Web viewModule 1. Evolution of Management and Leadership Theories Applied to Nursing. Nichole Crenshaw. Module guide – describes what the module entails. Objectives

Module 1. Evolution of Management and Leadership Theories Applied to Nursing

Nichole Crenshaw

A. Module guide – describes what the module entails1. Objectives

a. Discuss the history and progression of management styles in the nursing profession

b. Describe how the evolution of management is driven by the need to increase efficiency and quality and develop the workforce

c. Define different types of leadership theories and discuss how they can be applied to patient care settings

d. Review the differences between management and leadership

2. Module outline – brief description of each section

This module will allow you the opportunity to explore different management theories and styles as well as different leadership theories and styles.

a. Management and leadership Characteristics of Managers Characteristics of Leaders Integrating Leadership and Management

b. The evolution of management theories Historical development of Management theory

o Scientific Managemento Management Functions Identifiedo Human Relations Management

History of management styleso Matrono Team Leaderso Primary Nursingo Decentralizationo Patient Centered Careo Clinical Governance

c. Leadership theories applied to nursing Leadership influences

o Discuss importance of nursing leadership. o Discuss characteristics associated with

leadership

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Types of leadership styleso Authoritarian or Autocratic Leadership o Democratic Leadershipo Laissez-faire Leadershipo Servant Leadershipo Transactional Leadershipo Transformational Leadership

Nursing theories related to leadershipo Shared governanceo Kanter theoryo Equity theory o Herzberg’s two factor theoryo Transformational leadership theoryo Emotional Intelligence

Theories of organizational behavior and leadershipo Classical Organizational Theorieso Neoclassical Organizational Theorieso Modern Organizational Theories

How leadership theories can be applied to the clinical setting

o Teachingo Supportingo Leadingo Shaping nursing practiceo Shaping policy

3. Methodology- identifies learner strategies

In this self-study module, the participant can learn at his/her own pace. However, there is a 12-week time limit to complete the overall course.

a. Readings (All learning materials are available online and accessible upon demand; although links to supplemental resources are provided, there are no professors or facilitators.)

b. PowerPoint presentationc. Scenario reviewd. Test (Participants will be required to earn a passing score on

the final exam for each module before continuing to the subsequent module.)

4. Time requirementsa. 12 hours

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5. ReferencesAnonson, J., Walker, M. E., Arries, E., Maposa, S., Telford, P., &

Berry, L. (2014). Qualities of exemplary nurse leaders:

perspectives of frontline nurses. Journal of Nursing

Management, 22(1), 127-136.

http://dx.doi.org/org/10.1111/jonm.12092

Bishop, S. (2015). Theories of Organizational Behavior and

Leadership. In J. B. Butts, & K. L. Rich (Eds.), Philosophies

and Theories for Advanced Nursing Practice (2nd ed., pp.

339-354). Burlington, MA: Jones & Bartlett Learning.

Harris, R., Benett, J., & Ross, F. (2014). Leadership and

innovation in nursing seen through a historical lens. Journal

of Advanced Nursing, 70(7), 1629-1638.

http://dx.doi.org/10.1111/jan.12325

Hutchinson, M., & Jackson, D. (2013). Transformational

leadership in nursing: towards a more critical interpretation.

Nursing Inquiry, 20(1), 11-22.

http://dx.doi.org/10.1111/nin.12006

Jackson, J. P., Clements, P. T., Averill, J. B., & Zimbro, K. (2009).

Patterns of knowing: Proposing a theory for nursing

leadership. Nursing Economics, 27(3), 149-159. Retrieved

from http://www.ncbi.nlm.nih.gov/pubmed/19558075

Kelly, P. (2012). Nursing Leadership and Management (3rd ed.).

Clifton Park, NY: Delman Cengage Learning.

Krive, J. (2013). Building effective workforce management

practices through shared governance and technology

systems integration. Nursing Economics, 31(5), 231-249.

Lievens, I., & Vlerick, P. (2013). Transformational leadership and

safety performance among nurses: the mediating role of

knowledge-related job characteristics. Journal of Advanced

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Nursing, 70(3), 651-661.

http://dx.doi.org/10.1111/jan.12229

Marquis, B. L., & Huston, C. J. (2009). Leadership Roles and

Management Functions in Nursing: Theory and Application

(6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

Moiden, N. (2002). Evolution of leadership in nursing. Nursing

Management, 9(7), 20-25.

Porter-O’Grady, T., & Malloch, K. (2013). Leadership in Nursing

Practice. Burlington, MA: Jones & Bartlett Learning.

Reeves, S., Macmillan, K., & Van Soeren, M. (2010). Leadership

of inter-professional health and social care teams: a socio-

historical analysis. Journal of Nursing Management, 18,

258-264. http://dx.doi.org/10.1111/j.1365-

2835.2010.01077.x

Sherman, R., & Pross, E. (2010). Growing future nurse leaders to

build and sustain healthy work environments at the unit

level. The Online Journal of Issues in Nursing, 15(1).

http://dx.doi.org/10.3912/OJIN.Vol15No01Man01

Tomey, A. M. (2009). Guide to Nursing Management and

Leadership (8th ed.). St. Louise, MO: Mosby Elselvier.

Tornabeni, J., & Miller, J. F. (2008). The power of partnership to

shape the future of nursing: the evolution of the clinical

nurse leader. Journal of Nursing Management, 16, 608-613.

http://dx.doi.org/10.1111/j.1365-2834.2008.00902.x

B. Topics1. Broad overview of topics to be covered

a. Topics covered will include leadership and management characteristics, practices, and theories.

2. Actual content (in PDF narrative form and PowerPoint presentation with bullet points/speaker notes) including recommended readings for each section

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Management vs. LeadershipThere is a relationship between leadership and management that has been discussed and debated in the literature for years. Bennis & Nanus (1985) state that “leaders are people who do the right thing; managers are people who do things right.” One thought is that leadership is viewed as one of the many functions of management, while management is viewed as one role of leadership. Marquis and Huston (2009) put forth that through control, management has an effect on hours, costs, salaries, and overtime, as well as use of sick leave, inventory, and supplies. On the other hand leadership, through influence and inspiration, increases productivity by motivating and maximizing workforce effectiveness. Naturally, effective managers do seem to depend on leadership skills, and, likewise, effective leaders seem to possess management skills.

Management: Management is described as the act, manner, or practice of managing, handling, supervising, or controlling. Managers are usually assigned formal positions in the organization and are expected to carry out specific functions and duties. They have a legitimate source of power that comes with their position. Managers are able to emphasize control, decision making, decision analysis, and results. Manipulation of people, money, time, and other resources are used to achieve the goals of the organization. Managers have to direct both willing and unwilling subordinates. Managers have a more formal responsibility and accountability than leaders (Marquis & Huston, 2009).

Leadership: In contrast, leadership researchers and theorist do not agree on what leadership means. Definitions such as “a point of polarization for group cooperation” or “a management skill that focuses on the development and deployment of vision, mission, and strategy as well as the creation of a motivated workforce” show that there is no clear definition (Marquis & Huston 2009, p.32). It is agreed that leaders do not inherited power from a delegated authority but through other means, that their roles are more varied than they may or may not be a part of a formal organization. Leaders tend to focus on group process, gathering information, giving feedback, and empowering others. They emphasize interpersonal relationships and direct willing followers, and their goals may not necessarily be those of the organization (Marquis & Huston, 2009). In the end, it is important for nurses to be able to develop and integrate skills for both leadership roles and management functions.

Historical Development of Management Theory

Scientific management was born during the industrial revolution, an era during which workers achieved minimum standards doing the least amount of work possible. Engineering innovator Frederick Taylor imagined that if workers were taught one best way to accomplish a task, productivity would increase. He developed four main principles of scientific management:

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1. First, work must be scientifically designed to promote the most efficient use of time and energy.

2. Next, workers must be hired and trained based on technical competence and abilities so that they are best matched to the most appropriate job for them. ,

3. Workers who were seen as being motivated solely by money were then F reimbursed for their work based on production rather than an hourly wage.

4. Lastly, managers and workers were to be cooperative and independent but their roles were different. Managers, plan, prepare, and supervise, and workers worked. As a result of scientific management, productivity and profits soared, but a human touch that was absent. This type of management did not seem to be in the best interest of the workers (Marquis & Huston, 2009).

Management Functions Identified is an additional theory of management that uses five functions to constitute the management process.

1. It begins with planning phase of determining goals, objectives, policies, procedures, and rules. Long and short range projections and a fiscal plan are included.

2. Next, the organizing phase establishes the structure to carry out plans and determine the most appropriate way to meet this goal. For instance, how to deliver the most appropriate type of patient care. Organizing group activity to meet unit goals and using power and authority appropriately are important.

3. This is followed by Staffing, which consists of recruiting, interviewing, hiring, orienting, staff development, and team building.

4. Directing, motivating, managing conflict, delegating, communicating and facilitating collaboration is the next step of the management process.

5. Controlling functions can include performance appraisals, being held fiscally accountable, quality control, ethical and legal control, and professional and collegial control (Marquis & Huston, 2009).

Management scientists and organizational theorists began to look at the role of worker satisfaction as a result of worker unrest that developed during the Industrial Revolution. Human Relations Management developed during an era in which a failure to include the “human element” was perceived as a major shortcoming in theories introduced during the Industrial Revolution. The concept of participatory and humanistic management emphasized people rather than machines. Through participative management, employees and managers share authority, and one side does not dominate the other. The Hawthorne Effect was the result of a study which indicated that paying special

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attention to workers was likely to increase productivity. Theory X and Theory Y state that the attitude managers have toward employees is directly correlated to the employees’ satisfaction. Theory X managers believe their employees are lazy and need constant supervision and direction, while Theory Y managers believe that their employees enjoy their work and are self-motivated and willing to work hard to meet personal and organizational goals (Marquis & Huston, 2009).

History of Management Styles in Nursing

The way that nurses lead, manage, and follow has changed throughout the years. Nurses once took direction from physicians or from their head nurse or charge nurse. Modern matrons provided clinical leadership and helped to improve the quality of patient care. After some time, the team leader role developed, with the registered nurse on the team supervising and coordinating patient care provided by the team. The team usually included the registered nurse, a licensed practical nurse, and a nursing assistant. Primary nursing followed with the Registered Nurse as the primary provider, retaining 24 hour accountability for care coordination for a set of patients throughout the patients’ hospital stay. Decentralization was introduced as a process in which responsibility and decision making was redistributed from a few leaders to the many employees at the point of service. Patient centered care recognized the interdependence of every department in providing patient care. Clinical governance is concerned with having organization accountable for continuously improving quality of service and standards of care by creating an environment where excellence will flourish (Moiden, 2002).

Leadership Theories Applied to Nursing

Leadership Attributes

For the nursing profession to be able to deliver and maintain high quality care, nursing leadership is important. Harris and colleagues (2014) maintain that inspirational nurse leaders have had an impact on the profession, but specific accounts of their influence in the literature are rare, which weakens the influence and social legitimacy of nursing. The work of a leader is not easy. It is intentional work done by those who are fully conscious of the implications of their actions. Without this clarity of the impact of their role, they are at risk of developing characteristics that lean towards the management of functions and processes as opposed to those of vision and direction (Porter-O’Grady & Malloch, 2013).

Leaders typically have a consistent network of attributes that characterize leadership (Porter-O’Grady & Malloch, 2013). They must be able to use both their heart and their

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head to connect with others. When they are able to help others find a deeper purpose, they can collectively advance their purpose and reach their goals. Leaders understand the importance of creating a culture of ownership and investment in the collective action of work. Characteristics associated with leadership include intelligence, decisiveness, confidence, personal integrity, interpersonal skills, diplomacy, and creativity (Marquis & Huston, 2009).

Types of Leadership Styles

As health care changes and responsibilities of leaders grow, effective ways to manage organizations and lead people must be developed.

Marquis and Huston (2009) describe servant leadership as the leader making a conscious decision to put the needs of the group foremost and empower group members to achieve the goals of the organization. Democratic leadership involves others by delegating authority and influence using expert power and the power base that comes with having close relationships with those you work with (Kelly, 2012). The democratic leader maintains less control, gives constructive criticism, uses economic and ego awards to motivate, and directs others through the use of suggestions and guidance. The emphasis here is on “we” instead of “I” or “you”. This type of leadership works well for groups that work together for extended periods of time when cooperation and coordination are necessary (Marquis & Huston, 2009). This style of leadership can be particularly frustrating for those who want to make decisions rapidly because decision making may involve many people.

A type of non-directed leadership style is known as Laissez-faire leadership. In this passive and permissive form of leadership, leaders defer making decisions. There is little or no direction, and decision making is dispersed throughout the group. There is no criticism, and support is given when the group or an individual requests it. This style of leadership can also be frustrating if group apathy and disinterest occur. However, when the group is motivated and self-directed, creativity and productivity is enhanced (Marquis & Huston, 2009).

In contrast to the previous styles of leadership, the Authoritarian or Autocratic style of leadership involves centralized decision-making. The leader makes all the decisions and uses power to control others. This style of leadership differs from others in that status is emphasized and communication only flows in one direction, from top to bottom. The groups are less creative and there is less autonomy and self-motivation, but productivity is high. The actions of the group are typically well defined, and this structure reduces frustration and promotes a sense of security in the group (Marquis & Huston, 2009).

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According to Marquis and Huston (2009), there are two main types of leadership in management, transactional and transformational.

The transactional leader is seen as being concerned with day to day managerial tasks. This type of leader sets goals, directs the staff, and uses trade-offs or rewards to encourage the staff to meet these goals. This type of leadership style found often in nursing is, however, not considered an efficient style of leadership (Lievens & Vlerick, 2013). Performance that relies on this type of contingent reward is classified as a lower order leadership (Hutchinson & Jackson, 2012). This transactional leader does not identify shared values and seeks to control both the situation and their followers.

In contrast, the transformational leader is one who is confident, charismatic, and able to inspire, motivate, and empower followers by recognizing common values and sharing a vision with them. What sets apart the transformational leader is the ability to “motivate performance beyond expectations through their ability to influence attitudes” (Marquis & Huston, 209, p.42). The transformational leader is able to effect change by creating a synergistic environment. Creativity and innovation are appreciated, leading to change that reflects the focus of the leader and influences the direction of the organization.

Nursing Theories Related to Leadership

There are numerous leadership theories that are dynamic and that have over time continued to change. Shared governance, which emerged in the 1980’s, is a governance system based on accountability that empowers individuals and increases the authority and control that nurses have over their practice (Tomey, 2009). Nurses are invested and encouraged to participate at every level of the organization to contribute to the success of the organization (Krive, 2013). Marquis and Huston (2009) consider Kanter’s Theory, which hypothesizes that the leader is effective because of the formal and informal system organizations in the workplace. To be successful, a leader must develop relationships with different people and groups. Equity Theory explains that the presence of perceived inequity among employees creates tension. In comparing themselves against other employees, people who feel they are unfairly treated will alter their inputs or outputs, change the basis for comparison, or leave. Because of this, attention should be paid to the perceived equity of a reward system among employees (Tomey, 2009).

Herzberg’s Motivational Hygiene (Two-Factor) Theory finds that employees can be motivated when given challenging work for which they can assume responsibility. Hygiene factors such as pay, benefits, status, job security, supervision, and interpersonal relationships can prevent dissatisfaction and poor morale, but they are not motivators. Motivating factors include achievement and recognition for the achievement,

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responsibility, and opportunity for job growth and advancement. High hygiene factors and low motivation will result in employees who view their job as just a paycheck. However, when motivating and hygiene factors are both high, employees are more likely to be highly motivated and without complaints (Tomey, 2009).

In the Transformational leadership theory, a leader uses the ability to develop relationships with followers to motivate and persuade. This leadership theory encourages employees to do and achieve beyond their own expectations. Transformational leaders are able to communicate their vision with enthusiasm and confidence, thus building a strong sense of identification with the organization as individuals put the organization before their own self-interests (Hutchinson & Jackson, 2013).

The 1990s marked the emergence of the concept Emotional intelligence, the ability to work well with individuals and teams while also maintaining high personal achievement. Emotional intelligence includes five components: self-awareness, self-regulation, motivation, empathy, and social skills. Tomey (2009) states these are further divided by personal competence and social competence. If leaders understand their own emotional quotient and that of their staff, they are better able to lead and guide them as well as the organization (Anonson et al., 2014). Personal competence involves self-awareness and self-regulation in being able to managing ourselves. With self-regulation for instance, we must keep our disruptive impulses under control and maintain honesty and integrity (Tomey, 2009). We must be responsible for our behavior, flexible and comfortable with change, and accepting of new information and approaches. Social competence describes how we handle relationships. We must exhibit empathy and use social skills such as listening to others, inspiring others, managing change, nurturing relationships, and collaborating and cooperating toward shared goals (Tomey, 2009).

Theories of Organizational Behavior and Leadership

Theories of organizational behavior “are important because they continue to influence the assumptions people in organizations make.” (Bishop, 2015, p. 339).

Classical Organizational Theories became popular during the Industrial Revolution when structure, efficiency, and individual performance and achievement were attained through defined tasks.

Taylor’s Principles of Scientific Management used the scientific method to discover the best way to complete a job. He believed managers should be detailed-oriented when selecting, training, assigning tasks, and supervising workers. Similarly, workers should be detailed-oriented in performing their tasks. Taylor believed rewards and

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salary increases should be tied to production. Critics state that this approach to organizations prohibited creativity and dehumanized employees, placing them second to production (Bishop, 2015).

Fayol’s General Principles of Administration focuses on management. Fayol believed administration is the “art of managing people” and applies universally across industries. He bases his administrative theory on 14 basic but flexible universal principles. These principles include the following: specialization and division; formal authority based on the job, not the person; discipline; unity of command, one boss per person; unity of direction, orders coming from one boss; group interests over individual interests; fair and equitable pay; centralizing communication and authority; scalar chain; an orderly work environment; equity; stability of personnel; individual initiative; and esprit de corps- harmony and unity in the organization (Bishop, 2015).

Weber’s Bureaucratic Theory values hierarchical structure, specialization, and the division of labor, with promotions based on merit and impersonal rules. This theory recognizes three forms of legitimate authority: traditional authority invested in a hereditary line or determined by a higher power; rational or legal authority, which is enforced by regulations; and charismatic authority, which relies of the appeal of leaders. In this theory, the importance of individuals is not recognized, and emphasis is placed on the need to reduce ambiguity and diversity. The organization’s rules and offices are valued, and traditional authority is seen as the most suitable for administrators (Bishop, 2015).

Neoclassical Organizational Theories focus on the behaviors of workers and exhibit a concern for these workers. In the Human Resource Theory, organizations are viewed as large social systems. This theory was supported with the results of the Hawthorne Experiments done at Western Electric in Hawthorne, Illinois, which were originally conducted to determine whether increased lighting intensity improved worker productivity. Researchers unexpectedly found that regardless of increased, decreased, or no change in lighting intensity, an increase in productivity was observed, thought to be related to the increase in the attention given to the employees involved in the study. The results of this study led to a new view of organizations as social systems (Bishop, 2015).

The Economy of Incentives, another Neoclassical Organizational Theory, expresses the kinds of individual relationships within organizations. Barnard views workers as having social, behavioral, and psychological dimensions. He believed organizations could not operate without communication or willingness to contribute to a common goal. Organizations are viewed as hierarchies, with a defined leader and clear lines of communication. The leader’s ability to produce a unified and organized

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environment is associated with the success of the organization. Important to this theory is the fair treatment of workers and humane leadership (Bishop, 2015).

The Proverbs of Administration, introduced by Herbert Simon, proposes that the work done at one level in the organization serves as a means to accomplish the end purpose of the organizational level above it. In this way decision making is made from the bottom up (Bishop, 2015).

Modern theorists of organizational behavior recognize that conflict and change occur in all organizations. Organizations are considered to be systems and cultures working in an environment of certainty mixed with uncertainty. The Contingency Theory accepts that conflict occurs in organizations and should be managed to promote organizational performance. In the General Systems Theory, it is believed that in organizational systems, non-linear relationships exist between variables. A small change in one variable may cause significant change in another (Bishop, 2015).

Change Theory, another modern organizational theory, describes change as a dynamic force that moves in opposite directions in an organization. A driving force pushes participants towards change, while at the same time these participants are pushing back the change that is coming their way. Change is referred to as a dynamic balance of these forces, not as an actual event (Bishop, 2015).

Leadership theories applied to clinical settings can and have transformed workplace culture. Theories that value shared decision making, promote flow of information, encourage mutual respect, and advance nursing empowerment have had a large impact on the development of nursing.

Transformational leadership exemplifies a type of leadership theory that has significantly impacted nursing environments. It has been shown to be positively related to productivity and effectiveness. It is used quite often as it shapes and alters the goals and values of the staff leading to inclusive and productive work environments. Additionally, transformational leadership theory has been used in the preparation of nursing administrative curriculum (Kelly, 2012). This type of leadership encourages nurses to develop professionally and have an impact on many different areas in the nursing profession.

Likewise, transactional theories also have a place within healthcare environments. They can be an antecedent to transformational leadership. These two styles are not mutually exclusive. It has been noted that transformational leaders use a combination of transactional and transformational styles. Servant leadership is another example of how leadership theory impacts the culture in the clinical setting. This leadership theory is

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frequently found in the clinical setting. The empathy, awareness, and acceptance of putting others before self is practiced often in the workplace.

Leadership theories can recognize shared governance and encourage and support nursing staff to seek more autonomy to manage their practice or encourage them to represent nursing at every level of the organization. This can include sitting on hospital boards, or becoming active in shaping nursing practice and policy that has impacted and advanced the nursing profession.

C. Scenario/ Case Study1. Instructions

Please read the following case scenario and answer the questions.2. Background to scenario

In the following scenario, think about how as a leader and/or manager you would want to allow the staff to give quality patient care, while also permitting the family to feel that they are part of the patient’s care.

3. Actual scenarioYou are the nurse manager on a busy medical/surgical unit. Your unit has recently admitted a 17 year old Romanian male patient. He is recovering from a blood stream infection for which he was in the Intensive Care Unit for 1 week. He is a pleasant young man with a large family. For the past two nights, the number of overnight visitors has been excessive. Your hospital has a policy that 2 visitors may stay overnight; however, six individuals stayed in the patient’s room last night. When the nurse attempted to speak to the mother and father, they became upset and, against medical advice, threated to leave with their son. The staff complained to you this morning about the family being aggressive, disruptive, and refusing to abide by the visiting policy.

4. Practical exercises (Questions pertaining to scenario)a. What leadership style do you think is most appropriate in this

situation?b. Which characteristics of a leader and which characteristics of a

manager would assist in resolving this situation?c. How could you use Emotional Intelligence to improve the

communication with the family in order to provide high quality, compassionate care to the patient?

D. Library1. Glossary of Terms

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a. Management- as the act, manner, or practice of managing, handling, supervising, or controlling.

b. Leadership- a process of persuading and influencing others toward a goal and composed of a wide variety of roles.

2. Recommended Readings (not applicable)3. PowerPoints – recommended power points from other sites

a. http://www.slideshare.net/NurzPogz/leadership-in-nursing-revised

b. http://www.slideshare.net/uplakshgupta/leadership-1-theories?related=1

4. Recommended videos from other sitesa. www.youtube.com/user/AONEVIDEOS

E. Evaluation (Multiple choice questions)

1. Which best describes a characteristic of a leader?a. Always assigned a position of authorityb. Usually part of a formal organizationc. Focus on group process, information gathering and feedbackd. Focus on decision making and results

2. Which best describes a characteristic of a manager?a. Has a greater formal responsibility and accountability for

rationality and controlb. May or may not be a part of the formal organizationc. Does not have a delegated authority but obtains power

through other meansd. Emphasizes interpersonal relationships

3. Which type of theory is associated with Human Relations Management and includes managers and employees equally in decision making--so that both sides are satisfied?

a. Hertzberg’s Two Factor Theoryb. Weber’s Bureaucratic Theoryc. Participative Managementd. Contingency Theory

4. Which motivational theory reflects how managerial attitudes about the nature of humans correlates to employee satisfaction?

a. Employee participationb. Theory X and Theory Yc. Kanter Theoryd. Hawthorne Effect

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5. With which type of leadership style does the leader defer decision making?

a. Autocraticb. Democratic c. Authoritariand. Laissez-Faire

6. The Hawthorne Effect found that any change in the work environmenta. Led to a change in organizational hierarchyb. Led to conflictc. Increased productivityd. Pulled employees away from organizational goals

7. A leadership theory that is inspirational and encourages follower creativity is

a. Transformational Leadershipb. Contingency Theoryc. Change Theoryd. Equity Theory

8. The ability to use emotion effectively and get optimal results from others through relationships is

a. Shared Governanceb. Emotional Intelligencec. Autocratic Leadershipd. Scientific Management

9. According to Herzberger’s motivational factors, which of the following will contribute to job satisfaction?

a. Salaryb. Supervisionc. Growth and job advancementd. Job security

10. What is the leadership style that focuses on management tasks and exchanging rewards for performance?

a. Democratic Leadershipb. Transformational Leadershipc. Servant Leadershipd. Transactional Leadership

Answers: 1=C, 2=A, 3=C, 4=B, 5=D, 6=C, 7=A, 8=B, 9=C, 10=D

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Module 2. Ethics and the Role of Nurse as Advocate

Shavone Johnson

A. Module guide – describes what the module entails

This module provides information about the topic of ethics and how it applies to the nursing profession.

1. Objectives- At the end of this module the student will be able toa. Discuss the concept of ethics, ethical principles, and ethical

dilemmas.b. Recognize the International Council of Nurses (ICN) Code of

Ethics.c. Recognize the qualities of strong ethical leaders.d. Discuss nursing roles in ethical situations.e. Recognize the essentials of professionalism in the workplace.

2. Module outline – brief description of each section.a. Ethics and ethical dilemmas

Define the term ethicso Bioethicso Morality

Types of ethical inquiryo Normative ethicso Descriptive ethicso Applied ethicso Normative ethics

b. Leadership roles International Council of Nurses Code of Ethics for

Nurses o Purpose of the Nurse Code of Ethicso Understand the Nurses Code of ethics and it’s

implication to nursing practicec. Principles of ethical reasoningd. Ethics and the nursing process

How to prevent ethical conflictse. Essentials of professionalism in the workplace

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3. Methodology- identifies leaner strategies In this self-study module, the participant can learn at his/her own pace. However, there is a 12-week time limit for completion of the overall course.

a. Readings (All learning materials are available online and are accessible upon demand; although links to supplemental resources are provided, there are no professors or facilitators.)

b. PowerPoint presentationc. Scenario reviewd. Test (Participants will be required to earn a passing score on

the final exam for each module before continuing to the subsequent module.)

4. Time Requirements a. 12 hours

5. References

Beauchamp, T. L., & Childress, J. F. (2009). Principles of biomedical ethics

(6th ed). New York: Oxford University Press.

Begley (2010). On being a good nurse: Reflections on the past and

preparing for the future. International Journal of Nursing

Practice .16(6) 525-532. DOI: 10.1111/j.1440-172x.2010.01878.x

Butts, J.B., & Rich, K.L., (2013). Nursing ethics: Across the curriculum and

into practice (3rd ed.). Burlington, MA: Jones and Bartlett Learning

Chism, L.A. (2013). The doctor of nursing practice: A guidebook for role of

development and professional issues (2nd ed.). Burlington, MA:

Jones and Bartlett Learning.

Georgetown University Center for Child and Human Development, n.d.

Complex moral issues: End of life decisions for adults with

significant intellectual disabilities. Retrieved from

http://www.gucchdgeorgetown.net/ucedd/complex/ethics-

workup.html

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International Council of Nurses (ICN). 2013. The ICN code of ethics for

nurses. Retrieved June 28, 2014 from http://www.icn.ch/about-

icn/code-of-ethics-for-nurses/

Ong, W.Y., Yee, C.M., and Lee, A. (2012) Ethical dilemmas in the care of

cancer patients near the end of life. Singapore Medical Journal

53(1), 11-16 Retrieved from

http://smj.sma.org.sg/5301/5301ra2.pdf

B. Topics1. Broad overview of topics to be covered

a. Ethics/ethical dilemmasb. Leadership rolesc. Principles of ethical reasoningd. Ethics and the nursing processe. Essentials of professionalism in the workplace

2. Actual content (in PDF narrative form and ppt presentation with bullet points/speaker notes) including recommended readings for each section

The purpose of this module is to educate the participant about ethics in relation to the nursing profession and to teach important aspects of ethical decision making involving patient care. This module also provides examination and discussion of concepts related to ethical theories and guidelines for the practicing nurse in today’s healthcare environment.

Ethics and Ethical DilemmasEthics is a generic term that covers several different ways of understanding and examining the moral life (Beauchamp & Childress, 2009). Bioethics is the study of moral and social implications of developments in the biological sciences and related technology (Beauchamp & Childress, 2009). Bioethics first emerged as an academic interdisciplinary field in the 1960’s (Beauchamp & Childress, 2009). Beauchamp and Childress published the first American textbook of bioethics titled Principles of Biomedical Ethics in 1977. Bioethics addresses a broad range of human inquiry, ranging from debates over the boundaries of life, surrogacy, to the allocation of limited healthcare resources (e.g., healthcare rationing, organ donations) to the right to refuse medical care for religious or cultural reasons (Beauchamp & Childress, 2009).

Morality describes the norms of right and wrong human conduct that are so widely shared they form a stable social agreement (Beauchamp & Childress, 2009). Morality encompasses many standards of conduct, moral principles, rules, ideals, rights, and virtues (Beauchamp & Childress, 2009). One learns about morality while growing up, and the universal norms may

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differ for different groups such as physicians, nurses, lawyers, teachers, or public health officials (Beauchamp & Childress, 2009).

Common morality refers to the set of norms shared by all persons committed to morality (Beauchamp & Childress, 2009). Examples of the norms include to tell the truth, prevent evil or harm from occurring, do not cause pain or suffering, keep your promises, and many more (Beauchamp & Childress, 2009). Common morality also includes traits such as integrity, nonmalevolence, kindness, and fidelity, to name a few (Beauchamp & Childress, 2009). If a person lacks these personality traits, it is believed that he or she lacks moral character (Beauchamp & Childress, 2009).

Approaches to ethics are classified as either normative or non-normative (Beauchamp & Childress, 2009). Normative ethics describes values, behaviors, and ways of being that are considered right

or wrong when deciding what to do in a specific situation (Butts & Rich, 2013). Examples include the actions of being honest, lying, or stealing. Ethical principles are theories that are commonly used in an attempt to identify and justify these norms (Beauchamp & Childress, 2009).

Practical (Applied) ethics falls under the normative category. It applies general concepts to address particular problems (Beauchamp & Childress, 2009). It is the use of norms and other moral resources in deliberating about problems, practices, and policies in professions, institutions, and public policy (Beauchamp & Childress, 2009). Although there is no straightforward movement from general norms and principles to particular judgments, they serve as a starting point for the development of norms of conduct (Beauchamp & Childress, 2009).

Descriptive ethics and meta-ethics are two types of non-normative ethics (Beauchamp & Childress, 2009). Descriptive ethics is the factual investigation of moral beliefs and conduct that uses

scientific techniques (anthropology, sociology, psychology e.g.) to study how people reason and act (Beauchamp & Childress, 2009). Descriptive ethics studies the phenomena of surrogate decision-making (Beauchamp & Childress, 2009).

Meta-ethics involves an analysis of the language, concepts, and methods of reasoning in normative ethics (Beauchamp & Childress, 2009). This includes addressing the meaning of terms such as right, virtue, obligation, morality, justification, and responsibility (Beauchamp & Childress, 2009). Meta-ethics is also concerned with moral epistemology (the theory of moral knowledge), the logic and patterns of moral reasoning and justification, and the possibility and nature of moral truth (Beauchamp & Childress, 2009). Important questions in meta-ethics are whether morality is objective or subjective, relative or nonrelative, and rational or non-rational (Beauchamp & Childress, 2009).

An ethical dilemma is a situation in which an individual feels compelled to choose between two actions that will affect the welfare of a sentient being, and both actions are reasonably

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justified as being good, neither action is readily justified as being good, or the goodness of the actions is uncertain (Butts & Rich, 2013). Since one action must be chosen, the decision making process often burdens the person or group who must decide (Butts & Rich, 2013). Quite often when a person is facing an ethical dilemma, both choices may feel wrong (Butts & Rich, 2013).

Leadership RolesIn the past, the nursing profession focused on female traits (Garesche, 1944; Denesford, 1946; & Way, 1962) that included respect for authority figures, being faithful to duty, being tactful, cultivating a meek and mild disposition, loyalty, and cleanliness (as cited in Begley, 2010). Begley (2010) now credits modern day codes of ethics and standards of conduct for creating a shift in the traditional understanding and characteristics expected of a nurse.

Modern codes rely on the expectation that nurses will possess the intellectual capacity to practice effectively and to advance the knowledge base of the discipline (Begley, 2010). Baley (1986) states that Florence Nightingale, English nursing pioneer and reformer, believed that to be a good nurse, one must first be a good person (as cited in Begley, 2010). According to Beauchamp (1995), being a good person does not mean simply following the rules but instead considering what sort of person one ought to be rather than what one ought to do (as cited in Begley, 2010).

Codes of ethics are more virtue-based and focus more on the characteristics of a good practice and the character of the agents than on simple rules and statements (Begley, 2010).

The International Council of Nurses (ICN) Code of Ethics (2013) for nurses was first adopted in 1953 and revised in 2012. Its purpose is to serve as a standard for nurses worldwide by making clear that inherent in nursing is respect for human rights, including the rights to life, to dignity, and to be treated with respect (ICN, 2013). The Code of Ethics is reviewed regularly and revised in response to the realities of nursing and health care in a changing society (ICN, 2013). The ICN Code of Ethics reflects a shift in nursing responsibility from a focus on obedience to physicians to a focus on patient needs (Butts & Rich, 2013).

It is used to guide nurses every day in their choices, and it supports their refusal to participate in activities that conflict with caring and healing (ICN, 2013). The International Council of Nurses Code of Ethics is based on four responsibilities of the nurse: to promote health, prevent illness, restore health, and alleviate (Chism, 2013).

The International Council of Nurses (ICN) Code of Ethics is composed of four principle elements that outline the standards of ethical conduct. These elements are 1) Nurses and people, 2) Nurses and practice, 3) Nurse and the profession, and 4) Nurses and co-workers (ICN, 2013).

Element 1- Nurses and People: The nurse’s primary professional responsibility is to the people requiring nursing care (ICN, 2013). When providing care, the nurse should promote an environment in which human rights, values, customs, and spiritual beliefs of the

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individual, family, and community are respected (ICN, 2013). The nurse ensures that individuals receive accurate, sufficient, and timely information in a culturally appropriate manner on which to base their consent for care and related treatment (ICN, 2013). The nurse should hold in confidence personal information and use judgment in sharing this information (ICN, 2013). Nurses share with society the responsibility for initiating and supporting action to meet the social and health needs of the public, especially those of vulnerable populations (ICN, 2013). Nurses should serve as advocates for equity and social justice in resource allocation, access to health care, and other social and economic services (ICN, 2013). Lastly, the nurse demonstrates professional values such as respectfulness, responsiveness, compassion, trustworthiness, and integrity (ICN, 2013).

Element 2- Nurses and Practice: The nurse carries personal responsibility and accountability for nursing practice, and for maintaining competence by continual learning (ICN, 2013). The nurse should also maintain a standard of personal health so that the ability to provide care is not compromised (ICN, 2013). Judgment should always be used by the nurse regarding individual competence when accepting and delegating responsibilities (ICN, 2013). At all times, the nurse is to maintain a standard of personal conduct that reflects well on the profession and enhances its image and public confidence (ICN, 2013). The nurse, in providing care, ensures that the use of scientific advances and technology are compatible with the safety, dignity, and rights of the people (ICN, 2013). Nurses should strive to foster and maintain a practice culture promoting ethical behavior and open dialogue (ICN, 2013).

Element 3- Nurses and the Profession: Nurses assume the major role in determining and implementing acceptable standards of clinical nursing practice, management, research, and education (ICN, 2013). The nurse should be active in developing a core of research-based professional knowledge that supports evidence-based practice. Nurses should similarly be active in developing and sustaining a core of professional values (ICN, 203). Also, the nurse, acting through the professional organization, participates in creating positive practice environments and maintains safe, equitable social and economic working conditions in nursing (ICN, 2013). Nurses practice to sustain and protect the natural environment and are aware of its consequences on health (ICN, 2013). The nurse is to contribute to an ethical organizational environment and be willing to challenge unethical practices and settings (ICN, 2013).

Element 4- Nurses and Coworkers: The nurse should sustain a collaborative and respectful relationship with co-workers in nursing and other fields (ICN, 2013). The nurse should take appropriate action to safeguard individuals, families, and communities when their health is endangered by a co-worker or any other person (ICN, 2013). Appropriate action should be taken by the nurse to support and guide co-workers to advance ethical conduct (ICN, 2013).

The International Council of Nurses Code of Ethics for Nurses (2006) as well as the American Nurses Association (ANA, 2001) focus on the importance of compassionate patient care aimed at alleviating suffering (Butts & Rich, 2013). Nurses should support patients’ self-determination and protect the moral space where patients receive care (Butts & Rich, 2013).

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Principles of Ethical ReasoningEthical principles are based on the concepts, theories, literature, and techniques of moral philosophy and are central to bioethics (Beauchamp & Childress, 2009). The four categories of ethical principles are respect for: 1. Autonomy, 2. Nonmaleficence, 3. Beneficience, 4. Justice

Autonomy is the respect for individuals to make their own decisions (Beauchamp & Childress, 2009). Respecting one’s autonomy includes obtained informed consent for treatment; facilitating and supporting patients’ choices regarding treatment options; allowing patients to refuse treatments; disclosing comprehensive and truthful information, diagnoses, and treatment options to patients; and maintaining privacy and confidentiality (Butt & Rich, 2013). A surrogate decision maker must determine the highest net benefit among the available options, assigning different weights to interests the patient has in each option and discounting or subtracting inherent risks of costs (Beauchamp & Childress, 2009).

Nonmaleficence imposes the obligation not to inflict evil or harm on others (Beauchamp & Childress, 2009). In medical ethics, this concept is phrased as “first, do no harm” (Beauchamp & Childress, 2009). Issues that may arise when studying nonmaleficence Nonmaleficence include negligence and standards of care, withholding and withdrawing treatment, ordinary and extraordinary treatment, killing and allowing to die, and quality of life considerations (Beauchamp & Childress, 2009). Nonmaleficence supports moral rules such as do not kill, do not cause pain or suffering, do not incapacitate, do not cause offense, and do not deprive others of the goods of life (Beauchamp & Childress, 2009). The goal of the ethical principle of nonmaleficence is that we should avoid causing harm to people (Beauchamp & Childress, 2009).

The Rule of Double Effect distinguishes between intended effects and merely foreseen effects (Beauchamp & Childress, 2009). Four conditions must be met for an act with a double effect to be justified:

1. The nature of the act must be good. 2. The agent’s intent must be good, the bad effect can be foreseen but not

intended.3. The distinction between means and effects, meaning the bad effect must

not be a means to the good effect.4. The proportionality between the good effect and the bad effect, meaning

the good effect must outweigh the bad effect (Beauchamp & Childress, 2009). Looks at the relationship between optional treatments and obligatory treatments.

There are several conditions for overriding the obligation to treat, such as whatever 1. Physicians or providers cannot perform; 2. Will not produce physiological effect;3. Is highly unlikely to be efficacious;

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4. Probably will produce only low grade, insignificant outcomes; 5. Is highly likely to be more burdensome than beneficial;6. Is completely speculative because it is untried;7. In balancing the effectiveness, potential benefit, and potential burden,

warrants withdrawing or withholding treatment (Beauchamp & Childress, 2009). Justification for overriding treatment is usually granted when the burden of treatment outweighs the benefits (Beauchamp & Childress, 2009).

Beneficence, in terms of bioethics, refers to the moral obligation to act for the benefit of others (Beauchamp & Childress, 2009). The rules of obligation for the ethical principles of beneficence are to:

1. Protect and defend the rights of others2. Prevent harm from occurring to others3. Remove conditions that will cause harm to others 4. Help persons with disabilities5. Rescue persons in danger (Beauchamp & Childress, 2009). Beneficence

demands more than maleficence because it requires that we take positive steps to help others, provide benefits to others, and rescue others (Beauchamp & Childress, 2009). Benefits are measured by cost effectiveness analysis (CEA), cost benefit analysis (CBA), and the value of the quality-adjusted life years (QALY) (Beauchamp & Childress, 2009).

Justice describes fairness, what is deserved and entitled (Beauchamp, 2009). Distributive justice refers to fair, equitable, and appropriate distribution of benefits or burdens justified by norms that structure the terms of social cooperation (Beauchamp & Childress, 2009). Justices states people are entitled to an equal share according to:

1. Their need2. Their effort3. Their contribution4. Their merit5. Free market exchanges (Beauchamp & Childress, 2009).

Fair opportunity rule states that individuals should not receive social benefits on the basis of undeserved advantageous properties and should not be denied social benefits on the basis of undeserved disadvantageous properties, because they are not responsible for the properties (Beauchamp & Childress, 2009). These properties include: racial, ethnic and gender disparities, and vulnerable and exploited populations (Beauchamp & Childress, 2009). One must also consider issues of justice, such as looking at peoples’ access to care, enrolling economically disadvantaged individuals in research, the moral right to government–funded healthcare, the right to a decent minimum of healthcare, the right to forfeit their right to healthcare, the right to health, and the issue of rationing and setting priorities when it comes to resources (Beauchamp & Childress, 2009).

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Ethics and the Nursing ProcessAn important part of clinical reasoning is the ability to work up the ethical aspects of a case (Georgetown University Center for Child and Human Development, n.d.). The ethics workup emphasizes a sensible progression from the facts of the case to a morally sound decision, using a five-step process to guide the thought process behind morally troubling cases as follows (Georgetown University Center for Clinical Bioethics).

Step 1: What are the facts? This stage stresses the need to clarify the facts of the case in order to make a decision. It asks questions of the ‘who’ (persons involved), ‘what’ (prognosis, preferences, therapeutic options), ‘when’ (time constraints or chronology of events), ‘where’ (medical setting), and ‘why’ (reasons supporting the claims, goals of current care.

Step 2: What is the issue? Evaluates whether the conflict is personal, interpersonal, institutional, or at a societal level. Asks if there is a question at the level of thought or feeling (Georgetown University Center for Clinical Bioethics). Interprets whether the question has a moral or ethical component.

Step 3: Frame the Issue? Frames the ethical issue at stake in terms of areas of concern:1. Identify appropriate decision makers (which option is most likely to benefit

and not harm the patient?), 2. Apply criteria to be used in reaching clinical decisions (biomedical good of

the patient and goods and interests of other parties), and3. Establish healthcare professional’s moral and professional obligations.

Step 4: Identify and weigh alternative courses of action and then decide. Realize that a decision must be made and that there is no simple formula. This step requires clinical judgment for doing so, practical wisdom, and moral argument. Sources of justification include:

1. Internal morality of the profession: the nature of healthcare professional-patient relationship; compatibility of recommended course of actions with aims of profession

2. Approaches to ethical inquiry 3. Grounding and source of ethics4. Ethically relevant considerations

The ethically relevant considerations include balancing benefits and harms, disclosure, informed consent and shared decision making, norms of family life, relationship between clinicians and patients, professional integrity of clinicians, cost effectiveness of allocations, issues of cultural and religious variations, and considerations of power.

Step 5: The critique. The fifth step of the Ethics Workup considers the major objections and the ability to respond adequately or change your decision. It stresses the importance of

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seeking input of ethics of doing an analysis to better prepare for next time (Georgetown University Center for Clinical Bioethics).

Essentials of Professionalism in the WorkplaceEthics committees are formal teams composed of preselected members that come together regularly to discuss ethical issues within an organization. The members often include physicians, nurses, an on-staff chaplain, social worker, and facility administrative staff member, and sometimes include legal representatives as well as local community representatives. Times may arise when nurses do not agree with physician, family member, or surrogate decisions regarding treatment. When this occurs, nurses often seek an ethics consultation. This act is part of the nurse’s role as a patient advocate.

The role of the professional nurse has evolved, as there has been a shift from etiquette to ethics, from obedience to moral autonomy, assertiveness, accountability, and advocacy (Begley, 2010). The professional nurse is also an autonomous moral practitioner who collaborates, is assertive, operates in partnership with patients, and acts as an advocate when patients are unable to speak up for themselves (Begley, 2010).

The ideal ethical nurse should possess qualities such as moral integrity and concern, and should provide culturally sensitive care (Butts & Rich, 2013). Moral integrity suggests that a person is often described as being honest, truthful, trustworthy, courageous, benevolent, and wise (Butts & Rich, 2013). Moral integrity appears to represent the quality of one’s character (Butts & Rich, 2013). Nurses can show concern by serving as patient advocates (Butts & Rich, 2013). Nurses who provide culturally sensitive care provide care that acknowledges and respects the beliefs, values, and customs of the person receiving the care (Butts & Rich, 2013).

In conclusion, nurses should strive to uphold the moral agreement they make with patients and communities when they joined the nursing profession (Butts & Rich, 2013). Nursing care includes actions such as promoting health and preventing illness, but the most important responsibility of nursing care involves caring for patients who are experiencing varying degrees of physical, psychological, and spiritual suffering (Butts & Rich, 2013).

C. Scenario/ Case Study1. Instructions

The following section contains an ethical scenario in which the nurse must determine which way to best handle the situation. Read the scenario and answer the questions that follow.

2. Background to scenarioAn ethical dilemma is any situation one faces where they are compelled to choose between two actions that will affect the welfare of another person (Butts & Rich, 2013). Either action can reasonably be justified as

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being good, neither action is readily justified as being good, or the goodness of the actions is uncertain (Butts & Rich, 2013).

3. Actual scenario You are caring for a 42 year old woman who is scheduled for an abdominal hysterectomy because of uterine cancer. Her surgeon, Dr. Lee, is known to have a bad surgical record in general, but especially in performing hysterectomies. The woman has heard gossip to this effect and asks you about it before her surgery because she is apprehensive about using that surgeon. You know for a fact that there is at least one legal suit filed against Dr. Lee because you personally know the woman involved in the case—a botched hysterectomy.

Your choices are: You could be brutally honest and truthful with this patient; you could give her part of the truth by giving her information you know to be untrue about certain rumors regarding Dr. Lee, while not confirming the truth about certain rumors; or you could be totally untruthful by remaining silent or by telling her that you have heard nothing. (Obtained from Butts, J.B., & Rich, K.L., (2013). Nursing ethics: Across the curriculum and into practice (3rd ed.). Burlington, MA: Jones and Bartlett Learning)

4. Practical exercises- (Questions pertaining to scenario)a. Discuss the possible actions the nurse should take and the

positives and negatives to each. b. Which option would you select? Explain your answer.c. Virtue ethics is form of ethical thought that focuses on being

good and having good moral character rather than doing good by following rules or duties. Deontology judges morality based on adherence to accepted rules and duties.

How might your actions differ based on applying deontology versus the virtue ethics approach?

How are these two approaches similar or different?D. Library

1. Glossary of Termsa. Ethics- The study of ideal human behavior focused on the

understanding and distinguishing between right and wrong (Butts Rich, 2013). “The principles of conduct governing an individual or group” (Chism, 2013, p.181).

a. Morals- Thoughts and actions that are derived ethically and are judged as being “good” or “bad” based on ethical reasoning (Butts & Rich, 2013).

b. Bioethics- Ethical situations and moral issues that arise in the field of healthcare (Beauchamp & Childress, 2009)

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c. Nursing Ethics- Situations in which ethical or moral issues are viewed from a nursing perspective (Butts & Rich 2013).

d. Code of Ethics- Standards of conduct stating certain principles regarding responsibilities and duties of those professional to whom they apply (Chism, 2013).

e. Ethical Dilemma- A situation in which a decision must be made among two or more morally acceptable options or between equally unacceptable courses of action, when one choice will prevent selection of the other (Ong, Yee, & Lee, 2012).

2. Recommended Readingsa. International Council of Nurses. The ICN Code of Ethics for

Nurses. Rep. Geneva: Imprimerie Fornara, 2012. Print. b. Bioethics.net. The American Journal of Bioethics, 2014. Web.

2014.c. The Hastings Center. The Hastings Center, 2014. Web. 2014.

3. Power points- recommended power points from other sitesNot Applicable

4. Recommended videos from other sitesa. Ethical Issues in Nursing Video -

http://www.youtube.com/playlist? list=PL13D7F754D232B496

http://www.youtube.com/watch?v=D2NbNGIhvqw b. US Nurses supported by the American Association of Nurses

Video - http://www.nursingworld.org/MainMenuCategories/EthicsStandards/Resources/Texas-Nurses.html

c. Ethics in pop culture: Scene from Grey’s Anatomy http://www.youtube.com/watch?v=oF1CmtKyHNw

E. Evaluation (multiple choice test)

1. Which of the following defines bioethics?a. A set of norms shared by all persons committed to moralityb. Theories that are commonly used in an attempt to identify

and justify normative ethics.c. Several different ways of examining and understanding the

moral lifed. The study of moral and social implications of developments in

the biological sciences and related technology

2. Which of the following is an ethical principle?a. Autonomy

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b. Wisdomc. Honestyd. Virtues

3. Which of the following statements is not true regarding an ethical dilemma?

a. Both actions are reasonably justified as being goodb. Neither action may be readily justified as being goodc. Ethical dilemmas can always be avoidedd. Both choices may feel wrong

4. Which of the following is not among the four responsibilities of the nurse according to the International Council of Nurses Code of Ethics?

a. Promote healthb. Prevent illness c. Obedience to physicians d. Restore health

5. Which of the following is not a Principle of the International Council of Nurses Code of Ethics?

a. Nurses and Peopleb. Nurses and Hospitalc. Nurses and Practiced. Nurses and Coworkers

6. A factual investigation of moral beliefs and conduct that uses scientific technique is called?

a. Meta-ethicsb. Bioethicsc. Descriptive ethicsd. Beneficence

7. According to the International Council of Nurses Code of Ethics, to whom is a nurse’s responsibility?

a. Patientsb. Patient and patient’s familyc. Hospitalsd. Physicians

8. What is the ethical principle that encourages doing no harm?a. Justiceb. Non-maleficencec. Beneficenced. Autonomy

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9. What is common morality?a. Right to refuse medical care for religious or cultural reasonsb. Describes values, behaviors, and ways of being that are

considered right or wrong when deciding what to do in a situation

c. An analysis of the language, concepts, and methods of reasoning in normative ethics

d. A set of norms shared by all persons committed to morality

10. What is the purpose of the International Council of Nurses Code of Ethics?

a. Based on the concepts, theories, literature, and techniques of moral philosophy, and are central to bioethics

b. Used to guide nurses every day in choices, supports, and refusals to participate in activities that conflict with caring and healing

c. Justifies overriding treatment when the burden of treatment outweighs the benefits

d. Uses a 5 step process to guide the thought process behind morally troubling cases

Answers: 1=D, 2=A, 3=C, 4=C, 5=B, 6=C, 7=A, 8=B, 9=D, 10=B

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Module 3. Leadership of the Future

Joanne Christopher-Hines

A. Module guide – describes what the module entails1. Objectives:

a. Describe and discuss various styles of leadershipb. Discuss the impact on leadership of current and emerging

information technology in nursing practicec. Identify the impact of socio-politico-economic influences on

the practice of professional nursing at varying governmental levels.

2. Module outline – brief description of each sectionThis module focuses on advanced practice nurse leadership and the impact of organizational, public-private, and political factors

a. Leadership Competenciesb. Technology (how it has evolved in nursing leadership)c. Leading in a rapid-change health care environmentd. The role of the nurse in health policy and health systems

3. Methodology- identifies learner strategiesIn this self-study module, the participant can learn at his/her own pace. However, there is a 12-week time limit for completion of the overall course.

a. Readings (All learning materials are available online and are accessible upon demand; although links to supplemental resources are provided, there are no professors or facilitators.)

b. PowerPoint presentationc. Scenario reviewd. Test (Participants will be required to earn a passing score in

the final exam for each module before continuing to the subsequent module.)

4. Time requirements: a. 12 hours

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5. References

Adams, J. M., Erickson, J. I., jones, D. A., & Paulo, L. (2009). An evidence-based structurefor transformative nurse executive practice: The model of the interrelationship of leadership, environment, and outcomes for nurse executives (MILE ONE). Nursing Administration Quarterly, 33, 280-287.

Adams, J. M., Denham, D., & Neumeister, I. (2010). Applying the model of the interrelationship of leadership environments and outcomes for nurse executives: A community hospital’s exemplar in developing staff nurse engagement through documentation improvement initiatives. Nursing Administration Quarterly, 34(3), 201-207.

American Organization of Nurse Executives. (2009) Guiding Principles for the nurse Executive to enhance clinical outcomes by leveraging technology AONE_GP_Leveraging_Tehnology-2.pdf

American Organization of Nurse Executives. (2009) Defining the role of the nurseexecutive in technology acquisition and implementation, Retrieved fromhttp://www.aone.org/resources/PDFs/AONE_GP_Technology_and_Acquisition_and_Implementation.pdf

Balabanova, D., Mills, A., Contech, L., Akkazieva, B., Banteyerga, H., Dash, U., Gilson, L.,Harmer, A., et al., (2013) Good health at low cost 25 years on: Lessons for the future of health systems strengthening. Lancet, 381(9883), 2118 – 2133. doi.org/10.1016/S0140-6736(12)62000-5

Berwick, D. M., Nolan, T. W. & Whittington, J. (2008). The triple aim: Care, health, and cost. Health Affairs, 27(3), 759-769. Doi10.1377/hlthaff.27.3.759

Chappell, K. & Willis, L. (2013). The Cockcroft difference: an analysis of the impact of a nursing leadership development programme. Journal of Nursing Management. 21, 396-402. doi: 10.1111/j.1365-2834.2012.01425.x

Hall, H. R. & Roussel, L. A. (2014). Evidenced-Based Practice. An Integrative approach to research, administration, and practice.

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Jones & Bartlett Learning. ISBN: 078-1-4496-5171-8 @ 2013.

Institute of Medicine (2012). For the Public’s Health: Investing in a Healthier Future. Washington, D.C.: The National Academies Press. http://www.nap.edu/catalog.php?record_id=13268

Kraushaar, D., Kieny, M.P., Lazarus, J.P. (2012) Health systems global, the new international society for health systems research. Health Policy and Planning, 27, 535–540 doi:10.1093/heapol/czs079

Lacey-Haun, L., & Whitehead, T. (2009). Leading change through an international faculty development programme. Journal Of Nursing Management, 17(8), 917-930. doi:10.1111/j.1365-2834.2008.00955.x

Nickitas, D.M.. (2009). An Interview With Anthony Kovner. Nursing Economics, 27(2), 100-101.

Porter-O’Grady, T. & Malloch, K. (2008). Beyond myth and magic: The future of evidenced based leadership. Nursing Administrator Quarterly. 32(3), 176-187.

Swensen, S., Pugh, M., McMullan, C., & Kabcenell, A. (2013). High-Impact Leadership: Improve Care, Improve the Health of Populations, and Reduce Costs. Institute for Healthcare Improvement.

B. Topics1. Broad overview of topics to be covered

a. Leadership Competencies Nurse managers can focus on self-development and

peer group development through nursing leadership development programs that prepare nurses for present and future leadership in the changing health care environment.

Compare and contrast leadership styles of nurses in academia and in healthcare institutions.

Discussion on Transformational and other styles of leadership

b. Health Information Technology and Impact on Nurse Leadership

National Health Information Network: Dr. David Blumenthal, National Coordinator for Health

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Information Technology, U.S. Department of Health and Human Services

American Organization of Nurse Executives Guiding Principles & Innovation in Healthcare

Adopting integrated electronic health systems c. Leading in a Rapid Change Environment

Overview of Triple Aim focus Institute for Healthcare Improvement. White Paper:

High-Impact Leadership Improves Care, Improves the Health of Populations, and Reduces Costs

Importance of honing leadership skills in a complex healthcare delivery system

d. Role of the Nurse in Health Policy and Health Systems Discussion of the global effects of emerging health

systems policy Discuss the impact of policy on population health Compare Health Policy Agendas across Countries Panel on Understanding Cross National Health

Differences Among High Income Countries

2. Actual content (in PDF narrative form and PowerPoint presentation with bullet points/speaker notes) including assigned and recommended readings for each section.

Leadership Competencies

Chappell, K. et al, (2013) states that nurse managers should focus on self-development and peer group development through nursing leadership development programs that prepare nurses for present and future leadership in the changing health care environment. They further note that current nursing leadership programs are slow in developing nurses with the vision and capability for improving health care. With the complexity and unpredictability of healthcare the expectation is that professionals are prepared to succeed based on their formal education, and that nurse leaders will identify and hone needed skill sets.

Nursing education programs and healthcare organizations must prepare nurses to be effective leaders. Responsible nurse leaders help organizations to stay focused on mission and goals, and to question and redirect policy, politics, and practice. They become effective leaders using challenges, innovation, and learning to maintain a balance between the role and the self.

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The Amy Cockcroft Fellowship program, a graduate nursing initiative at the University of South Carolina, was evaluated to determine if there were measurable differences on the impact of nursing leadership development programs. Four themes were identified, which provide the basis for creating measureable indicators for nursing organizations to use in determining the value of nursing leadership development programs. Impact areas for program development were:

1. Improved Conflict Resolution/negotiation skills: This is a learned skill of reframing, decreasing emotional response, and employing systems thinking.

2. Strong Communication Skills: Organizational communication is vital to increased development in the nurse leader role. Nurse leaders are required to effectively communicate with multiple parties – patients, staff, providers, families, peers, and outside vendors. This involves active listening and improved handling of crucial conversations, as well as growth in decreasing personal or emotional reactions during conflict.

3. Personal Development: Pursuit of higher education.4. Career action or change: Empowerment to move up within the organization,

make a lateral move, or become a visionary.

These four themes are supported in current leadership development literature (Chappell, K. et al, (2013). Leadership is a set of skills that can be learned, and once mastered can be incorporated to change workplace cultures (Mathena, 2002, cited in Chappell, 2013).

Economically strapped healthcare facilities are challenged with allocating money to develop leaders. Determining effective means of developing competent leaders is essential for survival. For Chappell, K. (2013) it is essential to develop strong nursing leaders who are not afraid to make a difference and who have a voice and understand that they play an important role in our communities, in legislation, and in the financial arenas in our work places (Chappell, K. et al, 2013).

Evidence Based Leadership Practices (Hall & Roussel, 2013)

Leadership Models (Chap. 7)

Quantum Leadership Model of interrelationship of Leadership, Environments, and Outcomes for Nurse

Executives (MILE ONE) Evidence-Based Management

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Quantum Leadership

Every discipline must have some idea regarding the specific contributions it makes to patient care and must be able to clearly delineate those contributions within the language of its discipline. Physicians, nurses, therapists, technologists, and pharmacists, must all possess some level of internal clarity about their own contribution to the myriad of activities that clinically impact patients (Porter-O’Grady and Malloch, 2008). Porter-O’Grady and Malloch (2008) were the first to introduce an evidence-based framework for nursing leadership. The framework underpins the importance of processes, behaviors, and managing infrastructure. They identify five key elements of Evidenced Based Practice (EBP) leadership: Physical environment, caregiver demographics, operational structures, culture, and technology.

The belief is that greater integration of complex systems and relationships among leaders and frontline staff workers reduce barriers and improve care. The impact of differing combinations of culture, technology, delivery models, care-givers, and the physical environment on multiple outcomes such as patient satisfaction, length of stay, fall rates, medication errors, number of emergency codes, pressure ulcers, caregiver satisfaction, turnover, and labor cost per day can now be examined using multiple metrics and aggregated evaluation (see Fig 3).

Figure 3. Evidence-based leadership evaluation Model Porter-O’Grady and Malloch (2008)

Critical skills of new leaders include the abilities to innovate, think, plan, and implement. Measures of success are determined by patient and caregiver, and by organizational and financial outcomes (Porter-O’Grady & Malloch 2008).

To make this happen, leaders must continually think as innovators to become comfortable challenging the status quo and to develop better processes and more effective structures. Integrating evidence-based principles into leadership

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DNA is a significant step along the nursing continuum that provides opportunity for reflection, innovation, and challenge (Porter-O’Grady & Malloch 2008).

Model of interrelationship of Leadership, Environments, and Outcomes for Nurse Executives (MILE ONE)

The American Nurses Association (ANA) has created an Evidenced-based model for the Scope of Standards for Nurse Executives and the American Organization of Nurse Executives competencies called the Model of Interrelationship of Leadership, Environments, and Outcomes for Nurse Executives (MILE ONE). The aim of this model is to operationalize chief nurse executive (CNE) influence, identify measures of success, and delineate patient, workforce, and organizational improvement (Adams, 2009). A paradigm shift is implied in the interrelationship among the CNE, Professional Practice Work Environment (PPWE), and patient and organizational outcomes. A lack of universally accepted standards of success contributes to the role conflict experienced by nurse executives (Adams, 2009). Mile ONE shifts focus away from patient outcomes to emphasize the PPWE and emphasizes three major concepts. The 3 concept areas include the following (Adams, 2009):

1. Nurse executive influence on the PPWE Emphasis : executive influence, leadership development, knowledge-

based practice, role clarity Measurement strategies: the use of existing PPWE tools

2. Professional practice/work environments influence patient and organizational outcomes

Emphasis: staff engagement, staff empowerment, staff “ownership” of outcomes, knowledge-based practice

Measurement strategies: quality indicators, staff recruitment, staff retention, staff satisfaction, etc.

3. Patient and organizational outcomes influence nurse executives Emphasis: outcomes management, data management, reporting

strategies, informatics, budget management Measurement strategies: CNE recruitment, CNE retention, CNE

satisfaction, etc.

The MILE ONE Model is useful when applied to exemplar work on improving

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documentation, as has been evidenced by the Adams (2010) study. The MILE ONE provides an evidence-based framework as an initial step in the exploration of the chief nurse executive’s (CNE) influence on organizational and patient outcomes, as well as the work environment. The use of the MILE ONE in education, policy, practice, research, and theory development offered a way to frame the interrelated nature of leadership, environments, and outcomes, providing focus to both individual and organizational enhancement efforts. Continued understanding and defining the measures of success for the CNE are imperative. Ultimately, it is the CNE who leads nursing care and impacts quality, cost, and patient-centered care.

Figure 1. Model of the interrelationship of leadership, environments, and outcomes for nurse executives. CNE indicates chief nurse executive; PES-NWI,

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practice environment scale of the nursing work index; PNWE, perceived nursing work environment scale; Professional Practice Work Environment, professional practice/work environment; NWI-R, nursing work index—revised; RPPE, revised professional practice environment survey. Copyright © The Bogart Group, Inc.

Evidence-Based Management

The systematic application of the best available evidence to business processes, strategic decisions, and the evaluation of managerial practices are known as Evidence Based (EB) Management (Kovner, Fine, & D’Aquila, 2009, p.1). In EB Management, basic employee and organizational performance data are required for application.

In 2006 Kovner and Rundall suggested an Evidence Based model for management consisting of five steps for decision-making:

1. Formulating the research question2. Searching for relevant research findings and other evidence3. Determining the validity, quality, and applicability of the evidence4. Presenting the data in a manner to promote use of evidence in

decision-making5. Applying the evidence in decision-making

The Evidence Based model is similar to Evidence Based Practice clinical models and uses the fundamental steps of process improvement. The model was designed specifically to address questions in three management categories – business transaction management, operational management, and strategic management. Some exemplar questions (Kovner & Rundall, 2006) include:

How can nurse absenteeism be reduced? Does hospital discharge planning and follow-up improve patient outcomes? Does the implementation of an electronic medical record improve patient

care?

Smith and Roussel (2013) noted that although an abundance of evidence is available, Evidence Based management practices continue to be weak. There is a greater reliance by managers on the trial and error phenomenon than on evidence-backed practices. Often, when information has been available, managers did not use it. Little encouragement and support exists around Evidence Based management. Leaders are urged to request sound evidence to support practice changes, examine the logic underpinning evidence, and use

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pilot programs prior to dissemination of findings.

Good to Great Company Leaders

A 15-year study by Collins (2001) cited in Hall and Roussel (2013) demonstrated the qualities of leaders who transformed good companies into great companies. These leaders were found to be “self-effacing”, reserved, quiet, and, in some cases, shy. They did not display the typical powerhouse image so often portrayed by top leaders. According to Collins these were top or level 5 leaders who possessed characteristics of humility and professional will. They had a relentless drive toward the success of the company and basically did what was necessary to get the job done and to meet the organization’s goals and objectives. Leaders of great companies recognized that having the right people in place is important to organizational success. With the right people in place, employees take stock within the company, which means leaders spend less time coaxing employees toward the organization’s goals.

Antecedents of Leadership

Effective Leaders (Delineated on pg. 137 Hall & Roussel, 2013)

No clear outline or blueprint for leadership success has been identified, but Smith & Roussel (2013) have delineated some of the recurrent antecedent themes of effective leaders:

Relate the principles of complexity science to the healthcare system, noting dynamic subsystems and relational components

Identify traditional hierarchical and individual locus of control leadership styles as obsolete in multi-faceted dynamic enterprises

Appreciate the knowledge, talents, diversity, and contributions of workers from all spheres of an organization as they apply to process improvement

Recognize the importance of staff engagement to promoting commitment, ownership, and sustainability of process change

Value the importance of positive work environments and their link to nurse satisfaction

Understand the significance of staff empowerment to satisfaction in the workplace and intent to leave

Appreciate the importance of relationships, effective communication, collaboration, and teamwork as applicable to promotion of patient safety

The effective nurse leader not only knows and understands the precursors of effective leadership but also examines them and translates them into practice.

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Health Information Technology and Impact on Nurse Leadership

In the United States, Health Information Technology (HIT or Health IT) is slowly being adopted (Institute of Medicine [IOM] 2012). Health IT includes a broad range of products, such as electronic health records (EHRs), patient engagement tools (e.g., personal health records), and health information exchanges. More recently, Health IT has evolved to EHRs and other forms of technology that engage not just in transactions and data storage but also decision support and the capacity for clinicians and patients to see the patient’s clinical progress and data more easily. Clinicians and health care systems can potentially benefit from studying populations of similar patients, leading to learning health care systems (IOM, 2012). Clinicians expect Health IT to support delivery of high-quality care in several ways, including storing comprehensive health data, providing clinical decision support, facilitating communication, engaging patients, and reducing medical errors. In the near future, it is likely that patients, specifically those with chronic diseases, will consistently use the Internet to track their own health through personal health records and handheld device applications (IOM, 2012). Current Health IT products are still improving in terms of their capacity to increase communications and reduce errors by making the right thing to do easier to do. It is important that Health IT maximize patient safety while minimizing harm.

In an effort to improve health care, the U.S. government has invested and will continue to invest billions of dollars toward the meaningful use of effective Health Information Technology in the hopes of improving the quality of care, decreasing the cost of care through improved efficiency, and guiding clinicians to choose the most effective care interventions (IOM, 2012). See BOX S-4 below from the Institute of Medicine Report.

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Health Information Technology (Health IT) is not one specific product that, once implemented, can immediately result in highly safe and effective health care. It includes a technical system of computers, software, and other devices that operate in the context of a larger sociotechnical system—a collection of hardware and software working together within an organization that includes people, processes, and workflow. It is widely believed that, when designed and used appropriately, Health IT can help create an ecosystem of safer care while also producing a variety of benefits such reduced administrative costs, improved clinical performance, and better communication between patients and caregivers (IOM, 2012). When seen from this perspective, Health IT is a very positive force for delivering quality healthcare.

The Institute of Medicine (2012) developed a strategic framework for a Learning

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Health System, which is depicted in the diagram below.

Charter of the Institute of Medicine Roundtable on Value & Science-Driven Health Care

• Generate and apply the best evidence for the collaborative health care choices of each patient and provider

• Drive the process of new discovery as a natural outgrowth of patient care• Ensure innovation, quality, safety, and value in health care.

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Federal Health Information Technology Strategic Plan 2011 - 2015

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The American Organization of Nurse Executives on Technology Acquisition

The chief nurse executive (CNE) plays a critical role in the selection and implementation of information systems. Acquiring new systems is a complicated process that impacts the entire facility. Although some tasks may be delegated, the chief nursing officer (CNO) must remain actively involved in the overall decision-making and implementation process. These guidelines serve as a tool for the CNO and are not meant to identify all aspects of acquiring and implementing information technology in an organization.

1. Pre-Acquisition

The CNO focuses on framing the institution’s need and gaining necessary knowledge about the information technology (IT) industry.

2. Acquisition – Before Selection of Vendor

The work that occurs prior to the actual selection of a vendor lays a critical foundation for success. It is helpful for the selection committee to develop a standard set of questions to be used in the selection/rejection process and for

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site visits. Clinicians should be leaders of clinical implementations. Although operational responsibility is delegable, the CNO remains accountable for this process.

3. Contract and Negotiations

Although the CNO may not be the executive who manages the contracting process, once there is a contract, he/she should review the entire contract, paying special attention to the parts of the contract that refer to clinical practice, phasing, resources, and expectations for the CNO.

4. Implementation – Managing the Process

The CNO plays a critical role in managing an implementation process that should be congruent with his/her vision for the future. He/she should review the project timeline and budget to assure that it covers necessary activities and resources anticipated.

5. The Return on Investment (ROI) – Benefit Management and Value

The CNO should work with other members of the senior leadership team to determine the value proposition beyond the usual proposed saving of full-time equivalents. The CNO should integrate patient safety and quality into the ROI analysis/processes, regardless of where they are conducted. Base benefits on sound evidence whenever possible.

6. Post Implementation

The CNO should participate in the executive leadership meetings regarding all stages of IT acquisition and assure nursing representation in user group meetings. He/she should proactively evaluate current and new technology to know how these can serve the organization.

7. Understanding the Overall Policy Issues Related to IT

Policy depends on data, leading to information that leads to knowledge. In addition to the CNO’s local responsibility for the acquisition and implementation of IT systems in the organization, he/she should maintain a global perspective on information technology and its impact on policy.

8. Survival Tips for the CNO New to the Organization: Stop. Look. Listen.

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A CNO hired by an organization that has recently made an IT decision must learn the IT strategic plan for the facility and how it fits with nursing’s strategic plan and priorities. It will be critical for the CNO to establish a collaborative and sustainable working relationship with the Chief Information Manager (CIO), (American Organization of Nurse Executives, 2009).

Leading in a Rapid-Change Health Care Environment

The United States ranked in the 66th percentile on a High Performance Health System Scorecard by The Commonwealth Fund Commission (Berwick, D. et al, 2008). The Commission notes that although U.S. health care expenditures are much higher than the expenditures of other developed countries, the results are no better. U.S. spending on health care is nearly double that of the next most costly nation, yet the United States ranks thirty-first among nations on life expectancy, thirty-sixth on infant mortality, twenty-eighth on male healthy life expectancy, and twenty-ninth on female healthy life expectancy (Berwick, D. et al, 2008).

With the health care delivery system’s complex and quickly changing landscape, leaders are urged to make highly reliable and safe care across the continuum the norm and not the exception (Berwick, D. et al, 2008). A recent focus has been on an improvement initiative called the Triple Aim, which aimed at delivering high-value care to individuals. The Triple Aim has three objectives: improve the individual experience of care; improve the health of populations; and reduce the per capita costs of care for populations.

The idea of the Triple Aim is still in its infancy, as many health care delivery systems may opt to adapt each part separately or at most address two of the three aims. Several obstacles to pursuit of the Triple Aim continue to slow its progression. Supply driven demand, new technologies with limited outcomes, limited foreign competition to drive change, physician-centered care, and little interest by clinicians and organizations in system knowledge are all factors which contribute to the challenges in meeting Triple Aim success Berwick, et al (2008).

For Berwick, however, integration of the aims is not impossible. Some examples of innovations that have begun challenging the U.S. health care market and that align with the Triple Aim objectives are the primary care medical home, retail clinics, non-location specific care through telecommunications, and medical tourism. Another example, offered by Virginia Mason Medical Center and others, is the adaptation of systems knowledge by implementing the “Lean Production” to healthcare.

Berwick (2008) suggests three design constraints essential to accomplishing the Triple Aim: 1) recognition of a population as the unit of concern, (2) externally supplied policy constraints (such as a total budget limit or the requirement that all subgroups be treated equitably), and (3) existence of an “integrator” able to focus and coordinate services to help the population on all

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three dimensions at once.

Triple Aim Progress would look like this:

In our lighter moments, we have tried to imagine the most elegant possible “Triple Aim Test,” asking, “How would we know at first glance that the care for a population is actually making progress on the Triple Aim?” Our proposed test has only three items. First, hospitals involved in the Triple Aim would be trying to be emptier, not fuller. They would celebrate as success that the hospital is less and less often needed by the population. Second, Fisher and Wennberg would be happier. They would observe that the dynamics of supply-driven care are no longer strong and that patients pull resources, rather than vice versa. And third, patients would say of those who try to maintain and restore their health: “They remember me.” They would recognize that the health care system is mindful of their needs, wants, and opportunities for health even when they themselves forget. Health care would also be mindful that people have excellent uses for their wealth other than paying for care they do not need or for illnesses they could have avoided.

High - Impact Leadership

According to the Institute for Healthcare Improvement (2013), leadership is the cornerstone for delivering results in health care for individuals and for populations. The goal is the Triple Aim focus of simultaneously maximizing or optimizing what is in the best interest of patients and community: Improve the care experience, improve population health, and reduce per capita health care costs.

• Growing Leadership focus to achieve Triple Aim results for populations• Triple Aim is a shift from volume to value• Three Interdependent Dimensions of leadership:

1. New Mental Models2. High-Impact Leadership Behaviors3. Institute for Healthcare Improvement High-Impact Leadership Framework

How Leaders Think

High-impact leadership requires the adoption of new mental models:

1. Individuals and their families are partners in care. 2. Compete on value, with continuous reduction in operating cost. 3. Reorganize services to align with new payment systems. 4. Everyone is an improver.

How leaders think and view the world is critical in shaping their approach to transforming from volume-based to value-based health care delivery.

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High Impact Leadership Behaviors

The Institute for Healthcare Improvement (IHI) has identified high impact behaviors. These behaviors are an outgrowth of the mental models and align with the updated IHI High Impact Leadership Framework. The behaviors consist of:

1. person-centeredness,

2. frontline engagement,

3. relentless focus,

4. transparency, and

5. boundarilessness.

The Institute for Healthcare Improvement urges leaders to adopt these 5 behaviors and have confidence that they will be mobilizing themselves and their organizations in the right direction, which facilitates transitioning from volume to value, ultimately driving towards better performance.

The Leadership Framework

The Institute for Healthcare Improvement High-Impact Leadership Framework explicitly addresses three new required leadership efforts and actions:

1. Driven by persons and community2. Shape desired organizational culture3. Engage across traditional boundaries of health care systems

The framework actions and initiatives are shaped by the New Mental models and are supported by the High-Impact Behaviors previously discussed. The focus of this model is to lead improvement and innovation. It is a distillation of broad leadership experience, practice, theory, and approaches.

Role of the Nurse in Health Policy and Health Systems

Essential ingredients for renewed public health enterprise:

• Ensure adequate & sustainable funding for governmental public health – Generate info on influences on population health

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– Lead or support interventions • Reform how governmental public health infrastructure is funded and

operated (e.g., change funding allocations to align funding with needs, escape silo funding…)

• Use Public Health knowledge to help reform delivery of clinical care quality with emphasis on

– Efficiency– Appropriateness– Integration with Public Health population-based efforts

Recommendations fall into four general areas:

• Setting a national health improvement target• Reforming public health and its financing• Informing the investment in health• Strengthening funding sources and structures to build public health

Successful Health Systems and Health Systems Research

In 1985, the philanthropic Rockefeller Foundation published Good Health at Low Cost to discuss why some countries or regions achieve better health and social outcomes than others at a similar level of income, and to show the role of political will and socially progressive policies (Balabanova, D., et al., (2013). After 25 years, the Good Health at Low Cost project revisited these places but also looked at Bangladesh, Ethiopia, Kyrgyzstan, Thailand, and the Indian state of Tamil Nadu, all of which have either achieved strong improvements in health or access to services, or implemented innovative health policies in comparison to their neighbors. Comparative case studies spanning 2009 to 2011 looked at how and why these changes were achieved. Balabanova, D., et al., (2013) cited attributes of success as good governance and political commitment, effective bureaucracies that preserve institutional memory and can learn from experience, and the ability to innovate and adapt to resource limitations. In addition, the ability to respond to the needs of populations and to build resilience into health systems in the face of economic crises, political unrest, and natural disasters was also important. Transport infrastructure, female empowerment, and education also played a part Balabanova, D., et al., (2013).

Given the complexity of health systems, there is no simple recipe for success. However, in the countries and regions that were studied, great progress was demonstrated through institutional stability; with continuity of reforms in spite

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of political and economic turmoil, lessons learned from experience, taking advantage of opportunities, and ensuring sensitivity to context. These experiences show that improvements in health can still be achieved in countries with scarce resources, but strategic investment is needed to address new challenges such as complex chronic diseases and growing population expectations (Balabanova, D., et al., 2013).

Kraushaar, et al. (2012) discussed the value of building stronger interdisciplinary networks of stakeholders internationally to address imbalanced health systems. There is growing acknowledgement that health system performance problems in low- and middle-income countries are a major obstacle to making more rapid progress in achieving the Millennium Development Goals and ensuring universal health coverage. More research is needed to address the reasons for health system weaknesses and the ways and means of improving performance (Kraushaar, et al., 2012). While there is substantial ongoing research in this area, no regular forum exists where findings, methodologies, and tools can be shared. As a result, the participants of the First International Symposium on Health Systems Research, in Montreux, Switzerland (2010), called for the creation of an international society for health systems research (Kraushaar, et al., 2012).

Health Systems Global (HSG), which is the new society for health systems research intends to be a platform at the local and global levels where researchers, policy makers, civil society organizations, and concerned citizens interact to align research with national and global priorities and to ensure research findings inform policy that leads to health systems transformation. Ultimately the organization has broader advocacy goals of achieving universal healthcare (Kraushaar, et al., 2012).

C. Scenario/ Case Study1. Instructions

Read the following case scenario “On Being Transparent” and complete the questions that follow.

2. Background to scenario. You are the Chief Executive Officer (CEO) and a patient in your hospital dies from a medication error. What do you do next?

3. Actual scenarioOn Being Transparent

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The University of Rochester’s Dr. Paul Griner presents this case, about which he says, “One of the first things I learned after being appointed president of the hospital [Strong Memorial Hospital in Rochester, NY] was to deal openly with patients and families (and the community) when we made mistakes. Here’s one example that has always stuck with me”:

A 6-year-old patient with a defect in bowel function was hospitalized for severe constipation. He was given a dose of neostigmine (a drug that helps muscles contract and relax to move food through the system) that was 10 times the normal amount because of a decimal point error made by the resident who ordered the drug. Instead of 0.4 mg, the patient received 4.0 mg.

Tragically, the patient died the same day from the overdose. My human resources director advised me to immediately hold a press conference to announce our mistake. I did. The conference lasted for two hours and centered on reporter questions about why the resident and nurse had not been fired. I explained that both were highly regarded and that the problem was a “system” problem, not a problem of an incompetent physician or nurse. I explained that we should have a fail-safe system in place to prevent such a mistake. (Today, hospitals have electronic medication error avoidance systems. We didn’t have that in 1984.)

I indicated to the reporters that we would be examining the medication administration procedures in place from the point the medicine is ordered to the time it was given, and would put in place a procedure or procedures to ensure that such an error would not happen again.

This story contrasted sharply with an experience I had with a wealthy patient from Geneva, Switzerland, who came over to the states each year for a comprehensive examination.

Before coming to Rochester after his overseas flight, his routine was to spend a few days in New York City and visit friends. On one such annual trip, he fell while walking along a street in New York, fracturing his pelvis. He was admitted to a well-known hospital and spent three weeks recovering in bed.

After three weeks, I received a call from him asking to be transferred to Strong Memorial Hospital in Rochester. He was unhappy with his care, indicating that no one seemed to be attending to him. We arranged the transfer and, when I saw him that afternoon, I was astounded to find that he had a pressure ulcer on his heel that was an inch deep. The ulcer wouldn’t heal, so I secured a vascular surgeon to perform arterial bypass surgery. The surgery, which improved circulation in the patient’s leg, was successful and, after a

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period of weeks, the ulcer healed completely.

I wrote a letter to the president of the New York hospital to discuss the patient’s care. Some weeks later, after not receiving a response, I called his office. I was transferred to the hospital lawyer. I indicated the reason for the call and asked why I had not received a response. He said, “Oh, we would never acknowledge a mistake. We might get sued.”

4. Practical Exercises (Questions pertaining to scenario)

a. What is the difference between the two stories? Why do you think they were handled differently?

b. Pretend you were a reporter at the first press conference. What question would you ask the Chief Executive Officer (CEO)? Why?

c. How would you respond to the lawyer in the second story?d. Why is transparency important after a medical error?e. Have you ever made or observed an error involving a patient?

Was the patient harmed? How did you handle the error?D. Library

1. Glossary of Terms Triple Aim: an improvement initiative aimed at delivering high-

value care to individuals High-Impact Leadership: Three interdependent dimensions of

leadership that are required to achieve the Triple Aim: new mental models, High-Impact Leadership Behaviors, and the Institute for Healthcare Improvement High-Impact Leadership Framework.

Emotional Intelligence (EI): the ability to be aware of, understand, and control one’s emotions. EI has been proposed as an expression of transformational leaders (Hall, H. R. & Roussel, L. A. (2014).

Electronic Health Record (EHR or Electronic Medical Record (EMR): electronic versions of paper charts which contain patients’ medical history, progress notes and other information about the patient’s health including symptoms, lab results, diagnoses, vital signs, immunizations, and reports from diagnostic tests such as radiographs. (United States Department of Health and Human Services)

Health Information Technology (HIT): According to the United States Department of Health and Human Services (HHS), HIT involves the exchange of health information in an electronic

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environment. Widespread use of health IT within the health care industry will improve the quality of health care, prevent medical errors, reduce health care costs, increase administrative efficiencies, decrease paperwork, and expand access to affordable health care. (HHS)

Health Policy: refers to decisions, plans, and actions that are undertaken to achieve specific health care goals within a society. An explicit health policy can achieve several things: it defines a vision for the future which in turn helps to establish targets and points of reference for the short and medium term; it outlines priorities and the expected roles of different groups; and it builds consensus and informs people. (World Health Organization)

2. Recommended Readings

Johansen, B. (2012). Leaders Make the Future: Ten New Leadership Skills for an Uncertain World. San Francisco, California: Berrett-Koehler.

Grossmann, Claudia, Brian Powers, and J. Michael. McGinnis. Digital Infrastructure for the Learning Health System the Foundation for Continuous Improvement in Health and Health Care: Workshop Series Summary . Washington, D.C.: National Academies, 2011.

Smith, Mark D. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America . Washington, D.C.: National Academies, 2013.

Institute of Medicine. (2012). Committee on Patient Safety and Health Information Technology. Health IT and patient safety: building safer systems for better care / Committee on Patient Safety and Health Information Technology, Board on Health Care Services. ISBN 978-0-309-22112-2 (pbk.) — ISBN 978-0-309-22113-9 (PDF)

3. Powerpoints – recommended PowerPoints from other sites

Developing Team Leadershiphttp://samples.jbpub.com/9781449673581/Leadership_in_NursingPracticeKMTPOG.pptx

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http://www.phscof.org/docs/PresentationsFinal/Tuesday/Nurse/PorcheNursingLeadershipintheTransformationofHealthcareandEmergingRolesofNurseInformaticsLeaders_Dr.%20Porche.ppt

http://hcfgkc.org/sites/default/files/documents/hcf-hit-hrsa-kc409.ppt

http://ihealthtran.com/wordpress/2012/11/keynote-presentation-health-it-the-critical-tool-for-managing-clinical-care/

4. Recommended videos from other sites

Voice of Nursing Leadership Panel https://www.youtube.com/watch?v=BelX4Ej-pdA

National Health Information Network: Dr. David Blumenthal, National Coordinator for Health Information Technology, Department of Health and Human Services https://www.youtube.com/watch?v=WngGHJ1f7PY&feature=related%00

E. Evaluation (Multiple choice test)

1. Leadership skills include all of the following except:a. Foundational thinking skills and change management b. Succession planningc. The ability to use systems thinkingd. Personal journey disciplines e. Knowledge of Human Resource Practices

2. According to the American Organization of Nurse Executives, managers at all levels must demonstrate competence in all areas except:

a. Foreign and domestic policyb. Knowledge of the healthcare environmentc. Professionalism and business skillsd. Communication and relationship buildinge. Leadership

3. The four identified areas for successful leadership development that have been extensively documented in leadership research include - career action/change, strong communication skills, personal development and:

a. Emotional intelligenceb. Conflict resolution and negotiation skills

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c. Measurable indicatorsd. Honing of leadership essentials

4. Physical environment, caregiver demographics, operational structures, culture and technology are all examples of:

a. Quantum Leadership b. Model of interrelationship of Leadership, Environments, and

Outcomes for Nurse Executives (MILE ONE)c. Evidence-Based Practice elementsd. Professional Practice Work Environment

5. Health Information Technology involves many products including Health information exchanges, patient engagement tools and:

a. Software packagesb. Patient satisfaction toolsc. Firewallsd. Electronic Health Records (EHRs)

6. Health Information Technology includes a technical system of computers, software, and devices that operate in the context of a larger sociotechnical system—a collection of hardware and software working together within an organization that includes:

a. manuals, workbooks, and tutorialsb. administrators and staff workersc. people, processes, and workflowd. network, modems, and hardware

7. Acquiring new systems is a complicated process that impacts the entire healthcare facility. Although some tasks may be delegated there is a need for which healthcare professional to remain actively involved in the overall decision-making and implementation process?

a. The Chief Nursing Officerb. The Chief Information Officerc. The Chief Financial Officerd. The Human Resource Director

8. The “Triple Aim” has three objectives, which are to improve the individual experience of care, improve the health of populations, and:

a. eliminate obstacles to careb. shift from volume to valuec. focus on high impact leadershipd. reduce the per capita costs of care for populations

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9. The three interdependent Dimensions of Leadership according to the Institute for Healthcare Research include all except:

a. New Mental Modelsb. High-Impact Leadership Behaviorsc. Shift from volume to valued. High-Impact Leadership Framework

10. Health Systems Global (HSG), the new society for health systems research desires to be a platform at the local and global levels where research is aligned with national and worldwide priorities. The society wants to ensure research findings inform policy that leads to health systems transformation. All of the following groups are pivotal stakeholders in the HSG with the exception of:

a. Policy Makersb. Pharmaceutical Representativesc. Concerned citizens d. Researcherse. Civil society organizations

Answers:1=E, 2=A, 3=B, 4=C, 5=D, 6=D, 7=A, 8=D, 9=C, 10=C

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Module 4. Workforce

Claudia Warren-Taylor

A. Module Guide-describes what the module entails

This module describes the concepts of workforce as it applies to the role of the professional nurse in staffing and safe staffing, generational differences in the workforce, recruitment and retention, human resources leadership and management as applied to the nursing workforce, and performance appraisals.

1. Module Objectives—At the end of the module the student will be able to

a. Identify nursing knowledge from the natural and behavioral sciences, arts, humanities, and nursing science as a basis for culturally competent nursing practice as it relates to workforce development and utilizing evidence-based research in clinical decision making to promote safe quality care to culturally diverse persons, families, and communities.

b. Discuss the impact of current and emerging information management and patient care technology in nursing practice as it relates to staffing and safe staffing, recruitment and retention, human resources leadership, and performance appraisals.

c. Discuss the impact of current and emerging information management and patient care technology in nursing practice as it relates to staffing and safe staffing, generational differences in the workforce, recruitment and retention, human resources leadership and management as it applies to the nursing workforce, and performance appraisals as it relates to evaluating the nursing profession.

d. Discuss in-depth aspects of staffing and safe staffing, evidence based principles of staffing, and safe staffing decisions

2. Module Outline-brief description of each sectiona. Staffing and Safe Staffingb. Generational differences in the workforce todayc. Recruitment/Retentiond. Human resources leadership and management as applied to

the nursing workforce

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e. Performance appraisals—Evaluation the nursing professional (in-service training)

3. Methodology-Identifies learner and strategies

In this self-study module, the participant can learn at his/her own pace. However, there is a 12-week time limit for completion of the overall course.

a. Readings (All learning materials are available online and are accessible upon demand; although links to supplemental resources are provided, there are no professors or facilitators.)

b. PowerPoint presentationc. Scenario reviewd. Test (Participants will be required to earn a passing score in

the final exam for each module before continuing to the subsequent module.)

4. Time requirements a. 12 hours

5. References

Agency for Healthcare Research and Quality. (2013, May). Module

Measuring and benchamarking clinical performance. Retrieved

from Agency for Healthcare Research and Quality:

Aiken, L. H., Cinioti, J., Sloane, D. M., Smith, H. L., Flynn, L., & Neff,

S. (2011). The effect of nurse staffing and nurse education on

patient deaths in hospitals with different nurse work environments.

Medical Care, 49(12), 1047-1053 among urban hospital

nurses.   Work and Occupations   24 (4): 453-477.

American Nurses Association (ANA), (2014). ANA principles for nurse

staffing (2nd ed.). Silver Spring, MD: Author

Brewster,C., & Mayrhofer, W. (2012). Handbook of research on

comparative human resource management. Cheltenham, UK:

Edward Elgar Publishing

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Buerhaus, P. I., Staiger, D. O., & Auerbach, D. I. (2000). Implications of

an aging registered nurse workforce. Journal of the American

Medical Association, 283(22), 2948-2954.

Buerhaus, P. I., Staiger, D. O., & Auerbach, D. I. (2003). Is the current

shortage of hospital nurses ending? Health Affairs, 22(2), 191-198.

Carlson, S. (2005, October 7). The next generation in the classroom. The

Chronicle of Higher Education, pp. A34-A37.

Chao, L. (2005, November 29). What GenXers need to be happy at

work. The Wall Street Journal, p. B6.

Clausing, S. L., Kurtz, D. L., Prendeville, J., & Walt, J. L. (2003).

Generational diversity - the Nexters. AORN Journal, 78(3), 373-

379.

Cran, C. (2005). Generations at work. Retrieved October 18, 2005, from

www.sideroad.com/Human_Resources/generations-at-work.html.

Dominguez , C. (2003). Generational Diversity . Retrieved December 5,

2005, from Minority Corporate Counsel Association

Duffield c, M., Roche, M. a., O’Brien, P., & Catling-Paull, C. (2010).

The implications of soft “churn” for nurse managers, staff and

patients. Nursing Economics 27, 79-88.

Duchscher, J. E., & Cowin, L. (2004). Multigenerational nurses in the

workplace. Journal of Nursing Administration, 34(11), 493-501.

Finn, CP. 2001. Autonomy: an important component for nurses' job

satisfaction.   International Journal of Nursing Studies   38: 349-357.

Force, MV. 2005. The relationship between effective nurse

managers and nursing retention.   Journal of Nursing

Administration   35 (7/8): 336-341.

Greene, J. (2005, March 14). What nurses want: Different generations,

different expectations. Hospitals and Health Networks. Retrieved

10/21/2005, from

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www.hhnmag.com/hhnmag/hospitalconnect/search/article.jsp?

dcrpath=HHNMAG/PubsNewsArticle/data/

0503HHN_FEA_CoverStory&domain=HHNMAG

Halm, M, Kandels, M, Blalock, M, Gryczman, A, Krisko-Hagel, K., et

al. 2005. Hospital nurse staffing and patient mortality, emotional

exhaustion, and job satisfaction.   Clinical Nurse Specialist, 19(5):

241-251.

Hart, SE. 2005. Hospital ethical climates and registered nurses' turnover

intentions.   Journal of Nursing Scholarship, 37(2); 173-177.

Husin, S., Chelladurai, P., & Musa, G. (2012). HRM practices,

organizational citizenship behaviors, and perceived service quality

in golf courses. Journal of Sport Management, 26, 143-158.

Jones, CB. 2005. The costs of nurse turnover, part 2.   Journal of Nursing

Administration   35(1): 41-49.

Lavell, J., J., McMahan, G. C., & Harris, C. M.(2009). Fairness in

human resource management, social, exchange relationships, and

citizenship behavior: Testing linkages of the target similarity

model among nurses in the United, International Journal of Human

Resource Management, 20, 2491-

2434.Doi:10.1080/09585190903363748

O’Neil, M., O. (2008). Human resource leadership: the key to improved

results in health.

Rambur, B., McIntosh, B., Palumbo, MV and Reinier, K. 2005.

Education as a determinant of Career Retention and Job

Satisfaction among Registered Nurses.   Journal of Nursing

Scholarship, 37(2), 185-192

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Rashmi,t. K. (2010). Recruitment and management. Mumbai, India:

Himalayan books.

Sadovich, J.M. 2005. Work Excitement in Nursing: An Examination of

the Relationship Between Work Excitement and Burnout. Nursing

Economics, 23(2), 91-96.

Sherman, R., (May 31, 2006). "Leading a Multigenerational Nursing

Workforce: Issues, Challenges and Strategies". OJIN: The Online

Journal of Issues in Nursing. Vol. 11, No. 2, Manuscript 2 DOI:

10.3912/OJIN.Vol11No02Man02

Watty-Benjamin, W., & Udechukwu, I. (2014). The relationship

between HRM practices and turnover intentions: A study of

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82.

B. Topics

1. Broad overview of topics to be covereda. Staffing and safe staffing:

Nurse staffing act Staffing budget Staff mix designation philosophy Nursing model of care Problems that arises from issues with safe staffing Staffing to bolster nurse retention Major elements of optimal staffing achievement

b. Generational difference in the workforce today: The generational Cohorts The Veterans (1925 – 1945) The Baby Boomers (1946 – 1964) Generation X (1963 – 1980) The millennial Generation (1980-2000) Management of age-diverse workforces Leadership Strategies Generational Conflict

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c. Recruitment/retentionRecruitment

Focus on hiring the right people – Behavior-based interviewing vs. skill-based interviewing can build effective long-term skills

Redesign workforce processes and adopt technology to increase efficiency

Eliminate or retrain low performers Attract new generation of nurses to maintain staffing

levels Employment brand and materials to get the attention

of quality employees looking for a great place to work

Retention

Autonomy over practice decisions, i.e., part of the decision making

Reasonable workloads and flexible scheduling Provide continuing education Competitive pay Measure satisfaction to keep abreast of employees’

needs and expectations Reward and recognize

d. Human resources leadership and management as applied to the nursing workforce

Performance appraisals-Evaluating the nursing professional (in-service training)

Ways of performance appraising Concept of Performance appraisal

o Translating goals into practice Focus on individual employees, teams, programs,

processes, and the organization as a whole Addresses individual and organizational performance

matters necessary to properly create and sustain a healthy and effective results-oriented culture

Effective Performance appraisal will help your organization raise individual performance, foster ongoing employee and supervisor development, and increase overall organizational effectiveness

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2. Actual content (in PDF narrative form and PPT presentation with bullet points/speaker notes) including recommended readings for each section.

Staffing and Safe Staffing

Registered Nurse Staffing Act

Nursing Workforce Development programs in which staff is trained and cross trained in various capacities and that address shortage on any unit.

The Registered Nurse Safe Staffing Act requires the establishment of a staffing system that stipulates the number of Registered Nurses on each shift and in each unit of the hospital to ensure appropriate staffing levels for patient care. The bill also provides public reporting of staffing information. Hospitals must post daily the number of licensed and unlicensed staff providing direct patient care for each shift. When it comes to addressing the nursing shortage, it's important to attend to both recruitment and retention, as these interrelated. If organizations do not retain nurses, there is greater potential that they will consistently be challenged with nursing shortages. According to Aiken (2011), safe staffing is among nurses' top concerns.

Main areas of staffing:

1. There should be sufficient number of suitably qualified, competent, skilled, and experienced staff on each shift.

2. Have the right numbers of nurses with the right skills in the right place for each unit

3. Set work hours not to surpass a maximum of 16 hours a day4. Staffing is based on patient acuity and staff can be rotated to accommodate

shortage

Staffing budget

Staff Mix Philosophy: Methods of allocating nurses to patients are typically divided into four types: primary nursing, patient allocation, task assignment, and team nursing. Research findings are varied in regard to the relationship between these models of care and outcomes in areas such as satisfaction and quality. Skill mix has been associated with various models, with implications for collegial support, teamwork and patient outcomes, Duffield, et al., (2010). Skill mix plays a role in the choice of which method of care delivery is used.

Nursing models of care: Historically, the method of allocating patients to staff has been determined by the nurse in charge on the unit. Four methods have been described and used. The first of the four ‘classic’ models of delivering nursing care is ‘patient allocation’ or ‘total patient care,’ which has one nurse taking responsibility for the complete care of a group of patients and standards of care on the ward.

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Total patient care, also called patient allocation, remains popular with patients due to the high quality and consistency of care that is provided by qualified staff and, more importantly, by the same nurse (Wagner & Bear 2009, Wolf et al. 2008). It is also popular with nurses because of the degree of autonomy and control they have over their work, and because it provides for easily identifiable responsibility for a particular patient’s care (Gullick et al. 2004; Tiedeman & Lookinland 2004). It does, however, require a staff made up almost entirely of registered nurses.

Functional or task-oriented nursing emerged in the 1940s due to a war-related shortage of registered nurses, resulting in the employment of more support staff in hospitals (Marquis & Huston 1992). This model divides work into tasks assigned to nursing and ancillary personnel based on the complexity of the task. The Registered Nurse addresses more complex tasks, whereas lesser skilled staff members undertake more routine tasks. It has fallen out of favor recently due to its regimentation, lack of Registered Nurse staff accountability for recognition of the patients as an individual, and little time devoted to patients’ psychosocial and spiritual needs (Tiedeman & Lookinland, 2004). Patient satisfaction is low in this model, as patients cannot establish who ‘their nurse’ is (Ring, 1994).

Team nursing emerged following World War II (Tiedeman & Lookinland, 2004) in response to the impersonal nature of task-oriented nursing and in an effort to improve both patient and staff satisfaction (Marquis & Huston 1992). It is a model whereby a ‘team’ of nurses provides all the care to a specified group of patients, often allocated by geography. This model allows for supervision of aides, orderlies, and licensed practical or enrolled nurses by a smaller number of Registered Nurses. In this model, the Registered Nurse team leader supervises lesser-trained patient care providers and performs direct patient care that lesser-skilled staff is not qualified or licensed to provide. Other team members provide direct patient care to assigned patients (Tiedeman & Lookinland, 2004). In the team nursing model, task-oriented or even primary nursing elements of care may exist. Primary nursing, initially developed in 1968, focuses on providing care in a one patient to one nurse relationship that promotes continuity of care (Manthey, 2008). On admission patients are assigned a specific nurse who assumes 24-hour responsibility for their care for the duration of their stay, and their care is therefore not shift dependent. The primary nurse has the authority to assess, plan, organize, implement, coordinate, and evaluate care for his/her patients and when off duty delegates other nurses to follow through (Lyon 1993; Manthey, 1980; Tiedeman & Lookinland, 2004). Should this patient be readmitted, the same nurse (assuming s/he is still employed) would again undertake responsibility for their care. This model has been shown to be used widely in Magnet-designated hospitals and has been linked to positive patient outcomes (Aiken et al. 1999; Mondino, 2005) and staff satisfaction (Allen & Vitale-Nolen, 2005; Garon, et al., 2009).

Primary nursing, recently renamed Relationship-Based Care, is based on the philosophy that the development of a nurse-patient-family relationship is paramount to continuity of care. This model has been shown to empower nurses and promote autonomy; in addition, contrary to popular belief, it does not always

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require an all-RN staffing mix (Manthey, 2003). Despite the evidence, this model is rarely used in hospitals (Middleton, et al., 2008) with the exception of some critical care units (Watts, et al., 2007).

Shared care model incorporates aspects of patient allocation and team nursing. Skill mix plays a role in the choice of which method of delivery is used.

Staffing to bolster nurse retention: To prevent a nursing shortage and retain nurses, it is essential to prevent overload, cross train staff, create a pool for floating to other units, and require no overtime.

Problems that arises from issues with safe staffing: Situations where nurses being forced to take care of too many patients at once results in medication errors, preventable complications which result in decreased quality of care, increased length of stay, and readmissions. According to inadequate (nurses staffing levels have been a factor in nearly 25% of the most serious life-threatening event.

Approaches to safe staffing:

The need for safe and adequate staffing is inherent across all health care organizations. Critical elements identified as essential appropriate staffing include:

Staffing must ensure the effective match between patient needs and nurse competencies. The healthcare organization has staffing policies in place that are solidly grounded in ethical principles and support the professional obligation of nurses to provide high quality care.

Nurses participate in all organizational phases of the staffing process from education and planning—including matching nurses’ competencies with patients’ assessed needs—through evaluation.

The healthcare organization has formal processes in place to evaluate the effect of staffing decisions on patient and system outcomes. This evaluation includes analysis of when patient needs and nurse competencies are mismatched and how often contingency plans are implemented.

The healthcare organization has a system in place that facilitates team members’ use of staffing and outcomes data to develop more effective staffing models.

The healthcare organization provides support services at every level of activity to ensure nurses can optimally focus on the priorities and requirements of patient and family care.

The healthcare organization adopts technologies that increase the effectiveness of nursing care delivery. Nurses are engaged in the selection, adaptation, and evaluation of these technologies.

The following will also assist in staffing and safe staffing:

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1. Sets minimum RN-to-patient ratios by specialty/unit in hospitals2. Enforce minimum RN-to patient ratios as a condition of licensure3. Institute a standard patient classification system to increase nursing care as

needed4. Require hospitals to post minimum staffing ratios in all patients care areas5. Ban the use of mandatory overtime6. Improve recruitment and retention

The team model approach assists with safe staffing as it creates a team approach, lends support and creativity, decreases burn, out and extends shared governance. Models of care are not prescriptive but are varied according to ward circumstances and staffing levels based on complex clinical decision making skills.

Generational differences in the United States workforce today

The generational cohorts: Defined as an identifiable group that shares birth years, age, location, and important life events at critical developmental stages (Hendricks & Cope, 2012).

There are four major generational cohorts:

1. The veterans (1925 -1945). This group has the experience of living through economic hardship and living through the great wars. Their experience translates to loyalty, discipline, teamwork, reward for hard work, respect for authority and hierarchy, and seniority-driven entitlement. Nurses in this cohort are over 60 years of age and although having plans to retire are being encouraged by government incentives to remain in the workforce to prevent “brain drain”. Given the physical demands of nursing, this working generation of nurses is unlikely to be in direct-care positions but may hold senior-level healthcare management and decision-making positions, although there is no data to support this claim. This generation makes decisions based on a utilitarian and militaristic authority tradition and therefore respects authority and adheres to rules (Dols et al., 2010). This translates to an expectation for respect for age and experience in the workplace (Hendricks & Cope, 2012).

2. Baby boomers (1946 – 1964). Baby boomers grew up in a relative steady state of free expression, economic prosperity, and educational growth, and they believe that they are ‘entitled’ and this notion is central to their work ethic. This driven and dedicated cohort’s motto is living to work, and they look consistently to external sources for validation of their worth. This group equates work with personal fulfillment and self-worth; they are distinctly competitive, have little familiarity with delayed gratification, and are strong willed. Boomers want to be noticed and valued for their contributions through work-related ‘perks’ or recognition. They enjoy such

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things as monetary gain, promotions, titles, corner offices, and reserved parking; they are the ones responsible for coining the phrase “workaholic” (Hendricks & Cope, 2012).

3. Generation X (1965 – 1980). The nursing graduates of this generation are individualistic in their approach to work and do not align themselves with the ethos of being a member of a team. They have learned how to manage their own time, set their own limits, and get their work completed without supervision. Their formative experiences have cultivated adult workers with a strong propensity for outcome rather than process, a greater affinity for information than introspection, a desire to know facts over emotions, and an intimate familiarity with ambiguity and flexibility that renders them anxious when faced with fixed, rigidly imposed, or closed-off bottom lines (Ware 2007). This cohort values a work-life balance and is well suited albeit ironically to a job market that holds no promise of stability and every assurance of change (Wilson et al., 2008).

4. Millennial Generation (1980- 2000). Millennials share many attributes with Generation Xers. They often thrive on maintaining a balance between work and home and seek seamlessness between the way they play and work (Hendricks & Cope, 2012). Millennials enjoy strong peer relationships and favor a collective, cohesive, and collaborative approach to teamwork (Dols et al., 2010). This cohort is adaptable to change and is technology dependent. Consequently, they have spent their formative years interactively participating in the discovering of new knowledge, challenging their own and otherss assumptions and synthesizing unprecedented amounts of interfaced information at break-neck speed (Dols et al., 2010). For this cohort, job portability and lateral career moves are also of importance.

Management of age-diverse workforces

The nursing workforce has several concurrent challenges, including generational differences that possess their own distinct characteristics and values, working together within the same organizations. Several authors have pointed to the coexistence of different generations in the workforce as a source of workplace conflict, often contributing to decreased job satisfaction and impeding retention. A sustained partnership among different generations is an important element of achieving effective and supportive nursing teamwork. Fully understanding the differences among generations has been suggested as one way to improve nurse retention and optimize effective organizational outcomes.

Leadership strategies

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A leader of a diverse workforce must understand each generation’s characteristics and know that each generation’s characteristics are reflected in their nursing work environments in terms of performance, adaptation to organizations, work ethics, and vision about the organization and service. Management styles should take into account differences in values and attitudes among new nurses or different generations. At the organizational level, nursing leadership must anticipate generational differences and provide a positive environment for new nurses of all generations to develop and demonstrate their abilities. This environment can encourage staff nurses to understand and respect coworkers of all generational groups, recognizing not only areas of generational difference but also a commitment to common goals, including the delivery of safe, high-quality patient care in a supportive and collegial environment.

Generational conflict

Interventions to reduce generational conflict and promote a positive work environment include such measures as assessing each unit’s generational mix, acknowledging generational differences, understanding differing expectations, and building on the strengths of different cohorts while emphasizing common goals. Staff orientations present critical opportunities for introducing strategies to reduce generational conflicts. It is also important that these experiences be tailored to the needs of the different generations.

Recruitment/Retention

There is a clear link between lack of diversity in the nursing workforce and nursing’s capacity to effectively address diversity with high quality culturally competent care (American Association of Colleges of Nursing, 2011; Huston, 2008). Efforts to increase and maintain baccalaureate-prepared minority nurses to better reflect the diverse population needing culturally responsive, high quality care is a continuing goal of nursing education and practice. Because of this, initiatives focusing on increasing ethnic and cultural diversity of healthcare workers are of high priority. A goal of nurse educators and nursing programs should be to recruit, retain, and graduate a diverse cadre of professional nurses. Recruiting and retaining quality nurses are major challenges in today’s nursing shortage environment. Several factors contribute to whether a nurse chooses to stay with or leave an organization.

Recruiting factors

Several factors should be considered when hiring:

The focus should be on hiring the right people. This can be done through behavior-based interviewing vs. skill-based interviewing (focus on actual abilities and competencies), which can build effective long-term skills.

The workforce processes and adopts technology to increase efficiency. Eliminate or retrain low performers.

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Attract new generation of nurses to maintain staffing levels. Ensure that there is a mentorship program. Ensure staffing is sufficient to prevent burnout that results in turnover. To augment the workforce there should be a focus on increasing the number of

enrolled nursing students and retaining them through graduation, and on retaining new graduates and nurses at all stages of their professional careers.

Maintain older nurses and attract those who have left the national workforce, such as nurses otherwise employed or those who have retired, or attract nurses from other countries.

Recruitment efforts vary based on organizational needs, strategic goals, and competencies sought. Organizations are in constant battle to win over capable and qualified workers at all levels. This challenge often forces some organizations to differentiate themselves through recruitment incentives and pay strategies. However, decisions related to pay may negatively influence perception within and outside the specific area for jobs: these incentives included differentiated pay for the different departments, sign-on bonuses, and short-term housing allowances.

Retention Ways to enhance retention:

o Autonomy over practice decisions, e.g., part of the decision makingo Reasonable workloads and flexible schedulingo Provide continuing education for career developmento Competitive payo Measure satisfaction to keep abreast of employees’ needs and

expectationso Reward and recognitiono Empowero Work-life balanceo Create a culturally and ethnically diverse work placeo Improve technology and workflowo Decentralize work stations having everything in close proximity for staff to

access easily

Recruitment and retention issues dominate most discussions about the nursing shortage. The cost of staff turnover is immense and becomes a critical factor in the budgets of health care delivery systems, thereby introducing the opportunity for dialogue concerning work environment factors. The supply side of the equation must include creative and innovative solutions for attracting and keeping the nurses in the workforce. Replacement staff for nurses must be recruited and trained, and transitions are disruptive to work flow. Being able to predict the likelihood that nurses will leave their current employer and or the profession would benefit workforce planning at all levels.

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Human Resources Leadership and Management as applied to the nursing workforce

Different types of leadership styles exist in work environments. Advantages and disadvantages exist within each leadership style. The culture and goals of an organization determine which leadership style fits the firm best. Some companies offer several leadership styles within the organization, dependent upon the necessary tasks to complete and departmental needs. Five types of leadership styles are used in the day to day activity of a leader: Laissez-faire, Autocratic, Participative, Transactional, and Transformational.

Nurse leaders—including managers, administrators, advanced practice nurses, educators, and other formal and informal clinical leaders—seldom have the support resources commensurate with their scope of responsibilities and often do not have access to key decision-making forums within healthcare organizations. Nurse Managers in particular are key to the retention of satisfied nursing staff, yet they all too often receive little preparation, education, coaching, or mentoring to ensure success in their role. Nurse leaders must be skilled communicators, team builders, and agents for positive change who are committed to service, results oriented, and role models for collaborative practice.3 This requires skill in the core competencies of self-knowledge, strategic vision, risk taking and creativity, interpersonal and communication effectiveness, and inspiration.4 Healthy work environments require that individual nurses and organizations commit to the development of nurse leaders in a systematic and comprehensive way. Nurse leaders must be positioned within key operational and governance bodies of the organization in order to inform and influence decisions that affect nursing practice and the environment in which it is practiced.

Critical Elements of Authentic Leadership

The healthcare organization provides support for and access to educational programs to ensure that nurse leaders develop and enhance knowledge and abilities in skilled communication, effective decision making, true collaboration, meaningful recognition, and resources to achieve appropriate staffing.

Nurse leaders demonstrate an understanding of the requirements and dynamics at the point of care, and within this context successfully translate the vision of a healthy work environment.

Nurse leaders excel at generating visible enthusiasm for achieving the standards that create and sustain healthy work environments.

Nurse leaders lead the design of systems necessary to effectively implement and sustain standards for healthy work environments.

The healthcare organization ensures that nurse leaders are appropriately positioned to create and sustain healthy work environments. This includes

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participation in key decision-making forums, access to essential information, and the authority to make necessary decisions.

The healthcare organization facilitates nurse leaders in creating and sustaining a healthy work environment by providing the necessary time and the financial and human resources.

The healthcare organization provides a formal co-mentoring program for all nurse leaders. Nurse leaders actively engage in the co-mentoring program.

Nurse leaders model skilled communication, true collaboration, effective decision making, meaningful recognition, and authentic leadership.

The healthcare organization includes leadership contribution in creating and sustaining a healthy work environment as a criterion in each nurse leader’s performance appraisal. Nurse leaders must demonstrate sustained leadership in creating and sustaining a healthy work environment to achieve professional advancement.

Nurse leaders and team members mutually and objectively evaluate the impact of leadership processes and decisions on the organization’s progress toward creating and sustaining a healthy work environment.

The core of leadership also includes the ability to hire the right person through interviewing. Leaders should demonstrate core competencies, including coaching, performing disciplinary actions, following through with constructive feedback and progressive discipline. This includes potential termination when required due to consistent performance issues and non-responsiveness to coaching, feedback, and clear performance improvement plans.

Practices addressing the key areas of recruitment, training and development, compensation, performance management, and employer relations impact all organizations and define their failure or success. Research has presented guiding principles for developing human resource management practices. These practices include fairness and organizational support (Husin et al., 2012), flexibility that demonstrates an understanding of what makes workers happy, and a tenacity to attract and retain good employees, particularly the exceptional performers. Recruitment involves the activities that generate a pool of qualified applicants who have the desire to become part an organization. Staffing the organization is one of the most difficult, complicated aspects of human resource’s responsibilities, and inadequate or overstaffing can be costly (Rashmi, 2010).

Nurse leaders overseeing performance management are also tasked with maintaining employee relations and being actively involved with conflict negotiation and resolution.

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Performance Appraisals

Performance management involves establishing and implementing policies and procedures for planning, managing, and evaluating employee performance, as well as productivity improvement. A performance appraisal is a review and discussion of an employee’s performance of assigned duties and responsibilities. The appraisal is based on results produced by the employee in his/her job, not the employee’s personality characteristics. The appraisal measures skills and accomplishments with reasonable accuracy and uniformity. It provides a way to help identify areas to enhance performance and to help promote professional growth. It should not, however, be considered as the supervisor’s only communication tool. Open lines of communication through the year help to encourage effective working relationships. Each employee should receive a thoughtful and accurate appraisal with constructive feedback and a clear, concise development plan. The success of the process depends on the supervisor’s willingness to complete a constructive and objective appraisal and the employee’s willingness to respond to constructive suggestions and to work with the supervisor to reach future goals.

Concept of Performance appraisal: Appraisals are essential for the effective management and evaluation of staff performance. Appraisals assist in the development of organizational performance and service planning. They enable expectations and objectives to be agreed upon, and responsibilities and tasks to be delegated. Staff appraisals establish individual training needs, while enabling analysis and planning for organizational training needs. It is a method through which nurses skills can be assessed, with to the goal of improving these skills and providing the best patient care. The 5 R’s can be utilized to assist nurses to set goals that are Realizable, Relevant, Rational, Resourced, and Readily measureable.

Ways of performance appraising:

Merit pay theory: The merit pay systems focus on individual performance and seek to motivate employees to perform at a higher level by linking performance to monetary incentives. According to Schay & Fisher (2013), although some people believe pay is merely a “hygiene factor” or potential dissatisfier, research has shown that performance-contingent pay can be a powerful performance incentive because money can satisfy many different needs.

Pay for individual vs. collective performance: The principle of pay for performance involves providing monetary rewards through carefully designed compensation systems based on measures of performance within the control of participants (Schay & Fisher, 2013). Merit pay is based on individual performance. Typically, supervisors rate employee performance or contribution, and the ratings are translated into either pay points that are converted to dollars or a percentage of the employee’s pay. This is mostly used with nonexempt workers.

Success of Performance appraisals

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The success of the process depends on the supervisor’s willingness to complete a constructive and objective appraisal and on the employee’s willingness to respond to constructive suggestions and to work with the supervisor to reach future goals. Specifically, the nurse leader should focus on individual employees, teams, programs, processes, and the organization as a whole. It is also critically important to address individual and organizational performance matters necessary to properly create and sustain a healthy and effective results-oriented culture. An effective and consistent performance appraisal process raises individual performance, fosters ongoing employee and supervisor development, and increases overall organizational effectiveness.

C. Scenario/Case Study

1. Instructions

Describe a workplace problem requiring managerial intervention in a select health care setting.

2. Background to scenario

It has been determined that there is a need to shrink the actual budget due to institution wide budget cuts. One of the areas to be impacted will be staffing, which has been at its lowest in recent years. Nevertheless, analysis indicates that there will be staffing reduction based on the budget allocation. The determination must be made by the manager of the unit as to how she will accomplish budget cuts and reduce staff. Once the decision is final, the manager will determine the best way to complete the staff reduction: whether by decreasing two full time staff to part time or fully eliminating one full time position.

3. Actual scenario

While preparing the annual budget, a nurse manager is instructed to submit a plan that further decreases Intensive Care Unit (ICU) costs by 10%. Already behind on several other projects, the new manager is overwhelmed. Well aware that care by registered nurses is indispensable and intent on being fiscally responsible, the manager develops and submits a plan to discontinue evening clerical support and decrease nursing assistant hours. The director accepts the plan without question and asks the manager to inform the Intensive Care Unit staff. The manager relates the plan during an all-staff meeting in which he encounters significant negative nonverbal communication and very

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little spoken feedback. During the next week, tensions run high, rumors abound, 2 nurses resign, and morale reaches an all-time low.

4. Practical exercises (Questions pertaining to scenario)

Explain how you would accomplish this task in an efficient manner

D. Library1. Glossary of Terms

Word MeaningEthos The distinguishing character, sentiment, moral nature, or guiding

beliefs of a person, group, or institutionMagnet Designated hospital The Magnet Recognition Program recognizes health-care

organizations for quality patient care, nursing excellence, and innovations in professional nursing practice

Laissez-faire/”hands off” Manager provides little or no direction and gives staff as much freedom as possible, with all authority/powers given to staff who determine goals, make decision, and resolve problems on their own

Autocratic leadership Manager retains as much power and decision making authority as possible

Participative/Democratic leadership

Encourages staff to be a part of the decision making, and keeps staff informed about everything that affects their work

Transactional leadership Focuses on the role of supervision, organization, and group performance. Definitive and clear

Transformational leadership Creates and sustains a context that maximizes human and organizational capabilities

2. Recommended Readings a. Aiken, L. H., Cinioti, J., Sloane, D. M., Smith, H. L., Flynn, L.,

& Neff, S. (2011). The effect of nurse staffing and nurse education on patient deaths in hospitals with different nurse work environments. Medical Care, 49(12), 1047-1053 among urban hospital nurses.   Work and Occupations   24 (4)

b. American Nurses Association (ANA), (2014). ANA principles for nurse staffing (2nd ed.). Silver

c. Greene, J. (2005, March 14). What nurses want: Different generations, different expectations. Hospitals and Health Networks . www.hhnmag.com/hhnmag/hospitalconnect/search/article.jsp?

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dcrpath=HHNMAG/PubsNewsArticle/data/0503HHN_FEA_CoverStory&domain=HHNMAG

d. O’Neil, M., O. (2008). Human resource leadership: the key to improved results in health.

e. Agency for Healthcare Research and Quality. (2013, May). Module 7. Measuring and benchamarking clinical performance .

f. Center for Disease Control and Prevention. (2011). Performance management and quality improvement. Center for Disease Control and Prevention.

g. Sherman, R., (May 31, 2006). "Leading a Multigenerational Nursing Workforce: Issues, Challenges and Strategies". OJIN: The Online Journal of Issues in Nursing. Vol. 11, No. 2, Manuscript 2 DOI: 10.3912/OJIN.Vol11 No 02 Man 02 Spring, MD: Author

3. PowerPoints – recommended PowerPoints from other sitesN/A

4. Recommended videos from other sitesN/A

E. Evaluation (Multiple choice test)

1. Patients are added to a nurse’s assignment during a busy weekend because on-call staff is not available and back up plans do not exist to cover variations in patient census. All of the following except one is not an adverse situation due to staffing?

a. Patients are placed at risk for errorsb. Patients are placed at risk for injuryc. Nurses are happy, energetic, not angry, stay with organization,

resulting in staff turnoversd. Nurses leaving due to unsafe staffing

2. The standards for establishing and sustaining healthy work environments include all except:

a. Effective decision makingb. No on-call or float pool staffing teamc. Meaningful recognitiond. Appropriate staffing

3. Critical elements of appropriate staffing include all except:a. Health care organization staffing policies in place that support

the professional obligation of nurses to provide quality care b. The health care organization adopts technologies that

increases the effectiveness of nursing care deliveryc. The health care organization has a system in place that

facilitates team approach

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d. No team approach nor does it include technologies that increase effectiveness of care delivery

4. Which of the following does not apply to obtaining a sustained partnership among different generations:

a. Fully understanding the differences among generationsb. Improvement in nurse retention c. Effective organizational outcomes optimizationd. Not working in a unified manner

5. At the organizational level, nursing leadership needs to anticipate generational differences and provide a positive environment for new nurses of all generations in order to:

a. Prevent educational advancementb. Discourage staff nurses from understanding and respecting

coworkers of all generational groupsc. Obtain a commitment to common goals, delivery of safe and

high-quality patient care in a supportive and collegial environment

d. Increase fear and intimidation 6. The nursing graduates of this generation are individualistic in their

approach to work and do not align themselves with the ethos of being a member of a team. They manage their own time, set their own limits, and get their work completed without supervision:

a. Baby boomersb. The Veteransc. Generation d. Millennial generation

7. All of the below listed are essential to performance appraisal except:a. Effective management and evaluation of staff performanceb. Assist in the development of organizational performance and

service planningc. Does not apply to nursing because nurses are not appraised

for performanced. Enable expectations and objectives to be agreed upon,

establish individual training needs, and enable analysis and planning for organizational training needs

8. At the core of leadership is the ability to hire the right person through interviewing, to coach, to perform appraisals, to apply disciplinary actions, and to fire. Which of the following is not an essential function of a nurse leader?

a. Facilitatorb. Performance managementc. Training and developmentd. Indecisive

9. Which of these is not a form of reward for excellent performance:

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a. Merit pay theory and Reward for resultsb. Collective Performancec. Annual salary decrease d. Pay for performance structure

10. Performance appraisal is suitable for addressing all of the below mentioned except:

a. Poor performance and productivity improvement b. Acknowledging good performancec. Employee’s performance of assigned duties and

responsibilitiesd. Supervisors only communication tool

Answers: 1=C, 2=B, 3=D, 4=D, 5=C, 6=C, 7=C, 8=D, 9=C, 10=D

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Module 5. Quality Improvement and Culture of Safety

Lainey Kieffer

A. Module guide – describes what the module entails1. Objectives

a. Understanding the fundamentals of Quality Improvement (QI) and healthcare.

b. Adapting the basic principles of QI and incorporating into nursing management.

c. Identifying the basic tools to incorporate culture of safety for healthcare workers.

d. Addressing the culture of safety without fear of negative repercussions.

2. Module outline – brief description of each sectionThe U.S. Department of Health and Human Services along with the Health Resources and Services Administration (HRSA) has created an introduction to Quality Improvement (QI). Having a basic understanding of the principles will help you recognize the QI processes where you work. The Joint Commission (TJC), an independent accreditation and certification nonprofit of health care organizations in the United States, views QI as a collaboration of disciplines coming together to improve processes.

Assuring a culture of safety is a concern in health care worldwide. We are so focused on patient safety that our health care workers are over looked. By using evidence-based practices and incorporating Quality Improvement principles, healthcare providers can deliver superior patient care while also promoting a culture of safety for patients, families, and the healthcare team.

This module contains course work on Quality Improvement (QI) and Culture of Safety. There will be a case study involving staff to further improve patient safety and patient experience. Culture of safety is a global concern. Patient and employee safety are important aspects to quality improvement.

The simulation exercise will allow you to understand how to handle uncomfortable situations between different staff members while

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advocating the safety of patients. The case study will simulate real life situation that you may encounter while working in medicine.

Additional resources for obtaining more in depth understanding of these concepts will be presented throughout the module. There will also be an accompanying PowerPoint presentation available on the resource page.

3. Methodology- identifies learner strategiesIn this self-study module, the participant can learn at his/her own pace. However, there is a 12-week time limit for completion of the overall course.

a. Readings (All learning materials are available online and are accessible upon demand; although links to supplemental resources are provided, there are no professors or facilitators.)

b. PowerPoint presentationc. Scenario reviewd. Test (Participants will be required to earn a passing score in

the final exam for each module before continuing to the subsequent module.)

4. Time requirementsa. 12 hours

5. References

Agency for Healthcare Research and Quality. (2013, May). Module 7. Measuring and benchamarking clinical performance. Retrieved from Agency for Healthcare Research and Quality: http://www.ahrq.gov/professionals/prevention-chronic-care/improve/system/pfhandbook/mod7.htmlAgency for Healthcare Research and Quality. (2014). Uses of Quality Measures. Agency for Healthcare

Research and Quality.

Center for Disease Control and Prevention. (2011, June 11). Performance management and quality improvement. Retrieved from Center for Disease Control and Prevention: www.cdc.gov/stltpublichealth/performance/definitions.html

ECRI Institute. (2009). Culture of Safety. Plymouth Meeting, PA: ECRI Institute.

Glasgow, J. (2011). Introduction to Lean and Six Sigma approaches to quality improvement. National Quality Measures Clearinghouse.

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Health Resources and Services Administration. (2011). Quality Improvement. U.S. Department of Health and Human Services.

Health Resources and Services Administration. (2014). What are the key HRSA QI initiatives. U.S. Department of Helth and Human Services.

Institute for Healthcare Improvement. (2014). Involve patients in safety initiatives. Institute for Healthcare Improvement.

National Public Health Performance Standards. (2014, March 21). Strengthening systems improving the publics health . Retrieved from Center for Disease Control and Prevention

Occupational Safety & Health Administration. (2014). Healthcare. United States Department of Labor.

The Joint Commission. (2014). Core Measures Sets. The Joint Commission.

B. Topics1. Broad overview of topics to be covered

a. Identify and Define Terminology for QI and Culture of Safetyb. Quality Improvement (QI) programc. QI Initiatives (Health Resources and Services

Administration/The Joint Commission)d. Benchmarking , Standards, and Measurese. Audits/performance improvementf. Safety measures taken by nursesg. Involving patients in safety initiatives

2. Actual content (in PDF narrative form and ppt presentation with bullet points/speaker notes) including recommended readings for each section

Introduction:The purpose of this module is to educate the learner about quality improvement and culture of safety in health care. Quality improvement is used in other facets of business other than healthcare.

Definitions: Quality improvement:We will begin this module by Identifying and Defining Terminology. The Health Resources and Services Administration (HRSA) and Centers for Disease Control and Prevention (CDC) have their own definitions of Quality Improvement (QI) based on measurable improvement. HRSA defines QI as consisting of systematic and continuous actions that lead to measurable improvement in health care services and the health status of targeted patient groups (U.S.

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Department of Health and Human Services, 2011). The CDC uses the Plan-Do-Study-Act as a major model for QI. It refers to a continuous and ongoing effort to achieve measurable improvements in the efficiency, effectiveness, performance, accountability, outcomes, and other indicators of quality services or processes which achieve equity and improve the health of the community (CDC, 2011). This involves collaboration across disciplines coming together to improve processes. Throughout this module, QI’s will be discussed to see where improved processes can be placed to enhance the culture of safety. The Joint Commission (TJC) views QI as a as a collaboration of disciplines coming together to improve processes. There are two types of QI, Internal and External. Internal QI Measures quality improvement within an institution or system of care, and external QI measures quality improvement across institutions or systems of care. Culture of safety:Culture of safety encompasses patterns of behaviors in safety performance for both employees and patients. A safety culture can be considered as representing the workers’ understanding of the hazards in their workplace, and the norms and roles governing safe working are at the heart of a safety culture (Kagan, 2013). The Joint Commission has developed Core Measures along with the Centers for Medicare & Medicaid Services (CMS) to improve patient safety and outcomes. “In November 2003, CMS and The Joint Commission began to work to precisely and completely align these common measures so that they are identical. This resulted in the creation of one common set of measure specifications documentation known as the Specifications Manual for National Hospital Inpatient Quality Measures to be used by both organizations. The Manual contains common (i.e., identical) data dictionary, measure information forms, algorithms, etc. The goal is to minimize data collection efforts for these common measures and focus efforts on the use of data to improve the health care delivery process” (The Joint Commission, 2014). Please click on the link (The Joint Commission on Quality Improvement) to view the video.

Four key principles for a successful Quality Improvement program:According to the U.S. Department of Health and Human Services, there are two main aspects and four key principles for a successful Quality Improvement (QI) program. The two main aspects of a QI program are:

1. An organization commits to monitor, assess, and improve quality of healthcare

2. QI programs are cyclical, allowing organizations to continue seeking higher levels of performance to optimize care for patients and continuous improvement.

The four key principles are: 1. QI works as systems and processes2. Focus on patients3. Focus on being part of the team4. Focus on use of data (Health REsources and Services Administration, 2011).

a. QI works as systems and processesWhat are the major components of processes? What is done (what care is provided), and how is it done (when, where,

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and by whom is care delivered)? The chart below shows that the critical/clinical pathways can be mapped out to obtain specific outcomes. The resources or inputs are your people, infrastructure, materials (an example would be vaccines), information, and technology. This leads to your activities or processes. What is done and how is it done? This development depends on the QI project. Finally you have your results or your outputs and outcomes. These are the changes in behavior, health services that are delivered, the change in health status in patients, and patient satisfaction.

b. Focus on patientsWhat patient need must be met? What measure of quality can we use? These services can include:

Systems that affect patient access Care provision that is evidenced based Patient safety Support for patient engagement Coordination of care with other parts of the

team/health system Cultural competency Assessing health literacy Patient-centered communication.

c. Focus on being part of the teamQI is a team process that is most effective with a team approach. The process is complex and no single person knows all the dimensions of one issue. This is why we involve more than one discipline in the development of an effective QI process. These processes may require some creativity to build enthusiasm within the team, with team commitment especially important. This system is not only good for nursing, but also for other departments/ providers, direct health care, and patient access/wait times. Each member of the team should be an active and contributing member. It is also important that each team has effective infrastructure, leadership, policies, and procedures to facilitate the work.

d. Focus on use of dataData describes how well current systems are working, particularly when changes are applied. Documentation of successful performance is key to allowing for data to be collected. Baseline data which allows monitoring of

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procedural changes must be established. The use of data ensures improvements are sustained and allows for comparison to other sites. For example, quantitative data may be utilized to examine relationships between systems and identify information about patterns.

Plan, Do, Study, Act:Plan, do, study, act (PDSA) is a model cycle that forms the basis of most Quality Improvement (QI) activities. The Centers for Disease Control and Prevention (CDC) uses the PDSA model for their QI processes. It is an overview providing a framework for approaching a problem, but does not describe the best methods for solving the problem.

Plan the change to be implemented. The components of this section are objectives, predictions, plan to carry out the cycle (who, what, where, and when), and plan for the data collection.

Do – carry out the plan, document observations, and record data. Study – analyze the data, compare the results to the predictions, and summarize what

was learned. Act addresses what changes still need to be made, and what’s next. This is the time to

plan your next QI project.

Six Sigma:The Six Sigma approach, used across business environments, is also used in healthcare to enhance quality improvement (QI). It helps identify sources of variation and the potential sources of error in a process and work to reduce variation so the process can perform virtually error free (Glasgow, 2011). Six Sigma was first developed by Toyota Motor Company, but has evolved to be very effective in healthcare. For example, it has been used to reduce medication errors, improve hand hygiene compliance, and reduce catheter-related blood stream infections (Glasgow, 2011). Within the Six Sigma framework, the DMAIC process stands for Define, Measure, Analyze, Improve, and Control. This is an effective process for developing a QI program, but can also be complicated as it does involve a certification process. Increasingly, healthcare organizations are incorporating trainings such as Six Sigma as requirements for leadership development. This certification is also available to individuals through programs offered at local universities or private business corporations.

Quality Improvement Initiatives:This section has a reading assigned to it that you will find on slide 15 of the power point. The reading provided will review this topic in more detail. The quality improvement initiatives that the Health Resources and Services Administration and The Joint Commission have identified are as follows:

Clinical Quality Performance Measures Health Disparities Collaborative (HDC) Patient Safety and Clinical Pharmacy Services Collaborative (PSPC) HIV/AIDS Program Quality of Care

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Maternal and Child Health Bureau Collaborative (MCHB Collaborative)

Uses of Quality Measures: Standards and MeasuresQuality measures are used for three general purposes:

1. Quality improvement (QI)2. Accountability3. Research

Measuring clinical performance enables the practice/organization to track changes and improvements over time. Practice measures should be chosen based on identification of goals to track. When selecting performance measures, it is important to involve QI team, and they will establish how often data will be collected. Timelines should allow for change to be implemented and take effect. Collection of data should be generated frequently enough to show progress over time. When measuring performance, rates are generally used for the units of measure. The numerator indicates how many times the measure has been met, and the denominator indicates the number of opportunities to meet the measure (Agency for Healthcare Research and Quality, 2013).

Benchmarking in healthcare is “the continual and collaborative discipline of measuring and comparing the results of key work processes with those of the best performers in evaluating organizational performance” (Hughes, 2008). It is a process of comparing performance with external standards. It helps individuals and organizations better understand where performance falls in comparison to other benchmarked organizations. In this process, it is important to compare ‘apples to apples’ (Agency for Healthcare Research and Quality, 2013).

Internal benchmarking identifies best practices in an organization, compares best practices in the organization, and compares current practices across time (Hughes, 2008). Competitive (or external) benchmarking utilizes comparative data across organizations to evaluate performance and identify improvements that have been successful (Hughes, 2008). Benchmarking can often stimulate healthy competition.

Components of a culture of safety “Having a culture that supports and promotes safety efforts has been identified in healthcare and other industries as a key element in improving safety” (ECRI Institute, 2009). There are seven components to the culture of safety as follows:

1. Commitment to safety is articulated at the highest levels of the organization and translated into shared values, beliefs, and behavioral norms at all levels.

2. Necessary resources, incentives, and rewards provided by the organization allow this commitment to occur.

3. Safety is valued as the primary priority, even at the expanse of “production” or “efficiency.” and personnel are rewarded for erring on the side of safety even if they turn out to be wrong.

4. Communication between workers and across organizational levels is frequent and candid.

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5. Unsafe acts are rare despite high levels of production. 6. There is openness about errors and problems; they are reported when they do occur. 7. Organizational learning is valued; the response to a problem focuses on improving

system performance rather than on individual blame (ECRI Institute).

Safety measures taken by nursesSafety measures have always been a top priority for nursing. The two most important concepts that affect safety culture are

1. Error reporting 2. Disclosure of errors (ECRI Institute, 2009)

We are so focused on patient safety that sometimes the safety of our health care workers is overlooked. By using evidence based practice and Quality Improvement (QI), we can deliver superior patient care and take care of our employees. Commitment to safety is articulated at the highest levels of the organization and translated into shared values, beliefs, and behavioral norms at all levels. It takes commitment from the organization for safety to occur. It requires resources, incentives, and rewards provided by the organization for this commitment to occur. Safety is valued as the primary priority, even at the expanse of “production” or “efficiency,” and personnel are rewarded for erring on the side of safety even if they turn out to be wrong. Communication between workers and across organizational levels is frequent and candid. Unsafe acts are rare despite high levels of production. There is openness about errors and problems; they are reported when they do occur (ECRI Institute, 2009). Organizational learning is valued; the response to a problem focuses on improving system performance rather than on individual blame.

Nurses take safety measures with everything they do, such as hand hygiene, use of personal protective equipment, five rights to medication administration, patient identification, and core measures. The two most important concepts that affect safety culture are error reporting and disclosure of errors (ECRI Institute, 2009). A safety culture can be considered as representing the workers’ understanding of the hazards in their workplace. The norms and roles governing safe working are at the heart of safety culture (Kagan, 2013).

Involving patients in safety initiativesInvolving patients in safety initiatives is a key way to find errors in the system. Patients and families are often the best sources of information and can contribute to safety practices. Involving patients and families in multidisciplinary rounds, safety committees, and asking for their comments promotes a culture of safety. Questions and comments between patients and nurses can identify possible errors and potential solutions to the problem. Recommendations include having patients and families monitor compliance with safe practices (making sure nurses are identifying patients before administering medications).

Quality improvement (QI) and a culture of safety are important parts of healthcare. Patient safety is a priority in any organization. QI measures should be examined and reviewed on an ongoing basis to promote both quality care and a culture of safety throughout healthcare organizations, whether community clinics, private practices, hospitals, or major health systems.

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Nurses and particularly nurse leaders are critical to promoting an organizational culture that embraces quality improvement and a culture of safety for patients as well as the healthcare workforce.

C. Scenario/ Case Study1. Instructions

This module contains a scenario of a new safety program on hand hygiene that is being implemented by nursing administration to decrease infection rate in the hospital setting. Using this scenario, discuss the components of a Quality Improvement (QI) program and culture of safety.

2. Background to scenarioIt has been determined that hand hygiene is still a significant problem in the hospital and new protocols need to be set in place. Nursing administration needs to establish a QI program for the new hand hygiene project. They would like to incorporate culture of safety into this program.

3. Actual scenarioNursing administration is concerned about hand hygiene and adherence to the current guidelines. They have noticed a rise in hospital-acquired infections and must investigate whether it is due to hand hygiene. The hospital would like to pilot a new way to remind all staff members to wash their hands. They have given a monitor to each staff member to track how often they wash their hands or use hand sanitizer.

4. Practical exercises (Questions pertaining to scenario)Using the key principles for a successful QI program, how would you create a QI program based on the new hand hygiene monitors? Since infection control is part of patient safety, how would the components of culture of safety be incorporated to increase compliance? Explain how you would incorporate the QI and Culture of Safety program objectives into this scenario.

D. Library1. Glossary of Terms

a. Benchmarking – in healthcare, defined as the continual and collaborative discipline of measuring and comparing the results of key work processes with those of the best performers in evaluating organizational performance

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b. Culture of Safety – multiple definitions (please refer to PowerPoint presentation)

c. Numerator – indicates how many times the measure has been met

d. Denominator – indicates the opportunities to meet the measure

e. External Quality Improvement– Measures quality improvement across institutions or systems of care

f. Internal Quality Improvement- Measures quality improvement within an institution or system of care

g. Qualitative Data - satisfaction surveys (patient and staff)h. Quantitative data - looks at relationships between systems

and information about patternsi. Quality Improvement – multiple definitions (please refer to

PowerPoint presentation)

2. Recommended Readings a. Institute of Medicine. Crossing the Quality Chasm: A New

Health System for the 21st Century . Washington, D.C.: National Academy, 2001.

b. Health Resources and Services Administration. "What Are the Key HRSA QI Initiatives?" Health Resources and Services Administration . U.S. Department of Health and Human Services. Web. 2014.

3. PowerPoints – recommended power points from other sites4. Recommended videos from other sites

a. Quality and safety resources – TJC - http://www.jointcommission.org/multimedia/quality-and-safety-resources-for-joint-commission-customers/default.aspx

E. Evaluation (Multiple choice test)

1. What are the four key principles for a successful Quality Improvement (QI) program?

a. Focus on patients, focus on being part of the team, focus on the use of data, QI work as systems and processes

b. QI work as systems and processes, focus on patients, focus on being part of the team, focus on the use of data

c. Focus on the use of data, QI work as systems and processes, focus on patients, focus on being part of the team

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d. QI work as systems and processes, focus on patients, focus on the use of data, focus on being part of the team

2. How many QI initiatives are established with the Health Resources and Services Administration (HRSA) and The Joint Commission on Accreditation of Health Care Standards (TJC)?

a. 3b. 4c. 5d. 6

3. What is the continual and collaborative discipline at measuring and comparing the results of key work processes?

a. Benchmarkingb. Internal benchmarkingc. External benchmarking

4. What is a framework for approaching a problem, but does not describe the best method for solving the problem?

a. Plan, do, study, act (PDSA)b. Six-Sigmac. DMAIC

5. Committing to the safety at the highest level of the organization using the necessary resources, incentives, and rewards provided by the organization that allow this commitment to occur is part of

a. Culture of Safetyb. Quality Improvementc. Six-Sigmad. Plan, do, study, act (PDSA)

6. What are the two most important concepts that affect safety culture?a. Hand Hygieneb. Core measures and patient identificationc. Error reporting and disclosure of errorsd. Work place hazards

7. How many steps is the PDSA model?a. 2b. 3c. 4d. 5

8. What kind of process is quality improvements?a. Leadership process

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b. Team processc. Individual processd. Patient and staff process

9. What kind of data focuses on the patients and staff?a. Numeratorb. Quantitative datac. Denominatord. Qualitative data

10. How many steps is the Six Sigma model?a. 7b. 9c. 11d. 13

Answers: 1=B, 2=D, 3=A, 4=A, 5=A, 6=C, 7= C, 8=B, 9=D, 10=C

Module 6. Evidence Based ResearchAnna Lisa Chery

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A. Module Guide – describes what the module entails

This module explains the foundation on which nursing knowledge is established and practice decisions are made. In addition, it highlights the importance of and barriers to applying nursing research in clinical practice. Furthermore, it describes the process of evidence based practice and the models used by nurses to translate evidence into nursing care. The purpose of the module is to educate nurses from all levels on the significance of incorporating proven practices into the provision of health care. Moreover, it intends to inspire nurses to participate in evidence based research as an approach to finding answers to clinical questions and integrating the findings into clinical practice.

1. ObjectivesAt the end of the module, the student will be able to:

a. Explain the foundation for research and knowledge development in nursing

b. Identify and define terminology related to nursing researchc. Identify the importance of and barriers to Evidence Based

Practice in nursingd. Describe the process of Evidence-Based Practice in nursinge. Identify four Evidence-Based Practice models used in nursing

2. Module Outline– brief description of each sectiona. Foundation for research and knowledge development in

nursing b. Definition of Nursing Researchc. The importance of and barriers to Evidence Based Practice in

nursingd. Definition of Evidence-Based Practice (EBP)e. The steps in the EBP processf. Evidence-Based Practice Models in nursing

The Johns Hopkins Evidence-Based Practice Model ACE Star Model of Knowledge Transformation Iowa Model of Evidence-Based Practice to Promote

Quality Care Rosswurm and Larrabee Model of Evidence-Based

Practiceg. Additional resourcesh. Exam

3. Methodology- identifies learner strategies

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In this self-study module, the participant can learn at his/her own pace. However, there is a 12-week time limit for completion of the overall course.

a. Readings (All learning materials are available online and are accessible upon demand; although links to supplemental resources are provided, there are no professors or facilitators.)

b. PowerPoint presentationc. Scenario reviewd. Test (Participants will be required to earn a passing score in

the final exam for each module before continuing to the subsequent module.)

4. Estimated Time Requirementa. 12 hours

5. ReferencesBurns, N., & Grove, S. K. (2005). The practice of nursing research:

Conduct, critique, and utilization (5th ed.). St. Louis, MO: Elsevier

Mosby

Burns, N., & Grove, S. K. (2001). Understanding nursing research:

Conduct, critique, and utilization (4th ed.). St. Louis, MO: Elsevier

Mosby

Grinspun, D., Virani, T., & Bajnok, I. 2001/2002. Nursing best practice

guidelines: The RNAOproject. Hospital Quarterly , 4(2) 54-58

Melnyk, B. & Fineout-Overholt, E. (2011). Evidence-based practice in

nursing & healthcare: a guide to best practice (2nd ed.) Wolters

Kluwer/ Lippincott Williams & Wilkins

Newhouse, R.P., Dearholt, S.L., Poe, S.S., Pugh, L.C., White, K.M. (2007).

Johns Hopkins nursing evidence-based practice model and

guidelines. Indianapolis, IN: Sigma Theta International

Nieswiadomy, R.M.(2007). Foundations of nursing research (5th ed)

Pearson Prentice Hall

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Omery, A., & Williams, R.P. (1999). An appraisal of research utilization

across the United States. Journal of Nursing Administration , 29(12),

50-56

Rosswurm, A., & Larrabee, J.H., (1999). A model for change to evidence-

based practice. Image: Journal of Nursing Scholarship , 31(4), 317-

322 doi: 10.1111/j.1547-5069.1999.tb00510.x

Sackett, D.L., Rosenberg, W., Gray, J.A., Haynes, R. B., Richardson, W.S.

(1996). Evidence-based medicine-What it is and what it isn’t. BMJ .

312(7023):71-72 doi: 10.1136/bmj.312.7023.71

Sackett, D. L., Strauss, S. E., Richardson, W. S., Rosenberg, W., &

Haynes. R. B. (2000). Evidence based medicine: How to practice and

teach EBM. Edinburgh, Scotland: Churchill

Stevens, K. R. (2012). ACE Star Model of EBP: Knowledge

Transformation. Academic Center for Evidence-Based Practice. The

University of Texas Health Science Center San Antonio.

Stevens, K. (2013). The impact of evidence-based practice in nursing

and the next big ideas. The Online Journal of issues in Nursing .

18(2):4 doi: 10.3912/OJIN.Vol18No02Man04

Titler, M.G., Kleiber, C., Steelman, V.J., Rakel, B., Budreau, G., & Everett,

L. et al (2001). The iowa model of evidence-base practice to

promote quality care. Clinical Care Nursing Clinics of North America

13(4): 497-509 Retrieved from

http://www.ncbi.nlm.nih.gov/pubmed/11778337

B. Topics1. Broad overview of topics to be covered

The following topics will be covered in this module:a. The foundation on which knowledge is established and

practice decisions are made in nursingb. The definition of Nursing Researchc. The importance of and barriers to Evidence Based Practice in

nursingd. The different definitions of Evidence-Based Practice

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e. The process of Evidence-Based Practice f. The Evidence-Based Practice Models used in nursing

The Johns Hopkins Evidence-Based Practice Model ACE Star Model of Knowledge Transformation Iowa Model of Evidence-Based Practice to Promote

Quality Care Rosswurm and Larrabee Model of Evidence-Based

Practice

2. Evidence Based Research

“Knowing is not enough; we must apply. Willing in not enough, we must do.”-Johann Wolfgang von Goethe

Foundation for Research and Knowledge Development in NursingAs our health care system is evolving, nurses play a vital role in improving the quality of health care. Nurses are not just task-oriented health care personnel, but professionals who use their knowledge, skills, and clinical judgment and decisions to care for patients. The unique body of knowledge of the nursing profession is crucial to the health care system, as it is necessary for the improvement and efficiency of care. The identification of the knowledge base for nursing practice contributes to achieving better patient outcomes and making practice credible. Nurses have used multiple sources of knowledge to guide nursing practice. These sources include tradition, authority, borrowing, trial and error, personal experience, role modeling and mentorship, intuition, reasoning, and research (Burns & Grove, 2001). Although nursing knowledge is multifaceted, scientific research has proven to be the most objective and reliable source of knowledge (Nieswiadomy, 2007). Definition of Nursing Research- Nursing research is “a scientific process that validates and

refines existing knowledge and generates new knowledge that directly and indirectly influences nursing practice” (Burns & Grove, 2001 p.4). Nursing research is important in the delivery of health care, as it provides a foundation on which to make clinical practice decisions. Evidence from research can be utilized to make clinical decisions and guide care. For example, a nurse can use evidence from research to help determine the best treatment for a patient’s wound care. Therefore, it is essential for nurses to be informed on the latest research findings in order to provide the most up-to-date care for their patients. Moreover, nurses from all levels, especially those at the bedside, need to actively participate in the research process as their roles are central to patient care.

Research-Practice Gap- Nursing research is essential for the profession in building the scientific foundation for clinical practice. However, the application of research into practice continues to be a challenge. One may ask, if the research studies are available, why are nurses not utilizing the findings to improve patient care? Many factors contribute to the insufficiency in research utilization. First, educational preparation of nurses can influence their interest in research. The literature has suggested that the greater the level of

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education of a nurse, the greater the chance of using research in practice (Omery & Williams, 1999). Second, the attitudes and beliefs of nurses or organizations can influence the use of research. A negative attitude about research can be a barrier to incorporating the evidence into clinical practice (Omery & Williams, 1999). Third, support and resource availability can be an obstacle to incorporating research into practice. For example, lack of support from nursing leadership, access to research materials, and computer literacy can influence the use of research findings. In order to increase the body of knowledge for the nursing profession, it is imperative for nurses to overcome these individual and organizational barriers.

Evidence-Based Practice- Evidence Based Practice (EBP) has been gaining momentum since the mid 1990’s as an approach to bridge the gap between research and practice. The EBP movement started with nurses recognizing a need to translate their knowledge into a form that can be used in clinical settings to achieve better patient outcomes (Stevens, 2013). It is important for nurses to know about evidence based practice in order to close the research practice gap, keep current on the latest research, and prevent nurses from using outdated information in patient care. The goal of evidence based practice in nursing is to provide nurses with the best evidence based information, resolve problems in the clinical setting, minimize variations in nursing care, achieve excellence in care delivery, and introduce innovation (Grinspun, Virani, & Bajnok, 2001/2002).

Definition of Evidence-Based Practice - Evidence-based practice (EBP) has many definitions. Although these definitions share many similarities, each adds another aspect to the concept of EBP. The most common definitions are the following:

o (a) The conscientious integration of best research evidence with clinical expertise and patient values and needs in the delivery of quality, cost-effective health care (Burns & Grove, 2005, p. 736);

o (b) The conscientious, explicit, and judicious use of current best evidence in making decisions about the care of the individual patient (Sackett, 1996);

o (c) A problem solving approach to clinical practice and administrative issues that integrates: 1) a systematic search for and critical appraisal of the most relevant evidence to answer a burning clinical question; 2) one’s own clinical expertise; 3) patient preferences and values (Melnyk, & Fineout-Overholt, 2011).

Process of Evidence Based Practice (EBP)

Evidence based practice consists of 7 steps that range from step 0 to step 6:

Step 0: Cultivate a spirit of inquiryStep 1: Ask the burning clinical question in the PICOT formatStep 2: Search for and collect the most relevant best evidenceStep 3: Critically appraise the evidence

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Step 4: Integrate the best evidence with one’s clinical expertise and patient preferences and values in making a practice decision or changeStep 5: Evaluate outcomes of the practice decision or change based on evidenceStep 6: Disseminate the outcomes of the EBP decision or changeFigure 1: Melnyk, & Fineout-Overholt, 2011

Step 0: Cultivate a spirit of inquiryA spirit of inquiry is an essential foundation for evidence based practice. In other words, nurses must have a curious mind before initiating any research effort. This means that the nurse must possess an attitude of inquiry in which he or she is comfortable with asking questions regarding clinical issues. In addition to having a spirit of inquiry, another essential foundation to EBP is having a supportive organizational culture. Nurses are more likely to be intimidated about asking question in a culture that does not support a spirit of inquiry. Therefore, a culture of EBP must be cultivated to encourage nurses to ask clinical questions of interests. The following provides an overview of the steps involved:

Step 1: Ask the burning clinical question in the PICOT formatOnce the clinical question is generated, it should be formulated using the PICOT format. Using this format leads to a more effective search for evidence and the most current and relevant information. PICOT stands for:

o P= Patient population or problem: Who is the patient (Disease or health status, age, ethnicity, gender)?

o I= Intervention or interest area: What do you plan to do for the patient? (Specific tests, therapies, medications)

o C= Comparison intervention or group: What is the alternative to your plan? (i.e. no treatment, different type of treatment, etc.)

o O= Outcome: The clinical outcome of interest (i.e. fewer symptoms, no symptoms, full health, etc.)

o T= Timeframe to determine an outcome (This element is not always included)

This is an example of a clinical question in the PICOT format:In adult patients with total hip replacement (P), how effective is early ambulation (I) compared to bed rest (C) on decreasing post-op Deep Vein Thrombosis (O)?

Step 2: Search for and collect the most relevant best evidence

After the clinical question has been formulated, a search of the literature should be conducted in an effort to find relevant information. This process starts by entering key words or phrases from the PICOT question into electronic databases such as MedLine, PubMed, or Cumulative Index of Nursing and Allied Health Literature (CINAHL). Then the results of the search should be rated to determine the strongest level of evidence. There are 7 levels of evidence, with a level 1 being the strongest quality of evidence and level 7 being the weakest quality of evidence (Melnyk & Fineout-Overholt, 2011).

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Level 1 - Systematic review & meta-analysis of randomized controlled trials; clinical guidelines based on systematic reviews or meta-analysesLevel 2 - One or more randomized controlled trialsLevel 3 - Controlled trial (no randomization)Level 4 - Case-control or cohort studyLevel 5 - Systematic review of descriptive & qualitative studiesLevel 6 - Single descriptive or qualitative studyLevel 7 - Expert opinionFigure 2: Melnyk & Fineout-Overholt, 2011

Step 3: Critically appraise the evidence

Once the articles are selected for review, the next step is to conduct a rapid critical appraisal. This will determine the research studies that are most relevant, valid, reliable, and applicable to the clinical question. There are 3 key general critical appraisal questions that should be answered (Melnyk & Fineout-Overholt, 2011):

1. Are the results of the study valid? (Validity)- For the results to be considered as valid, they must be close to the truth, and the study must have been conducted using the best available research methods.

2. What are the results? (Reliability) – For example, in an intervention study, this includes whether the intervention worked, the size of the effect, and whether a clinician could expect to obtain similar results if the study were repeated in their own clinical practice setting.

3. Will the results help me in caring for my patients? (Applicability) – The third question of the appraisal process includes the following: (a) the subjects in the study are similar to the patients being cared for; (b) the benefits outweigh the risks of treatment; (c) the study is feasible to implement; (d) the patient desires the treatment.

The answers to these 3 questions provide the researcher the opportunity to make informed decisions about the quality of evidence. Besides, it confirms the relevance and transferability of the evidence to the patient population to whom care is being provided.

Step 4: Integrate the best evidence with one’s clinical expertise and patient preferences and values in making a practice decision or change

The evidence alone cannot determine a need for practice change. To decide whether a practice change is to be made, the evidence needs to be integrated with clinician expertise and patient preference and values.

Step 5: Evaluate outcomes of the practice decision or change based on evidence

After the implementation of the practice change, it is essential to evaluate the result to determine positive outcome from the Evidence-Based Practice (EBP) change.

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Step 6: Disseminate the outcomes of the EBP decision or change

The last step of the EBP process is to share the outcome of the practice change with others if positive outcomes are achieved. It is important to share the result so that others can benefit. Some of the methods that can be used to disseminate the results include presentations at conferences, journal and newsletter publications, and rounds within their own institutions (Melnyk, B. & Fineout-Overholt, E., 2011).

Evidence-Based Practice Models in Nursing

The use of evidence-based research to transform clinical practice can be complex and challenging. In order to facilitate the process, nurses have developed numerous models to guide evidence based practice in an organized approach. Currently, the literature has documented various models to assist with the implementation of evidence into practice. This section will provide an overview of four models that are recognized internationally to change practices based on evidence. The four models include:

1. The Johns Hopkins Evidence-Based Practice Model2. ACE Star Model of Knowledge Transformation3. Iowa Model of Evidence-Based Practice to Promote Quality Care4. Rosswurm and Larrabee Model of Evidence-Based Practice

Johns Hopkins Nursing Evidence-Based Practice Model

Johns Hopkins Nursing Evidence-Based Practice Model (JHNEBPM) was designed to help nurses translate evidence into practice. The model consists of three phases: Practice Question, Evidence, and Translation (PET). The phases are subdivided into different steps (Newhouse, Dearholt, Poe, Pugh, & White, 2007). Figure 3 depicts the steps of the JHNEBPM process:

Johns Hopkins Nursing Evidence-Based Practice ModelPractice Question, Evidence, and Translation (PET)

PRACTICE QUESTION

Step 1: Recruit interprofessional team

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Step 2: Develop and refine the EBP questionStep 3: Define the scope of the EBP question and identify stakeholdersStep 4: Determine responsibility for project leadershipStep 5: Schedule team meetings

EVIDENCE

Step 6: Conduct internal and external search for evidenceStep 7: Appraise the level and quality of each piece of evidenceStep 8: Summarize the individual evidenceStep 9: Synthesize overall strength and quality of evidenceStep 10: Develop recommendations for change based on evidence synthesis

Strong, compelling evidence, consistent results Good evidence, consistent resultsGood evidence, conflicting resultsInsufficient or absent evidence

TRANSLATIONStep 11: Determine fit, feasibility, and appropriateness of recommendation(s) for translation pathStep 12: Create action planStep 13: Secure support and resources to implement action planStep 14: Implement action planStep 15: Evaluate outcomesStep 16: Report outcomes to stakeholdersStep 17: Identify next stepsStep 18: Disseminate findingsFigure 3 © The Johns Hopkins Hospital/Johns Hopkins University. May not be used or reprinted without permission.

ACE Star Model of Knowledge TransformationThe ACE Star Model of Knowledge Transformation was developed by Dr. Kathleen Stevens at the University of Texas School of Nursing to translate evidence into practice. The model depicts five points or stages through which research knowledge must progress as newly discovered knowledge is moved into practice (Stevens, 2004).

Five major stages of the ACE Model of Knowledge Transformation:Star point 1. Knowledge DiscoveryStar point 2. Evidence SummaryStar point 3. Translation into guidelinesStar point 4. Integration into practiceStar point 5. Evaluation of process and outcomeFigure 4: Stevens, 2004

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Figure 4: Copyrighted material (Stevens, 2012). Reproduced with expressed permission

Iowa Model of Evidence-Based Practice to Promote Quality CareThe Iowa Model of Evidence-Based Practice to Promote Quality Care was developed by Marita Titler at the University of Iowa Hospitals and Clinics. The model describes seven essential steps to move research evidence into practice with the goal of improving the quality of care (Titler, et al., 2001).

Seven steps of Iowa Model of Evidence- Based Practice to Promote Quality Care:Step 1: Selection of a topicStep 2: Forming a teamStep 3: Evidence RetrievalStep 4: Grading the evidenceStep 5: Developing an EBP standardStep 6: Implement the EBPStep 7: Evaluation

Figure 6: Titler el al, 2001

Rosswurm and Larrabee Model of Evidence-Based PracticeRosswurm and Larrabee’s Model was designed to guide nurses and healthcare professionals through a systematic process for the change to evidence-based practice. The model consists of six steps (Rosswurm & Larrabee, 1999).

Six steps of Rosswurm and Larrabee Model:Step 1: Assess the need for change in practiceStep 2: Link the problem with interventions and outcomesStep 3: Synthesize the best evidence

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Step 4: Design a change in practiceStep 5: Implement and evaluate the practiceStep 6: Integrate and maintain the practice change

Figure 7: Rosswurm & Larrabee, 1999

SummaryResearch is the foundation on which nursing knowledge is established and practice decisions are made. Evidence from research can be utilized to make clinical decision and guide care. However, applying nursing research into clinical practice remains a challenge in today’s health care. In order to provide quality care, evidence based practice is a formal method used by nurses to close the gap between research and practice. With the challenges and complexity of changing clinical practice, nurses have developed numerous models to guide the implementation of evidence into practice. Nurses from all levels are encouraged to be educated on the skills and knowledge of incorporating the best evidence into the provision of nursing care in order to assure quality care to their patients.

C. Scenario/Case Study1. Instructions

Read the scenario and answer the questions that follow2. Background to Scenario

You are a nurse manager in a long term care facility. For the last 12 months, you have observed an increase in incidence of falls among the elderly population. Although the facility has a fall protocol in place, the screening tool has been ineffective in identifying the patients that are at high risk for falling. In order to address this safety issue, you have decided to revise and change the current practice by identifying an effective evidence based fall risk screening tool. This fall risk indicator will assist nurses in identifying patients that are at risk for falls in order to intervene appropriately.

3. Actual scenarioThe Iowa Model of Evidence-Based Practice (EBP) to Promote Quality Care has been selected as a framework to guide the EBP project. After formulating the clinical question, you developed an interdisciplinary team to collect and appraise the evidence. Then the assigned team members conducted a review of the literature to identify fall risk tools in long term care settings. After retrieving and appraising the evidence, a new tool was selected to identify patients that are at risk for fall. Then the team developed a clinical guideline with the new tool to pilot the change in practice over the next 3 months. After the pilot study was completed, the result has been evaluated to measure the outcome of the practice change.

4. Practical exercises

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1. Formulate a clinical question in a PICO or PICOT format based on the above scenario

2. What key words or phrases from the clinical question you would use to conduct your search?

3. Identify an issue you may see in your nursing practice that raises a question for you. Discuss the steps you would take to answer the question using the Iowa model.

D. Library

1. Glossary to terms

Evidence-Based Practice (EBP): The conscientious integration of best research evidence with clinical expertise and patient values and needs in the delivery of quality, cost-effective health careNursing Research: A scientific process that validates and refines existing knowledge and generates new knowledge that directly and indirectly influences nursing practicePilot Study: A smaller version of a proposed study conducted to develop or refine methodology, such as treatment, instruments, or data collection process to be used in a larger study

2. Recommended Readings a. Stevens, K. (2013). The impact of evidence-based practice in

nursing and the next big ideas. The Online Journal of issues in Nursing. 18(2):4 doi: 10.3912/OJIN.Vol18No02Man04

3. Powerpoints- recommended power points from other sitesa. http://www.powershow.com/view/3bc8c1-YjMzY/

Evidence_based_practice_evidence_based_nursing_EBP_EBN_powerpoint_ppt_presentation

4. Recommended videos from other sitesa. http://www.youtube.com/watch?v=me7BDrpiLd4 b. http://www.youtube.com/watch?v=blpv7xD3nsw

E. Evaluation (Multiple choice test)1. The most objective and reliable source of nursing knowledge is:

a. Traditionb. Scientific researchc. Authorityd. Intuition

2. Nursing research is defined as:a. A process of appraising the evidenceb. A scientific process that validates and refines existing

knowledge and generates new knowledge that directly and indirectly influences nursing practice

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c. A scientific process that influences nursing knowledged. A scientific process used by nurses to formulate a clinical

question3. One of the factors that contributes to a lack of research utilization is:

a. Nursing shortage b. Lack of research availability c. Negative attitudes about researchd. Lack of scientific knowledge

4. Which one of the following is not a goal of evidence based practice?a. Resolve problems in the clinical settingsb. Achieve excellence in care deliveryc. Provide nurses with the best evidence based informationd. Provide leadership in nursing

5. The definition of evidence based practice includes the following except:

a. Patients preferences and valuesb. Disseminate the outcomesc. Clinical expertised. Systematic search for and critical appraisal of the most

relevant evidence to answer a burning clinical question6. The following elements are essential foundations for nurses in order

to participate in evidence based practice (EBP):a. A spirit of inquiry and EBP cultureb. Validity and reliabilityc. Expert opinion and patient preferencesd. Controlled studies and systematic review

7. The PICOT format is used to: a. Formulate a clinical questionb. Collect the evidencec. Appraise the evidenced. Evaluate the outcomes

8. The purpose of the critical appraisal of the evidence is to determine:a. Validity, reliability, quality studiesb. Validity, applicability, guidelinesc. Validity, resources, translationd. Validity, reliability, applicability

9. EBP models were developed to:a. Guide nurse with the EBP process in an organized approachb. Determine the need for practice changec. Search for the evidenced. Demonstrate the outcomes

10. The Johns Hopkins Nursing Evidence Based Practice model includes the following phases except:

a. Translation

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b. Evidencec. Practice Questiond. Change in practice

Answers: 1=B, 2=B, 3=C, 4=D, 5=B, 6=A, 7=A, 8=D, 9=A, 10=D

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Module 7. Intra and Interprofessional Collaboration: Full Partners

Salma Hernandez

A. Module guide 1. Objectives

a. Identify and define key terminology & concepts related to intra/interprofessional collaboration

b. Discuss the history and application of critical team conceptsc. Discuss effective communication strategies that the nurse

leader can implement within an interdisciplinary team to improve patient health outcomes

d. Examine the ethical standards and professional values of effective teams

e. Identify traits shared by high performing teams2. Module outline– brief description of each section

a. Basics of Team Building Definition of teamwork The essential components of a team Identify effective team structures

b. Definition and Operationalization of Critical Team Concepts Leadership Communication Situation Monitoring Mutual Support Negotiation and Conflict Resolution

c. High Performing Teams Shared traits and efficiencies Innovative models and strategies

o Crew Resource Managemento Team STEPPS

d. Case Study/Scenario Instructions Background to scenario Actual scenario Practical Exercises

e. Evaluation

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3. Methodology- identifies learner strategiesIn this self-study module, the participant can learn at his/her own pace. However, there is a 12-week time limit for completion of the overall course.

a. Readings (All learning materials are available online and are accessible upon demand; although links to supplemental resources are provided, there are no professors or facilitators.)

b. PowerPoint presentationc. Scenario reviewd. Test (Participants will be required to earn a passing score in

the final exam for each module before continuing to the subsequent module.)

4. Time requirementsa. 12 hours

5. References

Agency for Healthcare Research and Quality. (2014). TeamSTEPPS 2.0:

Core curriculum. Retrieved, 2014, Retrieved from

http://www.ahrq.gov/professionals/education/curriculum-tools/teams

tepps/instructor/index.html

Anthony, R. N., & Govindarajan, V. (2006). Management control systems

(12th ed.). New York: Mcgraw Hill College.

Baker, D. P., Day, R., & Salas, E. (2006). Teamwork as an essential

component of high-reliability organizations. Health Services Research,

41 , 1576-1598. doi:10.1111/j.1475-6773.2006.00566.x

Eisler, R., & Potter T.M. (2014). Transforming interprofessional

partnerships: A new framework for nursing and partnership-based

health care (1st ed.). Indianapolis: Sigma Theta Tau International.

Institute for Healthcare Improvement. (2014). Teamwork and

communication. Retrieved, 2014, Retrieved from

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http://www.ihi.org/education/WebTraining/OnDemand/TeamworkCo

mmunication/Pages/default.aspx

Interprofessional Education Collaborative Expert Panel. (2011). Core

competencies for interprofessional collaborative practice: Report of an

expert panel. (). Washington D.C.:

Mitchell, P., Wynia, M., Golden, R., McNellis, B., Okun, S., Webb, C. E., Von

Kohorn, I. (2012). Core principles & values of effective team-based

health care: Discussion paper. Washington D.C.: Institute of Medicine.

Morey, J. C., Simon, R., Jay, G., Wears, R. L., Salisbury, M., & Dukes, K. A.

(2002). Error reduction and performance improvement in the

emergency department through formal teamwork training:

Evaluation results of the MedTeams project . Health Serv.Res., 37 (6),

1553-1508.

Pizzi, L., Goldfarb, N., & Nash, D. (2001). Crew resource management and

its application in medicine. UCSF-Stanford Evidence Based Practice

Center, 501-509.

Salas, E., Wilson, K. A., Murphy, C. E., King, H., & Salisbury, M. (2008).

Communicating, coordinating, and cooperating when lives depend on

it: Tips for teamwork. Joint Commission Journal on Quality & Patient

Safety, 34 (6), 333-341.

Sexton, J., Thomas, E., & Helmreich, R. (2000). Error, stress, and teamwork

in medicine and aviation: Cross sectional surveys. BMJ, (320), 745-749.

The Joint Commission. (2014). Sentinel event data: Root causes by event

type 2004 – 2013. Retrieved, 2014, Retrieved from

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http://www.jointcommission.org/assets/1/18/Root_Causes_by_Event

_Type_2004-2Q2013.pdf

White, M., Joe, Gutierrez, A., McLaughlin, C., Eziakonwa, C., Newman, L.,

Stephens, White, M., Asselin, G. (2013). A pilot for understanding

interdisciplinary teams in rehabilitation practice. Rehabilitation

Nursing, 38 (3), 142-152. doi:10.1002/rnj.75

World Health Organization (WHO). (2009). Human factors in patient safety,

review of topics and tools:Report for methods and measures working

group of WHO patient safety ( No. WHO/IER/PSP/2009.05).

Wright, M. C., Taekman, J. M., & Endsley, M. R. (2004). Objective measures

of situation awareness in a simulated medical environment. Quality &

Safety in Health Care, 13 Suppl 1 , i65-i71.

B. Topics1. Broad overview

The face of healthcare is changing on a global scale. Patients’ lives often depend on the functional status of the healthcare team (Salas, Wilson, Murphy, King, & Salisbury, 2008). To provide high quality care, healthcare professionals must learn to work in multidisciplinary teams that promote inter-professional collaboration (White et al., 2013). This requires the development of team building skills. Implementation of good teamwork and communication strategies amongst healthcare personnel ensures patient safety and improved outcomes. The purpose of this module is to outline the basics of team building, define and operationalize critical team concepts, and describe the characteristics of high performing teams.

2. Actual content

Basics of Team Building: Definition of Teamwork - According to the World Health Organization (WHO), teamwork “is a dynamic process

involving two or more people engaged in the activities necessary to complete a task” (World Health Organization (WHO), 2009).

The American Association of Colleges of Nursing, American Association of Colleges of Osteopathic Medicine, American Association of Colleges of Pharmacy, American Dental Education Association, Association of American Medical Colleges, and Association of Schools

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of Public Health, henceforth known as the Interprofessional Education Collaborative, joined forces in 2011 to develop core competencies for interprofessional collaborative practice. They defined interprofessional teamwork as “the levels of cooperation, coordination and collaboration characterizing the relationships between professions in delivering patient-centered care” (Interprofessional Education Collaborative Expert Panel, 2011).

The Institute for Healthcare Improvement defines teamwork as “a group of people who work together in a coordinated way, which maximizes each team member’s strengths, to achieve a common goal” (Institute for Healthcare Improvement, 2014).

In the 2012 Core Principles and Values of Effective Team-Based Healthcare, the Institute of Medicine (IOM) defined team-based care as “the provision of health services to individuals, families, and/or their communities by at least two health providers who work collaboratively with patients and their care givers – to the extent preferred by each patient – to accomplish shared goals within and across setting to achieve coordinated, high-quality care” (Mitchell et al., 2012). The common thread between all of these definitions is that a team is more than just a group of people working together. To achieve success, a team must work as cohesive unit in which cooperation, collaboration, and communication are at the forefront of its machinations (Institute for Healthcare Improvement, 2014; Interprofessional Education Collaborative Expert Panel, 2011). Teamwork is described as a process in which team members work towards a common goal with the patient as the primary focus.

Basics of Team Building: What are the essential components of a team?

The Agency for Healthcare Research and Quality (AHRQ) has identified 5 characteristics that are essential to all teams (Agency for Healthcare Research and Quality, 2014):

1. Teams consist of two or more individuals. 2. Team members have specific roles, perform specific tasks, and interact or

coordinate to achieve a common goal or outcome.3. Teams make decisions.4. Teams possess specialized knowledge and skills and often function under

conditions of high workload.5. Teams differ from small groups in that teams embody a collective action

arising out of task interdependency. Teamwork characteristically mandates an adjustment on the part of team members to one another, either sequentially or simultaneously, in an effort to accomplish team goals.

The Institute of Medicine has identified five principles of Team-Based Health Care (Mitchell et al., 2012):

1. Shared goals. The team, including the patient and, where appropriate, family members or other support persons, works to establish shared goals that

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reflect patient and family priorities and that can be clearly articulated, understood, and supported by all team members.

2. Clear roles. There are clear expectations for each team member's functions, responsibilities, and accountabilities, which optimize the team's efficiency and often make it possible for the team to take advantage of division of labor, thereby accomplishing more than the sum of its parts.

3. Mutual trust. Team members earn each other's trust, creating strong norms of reciprocity and greater opportunities for shared achievement.

4. Effective communication. The team prioritizes and continuously refines its communication skills. It has consistent channels for candid and complete communication, which are accessed and used by all team members across all settings.

5. Measurable processes and outcomes. The team agrees on and implements reliable and timely feedback on successes and failures in both the functioning of the team and achievement of the team's goals. These are used to track and improve performance immediately and over time.

Effective teams must possess pertinent knowledge, appropriate skills, and a cooperative attitude. Team work is vastly different from taskwork. Taskwork refers exclusively to the ability to perform certain skills. Taskwork is just one component of teamwork. Caring for patients requires more than possessing knowledge and skill. Healthcare providers must be able to anticipate the needs of their team members, adjust to changing circumstances, and have a shared vision of optimal patient outcomes (Baker, Day, & Salas, 2006). The synthesis of all of the components mentioned above is essential to forming a functional team.

Basics of Team Building: Identify effective team structures A team needs to be formally established for teamwork behaviors to be effective. Teamwork is sustained by a shared set of teamwork skills rather than permanent assignments. Each team member’s roles and responsibilities must be known to the entire team. The focus should be on designated responsibilities more than job titles, and these responsibilities should be linked to the team member’s individual skill set. There should be an established professional hierarchy that delineates relationships between team members and aligns the team’s strengths. Teamwork skills must be structured, practiced, and reinforced (Morey et al., 2002).

The structural characteristics of a team often affect its functional status. These characteristics include number of team members, presence of established team leaders, designated chain of command, clearly identified roles, and defined behavioral norms. Team structures will obviously differ with groups, but greater collaboration and cohesion are required when dealing

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with complex or stressful situations. The blurring of roles can affect team cohesion, but dictatorial leadership styles will deter open communication within the team. It is the responsibility of the team leader to assert authority while simultaneously empowering his or her team (World Health Organization (WHO), 2009).

Leadership There are many leadership theories and styles. The appropriateness of a certain leadership style may vary depending on the situation and the particular work setting. Various definitions of the term “leadership” are used in the literature, but they all have one thing in common. A leader must be able to bring people together to work towards a common goal. The following definitions from the Agency for Healthcare Research and Quality (AHRQ) and the World Health Organization (WHO) succinctly describe this broad term.

Leadership – The ability to coordinate the activities of team members by ensuring team actions are understood, changes in information are shared, and team members have the necessary resources (AHRQ, 2014).

Leadership is the process of influencing people towards achievement of organizational goals (WHO, 2009)

Figure 1: Critical Team Concepts (Agency for Healthcare Research and Quality, 2014)

Communication According to The Joint Commission (TJC), ineffective communication is often one of the top four reasons for preventable medical errors resulting in death or serious injury in the United States

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from 2004-2013 (The Joint Commission, 2014). Although the definition of communication may seem simple, it is difficult to successfully operationalize.

Communication – Process by which information is clearly and accurately exchanged among team members (Agency for Healthcare Research and Quality, 2014).

Communication is the transfer of information, ideas, or feelings (World Health Organization, 2009).

Categories of communication failures as per the World Health Organization (2009):

Organizational system failures in which the necessary channels for communication do not exist, or are not functioning, or are rarely used.

Transmission failures in which the channels exist, but the necessary information is not transmitted (e.g. sending unclear or ambiguous messages). Difficulties due to the transmission medium (e.g. background noise). Physical problems in sending the message (e.g. when wearing protective equipment).

Reception failures, in which the channels exist and the necessary information is sent but fails due to either misinterpretation by the recipient (e.g. expectation of another message, misinterpretation or disregard of the message) or timing (e.g. arrives too late). May be caused by physiological problems (e.g. impaired sight or hearing) or equipment problems (e.g. poor radio reception).

Failures due to interference between the rational and emotional levels (e.g. arguments).

The Institute of Medicine (2014) defined effective communication as “the team prioritizes and continuously refines its communication skills. It has consistent channels for candid and complete communication, which are accessed and used by all team members across all settings.” (Mitchell et al., 2012). Communication is a fluid and dynamic process, but basic principles must be adhered to in order for communication to be effective among teams. The Agency for Healthcare Research and Quality (AHRQ) recommends using the SBAR technique “for communicating critical information that requires immediate attention and action concerning a patient's condition” (AHRQ, 2014).

Situation — Describe the situation:Mr. Smith in room 251 is complaining of new onset shortness of breath.

Background — Pertinent background information:Patient is a 70 year old male post-operative day one from abdominal surgery. No prior history of cardiac or lung disease.

Assessment — What is the problem?

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Patient is tachycardic, BP 96/50, Respiratory rate is 32 breaths per minute and O2 saturation is 89% on 2L Nasal Cannula

Recommendation — What are the recommendations to correct the problem:I think the patient is either having a pulmonary embolus or a myocardial infarction. He needs a secure airway, supportive care, and further diagnostics.

Closed loop communication ensures that communication conveyed by the sender is acknowledged, understood, and carried out by the receiver as it was intended by the sender. Closed loop communication involves the use of Call-out and Check-backs. Call-out is a strategy used by the sender to broadcast important information. Check-backs are voiced by the recipient to inform the sender that the message has been received and is being acted upon (Agency for Healthcare Research and Quality, 2014).

Example of Closed loop communication using Call-outs and Check-backs:Leader: “Blood Pressure?”Nurse: “BP is 211/100”Leader: “Patient is having a hypertensive crisis, give Labetolol 10mg IV push”Nurse: “Labetolol 10mg IV push?”Leader: “That is correct”Nurse: “Labetolol 10mg IV push given”

Situational Monitoring/Situational AwarenessSituation monitoring entails continuously observing the environment in order to maintain situation awareness. In essence, it is knowing what is going on in your surroundings. It allows team members to understand what is going on in the environment and anticipate what will happen next. This facilitates a shared mental model among team members that helps with decision making in a dynamic environment (World Health Organization, 2009).

Situation Monitoring – “Process of actively scanning and assessing situational elements to gain information understanding or to maintain awareness to support functioning of the team” (Agency for Healthcare Research and Quality, 2014).

Situation awareness refers to an individual’s “perception of the elements in the environment within the volume of time and space, the comprehension of their meaning, and the projection of their status in the near future” (Wright, Taekman, & Endsley, 2004).

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Figure 2: Situation Monitoring Process (Agency for Healthcare Research and Quality, 2014)

Situational awareness may be difficult to quantify because it is a cognitive process. The following tools can be used to evaluate situation awareness among teams.

STEP - A tool for monitoring situations in the delivery of health care (Agency for Healthcare Research and Quality, 2014)

Assess Status of Patient:__ Patient History__ Vital Signs__ Medications__ Physical Exam

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__ Plan of Care__ Psychosocial

Assess Level of Team Members'__ Fatigue__ Workload__ Task Performance__ Skill__ Stress

Assess Environment__ Facility Information__ Administrative Information__ Human Resources__ Triage Acuity__ Equipment

Assess Progress Towards Goal:__ Status of Team's Patient(s)?__ Established Goals of Team?__ Tasks/Actions of Team?__ Plan Still Appropriate?

Tools for Measuring Situational Awareness

The Situation Awareness Rating Technique (SART) – This tool allows team members to evaluate the design of a system based on their perceived experience. The scales within the tool measure the participants’ situational awareness.

http://www.skybrary.aero/index.php/Situation_Awareness_Rating_Technique_(SART)http://www.satechnologies.com/wp-content/uploads/2013/06/HPSAA2000-SAmeas.pdf

Situation Awareness Global Assessment Technique (SAGAT) – a query technique that provides an objective measure of situational awareness with any given environment

www.satechnologies.com/capabilities-solutions/measurement/sagat/(may be adapted to suit healthcare professionals)

Situation Awareness Rule of Three – This rule helps leaders evaluate a situation in order to make decisions regarding the safety of the team.

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http://www.eimicrosites.org/heartsandminds/userfiles/file/ASA/ASA%20PDF%20rule%20of%20three%20paper,%20P%20Hudson,%20C%20vdGraaf.pdf

Critical Team Concepts

Mutual Support Maintaining mutual support requires teams to build trust, maintain trust, and have a procedure in place to actively address violations in trust among team members. Mutual trust and support allows teams to “learn from and build on each other’s assessments and conclusions” (Mitchell et al., 2012). When trust is established and maintained, team members can rely on the information provided by their colleagues, and they are confident that their team members will adequately fulfill their assigned duties and ask for help when it is needed. This permits the team to function at its highest capability (Mitchell et al., 2012).

Quality mutual support promotes a working environment where team members feel comfortable offering and seeking assistance. Proper work distribution amongst the team protects the individual from work overload. Mutual support is evident when team members have positive attitudes towards each other. This cultivates a climate that promotes cohesiveness and efficiency within the team (Agency for Healthcare Research and Quality, 2014).

Mutual support is the “ability to anticipate and support other team members’ needs through accurate knowledge about their responsibilities and workload” (Agency for Healthcare Research and Quality, 2014).

Mutual trust: Team members earn each other’s trust, creating strong norms of reciprocity and greater opportunities for shared achievement (Mitchell et al., 2012).

Negotiation and Conflict Resolution

“Negotiation is a dialogue between two or more people or parties, intended to reach an understanding…to produce an agreement upon courses of action”

-Anthony & Govindarajan

Effective negotiation is essential for conflict resolution within teams. The Agency for Healthcare Research and Quality (2014) has formulated steps to facilitate negotiation

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and conflict resolution within teams. The first step entails being a patient advocate. If a team member believes that the leader’s decisions are not in the best interest of the patient, it is the responsibility of the team member to address those concerns in a respectful manner. Communication must be clear and concise. The team member should voice their concern, clearly state the problem, propose a solution and negotiate an agreement as to how the team should proceed. The “Two-Challenge Rule” empowers all team members to call a time-out if they identify a patient safety issue. If an initial concern is ignored, it is the responsibility of that team member to be assertive and state the issue at least two times to ensure that the leader or other team member has heard the issue being voiced. The leader or team member being challenged must acknowledge the concern. If the patient safety issue is not addressed, it is the responsibility of the identifying team member to pursue the issue using the proper chain of command.

The acronym DESC has been advocated by the Agency for Healthcare Research and Quality (AHRQ) as an effective approach towards resolving conflict (AHRQ, 2014):

D—Describe the specific situation or behavior; provide concrete data.E—Express how the situation makes you feel/what your concerns are.S—Suggest other alternatives and seek agreement.C—Consequences should be stated in terms of impact on established team goals; strive for consensus.

High Performing Teams

Shared Traits and Efficiencies High performing teams must have the knowledge, skills and attitudes

needed to accomplish a shared goal. They must not only be proficient within their own roles but must also have the ability to monitor other team members. They must have a positive attitude and be willing to work as a team. Because patient management is an interdisciplinary task, it requires the full participation of all team members to deliver quality patient care. Teams as a whole make fewer mistakes than individuals. However, merely having a team structure in place does not ensure efficient operation. Team members must have a shared vision and common goals (Baker et al., 2006).

The Institute of Medicine (IOM) has identified five shared personal values among high functioning teams. These values are the individual fabric that allows individuals to function effectively within the team. They include honesty, discipline, creativity, humility, and curiosity (Mitchell et al., 2012).

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Honesty – Communication must be honest and transparent among team members. Team members should be vocal about their goals, uncertainties, and mistakes. Honesty is essential in order to maintain mutual trust and facilitate growth within the team.

Discipline – Team members must accomplish tasks and carry out their roles even when they are not being supervised. Individuals within the team should actively seek out and share new information. Discipline encourages team members to adhere to standards and protocol even when it is not the most convenient course of action.

Creativity – Team members are motivated to find ways to function better and more efficiently. Adverse outcomes are viewed as learning opportunities that will ultimately fortify the team.

Humility – Team members respect everyone’s abilities and skills. Different skill sets are valued and no one set of skills is considered superior to another. Teams recognize that its members are human and will make mistakes, but individuals can rely on their team and feel comfortable guiding each other through difficult situations.

Curiosity – During debriefing sessions innovative ideas are brought forth to improve team performance. Teams reflect on positive and negative outcomes as learning experiences.

Innovative Models and Strategies

Crew Resource Management (CRM)In the late 1970’s the aviation industry concluded that failures in professional collaboration and teamwork were responsible for approximately 70% of airline accidents (Pizzi, Goldfarb, & Nash, 2001). Crew Resource Management workshops were developed to address these deficiencies. The CRM model focuses on enhancing efficiency, safety, and the attitudes of team members. It exemplifies good teamwork structure because it looks beyond the technical skills required to fly an aircraft and emphasizes the human factors needed to make the system work safely and efficiently. It has been proposed that the structure of high functioning aviation teams may be applied to healthcare teams (Sexton, Thomas, & Helmreich, 2000). Teamwork behaviors such as “briefings, debriefings, standardized communication language and process, workload distribution, fatigue management, inquiry, graded assertiveness, contingency planning, and conflict resolution” can be easily translated into healthcare (Sexton et al., 2000). Team STEPPS

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In conjunction with the United States Department of Defense (DoD), the Agency for Healthcare Research and Quality (AHRQ) has developed the TeamSTEPPS program. This is a “teamwork system that offers a powerful solution to improving collaboration and communication” within healthcare teams (AHRQ, 2014). Teamwork is one of the key initiatives within the umbrella of patient safety that can transform the culture of an institution or interdisciplinary practice. Communication and other essential teamwork skills are necessary “for the provision of quality health care and for the prevention and mitigation of medical errors” (AHRQ, 2014).

The successful evolution of a complex healthcare system requires the implementation of team work strategies and interprofessional collaborations. The paradigm for a modern day health system must shift from a hierarchical framework in which professionals function in isolation to “high functioning interprofessional teams ready to be full partners with patients, families, communities, and one another” (Eisler & Potter T.M, 2014). The incorporation of interprofessional collaboration during the formative educational years is essential for healthcare providers to develop a common culture of safety and team work. In essence, we must deconstruct the old hierarchical culture and formulate a new culture that considers all providers, patients, and families’ equal partners. This can be accomplished using established team work models and theories. The ultimate goal is to develop every relationship in healthcare as a partnership (Eisler & Potter T.M, 2014)

C. Scenario/ Case Study1. Instructions

Please read the following case scenario and answer the questions that follow using the information presented in the module.

2. Background to scenario

Ineffective teamwork can affect performance in healthcare. The consequences of poor performance in this setting are severe and can impose serious injury upon patients. The case study that follows will expand your understanding of the importance of effective team work. It takes place in the operating room and shows how lack of organization and poor communication can negatively affect patient outcomes.

3. Actual scenario

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A healthy 30-year-old male is scheduled for a reversal of a colostomy that was placed a year ago secondary to a gunshot wound to the abdomen. This is considered a low-risk, straightforward procedure that should last about 30 minutes.

The surgery is scheduled as the last case of the day. This is the third case today for the surgeon performing the procedure. The first 2 cases were extremely complex and time consuming. Out of convenience for the surgeon, the case is moved to the trauma operating room (OR), where very few elective procedures are done. The OR is running late and the surgeon is eager to get home.

Because of staffing issues, two nurses are pulled from the orthopedic operating room to help with the case. Although they have 15 years of experience between them, neither one has ever assisted with this type of procedure. They do not know any of the personnel in the room. Both nurses express reservations about joining the OR team; however, they are told not to worry due to the simplicity of the case. They are left to set up and figure things out on their own. They are repeatedly interrupted and distracted, with the surgical team eager to get done and go home. The surgeon has loud music playing, and there is no briefing or formal team formation.

In this noisy operating room, the surgeon asks for 20mL of local anesthetic with dilute epinephrine that will serve to reduce postoperative pain and bleeding. In the noisy OR, the scrub nurse (one of the ne nurses) hears only “give me the epi”, and not knowing what it is for, she hands him a syringe with 20mL of concentrated epinephrine (1,000 times too much). The surgeon proceeds to give the patient the epinephrine. It is an almost fatal event; the patient suffers a massive heart attack and develops chronic vision problems.

If the members of the surgical team had taken time before the start of the procedure to acquaint themselves with one another and the procedure and express any concerns, and if the team had communicated effectively during the procedure, reconfirming critical points and functioning as a more cohesive unit, the entire event could have been prevented. A 30-second conversation that acquainted the team members, verified the experience and comfort level of the team members to provide the care, identified what drugs were going to be used, and outlined the plan is all they needed to avoid this nearly lethal event.

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(Adapted from the Institute for Healthcare Improvement, Teamwork and Communication Course PS 103)

4. Practical exercises (Follow-up questions for the module which do not count toward your final grade)

1. When teams communicate poorly: (complete the phrase with the appropriate answer)

a. Team members are able to provide quality care despite incomplete or missing information

b. Patient outcomes are not affectedc. Team members feel comfortable speaking up when there is a

problemd. Team members fail to share and communicate known

information which leads to more medical errors 2. What human factor issues are present in the case scenario?

a. The surgeon is fatiguedb. The nurses are unfamiliar with their environmentc. There are frequent interruptions and distractionsd. All of the above

3. What is the main reason for the medication error occurring?a. Ineffective Communication b. Poor surgical skillsc. Incompetent nursesd. Lack of supplies

Answers: 1=D, 2=D, 3=A

D. Library

1. Glossary of Terms

a. Communication – process by which information is clearly and accurately exchanged among team members (Agency for Healthcare Research and Quality, 2014).

b. Effective communication – the team prioritizes and continuously refines its communication skills. It has consistent channels for candid and complete communication, which are

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accessed and used by all team members across all settings. (Mitchell et al., 2012).

c. Interprofessional teamwork - the levels of cooperation, coordination. and collaboration characterizing the relationships between professions in delivering patient-centered care (Interprofessional Education Collaborative Expert Panel, 2011).

d. Leadership – the ability to coordinate the activities of team members by ensuring team actions are understood, changes in information are shared, and team members have the necessary resources (Agency for Healthcare Research and Quality, 2014).

e. Mutual support – the ability to anticipate and support other team members’ needs through accurate knowledge about their responsibilities and workload (Agency for Healthcare Research and Quality, 2014).

f. Mutual trust - team members earn each other’s trust, creating strong norms of reciprocity and greater opportunities for shared achievement (Mitchell et al., 2012).

g. Negotiation - a dialogue between two or more people or parties, intended to reach an understanding in order to produce an agreement upon courses of action (Anthony & Govindarajan, 2006).

h. Situation awareness - an individual’s perception of the elements in the environment within the volume of time and space, the comprehension of their meaning, and the projection of their status in the near future (Wright, Taekman, & Endsley, 2004).

i. Situation Monitoring – process of actively scanning and assessing situational elements to gain information understanding, or to maintain awareness to support functioning of the team (Agency for Healthcare Research and Quality, 2014).

j. Taskwork - the ability to perform certain skills.k. Team-based care - the provision of health services to

individuals, families, and/or their communities by at least two health providers who work collaboratively with patients and their care givers – to the extent preferred by each patient – to accomplish shared goals within and across setting to achieve coordinated, high-quality care (Mitchell et al., 2012).

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l. Teamwork – “a dynamic process involving two or more people engaged in the activities necessary to complete a task” (World Health Organization, 2009).

2. Recommended ReadingsMitchell, P., Wynia, M., Golden, R., McNellis, B., Okun, S., Webb, C. E., Von Kohorn, I. (2012). Core principles & values of effective team-based health care:   Discussion paper. Washington D.C.: Institute of Medicine.

3. Powerpoints- recommended power points from other siteshttp://www.vuse.vanderbilt.edu/~adamsja/Courses/CHMS/Lectures/SAMeasurement.pdf

4. Recommended videos from other siteshttp://www.rwjf.org/en/about-rwjf/newsroom/newsroom-content/2011/11/full-partners-collaboration-across-professions-improves-patient-.html

E. Evaluation (Multiple choice test)

1. What is the definition of team work?a. a dynamic process involving two or more people engaged in

the activities necessary to complete a task b. a group of people that come together to perform a taskc. a group made up of individuals that each have their own

agendad. a static process that is mostly task oriented

2. Characteristics that are essential to all teams include:a. Groups that have the same skill sets that work together to

accomplish different goalsb. Groups of two or more individuals that have specific roles that

come together to work towards a common goal c. Small groups that are rigid in their roles and fail to adapt to

accomplish shared goalsd. Teams generally work independently and lack specialized

knowledge

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3. What are the five principles of Team-Based Health Care according to the Institute of Medicine?

a. Mutually exclusive goals, clear roles, mutual support, non-directed communication, and variable outcome measure

b. Shared goals, overlapping roles, mutual trust, non-verbal communication, and random outcome measures

c. Shared goals, clear roles, mutual trust, effective communication, and measurable processes and outcomes

d. Mutually exclusive goals, overlapping roles, mutual support, effective communication, and random outcome measures

4. Teamwork is different from task work in that:a. Teamwork is one component of task workb. Teamwork only requires specific knowledge and skillsc. Teamwork refers exclusively to the ability to perform certain

skillsd. Teamwork is the synthesis of knowledge, skill, and the ability

to adapt when working towards a common goal 5. What leadership style will deter communication within the team?

a. Dictatorial b. Transformationalc. Authenticd. Democratic

6. A healthcare team must wear extensive personal protective equipment because they are caring for a patient that has been potentially exposed to a biological agent. The team leader asks for a central line insertion tray but is given an intubation tray. What category of communication failure does this fall under?

a. Organizational system failureb. Transmission failure c. Reception failured. Failure due to inference

7. The acronym SBAR is used to communicate critical information that requires immediate attention and action regarding a patient’s condition. What does SBAR stands for?

a. Simulation, Background, Acknowledgment, Receptionb. Situation, Briefing, Assessment, Receptionc. Situation, Background, Assessment, Recommendation d. Simulation, Briefing, Acknowledgement, Recommendation

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8. What is the ability to anticipate and support other team members’ needs through accurate knowledge about their responsibilities and workloads?

a. Mutual Trustb. Mutual Understandingc. Mutual Appreciationd. Mutual Support

9. What is a dialogue between two or more people or parties, intended to reach an understanding to produce an agreement upon courses of action?

a. Negotiation b. Conflict resolutionc. Bargainingd. Situational monitoring

10. What is a team work model that emerged in the 1970’s from the aviation industry? It focuses on enhancing efficiency, safety, and the attitudes of team members.

a. Team STEPPSb. STARc. Tuckman’s stages of group developmentd. Crew Resource Management

Answers:1=A,2=B,3=C,4=D,5=A,6=B,7=C,8=D,9=A,10=D

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Module 8. Financial Management and Cost Analysis

Lorraine Marie Keith

A. Module guide – describes what the module entails1. Objectives

At the end of this module the student will be able to:a. Define the financial responsibilities of a nurse leader.b. Identify the components of an operating budget in health

care.c. Describe the metrics used to develop an operating budget.d. Describe metrics used to develop a nursing staffing budget.e. Discuss fundamentals of cost analysis and project

development and explain the different types of cost analysis and when they would be used.

f. Discuss the principles of the Triple Aim project: Improving health in a defined population.

2. Module outline – brief description of each sectionThis module contains a scenario of a new program being requested by the Chief Executive Officer (CEO) of the hospital to the nursing leader. Using this scenario, will to develop a budget which includes the revenue and expenses cost to determine the financial feasibility of the project. Using a cost benefit analysis, determine the project goals and benefits, and discuss whether these have a positive or negative impact to the institution. Determine which cost analysis model will be used to further justify the program. Explain how this program meets the objectives of the Triple Aim: Improving health in a defined population, improving the patient’s experience, reducing or controlling the per capita.

3. Methodology – identifies learner strategiesIn this self-study module, the participant can learn at his/her own pace. However, there is a 12-week time limit for completion of the overall course.

a. Readings (All learning materials are available online and are accessible upon demand; although links to supplemental resources are provided, there are no professors or facilitators.)

b. PowerPoint presentationc. Scenario reviewd. Test (Participants will be required to earn a passing score in

the final exam for each module before continuing to the subsequent module.)

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4. Time requirementsa. 12 hours

5. References

Beasley, C, (2009). The triple aim; Optimizing health, care and cost .

Healthcare Executive, Jan/Feb 2009. Reprinted for Institute of

Healthcare Improvement

Berwick, D., Nolan, T., Whittington, J., (2008). The triple aim: care,

health, and cost. Health Affairs. 27(3) 759-769. DOI:

10.1377/hlthaff.27.3.759

Castro,A.,& Abraham, S. (2008). Using value-chain analysis to discover

customers’ strategic needs. Strategy & Leadership 36(4) 29-39.

DOI: 10.1108/10878570810886759

Centers for Disease Control (n.d.) Cost of illness analysis.

Douglas, K. (2010). Taking action to close the nursing-finance gap:

learning from success . Nursing Economics 28(4), 270-272.

Feldstein, P. (2012). Health Care Economics, Delmar Cengage Learning

Finkler, S., & McHugh, M. (2008). Budgeting concepts for nurse

managers. Saunders Elsevier

Gapenski, L., (2003). Understanding healthcare financial management.

The Foundation of the American College of Health Care

Executives.

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Hooshmond, M., Zabrana, D,(2013). Healthcare management,

economics financing, and ethics. Cost analysis frameworks.

Power Point Presentation, University of Miami.

Issel,L. (2014). Health Program Planning and Evaluation. Jones and

Bartlett Learning

Muller, R., & Karsten M. (2012). Do you speak finance? Nursing

Management 43(3) 50-54.

Stiefel, M., & Nolan, K., (2012). A guide to measuring the triple aim:

population health, experience of care and per capital cost . IHI

Innovation Series white paper. Cambridge, Massachusetts:

Institute for Healthcare Improvement.

Strickler, J. (2014). Learning the language of finance. Nursing 42(10), 45-

48. DOI: 10.1097/01.NURSE.000041861.53476.9d.

Valentine, N., & Wolf, K.(2011). The CNO/CFO partnership: navigating

the changing landscape. Nursing Economics 29 (4)201-209.

Waxman, K., (2008). A practical guide to finance and budgeting. HcPro,

Inc.

World Health Organization. (2014). Essential Medicines and Health

Products Information Portal A World Health Organization

resource.

B. Topics:1. Broad overview of topics to be covered

The purpose of the module is to educate the learner about the financial responsibilities of a nurse leader and to teach important aspects of budgeting and cost analysis in health care. Additionally, the module

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describes important initiatives of the Triple Aim as it relates to improving health in a defined population, improving the patient experience, and reducing or controlling the per capital cost of care (Stiefel, M. & Nolan, K.).

2. Actual content (in PDF narrative form and ppt presentation with bullet points/speaker notes) including recommended readings for each section

NURSE LEADERS ROLE IN FINANCE

The nurse leader’s role has evolved into requiring more financial and business skills. Nurse leaders control the largest part of a hospital’s budget, and they have a great responsibility in developing and effectively monitoring the finances of their departments (Douglas, 2010). Most nurse managers enter the role immediately after leaving the bedside, only to learn that the role has expanded beyond the clinical arena, to the management of budgets and hospital finance (Finkler & McHugh, 2008). Although the manager’s responsibilities vary from institution to institution, there are core competencies that are essential to nurse managers. Fiscal management and outcomes begin at the unit level, and nursing leaders are required to understand the impact they have on the bottom line of their institution.

At one time the nursing budgets were developed by the finance department without accounting for the complexities that drive nursing care. This model has been doomed to failure, and now nurse managers have the opportunity to learn and understand how to develop a practical budget for a unit or department that includes volume projections as well as salary and supply expenses (Waxman, 2008). They must be able to understand and monitor trends related to staff and material and supply usage, as well as understand the overall impact length of stay and overutilization of resources have on the financial institution.

As nurse managers leave their clinical and bedside roles, they are frequently conflicted between their commitment to being caregivers as well as patient advocates, and their acceptance of responsibility for the financial and business side of health care delivery (Douglas, 2008). Financial institutions that are financially sound can provide quality care and high quality services for patients (Finkler & McHugh, 2008). As healthcare reimbursement is changing, new trends related to patient management, outcomes, and population based healthcare are emerging. An effective nurse leader must be astute in understanding their impact on assuring not only the health of the patients they serve, but the financial health and viability of their hospital.

BUDGETS

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Operating Budget: The operating budget is the day to day plan for revenue and expenses for a year, and this generates the bottom line (revenue minus expenses) (Muller, 2012).

Capital Budget: Capital budgets are composed of major expenditures which typically last one to two years. These expenditures can be in the form of equipment, building renovations, and new constructions. Typically the purchase of a major piece of equipment must generate a return on investment (ROI), which will offset the cost of the purchase (Finkler & McHugh, 2008).

Flexible Budget: The flexible budget adjusts to variations and work load changes relative to volume and activity (Finkler & McHugh, 2012).

Fixed Budget: The fixed budget assumes no variations in activity or volume. An example is the building itself.

Approaches to Budgeting

Historical Budgeting This type of budgeting uses history or past performances to help predict the future. This is the most common approach to budgeting and uses actual performance from a prior period when preparing the budget. The manager should be aware of potential organizational growth opportunities or decreases in order to adjust the budget predictions. For example, if a new service line is being added that is projected to increase admissions to a unit by 10%, the budget must be adjusted accordingly.

Relationships and ratios are generally used to establish historical based budgets. Examples are:

Revenue per primary unit of measure Labor per primary unit of measure Supply expense per primary unit of measure

Zero based budgeting: This approach is more labor intensive and time consuming than the historical method. It involves starting from zero for most revenue and expense line items and developing the budget from the “bottom up” since historical data does not exist. The advantage of a zero based budget is that it is not influenced or corrupted by poorly managed or erroneous data that may be in a historical budget. While a zero based budget may produce a more accurate budget, it requires an extensive amount of time and expertise, and it is generally used in small to midsize organizations (Finkler & McHugh, 2008).

Planning for the Operating Budget Prior to the development of an operating budget, the nursing leader must be aware of potential factors that may affect the activity and volume of the department and then incorporate those assumptions into the budget (Finkler& McHugh, 2008). Budgets cannot be developed without knowing how many patients will be treated, the services the patients will be utilizing, and the severity of illness (acuity) of the patients being treated. Forecasting helps determine the revenue budget as well as all other budgets. Knowing the acuity of patients and average census, such as those in an intensive care unit, allows for the nurse manager to adequately

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project the number of staff to include in the budget. Forecasting can be done by using historical data, graphing the data, and analyzing trends (Finkler & McHugh, 2008).

The goals of the organization must also be communicated, and new programs or reductions in programs or activities that may impact a nursing unit must be identified in order to actually plan for a budget. For example, if a new Electronic Health Record (EHR) is being implemented in a hospital, the expenses related to staffing and education during the implementation must be considered when preparing the budget.

Units of Measurements Used to Determine Budget Prior to determining the budget, the nursing manager must know what unit of service will be used to describe the service or activity that will drive their revenue and expenses. The number of discharges, procedures, patient visits, appointments, and laboratory or radiology tests are examples of units of measurements used to determine a budget for a department.

When calculating a budget for an inpatient unit, the term patient day describes one patient staying one day (24 hours) in a bed. Patient days are calculated by taking the number of patients on a unit, for example 10 patients, multiplied by 365 days of the year, which equals 3,650 patient days. These days are the basis of further calculations used for budgeting expenses, labor, and supplies for a unit (Strickler, 2012).

The average daily census (ADC) is the average number of beds occupied each day by a patient. The ADC can be calculated by taking the number of patient days in a given time period divided by the number of days in the same time period (Finkler & McHugh, 2008). Using our example above, 3650 patient days divided by 365 days a year gives us an ADC of 10.

Length of StayThe average length of stay (ALOS or LOS) is the average number of days a patient stays in the hospital with each admission. The ALOS can be adjusted per case mix. For example, it can be adjusted by unit (such as Intensive Care Unit, Surgery, Obstetrics, Psychiatric Unit, Neonatal Intensive Care Unit, etc.), by payer class (insurance or self-pay, government regulation), or by both unit and payer class. A long length of stay can have a negative impact on inpatient profitability because it utilizes more resources and creates more expense. A lower length of stay typically leads to lower cost and more profitability to the hospital (Capenski, 2003).

Another important unit of measurement needed when calculating an inpatient budget is the hours per patient day (HPPD) or hours per patient visit (HPPV) in outpatient settings. The HPPD is the actual care being delivered per patient each day and is calculated by dividing the number of hours worked by the actual census or volume (Strickler, (2012). This is used when determining a staffing budget, which will be covered under the operating budget section.

Cost Cost per stay is the amount of expenses incurred by each patient per day, which can include room and board, staffing, supplies, and procedures. The cost per stay includes fixed costs, which are costs that occur even without a patient, such as cost of the building or utilities, and

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variable cost, which varies with each patient. Variable cost can include medications used, food cost, or staffing (Muller & Karsten, 2012).

Revenue Revenue is based on charges and is the money a hospital is paid for procedures and outpatient or inpatient care. The amount of revenue received by a hospital is dependent on the insurance, managed care rates, or self-pay. Revenue in hospitals is repaid after the services are provided, which is unlike purchasing a commodity and paying for it before taking delivery (Castro & Laymen, 2006).

Gross Patient Service Revenue (GPSR) The amount a patient is billed by an organization is based on the actual charges or “sticker price”. In the United States, most patients do not pay full charges because of contractual agreements made with third party payers (Muller, 2012).

Net Patient Service Revenue (NPSR) NPSR is the estimated net dollar amount collected from patients, insurers, and others for services rendered, including discounts and other adjustments made from all sources, and is the final negotiated price (Muller, 2012).

Ancillary Revenue When compiling a revenue budget, other ancillary items must also be calculated into the overall hospital revenue, such as cafeteria revenue, gift shop revenue, grants, and donations (Finkler & McHugh, 2008).

Charge capture: Charge capture is an essential element of revenue cycle. All clinical areas must assure the services and supplies used are adequately and correctly charged to the patient. It is incumbent on the nurse leader to assure proper charging mechanisms are in place.

The Revenue Budget As noted previously, there are many different sources of revenue within healthcare. Revenue must exceed expenses in order for the institution to be profitable and to be able to reinvest back into the company, such as through expanding services and equipment and through overall building improvements. Nurse managers are typically given responsibility for developing the expense budget; however, some managers may be responsible for developing a revenue budget if their department earns a profit, such as the OR. These profit centers or revenue centers use volume projections and historical charges and payments to predict future revenue. As the revenue budget is being prepared, future programs and growth must be taken into account. For example, if the OR is planning to add additional surgery procedures, each procedure volume and the typical reimbursement by payer must be used to forecast the amount of revenue that will be generated (Finkler & McHugh, 2008).

The payer mix of each hospital may vary based on region and geographic location. For example, an inner city hospital may see more patients who are self-pay and uninsured patients compared to a suburban hospital which sees more patients with the ability to pay. Nurse

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Managers should know the payer mix of their hospital and the patients they serve in order understand why expense management and revenue are important to the hospital’s bottom line.

In hospitals or large institutions, the forecasting of the revenue budget is typically done by the Revenue Cycle department, because they have access to historical payment data.

Example of a same day surgery clinic revenue budget:

Revenue Source

Quantity

Rate or charge

Gross Revenue

Average net charge

Revenue Net of discounts and allowances

Private Ins

1000 $1500.00

$1,500,000.00

75% $1.125,000.00

Other ins

600 1500.00

900,000.00

80% 720,000.00

Other ins

400 1500 00

600,000.00

60% 360,000.00

Self-pay 500 1500.00

750,000.00

70% 525,000.00

Gift Shop

5000 17.00

85,000.00

100% 85,000.00

Donations

400 200.00

80,000.00

100% 80,000.00

Subtotal 3,915,000.00

2,895,000.00

Less bad debt

-100,000.00

Net Revenue less bad debt

2,795,000.00

Taken from Finkler & McHugh, 2008 p.231

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Expense Budget The expenses nurse managers must include in the budgets for their units/wards are broken down into either direct expenses or indirect expenses. Direct expenses are those directly related to the activities occurring on the unit and to salaries, while indirect expenses, such as computer paper, are not related to patient care but are needed to run the unit (Finkler & McHugh, 2008).

The greatest expense in an operating budget is salaries, which are the largest portion of a nursing budget. In order to develop the personnel budget, it is important to understand the concept of a full time equivalent (FTE) position.

A position is not determined by the number of hours a person works, but is described as “one job for one person” (Finkler & McHugh, 2008). Positions can be categorized as full-time, part time, or per diem, as needed (PRN).

A full time person, who works a typical 40 hour week, works 2080 hours per year. This is called a full time employee. Based on a typical 8 hour day worked, and a typical work week of 5 days, this equates to a 40 hour work week. Multiplying the 40 hour work week by 52 weeks in the year equals 2080 worked hours per year, which is the definition of a full-time equivalent (FTE). Because there is a variation of hours worked by individuals, it is necessary to determine one denominator when developing a nursing salary budget. This denominator is the FTE (Finkler & McHugh). One employee can be hired as full time and work 2080 hours, or 2 employees can be hired to work 2080 hours, and each can work 1040 hours or any variation to equal 2080 hours.

There may be variations to the standard work week; for example, many hospitals are now using a 12 hour shift as the standard shift rather than the eight hour week, which will change the definition of a FTE. When determining the salary budget, it is important to know the definition of a FTE on a unit in terms of total hours paid (2080, 1872, or other variations).

When budgeting salaries, productive time (actual hours worked) and non-productive time (paid time off/PTO); educational time) must be taken into account. This can also be differentiated as “worked” staff, those who actually worked a shift, and “paid” staff, which includes those on educational time and PTO (Strickler, 2012).

To determine the salary budget, the total number of hours required to staff a unit or department by each job category—RN, LVN, and nursing assistant—is multiplied by the average hourly rate. Because the typical work week is 5 days, the other two days, plus possible PTO or sick time, must be taken into account when calculating the total hours worked. Each 8 hour work day is considered .2 FTE, and therefore, to cover 7 days a week, we must multiply the number staff needed by 1.4 (.2x7).

Non-productive time (PTO, education) is divided by the productive hours which will give a percentage of non-productive time.

Example:

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18 x 1.4 = 25.2 FTEs are needed to staff the unit. (2080 x 25.2 =52,416 productive hours).

If historically the non-productive time used was 10%, the unit is paying productive time plus 10% non-productive time. 52,416 x 10% =57,637 hours. 57,637 divided by 2080 will give us 27.7 FTEs required to staff the unit, including productive and nonproductive time.

Calculating Hours per Patient Day (HPPD)

HPPD reflects nursing care hour required in 24 hours for each unit of work. It is important to know that this is calculated using productive time only.

Total hours worked/patient days = HPPD or HPPV

Example:

52416 hours worked annually / 9490 patient days (ADC x 365) = HPPD of 5.52.

Multiplying the HPPD/HPPV by the patient days will get the number of hours required to work. That number divided by 2080 will give you the FTE’s needed. Example 52416/ 2080 (FTE) = 25.2 required to staff the unit.

Salary Budget by Mix and Shift

Following the determination of HPPD, hours by skill mix (RN/LPN/Nursing assistant) must be determined.

Example:

If 50% of the hours are worked by Registered Nurses (RN), those hours will be multiplied by the average hourly rate of RNs on that unit. 26,206 x $25.00 = $655,200.00 Use the same procedure for other staff mix.

Shift differential is added by using the hours worked on the shifts multiplied by the shift rate.

Example:

22000 hours are night shift hours at $3.00 an hour =$66,000.00.

Estimate increases for the next year including merit raises or any proposed skill mix.

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ICU BUDGET RN LPNProductivity Standard 5.52 5.52Budgeted Statistics (Patient days) 9490 9490

Total Productive Hours 26,206 26,206+ 10% non-productive time 2620 2620Total Paid Hours 28.926 28,926TOTAL FTES ( Divide hrs by 2080) 13.85 RNs 13.85 LPN

Avg hourly rate $ 23.00 $ 15.00Shift differential (if no shift diff leave blank). $ 3.00 $ 2.00

Merit increase 4% $ 0.92 $ 0.60New hourly rate $ 26.92 $ 17.60SALARY $ 778,688.00 $ 509,097.60TOTAL SALARY EXPENSE $ 1,287,785.60

Non-Salary Budget The non-salary budget includes all other direct expenses in a budget that are needed to support the unit and patient care. This typically consists of medical supplies, office supplies, professional fees, medical equipment, and instruments that do not meet the capital budgetary requirements, dietary costs, maintenance, educational expenses, etc. Each account is listed separately on the chart of accounts.

There are several ways to calculate the non-salaried budget, and the simplest method used is to calculate the total cost per unit of activity: cost per discharge, cost per patient day, or cost per work load unit (Finkler & McHugh, 2008). The key to budgeting non-salary supplies is identifying the most reasonable predictor and making expense projections based on that predictor.

The non-salary expenses are calculated using the projected volume, such as 200 procedures, multiplied by the current cost. Forecasting is a tool that can be used when preparing the non-salary budget because volume can be predicted based on current use, potential growth (such as a new service line), or even the possible decrease of a service line (Finkler and McHugh, 2008).

Example of a Budget and Budget Variance

Budget Variance: The budget variance is the difference between what is projected in the budget, and what is actually expensed or received. For example, salary dollars budgeted for a unit is $10.000. 00 per month, and $12,000.00 was used. This is a negative variance to the salary budget.

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Cost/Benefit Analysis Cost-benefit analysis and cost effectiveness analysis are methods used to determine the advantages and disadvantages of a program. When the benefit of a project exceeds the cost, the analysis is proven to be positive. The following are key elements needed in performing a cost-benefit analysis.

Determine project goals.o Understand what the project will accomplish. Example: A hospital wants to

add a robot in their surgical unit. What will this expensive piece of equipment add to the organization? Will it add more volume? Will it attract more surgeons? Will it improve the hospital’s competitive edge? (Finkler & McHugh, 2008).

Estimate project benefits.o The benefits will be calculated based on potential new volume and new

surgeons. If the robot is marketed as a non-invasive procedure, the benefit will be added volume and potential increased revenue to the hospital. Additionally, by using a non-invasive technique, another benefit will be reducing the length of stay, which will also improve cost (Finkler & McHugh, 2008).

Estimate project costs.o When evaluating costs, it is important to include all costs, which may be

cost of supplies and cost of staff dedicated to the robot. Discount cost and benefit flows

o Project benefits and costs may occur over several years. It may not be practical to assume the robot program will pay for itself in one year, which

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presents a problem when comparing benefits and costs. The cost of a program is often higher at the start up. The cost of the equipment in will depreciate in 5 years of the program, and this must be considered in calculating the profit (Finkler & McHugh, 2008).

Complete the decision analysiso Once all relevant costs and benefits are projected, they can be compared

to each other in the form of a ratio. Benefits are divided by costs, and if the result is greater than 1, the result is that the benefit exceeds the cost and the project is desirable. (Finkler & McHugh, 2008)

Cost of Illness Analysis: Determination of the economic impact of an illness or condition including associated treatment costs. This is typically done on a given population, region, or country. Examples include smoking and cancer (Hooshmand & Zanbrana, 2013). The Centers for Disease Control and Prevention (CDC) explains that “The Cost of illness (COI) is defined as the value of the resources that are expended or foregone as a result of a health problem” (CDC, n.d.). The COI includes costs of pain and suffering and lost productivity. It is important to know the economic burden of a health problem in order to make knowledgeable choices concerning which health problems to address and what interventions to use to alleviate them (CDC, n.d.).

Understanding the estimates of medical expenses and loss of employment provides an estimate of the extent of the economic impact of various health problems and the amount of money that is spent on an illness, compared to what may need to be spent on the intervention. This can then determine if the cost of the intervention is worth spending the resources to alleviate the problem. Key questions to ask are: What is the cost of the intervention? What is the cost of the illness without intervention? What is the cost of the illness with the intervention? (CDC, n.d.).

Cost Minimization Analysis: This analysis determines the best way to develop a program at the lowest cost. This should be done during the planning and budgeting phase, as it allows the manager to evaluate and compare costs of equal products (Issel, 2014). For example, if a new therapy or drug were no safer or no more effective than what is currently being used and there is no obvious benefit to the new therapy or drug, it would justify the same price (World Health Organization, 2014).

Cost Effectiveness Analysis: A program is determined to be cost effective if the desired outcomes are achieved at the least amount of cost. Using cost and benefits, cost effectiveness compares alternatives against and the desired outcome. For example, a boot has been used as a preventative measure for pressure ulcers on heels. A new treatment of Mepilex has been suggested, which is less expensive than the boot. The outcome must be the same or better using Mepilex to determine cost effectiveness (Issel, 2014).

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Cost Utility Analysis: In this analysis the outcome or benefit is measured by the increased utility received once an intervention has been established. The result is measured in cost per quality of adjusted life years (QALYs) gained (Feinstein, 2012). Issel defines QALYs as “the number of years of life at a given level of health and wellbeing” (Issel, 2014, p. 148). Both quality and length of life are important when evaluating a health condition. These are also referred to as burden of disease measures, and are used to evaluate economic value of programs or a community needs assessment (Issel, 2014). This type of analysis can be seen as controversial because it is difficult to put a value on health status or on an improvement in health status as perceived by different individuals or societies. Cost-utility analysis differs from the cost-benefit analysis because it compares two different therapies and the benefits of the therapies may be different (WHO, 2014).

Triple Aim

The Institute for Healthcare Improvement recognized that focusing on three objectives simultaneously will lead to better models of healthcare delivery systems. Those three objectives are:

Improve health in a defined population. Improve the patient experience. Reduce or control the per capita cost of care (Stiefel & Nolan, 2012).

The Triple Aim requires all public health departments, schools, social service entities, health care organizations, and employers to cooperate in this venture because no one entity can successfully improve the health of a population. Over 100 sites from around the world have been included in this initiative (Stiefel & Nolan, 2012).

Skill sets required by an organization to assure the success of establishing the Triple Aim include:

Segment a population by using predictive models Develop team based models of primary care Design and implement customized care plans with patients and families Remove wastes in specialty care and other services Discourage supply driven care and match capacity and demand Measure improvements in health Use outcomes vs volume as a basis of success (Healthcare executive, 2009)

Obstacles to pursuit of the Triple Aim: Supply driven demand New technology with limited impact on outcomes Physician Centric Care Little to no foreign competition to challenge domestic change (Berwick et

al, 2008).

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Preconditions of the Triple Aim Specifying a population concern, such as all heart failure patients in Dade

County. Policy constraints, for example, a Nation may determine Universal

coverage is required. Integrator that accepts responsibility for all 3 components of the Triple Aim

for a specified population. (Berwick et al, 2008).

Role of the Integrator:

Involves individuals and familieso Changes more is better attitudeo Assures care plans are developed for chronic conditionso Navigates the patients through the complexities and difficult

decisions of their care Redesigns primary care services

o Expand the role of the primary care physician as a medical home, which will include all sub specialists and the hospital

o Makes access to care, scheduling, and connection to community services available

Population health managemento Deploys resources to a populationo Anticipates the patients ongoing needs rather than focusing on the

acute phase of a disease Financial management systems

o Control costo Measure and make the per capita cost of care transparento Develop incentive programs for decreasing costs per capitao Carefully scrutinize new technology and evaluate outcomes (Berwick

et al, 2008)

C. Scenario/Case Study

1. Instructions

Read the following scenario and answer the questions.

2. Background to scenario

You are a nurse executive working in the field of cancer. Due to the many challenges with reimbursement related to chemotherapy infusions, your Chief Nursing Officer (CNO) and Chief Executive Officer

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(CEO) have asked you to explore avenues to increase volume and decrease cost of inpatient IV chemotherapy infusions.

3. Actual scenario

It has been determined that patients needing outpatient infusions, such as chemotherapy, may be a source of increased volume for the hospital. The CNO and CEO would like to have this explored as a source of increased revenue and patient and physician satisfaction.

The CNO has asked you to do a cost benefit analysis to determine whether this program will be a viable source of new revenue. When preparing the analysis, please include the revenue budget and salary and expense budget. Determine the hours and days of operation as well as the labor and supply expenses, which will include medications. Once the revenue and expense budget are completed, determine whether this program is a venture the hospital should pursue.

4. Practical exercises (Follow-up questions for the module which do not count toward your final grade)

1. What type of cost analysis would be used to determine whether implementing this type of unit would be beneficial to the hospital? Explain the rationale for choosing the analysis.

2. You have decided to use 2 Registered Nurses and one aide per shift 7 days a week. How would you determine the number of staff you would need by each category?

3. Develop your expense budget explaining each component (for example salary and supplies, describing each item and the rationale for including them in the budget).

4. Explain how this project can impact the objectives of the Triple Aim.

D. Library

1. Glossary of TermsAs foreign as medical terminology is to finance, the language of finance can also be confusing to a new nurse leader. It is essential nurse leaders learn the language of finance in order effectively communicate with the other leaders of the hospital. Valentine and colleagues (2011) stated that “Nursing leaders need to understand and appreciate the financial constraints and balance them with expected outcomes, and financial leaders need to understand and appreciate the core clinical business and what gaps in care mean to financial viability of the organization and to patient outcomes.”

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According to Finkler, a budget is simply a plan. This plan is formalized, (written down), quantified (stated in terms of dollars), and represents managements expectation related to revenue and expenses (Finkler & McHugh, 2008).

ADC- average daily census, average number of patients on a unit at midnight

Patient day- patient in a hospital bed at midnight

ALOS- average length of stay Productive time- worked timeCPUOS- cost per unit of service PTO- paid time offExpenses- costs Net revenue- Actual revenue

collectedFTE –full time equivalent Non-productive- non worked timeGross revenue- charges Volume- number of patients, tests or

procedures.HPPD- hours per patient dayLOS- length of stay

(Waxman, L 2008)

2. Recommended Readings A guide to measuring the triple aim: population health, experience of care, and per capital cost. Institute for Healthcare Improvement Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement

World Health Organization. (2014). Essential Medicines and Health Products Information Portal A World Health Organization resource.

3. Recommended Power point presentations:

http://www.google.com/url?url=http://www.nhnurses.org/Especially-for-You/Nurse-Staffing-Toolkit/StaffingBudgetPresentation.ppt&rct=j&frm=1&q=&esrc=s&sa=U&ei=v8HjU5TxDtWdygSwoYHICQ&ved=0CDcQFjAH&usg=AFQjCNED-8n61ssS_PV9mqlB76tA9tYfxA

http://www.slideworld.org/viewslides.aspx/BUDGET-IN-NURSING-SERVICE-ppt-2847057

http://www.google.com/url?url=http://www.oregon.gov/oha/ohpb/meetings/2010/100511-lab.ppt&rct=j&frm=1&q=&esrc=s&sa=U&ei=4cfjU-H2HsKSyASw2YKQDA&ved=0CCAQFjAC&usg=AFQjCNE-M3HusljJ9OYTDW1G9QRNGCChNQ

4. Recommended Videos

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http://www.youtube.com/watch?v=sk1rEOllG2g

http://www.youtube.com/watch?v=DRkhppxZzL0

http://www.healthcarefinancenews.com/video/healthcare-triage-malpractice-healthcare-costs-and-tort-reform

E. Evaluation (Multiple choice test)

1. Which best describes the relationship of a nurse leader to finance?a. Nurse leaders report to the finance department for budgetingb. Nurse leaders have responsibility to develop and monitor

finances of their department.c. A nurse leader provides clinical expertised. Nurse leader has no financial responsibilities

2. Which of these is an example of a capital budget item is?a. Bulk IV suppliesb. Lawn servicec. Foley Cathetersd. Major construction project

3. Metrics or units of service used for budgeting include:a. Patient daysb. Hours of operation in the cafeteriac. Number of Registered Nurses needed on a unitd. Salaries

4. Gathering historical data, analyzing trends and analyzing graphic data are used in what is called

a. Calculatingb. Budgetingc. Forecastingd. Planning

5. Cost per stay is the amount of expenses incurred by each patient per day. This includes:

a. Room and boardb. Performance improvementc. Patient satisfactiond. Facility planning

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6. How would one calculate the average daily census (ADC) for inpatient occupied beds?

a. Add the total number of days in a time period by the number of days in the same time period

b. Take the number of patient days in a time period and divide by the number of days in the same time period

c. Subtract the number of days in a time periodd. Multiply the number of days in the same time period

7. Hours per patient day describes which of the following?a. Time allotted on a shiftb. Hours of nursing care required in 24 hours for each unit of

workc. Time it takes to bathe a patientd. The number of hours in a nursing shift

8. How many FTEs does 52,416 hours represent?a. 25.2b. 21.6c. 43d. 34

9. Which of the following is not part of the Triple Aim?a. Population healthb. Revenue enhancementsc. Per capita costsd. Experience of care

10. The role of the integrator includes:a. Hiring full-time equivalencies (FTEs)b. Population health managementc. Evaluating performance improvementd. Performing exams on patients

Answers: 1=B, 2=D, 3=A, 4=C, 5=A, 6=B, 7=B, 8=A, 9=B, 10=B

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