Cardiovascular disease (CVD) is a major contributor to global morbidity and mortality; it is extremely costly and places a significant burden on individuals and communities. Cardiovascular nurses can play a key role in combating the increasing burden of CVD, which, similar to other chronic diseases, accompanies the demographic and epidemiologic transitions occurring worldwide.1,2 This article addresses the education and skills needed to prepare nurses for a leadership role in CVD prevention. Such a role often means challenging the status quo, lobbying for health system reform, and motivating and inspiring other health professionals to engage in a shared vision for improving health and well-being. For purposes of this article, the term cardiovascular disease will be used to encompass all cardiovascular conditions, including stroke.

The importance of leadership is crucial for effective preventive cardiovascular nursing. To provide a dynamic and sustainable workforce in CVD prevention, a range of competencies and skills is required. In addition to expert knowledge in cardiovascular care, cardiovascular nurses need to evaluate and implement evidence-based practice (EBP) within culturally appropriate frameworks. Developing clinical, research, and cultural competencies and engaging in the policy sphere are crucial for improving CVD outcomes.

Building and elaborating on the World Health Organization (WHO) core competencies for health care professionals in the 21st century,3,4 we propose specific competencies that should drive the preparation of preventive cardiovascular nurses. We further emphasize the importance of investing in leadership development,5 cultural,6 and system change7 competencies. In addition, we propose purposeful mentoring8 as a key strategy to drive the acquisition of these competencies, keeping in mind that interprofessional education9 is, or will be, the context for learning.

Leadership

Effective nurse leaders are needed to play key roles in shaping a health care delivery system that addresses CVD prevention within a population's myriad health care needs. Leadership is not synonymous to management. Where management is characterized by planning, organization, and control, leadership influences and engages individuals in a shared vision that often challenges existing systems and processes. Leadership, although it may include management skills, is oriented towards achieving goals and is closely related with group dynamics and team processes.10,11 Leadership potential can be found at any organizational level12; the challenge is to recognize and develop it.

A transformational leader has been defined as one who "will provide the skills for the profession to stretch its boundaries and be innovative in the way in which problems are viewed and solved."13 Qualities of a transformational leader include charisma (ie, the ability to instill faith and respect), individual consideration (ie, treating each employee as an individual), intellectual stimulation (ie, the ability to arouse innovative ways of problem solving), idealized influence (ie, the ability to transmit values and ethical principles), and inspirational role (ie, the ability to provide challenging goals and communicate a vision of the future).14 Maximizing the effects of leadership calls for a good mix between effective management and transformational leadership, to realize improvements in clinical care processes.15 The quality of leadership is a system factor that influences outcomes for both nurses and patients.16 Transformational leadership styles have been linked with positive outcomes for nurses, such as nurse satisfaction and retention, as shown in a comprehensive systematic review.17

Leadership development is thus an important aspect of the professional growth of cardiovascular nurses at all levels of health care system involvement. It is important for nurses to seek and receive mentorship for leadership, whether they are delivering patient care or doing policy work, conducting basic science research or translating research into practice, managing a hospital unit or a community agency, or holding a key membership position on policy-governing bodies nationally and internationally.5

Mentoring: Strategy for Leadership Development

Mentoring is a term widely used in the literature to indicate a reciprocal learning relationship between an individual who is experienced in an area and one who is a relative novice in that area. The mentoring in nursing construct was developed through a concept analysis conducted by Stewart and Krueger,18 who defined it as "a teaching-learning process acquired through personal experience within a one-to-one, reciprocal, career development relationship between 2 individuals diverse in age, personality, life cycle, professional status, and/or credentials." Most research in nursing and other fields has shown that mentorship relationships have very favorable personal and professional outcomes,8,19,20 although negative outcomes can also occur.8,21 Similar to leadership, mentorship should engage all levels of nursing. The characteristics of good mentors that have been reported in the academic and clinical health care literature include competence (ie, knowledge, experience, and the ability to command the respect of others), self-confidence (eg, successful, yet willing to share credit for achievements and provide access to a professional network of contacts), and commitment (ie, willing to invest time, energy, knowledge, and experiences to assist in another's professional development).20,22

Barondess22 suggested that good mentors must be trustworthy, honest, caring and have a positive attitude. Because mentorship involves a dynamic interaction between the mentor and mentee, characteristics of good mentees include being motivated, competent, willing to take responsibility for their learning, committed to their personal and professional growth, able to receive constructive feedback, and possessing good communication skills.19-21

Mentorship can take place in almost any setting and within and between disciplines.8,19 In the clinical area, mentoring often occurs when an experienced cardiovascular staff nurse or advanced nurse practitioner acts as a preceptor for a less experienced cardiovascular nurse or nursing student. Similarly, cardiovascular nurse researchers or educators may assist less experienced researchers or educators. Often the mentoring process is done on a short-term basis and without the mentor and mentee making a conscious decision to establish a mentorship relationship with mutually agreed-upon purposes, plans, and goals. In this article, we advocate intentionally establishing mentorship relationships with identifiable objectives and plans for achieving the goals. This is especially relevant in relation to preparing cardiovascular nurses for leadership.

Mentorship programs have been shown to work long distance within a country,21 as well as internationally between countries.20Transcultural or intercultural mentorship is a term used to explicitly acknowledge that mentoring activities between countries may occur in the context of 2 distinct cultures.20,23 These countries may have vastly different health care, political, social, and economic realities, with differences in perspectives, belief systems, language, customs, and behaviors that need to be considered and addressed.20,23

Professional organizations often provide a strong environment for promoting mentorship activities. For example, the American Heart Association (AHA) sponsors 2 mentoring programs that include nurses. One is an International Mentoring Program for young scientists outside the United States24 to promote collaboration and the professional growth of young scientists. The other is a Minority Mentoring Program25 for United States-based underrepresented minority scientists and clinicians who are early in their careers. In both programs, communication is primarily conducted by e-mail with opportunities for the mentor and mentee to meet face-to-face at the annual AHA Scientific Sessions. In addition, the AHA has developed a Mentoring Handbook26 to serve as a guide for mentorship relationships. Another example of an organization facilitating cardiovascular nurse mentoring was the 2008 pilot test of an international mentorship project jointly sponsored by the AHA Council on Cardiovascular Nursing and the Council on Cardiovascular Nursing and Allied Professions of the European Society of Cardiology. A US nurse researcher mentor was matched with a European nurse mentee who had similar interests. This mentorship pilot project was beneficial to both parties, but, unlike the AHA International Mentoring Program, this joint project included travel and other costs that proved to be too expensive to allow these organizations to continue their sponsorship. In the future, new communication technologies (eg, SKYPE video and/or teleconferences) will offer innovative and relatively inexpensive ways for developing long distance and international mentorship opportunities for cardiovascular nurses.

Core Competencies of Health Care Workers in the 21st Century

Major challenges for health care in the 21st century are the demographic and epidemiologic imperatives resulting from an aging population and the dramatic increase in the number of people living with 1 or more chronic illnesses. A large proportion of the burden of chronic illness is caused by CVD. This calls for action.1,2,27 Care for the chronically ill requires a proactive interdisciplinary team with the necessary competencies to successfully develop, implement, and operate chronic care models3,4 that incorporate prevention as an important building block.27

The WHO3,4 proposed 5 core competencies that should drive the curricula of all health professions: (1) patient-centered care, (2) partnering, (3) quality improvement, (4) information and communication technology, and (5) a public health perspective.3,4 These competencies should form the overarching structure of any curricula or postgraduate training of cardiovascular nursing education and thereby provide a solid basis from which nurses and other health care workers can become effective agents in the health care system.

Patient-centered care refers to health care institutions and care patterns being organized to better accommodate the experience of illness from the patient's perspective. Partnering reflects the ability to join with patients, other providers, and communities for effective care. Quality improvement requires being clear about the outcomes to be achieved, adhering to evidence-based guidelines, knowing what changes would lead to improvements, and being able to evaluate these efforts. Information and communication technology competencies refer to acquiring skills to use available technologies to support patient care. And finally, the public health perspective is linked to shifting the perspective from caring for 1 patient at a time to planning care for populations of patients. This last competency is also linked to system thinking,3,4 which requires shifting the focus away from the individual patient, as is commonly seen in many curricula. Using these core competencies as a basic framework from which to drive all health care curricula, specific competencies can be added that are linked to specific health professional profiles, such as CVD-prevention nurses.

Specific Competencies for Preventive Cardiovascular Nurses

To prepare cardiovascular nurses for leadership in preventive cardiovascular practice, it is important to identify the specific educational and clinical competencies that nurses need. Three recent documents address requisite competencies for the field of CVD prevention.

1. In 2006, a group of experts from subspecialty cardiovascular nursing organizations was convened by the American College of Cardiology to draft an update of the Scope and Standards of Practice of cardiovascular nursing.28 The purpose of this document, the previous iteration of which had been published in 1981, was to define cardiovascular nursing and describe its knowledge base, "providing a framework for the development of an educational curriculum."28 The contents of this document, although broad in scope, provide a template outlining the practice of cardiovascular nursing. The educational requirements for cardiovascular nurses proposed in this document include a broad knowledge base in anatomy, physiology, pharmacology, nutrition, psychology, and developmental theory.28

2. In 2001, the American Nurses Credentialing Center, which serves as the credentialing arm of the American Nurses Association, launched a certification examination for cardiac/vascular nurses. The certification is directed toward those who provide "[horizontal ellipsis]comprehensive nursing care to individuals diagnosed with cardiac/vascular disease and identified as at risk for cardiac/vascular events. These services are provided in a variety of settings, including acute, ambulatory care, community-based, worksite, and school-based programs. Cardiac/vascular nursing practice promotes achievement and maintenance of optimal cardiac vascular wellness."29 This certification represents the merger of the previous cardiac rehabilitation examination and the vascular nursing examination. The content of this "hybrid" examination acknowledges the evolution of cardiac rehabilitation programs into secondary prevention clinics and further acknowledges the systemic nature of atherosclerosis and the appropriateness of global risk reduction. The test content outline includes pathophysiology of cardiac and vascular disease, communication, provision of care, patient and family-caregiver education, psychosocial aspects of cardiac and vascular disease, leadership, and legal and ethical issues.30 The current certification was developed for registered nurses with basic educational preparation and serves to validate nursing knowledge and competency. A corresponding certification process at the graduate level is not yet available. Such a certification process for advanced practice nurses would serve to drive curriculum development in this content area.

3. The American College of Cardiology Foundation, the AHA, and the American College of Physicians formed a task force on clinical competence, and under its auspices, in 2009 a multidisciplinary group of stakeholders was convened to draft recommendations for competence and training for prevention of CVD. Nursing was represented in the writing group, and the recommendations were designed to be relevant for "shared responsibility among all health care professionals involved in the care of people at risk of developing CVD."31 The authors noted the suboptimal delivery of cardiovascular risk reduction in clinical practice, referenced the challenges of operationalizing the prevention of CVD posed by rapidly expanding knowledge, and addressed obstacles related to patient and provider adherence to recommendations. The topic areas referenced in these recommendations31 are synthesized in the following list for their relevance to nursing and to this document.

* Vascular biology-pathophysiology of atherothrombosis: Evidence-based cardiovascular preventive strategies are developed based on the pathophysiology of atherothrombosis. The nurse should have a working knowledge of the pathophysiologic process from early fatty streak to endothelial dysfunction, plaque formation, and plaque rupture. The recognition that diabetes is a CVD and an understanding of insulin resistance as it impacts risk for CVD are included.

* Epidemiology and research concepts: An understanding of population-based health concepts is integral to translating the large body of information (both clinical trial and observational findings) into clinical practice and to communicating complex information to the lay public in the clinical and community health settings.

* Pharmacology: The nurse requires a detailed knowledge of the large armamentarium of pharmacologic agents directed to cardiovascular risk reduction. Whether or not the nurse holds prescriptive authority, a strong understanding of pharmacology provides credibility in coaching patients on long-term persistence with therapy. A knowledge base of pharmacology in the management of dyslipidemia, hypertension, diabetes, heart failure, thrombosis, and tobacco addiction is required. In addition, knowledge of pharmacological agents that may increase cardiovascular risk is required.

* Gene-environment interaction: Knowledge of the gene-environment interaction provides the basis for the assessment and modification of risk. At minimum, the nurse requires a familiarity with the spectrum of inherited disorders that increase risk for CVD and basic skills in eliciting a thorough family history.

* Behavioral, psychosocial issues, and adherence to recommendations: Psychosocial factors such as depression contribute both to the pathophysiology of atherothrombosis and to behavioral adaptations to CVD management and risk reduction. One of the major challenges facing health care professionals is the development of skills in working with patients on long-term behavior change. These skills are particularly critical in the areas of smoking cessation and obesity management.

* Advanced risk assessment and assessment of subclinical disease: Although the Framingham risk score remains the recommended basic assessment tool, multiple tools for advanced risk assessment, particularly in the area of dyslipidemia, are available. Nurses should have an understanding of the complex area of novel risk factors for atherothrombosis, including markers of inflammation and measurement of lipoprotein particle size and density. In addition, knowledge of the evidence underlying various imaging modalities, including the measurement of carotid intima-media thickness and of coronary artery calcium, is needed, to advise patients of the usefulness of these strategies as risk assessment tools.

* Nutrition and exercise advice: A multidisciplinary approach to CVD risk reduction that leverages colleagues' knowledge and skills in nutrition and exercise physiology is optimal. However, limited resources and issues related to reimbursement often dictate that advice about dietary modification and physical activity "defaults" to nursing. Key elements include knowledge of the concepts of caloric balance; dietary recommendations for patients with hypertension, dyslipidemia, diabetes, and overweight; food label comprehension; and the role of functional foods.

Clearly, there exists a spectrum of competence levels required for staff nurse roles versus nurses in advanced practice or defined leadership roles, but the areas identified can serve as a useful common template. The other factor evident from these competencies is that cardiovascular nurses need to be prepared to work within an interprofessional context using skills and knowledge from the biomedical and social sciences. All nurses will benefit from the incorporation of core leadership skills to assume key roles in championing preventive strategies across the globe.

Cultural Competency

In addition to developing leadership potential, nurses must develop cultural competency to be able to deliver quality care to increasingly diverse patient populations. The risks of CVD and health outcomes are influenced by environmental, social, economic, and biological factors.32 Although cardiovascular nurses are well situated to address these factors, models to prevent CVD in racial and ethnic minority populations are limited. This is partially due to the challenges in engaging individuals who are not part of the dominant culture. The limited information available to cardiovascular nurses is also due to a lack of sufficient research on underrepresented populations because of methodological challenges associated with undertaking research in diverse populations.

Furthermore, the complex and multifaceted dimensions of addressing health inequity and increased costs due to the need for interpreters and translated material in cross-cultural research also diminish the capacity to engage vulnerable and marginalized groups.33,34

To achieve equitable outcomes, cardiovascular nurses must adapt to a range of cultural and social circumstances. The terms culture and ethnicity refer to the socioeconomic, religious, and political qualities of groups of individuals. These characteristics may refer to factors such as language, diet, dress, customs, kinship systems, and historical or territorial identity.35 For example, in indigenous populations, these considerations are crucial in engaging individuals and communities.

Behavior change is a critical element for ensuring that interventions and health care services are acceptable and appropriate to a diverse range of perspectives. Competence implies that the health practitioner has the capacity to function effectively with a culturally diverse group.36 Proctor and Davis6 identify 3 characteristics required for practitioners to become culturally competent. First, health professionals need to be aware of their own beliefs and attitudes about racial and ethnic minorities, not to impose their feelings on clinical interactions that may adversely impact patients. Second, they need to appreciate the views of patients and interact in a nonjudgmental manner. Third, health professionals must be able to use cultural competency skills in clinical interactions. Becoming culturally competent not only impacts clinical practice at the individual level, but also affects administration and leadership, policy-making and governing boards, clinical standards and guidelines, and organizational vision and mission.6

The prevalence and magnitude of risk factors for CVD vary across different cultural, ethnic, and racial groups, necessitating targeted strategies and increased awareness.37,38 To prepare cardiovascular nurses for service in multicultural environments, curricula in undergraduate, postgraduate, and professional development settings must warrant cultural competence and understanding of diverse perspectives. Cardiovascular nurse leaders should mentor nurses from culturally and linguistically diverse groups to maximize participation of individuals so that cardiovascular nursing services reflect the cultural composition of the wider community.

System Change Competencies and Evidence-Based Practice

Improving quality of preventive care and advancing patient care goals are accomplished by translating evidence into practice. Integration of research findings in practice is essential for improving the quality and outcomes of care and is integral to leadership activities of cardiovascular nurses.39 Yet, adoption of EBP has been slow and varied.

Competency in this area involves the integration of multiple sources of knowledge and the current best practice evidence into health care practice approaches.40 Knowledge and evidence arise from clinical trial data, clinical experiences, patient circumstances, and quality improvement efforts.3 For nurses to make an impact on reducing the global burden of CVD through prevention, preventive EBP must be developed that demonstrates effectiveness within the population of interest. Generation of evidence-based protocols and guidelines is essential. Evidence may be used to help inform a nurse's understanding of a specific preventive situation, to direct a specific approach, or to persuade others in decision-making positions about the need to make changes in policies or practices.41 For example, evidence about the preventive cardiovascular benefits of moving from sedentary status to increased physical activity42 might be used to incorporate physical activity assessment and counseling for every primary care patient, tailoring the advice to the age, sex, and ethnicity of the patient,43 and to advocate for reduction of barriers to physical activity in a "developed" environment. As such evidence-based approaches are implemented in specific settings and evaluated, and the results communicated, further evidence generation will occur.

Development of EBP can occur through a number of processes, including systematic reviews of the literature, meta-analyses incorporating a statistical evaluation of available quantitative research, and review of available evidence reports, as well as published clinical practice guidelines. Several models provide useful guidance on how to develop and test evidence-based approaches. Although the models have some innate differences, each begins with a focused definition of a problem to be solved or clinical improvement foci, followed by assessment of existing evidence (ie, a research critique)44; determination of the effect, size, or magnitude; the potential risks and benefits of adopting the practice; appropriateness of the evidence for the population and environment of interest; and the costs and potential cost-savings associated with the change. Incorporation of the patient's values is important as well. Additional key steps would include a plan for implementing the change, garnering organizational and interdisciplinary support, and evaluating and sharing the outcomes.45

Developing skills related to using EBP can also be achieved through formal and informal educational approaches. Ross and colleagues46 outline a creative approach for incorporating EBP skills in undergraduate nursing education based on increasing complexity of the tasks. Key EBP competencies are formulating questions about how to improve practice and outcomes, finding relevant sources of data and information, and integrating the information acquired into patient care.3 To make significant strides in implementing EBP, mentors at all levels who can guide the development and be actively involved at the point of care are needed.39 In addition to individual nurses' skills, EBP requires organizational leadership for EBP45 and technological support for access to resources and data.47

Strategies for Acquiring Clinical Competencies and Developing Leadership Skills

The purpose of this article was to address issues related to the education and training needed for leadership roles in CVD prevention. We identified mentorship as a key strategy and discussed the educational, leadership, cultural, and research (eg, EBP) competencies needed to prepare nurses for leadership roles in reducing the rates of occurrence of CVD. It is crucial to promote mentoring relationships at every nursing level, including academic, clinical, administrative, research, and across disciplines. The WHO competencies for the education of health professionals should guide our efforts, as well as research translated into practice. Development of cultural competency is also a critical component of nursing programs, and clinical sites should be designed to develop future nurses and nurse leaders. Membership and active participation in relevant professional organizations provide a rich source for dissemination of information, networking, and mentorship relationships. Nurse leaders in professional organizations can ensure that mentoring activities among the nurse members are promoted and supported. This pool of future leaders will support cardiovascular nurses in future leadership roles in CVD prevention.

In both developed and developing countries, the aging population, global economic crisis, and the growing shortage of nurses presents great challenges for nurses to continue to provide quality nursing care and good patient outcomes. Nurses need to take a leadership role in shaping health care and social policy, as well as in advocating for vulnerable and marginalized communities. Increasing our efforts to educate and mentor cardiovascular nurses to become leaders is crucial to combating the global burden of CVD.

Acknowledgments

The authors thank Kathleen Freimuth for her editorial assistance and Klara Remund and Lut Berben for their assistance with the formatting and reference management of the article.

REFERENCES