To the Class of 2011 APRN Graduates and the Hopeful Future

Teaching health policy at Pace University’s doctorate of nursing practice (DNP) program has taught me many things. It is a wholly enriching experience to work with talented NPs who are seeking more education, want more for their patients and communities, and have discovered a difficult truth—that their clinical experience alone is not enough to influence system transformation. They have reminded me why this pursuit to go deeper into nursing is so piercingly important. Some of them are the first in their families to go to college, overcoming huge obstacles to earn a doctorate. Others have pursued their doctorate after raising children, while still others have worked clinically for a year or a few decades. What they all share is a desire to earn the highest credential possible. They have taught me what strong determination, will, and perseverance can accomplish when it is aimed at making the people and communities they care for more whole. For the most part, they are working with patients who are underserved and impoverished. While caring for the disenfranchised, they constantly see the indignity stemming from a lack of access to care, especially amongst racial and ethnic minorities. Every day, they see the disparities played out: wildly uneven quality originating from a political and healthcare system that was not designed with patient-centeredness in mind.

DNPs Require Expanded System-Level Responsibility

The Pace University DNP program just graduated its first class of DNPs. As a witness to their final scholarly project presentations, I was left with a strong sense of awe and excitement about the future of advanced practice registered nurses (APRNs) and system transformation through a strong infusion of firm, grounded nursing leadership. I watched 20 DNP graduates present their scholarly projects, which included small groups going into large healthcare organizations, mutually identifying an area that needed improvement, summarizing the evidence, and developing an implementation plan. If the facility was in a state of readiness for change, they implemented the quality improvement measures.

As students presented their final projects, I was taken aback by the breadth and depth of their knowledge; their command of current healthcare policy issues; their strong sense of what is and is not in the evidence and what it means; and their clear, practical, science-driven solutions for improvement. Pace has unleashed 20 men and women from diverse backgrounds—experienced family NPs (FNPs) who are now armed with DNP degrees. They all have powerful toolkits showing them how to infuse evidence into practice, deliver patient-centered, culturally competent care, and provide much needed leadership to delivery systems. The final scholarly project presentations had a cumulative effect on me, and I am convinced that these new DNPs are not going to just roll over or accept what we have in place. In fact, as these FNPs moved through the program, enormous professional growth occurred. It became increasingly obvious that many of them had jobs that were too small and they required new positions with an ever-larger locus of responsibility. These presentations also brought home the truth that we most certainly do need NPs prepared at this level—we need more of them and need them now. Once again, NPs have adapted to meet patient needs. In these new DNPs, we have a force to be reckoned with. The techniques required to complete a major scholarly DNP project is very similar to the policy process, ie, learning to break it down into smaller steps, form alliances, push through large difficult obstacles, and achieve an outcome. These are precisely the skills needed in most healthcare delivery systems. These DNPs have already entered ever-larger spheres of influence. Many of them have published op-eds, been pulled into executive-level clinical leadership positions, been appointed to advisory boards through which they will help shape healthcare delivery, and, most importantly, acted as role models who influence their own practice and others through their expanded skill set and knowledge, which includes using an evidence base to strengthen primary care.

The “Anti-DNP”

And, there is a message for those who disagree with the DNP. You should not pursue this degree if you  are deeply satisfied in your current positions and are meeting patient needs. Earning a DPN requires a spirit dedicated to learning and an acknowledgement that something is pulling you ever deeper into nursing. A strong DNP program will kindle that bright spark, change you, and create tension between what is and what could be. It is not always a comfortable feeling since DNP students realize they have outgrown their flowerpot and must be repotted. If the program is well run, has a high degree of academic rigor, and fosters timely program completion, graduates will be positioned to meaningfully influence health reform and work towards building more humane, lower-cost delivery systems. This dedication and hard work may not be for everyone.

Final Word to New Graduates

As part of my sendoff to the DNP inaugural graduating class at Pace University and all of the 2011 APRN graduating classes, this is a reminder that you have a social covenant with the public to make health care better. So, for all the APRNs graduating in 2011, here are 10 things to remember as you launch your new careers.

1. Find out what you must do and do it. This is true at work, in your community, or with policymakers. Listen to the inner voice that wants to do the things you are here to do. Even if its urgings seem too big and too scary, listen to it. Gently acknowledge the inner critic voice (saboteur) and place it in the trunk of the car. Don’t let the saboteur drive the bus!

2. Policymaking in any venue is a process. Whether you use the Kindgon model or Longest, policymaking is incremental and often has a degree of irrationality (politics) and chaos overlying it. To be successful, you must have a vision and a slow and steady hand with unwavering commitment to that vision. Consider setbacks as buoyancy, and do not be discouraged.

3. Don’t do it alone. Find strategic partners. Even though we are largely pioneers blazing new roles, we simply must use all of the resources available to us. Big things cannot happen without your asking for help and broadening your circle of influence.

4. Know your opposition and “inoculate” it. This requires homework and knowing the position of the opposition. They may even raise good points, so be prepared to present evidence to inoculate against the opposing view. For example, when dealing with people who oppose expansion of nurse practice acts because of public safety concerns, cite the fact that Arizona, a state with a modern practice act, has not seen a spike in patient safety concerns.

5. Cite the evidence early and often. We are all aware that there are many ways of knowing; as APRNs, we use intuition, human caring, and other ways to express wisdom. However, since we are operating in a culture that relies very heavily on quantitative data, use all that are available. Preferably use government sources such as the Centers for Disease Control and Prevention, the Agency for Healthcare Research and Quality, and the Institute of Medicine. Do not couch your issues in nursing terms, but relate changes you want to make to cost, quality, and/or access.

6. Use frequent BBCs [Brief Brilliant Comments], but avoid being strident. It is important to be invited to the table, but it is even more important to be invited back because you are so constructive. Never be the person who generates eye rolls at the table and who is so predictable that everybody knows what you will say before you open your mouth. Rather, make brief, brilliant comments that are not self-serving or narrowly confined to nursing. Be sure your BBCs are linked to quality, cost, and/or access.

7. Be sure to have a mentor, and actively mentor others. As one example of mentoring, I have known some nurse leaders who have negotiated funding for an executive coach (ie, a person from outside the organization to act as a coach for them) in their hire package. It is best to identify a person outside of your institution who cares about you and your career and with whom you can freely discuss challenges. Having a coach or a mentor will help you reframe problems, identify resources, navigate politics more effectively, and/or help you see things you are too close to. Mentoring others will nourish you and remind you of your own growth.

8. Engage in electoral campaigns. Having political sophistication is a core responsibility of APRNs. Supporting candidates is one way to help shape and participate in our representative democracy. This can be as simple as supporting a candidate financially, volunteering for his/her campaign, or offering to advise him/her on local healthcare issues.

9. Don’t accept confining circumstances of any kind. For the most part, you can set out to do just about anything that will lower healthcare costs or improve the care experience. You may be surprised by how few people say “No.” Remember Clara Barton, who charged into the Civil War without asking or receiving permission. She saw what needed to be done and did it. Notice when others are trying to limit you, confine you, and put you in a box. If you are unable to create an environment in which you are free to do what needs to be done, it may be too small a venue for you.

10. Velocity and stress are your enemies. In order to be your best self, you must slow down and practice extreme selfcare. You are now a role model for others, showing them how to live a balanced life so that they don’t become a host to chronic diseases. Now that the frenetic pace of school is behind you, be thoughtful about what you add in, especially focusing on those things that nourish you most. Resist framing “busy-ness” as a badge of honor; rather, it is a way for us to “absent” ourselves from what is most important to us—our career goals, our loved ones, ourselves.