, and takes a productive approach by suggesting nurses lean in to shape our own future. This response will build on his approach, suggesting activities that could support practice transformation. Avoid Overplanning Too often, resources are invested only in studying, planning, writing or meeting about change. Although these activities have value, not every idea and project require a high degree of oversight, and highly detailed plans with clearly described outcomes, before starting. Nurses who see opportunities should take small steps to test their impact and scale solutions that work. Commentary: Nurses Positive Impact Across the Continuum Rob Fraser, MN, RN Registered Nurse, University Health Network Consultant, Rob D. Fraser & Associates Inc. Board Member, VON Canada 27. 25Nurses Positive Impact Across the Continuum The nursing process teaches us to assess, plan, intervene and monitor changes. These are skills that translate into project management and quality improvement, key activities in change management. However, we can learn from other profes- sions how to keep projects nimble and adaptive. For example, computer program- mers develop new tools with agile methodologies and share knowledge using social technologies, an approach that accelerates the rate of change in their field. An example of this is Hacking Health, a conference bringing clinicians, developers and designers together to build a health-related app in one weekend. Some partic- ipants learn a bit about group work and how hard it is to build a website, while other groups successfully launch apps or new companies. Nurses need to look for opportunities to turn ideas into reality, and organizations need to create ways to let clinicians try out innovations. As Porter-OGrady points out, nursing leaders need to bring different groups together, both within our profession and outside it, and embrace the journey though the unknown. Support and Learn from Others Leadership is too often misunderstood as being the smartest individual or best organization, which creates pressure to pretend to have the perfect solutions by themselves. Instead of trying to reinvent the wheel, leaders should pay attention to what is working elsewhere. They should adapt and improve upon previous work. A good leader listens to everyones ideas and always has an appetite to learn. Change also requires support and followers. Nurses need to support and collabo- rate with their peers rather than criticize those who push change forward. Porter-OGrady suggests reading widely and looking outside healthcare for ideas. Access to the Internet creates new ways to learn from other professions, organiza- tions and industries. Massive open online courses take learning beyond reading. For little or no cost, anyone can participate in courses ranging from healthcare practice to data analysis. These courses are taught by world-class faculty with engaging content, media and assignments readily available online through compa- nies like Coursera. Nurses at all levels can use these resources for new tools for self-development and to create a learning culture in their workplace. Be Ready for the Hard Part Nurses need to be present and participate in difficult organizational discussions and leadership decision-making. On top of the challenge of developing clinical skills and knowledge of care delivery, leaders need to be ready to develop fluency in other areas. Organizational finance, legal risk management and succession planning are key languages of organizational governance and leaders. 28. 26 Nursing Leadership Volume 27 Number 2 2014 Nurses must be part of the conversations that shape the future of our practice settings, organizations and healthcare systems. The skills required for this endeav- our are not more or less valuable than clinical skills. Instead, they are necessary to see, create and execute positive system transformation. If nurses do not participate at this level, there is a risk that organizations will cut resources, negatively affect- ing patients. At the same time, if nurses are making these decisions without neces- sary skills, organizations may not be sustainable, leaving patients and clinicians even more vulnerable. Focus on Impact The digital age has made it easier to measure impact beyond dollars. Digital information can be stored, transferred, extracted and analyzed in new ways. Quantitative and qualitative analysis of information focused on patient, family, community and societal health are critical. Nurses must expose indicators related to their work that focus on the patient. The outcomes must clearly demonstrate better health and better system performance. Further, we need to become comfortable working with data and exploring the insights that data can provide. Data ubiquity creates the opportunity to track vital signs and various health indicators across years rather than shifts. The impact that nurses and healthcare have on illness and wellness must be better measured, tested and learned from. Leaders Must Take the First Step The nursing profession is full of great ideas, as are many other professions. What makes a great leader is the ability to take ideas and turn them into reality. Florence Nightingale may be famous for many reasons, but the reason I admire her is her ability to apply her ideas and intuition. Writing books, applying statistical model- ling and tracking, as well as lobbying in Parliament, may all require ideas but more importantly, they require action. In order for nursing practice to truly be transformed, we must take steps to turn ideas into reality. Nurses need to explore how they can leverage new ideas and tools to improve the health of others. Knowing is not enough; we must apply. Willing is not enough; we must do. Johann Wolfgang von Goethe References Hrisson, J. 1835. The Sphygmometer: An Instrument Which Renders the Action of the Arteries Apparent to the Eye. London: Longman, Rees, Orme, Brown, Green and Longman. 29. 27 Baccalaureate Nursing Education: Has It Delivered? A Retrospective Critique Em M. Pijl-Zieber, RN, BScN, MEd PhD Candidate, University of Alberta Nursing Instructor, University of Lethbridge Lethbridge, AB Sonya Grypma, RN, PhD Professor & Dean, School of Nursing Trinity Western University Langley, BC Sylvia Barton, RN, PhD Associate Professor & Associate Dean, Global Health Faculty of Nursing, University of Alberta Edmonton, AB Abstract Despite political support for the baccalaureate degree as entry to practice, historical concerns over nursing education the value of education versus service, professional versus vocational identity and theoretical versus practical knowledge persist. The authors challenge the notion of a two-tiered nursing system and call for a nationwide curriculum review to help the profession adapt to the changing needs of the Canadian healthcare system. With the passing of legendary nursing leader Dr. Helen Mussallem in Ottawa on November 9, 2012 at the age of 97, it seems fitting to pause and reflect on the changes she and other nursing leaders of her day envisioned and accomplished, with an eye to what these changes mean for the future of nursing. On the strength of past leaders vision for baccalaureate education for all nurses, the current gener- ation of Canadian nurses has witnessed dramatic changes in nursing education the most remarkable of which is the comprehensive shift from hospital-based LEADERSHIP PERSPECTIVE 30. 28 Nursing Leadership Volume 27 Number 2 2014 training to university-based liberal arts education, and from primarily acute care centred curricula to community healthfocused curricula. And yet, not all nurses and students view these shifts as positive. Today, some nurses and students express a longing for the good old days of hospital-based schools, where students learned real nursing skills and could hit the ground running when they gradu- ated. Others disparage community health content within existing curricula, preferring instead more acute care content to align with the predominant struc- ture of healthcare in Canada. Tensions between Service and Learning Interests: From Hospitals to Universities The move from hospital schools of nursing to universities traces back to tensions between service and educational needs that surfaced in hospital training schools in the 1920s and 1930s. From the opening of the first Canadian hospital-based diploma school in 1874 (Kirkwood 2005) through the 1930s, when Canada boasted 330 hospital training schools (Paul and Ross-Kerr 2011), the structure and function of nurses training remained virtually unchanged: hospital schools used an apprenticeship model of on-the-job training (Bonin 1977; Hermann 2001). In exchange for room and board, uniforms, training and a small stipend, students provided the primary means of staffing hospitals (Saarinen 2008). Hospitals desired low-cost service, and young women desired low-cost education; hospital training provided both. Amid growing concern about the quality of student training, the Canadian Nurses Association (CNA) and the Canadian Medical Association jointly funded a nationwide study on nursing education. The resultant Survey of Nursing Education in Canada (Weir 1932; also called the Weir Report) revealed a lack of high-quality education, including insufficient classroom instruction and lack of variety in clinical experience, and expressed grave concern about the ethics of charging sick patients for the education of nurses. This report recommended that nurse preparation be transferred from hospital schools into the general educa- tion system of each province, and funded in a fashion similar to other educational programs. Weir advised that nurses receive adequate liberal arts, as well as techni- cal, education at the degree level. Despite these recommendations, by the 1960s, 95% of Canadian nurses were still being trained in hospitals (Romyn 1990). During this time, the CNA, sparked by an interest in accreditation, sponsored a second nationwide survey of nursing education. Conducted by Dr. Helen Mussallem, the resultant Spotlight on Nursing Education revealed that only 16% of schools met the criteria for accreditation, indicating ongoing quality problems at hospital schools of nursing. Mussallem (1960) recommended that the CNA focus on upgrading nursing education programs, leading to a report entitled A Path to Quality (Mussallem 1964), which 31. 29Baccalaureate Nursing Education: Has It Delivered? A Retrospective Critique was intended to prepare a plan for the re-development of basic nursing education programs within the higher education system. The concurrent Royal Commission on Health Services (Hall et al. 1965) also underlined the need to overhaul nursing education. All three of these reports failed to produce timely changes in nursing education. The reason for this failure has yet to be analyzed. It is plausible that the failed uptake was due to the fragmented delivery of nursing education across hundreds of disconnected hospitals that may have been more concerned about their staff- ing needs than about the education of nurses, or due to lack of collective political will among nurses and governing bodies. While college preparation for registered nurses eventually became the norm in Canada, the realization of the baccalaure- ate degree as the requirement for entry to practice (BETP), initiated in 1957 and taken up in the 1980s, was not fully realized until 2007. The impetus behind this mandate was the pursuit of professional legitimacy and the desire to better prepare new nurses for practice in an increasingly complex healthcare system (Kirkwood 2005; McIntyre et al. 2006). The BETP mandate effectively collapsed three existing educational pathways into one single route for becoming a registered nurse (RN) in Canada. Two- and three-year hospital- and college-based diploma programs were closed or folded into existing four-year university-based degree programs. Seen by some as a victory for professional nursing and an affirmation of the value and complexity of nursing knowledge, the establishment of BETP nonetheless left others wondering whether the move to universities signified a privileging of theoretical knowledge over practical skills. Having universities as the de facto site for nursing education exacerbated concerns that higher education prepares nurses for something other than the role in which most nurses are actually employed: as caregivers to sick and injured individuals in hospital settings. Tensions between Professional and Vocational Identity: The Rise of the BSN One impetus for discussions of a baccalaureate degree as entry to practice was a belief that its absence acted as a barrier to the establishment of nursing as a profession (Kergin 1970). Higher standards of education were thought to increase the social legitimacy of nursing (Baumgart and Kirkwood 1990; Hermann 2001; McPherson and Stuart 1994; Saarinen 2008). As separate, service-oriented institu- tions based on assumptions of the feminine propensity to care and serve, hospital schools of nursing lacked parity with other professional programs such as engi- neering, medicine and education. Without educational parity, it was feared, the profession would never be taken seriously, develop its own body of knowledge, have control over its own preparation or advance to being an equal partner in the healthcare system (Kirkwood 2005). Many nursing leaders believed that to realize 32. 30 Nursing Leadership Volume 27 Number 2 2014 its full potential the profession would need to be less focused on training and more on educating nurses that is, to exchange the traditional apprenticeship model for a curriculum that placed greater emphasis on the humanities and social sciences (Hermann 2001; Paul and Ross-Kerr 2011). Integrating liberal arts with traditional (technical) and emerging (theoretical) nursing knowledge promised to foster critical thinking, situate nursing within a humanistic perspective, support personal and professional development of the student, promote social consciousness for citizenship and social reform, promote the acquisition of general knowledge and prepare students for complex healthcare environments that were constantly changing (Hagerty and Early 1992; Hermann 2001; Priest 1970). While Mussallem and the Royal Commission on Health Services (Hall et al. 1965) proposed a two-tiered system with baccalaureate-prepared leaders and diploma- prepared bedside nurses, in actuality the realization of BETP threatened to elimi- nate the second tier. In the absence of diploma graduates traditionally trained for hospital-based care, it became unclear as to who would be best prepared to provide bedside care. Baccalaureate-prepared nurses may have been expected to step into the gap, but baccalaureate nursing programs in the 1990s and beyond reflected the widely held belief that healthcare was (and is) moving from acute care into the community (CNA 2008; ICN 2003; WHO 2008). In anticipa- tion of a new era in healthcare in which greater emphasis would be placed on health promotion and illness/injury prevention at the population level (Cohen and Gregory 2009), baccalaureate nursing programs continued to emphasize a community health perspective that had, in previous years, distinguished baccalau- reate education from diploma education. Not all nurses were in favour of BETP (Brooks and Rafferty 2010). To some, the occupational culture produced by the apprenticeship model of hospital train- ing schools seemed to prepare students better for the real world they faced than the professionalization campaigns of an elite minority of nurses (Strong-Boag 1991: 238). Nursing unions also largely opposed the baccalaureate policy, most likely because their focus was on member remuneration, working conditions and defending job security and upward mobility for diploma-prepared nurses (Rhaume 2003). Some nurses and nursing leaders were concerned that bacca- laureate-prepared graduates would be less competent and lack the level of skill and knowledge of a hospital-trained, diploma-level nurse (Bonin 1977; Crowe 1991; Kergin 1970). Today there is little evidence that the primary healthcare ideals so strongly represented in Canadian baccalaureate nursing curricula have actually come to fruition at the system level. If baccalaureate education was origi- nally intended to prepare nurses for roles beyond bedside nursing (and within 33. 31Baccalaureate Nursing Education: Has It Delivered? A Retrospective Critique an as-yet-unrealized primary healthcare model), it should not be surprising that the question continues regarding whether baccalaureate education adequately prepares nurses for acute care roles. Tensions between Theoretical and Practical Knowledge: The Case of Practical Nurses Although Mussallem and the Royal Commission on Health Services (Hall et al. 1965) identified two tiers of registered nurse preparation a baccalaureate level for leadership and complex care, and a diploma level for bedside care there has long been a third class of nurses: practical or vocational nurses (and even a fourth class, if one considers care aides). Largely relegated to the margins of nursing history, education and practice, practical nurses have nonetheless been a relatively inexpensive staple of the Canadian healthcare system since the Second World War. Intended as a temporary solution to the wartime shortage and as assistants to registered nurses, the utilization of practical nurses allowed RNs to focus on increasingly specialized and complex nursing care needs (Ford 1965; Paul and Ross-Kerr 2011; Saarinen 2008). When RN shortages continued after the war, so did the market for practical nurses. The shorter training period and lower wages made the schooling and hiring of practical nurses economically desir- able (Saarinen 2008) a trend that continues to this day, with senior licensed/ registered practical nurses (LPNs/RPNs) earning 1420% less than newly gradu- ated baccalaureate-prepared registered nurses (BCNU 2013; UNA 2012). Practical nurses were never intended to replace registered nurses, yet RNs have long expressed fear that practical nurses might do just that (Ford 1965; Saarinen 2008). And in the post-BETP world of Canadian nursing, it seems apparent that this is exactly what is happening: it is LPNs/RPNs who now occupy the second tier of nursing practice previously held by diploma nurses albeit with a less standard- ized (and, some would argue, less rigorous) system for education, licensing and registration. In this sense, Mussallems vision of two tiers of nurses has been realized, with baccalaureate-prepared nurses and practical nurses occupying essential positions in the nursing staff mix (CNA 2005). Nursing Education: Emerging from the Past and into the Future According to the CNAs A Nursing Call to Action (National Expert Commission 2012), nursing continues to value community care that focuses on health promotion and that acts on the determinants of health. The National Expert Commission continues the as-yet-unrealized transformation of our out-of-date, hospital- and illness-focused system into one that looks at the whole patient through the lens of the social and economic determinants of health, and provides care to people that reflects how they live in their community (National Expert Commission 2012: 30). Nurses, other professionals and the public across Canada favour an acceleration of the transition from acute care to community care, 34. 32 Nursing Leadership Volume 27 Number 2 2014 better service integration, greater health promotion at the population level and addressing the root causes of poorer health (National Expert Commission 2012); however, lack of commitment at all levels of government makes realizing these aspirations unlikely, at least in the near future. Despite political support for the baccalaureate degree as entry to practice, histori- cal concerns about the value of education versus service, professional versus vocational identity and theoretical versus practical knowledge continue to inform nursing discourse today. While it is clear that a two-tiered system of education and practice exists, what remains unclear is whether baccalaureate education is, or was ever, intended to fill the second tier the one focused on direct bedside care, primarily in acute care settings. Until or unless the Canadian healthcare system shifts more resources to primary healthcare (prevention and health promotion), the need for bedside nurses will remain a key driver for economic decisions regarding nursing education and practice. The question remains: How do we best prepare nurses baccalaureate and practical for the realities of a healthcare system that requires, and deserves, excellence in bedside nursing? The historical tendency to stratify nursing in Canada into two tiers with differentiated roles, status and pay continues to influence Canadian education and practice today. We urge nursing leaders to consider what it means to nursing to allow this strati- fication and the assumptions underlying it to continue unchallenged. While nurs- ing leaders recognize that baccalaureate-prepared nurses are needed across the healthcare system, we suggest that until we challenge the uncritical acceptance of a two-tiered (or more) nursing system or unless we are willing to critically exam- ine how status, historically embedded in the different tiers, influences decisions about education and practice we will not resolve the question of what the role of baccalaureate nurses should be in healthcare today. What is needed, then, is a continued effort at all levels of Canadian nursing to be proactive in the radical transformation of nursing education (Benner et al. 2010), nursing practice (Browne et al. 2012; Gottlieb et al. 2012; Villeneuve 2006) and healthcare organization and funding (National Expert Commission 2012). It is timely, also, for a review of nursing education in Canada, given that a compre- hensive national review of nursing education has not been completed since Mussallems (1960) report. Nurse leaders are also calling for such a review one that will provide curricular direction that will help nursing education adapt to the changing needs of Canadians and the changing healthcare system (Eggertson 2013; MacMillan 2013; MacMillan and Gurnham 2013). Surely the ideal of a well- educated professional nurse remains. But without clarity regarding what we are preparing nurses for, or clarity regarding how a historically informed resistance to baccalaureate-prepared nurses at the bedside influences messages about the rela- tive importance of bedside excellence, the two-tier approach to nursing education and practice that assigns less status to bedside nursing will continue unchallenged. 35. 33Baccalaureate Nursing Education: Has It Delivered? A Retrospective Critique Correspondence may be directed to: Em M. Pijl-Zieber at the Faculty of Health Sciences, University of Lethbridge; Telephone: 403-332-5232. E-mail: em.pijlzieber@uleth.ca. References Baumgart, A.J. and R. Kirkwood. 1990.Social Reform versus Education Reform: University Education in Canada, 19191960. Journal of Advanced Nursing 15: 51016. Benner, P., M. Sutphen, V. Leonard and L. Day. 2010. Educating Nurses: A Call for Radical Transformation. San Francisco: Jossey-Bass. Bonin, M.A. 1977. Trends in Integrated Basic Degree Nursing Programs in Canada, 19421972. Doctoral dissertation, University of Ottawa. British Columbia Nurses Union (BCNU). 2013. Wage Rate Schedule. Retrieved April 28, 2014. . Brooks, J. and A.M. Rafferty. 2010.Degrees of Ambivalence: Attitudes towards Pre-Registration University Education for Nurses in Britain, 19301960. Nurse Education Today 30(6): 57983. doi: 10.1016/j.nedt.2009.12.004. Browne, G., S. Birch and L. Thabane. 2012.Better Care: An Analysis of Nursing and Healthcare System Outcomes. Canadian Health Services Research Foundations Series of Reports to Inform the CNA National Expert Commission Part II. Ottawa: Canadian Nurses Association. Canadian Nurses Association (CNA). 2005 (January).Nursing Staff Mix: A Key Link to Patient Safety. Nursing Now: Issues and Trends in Canadian Nursing 19. Retrieved April 28, 2014. . Canadian Nurses Association (CNA). 2008. CNAs Preferred Future: Health for All. Ottawa: Author. Retrieved April 28, 2014. . Cohen, B.E. and D. Gregory. 2009.Community Health Clinical Education in Canada: Part 1 State of the Art. International Journal of Nursing Education Scholarship 6(1): 117. doi: 10.2202/1548- 923X.1637. Crowe, S.J. 1991. Who Cares? The Crisis in Canadian Nursing. Toronto: McClelland & Stewart. Eggertson, L. 2013.The Gap between Clinical Practice and Education. Canadian Nurse 109(7): 2226. Ford, A. 1965.Dilemma of the Nursing Assistant. Canadian Nurse 61(4): 29799. Gottlieb, L.N., B. Gottlieb and J. Shamian. 2012.Principles of Strengths-Based Nursing Leadership for Strengths-Based Nursing Care: A New Paradigm for Nursing and Healthcare for the 21st Century. Canadian Journal of Nursing Leadership 25(2): 3850. Hagerty, B.M.K. and S.L. Early. 1992.The Influence of Liberal Education on Professional Nursing Practice: A Proposed Model. Advances in Nursing Science 14(3): 2938. Hall, E.M., A. Girard, D.M. Baltzan, O.J. Firestone, C.L. Strachan, A.F. van Wart et al. 1965. Royal Commission on Health Services. Ottawa: Government of Canada. Hermann, M.L.S. 2001. The Current Nature of the Integration of the Humanities within Baccalaureate Nursing Education. Doctoral dissertation, Widener University, Chester, PA. International Council of Nurses (ICN). 2003. ICN Framework of Competencies for the Generalist Nurse: Report of the Development Process and Consultation. Geneva: International Council of Nurses. Kergin, D.J. 1970.Nursing as a Profession. In M.Q. Innis, ed., Nursing Education in a Changing Society (pp. 4663). Toronto: University of Ontario Press. Kirkwood, L. 2005.Enough But Not Too Much: Nursing Education in English Language Canada (18742000). In C. Bates, D. Dodd and N. Rousseau, eds., On All Frontiers: Four Centuries of Canadian Nursing (pp. 18396). Ottawa: University of Ottawa Press. 36. 34 Nursing Leadership Volume 27 Number 2 2014 MacMillan, K. 2013. Proceedings of a Think Tank on the Future of Undergraduate Nursing Education in Canada. Halifax: Dalhousie University School of Nursing. MacMillan, K. and M.E. Gurnham. 2013.Leaders Hold an Invitational Think Tank on Undergraduate Nursing Education. Canadian Journal of Nursing Leadership 26(2): 2528. McIntyre, M., E. Thomlinson and C. McDonald. 2006. Realities of Canadian Nursing: Professional, Practice, and Power Issues (2nd ed.). Philadelphia: Lippincott Williams & Wilkins. McPherson, K. and M. Stuart. 1994.Writing Nursing History in Canada: Issues and Approaches. Canadian Bulletin of Medical History 11(1): 322. Mussallem, H.K. 1960. Spotlight on Nursing Education: The Report of the Pilot Project for the Evaluation of Schools of Nursing in Canada. Ottawa: Canadian Nurses Association. Mussallem, H.K. 1964. A Path to Quality: A Plan for the Development of Nursing Education Programs within the General Educational System of Canada. Ottawa: Canadian Nurses Association. National Expert Commission. 2012. The Health of Our Nation, the Future of Our Health System. A Nursing Call to Action. Ottawa: Canadian Nurses Association. Paul, P. and J.C. Ross-Kerr. 2011.The Origins and Development of Nursing Education in Canada. In J.C. Ross-Kerr and M.J. Wood, Canadian Nursing: Issues and Perspectives (5th ed.). Toronto: Mosby Canada. Priest, R.R. 1970.The Humanities in the Nursing Curriculum. In M.Q. Innis, ed., Nursing Education in a Changing Society (pp. 18489). Toronto: University of Toronto Press. Rhaume, A. 2003.Establishing Consensus about the Baccalaureate Entry-to-Practice Policy. Journal of Nursing Education 42(12): 54652. Romyn, A. 1990.The Future of Nursing Education within British Columbias Community Colleges. Masters thesis, University of British Columbia, Vancouver, BC. Saarinen, J.M. 2008.Dominant Discourses and Ideologies That Have Shaped the Education of Registered Nurses and Licensed Practical Nurses in Canada. Masters thesis, University of Victoria, BC. Strong-Boag, V. 1991.Making a Difference: The History of Canadas Nurses. Canadian Bulletin of Medical History 8: 23148. United Nurses of Alberta (UNA). 2012.Appendix of Nursing Salaries in Alberta 19482013. Retrieved April 28, 2014. . Villeneuve, M.M. and J. MacDonald. 2006.Toward 2020: Visions for Nursing (Special Report). Canadian Nurse 102(5): 2223. Weir, G.M. 1932. Survey of Nursing Education in Canada. Toronto: University of Toronto Press. World Health Organization (WHO). 2008. Primary Health Care: Now More Than Ever. Geneva: Author. 37. 35 Critical reflection on the introduction of baccalaureate education as the entry-to- practice requirement in Canada is timely. Major changes in the healthcare needs of the population are emerging and are likely to grow exponentially in the next three decades. Efforts to chart future directions for nursing education in this changing context must take into account long-standing issues from the past. The authors (Pijl-Zieber et al. 2014) identify historical tensions between the immediate needs of the health services sector and the populations needs for an appropriately educated nursing workforce. Differing perspectives about what constitutes an appropriate education for nurses have been rooted in tensions between both professional and vocational nursing identities, and theoretical versus practical knowledge. Hospital Training Schools The authors note that lay education for nurses in Canada began in 1874, when Dr. Theophilus Mack established a hospital training school in St. Catharines, Ontario with the assistance of two nurses who had trained under Florence Nightingale (Kirkwood 2005). Convinced that respectable young women educated to be nurses were needed to improve hospital outcomes, Dr. Mack wrote:all the most brilliant achievements of modern surgery are dependent to a great extent upon careful and intelligent nursing (cited in Gibbon 1947: 145). He also Future Directions for Nursing Education Cynthia Baker, RN, PhD Executive Director, Canadian Association of Schools of Nursing Ottawa, ON COMMENTARY 38. 36 Nursing Leadership Volume 27 Number 2 2014 believed that trained nurses would alter the publics prejudice against hospitals. These views reflected an international movement involving the ascent of medical control and the evolution of hospitals from charitable and custodial institu- tions to socially respectable and therapeutic ones (McPherson 1996: 6). This shift required an educated nursing workforce. Dr. Mack stressed the educational component of the training school, arguing that every possible opportunity is seized to impart instruction of a practical nature in the art of nursing, while teaching will be given in chemistry, sanitary science, popular physiology and anatomy, hygiene and all such branches of the healing art (cited in Gibbon 1947: 145). The training was based on apprenticeship, however, and nursing students quickly became the workforce of a rapidly burgeoning system of hospitals and hospital-based healthcare. Economic benefits quickly became the major driving force of the hospital training school. Except for a very small number of supervisors and instructors, students provided all nursing services in the hospital. Nevertheless, the initial desire to increase the social acceptability of hospital care by training nursing students continued. Entrance requirements were used to define nursing as a respectable occupation for young, single Caucasian women. Applicants were required to be unmarried or widowed females between 18 and 35, with a grade 9 educa- tion (which soon increased to grade 11 or 12), who spoke English or French proficiently. Until the 1940s, no African-Canadian or First Nation women were admissible (McPherson 2005). The schools kept their young, fema