gement
The Health Care Environment
Organizational Behavior and M
agnet Hospitals
Basic Clinical Health Care Econ
omics
Evidence-Based Health Care
Nursing and Health Care Inform
atics
Population-Based Health Care P
ractice
Personal and Consumer Partner
ships
Politics and Consumer Partne
rships
Strategic Planning and Organ
izing Patient Care
Effective Team Building
Power
Change, Innovation, and Con
flict Management
Budget Concepts for Patient
Care
Effective Staffing
Delegation of Patient Care
Organizational of Patient Care
Time Management and Setting Pati
ent Care Priorities
Managing Outcomes Utilizing an
Organizational Quality Improvem
ent Model
Evidence-Based Strategies to Im
prove Patient Care Outcomes
Decision Making and Critical Thin
king
Culture, Generational, Differences
, and Spirituality
Collective Bargaining
Career Planning
Emerging Opportunities
Nursing Leadership and
Management
<Insert Picture Here>
Definition of Management
A process of coordinating
actions
and
allocating
resources
to
achieve
organizational goals
An art of accomplishing
things through people
Managerial Roles
• Role includes behaviors, expectations,
and recurrent activities within a
pattern
that
is
part
of
the
organization’s structure
– Information-processing role: used
to manage information people need
– Interpersonal
role:
figurehead,
leader, liaison
– Decision-making role: entrepreneur,
disturbance handler, allocator of
resources
Management Functions
Managing the work
Managing relationships
Managing the Work
• Planning
• Informing
• Organizing
• Monitoring
• Problem
• Consulting
solving
• Delegating
• Clarifying roles
and objectives
Managing Relationships
Networking
Supporting
Developing and mentoring
Managing conflict and team
building
Motivating and inspiring
Recognizing and rewarding
Scientific Management
Focus
is
on
goals
and
productivity
Organization
viewed
as
machine to run efficiently to
increase production
Workers must have proper
tools and equipment
Time and motion studies
Bureaucratic Management
Focus
on
superior–
subordinate communication
Top down approach
Uses
explicit
rules
and
regulations for governing
activities
Uses merit and skill as basis
for promotion/reward
Concern
for
economic
efficiency
Administrative Management
Focus is on science of
management
Commonly referred to as the
management process
Identifies need for Planning,
Organizing,
Supervising,
Directing,
Controlling,
Reviewing, and Budget =
POSDCORB
Human Relations
Focuses on the empowerment of the
individual worker as source of control
Hawthorne effect
Phenomena of being observed or
studied results in changes in
behavior
Participatory
decision
increases worker autonomy
making
Provides training to improve work
First-Level Manager Roles
Nurse manager
clinical bedside
at
the
Manages patient care and
supervision
of
others
delivering care
Plans for care
Middle-Level Nurse Manager
Unit manager or director
Spends
most
time
coordinating and planning
on
Executive-Level Manager
Expanded role of planning
and being generalist
May have title of Chief
Nurse Executive or Vice
President of Patient Care
Services
Administrative Principles
• General principles of management relevant to
any organization
• Unity of command and direction
– Worker
gets
supervisor
orders
from
only
one
• Acceptance theory of authority
– People have free will and choose to comply
with the orders they are given
• Organizations have naturally forming social
groups that can become strong and powerful
Human Relations
The effect of being watched
and
receiving
special
attention may alter a person’s
behavior
People benefit and are more
productive and satisfied when
they participate in decisions
about their work environment
Motivation Theories
Belief that worker output greater when workers
treated humanistically
Motivation
Whatever influences our choices and creates
direction
Process that occurs internally to influence and
direct our behavior in order to satisfy needs
Helpful because they explain why people act the
way they do and how a manager can relate to
workers as human beings and workers
Selected Motivation Theories
Maslow: Hierarchy of Needs
Motivation occurs when needs are not
met
Must satisfy one need to move on to
next
Herzberg:
Job
dissatisfaction
occurs
when
adequate
salary,
safe
working
conditions and relationships are not
met
Motivation occurs with meaningful
work and advancement opportunities
Selected Motivation Theories
• McGregor: Theory X
– Leaders must direct and control
– Employees prefer security, direction,
and minimal responsibility to get the
job done
• McGregor: Theory Y
– Leaders remove obstacles as workers
have self-control and self-discipline
– The
worker’s
reward
is
their
involvement in their work
Selected Motivation Theories
• Ouchi: Theory Z
–
–
–
–
Collaborative decision making
Long-term employment
Mentoring
Holistic concern
Leadership
A process influence by which the
leader influences others toward
goal achievement
Leaders inspire, enliven, and
engage others to participate
Reciprocal relationship
Nurses are leaders
Formal and informal leaders
Formal and Informal
Leaders
Formal
Person
in
authority
has
sanctioned role in organization
Informal
An individual who has emerged
as a leader outside the scope of a
formal leadership role
Perceived to have influence
Leadership Characteristics
Guiding vision
Provides
direction
preferred future
Have high
standards
Value education
Value professional
development
Demonstrate
power in the
organization
Active in a
professional
organization
Differences in Leaders versus Nonleaders
Drive
Desire to lead
Honesty and integrity
Self-confidence
Cognitive ability
Knowledge of the business
Behavioral Theories
• Autocratic
– Centralized decision making
– Leader makes decisions and has power to
command others
• Democratic
– Participatory leader
– Delegates authority to others
– Expert power
• Laissez-faire
– Passive and permissive
– Defers decision making
Behavioral Leadership
Employee-centered leadership
Focus is on human needs of
subordinates
Job-centered leadership
Focus
is
on
costs
efficiency
and
Leader Behavior
• Initiating structure
Emphasis on work to be done
Focus on task and production
Focus on how work is organized
Focus on achievement of goals
Planning, directing others, and
establishing deadlines
Focus on details of how work is to
be done
Leader Behavior
Consideration
Focus on employee
Emphasizes
relating
and
getting along with others
Focus on well-being of others
Fosters
communication
and
trust
Contingency Approaches
Acknowledges that other factors
in the environment influence
outcomes as much as leadership
style
Leader
effectiveness
is
contingent upon or depends upon
something
other
than
the
leader’s behavior
Different
patterns
leader
behavior
will be effective in
Fielder’s Contingency Theory
• Belief that a leader’s behavior is
dependent upon the interaction of
the personality of the leader and the
needs of the situation
• The needs of the situation, or how
favorable the situation is, toward the
leader involves:
– Leader-member relationships
– The degree of task structure
– The attitudes of the followers
Leader-Member Relations
• Feelings and attitudes of followers regarding
acceptance,
leader
trust,
and
credibility
of
the
• Good leader-member relationships
− Followers
respect,
trust
confidence in the leader
and
have
• Poor leader-member relations
– Reflect distrust
– Reflect a lack of confidence and respect
– Dissatisfaction with the leader by the
followers
Task Structure
The degree to which work is
defined, with specific procedures,
explicit directions, and goals
High
task
structure
routine,
predictable,
defined work tasks
involves
clearly
Low task structure involves work
that is not routine, predictable, or
clearly defined
Position Power
The degree of formal authority
and influence associated with the
leader
High position power
Favorable to the leader
Low position power
Not favorable to the leader
Hersey and Blanchard’s Situational
Theory
• Addresses follower characteristics in
relation to effective leader beliefs
• Considers follower readiness as a factor
in determining leadership style
• Uses
behavior
and
relationship
behavior
• Types
– Telling leadership style
– Selling leadership style
– Participating leadership style
– Delegating leadership style
Path-Goal Theory
• Leader
works to motivate
followers and influence goal
accomplishment
• Leadership style is:
– Directive
– Supportive
– Motivating
Path-Goal Theory
• Provides
structure
through
direction and authority, with
leader focusing on task and
getting job done
• Leadership style is matched to
the situational characteristics of
the followers and situational
factors in the environment
Contemporary Approaches
Charismatic theory
Charismatic
leaders
have
selfconfidence and strength in their
convictions and communicate high
expectations
and
confidence
in
others
Transformational theory
Seeks to empower others to engage
in pursuing a collective purpose by
working together
Types of Leaders
Transactional
Concerned
operations
with
day-day
Transformational
Committed to a vision that
empowers others
Change agents
Communities of Practice
Forming informal groups
Using
group
process
of
organizing
Using principles of learning
Sharing information
Form by self-organization
They
come
together
naturally
The Knowledge Age
Rapid,
instant
access
to
information
Organizations
have
expert,
specialized knowledge workers
Will be influenced by three
trends
Mobility
Virtuality
User-driven practices
Key Trends
• Mobility
– The ability to change skill sets as well as
the work being dispersed
• Virtuality
– Working through virtual means using digital
networks
• User-driven practices
– Individual acts more independently and is
increasingly accountable for choices and
actions
BACK
The Health Care
Environment
<Insert Picture Here>
History of Health Care
• Advances
in health care science and
technology continually change what health
care can accomplish
• Many
problems in health care remain a
challenge
– Preventing the spread of disease
– Structuring organizations to benefit both
clinicians and patients
– Collecting and using data and information
to encourage improvement
– Understanding
how
external
forces
influence care delivery
Structuring Hospitals around
Nursing Care
• Nightingale
described the importance
structuring hospitals around nursing care
of
• The physical environment of hospitals can
create stress for patients, their families, and
clinical staff
• Designs of hospitals lead to improvements in:
Collecting Data
• Data can be collected through patient
records,
systems
surveys,
and
administrative
• Many reports are developed from this
data that provide valuable information
• Data
is displayed with charts and
pictures to emphasize the successes and
failures of health care throughout the
nation
Influence of External Forces on
Health
Care
• Health care is the largest sector of
our economy
• Employers,
clinicians, managers,
and patients all have a vested
interest in the proposed changes to
health care financing, organization,
and the responsibilities and scope
of practice for clinicians
Organization of Health Care
• Structure
– Resources or structures needed to deliver
quality care
(doctors, nurses, buildings,
medical records, pharmaceuticals)
• Process
– Quality activities, procedures, tasks, and
processes performed within the health care
structure (hospital admissions, surgery, nursing
care)
• Outcome
– The results of good care delivery
Goals of Good Health Care
• Ensure
that the health status of
everyone is the best that is possible
across the life span
• Health care must respond to patient’s
expectations of respectful treatment,
and there must be a patient focus by
health care clinicians
• Health
care must provide financial
protection for everyone regardless of
their ability to pay
Absence of a Universal Health Care
System
• United States is only one of a few
large countries without a universal
health care system
• Health
care is tied directly
having health insurance
to
• Leaves serious gap in health care
payment coverage for millions
Emphasis on Hospital Care
• The
emphasis on acute health care
services has driven health care costs
higher, but has not necessarily improved
the quality of care or outcomes
• Only eight out of one thousand people
will benefit from hospitalization
• Majority of people benefit from primary
health care delivery
Need for Primary Health Care
• Primary
care provides
accessible health care
integrated,
• Clinicians are accountable for:
– Addressing a large majority of
personal health needs
– Developing
a
sustained
partnership with patients
– Practicing in the context of family
and community
Primary Care
• Emphasizes seven features
–
–
–
–
–
–
–
Continuous
Comprehensive
Coordinated
Community oriented
Family centered
Culturally competent
Begun at first contact with the
patient
Foundations of Primary Care
• First contact
– Conduct the initial evaluation and define the
health dysfunction, treatment options, and goals
• Longitudinality
– Sustain a patient-clinician relationship over time
• Comprehensiveness
– Manage the wide range of health care needs
• Coordination
– Care through referrals and other providers is
integrated
The Federal Government
• Agency
for
Healthcare Research
and Quality (AHRQ)
• Centers for Disease
Control
and
Prevention (CDC)
• Centers for Medicare
and
Medicaid
Services (CMS)
• Food
and
Drug
Administration
(FDA)
• Health Resources and
Services
Administration (HRSA)
• Indian Health Service
(IHS)
• National Institutes of
Health (NIH)
• Substance Abuse and
Mental Health Services
Administration
(SAMHSA)
State and Local Levels
• Include the boards of health
and state and
departments
• Efforts
local
health
for bioterrorism and
disaster preparedness funding
have left little money focused
on public health needs
Home Health Care
• Fastest growing segment
of the health care delivery
system
• Almost as many persons
receive care in the home
as in acute care settings
Health Care Disparities
• Enabling
factors affect one’s
ability to have access to health
care
– Income
– Type of insurance coverage
– Gender
– Race or ethnicity
– Geographic proximity
– System characteristics
Health Care Spending
• In the United States, health insurance is
generally based on employment
• This leaves gaps between those with high
incomes and employment and those with
low income or no employment
• Providers of health care deliver service to
patients and bill third-party payers
• Health insurance distributes health care
funds from the healthy to the sick
Rising Health Care Costs
• By making health care more affordable, health
insurance has contributed to rising health
care costs
• Health care costs grow faster than wages
• Employees are bearing more of the financial
burden for their cost
• Underinsurance and cost sharing items reduce
health service utilization for both appropriate
and inappropriate medical services
Medicare and Other Health Care
Costs
• The elderly have virtually universal
health
care
Medicare
coverage
through
• This universal health care coverage
indicates the United States will
likely experience very rapid growth
in overall health expenditures in
coming years as the population
continues to age
Health Care Insurance
• People
are not covered because the
cost is too great
• As health care costs increase and rising
costs
cut
into
business
profits,
employers are choosing to offer fewer
insurance options
• Factors contributing to high numbers of
uninsured are people between jobs and
not being eligible for public programs
Medicare and Medicaid
• Public health programs are intended to fill the gap of
coverage
insurance
for
those
without
employer-based
• The Social Security Act of 1965 provided needed
services to uninsured populations
• XVIII Medicare
– Provides public insurance based on age 65 or
above
• XIX Medicaid
– Provides insurance for low income and/or disability
Other Public Programs
• American
Heritage
Indian
and
Alaska
Native
• The Indian Self-Determination Act of 1975
gave
tribal
organizations
the
responsibility for the provision of health
care services
• The Department of Defense
– Tricare
– Champus
– Department of Veteran Affairs
State Regulation of Health
Insurance
• Three
key
pieces
of
federal
legislation
set
forth
national
standards for individual states to
regulate health insurance
– Employee
Retirement
Income
Security Act (ERISA) 1974
– Consolidated
Omnibus
Budget
Reconciliation Act (COBRA) 1985
– Health Insurance Portability and
Accountability Act (HIPAA) 1996
The Rising Cost of Health Care
• 16%
of the Gross Domestic
Product (GDP) is spent on health
care
• Health care spending continues
to increase faster than the
overall U.S. economy
– It is growing at an annual rate
of 9.9%
Factors Contributing to Rising Health
Care Costs
• Aging population
– Average life expectancy is increasing
– Elderly are becoming the largest
group of the population
• Increased
utilization
of
pharmaceuticals
– Increased
utilizations,
cost
of
research, and increased insurance
coverage
Factors Contributing to Rising Health
Care Costs
• Technological advances
– Greater availability of new technology drive
per capita expenditures higher
• Rising hospital costs
– A large proportion of health care dollars are
devoted to hospital care
• Physician behavior
– Diagnostic tests and procedures may be done
which are not medically necessary
Factors Contributing to Rising Health
Care Costs
• Cost shifting
– Health care providers raise prices for
the privately insured to offset the
lower health care payments from both
Medicare and Medicaid and non
payment
• Administrative costs
– Information
technology
(IT)
has
played a role in improving quality, but
increasing costs
Forces that Affect Overall Health Care
Utilization
• Financial incentives that reward practitioners
• Increased accountability for performance
• Technological advances in the biological and
clinical sciences
• Increase in chronic illness
• Increased ethnic and cultural diversity
Forces that Affect Overall Health Care
Utilization
• Increased
population
ethnic
and
cultural
diversity
of
the
• Changes
in the supply and education of health
professionals
• Social morbidity
• Access to patient information
• Globalization and expansion of the world economy
• Cost control and competition for limited resources
Cost Containment Strategies
• Cost
containment
strategies
have
targeted the financing and reimbursement
of health care
• Reimbursement
containment strategies
use regulatory and competitive price and
utilization controls
– Capitation
– Patient cost sharing
– Utilization management
– Prospective payment
Capitation
• The
payment of a fixed dollar
amount, per person, for the
provision of health services to a
patient population for a specified
period of time
• Under
capitation, health care
organizations benefit from using
their financial resources to keep
people well
Prospective Payment
• The
Tax
Equity
and
Fiscal
Responsibility
Act
(TEFRA)
1982
mandated the Prospective Payment
System (PPS) to control health care
costs
• A method of reimbursement in which
Medicare payment is made based on
predetermined, fixed amount for
reimbursement to acute inpatient
hospitals and other health care
organizations
Health Care Quality
• Several
large
studies
have
produced information about the
poor quality of health care
attributable to misuse, overuse,
and underuse of resources and
procedures
– To Err Is Human 1999
– Crossing the Quality Chasm
2001
Health Care Variations
• Significant variations in health care
have been found to be associated
with:
– Geographic location
– Provider preferences and training
– Types of insurance
– Age, gender, and race
–
Availability
of
services
and
technology
– Patient adherence
Improvements in the Process of
Care
• Evidence-based care changes
lower health care dollars and
save lives
• These changes in the process
of care delivery can improve
the cost of health care and
reduce mortality rates
Performance and Quality
Measurement
• Measured to:
–
–
–
–
Determine resource allocation
Organize care delivery
Assess clinician competency
Improve health care delivery processes
• When
the quality of care is measured, it
improves
• Reliable methods and measures need to be
developed and tested to be able to measure
quality care
Public Reporting of
Performance
• Information can be used to determine where
there are health care deficiencies and poor
quality of care
• Can be used by major health care payers as a
condition
of
organization
• Used
doing
to influence
utilization behavior
business
clinician
with
and
an
patient
• Moves health care towards a population-based
approach
Institute of Medicine Health Care
Reports
• Institute of Medicine (IOM) 1996 launched
an effort to assess and improve the nation’s
quality of care
• Established
misuse,
services
the problems
and underuse of
as overuse,
health care
• Sets
vision for how to close the gap
between good quality care and what
actually exists
• Defined ten rules for care delivery redesign
Other National Quality Reports
• AHRQ National Healthcare Quality Report
(2005)
• AHRQ
National
Report (2205)
Healthcare
Disparities
• Healthy People 2010
• Health Grades for Hospitals and Physicians
• Leapfrog
Disease Management
•A
systematic population-based
approach to identifying persons
at risk, intervening with specific
programs of care, and measuring
clinical and other outcomes
• Many
patients
with
chronic
diseases have multiple chronic
conditions
Evidence-Based Practice
• Supplements clinical expertise with the
judicious
and
conscientious
implementation of the most current
and best evidence along with patient
values and preferences to guide health
care decision making
• Even when evidence-based quality care
guidelines are available, they are not
fully implemented in actual patient
care
Improvement of Health Care
Quality
• Patients need to participate in shared decision
making
• Care is customized according to patient’s needs
and values
• Care is patient centered
• Clinicians and patients communicate effectively
and share information
• Decision making is based on evidence
• Improved patient safety
Impact of Accreditation
• A
mechanism
organizations
standards
• Accreditation
is
used
meet
to
ensure
that
certain
national
provided
by
The
Joint
Commission
• Accreditation is linked to:
– The ability to serve Medicare beneficiaries
– Meeting patient safety goals
– Hospital regulations by the Centers for
Medicare and Medicaid Services
The Magnet Program
• Provided by The Magnet Recognition Program
of the American Nurse Credentialing Center
• Recognizes excellence in nursing services as
a health care system
• Positive nursing outcomes are:
– Increased job satisfaction
– Improved retention
– Prevention of job burnout
– Improvement in perceived quality of care
Improving Quality through Health Professions
Education
• Needs an “overhaul” of curriculum to
transform current skills and knowledge
• Curriculum
includes training clinicians
to:
– Effectively work in interdisciplinary
teams
– Have an educational foundation in
informatics
– Deliver patient-centered care with an
evidence base
Current Practices
• Limited by the use of external
oversights of credentialing,
certification, and licensure
• These oversight processes are
generally
oversight
clinicians
not part of the
of
individual
Keeping Patients Safe
• Critical factors in patient safety
– Organizational
management
practices
– Strong nursing leadership
– Adequate nurse staffing
• The nursing shortage is affected by:
– The aging nursing workforce
– Lack of qualified faculty
– Lower nursing wages
Doctorate of Nursing Practice
• Relatively new
• May
supplant current masters
level
nurse
practitioner
programs
•A
challenge
is
to
clearly
establish the scope of work and
reimbursement for DNPs
Organizational Behavior
and Magnet Hospitals
<Insert Picture Here>
Definition of Organization
• A
coordinated
and
deliberately
structured social entity
– Consists of two or more people
– Functions on a relatively continuous
basis to achieve a predetermined set
of goals
• An
organization’s
long-term
effectiveness may be determined by
its ability to anticipate, manage, and
respond to changes in its environment
High Performance Organizations
• Value people as human assets, respect diversity,
and empower individuals to use their talents to
advance personal and organizational performance
• Mobilize
teams that
talents of its members
build synergy from the
• Successfully bring people and technology together
• Thrive on learning
• Are achievement-oriented
Magnet Hospital
• Voluntary credentialing process
• Health care organization that has
met
the
rigorous
nursing
excellence requirement of the
American Nurses Credentialing
Center (ANCC), a division of the
American
Nurses
Association
(ANA)
Goals of Magnet Recognition
• Promote
quality in a milieu that
supports
professional
nursing
practice
• Identify excellence in the delivery of
nursing services to patients
• Provide
a
mechanism
for
the
dissemination of best practices in
nursing services
Characteristics of Magnet
Nursing
Services
• High-quality
patient
care
• Clinical autonomy and responsibility
• Participatory decision making
• Strong nurse leaders
• Two-way communication with staff
Characteristics
• Community involvement
• Opportunity and encouragement
of professional development
• Effective use of staff resources
• High levels of job satisfaction
Essentials of Magnetism
• Opportunities to work with other nurses who are
clinically competent
• Good
nurse–physician
communication
relationships
and
• Nurse autonomy and accountability
• Supportive nurse manager-supervisor
• Control
over
environment
nursing
• Support for education
• Adequate nurse staffing
practice
and
practice
Forces of Magnetism
• Quality nursing leadership
• Organizational structure
• Management style
• Personnel polices and programs
• Professional models of care
• Quality of care
• Quality improvement
Forces of Magnetism
• Consultation and resources
• Autonomy
• Community and the hospital
• Nurses as teachers
• Image of nursing
• Interdisciplinary relationships
• Professional development
Magnet Appraisal Process
• Establish database to collect data on nursing-
sensitive indicators (measures that reflect the
outcome of nursing actions)
• Benchmark
• Conduct gap analysis
• Receive written application
• Visit site
• Award decision
BACK
Basic Clinical Health
Care Economics
<Insert Picture Here>
Principles of Economics
• Scarcity
– Resources exist in finite quantities, and
consumption demand is typically greater than
resource supply
• Choice
– Decisions are made about which resources to
produce and consume among many options
• Preference
– Individual and societal values and preferences
influence the decisions that are made
Health Care Difference
• In a typical market, the buyer is also the
payer
• In health care, the payer is not the provider
or the buyer
• The
actual payer is the third-party
reimburser (the insurance company or
government)
• The end result is a skewed financial picture
Traditional Perspective on Cost of
Health Care
• Health care as altruism
– Altruism: the unselfish concern for
the welfare of others
– Ethics: the doctrine that the
general welfare of society is the
proper goal of an individual’s
actions
– Early nursing generally focused on
altruistic service, which evolved
from early charitable institutions
Traditional Perspective on Cost of
Health Care
• Need
for health care determined by
provider
– Paternalistic model of governance and
control
– Health professionals controlled medical
knowledge and skill
– Knowledge and skill required extensive
and expensive education not shared with
“outsiders”
– Health care professionals determined
what health care was needed and what to
charge for it
Traditional Perspective on Cost of
Health Care
• Right to health care at any cost
– Prior
to
1960s,
Americans
considered health care a “right”
– American government established
Titles XVIII (Medicare) and XIX
(Medicaid) of the Social Security
Act, to control spiraling health
care costs
– Private insurers established their
own requirements, beginning the
overall budgeting of health care
Traditional Perspective on Cost of
Health Care
• Cost plus
– Includes actual cost incurred
by
provider
plus
profit
incentive
– Incentive was “the more you
spend the more you get”
rather than “how can this be
accomplished
more
economically?”
Contemporary Perspective on Cost of
Health Care
• Health care as a business
– HCFA and TEFRA, which established
government payments at flat rates
(prospective payment)
– Emphasis
among
providers
on
providing
care
for
less
than
prospective
payment,
thereby
making profit
– Cost became the focus of managers,
administrators, and employees at all
levels of health care
Contemporary Perspective on Cost of
Health Care
• Need for care determined by the consumer
– Emphasis on cost has led to concerns
that safety and quality have suffered
– Total quality improvement (TQI) and
continuous quality improvement (CQI)
were initiated to assure society that cost
management was not compromising
safety or quality
– Emphasis on involvement of patients,
health care consumers, and allied health
care providers
Contemporary Perspective on Cost of
Health Care
• Right
to
health
care
at
reasonable cost
– Insurers
determine
reasonable cost
– Lack of consensus on what
constitutes reasonable cost
is
at
the
heart
of
contemporary controversy
Contemporary Perspective on Cost of
Health Care
• Managed care
– Integrates financial and clinical care
delivery functions into a single
organized system by contracting to
be responsible for the clinical
outcomes of an enrolled population
for a fixed fee
– Emphasizes delivery of a coordinated
continuum of services across the
care spectrum from wellness to
death, using financial incentives to
achieve cost efficiency
Contemporary Perspective on Cost of
Health Care
• Managed care
– The only health services program generated
from a market response, rather than from a
formal
federal
government
legislative
initiative
– Is not about providing healthcare; it is
about being a for-profit brokerage business
– Care is rationed through requirements such
as preapproval, physician choice, and
copayment
• Coordinated
care is replacing the term
“managed care”
Contemporary Perspective on Cost of
Health Care
• Socialized health care
– In theory, socialized medicine
provides complete medical
and hospital care to all the
citizens in a community,
district, or nation (universal
access)
– Funding
usually
comes
through taxation of citizens
Future Perspective on Cost of
Health Care
• Future costs may be affected
by
expensive
technologies,
new
diseases,
and
an
increasingly aged population
• Changes in demographics and
cost may affect the way health
care is provided
The Cost Equation: Money = Mission =
Money
• There must be cohesion and consistency
across the mission, vision, and strategic
plan for the business
• The health care facility must determine
what is the cost in achieving its mission
• The health care facility must decide if
providing health care services not
directly related to the mission is a viable
option
Business Profit
• Revenue (income) minus cost (expense) equals
profit
• Every
business must generate more income
than it spends in order to remain in business
• For-profit business
– The profit is distributed to stockholders and
to maintain and grow the organization
• Not-for-profit business
– All monies are fed back into the business
– All profit is referred to as margin
Fundamental Costs
• Direct cost
–
Directly related to patient care
(wages and supplies)
• Indirect cost
– Not explicitly related to care, but
are necessary to support care
(utilities, maintenance)
Fundamental Costs
• Fixed cost
– One that exists irrespective of the
number of patients for whom care is
provided
• Variable cost
– Varies with the volume of patients
– Can increase or decrease with
volume of patients or costs of
supplies
Cost Analysis
• Budget
– A plan for how much will need to be spent in the
ensuing time period (generally one year)
• It is based on:
– What is known about how much was spent in the
past
– How that will inevitably change in the coming
year
• A cost prediction is a tool for developing a budget
High-Low Cost Analysis
• Not extremely accurate, but provides
“good enough” estimate
• Examines both fixed and variable cost
information from the most recent five
years for each category of expense
• Both fixed and variable dollars must
be adjusted upward to account for
inflation
Regression Analysis
• More precise than high-low analysis
• Examines
all
available
past
cost
information over a specific time period
• Only one dependent variable: cost
• Only one independent variable: volume,
which causes change in cost
• All cost information plotted on a vertical
axis
Regression Analysis
• All
volume information
horizontal axis
plotted
on
a
• Scatter diagram results
• Straight
line through scatter diagram
best approximating all the points is used
to predict cost at a specific volume of use
• Analysis is carried out for each item for
which cost needs to be predicted
Break-Even Analysis
• Projecting whether and when profitability
will be achieved is necessary for both
proposed and well-established programs
and services
• Break-even analysis assists the provider in
predicting the volume of services that
must be provided (and for which payment
must be received) in order for the cost of
providing the services to be equally
matched by the payment received, yielding
neither a profit nor a loss
Diagnostic, Therapeutic, and Information
Technology Cost
• The most expensive items on the total
budget are diagnostic, therapeutic, and
information technologies
• Managed
care programs have begun
requiring
justification
for
and
preapproval
of
use
of
complex,
expensive technology
• Concerns
have arisen about rationing
technology to those who can afford to
pay
Nursing Cost
• Fiscally, nursing is viewed as a cost center that
does not independently generate revenue
• Ongoing efforts to measure and establish the
cost of the various components of nursing care
are disappointing
• Nursing cost is associated with budgeted and
actual nursing care hours per patient day
– A measure of time rather than a measure of
type or level of care
Patient Classification System
(PCS)
• The
tool most broadly used to identify
nursing cost
– A system for distinguishing patients
based on their acuity, functional ability,
or resource needs
• Patients with similar requirements for care
are assigned to five progressively weighted
categories of acuity
– The higher the acuity of the patients, the
more nursing resources the PCS assigns
Relative Value Unit (RVU)
• An
index number assigned to
various health care services based
on the amount of resources used
• This
approach
provides
a
reasonably accurate per patient
costing approach
– It does not account for the
differences in costs based on the
type of health care worker
Quality Measurement
• An evidence-based concept of quality
– Grounded on scientific evidence that a diagnostic
or therapeutic approach to care improves patient
outcomes
• Four core components
– A mechanism that establishes consensus about
what constitutes best practices
– Strong feasible processes to accomplish such
practices
– A disease prevention and health promotion
component
– A system to review actual performance and
outcomes
Regulatory Oversight
• The quality industry measures and
tracks organizational performance
– The primary accrediting body is
The Joint Commission
– Accreditation signifies that the
organization meets the standard
of practice and influences market
perception
Customer Satisfaction
• No matter how superior providers
feel their product is, if customers
perceive it not to be needed or
wanted, the product will fail
• Commercial surveys measure how
satisfied customers are with their
care,
environment,
and
interactions with the staff
Health Care Site Economics
• Economics focuses on how choices
are made to overcome a scarcity of
resources
• Requires:
– Redesigning
– Restructuring
– Reengineering
Health Care Provider
Economics
• Economic risk is borne by individuals, as well
as by organizations
• Individual providers receiving direct payment
from insurers bear risk when they must lower
their usual fees to a flat rate in order to be
included for payment by the HMO
• Patients bear the risk of being unable to
access services they regard as either optimal
or as minimal, jeopardizing their health
Evidence-Based
Health Care
<Insert Picture Here>
History of Evidence-Based Care
• Initially began in Canada
• Evidence-based care
– The process of providing clinically
competent care that is based on
the
best
scientific
evidence
available
• Includes all health disciplines
Implementation of Evidence
Practice
• Find a source of evidence-based content
that is developed using good research
techniques
• The evidence-based content itself must
be efficient for clinicians to use at the
bedside
• Integrate
the evidence-based content
into order sets, plans of care, and
documentation forms
The ACE Star Model of Knowledge
Transformation
• Provides
a
framework
for
systematically putting evidence-based
practice into operation
• Star points
– Knowledge discovery
– Evidence summary
– Translation
into
recommendations
– Integration into practice
– Evaluation
practice
Research Terminology
• Absolute benefit
•
•
•
•
•
increase
Best practice
Case-control
study
Clinical practice
guidelines
Cohort study
Control group
• Correlational
•
•
•
•
•
•
research
Dependent variable
Descriptive
research
Evidence-based
health care
Follow-up study
Health outcomes
Independent
variable
Research Terminology
• Integrative review
• Longitudinal study
• Prospective study
• Qualitative
analysis
• Quantitative
analysis
• Nonexperimental
• Quasi-experiment
research
• Number needed to • Randomized
clinical trial
treat
• Relative risk
• Outcomes
research
• Research
utilization
• Matching
• Meta-analysis
Research Terminology
• Retrospective design
• Systematic review
• Time series design
• Translation
• Treatment effect
• Variable
Importance of EBC
• There is a lack of agreed-upon standards or
processes that are based on evidence
• EBC
is a process approach to collecting,
reviewing,
interpreting,
critiquing,
and
evaluating research
• Leads
to a state-of-the-art integration of
knowledge and evidence that can be
evaluated and measured through outcomes
• Should be viewed as the highest level of care
Nursing and EBC
• The
agency for Healthcare Research
and Quality (AHRQ) launched twelve
evidence-based practice centers
• The initiative partnered with public and
private organizations to improve the
quality,
effectiveness,
and
appropriateness of care
• Nurses work with patients in deciding
treatment options
Attributes of EBC
• Need to define the meaning of evidence in
each health care agency
– Use the term in daily practice
– Look for best evidence when evaluating
new goals and programs
• Fundamental principles in EBC
– Evidence alone is never sufficient to
make a clinical decision
– Evidence-based care involves a hierarchy
of evidence to guide decision making
Challenges for Nurses
• Rapidly growing body of scientific
literature
– No unaided human being can
read, recall, and act effectively on
the volume of material
• Literature is not in a form that is
suitable for application to practice
– Needs to be evaluated and
transformed in order to be useful
Conducting Evidence Reports in
Nursing
• Select problem
• Review the evidence
• Summarize the evidence
• Report results
• Make
recommendations
for
potential clinical applications
• Implement
agreed-upon
practice changes
Promoting Evidence-Based Best
Practices
• The
U.S. health care system
does
not
have
uniform
definitions of what constitutes
efficient,
effective,
quality
health care
• It is difficult to get all clinical
health care providers to apply
EBC processes at the unit level
Promoting Evidence-Based Best
Practices
• EBC processes must be uniform
enough to be valid, but also
adaptable to specific needs of
institutions
• EBC
requires involvement of
and
collaboration
between
clinical practitioners and health
care researchers
Nursing and Health
Care Informatics
<Insert Picture Here>
Nursing Informatics
• Recognized specialty group who function
to integrate nursing, its information, and
information
management
with
information
processing
and
communication technology to support
the health of people worldwide
• The use of information technology by
nurses carrying out their duties in
relation to any function in the purview of
nursing
Focus of Nursing Informatics
• Technology focused
• Conceptually focused
• Role oriented
E-health
• Multiple functions
– Health
care
and
information
delivered or enhanced through
the Internet
– Involves
medical
informatics,
public health, and business
– Commitment
for
networked,
global thinking to improve health
care
locally,
regionally,
and
worldwide
Telehealth
• Delivery
of
health-related
services and information via
telecommunications
technology
• May be simple or complex
Elements of Nursing
Informatics
• Computerized order entry
• Electronic health record
• Patient decision tools
• Laboratory and x-ray results
• Electronic
prescribing and order
entry including barcoding
• Community and population health
management and information
Elements of Nursing
Informatics
• Communication,
administrative systems
staffing,
• Evidenced-based
knowledge
information retrieval systems
and
and
• Quality improvement data collection/data
summary systems
• Documentation and care planning
• Patient monitoring and problem alerts
Implementation of Health Information
Technologies
• Standards needed so all health care
providers
can
share
patient
information which is timely, patientcentered, and portable
• Office of the National Coordinator for
Health Information Technology (ONC)
established 2004
• The
Joint Commission established
National Patient Safety Goals
Recommended Changes
• Care based on continuous healing
•
•
•
•
•
•
•
•
relationships
Customized care based on patient needs
and values
The patient as the source of control
Shared knowledge and the free flow of
information
Evidenced-based decision making
Safety as a system property
The need for transparency
Anticipation of needs
Continuous decrease in waste
Core Competencies
• Provide patient-centered care
• Work in interdisciplinary teams
• Employ evidenced-based practice
• Apply quality improvement
• Utilize informatics
Specialty of Nursing
Informatics
• Use decision-making systems or artificial intelligence
to support the nursing process
• Use
software
organizations
application
to
support
health
care
• Integrate IT into patient education
• Use computer-aided learning for nursing education
• Develop and use nursing databases
• Use
research
related
to
nurses’
management and communication
information
Clinical Information System
• A computer-based system
– Used to inform clinicians about
tests, procedures, and treatment
– Used to improve the quality of
care through real-time assistance
in decision making
– Used to increase the efficiency
and effectiveness of care delivery
– Can
be
patient
focused
or
department focused
Computerized Patient Records
• Replacement for the paper record
• Permits health information to be used
to
support
the
generation
communication of knowledge
and
• Multiple functions and requirements
– Capture data
– Store data
– Process and retrieve data
Information Communication
• Interoperability
of systems and
linkages for exchange of data
across disparate systems
• Must be secure
• Security
functions
must
be
designed to ensure compliance
with applicable laws, regulations,
and standards
Security
• Privacy
– The right of individuals to keep information
about themselves from being disclosed to
anyone
• Confidentiality
– Limiting disclosure of private matters
• Security
– The means to control access and protect
information from accidental or intentional
disclosure to unauthorized persons
Trends in Computing
• Computer literacy
– The knowledge and understanding
of computers combined with the
ability to use them effectively
• Information literacy
– The
understanding
of
the
architecture of information
– The ability to navigate among
print and electronic tools
Virtual Reality
• Allows a person to see, move through,
and react to computer-simulated items
or environments
• Has
allowed surgeons to develop
minimally invasive surgical techniques
• PDA
software has the potential to
bring evidence-based care to the
bedside
Using the Internet for Clinical
Practice
• Information can be presented in
different forms and different
languages
• Provides
different organization
structures
for
information
storage
and
access
to
accommodate user’s preference
and need
The P-F-A Assessment
• Purpose-Focus-Approach
• Determine your purpose (why are you doing
the search?)
• Focus of the search may be:
– Broad or general
– Lay oriented
– Narrow and technical
• The
purpose combined with the focus will
determine the approach to the search
Strategies for Internet
Searches
• Use Web sites published by governmental or
professional organization
• Use
consumer health sites organized by
medical librarians
• Use precise terms
• Draw on search engines
• Refine your Internet searches with filters
Evaluating Internet Material
• Use critical-thinking skills
• Evaluate with PLEASED
–
–
–
–
–
–
–
Purpose
Links
Editorial
Author
Site navigation
Ethical Disclosure
Date last updated
BACK
Population-Based
Health Care Practice
<Insert Picture Here>
182
Population-Based Health Care
Practice
• The
development, provision, and
evaluation of multidisciplinary health
care services to population groups
experiencing increased health care
risks or disparities
• It involves partnership with health
care consumers and the community
in order to improve the health of the
community and its population groups
Population-Based Health Care
Practice
• Vulnerable population groups
– Subgroups of a community
that
are
powerless,
marginalized,
and
disenfranchised
and
are
experiencing
health
disparities
Population-Based Health Care
Practice
• Health
risk factors are variables that
increase or decrease the probability of
illness or death
• Health determinants are variables that may
cause changes in the health status of
individuals or groups and include:
– Biological factors
– Psychosocial factors
– Environmental factors (physical and social)
– Health systems factors or etiologies
Goals of Population-Based Health
Care
• Improvement of access to health care
services
• Improvement of quality of health care
services
• Reduction of health disparities among
different population groups
• Reduction of health care delivery costs
Outcomes Measurement
• Population health status
• Quality of life
• Functional health status
Health Status
• Health status
– The level of health of an individual, family,
group, population, or community
• Quality of life
– The level of satisfaction one has with the
actual conditions of one’s life
• Health-related quality of life
– Refers to one’s level of satisfaction with
those aspects of life that are influenced by
one’s health status and health risk factors
Functional Health Status
• Functional health status
– The ability to care for oneself and meet one’s
human needs
• Activities of daily life
– Activities
related
to
toileting,
bathing,
grooming, dressing, feeding, mobility, and
verbal and written personal communication
• Instrumental activities of daily living
– Related to
home management, financial
management,
seeking
health
care,
and
meeting spiritual needs
Health Determinant Models
• Provide
conceptual tools to use in
assessing and addressing the priority
health needs of at-risk population groups
• Healthy
People 2010 emphasizes four
key
elements
to
achieve
health
improvement
– Goals
– Objectives
– Determinants of health
– Health status
Health Disparities
• Differences in health risks and health
status measures that reflect the poorer
health
status
that
is
found
disproportionately
in
certain
population groups
• Leads to unequal burdens in disease
morbidity and mortality rates borne by
racial and ethnic groups in comparison
to the dominant racial or ethnic group
in society
Health Care Systems
Disparities
• Differences in health care system
access and quality of care for
different
racial,
ethnic,
and
socioeconomic population groups
that persist across settings, clinical
areas, age, gender, geography, and
health needs and disabilities
• Result
in
outcomes
poorer
health
care
Major Health Indicators
• Physical activity
• Overweight/obesity
• Tobacco use
• Substance abuse
• Responsible sexual behavior
• Mental health
• Injury and violence
• Environmental quality
• Immunizations
care
and
access
to
health
Culturally Inclusive Health Care
• U.S. population is becoming more diverse
• Ethnic minorities in the United States who
have been marginalized from mainstream
society experience more health care
disparities
and
increased
rates
of
morbidity, mortality, and burden of disease
• The proportion of ethnic minorities in the
registered
nurse
workforce
in
2004
continues to lag behind the proportion of
ethnic minorities in the U.S. population
Barriers in the Workplace
• Lack of awareness of differences
• Lack of time
• Ethnocentrism
• Bias and prejudice
• Lack of skills to address differences
• Lack of organizational support
Culturally Inclusive Health Care
System
• One
in which health care is
population based
• Requires significant change in
the current health care system
• Will require increased diversity
in the health care workforce
Population-Focused Nursing
Practice
• Nursing activities that focus on all
of
the
people
and
reflect
responsibility to and for the people
• Focus is on:
– Maximizing health status
– Maximizing functional abilities
– Improving the quality of life of
groups of health care consumers
Population-Based Nursing
Practice
• The practice of nursing in which the focus of
care is to improve the health status of
vulnerable or at-risk population groups
within the community by employing health
promotion
and
disease
prevention
interventions across the health continuum
• Holistic in nature
• Seeks
to empower population groups by
enhancing their protective factors and
resiliency
Protective Factors
• Client
strengths and resources are
used to combat health threats that
compromise core human functions
• Resilience
– The social and psychosocial capacity
of individuals and groups to adapt,
succeed, and persevere over time in
face
of
recurring
threats
to
psychosocial and physiologic integrity
Population-Based Nursing Practice
Model
• Population-based
interventions
three levels:
– Community
– Systems
community
– Individuals,
groups
encompass
within
the
families,
and
Population-Based Nursing Practice
Interventions
• Initiate
a
assessment
community
health
• Provide nursing interventions in a
culturally sensitive and appropriate
manner
• Apply the nursing process in working
with
communities,
organizations,
and population groups
Nontraditional Model of Population-Based Nursing
Practice
• Vulnerable
or at-risk populations are
identified before community assessment
• Subsequent
community
assessment
focuses on health determinants related
to the at-risk groups
• Traditional
model
assesses
community needs first, and
population needs second
overall
at-risk
Nursing Process Applied to Population-Based Nursing
Practice
•Assessment
•Diagnosis
•Planning and implementation
•Evaluation
Assessment
• Community level
– Physical environment
– Social environment
– Policies and interventions
• Health systems level
– Access to quality health care
– Behavioral
– Data analysis
Diagnosis
• Identify
North
American
Nursing Diagnosis Association
(NANDA) category
• Identify etiology and list key
evidence supporting diagnostic
category
Planning and Implementation
• Select
based
model
and employ populationnursing
intervention
• Examples
of population-based
nursing intervention models:
– Minnesota model
– Virginia model
Evaluation
• Program
evaluation is integral part of
evaluation process
• Justification of resources and budget is
necessary
• Cost benefit analysis is appropriate
• Evaluate access, quality, cost, and equity
• Collect data and develop statistics
• Share
results
with
multidisciplinary
teams, health consumers, and community
partnerships
• Identify
unmet
needs
and
further
interventions
BACK
ersonal and Interdisciplina
Communication
<Insert Picture Here>
Trends in Society that Impact
Communication
Increasing social diversity
Changing/differing beliefs
Aging population
Shift to computerized
communication
Elements of the Communication
Process
Communication is an interactive
process that occurs when a
person (the sender) sends a
verbal or nonverbal message to
another person (the receiver) and
receives feedback
Influenced by emotions, needs,
perceptions, values, education,
culture, goals, literacy, cognitive
ability, and the communication
mode
Health Insurance Portability and
Accountability Act
Became law 1996
Privacy Rule enacted 2003
Protects
all
individually
identifiable health information
held or transmitted by a
covered entity or business
associate, in any form or
media,
whether
electronic,
paper, or oral
Law lists 18 personal health
Modes of Communication
Verbal
Spoken
Nonverbal
Facial expressions, posture, gait, body
movements, position, gestures, and
touch
Electronic
Uses electronic media that do not have
characteristics of the other modes
Electronic Communication
• Plays an increasing dominant role in health care
• Accurate
spelling,
correct
grammar,
and
organization
of
thought
assume
greater
importance in the absence of verbal and
nonverbal cues that are given in face-to-face
encounters
• Always
proofread correspondence prior to
sending it
• Keep the message brief and use standard font
Levels of Communication
Public
Communication with a group
people with a common interest
of
Intrapersonal
Internal communication within an
individual
Interpersonal
Communication between individuals,
person to person, or in small groups
Organizational
Communication
Avenues of communication are
often defined by an organization’s
formal structure
Downward:
communication
originates at top or upper levels
of
organization
and
works
downward
Upward:
communication
originates at some level below
the top of the structure and
moves upward
Organizational Communication
Lateral:
communication occurs among
people at similar levels within the
organization
Diagonal:
communication occurs when
people who may be on different levels of
the organizational chart communicate
with each other
Grapevine: an informal and unstructured
avenue of communication; major benefit
is speed, but its major drawback is its
unreliability
Communication Skills
Attending: active listening
Responding: verbal and nonverbal
acknowledgment of the sender’s
message
Clarifying:
communicating
as
specifically as possible to help the
message become clear
Confronting: working jointly with
others to resolve a problem or
conflict
Barriers to Communication
Gender
Men and women may process information
differently
Culture
Different cultures may have different
beliefs, practices, and assumptions
Anger
An irrational response that arises from
irrational ideas: awfulizing, can’t-stand-ititis
,
shoulding
and
musting,
and
undeservingness and damnation
Barriers to Communication
Incongruent responses
When words and actions in a
communication do not match the inner
experience
of
self
and/or
are
inappropriate to the context
Conflict
Arises when
opposed
ideas
or
beliefs
are
Offering false reassurance
Promising something that cannot be
delivered
Barriers to Communication
• Being defensive
– Acting as
attacked
though
someone
has
been
• Stereotyping
– Unfairly categorizing someone based on his
or her traits
• Interrupting
– Speaking before other has completed his
or her message
Barriers to Communication
• Inattention
– Not paying attention
• Stress
– A state of tension that gets in the way of
reasoning
• Unclear expectations
– Ill-defined tasks or duties that make
successful
completion
of
the
communication unlikely
Overcoming Communication
Barriers
• Understand the receiver
• Communicate assertively
• Use two-way communication
• Unite with a common vocabulary
• Elicit verbal and nonverbal feedback
Overcoming Communication
Barriers
• Enhance listening skills
• Be sensitive to cultural
differences
• Be sensitive to gender differences
• Engage in meta-communication
Use of Language in the
Workplace
• Oral language is used to verbally communicate
with patients and other health care professionals
• Great diversity in spoken languages
• Title VI of the Civil Rights Act of 1964 entitles an
individual seeking health care who has limited
English proficiency to have an interpreter
available to facilitate communication
• Language assistance needs to be comprehensive
Generational Differences in
Communication
• Can
create
tensions
among
workers because of the divergent
outlooks on life
• Generations working together
–
–
–
–
Matures, veterans
Baby boomers
Generation X
Generation Y
Literacy
• Health
literacy represents the cognitive
and social skills that determine the
motivation and ability of individuals to gain
access to, understand, and use information
in ways that promote and maintain good
health
• It is an outcome of health promotion and
health education efforts
• Most health care materials are written at
the 10th grade level; most adults read
between an 8th and 9th grade level
Workplace Communication
• Superiors
Observe professional courtesies
Dress professionally
Arrive for the appointment on time
Be prepared to state the concern
clearly and accurately
Provide supporting evidence and
anticipate resistance to any requests
Separate your need from your desires
State a willingness to cooperate in
finding a solution and then match
behaviors to words and persist in the
pursuit of a solution
Workplace Communication
Coworkers
Report
patient
information
accurately,
informatively,
and
succinctly
Remember professional courtesies
Be mindful of an appropriate time
and place to share your concerns
Do unto others as you would have
them do unto you
Delegate clearly and effectively
Offer positive feedback
Workplace Communication
Physicians, nurse practitioners, and other
health care professionals
Strive for collaboration, keeping the
patient goal central to the discussion
Present
information
in
a
straightforward manner
Remain calm and objective even if the
physician does not cooperate
Follow the institution’s procedure for
getting the patient treated and then
document the actions taken
Workplace Communication
Patients and families
Use
touch
as
a
way
to
communicate caring and concern
Occasionally, language barriers
will limit communication to the
nonverbal mode
Be
open
and
honest
while
respecting patients and families
Honor
and
protect
patients’
privacy with both actions and
words
Workplace Communication
Between mentor and prodigy
Mentor’s wisdom shared through
counseling,
encouraging
and
seeking the novice out
Mentor can anticipate challenges
for novice and make suggestions
for how to manage them
Use
role-playing,
where
the
mentor describes a theoretical
situation and allows the novice to
practice her response
BACK
Politics and Consumer
Partnerships
<Insert Picture Here>
Politics
• Predominantly a process by which
people use a variety of methods to
achieve their goals
• Methods
inherently involve some
level of competition, negotiation,
and/or collaboration
• Politics exist because resources can
be limited and some people control
more resources than others
Stakeholders and Health Care
• Stakeholders
– Vested interest groups who control
health care resources
• All
these stakeholders tend to exert
political pressure on health policy makers
in an effort to make the health care system
work to their economic advantage
• Nurses can garner consumer support for
professional nursing positions to help
patients and help the profession of nursing
by tapping into strong consumer support
Stakeholder Groups
• Insurance companies
• Consumer groups
• Professional organizations
• Health care groups
• Educational groups
Why Should the Professional Nurse Be Involved in
Politics?
• All nurses and patients are affected on a
daily basis by public policy, as well as by
the political actions of other stakeholders
in the health care system
• By
understanding the influence of both
internal and outside pressures on nursing
practice and patients, nurses are more able
to support what is most important to them
• To be able to advocate for health care for
those who have little or no voice
The Politics and Economics of Human
Services
• All
health care is inextricably linked to
politics and economics, as well as to the
availability and services of providers
• Health care in the United States depends
heavily on a continual supply of resources
from both public and private sectors
• If nurses fail to exert political pressure on
the health policy makers, nursing will lose
ground to others who are more politically
active
Health Policy
• Formulated,
enacted, and enforced through
political processes at the local, state, or federal
level
• Local
level
policies
are
established
and
implemented by an individual hospital board or
directors of a hospital system
• State policy governs nurses by defining nursing
practice, education, and licensure
• Federal policies include the rules and regulations
governing Medicare and Medicaid funding
Cultural Dimensions of Partnerships and
Consumerism
• If nurses intend to form partnerships with
consumer groups distinguished by cultural
heritage, racial makeup, and/or ethnic
background, they must understand and
value diversity
• Nurses
can work with the consumer
movement to combine traditional consumer
concerns with a wider sense of civic rights
and responsibilities, and move culturally
related health care issues to the forefront
of politics
Politics and Demographic
Changes
• The fastest growing consumer group is the
elderly
• Many seniors are joining consumer groups to
have a greater political voice, to influence
health policy decisions, and to ensure that
they receive the health care services they
will need for years to come
• AARP
constitutes
a
growing
political
powerhouse and an ideal consumer partner
for nursing in many ways
Nurses as Political Activists
• Nurses
who are politically active have a
definitive voice in their work environments
for
patient
welfare,
as
well
as
for
themselves
• As nurses develop politically, they come to
understand the need for political strategy
• Nurses join professional organizations and
actively participate to ensure a more
collective, unified voice supporting health
care issues
Political Roles for Nurses
• Nurse individual
– Sets goals to strengthen nursing as a profession
• Nurse citizen
– Votes and writes members of Congress and state
legislators on issues of interest
• Nurse activist
– Active member of professional organization
• Nurse politician
– Runs for political office
Advocacy and Consumer
Partnerships
• Nurses must understand the political
forces that define their relationships
with consumers
• Nurses
can
work
with
their
professional organizations to promote
the role of the nurses as consumer
advocates in health policy arenas
• The concept of patient advocacy is a
fundamental aspect of nursing
The Nurse as Political Activist
• To be most effective politically, nurses
must be able to clearly articulate at
least four dimensions of nursing to any
audience or stakeholder:
– What nursing is
– What distinctive services nurses
provide to consumers
– How nursing benefits consumers
– What nursing services cost in
relation to other health care services
Essential Dimensions of
Nursing
• Establishing a caring relationship that
enhances healing and health
• Focusing
on
the
full
range
of
experiences and human responses to
illness and health within both the
physical and social environment
• Appreciating the subjective experience
and the integration of such experience
with objective data
Essential Dimensions of
Nursing
• Diagnosing and intervening in care
by using scientific knowledge,
judgment, and critical thinking
• Advancing
nursing
knowledge
through scholarly inquiry
• Influencing social and public policy
to promote social justice
Advocacy and Consumer
Partnerships
• Consumers expect the best people to be
health care providers, but are confused
about what the roles and responsibilities
of professional nurses entail
• Nurses are responsible for ensuring that
consumers understand the critical role
nurses play as consumer advocates and
political activists in health care politics,
as well as what nurses do as direct care
providers
Advocacy and Consumer
Partnerships
• Working
through
their
professional organizations, nurses
can collaborate with consumer
groups
by
creating
formal
partnerships,
which
serve
to
promote the role of nurses as
consumer advocates in health
policy
arenas,
as
well
as
strengthen the political position of
both partners
Making Health Care More ServiceOriented
• As
recipients of health care are
required to pay a larger portion of the
cost
for
health
care
services,
consumers are demanding to be
treated as something more than
passive recipients of health care
• Nurses, working through professional
organizations, have been strong, early
supporters
for
patient
rights,
regardless of the patient’s ability to
pay
Making Health Care More ServiceOriented
• Any
political vision to make
health care more consumerfriendly and service-oriented
must address cost, access,
choice, and quality
Turning a Consumer-Oriented Vision into
Reality
• Nurses have opportunities to be more
than
supporters
of
a
consumeroriented vision for health care; they
can be co-creators of it
• Nurses must have a clear image of the
vision, develop a sound philosophy,
demonstrate intelligent and strategic
thinking, and wield more political
influence
Turning a Consumer-Oriented Vision into
Reality
• Health
care operates in a
political context of rapid change
and high financial risks
• Stakeholders who are willing to
take the greatest risks are
afforded the most opportunities,
pending
good
timing
and
appropriate political action
The Consumer Demand for
Accountability
• People who will own the future of
health care must address the
growing problem of accountability
• Most people comprehend that being
accountable requires being held
responsible for one’s behavior,
decisions,
and
affiliations
with
others
The Consumer Demand for
Accountability
• Health
care professionals, including
nurses, depend upon each other to
ensure the quality, consistency, and
overall effectiveness of health care
within their work environments
• The practice of nursing is based on a
social contract with society that gives
nurses
certain
rights
and
responsibilities
and
requires
that
nursing is accountable to the public
Credibility and Politics
• To
have
credibility,
nurses
must
demonstrate professional competence and
a degree of professional accountability that
exceeds consumer expectations
• Nurses
gain credibility through more
education, higher level functioning, and
greater accountability
• As
consumer
advocates,
nurses
are
accountable
to
the
public
and
the
profession beyond a particular employment
setting
Helping Consumers Make Better Health Care
Choices
• Nurses have a professional responsibility to
help consumers make better health care
choices and not fall victim to misleading
information, quick cures, or dangerous
practices
• Beyond advocacy for an individual patient or
a patient group, nurses can work to create a
more supportive health care environment
that encourages input and feedback among
the various stakeholders or constituencies
Helping Consumers Make Better Health Care
Choices
• If nurses believe that what they
do for consumers is essential or
highly
valuable, nurses
must
manifest
strategic
political
behaviors
and
take
political
actions for consumers of health
care services
New Challenges and Better
Opportunities
• Nurses strengthen their political position by
sharing accountability for health care problems
with other health care providers
• Effective
dialogue among professionals and
individuals being served by those professionals
takes time and considerable effort to build
• An understanding of the perspectives of the
people being served is vital for real social
change to occur
New Challenges and Better
Opportunities
• When a consumer group forms a
political
coalition
with
other
groups such as nurses in a given
community, the political influence
of both is strengthened
• Consumer
partnerships
will
become more critical for all
stakeholders in health care
BACK
Strategic Planning
and Organizing
Patient Care
<Insert Picture Here>
− A formal expression of the purpose or
reason for existence of the organization
• Philosophy
− A value statement of the principles and
beliefs that direct the organization’s
behavior
• Values
− May be formally stated and explicit, or
may
be
implicit
and
part
of
the
organizational culture
Strategic Planning
• A strategic plan is the sum total or outcome
of the processes by which an organization
engages in environmental analysis, goal
formulation, and strategy development with
the purpose of organizational growth and
renewal
• Provides unified vision and goals for the
organization
• Helps ensure that the needed resources are
available to carry out initiatives
Steps in Strategic Planning
Process
• Perform environmental assessment
• Conduct stakeholder analysis
• Review literature for evidence-based best practices
• Determine congruence with organizational mission
• Identify planning goals and objectives
• Estimate resources required for the plan
• Prioritize according to available resources
• Identify timelines and responsibilities
• Develop marketing plan
• Write and communicate business plan/strategic plan
• Evaluation
Environmental Assessment
• A situational assessment requiring a broad
view
of
the
environment
organization’s
current
• An external assessment
– Is broadly based and attempts to view
trends and future issues and needs that
could impact the organization
• An internal assessment
–
Seeks to inventory
assets and liabilities
the
organization’s
SWOT Analysis
• Tool
for
assessments
conducting
environmental
• Identifies both strengths and weaknesses in
the internal environment and opportunities
and threats in the external environment
• Stands for
–
–
–
–
S –Strengths
W –Weaknesses
O – Opportunities
T – Threats
Community and Stakeholder
Assessment
•A
stakeholder is any person, group, or
organization that has a vested interest in the
program or project under review
• A systematic consideration of all potential
stakeholders to ensure that the needs of
each of these stakeholders are incorporated
in the planning phase
• When stakeholders are not involved in the
project planning, they do not get a sense of
ownership
Other Methods of Assessment
• Surveys/questionnaires
– Used when large numbers of stakeholders
and general idea of the options are available
• Focus groups/interviews
– Focus groups: small groups of individuals
with a common characteristic who meet in a
group and respond to questions about a topic
– Time-consuming and expensive to conduct
– Work best when the topic is broad and the
options are not as clear
Other Methods of Assessment
• Advisory board
– Benefits large projects
– Board members come from various
constituencies affected by project
– Has no formal authority, but reviews
plan and makes recommendations
Other Methods of Assessment
• Review
of
literature
on
similar
programs
– Should
be
completed
prior
to
strategic planning or beginning any
new project or program
– Allows project team to identify similar
programs,
their
structures
and
organization, potential problems and
pitfalls, and successes
– Ongoing process
Other Methods of Assessment
• Best practices
– Identify best practices or evidencebased innovations that have been
adopted with success by other
organizations
– Nurses planning to develop a new
program need to carefully examine
the existing evidence and practices
prior to beginning the planning
Other Assessments
• Planning goals and objectives
– Prioritize according to strategic importance,
resources required, and time and effort
involved
– Set timeline
• Develop a marketing plan
– Communicate
the
plan,
the
goals,
and
objectives
– Design, implement, train, and evaluate the new
program
– Assures that all stakeholders have the needed
information
Organizational Structure
• Organizations are structured or
organized
to
facilitate
the
execution
of
their
mission,
strategic plans, reporting lines,
and communication within the
organization
• Functions on a continuum with
levels of authority
Types of Organizational
Structures
• Communicated
by the use of an
organizational chart
• Types
– Matrix
– Flat versus tall
– Decentralized versus centralized
•
•
•
•
•
•
•
•
Other Characteristics to Use as a
Framework
Division of labor
Roles and responsibilities
Reporting relationships
Basis for division of labor
Functional division of labor
Geographic area
Product or service
Primary nursing
– New programs, services, or product
lines
– Change in leadership
• Technology
• Socio-cultural environment
• Size
– The larger an organization, the more
complex the structures needed
Factors Influencing Organizational Structures
• Repetitiveness of tasks
– If there is a great deal of differentiation
among
tasks,
more
levels
of
management are usually needed
• Trends in organizations
– There is a need for leadership that
promotes sound ethical values and
quality assurance
– Transformational nurse leaders are
needed to assist nurses to strive for
quality outcomes and personal mastery
BACK
Effective Team
Building
<Insert Picture Here>
Definition of a Team
• A
small number of people with
complementary
skills
who
are
committed to a common purpose,
performance goals, and approach
for
which
they
are
mutually
accountable
• Teams exist for specific purposes
Types of Teams
• Multidisciplinary or interdisciplinary
– Comprised
of
varied
disciplines
contributing to an individual patient’s care
– Team works closely and communicates
frequently
– Allows the disciplines to work together
collaboratively
• Committees
– Teams serve on several types of
committees, which are created for specific
goals or tasks
– The goal is to improve patient care
Advantages of Teamwork
• Promotes safe and efficient patient care
•
•
•
•
•
delivery
Creates
effective
interprofessional
communication
Equalizes
power
through
shared
governance
Improves interpersonal relationships and
job satisfaction
Promotes free exchange of ideas, team
cohesion, trust, and mutual respect
Improves stability in employee satisfaction
Disadvantages of Teamwork
• May take longer to achieve a goal
than one individual
• Team
members
may
have
disagreements on the best course of
action
• Teams
develop
through
timeconsuming predictable stages of
selecting the right members for the
team, organizing team goals and
manpower, and team collaboration
• Some
team members may lack
interest, motivation, or skills to
participate in the team process
Informal Teams
• Can
influence the organization
either positively or negatively
• Are not directly established or
sanctioned by the organization,
but often form naturally
• Can become very powerful
• Often responsible for facilitating
improvements in the working
conditions
Stages of Group and Team
Process
• Forming stage
• Storming phase
• Norming phase
• Performing stage
• Adjourning phase
Forming Stage
• Occurs when the group is created and
they meet as a team for the first time
• They
explore the purpose of the
team, why they are called to be part
of a team, and what contribution they
can bring to the table
• Proceed to establishing team goals
and expectations
Storming Stage
• As
the group relaxes into a more
comfortable team setting, interpersonal
issues or opposing opinions may arise to
cause conflict between the members
• Conflict is healthy and a natural process
• Must openly confront issues and conflict
• Real teams don’t emerge unless individuals
on them take risks involving conflict, trust,
interdependence, and hard work
Norming Stage
• A feeling of group cohesion develops
• Team members master the ability to
resolve conflict
• Team
members learn to respect
differences of opinion and work
together
• Overcoming barriers to performance is
how groups become teams
Performing Stage
• Group
cohesion, collaboration,
solidarity are evident
and
• Personal opinions are set aside in order
to achieve group goals
• Team
members
are
openly
communicating, know each other’s roles
and responsibilities, are taking risks,
and trusting and relying on each other
Adjourning Stage
• Termination
and consolidation occur in this
stage
• The team reviews their activities and evaluates
their progress
• The
team leader summarizes the group’s
accomplishments and the roles each member
played in achieving these goals
• It
is important to provide closure so each
member leaves with a sense of accomplishment
A Winning Team
• Achieved when there is synergy
– Things
work
together
harmoniously
– The whole is greater than the
sum of the parts
– The needs and characteristics
of a patient, clinical unit, or
system are matched with the
nurse’s competencies
Conducive Teamwork
Environment
• Requires ongoing time and effort
• Facility design allows for collaboration and
interaction
• Social factors
– Clear identification and ownership of the
team goal
– Clear definition and acceptance of each
person’s roles and responsibilities
– Clear delineation of team processes
– Clear opportunities to build trust
Team Communication
• Ambassador activities
– Communicate with those in the hierarchy
– Used to protect the team from outside
pressures
• Task coordinator activities
– Communicate with lateral levels in the
organization
• Scout activities
– Occur in general ideas
– Scanning in the external environment
Team Size
• Team size affects performance in that
too few or too many affect performance
– Communication
and
coordination
problems increase with large teams
– Smaller teams have lower incidence
of social loafing
– Individuals in large teams are able to
maintain anonymity and gain from
the work of the group without making
a suitable contribution
Status Differences
• Status is the measure of worth conferred on
an individual by a group
– High-status
members
initiate
communication
more
often
and
are
provided more opportunities to participate
– A lower-status member may be ignored or
intimidated
• Status differences have significant impacts
on patient outcomes
• Need to build a trust-sensitive environment
Psychological Safety
• Describes
individual’s perceptions
about
the
consequences
of
interpersonal risks in their work
environment
• Created by mutual respect and trust
among team members
• Describes
a
climate that fosters
productive
discussion
and
nonpunitive action
Qualities of Effective Team
Members
• Proactive
• Motivated
• Take
responsibility
for
one’s
actions, decisions, and behavior
• Seize initiatives to do whatever is
necessary to get the job done
consistent with correct principles
Qualities of Effective Team
Leaders and manage
• Will organize, facilitate,
the
entire team
• Must understand how various learning
styles, cultural diversity, and personality
differences play into the dynamics of
teamwork
• Have good communication skills, conflict
resolution skills, and leadership skills
•
Qualities of Effective Team
Leaders
Focus the team
on outcome
improvement
• Track reports
• Recognize contributing members
Guidelines for Meetings
• Set a time frame for the meetings and stick to it
• Review the progress
• Help group members feel comfortable with one
•
•
•
•
•
•
•
another
Establish ground rules
Get a report from each member
Sustain the flow of the meetings
Manage the discussion
Work to avoid groupthink
Close
the
meetings
by
summarizing
accomplishments
Identify a time frame for future meetings
Avoiding Groupthink
• Occurs when the desire for harmony and
consensus overrides members’ rational
efforts to appraise the situation
• The consequences of groupthink are that
teams may limit themselves to one
possible solution and fail to conduct a
comprehensive analysis of a problem
• Team leaders can help avoid groupthink
Symptoms of Groupthink
• The illusion of invulnerability
• Collective rationalization
• Belief in the inherent morality of the team
• Stereotyping others
• Pressures to conform
• The use of mindguards
• Self-censorship
• Illusion of unanimity
BACK
Power
<Insert Picture Here>
Definitions of Power
• The
ability to create, get, and/or
resources to achieve one’s goals
use
• Power can be defined at various levels
– Personal,
cultural,
organizational
professional,
or
• Power at the personal level is closely linked
to how an individual perceives power, how
others perceive the individual, and the
extent to which an individual can influence
events
Levels of Power
• Personal
– Derives from characteristics of the individual
• Professional
– Conferred on members of the profession by
one another and the larger society to which
they belong
• Organizational
– One’s position in an organizational hierarchy
– Being authorized to function powerfully
within an organizational culture
Power and Accountability
• Accountability is considered one of the major
hallmarks of the health care professions
• Nurses
have accountability and direct
responsibility for decisions made and actions
rendered
• Effective nurses see power as positive and
view their ability to understand and use
power as a significant part of their
responsibilities to patients, coworkers, the
nursing profession, and themselves
Sources of Power
• Diverse,
and
vary
situation to another
• A
from
one
combination of conscious and
unconscious factors that allow an
individual to influence others to do
as the individual wants
• Multiple types of power
Expert Power
• Derived from the knowledge and skills a
nurse possesses
• The less acknowledged that experts are
in a group, the less effective their expert
powers become
• Visible
reciprocal acknowledgment of
expertise
among
group
members
balances
power
and
enhances
productivity
Legitimate Power
• Power that is derived from a position a
nurse holds in a group, and it indicates
the nurse’s degree of authority
• The more comfortable nurses are with
their legitimate power as nurses, the
easier it is for them to fulfill their role
• Nurses in authority are expected to
use what authority they have and may
be punished for not doing so
Referent Power
• Power
derived from how much
others respect and like any
individual, group, or organization
• Nurses
who are identified with
respected,
trustworthy
individuals or groups will benefit
from referent power by virtue of
such identification
Reward Power
• The ability to reward or punish others, as
well as to create fear in others to
influence them to change their behavior
• Also referred to as coercive power
• Rewards are not likely to permanently
change attitudes
• Withholding rewards or achieving a goal
by instilling fear in others often results in
resentment
Connection Power
• The
extent
to
which
connected with others
others
are
• Leaders can dramatically increase their
influence by understanding that people
are attracted to those with power and
their associates
• Nurses should work to resolve issues at
the appropriate level before they take
their concerns to a higher level of
authority
Information Power
• The ability to influence others with the
information they provide to the group
• Nurses must share knowledge that is
both accurate and useful
• Information sharing can improve patient
care, increase collegiality, enhance
organizational
effectiveness,
and
strengthen
one’s
professional
connections
Positive Personal Orientation to
Power
• A person’s desire for power takes
one of two forms
– An orientation toward achieving
personal
gain
and
selfglorification
– An orientation for achieving gain
for others or the common good
Empowerment
•A
process of power sharing by
involvement in the decision-making
process
• A process of personal growth and
development
• Something positive, or highly desirable
to be aspired to, advocated for, or
attained
• Nurses disempower themselves if they
see nurses or nursing as powerless
Power and the Media
• There
is a relationship between
power and perception
• The media can be used to create or
change perceptions
• The way the media present nursing
to the public will empower or
disempower nursing
• Nurses must work to consistently
use the media as effectively as
other more powerful occupational
groups
Power Development
• Understanding power from a variety of
perspectives is not just important for
nurses professionally, it is important for
them personally as well
• It allows nurses to gain control of their
work and personal lives
• Three ways to imagine the future
– What is possible
– What is probable
– What is preferred
Power and the Limits of
Information
• To make good decisions, nurses must
be able to gather enough information
and realistically interpret its value, as
well as share and apply information in
a safe competent manner
• Effective
nurses understand time
constraints and set priorities to
ensure that what is most important
receives the most attention
A Framework for Becoming
Empowered
• Personal
– Find a mentor
– Introduce yourself to powerful people in
your personal and professional life
– Find and maintain evidenced-based
sources of ongoing information
– Seek answers to questions
– Notice who holds power in your
personal,
professional,
and
organizational life
– Make and evaluate a plan
A Framework for Becoming
Empowered
• Professional
– Assess patient’s condition using relevant
objective measurements
– Collaborate with administrators, other
nurses, physicians, and other health care
workers involved in the care of your
patients
– Join
your
professional
nursing
organization
– Collaborate
with
significant
others,
friends, and members of the patient’s
family
A Framework for Becoming
Empowered
• Organizational
– Actively monitor and improve patient
care quality
– Volunteer for committee assignments
that will challenge you to learn and
experience
more
than
what
is
expected of you in a staff nurse role
– Evaluate your plans
– Volunteer to be involved with health
care at the local, state, and national
levels
Power and Decision Making
• Power and decision making are intricately
connected
• Emphasis on cost containment in health
care has created opportunities for nurses
• Nurses’
knowledge
allows
them
to
participate in health care and costcontainment discussions, giving them
more opportunities for decision making
• This, in turn, gives nurses greater power
The Power of Critical Thinking
• Critical thinking enables nurses to
understand more and to find better
information
• Effective nurses can take information
they have acquired in the past and
apply it to their present situation
• Power
is
associated
with
transforming thought into action
BACK
Change,
nnovation, and Conflic
Management
<Insert Picture Here>
Definition of Change
• Change
– Making something different than it
was
• In
many instances, the outcome
remains the same, but the process is
changed
• Living
organisms must constantly
adapt to changes in the environment
in order to thrive
•
The Changing Health Care
Environment
Access to information
has transformed
the relationship between the patient
and health care providers
• Evidence-based practice is changing the
way decisions are made regarding
health care treatment and how nursing
care is delivered
• Changing
demographics within the
population have resulted in a diversity
of cultures and languages
The Changing Health Care
• The aging Environment
of the baby boomers
• The
rising costs of health care
services
• The underinsured/noninsured
• Patient safety
Types of Change
• Personal change
– Voluntary change with the goal of
self-improvement
• Professional change
– Deliberate change with the goal of
improving professional ability/status
• Organizational change
– A planned change in an organization
to improve efficiency
Traditional Change Theories
• Lewin’s force-field model
• Lippitt’s phases of change
• Havelock’s six-step change model
• Rogers’ diffusion of innovations
theory
Lewin’s Force-Field Model
• Unfreezing
– The current or old
something is flawed
way
of
doing
• Moving
– The intervention or change is introduced
and explained
• Refreezing
– The new way of doing is incorporated
into the routines or habits of the people
affected
Lippitt’s Phases of Change
• Diagnosis of the problem
• Assessment of the motivation and capacity for change
• Assessment of the change agent’s motivation and
resources
• The selection of progressive change objectives
• Choosing an appropriate role for the change agent
• Maintenance of the change once it has been started
• Termination of the helping relationship
Havelock’s Six-Step Change
Model
• Planning stage
– Build a relationship, diagnose the
problem, and acquire resources
• Moving stage
– Choose
the
acceptance
solution
and
• Refreezing stage
– Stabilization and self-renewal
gain
Rogers’ Diffusion of Innovations
Theory
• Five-step
innovation/decision-making
process
– Awareness, interest, evaluation, trial,
adoption
• Believes change can be rejected initially
and adopted at a later time
• Believes change is reversible and initial
rejection does not mean the change will
never be adopted
Commonalities among the Change
Models
• All the theories relate to the process
of “unfreezing, moving, freezing”
• Many of the theories describe linear
processes that move in a step-bystep manner
Differences among the Change
Models
• Some theories do not work well
in
complex
situations
or
nonlinear
• Some theories work better for
one type
another
of
change
than
Chaos Theory
• Belief that chaos is not random, but
may have order
• Order emerges through fluctuations
and chaos
• Nurses and organizations must be
able to organize and implement
change quickly and forcefully
• Does not work well for linear change
Learning Organization Theory
• Emphasis is on interrelationships of
all parts of the organization
• Organizations respond to changes
by using a learning approach
• Focus
on
communication,
education, and cooperation among
all parts of organization
The Change Process
• Planned change in the work environment is
similar to planned change on a personal level
• Basic reasons to introduce change
– To solve a problem
– To improve efficiency
– To reduce the unnecessary workload for
some group
• To plan change, one has to know what has to
be changed
Steps in the Change Process
• Assessment
• Planning
• Implementation
• Evaluation
Assessment
• Identify
the
problem
or
the
opportunity
for
change
• Collect and analyze data
• Data collection and analysis should come from
different sources
– Structural (physical space or configuration)
– Technological (lack of wall outlets, poorly
situated computer locations, lack of computers)
– People
(commitment of
staff,
levels
of
education, and interest in the project)
Planning
• Identify
the who,
when of change
how,
and
• Identify the target date
• Goals
and outcomes clearly
determined
and
stated
in
measurable terms
Implementation
• Plan goes live
• Provide information
• Competency-based education
• The
benefits stated
outcomes
actually
materialize
as positive
begin
to
Evaluation
• The
effectiveness of the change is
evaluated according to the outcomes
identified during the planning and
implementation steps
• The most overlooked step
• Time intervals for evaluation should be
identified and allowed to elapse before
modifications and declarations of failure
are asserted
Responses to Change
• The more the relationships or social
mores are challenged,
resistance to change
the
more
• Factors affecting resistance to change
– Trust
– The ability to cope with change
– Evaluation
of
the
immediate
situation
– Anticipated consequences of change
– Individual’s stake
Responses to Change
• Innovator
– Change embracer; enjoys the challenge;
often leads change
• Early adopter
– Open and receptive, but not obsessed
with change
• Early majority
– Enjoy and prefer the status quo, but do
not want to be left behind
Responses to Change
• Late majority
– Followers; often skeptics
• Laggards
– Last group to adopt change; prefer
tradition
• Rejectors
– Openly oppose and reject the change
The Change Agent
• Leads the change process
• Manages
•
•
•
•
•
•
•
•
the
change
process
and
group
dynamics
Understands the feelings of the group
Maintains momentum and enthusiasm
Maintains vision of change
Communicates change, progress, and feelings
Knowledgeable about the organization
Trustworthy
Respected
Intuitive
Innovation
• The process of creating new services
or products
• Change and innovations are different
– Change deals with any modification
– Innovation is restricted to new
modifications in ideas and practices
• Innovation is a team event
Types of Change Strategies
• Power-coercive
– Uses authority and threat of job loss to
gain compliance with change
• Normative-reeducative
– Uses social orientation and the need to
have satisfactory relationships in the
workplace as a method of inducing
support for change
– Focuses on the relationship needs of
workers
Types of Change Strategies
• Rational-empirical
– Uses knowledge as power base
– Assumes that once workers
understand the organizational
need or the meaning of the
change they will change
Conflict
• Two or more parties holding differing
views about a situation
• Disagreement
about something of
importance to each person involved
• Ability
to resolve conflict is an
important part of change management
• Conflict is not necessarily bad
Sources of Conflict
• Allocation/availability of resources
• Personality differences
• Differences in values
• Internal/external pressures
• Cultural differences
• Competition
• Differences in goals
• Issues
control
of
personal/professional
Types of Conflict
• Intrapersonal
– Disagreement in philosophy
values, policy or procedure
• Interpersonal
– Personality conflict
• Organizational
– Competition for resources
or
The Conflict Process
• Antecedent conditions
• Perceived and/or felt conflict
• Manifest behavior
• Conflict resolution or suppression
• Resolution aftermath
Meaning of Conflict
• Individuals form an idea or concept
of what the conflict is about
• Four aspects of conflict
–
–
–
–
Facts
Goals
Methods of goal achievement
Values or standards used
select the goals or methods
to
Conflict Management
• Avoiding
– Ignoring the conflict
• Accommodating
– Smoothing or cooperating
– One side gives in to the other side
• Competing
– Forcing
– The two or three sides are forced to
compete for the goal
Conflict Management
• Compromising
– Each side gives up something and gains something
• Negotiating
– High-level discussion that seeks agreement
– Not necessarily consensus
• Collaborating
– Both sides work together to develop optimal
outcome
• Confronting
– Immediate and obvious movement to stop conflict
at the very start
Strategies to Facilitate Conflict
Management
• Open, honest communication
• Private,
relaxed,
setting for discussion
• Expectation
comfortable
of
compliance
results by both sides
to
Leadership and Management
Roles
• Model conflict resolution behaviors
• Lessen perceptual differences of parties
• Assist
parties
techniques
to
identify
resolution
• Create environment conducive to conflict
resolution
• If conflict cannot be resolved, minimize or
lessen perceptions of conflicting parties
BACK
Budget Concepts for
Patient Care
<Insert Picture Here>
Types of Budgets
• Operational budget
– Account for the income and expenses
associated with day-to-day activity within a
department or organization
• Capital budget
– Account for the purchase of major new or
replacement equipment
• Construction budget
– Developed
when
renovation
structures are planned
or
new
Budget Overview
• Operational budget
– A financial tool that outlines anticipated
revenue and expenses over a specified period
• Accounting
– An activity that managers engage in to record
and report financial transactions and data
• Profit
– Determined by the relationship of income to
expenses
Budget Overview
• Dashboard
– A documentation tool providing a
snapshot image of pertinent
information
and
activity
reflecting a point in time
• Variance
– The difference between what was
budgeted and the actual result
Budget Preparation
• Budgets are generally developed for a
12-month period, or yearly cycle
• The yearly cycle can be based on a
fiscal
year
determined
by
organization or a calendar year
the
• Prior to the beginning of the budget
year,
most
organizations
devote
approximately 6 months to preparing
and developing an operational budget
Budget Preparation: Competitive
Analysis
• Probes into how the competition is
performing as compared
health care organizations
to
other
• Examines other hospitals or practices
strengths or weaknesses
• This
information
can
influence
decisions regarding implementation
of new programs, hiring of specialty
staff, and purchasing equipment
Budget Preparation: Regulatory
Influences
• Centers for Medicare and Medicaid Services
– Federal control over quality assurance, and
fraud and abuse prevention
• Department of Health and Human Services
– Coordinates health care policy and legislation
• Food and Drug Administration
– Regulates the use of drugs and medical devices
• The Joint Commission
– Ensures organizations meet specific standards
Strategic Plans
• Maps
out the direction for
organization over several years
the
• Guides the staff at all levels so that
the entire organization can have a
shared mission and vision with clearly
defined steps to meet the goals
• Each
department
develops
unitspecific plans to help the organization
follow its overall strategic plan
Scope of Service and Goals
• Hospital
systems are frequently divided into
subsections or units, commonly called cost
centers
– Each cost center defines its own scope of
service
– Departmental
goals
may
include
the
introduction of new technology, facilities, or
services
– The manager is responsible for identifying the
expenses associated with patient care up front
so they will be covered by the charge
• Charge
– The dollar amount the patient is responsible
for paying as a result of service
Budget History
• History or past performance is typically used
as a baseline of experience and data to better
understand activity in a department or unit
• Buying
contracts are negotiated so that
predetermined reduced rates can be realized
when organizations purchase large quantities
of supplies
• Knowledge about historical volume provides a
perspective as to how a department has grown
or declined over time
Revenue
• Income generated through a variety of means
– Billable patient services
– Investments
– Donations to the organization
• Reimbursement
rates of third-party payers
affect revenue and continue to change from
year to year
• The
reimbursement
rates
or
payments
received by hospitals often do not equal the
actual unit charges for the services rendered
Revenue
• Payer mix
– Third-party
payer
reimbursement rates
– Diagnosis-related
groups
(DRGs)
– Partial or nonpayment from
uninsured
Expenses
• Determined
by identifying the cost
associated with the delivery of service
• Expenditures are resources used by an
organization to deliver services
– Labor
– Supplies
– Equipment
– Space
– Utilities
Supplies
• Expenses are commonly broken down into
line items
• Line items
– Represent
specific
categories
that
contribute to the cost of the procedure
or activity, e.g., paper supplies, medical
supplies, drugs, etc.
• Zero-based budgeting
– Details every supply item and quantity
of items typically used
Labor
• Health care services are very labor
intensive
• Salaries and benefits account for
approximately 50%
operational costs
to
60%
of
Staffing Models
• The amount and types of staff are
often accounted for in a staffing
model
– Market wages and benefit costs
– Types of staff (RN, LPN, CAN, etc.)
– Staff-to-patient ratio
– Recruitment and training costs
• Unproductive time usually includes
sick, vacation, personal, holiday,
and education time
Direct and Indirect Expenses
• Direct expenses
– Those expenses that are directly
associated
with
the
patient
(medical and surgical supplies and
drugs)
• Indirect expenses
– Items such as utilities (gas,
electric, phones) that are not
directly related to patient care
Fixed and Variable Costs
• Fixed costs
– Those expenses that are constant and
are not related to productivity or
volume
(building
and
equipment
depreciation, utilities, fringe benefits,
and administrative salaries)
• Variable costs
– Fluctuate depending upon the volume
or census and types of care required
Budget Approval and
Monitoring
• Approval process
Budgets are submitted to administration
for review and final approval
May take several months
• Control of budget
Responsibility
of
unit
or
department
manager
Budget monitoring is generally carried out
on a monthly basis
Budget analysis is conducted to determine
if expenses are kept within the budget
allotted amount
Variance Reports
• A budget variance report is a tool
used to identify when budget
categories are out of line and what
corrective action can be taken
• Some
institutions request that
budget dashboards be developed
reflecting departmental activity at
a glance
BACK
Effective Staffing
<Insert Picture Here>
Determination of Staffing
Needs
• Patient
census was historically
used to determine staffing needs
• Has proven to be inaccurate, since
patient care needs vary greatly
• Better matching of patient needs to
nursing resources is now an
important financial quest in health
care institutions
Core Concepts
• Full-time
equivalent (FTE) is a
measure of the work commitment of
an employee who works 5 days a
week or 40 hours per week for 52
weeks per year; some agencies
consider 36 hours (three 12-hour
shifts)
full time
• FTE hours are a total of all paid time
Core Concepts
• Productive hours
– Hours worked and available for patient care
• Nonproductive hours
– Benefit time such as vacation, sick time, and
education time
• Direct care
– Time spent with hands-on care to patients
• Indirect care
– Time spent with activities that support patient
care
Units of Service
•A
variety of volume measures
used to reflect different types of
patient encounters as indicators
of nursing workload
• Used
in budget negotiations to
project nursing needs of patients
and to assure adequate resources
for safe patient care
Nursing Hours per Patient Day
(NHPPD)
• A standard measure that quantifies the
nursing time available to each patient
by available nursing staff
• NHPPD reflects only productive nursing
time available based on:
– Midnight census
– Past unit needs
– Expected practice trends
– National benchmarks
– Budget negotiations
Patient Classification Systems
• Patient classification system (PCS)
– A
measurement
tool
used
to
determine the nursing workload for a
specific patient or group of patients
over a specific period of time
• Patient acuity
– The measure of nursing workload that
is generated for each patient
Patient Classification Systems
• Nurse intensity
– A measure of the amount and
complexity
of
nursing
care
needed by a patient
• Patient turnover
– A measure
admission,
discharge
reflecting
transfer,
patient
and
Factor Classification Systems
• Use units of measure that equate to
nursing time
• Attempt
to
capture
assessment,
planning, intervention, and evaluation
of patient outcomes along with
written documentation processes
• Are
the most popular
classification system
type
of
Factor Classification Systems
• Advantages
– Data readily available for day-to-day operations
– Provide information against which one can justify
changes in staffing requirements
• Disadvantages
– Create an ongoing workload for the nurse in
classifying patients every day
– Problems with “classification creep”
– Do not capture patient needs for psychosocial,
environmental, and health management support
– Calculate nursing time based on a “typical”
nurse
Prototype Systems
• Allocate nursing time to large patient groups
based on an average of similar patients
• Advantage
– Reduction of work for the nurse by not
classifying patients daily
• Disadvantages
– No ongoing measure of the actual nursing
work required by individual patients
– No ongoing data to monitor the accuracy of
the preassigned nursing care requirements
Utilization of Classification System
Data
• Can
be utilized by staff and managers
planning nursing care over the next 24 hours
for
• Essential for preparing month-end justification
for variances in staff utilization
• Used to cost out nursing services for specific
patient populations and global patient types
• Information useful in negotiating payment rates
with third-party payers
• Used in preparing the budget
Considerations in Developing a
Staffing Plan
• Benchmarking
– A
tool
used
to
compare
productivity across facilities to
establish performance goals
– Does not always reflect quality of
care indicators that can link
quality patient care outcomes to
productivity measures
– Can be helpful in establishing a
starting point for a staffing
pattern
Considerations in Developing a
Staffing Plan
• Regulatory requirements
– One controversial issue is nurse
staffing levels
– Mandated nurse staffing plans are
enacted by law
• The Joint Commission does not regulate
staffing levels
– Does assess staffing effectiveness
– Requires organizations to monitor
four of twenty-one specified indicators
Considerations in Developing a
Staffing Plan
• Skill mix
– The percentage of RN staff to other direct
care staff
– Should vary according to the care that is
required and the care delivery model utilized
• Staff support
– The supports in place for the operation of
the unit or department (a systematic
process to deliver medications, patient
transport services, secretarial services, etc.)
Establishing a Staffing Plan
• Articulates how many and what kind of staff
are needed by shift and day to staff a unit or
department
• Two ways of development
– Determine the ratio of staff to patients;
nursing hours and total FTEs are then
calculated
– Determine the nursing care hours needed
for a specific patient or patients and then
generating
the
staff-to-patient
ratio
needed to provide the care
Inpatient Unit
• An inpatient unit is a hospital unit that is able
to provide care to patients 24 hours a day, 7
days a week
• Using data from all your sources, you can build
a staffing pattern that will meet the needs of
the patients, the staff, and the organization
• Average daily census
– The total numbers of patients at census time,
usually midnight, over a period of time, e.g.,
weekly, monthly or yearly, and dividing by the
number of days in the time period
Determining the FTEs Needed to Staff an
Episodic Unit
• Episodic care units
– Units that see patients for defined
episodes of care
– Examples
are
dialysis
and
ambulatory care units
• Start with an assessment of the hours
of care required by the patients
• Add FTEs to cover days off and benefit
time
Scheduling
• Scheduling
responsibility
manager
of
staff
is
the
of
the
nurse
• The manager must ensure that
the
schedule
places
the
appropriate staff on each day
and shift for safe, effective care
Considerations for Staffing
• The patient type and acuity
– The higher the patient acuity, the more
consistent the staffing needs are across
shifts
• The experience of the staff
– Novice nurses take longer to accomplish the
same task than an experienced nurse
– An experienced RN can handle more
workload and higher acuity patients
• Good staffing requires putting the patient first
Scheduling
• Volume
– Patient volume numbers reviewed for
peaks and valleys in the census and
patient acuity
– Scheduling adjustments are necessary
• Experience and capability of staff
– Different
degrees
of
knowledge,
experience, and critical thinking skills
– Number of inexperienced staff (add hours)
– Number of experienced staff
– Need for staff with special skills
Shift Variations
• Traditional staffing patterns
– Generally 8-hour shifts
– Start
times
may
vary
organization or nursing unit
by
• Shift variations occur to meet the
needs of patients and the staff
– 12-hour shifts
– Weekend programs
Concerns for Scheduling
• Impact on patient care
– Possible disruption of continuity of care
– Weekend staff should be familiar with
patients and recent care events
• Financial implications
– Weekend programs are more expensive
than traditional staffing patterns
– They are a recruitment and retention
tool for nursing leadership
Self-Scheduling
• A
process in which unit staff take
leadership in creating and monitoring
the work schedule while working within
defined guidelines
• Increasing
staff control over their
schedule is a major factor in nurse job
satisfaction and retention
• Has
been associated with sick time
usage
Implementing Self-Scheduling
• Form a committee made up of unit staff
who report to the manager
• Define the roles
and responsibilities of
each committee member
• Establish generic boundaries regarding
fairness, fiscal responsibility, evaluation
of the self-scheduling process, and the
approval process
• Educate the staff
Evaluation of Staffing
Effectiveness
• Patient
outcomes
and
nurse
staffing
– Studies have found consistent
significant
relationships
between nurse staffing and
some patient outcomes
– Certain outcomes are affected
negatively when nurse staffing
or skill mix is inadequate
Evaluation of Staffing
Effectiveness
• Nurse staffing and nurse outcomes
– Effect
of
staffing
on
nurse
performance
should
also
be
considered
– Track staff’s perception of staffing
adequacy
– Provide
ability
for
staff
to
communicate concerns in written and
verbal form
– Track recommended staffing versus
actual staffing
Models of Care Delivery
• Care delivery models
–
Organize
patients
the
work
of
caring
for
• The
decision for which care delivery
model is used is based on the needs of
the
patients
and
availability
of
competent staff
• Managers
have the responsibility to
implement models and evaluate the
outcomes in their areas
Total Patient Care
• Total patient care
– The nurse is responsible for
the total care for his or her
patient assignment for the
shift he or she is working
Total Patient Care
• Advantages
– Consistency of one individual caring for
patients an entire shift
– Enables development of patient and family
trust
– Provides a higher number of RN hours of care
than other models
– The nurse has more opportunity to monitor
progress of the patient
• Disadvantages
– Utilizes a high number of RN staffing
– More costly than other models
Functional Nursing
• Divides
nursing work into functional
roles that are then assigned to one of
the team members
• In
this model, each care provider is
responsible for specific duties or tasks
• Technical
rather
than
nursing care often results
professional
• Decision making usually at the level of
the charge nurse
Functional Nursing
• Advantages
– Care can be delivered to a large
number of patients
– Uses other types of health care
workers when there is a shortage of
RNs
• Disadvantages
– Lack of continuity of care
– Patient may feel that care is disjointed
Team Nursing
• A care delivery model that assigns staff to
teams that are then responsible for a
group of patients
• A unit is divided into two or more teams,
each led by a registered nurse
• The
team
leader
supervises
and
coordinates all of the care provided by
those on the team
• Care
is
divided
into
the
simplest
components and then assigned to the care
provider with the appropriate level of skills
Team Nursing
• Modular nursing delivery system
– A kind of team nursing that
divides a geographic space into
modules of patients, with each
module having a team of staff
led by an RN to care for them
– Useful
with
decentralized
nursing stations
Team Nursing
• Advantages
– Maximizes the role of the registered nurse
– Nurse is able to get work done through
others
• Disadvantages
– Patients
often
receive
fragmented,
depersonalized care
– Communication is complex
– Shared responsibility and accountability
can
cause
confusion
and
lack
of
accountability
Primary Nursing
• Clearly delineates the responsibility and
accountability of the RN
• Places the RN as the primary provider of
care to patients
• Patients are assigned a primary nurse
– The primary nurse is responsible for
developing with the patient a plan of
care
– Other nurses caring for the patient
follow this plan of care
– Patients are assigned to their primary
nurse
regardless
of
geographic
location
Primary Nursing
• Advantages
– Patients and families are able to
develop a trusting relationship with
the nurse
– Accountability and responsibility of
the nurse developing a plan of care
with the patient and family are
defined
– Facilitates continuity of care
– Authority for decision making is given
to the nurse at the bedside
Primary Nursing
• Disadvantages
– Cost is high due to the higher RN skill mix
– The person making assignments needs to
be knowledgeable about all the patients
and staff to ensure appropriate matching
of nurse to patient
– Lack of geographical boundaries within
the unit may require nursing staff to
travel long distances at the unit level to
care for their primary patients
– Nursing time is often used in functions
that could be completed by other staff
– Nurse-to-patient ratios must be realistic
Patient-Centered or Patient-Focused
Care
• Designed
to focus on patient needs
rather than staff needs
• All patient services are decentralized to
the patient area
• Care teams are established for a group
of patients
– The care team includes all disciplines
– Disciplines collaborate to ensure that
patients receive the care they need
Patient-Centered or PatientFocused Care
• Advantages
– Most convenient for patients
– Expedites services to patients
• Disadvantages
– Can be extremely costly to decentralize
major services in an organization
– Some perceive model as a way of
reducing RNs and cutting costs in
hospitals
Patient Care Redesign
• Initiative that developed in the 1990s to
redesign how patient care was delivered
• Motivated by need to reduce costs
• Goals
are to make care more patientcentered and not caregiver-centered
• Reduces
the number of caregivers a
patient has to interface with, thus
increasing patient satisfaction
Care Delivery Management
Tools
• Work flow analysis
– A tool used to determine what activities
are value- added
– Determines how to streamline or eliminate
those activities that do not contribute to
improved patient outcomes
• Value-added
– The customer is willing to pay for this
activity
– Activity must be done right the first time
– Activity
must
somehow
change
the
product or service in some desirable
manner
Care Delivery Management
Tools
• In diagnosis-related groups (DRGs) the
national average length of stay (LOS) for
a specific patient type was used to
determine payment for that grouping of
patients
• Hospitals
looked to
reduce hospital costs
reduce
LOS
and
• Clinical pathways and case management
surfaced as significant strategies
Clinical Pathways
• Clinical pathways
– Care management tools that outline
the expected clinical course and
outcomes for a specific patient type
– Should be evidence-based
• Pathways
include expected outcomes
specified for each day of care
• Patient progress is measured against
the expected outcomes
Clinical Pathways
• Advantages
– Very instructive to new staff
– Save a significant amount of time
in the process of care
– In most cases, improved care and
shortened lengths of stay for the
population on the pathway are
the results
– Allow for data collection of
variances to the pathway
Clinical Pathways
• Disadvantages
– Some physicians perceive pathways to be
cookbook medicine and are reluctant to
participate in their development
– Development
requires
a
significant
amount of work to gain consensus from
the various disciplines on the expected
plan of care
– Pathways are less effective for patient
populations that are nonstandard, since
they are constantly being modified to
reflect individual patient needs
Case Management
•A
strategy to improve patient care and
reduce hospital costs through coordination of
care
• Typically a case manager:
– Is responsible for coordinating care and
establishing
goals
from
preadmission
through discharge
– Evaluates the patient’s outcomes daily and
compares them to the predicted outcomes
articulated in the clinical pathway
– Works with all the disciplines to facilitate
care
Case Management
• In other models, the case management
function is provided by the staff nurse at
the bedside
• The case manager also collects data on
patient variances from the clinical pathway
– Shares this data with the responsible
physicians and other disciplines that
participate in the clinical pathway
– This data is then used to explore
opportunities for improvement in the
pathway or in hospital systems
BACK
Delegation of
Patient Care
<Insert Picture Here>
Perspectives on Delegation
• Delegation
in nursing has been
emphasized and deemphasized at
different periods in history
• Delegation
has not always been
emphasized in nursing education
• Current staffing practices require a
greater amount of delegation from
the nurse
Delegation
• The transfer to a competent individual of the
authority to perform a selected nursing task in a
selected situation
• The
nurse
delegation
retains
accountability
for
the
• All delegation involves at least two individuals as
well as specifying duties to be accomplished
• Successful
delegation addresses the personal
needs of the patient and the nurse’s professional
goals
Accountability
• Being
responsible and answerable for
actions and inactions of self or others in
the context of delegation
• Involves
compliance
with
legal
requirements
as
set
forth
in
the
jurisdiction’s law and rules governing
nursing
• Involves the preparedness and obligation
to explain or justify to relevant others
(including the regulatory authority) one’s
judgments, intentions, decisions, actions,
and omissions and their consequences
Responsibility
• Involves
reliability,
responsibility,
obligation
• Involves each person providing patient
care to perform at an acceptable level for
which they have been educated
• The
nurse transfers responsibility and
authority for a delegated task, but
retains accountability for the delegation
process
Authority
• Occurs when a person has been given the right
to delegate
Practice Act
as
defined
by
the
state
Nurse
• Occurs when the nurse has the official power
from an agency to delegate
• The right to delegate duties and give directions
to unlicensed assistive personnel places the RN
in a position of authority
• Authority given by an agency legitimizes the
right of the nurse to give direction to others
Assignment versus Delegation
• Significant
difference
between
assigning care to another RN and
delegating to an LPN/LVN or nursing
assistant
– Assign: a verb, describes the
process of working through others
– Assignment: a noun, describes
what a person is directed to do
Competence
• The ability of the nurse to act and integrate
the knowledge, skills, values, attitudes,
abilities, and professional judgment that
underpin effective and quality nursing
• Required to practice safely and ethically in a
designated role and setting
• Built upon knowledge gained in a nursing
education program
• Requires
the application
interpersonal
decision
psychomotor skills
of knowledge,
making,
and
Supervision
• The
provision of guidance or direction,
evaluation, and follow up by the licensed nurse
for accomplishment of nursing tasks delegate
to the unlicensed assistive personnel (UAP)
• Direct supervision
– The presence of a licensed nurse working
with other nurses and/or UAP to observe and
direct
• Indirect supervision
– Licensed nurse is not present
Levels of Supervision
• Unsupervised
– Occurs when one RN works with another RN
• Initial direction and periodic inspection
– RN supervises licensed or unlicensed staff
of whom the RN knows their training and
competency levels
• Continuous supervision
– RN determines that the delegate needs
frequent
to
continuous
support
and
assistance
Assignment Making
• The education, skill, knowledge, and
judgment levels of the personnel
being assigned to a task must be
relative to the assignment
• The
expected
outcome
of
the
assignment,
time
frame
for
completion, and any limitations on
the assignment should be specified
when the assignment is made
Considerations for Delegation
• Potential for harm
• Complexity of the task
• Amount
of problem
innovation required
solving
• Unpredictability of outcomes
• Level of patient interaction
personnel
Assess what is to be delegated and
who could best complete the task
Communicate
the
duty
to
be
performed
Avoid changing duties once assigned
Evaluate the effectiveness of the
delegation of duties
Accept minor variations in style
Responsibilities of the RN
• RN
– New graduates should focus on
duties for which they are directly
responsible
– Responsible and accountable for
the provision of nursing care
– Always responsible for patient
assessment,
diagnosis,
care
planning, and evaluation
Responsibilities of the LVN/LPN and Unlicensed
Assistive Personnel
• LPN/LVN
– Usually assigned to stable patients with
predictable outcomes
– Does not complete the initial patient
assessment
• UAP
– Skills gained through training program
– Cannot
complete
assessments
or
patient
potential
responses
to
treatment
Rights of Delegation
• Right task
• Right circumstance
• Right person
• Right direction/communication
• Right supervision
Direct versus Indirect Patient
Care
• Direct care
– Activities that include assisting the
patient
– Involves reporting and documenting
• Indirect care
– Activities necessary to support the
patient and their environment
– Assists in providing clean, efficient,
and safe patient care milieu
Overdelegation
• Leads to delegating duties to personnel
who are not educated for the tasks
• Can
overwork
some
underwork others
personnel
and
• Can place the patient at risk
• Personnel
may
feel
uncomfortable
performing duties that are unfamiliar to
them, so they depend too much on others
Underdelegation
• Personnel in new job roles tend to
underdelegate
• May occur due to personnel avoidance
• New
nurses may be reluctant to
delegate because they do not know or
trust individuals or the team or are not
clear on their scope of duties
Obstacles to Delegation
• Fear of being disliked
• Inability to give up
•
•
•
•
control
of
the
situation
Inability to determine what to delegate
and to whom
Past experience with delegation that did
not turn out well
Lack of confidence to move beyond being
a novice nurse
Tendency to isolate one’s self and
choosing to complete all tasks alone
Obstacles to Delegation
• Lack of confidence to delegate to staff
•
•
•
•
•
who was previously one’s peers
Inability to prioritize using Maslow’s
Hierarchy of Needs and the Nursing
Process
Thinking of oneself as the only one who
can complete a task “the way it is
supposed to be”
Inability to communicate effectively
Inability to develop working relationships
Lack of knowledge of staff capability
Organizational Responsibility for
Delegation
• Follow
professional
standards
for
education, licensure, and competency in
all hiring decisions
• Have clear job descriptions
• Facilitate
clinical
and
educational
specialty certification
• Provide standards for ongoing evaluation
• Provide access to professional health
care standards and policies
•
•
•
•
•
•
Organizational Responsibility for
Delegation
Facilitate regular
evidence-based review
of critical standards and policies and
procedures
Have clear policies and procedures for
delegation and chain of command
Provide administrative support
Clarify
health
care
provider
accountability
Provide
standards
for
regular
RN
evaluation of NAP and LVN/LPN
Develop safe transfer policies
•
•
•
•
•
•
Organizational Responsibility for
Delegation
Develop physical, mental, and verbal
“No Abuse” policy
Consider applying for Magnet status
Monitor patient outcomes
Maintain
ongoing
monitoring
of
patient incident reports
Develop
systematic,
error-proof
systems for medication administration
Attain The Joint Commission Patient
Safety Goals
Chain of Command
• All members of the organization are
accountable for their actions to the
patients and communities they serve
• All employees are accountable to
someone in a higher position
– The RN is responsible to the charge
nurse
– The charge nurse is responsible to
the manager
– The manager is responsible to the
chief nurse executive
Delegation of the Nursing
Process
• Some professional activities
can never be delegated
–
–
–
–
–
–
–
–
Patient assessment
Triage
Making a nursing diagnosis
Establishing a nursing plan of care
Teaching or counseling
Telephone advice
Evaluating outcomes
Discharging patients
•
Delegation of the Nursing
Process
Delegated tasks:
– Typically those tasks that occur
frequently
– Considered technical
– Considered standard and unchanging
– Have predictable results
– Have minimal potential for risks
• Delegated
tasks
fall
within
the
implementation phase of the nursing
process
•
Delegation Decision Making
Tree
Developed by the
NCSBN
• Steps
–
–
–
–
Assessment and planning
Communication
Surveillance and supervision
Evaluation and feedback
Transcultural Delegation
• The
process of having personnel
perform duties with the diversities
of culture taken into consideration
• Cultural phenomena to consider:
– Communication
– Space
– Social organization
– Time
– Environmental control
– Biological variations
BACK
Organization of
Patient Care
<Insert Picture Here>
Strategic Planning
• A process designed to achieve
goals in dynamic, competitive
environments
through
the
allocation of resources
Unit Strategic Planning
• Unit or departmental strategic planning
begins
with
examining
the
organization’s mission, vision, strategic
plan, and annual operating plans
• Unit
strategic
plans
should
be
congruent with and support the
mission
and
vision
of
the
organizational system of which they
are a part
Philosophy Development
• Philosophy
– A statement of beliefs based on
core values—inner forces that give
us purpose
• A unit’s mission and vision are most
authentic they are developed based
on the philosophy or core beliefs of
the work team
• A unit’s core beliefs or values should
be incorporated into the unit’s
mission and vision statements
Mission Statement
• Mission
– A call to live out something that matters or is
meaningful
• An organization’s mission reflects the purpose
and direction of the health care agency or a
department within it
• A mission statement has three elements:
– Reflects what the unit seeks to do and become
– A view of what the unit is trying to accomplish
– Indicates what is unique about the care that is
provided
Vision Statement
• A unit vision statement describes how the
mission of the unit within an organization will
be actualized
• A vision statement includes four elements:
– A vision statement is written down
– It is written in present tense, using action
words, as if it were already accomplished
– It covers a variety of activities and spans
broad time frames
– It addresses the needs of providers,
patients, and environment in a balanced
manner that anchors it to reality
Goals and Objectives
• The work unit develops broad strategies that
span the next three to five years, and then
develops annual goals and objectives to meet
each of these strategies
• Goals
– Are written as specific aims or targets that the
unit wishes to attain within the time span of
one year
• Objectives
– Are the measurable steps to be taken to reach
each goal
•
Structure of Professional
Practice
In
an
organization
where
professional nursing practice is
valued,
development
and
implementation
of
strategic
initiatives is most effectively carried
out through a structure of shared
governance and shared decision
making between management and
clinicians
Shared Governance
• An organizational framework based on
the idea of decentralized leadership that
fosters autonomous decision making and
professional nursing practice
• It
implies the allocation of control,
power, or authority (governance) among
mutually (shared) interested vested
parties
• Shared
governance
council models
structures
are
Shared Governance
• In
most health care settings, vested
parties in nursing fall into two distinct
categories:
– Nurses practicing direct patient care,
such as staff nurses
– Nurses managing or administering the
provision of that care, such as
managers
• In
shared governance, management
relinquishes control over issues related
to clinical practice
Clinical Practice Council
• The
purpose is to establish the
practice standards for the work group
• A unit level committee that works in
conjunction with the organizational
committee
accountable
for
determining policy and procedures
related to clinical practice
• Develops
standards
evidence-based
practice
Quality Council
• Has two purposes:
– The credentialing of staff
– Oversee
the
unit
management initiatives
quality
• Can make recommendations for hiring
and promotions
• Reviews
indicators for the
overall clinical performance
unit’s
Education Council
• Purpose is to assess the learning needs
of the unit staff
• Develop
and implement programs to
meet learning needs
• Learning organizations
– Promote professional practice through
the
encouragement
of
personal
mastery, an awareness of our mental
models, and team learning
Research Council
• Advances evidence-based practice with
the
intent
of
staff
incorporating
research-based findings into the clinical
standards of unit practice
• Staff
critiques research literature and
make recommendations to the clinical
practice council for changes based on
evidence
• May coordinate research projects
Management Council
• Ensures that the standards of
practice
and
governance
agreed upon by unit staff are
upheld
• Ensures
that
there
are
adequate resources to deliver
patient care
Coordinating Council
• Facilitates and integrates the activities of
the other councils
• Composed
managers
councils
of
and
first-line
patient care
chairpersons of other
• Facilitates the annual review of the unit
mission and vision
• Develops the annual operational plan
Competency
• A
possession of the required skill,
knowledge, qualification, or capacity
• Competency of professional staff can be
ensured through credentialing processes
developed around a clinical or career
ladder staff promotion framework
• Career ladder
– Acknowledges that staff have varying
skill sets based on education and
experience
•
Benner’s Novice to Expert
Model
Facilitates
professional
staff
development by building on the skill
sets
and
experience
of
each
practitioner
• Acknowledges that there are tasks,
competencies, and outcomes that
practitioners can be expected to
have acquired based on five levels
of experience
Benner's Novice to Expert Model
• There are five progressive stages of Benner’s
model of nursing practice:
– Novice (task-oriented and focused)
– Advanced beginner (demonstrates marginally
acceptable independent performance)
– Competent (has been in the same role for one
to three years; demonstrates conscious,
deliberative planning)
– Proficient (perceives the whole situation
rather than a series of tasks)
– Expert (intuitively knows what is going on
with patients)
•
The Process of Professional
Practice
Ongoing
professional
staff
development is part of the regular
performance feedback staff can
expect
from
the
patient
care
manager or credentialing committee
• Ongoing
professional development
determines the staff member’s
readiness
for
leadership
development and advancement
Situational Leadership
• Maintains that there is no one best
leadership style
• Effective
leadership lies in matching
the appropriate leadership style to the
individual’s or group’s level of taskrelevant readiness
• The leader should help staff grow in
their readiness to perform new tasks as
far as they are able and willing to go
Situational Leadership
• Accomplished through four styles of
style is used with different
leadership readiness of the nursing
staff
•
Accountability-Based Care
Delivery
Focuses on roles,
their relationship
to
the work to be done, and the outcomes
they are intended to achieve
• Includes the activities inherent in a role
and not legitimately controlled outside
the role
• Competence is evidenced not by what a
person brings to the work, but instead
by the results of the application of the
person’s skills to the work
Elements of Accountability-Based
Care is
Delivery
• Accountability
about outcomes,
not processes
• Accountability is individually defined
• Accountability
is inherent
role, not delegated
in
the
• Accountability is the foundation for
evaluation
Measurable Quality Outcomes
• Regular evaluation of a work unit’s
performance to ensure that the
outcomes of care delivery are meeting
the objectives of professional practice
• The
development
of
process
improvement measures is driven by
The
Joint
Commission
and
the
National Council for Quality Assurance
•
Unit-Based Performance
Outcomes Improvement
from four domains must
be
measured:
– Access
– Service
– Cost
– Clinical quality
• Quality must be measured in four domains:
– Functional status
– Clinical outcomes
– Cost and utilization
– Patient satisfaction
BACK
Time Management and
Setting Patient Care Prioriti
<Insert Picture Here>
•
General Time Management
Concepts
Time management
– A set of related commonsense skills that
helps you use your time in the most
effective and productive way possible
• There
are
three
time
management
concepts to master:
– The relative effectiveness of the effort
– The importance of outcome versus
process orientation
– The value of organizing how time is
currently being used
The Pareto Principle
• States
that 20 percent of focused
effort results in 80 percent outcome
results, or conversely 80 percent of
unfocused efforts results in 20
percent results
• A
strategy for balancing life and
work through prioritization of effort
Outcome Orientation
• More
is achieved through an outcome
orientation than an emphasis on task
completion
• Determine
long-term goals, then break
them down into achievable outcomes that
are the steps toward those goals
• Write down long-term goals and outcomes
• Flexibility
orientation
should
be
part
of
outcome
Time Analysis
• Analyze how time is currently used
• Understand the value of nursing
time
• Consider
what
tasks
can
be
delegated
to
personnel
who
receive less compensation than
nurses
Prioritizing the Use of Time
• Understand the big picture
– No nurse works in isolation
– Less likely to be frustrated when asked to
assist others
• Decide on optimal outcomes
– At the beginning of their shift nurses need to
decide what outcomes can be achieved
– They also should decide what outcomes can be
achieved
given
less-than-optimal
circumstances
• Do first things first
Establishing Priorities
• First priority
– Life threatening or potentially life
threatening
• Second priority
– Activities essential to safety
• Third priority
– Activities essential to the plan of
care
Environment
• If
possible,
arrange
the
environment to provide nurses
with efficient access to supplies,
equipment, and patient areas
• Stock
supplies
available
to
make
them
• Have specialty carts available
Shift Report
• The shift handoff report can best lead to
an efficient, effective, and safe start to
the shift
• The
Joint
Commission
included
a
standardized report approach to shift
handoff as a 2006 patient safety goal
• Shift report can be accomplished by a
face-to-face meeting,
walking rounds
audiotaping,
or
Formulating the Shift Action
Plan
• A written plan that
sets the priorities for
the accomplishment of shift outcomes
that are both optimal and reasonable
• Should
be written so that
members are aware of it
all
team
• Must be based clearly on priorities set at
the beginning of the shift with built-in
flexibility
Making Assignments
• Nurses
cannot accomplish patient
objectives completely by themselves,
requiring them to delegate
• The assignment sheet should identify
who will perform the intervention
• Assignments
should be part of the
planning process
Timing the Actions
• The shift action plan should identify
by what time an intervention should
be completed
• It is important to remember that
plans are just plans
– They have to be flexible, based on
ever-changing patient care needs
• At the
Evaluating Outcome
Achievement
end of
the shift, reexamine the
shift
action plan
– Did you achieve the optimal outcomes? If
not, why not?
– Were there staffing problems or patient
crises?
– Did you achieve the realistic outcomes? If
not, why not?
– Were the activities necessary for outcome
achievement carried out? If not, why not?
– What did you learn from this for future
shifts?
Strategies to Enhance Personal
Productivity
• Schedule activities that take focus and
creativity at high-energy times and dull,
repetitive tasks at low-energy times
• Create more personal time
– Delegate work to others
– Eliminate chores or tasks that have
no value
– Get up earlier in the day
– Use downtime
– Control unwanted distractions
Avoiding Priority Traps
• Traps that nurses should avoid
– Doing whatever hits first
– Taking
the
path
of
least
resistance
– Responding to the squeaky wheel
– Completing tasks by default
– Relying on misguided inspiration
Strategies for Avoiding Personal Time
Distraction
• Clear your work area of clutter and
•
•
•
•
keep it clean
Organize your work area
Open your mail over your garbage
can; respond, delegate, or throw it out
Break a task down into manageable
segments; return to it again and again
until it is complete
Become a pursuer of excellence, not a
perfectionist
Behaviors of Perfectionists
• Hate criticism
• Are devastated by failure
• Get depressed and give up
• Reach for impossible goals
• Value themselves for what they do
• Have to win to maintain high self-
esteem
• Can only live with being number one
• Remember mistakes and dwell on
them
Pursuers of Excellence
• Welcome criticism
• Learn from failure
• Experience disappointment, but keep going
• Enjoy meeting high standards within reach
• Value themselves for who they are
• Do not have to win to maintain high self-
esteem
• Are pleased with knowing they did their
best
• Correct mistakes, then learn from them
Returning to School
• Let
•
•
•
•
•
your employer know of your
intentions
Develop computer skills
Find a flexible educational program
Do not be surprised by the demands
of school
Solicit support from family and
friends
Utilize all available resources
Returning to School
• Focus on the outcome
• Be careful of the sacrifice
• Manage time
• Take care of yourself and your
responsibilities
• If you need a break, take one
• Study on the run
BACK
History of Quality Assurance
• Quality assurance (QA)
– Emerged in health care in the 1950s
as an inspection approach to ensure
that minimum standards of care
existed in health care institution
• Because of its emphasis on “doing it
right,” some thought that QA was
very punitive and did little to sustain
change
or
proactively
identify
problems before they occurred
Total Quality Management
• Began in the (TQM)
manufacturing industry
when
W. Edwards Deming and Joseph Juran
consulted with Japanese corporations in
the 1950s
• Also referred to as quality improvement
(QI) and performance improvement (PI)
• This approach became integrated in the
health care industry in the 1980s
• A
proactive
approach
emphasizing
“doing the right thing” for customers
Quality Improvement (QI)
•A
systematic
approach
of
organization-wide
participation
and partnership in planning and
implementing
continuous
improvement
methods
to
understand and meet customer
needs and expectations and
improve patient outcomes
General Principles of Performance
Improvement
• The priority is to benefit patients and all
other internal and external customers
• Quality
is
achieved
through
the
participation
of
everyone
in
the
organization
• Improvement
opportunities
are
developed by focusing on the work
process
• Decisions to change or improve a
system or process are based on data
• Improvement of the quality of service is
a continuous process
Focus of Quality Assurance (Doing It
Right)
• Assessing
or
measuring
performance retrospectively
• Reviewing
chart audits and
incident reports
• Determining
whether
performance
conforms
to
standards
• Improving
performance when
standards are not met
Focus of Quality Improvement(Doing the Right Thing)
• Meeting
•
•
•
•
the needs of the customer
proactively
Building quality performance into the
work process
Assessing the work process to identify
opportunities for improved performance
Employing a scientific approach and using
data for assessment and problem solving
Improving health care performance and
changing
the
health
care
system
continuously as a management strategy,
not just when standards are not met
Who Are the Customers in Health
• A customer is anyone
Care?
who receives the output
of your efforts
• Customers
can
be
internal,
within
the
outside
the
organization
– Employees
– Health care staff
• Customers
can
be
organization
– Patients
– Accrediting bodies
external,
Empowerment of Everyone in the
Organization
• Each
person
participates
must
feel
that
he
or
she
• Each takes responsibility for the success or
failure of an organization
• Each takes an active part in developing new
ways of doing business and securing new
customers
• Each trusts that his or her efforts are valued
Who Participates in the Improvement
Process?
• All staff members should be encouraged to
participate
• All those involved with or affected by a goal or
process should participate
• Staff
can participate
organizational level
on
individual,
unit,
or
• Participants should include point-of-service staff
– Those workers on the front line who do the
direct work involved in the process being
changed
Improvement of the Health Care
Process
• Process
– A set of causes and conditions that
repeatedly come together in a series of
steps to transfer inputs into outcomes
• All processes have inputs, steps, and
outputs
• All the steps of the work process can be
measured
Improvement of the System
• System
– An interdependent group of items,
people, or processes with a common
purpose
• By
examining the
relationships, you
outcome
work process
can improve
and
the
• In a system, each step of the process
affects the following step
Continuous Improvement
• The cycle of continuous improvement
– Developed by Shewhart in the 1920s
– Suggests products and services are
designed
and
made
based
on
knowledge about the customer
– These
products
or
services
are
marketed to and judged by the
customer
• The process of QI becomes continuous
because it is linked to changing customer
needs and judgments
Improvement Based on Data
• Decisions to change or improve a
work system or work process are
made based on data
• Data should be used for learning, not
for judging
• It is critical to look at work processes
rather than people for improvement
opportunities
Implications for Client Care
• Quality improvement for patient care can be
measured by the overall value of care
– Value is determined by outcomes and cost
– Outcomes can be clinical or functional
– Outcomes can be related to patient
satisfaction
• Cost can be direct or indirect
– The cost of care decreases when
standardized care delivery of the work
process is joined with evidence-based
practice
•
Methodologies for Quality
Improvement
Plan-do-study-act
(PDSA) cycle
• Asks three questions:
– What are we trying to accomplish?
– How will we know that a change is an
improvement?
– What changes can we make that will result
in improvement?
• The goal is to increase the ability to predict
the effect that one or more changes would
have if they were implemented
Methodologies for Quality
Improvement
• FOCUS Methodology
• Describes a stepwise process how to move
through the improvement process
– F: focus on an improvement idea
– O: organize a team that knows the work
process
– C: clarify what is happening in the
current work process
– U: understand the degree of change
needed
– S: select a solution for improvement
Other Improvement Strategies
• Benchmarking
– A continual and collaborative discipline of
measuring and comparing the work of key
work processes with those of the best
performers
– Focuses on key services or work processes
• Regulatory requirements
• Sentinel event review
– An unexpected occurrence involving death
or serious physical or psychological harm
– Placed in a high traffic area
– Outlines the progress of
improvement process
• Patient satisfaction data
the
quality
Using Data
• Time series data
– Allows the QI team to see change in
quality over time
– Allows you to see how a process is
behaving
• Charts
–
–
–
–
Pareto diagrams
Pie charts
Flowcharts
Histograms
•
Principles in Action in an
Organization
Organizational
structure
– Encourage accountability
– Maximize communication
– Communicate
and
priorities at all levels
focus
Outcomes Monitoring
• Outcomes
– A measurement of the patient
response to structure and process
– Measure actual clinical process
– Can be short term or long term
• Outcome
data
identifying
improvement
causes
can be helpful in
opportunities
for
by determining root
BACK
Evidence-Based Strategies
to Improve Patient Care
Outcomes
<Insert Picture Here>
Evidence-Based Practice (EBP)
• The
conscientious,
explicit,
and
judicious use of current best evidence
in making decisions about the care of
individual patients
• Is also referred to as outcomes research
• It is a total process:
– Know what clinical questions to ask
– Know how to find the best practice
– Know how to critically appraise the
evidence
– Apply the evidence
care
for
acute
myocardial
infarction
Prevent
adverse
drug
events
through medication reconciliation
Prevent central line infections
Prevent surgical site infections
Prevent
ventilator-assisted
pneumonia
Role of the ANA
• Active
advocate
evaluation
• Outcomes
of
outcomes
emphasized
measure of quality care
as
a
• Developed indicators for patient-
focused outcomes, structures of
care, and care processes
Evolution of EBP
• Practice guideline
– A
descriptive
tool
specification of care
or
a
standardized
• Evidence-based nursing practice
– The conscientious, explicit, and judicious use
of theory-derived, research-based information
in making decisions about making nursing care
delivery to individuals or groups of individuals
– EBP has a medical focus, whereas evidencebased nursing practice considers the patient’s
needs and preferences
Evidence-Based Multidisciplinary Practice Improvement
Models
• The
University of Colorado Hospital
model
– Presents a framework for thinking
about how you use different sources
of information to change or support
your practice
– Depicts nine sources of evidence that
are linked to the research core
– Provides a way for the nurse to
organize information and data for care
of a patient and to evaluate the care
Practice Improvement Models
• The Model for Improvement
– Begins with three essential
questions
– Forms the foundation for the
plan-do-study-act cycle
Improvement Models
• Plan-do-study-act cycle (PDSA)
• The cycle begins with a plan and ends
with action based on the learning gained
during the cycle
– Plan: develop a plan to change or test a
process
– Do: implement the plan
– Study: summarize what was learned
– Act: determine what actual changes to
make
BACK
Decision Making and
Critical Thinking
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Critical Thinking
• Rapid
changes in the health care
environment
have expanded the
decision-making role of the nurse
– Stringent budgets
– Patient care is more complex
– Patients are being discharged earlier
• Critical
thinking is essential when
making decisions and solving problems
Decision Making
• Considering and selecting interventions
from a repertoire of actions that
facilitate the achievement of the
desired outcome
• Process consists of five steps
–
–
–
–
–
Identify the need for a decision
Determine the goal
Identify actions
Determine which action to implement
Evaluate the decision
Critical Thinking
• Purposeful, outcome-directed thinking that
is based on a body of scientific knowledge
derived from research and other courses of
evidence
• A good critical thinker
– Examines decisions from all sides and
takes into account varying points of view
– Generates new ideas and alternatives
when making decisions
– Asks “why” questions about a situation in
order to arrive at the best decision
Reflective Thinking
• Watching or observing oneself as
one performs a task or makes a
decision about a certain situation
• Two selves
– Reflective: acts as an observer
and offers suggestions
– Active: active participation
Problem Solving
• An active process that starts with a
problem and ends with a solution
• The problem-solving process consists of
five steps
– Identify the problem
– Gather and analyze data
– Generate alternatives and select an
action
– Implement the selected action
– Evaluate the action
Decision Making
• A behavior exhibited in making a
selection and implementing a course
of action from alternatives
• Decision making is not necessarily
related to solving a problem
Problem Solving and Decision Making: Tools for Viewing
Choices
• Decision grid
– Useful when
choices
making a decision
between
two
• PERT chart
– Useful in making time line decisions
• Decision tree
– Useful in making the alternatives visible
• Gantt chart
– Useful for illustrating a project from beginning to
end
Group Decision Making
• Group decision making may be necessary
in some situations
• People affected by a decision often will be
involved in the decision
• Involve
people
with
information
or
resources that contribute to the decision
• Consider the size of the group and the
personalities of group members
•A
Group Decision Making:
group canAdvantages
generate more ideas,
thus
allowing for more choices and an
increased chance of higher quality
outcomes
• When
members participate in the
decision-making process, the decision is
more likely to be accepted
• Groups may be used as a medium for
communication
Group Decision Making:
Disadvantages
• Time consuming
• Can be wasteful and unproductive
if not managed effectively
• Can be costly
• Can generate conflict
•
Techniques for Group Decision
Making
Nominal group
technique
– Group
members
write
ideas,
without discussion
– Each idea is presented with
advantages and disadvantages
– Group discusses, clarifies, and
evaluates ideas
– Group votes privately on ideas
•
Techniques for Group Decision
Making
Delphi technique
– Group members do not meet face
to face
– Questionnaires
are
distributed
seeking
opinions
from
group
members
– Summaries are disseminated to
group members
– Process continues until group
members reach a consensus
Techniques for Group Decision
Making
• Consensus building
– Means that all group members can live
with and fully support the decision
regardless of whether they totally
agree
– Useful because all group members
participate
and
realize
the
contributions of each member to the
group
– Requires more time
– Should be reserved for important
decisions that need strong support
•
Techniques for Group Decision
Making
Groupthink
– Different from consensus building
– Goal is for everyone to be in 100
percent agreement
– Discourages questions and divergent
thinking
– Hinders creativity
– Groups can reach a decision early
without exploring all options
– Can cause stereotyping and challenges
of disagreement
•
Obstacles to Effective Decision
Making
Past experiences,
values, personal bias
• Jumping
•
•
•
•
to
conclusions
without
examining the situation thoroughly
Failing to obtain all of the necessary
information
Choosing decisions that are too broad,
too complicated, or lack definition
Failing to choose and communicate a
rational solution
Failing to intervene and evaluate the
decision or solution appropriately
Use of Technology in Decision
Making
• Technology can support, but not take
over, the decision-making process
• Clinical practitioners should evaluate
technology before adopting it
• Other staff on which technology will
have an impact should have input
into decisions on its adoption
Strategies to Strengthen Patient Decision
Making
• Consumers
of
health
care
are
knowledgeable and cost conscious
more
• Nurses must be aware of patients’ rights in
making decisions about their treatments and
must assist patients in their decision making
• Ask
“why,”
questions
“what
else,”
and
“what
if”
• Anticipate questions and outcomes
BACK
Culture, Generational
ifferences, and Spiritual
<Insert Picture Here>
Cultural Competence
• Culturally competent care
–A
complex
integration
of
knowledge,
attitudes, and skills that enhance crosscultural communication and appropriate and
effective interactions
• A process that includes:
–
–
–
–
–
Awareness
Cultural knowledge
Cultural skills
Cultural encounters
Cultural desire
Cultural Nursing Theories and
Models
• Leininger
– Transcultural Nursing
• Purnell
– Model for Cultural Competence
• Campinha-Bacote
– The Process of Cultural
Competence in the Delivery of
Health Care Service
• Giger and Davidhizar
– Transcultural Assessment Model
Levels of Response
• Greet
• Accept
• Help
• Background
• Advocate
Transcultural Assessment
• Determine
communication
conversational style
• Understand
differences
that beliefs about personal
space vary
• Eye contact may vary from cultural groups
• Subject matter and conversation length
vary from cultural groups
Organizational Culture
• The system of shared values and
beliefs that actively influences the
behavior of organization members
• Shared
values
are
important
because many people are guided by
the same values and they interpret
them in the same way
• Values
develop over time and
reflect an organization’s history
and traditions
reward
• Degree of change
• Strength of the culture
and
Organizational Behavior Styles
• Greetings
– Determined by casual or business acquaintance
• Titles
– Introduce yourself by your first and last name
• Time
– Punctuality is important
• Body language
– Use of direct eye contact is expected in all work
situations
• Dress
– Ask what traditional dress is used in your department
Workplace Behavior Guidelines
• Adapt to your organization’s culture
• Good
communication
requires
listening and clarifying
• Go
to
the
source
of
the
communication
• Observe for cultural differences in
the workplace
• Realize that health care is a 24/7
business; make arrangements early
with your manager for time off for
religious or cultural holidays
Nursing Cultural Variations
• Staff nurses from different cultures have
different perceptions of staff responsibilities
• Collectivism
– Emphasizes the importance of group
decisions and places the rights of the
group as a whole above the rights of any
individual in the group
• Individualism
– Emphasizes the importance of individual
rights and rewards
•
Different Perceptions of the
Nurse’s
Role
Nurses from different cultures have
different perceptions of the nurse’s
role and nursing care values
• Obligation to care
– Prevails
in
the
Philippine
American nurse’s values
– Not as strong in the American
nurse’s values
Locus of Control
• The degree of control that individuals feel they
have over events
• People who feel in control of their environment
have an internal locus of control
– Health care workers trained in the United States
generally have an internal locus of control
• People who believe that luck, fate, or chance
controls their lives have an external locus of
control
– Believe they cannot control matters of life and
death
Differences in Time Orientation
• Cultural groups are either past,
present, or future oriented
• Ways in which cultural groups
value time create challenges in
the health care workplace
Educational Differences
• Generally,
nurses educated outside the
United States have less theory and more
clinical skills
• A cultural difference in the education of
nurses revolves around who provides the
majority of the care: the nurse, the patient’s
family, or the patient
• Nurses taught under a system of socialized
medicine may find it difficult to adapt to the
health care in the United States
Language Differences
• Language differences, more than any
other barrier, raise the potential for
serious miscommunication
• Nonverbal
communication
mistaken as well as verbal
• Language
can
be
differences can be a
source of friction between foreign
and American nurses
Improving Communication on the
• Recognize
that Team
your coworker has an
educational background different from yours
• Acknowledge
that the coworker’s value
system and perception of what constitutes
good patient care may differ from your own
• Try to assess your coworker’s understanding
• Avoid the use of slang terms and regional
expressions
Improving Communication on the
Team with resources
• Provide your coworker
• Praise
your coworker’s competency in
technical skills
• Appreciate the knowledge that you can
gain by working alongside a skilled nurse
from another country
• Try
to use “I” statements instead of
“you”
statements
when
offering
constructive criticism
Communication with Others
• Do not take verbal orders from a
foreign physician whose language
is difficult to understand
• Use
caution when supervising
unlicensed
assistive
personnel
who have difficulty understanding
and speaking English
Managerial Responsibility
• Determine
which cultural groups are
represented on staff
• Understand the organization’s values and
goals
• Decide what is best for the future of the
organization
• Analyze present conditions within the
organization
• Plan ways to reach the desired future state
and decide how to manage transitions
• Evaluate the results
Techniques to Reduce Cultural
• Plan informal Tension
meetings for nurse to
•
•
•
•
•
discuss their cultural values
Provide cultural workshops
Provide classes in English as a second
language
Establish a program for orienting
foreign nurses to the hospital or agency
Plan potluck dinners and socialize
Confer with specialists in transcultural
communication
Generational Perceptions
• Generation
– A group that shares birth
years,
age,
location,
and
significant life events
– Approximately 15 to 20 years
in length
– Has a different value system
from the preceding generation
and later generations
Generations in the Workplace
• Traditional
– Born before 1940
• Baby Boomers
– Born between 1940 and 1960
• Generation X (GenXers)
– Born between 1960 and 1980
• Generation Y (Echo Boomers or Millennials)
– Born after 1980
Traditional Generation
• Came
of age
Depression
after
the
Great
• Raised to be disciplined and obey
their elders
• Feel obligated to conform
• Believe that work is one’s duty
Baby Boomers
• Came of age when there was much available
education and economic expansion
• Work
for the challenge of work and career
advancement
• Characterized
as
workaholic,
strong-willed
individuals
working
for
material
gain,
promotions, recognition, job security, and corner
offices
• Largest
impact
generation
with
dramatic
financial
Generation X
• Latch-key kids
• Have
•
•
•
•
learned to be self-reliant and
independent
Look for career security, not job security
Willing to change jobs and have little
loyalty to their employers
Not
workaholics;
seek
a
balance
between work and leisure
Want a work environment that is
technologically current
Generation Y
• Primarily children of the baby
•
•
•
•
•
boomers
Grew up at the end of the Cold
War, the Internet, and speak-yourmind philosophy
Just beginning to make their mark
in the workforce
Focusing on early retirement
Change is their mantra
Expect countless options
Effect on the Workplace
• Generations
have different goals
and needs
• Generations are working alongside
each other
• Requires a different management
style and increased flexibility
• Each
generation
has
different
needs for orientation, training, and
opportunities for advancement and
benefits
Spirituality
• Spirituality
is a component
healing in nearly every culture
of
• There
is increasing amount of
research and thought on spirituality
to provide holistic care
• Spirituality is a multifaceted concept
specific to the spiritually
experience of an individual
lived
Spiritual Assessment
• To provide spiritual care, an understanding of the
patient’s beliefs can be used to plan appropriate
care
• Nurses
need to understand more than the
patient’s labels of “religion” or “religious needs”
• Nurses need to ask patients if they would like to
see
their
spiritual
leader
or
understanding that not all patients will
advisor,
• Pastoral care departments can provide prayer,
visits, and
donation
bereavement
and
discuss
organ
Spiritual Distress
• A
North American Nursing Diagnosis
Association (NANDA) term used to identify
when an individual has an impaired ability
to integrate meaning and purpose in life
through the individual’s connectedness
with self, others, art, music, literature,
nature, or a power greater than oneself
• To connect with these elements, patients
will use meditation, prayer, participating
in
religious
services
or
rituals,
communicating with nature, and sharing
of self
Barriers to Spiritual Care
• Personal beliefs of the nurse
• Nurse
may be uncomfortable and
embarrassed
by
their
own
spirituality
• Does not believe spirituality is a
nursing responsibility
• Lack of knowledge regarding the
specific beliefs of the patient’s
religion
• Insufficient nursing time or privacy
Spiritual Nursing Interventions
• Open a dialogue with the patient
•
•
•
•
regarding the meaning and purpose
of life
Allow the patient to describe their
spiritual life
Ask the patient if prayer plays a role
in their life
Offer to seek the spiritual or
religious leader of their choice
Be physically present
Spiritual Nursing Interventions
• Use therapeutic touch
• Seek
an answer to how you can
provide support to the individual
patient
• Support patient-directed spiritual
activities
• Focus on spiritual relationships and
how the nurse might provide
support for patients with spiritual
needs
Championing Spirituality
• The
nurse leader who champions
spirituality for all staff ensures that
this component of holistic care is
not forgotten or marginalized
• Develop
an
understanding and
empathetic approach to nurses’
needs for religious holidays and
celebrations that have spiritual
significance
Developing Spiritual Leadership
• Use compassion, caring, and nurturing to create
an environment that reflects the values and
beliefs of the leaders, patients, and staff
• Spiritual leaders develop trust and connect with
their staff on both a personal and a professional
level
• This connection is the basis for change and
growth
• Provides
a cohesive and positive workplace
environment
BACK
Collective Bargaining
<Insert Picture Here>
586
Definitions
• Collective action
– Acting as a group with a single
voice
• Collective bargaining
– The practice of bargaining with
reference to wages, work practice,
and other benefits by employees in
a
collective
group
with
management
Collective Action Models
• Workplace advocacy
– Activities nurses undertake to
address
problems
in
their
workplace
– Most common type of collective
bargaining in nursing
– Can be demonstrated through
committee work and patient
advocacy
Collective Action Models
• Collective bargaining
– The
group
bargains
with
management for what the
group desires
– If the group cannot achieve the
desired
goals
through
collective bargaining, they may
decide to form a union
Factors Affecting Nurses’ Impetus to
Unionize
•
•
•
•
•
•
•
Nurses feel powerless
Job stress
Physical demands
Need to be able to communicate needs
to
management
without
fear
of
reprisal
Poor wages and job security
Unsafe staffing and health and safety
issues
Mandatory overtime and poor quality
of care
Unions
• A formal and legal group that
works through a collective
bargaining agent to present
desires
to
management
formally
Whistle-Blowing
• The
act in which an individual
discloses information regarding a
violation of a law, rule, or
regulation or a substantial and
specific danger to public health or
safety
• The employer does not know who
attempted to “blow the whistle”
Proper Steps for WhistleBlowing
• File a qui tam lawsuit
in secret with the court
– Do not let the agency or hospital know you
filed the suit
• Serve a copy of the complaint to the Department
of Justice with a written disclosure of all the
information you have concerning the fraud
• If the government decides to go forward with
the lawsuit, the government will bear the
responsibility for litigating the lawsuit, and pay
for it
Process of Unionization
• Obtain a collective bargaining agent
– An agent that works with employees to
formalize collective bargaining through
unionization
• Obtaining a collective bargaining agent and
negotiating a contract may take 3 months to
3 years
• The American Nurses Association provides
steps to organize a collective bargaining unit
Manager’s Role
• The National Labor Relations Board has
deemed eight collective bargaining
units for the health care industry
• Managers who work in a union setting
must have at least eight different
contracts for the various employees
• Unionization may result in increased
costs for the hospital
Employee’s Role
• Nurses
must
follow
the
pertaining to unionization
laws
• Choose
bargaining
a collective
agent carefully
• Network
with other nurses who
have unions to determine issues
and problems
Striking
• A collective bargaining agent cannot make
the decision to strike
– The decision to strike can be made only by
a majority of union members
• Most nursing collective bargaining agents
put a no-strike clause in the contract
• The 1974 Health Care Amendments to the
National
Labor
Relations
Act
contain
provisions that guarantee the continuation
of adequate patient care in a strike situation
Collective Bargaining Agents
• Different
organizations
act
as
collective bargaining agent
– Teamsters Union
– General Service Employees Union
– United American Nurses AFL-CIO
– American Nurses Association and
state nurses associations
– National Union of Hospital and
Health Care Employees
•
Professionalism and
Unionization
Characteristics
of a profession include:
– Requiring a long period of specialized
education
– Having a service orientation
– Having autonomy
• Many
nurses believe that autonomy
precludes involvement in a union
• Others
believe unionization is the only
way to achieve autonomy
Definition of Supervisor
• Supervisor
– Defined as any individual having authority, in
the interest of the employer, to hire, transfer,
suspend, lay off, recall, promise, discharge,
assign, reward, or discipline other employees
– Defined in The National Labor Relations Act
(1994)
• Only nurses defined as employees can unionize
– The ambiguity of the terms employee and
supervisor has led to legal disputes as to
who can unionize
Physician Unionization
• In some health care settings, physicians
are seen as employees, not supervisors
– This means they have the ability to
join unions
• Factors
influencing
physicians
to
unionize
– Loss of autonomy
– Low wages
• The
American
Medical
Association
supports doctors’ rights to collective
bargaining, but does not support
unionization
Unionization of University
Professors
• The unionization
of kindergarten
through twelfth grade teachers
is established in this country
• Increases
in university faculty
unionization seen due to:
– Wages and work environment
– Ages of faculty
Managing in a Union
Environment
Nursing management
may not be
part of
the union, but nurse managers must work
with the union to manage within the rules
and context of contract agreements
• Grievance
– Where a union member feels that
management has failed to meet the
terms
of
the
contract
or
labor
agreement and communicates this to
management
– All union contracts specify grievance
proceedings for their members
•
Collective Bargaining:
Advantages
Contract to guide
standards
•
• Participation in decision-making process
• All union members and management
•
•
•
•
must conform to terms of contract
without exception
Process exists to question manager’s
authority if member feels something
was done unjustly
Union dues are required to make the
union work
Gives collective voice to employees
Employees can voice concerns without
fear of reprisal
Collective Bargaining:
• There
isDisadvantages
reduced
allowance
•
•
•
•
•
•
for
individually
Other union members may outvote your
decisions
All union members and management
must conform to the terms of the
contract
Less room for personal judgment
Union dues must be paid even if
individuals do not support unionization
Employee may not disagree with the
collective voice
Unions may not be seen as professional
BACK
Career Planning
<Insert Picture Here>
Career Planning
• An ongoing process
• Involves:
– A personal and professional selfassessment
– Setting goals
– Searching for a job
– Preparing a cover letter and résumé
– Participating
in
an
interview,
including
follow-up
Strategic Career Planning
• Similar to the nursing process
• Requires:
– Assessment and clarification of
your values, interests, and the job
market
– Determining your vision and goals
– Planning and implementing a job
search
– Ongoing
evaluation
to
assure
alignment
with
your
strategic
planning vision and goals
Strategic Planning Process
• Take into consideration your values,
interest, and the job market
• Assess your resilience in nursing
– The ability to recover from or
adjust
to
a
misfortune
or
significant change
– Many changes have occurred in the
nursing workforce, testing the
resilience of nurses
Determining Your Goals
• S = specific
• M = measurable
• A = achievable
• R = realistic
• T = timely
• Putting
your goals in writing
permits you to analyze the current
situation and make the necessary
changes to achieve your goals
Planning and Implementing a Job
Search
• Network
• Look at advertised positions
• Attend a job fair
• Review
any organizations you are
considering
• Consider obtaining a residency
• Determine if there is a multistate
license compact
• Make an appointment with the nurse
recruiter
Preparation of a Cover Letter and
Résumé
•
•
•
•
•
•
•
A form of marketing strategy to
market yourself
Highlights your credentials and skills
The cover letter is a brief commercial
about yourself
Address your cover letter to a person
rather than a company
Keep them brief and specific
Make sure all dates are accurate
Proofreading is essential
Résumé
• Chronological
– Lists jobs in reverse chronological order
– Good for those with little or no gaps in work
history
– Serves to highlight a progression of work
experiences
• Functional
– Can illustrate experience in multiple
careers
– Emphasizes skills and abilities rather than a
sequence of job experiences
Personal Information on the
Résumé
• Include personal
attributes on the
•
•
•
•
•
résumé that portray you as a
continuous learner
Pay attention to detail
Take responsibility for own learning
Seek out learning opportunities
Demonstrate resilience in solving
conflict
Demonstrate
reliability
in
attendance and punctuality
Preparation for the Interview
• Learn more about the agency
• Develop possible questions to ask
• Arrive shortly before the interview to
demonstrate time management skills
• The
nurse
manager
or
human
resources representative will:
– Verify your license and credentials
– Complete
background
and
employment references
• Types of interviews can vary
The Interview Process
• Introductory phase
– Employer will outline the
conditions of employment
job
and
• Working phase
– Employer will ask you questions that
reflect your cover letter and résumé
– Highlight
specific
personal
and
professional accomplishments
– Respond in a calm, problem-solving
fashion to all questions
Dressing for the Interview
• Women
– Solid-color, conservative suit
– Limited jewelry
– Neat, professional hairstyle
• Men
– Conservative suit and tie
– Limited jewelry
– Neat hairstyle
•
Termination Phase of the
Interview
The employer
will close an interview
by asking if you have any questions
• Seek clarification for any concerns
• Conclude by asking when you can
expect to hear from them
• Wait to ask salary questions
Obtaining References
• Seek
permission to use your
references
prior
to
your
interview
• May
use faculty, past job
experiences,
character
references, or volunteer service
Interview Follow-up
• Within 24 hours, follow up your interview with a
simple thank-you note
• Reflect objectively upon the event with a colleague
or friend
• Consider each interview a good learning experience
• Call the employer with a phone call if you do not
hear from them from the specified time
• If the job is offered, you may suggest a follow-up
meeting to clarify any needed information
Evaluation
• Carry
out every step in your
strategic planning for your career
• Career planning means thriving
rather than surviving
• Share a mutual goal of providing
safe and competent care
BACK
Emerging
Opportunities
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Case Manager
• This new delivery of care method includes
providing and coordinating care across the
continuum of prevention, wellness, acute
care, rehabilitation, long-term, hospice,
and respite care
– The nurse case manager should have at
least a baccalaureate degree and expert
clinical skills
– Should possess knowledge of the health
care system, health care finances, and
legal issues
– Should be an effective communicator
Nurse Entrepreneur
• Many
nurses
are
becoming
entrepreneurs
in
a
variety
of
consultative,
educational,
and
technical areas
• Advantages:
–
–
–
–
Independence
Job satisfaction
Flexibility
Choice
Nurse Entrepreneur
• Disadvantages:
– Competition
– Volatility
– Lack of provided benefits
– Must learn to develop
follow a business plan
and
•
Characteristics of Nurse
Entrepreneurs
Visionary, self-motivated,
and a risk taker
• Have common sense
• Good
•
•
•
•
decision
makers
and
problem
solvers
Self-confident, assertive, autonomous,
creative
Responsive to perceived need
Market-driven,
with
good
financial
foresight
Recognize the possibility of success as
well as failure
Advanced Practice Nursing
• An advanced practice nurse:
– Conducts comprehensive health
assessments
– Demonstrates a high level of
autonomy
– Possesses expert skills in the
diagnosis
and
treatment
of
complex responses of individuals,
families, and communities to actual
or potential health problems
Examples of Advanced Practice
Nursing
•Certified
Registered
Nurse
Anesthetist (CRNA)
– Requires a master’s degree
– Takes care of the patient’s
anesthesia
needs
before,
during, and after surgery
– Requires a BSN and at least 1
year of acute care nursing for
entry into the program
Examples of Advanced Practice
Nursing
• Certified Nurse-Midwife (CNM)
– Requires a master’s degree
– Practice in a variety of settings
– Can
provide
well
woman
gynecological
and
low-risk
obstetrical
care,
including
prenatal, labor and delivery,
and postpartum care
•
Examples of Advanced Practice
Nursing
Nurse Practitioner
(NP)
– Requires graduate level education
– Practices throughout the continuum of care
in a multitude of settings and patient
populations
• Clinical Nurse Specialist
– Primarily hospital based
– Clinical expert in evidence-based nursing
practice within a specialty area
– Provides direct patient care, is an educator,
consultant, and researcher