The Essentials of Master’s Education in Nursing
March 21, 2011
TABLE OF CONTENTS
Master’s Education in Nursing and Areas of Practice 5 Context for Nursing Practice 6 Master’s Nursing Education Curriculum 7
The Essentials of Master’s Education in Nursing I. Background for Practice from Sciences and Humanities 9 II. Organizational and Systems Leadership 11 III. Quality Improvement and Safety 13
IV. Translating and Integrating Scholarship into Practice 15 V. Informatics and Healthcare Technologies 17
VI. Health Policy and Advocacy 20 VII. Interprofessional Collaboration for Improving Patient
and Population Health Outcomes 22 VIII. Clinical Prevention and Population Health for
Improving Health 24 IX. Master’s-Level Nursing Practice 26 Clinical/Practice Learning Expectations for Master’s Programs 29 Summary 31 Glossary 31
References 40 Appendix A: Task Force on the Essentials of Master’s Education in Nursing 49 Appendix B: Participants who attended Stakeholder Meetings 50 Appendix C: Schools of Nursing that Participated in the Regional Meetings
or Provided Feedback 52 Appendix D: Professional Organizations that Participated in the Regional Meetings or Provided Feedback 63 Appendix E: Healthcare Systems that Participated in the Regional Meetings 64
The Essentials of Master’s Education in Nursing March 21, 2011
The Essentials of Master’s Education in Nursing reflect the profession’s continuing call for imagination, transformative thinking, and evolutionary change in graduate education. The extraordinary explosion of knowledge, expanding technologies, increasing diversity, and global health challenges produce a dynamic environment for nursing and amplify nursing’s critical contributions to health care. Master’s education prepares nurses for flexible leadership and critical action within complex, changing systems, including health, educational, and organizational systems. Master’s education equips nurses with valuable knowledge and skills to lead change, promote health, and elevate care in various roles and settings. Synergy with these Essentials, current and future healthcare reform legislation, and the action-oriented recommendations of the Initiative on the Future of Nursing (IOM, 2010) highlights the value and transforming potential of the nursing profession.
These Essentials are core for all master’s programs in nursing and provide the necessary curricular elements and framework, regardless of focus, major, or intended practice setting. These Essentials delineate the outcomes expected of all graduates of master’s nursing programs. These Essentials are not prescriptive directives on the design of programs. Consistent with the Baccalaureate and Doctorate of Nursing Practice Essentials, this document does not address preparation for specific roles, which may change and emerge over time. These Essentials also provide guidance for master’s programs during a time when preparation for specialty advanced nursing practice is transitioning to the doctoral level.
Master’s education remains a critical component of the nursing education trajectory to prepare nurses who can address the gaps resulting from growing healthcare needs. Nurses who obtain the competencies outlined in these Essentials have significant value for current and emerging roles in healthcare delivery and design through advanced nursing knowledge and higher level leadership skills for improving health outcomes. For some nurses, master’s education equips them with a fulfilling lifetime expression of their mastery area. For others, this core is a graduate foundation for doctoral education. Each preparation is valued.
The dynamic nature of the healthcare delivery system underscores the need for the nursing profession to look to the future and anticipate the healthcare needs for which nurses must be prepared to address. The complexities of health and nursing care today make expanded nursing knowledge a necessity in contemporary care settings. The transformation of health care and nursing practice requires a new conceptualization of master’s education. Master’s education must prepare the graduate to:
• Lead change to improve quality outcomes,
• Advance a culture of excellence through lifelong learning,
• Build and lead collaborative interprofessional care teams,
• Navigate and integrate care services across the healthcare system,
• Design innovative nursing practices, and
• Translate evidence into practice.
Graduates of master’s degree programs in nursing are prepared with broad knowledge and practice expertise that builds and expands on baccalaureate or entry-level nursing practice. This preparation provides graduates with a fuller understanding of the discipline of nursing in order to engage in higher level practice and leadership in a variety of settings and commit to lifelong learning. For those nurses seeking a terminal degree, the highest level of preparation within the discipline, the new conceptualization for master’s education will allow for seamless movement into a research or practice-focused doctoral program (AACN, 2006, 2010).
The nine Essentials addressed in this document delineate the knowledge and skills that all nurses prepared in master’s nursing programs acquire. These Essentials guide the preparation of graduates for diverse areas of practice in any healthcare setting.
• Essential I: Background for Practice from Sciences and Humanities o Recognizes that the master’s-prepared nurse integrates scientific findings
from nursing, biopsychosocial fields, genetics, public health, quality improvement, and organizational sciences for the continual improvement of nursing care across diverse settings.
• Essential II: Organizational and Systems Leadership o Recognizes that organizational and systems leadership are critical to the
promotion of high quality and safe patient care. Leadership skills are needed that emphasize ethical and critical decision making, effective working relationships, and a systems-perspective.
• Essential III: Quality Improvement and Safety o Recognizes that a master’s-prepared nurse must be articulate in the
methods, tools, performance measures, and standards related to quality, as well as prepared to apply quality principles within an organization.
• Essential IV: Translating and Integrating Scholarship into Practice
o Recognizes that the master’s-prepared nurse applies research outcomes within the practice setting, resolves practice problems, works as a change agent, and disseminates results.
• Essential V: Informatics and Healthcare Technologies
o Recognizes that the master’s-prepared nurse uses patient-care technologies to deliver and enhance care and uses communication technologies to integrate and coordinate care.
• Essential VI: Health Policy and Advocacy o Recognizes that the master’s-prepared nurse is able to intervene at the
system level through the policy development process and to employ advocacy strategies to influence health and health care.
• Essential VII: Interprofessional Collaboration for Improving Patient and Population Health Outcomes
o Recognizes that the master’s-prepared nurse, as a member and leader of interprofessional teams, communicates, collaborates, and consults with other health professionals to manage and coordinate care.
• Essential VIII: Clinical Prevention and Population Health for Improving Health
o Recognizes that the master’s-prepared nurse applies and integrates broad, organizational, client-centered, and culturally appropriate concepts in the planning, delivery, management, and evaluation of evidence-based clinical prevention and population care and services to individuals, families, and aggregates/identified populations.
• Essential IX: Master’s-Level Nursing Practice o Recognizes that nursing practice, at the master’s level, is broadly defined
as any form of nursing intervention that influences healthcare outcomes for individuals, populations, or systems. Master’s-level nursing graduates must have an advanced level of understanding of nursing and relevant sciences as well as the ability to integrate this knowledge into practice. . Nursing practice interventions include both direct and indirect care components.
Master’s Education in Nursing and Areas of Practice Graduates with a master’s degree in nursing are prepared for a variety of roles and areas of practice. Graduates may pursue new and innovative roles that result from health reform and changes in an evolving and global healthcare system. Some graduates will pursue direct care practice roles in a variety of settings (e.g., the Clinical Nurse Leader, nurse educator). Others may choose indirect care roles or areas of practice that focus on aggregate, systems, or have an organizational focus, (e.g. nursing or health program management, informatics, public health, or clinical research coordinator). In addition to developing competence in the nine Essential core areas delineated in this document, each graduate will have additional coursework in an area of practice or functional role. This coursework may include more in-depth preparation and competence in one or two of the Essentials or in an additional/ supplementary area of practice. For example, more concentrated coursework or further development of the knowledge and skills embedded in Essential IV (Translational Scholarship for Evidence-Based Practice) will prepare the nurse to manage research projects for nurse scientists and other
healthcare researchers working in multi-professional research teams. More in-depth preparation in Essential II (Organizational and System Leadership) will provide knowledge useful for nursing management roles. In some instances, graduates of master’s in nursing programs will seek to fill roles as educators. As outlined in Essential IX, all master’s-prepared nurses will develop competence in applying teaching/learning principles in work with patients and/or students across the continuum of care in a variety of settings. However, as recommended in the Carnegie Foundation report (2009), Educating Nurses: A Call for Radical Transformation, those individuals, as do all master’s graduates, who choose a nurse educator role require preparation across all nine Essential areas, including graduate-level clinical practice content and experiences. In addition, a program preparing individuals for a nurse educator role should include preparation in curriculum design and development, teaching methodologies, educational needs assessment, and learner-centered theories and methods. Master’s prepared nurses may teach patients and their families and/or student nurses, staff nurses, and variety of direct-care providers. The master’s prepared nurse educator differs from the BSN nurse in depth of his/her understanding of the nursing discipline, nursing practice, and the added pedagogical skills. To teach students, patients, and caregivers regarding health promotion, disease prevention, or disease management, the master’s-prepared nurse educator builds on baccalaureate knowledge with graduate- level content in the areas of health assessment, physiology/pathophysiology, and pharmacology to strengthen his/her scientific background and facilitate his/her understanding of nursing and health-related information. Those master’s students who aspire to faculty roles in baccalaureate and higher degree programs will be advised that additional education at the doctoral level is needed (AACN, 2008).
Context for Nursing Practice
Health care in the United States and globally is changing dramatically. Interest in evolving health care has prompted greater focus on health promotion and illness prevention, along with cost-effective approaches to high acuity, chronic disease management, care coordination, and long-term care. Public concerns about cost of health care, fiscal sustainability, healthcare quality, and development of sustainable solutions to healthcare problems are driving reform efforts. Attention to affordability and accessibility of health care, maintaining healthy environments, and promoting personal and community responsibility for health is growing among the public and policy makers.
In addition to broad public mandates for a reformed and responsive healthcare system, a number of groups are calling for changes in the ways all health professionals are educated to meet current and projected needs for contemporary care delivery. The Institute of
Medicine (IOM), an interprofessional healthcare panel, described a set of core competencies that all health professionals regardless of discipline will demonstrate: 1) the provision of patient-centered care, 2) working in interprofessional teams, 3) employing evidence-based practice, 4) applying quality improvement approaches, and 5) utilizing informatics (IOM, 2003).
Given the ongoing public trust in nursing (Gallup, 2010), and the desire for fundamental reorganization of relationships among individuals, the public, healthcare organizations and healthcare professionals, graduate education for nurses is needed that is wide in scope and breadth, emphasizes all systems-level care and includes mastery of practice knowledge and skills. Such preparation reflects mastery of higher level thinking and conceptualization skills than at the baccalaureate level, as well as an understanding of the interrelationships among practice, ethical, and legal issues; financial concerns and comparative effectiveness; and interprofessional teamwork.
Master’s Nursing Education Curriculum
The master’s nursing curriculum is conceptualized in Figure 1 and includes three components:
1. Graduate Nursing Core: foundational curriculum content deemed essential for all students who pursue a master’s degree in nursing regardless of the functional focus.
2. Direct Care Core: essential content to provide direct patient services at an advanced level.
3. Functional Area Content: those clinical and didactic learning experiences identified and defined by the professional nursing organizations and certification bodies for specific nursing roles or functions.
This document delineates the graduate nursing core competencies for all master’s graduates. These core outcomes reflect the many changes in the healthcare system occurring over the past decade. In addition, these expected outcomes for all master’s degree graduates reflect the increasing responsibility of nursing in addressing many of the gaps in health care as well as growing patient and population needs.
Master’s nursing education, as is all nursing education, is evolving to meet these needs and to prepare nurses to assume increasing accountabilities, responsibilities, and leadership positions. As master’s nursing education is re-envisioned and preparation of individuals for advanced specialty nursing practice transitions to the practice doctorate these Essentials delineate the foundational, core expectations for these master’s program graduates until the transition is completed.
Figure 1: Model of Master’s Nursing Curriculum
* All master’s degree programs that prepare graduates for roles that have a component of direct care practice are required to have graduate level content/coursework in the following three areas: physiology/pathophysiology, health assessment, and pharmacology. However, graduates being prepared for any one of the four APRN roles (CRNA, CNM, CNS, or CNP), must complete three separate comprehensive, graduate level courses that meet the criteria delineated in the 2008 Consensus Model for APRN Licensure, Accreditation, Certification and Education. (http://www.aacn.nche.edu/education/pdf/APRNReport.pdf). In addition, the expected outcomes for each of these three APRN core courses are delineated in The Essentials of Doctoral Education for Advanced Nursing Practice (pg. 23-24) (http://www.aacn.nche.edu/DNP/pdf/Essentials.pdf). + The nursing educator is a direct care role and therefore requires graduate-level content in the three Direct Care Core courses. All graduates of a master’s nursing program must have supervised practice experiences that are sufficient to demonstrate mastery of the Essentials. The term “supervised” is used broadly and can include precepted experiences with faculty site visits. These learning experiences may be accomplished through diverse teaching methods, including face-to-face or simulated methods.
In addition, development of clinical proficiency is facilitated through the use of focused and sustained clinical experiences designed to strengthen patient care delivery skills, as
well as system assessment and intervention skills, which will lead to an enhanced understanding of organizational dynamics. These immersion experiences afford the student an opportunity to focus on a population of interest or may focus on a specific role. Most often, the immersion experience occurs toward the end of the program as a culminating synthesis experience.
The Essentials of Master’s Education in Nursing
Essential I: Background for Practice from Sciences and Humanities
Master’s-prepared nurses build on the competencies gained in a baccalaureate nursing program by developing a deeper understanding of nursing and the related sciences needed to fully analyze, design, implement, and evaluate nursing care. These nurses are well prepared to provide care to diverse populations and cohorts of patients in clinical and community-based systems. The master’s-prepared nurse integrates findings from the sciences and the humanities, biopsychosocial fields, genetics, public health, quality improvement, health economics, translational science, and organizational sciences for the continual improvement of nursing care at the unit, clinic, home, or program level. Master’s-prepared nursing care reflects a more sophisticated understanding of assessment, problem identification, design of interventions, and evaluation of aggregate outcomes than baccalaureate-prepared nursing care.
Students being prepared for direct care roles will have graduate-level content that builds upon an undergraduate foundation in health assessment, pharmacology, and pathophysiology. Having master’s-prepared graduates with a strong background in these three areas is seen as imperative from the practice perspective. It is recommended that the master’s curriculum preparing individuals for direct care roles include three separate graduate-level courses in these three content areas. In addition, the inclusion of these three separate courses facilitates the transition of these master’s program graduates into the DNP advanced-practice registered-nurse programs.
Master’s-prepared nurses understand the intersection between systems science and organizational science in order to serve as integrators within and across systems of care. Care coordination is based on systems science (Nelson et al., 2008). Care management incorporates an understanding of the clinical and community context, and the research relevant to the needs of the population. Nurses at this level use advanced clinical reasoning for ambiguous and uncertain clinical presentations, and incorporate concerns of family, significant others, and communities into the design and delivery of care. Master’s-prepared nurses use a variety of theories and frameworks, including nursing and ethical theories in the analysis of clinical problems, illness prevention, and health promotion strategies. Knowledge from information sciences, health communication, and health literacy are used to provide care to multiple populations. These nurses are able to
address complex cultural issues and design care that responds to the needs of multiple populations, who may have potentially conflicting cultural needs and preferences. As healthcare technology becomes more sophisticated and its use more widespread, master’s-prepared nurse are able to evaluate when its use is appropriate for diagnostic, educational, and therapeutic interventions. Master’s-prepared nurses use improvement science and quality processes to evaluate outcomes of the aggregate of patients, community members, or communities under their care, monitor trends in clinical data, and understand the implications of trends for changing nursing care.
The master’s-degree program prepares the graduate to:
1. Integrate nursing and related sciences into the delivery of advanced nursing care to diverse populations.
2. Incorporate current and emerging genetic/genomic evidence in providing advanced nursing care to individuals, families, and communities while accounting for patient values and clinical judgment. 3. Design nursing care for a clinical or community-focused population based on biopsychosocial, public health, nursing, and organizational sciences. 4. Apply ethical analysis and clinical reasoning to assess, intervene, and evaluate advanced nursing care delivery.
5. Synthesize evidence for practice to determine appropriate application of interventions across diverse populations.
6. Use quality processes and improvement science to evaluate care and ensure patient safety for individuals and communities.
7. Integrate organizational science and informatics to make changes in the care environment to improve health outcomes. 8. Analyze nursing history to expand thinking and provide a sense of professional heritage and identity.
• Healthcare economics and finance models • Advanced nursing science, including the major streams of nursing scientific
development • Scientific bases of illness prevention, health promotion, and wellness • Genetics, genomics, and pharmacogenomics • Public health science, such as basic epidemiology, surveillance, environmental
science, and population health analysis and program planning • Organizational sciences
• Systems science and integration, including microsystems, mesosystems, and macro- level systems
• Chaos theory and complexity science • Leadership science • Theories of bioethics • Information science • Quality processes and improvement science • Technology assessment • Nursing Theories Essential II: Organizational and Systems Leadership
Organizational and systems leadership are critical to the promotion of high quality and safe patient care. Leadership skills are needed that emphasize ethical and critical decision making. The master’s-prepared nurse’s knowledge and skills in these areas are consistent with nursing and healthcare goals to eliminate health disparities and to promote excellence in practice. Master’s-level practice includes not only direct care but also a focus on the systems that provide care and serve the needs of a panel of patients, a defined population, or community.
To be effective, graduates must be able to demonstrate leadership by initiating and maintaining effective working relationships using mutually respectful communication and collaboration within interprofessional teams, demonstrating skills in care coordination, delegation, and initiating conflict resolution strategies. The master’s- prepared nurse provides and coordinates comprehensive care for patients–individuals, families, groups, and communities–in multiple and varied settings. Using information from numerous sources, these nurses navigate the patient through the healthcare system and assume accountability for quality outcomes. Skills essential to leadership include communication, collaboration, negotiation, delegation, and coordination.
Master’s-prepared nurses are members and leaders of healthcare teams that deliver a variety of services. These graduates bring a unique blend of knowledge, judgment, skills, and caring to the team. As a leader and partner with other health professionals, these nurses seek collaboration and consultation with other providers as necessary in the design, coordination, and evaluation of patient care outcomes.
In an environment with ongoing changes in the organization and financing of health care, it is imperative that all master’s-prepared nurses have a keen understanding of healthcare policy, organization, and financing. The purpose of this content is to prepare a graduate to provide quality cost-effective care; to participate in the implementation of care; and to
assume a leadership role in the management of human, fiscal, and physical healthcare resources. Program graduates understand the economies of care, business principles, and how to work within and affect change in systems.
The master’s-prepared nurse must be able to analyze the impact of systems on patient outcomes, including analyzing error rates. These nurses will be prepared with knowledge and expertise in assessing organizations, identifying systems’ issues, and facilitating organization-wide changes in practice delivery. Master’s-prepared nurses must be able to use effective interdisciplinary communication skills to work across departments identifying opportunities and designing and testing systems and programs to improve care. In addition, nurse practice at this level requires an understanding of complexity theory and systems thinking, as well as the business and financial acumen needed for the analysis of practice quality and costs.
The master’s-degree program prepares the graduate to:
1. Apply leadership skills and decision making in the provision of culturally responsive, high-quality nursing care, healthcare team coordination, and the oversight and accountability for care delivery and outcomes.
2. Assume a leadership role in effectively implementing patient safety and quality improvement initiatives within the context of the interprofessional team using effective communication (scholarly writing, speaking, and group interaction) skills.
3. Develop an understanding of how healthcare delivery systems are organized and financed (and how this affects patient care) and identify the economic, legal, and political factors that influence health care.
4. Demonstrate the ability to use complexity science and systems theory in the design, delivery, and evaluation of health care.
5. Apply business and economic principles and practices, including budgeting, cost/benefit analysis, and marketing, to develop a business plan.
6. Design and implement systems change strategies that improve the care environment.
7. Participate in the design and implementation of new models of care delivery and coordination.
• Leadership, including theory, leadership styles, contemporary approaches, and strategies (organizing, managing, delegating, supervising, collaborating, coordinating) • Data-driven decision-making based on an ethical framework to promote culturally responsive, quality patient care in a variety of settings, including creative and imaginative strategies in problem solving • Communication–both interpersonal and organizational–including elements and channels, models, and barriers • Conflict, including conflict resolution, mediation, negotiation, and managing conflict • Change theory and social change theories • Systems theory and complexity science • Healthcare systems and organizational relationships (e.g., finance, organizational structure, and delivery of care, including mission/vision/philosophy and values) • Healthcare finance, including budgeting, cost/benefit analysis, variance analysis, and marketing • Operations research (e.g., queuing theory, supply chain management, and systems designs in health care) • Teams and teamwork, including team leadership, building effective teams, and nurturing teams Essential III: Quality Improvement and Safety
Continuous quality improvement involves every level of the healthcare organization. A master’s-prepared nurse must be articulate in the methods, tools, performance measures, culture of safety principles, and standards related to quality, as well as prepared to apply quality principles within an organization to be an effective leader and change agent.
The Institute of Medicine report (1998) To Err is Human defined patient safety as “freedom from accidental injury” and stated that patients should not be at …