Professional Nursing Concepts Competencies

Anita Finkelman
PROFESSIONAL
NURSING
CONCEPTS
Competencies for Quality Leadership
FOURTH EDITION
Anita Finkelman
PROFESSIONAL
NURSING
CONCEPTS
Competencies for Quality Leadership
FOURTH EDITION
Anita Finkelman, MSN, RN

Visiting Lecturer, Nursing Department
Recanati School for Community Health Professions
Faculty of the Health Sciences
Ben-Gurion University of the Negev
Beersheba, Israel
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Library of Congress Cataloging-in-Publication Data
Names: Finkelman, Anita, author.

Title: Professional nursing concepts : competencies for quality leadership /
Anita Finkelman.
Description: Fourth edition. | Burlington, MA : Jones & Bartlett Learning,
[2019] | Includes bibliographical references and index.
Identifiers: LCCN 2017035478 | ISBN 9781284127270
Subjects: | MESH: Nursing | Nursing Care | Nurse’s Role | Leadership | United
States
Classification: LCC RT82 | NLM WY 100 AA1 | DDC 610.7306/9--dc23 LC record available at https://secure-web.cisco.com
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Contents
Acknowledgments Professional Nursing Associations 22
Major Nursing Associations 23
Preface
Why Belong to a Nursing Professional
Organization? 28
Section 1: The Nursing Workforce 28
The Image of Nursing 30
Profession of Nursing Chapter Highlights 33
Engaging in the Content 33
Chapter 1 Professional Nursing: Critical Thinking Activities 33
History and Development of the
Electronic Reflection Journal 34
Nursing Profession. . . . . . . . . . . . . . . . . . . . . 3
Case Studies 35
Introduction 4 Working Backward to Develop a Case 35
From Past to Present: Nursing History 4 References 36
The History Surrounding the Development
Chapter 2 The Essence of Nursing:
of Nursing as a Profession 4
Knowledge and Caring. . . . . . . . . . . . . . . 39
Early History 5
Rise of Christianity and the Middle Ages 5 Introduction 40
Renaissance and the Enlightenment 6 Nursing: How Do We Define It? 40
Industrial Revolution 6 Knowledge and Caring 42
Colonization of America and the Growth Knowledge 42
of Nursing in the United States 6 Knowledge Management 43
Nurse Leaders: History in the Making 10 Critical Thinking and Clinical Thinking
Themes: Looking into the Nursing and Judgment: Impact on Knowledge
Profession’s History 16 Development and Application 44
Professionalism: Critical Professional Caring 47
Concepts and Activities 18 Competency 49
Nursing as a Profession 18 Scholarship in Nursing 50
Sources of Professional Direction 20 What Does Scholarship Mean? 50
v
vi Contents
Nursing Theory 55 Quality and Excellence in Nursing

Nursing Research 60 Education 88
Professional Literature 61 Nursing Education Standards 88
New Modalities of Scholarship 62 NLN Excellence in Nursing Education 88
Multiple Nursing Roles and Leadership 63 Focus on Competencies 89
Key Nursing Roles 63 Curriculum 89
Provider of Care 63 Didactic or Theory Content 90
Educator 63 Practicum or Clinical Experience 91
Counselor 64 Distance Education 92
Manager 64 Accreditation of Nursing Education
Researcher 64 Programs 93
Collaborator 64 Critical Nursing Education Problems 95
Change Agent (Intrapreneur) 64 Faculty Shortage 95
Entrepreneur 64 Access to Clinical Experiences 95
Patient Advocate 65 A Response and Innovation: Laboratory
Leader 65 Experiences and Clinical Simulation 96
Summary Points: Roles and What Is Required 65
Transforming Nursing Education 97
Chapter Highlights 66 Interprofessional Healthcare Education 97
Engaging in the Content 66 Regulation 99
Critical Thinking Activities 66 Nurse Practice Acts 100
Electronic Reflection Journal 67 State Boards of Nursing 100
Case Studies 67 National Council of State Boards of Nursing 101
Working Backward to Develop a Case 71 Licensure Requirements 101
References 71 National Council Licensure Examination 102
Critical Current and Future Regulation Issues 103
Chapter 3 Nursing Education,
Nurse Licensure Compact 103
Accreditation, and Regulation. . . . . . . 73
Mandatory Overtime 104
Introduction 74 Foreign Nursing Graduates: Entrance to
Nursing Education 75 Practice in the United States 104
A Brief History of Nursing Education 76 Global Health Regulatory Issues 105
Major Nursing Reports: Improving Nursing Chapter Highlights 105
Education 77 Engaging in the Content 106
Entry into Practice: A Long Debate 78 Critical Thinking Activities 106
Differentiated Nursing Practice 80 Electronic Reflection Journal 106
Types of Nursing Education Programs 81 Case Studies 107
Diploma Schools of Nursing 82 Working Backward to Develop a Case 108
Associate Degree in Nursing 82 References 108
Baccalaureate Degree in Nursing 83
Master’s Degree in Nursing 84 Chapter 4 Success in Your Nursing
Research-Based Doctoral Degree in Nursing 85 Education Program . . . . . . . . . . . . . . . . . . 113
Doctor of Nursing Practice 85
Nursing Education Associations 86 Introduction 114
National League for Nursing 86 Your Pursuit of a Profession: Making the Most
American Association of Colleges of Nursing 87 of Your Educational Experience to Reach
Organization for Associate Degree Nursing 87 Graduation and Licensure 114
Contents vii
Roles of the Student and the Faculty 115 Policy: Relevance to the Nation’s Health
Student Learning Styles 116 and to Nursing 149
Tools for Success 117 General Descriptors of U.S. Health Policy 150
Time Management 117 Examples of Critical Healthcare Policy
Study Skills 121 Issues 151
Preparation 122 Cost of Health Care 152
Reading 122 Healthcare Quality 153
Using Class Time Effectively 123 Disparities in Health Care 153
Using the Internet 125 Consumers 153
Preparing Written Assignments and Team Commercialization of Health Care 153
Projects 125 Reimbursement for Nursing Care 154
Preparing to Take Quizzes and Exams 126 Immigration and the Nursing Workforce 154
Participating in Team Discussions in the Nursing Agenda: Addressing Health
Classroom and Online 128 Policy Issues 154
Networking and Mentoring 128 The Policy-Making Process 155
Clinical Learning Experiences 129 The Political Process 157
Clinical Lab and Simulation 129 Nurses’ Role in the Political Process:
Clinical Experiences or Practicums 130 Impact on Healthcare Policy 159
Additional Learning Experiences to Getting into the Political System and
Expand Graduate Competency 132 Making It Work for Nursing 159
Cooperative Experiences 132 Patient Protection and the Affordable
Nurse Internships/Externships 133 Care Act of 2010 163
Nurse Residency Programs 133 Chapter Highlights 165
Lifelong Learning for the Professional 134 Engaging in the Content 165
Certification and Credentialing 137 Critical Thinking Activities 166
Caring for Self 138 Electronic Reflection Journal 166
Chapter Highlights 141 Case Studies 166
Engaging in the Content 141 Working Backward to Develop a Case 167
Critical Thinking Activities 141 References 167
Case Studies 142 Chapter 6 Ethics and Legal
Working Backward to Develop a Case 143
Issues. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
References 143 Introduction 170
Ethics and Ethical Principles 170
Section 2: The Definitions 170
Ethical Principles 171
Healthcare Context Ethical Decision Making 172
Professional Ethics and Nursing Practice 172
Chapter 5 Health Policy American Nurses Association Code
and Political Action . . . . . . . . . . . . . . . . . 147 of Ethics 173
Reporting Incompetent, Unethical,
Introduction 148 or Illegal Practices 173
Importance of Health Policy and Political Critical Ethical Issues in Healthcare
Action 148 Delivery 175
Definitions 148 Healthcare Fraud and Abuse 175
viii Contents
Ethics and Research 176 Across the Life Span 206

Research: Informed Consent 176 Health Disparities 206
Research: Risk of Physical Harm 178 Health Promotion and Disease Prevention 207
Research: Risk of Psychological Harm 178 Health Promotion 207
Research: Risk of Social and Economic Disease Prevention 209
Harm 178 Important Concepts 210
Organizational Ethics 179 Patient as Focus of Care and Member of the
Legal Issues: An Overview 180 Healthcare Team 210
Critical Terminology 181 Vulnerable Populations 211
Malpractice: Why Should This Concern You? 182 Health and Illness 211
Examples of Issues with Ethical and Stress, Coping, Adaptation, and Resilience:
Legal Implications 185 A Public/Community Perspective 213
Privacy, Confidentiality, and Informed Acute Illness 214
Consent 185 Greater Emphasis on Chronic Disease 214
Rationing Care: Who Can Access Care when Medical Home Model 217
Needed 186 Self-Management 217
Advance Directives, Living Wills, Medical Health Literacy 218
Powers of Attorney, and Do-Not-Resuscitate Multiple Perspectives of Public/Community
Orders 186 Health Services 218
Organ Transplantation 187 Community Emergency Preparedness 218
Assisted Suicide 188 Managing Population Health 219
Social Media and Ethical and Legal Issues: Migrant and Immigrant Issues 220
A New Concern 188 Home Health Care 220
Chapter Highlights 189 School Health 220
Engaging in the Content 190 Rehabilitation 221
Critical Thinking Activities 190 Extended Care, Long-Term Care,
Electronic Reflection Journal 190 and Elder Care 221
End-of-Life Care and Palliative Care 221
Case Studies 191
Case Management 223
Occupational Health Care 223
References 192
Complementary and Alternative Therapies
Chapter 7 Health Promotion, or Integrative Medicine 224
Disease Prevention, and Illness: Genetics 224
A Community Perspective . . . . . . . . . . 195 The Changing Nature of Public/Community
Health Problems 225
Introduction 196
Violence in Communities 225
A National Initiative to Improve the Nation’s
Opioid Epidemic 226
Health: Healthy People 2020 197
Global Healthcare Concerns and
Public/Community Healthcare Delivery
International Nursing 227
System 200
Chapter Highlights 228
Structure and Function of the Public/
Engaging in the Content 228
Community Healthcare Delivery System 200
Continuum of Care 202 Critical Thinking Activities 229
Continuity of Care 202 Electronic Reflection Journal 229
Individual, Family, and Community Case Studies 229
Health 203 Working Backward to Develop a Case 230
Access to Care 204 References 231
Contents ix
Chapter 8 The Healthcare Delivery The Competency: Provide Patient-Centered

System: Focus on Acute Care . . . . . . . 235 Care 271
Support of Patient-Centered Care 271
Introduction 236 Levels of Patient-Centered Care 273
Corporatization of Health Care: How Did Does a Patient-Centered Healthcare
We Get Here? 237 System Exist in the United States? 274
The Healthcare Organization 238 Related Nursing Theories 277
Structure and Process 240 Consumerism: How Does
Classification of Hospitals 241 It Affect Health Care and Nursing? 278
Typical Departments in a Hospital 242 Who Are the Consumers or Customers? 279
Healthcare Providers: Who Is on the Patient Rights 280
Team? 244 Information Resources and Consumers 280
Healthcare Financial Issues 247 Patient Satisfaction 281
The Nation’s Health Care: Financial Status Culture, Diversity, and Disparities
(Macro View) 248 in Health Care 283
The Individual Healthcare Organization and Its Culture 283
Financial Needs (Micro View) 248 Cultural Competence 284
Reimbursement: Who Pays for Health Disparities in Health Care 284
Care? 250 Disparities: Examples and Importance 286
The Third-Party Payer System 252 Diversity in the Healthcare
Government Reimbursement of Healthcare Workforce 287
Services 253 Patient Advocacy 288
The Uninsured and the Underinsured 255 Care Coordination: A Plan of Care 288
The Nursing Organization Within Application of Critical Thinking and
the Hospital 255 Clinical Reasoning and Judgment 289
Organizational Culture 259 Nursing Process 289
Changes in Healthcare Delivery 261 Assessment 290
Chapter Highlights 263 Diagnosis 290
Engaging in the Content 264 Planning 290
Critical Thinking Activities 264 Implementation 291
Electronic Reflection Journal 264 Evaluation 291
Care/Concept Mapping 292
Case Studies 265
Working Backward to Develop a Case 265 Self-Management of Care 293
Health Literacy: A Barrier 293
References 266
Patient/Family Education: Inclusion
in the Plan of Care 294
Section 3: Core Therapeutic Use of Self in the Nurse–Patient
Healthcare Relationship 296
Chapter Highlights 299
Professional Engaging in the Content 301
Competencies Critical Thinking Activities 301
Chapter 9 Provide Patient-Centered Case Studies 302
Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269 Working Backward to Develop a Case 303
Introduction 270 References 303
x Contents
Chapter 10 Work in Interprofessional Chapter 11 Employ Evidence-Based

Teams . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307 Practice. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 349
Introduction 308 Introduction 350
The Core Competency: Work in The Competency: Employ Evidence-Based
Interprofessional Teams 309 Practice 350
Teamwork 311 Nursing Research 352
Clarification of Terms 311 Historical Background 352
Microsystem 312 National Institute of Nursing Research 353
Team Leadership 312 The Research Process 354
Development of Effective Teams 313 Types of Research Design 357
Improving Team Communication 316 Research Funding 357
Overview of Communication 317 Ethics and Legal Issues 358
Formal Meetings 318 Barriers to and Facilitators of Research 359
Debriefing 320 Other Influential Organizations: Impact
Assertiveness 320 on Research 360
Listening 321 Evidence-Based Practice 360
Mindful Communication 322 Definitions 360
SBAR 322 Types of EBP Literature 361
Checklists 322 Searching for EBP Literature: Evidence 362
Healthcare Team Members: Which The Roles of Staff Nurses Related to Systematic
Knowledge and Competencies Reviews 362
Do They Need? 323 Evidence-Based Management 363
Teams and Decision Making 324 Improving EBP Implementation 363
Collaboration 326 Tools to Ensure a Higher Level of Use of EBP 364
Coordination 326 Policies and Procedures Based on EBP 366
Barriers and Competencies Related Clinical Guidelines Based on EBP 367
to Coordination 327 Confusion: Difference in Research, EBP,
Tools to Improve Coordination 328 and Quality Improvement 367
Incivility in Healthcare Work Environment 329 Importance of EBP to the Nursing
Delegation 331 Profession 368
Importance of Delegation 332 Impact of Evidence-Based
Five Delegation Rights 333 Practice over the Last Decade 368
Delegation Principles 334 Nursing Practice and Management 368
Evaluation of Effective Delegation 337 Nursing Education 369
Change 338 Government Initiatives Supporting
Conflict and Conflict Resolution 339 Research and EBP 370
Power and Empowerment 341 Applying EBP as a Student 370
Chapter Highlights 343 Chapter Highlights 371
Engaging in the Content 344 Engaging in the Content 372
Critical Thinking Activities 344 Critical Thinking Activities 372
Electronic Reflection Journal 344 Electronic Reflection 372
Case Studies 345 Case Studies 373
Working Backward to Develop a Case 346 Working Backward to Develop a Case 373
References 346 References 374
Contents xi
Chapter 12 Apply Quality Measurement and Analysis 407

Improvement. . . . . . . . . . . . . . . . . . . . . . . .375 Data Collection 408
Analysis 408
Introduction 376 Patient Outcomes and Nursing Care:
The Competency: Apply Quality Do We Make a Difference in Quality
Improvement 377 Improvement? 410
Quality Health Care 377 Chapter Highlights 414
To Err Is Human: Impact on Safety 377 Engaging in the Content 415
Crossing the Quality Chasm: Impact Critical Thinking Activities 415
on Quality Care 380
Case Studies 416
Envisioning the National Healthcare
Quality Report: Need for
Monitoring 382
Defining Quality Health Care 383
References 418
Safety in Health Care 383 Chapter 13 Utilize Informatics . . . . . . 423
Critical Safety Terms 383
A Culture of Safety and a Blame-Free Work Introduction 424
Environment 385 The Core Competency: Utilize Informatics 425
Staff Safety 388 The Federal Health Informatics Reports 426
Quality Improvement 391 Informatics 428
Examples of Safety Initiatives 392 Description and Definitions 429
The Joint Commission 394 Nursing Standards: Scope and Standards
Healthcare Report Cards 395 of Nursing Informatics 431
National Quality Strategy 396 Certification in Informatics Nursing 432
Federal Initiatives to Improve Care: Informatics: Impact on Care 432
Hospital-Acquired Conditions and Implications for Nursing Education and
30-Day Unplanned Readmissions 398 Nursing Research 433
Examples of High-Risk Healthcare Documentation 434
Activities 401 Meaningful Use 436
Medication Administration 401 Standardized Terminology 437
Care Transitions and Handoffs 403 Systems and Terminologies 438
Failure to Rescue 403 Informatics: Types and Methods 439
Alarm/Alert Fatigue 403 Automated Dispensing of Medications
Missed Nursing Care 404 and Bar Coding 440
Tools and Methods to Monitor and Computerized Monitoring of Adverse Events 440
Improve Healthcare Delivery 404 Electronic Medical/Health Records 441
Utilization Review/Management 404 Clinical Provider Order-Entry System 442
Benchmarking 405 Clinical Decision Support Systems 443
Assessment of Access to Healthcare Tablets and Smartphones 443
Services 405 Computer-Based Reminder Systems 444
Medication Reconciliation 405 Access to Patient Records at the Point
Standardized Communication of Care 444
Methods 406 Internet Prescriptions 444
Rounds 406 Nurse Call Systems 445
Incident Reports 407 Voice Mail and Texting 445
Sentinel Events 407 Telephone for Advice and Other Services 445
xii Contents
Internet or Virtual Appointments 445 Scope of Practice: A Profession of Multiple

Online Support Groups for Patients Settings, Positions, and Specialties 472
and Families 446 Multiple Settings and Positions 472
The Future of Health Informatics and Nursing Specialties 475
Medical Technology 446 Advanced Practice Registered Nurse:
Nanotechnology 447 Changing Scope of Practice 476
Wearable Computing 447 Professional Practice 477
Telehealth and Remote Telemetry Differentiated Nursing Practice 478
Monitoring 447 Examples of Professional Practice Models 478
Robotics 448 Impact of Legislation/Regulation/Policy on
Genetics and Genomics 448
Nursing Leadership and Practice 481
Medical Devices 449
Economic Value and the Nursing Profession 482
HIPAA: Ensuring Confidentiality 449
The Nursing Work Environment 483
High-Touch Care versus High-Tech Care 450 The Work Environment and Leadership 483
Nursing Leadership in Health Informatics 451 Workforce Issues and Effective Staffing 484
Chapter Highlights 451 Interprofessional Teams and the Work
Engaging in the Content 453 Environment 486
Critical Thinking Activities 453 Improving the Work Environment 487
Electronic Reflection Journal 453 Finding the Right Workplace for You 488
Case Studies 454 Quality Improvement and Nursing
Working Backward to Develop a Case 455 Leadership 488
References 455 Transforming Care at the Bedside 490
Magnet Recognition Program® 490
Moving the Profession Forward: Students
Are the Future of Nursing 493
Section 4: The Practice The Future of Nursing: Leading Change,
of Nursing Today and Advancing Health 493
in the Future Progress Report on The Future of Nursing:

Leading Change, Advancing Health 494
Student Leadership 498
Chapter 14 The Future: Transformation
of Nursing Practice through Chapter Highlights 499
Leadership 461 Engaging in the Content 501
Critical Thinking Activities 501
Introduction 462 Electronic Reflection Journal 501
Leadership and Management in Nursing 463 Case Studies 502
Leadership Models and Theories 463 Working Backward to Develop a Case 503
Shared Governance: Empowering Nursing References 503
Staff 464
Leadership versus Management 465 Appendix A Quality Improvement
Nursing Management Positions 466 Measurement and Analysis Methods
Factors that Influence Leadership 467 Appendix B Staffing and a Healthy
Generational Issues in Nursing: Impact Work Environment
on Image 467
Appendix C Getting the Right Position
Power and Empowerment 470
Assertiveness 471 Glossary
Advocacy in Leadership 472 Index
Acknowledgments
I thank my family for all of their support of my this project; and the production team. I also want
writing: Fred, Shoshannah, and Deborah. Thank you to recognize all students and faculty I have worked
to Elisabeth Garofalo for her role as developmental with who taught me so much about what students
editor; Amanda Martin for her guidance in the on- need to know to practice competently and guidance
going editions of this text; Emma Huggard for her faculty need to provide effective learning experi-
hands on management of the project; Wes Deshano ences for students in the classroom, simulation,
for his guidance regarding copyright; the editing and clinical settings.
team; all the team at JBL who have participated in
xiii
Preface
The development of this text is motivated by the need healthcare experience. Nurses need to assume crit-
to provide students who are beginning their nursing ical roles in this experience through their unique
education or working toward their baccalaureate professional expertise and leadership. They are also
degree for career development with background members of the interprofessional healthcare team;
information about the nursing profession and the they must work with others to provide and improve
critical healthcare delivery issues that affect our care in a healthcare environment that provides a
profession. This goal has been the same for all of healthy workplace and a positive patient experience.
its editions, but it is even more imperative today This text consists of 14 chapters, divided into
as we have experienced changes due to healthcare four sections. Section 1 focuses on the profession
legislation and as we experience more changes with of nursing. In these chapters, students will learn
a new presidential administration. Change is part of about the dynamic history of nursing and how
health care, and we need to understand where we the profession developed; the complex essence of
came from and update ourselves so we can effectively nursing (knowledge and caring); nursing education,
engage in the change process that lies ahead of us. accreditation, and regulation; and how to succeed
We hear much about healthcare reimbursement as nursing students.
in the news, and this is important—but we cannot Section 2 explores the healthcare context
ignore that we have a healthcare system that needs in which nursing is practiced. Health policy and
repair and improvement. Thus, this fourth edition political action are very important today in health
continues to emphasize quality improvement and care and in nursing. Students need to know about
the nurse’s role in quality improvement, ensuring ethical and legal issues that currently apply to their
patient-centered care. practice and issues that might apply in the future
Nursing students today are asked to cover much as registered nurses. Students typically think most
information in their courses and develop clinical about caring for the acutely ill, but the health
competencies in a short period of time. It is critical context is broader than this and includes health
that each student recognize that nursing does not promotion, disease prevention, and illness across
happen in isolation, but rather it is part of the entire the continuum of care in the community. Though
xv
xvi Preface
nursing is practiced in many different settings and just covered. This is not meant to be a question or
healthcare organizations, the final chapter in this a summary statement of the preceding content. The
section focuses on acute care organizations, providing end-of-chapter section, Engaging in the Content,
students with an in-depth exploration of one type includes a number of features to augment student
of healthcare organization. learning. This section expands on features found
Section 3 moves the discussion to the core in the third edition. Discussion Questions, Critical
healthcare professions competencies that are expected Thinking Activities, and Case Studies provide a variety
for all healthcare professions. Each chapter in this of methods to examine the chapter content. Some of
section focuses on one of the core competencies. these may be done by individual students, and others
Though this section covers these competencies in by student teams, either in the classroom or online.
depth, the competencies are relevant to all the content The Electronic Reflection Journal directs students to
in this text. The five competencies are (Institute of develop a log or diary over the course of using the text.
Medicine, 2003): The journal can be maintained in students’ computers
1. Provide patient-centered care. or tablets and updated throughout the course; it can
2. Work in interprofessional teams. also be expanded as students progress in their nursing
3. Employ evidence-based practice. program, encouraging them to keep a professional
4. Apply quality improvement. journal for reflection. This process provides students
5. Utilize informatics. with opportunities to reflect on content, supporting
the development of professional self-awareness.
Section 4 brings us to the end of this text,
Each chapter has two Case Studies with questions. A
although not to the end of learning. The chapter
new feature in this edition is Working Backward to
in this section focuses on the transformation of
Develop a Case, which allows students to be creative
nursing practice through leadership, connecting
in applying chapter content by using the questions
the key concepts in the text.
provided to develop a case scenario. Individual students
This fourth edition also includes three appen-
or student teams may develop the case scenario and
dices. The first focuses on quality improvement
then exchange the case scenario with other students
measurement and analysis methods, providing
to use in a traditional case experience—reviewing
students with a quick reference for information about
the scenario and responding to the questions. Above
quality improvement that can be used throughout
all, this text is patient centered—its content and
the nursing program and to develop their expertise
learning activities for students. Nurses care for and
in quality improvement. The other appendices pro-
about patients.
vide students with important information related
to staffing and healthy work environments, as well
as finding the right job. Special Note: The Affordable Care Act of 2010
Each chapter includes objectives, an outline (ACA) is discussed in this text because it has been
of the chapter to help organize students’ reading, a major factor in healthcare delivery since 2010.
key terms that are found in the chapter and defined Due to the change in presidential administrations
in the Glossary, content with headers that apply to and possible changes in healthcare policy and laws
the chapter outline, and chapter highlights. A new that guide healthcare policy, some of the informa-
chapter feature is the Stop and Consider statement tion in this text about the ACA may change. This
found after each major section in a chapter. This is a good example of the need for nurses to remain
statement asks the student to take a break from vigilant to changes in healthcare policy because these
reading and to reflect on some aspect of the content changes usually affect nurses and nursing practice.
Preface xvii
Information up through June 2017 is accurate, but

Reference
after this date, the information about ACA may be
reflective of past healthcare policy. It is important Institute of Medicine. (2003). Health professions edu-
to understand health policy from past to current cation: A bridge to quality. Retrieved from http://
policy, and with the ACA and subsequent policy www.iom.edu/Reports/2003/Health-Professions
we have a living experience of this need. -Education-A-Bridge-to-Quality.aspx
Section 1
© Galyna Andrushko/Shutterstock
The Profession
of Nursing
The first section of this text
introduces the nursing student
to the profession of nursing. The
Development of Professional
Nursing: History, Development,
and the Nursing Profession
chapter reviews the history and
development of the nursing
profession and what it means for
nursing to be a profession. The
Essence of Nursing: Knowledge
and Caring chapter discusses
the essence of nursing, focusing
on the need for knowledge
and caring and how nursing
students develop throughout the
nursing education program to be
knowledgeable, competent, and
caring. The Nursing Education,
Accreditation, and Regulation
chapter examines nursing
education, accreditation of
nursing education programs,
and regulation of the practice
of nursing. The Success in Your
Nursing Education Program
chapter provides information
about the nursing student
experience.
Chapter
1
Professional Nursing: History
and Development of the
Nursing Profession
CHAPTER OBJECTIVES
At the conclusion of this chapter, the learner will be able to:
■■ Examine key figures, events in nursing history, standards and professional organizations to
and critical nursing historical themes within the nursing profession.
the sociopolitical context of the time. ■■ Describe the current and past image of
■■ Discuss critical professional concepts, nursing and related critical issues.
professionalism in nursing, and relevance of
CHAPTER OUTLINE
●● Introduction ●● Nursing as a Profession

●● From Past to Present: Nursing History ●● Sources of Professional Direction
●● The History Surrounding the ●● Professional Nursing Associations
Development of Nursing as a ●● Major Nursing Associations
Profession ●● Why Belong to a Nursing Professional
●● Early History Association?
●● Rise of Christianity and the Middle ●● Nursing Workforce
Ages ●● The Image of Nursing
●● Renaissance and the Enlightenment ●● Chapter Highlights
●● Industrial Revolution ●● Engaging in the Content
●● Colonization of America and the ●● Discussion Questions
Growth of Nursing in the United ●● Critical Thinking Activities
States ●● Electronic Reflection Journal
●● Nurse Leaders: History in the Making ●● Case Studies
●● Themes: Looking into the Nursing ●● Working Backward to Develop a Case
Profession’s History ●● References
●● Professionalism: Critical Professional
Concepts and Activities
3
4 Section 1: The Profession of Nursing
KEY TERMS
Accountability Nursing Scope of practice

Autonomy Professional organization Social policy statement
Code of ethics Professionalism Standards
Colleagueship Responsibility
The past portrayal of nurses as handmaidens and

Introduction assistants to physicians has its roots in the profes-
sion’s religious beginnings, but over time this view
This text presents an introduction to the nursing
of nurses changed. The following sections examine
profession and critical aspects of nursing care and
the story of nursing and explore how it developed
the delivery of health care. To begin the journey to
as a profession.
graduation, licensure, and then practice, it is im-
portant to understand several aspects of the nursing
profession. What is professional nursing? How did The History Surrounding
it develop? What factors influence the view of the the Development of Nursing
profession? This chapter addresses these questions. as a Profession
When nursing history is described, distinct historical
periods typically are discussed: early history (AD
From Past to Present: 1–500), rise of Christianity and the Middle Ages
Nursing History (500–1500), Renaissance (mid-1300s–1600s), and
the Industrial Revolution (mid-1700s–mid-1800s).
It is important for nursing students to learn about In addition, the historical perspective must include
nursing history. Nursing’s history provides a frame- the different regions and environments in which
work for understanding how nursing is practiced the historical events took place. Early history
today and the societal trends shaping the profession. focuses on Africa, the Mediterranean, Asia, and
The characteristics of nursing as a profession and the Middle East. The focus then turns to Europe,
what nurses do today have their roots in the past, with the rise of Christianity and subsequent major
not only in the history of nursing, but also in the changes that span several centuries. Nursing history
history of health care and society in general. Today, expands as British colonists arrive in America, and
health care is highly complex; diagnostic methods a new country and environment helped to slowly
and therapies have been developed that offer many develop the nursing profession, which at the time
opportunities for prevention, treatment, and cures was not a profession. Throughout all these periods
that did not exist even a few years ago. Understand- and locations, wars had an impact on nursing. As
ing this development is part of this discussion; it a consequence of the varied places and times in
helps us to appreciate where nursing is today and which nursing has existed, major historical events,
may provide stimulus for changes in the future. different cultures and languages, varying views on
“Nursing is conceptualized as a practice discipline what constitutes disease and illness, roles of women,
with a mandate from society to enhance the health political issues, and location and environment have
and well-being of humanity” (Shaw, 1993, p. 1654). influenced these professions. Nursing has probably
Chapter 1: Professional Nursing: History and Development of the Nursing Profession 5
existed for as long as humans have been ill; someone this period—which represents thousands of years
always took care of the sick. This does not mean that and involved several major cultures that rose and
there was a formal nursing position; rather, in most fell—nursing care was provided, but not nursing
early cases, the nurse was a woman who cared for as it is thought of today. People took care of those
ill family members. This discussion begins with this who were sick and those going through childbirth,
group and then expands to the development and representing an early nursing role.
implementation of a formal nursing position and
then later to multiple roles and different healthcare Rise of Christianity and the
settings and recognition of nursing as a profession. Middle Ages
The rise of Christianity led to more structured nursing
Early History care, but still it was far from professional nursing.
Early history of nursing focused on the Ancient Women continued to carry most of the burden of
Egyptians and Hebrews, Greeks, and Romans. During caring for the poor and the sick. The church set
this time, communities often had women who as- up a system for care that included the role of the
sisted with childbearing as a form of nursing care, deaconess, who provided care in homes. Women
and some physicians had assistants. The Egyptians who served in these roles had to follow strict rules
had physicians, and sick persons looking for magical set by the church. This role eventually evolved into
answers would go to them or to priests or sorcerers. that of nuns, who began to live and work in con-
Hebrew (Jewish) physicians kept records and vents. The convent was considered a safe place for
developed a hygiene code that examined issues such women. The sick came to the convents for nursing
as personal and community hygiene, contagion, care and also received spiritual care (Wall, 2003).
disinfection, and preparation of food and water The establishment of convents and the nursing care
(Masters, 2005). This occurred at a time when hy- provided there formed the seed for what, hundreds
giene was very poor—a condition that continued of years later, would become the Catholic system of
for several centuries. Disease and disability were hospitals that still exists today.
viewed as curses and related to sins, which meant Men were also involved in nursing at this time.
that afflicted persons had to change or follow the For example, men in the Crusades cared for the sick
religious statutes (Bullough & Bullough, 1978). and injured. These men wore large red crosses on
Greek mythology recognized health issues and their uniforms to distinguish them from the fighting
physicians in its gods. Hippocrates, a Greek physician, soldiers. The “red cross” later became the symbol
is known as the father of medicine. He contributed for the International Committee of the Red Cross.
to health care by writing a medical textbook that was Altruism and connecting care to religion were
used for centuries, and he developed an approach major themes during this period. Even Nightingale
to disease that would later be referred to as epide- continued with these themes in developing her
miology. Hippocrates wrote the Hippocratic Oath view of nursing. Disease was common and spread
(Bullough & Bullough, 1978), which is still recited quickly, and medical care had little to offer in the
by new physicians and also influenced the writing way of prevention or cure. Institutions that were
of the Nightingale Pledge (see Exhibit 1-1). The called hospitals were not like modern hospitals;
Greeks viewed health as a balance between body and they primarily served travelers and sometimes the
mind—a different perspective from earlier views of sick (Kalisch & Kalisch, 1986, 2005).
health that focused on curses and sins. The Protestant Reformation had a major impact
Throughout this entire period, the wounded on some of the care given to the sick and injured.
and ill in the armies required care. Generally, during The Catholic Church’s loss of power in some areas
resulted in the closing of hospitals, and some convents As a result of this work, he became known
closed or moved. The hospitals that remained were as the father of microbiology.
no longer staffed by nuns, but rather by women from ■■ Klebs, Pasteur, Lister, and Koch all contrib-
the lower classes who often had major problems, uted to the development of the germ theory.
such as alcoholism or were former prostitutes.
This is what Florence Nightingale found when she Industrial Revolution
entered nursing. The Industrial Revolution brought changes in the
workplace, but many were not positive from a
Renaissance and the
health perspective. The crowded factories of this
Enlightenment
era were hazardous and served as breeding grounds
The Renaissance had a major impact on health and for disease. People worked long hours and often
the view of illness. This period was one of significant under harsh conditions. This was a period of great
advancement in science, though by today’s standards, exploitation of children, particularly those of the lower
it might be viewed as limited. These early discoveries classes, who were forced to work at very young ages
led to advancements that had never been imagined. (Masters, 2005). No child labor laws existed, so
This is the period, spanning many years, of preteen children often worked in factories alongside
Columbus and the French and American Revolutions adults. Some children were forced to quit school to
when education became more important. Leonardo earn wages to help support their families. Cities were
da Vinci’s drawings of the human anatomy, which crowded and very dirty, with epidemics erupting
were done to help him understand the human about which little could be done. There were few
body for his sculptures, provided details that had public health laws and services to alleviate the causes.
not been recognized before (Donahue, 1985). The
18th century was a period of many discoveries and Colonization of America and
changes (Dietz & Lehozky, 1963; Masters, 2005; the Growth of Nursing in the
Rosen, 1958), including the following: United States
■■ Jenner’s smallpox vaccination method was The initial experiences of nursing in the United States
developed during a time of high death rates were not much different from those described for
from smallpox. Britain and Europe. Nurses were of the lower class
■■ Psychiatry became a medical specialty area, and had limited or no training; hospitals were not
through the influence of Freud and others. used by the upper classes, but rather by the lower
■■ The pulse watch and the stethoscope were classes and the poor. Hospitals were dirty and lacked
developed, changing how physical assessment formal care services.
was conducted. Nursing in the United States did move forward,
■■ Pasteur discovered the process of pasteur- as described in Exhibit 1-2 demonstrating nursing
ization, which had an impact on food and activities and changes that occurred over time.
milk contamination. Significant steps were taken to improve nursing
■■ Lister used some of Pasteur’s research and education and the profession of nursing. The first
developed approaches to antiseptic surgery; nursing schools—or, as they were called, training
as a result of this work, Lister is known as schools—were modeled after Nightingale’s school.
the father of surgery. Some of the earlier schools were in Boston, New
■■ Koch studied anthrax and cholera, both major York, and Connecticut. The same approach was
diseases of the time, demonstrating that they taken in these schools as in Britain. Stress was
were transmitted by water, food, and clothing. placed on moral character and subservience, with
efforts to move away from using lower-class women In the 1930s, the Great Depression also had an
with dubious histories (Masters, 2005). Limitations impact on the nursing field, “resulting in widespread
regarding what women could do on their own con- unemployment of private duty nurses and the closing
tinued to be a major problem—for example, women of nursing schools, while simultaneously creating the
could not vote and had limited rights. increasing need for charity health services for the
In the early 1900s, this situation began to population” (Masters, 2005, p. 28). This meant that
change when women obtained the right to vote, there were fewer student nurses to staff the hospitals.
but only with great effort. The Nurses’ Associated As a consequence, nurses were hired, albeit at very
Alumnae, established in 1896, was renamed the low pay, to replace them. Until that time, hospitals
American Nurses Association (ANA) in 1911. At had depended on student nurses to staff the hospitals,
the same time, the first nursing journal, American and nurses who had completed training (term then
Journal of Nursing (AJN), was created through the used for nursing education) served as private-duty
ANA. The AJN was published until early 2006, nurses in homes. Using students to staff hospitals
when the ANA replaced it with American Nurse continued until the university-based nursing effort
Today as its official journal. The AJN, the oldest grew; however, during the Depression, there was a
U.S. nursing journal, still exists today, but a com- greater need to replace nursing students with nurses
pany that is not associated with ANA publishes when schools closed. On one level, this could be
it. Its content has always focused on issues facing seen as an improvement in care, but the obstacle
nurses and their patients. Additional information of low pay was difficult to overcome, resulting in a
about significant nursing professional activities long history of low pay scales for nurses.
is discussed in this chapter and other chapters In the 1940s and 1950s, other changes occurred
throughout this text. in the U.S. healthcare system that had a direct
Although some nurse leaders were ardent impact on nursing. Certainly, scientific discoveries
suffragists, Nightingale was not interested in these were changing care, but important health policy
ideas, even though women in Britain did not have the changes occurred as well. The Hill-Burton Act
right to vote. Nightingale felt that the focus should (1946) established federal funds to build more
be on allowing (a permissive statement indicative hospitals; as a result of this building boom, at one
of women’s status) women to own property and point in the 1980s, there were too many hospital
then linking voting rights to this ownership right beds. In turn, many nurses lost their jobs in hos-
(Masters, 2005). There was, however, communication pitals because their salaries represented the largest
across the ocean between U.S. and British nurses. operating expense and there were not enough
They did not always agree on the approach to take patients to fill the beds. There is some belief that
on the road to professionalism; in fact, nurses did this decision still affects fluctuating problems of
not always agree on this issue within the United nursing shortage either at the national level or in
States. Nurse leaders and practicing nurses helped specific states and healthcare organizations, though
nursing to grow into a profession during times of its scope has varied over the past few years. When
war (American Revolution, Civil War, the Spanish– more nurses are needed, some of the nurses who
American War, World War I, World War II, Korean are laid off move into new jobs or careers or leave
War, Vietnam War, and modern wars today). The the workforce so they are not available when the
website Experiencing War: Women at War offers need for nurses increases again. The latter half of
information about some of the nurses who served the 20th century represented a period of rapid
in these wars, providing nursing care leadership and change in healthcare reimbursement due to the
further developing the nursing profession. growth of health insurance; greater attempts to
manage care, particularly to reduce costs; and the ■■ Colleges and universities should provide an
establishment of Medicare and Medicaid. Such array of support services to minority students,
rapid changes are now being seen again in the 21st including mentoring, resources for developing
century with the passage of the Patient Protec- test-taking skills, and application counseling.
tion and Affordable Care Act of 2010 (ACA) and ■■ Schools of nursing granting baccalaureate
possible future changes to this law. During these degrees should provide and support bridging
times, typically more nurses and other healthcare programs that enable graduates of 2-year
providers are needed. The Healthcare Delivery Sys- colleges to succeed in the transition to 4-year
tem: Focus on Acute Care chapter discusses some institutions. Graduates of associate degree
of these issues in more detail. The Health Policy nursing programs should be encouraged to
and Political Action: Critical Actions for Nurses enroll in baccalaureate nursing programs
chapter examines the most significant issue in and supported after they enroll.
current healthcare delivery—namely, the ACA. In ■■ AACN and other health profession organi-
addition in 1922, 1946, and then in 2010, critical zations should work with schools to promote
reports were published describing the status of enhanced admissions policies, cultural
nursing education, as discussed later in this text competence training, and minority student
in content about nursing education. recruitment.
Little has been said in this description of nurs- ■■ To remove financial barriers to nursing educa-
ing history about the role of men and minorities in tion, public and private funding organizations
nursing; groups that had limited involvement in should provide scholarships, loan forgiveness
the profession’s early history. This lack of diver- programs, and tuition reimbursement to
sity—men and minorities—has been a long-term students and institutions.
problem for the profession. Segregation and dis- ■■ Congress should substantially increase funding
crimination also existed in nursing, just as they did for diversity programs within the National
in the society at large. The National Association of Health Service Corps and Titles VII and VIII
Colored Graduate Nurses closed in 1951 when the of the Public Health Service Act.
ANA began to accept African American nurses as These recommendations and efforts to improve
members. Nevertheless, concern remains about the the number of minorities in all health professions
limited number of minorities in health care. The have had some impact, but more improvement is
Sullivan Commission’s report on health profession required. This topic also relates to the problem of
diversity, Missing Persons: Minorities in the Health healthcare disparities, as noted in other chapters.
Professions (L. Sullivan, 2004), is an important The number of men in nursing has increased
document offering recommendations to improve over the years but still is not where it should be.
diversity in the health professions. The American Men served as nurses in the early history period,
Association of Colleges of Nursing (AACN, 2004) such as noted earlier in the chapter in the Crusades
responded to this critical report by recommending and monks provided care in monasteries. After this
the following actions: period, however, men were not accepted as nurses
■■ Health profession schools should hire diver- because nursing was viewed as a woman’s role. The
sity program managers and develop strategic poet Walt Whitman was a nurse in the Civil War.
plans that outline specific goals, standards, Thus, there were men in nursing, though few, and
policies, and accountability mechanisms to some were well known—but perhaps not for their
ensure institutional diversity and cultural nursing (Kalisch & Kalisch, 1986). Early in the history
competence. of nursing schools in the United States, men were
not accepted. This may have been influenced by the Sullivan, Christman stated that “men in medicine
gender-segregated housing for nursing students and were reluctant to give up power to women and, by
the model of apprenticeship that focused on women the same token, women in nursing have fought to
(Bullough, 2006). In part, this female dominance retain their power. Medicine, however, was forced
was also the result of nursing’s religious roots, which to admit women after affirmative action legislation
promoted sisters as nurses. This made it difficult for was enacted” (2002, p. 10). “Sadly,” Christman
men to come into the system and the culture—it reported, “nursing, with a majority of women, was
was a women’s profession. not required to adhere to affirmative action policies”
After the major wars—such as World Wars I and (Sullivan, 2002, p. 12). There is an organization for
II, Korean War, and Vietnam War—medics came home men in nursing, the American Assembly for Men
and entered nursing programs, and they continue to in Nursing (AAMN), and men are also members of
do so. In 1940, the ANA did recognize men by having other nursing organizations. In 2010, the AAMN
a session on men in nursing at its convention. When began a campaign to increase the number of men
schools of nursing began to transition to academic in the profession by increasing enrollment of men
settings, more men applied to nursing programs. Men in nursing programs from current 10% to 20%
in nursing have to contend with male-dominated (American Assembly for Men in Nursing, 2017).
medicine, which has influenced men becoming The campaign is called “20 3 20: Choose Nursing.”
nurses. There was a time when male nurses were There is no question that the majority of nurses
also able to get commissions in the military when are White females, and this needs to change. There
women could not, and this increased their numbers has been an increase in the number of male and
in the military (Bullough, 2006). These changes minority nurses, but not enough. There is a greater
did have an impact, but the increase in salaries and need to actively seek out more male and minority
improvement in work conditions had the strongest students (Cohen, 2007). Men and minorities in
effect on increasing the number of men in nursing. nursing should reach out and mentor student nurses
In 2001, Boughn conducted a study to explore and new nurses to provide them with the support
why women and men choose nursing. The results of they require as they enter a profession predomi-
this study indicated that female and male participants nantly composed of White women. More media
did not differ in their desire to care for others. Both coverage would also be helpful in publicizing the
groups had a strong interest in power and empow- role of men and minorities in nursing; for example,
erment, but female students were more interested when photos are distributed to the media, photos
in using their power to empower others, whereas should emphasize the diversity of the profession.
male students were more interested in empowering Men are a very small percentage of the total
the profession. The most significant difference was number of registered nurses (RNs) living and work-
found in the expectations of salary and working ing in the United States, although their numbers
conditions, with men expecting more. Why would continue to grow (U.S. Department of Health and
not both males and females expect higher salaries Human Services [HHS], Health Resources and Ser-
and better working conditions? Is this still part of vices Administration [HRSA], & Bureau of Health
the view of nursing and nurses from nursing’s past? Professions [BOHP], 2010). Before 2000, 6.2% of RNs
Luther Christman was a well-known nurse were men; by 2008, this percentage had increased
leader who served as a nurse for many years, retiring to 9.6%. Male and female RNs are equally likely to
at the age of 87, and after retirement, he continued have a baccalaureate degree, but male RNs are more
to be an active voice for the profession and for men likely to also have a non-nursing degree. By 2013,
in nursing until his death in 2011. According to men represented 10.7% of the RN workforce, which
was not a major increase from 2008, but an increase however, although Nightingale did much for nursing,
nevertheless (Farmer, 2015). The AACN noted that in many who came after her provided even greater
2014–2015, enrollment of men in nursing programs direction for the profession. A focus on Nightingale
improved: 11.8% in baccalaureate programs, 10.8% helps to better understand the major changes that
in master’s programs, 9.6% in research-focused occurred in the profession and in nursing leaders. In
doctoral programs (PhD), and 11.7% in doctor of 1859, Nightingale wrote, “No man, not even a doctor,
nursing practice (DNP) programs (AACN, 2015a). ever gives any other definition of what a nurse should
The AACN also notes that 41% of men in the nursing be than this—‘devoted and obedient.’ This definition
workforce are in nurse anesthetist positions. would do just as well for a porter. It might even do for
a horse. It would not do for a policeman” (Nightingale,
Nurse Leaders: History 1992, p. 20). This quote clearly demonstrates that she
was outspoken and held strong beliefs, though she
in the Making
lived during a time when this type of forthrightness
The best place to begin to gain a better understand- from a woman was extraordinary.
ing of nursing history is with a description of its Nightingale was British and lived and worked
leaders—that is, the nurses who made a difference in London in the Victorian era during the Industrial
to the development of the profession. Florence Night- Revolution. During this time, the role of women—
ingale is viewed as the “mother” of modern nursing especially women of the upper classes—was clearly
throughout the world. Most nursing students at some defined and controlled. During this time, women
point say the Nightingale Pledge, which helps all did not work outside the home and maintained a
new nurses connect the past with the present. The monitored social existence. Their purpose was to
Nightingale Pledge is found in Exhibit 1-1. It was be a wife and a mother, two roles that Nightingale
composed to provide nurses with an oath similar never assumed. Education of women was also lim-
to the physician’s Hippocratic Oath. The oath was ited. With the support of her father, Nightingale did
not written by Nightingale but emphasized her view obtain some classical education, but there was never
of nursing, and it is easy to also see the influence of any expectation that she would “use” the education
the culture at the time this was written. (Slater, 1994). “Nightingale grew up knowing what
Volumes have been written about Nightingale. was expected of her life: Women of her class ran the
She has become the almost-perfect vision of a nurse; home and supervised the servants. Although this was
Exhibit 1-1 The Original Nightingale Pledge
I solemnly pledge myself before God and in elevate the standard of my profession, and
the presence of this assembly, to pass my will hold in confidence all personal matters
life in purity and to practice my profession committed to my keeping and all family affairs
faithfully. I will abstain from whatever is coming to my knowledge in the practice of
deleterious and mischievous, and will not my calling. With loyalty will I endeavor to aid
take or knowingly administer any harmful the physician, in his work, and devote myself
drug. I will do all in my power to maintain and to the welfare of those committed to my care.
Composed by Lystra Gretter in 1893 for the class graduating from Harper Hospital, Detroit, Michigan.
not her goal, the household management skills that as the basis of nursing’s holistic view of health.
she learned from her mother were put to good use Nightingale’s convictions also influenced her views
when she entered the hospital environment. Because of nurses and nursing practice. She viewed patients
of her social standing, she was in the company of as persons who were unable to help themselves or
educated and influential men, and she learned the who were dying. She is quoted as saying, “What
“art of influencing powerful men” (Slater, 1994, p. nursing has to do . . . is to put the patient in the best
143). This skill was used a great deal by Nightingale condition for nature to act upon him” (Seymer, 1954,
as she fought for reforms. p. 13). Nightingale also recognized that a patient’s
Nightingale held different views about the health depends on environmental factors such as
women of her time. She had “a strong conviction light, noise, odors, and heat—something that we
that women have the mental abilities to achieve examine more closely today in nursing and in health
whatever they wish to achieve: compose music, care by also using alternative and complementary
solve scientific problems, create social projects of methods. In her work during the Crimean War,
great importance” (Chinn, 2001, p. 441). She felt she applied her beliefs about the body and mind
that women should question their assigned roles, by arranging activities for the soldiers, providing
and she herself wanted to serve people. When she them with classes and books, and supporting their
reached her 20s, Nightingale felt an increasing desire connection with home—an early version of what
to help others and decided that she wanted to become is now often called holistic care. Later, this type of
a nurse. Nurses at that time came from the lower focus on the total patient became an integral part
classes, and, of course, any training for this type of of psychiatric–mental health nursing and then
role was out of the question. Her parents refused nursing in general. Nightingale’s other interest—in
to support her goal, and because women were not sanitary reform—also grew from her experience
free to make this type of decision by themselves, she in the Crimean War. She worked with influential
was blocked. Nightingale became angry and then men to make changes. Although she did not agree
depressed. When her depression worsened, her with some of the new theories, she did support the
parents finally relented and allowed her to attend value of education in improving social problems and
nurse’s training in Germany. This venture was kept believed that education should also include moral,
a secret, and people she knew were told that she physical, and practical aspects (Widerquist, 1997).
was away at a spa for 3 months’ rest (Slater, 1994). Later, nurses based more of their interventions on
Nightingale was also educated in math and science, science and evidence-based practice.
which would lead her to use statistics to demonstrate The many important discoveries noted earlier
the nurse’s impact on health outcomes. Had it not such as the work done by Lister and Pasteur had an
been for her social standing and her ability to obtain impact on nursing over the long term and changed
some education, coupled with her friendship with the sociopolitical climate of health care—for example,
Dr. Elizabeth Blackwell, nurses might well have public health policy and services. Nightingale, how-
remained uneducated assistants to doctors, at least ever, did not agree with the new theory of contagion,
for a longer period of time than they did. but over time, the nursing profession accepted these
An important fact about Nightingale is that she new theories, which remain critical components of
was very religious—to the point that she felt God patient care today. Nightingale stressed, however,
had called on her to help others (Woodham-Smith, that the mind–body connection—putting patients
1951). She also felt that the body and mind were in the best situation for healing—ultimately made
separate entities, but both needed to be considered the difference. Discovering methods for prevent-
from a health standpoint. This view later served ing disease and using this information in disease
prevention is an important part of nursing today. on the idea of care provided by women as a form of
Public/community health is certainly concerned service to family and friends. This text was popular
with many of the same issues that led to critical new when it was published because, at the time, family
discoveries so many years ago, such as contami- members provided most of the nursing care.
nation of food and water and preventing disease Nightingale’s religious and upper-class back-
worldwide. ground had a major impact on her important
During the Industrial Revolution, Nightingale efforts to improve both nursing education and
and enlightened citizens tried to reform some of nursing practice in the hospital setting. Nurses
working conditions that were leading to health and were of the lower class; usually had no education;
public problems. Indeed, as Nightingale stated in and were often alcoholics, prostitutes, and women
Notes on Nursing and Notes on Hospitals (1992, 1859), who were down on their luck. Nightingale changed
“there are five essential points in securing the health all that. She believed that patients needed educated
of houses: pure air, pure water, efficient drainage, nurses to care for them, and she founded the first
cleanliness, and light.” She strongly supported more organized school of nursing. Nightingale’s school,
efforts to promote health and felt that this was more which opened in London in 1860, accepted women
cost-effective than treating illness—important of a higher class—not alcoholics and former pros-
healthcare principles today. These ideas are good titutes, as had been the case with previous gener-
examples reflecting the influence of the environment ations of nurses. The students were not viewed as
and culture in which a person lives and works on servants, and their loyalty was to the school, not
personal views and problems. to the hospital. This point is somewhat confusing
Nightingale wrote four small books—or trea- and must be viewed from the perspective that im-
tises, as they were called—thus starting the idea that portant changes were made; however, these were
nurses need to publish and share what they do and not monumental changes, but a beginning. For
what they learn about patient care. The titles of the example, even in Nightingale’s school, students were
books were Notes on Matters Affecting the Health, very much a part of the hospital; they staffed the
Efficiency, and Hospital Administration of the British hospital, representing free labor and worked long
Army (1858a), Subsidiary Notes as to the Introduction hours. This approach developed into the diploma
of Female Nursing into Military Hospitals (1858b), school model, considered an apprenticeship model.
Notes on Hospitals (1859), and Notes on Nursing Today, diploma schools have less direct relation-
(1860, republished in 1992). The first three focused ships with hospitals, and in some cases, they have
on hospitals that she visited, including military transitioned to associate degree programs and, in
hospitals (Slater, 1994). Nightingale collected a other cases, baccalaureate degrees. There are few
lot of data. Her interest in healthcare data analysis schools of nursing today that are diploma schools
helped to lay the groundwork for epidemiology, (see the Nursing Education, Accreditation, and
highlighting the importance of data in nursing, Regulation chapter).
particularly in a public health context, and also Nightingale’s students did receive some train-
established an initial foundation for nursing research ing, which had not been provided in an organized
and evidence-based practice. These early initiatives manner prior to her efforts. Her religious views also
also relate to the current quality improvement ef- had an impact on the rigid educational system she
forts requiring measurement and analysis of large proposed and implemented. She expected students
quantities of data. An interesting fact is that Notes to have high moral values. Training was still based
on Nursing was not written for nurses, but rather for on an apprenticeship model and continued to be
women who cared for ill family members. As late for some time in Britain, Europe, and the United
as 1860, Nightingale had not completely given up States. The structure of hospital nursing was also
very rigid, with a matron in charge. This rigidity the changes also had negative effects, including
persisted for decades and, in some cases, may still delaying the development of the profession (par-
be present in some hospital nursing organizations. ticularly supporting nurses’ subordinate position to
Nurses in Britain began to recognize the need physicians), failing to encourage nursing education
to band together, and they eventually formed the offered at a university level, and delaying licensure
British Nurses Association. This organization (Freeman, 2007). Despite this criticism, Nightingale
took on the issue of regulating nursing practice. still holds an important place in nursing history as
Nightingale did not approve of efforts made to a major leader for the profession.
establish state registration (licensure) of nurses, The vignettes in Exhibit 1-2 describe some of the
mostly because she did not trust the leaders’ goals contributions made by nursing leaders, emphasizing
(Freeman, 2007). There were no known standards that Nightingale is not the only important nursing
for nursing, so how one became a registered nurse leader. People do not operate in a vacuum, of course,
was unclear. Many questions were raised regarding and neither did the nurses highlighted in this exhibit.
the definition of nursing, who should be registered, Many factors influenced nurse leaders, such as their
and who controlled nursing. Some critics agree that communities, the society, their education, and the
Nightingale did make changes, but the way she made time in which they practiced.
Exhibit 1-2 A Glimpse into the Contributions of Nurses in the

United States
This list does not represent all the important Clara Barton (1881)
nursing leaders but does provide examples The need in America for an institution
of the broad range of their contributions that is not selfish must originate in the
and highlights specific achievements. These recognition of some evil is adding to the sum
glimpses are written in the first person, but of human suffering or diminishing the sum
they are not direct quotes. of happiness. Today, my efforts to organize
Dorothea Dix (1840–1841) such an institution have been successful: the
National Society of the Red Cross.
I traveled the state of Massachusetts to call
attention to the present state of insane persons Isabel Hampton Robb (1896)
confined within this Commonwealth, in cages, In 1896, I organized the Nurses’ Associated
stalls, pens! Chained, naked, beaten with rods, Alumnae of the United States and Canada
and lashed into obedience. Just by bettering and served as the first president. Later
the conditions for these persons, I showed that this organization became the American
mental illnesses aren’t all incurable. Nurses Association (ANA). I also founded
Linda Richards (1869) the American Society of Superintendents
of Training Schools for Nurses, which later
I was the first of five students to enroll in the
became the National League of Nursing
New England Hospital for Women and Children
Education (NLNE) and then changed
and the first to graduate. Upon graduation, I was
its name to the National League for
fortunate to obtain employment at the Bellevue
Nursing (NLN). Through these professional
Hospital in New York City. Here I created the
organizations, I was able to initiate many
first written reporting system, charting and
improvements in nursing education.
maintaining individual patient records.
(Continues)
Exhibit 1-2 (continued)
Sophia Palmer (1900) nursing, housing reform, suffrage, world peace,

I launched the American Journal of Nursing and the rights of women, children, immigrants,
and served as editor-in-chief of the journal for and working people.
20 years. I believe my forceful editorials helped Mary Breckenridge (1920)
guide nursing thought and shape nursing
Through my own personal tragedies, I realized
practice and events.
that medical care for mothers and babies
Lavinia L. Dock (1907) in rural America was needed. I started the
I became a staunch advocate of legislation Frontier Nursing Service in Kentucky.
to control nursing practice. Realizing the Elizabeth Russell Belford, Mary Tolle
problems that students faced in studying Wright, Edith Moore Copeland, Dorothy
drugs and solutions, I wrote one of the first Garrigus Adams, Ethel Palmer Clarke,
nursing textbooks, Materia Medica for Nurses. Elizabeth McWilliams Miller, and Marie
I served as foreign editor of American Journal Hippensteel Lingeman (1922)
of Nursing and coauthored the book, The
We were the founders of the Sigma Theta
History of Nursing.
Tau International Honor Society of Nursing.
Martha Minerva Franklin (1908) Each of us provided insights that advanced
I actively campaigned for racial equality in scholarship, leadership, research, and
nursing and guided 52 nurses to form the practice.
National Association of Colored Graduate
Susie Walking Bear Yellowtail
Nurses.
(1930–1960)
Mary Mahoney (1909) I traveled for 30 years throughout North
In 1908, the National Association of Colored America, walking to reservations to improve
Graduate Nurses was formed. As the health care and Indian health services. I
first professional Black nurse, I gave the established the Native ANA and received the
welcome address at the organization’s first President’s Award for Outstanding Nursing
conference. Healthcare.
Mary Adelaide Nutting (1910) Virginia Avenel Henderson (1939)

I advocated for university education for nurses I am referred to as the first lady of nursing.
and developed the first program of this type. I think of myself as an author, an avid
Upon accepting the chairmanship at the researcher, and a visionary. One of my
Department of Nursing Education at Teachers greatest contributions to the nursing
College, Columbia University, I became the profession was revising Harmer’s Textbook
first nurse to be appointed to a university of the Principles and Practice of Nursing,
professorship. which has been widely adopted by schools of
nursing.
Lillian Wald (1918)
My goal was to ensure that women and Lucile Petry Leone (1943)
children, immigrants and the poor, and As the founder of the U.S. Cadet Nurse Corps,
members of all ethnic and religious groups I believe we succeeded because we had a
would realize America’s promise of life, liberty, saleable package from the beginning. Women
and the pursuit of happiness. The Henry Street immediately liked the idea of being able
Settlement and the Visiting Nurse Service to combine war service with professional
in New York City championed public health education for the future.
Esther Lucille Brown (1946) Connecticut, which is the model for hospice
I issued a report titled Nursing for the care in the United States and abroad.
Future. This report severely criticized the Joann Ashley (1976)
overall quality of nursing education. Thus,
I wrote Hospitals, Paternalism, and the Role
with the Brown report, nursing education
of the Nurse during the height of the women’s
finally began the long-discussed move to
movement. My book created controversy
accreditation of nursing education programs.
with its pointed condemnation of sexism
Lydia Hall (1963–1969) toward, and exploitation of, nurses by hospital
I established and directed the Loeb Center administrators and physicians.
for Nursing and Rehabilitation at Montefiore Luther Christman (1980)
Hospital in the Bronx, New York. Through
As founder and dean of the Rush University
my research in nursing and long-term care,
College of Nursing, I was linked to the
I developed a theory (core, care, and cure)
“Rush Model,” a unified approach to nursing
that the direct professional nurse-to-patient
education and practice that continues to
relationship is itself therapeutic and nursing care
set new standards of excellence. As dean
is the chief therapy for the chronically ill patient.
of Vanderbilt University’s School of Nursing,
Martha Rogers (1963–1965) I was the first to employ African American
I served as editor of Journal of Nursing women as faculty at Vanderbilt University, and
Science, focusing my attention on improving I became one of the founders of the National
and expanding nursing education, developing Male Nurses Association, now known as the
the scientific basis of nursing practice through American Assembly for Men in Nursing.
professional education, and differentiating Hildegard E. Peplau (1997)
between professional and technical careers
I became known as the “Nurse of the Century.”
in nursing. My book, An Introduction to the
I was the first nurse to serve the ANA as
Theoretical Basis of Nursing (1970), marked the
executive director and later as president,
beginning of nursing’s search for a theoretical
and I served two terms on the Board of the
base. Later, my work led to a greater emphasis
International Council of Nurses. My work in
on research and evidence-based practice.
psychiatric–mental health nursing emphasized
Loretta Ford (1965) the nurse–patient relationship.
I co-developed the first nurse practitioner Linda Aiken ( 2007)
program in 1965 by integrating the traditional
My policy research agenda is motivated by
roles of the nurse with advanced medical
a commitment to improving healthcare
training and the community outreach mission
outcomes building an evidence base for health
of a public health official.
services care and management and providing
Madeleine Leininger (1974) direction for national policy makers, resulting in
I began, and continued to guide, nursing in greater recognition of the role that nursing care
the recognition that the culture care needs has on patient outcomes. Nurses need to be
of people in the world will be met by nurses actively engaged in research to improve care.
prepared in transcultural nursing. Patricia Benner (current)
Florence Wald (1975) I have long been involved in nursing
I devoted my life to the compassionate care for education and developed many initiatives to
the dying. I founded Hospice Incorporated in improve nursing education and thus nursing
(Continues)
practice. In 1982, I published a major book many roles of nurses and issues that impact
that discussed the process that nurses go their work, such as workforce shortages. In our
through from novice to expert. In 2010, I led examination we have included different media
an extensive study on the current status of as sources such as films, television, fiction,
nursing education, the first such study since and press coverage. The profession should not
the 1922 Goldmark report and the 1948 Brown ignore its professional image.
report. My report, Educating Nurses: A Call
National Academy of Nursing Living
for Radical Transformation (2010), noted
Legends
many areas of nursing education that need
improvement. The National Academy of Nursing selects
exemplar nursing leaders for recognition of
Beatrice Kalisch and Phillip Kalisch their leadership in health care in the United
(current) States and globally. The organization’s website
We have worked together to recognize the provides information on these leaders and
importance of the image of nursing as a their contributions.
profession. In doing this, we have examined the
Themes: Looking into the which events unfolded” but, instead, emphasized the
“profession’s purity, discipline, and faith” (Connolly,
Nursing Profession’s History
2004, p. 10). Part of the reason for this narrow view
The discipline of nursing slowly evolved from the of nursing history is that the discipline of history had
traditional role of women, apprenticeship, human- limited, if any, contact with the nursing profession.
itarian aims, religious ideals, intuition, common This began to change in the 1950s and 1960s, when
sense, trial and error, theories, and research and the scholarship of nursing history began to expand,
was influenced by medicine, technology, poli- though very slowly. In the 1970s, one landmark
tics, social issues, war, economics, and feminism publication, Hospitals, Paternalism, and the Role
(Brooks & Kleine-Kracht, 1983; Gorenberg, 1983; of the Nurse (Ashley, 1976), addressed social issues
Keller, 1979; Jacobs & Huether, 1978; Kidd & Morrison, as an important aspect of nursing history. The
1988; Lynaugh & Fagin, 1988; Perry, 1985). It is key issue considered in this text was feminism in
impossible to provide a detailed history of nursing’s the society at large and its impact on nursing. As
evolution in one chapter, so only critical historical social history became more important, increased
events are discussed. examination of nursing, its history, and influences
Writing about nursing history itself has its own on that history took place. In addition, nursing
interesting history (Connolly, 2004). Historians is tied to political history today. For example, it
who wrote about nursing prior to the 1950s tended is very difficult to understand current healthcare
to be nurses, and they wrote for nurses. Although delivery concerns without including nursing (such
nursing throughout its history has been influenced as the impact of the current reports on quality
by social issues of the day, the early publications care). All of these considerations have an impact
about nursing history did not link nursing to “the on health policy, including legislation at the state
broader social, economic, and cultural context in and national levels.
Schools of nursing often highlight their own caring, take-charge person who would go to great
history for students, faculty, and visitors. This might lengths and even sacrifice her own safety and health
be done through exhibits about the school’s history to provide care (Shames, 1993). The message sent to
and, in some cases, a mini-museum. Such materials the public was that nurses were not powerful. They
provide an opportunity to identify how the school’s were caring, but they would not fight to change the
history has developed and how its graduates have conditions of hospitals and patient care. Hospitals
affected the community and the profession. The “owned” nurses and considered them cheap labor.
purpose of this chapter is to explore some of the Today, some hospitals still hold the same view,
broad issues of nursing history, but this discussion though they would never admit it publicly. This
should not replace the history of each school of view of healthcare delivery suggests that doctors
nursing as the profession developed. are defined by their scope of practice in treating
Nursing’s past represents a movement from diseases, whereas nurses are seen as promoting
a role based on family and religious ties and the health, adding to the view of the lesser status of
need to provide comfort and care (because this nursing (Shames, 1993). This view also has led to
was perceived as a woman’s lot in life) to educated problems between the two professions as they argue
professionals serving as the “glue” that holds the over which profession is better at caring for patients.
healthcare system together. From medieval times The view that nurses are angels of mercy rather than
through Nightingale’s time, nursing represented well-educated professionals reinforces the idea that
a role that women played in families to provide nurses care but really do not have to think; this
care. This care extended to anyone in need, but view may be perpetuated by advertisements that
after Nightingale highlighted what a woman could depict nurses as angels or caring ethereal humans
do with some degree of education, physicians/ (Gordon, 2005). Most patients—especially at 3 a.m.,
doctors recognized that women needed to have when few other professionals are available—hope
some degree of training. Education was introduced, that the nurse is not just a caring person, but also
but mainly to serve the need of hospitals to have a critical thinker who uses clinical reasoning and
a labor force. Thus, the apprenticeship model of judgment and knows when to call the rest of the
nursing was born. team. As discussed in this text, there is increasing
Why would nursing perceive a need for greater evidence to support this view of the professional
education? Primarily because of advances in sci- nurse and needed competencies, such as the report
ence, increased knowledge of germs and diseases, Healthcare Education: A Bridge to Quality (Insti-
and increased training of doctors, nurses needed tute of Medicine [IOM], 2003) and The Future of
to understand basic anatomy, physiology, patho- Nursing. Leading Change, Advancing Health (IOM,
physiology, and epidemiology to provide better 2010). These reports and others have had a major
care. Slowly it was recognized that to carry out impact on the image of the profession and provide
doctors’ orders efficiently, nurses required some recommendations for improving care and the
degree of understanding of causes and effects of roles and responsibilities of nurses as healthcare
environmental exposures and of disease causation. professionals and emphasize the need for nursing
Thus, the move from hospital nursing schools to leadership and graduate education.
university education occurred.
Critics of Nightingale suggest that although
the “lady with the lamp” image—that is, a nurse Stop and Consider #1
Nursing has existed a long time but in many differ-
with a light moving among the wounded in the
ent forms.
Crimea—is laudable, it presented the nurse as a
Professionalism: Nursing as a Profession

Critical Professional Concepts The current definition of nursing, as established
by the ANA is “the protection, promotion, and
and Activities
optimization of health and abilities, prevention of
Today, nursing is an applied science, a practice pro- illness and injury, alleviation of suffering through
fession. To appreciate the relevance of this statement the diagnosis and treatment of human response,
requires an understanding of professionalism and advocacy in the care of individuals, families,
and how it applies to nursing. Nursing is more communities, and populations” (2015a, p. 89).
than just a job; it is a professional career requiring Exhibit 1-3 provides a historical perspective on the
commitment. Table 1-1 describes some differences development of a definition for nursing.
in attitudes when comparing an occupation/job The Essence of Nursing: Knowledge and Caring
and a career/profession. chapter contains a more in-depth discussion of the
But what does this really mean, and why does nature of nursing, but a definition is needed here as
it matter? As described previously in this chapter, a framework for further understanding of nursing
getting to where the nursing profession is today as a profession. Is nursing a profession? What is
was not easy, nor did it happen overnight. Many a profession? Why is it important that nursing be
nurses contributed to the development of nursing recognized as a profession? Some nurses may not
as a profession; it mattered to them that nurses be think that nursing is a profession, but this is not the
recognized as professionals. position taken by recognized nursing organizations,
Table 1-1 Comparison of Attitudes: Occupation Versus Career
Occupation Career
Longevity Temporary, a means to an end Lifelong vocation
Educational preparation Minimal training required, University professional degree
usually associate degree program based on foundation
of core liberal arts
Continuing education Only what is required for the job Lifelong learning, continual
or to get a raise/promotion effort to gain new knowledge,
skills, and abilities
Level of commitment Short-term, as long as job meets Long-term commitment to
personal needs organization and profession
Expectations Reasonable work for reasonable Will assume additional
pay; responsibility ends with shift responsibilities and volunteer
for organizational activities
and community-based events
Reproduced from Wilfong, D., Szolis, C., & Haus, C. (2007). Nursing school success: Tools for constructing your
future. Sudbury, MA: Jones & Bartlett Learning.
Exhibit 1-3 Definitions of Nursing: Historical Perspective
The following list provides a timeline of some health within the potential of each person.”
of the definitions of nursing. (Rogers, 1988, p. 100)
Florence Nightingale American Nurses Association

Having “charge of the personal health of “Nursing is the protection, promotion, and
somebody . . . and what nursing has to optimization of health and abilities, prevention
do . . . is to put the patient in the best possible of illness and injury, facilitation of healing,
condition for nature to act upon him.” alleviation of suffering through the diagnosis
(Nightingale, 1859, p. 79) and treatment of human responses, and
advocacy in the care of individuals, families,
Virginia Henderson
communities, and populations.” (ANA, 2015b,
“The unique function of the nurse is to assist p. 89; also published in earlier ANA standards)
the individual, sick or well, in the performance
International Council of Nursing
of those activities contributing to health
or its recovery (or to peaceful death) and “Nursing encompasses autonomous and
that he would perform unaided if he had collaborative care of individuals of all ages,
the necessary strength, will or knowledge. families, groups and communities, sick or
And to do this in such a way as to help him well and in all settings. Nursing includes the
gain independence as rapidly as possible.” promotion of health, prevention of illness,
(Henderson, 1966, p. 21) and the care of ill, disabled and dying people.
Advocacy, promotion of a safe environment,
Martha Rogers research, participation in shaping health
“The process by which this body of knowledge, policy and in patient and health systems
nursing science, is used for the purpose of management, and education are also key
assisting human beings to achieve maximum nursing roles.” (ICN, 2002)
Data from Nightingale, F. (1859). Notes on nursing: What it is and what it is not (commemorative ed.). Philadelphia,
PA: Lippincott; Henderson, V. (1966). The nature of nursing: A definition and its implications for practice, research,
and education. New York, NY: Macmillan; Rogers, M. (1988). Nursing science and art: A prospective. Nursing
Science Quarterly, 1, 99; American Nurses Association. (2015). Nursing scope and standards of practice. Silver
Spring, MD: Author; International Council of Nurses. (2002; retrieved on 2017). Definition of nursing. Retrieved from
http://www.icn.ch/who-we-are/icn-definition-of-nursing/
nursing education, and state boards of nursing that Huber, 2014; Lindberg, Hunter, & Kruszewski, 1998;
are involved in licensure of nurses. Each state has Quinn & Smith, 1987; Schein & Kommers, 1972;
its own definition of nursing that is found in the Bixler & Bixler, 1959):
state’s nurse practice act, but the ANA definition A systematic body of knowledge that provides
■■
noted here encompasses the common character- the framework for the profession’s practice
istics of nursing practice and is reflected in state Standardized, formal higher education
■■
board definitions. Commitment to providing a service that

■■
In general, a profession—whether nursing or benefits individuals and the community

another profession, such as medicine, teaching, or Maintenance of a unique role that recognizes
■■
law—has certain characteristics (Finkelman, 2016; autonomy, responsibility, and accountability

■■ Control of practice responsibility of the proof nursing practice” (ANA, 2015a, p. 85). It is the
fession through standards and a code of ethics right to make a decision and take control. Nurses
■■ Commitment to members of the profession have a distinct body of knowledge and develop com-
through professional organizations and petencies in nursing care that should be based on
activities this nursing knowledge. When this is accomplished,
Does nursing demonstrate these professional nurses can then practice nursing. “Responsibility
characteristics? Nursing has a standardized content, refers to being entrusted with a particular function”
although schools of nursing may configure the (Ritter-Teitel, 2002, p. 34). “Accountability means
content in different ways; there is consistency in being responsible and accountable to self and others
content areas such as adult health, maternal–child for behaviors and outcomes included in one’s pro-
health, behavioral or mental health, pharmacology, fessional role. A professional nurse is accountable
assessment, and so on. The National Council Licen- for embracing professional values, maintaining
sure Examination (NCLEX) covers standardized professional values, maintaining competence, and
content areas. This content is based on systematic, maintenance and improvement of professional
recognized knowledge as the profession’s knowledge practice environments” (Kupperschmidt, 2004, p. 114).
base for practice. The Nursing Education, Accred- A nurse is also accountable for the outcomes of
itation, and Regulation chapter discusses nursing the nursing care that the nurse provides; what nurses
education in more detail. It is clear, though, that the do must mean something (Finkelman, 2016). The
focus of nursing is practice—care provided to assist nurse is answerable for the actions that the nurse
individuals, families, communities, and populations. takes. Accountability and responsibility do not have
Nursing as a profession has a social contract with the same meaning. A nurse often delegates tasks
society, as described in the ANA’s Nursing’s Social to other staff members, telling staff what to do and
Policy Statement, which is now an appendix in the when. The staff member who is assigned a task is
ANA standards, Nursing: Scope and Standards of responsible both for performing that task and for the
Practice, and Nursing’s Code of Ethics (American performance itself. The nurse who delegated the task
Nurses Association [ANA], 2015a, 2015b; Fowler, to the staff person is accountable for the decision to
2015a, 2015b). The contract between nursing and delegate the task. Delegation is discussed in more
society is based on professional and regulatory re- detail in the Work in Interprofessional Teams chapter.
quirements, but also on what society expects from
healthcare services and healthcare professionals. As Sources of Professional
a profession, we have the right to autonomy in our Direction
practice, authority to practice based on our education
and scope of practice, and self-governance. Society Professions develop documents or statements about
protects a profession through government legislation what the members consider is important to guide
and regulation (for example, licensure to protect our their practice, to establish control over practice,
titles and scope of practice, need to decrease staff and to influence the quality of that practice. Some
safety risk in the workplace, and so on). of the important sources of professional direction
Autonomy, responsibility, and accountability for nurses follow:
are intertwined with the practice of nursing and are 1. Nursing’s Social Policy Statement (ANA, 2015a)
critical components of a profession. Autonomy is is an important document that describes the
the “capacity of a nurse to determine his/her own profession of nursing and its professional frame-
actions through independent choice, including work and obligations to society. The original 1980
demonstration of competence, within the full scope statement has been revised three times—in 1995,
2003, and 2010. The social policy statement are discussed in more detail in The Essence of
informs consumers, government officials, other Nursing: Knowledge and Caring chapter, are
healthcare professionals, and other important part of the scope of practice, along with the
stakeholders about nursing and its definition, definition of the “what and why” of nursing.
knowledge base, scope of practice, and regula- Nursing care is provided in a variety of settings
tion. “Nursing is called a helping profession and by the professional registered nurse, who may
many of us went into nursing to help others. have an advanced degree and specialty training
The social policy statement of our profession and expertise. Additional information about
is about the multiple ways in which nursing the standards, as well as the nurse’s roles and
helps others: through direct patient care, and functions, is found throughout this text. Part
by changing institutions, society, and global of being a professional is a commitment to the
health. Nurses can be civic professionals and profession—a commitment to lifelong learning,
cosmopolite professionals and be active in any adhering to standards, maintaining membership
or all of these ways of helping between here and in professional organizations, publishing, and
nursing’s furthest horizon, and to find good ensuring that nursing care is of the highest
colleagues and companions along the way” quality possible.
(Fowler, 2015a, p. xv). 3. Code of Ethics for Nurses (ANA, 2015b) de-
2. Nursing: Scope and Standards of Practice (ANA, scribes nursing’s central beliefs and assists
2015a) was developed by the ANA and its the profession in controlling its practice. This
members; however, these standards as is true code “makes explicit the primary obligations,
for other ANA professional documents apply values, and ideals of the profession. In fact, it
to all registered nurses. Nursing standards, informs every aspect of the nurse’s life” (ANA,
which are “authoritative statements defined 2015a, p. vii). Implementation of this code is
and promoted by the profession by which the an important part of nursing’s contract with
quality of practice, service, or education can society. As nurses practice, they need to reflect
be evaluated” (ANA, 2015a, p. 89), are critical these values. The Ethics and Legal Issues chap-
to guiding quality patient care. Standards deter focuses on ethical and legal issues related
scribe minimal expectations. “We must always to nursing practice and describes the code in
remember that as a profession the members are more detail.
granted the privilege of self-regulation because To go full circle and return to the social contract,
they purport to use standards to monitor and nursing care must be provided and should include
evaluate the actions of its members to ensure consideration of health, social, cultural, economic,
a positive impact on the public it serves” legislative, and ethical factors. Content related to
(O’Rourke, 2003, p. 97). Standards also include these issues is discussed in other chapters in this text.
a scope of practice statement that describes Nursing is not just about making someone better;
the “who, what, where, when, why, and how” it is about providing health education, assisting
of nursing practice. The ANA definition of patients and families in making health decisions,
nursing is the critical foundation. As noted in providing direct care and supervising others who
Exhibit 1-3, the definition of nursing evolved provide care, assessing care and applying the best
and will most likely continue to evolve over evidence in making care decisions, communicating
time as healthcare needs change and healthcare and working with the interprofessional treatment
delivery and practice evolve. Nursing knowledge team, developing a plan of care with the team that
and the integration of science and art, which includes the patient and family when the patient
agrees to family participation, evaluating patient State boards of nursing also assume an import-
outcomes, advocating for patients, and much more. ant role in guiding and, in some cases, determining
The Apply Quality Improvement chapter discusses professional direction through legislation. Each state
quality care in more detail, but as the student becomes board operates under a state practice act, which al-
more oriented to nursing education and nursing as a lows the state government to meet its responsibility
profession, it is important to recognize that establishing to protect the public—in this case, the health of the
and maintaining standards is part of being in a pro- public—through nursing licensure requirements. Each
fession. The generic standards and their measurement nurse must practice, or meet the description of, nursing
criteria, which apply to all nurses, are divided into two as identified in the state in which the nurse practices.
types of standards: standards of practice and standards Regulation is discussed in more detail in the Nursing
of professional performance. The major content areas Education, Accreditation, and Regulation chapter.
of the standards follow (ANA, 2015a).
Standards of Practice (competent level of practice
based on the nursing process) Professional Nursing
1. Assessment Associations
2. Diagnosis Nurses have a history of involvement in organi-
3. Outcomes identification zations that foster the goals of the profession. The
4. Planning existence of professional associations and organi-
5. Implementation (coordination of care, health zations is one of the characteristics of a profession.
teaching and health promotion, consultation, A professional organization is a group that has
and prescriptive authority) specific goals, objectives, and functions that relate to
6. Evaluation the mission of a specific profession. Typically, mem-
Standards of Professional Performance (competent bership is open to members of that profession and
level of behavior in the professional role) requires payment of dues. Some organizations have
1. Ethics more specific membership requirements or may be
2. Culturally congruent practice by invitation only. Nursing has many organizations
3. Communication at the local, state, national, and international levels,
4. Collaboration and some organizations function on all of these levels.
5. Leadership Professional organizations often publish journals
6. Education and other information related to the profession and
7. Evidence-based practice and research offer continuing education opportunities through
8. Quality of practice meetings, conferences, and other formats. As discussed
9. Professional practice evaluation previously, many of the organizations, particularly
10. Resource utilization ANA, have been involved in developing professional
11. Environmental health* standards. Professional education is a key function
of many organizations. Some organizations are very
Nursing specialty groups—in some cases, in
active in policy decisions at the government level,
partnership with the ANA—have developed spe-
taking political action to ensure that the profession’s
cialty standards, such as those for cardiovascular
goals are addressed and advocating for health care
nursing, neonatal nursing, and nursing informatics.
in general. This activity is generally done through
However, all nurses must meet the generic standards
lobbying and advocacy. Some of the organizations
regardless of their specialty.
are involved in advocacy in the work environment,
*© 2015 by American Nurses Association. Reprinted with for example, a union, with the aim of making the
permission. All rights reserved. workplace environment better for nurses.
Major Nursing Associations perspective of the many organizations representing

different aspects of the profession Exhibit 1-4 lists
The following description highlights some of the
some of these organizations and their websites.
major nursing organizations (keep in mind that
many other professional organizations exist). Or- American Nurses Association. The ANA is
ganizations that focus on nursing specialties have the organization that represents all RNs in the
expanded. Other organizations related to nursing United States, but not all RNs belong to the ANA. The
education are described in the Nursing Education, ANA also represents nurses who are not members
Accreditation, and Regulation chapter. To give you a because many in healthcare, government, and business
Exhibit 1-4 Specialty Nursing Organizations
Academy of Medical–Surgical Nurses: http://www.medsurgnurse.org

Academy of Neonatal Nursing: http://www.academyonline.org
American Academy of Ambulatory Care Nursing, http://www.aaacn.org
American Academy of Nurse Practitioners: http://www.aanp.org
American Academy of Nursing: http://www.aannet.org
American Assembly for Men in Nursing: http://aamn.org
American Association for the History of Nursing: http://www.aahn.org
American Association of Colleges of Nursing: http://www.aacn.nche.edu
American Association of Critical-Care Nurses: http://www.aacn.org
American Association of Legal Nurse Consultants: http://www.aalnc.org
American Association of Neuroscience Nurses: http://www.aann.org
American Association of Nurse Anesthetists: http://www.aana.com
American Association of Nurse Attorneys: http://www.taana.org
American Association of Occupational Health Nurses: http://www.aaohn.org
American College of Nurse–Midwives: http://www.midwife.org
American College of Nurse Practitioners: http://www.acnpweb.org
American Holistic Nurses’ Association: http://www.ahna.org
American Nephrology Nurses’ Association: http://www.annanurse.org
American Nurses Association: http://www.nursingworld.org
American Nurses Foundation: http://www.anfonline.org
American Nursing Informatics Association: http://www.ania.org
American Organization of Nurse Executives: http://www.aone.org
American Psychiatric Nurses Association: http://www.apna.org
American Public Health Association–Public Health Nursing: http://www.apha.org
American Society of PeriAnesthesia Nurses: http://www.aspan.org
American Society of Plastic Surgical Nurses: http://www.aspsn.org
(Continues)
Association for Nursing Professional Development: http://anpd.org

Association of Camp Nurses: http://www.campnurse.org
Association of Nurses in AIDS Care: http://www.nursesinaidscare.org
Association of Pediatric Hematology/Oncology Nurses: http://www.apon.org
Association of periOperative Registered Nurses: http://www.aorn.org
Association of Rehabilitation Nurses: http://www.rehabnurse.org
Association of Women’s Health, Obstetric and Neonatal Nurses: http://www.awhonn.org
Commission on Graduates of Foreign Nursing Schools: http://www.cgfns.org
Council of International Neonatal Nurses: http://www.coinnurses.org
Emergency Nurses Association: http://www.ena.org
Home Healthcare Nurses Association: http://www.hhna.org
Hospice and Palliative Nurses Association: http://www.hpnaadvancingexpertcare.org
Infusion Nurses Society: http://www.ins1.org
International Association of Forensic Nurses: http://www.forensicnurses
International Council of Nurses: http://www.icn.ch
International Home Care Nurses Association: http://ihcno.org
International Society for Psychiatric–Mental Health Nurses: http://www.ispn-psych.org
International Transplant Nurses Society: http://itns.org
National Alaskan Native American Indian Nurses Association: http://www.nanainanurses.org
National Association of Clinical Nurse Specialists: http://www.nacns.org
National Association of Neonatal Nurses: http://www.nann.org
National Association of Orthopaedic Nurses: http://www.orthonurse.org
National Association of Pediatric Nurse Practitioners: http://www.napnap.org
National Association of School Nurses: http://www.nasn.org
National Black Nurses Association: http://www.nbna.org
National Council of State Boards of Nursing: https://www.ncsbn.org
National Gerontological Nursing Association: http://www.ngna.org/
National League for Nursing: http://www.nln.org
National Nursing Staff Development Organization: http://www.nnsdo.org
National Student Nurses Association: http://www.nsna.org
Oncology Nursing Society: http://www.ons.org
Society of Gastroenterology Nurses and Associates: http://www.sgna.org
Society of Pediatric Nurses: http://www.pedsnurses.org
Society of Trauma Nurses: http://www.traumanurses.org
State Nurses Associations: http://www.nursingworld.org/functionalmenucategories/aboutana
/whoweare/cma.aspx
The Association for Radiologic & Imaging Nursing: http://www.arinursing.org
Transcultural Nursing Society: http://www.tcns.org
Wound, Ostomy and Continence Nurses Society: http://www.wocn.org
view the ANA as the voice of nursing. When the ANA than 1,000 nursing scholars have received ANF grants
lobbies for nursing, it is lobbying for all nurses, not just representing more than $5 million (ANF, 2015).
its membership. This organization represents more
American Academy of Nursing. The AAN was
than 3.6 million RNs through its multiple constituent
established in 1973, and it serves the public and the
member associations and state and territorial
nursing profession through its activities to advance
associations, although the actual membership is
health policy and practice (American Academy of
much less than the total number of RNs (ANA, 2016).
Nursing [AAN], 2015a). The academy is considered the
This shift in membership must be considered in light
“think tank” for nursing. Membership as an academy
of generational issues. New nurses typically do not
fellow is by invitation; fellows may then list “FAAN”
join organizations, and there is continual unrest
in their credentials. There are approximately 2,100
regarding the perception by some nurses of the
fellows, representing nursing’s leaders in education,
ANA’s lack of response to vital nursing issues.
management, practice, and research. This is a very
In addition to being a professional organization,
prestigious organization, and fellows have demonstrated
some state chapters have formed labor unions.
their leadership in practice, management, and academic
Participation in the labor union is optional for
nursing. The AAN also publishes the journal Nursing
members, and each state organization’s stance on
Outlook. Examples of some of the AAN’s current
unions has an impact on membership. The ANA’s
initiatives follow (AAN, 2015b):
major publication is American Nurse Today. The
organization’s 2017–2020 strategic plan identifies ■■ Choosing Wisely is a campaign to ensure that
the three goals (ANA, 2017): more Americans hear about and understand
the need for the right care provided at the right
1. Increase the number and engagement of nurses
time. ANA fellows are working in partnership
in ANA.
with other organizations in this initiative.
2. Stimulate and disseminate innovation that in- ■■ The AAN provides expert panels to address
creases recognition of the value of nursing and
current healthcare concerns.
drives improvement in health and health care. ■■ The Council for the Advancement of Nursing
3. Leverage the ANA Enterprise to position
Science serves as a voice for nurse scientists
nurses as integral partners consumers’ health
and supports development of nursing science.
and health care journeys. ■■ Have You Ever Served? An AAN initiative
The ANA has three affiliated organizations: the in collaboration with other organizations
American Nurses Foundation (ANF), the American and the federal government to improve the
Academy of Nursing (AAN), and the American health of veterans.
Nurses Credentialing Center (ANCC). ■■ Institute for Nursing Leadership supports nurse
American Nurses Foundation. The ANF is appointments and leadership development.
“dedicated to transforming the nation’s health through
American Nurses Credentialing Center. The
the power of nursing. It is the only philanthropic
ANA established the ANCC in 1973 to develop and
organization with a mission to improve health
implement a program that would provide tangible
care and support the 3.6 million nurses across the
recognition of professional achievement. Additional
United States health through the power of nursing.
programs were added to the work done by the ANCC
We help nurses step into leadership roles in their
including (American Nurse Credentialing Center, 2016):
communities and workplaces to ensure that they
can play a meaningful role in shaping decisions on ■■ Accreditation Program: The ANC C Accredi-
the quality and capacity of health care” (American tation program recognizes the importance of
Nurses Foundation [ANF], 2017). As of 2015, more high-quality continuing nursing education (CNE)
and skills-based competency programs. Around ■■ Goal I—Leader in Nursing Education: Enhance
the world, ANCC-accredited organizations the NLN’s national and international impact
provide nurses with the knowledge and skills as the recognized leader in nursing education.
to help improve care and patient outcomes. ■■ Goal II—Commitment to Members: Build a
■■ Certification Program: ANC C’s Certification diverse, sustainable, member-led organization
Program enables nurses to demonstrate their with the capacity to deliver the NLN’s mission
specialty expertise and validate their knowledge effectively, efficiently, and in accordance with
to employers and patients. Through targeted the NLN’s values.
exams that incorporate the latest nursing prac- ■■ Goal III—Champion for Nurse Educators: Be
tice standards, ANC C certification empowers the voice of nurse educators and champion
nurses with pride and professional satisfaction. their interests in political, academic, and
■■ Pathway: The Pathway to Excellence Pro- professional arenas.
gram recognizes a healthcare organization’s ■■ Goal IV—Advancement of the Science of Nursing
commitment to creating a positive nursing Education: Promote evidence-based nursing
practice environment. The Pathway to Ex- education and the scholarship of teaching.
cellence in Long Term Care program is the
American Association of Colleges of
first to recognize this type of supportive
Nursing. The AACN is the national organization
work setting. Pathway organizations focus
for educational programs at the baccalaureate level
on collaboration, career development, and
and higher. The organization is particularly concerned
accountable leadership to empower nurses.
with development of standards and resources
■■ Magnet Recognition Program®: ANC C’s Magnet
and promotes innovation, research, and practice
Recognition Program is the most prestigious
to advance nursing education. The organization
distinction a healthcare organization can
represents more than 780 schools of nursing at the
receive for nursing excellence and quality
baccalaureate and higher levels (AACN, 2016, 2015b).
patient outcomes. Organizations that achieve
The dean or director of a school of nursing serves
Magnet recognition are part of an esteemed
as a representative to the AACN. The organization
group that demonstrates superior nursing
holds annual meetings for nurse educators that focus
practices and outcomes.
on different levels of nursing education. The AACN
■■ Nursing Knowledge Center: The Nursing
has been involved in creating and promoting new
Knowledge Center provides educational
roles, such as the clinical nurse leader and the DNP,
materials and guidance to support nurses
as well as educational programs, which are discussed
and organizations in their quest to achieve
in other chapters of this text. The major AACN
success through its credentialing programs.
publication is the Journal of Professional Nursing.
National League for Nursing. The NLN is This organization’s strategic goals for 2017–2019
a nursing organization that focuses on excellence are as follows (AACN, 2017):
in nursing education. Its membership is primarily ■■ Goal 1: AACN is the driving force for inno-
composed of schools of nursing and nurse educators. vation and excellence in academic nursing.
The organization began in 1893 as the American ■■ Goal 2: AACN is a leading partner in advanc-
Society of Superintendents of Training Schools. It ing improvements in health, health care, and
holds a number of educational meetings annually higher education.
and provides continuing education and certification ■■ Goal 3: AACN is a primary advocate for
for nurse educators. This organization has four advancing diversity and inclusivity with
major goals (National League for Nursing, 2017): academic nursing.
■■ Goal 4: AACN is the authoritative source of the organization takes place. There are about
of knowledge to advance academic nursing 500 chapters at approximately 695 institutions of
through information curation and synthesis. higher education, which include schools in Armenia,
Australia, Botswana, Brazil, Canada, Colombia,
Organization for Associate Degree Nursing. England, Ghana, Hong Kong, Japan, Kenya, Lebanon,
The Organization for Associate Degree Nursing Malawi, Mexico, the Netherlands, Pakistan, Portugal,
(OADN) [formerly N-OADN] represents associate Singapore, South Africa, South Korea, Swaziland,
degree (AD) nurses, AD nursing programs, and Sweden, Taiwan, Tanzania, Thailand, the United
individual member nurse educators. The organization Kingdom, and the United States. Other countries are
joined the ANA as an organizational affiliate in considering establishing chapters. This is an important
December 2016 along with 30 other specialty nursing organization, and students should learn more about
organizations that are ANA affiliates (The American their school’s chapter (if the school has one) and aspire
Nurse, 2017). The OADN focuses on enhancing the to an invitation for induction into STTI. Inductees
quality of AD nursing education, strengthening the meet specific academic and leadership standards.
professional role of the AD nurse, and protecting The major STTI publications are Journal of Nursing
the future of AD nursing in the midst of healthcare Scholarship, Reflections on Nursing Leadership, and
changes. Its major goals follow (Organization for the newest publication, Worldviews on Evidence-Based
Associate Degree Nursing, 2016): Nursing. The organization manages the major online
■■ Collaboration Goal: Advance associate degree library for nursing resources, the Virginia Henderson
nursing education through collaboration International Nursing Library, through its website.
with a diversity of audiences. International Council of Nurses. The ICN,
■■ Education Goal: Advance associate degree founded in 1899, is a federation of 130 national
nursing education. nurses’ associations representing approximately
■■ Advocacy Goal: Advocate for issues and activ- 16 million nurses worldwide, representing more than
ities that support the organization’s mission. 130 national nurse associations such as the ANA
Sigma Theta Tau International. Sigma (International Council of Nurses [ICN], 2015). This
Theta Tau International (STTI) is a not-for-profit organization is the international voice of nursing
international organization based in the United States. and focuses on activities to better ensure quality
This nursing honor society was created in 1922 by a care for all and sound health policies globally. Its
small group of nursing students at what is now the activities focus on (1) professional nursing practice
Indiana University School of Nursing. Its mission (for example, specific health issues, International
is to provide leadership and scholarship in practice, Classification of Nursing Practice), (2) nursing
education, and research to improve the health of regulation (for example, regulation and credentialing,
all people (Sigma Theta Tau International, 2016). ethics, standards, continuing education), and (3)
Membership in this organization is by invitation to socioeconomic welfare for nurses (for example,
baccalaureate and graduate nursing students who occupational health and safety, salaries, migration,
demonstrate excellence in scholarship and to nurse and other issues). The ICN headquarters is in
leaders who demonstrate exceptional achievements Geneva, Switzerland.
in nursing. STTI has more than 135,000 active National Student Nurses Association. The
members, and 85 countries are represented in its National Student Nurses Association (2016) has
membership. a membership of approximately 60,000 students
Schools of nursing may form STTI association enrolled in diploma, AD, baccalaureate, and general
chapters. The chapters are where most of the work graduate nursing programs in 50 states, the District of
Columbia, Puerto Rico, and the U.S. Virgin Islands. It together. Membership in a professional organization
is a national organization with chapters within schools is one way to develop one strong voice.
of nursing. Its major publication is Imprint. Joining Nurses who attend meetings, hold offices, and
the NSNA is a great way to get involved and to begin serve on committees or as delegates to large meet-
to develop professional skills needed for the future ings benefit more from membership than those
(such as learning more about being a leader and a who do not participate. Submitting abstracts for
follower, critical roles for practicing nurses). The NSNA a presentation or poster at a meeting is excellent
website provides an overview of the organization experience for nurses and offers even more op-
and its activities. Attending a national convention is portunities for networking with other nurses who
also a great way to find out about nursing in other might also provide resources and mentoring for
areas of the country and network with other nursing professional development. There are some factors
students. Annual conventions attract more than that are important to recognize as you consider
3,000 nursing students and are held at different sites joining a professional organization. Belonging to a
each year. This professional networking also affords nursing association requires money for membership
students opportunities to learn about graduate and commitment to the association, which means
education, specialty groups, and nursing careers. Active it takes time to engage in the organization.
engagement in your school’s NSNA chapter and national Students can begin to meet this professional
activities provide you with opportunities to develop obligation by joining local student organizations,
leadership competencies. Hopefully, these experiences which may or may not be directly related to the
will provide a springboard to later professional nursing program but to the campus in general, and
engagement in nursing professional organizations. developing skills that can be used after graduation
when they join professional organizations. Mem-
Why Belong to a Nursing bership offers opportunities to serve as a committee
Professional Organization? member and even chair a committee. Organization
The previous section described many nursing communication methods can be observed, and the
professional organizations, and there is further student can participate in the processes, developing
information in the Nursing Education, Accredita- leadership competencies. Engagement in organizations
tion, and Regulation chapter about some of these allows members to participate in making decisions
organizations. Why is it important to belong to a about nursing and health care in general. When new
professional organization? Joining a professional nurses enter the profession today, they find a healthcare
organization and becoming active in the orga- system that is struggling to improve its quality and
nization’s activities is a professional obligation. keep up with medical changes, and nurses need to be
Membership and, it is hoped, active involvement engaged in the process to improve health care. Orga-
can help nurses develop leadership skills, improve nizations also sometimes band together—increasing
networking, and find mentors. Additionally, collaboration to have a greater voice about critical
membership gives nurses a voice in professional healthcare policy issues such as the need to expand
issues and in some cases, health policy issues. It the nursing profession or improve care in a local area.
provides a range of opportunities for professional
development. Nurses represent the single largest
Nursing Workforce
voting bloc in any state. By using this political
power through nursing and other professional Nursing is one of the largest healthcare professions,
organizations, nurses can speak in one powerful and nurses have many opportunities to serve as leaders
voice. Yet as nurses, we have often failed to pull in health care. Nurses work in a variety of settings,
such as hospitals, clinics, home health care, hospice ■■ While not considered in this study, emerging
care, long-term care, rehabilitation, physician offices, care delivery models, with a focus on manag-
school health, employment services, and numerous ing health status and preventing acute health
other service sites. The majority of nurses work in issues, will likely contribute to new growth
acute care hospital settings, but this is changing as in demand for nurses—for example, nurses
more care moves into the community. taking on new and/or expanded roles in
According to the U.S. Bureau of Labor Statistics’ preventive care and care coordination (p. 2).
(2015) employment projections for 2014–2024, ■■ Supply and demand will continue to be affected
employment opportunities for registered nurses are by numerous factors, including population
expected to increase 16%, which is faster than ex- growth and the aging of the nation’s popu-
pected for most other occupations. Over this period, lation, overall economic conditions, aging
another 495,500 nursing workforce replacements of the nursing workforce, and changes in
may be needed, bringing the total number of job healthcare reimbursement (p. 4).
openings for nurses due to growth and replace- ■■ While the evidence in this report points
ments to 1.2 million by 2020. We have experienced toward the United States currently educating
a number of years of fluctuating nursing shortages. slightly more nurses than required to meet
As the number of nurses in practice and nursing future demand, a reduction in people choos-
school enrollments fluctuate, any nursing shortage, ing nursing as a career or a combination of
whether this is geographic specific or healthcare factors such as early retirement or increased
organization specific, affects access to care in the demand could be sufficient to erase projected
years to come—and there can be great variation surpluses for RNs and LPNs (licensed practical
from one area of the country to another. Because of nurses) (p. 14).
demographic changes, the older adult population in ■■ If the growing emphasis on care coordi-
the United States is increasing rapidly, and from 2010 nation, preventive services, and chronic
to early 2017, the ACA extended insurance coverage disease management in care delivery models
to more people. Taken together, these developments leads to a greater need for nurses, this brief
signal that the demand for nurses and other health- may underestimate the projected nurse
care professionals will increase. Changes in future demand (p. 15).
federal legislation and their impact on states need to Nursing is a profession. It meets all the re-
be followed by the nursing profession to determine quirements for a profession and serves as a major
impact on nursing practice and need for nurses. profession in healthcare delivery and the healthcare
The 2014 Health Resources and Services Admin- workforce. In the early part of its history, nursing
istration (HRSA) report, The Future of the Nursing was not viewed as a profession, as noted in the
Workforce: National- and State-Level Projections, review of nursing history described earlier in this
2012–2025, indicates that the United States is on chapter, but it is now recognized as a profession built
track to meet the projected demand for nursing staff on knowledge that reflects its dual components of
(registered nurses and licensed practical nurses in science and art with clear roles and responsibilities
the next 10 years (HHS, HRSA, & BHW, 2014). The in the healthcare workforce. The Essence of Nursing:
number of new graduates entering the workforce Knowledge and Caring chapter explores the art and
has increased. Many factors impact supply and
demand for nursing staff. This report notes some
Stop and Consider #2
trends and study limitations that might alter this
It is easy to see how nursing is a profession.
projection; for example:
science of the profession of nursing, expanding on name, first and last, and title and explaining your
the view of nursing as a profession and an active role is an important step in establishing trust and
member of the healthcare workforce. maintaining accountability—demonstrating pro-
fessionalism (LeBlanc, Burke, & Henneman, 2016).
Most nurses do not even consider the implications
The Image of Nursing of the introduction and quickly move on to a task
that must be done. They may not provide their first
The image of nursing may appear to be an unusual and last name due to concerns about their privacy,
topic for a nursing text, but it is not. Image is part though this does not really protect privacy because
of any profession. It is the way a person appears it is easy for a patient to find out a nurse’s name.
to others, or in the case of a profession, the way The public’s views of nursing and nurses are
a profession appears to other professionals and typically based on personal experiences with nurses,
others in the work environment and to the general which can lead to a narrow view of a nurse often
public—in nursing’s case, consumers of health care. based on only a brief personal experience. This
Image and the perception of the profession affect experience may not provide an accurate picture of
recruitment of students; the view of the public; all that nurses can and do provide in the healthcare
funding for nursing education and research; rela- delivery process. In addition, this view may be
tionships with healthcare administrators and other influenced by the emotional response of a person
healthcare professionals, government agencies, and to the situation and the encounter with a nurse.
legislators at all levels of government; and, ultimately, But the truth is that most often the nurse is
the profession’s self-identity. Just as individuals may invisible. “Although nurses comprise the majority
feel depressed or less effective if others view them of healthcare professionals, they are largely invisible.
negatively, so can professionals experience similar Their competence, skill, knowledge, and judgment
reactions if their image is not positive. Image in- are—as the word ‘image’ suggests—only a reflection,
fluences everything the profession does or wishes not reality” (E. Sullivan, 2004, p. 45). Consumers
to do. How nurses view themselves—their profes- (patients, families) may not understand the knowl-
sional self-image—has an impact on professional edge and competencies required to be a registered
self-esteem (Buresh & Gordon, 2006). How one is nurse, may not recognize they are interacting with
viewed has an impact on whether others seek that a nurse, or they may think someone is a nurse who
person out and how they view the effectiveness is not. When patients go to their doctor’s office, they
of what that person might do. Every time a nurse interact with staff, and often these patients think
says to family, friends, or members of the public that that they are interacting with a registered nurse.
he or she is a nurse, the nurse is representing the Most likely, they are not—the staff person may be a
profession. “We cannot expect outsiders to be the medical assistant of some type or a licensed practi-
guardians of our visibility and access to public cal/vocational nurse. When in the hospital, patients
media and health policy arenas. We must develop interact with many staff members, and there is little
the skills of presenting ourselves in the media and to distinguish one from another, so patients may refer
to the media—we have to take the responsibil- to most staff as nurses. Uniforms do not help identify
ity for moving from silence to voice” (Buresh & roles because many staff wear scrub clothes and lab
Gordon, 2006, p. 15). The professional introduction coats, and there has been less emphasis placed on
is an example of critical communication that sets professional attire. In the past, hospitals had strict
the stage for a nurse–patient relationship, and it is dress codes, with standard uniforms per type of
associated with the image of nursing. Saying one’s staff. Over time, this approach changed—affecting
not only what staff wore, but also appearance such strong statement and may be a confusing one. What
as hair, wearing of jewelry, and so on. Healthcare is the nurse’s voice? It is the “unique perspectives
organizations now find it difficult to change dress and contributions that nurses bring to patient care”
codes with staff complaining this is not needed. One (Pike, 2001, p. 449). Nurses have all too often been
organization conducted an extensive study of the silent about what they do and how they do it, but
issue of dress and image, examining how patients this has been a choice that nurses have made—to be
viewed nurses, and noted at the conclusion of the silent or to be more visible. Both external and internal
study that standardizing nurse uniforms would factors affect the nurse’s voice and this silence. The
have a positive impact on the nurse’s professional external factors include the following (Pike, 2001):
image and this then would affect the nurse–patient ■■ Historical role of nurse as handmaiden (not
relationship (West et al., 2016). an independent role)
This does not mean that the public does not ■■ Hierarchical structure of healthcare orga-
value nurses—quite the contrary. When a person nizations (may limit the role of nurses in
tells another that he or she is a nurse, the typical decision making and leadership)
response is positive. However, many people do not ■■ Perceived authority and directives of physicians
know about the education required to become a nurse (may limit the independent role of nurses)
and to maintain current knowledge or about the ■■ Hospital policy (may limit nursing actions
great variety of educational entry points into nursing and leadership)
that all lead to the RN qualification. Consumers ■■ Threat of disciplinary or legal action or loss
generally view nurses as good people who care for of job (may limit a nurse when he or she
others. In 2017, nurses continue to rank number needs to speak out—advocate)
one in ethics and honesty in the annual Gallup Poll
Nurses who can deal with the internal factors can
compared to other occupations (Jimenez, 2016).
be more visible and less silent about nursing and
This high vote of confidence has been a consistent
better advocate for patients. The internal factors to
annual result in this poll. What is not mentioned in
consider include:
the poll is the knowledge and competency required
to do the job properly—important aspects of the ■■ Role confusion
nursing profession. ■■ Lack of professional confidence
You might wonder why it is so important for ■■ Timidity
nurses to make themselves more visible. You chose ■■ Fear
nursing, so you know that it is an important profession. ■■ Insecurity
Nevertheless, many students have a narrow view of ■■ Sense of inferiority
the profession, much closer to what is portrayed in Nurses’ loss of professional pride and self-es-
the media—the nurse who cares for others, albeit teem can also lead to a more serious professional
with less understanding of the knowledge base re- problem: Nurses feel like victims and then act like
quired and competency needed to meet the complex victims. Victims do not take control, but rather
needs of patients. There is limited recognition that see others as being in control; they abdicate re-
nursing is a scientific field. The profession needs sponsibility. They play passive–aggressive games
to be more concerned about visibility because the to exert power. This can be seen in the public
profession needs to attract qualified students and image of nurses, which is predominantly driven
keep current nurses in practice. by forces outside the profession. It also affects the
The nurse’s voice is typically silent, and this nurse’s ability to collaborate with others—both
factor has demoralized nursing (Pike, 2001). This is a other nurses and other healthcare professionals.
It is all too easy for nurses to feel like victims, and the media are simply reflecting the public image
this perception has led in many ways to nurses of nursing (Buresh & Gordon, 2006). Nurses have
viewing physicians in a negative light, emphasizing not taken the lead in standing up and discussing
that “physicians have done this to us.” As a conse- their own image of nursing—what it is and what
quence, nurses may have problems saying they are it is not. It is not uncommon for a nurse to refuse
colleagues with other healthcare professionals and to talk to the press because the nurse feels no
acting like colleagues. Colleagueship “involves need to do so, may not feel competent to do so,
entering into a collaborative relationship that is or fears reprisals from his or her employer. When
characterized by mutual trust and response and nurses do speak to the press—often when being
an understanding of the perspective each partner praised for an action—they say, “Oh, I was just
contributes” (Pike, 2001, p. 449). Colleagues have doing my job.” This statement undervalues the
the following characteristics: reality that critical thinking and clinical reason-
■■ Control interprofessional and intraprofes- ing and judgment on the part of nurses makes a
sional competition and antagonism from the difference in the health of patients (individuals,
past conflict that may influence the present families, communities) every day. What is wrong
and the future. with taking that credit? Because of these types of
■■ Integrate work to provide the best care. responses in the media, nursing is not directing
■■ Acknowledge they share a common goal: the image, but rather accepting how those outside
quality patient care. the profession describe nursing.
■■ Recognize their interdependence and also Gordon and Nelson (2005) comment “nursing
independent responsibilities. needs to move away from the ‘virtue script’ toward a
■■ Share responsibility and accountability for knowledge-based identity” (p. 62). The “virtue script”
patient care outcomes. continues to be present in current media campaigns
■■ Respond to conflict in a positive manner that are supported by the profession. For example, a
before it accelerates. video produced by the NSNA mentions knowledge
but not many details; instead, it includes statements
What is unexpected is how nurses’ silence may
such as “[Nursing is a] job where people will love
actually have a negative impact on patient care. This
you” (Gordon & Nelson, 2005). How helpful is this
factor may influence how a nurse speaks out or ad-
approach? Is this view of being loved based on today’s
vocates for care that a patient needs, how effective
nursing reality? Nursing practice involves highly
a nurse can be on the interprofessional treatment
complex care; it can be stressful, demanding, and at
team, and how nurses participate in healthcare
times rewarding, but it is certainly not as simple as
program planning and implementation of services.
“everyone will love you.” Why do nurses continue to
Each nurse has the responsibility and accountabil-
describe themselves in this way? “One reason nurses
ity to define himself or herself as a colleague, and
may rely so heavily on the virtue script is that many
empowerment is part of this process.
believe this is their only legitimate source of status,
The role of nursing has experienced many
respect, and self-esteem” (Gordon & Nelson, 2005,
changes, and many more will occur in the future.
p. 67). This, however, is a view that perpetuates the
How has nursing responded to these changes and
victim mentality.
communicated them to the public and other health-
care professionals? Suzanne Gordon, a journalist
who has written extensively about the nursing
profession, noted that often the media are accused The image of nursing is not simple to describe.
of representing nursing poorly when, in reality,
CHAPTER HIGHLIGHTS
1. Nursing history provides a framework for 5. The sources of professional direction include
understanding how nursing is practiced today. ANA documents that describe the scope of
2. The history of nursing is complex and has practice, standards, and an ethical code.
been influenced by social, economic, and 6. Professional organizations have a key role
political factors. in shaping nursing as a profession. Nurses
3. Florence Nightingale was instrumental in should participate in these organizations
changing the view of nursing and nursing to have a voice in the profession.
education to improve care delivery, but she 7. The public, the media, interprofessional
is not the only nurse leader who has led colleagues, and nurses have an influence
the profession. on the image of nursing. Nursing’s image
4. Nursing meets the critical requirements as a profession has both positive and neg-
for a profession. ative aspects.
ENGAGING IN THE CONTENT
Discussion Questions
1. How might knowing more about nursing 5. Why are standards important to the nursing
history affect your personal view of nursing? profession and to healthcare delivery?
2. How did the image of nursing in Nightin- 6. Review the ANA standards of practice and
gale’s time influence nursing from the 1860s professional performance. Are you surprised
through the 1940s? by any of the standards? If so, why?
3. How would you compare and contrast ac- 7. How would you explain to someone who is
countability, autonomy, and responsibility? not in health care the reason that nursing
4. Based on content in this chapter, how would emphasizes its social policy statement?
you define professionalism in your own words?
CRITICAL THINKING ACTIVITIES
1. Describe how the Nightingale Pledge may 3. Attend an NSNA meeting at your school.
or may not have relevance today and how it What did you learn about the organization?
might be altered to be more relevant. Work What did you observe in the meeting about
with a team of students to accomplish this leadership and nursing? Do you have any
activity and arrive at a consensus statement. criticisms of the organization and how it
2. Interview two registered nurses, ask them might be improved? If your school does not
if they think nursing is a profession, and have an NSNA chapter, why is this the case?
determine the rationale for their viewpoints. 4. Complete a mini-survey of six people
How does what they say compare with what (non-nurses), asking them to describe their
you have learned about professionalism in image of nursing and nurses. Try to pick a
this chapter? variety of people. Summarize and analyze
(Continues)
CRITICAL THINKING ACTIVITIES (CONTINUED)
your data to identify any themes and un- www.nursingworld.org/MainMenuCatego

usual views. How does what you learned ries/ ANAMarketplace/ANAPeriodicals/OJIN
relate to the content in this chapter? List /TableofContents/Vol-16-2011/No2-May-2011
the similarities and differences, and then /Articles-Previous-Topics/Nursing-at-its-Best.
discuss your findings with a group of your html. Debate this issue in class.
classmates and compare with their findings. 6. Analyze a television program that focuses
5. You are told that the profession of nursing on a healthcare situation/story line. How
needs to abandon its image of nurses as are nurses depicted compared with other
angels and promote an image of nurses healthcare professionals? Compose a letter
as competent professionals who are both to the program describing your analysis, and
knowledgeable and caring. Review this document your arguments to support your
article: Rhodes, M., Morris, A., & Lazenby, R. viewpoint. This could be done with a team
(2011, May). Nursing at its best: Competent of students; watch the same program and
and caring. OJIN, 16. Retrieved from http:// then discuss opinions and observations.
ELECTRONIC REFLECTION JOURNAL

You are asked to develop an Electronic Reflection Journal that you will use after you
complete each chapter. This is the place for you to reflect on some aspect of the
chapter’s content identified at the end of the chapter. You may also want to keep notes about
issues that you want to expand on as you progress through your nursing education. If you are
using technology that allows you to make visuals, use drawings and graphics as one method to
reflect in your journal.
In your first entry in your Electronic Reflection Journal, consider the following questions
related to the image of nursing. Connect your responses so that you can better understand the
importance of image to the profession and the meaning of profession.
1. Why is the image of nursing important to the profession? To health care in general?
2. What role do you think you might have as a nurse in influencing the image of nursing? Provide
specific examples.
3. What is your opinion about nursing uniforms, and how do you think they influence the image
of nursing?
4. What stimulated your interest in nursing as a profession? Was the image of nursing in any way
related to your decision, and in what way did it affect your decision?
Special assignment for this chapter: Write your own definition of nursing and include it in your
Electronic Reflection Journal. Work on this definition throughout this course as you learn more
about nursing. Save the final draft, and at the end of each semester or quarter, go back to your
definition and make any changes you feel are necessary. Keep a draft of each definition so that
you can see your changes. When you graduate, review all your definitions, illustrating how you
have developed your view of professional nursing. Ideally, you might then review your definition
again one-year post graduation.
CASE STUDIES
Case 1
You and your friends in the nursing program are having lunch after a class that covered
content found in this chapter. One of your friends says, “I was bored when we got to all that
information on professionalism and nursing organizations. What a waste of time. I just want to
be a nurse.” All of you are struggling to figure out what you have gotten yourself into. You turn
to your friends and suggest it might be helpful to have an open discussion on the comment
just made. So over lunch, you all talk about the comment. It was clear that the students who
had read the chapter were better able to discuss the issue, but everyone had an opinion.
Case Questions
1. What is the purpose of nursing organizations?
2. What role should professional organizations assume to increase nursing status in the
healthcare system?
3. What are some of the advantages and disadvantages to joining a professional organization?
4. What do you know about your school’s NSNA chapter?
5. Which nursing organization mentioned in this chapter interests you, and why? Compare
your response with those of your other classmates.
6. Search on the Internet for a specialty nursing organization and pick one that interests
you. What can you find out about the organization?
Case 2
The NSNA chapter in your school wants to help the school develop a campaign to increase
enrollment. You have volunteered along with three other members to meet with the
associate dean to discuss ideas for the campaign. The associate dean tells you that the
school is going to use its standard marketing materials. She shows them to you. The
materials focus on the importance of being a caring person to be a “good” nurse. When you
ask to see print materials and materials to be posted on the Internet, you are told that the
focus is on print, and you see a photo of a nurse holding a patient’s hand.
Case Questions
1. How do you respond to this marketing material?
2. What recommendations would you make?
3. How might you get data from fellow students to support your recommendations?
Working Backward to Develop a Case

This type of case is a different format from usual cases. It is a “backward case.” Students
are provided with several questions and are asked to develop a case scenario that would
CASE STUDIES (CONTINUED)
relate to the questions and chapter content (paragraph or two). After the scenario is
written, students answer the questions. A second option is for this to be a team activity. A
team of students develops the scenario and then passes it on to another team to answer
the questions. Following this, the teams discuss the case. This description and use of this
learning activity will not be repeated in each chapter guide.
Write a brief paragraph that describes a case related to the following

questions and comments.
1. What do we need to do to be more professional as students?
2. I think this topic is not important now as we are students. We deal with it when we get
our first job.
3. We now have to wear our uniforms in the simulation lab. What is all this about? So an-
noying as we have other things to think about.
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Design Credits: Electronic Circuit: © Photos.com; Chapter opener image: © Galyna Andrushko/Shutterstock; Paper texture: © Roobcio/Shutterstock
Chapter
2
The Essence of Nursing:
Knowledge and Caring
CHAPTER OBJECTIVES
■■ Discuss issues related to defining nursing. ■■ Explain the relevance of scholarship to nursing
■■ Examine nursing knowledge and the and implications of research.
knowledge–caring dyad, knowledge workers, ■■ Compare and contrast major nursing roles and
and knowledge management. responsibilities.
CHAPTER OUTLINE
●● Introduction ●● Educator
●● Nursing: How Do We Define It? ●● Counselor
●● Knowledge and Caring ●● Manager
●● Knowledge ●● Researcher
●● Knowledge Management ●● Collaborator
●● Critical Thinking and Clinical ●● Change Agent (Intrapreneur)
Thinking and Judgment: Impact ●● Entrepreneur
on Knowledge Development and ●● Patient Advocate
Application ●● Leader
●● Caring ●● Summary Points: Roles and What is
●● Competency Required
●● Scholarship in Nursing ●● Chapter Highlights
●● What Does Scholarship Mean? ●● Engaging in the Content
●● Nursing Theory ●● Discussion Questions
●● Nursing Research ●● Critical Thinking Activities
●● Professional Literature ●● Electronic Reflection Journal
●● New Modalities of Scholarship ●● Case Studies
●● Multiple Nursing Roles and Leadership ●● Working Backward to Develop a Case
●● Key Nursing Roles ●● References
●● Provider of Care
39
KEY TERMS
Advocate Dichotomous thinking Provider of care

Applied or clinical research Educator Reality shock
Basic research Entrepreneur Reflective thinking
Caring Groupthink Research
Change agent Identity Researcher
Clinical judgment Intuition Role
Clinical reasoning Knowledge Role transition
Collaboration Knowledge management Scholarship
Competency Knowledge workers Sensemaking
Counselor Leader Status
Critical thinking Management Theory
must be present for quality nursing care. Content

Introduction includes the effort to define nursing, knowledge and
caring, competency, scholarship in nursing, major
In the fall of 2016, the National Institute of Nursing
nursing roles, and leadership.
Research (NINR) celebrated its 30th anniversary
with activities to communicate the theme of “Ad-
vancing Science, Improving Lives. A Window to
the Future” (NINR, 2016). Nursing has developed Nursing: How Do We
into a profession that now has greater emphasis on Define It?
research and application of research. This chapter
focuses on knowledge representing the science of Defining nursing is relevant to this chapter and re-
nursing and the art and caring of nursing. We must quires further exploration. Can nursing be defined,
always consider both aspects of the profession. and if so, why is it important to define it? Before this
A 2006 publication by Nelson and Gordon, The discussion begins, you should review your personal
complexities of care: Nursing reconsidered, expanded definition of nursing. You may find it strange to
on this topic. The authors stated, “Because we take spend time on the question of a definition of nurs-
caring seriously, we (the authors) are concerned that ing, but the truth is, there is no universally accepted
discussions of nursing care tend to sentimentalize definition by healthcare professionals and patients.
and decomplexify the skill and knowledge involved The easy first approach to developing a definition is
in nurses’ interpersonal or relational work with to describe what nurses do; however, this approach
patients” (p. 3). Nelson and Gordon make a strong leaves out important aspects and essentially reduces
case that there is an ongoing problem of nurses de- nursing to tasks. Diers noted that even Florence
valuing the care they provide, particularly regarding Nightingale’s and Virginia Henderson’s definitions are
the required knowledge component of nursing care not definitions of what nursing is, but more of what
and technical competencies needed to meet patient nurses do—more consideration needs to be given
care needs, although caring is important part of the to (1) what drives nurses to do what they do or why
process—both of these aspects relate to the goal of they do what they do (rationales, evidence-based
providing quality care. This chapter explores the practice [EBP]) and (2) what is achieved by what
knowledge and caring of nursing practice. Both they do (outcomes) (2001). Henderson’s definition
Chapter 2: The Essence of Nursing: Knowledge and Caring 41
focuses more on a personal concept of nursing ■■ Health: “An experience that is often expressed
rather than a true definition. Henderson herself in terms of wellness and illness, and may
even said that what she wrote was not the complete occur in the presence or absence of injury”
definition of nursing (Henderson, 1991). Diers (ANA, 2015a, p. 87).
also commented that there really are no complete ■■ Prevention of illness and injury: Interventions
definitions for most disciplines. Yet nursing is still taken to keep illness or injury from occurring—
concerned with a definition. Having a definition for example, immunization for tetanus or
serves several purposes that really drive what that teaching parents how to use a car seat.
definition will look like (Diers, 2001, p. 7): ■■ Illness: “The subjective experience of dis-
comfort” (ANA, 2015a, p. 88).
■■ Providing an operational definition to guide
■■ Injury: Harm to the body—for example, a
research
broken arm caused by a fall from a bicycle.
■■ Acknowledging that changing laws requires a
■■ Diagnosis: “A clinical judgment about the
definition that will be politically accepted—for
patient’s response to actual or potential
example, in relationship to a nurse practice act
health conditions or needs. The diagnosis
■■ Convincing legislators about the value of
provides the basis for determination of a
nursing—for example, to gain funds for
plan to achieve expected outcomes. Reg-
nursing education
istered nurses utilize nursing and medical
■■ Explaining what nursing is to consumers/
diagnosis depending upon educational and
patients (although no definition is totally
clinical preparation and legal authority”
helpful because patients/consumers respond
(ANA, 2015a, p. 86).
to a description of the work, not a definition)
■■ Treatment: To give care through interventions—
■■ Explaining to others in general what one
for example, administering medication,
does as a nurse, which often represents a
teaching a patient how to give him- or herself
personal description of nursing
insulin, wound care, preparing a patient for
One could also say that a definition is help- surgery, and ensuring that the patient is not
ful in determining what to include in a nursing at risk for an infection.
curriculum, but nursing has been taught for years ■■ Advocacy: The act of pleading for or supporting
without a universally accepted definition. As men- a course of action on behalf of individuals,
tioned in other content in this text, the American families, communities, and populations—
Nurses Association (ANA, 2015a) defines nursing for example, a nurse who works with the
as “the protection, promotion, and optimization city council to improve health access for a
of health and abilities, prevention of illness and community.
injury, alleviation of suffering through the diagnosis Essential features of professional nursing are
and treatment of human response, and advocacy identified from definitions of nursing (ANA, 2015a,
in the care of individuals, families, communities, pp. 7–9):
and populations” (p. 88). Some of the critical terms
1. Caring and health are central to the practice
in this definition include the following; others are
of the registered nurse.
discussed in the ANA standards:
2. Nursing practice is individualized.
■■ Promotion of health: Assisting people to 3. Registered nurses use the nursing process
maintain their health within their abilities; to plan and provide individualized care for
supporting families, populations and com- healthcare consumers.
munities to maintain a healthy lifestyle. 4. Nurses coordinate care by establishing relationships.
5. A strong link exits between the professional information about something, and caring is behavior
work environment and the registered nurse’s that demonstrates compassion and respect for another.
ability to provide quality health care and achieve But these are very simple definitions. The depth of
optimal outcomes. nursing practice goes beyond basic knowledge and the
Knowledge and caring are the critical dyad in any ability to care. Nursing encompasses a distinct body
description or definition of nursing, and both re- of knowledge coupled with the art of caring. As stated
late to nursing scholarship and leadership and are by Butcher (2006), “A unique body of knowledge is
integrated in the above features. a foundation for attaining the respect, recognition,
As part of a project to define the work of and power granted by society to a fully developed
nursing, the North American Nursing Diagnosis profession and scientific discipline” (p. 116).
Association (2016) described nursing diagno-
ses and developed the Nursing Interventions Knowledge
Classification (NIC) (University of Iowa, 2016a)
Knowledge can be defined and described in a num-
and the Nursing Outcomes Classification (NOC)
ber of ways. There are five ways of knowing that are
(University of Iowa, 2016b). Maas (2006) discussed
useful in understanding how one knows something.
the importance of these initiatives, which she de-
A nurse might use all or some of these ways of
scribed as the building blocks of nursing practice
knowing when providing care (Cipriano, 2007):
theory, and noted that “rather than debating the
issues of definition, nursing will be better served 1. Empirical knowing focuses on facts and is re-
by focusing those energies on its science and the lated to quantitative explanations—predicting
translation of the science of nursing practice” (p. 8). and explaining.
In summary, there are three conclusions about 2. Ethical knowing focuses on a person’s moral
defining nursing that are important to consider: values—what should be done.
(1) No universally accepted definition of nursing 3. Personal knowing focuses on understanding and
exists, although several definitions have been devel- actualizing a relationship between a nurse and
oped by nursing leaders and nursing organizations; a patient, including knowledge of self (nurse).
(2) individual nurses may develop their own per- 4. Aesthetic knowing focuses on the nurse’s per-
sonal description of nursing to use in practice; and ception of the patient and the patient’s needs,
(3) a more effective focus is the pursuit of nursing emphasizing the uniqueness of each relationship
knowledge to build nursing scholarship. The first and interaction.
step is to gain a better understanding of knowledge 5. Synthesizing, or pulling together the knowledge
and caring in relationship to nursing practice. gained from the other types of knowing, allows
the nurse to understand the patient better and
to provide higher-quality care.
The ANA (2015b) identifies key issues related to
Your personal definition of nursing is as important
as a formal definition of nursing. the knowledge base for nursing practice, including
both theoretical and evidence-based knowledge
(pp. 189–190):
Knowledge and Caring ■■ Promotion of health and wellness

■■ Promotion of safety and quality of care
Understanding how knowledge and caring form ■■ Care, self-care processes, and care coordination
the critical dyad for nursing is essential to provid- ■■ Physical, emotional, and spiritual comfort,
ing effective quality care. Knowledge is specific discomfort, and pain
■■ Adaptation to physiologic and pathophysi- ■■ Teamwork

ologic processes ■■ Coordination
■■ Emotions related to experiences of birth, ■■ Analysis
growth and development, health, illness, ■■ Critical thinking, clinical reasoning, and
disease, and death judgment
■■ Meanings ascribed to health and illness and ■■ Evaluation
other concepts ■■ Willingness to be flexible
■■ Linguistic and cultural sensitivity Knowledge workers recognize that change
■■ Health literacy is inevitable and that the best approach is to be
■■ Decision making and the ability to make ready for change and view it as an opportunity for
choices learning and improvement. Nurses use knowledge
■■ Relationships, role performance, and daily in their work. They work in an environment
change processes within relationships that expects healthcare providers to use the best
■■ Social policies and their effects on health evidence in providing care. “Transitioning to an
■■ Healthcare systems and their relationships evidence-based practice requires a different per-
to access, cost, and quality of health care spective from the traditional role of nurse as ‘doer’
■■ The environment and the prevention of of treatments and procedures based on institutional
disease and injury policy or personal preference. Rather, the nurse
This is the basic knowledge that every nurse should practices as a ‘knowledge worker’ from an updated
have to practice. Nurses use this knowledge, but and ever-changing knowledge base” (Mooney, 2001,
they also must integrate it as they collaborate with p. 17). The knowledge worker focuses on acquiring,
patients and the healthcare team to assess, plan, analyzing, synthesizing, and applying evidence to
implement, and evaluate care. guide practice decisions (Dickenson-Hazard, 2002).
The knowledge worker uses synthesis, competencies,
Knowledge Management multiple intelligences, a mobile skill set, outcome
practice, and teamwork, as opposed to the old skills
Knowledge work is a critical component of healthcare of functional analysis, manual dexterity, fixed skill
delivery today, and nurses are knowledge workers. Forty set, process value, process practice, and unilateral
percent or more of workers in knowledge-intensive performance (Porter-O’Grady & Malloch, 2007).
businesses, such as a healthcare organization, are This nurse is a clinical scholar. The employer and
knowledge workers (Sorrells-Jones & Weaver, patients should value a nurse for what the nurse
1999). Knowledge management includes both knows and how this knowledge is used to meet pa-
routine work (such as taking vital signs, admin- tient care outcomes—not just for technical expertise
istering medications, and walking a patient) and and caring, although these aspects of performance
nonroutine work, which (1) involves exceptions, are also important (Kerfoot, 2002).
(2) requires judgment and use of knowledge, and This change in a nurse’s work is also reflected
(3) may be confusing or not fully understood. In a in the Carnegie Foundation Report on nursing
knowledge-based environment, a person’s title is not education, as reported by Patricia Benner and
as important as the person’s expertise, and use of colleagues (2010). Benner suggests that instead of
knowledge and learning are important. Knowledge focusing on content, nurse educators should focus
workers actively use the following skills: on teaching nurses how to access information, use
■■ Communication and manipulate data (such as data from patient
■■ Collaboration information systems), and document effectively
in the electronic interprofessional format—using It means being aware of change and willing to take
knowledge to improve practice and care. some risks. Critical thinking allows the nurse to
avoid using dichotomous thinking—seeing
Critical Thinking and Clinical situations as either good or bad, or Black or White.
Thinking and Judgment: Impact This limits possibilities and clinical choices for
on Knowledge Development and patients (Finkelman, 2001).
Application Critical thinking skills that are important to
Critical thinking, reflective thinking, and intuition develop include affective learning; applied moral
are different approaches to thinking and can be reasoning and values (relates to ethics); com-
used in combination. Nurses use all of them to prehension; application, analysis, and synthesis;
explore, understand, develop new knowledge, and interpretation; knowledge, experience, judgment,
apply knowledge as evidence for best practice and and evaluation; learning from mistakes when they
caring in the nursing process. Experts such as Dr. happen; and self-awareness (Finkelman, 2001). A
Patricia Benner suggests that we often use the term person uses four key intellectual traits in critical
critical thinking, but there is high variability and thinking (Paul, 1995). Each of the traits can be
little consensus on what constitutes critical thinking learned and developed.
(Benner, Sutphen, Leonard, & Day, 2010). Clinical
reasoning and judgment are also very important ■■ Intellectual humility: Willingness to admit
and include critical thinking. what one does not know. (This is difficult to
Critical thinking is clearly a focus of nursing do, but it can save lives. A nurse who cannot
practice. The ANA standards state that the nursing admit that he or she does not know something
process is a critical thinking tool, albeit not the and yet proceeds is taking a great risk. It is
only one used in nursing (ANA, 2015a). This skill important for students to be able to use intel-
emphasizes purposeful thinking, rather than sudden lectual humility as they learn about nursing.)
decision making that is not based on thought and ■■ Intellectual integrity: Continual evaluation of
knowledge. Alfaro-LeFevre (2011) identified four one’s own thinking and willingness to admit
key critical thinking components: when thinking is not adequate. (This type
of honesty with self and others can make a
■■ Critical thinking characteristics (attitudes/
critical difference in care.)
behaviors)
■■ Intellectual courage: Ability to face and fairly
■■ Theoretical and experiential knowledge
address ideas, beliefs, and viewpoints for which
(intellectual skills/competencies)
one may have negative feelings. (Students
■■ Interpersonal skills/competencies
enter a new world of health care and may
■■ Technical skills/competencies
experience confusing thoughts about ideas,
In reviewing each of these components, one can beliefs, and viewpoints, and sometimes their
easily identify the presence of knowledge, caring personal views may need to be put aside in
(interpersonal relationships, attitudes), and technical the interest of the patient and quality care.)
expertise. The nursing process (assessment, diagnosis, ■■ Intellectual empathy: Conscious effort to
planning, implementation, and evaluation) applies understand others by putting one’s own feel-
all of these components and is discussed in more ings aside and imagining oneself in another
detail in later content in this text. person’s place.
Critical thinking requires nurses to generate
and examine questions and problems, use intuition, Critical thinking also helps to reduce the ten-
examine feelings, and clarify and evaluate evidence. dency toward dichotomous thinking and groupthink,
avoiding focus on just two options. Dichotomous Reflective thinking needs to become a part
thinking is related to groupthink, which occurs of daily learning and practice. Critical reflective
when all group or team members think alike. While thinking requires that the student or nurse examine
all of the team members might be working together the underlying assumptions and really question or
smoothly, groupthink limits choices, discourages even doubt the arguments, assertions, or facts of a
open discussion of possibilities, and diminishes the situation or case (Benner, Hughes, & Sutphen, 2008).
ability to consider alternatives. Problem solving is This allows the nurse to better grasp the patient’s
not a critical thinking skill, but effective problem situation. Conway (1998) noted that nurses who
solvers use critical thinking. use reflective thinking implement care based on the
The following methods will help develop your individualized care needs of the patient, whereas
critical thinking skills (Finkelman, 2001, p. 196): nurses who may not use reflective thinking or use
1. Seek the best information and data possible to it less often tend to provide illness-oriented care.
allow you to fully understand the issue, situation, Reflection is seen as a part of the art of nursing,
or problem. Questioning is critical. Examples of which requires “creativity and conscious self-
some questions that might be asked are: What is evaluation over a period of time” (Decker, 2007, p. 76).
the significance of ________? What is your first Reflection helps nurses cope with unique situations.
impression? What is the relationship between The skills needed for reflective thinking are
_________ and ________? What impact might the same skills required for critical thinking—the
________ have on ________? What can you ability to monitor, analyze, predict, and evaluate
infer from the information/data? (Pesut & Herman, 1999) and to take risks, be open,
2. Identify and describe any problems that re- and have imagination (Westberg & Jason, 2001).
quire analysis and synthesis of information— Guided reflection with faculty who assist students
thoroughly understand the information/ in using reflective thinking during simulated learn-
data. ing experiences can enhance student learning and
3. Develop alternative solutions—more than two help students learn reflective learning skills. It is
is better because this forces you to analyze recommended that this process be done with fac-
multiple solutions even when you discard one ulty to avoid negative thoughts that a student may
of them. Be innovative, and avoid proposing experience (Decker, 2007; Johns, 2004). The student
only typical or routine solutions. should view the learning experience as an opportu-
4. Evaluate the alternative solutions and consider nity to improve and examine the experience from
the consequences for each one. Can the solutions different perspectives. Some strategies that might
really be used? Do you have the resources you be used to develop reflective thinking are keeping a
need? How much time will it take? How well journal (such as the Electronic Reflection Journal and
will the solution be accepted? Identify pros the Working Backward Cases offered as an end-
and cons. of-chapter activities), engaging in one-to-one dialogue
5. Make a decision, choosing the best solution, with a faculty facilitator, joining in email dialogues,
even though there is risk in any decision making. and participating in structured team/group forums
6. Implement the solution but continue to question. in the classroom or online to help you understand
7. Follow-up and evaluate; plan for evaluation how others examine an issue and learn more about
from the very beginning. Self-assessment of constructive feedback. Reflective thinking strate-
critical thinking skills is an important part gies are not usually used for grading or evaluation,
of using critical thinking. How does one use but rather are intended to help you think about
critical thinking, and is it done effectively? your learning experience in an open manner.
Intuition is part of thinking. Including in- which nurses come to understand the problems,
tuition in critical thinking and clinical reasoning issues or concerns of clients/patients, to attend to
and judgment helps to expand the person’s ability salient information, and to respond in concerned
to know (Hansten & Washburn, 2000). The most and involved ways” (Benner, Tanner, & Chesla,
common definition of intuition is having a gut feel- 1996, p. 2). This process includes both deliberate,
ing about something. Nurses often have this feeling conscious decision making and intuition. “In the
as they provide care—“I just have this feeling that real world, patients do not present the nurse with
Mr. Wallace is heading for problems.” It is hard to a written description of their clinical symptoms
explain what this is, but it happens. The following and a choice of written potential solutions” (Del
are examples of thoughts that a person might have Bueno, 2005, p. 282). Beginning nursing students,
related to intuition (Rubenfeld & Scheffer, 2015): however, are looking for the clear picture of the
patient that matches what the student has read
■■ I felt it in my bones.
about in the text. This patient really does not ex-
■■ I couldn’t put my finger on why, but I thought
ist, so critical thinking and clinical reasoning and
instinctively I knew.
judgment become more important as the student
■■ My hunch was that . . . .
learns to compare and contrast what might be
■■ I had a premonition/inspiration/impression.
expected with what is reality (Benner, Sutphen,
■■ My natural tendency was to . . . .
Leonard, & Day, 2010).
■■ Subconsciously I knew that . . . .
A systematic review of studies published between
■■ Without thought I figured it out.
1980 and 2012 arrived at a sample of 23 studies to
■■ Automatically I thought that . . . .
examine the status of knowledge on clinical judgment
■■ While I couldn’t say why, I thought imme-
and reasoning (Cappelletti, Engle, & Prentice, 2014).
diately that . . . .
The following results from the study describe some
■■ My sixth sense said I should consider . . . .
aspects of clinical judgment (2014, pp. 455–456):
Intuition is not science, but sometimes intu- ■■ Clinical judgments are more influenced by
ition can stimulate research and lead to greater
what the nurse brings to the situation than
knowledge and questions to explore. Intuition is
the objective data about the situation at hand.
related to experience. A student would not likely ■■ Sound clinical judgment rests to some degree
experience intuition about a patient care situation,
on knowing the patient and his or her typical
but over time, as nursing expertise is gained, the
pattern of responses, as well as engagement
student may be better able to use intuition. Benner’s
with the patient and his or her concerns.
(2001) work, From Novice to Expert, suggests that ■■ Clinical judgments are influenced by the
intuition for nurses is really the putting together of
context in which the situation occurs and
the whole picture based on scientific knowledge and
the culture of the nursing unit.
clinical expertise, not just a hunch, and intuition ■■ Nurses use a variety of reasoning patterns
continues to be an important part of the nursing
alone or in combinations.
process (Benner, Hughes, & Sutphen, 2008). ■■ Reflection on practice is often triggered by
Clinical reasoning and clinical judgment
breakdown in clinical judgment and is critical
require more than recall and understanding of
for the development of clinical knowledge
content or selection of the correct answer; they
and improvement in clinical reasoning.
also require the ability to apply, analyze, and syn-
thesize knowledge (Del Bueno, 2005). Nursing Sensemaking is a term that has been ap-
clinical judgment is the process, or the “ways in plied to “making sense of a problem.” It is part of
using critical thinking and clinical reasoning and or administering medications is an example of this
judgment. You do this all the time in your daily type of caring. The fourth perspective is “competence
life and then carry it forward into your nursing in carrying out all the required procedures, personal
practice—solving a problem effectively requires and technical, with true concern for providing the
understanding the situation. Individuals experience proper care at the proper time in the proper way”
situations; confront gaps better; understand and/or (Mustard, 2002, p. 37). Not all four types of caring
take action; and then, after the experience, evaluate must be used at one time to be described as car-
information that was used in the process. This is all ing. Caring practices have been identified by the
done primarily unconsciously (Linderman, Pesut, & American Association of Critical-Care Nurses (2011)
Disch, 2015). You use data that you receive through in the organization’s synergy model for patient care
observation, communication, and other methods as “nursing activities that create a compassionate,
to make sense of the experience or situation. From supportive, and therapeutic environment for patients
this, you move on to other experiences and may and staff, with the aim of promoting comfort and
or may not reflect on past sensemaking or apply healing and preventing unnecessary suffering”. The
what was learned. We also help others, such as our model is discussed in other chapters in this text.
patients and their families, to get a better sense of Caring is an important component of patient-cen-
what is happening to them. Sensemaking happens tered care and supports quality care.
on the cognitive level as we use our cognitive tools Nursing theories often focus on caring. Theo-
to understand and formulate a view, physical level ries are discussed later in this chapter, but here it
when we take actions, and emotional levels as is important to note one theory in particular that
we experience a situation and respond. Nursing is known for its focus on caring—Watson’s theory
leaders should make more use of sense making on caring. In 1979, Watson defined nursing “as the
to build on their experiences and apply these to science of caring, in which caring is described as
new experiences. transpersonal attempts to protect, enhance, and
preserve life by helping find meaning in illness
and suffering, and subsequently gaining control,
Caring self-knowledge, and healing,” and this contin-
There is no universally accepted definition for caring ues to be relevant today (Scotto, 2003, p. 289).
in nursing, but it can be described from four perspec- Patients today need caring. They feel isolated
tives (Mustard, 2002). The first is the sense of caring, and are often confused by the complex medical
which is probably the most common perspective for system. Many patients have chronic illnesses such
students to appreciate. This perspective emphasizes as diabetes, arthritis, and cardiac problems that
compassion or being concerned about another require long-term treatment, and these patients
person. This type of caring may or may not require need to learn how to manage their illnesses and
knowledge and expertise, but in nursing, effective be supported in the self-management process.
caring requires both knowledge and expertise. The Even many patients with cancer who have longer
second perspective is doing for other people what survival rates today are now described as having
they cannot do for themselves. Nurses do this all a chronic illness.
the time, and it requires knowledge and expertise How do patients view caring? Patients may
to be effective. The third perspective is to care for not see the knowledge and skills that nurses
the medical problem; this, too, requires knowledge need, but they can appreciate when a nurse is
of the problem, interventions, and so on, as well as there with them. The nurse–patient relationship
expertise to provide the care. Providing wound care can make a difference when the nurse uses caring
consciously (Schwein, 2004). Characteristics of For students to be able to care for others, they
the patient-centered relationship are as follows: need to also care for themselves. This is also import-
■■ Being physically present with the patient ant for practicing nurses. It takes energy to care for
■■ Having a dialogue with the patient another person, and this effort is draining. Devel-
■■ Showing a willingness to share and hear—to oping positive, healthy behaviors and attitudes can
use active listening protect a nurse later when more energy is required
■■ Avoiding assumptions in the practice of nursing and also have an impact
■■ Maintaining confidentiality on performance and thus on quality care outcomes,
■■ Showing intuition and flexibility as discussed in other chapters in this text.
■■ Believing in hope As students begin their nursing education
program (and indeed throughout the program),
As will be discussed in this text, patient-centered
the issue of the difference between medicine and
care is now a critical focus of healthcare delivery and
nursing often arises. Caring is something that only
nursing. Caring is part of focusing on patients—who
nurses do, or so nurses say. Nurses are not the only
should make decisions about their health care and
healthcare professionals—for example, physicians
expect respect from healthcare professionals during
would say they have a caring attitude and caring is
the care process.
part of their profession; however, what has happened
Caring is offering of self. As Scotto (2003)
with nursing (which may not have been so helpful) is
comments, this means “offering the intellectual,
that when caring is discussed in relation to nursing,
psychological, spiritual, and physical aspects one
it is described only in emotional terms (Moland,
possesses as a human being to attain a goal. In nurs-
2006). This view ignores the fact that caring often
ing, this goal is to facilitate and enhance patients’
involves competent assessment of the patient to
ability to do and decide for themselves” (p. 290).
determine what needs to be done and the ability to
To be competent to care there are four aspects that
subsequently provide that care. For both of these
need to be considered (Scotto, 2003, pp. 290–291):
endeavors to be effective, the healthcare provider
■■ The intellectual aspect of nurses consists of must have knowledge. The typical description of
an acquired, specialized body of knowledge, medicine is curing; for nursing, it is caring. This
analytical thought, and clinical judgment, type of extreme dichotomy is not helpful for either
which are used to meet human health needs. the nursing or medical profession individually
■■ The psychological aspect of nurses includes and also has implications for the interrelation-
the feelings, emotions, and memories that ship between the two professions, adding conflict
are part of the human experience. and creating difficulty in communication in the
■■ The spiritual aspect of nurses, as for all human interprofessional team.
beings, seeks to answer the questions, “Why? The use of technology in health care has in-
What is the meaning of this?” creased steadily since 1960, particularly since the end
■■ The physical aspect of nurses is the most of the 20th century. Nurses work with technology
obvious. Nurses go to patients’ homes, the daily, and more and more care involves some type
bedside, and a variety of clinical settings of technology. This has a positive impact on care;
where they apply their strength, abilities, and however, some wonder about the negative impact
skills to attain a goal. For this task, nurses of technology on caring. Does technology create
first must care for themselves, and then they a barrier between the patient and the nurse that
must be accomplished and skillful in nursing interferes with the nurse–patient relationship?
interventions. Because of this concern, “nurses are placing more
emphasis on the ‘high touch’ aspect of a ‘high tech’ and graduate. Competencies include elements of
environment, recognizing that clients (patients) knowledge, caring, and technical skills and affect
require human interactions, such as warmth, care, curricula as discussed in other chapters in this text.
acknowledgement of self-worth, and collaborative After a number of reports described serious
decision-making” (Kozier, Erb, & Blais, 1997, p. 10). problems with health care, including errors and
There must be an effort to combine technology and poor-quality care, an initiative was developed
caring because both are critical to positive patient to identify core competencies for all healthcare
outcomes. This synergistic relationship is referred to professions, including nursing, to build a bridge
as “technological competency as caring” in nursing across the quality chasm to improve care (IOM,
(Locsin, 2005). Nurses who use technology but ig- 2003). It is hoped that these competencies will have
nore the patient as a person are just technologists; an impact on education for, and practice in, health
they are not nurses who use knowledge, caring, professions. The core competencies are identified
critical thinking, clinical reasoning and judgment, here and discussed throughout this text (2003, p. 4).
technological skills, and recognition of the patient
as a person as integral parts of the caring process. 1. Provide patient-centered care: Identify, respect,
For example, the nurse who focuses on the computer and care about patients’ differences, values, pref-
monitor in the room may get the data needed but erences, and expressed needs; relieve pain and
does not engage the patient or demonstrate caring in suffering; coordinate continuous care; listen to,
an effective manner—and may miss some important clearly inform, communicate with, and educate
observation data. patients; share decision making and management;
and continuously advocate disease prevention,
wellness, and promotion of healthy lifestyles,
Competency
including a focus on population health. The
Competency is the behavior that a student is expected description of this core competency relates to
to demonstrate. The ANA (2015a) standards define content found in definitions of nursing, nursing
competency as “an expected and measurable level standards, nursing social policy statement, and
of nursing performance that integrates knowledge, nursing theories.
skills, abilities, and judgment based on established 2. Work in interdisciplinary [interprofessional]
scientific knowledge and expectations for nursing teams: Cooperate, collaborate, communicate,
practice” (p. 86). The ultimate goal of competence and integrate care in teams to ensure that
is to promote quality care. The report, The Future care is continuous and reliable. There is much
of Nursing. Leading Change, Advancing Health, knowledge available about teams and how they
recommends, that that all nurses to engage in life- impact care. Leadership is a critical component
long learning (Institute of Medicine [IOM], 2010). of working on teams—both as team leader and
Competency levels change over time as students gain as followers or members. Many of the major
more experience. Development of competencies nursing roles that are discussed in this chapter
continues throughout a nurse’s career. Nurses in require working with teams.
practice have to demonstrate certain competencies 3. Employ evidence-based practice: Integrate best
to continue practice. Meeting staff development/ research with clinical expertise and patient values
education requirements assist in improving staff for optimal care, and participate in learning
practice at level expected, but it does not ensure and research activities to the extent feasible.
it. Students, however, must satisfy competency re- EBP has been mentioned in this chapter about
quirements to progress through the nursing program knowledge and caring as it relates to research.
4. Apply quality improvement: Identify errors and creative, (3) can be documented, (4) can be replicated
hazards in care; understand and implement basic or elaborated, and (5) can be peer-reviewed through
safety design principles, such as standardization various methods” (p. 1). The common response
and simplification; continually understand and when asking which activities might be considered
measure quality of care in terms of structure, scholarship is “research.” Boyer (1990), however,
process, and outcomes in relation to patient questioned this view of scholarship, suggesting that
and community needs; and design and test other activities may also be scholarly:
interventions to change processes and systems ■■ Discovery, in which new and unique knowledge
of care, with the objective of improving quality. is generated (research, theory development,
Understanding how care is provided and which philosophical inquiry)
problems in providing care arise often leads to ■■ Teaching, in which the teacher creatively builds
the need for additional knowledge development bridges between his or her own understanding
through research. and the students’ learning
5. Utilize informatics: Communicate, manage ■■ Application, in which the emphasis is on the
knowledge, mitigate error, and support use of new knowledge in solving society’s
decision-making using information technology. problems (practice)
This chapter focuses on knowledge and caring, ■■ Integration, in which new relationships
both of which require use of informatics to among disciplines are discovered (publish-
meet patient needs. ing, presentations, grant awards, licenses,
patents, or products for sale; must involve
two or more disciplines, thus advancing
Critical thinking and clinical reasoning and judgment
knowledge over a broader range)
are related but not the same. These four aspects of scholarship are critical com-
ponents of academic nursing and support the values
of a profession committed to both social relevance
Scholarship in Nursing and scientific advancement.
Some nurses think that the AACN definition of
There is a great need to search for better solutions scholarship limits scholarship to educational institu-
and knowledge and to disseminate knowledge in tions only. Mason (2006) commented that this is a
health care. This discussion about scholarship in problem for nursing; science needs to be accessible
nursing explores the meaning of scholarship, the to practitioners, defining scholarship as “an in-depth,
meaning and impact of theory and research, use careful process of exploring current theory and research
of professional literature, and new scholarship with the purpose of either furthering the science or
modalities. translating its findings into practice or policy” (p. 11).
The better approach, then, is to consider scholarship
What Does Scholarship in both the education and practice arenas and still
emphasize that nursing is a patient-centered practice
Mean? profession. Nursing theory and research are described
The American Association of Colleges of Nursing in this chapter—and by Mason—as integral parts of
(AACN, 2005) defines scholarship in nursing “as knowledge and caring and scholarship of nursing.
those activities that systematically advance the teaching, If all nurses should demonstrate scholarship and
research, and practice of nursing through rigorous leadership, it is important that nurses understand
inquiry that: (1) is significant to the profession, (2) is what they mean and how they affect practice.
Nursing has a long history of scholarship, some of the milestones that are important in
although some periods seem to have been more understanding nursing scholarship as the pro-
active than others in terms of major contributions fession developed first in Britain and then in the
to nursing scholarship. Exhibit 2-1 describes United States.
Exhibit 2-1 A Brief History of Selected Nursing Scholarship Milestones
1850 Nightingale conducted first nursing research by collecting healthcare data

during the Crimean War.
1851 Florence Nightingale, age 32, attended the Institution of Deaconesses at
Kaiserswerth to train in nursing. She was interested in care focused on spirituality
and healing. This experience had an impact on her later work in nursing and
nurses’ training (education).
1854–1855 Nightingale created the first standards for care.
1854–1856 Nightingale applied knowledge of statistics and care training. She took charge of
lay nurses and the Anglican sisters.
1860 The first training school for nurses was founded in London.
1860 Notes on Nursing by Nightingale was published.
Early in the history of the United States, some steps were taken that later would
serve as stepping-stones to a more structured healthcare system and affect the
education and roles and responsibilities of nurses.
●● A lack of organized nursing and care led to the development of Bellevue
Hospital, which was founded in 1658 in New York.
●● In 1731, the Philadelphia Almshouse was started by the Sisters of Charity,
spearheaded by Elizabeth Ann Bayley Seton, a physician’s daughter who
married, was widowed, and then entered religious life and provided nursing
care.
●● Charity Hospital in New Orleans, Louisiana, was founded in 1736 and funded
by private endowment.
1860–1865 During the Civil War, Dorothea Dix was Superintendent of Female Nurses for the
Union Army. She identified the first qualifications for nurses in the United States.
1860s Dr. Elizabeth Blackwell, first female U.S. physician, started the Women’s Central
Association for Relief in New York City, which later became the city’s Sanitary
Commission.
The New England Hospital for Women and Children in Boston, Massachusetts,
opened in 1860. During its early years, there was no structured care, such as what
we know of care today, in the hospital.
Woman’s Hospital of Philadelphia opened in 1861, also with no structured care
but a place sick people came for general caring.
In 1863, the state of Massachusetts established the state first board of nursing,
which was the first attempt at regulation of the practice of nursing in the United
States.
(continues)
1870s The first U.S. nursing school graduate was Linda Richards in 1873 from the New
England Hospital for Women and Children in Boston, Massachusetts.
Although Nightingale had made a plea for attention to the hospital environment
in Britain, it was not until the 1870s that lights were introduced in hospitals.
Written patient reports were instituted during this time, replacing the use of only
verbal reports.
Hospitals began to examine the causes of mortality among their patient
population, representing initial steps toward quality improvement.
Mary Mahoney, the first Black nurse, graduated in 1879.
1873 Three nursing schools were founded: Bellevue Training School in New York City;
Connecticut Training School in New Haven, Connecticut; and Boston Training
School in Boston, Massachusetts.
1882 Clara Barton, a schoolteacher, founded the American Red Cross.
1884 Isabel Hampton Robb wrote Nursing: Its Principles and Practice for Hospital
and Private Use.
1885 The first nursing text was published: A Textbook of Nursing for the Use of Training
Schools, Families and Private Students.
1890s The Visiting Nurses Group started in England.
1893 The American Society of Superintendents of Training Schools was formed.
Lillian Wald founded the Henry Street Settlement, a community center in New
York City. This was the beginning of community-based care.
1897 The nursing school in Galveston, Texas, moved its undergraduate nursing
education into the university setting—the University of Texas at Galveston.
1900–1930s A shortage of funds put nursing education under the control of doctors and
hospitals. This situation resulted from:
●● Leaders believing that the only way to change was to organize.
●● The need to provide protection for the public from poorly educated nurses.
●● A lack of sanitation.
●● Schools providing cheap services for hospitals.
1900 Columbia Teachers College offered the first graduate nursing degree.
As nursing moved from a practice-based discipline to a university program,
subjects such as ethics were introduced for the first time.
Isabel Hampton Robb, considered the architect of American nursing, wrote
Nursing Ethics, the first ethics text for nurses.
Both textbooks and journals for nurses became available. Among the first of the
journals was the American Journal of Nursing.
1901 Mary Adelaide Nutting started a 3- to 6-month preparatory course for nurses; by
1911, 86 schools had some form of formalized, structured nurse training.
1907 Mary Adelaide Nutting became the first nursing professor and began the first
state nursing association in Maryland. At this time, nursing was moving toward a
more formal educational system, similar to that of the discipline of medicine. A
professional organization at a state level gave recognition to nursing as a distinct
discipline.
As a distinct discipline, nursing needed standards to guide practice and

education. Isabel Hampton Robb wrote Educational Standards for Nurses.
1908 Other professional organizations grew, including the National Association of
Colored Graduate Nurses.
1909 The first baccalaureate degree program in nursing was started at the University of
Minnesota.
1911 The development of specialties within nursing began with Bellevue Hospital’s
midwifery program.
1912 The American Society of Superintendents of Training Schools became the
National League for Nursing Education (NLNE).
The National Organization for Public Health Nursing was founded.
The Public Health Nursing journal was started.
1917 The National League for Nursing Education identified its first Standard
Curriculum for Schools of Nursing, a remedy for the lack of standards in nursing
education.
1920 The first master’s program in nursing began at Yale School of Nursing.
1922 Sigma Theta Tau International (STTI), the nursing honor society, was formed.
1923 The Goldmark Report called for nursing education to be separate from (and
precede) employment; it also advocated nursing licensure and proper training for
faculty at nursing institutions.
1925 Mary Breckenridge founded the Frontier Nursing Service in Kentucky. Her intent
was to provide rural health care; this organization was the first to employ nurses
who could also provide midwifery services.
As the status of women increased, nurses were among the first women to lead
the women’s rights movements in the United States.
1930 A total of 41 (out of 48) states established regulatory state boards of nursing.
1934 New York University and the Teachers College started PhD and EdD in programs
in nursing.
1940 The Nursing Council on National Defense, formed after World War I (1917–1918),
underwent changes during 1940.
As nursing education moved into university settings, nursing research became
more important for well-educated nurses to study. The first research studies
focused on nursing education.
1948 The Brown Report recommended that nursing education programs be located in
universities; this report also formed the basis for evaluating nursing programs.
1950s–1960s Early nursing theory was developed.
1950 The American Nurses Association published the first edition of the Code for
Nurses.
Graduate nursing education began programs to prepare clinical nurse specialists.
(continues)
1952 The NLNE changed its name to the National League for Nursing (NLN).
Publication of Nursing Research began under the direction of the ANA.
Mildred Montag started the first associate degree-nursing program.
1954 The University of Pittsburgh started a PhD program in nursing (academic

doctorate).
1955 The American Nurses Foundation was formed to obtain funds for nursing
research.
1956 Columbia University granted its first master’s degree in nursing.
1960 The doctorate in nursing science (DNS) degree was started at Boston University
(professional doctorate).
1960s Federal monies were made available for doctoral study for nurse educators.
1963 The initial publication of International Journal of Nursing Studies became
available.
1964 Loretta Ford established the first nurse practitioner program at the University of
Colorado.
1965 The first nursing research conference was held.
The ANA made the statement that a baccalaureate degree should represent
the entry level for nursing practice. As of 2017, this recommendation was still
not fully implemented, although there has been significant improvement since
the publication of The Future of Nursing. Leading Change, Advancing Health
(IOM, 2010).
1967 The STTI launched its publication Image (Now known as the Journal of Nursing
Scholarship.)
1969 The American Association of Colleges of Nursing (AACN) formed, with its 121
members serving as representation for baccalaureate degree and higher
education nursing programs.
1970s–1990s This period of development saw the birth of most nursing theories; some of these
theories have been tested and expanded upon.
1973 The first nursing diagnosis conference was held.
The American Academy of Nursing (AAN) was formed under the aegis of the ANA
to recognize nursing leaders.
The ANA published the first edition of Standards of Nursing Practice.
1978–1979 Several new nursing research journals had their initial publication.
1985 The National Center for Nursing Research was established at the National
Institutes of Health, later to become the National Institute of Nursing Research
(NINR).
1990s Evidence-based practice became a major focus.
1993 The ANA published its position statement on nursing education.

The American Association of Colleges of Nursing (AACN) established the
Commission on Collegiate Nursing Education (CCNE) to accredit nursing
programs, with an emphasis on baccalaureate and master’s degree
programs.
The Cochrane Collaborative was formed in Britain to develop and publish
systematic reviews, expanding access to evidence-based literature.
1995 The ANA published the first edition of Nursing’s Social Policy Statement.
1996 The Joanna Briggs Institute for Evidence-Based Practice, which focused on
nursing to provide access to this literature, was founded in Adelaide, Australia.
1997 The National League for Nursing Accrediting Commission (NLNAC) became a
separate corporation from the NLN. It changed its name to the Accreditation
Commission for Education in Nursing (ACEN) in 2013.
1999 The AACN published its position statement on nursing research.
2004 The NLN established Centers for Excellence in Nursing Education to recognize
exemplar schools of nursing and later the Academy of Nursing to recognize
nurse educators.
The AACN endorsed the development of and called for pilot schools to create
the Clinical Nurse Leader (CNL).
The AACN issued a statement endorsing the movement of the level of
preparation for advanced practice nursing from master’s level to doctorate by
2015—date has been revised for some specialty areas.
2010 The landmark nursing education report, Educating Nurses: A Call for Radical
Transformation (Benner, Sutphen, Leonard, and Day), was published.
A significant Institute of Medicine report, The Future of Nursing: Leading Change,
Advancing Health, was published (IOM, 2010). In 2015, a progress report was
published indicating need to continue work on the report’s recommendations.
Passage of the Patient Protection and Affordable Care Act (ACA), which had an
impact on the number of people with healthcare coverage in the United States
(from 2010 to early 2017) and included provisions that affect nursing and nursing
education, such as funding. Status of this legislation may change over time and
change these outcomes and provisions.
number of nursing theories have been developed

Nursing Theory
since Nightingale’s contributions to nursing, par-
A simple description of a theory is “words or ticularly during the 1960s through 1980s. These
phrases (concepts) joined together in sentences, with theories vary widely in their scope and approach.
an overall theme, to explain, describe, or predict This surge in development of nursing theories was
something” (Sullivan, 2006, p. 160). Theories help related to the need to “justify nursing as an academic
nurses understand and find meaning in nursing. A discipline”—the need to develop and describe nursing
knowledge” (Maas, 2006, p. 7). Some of the major used to provide frameworks for research studies
theories are described in Exhibit 2-2 from the and to test their applicability. In addition, practice
perspective of how each description, beginning with may be guided by one of the nursing theories. In
Nightingale, consider the concepts of the person, hospitals and other healthcare organizations, the
the environment, health, and nursing. nursing department may identify a specific theory
Since the late 1990s, nursing education has or a model on which the staff bases its mission. In
placed less emphasis on nursing theory. This these organizations, it is usually easy to see how
change has been controversial. Theories may be the designated theory is present in the official
Exhibit 2-2 Overview of Major Nursing Theories and Models
Theories
and Models Person Environment Health Nursing
Systematic Recipient of External Health is “not only Alter or manage
approach to nursing care. (temperature, to be well, but the environment
health care bedding, to be able to use to implement the
Florence ventilation) and well every power natural laws of
Nightingale internal (food, we have to use” health.
water, and (Nightingale, 1969
medications). [reissue], p. 24).
Theory of A “unity of mind A “field of Harmony, Reciprocal
caring in body spirit/ connectedness” at wholeness, and transpersonal
nursing nature” (Watson, all levels (Watson, comfort. relationship in
Jean Watson 1996, p. 147). 1996, p. 147). caring moments
guided by curative
factors.
Science An irreducible, An irreducible, Health and illness Seeks to promote
of unitary irreversible, pandimensional, area a part of symphonic
human pandimensional, negentropic a continuum interaction
beings negentropic energy field, (Rogers, 1970). between
Martha E. energy field identified by human and
Rogers identified pattern and environmental
by pattern; a manifesting fields, to
unitary human characteristics strengthen the
being develops different from integrity of the
through three those of the parts human field, and
principles: helicy, and encompassing to direct and
resonancy, all that is other redirect patterning
and integrality than any given of the human and
(Rogers, 1992). human field environmental
(Rogers, 1992). fields for
realization of
maximum health
potential (Rogers,
1970).
Self-care A person under Physical, chemical, “A state Therapeutic self-

deficit nursing the care of a biologic, and social characterized care designed to
theory nurse; a total contexts with by soundness supplement self-
Dorothea E. being with which human or wholeness of care requisites.
Orem universal, beings exist; developed human Nursing
developmental environmental structures and of actions fall into
needs, and components bodily and mental one of three
capable of self- include functioning” categories: wholly
care (patient). environmental (Orem, 1995, compensatory,
factors, p. 101). partly
environmental compensatory,
conditions, and or supportive
developmental educative system
environment (Orem, 1985).
(Orem, 1985).
Roy “A whole with Internal and “A state and Manipulation
adaptation parts that external stimuli; process of being of stimuli to
model function as a “the world within and becoming an foster successful
Callista Roy unity” (Roy & and around integrated and adaptation.
Andrews, 1999, humans as whole human
p. 31). adaptive systems” being” (Roy &
(Roy & Andrews, Andrews, 1999,
1999, p. 51). p. 54).
Neuman A composite of All internal and A continuum of Prevention as
systems physiological, external factors wellness to illness. intervention;
model psychological, of influences concerned with
Betty sociocultural, surrounding the all potential
Neuman developmental, client system. stressors.
and spiritual
variables in
interaction with
the internal
and external
environment;
represented
by central
structure, lines
of defense,
and lines of
resistance.
(continues)
Systems A personal A context “within “Dynamic life A process

framework system that which human experiences of of human
and theory interacts with beings grow, a human being, interaction; the
of goal interpersonal develop, and which implies goal of nursing is
attainment and social perform daily continuous to help patients
Imogene M. systems (human activities” (King, adjustment achieve their
King being). 1981, p. 18). to stressors in goals.
“The internal the internal
environment of and external
human beings environment
transforms energy through optimum
to enable them use of one’s
to adjust to resources to achieve
continuous external maximum potential
environmental for daily living” (King,
changes” (1981, p. 5). 1981, p. 5).
Behavioral A biophysical Includes internal Efficient and An external
systems being is a and external effective regulatory force
model behavioral environment. functioning of that acts to
Dorothy system system; behavioral preserve the
Johnson with seven system balance organization and
subsystems of and stability. integrity of the
behavior (human patient’s behavior
being). at an optimal
level under those
conditions in
which the behavior
constitutes a threat
to physical or social
health or in
which illness is
found (Johnson,
1980, p. 214).
Theory of An open being, In mutual process Continuously Use of true
human more than and with the person. changing process presence to
becoming different from of becoming. facilitate the
Rosemarie the sum of becoming of the
Parse parts in mutual participant.
simultaneous
interchange with
the environment,
who chooses
from options
and bears
responsibility for
choices (Parse,
1987, p. 160).
Transcultural Human beings, “Totality of an “A state of well- Activities directed

nursing family, group, event, situation, or being that toward assisting,
model community, or experience that is culturally supporting, or
Madeleine institution. gives meaning defined, valued, enabling with
Leininger to human and practiced” needs in ways that
expressions, (Lei ni nger, 1991, are congruent
interpretations, p. 46). with the cultural
and social values, beliefs, and
interactions lifeways of the
in physical, recipient of care
ecological, (Leininger, 1995).
sociopolitical, and/
or cultural settings”
(Leininger, 1991,
p. 46).
Interpersonal “Encompasses Includes culture as “Implies forward The therapeutic,
relations the patient important to the movement of interpersonal
model (one who has development of personality and process between
Hildegard problems for personality. other ongoing the nurse and the
Peplau which expert human processes patient.
nursing services in the direction
are needed or of creative,
sought) and constructive,
the nurse (a productive,
professional personal, and
with particular community living”
expertise)” (Peplau, 1952,
(Peplau, 1952, p. 12).
p. 14).
Data from Johnson, D. (1980). The behavioral systems model for nursing. In J. Riehl & C. Roy (Eds.), Conceptual
models for nursing practice (2nd ed., pp. 207–216). New York, NY: Appleton-Century-Crofts; King, I. M. (1981).
A theory of nursing: Systems, concepts, process. New York, NY: Wiley; Leininger, M. M. (1991). Culture care
diversity and universality: A theory of nursing. New York, NY: National League for Nursing; Leininger, M. M. (1995).
Transcultural nursing perspectives: Basic concepts, principles, and culture care incidents. In M. M. Leininger
(Ed.), Transcultural nursing: Concepts, theories, research, and practices (2nd ed., pp. 57–92). New York, NY:
McGraw-Hill; Nightingale, F. (1969 [reissue]). Notes on nursing: What it is and what it is not. New York, NY: Dover;
Orem, D. (1985). Nursing: Concepts of practice (3rd ed.). St. Louis, MO: Mosby; Orem, D. (1995). Nursing: Concepts
of practice (5th ed.). St. Louis, MO: Mosby; Parse, R. R. (1987). Nursing science: Major paradigms, theories,
and critiques. Philadelphia, PA: Saunders; Peplau, H. (1952). Interpersonal relations in nursing. New York, NY:
G. P. Putnam’s Sons; Rogers, M. E. (1970). An introduction to the theoretical basis of nursing. Philadelphia, PA:
Davis; Rogers, M. E. (1992). Nursing science and the space age. Nursing Science Quarterly, 5, 27–34; Roy, C., &
Andrews, H. A. (1999). The Roy adaptation model. New York, NY: Appleton-Lange; Watson, J. (1996). Watson’s
philosophy and theory of human caring in nursing. In J. P. Riehl-Sisca (Ed.), Conceptual models for nursing
practice (pp. 219–235). Norwalk, CT: Appleton & Lange, as cited in K. Masters (2005), Role development in
professional nursing practice. Sudbury, MA: Jones & Bartlett Learning.
documents about the department, but it is not them to receive optimum care and to maintain
always so easy to see how the theory impacts the optimum health
day-to-day practice of nurses in the organization. ■■ The effort to broaden nursing’s perspective,
It is important to remember that theories do not which includes efforts to understand the
tell nurses what they must do or how they must practice of nursing in third world countries
do something; rather, they are guides—abstract These potential characteristics of nursing are
guides. Figure 2-1 describes the relationship among somewhat different from those evidenced in past
theory, research, and practice. theories. Consumerism is highlighted through
Most of the existing nursing theories were de- better understanding consumers/patients and
veloped from the 1970s through 1990s. What issues empowering them. Empowering nurses is also
might future theories address? In 1992, the following emphasized. The suggestion that female nurses and
were predicted as possible areas to be included in male nurses might approach care issues differently
nursing theories (Meleis, 1992, pp. 112–114): has not really been addressed in the past. The effort
■■ The human science underlying the disci- to broaden nursing’s perspective is highly relevant
pline that is predicated on understanding today, given the increase in globalization and the
the meanings of daily-lived experiences as emphasis on culturally appropriate care. Developed
they are perceived by the members or the and developing countries can share information
participants of the science via the Internet in a matter of seconds. There are
fewer boundaries than ever before, such that better
communication and information exchange have
become possible. A need for nursing to expand its
geographic scope certainly exists because globally
nursing issues and care problems are often the
same or very similar. Indeed, efforts to solve these
problems on a worldwide scale are absolutely nec-
essary. Take, for example, issues such as infectious
diseases: Because of the ease of travel, they can
quickly spread from one part of the world to another
in which the disease is relatively unknown. How we
understand nursing and the knowledge required
to improve performance are critical aspects that
may be assisted by greater sharing of experiences
globally. In conclusion, theory development is
not as active today as it was in the past—it is not
really clear what role nursing theories might play
and how theories might change in the future.
Nursing Research
Nursing research is “systematic inquiry that uses
disciplined methods to answer questions and solve
problems” (Polit & Beck, 2013, p. 4). The major purpose
of doing research is to expand nursing knowledge to
Examples of
Nursing Journals

Because scholarship is a critical aspect of profes-
sionalism, you need to demonstrate scholarship as
a professional nurse.
these dimensions. Some roles such as teaching, ad-

Multiple Nursing Roles ministration, and research do not focus as much on
and Leadership the teacher, administrator, or researcher providing
direct patient care. Different levels of knowledge,
Nurses use knowledge and caring as they provide caring, and education may be required for different
care to patients; however, there are other aspects of roles. All of the roles require leadership. The key
nursing that are important. As nurses apply knowl- roles found in nursing are discussed in the following
edge and caring, they function in multiple roles. sections. Within a position title such as a staff nurse,
the nurse may actually have multiple roles such as
Key Nursing Roles provider of care, patient educator, and so on.
Before discussing nursing roles, it is important to Provider of Care
discuss some terminology related to roles. A role
can vary depending on the context. Role means The provider of care role is probably what stu-
the expected and actual behaviors that one would dents think nursing is all about—this is the role
associate with a position such as a nurse, physician, typically seen in the hospital setting and the role that
teacher, pharmacist, and so on. Connected to role most people think of when they think of a nurse.
is status, which is a position in a social structure, Caring is attached most to this role, but knowledge
with rights and obligations—for example, a nurse is critical to providing quality care. When the nurse
manager would have more status compared with is described, it is often caring that is emphasized,
a staff nurse. As a person assumes a new role, the with less emphasis on knowledge and expertise
person experiences role transition. Nursing required to provide quality care. This perspective
students are in role transition as they gradually is not indicative of what really happens because
learn about nursing roles. All nursing roles are nurses need to use knowledge and be competent,
important in patient care, and typically these roles as discussed earlier in this chapter. Providing care
are interconnected in practice. Students learn about has moved far beyond the hospital, with nurses
the roles and what is necessary to be competent to providing care in clinics, schools, the community,
meet role expectations. Identity is also involved: homes, industry, and at many more sites.
“Identity is foundational to professional nursing
practice. Identity in nursing can be defined as the Educator
development within nurses of an internal repre- Nurses spend a lot of time teaching—teaching
sentation of people–environment interactions in patients, families, communities, and populations.
the exploration of human responses to actual or In the educator role, nurses focus on health
potential health problems. Professional identity is promotion and prevention and helping the patient
foundational to the assumption of various nursing (individuals, families, communities, and popula-
roles” (Cook, Gilmer, & Bess, 2003, p. 311). tions) cope with illness and injury and maintain
Nursing is a complex profession and involves health. Teaching needs to be planned and based
multiple types of consumers of nursing care (for on needs, and nurses must know about teaching
example, individuals, families, specific populations, principles and methods. Some nurses teach other
and communities), multiple types of problems nurses and healthcare providers in healthcare
(for example, physical, emotional, sociological, settings—an activity called staff development or
economic, and educational), and multiple settings staff education or in nursing schools. Nursing
(for example, hospitals, clinics, communities, schools, education is considered to be a type of nursing
the patient’s home), and specialties within each of specialty/advanced practice.
Counselor focuses on a win-win strategy. Each individual

needs to recognize the perspective of others who
A nurse may act as a counselor, providing advice
are involved and eventually reach a consensus of
and counseling to patients, families, communities,
common goal(s)” (Finkelman, 2016, p. 318). A
and populations. This is often done in conjunction
nurse collaborates with other healthcare providers,
with other roles.
members of the community, government agencies,
Manager and many other individuals and organizations.
Teamwork is a critical component of daily nursing
In daily practice, nurses act as managers, even if
practice.
they do not have a formal management position.
Management is the process of getting something Change Agent (Intrapreneur)
done efficiently and effectively through and with
It is difficult to perform any of the nursing roles
other people. Nurses might do this by ensuring that
without engaging in change. Change may be found
a patient’s needs are addressed—for example, the
in how care is provided, where care is provided and
nurse might ensure that the patient receives needed
when, to whom care is provided, and why care is
laboratory work or a rehabilitation session. The
provided. Change is normal today in our personal
nurse who provides patient care needs to plan the
lives. The healthcare delivery system experiences
care (interventions, timeline, and who will provide
constant change. Nurses deal with change wherever
specific care), implements the plan, and evaluates
they work, but they may also initiate change for
outcomes, making changes as need. Managing care
care improvement. When a nurse acts as a
involves critical thinking, clinical reasoning and
change agent within the organization where
judgment, planning, decision making, delegating,
the nurse works, the nurse is an intrepreneur.
collaborating, coordinating, communicating,
This requires risk and the ability to see change in
working with interprofessional teams, and leader-
a positive light. An example of a nurse acting as a
ship. There are also nurses in formal management
change agent would be a nurse who sees the value
positions such as a manager of a unit, director of
in extending visiting hours in the intensive care
nursing or vice president of nursing, dean of a school
unit. The nurse reviews the literature on this topic
of nursing, and so on—all are formal managers.
to support EBP interventions and then approaches
Researcher management with the suggestion about making a
change. The nurse then works with the interpro-
Only a small percentage of nurses are actual nurse
fessional team to plan, implement, and evaluate
researchers leading research studies; however, nurses
this change to assess the outcomes.
may participate in research in other ways. The most
critical means is by using EBP or evidence-based
management (EBM), which is one of the five core
Entrepreneur
healthcare professions competencies. Some nurses This role is not as common as other roles, though
now hold positions in research studies that may or it is found more often today. The entrepreneur
may not be nursing research studies. These nurses works to make changes in a broader sense. Examples
assist in obtaining informed consent, data collection, include nurses who are healthcare consultants and
and may manage research projects. legal nurse consultants and nurses who establish
businesses related to health care, such as a staffing
Collaborator agency, a business to develop a healthcare product,
Every nurse is a collaborator. “Collaboration a healthcare media business, or a collaboration
[boldface added] is a cooperative effort that with a healthcare technology venture.
Patient Advocate When students transition to the work setting

as registered nurses, they should be competent as
Nurses serve as an advocate on behalf of the patient
beginning nurses; even so, the transition is often
(individual, groups, populations, communities) and
difficult. Reality shock may occur. This reaction
family. In this role, the nurse acts as a change agent
may occur when a new nurse is confronted with
and a risk taker. The nurse speaks for the patient but
the realities of the healthcare setting and nursing,
does not take away the patient’s independence. A
which are typically very different from what the nurse
nurse caring for a patient in the hospital, for example,
experienced in school (Kramer, 1985). Knowledge
might advocate with the physician to alter care so as
and competency are important, but new nurses also
to allow a dying patient to spend more time with his
need to build self-confidence, and they need time to
or her family. A nurse might also advocate for better
adjust to the differences between the academic world
health coverage by writing to the local congressional
and real-life practice. Some schools of nursing, in
representative or by attending a meeting about care
collaboration with hospitals, now offer internship/
in the community—influencing health policy.
externship and residency programs for new graduates
Leader to decrease reality shock, which are discussed in more
detail in other chapters. The major nursing roles that
In all of these roles, nurses need to act as leaders;
you will learn about in your nursing programs are
however, it is important to recognize that being a leader
important in practice, but it is also important for
is a role that nurses assume, either formally by taking
you to learn about being an employee, working with
an administrative position or informally with others
and in teams, communicating in real situations, and
recognizing that someone has leadership characteristics.
functioning in complex organizations.
Leadership is discussed throughout this text.
More nurses—particularly new graduates—
work in hospitals than in other healthcare settings,
Summary Points: Roles and although the number of nurses working in hospitals
What Is Required is decreasing. Hospital care has changed, with sicker
To meet the demands of these multiple roles, nurses patients staying in the hospital for shorter periods
need to be prepared and competent. Prerequisites and with greater use of complex technology. These
and the nursing curriculum, through its content, changes have an impact on what is expected of
simulation laboratory experiences, and clinical nurses—namely, in terms of competencies.
experiences, help students to transition to these Nursing standards, nurse practice acts, pro-
roles. The prerequisites provide content and ex- fessional ethics, and the nursing process influence
periences related to biological sciences, English nursing roles. Health policy also has an impact on
and writing, sociology, government, languages, roles; for example, legislation and changes in state
psychology, mathematics, and statistics. In nursing, practice guidelines were required before the advanced
course content relates to the care of diverse patients practice registered nurse could obtain have prescrip-
in hospitals, homes, and communities; planning, tive authority (ability to prescribe medications). This
implementing, and evaluating care; communication type of role change requires major advocacy efforts
and interpersonal relationships; culture; legal and from nurses and nursing organizations.
ethical issues; teaching; public/community health;
epidemiology; quality improvement; research and
EBP and EBM; health policy; and leadership and Stop and Consider #4
Though holding one position, a nurse may have
management. As discussed earlier in this chapter, multiple roles as part of that position.
this content relates to the required knowledge base.
CHAPTER HIGHLIGHTS
1. The definition of nursing varies depending 6. Competency is defined by and related to

on the source. the skills that a nurse needs to function in
2. The need to define nursing relates to the today’s healthcare environment.
ability to describe what nursing is and 7. Nursing scholarship is demonstrated in
what nurses do. nursing theory, research, and professional
3. Effective nursing practice utilizes critical literature.
thinking and clinical reasoning and judgment. 8. The key roles of the nurse are care provider,
4. Caring and knowledge are critical compo- educator, manager, advocate, counselor,
nents of the nursing profession. researcher, collaborator, change agent
5. Today, the trend is toward preparing nurses (intrepreneur), entrepreneur, and leader.
to serve as knowledge workers.
1. Discuss the relationship between knowledge 7. Discuss the role of critical thinking in
and caring in nursing. nursing education and explain why there
2. How might a definition of nursing impact is little agreement about what constitutes
your practice? critical thinking. What is the importance of
3. What does knowledge worker mean? clinical reasoning and judgment? Identify
4. Why is leadership important in nursing? examples from your own practice that apply
5. Describe nurses’ roles in today’s healthcare to critical thinking and clinical reasoning
system. and judgment and their application to
6. Why are competencies important? nursing roles.
1. Based on what you have learned about 2. Review the descriptions of the nursing theories
critical thinking, assess your own ability found in Exhibit 2-2. Compare and contrast
to use critical thinking. Make a list of your the theories in relationship to their views of
strengths and limitations regarding your person, environment, health, and nursing.
use of critical thinking. Determine several Identify two similarities and dissimilarities
strategies that you might use to improve in the theories. Select a theory that you feel
your critical thinking. Write down these represents your view of nursing at this time.
strategies and track your improvement over Why did you select this theory?
the semester. Apply the critical thinking 3. Go to the National Institute of Nursing
skills mentioned in this chapter to guide Research (NINR) website (http://www.ninr
you in this activity. .nih.gov/AboutNINR/) and click on “Mission
(Continues)
& Strategic Plan.” Explore the Ongoing 5. Select one of the major nursing roles and
Research Interests section. What are some describe it. Explain why you would want to
of the interests? Do any of them intrigue function in this role.
you? If so, why? What is the NINR’s current 6. Develop questions you will use in an inter-
strategic plan? What can you learn about view of a staff nurse, a nurse manager, or an
past and current nursing research? Did educator to inquire about their definition of
you think of these areas of study as part nursing. You can do this in a team and then
of nursing before this course? Why or why compare answers. Why do you believe there
not? What impressed you about the re- are differences? How do these definitions relate
search results? Do you think these results to what you have learned in this chapter?
are practice oriented? 7. Ask a patient to describe the role of a nurse
4. Do you think nursing scholarship is import- then compare this description with your view
ant? Provide your rationale for your response. of nursing. Is it similar or different, and why?
Electronic Reflection Journal

What does caring mean to you? How does your view of caring compare with what you
have learned in this chapter?
CASE STUDIES
Case 1
A nurse who works in a community clinic has a busy day ahead of her. The first half of the
day is focused on seeing four patients as follow-up to their appointments last week for
high blood pressure (hypertension). The nurse checks each patient’s blood pressure, asks
about symptoms, weighs each patient, and asks if the patient has any questions. If there
are negative changes, the patient sees the physician. The nurse also assists the physician
with physical examinations as needed. Two new patients require patient education about
their diets. A dietician appointment is scheduled for one patient who needs more intensive
assistance. In the afternoon, the nurse leads a group for diabetic patients. At the end of
the day, the nurse meets with her nurse manager for her annual performance evaluation,
and the nurse manager tells the nurse that she should write a journal article about the
group for patients with diabetes. The nurse is getting into her car to go home and thinks to
herself, “Now when would I have time to write a journal article!”
Case Questions
1. During the day, which ways of knowing did the nurse use in providing care?
2. What makes this nurse a knowledge worker?
3. Identify what the nurse did that was routine and nonroutine (knowledge management).
4. How did change impact this nurse?
Case 2
A Historical Event to Demonstrate the Importance of the Art and Science of Nursing,
Nursing Roles, and Leadership
The following case is a summary of a change in healthcare delivery that had an impact
on nursing. After reading the case, respond to the questions.
In the 1960s, something significant began to happen in hospital care, and
ultimately in the nursing profession. But first, let’s go back to the 1950s for some
background information. There was increasing interest in coronary care during this time,
particularly for acute myocardial infarctions. It is important to remember that changes
in health care are influenced by changes in science and technology, but incidents and
situations within the country as a whole also drive change and policy decisions. This
situation was no exception. Presidents Dwight D. Eisenhower and Lyndon B. Johnson
both had acute myocardial infarctions, which received a lot of press coverage. The
mortality rate from acute myocardial infarctions was high. There were also significant
new advances in care monitoring and interventions: cardiac catheterization, cardiac
pacemakers, continuous monitoring of cardiac electrical activity, portable cardiac
defibrillators, and external pacemakers. This really was an incredible list to come onto
the scene at the same time.
Now, what was happening with nursing in the 1950s regarding the care of cardiac
patients? Even with advances, nurses were providing traditional care, and the boundaries
between physicians and nurses were very clear.
Physicians
●● Examined the patient
●● Administered the electrocardiogram
●● Drew blood for laboratory work
●● Diagnosed cardiac arrhythmias
●● Determined interventions
Nurses
●● Made the patient comfortable
●● Took care of the patient’s belongings
●● Answered the family’s questions
●● Assessed vital signs (blood pressure, pulse, and respirations)
●● Made observations and documented them
●● Administered medications
●● Provided the diet ordered and ensured patient rest
In the 1960s, change began to happen. Dr. Hughes Day, a physician at Bethany
Hospital in Kansas City, had an interest in cardiac care. The hospital redesigned its units,
moving away from open wards to private and semiprivate rooms. This was nice for the
patients, but it made it difficult for nurses to observe patients. (This is a good example
of how environment and space influence care.) Dr. Day established a Code Blue to
communicate the need for urgent response to patients having critical cardiac episodes
(Day, 1972). This was a great idea, but the response often came too late for many patients
who were not observed early enough. Dr. Day then instituted monitoring of patients with
cardiac problems who were unstable. Another good idea, but if there was a problem, what
would happen? Who would intervene, and how? Dr. Day would often be called during the
day and when he was at home at night, but in such a critical situation, how could he get to
the hospital in time? Nurses had no training or experience with the monitoring equipment
or in recognizing arrhythmias or knowledge about what to do if there were problems. Dr.
Day was beginning to see that his ideas needed revision.
At the same time that Dr. Day was exploring cardiac care, Dr. L. Meltzer was involved
in similar activity at Presbyterian Hospital in Philadelphia. These physicians did not
know of the work that the other was doing. Dr. Meltzer went about the problem a little
differently. He knew that a separate unit was needed for cardiac patients, but he was
less sure about how to design it and how it would function. Dr. Meltzer approached
the Division of Nursing, U.S. Public Health Services, for a grant to study the problem. He
wanted to establish a two-bed cardiac care unit (CCU). His research question was: Will
nurse monitoring and intervention reduce the high incidence of arrhythmic deaths
from acute myocardial infarctions? At this time (and a development that was good for
nursing), Faye Abdella, PhD, RN, was leading the Division of Nursing. She really liked the
study proposal, but she felt that something important was missing. To receive the grant,
Dr. Meltzer needed to have a nurse lead the project. Dr. Meltzer proceeded to look for
that nurse. He turned to the University of Pennsylvania and asked the dean of nursing for
a recommendation. Rose Pinneo, MSN, RN, a nurse who had just completed her master’s
degree and had experience in cardiac care, was selected. Dr. Meltzer and Pinneo became
a team. Pinneo liked research and wanted to do this kind of work, and by chance, she had
her opportunity. What she did not know was this study and its results would have a major
long-term impact on cardiac care and the nursing profession.
Dr. Zoll, who worked with Dr. Meltzer, recognized the major barrier to success in
changing patient outcomes: Nurses had no training in what would be required of them in the
CCU. The proposed change represented a major shift in what nurses usually did. They needed
to examine the role of the nurse and it needed to be changed, and so a study was conducted.
Notably, Dr. Meltzer, a physician not a nurse, then proposed a new role for nurses in the CCU:
●● The nurse has specific skills in monitoring patients using the new equipment.
●● Registered nurses (RNs) would provide all the direct care. Up until this time, the typical
care organization consisted of a team of licensed practical nurses and aides, who
provided most of the direct care, led by an RN (team nursing). This led to changes in
CCU staffing and increased the need for more qualified RNs in CCU.
●● RNs would interpret heart rhythms using continuous-monitoring electrocardiogram
data.
●● RNs would initiate emergency interventions when needed.

●● RNs, not physicians, would be central in providing care in CCU 24 hours a day, 7 days a
week, but they must practice with the physicians.
There were questions as to whether RNs could be trained for this new role, but Dr. Meltzer
had no doubt that they could be.
Based on Dr. Meltzer’s plan and the new nursing role, Pinneo needed to find the
nurses for the units. She wanted nurses who were ready for a challenge and who were
willing to learn the new knowledge and skills needed to collect data. Collecting data would
be time consuming, plus the nurses had to provide care in a very new role. The first step
after finding the nurses was training. This, too, was unique. An interprofessional approach
was taken, and it took place in the clinical setting, the CCU. Once the unit opened, clinical
conferences were held to discuss the patients and their care.
The nurses found that they were providing care for highly complex problems. They were
assessing and diagnosing, intervening, and helping patients with their psychological patients
with their psychological responses to having had an acute myocardial infarction. Clearly,
knowledge and caring were important, but added to this was curing. With the interventions
that nurses initiated, they were helping to save lives. Dr. Meltzer developed standing orders
telling CCU nurses what to do in certain situations based on clinical data they collected.
House staff—physicians in training—began to turn to the nurses to learn more about cardiac
care because the CCU nurses had experience with these patients. Dr. Meltzer called his
approach the scientific team approach. In 1972, he wrote, “Until World War II even the
recording of blood pressure was considered outside the nursing sphere and was the
responsibility of a physician. As late as 1962, when coronary care was introduced, most
hospitals did not permit their nursing staff to perform venipunctures or to start intravenous
infusions. That nurses could interpret the electrocardiograms and defibrillate patients indeed
represented a radical change for all concerned” (Meltzer, Pinneo, & Kitchell, 1972, p. 8).
What were the results of this study? Nurses could learn what was necessary to function in
the new role. Nurses who worked in CCU gained autonomy, but now the boundaries between
physicians and nurses were less clear. This began to spill over into other areas of nursing. There
is no doubt that nursing began to change. CCUs opened across the country. They also had an
impact on other types of intensive care and then nursing in general.
Case Questions
If you do not know any terms in this case, look them up in a medical dictionary.
1. Based on this case, discuss the implications of the art and science of nursing.
2. What were the differences in how Dr. Day and Dr. Meltzer handled their interests in
changing cardiac care?
3. Who led this initiative? Why is this significant?
4. Compare and contrast the changes in nursing roles before the Meltzer and Day studies.
What was the new role supported by their work?
5. What is unique and unexpected about this case?
6. What does this case tell you about the value of research?
Sources: Day, H. (1972). History of coronary care units. American Journal of Cardiology, 30, 405; Meltzer,
L., Pinneo, R., & Kitchell, J. (1972). Intensive coronary care: A manual for nurses. Philadelphia, PA: Charles
Press.

Write a brief paragraph that describes a case related to the following questions and
comments.
1. A nurse says, “I think to get our message across we need to look at who we are and how
we have changed as a profession.”
2. What do we mean when we say “we all care about patients”?
3. A nurse says, “Our patients and families do not know what we really do.”
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Chapter
3
Nursing Education,
Accreditation, and Regulation
CHAPTER OBJECTIVES
■■ Discuss the differences between nursing ■■ Discuss critical problems in nursing education.
education and other types of education. ■■ Examine the need to transform nursing
■■ Compare the types of nursing programs and education and possible methods to do so.
degrees. ■■ Examine the implications of interprofessional
■■ Examine the roles of major nursing healthcare education.
organizations that affect nursing education. ■■ Discuss the importance of regulation and
■■ Critique examples of methods used to better critical issues related to the nursing profession.
ensure quality and excellence in nursing
education.
CHAPTER OUTLINE
●● Introduction ●● Nursing Education Associations

●● Nursing Education ●● National League for Nursing
●● A Brief History of Nursing Education ●● American Association of Colleges of
●● Major Nursing Reports: Improving Nursing
Nursing Education ●● Organization for Associate Degree
●● Entry into Practice: A Long Debate Nursing
●● Differentiated Nursing Practice ●● Quality and Excellence in Nursing
●● Types of Nursing Education Programs Education
●● Diploma Schools of Nursing ●● Nursing Education Standards
●● Associate Degree in Nursing ●● NLN Excellence in Nursing Education
●● Baccalaureate Degree in Nursing ●● Focus on Competencies
●● Master’s Degree in Nursing ●● Curriculum
●● Research-Based Doctoral Degree in ●● Didactic or Theory Content
Nursing ●● Practicum or Clinical Experience
●● Doctor of Nursing Practice ●● Distance Education
73
●● Accreditation of Nursing Education ●● Critical Current and Future Regulation

Programs Issues
●● Critical Nursing Education Problems ●● Nurse Licensure Compact
●● Faculty Shortage ●● Mandatory Overtime
●● Access to Clinical Experiences ●● Foreign Nursing Graduates:
●● A Response and Innovation: Laboratory Entrance to Practice in the United
Experiences and Clinical Simulation States
●● Transforming Nursing Education ●● Global Health Regulatory Issues
●● Interprofessional Healthcare Education ●● Chapter Highlights
●● Regulation ●● Engaging in the Content
●● Nurse Practice Acts ●● Discussion Questions
●● State Boards of Nursing ●● Critical Thinking Activities
●● National Council of State Boards of ●● Electronic Reflection Journal
Nursing ●● Case Studies
●● Licensure Requirements ●● Working Backward to Develop a Case
●● National Council Licensure Examination ●● References
KEY TERMS
Academic health center Clinical experiences Nurse migration

Academic nursing Continuing education Nurse practice act
Accelerated program Curriculum Practicum
Accreditation Differentiated practice Preceptor
Advanced practice registered Diploma schools of nursing Prescriptive authority
nurse Direct entry program Regulation
Apprenticeship Distance education RN-BSN
Articulation agreement Doctor of nursing practice Research-based doctorate
Associate degree in nursing Education Self-directed learning
Baccalaureate degree in Master’s degree in nursing Standard
nursing Nurse licensure compact Training
Even after graduation, nurses should be aware of

Introduction educational issues, such as appropriate and reasonable
accreditation of nursing programs and ensuring
This chapter focuses on three critical concerns that regulatory issues support the critical needs
in the nursing profession: (1) nursing education, of the public for quality health care and the needs
(2) quality of nursing education, and (3) regula- of the profession. The Tri-Council for Nursing—an
tory issues such as licensure. These concerns are alliance of four nursing organizations (American
interrelated because they change, are dependent Association of Colleges of Nursing [AACN],
on each other (for example, graduating from an American Nurses Association [ANA], American
accredited program is required for licensure), and Organization of Nurse Executives [AONE], and
require regular input from the nursing profession. National League for Nursing [NLN])—issued a
Chapter 3: Nursing Education, Accreditation, and Regulation 75
consensus policy statement in 2010 following Nursing profession and schools of nursing
Congress’s passage of the Patient Protection and market to attract qualified applicants to the
nursing profession
Affordable Care Act (ACA). This demonstrates
the engagement of the nursing professional in
health policy and its collaborative efforts with Qualified applicants apply to a specific
entry-level nursing program
other healthcare professionals. In part, this policy
statement reads as follows: “Current healthcare
reform initiatives call for a nursing workforce that Qualified applicants admitted to a
integrates evidence-based clinical knowledge and specific nursing program
research with effective communication and leader-

ship skills. These competencies require increased Entering students complete prerequisites
education at all levels. At this tipping point for
the nursing profession, action is needed now to
Students begin nursing courses
put in place strategies to build a stronger nursing
workforce. Without a more educated nursing
workforce, the nation’s health will be further at Nursing students complete nursing
program and receive degree
risk” (Tri-Council for Nursing, 2010, p. 1). This
statement is in line with the Institute of Medicine
(IOM, 2003) recommendations for healthcare Graduates successfully complete
professions education. Figure 3-1 highlights licensure exam (NCLEX)
the components of the education-to-practice

process. Graduates receive RN licensure
Employment in health care as RN

Nursing Education
A nursing student might wonder why a nursing text
Quality, safe care based on evidenced-
has a chapter that includes content about nursing based practice provided by RN as member of
education. By the time, students are reading this interprofessional team
text, they have selected a nursing program and

enrolled. This content is not included here to help
someone decide whether to enter the profession Outcome:
or which nursing program to attend. Rather, it is Patient-centered care with
effective patient outcomes
essential because education is a critical component
of the nursing profession. Nurses need to under-
stand the structure and process of the profession’s Figure 3-1 From Education to Practice
education, education quality issues, and current
issues and trends.
Data from 2014 indicate that nursing students in 2014: 4.2% increase in entry-level baccalaureate
represent more than half of all healthcare pro- programs (BSN); 10.4% increase in RN-BSN pro-
fessionals (American Association of Colleges of grams (degree completion programs); 6.6% increase
Nursing [AACN], 2015a). The number of students in master’s programs; 3.2% in research-focused
enrolling in all levels of nursing programs increased (PhD); and 26.2% practice-focused (DNP) doctoral
programs. There was also an increase in RN-BSN

A Brief History of Nursing
program enrollment and graduates, which is very
positive, supporting The future of nursing report
Education
recommendation to increase the proportion of RNs It is impossible to discuss the history of nursing
with baccalaureate degrees to 80% by 2010 (IOM, education without reflecting on the history of
2010), but the goal has not yet been reached though the profession and the history of health care,
there has been improvement. As of 2014, 55% of as discussed in other chapters—all three are
registered nurses held a BSN (AACN, 2015a). interconnected.
A key concern for nurse educators is not only the A key historical nursing leader was Florence
need to increase enrollment and completion rates, Nightingale. She changed not only the practice of
but also the need to reduce the number of qualified nursing, but also nurses’ training, which eventually
applicants who are not able to enroll because nursing came to be called education rather than training.
programs do not have places for them. Data from Training focuses on fixed habits and skills; uses
the AACN 2014 survey of 816 schools of nursing repetition, authority, and coercion; and emphasizes
indicate that 68,936 qualified applicants could not dependency, and education focuses more on
enroll in entry-level baccalaureate programs and self-discipline, responsibility, accountability, and
15,288 to master’s and doctoral programs (AACN, self-mastery (Donahue, 1983). Up until the time that
2015a). Over the past few years, the common rea- Nightingale became involved in nursing, there was
sons for programs turning away students have been little, if any, training for the role. Apprenticeship
insufficient clinical sites, lack of qualified faculty, was used to introduce new recruits to nursing,
limited classroom space, insufficient preceptors, and and often it was not done effectively. As nursing
budget cuts. The percentage of minorities enrolling changed, so did the need for more knowledge and
in such programs has increased (AACN, 2015a). skills, leading to increasingly structured educational
Nursing students from minority backgrounds in- experiences. This did not occur without debate
creased in 2014: 30.1% of students in entry-level and disagreement regarding the best approach.
baccalaureate programs, 31.9% in master’s programs, What did happen, and how does it impact nursing
29.7% in research-focused doctoral programs (PhD), education today?
and 28.7% in practice-focused doctoral programs In 1860, Nightingale established the first school
(DNP). RN workforce diversity, nurses who are of nursing, St. Thomas, in London, England. She
working (2014 AACN data), however, continues was able to do this because she had received a very
to be a problem, though it is slowly improving: good education in the areas of math and science,
73% White, 11% African American, 9% Asian, 7% which was highly unusual for women of her era.
Hispanic, and 1% other (Robert Wood Johnson With her experience in the Crimean War, Night-
Foundation [RWJF], 2016). ingale recognized that many soldiers were dying
This snapshot of data indicates that there has not just because of their wounds, but also because
been improvement in the number of applicants to of infection and failure to place them in the best
the various nursing degree programs, in enrollment situation for healing. To improve care, she devoted
rates, and in student diversity, but much work re- her energies to upgrading nursing education, placing
mains to reach the desired levels so as to meet the less focus on on-the-job training and more focus on
needs of the healthcare delivery system for qualified a structured educational program of study, creating
nurses. Reported data are typically behind the current a nurse training school. This training school and
year, and the AACN website periodically provides those that quickly followed also became a source of
updated data as does the NLN. cheap labor for hospitals. Students were provided
with some formal nursing education, but they ■■ Inexperienced instructors with few teaching
also worked long hours in the hospitals and were resources often taught science, theory, and
the largest staff source. The apprenticeship model practice of nursing.
continued, but it became more structured and in- ■■ Graduate nurses had limited experience and
cluded a more formal educational component. This time to assist the students in their learning
educational component was far from ideal, but over supervised students.
time, it expanded and improved. During the same ■■ Classroom experiences frequently occurred
era, similar programs opened in the United States. after the students had worked long hours,
These programs were called diploma or hospital even during the night.
schools of nursing. ■■ Students typically were able to only get the
Hospitals across the United States began to experiences that their hospital provided,
open schools as they realized that students could with all clinical practice experiences located
be used as staff in the hospitals. The quality of in one hospital. As a consequence, students
these schools varied widely because there were might not get experiences in specialties such
no standards aside from what the individual as obstetrics, pediatrics, and psychiatric–
hospital wanted to do. A few schools recognized mental health.
early on the need for more content and improved The Goldmark Report had an impact, partic-
teaching. Over time, some of these schools were ularly through its key recommendations: (1) sep-
creative and formed partnerships with universi- arate university schools of nursing from hospitals
ties so that students could receive some content (this represented only a minority of the schools of
through an academic institution. Despite these nursing); (2) change the control of hospital-based
small efforts to improve, the schools continued programs to schools of nursing; and (3) require a
to be very different from one another, and there high school diploma for entry into any school of
were concerns about the lack of standardized nursing. These recommendations represented sug-
quality nursing education. gestions for major improvements in nursing educa-
tion. New schools opened based on the Goldmark
Major Nursing Reports: recommendations, such as Yale University (New
Improving Nursing Education Haven, Connecticut) and Case Western Reserve
University (Cleveland, Ohio).
In 1918, an important step was taken through an
In 1948, the Brown report was also critical of
initiative supported by the Rockefeller Foundation
the quality of nursing education (Brown, 1948).
to address the issue of the diploma schools. This
This led to the implementation of an accreditation
initiative culminated in the Goldmark Report
program for nursing schools, which was conducted
(Nursing and nursing education in the United States),
by the NLN. Accreditation is a process of review-
the first of several major reports about U.S. nursing
ing what a school is doing and its curriculum based
education. This report included the following key
on established standards. Movement toward the
points, which provide a view of some of the common
university setting and away from hospital-based
concerns about nursing education in the early 1900s
schools of nursing and establishment of standards
(Goldmark, 1923):
with an accreditation process were major changes
■■ Hospitals controlled the total education for the nursing profession. The ANA and the NLN
hours, offering minimal content and, in some continue to establish standards for practice and
cases, no content even when that content education and to support implementation of those
was needed. standards. In addition, the AACN developed a
nursing education accreditation process, as discussed and regulation that many of the recommendations
later in this chapter. Changes were made, but slowly. require more work. For example, the recommenda-
The NLN started developing and implementing tion to double the number of doctoral degrees by
standards for schools, but it took more than 20 years 2020 was not progressing as of 2015 in a manner
to accomplish this mission. expected to reach this objective.
The third report on the assessment of nursing
education was published in 2010, Educating nurses: Entry into Practice:
A call for radical transformation (Benner, Sutphen,
A Long Debate
Leonard, & Day, 2010). This report addressed the
need to better prepare nurses to practice in a rap- The challenges in making changes in the entry into
idly changing healthcare system in order to ensure practice debate were great when one considers that
quality care. The conclusion of this qualitative study a very large number of hospitals in communities
of nursing education was that there is need for great across the country had diploma schools based
improvement. Students should be engaged in the on the old model, and these schools were part of,
learning process. There needs to be more connection and funded by, their communities. It was not easy
between classroom experience and clinical experi- to change these schools or to close them without
ence, with a greater emphasis on practice throughout major nursing and community debate and conflict.
the nursing curriculum. Students should be better These schools constituted the major type of nursing
prepared to use clinical reasoning and judgment education in the United States through the 1960s,
and understand the trajectory of illness. To meet and some schools still exist today. The number of
the recommendations of this landmark report, diploma schools has decreased primarily because
nursing education must make major changes and of the critical debate over what type of education
improvements. Exhibit 3-1 describes the report’s nurses need for entry into practice. The drive to
recommendations. move nursing education into college and university
The most recent report on the nursing profession, settings was great, but there was also great support
published by the IOM (2010), The future of nursing: to continue with the diploma schools of nursing.
Leading change, advancing health, delineates several In 1965, the NLN and the ANA made strong
key messages for nurses and nursing education. statements endorsing college-based nursing ed-
Nurses should practice to the fullest extent possible ucation as the entry point into the profession. In
based on their level of education. There should be 1965, the ANA stated that “minimum preparation
mechanisms for nurses to advance their education for beginning technical (bedside) nursing practice
easily, act as full partners in healthcare delivery, and at the present time should be associate degree edu-
be involved in policy making especially as it relates cation in nursing” (p. 107). The situation was very
to the healthcare workforce. This report, along tense. The two largest nursing organizations at the
with the report by Benner and colleagues (2010), time—one primarily focused on education (NLN)
is transforming nursing’s role in health care and and the other more on practice (ANA)—clearly took
calling for radical changes in nursing education. a stand. From the 1960s through the 1980s, these
In late 2015, a progress report was published to organizations tried to alter accreditation, advocated
assess the current status of The future of nursing for the closing of diploma programs, and lobbied
recommendations (National Academy of Medicine, all levels of government (Leighow, 1996). It was
2015). This report is discussed further in other an emotional issue, and even today it continues
chapters; however, it is important to note in this to be a tense topic because it has not been fully
discussion about nursing education, accreditation, resolved, although stronger statements were made
Exhibit 3-1 Recommendations from Educating Nurses: A Call for

Radical Transformation
Entry and Pathways Teaching

●● Come to agreement about a set of ●● Fully support ongoing faculty
clinically relevant prerequisites. development for all who educate student
●● Require the BSN for entry to practice. nurses.
●● Develop local articulation programs to ●● Include teacher education courses in
ensure a smooth, timely transition from master’s and doctoral programs.
ADN to BSN programs. ●● Foster opportunities for educators to learn
●● Develop more ADN-to-MSN programs. how to teach students to reflect on their
practice.
Student Population ●● Support faculty in learning how to coach
students.
●● Recruit a more diverse faculty and student
●● Support educators in learning how to use
body.
narrative pedagogies.
●● Provide more financial aid, whether from
●● Provide faculty with resources to stay
public or private sources, for all students, at
clinically current.
all levels.
●● Improve the work environment for staff
nurses, and support them in learning to
The Student Experience
teach.
●● Introduce pre-nursing students to nursing ●● Address the faculty shortage.
early in their education.
●● Broaden the clinical experience. Entry to Practice
●● Preserve post-clinical conferences and
●● Develop clinical residencies for all
small patient-care assignments.
graduates.
●● Develop pedagogies that keep students
●● Change the requirements for licensure.
focused on the patient’s experience.
●● Vary the means of assessing student
performance. National Oversight
●● Promote and support learning the skills of ●● Require performance assessments for
inquiry and research. licensure.
●● Redesign the ethics curricula. ●● Cooperate on accreditation.
●● Support students in becoming agents of
change.
Data from Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Educating nurses. A call for radical transformation.
San Francisco, CA: Jossey-Bass.
in 2010 to change to a baccalaureate entry level ■■ The number of associate degree in nursing
(Benner, Sutphen, Leonard, & Day, 2010; IOM, (ADN) programs has increased. However,
2010). Since 1965, however, there have been many there was, and continues to be, concern over
changes in the educational preparation of nurses: the potential development of a two-level
■■ The number of diploma schools have gradually nursing system—ADN and baccalaureate
decreased, but they still exist. degree in nursing (BSN)—with one viewed
as technical and the other as professional. In 1995, a joint report was published by the
In fact, this did not happen. ADN programs AACN in collaboration with the American Or-
continue to increase, and there has been no ganization of Nurse Executives and the National
change in licensure for any of the nursing Organization (AONE) and the National Organiza-
programs—graduates of all RN pre-licensure tion for Associate Degree Nursing (now known as
programs continue to take the same exam the Organization for Associate Degree Nursing or
and receive the same license. OADN). This document described the two roles of
■■ BSN programs continue to grow but still have the BSN and the ADN graduate (p. 28):
not outpaced ADN programs, though there ■■The BSN graduate is a licensed RN who pro-
has been some decrease in ADN programs. vides direct care that is based on the nursing
process and focused on patients/clients with
complex interactions of nursing diagnoses.
Differentiated Nursing
Patients/clients include individuals, families,
Practice groups, aggregates, and communities in struc-
Another issue related to entry into practice is differen- tured and unstructured healthcare settings.
tiated nursing practice. Differentiated practice is The unstructured setting is a geographical
not a new idea; it has been discussed in the literature or a situational environment that may not
since the 1990s. It is described as a “philosophy that have established policies, procedures, and
structures the roles and functions of nurses according protocols and has the potential for variations
to their education, experience, and competence,” or requiring independent nursing decisions.
“matching the varying needs of clients [patients] ■■The ADN graduate is a licensed RN who pro-
with the varying abilities of nursing practitioners” vides direct care that is based on the nursing
(AONE, 1990, as cited in Hutchins, 1994, p. 52). process and focused on individual patients/
How does this actually work in practice? Does clients who have common, well-defined nurs-
a clinical setting distinguish among RNs who have ing diagnoses. Consideration is given to the
a diploma, associate degree, and BSN degree? patient’s/client’s relationship within the family.
Does this affect role function and responsibilities? The ADN functions in a structured healthcare
Does the organization even acknowledge degrees setting, which is a geographical or situational
on name badges? Most healthcare organizations environment where the policies, procedures,
do note differences when it comes to RNs with and protocols for provision of health care are
graduate degrees, and many do not necessarily established. In the structured setting, there
note other degrees such as the BSN. This approach is recourse to assistance and support from
does not recognize that there are differences in the full scope of nursing expertise.
the educational programs that award each degree Despite increased support, such as from AONE,
or diploma. The ongoing debate remains difficult for making the BSN the entry-level educational
to resolve because all RNs, regardless of the type requirement, this question continues to be one of
and length of their basic nursing education pro- the most frustrating issues in the profession and
gram, take the same licensing exam. Patients and has not been clearly resolved (AACN, 2005a). The
other healthcare providers rarely understand the AACN believes that “education has a direct impact
differences or even know that differences exist. on the skills and competencies of a nurse clinician.
A difference in salaries due to degrees is the high- Nurses with a baccalaureate degree are well-prepared
est level of recognition, and this is done in some to meet the demand placed on today’s nurse across
healthcare organizations. a variety of settings and are prized for their critical
thinking, leadership, case management, and health in the likelihood of a patient dying within 30 days
promotion skills” (AACN, 2005a, p. 1). of admission. These associations imply that patients
Since 2001, there has been an increase in the receiving care in hospitals in which 60% of nurses
number of students enrolling in entry-level BSN had baccalaureate degrees and nurses cared for an
programs, and the number of RNs returning to school average of six patients would have almost a 30%
for their BSN also continues to increase. The result lower mortality than patients in hospitals in which
has been nine years of steady growth in the number only 30% of nurses had baccalaureate degrees and
of RNs with baccalaureate degrees (ANA, 2011). nurses cared for an average of eight patients. The
A study by Aiken, Clarke, Cheung, Sloane, and Silber results indicate there is value in using BSN-prepared
(2003) indicates that there is a “substantial survival nurses in these hospitals, whereas reducing nursing
advantage” for patients in hospitals with a higher staff may have a negative impact on patient outcomes.
percentage of BSN RNs. Other studies (Estabrooks, In the last few years, many more hospitals have
Midodzi, Cummings, Ricker, & Giovannetti, 2005) implemented initiatives to hire only RNs with BSN
support these outcomes. McHugh and Lake (2010) degrees and to encourage staff members without
examined how nurses rate their level of expertise as a a BSN degree to return to school. Studies such
beginner, competent, proficient, advanced, and expert as the ones mentioned here have had an impact
and how often they were selected as a preceptor or on increasing hospital support for RNs with BSN
consulted by other nurses for their clinical judgment. degrees. This decision by hospitals, however, is
The survey, which was done in 1999 and then the highly dependent on the availability of RNs with
data used in this 2010 study, included 8,611 nurses. the BSN degree in the local area and has also been
More highly educated nurses rated themselves as influenced by the Magnet Recognition Program®,
having more expertise than less educated nurses, which supports the BSN degree as a requirement
and this correlated with how frequently they were for initial practice, though it does make this a re-
asked to be preceptors or consulted by other nurses. quirement to receive Magnet recognition.
The long-term impact of these types of studies on
the entry into practice is unknown, but there is
more evidence now to support the decision made Stop and Consider #1
The nursing degree required for entry into practice
in 1965 along with recommendations from major
continues to be a problem.
reports (Benner, Sutphen, Leonard, & Day, 2010;
IOM, 2010).
Aiken and colleagues published a study in 2014
addressing nurse staffing and hospital mortality in Types of Nursing
nine European countries. This study received major Education Programs
recognition by healthcare organizations and the me-
dia. The sample included discharge data for 422,730 Nursing is a profession with a complex education
patients aged 50 years or older who had common pattern: It has many different entry-level pathways
surgeries in the nine countries. The survey included to the same license to practice and many different
26,516 nurses in the study hospitals. The findings graduate programs. The following content provides
indicate that increasing a nurse’s workload by one descriptions of the major nursing education pro-
patient increased the likelihood of a patient dying grams. Because several types of entry-level nursing
within 30 days of admission by 7%; in contrast, every programs exist, this complicates the issue and raises
10% increase in the number of nurses with bacca- concerns about the best way to provide education
laureate degrees was associated with a 7% decrease for nursing students.
still doing so in ADN programs (RWJF, 2015). The

Diploma Schools of Nursing
big difference is the increase in RN-BSN programs
Diploma schools of nursing still exist, now rep- pushing the number of nurses with a BSN up. In 2014,
resenting less than 10% of all entry-level nursing there were 67 diploma programs and 1,092 ADN
programs. Many of these programs have transitioned programs identified in the NLN Survey of Schools
to other types of degree programs—for example, by of Nursing (NLN, 2014). From 2005 to 2014, the
forming partnerships with colleges or universities NLN data indicate there was a slight fluctuation in
where students might take some of their courses. the data for these two programs. Associate degree
Many of these schools have closed—some have been programs are accredited by the NLN’s accrediting
converted into associate degree and baccalaureate services. The ADN curriculum includes some liberal
programs, and some have partnered with ADN art and science courses at the community college level
and BSN programs. These programs still interest and focuses more on technical nursing. Graduates
some employers when they are short of staff and take the same licensing exam as graduates from all
degree programs are not meeting these needs. The other pre-licensure nursing programs.
Association of Diploma Schools of Professional Recently, a variety of models and opportunities
Nursing represents these schools. Diploma schools for ADN students and graduates have been intro-
are accredited by the NLN. Graduates take the same duced. Montag envisioned the ADN as a terminal
licensing exam as graduates from all the other types degree, but this perception has since changed,
of nursing programs. The nursing curriculum is with the degree now typically viewed as part of a
similar; the graduates need the same nursing con- career mobility path. The RN-BSN or BSN com-
tent for the licensing exam. The students, however, pletion programs are a way for ADN graduates to
typically have fewer prerequisites, particularly complete the requirements for a BSN. There are
in liberal arts and sciences, though they do have also LPN-ADN and LPN-BSN programs to assist
some science content. Curricula requirements may staff in their career paths. Typically, in all of these
vary in these schools because some schools allow programs, nurses work for a time and then go back
students to take some of their required courses in to school, often on a part-time basis, to complete a
local colleges. BSN in a university-level program. Some prerequisite
courses must be taken before these students enter
most BSN programs. Examples of additional nursing
Associate Degree in Nursing
courses these students may take in the RN-BSN
Programs awarding an associate degree in nursing program are health assessment, public/community
(AD/ADN) began when Mildred Montag pub- health with clinical practice, leadership and man-
lished a book on the need for a different type of agement, research/evidence-based practice, and
nursing program—a 2-year program that would health policy. Until recently, these students rarely
be established in community colleges (Montag, took additional clinical courses, as this is not the
1959). The first programs opened in 1958. At the major focus of the RN-BSN programs; however, all
time Montag created her proposal, the United States programs accredited by AACN must now include
was experiencing a shortage of nurses. For students, clinical experiences or a practicum. The Com-
ADN programs are less expensive and shorter. The mission on Collegiate Nursing Education (CCNE,
percentages of ADN and BSN programs vary from 2013), accrediting body for the AACN, defines
state to state—for example, in California, 61% of clinical practice experiences as “planned learning
RNs completed a BSN or higher degree; however, activities in nursing practice that allow students
more than half the students entering nursing are to understand, perform, and refine professional
competencies at the appropriate program level” In these types of programs, both the participat-
(p. 21). The content typically included for the ing ADN and BSN programs collaborate on the
clinical experience is public/community health, curriculum and determine how to best transition
focusing on what these students typically do not the students. One benefit of this model is for the
cover in an ADN program. Today, many of the first 2 years students pay the community college
RN-BSN programs offer courses online. The type fees, which are less costly than the university fees.
of clinical experiences can vary greatly; however, Another advantage is if there is no BSN program
not having any clinical experiences in a RN-BSN in a community students have the option of staying
program may be a problem for students who want within their own community while they pursue
to continue on to a graduate degree. a nursing degree and then transition to a more
Greater efforts are now made to facilitate the distant BSN program or complete the BSN online.
transition from the ADN program to the BSN pro-
gram. The overall goal is to guide all ADN graduates Baccalaureate Degree
back to school for a BSN, though this has not yet
in Nursing
been accomplished. These graduates do not have
to take the licensure exam because they are already The idea for the BSN, an entry-level degree, was
RNs, but to participate in a RN-BSN program, they introduced in the Goldmark Report (Goldmark,
are expected to maintain an active registered nurse 1923), although it took many years for this recom-
license. ADN and BSN programs have increased mendation to have an impact on nursing education.
their efforts to partner with each other to provide The original programs took 5 years to complete, with
a seamless transition from one program to the the first 2 years focused on liberal arts and sciences
other. Establishing an articulation agreement courses, followed by 3 years in nursing courses. Most
describing the responsibilities of the partners, BSN programs have changed to a 4-year model, with
benefits to the students, and how the students will various configurations of liberal arts and sciences
meet the expected BSN outcomes or competencies and then 2 years in nursing courses. Some schools
clarifies these partnerships. “Articulation agree- introduce students to nursing content during the first
ments are important mechanisms that enhance 2 years, but typically the amount of nursing content
access to baccalaureate level nursing education. is limited during this period. In many colleges of
These agreements support education mobility and nursing, students are not formally admitted to the
facilitate the seamless transfer of academic credit school/college of nursing until they complete the
between associate degree (ADN) and baccalaureate first 2 years, although the students are in the same
(BSN) nursing programs” (AACN, 2005c, p. 1). university. These programs may be accredited by
Academic progression supports “life long learning the NLN or through the AACN, both of which
through the attainment of academic credentials” have accrediting services. (More information about
(Organization for Associate Degree Nursing & accreditation appears later in the chapter.) The licen-
American Nurses Association, 2015, p. 5). State sure exam is taken after successful completion of the
law may mandate these agreements, which may be BSN program. A BSN is required for admission to a
partnerships between individual schools or may nursing graduate program, and this has influenced
be part of statewide articulation plans to facilitate more nurses to return to school to get a BSN degree.
more efficient transfer of credits. Typically, in these The movement of many nursing schools into
partnerships, students spend their first 2 years in the the university setting was not all positive. Nursing
ADN program and then complete the last 2 years programs lost their strong connection with hospitals.
of the BSN degree in the partner BSN program. Rather than establish different educational models
with hospitals, the nursing education community program is 2 years, and students may attend full-time
sought to get away from the control of hospitals and or part-time. The following are examples of master’s
move to an academic setting; however, now nursing degree programs:
educators and students are visitors in hospitals with ■■ Advanced practice registered nurse (APRN):
little feeling of partnership and connection. This has This master’s degree can be offered in any
an impact on clinical experiences, in some cases clinical area, but typical areas are adult health,
limiting effective clinical learning. pediatrics, family health, women’s health,
neonatal health, and psychiatric–mental
health. Graduates take APRN certification
Master’s Degree in Nursing
exams in their specialty area and must then
Graduate education and the evolution of the meet specific state requirements, such as for
master’s degree in nursing (MSN) have a long prescriptive authority, which gives them
history. Early in the development of graduate-level limited ability to prescribe medications. These
nursing, it was called postgraduate education, and nurses usually work in independent roles.
the typical focus areas were public health, teaching, The American Nurses Credentialing Center
supervision, and a few clinical specialties. The first (ANCC) provides national certification exams
formal graduate program was established in 1899 at for advanced practice registered nurses
Columbia University Teachers College (Donahue, in a variety of areas.
1983). The NLN supported the establishment of ■■ Clinical nurse specialist (CNS): This master’s
graduate nursing programs, and these programs degree can be offered in any clinical area.
were developed in great numbers and developed new Specialty exams may also be taken. These
models. For example, some of the early programs, nurses usually work in hospital settings.
such as Yale School of Nursing, admitted students The ANCC provides national certification
without a BSN who had a baccalaureate degree in for CNSs in a variety of areas, as discussed
another major. Today, this is very similar to the later in this chapter.
accelerated programs or direct entry programs ■■ Certified registered nurse anesthetists (CRNA):
in which students with other degrees are admitted This has been a master’s degree and is not
to a BSN program that is shorter, covering the offered at all colleges of nursing. This is
same basic entry-level nursing content but with an a highly competitive graduate program.
accelerated approach. These students are typically The Council on Accreditation of Nurse
categorized as graduate students because of their Anesthesia Educational Program, as part
previous degree even though the degree is not in of the American Association of Nurse
nursing. Even so, they must complete pre-licensure Anesthetists, focuses on accreditation of
BSN requirements, including successful completion these programs and certification. This
of the licensure exam before they can take nursing educational program is now moving to
graduate clinical courses, and in some cases, they the level of doctor of nursing practice
are not admitted to the nursing graduate program (DNP). All master’s-level programs must
automatically until completion of a direct entry transition to entry-level DNP programs
program. They must apply to the program in same by 2022, and thereafter, all new programs
manner as any student who wants to attend a grad- must be entry-level DNP programs. The
uate program in nursing. data indicate that the programs are rapidly
The master’s programs in nursing have evolved moving in this direction. As of December
since the 1950s. The typical length for a master’s 2016, 53 programs have been approved for
entry-level doctoral degrees; 27 programs

Research-Based Doctoral
offer post-master’s doctoral degree comple-
tion programs for CRNAs; and 63 programs
Degree in Nursing
remain to be approved for entry-level doctoral The doctoral degree (doctor of philosophy—PhD)
degrees by the deadline of January 1, 2022 (research-based doctorate) in nursing has had
(Council on Accreditation, 2017). a complicated development history. The doctorate
■■ Certified nurse–midwife: This master’s of nursing science (DNSc) was first offered in 1960,
degree focuses on midwifery—pregnancy but this degree program has since transitioned to
and delivery—as well as gynecologic care of other types of doctoral programs. There were PhD
women and family planning. These programs programs in nursing education as early as 1924,
are accredited by the American College of and New York University started the first PhD
Nurse–Midwives. program in nursing in 1953. Today, not enough
■■ Clinical nurse leader (CNL): This is one of students are entering these programs, and this has
the newer master’s degrees, which prepares an impact on nursing faculty because schools of
nurses for leadership positions that have a nursing want faculty with doctoral degrees. Someone
direct impact on patient care. The CNL is a with a PhD is not always required to teach but is
provider and a manager of care at the point encouraged to do so. Nurses with PhDs usually are
of care to individuals and cohorts. The CNL involved in research, although a nurse at any level
serves as a nurse leader and designs, imple- can be involved in research and may or may not
ments, and evaluates patient care by coordi- teach. Study for a PhD typically takes place after
nating, delegating, and supervising the care receiving a master’s degree in nursing and includes
provided by the healthcare team, including coursework and a research-focused dissertation.
licensed nurses, technicians, and other health This process can take 4 to 5 years to complete, and
professionals, and advocates for patients much depends on completion of the dissertation.
(AACN, 2013). Certification is available Nurses with PhDs may be called “doctor”; this
for CNLs. is not the same as the “medical doctor” title, but
■■ Master’s degree in a functional area: This type rather a designation or title indicating completion
of master’s degree focuses on the functional of academic doctoral work in the same way that an
areas of administration or education. It English professor with a doctorate is called “doctor.”
was more popular in the past, but with the Some schools of nursing now offer BSN-PhD
growing need for nursing faculty, there has or BSN-DNP options. This means the student does
been a resurgence of master’s programs in not have to obtain a master’s degree prior to entering
nursing education. In some cases, colleges the program, and the students typically enter the
of nursing are offering certificate programs process as BSN students and complete with a PhD
in nursing education. In these programs, a or DNP degree. The goal is to increase the number
nurse with a nursing master’s degree may of nurses with doctoral degrees (terminal degree) by
take a certain number of credits that focus encouraging nursing students to make this career
on nursing education; then, if the nurse decision early.
successfully completes the NLN certification
exam, the nurse is then a certified nurse
Doctor of Nursing Practice
educator. This provides the nurse with
additional background and experience in The DNP is the newest nursing degree. The DNP
nursing education. is not a traditional PhD program, although nurses
with a DNP degree are also called “doctor.” However, level of scientific knowledge and expertise for quality
this does not represent the same title as someone care. The change is based on “the rapid expansion
with a PhD or a doctor or medicine. The DNP is of knowledge underlying practice; increased com-
a practice-focused doctoral degree program. This plexity of patient care; national concerns about
position has been controversial within nursing and the quality of care and patient safety; shortages of
within health care, particularly among physicians. nursing personnel which demands a higher level of
The ANCC defines advanced nursing practice as preparation for leaders who can design and assess
“any form of nursing intervention that influences care; shortages of doctoral-prepared nursing faculty;
outcomes for individuals or populations, including and increasing educational expectations for the
the direct care of individual patients, management preparation of other members of the healthcare
of care for individuals and populations, adminis- team” (AACN, 2016a, p. 1).
tration of nursing and health organizations, and Because the DNP is a relatively new degree
the development and implementation of health and has led to the development of new roles, it is
policy” (AACN, 2015b, p. 11). This description is not clear at this time what its long-term impact
important due to transition of the requirement of will be on nursing and on healthcare delivery.
master’s programs for APRNs to the DNP degree. Some have questioned the decision to confer such
APRN refers to the nursing role for a nurse who a degree in light of the need for a greater number of
meets certain qualifications; some refer to this also APRNs for primary care (Cronenwett et al., 2011);
as advanced practice nurse. others have questioned it because there is need
Practice-focused doctoral nursing programs for nurses with research-focused degrees (PhDs).
prepare leaders for nursing practice. The long-term There is concern that nurses who might have once
goal is to make the DNP the terminal practice de- considered pursuing a PhD would instead seek a
gree for APRN preparation, including clinical nurse DNP; indeed, data indicate that there is now greater
specialists, certified registered nurse anesthetists, enrollment in DNP programs, so this prediction
certified nurse–midwifes, and nurse practitioners. has proven correct.
This means that by 2015—a date identified by the
AACN—and by 2022—a date identified by the American
Association of Nurse Anesthetists—APRNs would Stop and Consider #2
be required to have a DNP degree or an entry-level We have confusion when it comes to our pre-
licensure degree programs.
DNP for advanced practice nursing. As of 2017 much
more needs to be done to meet this goal.
Some of the reasons that the DNP degree was
developed relate to the process for obtaining an APRN Nursing Education
master’s degree, which requires a large number of
Associations
credits and clinical hours. It was recognized that
students should be getting more credit for their There are three major nursing education organizations,
coursework and effort. Going on to a DNP program each with a different program focus. These organi-
allows them to apply some of this credit toward a zations are the NLN, the AACN, and the OADN.
doctoral degree. As of April 2016, there are 289
DNP programs, with 128 in the planning stages;
National League for Nursing
62 are post-baccalaureate and 66 are post-master’s
programs (AACN, 2016a). Our healthcare system The NLN is an older organization than the AACN. It
and healthcare service needs demand the highest “promotes excellence in nursing education to build
a strong and diverse nursing workforce to advance improvements in health, health care, and higher
the health of our nation and the global community,” education; (3) the AACN is a primary advocate for
and the NLN’s goals are as follows (NLN, 2017a): advancing diversity and inclusivity within academic
nursing; and (4) the AACN is the authoritative source
■■ Leader in nursing education: Enhance the
of knowledge to advance academic nursing through
NLN’s national and international impact as
information (AACN, 2017). The organization also
the recognized leader in nursing education.
offers accreditation of baccalaureate and master’s
■■ Commitment to members: Engage a diverse,
degree nursing programs as described in another
sustainable, member-led organization with
section in this chapter.
the capacity to deliver our mission effectively,
efficiently, and in accordance with our values.
Champion for nurse educators: Be the voice of
Organization for Associate
Degree Nursing
■■
nurse educators and champion their interests

in political, academic, and professional arenas. The Organization for Associate Degree Nursing
■■ Advancement of the science of nursing ed- (OADN) began in 1984 after Mildred Montag
ucation: Promote research that generates proposed the ADN degree in 1952. The OADN,
evidence about nursing education and the formerly known as N-OADN, is the organization
scholarship of teaching. that advocates for associate degree nursing edu-
The NLN represents several types of registered cation and practice. Its major goals are as follows
nurse programs (diploma, ADN, BSN, master’s) and (OADN, 2017):
vocational/practical nurse programs. Accreditation ■■ Education: Advance associate degree nursing
of nursing education programs is discussed in a education.
later section of this chapter. The NLN offers edu- ■■ Leadership: Develop leadership within associate
cational opportunities for its members (individual degree nursing to create meaningful change.
membership and school of nursing membership) ■■ Inclusivity: Foster an environment in associate
and addresses policy and standards issues related degree nursing that advances inclusivity.
to nursing education. ■■ Collaboration: Further associate degree nurs-
ing education through collaboration with a
American Association diverse group of stakeholders.
Advocacy: Advocate for associate degree
of Colleges of Nursing ■■
nursing as it relates to the delivery of quality

The AACN is the national organization that represents health care.
baccalaureate and graduate programs in nursing, The organization supports academic progression
including doctoral programs. It has approximately of its graduates so that they can reach their po-
725 members (schools/colleges of nursing). Its ac- tential. The organization does not offer accredita-
tivities include educational research, government tion services. Accreditation of ADN programs is
advocacy, data collection, publishing, and initiatives done through the NLN accrediting organization
to establish standards for baccalaureate and graduate (CNEA).
degree nursing programs, including implementa-
tion of the standards. Its goals for 2017–2019 are
as follows: (1) The AACN is the driving force for Stop and Consider #3
We have three nursing education organizations; maybe
innovation and excellence in academic nursing; due to the confusion over our degree programs.
(2) the AACN is a leading partner in advancing
care but also intentionally design care, assign care,

Quality and Excellence in and supervise others who provide care. To achieve
Nursing Education desired patient outcomes, nurses must be proficient
in understanding how to establish and maintain
There is greater emphasis today on quality health healthy work environments; use research-based
care, as discussed in this text, but also, for us to have knowledge to adjust their standards of practice; collect,
quality care, we need to have healthcare providers interpret, and recommend changes to care on the use
who meet standards for quality performance. This of established quality improvement” (2016, p. 396).
requires us to consider the quality of our nursing In addition, as noted in the outcome categories, there
education programs. is need for community understanding and focus and
inclusion of systems at all levels and professional input
through professional organizations.
Nursing Education Standards
Nursing education standards are developed by NLN Excellence in Nursing
the major nursing professional organizations that
Education
focus on education: NLN, AACN, and OADN. The
accrediting bodies of the NLN and the AACN also The NLN Hallmarks of Excellence© identifies
set nursing education standards. State boards of 30 hallmarks or indicators, which are posed as
nursing are involved as well. In addition, colleges questions focusing on students, faculty, continu-
and universities must meet certain standards for ous quality improvement, curriculum, teaching/
non-nursing accreditation at the overall college or learning evaluation strategies, resources, innovation,
university level. Standards guide decisions, organi- educational research, environment, and leadership
zational structure, process, policies and procedures, (NLN, 2017c). These indicators are applied in
budgetary decisions, admissions and progress of two of its programs that recognize excellence.
students, evaluation/assessment (program, faculty, The NLN Center of Excellence in Nursing Edu-
and student), curriculum, and other academic issues. cation identifies schools of nursing that demonstrate
Critical standard documents published by the AACN “sustained, evidence-based, and substantive innovation
are The Essentials covering baccalaureate, master’s, in the selected area; conduct ongoing research to
and DNP degrees (AACN, 2006, 2008, 2011). The document the effectiveness of such innovation; set
baccalaureate Essentials emphasizes the three roles of high standards for themselves; and are committed to
the baccalaureate generalist nurse: provider of care; continuous quality improvement” (NLN, 2017d). These
designer/manager/coordinator of care; and member of schools make a commitment to pursue excellence in
a profession, which includes advocating for the patient (1) student learning and professional development,
and profession by applying the Essential standards. (2) development of faculty expertise in pedagogy,
These standards include student learning outcomes and/or (3) advancing the science of nursing education.
expected for nursing pre-licensure graduates related to The award is given to a school or college of nursing—
the following topical areas and associated percentage not a program within a school—and remains in
of the outcomes: 25% nursing across the lifespan, 25% effect for 3 years. After this period, the school must
professional identity/communication, 25% leadership, be reviewed again to retain the Center of Excellence
13% population health, and 12% evidence-based recognition. This NLN initiative is an excellent example
practice/quality improvement (Godfrey & Martin, of efforts to improve nursing education.
2016). These authors also note, “in today’s healthcare Another NLN initiative to recognize excel-
environment, nurses must be able to not only deliver lence is the Academy of Nursing Education. The
purpose of the Academy of Nursing Education nursing program. There is greater emphasis today on
is to “foster excellence in nursing education by implementing healthcare professions competencies,
recognizing and capitalizing on the wisdom of particularly the core competencies for all healthcare
outstanding individuals in and outside the profes- professions: (1) provide patient-centered care, (2) work
sion who have contributed to nursing education in interdisciplinary/interprofessional teams,
in sustained and significant ways” (NLN, 2017d). (3) employ evidence-based practice, (4) apply quality
It selects nurse educator fellows that demonstrate improvement, and (5) utilize informatics (IOM,
significant contributions to nursing education in 2003). This does not mean that profession-specific
one or more areas (teaching/learning innovations, competencies are not relevant, such as the Quality
faculty development, research in nursing education, and Safety Education for Nurses (QSEN, 2017)
leadership in nursing education, public policy related competencies, but rather recognizes the existence
to nursing education, or collaborative education/ of basic competencies that all healthcare professions
practice/community partnerships) and continue should demonstrate. See Table 3-1 comparing the
to provide visionary leadership in nursing educa- core competencies and QSEN competencies.
tion and in the academy (NLN, 2017d, 2017e). It You need to know what the expected competen-
inducted its first nurse education fellows in 2007, cies are so that you can be an active participant in
and continues to do so annually. your own learning to reach these competencies. The
competencies are used in evaluation and to identify
the level of learning or performance expected of
Focus on Competencies
the student. Nursing is a profession—a practice
In 2003, the IOM published the Health Professions profession—so performance is a critical factor.
Education report to address the need for education Competency is “the application of knowledge and
in all major health professions describing critical the interpersonal, decision-making, and psycho-
common competencies. The development of this motor skills expected for the nurse’s practice role,
report was motivated by grave concerns about the within the context of public health, welfare, and
quality of care in the United States and the need safety” (National Council of State Boards of Nurs-
for healthcare education programs to prepare pro- ing [NCSBN], 2005, p. 1). The ANA (2015) defines
fessionals who provide quality care. “Education for competency as “an expected and measurable level
health professions is in need of a major overhaul. of nursing performance that integrates knowledge,
Clinical education [for all healthcare professions] skills, abilities, and judgment, based on established
simply has not kept pace with or been responsive scientific knowledge and expectations for nursing
enough to shifting patient demographics and desires, practice” (p. 86). Competencies should clearly state
changing health system expectations, evolving prac- the expected parameters related to the behavior or
tice requirements and staffing arrangements, new performance. The curriculum should support the
information, a focus on improving quality, or new development of competencies by providing necessary
technologies” (IOM, 2001, as cited in IOM, 2003, prerequisite knowledge and learning opportunities
p. 1). The core competencies are also emphasized in to meet the competency. The ultimate goal is a
the Essentials of Baccalaureate Education (AACN, competent RN who can provide quality care.
2008); however, schools of nursing need to make
changes to include the competencies and, in some
Curriculum
cases, add new content to meet these needs.
The nursing curriculum should identify the A nursing program’s curriculum is the plan that
competencies expected of students throughout the describes the program’s philosophy, levels, student
Table 3-1 Comparing the Five Healthcare Professions Core

Competencies and the QSEN Competencies for Nurses
Healthcare Professions Core

Competencies* QSEN Competencies for Nurses**
Provide patient-centered care. Patient-centered care: knowledge, skills, attitudes
Work on interdisciplinary Teamwork and collaboration: knowledge, skills,
[interprofessional] teams. attitudes
Employ evidence-based practice. Evidence-based practice: knowledge, attitudes, skills
Apply quality improvement. Quality improvement: knowledge, skills, attitudes
Utilize informatics. Safety: knowledge, skills, attitudes
Informatics: knowledge, skills, attitudes
Data from *Institute of Medicine (IOM). (2003). Health Professions Education. A Bridge to Quality. Washington,
DC: The National Academies Press;
**QSEN Institute (2015). Pre-licensure competencies. Retrieved from http://qsen.org/competencies/pre

-licensure-ksas/ and graduate level competencies retrieved from http://qsen.org/competencies/graduate-ksas/
terminal competencies (outcomes or what students have an impact on the curriculum; for example, The
are expected to accomplish by the end of the pro- essentials of baccalaureate education for professional
gram), and course content (described in course nursing practice provides guidelines for baccalaureate
syllabi). Also specified are the sequence of courses curricula (AACN, 2008).
and a designation of course credits and learning
Didactic or Theory Content
experiences, such as didactic courses (typically
offered in a lecture/classroom, seminar setting or Nursing curricula may vary as to titles of courses,
both venues; in some cases in online format) and course descriptions and objectives/learning outcomes,
clinical or practicum experiences. In addition, sim- sequence, number of hours of didactic content, and
ulation laboratory experiences are included either clinical experiences, but there are some constants
at the beginning of the curriculum or throughout even within these differences. To ensure consistency
the curriculum. The nursing curriculum is very in the practice of nursing and to prepare for the
important. It informs potential students what they licensure exam nursing content needs to include
should expect in a nursing program and may influence the following broad topical areas:
a student’s choice of programs, particularly at the ■■ Professional issues and trends
graduate level. It helps orient new students and is ■■ Health assessment
important in the accreditation of nursing programs. ■■ Pharmacology
State boards of nursing also review the curricula of ■■ Adult health or medical–surgical nursing
schools of nursing in their state. To keep current, ■■ Psychiatric/mental health nursing
faculty need to review the curriculum regularly, in ■■ Pediatrics
a manner that allows changes to be made as easily ■■ Maternal–child nursing (obstetrics, women’s
and quickly as possible and includes student input. health, neonatal care)
Standards for nursing education accreditation also ■■ Public/community health
■■ Gerontology been more successful than others. The hours for

■■ Leadership and management the practicum or clinical experiences can be highly
■■ Palliative care and care of the dying patient variable within one school and from school to school
■■ Communication, collaboration, and (for example, the number of hours per week and
coordination sequence of days, such as practicum on Tuesdays
■■ Teamwork and Thursdays from 8 a.m. to 3 p.m.). Many schools
■■ Evidence-based practice are now offering 12-hour clinical sessions. There is
■■ Research greater acknowledgment that 12-hour work shifts
■■ Health policy may lead to staff fatigue and an increased number of
■■ Legal and ethical issues errors, but this has not stopped some schools from
■■ Quality improvement offering this time schedule for student practica. Some
schools offer clinical experiences in the evenings, at
Many schools offer courses focused on other topics,
night, and on weekends. It is important for students
such as informatics and genetics. Quality improve-
to understand the time commitment and scheduling
ment content is often weak, even though it is now
related to clinical experience requirements, which
considered critical knowledge that every practicing
have a great impact on students’ personal lives, time
nurse needs to have if care is to be improved.
with family, and social relationships. If a student is
Nursing content may be provided in clearly
employed while going to school, scheduling will be
defined courses that focus on only one overall topical
complex. In addition, these clinical experiences re-
area, or it may be integrated with multiple topics.
quire preparation time. The types of clinical settings
Clinical experience/practicum may be blended with
are highly variable and depend on the objectives
related didactic content—for example, pediatric
and the available sites. Typical types of settings
content and pediatric clinical experience—such
are acute care hospitals (all clinical areas); mental
that they are considered one course; alternatively,
health/psychiatric hospitals; pediatric hospitals;
the clinical/practicum and didactic content may be
women’s health (may include obstetrics) clinics;
offered as two separate courses, typically in the same
public/community health clinics and other health
semester. Faculty who teach didactic content may
agencies; home health agencies; hospice centers,
or may not teach in the clinical setting.
including freestanding sites, hospital-based centers,
and patients’ homes; schools; camps; health-oriented
Practicum or Clinical Experience consumer organizations such as the American
Clinical experience or practicum is a critical compo- Diabetes Association; health mobile clinics; home-
nent of a nursing curriculum. These experiences must less shelters; doctors’ offices; clinics of all types;
be planned; correlate with the curriculum; require ambulatory surgical centers; emergency centers;
intensive faculty supervision to facilitate effective Red Cross centers; businesses with occupational
learning; and focus on active student engagement in health services; and many more. In some of these
the experiences, requiring extensive time and effort. settings—for example, in acute care—faculty remain
Extensive faculty effort and coordination with with the students for the entire rotation time. In
clinical sites is required for effective planning, other settings, particularly public/community
implementing, and evaluating of student clinical healthcare settings, faculty visit students at the site
experiences. A critical issue today for many schools because, typically, only 1 to 4 students are in each
is access to clinical sites. This has led to various site, and the clinical group might include as many
methods to alleviate the problem to ensure effec- as 10 students at different sites—which is different
tive clinical experiences for students—some have from acute care, when a group (8 to 10 students) is
usually assigned to a faculty member in on clinical The AACN describes distance education as “a set
area for hospital experiences. The ratio of students of teaching and/or learning strategies to meet the
to faculty in clinical settings may vary depending learning needs of students separate from the tradi-
on the state board of nursing requirements. The tional classroom and sometimes from traditional
number of hours per week in clinical experiences roles of faculty” (AACN, 2005b; Reinert & Fryback,
increases each year in the program, with the most 1997). This definition is still applicable today.
hours assigned at the end of the program. Distance education technologies have expanded
During some part of a nursing program, schools of over the past few years as technology developed.
nursing use preceptors in the clinical settings, in both Some of the common distance education technolo-
undergraduate and graduate programs. In entry-level gies that are used are email, audiotaped instruction,
programs, preceptor experiences are typically used conference by telephone or via Internet, desktop
toward the end of the program, but some schools videoconference, and Internet-based programming
use preceptors throughout the program for certain or online format. There is no doubt that these meth-
courses such as in master’s programs. A preceptor ods will continue to expand as new ones are added
is an experienced and competent staff member (for and some discarded as not effective or efficient.
example, an RN for undergraduate students; APRN The most common and increasingly more widely
graduate or medical doctor for APRN students; adopted education approach is online courses.
certified registered nurse anesthetist or a certified Distance education can be configured in several
nurse–midwife for graduate nursing students in these ways, including the following:
specialties). Preceptors should have formal training
■■ Self-study or independent study
to function in this role. The preceptor serves as a
■■ Hybrid model—distance education combined
role model and a resource for the nursing student
with traditional classroom delivery (the most
and guides learning. The student is assigned to
common configuration; an example is the
work alongside the preceptor. Faculty provide
flipped classroom)
overall guidance to the preceptor regarding the
■■ Faculty-facilitated online learning with no
nature of, and objectives for, the student’s learning
classroom activities (the approach that is
experiences; monitor the student’s progress by
growing most rapidly)
meeting with the student and the preceptor; and
are on call for communication with the student Distance education courses must require
and preceptor as needed. The preceptor partic- students to meet the same course competencies or
ipates in evaluations of the student’s progress, outcomes as described in the program curriculum.
along with the student, but the faculty member Students who participate in distance education
has the ultimate student evaluation responsibil- typically have certain characteristics that lead to
ity. The state board of nursing may dictate how success in this type of educational program. Most
many total hours may be assigned to preceptor notably, they need to be responsible for their own
experiences for undergraduate students. At the learning, with faculty facilitating their learning.
graduate level, the number of preceptor hours is Computer competencies are critical for completing
much higher. coursework and reducing student stress. Nursing
programs must be clear about required hardware and
Distance Education software needed to complete course work. Students
Distance education, which is often offered online, who are organized and able to develop and meet a
has become quite common in nursing education, schedule will be able to handle the course require-
although not all schools offer courses in this manner. ments. If students are assertive, ask questions, and
request help when they need it they will be more ■■ Pace their own learning
successful. Effective online learning also requires ■■ Participate in monitoring their own progress;
active, engaged competent faculty. perform self-assessment
Self-directed learning is important for all As noted in the report on nursing education (Benner,
nursing students because it leads to greater ability Sutphen, Leonard, & Day, 2010), there is need for
to achieve lifelong learning as a professional. There greater student engagement in the classroom, which
are a variety of definitions of self-directed learning, emphasizes adult principles of learning.
most of which are based on Knowles’s (1975, p. 18, The quality of distance education is as important
as cited in O’Shea, 2003, p. 62) definition: “a process as the quality of traditional classroom courses. Syllabi
in which individuals take the initiative, with or with- that provide the course description, credits, objec-
out the help of others, in diagnosing their learning tives or learning outcomes, and other information
needs, formulating learning goals, identifying human about the course should ensure that the same general
and material resources for learning, choosing and structure and expectations are followed whether
implementing appropriate learning strategies and a course is taught using a traditional approach or
evaluating learning outcomes.” Student-centered through distance education—ensuring this is part
learning approaches assist effective student learning of a school’s evaluation process. Student evaluation
by helping students apply learning—for example, must be built into a distance education course just
problem-based learning or team-based learning. as it is in traditional courses; however, more details
This type of approach means that the faculty must are typically provided in distance education course
also change how they teach. Faculty members materials and teaching–learning practices may be
assume the role of a facilitator of learning, which different. Students and faculty also need access to
requires establishing a more collaborative relation- timely technology support. Schools should ensure
ship between faculty and students. Faculty work that students provide anonymous evaluations of
with students to develop active participation and the course and faculty, as required for traditional
goal setting: help students in setting goals, make course format.
plans with clear strategies to meet the goals, and
encourage self-assessment. The flipped classroom
approach is also used, for example, with content Accreditation of Nursing
provided online, in textbooks, and so on and the
Education Programs
expectation that students come to class prepared
so that they can actively participate in learning Accreditation is important in assessing and maintain-
activities in the classroom rather than listening to ing standards to better ensure effective programs for
lectures. Compared to the traditional classroom students that meet practice requirements. Potential
approach, distance education typically emphasizes nursing students may not be as aware of accredita-
adult teaching and learning principles more, and tion of the schools they are considering, but they
approaches such as the flipped classroom also focus should be. Accreditation is a process in which
more on these principles. Knowles (1984) originally an organization is assessed regarding how it meets
described principles that emphasized how learners established standards. The focus here is on education
engage with this type of educational program: accreditation; in other chapters, accreditation of
■■ Accept responsibility for collaborating in healthcare organizations is discussed. The accrediting
the planning of their learning experiences organization identifies minimum standards that
■■ Set goals guide the process, and nursing schools incorporate
■■ Actively participate these standards into their programs. The accrediting
organization then reviews the school and its programs. ■■ Faculty and faculty outcomes
This is supposedly a voluntary process, but in reality, ■■ Curriculum and implementation
it is not; to be effective, a school of nursing must ■■ Student support services
be accredited—to attract faculty, students, funding ■■ Admissions process and other academic
for education programs and research grants, and processes
so that their graduates can attend other nursing ■■ Policies and procedures
programs such as graduate programs. Attending a ■■ Ongoing assessment process (continuous
nursing program that is not accredited can lead to quality improvement, student and program
complications in licensure, employment, and oppor- outcomes)
tunities to continue on to higher degree programs. The standards are periodically reviewed and revised;
Currently, two organizations offer accreditation of for example, in 2016, the CNEA revised its standards
nursing programs: NLN and ANCC through their (NLN, 2016). The NLN accrediting standards support
accrediting services CNEA and CCNE. diversity in schools’ missions, curricula, students,
What is accreditation? The process is complex and faculty as well as support continuous quality
and takes time. Schools of nursing must pay for improvement in education; in doing so, the NLN
the review. Schools may or may not receive initial has an impact on a caring and competent nursing
accreditation, and when they do, programs may be workforce (NLN, 2017b).
required to make changes. During the time period in After the school of nursing completes a self-
which they are accredited, the accrediting body may study based on the accreditation standards estab-
determine that a school is not in compliance with the lished by the accrediting organization, the written
expected standards; therefore, the school may lose self-study results are submitted to the accrediting
accreditation or additional reviews may be required. organization. The next step in the accreditation
Accreditation is not a legal requirement, but state process is the onsite survey at the school. Surveyors
boards of nursing require this type of accreditation visit the school: They observe classes and clinical
from the NLN or ANCC to maintain state board of experience/practicum, meet with staff at clinical
nursing accreditation. Some specialty organizations sites, review documents (for example, curriculum,
accredit specific graduate programs within a school, completed student assignments, budget, faculty
such as the American College of Nurse Midwifery organization, grants, and so on), and meet with
and the American Association of Nurse Anesthetists. school administrative staff. If the school of nursing
A school may choose which organization (CNEA or is part of a university, they also meet with university
CCNE) accredits its school unless mandated by state administrative staff. In addition, surveyors meet
agency or law; however, schools with diploma and with faculty, students, and alumni. They typically
associate degree programs can be accredited only by remain at the school for several days. Students have
the CNEA (NLN, 2017b). The state board of nursing an obligation to participate in accreditation surveys
in each state is involved in this requirement and in and provide feedback. The goal is maintenance of
its own state accreditation process. minimum standards to ensure an effective learning
During the accreditation process, the review environment that supports student learning and
team assesses the schools of nursing for the following, meets the needs of the profession. Schools must
based on the accrediting organization’s standards: undergo reviews after they receive initial accredi-
■■ Mission and vision tation to continue their accreditation status, typi-
■■ Structure and governance cally at a designated time period, but such reviews
■■ Resources and physical facilities, including may occur if changes in the school or problems
budget arise.
age. It is also difficult to attract nurses to teaching

Stop and Consider #4 because the pay is lower than for nursing practice;
Continuous improvement is not only needed in
healthcare delivery, but also in nursing education.
for this reason, nurses with graduate degrees often
opt to stay in active practice. Attracting nurses to
attend graduate school is an issue, particularly at
the doctoral level. The DNP degree has attracted
Critical Nursing more nurses to these advanced degree programs,
Education Problems but these nurses may not be interested in teach-
ing—and the DNP program was not intended to
Today, two critical problems that concern participants prepare faculty but rather to prepare practitioners.
in nursing education programs are the growing However, even if more students apply to DNP pro-
faculty shortage and the need to find clinical expe- grams, they may be denied admission due to the
riences for students, particularly as efforts are made lack of sufficient faculty to teach in the programs. The
to increase enrollment. These complex problems ACA offers some opportunities to expand nursing
require more than one solution, and they have a faculty through provisions supporting funding for
great impact on the quality of nursing education and education so that nurses can prepare for the faculty
student outcomes. role, and this has improved the situation. Changes
in the law may impact these provisions.
Faculty Shortage
The faculty shortage has an impact on the avail- Access to Clinical
ability of graduates to practice because it means
Experiences
that fewer new nurses can enter the profession.
As noted earlier in this chapter, one of the reasons Aside from having a limited number of faculty,
that potential qualified students cannot enroll in a nursing programs struggle to provide space for
nursing program is the shortage of qualified faculty. clinical laboratories and to secure a sufficient
A school’s faculty should reflect a balance of expert number of clinical sites at healthcare facilities—all
clinicians who can teach, expert researchers and of this requires a certain number of faculty to meet
grant writers who can teach and meet research ob- standards for quality education and faculty–student
ligations, and expert teachers who are pedagogical ratios. With the drive to increase student enroll-
scholars (NLN, 2016). Today, schools of nursing, ment, securing enough clinical sites to meet course
regardless of the type of program, are struggling to objectives is a challenge for schools of nursing. If
meet the demand for greater enrollment of students a number of nursing schools are located in the
because of the limited number of faculty. They have same area, there is also competition for clinical
problems recruiting experienced faculty, and thus slots. This is particularly a problem in healthcare
many faculty are new to teaching. Some of the same specialties that may have fewer patient services in
factors that affect the fluctuating nursing shortage a location, which translates into tight demand for
have an impact on the faculty shortage, such as faculty clinical slots—such as pediatrics, obstetrics, and
retirement (for example, 2013–2014 data indicate mental health. Schools of nursing need to be more
average ages of doctoral-prepared faculty range from innovative and recognize that every student may
61.6 to 51.4 years; master’s prepared range is 57.1 not get the same clinical experiences. For example,
50 51.2 years [AACN, 2015a]). This challenge will there is increasing use of non–acute care pediatric
only increase in the future because a large number of settings. Some communities do not have pediatric
nursing faculty members are approaching retirement hospitals and may have limited beds assigned to
pediatric care in other hospitals. Other sites that in a safe setting before they begin caring for real
might be used are pediatrician offices, pediatric patients and can help students to develop teamwork
clinics, schools, daycare centers, and camps. For competencies. This is supported by the NCSBN
obstetrics, possible clinical sites are birthing centers, study on the role and outcomes of simulation in
obstetrician offices, and midwifery practices. Mental pre-licensure programs, which indicates that, “up
health clinical experiences may take place in clinics, to 50 percent of traditional clinical experiences
homeless shelters, mental health emergency and under conditions comparable to those described in
crisis centers, and may even use a mental health the study” may be used instead of clinical experi-
association or other type of community organization ences (NLN, 2015, p. 2; Hayden, Smiley, Alexander,
focused on health needs. Kardong-Edgren, & Jeffires, 2014). The simulated
This difficulty in getting sites has forced some environment provides opportunities for teams of
schools to move away from the traditional clinical nurses, or ideally, interprofessional students to work
hours offered—Monday through Friday during the together to respond to simulated clinical situations.
day. Some schools are recognizing that operating on Student evaluation and real-time feedback can be
a 9-month basis with a long summer break affects the done in a simulated structured learning situation.
availability of clinical experiences. To accommodate Simulated experiences should be as close to real
the needs of all schools of nursing and the need life as possible—although they are not, of course,
to increase student enrollment, community-area totally real. This does not, however, mean that
healthcare providers often collaborate with schools to these learning situations are not very helpful for
determine how all these needs can be met effectively. student learning. Clinical training laboratories
that are not as high-tech as simulation centers may
A Response and Innovation: be used to learn basic skills. Most schools do not
Laboratory Experiences and have their own full simulation laboratories due to
the expense of setting up and running such labs. The
Clinical Simulation
simulation laboratory may be established through
Laboratory and simulation experiences have become a partnership of multiple health practice education
important teaching–learning settings for develop- programs and/or hospitals to reduce the financial
ing competencies, partly because of problems in burden on each institution and offer simulation to
accessing clinical experiences, but also as a result of a variety of students, often as an interprofessional
the recognition that they provide effective learning student and/or staff experience.
experiences for students with no risk of harm to A simulation laboratory is expensive to d evelop
patients. A new simulation dictionary developed and maintain. Students need to respect the equip-
and published by the Agency for Healthcare Re- ment and supplies and follow procedures so that
search and Quality (AHRQ) defines healthcare costs can be managed. Faculty supervision in the
simulation as: “A technique that creates a situation simulation laboratory may be based on a higher
or environment to allow persons to experience a ratio of students to faculty than the required ratio for
representation of a real healthcare event for the clinical experiences, providing more cost-effective
purpose of practice, learning, evaluation, testing, or teaching and learning. With the development of more
to gain understanding of systems or human actions; sophisticated technology, computer simulation can
the application of a simulation activity to training, even be incorporated into distance education. State
assessment, research, or systems integration toward boards of nursing may have requirements as to the
patient safety” (Lopreiato, 2016, p. 15). Simulation number of simulation hours that can be substituted
helps students develop confidence in their skills for clinical hours.
inquiry, generate new knowledge for the disci-

Stop and Consider #5 pline, connect practice with education, and lead
The critical problems in nursing education are
interrelated.
scholarly pursuits that improve health and health
care” (Manatt Health Project Team, 2016, p.5). The
findings from the report indicate that academic
nursing is not currently positioned as a real part-
Transforming Nursing ner in healthcare transformation—for example,
Education nursing has limited participation in governance
and faculty leadership roles in the AHCs. This
Recent reports on quality in healthcare deliv- needs to change, though resources will be needed
ery indicate an urgent need to institute changes to increase this participation and collaboration.
in nursing education. In fact, the most recent major An example that was given as a barrier is lack of
nursing education report identified preparation nursing faculty practices that bring in income and
of nurses to meet these quality demands as a critical the over-reliance on tuition for academic nursing
topic (Benner, Sutphen, Leonard, & Day, 2010). Thus, budgets. The AACN (2016b)report’s recommen-
quality improvement relies, in part, on improvement dations are to “embrace a new vision for academic
of nursing education. Nursing students need to be nursing, enhance the clinical practice of academic
included in the evaluation of nursing education and nursing, partner in preparing the nurses of the
changes. As a student, you can help meet this need future, partner in the implementation of account-
by providing course feedback and participating in able care, invest in nursing research programs and
curriculum committees when requested. Nursing better integrate research into clinical practice, and
education leaders should always review content and implement the advocacy agenda in support of a
improve curriculum, but they must have methods new era for academic nursing” (p. 1).
to do this in a timely, effective manner. When ac-
creditation surveyors come to schools of nursing,
they talk to students to get their feedback, as there Stop and Consider #6
is recognition that students need to be engaged in Transforming nursing education is connected to
nursing practice.
the transformation of nursing education.
One aspect of transforming health care related
to nursing education was addressed in a recent
report sponsored by the AACN focusing on aca- Interprofessional
demic health centers (AHCs) and nursing education Healthcare Education
(academic nursing) and practice—noting that
nurses are the primary care givers and advocates One of the healthcare professions core competencies
for patients (Manatt Health Project Team, 2016). is focused on interprofessional teams; an important
The report clarifies two key terms. An AHC is a competency for nursing education and has impact
center of multiple health profession schools, ac- on patient care (IOM, 2003). Emphasis on this com-
credited, and connected to a teaching healthcare petency has stimulated collaboration toward better
organization, such as a hospital or health system. understanding of interprofessonal collaborative
Academic nursing is the integration of practice, practice. The interprofessional education collaborative
education, and research associated with baccalau- (IPEC) established key competencies in 2009 and
reate and graduate schools of nursing—academic published updates in 2011 and 2016. Initially, IPEC
nursing faculty demonstrate “a commitment to identified four topical areas or domains as values and
ethics, roles and responsibilities, interprofessional Interprofessional Collaborative

Competency Domain
communication, and teams and teamwork; however,
a fifth domain has been added as the central domain: and population o
interprofessional collaboration supported by four nity rie
mu nt
ed
competencies (IPEC, 2016, p. 11): om
tic se d l
ac a an na
In om pra
Work with individuals of other professions
pr m-b rk sio
te m ct
■■
c
rp u ic
o s
to maintain a climate of mutual respect and
te w fe
ro nic es
e d
am ro
fe a
te erp
ss tio
shared values (values and ethics domain).
io n
t
In
na
a
Use the knowledge of one’s own role and
l
■■
those of other professions to assess and
Va
pr llab ibi nd
tic rat es
address the healthcare needs of the patients
lue for ess e
e ive
o ns a
ac o liti
int p
rc o s
s/e
er ra
fo esp ole
and populations served (roles and respon-
pr ct
th
r R
of ic
ics
sibility domain).
ion
al
Communicate with patients, families, com- Pa d
re
■■
ti e
nt a te
munities, and other health professionals n d f a m ily c e n
in a responsive and responsible manner
that supports a team approach to health
maintenance and the treatment of disease
(interprofessional communication domain). Figure 3-2 The Learning Continuum Pre-
■■Teams and teamwork: Apply relationship- Licensure through Practice Trajectory
building values and the principles of team Reproduced with permission from Interprofessional
dynamics to perform effectively in different Education Collaborative. (2016). Core competencies
for interprofessional collaborative practice: 2016
team roles to plan and deliver patient-/ update. Washington, DC: Interprofessional Education
population-centered care that is safe, timely, Collaborative. p. 9. Retrieved from https://ipecollaborative.
org/uploads/IPEC-2016-Updated-Core-Competencies
efficient, effective, and equitable (teams and -Report__final_release_.PDF
teamwork domain).
Figure 3-2 describes a model for interprofessional nursing education must work to provide effective
collaboration and its associated domains. learning experiences for nursing students so that
These efforts strongly support the need for they are prepared to work on interprofessional
“safe, high-quality, accessible, patient-centered teams. Nursing students, pre-licensure and grad-
care” for all and interprofessional collaboration is uate, also have responsibilities, such as to actively
required to accomplish this” (IPEC, 2016, p. 4). Not engage in the learning activities planned by faculty
only are healthcare profession education programs and to seek out learning situations that support
including more on interprofessional content and interprofessional competencies. Students might do
experiences with interprofessional teams, but also this by observing work teams in clinical, asking to
there is more faculty development on the topic. join an interprofessional activity in clinical, and
This emphasis on interprofessional teams is also working to increase communication with and
now included in accreditation of education pro- respect of other healthcare professionals.
grams. Interprofessional education occurs, “when
students from two or more professions learn about,
from and with each other to enable effective col- Stop and Consider #7
Interprofessional education is critical for effective
laboration and improve health outcomes” (World interprofessional teams.
Health Organization, 2010). To meet these needs,
focus on recognizable harm. That harm could

Regulation result from the practices inherent in the nature
of the profession, the characteristics of the
How are professional regulation and nursing regula-
clients/patients, the settings, or supervisory
tion for practice licensure related? Regulation for
requirements, or a combination of these
practice or licensure is clear, though problematic in
factors. Licensure is applied to a profession
some cases. This type of regulation is based on state
when the incompetent or unethical practice
laws and regulations and leads to licensure. However,
of that profession could cause greater risk
this is different from the professional regulation,
of harm to the public unless there is a high
in which the profession itself regulates its practice.
level of accountability; at the other extreme,
State boards of nursing are not nursing professional
registration is appropriate for professions
organizations, but rather state government agencies.
where such a high level of accountability is
This distinction can make it difficult to make changes
not needed.
in a state’s practice of nursing, which requires state ■■ Skill and training needed: The more highly
legislative changes. Professional organizations do
specialized the services of the professional,
have an impact on practice through the standards
the greater the need for an approach that
they propose and other elements of support and data
actively inquires about the education and
that they provide. “For effective nursing workforce
competence of the professional.
planning to occur and be sustained, [state] boards of ■■ Level of autonomy: Licensure is indicated when
nursing must collaborate with nursing education and
the professional uses independent judgment
practice to support the safe and effective evolution
and practices independently with little or
of nursing practice” (Damgaard, VanderWoude, &
no supervision. Registration is appropriate
Hegge, 1999, as cited in Loquist, 2002, p. 34).
for individuals who do not use independent
“In 1950, nursing became the first profession
judgment and practice with supervision.
for which the same licensure exam, the State Board ■■ Scope of practice: Unless there is a well-demarcated
Test Pool (now called NCLEX), was used throughout
scope of practice for the profession that is
the nation to license nurses. This increased mobility
distinguishable from other professions and
for the registered nurse and resulted in a significant
definable in enforceable legal terms, there
advantage for the relatively new profession of nurs-
is neither basis nor need for licensure. This
ing” (Lundy, 2005, pp. 21–22). The major purpose of
scope may overlap other professions in
regulation is to protect the public, and it is based on
specific duties, functions, or therapeutic
the Tenth Amendment of the U.S. Constitution, the
modalities.
states’ rights amendment. Each state has the right ■■ Consumer expectation: Consumers expect
to regulate professional practice, such as nursing
that those professions that have a potentially
practice, within its own state.
high impact on the consumer or on their
In general, the regulatory approach selected
physical, mental, or economic well-being
should be sufficient to ensure public protection.
will be subject to regulatory oversight. The
The following criteria are still relevant today in
costs of operating regulatory agencies and the
providing a framework for professional licensure
restriction of practitioners who do not meet
(NCSBN, 1996, pp. 8–9):
the minimum requirements are justified to
■■ Risk of harm for the consumer: The evaluation protect the public from harm.
of a profession to determine whether unreg- ■■ Alternative to regulation: There are no alter-
ulated practice endangers the public should natives to the selected regulatory approach
that would adequately protect the public.

State Boards of Nursing
It should also be the case that when it is
determined that regulation of the profes- State boards of nursing implement the state’s nurse
sion is required; the least restrictive level of practice act and recommend state regulations and
regulation consistent with public protection changes to this act when appropriate. This board is
is implemented. part of state government, although how it fits into
Influenced by the above, today eight guiding prin- a state’s governmental organization varies from
ciples apply to nursing regulation: (1) protection state to state. RNs serve on state boards of nursing,
of the public, (2) competence of all practitioners and the governor typically selects board members
regulated by the board of nursing, (3) due process who serve for a specific term of office. Licensed
and ethical decision making, (4) shared accountabil- vocational/practical nurses (LVN/LPNs) and lay-
ity, (5) strategic collaboration, (6) evidence-based persons or consumers (non-nurses) may also have
regulation, (7) response to the marketplace and representation on the board. The primary purpose
healthcare environment, and (8) globalization of of the state board of nursing is to protect the health
nursing (NCSBN, 2007). and safety of the public (citizens of the state). A
board of nursing has an executive director who
runs the business of the board, along with staff who
Nurse Practice Acts work for the state board—all are state employees.
Each state has a nurse practice act that determines The size of the state has an impact on the size of
the nature of nursing practice within the state. the board of nursing and its staff. Boards are not
The nurse practice act is a state law passed by the only involved in setting standards and licensure
state legislative body. Nurse practice acts for each of nurses (RNs and LVN/LPNs), but also are re-
state can be found on state government websites. sponsible for monitoring nursing education (RN
Every licensed nurse should be knowledgeable and LPN) programs in the state. The board serves a
about the nurse practice act that governs practice regulatory function; as part of this function, it can
in the state where the nurse practices under his issue administrative rules or regulations consistent
or her RN license, and nursing students should with state law to facilitate the enforcement of the
be aware of the nurse practice act in the state in nurse practice act.
which they are enrolled as a student. Typically, The board of nursing in each state also reviews
nurse practice acts do the following for their state problems with individual licensure and is the agency
(Masters, 2005, p. 166): that administers disciplinary actions. If a nurse
fails to meet certain standards, participates in un-
■■ Define the authority of the board of nursing,
acceptable practice, or has problems that interfere
its composition, and its powers.
with safe practice and if any of these violations are
■■ Define nursing and boundaries of the scope
reported to the board, the board can conduct an
of practice.
investigation and review and determine actions that
■■ Identify types of licenses and titles.
might need to be taken. Examples of these issues
■■ State the requirements for licensure.
are assault or causing harm to a patient; having a
■■ Protect titles.
problem with illegal drugs or with alcohol (sub-
■■ Identify the grounds for disciplinary action.
stance abuse); conviction of, or pleading guilty to,
The most important function of the nurse practice a felony (examples of felonies are murder, robbery,
act is to define the scope of practice, boundaries of rape, and sexual battery); and having a psychiatric
practice, for nurses in the state to protect public safety. illness that is not managed effectively and interferes
with safe functioning. A nurse may be reprimanded significant weight. Individual state boards of nursing,
by the board or denied a license, may be subject to unlike the NCSBN, are part of, and report to, state
suspended or revoked licensure, or may face licen- government. The NCSBN performs the following
sure restriction with stipulations (for example, the functions (NCSBN, 2013):
nurse must attend an alcohol treatment program ■■ Develops the NCLEX-RN, NCLEX-PN,
to retain licensure). NNAAP, and MACE examinations.
The board must follow strict procedures when ■■ Monitors trends in public policy, nursing
taking any disciplinary action, which must first be- practice, and education.
gin with an official complaint to the board. Anyone ■■ Promotes uniformity in relationship to the
can make a complaint to the board—another nurse, regulation of nursing practice.
another healthcare professional, a healthcare orga- ■■ Disseminates data related to the licensure
nization, or a consumer. The state nursing practice of nurses.
act identifies the possible reasons for disciplinary ■■ Conducts research on nursing practice issues.
action. Boards of nursing publish their disciplinary ■■ Serves as a forum for information exchange
action decisions because they are part of the public for members (individual state boards of
record. When nurses obtain a license in another state, nursing).
they are asked to report any disciplinary actions ■■ Provides opportunities for collaboration
that have been taken by another state’s board of among its members and other nursing and
nursing. Not reporting disciplinary board actions healthcare organizations by maintaining
has serious consequences for obtaining (and losing) the Nursys database, which coordinates
licensure. A key point is that licensure is a privilege, national publicly available nurse licensure
not a legal right. It is important to consider this information.
point as a student because the same rules apply
when getting the first license—even if a student Licensure Requirements
graduates from a nursing program, this does not
mean he or she has a right to take the NCLEX exam Each state’s board of nursing determines its state’s
or to be given a license. licensure requirements based on state law; how-
ever, all states require passage of the NCLEX-RN,
National Council of State which is a national exam. Other requirements
include criminal background checks for initial
Boards of Nursing
licensure and continuing education (CE) for re-
The NCSBN is a not-for-profit organization that newal, though the latter requirement varies from
represents all of the boards of nursing in the 50 state to state. Many nurses hold licenses in several
states, the District of Columbia, and 4 U.S. territories states, which is obtained through endorsement, or
(American Samoa, Guam, Northern Mariana Islands, may be on inactive status in some states. An RN
and Virgin Islands). Through this organization, all should always maintain one license, even if not
state boards of nursing work together on issues practicing, to make it easier to return to practice.
related to the regulation of nursing practice that Fees are paid for the initial license and for license
affect public health, safety, and welfare, including renewal. States in which a nurse is licensed notify
the development of registered nurse licensing ex- the nurse when the license is up for renewal. It is
aminations. Although the NCSBN cannot dictate the nurse’s responsibility to complete the required
change to individual state boards of nursing, it forms and submit payment, and many states now
can make recommendations, which often carry do this electronically. Examples of initial licensure
and renewal requirements, which vary from state protection, each jurisdiction requires a candidate
to state, include the following: for licensure to pass an examination that measures
the competencies needed to perform safely and
■■ Fee (always required, though the amount
effectively as a newly licensed, entry-level RN (or
varies and depends on whether the nurse has
LPN/LVN). RN content relates to the following
active or inactive licensure status)
patient/client needs categories: safe effective care
■■ Passage of NCLEX (required for first licensure
environment (management of care, safety, and
but no further testing required for renewals or
infection control), health promotion and main-
change of license from one state to another)
tenance, psychosocial integrity, and physiological
■■ For renewal, CE contact hours within a spec-
integrity (basic care and comfort, pharmacologic
ified time period (number of contact hours
and parenteral therapies, reduction of risk potential,
varies from state to state, and some states do
physiological adaptation).
not require any CE for licensure renewal)
The examination is offered online. Most of
■■ Criminal background check (required typi
the questions are written at the cognitive level of
cally for initial licensure in a state; also
application or higher, requiring the candidate to
asked if any felonies when renewing license
use problem-solving skills to select the best answer.
or getting a license in a different state may
The exam is a computerized adaptive test. In this
require background check)
type of exam, the computer adjusts questions to the
■■ For renewal or new state, active employment
individual candidate so that the exam is then highly
for a specific number of hours within a spec-
individualized, offering challenging questions that are
ified time period (varies from state to state)
neither too easy nor too difficult. The exam ends when
■■ For renewal or new state, number of hours of
the computer determines with 95% certainty that the
professional nursing activities (varies from
person’s ability is either below or above the passing
state to state)
standard. The exam can also end when the time runs
Ultimately, each RN is responsible for maintain- out or there are no more questions. Because of these
ing competency for safe practice. Any person who factors, all candidates do not receive the same number
practices nursing without a valid license commits of questions. The exam includes a variety of types of
a minor misdemeanor. If licensed in one state, the questions such as multiple-response, fill-in-the-blank,
nurse can typically do the following in another state and hot spot items using a picture or graphic.
in which the nurse is not licensed: consult, teach If a candidate does not pass the NCLEX, he or
as guest lecturer, and conduct evaluation of care as she may retake the exam. Most schools of nursing
part of an accreditation process. provide some type of preparation (for example,
throughout the nursing program or near the end);
National Council Licensure some may recommend that students complete a prep
course on their own. These prep courses require a
Examination
fee and are of varying length. Many publications
The NCLEX is the national nursing exam that is are also available to assist with NCLEX preparation.
developed and administered through the NCSBN In reality, exam preparation takes place every day
(2017a). There are two forms of the exam: NCLEX-RN in nursing programs—in courses and clinical ex-
for RN licensure and NCLEX-PN for practical nurse periences as students learn and practice receiving
licensure. In each jurisdiction (state) in the United faculty feedback.
States and its territories, licensing authorities regu- Students are asked by their school to complete
late entry into practice of nursing. To ensure public an application for NCLEX in the final semester before
graduation. This application is sent to the state board

Critical Current and Future
of nursing in the state where the student is seeking
licensure. After a student completes the nursing
Regulation Issues
program, the school must verify that the student Nursing regulation covers many issues related
has graduated. At this point, the student becomes to legal requirements about nursing practice.
an official NCLEX candidate. The student receives Most of the focus and responsibility for nursing
an authorization to test and exam instructions and regulation falls on the state boards of nursing
information about scheduling the exam. The autho- and their respective legislative bodies; however,
rization to test is the nursing graduate’s pass to take the National Council for State Boards of Nursing
the exam, so it is important to keep it. Students then offers advise to state boards of nursing. Nursing
schedule their own exam within the given time frame. professional organizations also offer their advice
Testing sites are available in every state, and a but cannot formally regulate practice. There
candidate may take the exam in any state. Licensure, have been some regulatory efforts at the federal
however, is awarded by the state in which the candi- level, though this is not common but if done
date has applied for licensure. On the scheduled date, more routinely would lead to more consistency
the student goes to the designated testing site to take across states.
the computerized exam. Candidates are fingerprinted
and photographed to ensure security for the exam Nurse Licensure Compact
and are provided an orientation and a brief practice There has been a growing need to design licensure
session prior to taking the exam. An exam session methods that address the following situations: a nurse
lasts several hours, but because of the computerized lives in one state but works in an adjacent state, a nurse
adaptive test method, the amount of time that an works for a healthcare company in several states, and
individual candidate takes on the exam varies; that a nurse works in telehealth with care provided via
time is not an indicator of passing or failing. technology in more than one state. To address these
Passing scores are the same for every state and types of issues, the NCSBN created a new model
are set by the NCSBN; they can vary from year to year. for license portability called mutual recognition or
Candidates are usually informed of their results within nurse licensure compact (NLC) (Wallis, 2015).
4 weeks; the result is pass or fail, with no specific score Each state in a mutual recognition compact must
provided. Schools of nursing receive composites of enact legislation or regulation authorizing the NLC
student results. Data on individual school pass rates and also adopting administrative rules and regu-
are available on state board of nursing websites and lations to implement the compact. Each compact
are open to the public. Results from the NCLEX state must also appoint an NLC administrator to
are an important element in a school of nursing’s facilitate the exchange of information between the
evaluation/assessment process. The first-time pass states that relates to compact nurse licensure and
rate is reviewed routinely and must be reported to regulation. Twenty-five states have adopted this
the school’s accreditation organization; in addition, model (NCSBN, 2017a). Other states have decided
the state board monitors these results. Schools of that this model is unconstitutional in their states
nursing can be put on probation by their state boards because it delegates authority for licensure decisions
of nursing if pass rates are a problem. This leads to to other states. A list of current states offering this
further evaluation of the program and monitoring of multistate licensure is available from the NCSBN
outcomes. The state boards of nursing protect students website. There have been suggestions that what is
and potential students in ensuring that the education needed is national licensure, but it is not likely to
provided will prepare them at the level expected. occur at this time (Wallis, 2015).
The same type of licensure questions applies number of hours that flight crews can work without
to APRNs. In 2002, the NCSBN Delegate Assem- sleep; the number of hours that medical residents
bly approved the adoption of model language for can work consecutively has been decreased because
a licensure compact for APRNs. Only those states of concern about fatigue and errors.
that have adopted the RN and LPN/LVN licensure
compact may implement a compact for APRNs. Foreign Nursing Graduates:
Many states are now working on implementation Entrance to Practice in the
regulations, which must be put into effect prior to United States
implementation of the compact. The APRN compact The number of nurses from other countries coming to
offers states the mechanism for mutually recognizing the United States to work and/or study has increased.
APRN licenses and authority to practice. Some nurses want to work here only temporarily;
others want to stay permanently. This movement of
Mandatory Overtime nurses internationally typically increases during a
A critical concern in practice today is requiring shortage, and today there is a worldwide shortage
nurses to work overtime. Employers make this and a lot of nursing migration (International Centre
decision, and it is called mandatory overtime. This on Nurse Migration, 2017). Nurse migration is
policy impacts the quality of care and has affected a complex area—affecting the country of origin,
staff satisfaction and burnout. Some state boards of which may then experience a shortage and the need
nursing have become involved in state legislative to effectively integrate foreign nurses in the United
efforts related to mandatory overtime. States who may not have had a the type of nursing
Although legislative and regulatory responses education we expect (Jacobson, 2015). The Interna-
have provided nurses with additional support for tional Centre for Nurse Migration provides resources
creating safer work environments, each of these for nurses who are moving from one country to
legislative responses has a significant effect on the another and information about this critical topic to
numbers and types of nursing personnel that will increase the profession’s understanding of this issue.
be required for care delivery systems in the future The NCSBN notes that each state board of
as well as the cost of care. Clearly, there is concern nursing is responsible for RN licensure for its state.
at the state and national levels regarding the impact States may vary in requirements, but all internation-
that fewer staff will have on the health and safety of ally educated nurses must pass the NCLEX exam;
patients (Loquist, 2002, p. 37). comply with standards of approved or comparable
As students and new graduates interview for education, hold a verified valid and unencumbered
their first positions, they should ask about manda- state license, and be proficient in their written and
tory overtime if they are not in a state that has a law spoken English language skills (NCSBN, 2017b).
to protect them from it. Research has been done What do these nurses have to do to meet practice
regarding sleep deprivation and its connection to requirements in the United States? The Commission
the rising number of medical errors (Girard, 2003; on Graduates of Foreign Nursing Schools (2017) is
Manfredini, Boari, & Manfredini, 2006; Montgomery, an organization that assists these nurses in evalu-
2007; Sigurdson & Ayas, 2007). This area of research ating their credentials and verifies their education,
is fairly new, and researchers will need to continue to registration, and licensure. This is an internationally
provide concrete evidence of the links among sleep recognized, immigration-neutral, nonprofit organi-
deprivation, long work hours, and medical errors. zation that protects the public by ensuring that these
Other work areas and professions have examined nurses are eligible and qualified to meet U.S. licensure
this problem and taken steps to reduce hours, for and immigration requirements. These nurses must
example, the aviation industry has cut back the also take the English as a Foreign Language Exam
to ensure that their English language ability is at future. Electronic technologies provide an opportu-
an acceptable level. This requirement also applies nity to develop a new identity for nursing practice.
to students who want to enter U.S. nursing educa- New regulatory requirements will emerge to meet
tion programs. A nurse who is licensed in another the need of practitioners to ensure public safety.
country must successfully complete the NCLEX As a new paradigm for ensuring competencies and
and meet the state licensure requirements where self-regulation in a global market evolves, the need
the nurse will practice. If the nurse wants to enter a to explore global licensure will emerge. The future
graduate nursing program, the nurse needs to get a belongs to those who will accept the challenge
U.S. RN license for clinical work that is required in to make a difference in a global marketplace and
the educational program. Licensure is not required take the necessary risks to make things happen”
to enter a pre-licensure program (BSN) in nursing, (Fernandez & Hebert, 2004, p. 132).
but it is required for a graduate nursing program. The Global Alliance for Leadership in Nursing
Education (GANES, 2017) is a nursing organization
Global Health Regulatory Issues that focuses on getting nurse educators from around
With the development of the Internet, telehealth and the world to work together to develop and facilitate
global migration have forced nursing to confront the nursing education and professional development for
need to examine changes related to interstate nursing nurses worldwide in order to improve care globally.
practice and possible responses. Globalization has These efforts recognize the need for international
had a similar impact on migration (Fernandez & standards in nursing education. Nursing has moved
Hebert, 2004). This migration phenomenon sup- from a focus on individual hospitals, to the state
ports the need for an international credentialing of level, to the national level, and now to a global level.
immigrant nurses to ensure public safety as defined
by the International Council of Nurses (Schaefer,
1990). “New models for practice will continue to Regulation protects patients.
emerge to manage change, care, and plan for the
CHAPTER HIGHLIGHTS
1. The evolution of nursing education influ- Different levels of nursing pre-licensure

ences how nursing is taught. education have different competencies and
2. Nursing has multiple types of programs expectations, yet nurses at all levels take the
and degrees: diploma, associate degree, same licensure examination.
baccalaureate, master’s, and doctoral levels. 6. Nursing education is undergoing changes
3. Nursing organizations, such as AACN and to improve and meet needs.
NLN, guide nursing education, provide 7. Interprofessional education is now an im-
resources, and accreditation. portant consideration in nursing education.
4. There is a need to improve nursing educa- 8. Examples of critical concerns related to
tion to better meet patient care needs—for education, regulation, and practice are
example, use of standards, competencies, compact licensure, mandatory overtime,
recognition of excellence, and accreditation. and global migration of nurses.
5. Licensure and regulation of nursing practice
set standards and rules for nursing education.
1. Why do you think it is important that nursing 4. Visit the NCLEX website (https://www.ncsbn
now emphasize education over training? .org/nclex.htm). Review and describe the
Consider Donahue’s definitions for education exam process and what happens on exam
and training found in the chapter. How has day. Go to https://www.ncsbn.org/1287
apprenticeship been adapted to current .htm and review the current NCLEX-RN
nursing education needs? detailed test plan for candidates. Which
2. Compare and contrast the types of entry type of information is included in the plan?
programs in nursing: diploma, ADN, BSN, How might this information help you, both
and accelerated or direct entry programs. now and closer to the time when you take
3. Select one of the following graduate nursing the NCLEX?
programs (master’s—any type; DNP or PhD) 5. Does your state participate in the NLC? Visit
and find, through the Internet, two different https://www.ncsbn.org/158.htm to find out.
universities that offer the program. Compare Why might this be important to you if you
and contrast admission requirements and choose to be licensed in your state after
the curricula. graduation?
1. Conduct a debate in class with another PhD in nursing, with the other classmate
classmate. Take the side of diploma, associate supporting the DNP. The class should
degree, or both levels of entry into practice, then vote on the side that presents the
with the other classmate supporting the best support for one of the perspectives.
BSN as the entry into practice level. The class You will need to research your issue and
should then vote on the side that presents present a substantiated rationale for your
the best support for one of the perspectives. side of the issue.
You will need to research your issue and 3. Consider your nursing education program.
present a substantiated rationale for your What aspects do you think are effective
side of the issue. for you as a student, and why? What are
2. Conduct a debate in class with another problems you identify, and what ideas do
classmate. Take the side supporting the you have for solutions?
Electronic Reflection journal

Assess your current nursing program—you may not be in the program long, but
consider your admission process, orientation, any courses you have taken (non-nursing
and nursing), communication with faculty, relationships with other students and the culture of
the school, and any clinical or lab experiences you have had. How might you use your reflection to
improve your nursing education experiences?
CASE STUDIES
Case 1
The executive committee of your school’s Student Nurses’ Association chapter is meeting
to plan a program for the membership. A lively discussion is going on to select the topic.
One board member mentions the need to have a program about nursing education
accreditation because the school will have an accreditation survey visit next semester. The
SNA chapter president speaks up and says, “Many of us are getting ready to take NCLEX,
and we have many questions about licensure.” Both of these topics are important topics.
Consider the questions that follow.
Case Questions
1. Which topic would you choose, and why?
2. If someone said to you, “Accreditation is the business of the faculty,” what would you say?
3. Which type of content might you include in the content for a program on accreditation
and a program on licensure for your membership?
Case 2
Nursing education and the profession in general have experienced a very long
disagreement about the appropriate entry-level degree for nursing. This debate first
emerged in 1965, as noted in this chapter. In addition, authors such as Kutney-Lee, Sloane,
and Aiken have conducted studies that have concluded the BSN should be the entry-level
degree (2013). Cynthia Maskey, PhD, RN, CNE, in the March 2013 issue of Health Affairs,
responded to this study. Dr. Maskey is an OADN board member. Review the study and
Dr. Maskey’s response:
●● Article: Kutney-Lee, A., Sloane, D., & Aiken, L. (2013). An increase in the number of nurses
with baccalaureate degrees is linked to lower rates of postsurgery mortality. Health
Affairs, 32, 3579–3586.
●● At the link for this study see response by C. Maskey, The study focuses on problems, not
solutions. Retrieved from http://content.healthaffairs.org/content/32/3/579
/reply#healthaff_el_476350
Case Questions
After reading this article and visiting the website with Maskey’s response, consider the
following questions.
1. What is the study that is highlighted? Why is it important?
2. What is your view of the entry-level disagreement?
3. Does it surprise you that this issue is cause for disagreement? If so, why does it surprise you?
4. What is your opinion of the response from the ADN perspective?
5. What are the possible negative results from such a disagreement in the profession?

Write a brief paragraph that describes a case related to the following questions.
1. What is the purpose of nursing education accreditation?

2. Why do we as students need to be involved?
3. What do we want to share about our school?
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Chapter
4
Success in Your Nursing
Education Program
CHAPTER OBJECTIVES
■■ Examine how you can make the most of your ■■ Compare various methods to expand
nursing education experiences. graduate competency, such as cooperative
■■ Describe the roles of the nursing student and learning, internships, and residencies.
faculty. ■■ Explain the importance of lifelong
■■ Assess your learning style. learning.
■■ Apply tools for success in a nursing education ■■ Compare certification and credentialing.
program. ■■ Examine the need for care of self and
■■ Explain the use of clinical learning in nursing methods to support oneself as a student and
education. as a nurse.
CHAPTER OUTLINE
●● Introduction ●● Using Class Time Effectively

●● Your Pursuit of a Profession: Making the ●● Using the Internet
Most of Your Educational Experience to ●● Preparing Written Assignments and
Reach Graduation and Licensure Team Projects
●● Roles of the Student and the Faculty ●● Preparing to Take Quizzes and Exams
●● Student Learning Styles ●● Participating in Team Discussions in the
●● Tools for Success Classroom and Online
●● Time Management ●● Networking and Mentoring
●● Study Skills ●● Clinical Learning Experiences
●● Preparation ●● Clinical Lab and Simulation
●● Reading ●● Clinical Experiences or Practicums
113
●● Additional Learning Experiences to Expand ●● Chapter Highlights

Graduate Competency ●● Engaging in the Content
●● Cooperative Experiences ●● Discussion Questions
●● Nurse Internships/Externships ●● Critical Thinking Activities
●● Nurse Residency Programs ●● Electronic Reflection Journal
●● Lifelong Learning for the Professional ●● Case Studies
●● Certification and Credentialing ●● Working Backward to Develop a Case
●● Caring for Self ●● References
KEY TERMS
Burnout Debriefing Nurse residency

Certification Internship/externship Professional socialization
Clinical experiences/ Learning style Reality shock
practicum Lifelong learning Simulation
Compassion fatigue Mentor Stress
Continuing education Mentoring Stress management
Credentialing Networking Time management
Introduction Your Pursuit of a Profession:

Making the Most of Your
There is much work to do to become a professional
nurse. The history of nursing indicates that the Educational Experience to
development of the profession and its education Reach Graduation and Licensure
has been a long process. As you strive to reach
your goal, you will find that the program of study Beginning a nursing program is a serious decision.
is rigorous and not like other learning experiences It means that you have chosen to become a profes-
you have had. This chapter focuses on each student sional registered nurse (RN). This text introduces
and the experience of a nursing student—what it you to the profession and provides an orientation to
is and what you need to understand and do to be a variety of important material that will be covered
successful. Nursing education differs from other in more depth in your future courses. One topic that
types of education programs and requires extensive needs to be addressed in the initial stages of your
experiences in labs, simulation, and clinical settings. nursing education is how to make the most of the
Students are encouraged to assess their learning experience to reach your goal of graduation and
styles and methods used to successfully meet the licensure to practice as an RN and provide quality
education outcomes. Long-term education is an care. The following content discusses the roles of
important part of any profession, but especially the student and faculty, tools for success, different
for nursing. Caring for self is important both as a teaching and learning practices used in nursing ed-
student and as a practicing nurse as you prepare to ucation, opportunities to expand your experiences,
be a nurse and then when you practice. and caring for self. This is all critical content—it
Chapter 4: Success in Your Nursing Education Program 115
may not be something you will be tested on, but the or her occupational identity” (Young, Stuenkel, &
content provides some guidance to help you navigate Bawel-Brinkley, 2008, p. 105). This process takes
through the nursing education process effectively. time and is integrated throughout your nursing
This Is Not an English Lit Course! Nursing education experiences and continues through the
education is different—different from other edu- first few years of your professional life as an RN.
cational programs and courses. Students who enter
a college- or university-based nursing program
complete many courses in liberal arts and sciences Stop and Consider #1
as prerequisites to entering the full nursing curric- You can gain control of your nursing education
ulum. When they enter a nursing program, they experience.
arrive with certain expectations that are derived
from their previous experiences. Students expect a
didactic course similar to other courses they have Roles of the Student
taken, such as an English literature course. That is, and the Faculty
they expect to go to the class, sit at their desk and
listen, and then periodically turn in assignments Throughout your nursing education, you need to
and take exams. Recently, in some cases, students assume a very active role in the learning process and
have taken some of these courses online and now take responsibility for your own learning; this is not
may even expect that nursing courses are online. passive learning. Students who ask questions, read
Whether you take courses in a face-to-face and critique, apply information even if it is risky,
venue or online, nursing courses demand more. and are interested in working with others—not just
Much of the content relies on knowledge gained patients and their families, but also fellow students
in previous courses and builds to subsequent and faculty—will be more successful. Students who
courses. The expectation is that students will apply wait to be told what to do and when to do it will
content from their previous courses to their current not be as successful.
courses and to their clinical experiences. Learning Nursing faculty facilitate student learning. This
becomes more of a continuum, as opposed to neat is done by developing course content and by using
packages of content that can be filed away when teaching–learning practices to assist the student in
a course ends. Understanding is more important learning the required content and developing the
than memorizing (though some memorization is required competencies. Faculty enhance learning
required), and application of information becomes situations in the simulation laboratory and in
more important on exams and in practice. As this clinical settings by guiding students to practice and
chapter makes clear, nursing education is definitely become competent in areas of care delivery. The
not English lit! Nursing education is demanding best learning takes place when faculty and students
and complex—but how did it get this way, and why work together and communicate about needs and
is it this way? expectations. Faculty members not only plan for a
Professional socialization is part of nursing group of students, but also assess the learning needs
education. It is described as follows: “[T]ransition of individual students and work with them to meet
into professional practice is characterized by the the course and program objectives or outcomes.
acquisition of the skills, knowledge, and behaviors A critical key to success with faculty is communica-
needed to successfully function as a professional nurse. tion: Ask questions, ask for explanation if confused,
This process involves the new nurse’s internalization meet course requirements when due, and use the
of the values, attitudes, and goals that comprise his faculty as a resource to enhance learning.
Becoming an RN involves more than just What does learning style mean? Learning style
graduating from a nursing program. New graduates is a student’s preferences for different types of
must pass the NCLEX, an examination that is not learning and instructional activities. There are a
offered by the school of nursing but rather through variety of views of these styles. In doing a personal
the National Council of State Boards of Nursing learning style self-assessment, you might apply
(NCSBN) and state boards of nursing as discussed Kolb’s (1984) learning style inventory, which was
in other content in this text. Throughout the nursing further developed by Honey and Mumford (1986,
program, students may be offered opportunities 1992). Kolb described a continuum of four learn-
to complete practice exams and receive feedback. ing styles: (1) concrete experiences, (2) reflective
In addition, course exam questions are typically observation, (3) abstract conceptualization, and
written in the formats found in the NCLEX, such (4) active experimentation. No person can be placed
as application of knowledge questions rather than in only one style category, but most people have a
questions relating to memorized content. Becoming predominant style (Kolb, 1984, as cited in Rassool &
comfortable with this format is often difficult for Rawaf, 2007, pp. 36–37):
new nursing students because they are accustomed
■■ Divergers: Sensitive, imaginative, and people
to taking exams in non-nursing courses that focus
oriented; often enter professions such as
less on application and do not build on knowledge
nursing; excel in brainstorming sessions.
gained from course to course. For example, in nursing
■■ Assimilators: Less focused on people and more
you complete the anatomy and physiology course,
interested in ideas and abstract concepts.
and then you are expected to apply this information
Excel in organizing and presenting informa-
later when you take exams on clinical content. You
tion; prefer formal education formats; prefer
learn about blood flow through the heart, and then,
reading, lectures, exploring analytical models,
in conjunction with adult health content, you are
and having time to think things through.
expected to understand this content and apply it
■■ Convergers: Solve problems and prefer tech-
when providing care to a patient with a myocardial
nical tasks; less concerned with people and
infarction (heart attack). Months or even a year or
interpersonal aspects; often choose careers
more may elapse between when you complete the
in technology; excel in getting things done.
anatomy and physiology course and when you take
■■ Accommodators: People-oriented, active learn-
an adult health course or care for a patient with a
ers; excel in concrete experience and active
myocardial infarction.
experimentation; prefer to take a practical
or experimental approach; attracted to new
Stop and Consider #2 challenges and experiences.
Both faculty and students have responsibilities in
Adapting Kolb’s proposed styles, the following
the nursing education process.
has been described by Rassool and Rawaf (2007):
■■ Activists: Having an experience. Focus on
Student Learning Styles immediate experience; interested in here
and now; like to initiate new challenges and
As you enter nursing courses, it is helpful for you be the center of attention.
to consider your own preferred learning style and ■■ Reflectors: Reviewing the experience.
to determine how your style might or might not ■■ Observers: Prefer to analyze experiences before
be effective. If it is not effective, you may need to taking action; good listeners; cautious; tend
consider changes. to adopt a low profile.
■■ Theorists: Concluding from experience. Adopt the clinical component of the program has a major
a logical and rational approach to problem impact on your schedule. You need to prepare for
solving but need some structure with a clear the clinical component and work this activity into
purpose or goal; learning is weakest when your schedule to meet course requirements. Study
they do not understand the purpose, when skills and test-taking skills are critical. This educa-
activities are less structured, and when feelings tional experience will not be without some stress;
are emphasized. thus, if you develop stress management skills to help
■■ Pragmatists: Planning the next steps. Prefer to you cope, you will find that the experience can be
try out new ideas and techniques to see if they handled better. Exhibit 4-1 provides some links to
work in practice; are practical and down to earth; websites with tools for student success.
like solving problems and making decisions.
Understanding your style can help you when you Time Management
approach new content, read assignments, and Time management is not difficult to define, but
participate in other learning activities. It can affect it is difficult to achieve. Learning how to manage
how easy or difficult the content and assignments time and requirements is also very important to
may be for you. You may need to stretch—that is, to effective nursing practice. Time management skills
try to learn or do something that is challenging for in school are not different from what is required for
you—and you may need to adapt your learning style. clinical practicums and after graduation in practice.
Figure 4-1 describes how to get started with time
management.
Your past learning styles may or may not effective There never is enough time, it seems, and no one
for you in the nursing program. can make more time, so it is best to figure out how
to make the most of your available time. Everyone
has felt unproductive or been guilty of squandering
Tools for Success time. In simple terms, productivity is the ratio of
inputs to outputs. What does a person put into a
Organization and time management are very important task or activity (resources such as time, energy,
tools for success in a nursing program. In the past, money, give up doing something else, and so forth)
you may have gone to class for a few hours a day, that then leads to outcomes or results? For example,
but in nursing programs, some courses meet once or one student studies 12 hours for an exam and then
several times a week for several hours. Some courses gives up going to a film with friends; another student
may be taught online but require some attendance in studies 5 hours and goes to the same film. These two
a classroom setting—but maybe none. In addition, students put different levels of resources into exam
Exhibit 4-1 Links for Student Success
Study tips: https://www.studytips.org/

Controlling procrastination: http://www.how-to-study.com/study-skills-articles/procrastination.asp
Test-taking strategies: http://www.d.umn.edu/kmc/student/loon/acad/strat/test_take.html
Test-taking checklist: http://www.d.umn.edu/kmc/student/loon/acad/strat/testcheck.html
Formulate a chart for keeping

track of the activities completed...
(daily, weekly, and monthly).
Stick to completing
the task on time Make sure to
within the time review your
frame you allotted. daily schedule.
Stay focused on the Time

Develop strategies to
assignment that is management
most important and follow in order to meet
needs to be your schedules (daily,
(Can be used monthly,
completed first. weekly, and daily) weekly, or monthly).
It could be Take notice of the

necessary to assignments that
change your must be completed
priorities daily. by the end of the day,
week, or month.
Make sure to prioritize

your assignments based
on the due date and
importance.
Figure 4-1 Getting Started with Time Management

Reproduced from Wilfong, D., Szolis, C., & Haus, C. (2007). Nursing school success: Tools for constructing your future.
Sudbury, MA: Jones & Bartlett Learning.
preparation, and they get different results—the first all of your activities, including time spent on each
student makes an A on the exam and the second a B. activity and interruptions. If you commit to doing
The second student then has to decide if it was worth this, you need to be honest so that the data truly
it. Should more time be spent on studying for exams reflect your activities. After the data are collected, you
and the personal schedule arranged to allow for some then need to analyze the data using these questions:
fun, but after exams? Or is the B grade acceptable? ■■ Did you set any priorities, and did you
The student with the A grade may decide too much adhere to them?
time was spent on studying, was not productive, and ■■ What were your activities, and how long
could have been organized better to reduce study did each take?
time. This more global perspective is certainly one ■■ Do you see a difference on certain days as to
aspect of time management, but time management activities and time?
also gets into the details of how one uses time to be ■■ What did you complete, and what did you
efficient and effective, such as what the student with not complete? Can you identify reasons for
the A grade considered. You need to know yourself not completing a task or project?
and what works for you. ■■ Which types of interruptions did you have?
Time analysis is used to assess how one uses How many interruptions were really import-
time. You might keep a log for a week and record ant, and why?
■■ Did you procrastinate? Are there certain can also interfere with time management. For ex-
activities that you put off more than others? ample, you may stop what you are doing to answer
Why? an email or a text message that just arrived, or you
■■ Did you jump from one task to another, may spend so much time syncing all this technology
and why? that the work does not get done. Managing time
■■ Look at your telephone calls, e-mails, texting, today means managing personal technology, too.
and so on. How did they affect your time Many people struggle with the same time
management? management problems. Consider these examples
■■ Did you spend time getting ready to do a and how they might apply to you:
task, to communicate with others, and so ■■ No planning—not using a calendar effectively
on? Was some of this required, or could it or not using one
have been done more effectively? ■■ Not setting goals and priorities, or having
■■ Did you take breaks? (Breaks are important.) unclear goals and priorities
How many breaks did you take, how long were ■■ Allowing too many interruptions
they, and what did you do? Did it refresh you? ■■ Getting started without preparing
■■ Did you consult your calendar and use it as a ■■ Inability to say, “No,” often leading to over-
guide? commitment (the most common problem
■■ Are there times during the day when you for many people)
are more productive? Knowing when you ■■ Inability to concentrate
tend to be more productive provides you ■■ Insufficient rest, sleep, exercise, and unhealthy
with opportunity to capitalize on this and diet, making one feel perpetually tired
be more productive. ■■ High stress level
You need to work on time management and ■■ Too much socializing when work needs
planning as a student because nurses need to be to be done—not knowing how to find the
able to plan their day’s work and still be flexible right balance
as changes occur. Ideally, nurses set priorities and ■■ Ineffective use of communication tools,
follow through, evaluate how they use their time, including overuse of email, computer and
and cut down on wasted time so that care can Internet, cell phone, and so on
be delivered effectively and in a timely manner. ■■ Too much crisis management—waiting too
They use communication effectively and prepare long to act so that it is then a crisis to get
for procedures and other care delivery activities the work done
in an organized manner so that they are not ■■ Inability to break down large projects into
running back and forth to get supplies and so on. smaller projects or steps
They handle interruptions by determining what ■■ Wasting time—little tasks, procrastination
is important and what can wait. Your success in Other, more serious problems can have a major
meeting these demands relates to your need to impact on time management. These difficulties arise
assess your own time management and learn time when the student does not feel competent or does not
management skills. know what is expected. Students often experience
Technology has made life easier and more these problems, although they may not recognize
organized in some respects, especially the use of them or want to admit them. Nevertheless, these
computers, smartphones, and tablets, as well as feelings can lead to problems with time manage-
emails, text messaging, and other communication ment as students struggle to feel better and/or try
methods. However, these new devices and methods to figure out what they are supposed to do. If you
experience one or both of these feelings, you need issues when prioritizing is determining who should
to talk to your faculty openly about your concerns. complete the task. Perhaps someone else is a better
You are not expected to be perfect. The educational choice to complete the task; in this case, the task
process is focused on helping you gradually build may be delegated, a topic discussed in this text.
your competence. In some cases, perfectionism Tasks and activities can be dissected. Consider
actually becomes a barrier to completing a task; what the needs of the task are; when it is due; how
you may fear that the task will not be completed long it will take; how critical it is; what impact it
perfectly, so you avoid the task or work on it longer will have; and what the consequences will be if it
than needed. is postponed or not completed. Plan how the work
Benner (2001) described the experience of will be done to meet the due date. Large projects are
moving from novice to expert in nursing, which best broken into smaller parts or steps. For example,
is a practice profession. Beginners or novices have the preparation of a major paper should be broken
no experience as nurses, and therefore, must gain into a series of tasks, such as identifying the topic or
clinical knowledge and expertise (competence) problem, working with a team (if writing the paper
over time. A beginning student may enter a nurs- is a team assignment), completing the research for
ing program with some nursing care experience, the paper, writing the paper (which should begin
such as nursing aide experience. That student may with an outline), reviewing and editing, and pol-
then be at a different novice level but still a novice. ishing the final draft. Building in deadlines for the
A graduate will not be an expert; this comes with steps will help ensure that the final due date is met.
time and experience. This change in status can be Many large papers or projects in nursing courses
difficult for students who may have felt that they cannot be completed overnight. They may require
were competent in understanding the content after active learning, such as interviews, assessments,
a course such as American history or introduction and other types of activities. A presentation may
to sociology. Nursing competency, however, is need to be developed after the paper is written
developed over time. Each course and its content or a poster designed. Often, this type of work is
are relevant to subsequent courses. There is no neat done with a team of students, which is important
packaging that allows one to say, “I have mastered because nurses work in teams. Group efforts take
all there is to know about nursing” or this topic. more time because team members have to learn
Health care is ever changing. The profession must to work together, develop a teamwork plan, and
adapt to changes, new knowledge and technology, meet if necessary. Some team assignments are now
identification of new health problems, and so on. done “virtually,” through online activities in which
Another component of time management is students never physically meet. Getting prepared
setting clear goals and priorities. This helps to orga- for the clinical experience/practicum is also a larger
nize your time and focus your activities. You need task that will be described later in this chapter. All
to consider what is needed now and what is needed of this takes organization.
later. This is not always advice that is easy to follow; Some strategies for improving time manage-
sometimes a student might prefer to work on a task ment that you might consider include the following:
that is not due for a while, avoiding work that needs ■■ Use a calendar or electronic method for a
to be done sooner. Sometimes writing down goals calendar; update it as needed.
and priorities and putting this information where ■■ Develop a daily time management plan (see
it can be seen to focus more on a time management Figure 4-2).
plan. Delegation plays a major role in health care ■■ Decrease socializing at certain times to
and is related to time management. One of the key improve production.
DAILY TIME MANAGEMENT WORKSHEET
Projected Projected Actual Time Taken

Primary Task Start Time Finish Time to Complete Task
Secondary Task
Figure 4-2 Daily Time Management Worksheet

■■ Limit use of your cell phone, text messaging, ■■ Do not use electronic communication during
and email during key times. class for non-class-related interaction or during
■■ Identify typical interruptions and control them. clinical experiences.
■■ Anticipate—flexibility is necessary because ■■ Do the right thing right, working effectively
something can happen that will disturb the and efficiently.
plan. ■■ Remember that time management is not
■■ Determine the best time to read, study, prepare a static process, but rather a dynamic one;
for an exam, write papers, and so on. Some your time management needs will change.
people do better in early morning; others ■■ Organize your electronic course files so that
are more effective late at night. Know what they are easy to use.
works best for you.
Work in blocks of time, minimizing interruptions.
Study Skills
■■
■■ Develop methods for note taking and or-

ganizing learning materials to decrease the Study skills are developed over time; however, this
need to hunt for these materials. does not mean that these skills cannot always be
■■ Conquer procrastination. Try dividing tasks improved. You may also find you need to use dif-
into smaller parts to get a project done. ferent study skills for nursing courses and clinical
■■ Come prepared to class, clinical laboratory, experiences. This is the time to review your study
and clinical settings. Preparation means that skills and determine what can be done to improve
less time will be spent figuring out what needs them. Typical components of study skills are read-
to be done when you need to be doing it. ing, using class time effectively, preparing written
assignments and team projects, and preparing for rather than entire chapters, so making note of the
discussions and other in class learning activities, details of a reading assignment is critical. Review
quizzes, and exams. In nursing, clinical prepara- a chapter to become familiar with its structure.
tion, which is new for students entering nursing Typically, there are objectives or outcomes, chapter
programs, is also a key area. outline, and key terms; content divided into sec-
tions; additional elements, such as exhibits, figures,
Preparation and boxed information; and finally the summary,
Students need to prepare for class, whether it is a learning activities, and references. An increasing
face-to-face class, a seminar, or an online course. number of textbooks have an affiliated website that
The first issue is what to prepare. The guide for this offer additional information and learning activities
is the focus of the experience and its objectives/ and, in some cases, quiz-style questions.
learning outcomes. Use the course syllabus and Many textbooks are now published as e-books,
other course materials as a guide to the course and as an option or offered in both e-book and hard copy.
the expectations of students. The format influences E-books are often highly interactive (for example,
preparation—for example, use of a class session you can highlight material, take notes, and search
with 60 students versus a seminar with 10 students. for content in the text) and can be downloaded to
The latter is an experience in which the student will computers and tablets, smartphones, and so on.
undoubtedly be expected to respond to questions These trends are likely to continue.
and discuss issues. The larger class may vary; it Yes, this is all overwhelming, and where does
could be a straight lecture, with little participation one begin? How do you make the best use of your
expected, or it could include participation requiring reading time? Reading should focus on four goals:
preparation—in class team discussion. You need 1. Learning information for recall is memorizing.
to be clear about the course expectations. If the This is important for some content, but if it is
course syllabus or other course materials do not the only focus of reading, you will not be able
provide clear explanations, you are responsible for to apply the information and build on learning.
asking about expectations or seeking clarification of 2. Comprehension of general principles, facts,
confusing expectations. You then need to complete and examples is an important component of
any work such as reading or research a topic that effective reading.
is expected prior to the class or the learning expe- 3. Critical evaluation of the content should be part
rience to improve your learning. Class time often of your reading process. Ask yourself questions
emphasizes application of information. and challenge the content. Does it make sense?
4. Application of content is critical in nursing
Reading because nursing is a practice-oriented profes-
There is much reading to do in a nursing program, sion. For example, at some point you will take a
ranging from textbooks and published articles to In- course that focuses on maternal–child content;
ternet resources and handout materials that faculty later, you will be expected to apply that content
may provide. It is very easy to become overwhelmed in a clinical pediatric unit. How you read and
by these materials. Explore the textbook(s) for the understand the content will make a difference
course from front to back. Sometimes students do on your ability to apply the content to a case
not realize that a textbook has a valuable glossary, in the classroom, a simulation experience, or
appendix, and index that could help them. Review in a clinical setting.
the table of contents to become familiar with the As noted in the previous section on time man-
text content. Some faculty may assign specific pages agement, time is precious. The student who is trying
to develop more effective reading skills should not ■■ Note exhibits, figures, and boxes. (This is
waste time reading ineffectively, but rather should when it is important to check the reading
accomplish specific goals in a timely manner. The assignment. Does it specify pages or content
following are some tips to use in tackling a chapter: to read or ignore?)
■■ Take a quick look at the chapter elements— ■■ Some students make notes in the margins,
objectives, terms, and major headers—and highlight key points, and so on.
compare them with the course content Figures 4-3 and 4-4 illustrate two different formats
expectations. Pay particular attention to the for organizing notes from readings (if notes are
chapter outline, if there is one, and to the taken). The format in Figure 4-3 can also be used
summary, conclusions, and/or key points to take notes in class.
at the end of the chapter.
■■ Read through the chapter not for details, but Using Class Time Effectively
to get a general idea of the content. Attending a class session can be a positive or nega-
■■ Go back and use a marker to highlight key tive learning experience. Preparation is important.
concepts, terms, and ideas. If this is done first, In addition, how you approach the course and an
it can lead to over-marking. Using different individual course session is important. If you have
colors for different levels of content may be trouble concentrating, sitting in the back of the
useful for some students. You will need to go room may not be the best approach. Sitting with
back and study the content; just highlighting friends can be helpful, but if it means you cannot
content is not studying. The goal is to find a concentrate, alternatives need to be considered. It is
system that works for you. If using an e-book, often difficult to disconnect from other issues and
understand and use its features. problems, but class time is not the place to focus
Left-hand column Right-hand column
Main ideas go here Details go here
Figure 4-3 Taking Two-Column Notes

UNIT
Topic
U O
N R
I G
Is about
T A
N
I
Z
E
R
Your test questions Strategies and tasks
Figure 4-4 Unit Organizer

on them. One of the most common issues in class access to e-books. If you choose to use these options,
involves students who use class time to prepare for research carefully what is available and how it might
another class—working on assignments, studying provide support for your learning. Make sure you
for an exam, and so on. In the end, the learning know how to use the new options prior to using them
experience on both ends is less effective. Students in a course. The Internet includes a lot of information
waste their time if they come to class without and reviews of apps that may be used by students.
completing the reading, analyzing the content, or If a course has face-to-face sessions, taking
preparing assignments. notes is important. Figures 4-3 and 4-4 illustrate
Another element of preparation for class and two methods for organizing notes. It is critical to
other learning experiences involves identifying and find a note-taking strategy that works for you. Some
accessing needed resources, such as the textbook, a students may be visual learners, in which case they
notebook, assignments, and so on. Some students may draw figures, charts, concept maps, and so on
use laptops and tablets, so planning for access if the to help them remember something—for example,
battery runs out is important. Learning will be com- using a tablet with a stylus pen to make sketch figures.
promised if a student uses electronic equipment such Going back and reviewing notes soon after a class
as a laptop, tablet, or smartphone for purposes that session will help you remember items that may need
do not involve course content. Today, tablets are used to be added and to recall information over the long
more frequently in the classroom and for studying. term. As notes are taken in class, include comments
Student options with tablets have expanded with the from faculty that begin with “This is important,”
development of apps and pens for tablet writing and “You might want to remember this,” and similar
indicators of the material’s importance. Questions Preparing Written Assignments

that faculty ask should be noted. and Team Projects
It is easy to get addicted to PowerPoint slide
The critical first step for any written assignment is to
presentations and think that if you have these
understand the assignment—what is expected. Read
available in a handout or in electronic form learn-
directions for assignments carefully and ask questions
ing has taken place. In reality, this presentation
if unsure of expectations. What are the evaluation
content is only part of the content that nursing
rubrics? You then complete the assignment based
students are expected to learn—and just having
on these expectations. If the assignment describes
them does not mean you understand the mate-
specific areas to cover in a paper, this should be an
rial. The faculty may make additional comments
important part of the outline for the paper—and
related to the content on the slides. Students
these areas may even be used as key headers in the
need to pay attention to content found in reading
paper. Faculty will look for the content based on
assignments, research, written assignments, and
the assignment outline. If you have questions about
clinical experiences. Online courses also may
the assignment as you work on the assignment, ask
include PowerPoint slide presentations, and some
prior to submission.
may have audio components.
For some assignments, students select their
topics. If possible, selecting a topic similar to one
Using the Internet used for a different assignment might save some
The Internet has become a critical tool in the world time, but this does not mean that the student may
today. As students increasingly turn to the Internet to submit an assignment that was done for another
get information, it is important that reputable websites course. Plagiarism and submitting the same paper
are used. Government sites are always appropriate or assignment for more than one course are not
sources, and professional organization sites also acceptable. You need to be aware of and apply
have valuable and appropriate information. Identify your school’s honor code. This includes cheating
who sponsors the site. Bias is always a concern; for on exams or quizzes, which demonstrates a lack of
example, the site for a pharmaceutical company professional ethics.
will inevitably praise that company’s own products. Correct grammar, spelling, writing style, and
Wikipedia is not considered a scholarly resource for citation format are critical for every written assign-
references. When using a site, check when it was last ment. Nurses need to know how to communicate
updated. Sites that are not updated regularly have a both orally and in written form. Use your school’s
greater chance of including outdated information. required method for citations. Editing your work
In addition, the Internet is now used frequently and checking is your responsibility before you
for literature searches, usually through university submit it.
libraries that offer online access to publications. Some assignments will require that you work
Students need to learn about the resources available with a team or group of students. Some students do
to them through their school libraries and learn how not like this type of project, but these experiences
to use them effectively. Often, libraries offer short provide great opportunities to learn about working
workshops to assist you (face-to-face and online) on teams, which is important in nursing. Teamwork
and also orientation materials on the library website. requires clear communication among members and
It is important to properly attribute the source for an understanding of the expectations for the work
content taken from the Internet for an assignment, that the team needs to do. Effective teams spend time
using the correct citation format required by your organizing their work and determining how they
school of nursing. will communicate with one another. To complete
team projects successfully, teams must decide how Before a major exam, getting enough rest is an
to complete the assignment, which might involve important aspect of preparation. Fatigue and sleep
analysis of a case; writing a paper; developing a poster, deprivation interfere with functioning—reading,
presentation, or educational program; or another thinking, managing time during the exam, clinical
type of activity. Having a clear plan of what needs practice, and so on. Eating is also important. Students
to be done, by whom, and when will help guide usually know how they respond if they eat too little
the work and decrease conflict. Everyone is busy, or too much before an exam.
and preventing conflicts and miscommunication One aspect of nursing exams that seems to
decreases the amount of time needed to do the work. create problems for new students is the use of ap-
If serious problems arise with communication or plication questions. Preparing for a nursing exam
equality in workload that the team cannot resolve, by just memorizing facts will not lead to a positive
faculty should be consulted for guidance. Conflicts result. You do need to know factual information,
may occur, and these conflicts need to be dealt with but you must also know how to use that information
before they get worse. If the team must document in examples.
its work and evaluate peer members, this should Another common exam-taking problem is the
be done honestly, with appropriate feedback and inability to understand a multiple-choice question
comments about the work. Such evaluations are and its possible responses/answers. Students may
not easy to do. Additional information on teams is skip over words and think something is included
provided in other chapters in this text and apply to in the question that is not. They may not be able to
work you may do with a student team to complete define all the words in the question and may not
a team project. identify the key words. Reading the question and
the response options carefully will make a differ-
Preparing to Take Quizzes ence. You should identify the key words and define
and Exams them. If you do not know the answer to a question,
Quizzes and exams are inevitable parts of nursing you should narrow the choices by eliminating re-
education. Students who routinely prepare for sponses that you do understand or think might be
them will experience less pressure at quiz or exam wrong. Then, you should look for qualifiers such as
time—but this takes discipline. Building reviews “always,” “all,” “never,” “every,” and “none” because
into your study time, even if a review lasts for only these may indicate that the answer is not correct.
a short period, does make a difference. Figure 4-5 describes a system for preparing for
As is true for any aspect of a learning experience, multiple-choice exams.
knowing what is expected comes first during quiz Essay questions require different preparation and
and exam preparation. What content will be covered skills. You need to have a greater in-depth understand-
in a specific quiz or exam? What is the timeframe ing of the content to respond to an essay question.
for the quiz or the exam? What types of questions Some questions may ask for opinions. In all cases, it
are expected, and how many? Exams in nursing is important that your answer is clear and concise,
typically use multiple-choice, true or false, essay, and provides rationales, includes content relevant to the
some fill-in-the-blank questions, although the most question and to the material covered in the course,
common format is multiple-choice questions. The and presents the response in an organized manner.
first quiz or exam is always the hardest, as students This requires you to read the question carefully and
get to know the faculty and the style of questions. make sure you understand it. Sometimes the exam
Some faculty may provide a review guide, which directions may provide guidelines as to the length
should always be used. of response expected, but in many cases, this must
Scan all test

Save difficult questions
questions for last
Answer all
questions
How to take
Read the entire the test
question
Look for and use
clue words
Eliminate the
wrong answers
Pay attention to the test-

taking skills used during Multiple-choice
the exam tests
Review
the test
Study wrong answers

and list the reason for
Check correct the incorrect answer Be aware of your
answers usual test taking
errors
Pay close attention
to details
Preparing
for the test
Do sample
questions
Know the topic

to be tested
Figure 4-5 Multiple-Choice Exams

be judged according to what is required to answer important. Jotting down a quick outline will help
the question. The amount of space provided on the in focusing your response and manage your time
exam may be a good indication, but may not be. during the exam. It is important for you to review
Grammar, spelling, and writing style are also the essay response to make sure the question (or
questions) has been answered. As is true for all and begin to work toward using networking and
types of exams, you must pace yourself based on the mentoring.
allotted time for essay questions and other types of Networking is a strategy that involves using
exam questions. Spending a lot of time on questions any contact that might be helpful to you. Applying
that may be difficult is unwise. You can return to networking effectively is a skill that takes time
difficult questions and should keep this tactic in to develop. Nurses typically use networking at
mind when managing time during the exam. professional meetings. You can begin to network
in student organization activities, whether local,
Participating in Team Discussions statewide, or national. Networking allows a person
in the Classroom and Online to meet and communicate with a wide variety of
Nursing courses often include team discussion in people, exchange ideas, explore new approaches,
the classroom and/or online. You need to focus on and obtain information that might be useful. Some
the assignment requirements such as the questions networking skills are knowing how to meet new
to consider. These are critical learning experiences people, approaching an admired person, learning
that allow you to apply content, use critical thinking how to start a conversation and keep it going, re-
and clinical reasoning and judgment, and develop membering names, asking for contact information,
your communication and teamwork. Faculty may and sharing because networking works both ways.
assign students to small teams to analyze and discuss Networking can take place anywhere: in school, in
cases in the classroom or work on projects in the a work setting, at a professional meeting or during
classroom and outside the classroom. You may work organizational activities, and in social situations. It
with the same team throughout the course or work can even happen online through the use of social
with a team for a specific assignment; sometimes networking media such as LinkedIn, Facebook,
multiple teams may work together. Why is this and Twitter, but you have to be careful with what
not called group discussion? Nurses are members is communicated and how—today information can
of teams in healthcare settings, not members of become public very quickly and once public it is
groups. Students need to think of themselves as difficult to change it or delete it.
team members. You need to start thinking about Mentoring is a career development tool. A
teams and teamwork in the classroom, in online mentor–mentee relationship cannot be assigned or
learning experiences, in simulation, and during forced. A mentor is a role model and a career advisor.
clinical experiences. The critical factor with these The mentor should not have a formal relationship,
experiences is each student must feel responsible such as a supervisory or managerial relationship, with
for the work that needs to be done in these learn- the mentee. Such a linkage could cause stress and not
ing activities, which may and often does include allow the mentor and mentee to communicate openly
preparation prior to the experience such as reading without concern about possible repercussions; how-
assignments or research for more information. ever, there may come a time when a past supervisor
During the experiences all students on the team becomes a mentor to a former employee.
should be actively engaged. The mentee needs to feel comfortable with the
mentor and usually chooses the mentor. The mentor,
Networking and Mentoring of course, must agree to be part of this relationship.
A mentorship can be short term or long term. It
Professional nurses use networking and mentoring to does take some time to develop the mentor–men-
develop themselves and to help peers. Consequently, tee relationship. Today, such a relationship could
you need to understand what these concepts are occur virtually.
When entering a nursing education program, didactic/theory- or content-focused experiences, but

you might think about acquiring a mentor, yet not also clinical experiences in clinical lab or simula-
know when a possible mentor might be met. Keep tion labs and in clinical experiences in healthcare
your eye out for possible future mentors. The mentor settings (practicum). What does this mean to you
may be a nurse who works in an area where a student as a student?
has clinical experience/practicum. New graduates
can benefit from a mentorship relationship to help Clinical Lab and Simulation
guide them in early career decisions. Mentors
can give them constructive feedback about their Schools of nursing use a variety of methods for devel-
strengths and limitations and suggest improvement oping student clinical competencies. A competency
strategies. The mentor does not make decisions for is an expected behavior that you must demonstrate.
the mentee, but rather serves as a sounding board Two methods of developing clinical competencies that
to discuss options and allow the mentee to benefit have become common in nursing education are the
from the mentor’s expertise. In this way, the mentor clinical laboratory (lab) and simulation learning,
acts as a guide and a teacher. An effective mentor which is often combined with the lab experience.
has the following characteristics: The simulation lab is a learning environment that
■■ Expert in an area related to the mentee’s is configured to look like a hospital or other type
needs and interests of clinical setting and provides structured learning
■■ Honest and trustworthy experiences. The lab may take the form of a hospital
■■ Professional room, a room with multiple beds, or a specialty
■■ Supportive room such as a procedure room or operating room.
■■ Effective communicator It contains the same equipment and supplies that
■■ Teacher and motivator are used in a healthcare setting, typically a hospital.
■■ Respected and influential Some schools have a simulation area that looks like
■■ Accessible a patient’s home so that students can practice home
care prior to an actual home care visit or a clinic. The
clinical lab is typically not configured to replicate a
Stop and Consider #4 clinical setting in the same way as simulation lab;
Trying out different tools for success in learning may
although it will have some of the same equipment,
lead you to greater success.
it typically does not use the high-level equipment.
Some schools have only one type of lab—that is, a
lab for developing basic nursing skills—with less
Clinical Learning opportunity for more complex learning in a simu-
Experiences lated environment.
Students are assigned specific times in the lab
As a new student begins a nursing program, it as part of a course. Some didactic content might be
usually quickly becomes clear that nursing pro- delivered prior to the lab experience. Students are
grams are different from past learning experiences. expected to come to the lab prepared (for example,
Students need to develop competencies to provide having completed a reading assignment, viewed
quality care to patients, families, communities, a video, or completed online learning activities).
and populations. Nursing education not only uses Preparation makes the lab time more effective,
traditional didactic learning experiences, which and well-prepared students will be able to practice
may be offered through face-to-face classes offering applying what they have learned. To succeed in
this setting, students need to be motivated and give students time to incorporate their learning.
self-directed learners. (This is true for any learning Time is devoted to discussing the care provided
experience in the nursing program.) Schools have without concern for additional care that needs
different guidelines about dress and behavior in to be provided, as would occur in a clinical
the lab. In some schools, the lab is treated as if it setting. This kind of debriefing is an import-
were an actual clinical setting/agency with certain ant component of the simulation experience.
dress and behavior expectations, such as wearing During a simulation, students may work alone,
the school uniform or a lab coat and meeting all with faculty, and with other nursing students,
other uniform requirements related to appearance as well as with other healthcare professions stu-
and professional behavior in the clinical setting. dents in an interprofessional team. Faculty can
Simulation is an effective method to develop better control the types of experiences in which
clinical competency and is used as part of the students engage, whereas in the clinical setting
educational experiences of nursing students at all it is not always easy to find a patient who needs
levels—pre-licensure and graduate (Hovancsek, a specific procedure or has certain complex care
2007). Practice is important, but guided practice needs at one time. Simulation is an active learning
is even more important, and ideally this should be method, which helps the student improve critical
risk free. Practicing on a real patient always carries thinking/clinical reasoning and judgment (Billings
a risk. It is not realistic to expect that a student will & Halstead, 2005). Some schools are developing
be able to provide care without some degree of harm interprofessional simulation experiences that
potential the first time such care is given. For this involve medical, pharmacy, respiratory therapy,
reason, practicing in a setting without a real patient and other healthcare professions students. These
allows students to develop competence and gain can be very important experiences that improve
self-confidence. What does the student learn in the interprofessional teamwork over the long term.
lab? Most procedures and related competencies can
be taught in a lab, such as health assessment, wound Clinical Experiences
care, catheterization, medication administration,
or Practicums
enema, general hygiene, and much more. Complex
care may also be practiced in the simulation lab Clinical experience or practicum is part of every
setting using teams of students. nursing program. This experience occurs when
Simulation is a method that provides students students, with faculty supervision, provide care to
with as near-to-life experience as possible in which patients. Such care may be provided to individual
no patient is at risk. Levels of simulations vary, patients or to their families or significant others
ranging from low fidelity to high fidelity. The differ- (for example, providing care to a patient after
ence between levels lies in how close the simulated surgery and teaching the family how to provide
scenario comes to reality (Jeffries & Rogers, 2007). care after discharge), to communities (for example,
Simulation also can involve task trainers for learning working with a school nurse in a community), or
skills such as IV insertion. Some simulation labs to specific populations (for example, developing a
provide experiences for students in which they in- self-management education program for a group of
teract with standardized patients (actors) who role patients with diabetes). Some nursing programs begin
play for the student, following a script and scenario. this experience early in the program and others later,
Simulation also allows faculty to design learn- but all include it as part of the nursing curriculum.
ing experiences that meet a variety of learning In addition, many nursing courses include a clinical or
styles—visual, auditory, tactile, or kinesthetic—and practicum component, or they may have no didactic
component and only a clinical focus. A student procedures, and critical care issues, and plan care
might think that these courses are equivalent to effectively. Often, the student develops a written
a chemistry lab, but this is not a fair comparison. plan—perhaps in the form of a nursing care plan or
A nursing clinical experience/practicum usually a concept map—that is evaluated by faculty. Students
covers several hours per session and, in some cases, who arrive at clinical care settings unprepared will
can require 8 to 12 hours several days each week. likely be unable to meet the requirements for that day.
Students must prepare for these experiences and Typically, the clinical day begins with a short
work these hours as students. Faculty are available pre-conference where faculty may highlight par-
to guide student learning, and in some situations, ticular goals for the experience and students may
students are assigned to preceptors, who are nurses introduce their assigned patients by sharing infor-
working in the healthcare organization. Students do mation, and then the day ends with an in-depth
their clinical work in a variety of clinical settings, post-conference to discuss the day’s experiences
such as hospitals, clinics, homes, and community and outcomes.
settings. Such experiences are not equivalent to Sometimes students are assigned an obser-
taking a 2-hour chemistry lab once a week. vation experience. In this case, the student does
Typically, these practicums are conducted not participate in the care provided but observes.
in blocks of time—for example, students are in The observation should be planned. If the student
clinical practice 2 days a week for 6 hours each knows ahead of time, the student should prepare by
day. Faculty may be present the entire time or reviewing relevant information. During the obser-
may be available at the site or by telephone. The vation, the student should note factors such as what
amount of supervision depends on the level and was done, team member roles and communication,
competency of the student, the type of setting, quality care, and so on. Time should be provided to
and the objectives of the experience. The clinical discuss the observation, or other methods should be
setting may also dictate the student–faculty ratio used to report on the observation such as a written
and supervision. Settings are highly variable in their summary. These are important learning activities
requirements—a hospital, clinic, physician’s office, allowing the students and faculty to reflect on content
school, community health service, patient home, and application in practice.
rehabilitation center, long-term care facility, senior Another important aspect of clinical experi-
center, child daycare center, or mental health center, ences relates to professional responsibilities and
among others. Some experiences require that you appearance. When a nursing student is providing
are with a group of students; in others, you may care, the student is representing the profession—a
be alone. In the latter case, for example, you may point pertinent to content in this text about the image
be assigned to work with a school nurse or with a of nursing. The student needs to meet the school’s
preceptor in the intensive care unit. uniform requirement for the assigned experience,
Participating in clinical experiences (practi- be clean, and meet safety requirements (such as
cums) requires preparation. For many assigned appearance of hair) to decrease infection risk—for
experiences, you may need to go to the site of the example, washing hands as required. Students who
clinical practicum before the clinical day begins go to their clinical experience site and do not meet
(sometimes the day before) to obtain information these requirements may be sent home. Making up
about your patient(s) and plan the care for the as- clinical experiences is very difficult, and in some cases
signed time. This is done so that you are ready to impossible, because it requires reserving a clinical
provide care. You need to understand the patient’s site again and securing faculty time, student time,
history and problems, laboratory work, medications, and so on. Minimizing absences is critical; however,
if the student is sick, the student should not care for experience reality shock, but many do. One mea-
patients. Schools have specific requirements related sure that can prevent reality shock is developing
to illness and clinical experiences that should be better stress management techniques during the
followed. You should show up for every clinical nursing education experience. This will not make
experience dressed appropriately, prepared, and with the difference between your clinical experience
any required equipment, such as a stethoscope. In and the real world of work completely disappear,
addition, you need to be on time—set your alarm but it will help the new graduate cope with this
to allow plenty of preparation time and plan for change in roles and views of what is happening in
delays in traffic. All this relates to the practicing the healthcare delivery system. Another method
nurse: Employers expect nurses to come to work that helps with adjustment later after graduation
dressed as required, prepared, and on time. is to discuss situations with faculty that seem out
Students need to recognize that when they of sync with what should be done in practice.
are in clinical, they should practice at the level Faculty should be used as resources to openly
expected for their education level and to respond discuss your concerns and to learn from these
in a professional manner. Faculty expect this as do experiences. To try to reduce the postgraduate
staff. Family view students as part of the health- stress as one transitions to practice and profes-
care team and also expect that faculty and staff sional nursing has led to an increasing number
supervise students. Each student must ask for help of healthcare organizations creating externship/
when the situation is something the student does internship and residency programs to guide new
not feel comfortable doing. A critical factor with graduates through the first year of transition to
students is communication at times of transition graduate nursing status. Some schools of nursing
or handoffs. Students are responsible for sharing have also developed cooperative learning experi-
information with staff just as staff are responsible ences for their students. Nursing, unlike medicine,
for providing the information the students need pushes its “young” out of the nest without the
to care for patients. safety net of a residency period (Goode, 2004,
2007). Some of these newer methods may assist
with this problem.
Your preparation for clinical experiences makes a
difference in your learning. Cooperative Experiences
Some schools of nursing offer cooperative (co-op)
experiences during the nursing program. These
Additional Learning experiences are not common and vary in their
Experiences to Expand Graduate design. Such a program might allow students (or
Competency even require students) to take a break from courses
and work in healthcare settings. Students receive
When students approach their first nursing job after guidance in job searches, résumé development,
graduation, many experience reality shock. This interviews, and selecting the best experience. Some
is a shock reaction that occurs when an individual schools maintain lists of healthcare organizations
who has been educated in a nursing education that students often use. A co-op experience typi-
system with one view of nursing encounters a cally means the student is hired by the healthcare
different view of nursing in the practice setting organization for several months and functions in
(Kramer, 1985). New graduates do not have to an aide or assistant position supervised by RNs.
examine the use of a national accreditation program

Nurse Internships/Externships
based on standards it developed for nurse residency
Students frequently want more clinical experiences programs. The National Council of State Boards of
in the summer, when many schools of nursing do Nursing (NCSBN, 2017a) has also worked on a pilot
not offer courses, and they also want to be employed. residency program known as Transition to Practice
The nurse internship/externship is a program that (TTP) in combination with its Taxonomy of Error,
offers this kind of opportunity for students. Students Root Cause Analysis, Practice-Responsibility (TER-
are often concerned about their first job as well; they CAP) initiative. TTP and TERCAP are based on the
wonder if they are ready, and this type of experience five healthcare professions core competencies and
can help students later as they adjust to their first quality care definitions identified by the Institute
positions. Nurse internships/externships are available of Medicine (Institute of Medicine [IOM], 2003;
in some communities as opportunities sponsored by NCSBN, 2011; IOM, 2003). Figure 4-6 describes
hospitals (Beecroft, Kunzman, & Krozek, 2001). These the transition to practice model. Both The Future of
programs are not usually associated with a school of Nursing report (IOM, 2010) and the recent nursing
nursing. They are short programs, such as 10 weeks, education report (Benner, Sutphen, Leonard, &
usually offered in the summer for students who will Day, 2010) recommend residency programs as a
enter their senior year in the fall. There is variation standard part of nursing education, although at this
in the length of these programs, in what is offered to time they are not required. The progress report for
the student in the program, and in how much support The Future of Nursing report also supports the need
the student receives in the program. The student is for more residency programs in acute care and also
employed by the hospital and provided with orien- in public/community care (National Academy of
tation to the hospital, some content experiences, and Medicine, 2015).
preceptored and/or mentored experiences. Students A residency program requires that a healthcare
need to investigate these programs and find out what organization assign staff to manage the program;
each program offers and whether it meets their needs. develop content and learning activities, precepted
This type of program is particularly helpful if students experiences, and mentoring; and support gradual
want more time in an organization to determine if adjustment to higher levels of responsibility. These
they might want to work there after graduation. are paid positions, and typically the nurse resident
must commit to working for the institution for a
period of time after the residency. Such programs
Nurse Residency Programs
are proving to be helpful to new nurses and are de-
Because of concern about nursing staff turnover, creasing new graduate turnover and improving staff
replacing nurses who leave, and other job-related retention. However, not all hospitals have residencies,
issues, such as staff burnout and concern about the and admission to these programs is competitive.
level of new graduates’ preparation and retention, Some residency programs partner with schools
some hospitals have developed nurse residency of nursing—a relationship recommended by the
programs (Bowles & Candela, 2005; Casey, Fink, AACN residency standards. Residencies focus on
Krugman, & Propst, 2004; Halfer & Graf, 2006a, leadership, patient safety outcomes, and professional
2006b). After the nurse passes the licensure exam, development (American Association of Colleges of
the residency program offers the new graduate a Nursing [AACN], 2016a). In the first 6 years of the
structured transition to professional nursing practice. implementation of the AACN’s residency program,
The American Association of Colleges of the organization established 62 sites in 30 states, and
Nursing (AACN) conducted a pilot program to more have been added (AACN, 2016b). Students
REGULATION
License Nursing regulators

renewal provide new
graduates with
information on their
scope of practice, the
Educators are the Nurse Practice Act,
HS
experts in curriculum and maintaining their
T
ON
design and evaluation license throughout
2M
and will be able to their careers.
Ongoing
6–1
assist with the design institutional
of the transition support
modules.
C L I N I CA L R Practice provides
ION
• E
FEE
Y a crucial link that
ECT
will provide new
DB
AS
T
FE
S
FL
Transition modules graduates with
AC
ON
ION
RE
• SA
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planned practice
LAT
• Patient concerned care
ING
• Communication and experiences with
RE
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teamwork qualified nurses to

CE
NT
• Evidence-based practice mentor them.

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• SA
• Quality improvement
RF
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Workforce orientation
Pass NCLEX®/Newly Licensed RN/LPN
EDUCATION Transition to practice model PRACTICE
Figure 4-6 Transition to Practice Model

Reproduced from National Council State Boards of Nursing. (2017) Transition to practice model. Retrieved from
https://www.ncsbn.org/transition-to-practice.htm
who are interested in a residency experience need

to investigate these opportunities early in their Lifelong Learning
senior year. Only BSN graduates can participate in for the Professional
residency programs that follow the AACN residency
model, but some other residency programs do not Lifelong learning is one of the major characteristics
require a BSN and are open to ADN graduates. These of a professional. This model of learning includes
programs usually encourage new ADN graduates three major components:
to consider completing a BSN degree. ■■ Academic education: The courses students
take for academic credit—undergraduate and
graduate—in an institution of higher learning
Stop and Consider #6 that typically lead to a degree or completion
Nurse residency programs might be a good choice
of a certificate program. Nurses who return
for you.
to school are pursuing lifelong learning goals.
■■ Staff development education: The systematic As a student, you may wonder why lifelong
process of assessing and developing oneself learning is important to you when you are just now
to enhance performance or professional entering nursing education. In fact, lifelong learning—
development—continued competence. In- particularly the need to recognize its importance for
cluded in staff development are orientation individual nurses, the profession, healthcare orga-
(the process of introducing nursing staff to the nizations, and patient outcomes—begins when you
organization and position), training required enter a nursing education program. Students often
to do a job, and professional development. have opportunities to participate in a variety of these
■■ Continuing education: Systematic professional learning activities even as students. Such activities are
learning designed to augment knowledge, excellent opportunities to gain further knowledge
skills, and attitudes. and to better understand the importance of lifelong
In 2010, the American Nurses Association (ANA) learning. You also need to know the requirements for
published a revised version of Nursing professional continuing education (CE) in the state(s) where
development: scope and standards of practice. The you wish to apply for licensure. Lifelong learning must
following is a summary description of the standards be driven by personal responsibility to improve, even
(American Nurses Association & National Nursing in regard to required practice components. Although
Staff Development Organization, 2010). professional organizations, regulatory agencies, and
employers influence whether nurses participate in life-
■■ Assessment of educational needs
long learning, successful lifelong learning is ultimately
■■ Identification of issues and trends that might
in the hands of the learner—that is, the nurse. The
require further education
major report on nursing from the IOM (2010) includes
■■ Outcomes identification for learning activities
the recommendation that the profession ensure that
■■ Planning of learning activities
nurses engage in lifelong learning. In addition, a major
■■ Implementation of learning activities including
report focused on collaboration between nursing and
coordination of the activities, the learning
medicine examined the need for a clearer vision for
and practice environment, and consultation
lifelong learning for nurses and physicians (Ameri-
with others to enhance the learning
can Association of Colleges of Nursing & American
■■ Evaluation of the learning activities
Association of Medical Colleges, 2010). The report’s
■■ Quality of nursing professional development
recommendations focus on four areas: CE methods
practice
(for example, meetings, rounds, conferences, and so
■■ Education of the professional development
on), interprofessional education, lifelong learning,
specialist
and workplace learning. Interprofessional education
■■ Professional practice evaluation of the pro-
is mentioned in other content about academic nurs-
fessional development specialist
ing education; however, it is also relevant to lifelong
■■ Collegiality to ensure partnerships to enhance
learning. If different professions can continue to learn
learning activities
together after completion of academic programs, this
■■ Collaboration to facilitate learning
can be supportive of interprofessional collaboration
■■ Ethics
and understanding of the roles and responsibilities
■■ Advocacy
of other professions. This report also discusses an
■■ Research findings integrated into learning
issue that is not often addressed for CE—regulation.
activities
There is great variation among professions, and
■■ Resource utilization to most effectively provide
even within a profession, as to requirements for CE
learning activities
and accreditation of CE. This needs to be improved.
■■ Leadership
The natural assumption is that all nurses would to attend or complete, they should evaluate the
want to get more education and stay current, but following factors:
this is not necessarily the case. Required CE is a
■■ Accreditation of the program
great motivator. Many states require CE if nurses are
■■ Acceptance of the CE by the required body,
to maintain their licensure after initial licensure is
such as state board of nursing for licensure
received. In these states, the state board of nursing
or organization sponsoring certification
designates the number of CE credits required for
■■ Number of CE credits and related time
licensure renewal. States vary in terms of what is
commitment
considered CE—short, structured CE programs;
■■ Schedule and location, including travel issues
academic courses; attending conferences where
■■ Cost (registration fee, parking and travel,
educational content is presented; publishing; and
housing, and meals)
so on. Nurses must follow their state’s require-
■■ Qualifications of faculty
ments. Another reason for obtaining CE is to meet
■■ Whether the program is based on adult
certification requirements. The certification body
learning principles (Is the program designed
determines the amount and type of required CE. If
for the adult learner?)
a nurse is licensed in more than one state, then the
■■ Identification of needs (What does the nurse
nurse must meet the CE requirements for all states
need to gain? What are the personal or pro-
in which he or she is licensed.
fessional objectives? Does the course offer
Sources for CE contact hours are highly variable.
content to meet these objectives?)
Credit can be obtained, for example, by attending a
■■ The program’s learner objectives (Do they
1-hour or full-day educational offering, attending
correlate with personal professional objectives?)
part or all of conference, reading an article in a
■■ Whether the program is based on current
professional journal and then taking an assessment
and relevant content
quiz, or participating in an online program. Typically,
■■ Teaching methods
a fee is charged unless the costs for the program
■■ Past experiences with the provider of the
are covered, such as by a grant to the sponsoring
educational program (Quality programs
organization. Nurses do need to be careful and
attract nurses who return for other programs.)
make sure that the program’s credit is accepted by
■■ Receipt of documentation of completion with
the organization requiring the CE, so it is best that
title of program, sponsoring organization,
the organizations offering CE be accredited pro-
date, and hours noted
grams. The American Nurses Credentialing Center
(ANCC) accredits these programs, and some state Nurses are responsible for maintaining their own
boards of nursing may offer an accrediting process. CE activity records. In states where CE is required
Obtaining accreditation is voluntary, but the reality for licensure renewal, nurses may be required to
is that to get nurses to participate, accreditation is produce documentation of these activities. In addi-
critical. When a CE program is accredited through tion, nurses need to update their résumés to ensure
an organization such as ANCC, the consumer is that learning activities are included. In some cases,
assured that national standards of quality education employers require documentation of CE activities.
have been applied (American Nurses Credentialing Nurses are usually required to document learning
Center [ANCC], 2007). It is assumed that CE has activities on an annual or biannual basis.
an impact on patient outcomes and quality care, but A current issue in CE is the need for greater
this relationship is not easy to prove in a consistent emphasis on interprofessional CE to increase support
manner. When nurses select learning programs for more interprofessional teamwork. The issue is
addressed in a major report, which recommends Credentialing is a process that ensures prac-
that a national system be developed to support titioners such as RNs are qualified to perform as
interprofessional CE: “The current system of con- demonstrated by having licensure. Typically, it is used
tinuing education for health professionals is not by healthcare organizations to check for licensure
working. Continuing education for the professional of healthcare professionals (such as nurses) and to
health workforce needs to be reconsidered if the monitor continued licensure. Nurses are required to
workforce is to provide high quality health care. show their current license to their employer, and the
A more comprehensive system of CE is needed, employer may then keep a copy of the license. Every
and CPD (Continuing Professional Development) state provides access to online checks of licensure
provides a promising approach to improve the status. Education, certification, and maintenance of
quality of learning. An independent public–private malpractice insurance may also be reviewed, although
Continuing Professional Development Institute this practice varies from one healthcare organiza-
will be key to ensuring that the entire health tion to another. The goal is to protect the public by
care workforce is prepared to provide high quality, ensuring that specific state requirements are met.
safe care” (IOM, 2010, p. 3). As a follow-up to these Certification is “a process by which a nongov-
proposals, in 2013, CE accreditor organizations for ernmental agency validates, based upon predeter-
nursing, pharmacy, medicine, and other healthcare mined standards, an individual nurse’s qualification
professions met together to discuss interprofessional and knowledge for practice in a defined functional
continuing education (Accreditation Council for or clinical area of nursing” (American Association
Continuing Medical Education, 2013). Participants of Critical-Care Nurses, 2014, p. 4). It is a method
in this meeting identified goals, including creating of recognizing expertise through successful com-
standardized terminology and exploring a shared pletion of an exam focused on the certification
set of expectations and measures for interpro- specialty, recognition of completed education, and
fessional education in support of collaborative the description of clinical experience in a desig-
practice. nated specialty area covered by the certification.
Certification of nurse practitioners in the areas of
adult, family, and adult–gerontology primary care is
Stop and Consider #7 managed through the American Academy of Nurse
Even after you get your nursing degree and license,
Practitioners Certification Program (AANPCP).
you need to continue learning.
Other specialty nurse practitioner certifications are
managed through different organizations. Pursuing
this type of recognition is voluntary in that nurses
Certification and are not required to have certification, although many
Credentialing employers acknowledge its importance, and some
may require certification for certain positions—for
Certification and credentialing are recognition example, for APRNs. This recognition is now avail-
systems that identify whether nurses meet certain able in most specialty areas. For example, the ANCC
requirements or standards. These recognitions offers certification in multiple nursing specialties.
may be required or voluntary, depending on the After the nurse receives the initial certification,
circumstances. Credentialing is typically required, recertification is accomplished through demon-
whereas certification may be voluntary. To obtain strating ongoing practice and through CE. Nurses
certification or meet credentialing requirements, may be certified in multiple areas as long as they
nurses must first be licensed as RNs. meet the requirements for each area. Professional
certification in nursing is a measure of distinctive at work with patients and in their personal lives.
nursing practice, and the benefits of certification are There is still much to learn about nursing, working
widely accepted. The value of certification is not just with others, pacing oneself, and figuring out the best
significant for nursing practice—focus on profes- way to mesh a career with a personal life—finding a
sional certification is also essential to meet multiple balance and accepting that nursing is not a career of
standards within the ANCC’s Magnet Recognition perfection. All nurses need to be aware of the poten-
Program® for excellence in nursing services (ANCC, tial for burnout, which is a “syndrome manifested
2004, as cited in Shirey, 2005, p. 245). by emotional exhaustion, depersonalization, and
Certification may also be given by a healthcare reduced personal accomplishments; it commonly
organization for accomplishing a specific goal, such occurs in professions like nursing” (Garrett & Mc-
as learning to perform cardiopulmonary resuscita- Daniel, 2001, p. 92). You need to be aware of your
tion, but this is not the same type of certification work–life balance, which is “a state where the needs
that is awarded after meeting specific professional and requirements of work are weighed together to
standards described above. create an equitable share of time that allows for work
The nursing profession has proposed a con- to be completed and a professional’s private life to
sensus model for regulation that includes licensure, get attention” (Heckerson & Laser, 2006, p. 27).
accreditation, certification, and education to ensure Learning how you routinely respond to stress
greater consistency and clarity for APRN practice and developing coping skills to manage stress can
(NCSBN, 2008, 2017b). This model reflects ongoing have a major impact and, it is hoped, prevent burn-
concern about the need for uniformity in educational out later. Symptoms such as headaches, abdominal
requirements for and regulations related to APRNs. complaints, anxiety, irritability, anger, isolation,
The consensus model was fully implemented in 2015 and depression can indicate a high level of stress.
(ANCC, 2017; NCSBN, 2013). A review of anatomy and physiology explains how
stress affects the body. When you experience stress,
two hormones—adrenaline and cortisol—trigger
Stop and Consider #8 the body to react and put the nervous, endocrine,
Certification recognizes specialty nursing.
cardiovascular, and immune systems on a state of
alert. This physiological process actually is helpful
because it helps you to cope with the stress. The
Caring for Self problem may expand when these stress responses
happen frequently and over a period of months or
Caring for others is clearly the focus of nursing, but years. Stress can be felt from a real or imagined threat,
the process of caring for others can be a drain on the and the stressed person feels powerless. Exposure to
nurse. Students quickly discover that they are very constant or frequent stress can lead to chronic stress,
tired after a long day in their clinical sessions. The which can have an overall impact on a person’s health.
number of hours worked and the pace of clinical The National Institute of Occupational Safety
experiences affect staff fatigue, but stress also has an and Health (NIOSH) provides support for employees,
impact. When you graduate and practice, you may including nurses, to ensure a safe and healthy work
find that the stress does not disappear; indeed, in experience. Stress is a topic of concern for NIOSH.
some cases, it may increase, particularly during early Figure 4-7 describes a model of job stress. Six factors
years of practice. Nurses often feel that they must be generally impact job stress in a variety of settings
perfect. They may feel guilty when they cannot do and influence this model (U.S. Department of Health
everything they think they should be doing, both and Human Services [HHS], Centers for Disease
■■ Interpersonal relationships: Poor social envi-

ronment and communication, lack of support,
Stressful and so on
Risk of Career concerns: Job insecurity, lack of ad-
job ■■
injury
conditions
and
vancement, changes in staff and management,
illness and son on
■■ Environmental concerns: Risky work envi-
Individual and
ronment, high levels of noise, air pollution,
situational factors ergonomic risk, and so on
Nurses are at risk when there is work overload,
Figure 4-7 Model of Job Stress time pressure, lack of social support, staff incivility,
Reproduced from U.S. Department of Health and Human
Services. Centers for Disease Control and Prevention.
exposure to infections diseases, risk of needlestick inju-
National Institute of Occupational Safety and Health. ries, exposure to work-related violence or threats, sleep
(2014). STRESS…at work. Retrieved from http://www.cdc
deprivation, role ambiguity and conflict, understaffing,
.gov/niosh/docs/99-101/default.html
career development issues, and dealing with difficult
or seriously ill patients (HHS, CDC, NIOSH, 2008).
Control and Prevention [CDC], & National Insti- The best time to begin stress management
tute of Occupational Safety and Health [NIOSH]): is now, while you are still a student. Strategies for
■■ Design of tasks: Aspects to consider are work coping with stress can be found in a great variety
hours, heavy workload, frequency of breaks, of resources. Exhibit 4-2 identifies some websites
shift work, lack of routine and increased that provide general information about stress. The
hectic work environment, feeling of loss of following are some guidelines that can prevent and/
control when required to do tasks, and so on or reduce stress:
■■ Management style: Lack of staff input into ■■ Set some goals to achieve a work–life balance.
decisions, poor communication, lack of clear ■■ Use effective time management techniques
policies, and so on and set priorities.
Exhibit 4-2 Links to Help You Cope with Stress
Understanding and dealing with stress: http://www.mtstcil.org/skills/stress-intro.html

Understanding stress: Signs, symptoms, causes, and effects: http://helpguide.org/mental/stress
_signs.htm
Eight immediate stress-busters: http://www.medicinenet.com/script/main/art.asp?articlekey
=59875
Psych central: Stress busters: http://psychcentral.com/blog/archives/2009/03/18/10-stress-busters/
Tips to manage anxiety and stress: https://www.adaa.org/tips-manage-anxiety-and-stress
Stress management for nursing students: http://www.ahna.org/Resources/Stress-Management
/For-Nursing-Students
How to cope with stress on the job: http://nursingworld.org/Content/Resources/How-to-Cope
-with-Stress-on-the-Job.html
■■ Prepare ahead of time for assignments, quality of care. We need to make efforts as individual
quizzes, and exams. providers, a healthcare profession, and also healthcare
■■ Ask questions when confused and ask for organizations to support staff well-being and reduce
help—do not view this as a sign of weakness, burnout. This will have an impact on retaining staff
but rather as strength. and patient care improvement.
■■ Take a break—a few minutes of rest can do Compassion fatigue is the feeling of emotion
wonders. that ensues when a person is moved by the distress
■■ Get an appropriate amount of exercise, sleep, or suffering of another (Boyle, 2011; Hooper, Craig,
and a healthy diet. (Watch excessive use of Janvrin, Wetsel, & Reimels, 2010; Schantz, 2007).
caffeine.) Compassion is necessary for effective caring, but
■■ Practice self-assertion. long-term coping with exposure to the distress
■■ When you worry, focus on what is happening (both physical and emotional) of others can lead to
rather than what might happen. compassion fatigue or a state of psychic exhaustion.
■■ When you approach a problem, view it as It is the interpersonal connection with patients and
an opportunity. families that nursing provides its best care, but this
■■ Use humor. context carries risks for the nurse over time. Burnout
■■ Set aside some quiet time to just think—even is often also a reaction response to work stressors such
a short period can be productive. as staffing, workload, managerial style, staff behavior,
■■ Care for self. and so on, and occurs gradually; in contrast, compas-
Two experiences that many nurses have after sion fatigue is relational, related to caring for others,
they practice for a while are burnout and compassion and has a sudden onset (Boyle, 2011). This topic is
fatigue. These are the costs of caring, and they are included here because it relates to stress management,
similar but have some major differences. Burnout a set of skills that students need to develop while in
occurs when assertiveness–goal achievement inten- school and continue to use throughout their career.
tions are not met, and compassion fatigue occurs Interventions for burnout and compassion
when rescue-caretaking strategies are not successful fatigue fall into three categories (Boyle, 2011). First,
(Boyle, 2011). Both lead to physical and emotional maintaining a healthy work–life balance is critical,
responses and affect quality of care and staff retention. nurturing self when you can. Second, you need to
Burnout is often discussed as part of an unhealthy understand the sources of burnout and compassion
work environment that is stressful and may be fatigue. For example, compassion fatigue is often
characterized by disruptive or uncivil staff behavior associated with basic communication skills—how
and lack of staff wellbeing. The nurse may reach the do you effectively communicate with patients and
point of not wanting to go to work and have difficulty families under stress without experiencing fatigue
completing work and difficulty working with others. yourself? Third, work-setting interventions are often
In a systematic review of 27 studies that measured helpful. For example, onsite counseling, support
staff well-being and patient safety, and it was noted groups for staff, debriefing, onsite exercise and yoga,
that in 16 of the studies there was a significant cor- space to take a break, stress management techniques,
relation between poor well-being and patient safety nutritious food and snack offerings, and so on, are
(Hall, Johnson, Watt, Tsipa, & O’Connor, 2016). This important in preventing and reducing burnout and
is important information because it demonstrates compassion fatigue.
that staff status (burnout, well-being, stress levels,
and so on) affects performance, which also affects Stop and Consider #9
Self-care is important to every nurse.
patient outcomes such as safety and, ultimately,
CHAPTER HIGHLIGHTS
■■ The educational experience in nursing ■■ Students use cooperative experiences to

differs in important ways from educational expand their learning experiences during
experiences in other areas. their education program. Internships/
■■ Students and faculty have active roles externships may also be part of a student’s
in the education process, whether in education program, but they are more
the classroom setting, online, or in lab/ formalized summer programs. Residencies
simulation/clinical experiences. are formal programs, used after completion
■■ Students need to understand their own of a nursing program and obtaining licensure,
learning styles and then use this information to provide a gradual integration into nursing.
to improve their learning methods. ■■ Nurses need to be lifelong learners.
■■ Tools for success—such as reading ■■ Certification and credentialing are methods
methods, taking quizzes and exams, used to assess competency, but they do not
preparing written assignments, and so ensure competency.
on—can make a difference in student ■■ Taking care of self is critical both as a
performance. student and a practicing nurse.
1. Why is stress management important to How do they differ from one another? How
you as a student nurse and to practicing are they similar?
nurses? 3. Participate in a team discussion in class and
2. What is the purpose of a nurse residency share tools for success. You might discover
program? Search the Internet for information some new tools to help you be more suc-
about specific nurse residency programs. cessful in your studies.
1. Consider the learning styles described in success. Include an assessment of how you
this chapter. Where do you fit in? Why do use your time.
you think the style(s) applies to you? What 3. Review your school’s philosophy and curriculum.
impact do you think the style(s) you iden- What are the key themes in this information?
tified will have on your own learning in the Do you think that the themes and content are
nursing program? Are there changes you relevant to nursing practice, and if so, why?
need to work on? Do you think anything important is missing,
2. Develop a study plan for yourself that and if so, what is it? As a student, is your
incorporates information about tools for responsibility in relation to the curriculum?

During your clinical experiences, observe how nurses use their time. Describe what
you observe: Is the nurse effective? Which methods does the nurse use? How might
you learn from this observation? Keep track of your time management when in clinical sessions
and periodically comment on it in your Electronic Reflection Journal.
CASE STUDIES
Case 1
Bowers, Lauring, and Jacobson (2001) conducted a study to better understand how
nurses manage their time in long-term care settings. Their data indicated that the nurses
attempted to “create new time” when time was short. As a student, you will be confronted
with issues of time when you begin your clinical experience and then throughout your
career as a nurse. As you review this study and answer the questions consider the following
information this study that discusses the factors of longevity, working faster, changing
sequence of tasks, communicating inaccessibility, converting wasted time, and negotiating
“wasted time.”
Case Questions
1. Consider your own schedule for a week. How would these strategies apply to your own
personal methods for handling your time? How would they affect your time management,
both positively and negatively?
2. Keep this list, and during your clinical experiences, consider whether you are using these
strategies to create more time. Can time really be created? How might you solve this
problem?
Source: Bowers, B., Lauring, C., & Jacobson, N. (2001). How nurses manage time and work in long-term
care. Journal of Advanced Nursing, 33(4), 484–491.
Case 2
A nursing student is completing his first year and meets with his advisor. The discussion
is a difficult one. His advisor tells the student that he is passing, but in several courses he
is just barely passing. The student is defensive and says that no one said he had to make
all A’s. The advisor agrees with him that this is not the expectation; however, some of the
student’s grades are borderline, and more importantly, his performance in clinical sessions
has been weak. The advisor tells the student that he needs to improve. The student leaves
the meeting discouraged and not sure what to do.
Case Questions
1. What more could the advisor have done in this meeting?
2. What does the student need to do? Describe steps the student might take (consider the
content in this chapter).

questions.
1. A staff member asks: What is going on with quality data?
2. How might time management be a factor?
3. Another staff member asks: What is wrong with the staff schedule recently?
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American Association of Colleges of Nursing. (2016a). Nurse sensus model. Retrieved from http://nursecredentialing
residency. Retrieved from http://www.aacn.nche.edu .org/Certification/APRNCorner
/education-resources/nurse-residency-program Beecroft, P., Kunzman, L., & Krozek, C. (2001). RN intern-
American Association of Colleges of Nursing. (2016b). Nurse ship: Outcomes of a one-year pilot program. Journal
residency locations. Retrieved from http://www.aacn of Nursing Administration, 31(12), 575–582.
.nche.edu/education-resources/NRP-Participants Benner, P. (2001). From novice to expert (commemorative
-by-State.pdf edition). Upper Saddle River, NJ: Prentice Hall Health.
American Association of Critical-Care Nurses. (2014). Benner, P., Sutphen, P., Leonard, V., & Day, L. (2010).
Certification exam policy handbook. Retrieved from Educating nurses: A call for radical transformation.
http://www.aacn.org/wd/certifications/docs/cert San Francisco, CA: Jossey-Bass.
-policy-hndbk.pdf Billings, D., & Halstead, J. (2005). Teaching in nursing: A
American Nurses Association, & National Nursing Staff guide for faculty (2nd ed.). Philadelphia, PA: Saunders.
Development Organization. (2010). Nursing profes- Bowers, B., Lauring, C., & Jacobson, N. (2001). How nurses manage
sional development: Scope and standards of practice. time and work in long-term care. Journal of Advanced
Silver Spring, MD: Authors. Nursing, 33(4) 484–491.
Bowles, C., & Candela, L. (2005). First job experiences of Jeffries, P., & Rogers, K. (2007). Evaluating simulations. In
recent RN graduates. Journal of Nursing Administration, P. Jeffries (Ed.), Simulation in nursing education
35(3), 130–137. (pp. 87–103). New York, NY: National League for Nursing.
Boyle, D. (2011, January). Countering compassion fatigue: Kolb, D. (1984). Experiential learning: Experience as the
A requisite nursing agenda. OJIN, 16. Retrieved from source of learning and development. Toronto, ON:
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/ANAMarketplace/ANAPeriodicals/OJIN/Table Kramer, M. (1985). Why does reality shock continue? In
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Section 2
The Healthcare
Context
Section II sets the stage for
the student by introducing the
complex healthcare environment
the student now enters. The
Health Policy and Political
Action chapter introduces these
topics and considers how they
relate to the nursing profession.
The Ethics and Legal Issues
chapter discusses these related
topics affect on practice. With
this background, the Health
Promotion, Disease Prevention,
and Illness: A Community
Perspective chapter describes
the importance of the public/
community focus on healthcare
delivery. The last chapter in this
section, The Healthcare Delivery
System: Focus on Acute Care,
examines one type of healthcare
organization, the acute care
hospital, in depth as an exemplar
of how a healthcare organization
functions and nurses involvement
in these organizations.
Chapter
5
Health Policy and
Political Action
CHAPTER OBJECTIVES
■■ Discuss the importance of health policy and ■■ Discuss the role of the nurse in the political
political action. process and its importance to the profession
■■ Examine critical health policy issues and their as a whole.
impact on nurses and nursing. ■■ Analyze the impact of the Patient Protection
■■ Critique the policy-making process. and Affordable Care Act of 2010.
CHAPTER OUTLINE
●● Introduction ●● The Policy-Making Process

●● Importance of Health Policy and Political ●● The Political Process
Action ●● Nurses’ Role in the Political Process:
●● Definitions Impact on Healthcare Policy
●● Policy: Relevance to the Nation’s Health ●● Getting into the Political System and
and to Nursing Making It Work for Nursing
●● General Descriptors of U.S. Health Policy ●● Patient Protection and Affordable Care Act
●● Examples of Critical Healthcare Policy Issues of 2010
●● Cost of Health Care ●● Chapter Highlights
●● Healthcare Quality ●● Engaging in the Content
●● Disparities in Health Care ●● Discussion Questions
●● Consumers ●● Critical Thinking Activities
●● Commercialization of Health Care ●● Electronic Reflection Journal
●● Reimbursement for Nursing Care ●● Case Studies
●● Immigration and the Nursing Workforce ●● Working Backward to Develop a Case
●● Nursing Agenda: Addressing Health Policy ●● References
Issues
147
148 Section 2: The Healthcare Context
KEY TERMS
Advocacy Lobbyist Private policy

Executive branch Policy Public Health Act of 1944
Judicial branch Political action committee Public policy
Legislative branch Political competence Social Security Act of 1935
Lobbying Politics
Expertise
Introduction
■■
■■ Understanding of consumer (patient, family,

community) needs
This chapter introduces content about health policy ■■ Experience in assisting patients in making
and the political process. Both have a major impact
healthcare decisions
on individual nurses, nursing care, the nursing ■■ Understanding of the healthcare system
profession, and healthcare delivery. When nurses ■■ Understanding of interprofessional care
participate in the policy process, they are acting as ■■ A link to other healthcare professionals and
advocates for patients, as Abood explained: “Nurses
organizations
are well aware that today’s healthcare system is in
trouble and in need of change. The experiences of Nurses may assume roles in policy making at
many nurses practicing in the real world of health- the local, state, and federal levels of government.
care are motivating them to take on some form of Within these roles, they demonstrate leadership,
an advocacy role in order to influence change in expertise, advocacy, and the ability to collaborate
policies, laws, or regulations that govern the larger with others to meet identified outcomes. Sometimes
healthcare system. This type of advocacy necessitates nurses are successful in getting the policy that they
stepping beyond their own practice setting and feel is needed for patients and for nursing, and
into the less familiar world of policy and politics, a sometimes they are not. The key to policy making
world in which many nurses do not feel prepared to is to learn from past experiences and try again.
participate effectively” (Abood, 2007, p. 3).
Definitions
A policy is a course of action that affects a large
Importance of Health number of people and is inspired by a specific need
Policy and Political Action to achieve certain outcomes. The best approach
to understanding health policy is to describe the
Understanding healthcare policy requires the nurse difference between public policy and private policy.
to step back and see the broader picture of healthcare Public policy is “policy made at the legislative,
needs and delivery while understanding how such executive, and judicial branches of federal, state,
policy influences individual care. Political action is part and local levels of government that affects individual
of recognizing the need for health policy; developing and institutional behaviors under the government’s
policy and implementing policy, including financing respective jurisdiction. Public policy includes all
policy decisions; and evaluating outcomes. Nurses policies that come from government at all levels”
offer the following resources to health policy making: (Block, 2008, p. 7). Developing and implementing
Chapter 5: Health Policy and Political Action 149
policy is a method for finding solutions to problems, who receives care, which types of services are re-
but not all solutions are policies. Many solutions ceived, how reimbursement is doled out, and which
have nothing to do with government. There are two types of providers and organizations provide health
main types of public policies: (1) regulatory policies care. Because nursing is a major part of healthcare
(for example, registered nurse [RN] licensure that delivery policy, nurses need to be involved in policy
regulates practice) and (2) allocative policies, which making and be aware of policy changes.
involve money distribution. Allocative policies Each of the areas in Figure 5-1 relates to indi-
provide benefits for some at the expense of others vidual nurses and to the profession. Roles and stan-
to ensure that certain public objectives are met. dards are found in state laws and rules/regulations.
Often the allocative decision relates to funding Boards of nursing and each state’s nurse practice act
of certain healthcare programs but not others. set professional expectations and identify the scope
Health policy is policy that focuses on health and of practice for nurses in the state. Federal laws and
health-related issues, and it may be a public or rules/regulations related to Medicare and Medicaid
private policy. Examples of public policies that have address issues such as reimbursement for advanced
had national impact on health are those prohibiting practice registered nurses (APRNs). How nursing
smoking in public places (initiated through the care is provided and which care is provided are
legislative branch, which makes laws) and abortion influenced by Medicare, Medicaid, nurse practice
rulings made by the U.S. Supreme Court (initiated acts, and other laws and rules and regulations made
through the judicial branch). Private policy is by federal, state, and local governments. Health is
made by nongovernmental organizations, such as influenced by federal policy decisions related to
professional organizations, about a profession and Medicare reimbursement for preventive services,
healthcare organizations (for example, hospital, the U.S. Department of Health and Human Services
clinic). The second type of private policy, healthcare (HHS), and its agencies’ rules and regulations. An
organization policies, is discussed in later chapters agency for which rules and regulations are very
along with procedures that are usually associated
with this type of policy.
This chapter focuses on public policy related ing care
Nurs
to health. A general description of these policies Nur
sin
includes the following (Block, 2008, p. 6): re g
ca ed
to
Health-related decisions made by legislators

uca
ess
■■ tion
that then become laws
Acc
■■ Rules and regulations designed to implement

Stan
legislation and laws or are used to operate

dards of pra
government and its health-related programs

ffing
■■ Judicial decisions related to health that have

an impact on how health care is delivered,
Sta
ctic
reimbursed, and so on
e
re s
Policy: Relevance to the

du
ol ce
R
es p ro
Policies and
Nation’s Health and to Nursing
Policy has an impact on all aspects of health and Figure 5-1 Healthcare Policy: Impact on Health
healthcare delivery, such as how care is delivered, Care and Nursing
important is the Food and Drug Administration health care for citizens. When nurses advocate for
(FDA), which manages the drug approval process professional issues such as pay, work schedules,
in the United States. State laws, such as those passed the need for more nurses, and so forth, they also
in California and other states limiting or eliminating influence healthcare delivery. If there is not enough
mandatory overtime, may determine staffing levels. nurses because pay is low, then care is compromised.
Access to care is often influenced by policy, partic- If there is not enough nurses because few are entering
ularly when related to reimbursement policy and the profession or because schools do not have the
limits set on which services can be provided and funds to increase enrollment or not enough quali-
by whom. This is particularly relevant to Medicare, fied faculty, this compromises care. In other cases,
Medicaid, and state employee health insurance. nurses advocate directly for healthcare delivery
Individual organizations have their own policies issues, such as by calling for reimbursement for
and procedures, and often these are influenced hospice care or by supporting mental health parity
by public policy. Public policy also has an impact legislation to improve access to care for people with
on nursing education through laws and rules and serious mental illness.
regulations—for example, through funding for fac-
ulty and scholarships, funding to develop or expand General Descriptors of U.S.
schools of nursing and their programs, evaluation
Health Policy
standards through state boards of nursing, funding
for new nursing education programs, and much U.S. health policy can be described by the following
more. Nursing research is also influenced by policy; long-standing characteristics, which have an impact
funding for research primarily comes through gov- on the types of policies that are enacted and the
ernment sources, and legislation designates funding effectiveness of the policies (Shi & Singh, 2015).
for government research (for example, funding for First, whereas most other countries have national,
the National Institute of Nursing Research). government-run healthcare systems, the United
Nurses are experts in health care, and in that States does not. Instead, the private insurance
role they can make valuable contributions to the sector is the dominant player in the U.S. system,
healthcare policy-making process. Nurses’ expertise which is primarily employer-based insurance. The
and knowledge about health and healthcare delivery issue of a universal right to health care has been a
are important resources for policy makers. Nurses contentious one for some time. Government does
also have a long history of serving as consumer have an important role in the U.S. healthcare system,
advocates for their patients and patients’ families. but it does not have the only major role. This stance
Advocacy means to speak for or be persuasive for reflects Americans’ view that the government’s role
another’s needs. This does not mean that the nurse should be limited.
takes over for the patient. When nurses are involved The second characteristic is the approach taken
in policy development, for example, they are acting to achieve healthcare policy, which has been, and
as advocates. Nurses may get involved in policy continues to be, often fragmented and incremental.
making both as individuals and as representatives This approach does not look at the whole system and
of the nursing profession, such as by representing a how its components work or do not work together
nursing organization. Each of these forms of advocacy effectively; parts are not connected to constitute a
is an example of nursing leadership. whole. Coordination between state and federal policies,
Collaboration is very important for effective and even between the branches of the government,
policy development and implementation. The goal is also limited. The system is further complicated by
of health policy should be the provision of better the wide array of reimbursement sources.
The third characteristic is the role of the states. most recent example is S-CHIP. In 2007, Congress
States have a significant role in policy in the United tried to expand this program, but President George
States, and consequently health policies may vary W. Bush vetoed the bill. S-CHIP was established to
from state to state. Local government within states also provide states with matching funds from the federal
are involved in making policy and supporting or not government that would enable states to extend health
supporting state-level policy. In some cases, there is a insurance for children from families with incomes too
shared role with the state and federal governments—for high to meet Medicaid criteria but not high enough
example, with the Medicaid program. to purchase health insurance. Matching funds is one
The last important characteristic is the role of method used by the government to fund programs.
the president (head of the executive branch of With this method, the federal government pays for
government), which can be significant. How does half, and the states pay for the other half (or some other
the president influence healthcare policy? Consider configuration of sharing costs). Medicaid is funded with
President Clinton and his initiative to review the matching funds, whereas only the federal government
quality of health care in the United States. Clinton funds Medicare. The issue of S-CHIP came up again
established a commission to start this process. when the legislation was expiring, which opened it up
Although this commission was short term, which for cancellation or renewal with or without changes.
is the case for most commissions of this type, it set S-CHIP has been an effective program; it has provided
the direction for extensive reviews and recommen- reimbursement for needed care for many children,
dations that have been identified by the Institute improved access to care and preventive care, and im-
of Medicine (IOM). Clinton also pushed to get the proved the health status of children. Congress and the
Health Insurance Portability and Accountability administration disagreed over expansion and funding
Act (HIPAA) and the State Children’s Health of this program, and this dispute reached a stalemate
Insurance Program (S-CHIP) passed. Both laws, during the Bush administration. When President
which are examples of policies, resulted from the Obama took office, the first bill he signed was one that
work of this healthcare commission. The work of continued the expansion of this program, blocking its
this commission was supposed to be part of a major expiration. This is an example of how legislation can
healthcare reform initiative that did not succeed at be passed by one administration, vetoed by another
the time of the Clinton administration. Its initial administration, not extended, or taken up again by
goal was to make major changes in healthcare yet another administration.
reimbursement, but this did not happen. Some
significant policies did emerge from these efforts, Stop and Consider #1
such as the two previously mentioned laws and the Health policy has an impact on healthcare profes-
IOM initiative to further examine the quality of U.S. sionals, healthcare organizations, reimbursement,
healthcare delivery. The issue of healthcare reform and all aspects of health care from local, state, and
national perspectives.
was not seriously addressed again until the Obama
administration, which developed and pushed for
passage of the Patient Protection and Affordable
Care Act of 2010 (ACA). The Trump administration Examples of Critical
may initiate changes regarding the ACA; however, Healthcare Policy Issues
if this is done, it will take some time.
Some legislative efforts are diluted over time, Many healthcare policy issues are of concern to local
canceled as they run out of designated implementation communities, states, and the federal government.
time period (expiring), or they are not renewed. The Exhibit 5-1 highlights some of these issues, which
Exhibit 5-1 Potential Healthcare Policy Issues
●● Access to care ●● Immigration: Impact on care and on

●● Acute and chronic illness providers
●● Advanced practice nursing ●● Global health issues
●● Aging ●● Mental health parity
●● Changing physician practice patterns ●● Minority health
●● Healthcare costs ●● Move from acute care to increased use of
●● Healthcare reimbursement ambulatory care
●● Disparities in health care ●● Nursing education
●● Diversity in healthcare workforce ●● Poverty and health
●● Health promotion and prevention ●● Public/community health
●● Healthcare commercialization and the ●● Quality care
healthcare industrial complex ●● Reimbursement
●● Healthcare consumerism ●● Rural health care
●● Healthcare staff role changes ●● Urban health care
●● Healthcare staffing ●● Uninsured and underinsured
●● Workforce issues ●● Opioid epidemic
are often of particular concern to nurses, nursing, costs. Insurance coverage has expanded, and ben-
other healthcare professionals, and healthcare deliv- eficiaries or enrollees expect to get care when they
ery in general. How policy is developed or whether feel they need it. Insurance costs money—premiums
policy related to each of these issues is developed and other payment required of enrollees, cost to
at all may vary. Examining some of these issues in employers and to government, insurer costs, and so
more depth provides a better understanding of the on. In turn, cost containment and cost-effectiveness
complexity of health policy issues. The examples have become increasingly important. Health policy
of policy issues related to nursing covered in this often focuses on reimbursement, control of costs,
section are not the only healthcare policy issues, and greater control of provider decisions to reduce
but they illustrate the types that can be considered costs. The last of these measures has not proved
health policy issues. popular with consumers/patients.
For a long time, a critical issue has been whether
the United States should move to a universal (na-
Cost of Health Care tional) healthcare system. Coffey (2001) discussed
The cost of health care in the United States has universal health coverage and identified five reasons
risen steadily. There is no doubt that better drugs, it should be of interest to nurses, and these reasons
treatment, and technology are available today to still apply today:
improve health and meet treatment needs for many ■■ Insuring everyone with one national health
problems; unfortunately, these new preventive and program would spread the insurance risk
treatment interventions typically have increased over the entire population.
costs. Defensive medicine, in which the physician and ■■ The cost of prescription drugs would decrease.
other healthcare providers order tests and procedures ■■ Billions of dollars in administrative costs
to protect themselves from lawsuits, also increases would be saved.
■■ Competition could focus on quality, safety, workforce diversity drew attention to a critical
and patient satisfaction. policy concern—namely, inequality in access to
■■ Resources would be redirected toward patients. and services received in the U.S. healthcare system
(Institute of Medicine [IOM], 2002, 2004; Sullivan,
The ACA does not establish universal healthcare
2004). Nurses need more knowledge about culture
coverage in the United States, though it does provide
and health needs, health literacy, the ways in which
insurance coverage through Medicaid for more peo-
different groups respond to care, and healthcare
ple who cannot afford insurance and provides other
disparities. How does this impact health policy?
methods for people to enroll in healthcare insurance.
Does it mean that certain groups may not get the
It also establishes requirements for health insurance
same services (disparities)? If so, what needs to
for the U.S. population as a whole. However, it is not
change? We need regular monitoring of healthcare
clear if future changes in the ACA or new legislation
disparities, and we now do this annually when we
will alter the approach to healthcare reimbursement.
monitor healthcare quality (National Healthcare
Quality and Disparities Report, QDR) (HHS &
Healthcare Quality AHRQ, 2017b). There is additional content on
Healthcare quality is a critical topic in health care today, this critical topic in several chapters in this text,
recognizing we need to effectively monitor healthcare particularly content related to patient-centered care.
delivery and improve outcomes. Following President
Clinton’s establishment of the Advisory Commission Consumers
on Consumer Protection and Quality in Healthcare There is increasing interest in the role of consumers
(1996–1998), a whole area of policy development in health care. Today, consumers are more informed
opened up. How can healthcare quality be improved? about health and healthcare services than members
What needs to be done to accomplish this? This of previous generations. An example of a law that
focus led to the federal government’s request for the focuses on health and the consumer is the Health
Institute of Medicine, which as of 2015 is known as Insurance Portability and Accountability Act of 1996
the National Academy of Sciences, National Academy (HIPAA). The major focus of this law addresses the
of Medicine (NAM), to further assess health care in issue of transferring health insurance from one em-
the United States. This resulted in the publication of ployer to another, but it also includes expectations
major reports with recommendations related to quality regarding privacy of patient information, which
and patient and staff safety, which are components of is now a critical factor considered by healthcare
quality care. Quality health care is discussed in several providers in daily practice. With the increased em-
chapters in this text. The National Quality Strategy phasis on patient-centered care and then addition
(NQS) is a new addition to the healthcare quality of family-centered care, consumers have gained a
resources for the nation; it is included in this text’s stronger voice in their health care.
discussion about quality (U.S. Department of Health
and Human Services [HHS] & Agency for Healthcare Commercialization of
Research and Quality [AHRQ], 2017a). The mandate
Health Care
to establish the NQS is included in the ACA of 2010.
The organization of healthcare delivery systems
has been changing into a series of multipronged
Disparities in Health Care
systems, though not all healthcare organizations
The IOM reports on diversity in health care and are this type. These organizations generally form
disparities and the Sullivan report on healthcare a corporate model. Such corporations may exist in
a local community, statewide, or even nationally.

Immigration and the
In fact, some of the large healthcare corporations
also have hospitals in other countries. This change
Nursing Workforce
has had an impact on policies related to financ- Immigration of nurses to the United States has
ing health care and quality concerns. Over time, an impact on international and U.S. healthcare
commercialization of health care has led to more delivery. This is an important international policy
business practices in healthcare delivery such as issue, but one that is not yet resolved. Important
marketing, control of budgets, and so on; not all considerations in this area include regulations
of it is positive. (visas to enter the United States and work; nursing
licensure), level of language expertise, quality of
Reimbursement for education, orientation and training needs, and
Nursing Care potential limits on immigration of RNs. Some of
the issues need to be addressed by laws, rules and
Reimbursement for nursing care must be viewed
regulations, and state boards of nursing and greater
from two perspectives. The first view considers
global collaboration. Other chapters discuss issues
reimbursement methods for nursing care services,
related to this policy concern.
particularly inpatient or hospital services. There has
not been much progress in this area. Hospitals still
do not clearly identify the specific costs of nursing Stop and Consider #2
care in a manner that directly affects reimburse- Multiple healthcare policy issues are influencing
ment. The second view involves reimbursement us today.
for specific individual provider services instead

of reimbursement for an organization provider,
such as a hospital. Physicians are reimbursed for Nursing Agenda:
their services. There have been major changes in Addressing Health Policy Issues
how APRNs are reimbursed; thus, this situation
is improving though more needs to be done. For The American Nurses Association (ANA) has long
example, if an APRN provides care in a clinic or a advocated for a variety of healthcare issues through
private practice, the question arises: How are the its membership and political action. The ANA
APRN services reimbursed? Will the patient’s health identifies key issues that it will focus on during each
insurance pay for these services? Some services are congressional session. The issues vary depending
covered by federal government plans, but there is upon need; for example, the ANA advocated for
great variation in reimbursement from nongovern- the passage of the ACA and spoke about changes
ment plans. The ACA and other initiatives such as that have been recommended by some experts and
those identified in the report, The future of nursing: politicians. Examples of issues identified on the
leading change, advancing health (IOM, 2010), have ANA website for early 2017 include safe staffing,
supported greater use of APRNs. To make this safe patient handling and mobility, home health,
work, reimbursement practices will also need to nurse workforce development, health reform,
support use of APRNs. There has been, however, APRNs and veterans, RN nursing home staffing,
more movement to improve APRN reimbursement and APRNs and prescribing use of durable medical
then there has been clarification of reimbursement equipment (DME) (American Nurses Association
for nursing services in hospitals and other types [ANA], 2017). The latter issue has been successful
of healthcare organizations. in that former President Obama signed into law
the Medicare Access and CHIP Reauthorization

Act of 2015. This law provides better options for The Policy-Making Process
merit-based incentive payment and also allows
Health policy is developed at the local, state, and
APRNs to order DME for patients and meet doc-
federal levels of government, but the two most
umentation requirements for DME (ANA, 2015).
common levels are state and federal. At the state
This action opens up greater access for patients
level, the typical broad focus areas are public health
to easily get DME services with assistance from
and safety (for example, immunization, air quality,
APRNs rather than just physicians.
water safety, and so forth); care for those who cannot
Access to care means that care should be
afford it; purchasing care through state insurance,
affordable for, available to, and acceptable to a
such as for state employees; regulation (for example,
great variety of patients. Quality of care remains a
RN licensure); and resource allocation (for example,
problem in the United States. The ANA supports
funding for care services, research grants, funding
the recommendations of the IOM Quality Chasm
for nursing education). At the federal level, there
report series supporting care that is safe, timely
are many different needs and policy makers. The
effective, efficient, equitable, and patient centered.
focus areas are much the same as at the state level but
“The ANA believes that the development and im-
apply to the nation as a whole and usually are more
plementation of health policies that reflect these
complex because they require more collaborative
aims, and are based on effectiveness and outcomes
efforts to ensure national acceptance.
research, will ultimately save money” (ANA, 2005,
Federal legislation is an important source of health
p. 7). The organization’s agendas have long addressed
policy. Prior to the healthcare reform legislation of
the critical nature of the nursing workforce and
2010, the two laws that had the greatest impact on U.S.
the need for an “adequate supply of well-educated,
health care were the Social Security Act of 1935
well-distributed, and well utilized registered nurses”
and the Public Health Act of 1944. The Social
(ANA, 2005, p. 10).
Security Act established the Medicare and Medicaid
The ANA agenda is an example of how a pro-
programs, the two major government-run healthcare
fessional organization speaks for the profession,
reimbursement programs. The Public Health Act
delineates issues that need to be addressed through
consolidated all existing public health legislation
policies, commits to collaborating with others to
into one law, and it, too, has been amended over the
accomplish the agenda, and advocates for patients
years. Some of the programs and issues addressed in
through such statements and lobbying efforts.
this law are health services for migratory workers,
Individual nurses and nursing students should par-
establishment of the National Institutes of Health,
ticipate in this process. Other nursing professional
nurse training funding, prevention and primary
organizations such as specialty organizations and
care services, rural health clinics, communicable
the major nursing education organizations (the
disease control, and family planning services. These
National League for Nursing and the American
laws also provided funding for nursing education
Association of Colleges of Nursing) are also engaged
through subsequent amendments to the law. An
in policy as it pertains to their members and their
amendment to this law established Healthy People
organization goals.
in 1990 and its subsequent extensions (its current
iteration is Healthy People 2020).
Stop and Consider #3 The policy-making process is described in
The nursing agenda may have an impact on health-
Figure 5-2. The first step is to recognize that an
care policy.
issue might require a policy. The suggestion of the
1. Define the 2. Specify 3. Identify solution 4. Implement 5. Monitor and

problem criteria options and the policy evaluate the
select best policy
Figure 5-2 The Policy-Making Process
need for a policy can come from a variety of sources, be considered as the solution is selected and policy
including professional organizations, consumers/ developed. Perhaps implementation is very complex,
citizens, government agencies, and lawmakers. which in turn will affect the policy. For example, if
The second step is not to develop a policy, but a policy decision states that all U.S. citizens should
rather to learn more about the issue. This investi- receive healthcare insurance, the policy statement
gation may reveal that there is no need for a policy. is very simple; however, when implementation is
There may be, and often is, disagreement about the considered, this policy would be very complicated
need, and there may also be disagreement about to implement. How would this be done? Who would
how to resolve it if the need exists. Information and administer it? Which funds would be used to pay for
data are collected to get a clearer perspective on this system? What would happen to current employer
the issue from sources such as experts, consumers, coverage? Would all services be provided? How
professionals, relevant literature (such as professional much decision-making power would the consumer
literature), and research. have? How would providers be paid, and which
Using this information, policy makers then providers would be paid? Many more questions
identify possible solutions. They should not con- could be asked. Policy development must include
sider just one solution because only under rare an implementation plan. Social, economic, legal,
circumstances is a single solution possible. During and ethical forces influence policy implementation.
this process, policy makers consider the costs The best policy can fail if the implementation plan is
and benefits of each potential solution. Costs are not reasonable and feasible. As will be discussed in
more than financial—a cost might be that some the next section on the political process, the policy
people will not receive a service, whereas others often is legislation (law).
will. What impact will this have on both groups? Coalition building is important in gaining
After the cost–benefit analysis is done, a solution is support for a new policy and important in the
selected, and the policy is developed. It must then legislative process. As will be discussed in the
go through the approval process, a process that is next section on the political process, gaining
greatly influenced by politics. support is especially important in getting laws
It is at this time that implementation begins, passed. Regarding a healthcare issue, some groups
although how a policy might be implemented must that might be included in coalition building are
healthcare providers (for example, physicians, reality, it is more complex than this. Politics influ-
nurses, pharmacists); healthcare organizations, ences policy development and implementation, and
particularly hospitals; professional organizations sometimes politics interferes with the effectiveness
(for example, the ANA, the American Medical of policy development and implementation. Political
Association, the American Hospital Association, feasibility must be considered because this aspect
The Joint Commission, the American Association can mean the difference between a successful policy
of Colleges of Nursing, the National League for and an unsuccessful policy. Political support, usually
Nursing); state government and other organizations; from multiple groups, is critical.
elected officials; business leaders; third-party pay- As discussed, most major healthcare policy
ers; and pharmaceutical industry representatives. changes or new policies are made through the
Members of a coalition that support a policy may legislative process, though some may be made or
offer funding to support the effort, act as expert influenced by executive or judicial components of
witnesses, develop written information in support government. Steps 1–4 of the policy-making process
of the policy, and work to get others to support depicted in Figure 5-2 are similar to the legislative
the policy; some, such as lawmakers, may be in a process steps. Once the policy is developed in the
position to actually vote on the legislation. form of a proposed law, the legislative process merges
After a policy is approved and implemented, it with the policy-making process. The legislative
should be monitored and its outcomes evaluated. process varies from state to state, but all states have
Congress may require routine reports to ensure it a legislative process that is similar to the federal
is informed of the status. This type of monitoring process. When a federal bill is written and then
would also apply to the state legislative process that introduced in Congress, in addition to its title, it is
leads to state policies. This all may lead to future given an identifier that includes either H.R. (House
changes or to the determination that a policy is not of Representatives) or S. (Senate), based on which
effective or may not be needed. The process may house initiates the bill, plus a number—for example,
then begin again. H.R. 102. The bill is then assigned to a committee
or subcommittee by the leadership of the Senate
Stop and Consider #4 or House, depending on where the bill begins its
To develop effective healthcare policy, the policy- long process to determine approval through a final
making process should be followed. vote. In the committee, the bill may figuratively die,
meaning that nothing is done with it. Conversely, if
there is some support for the bill, the committee or
The Political Process the subcommittee will assess the content. This might
include holding hearings on the bill for extensive
The preceding description of the policy-making discussion, often with witnesses. Amendments may
process may seem to be a clear step-by-step process, be added. If the bill began in a subcommittee, it may
but it is not. It is greatly influenced by politics and be sent on to a full committee, and then progress to
stakeholders who are either invested in the policy the full House or Senate for vote. If the bill began
or do not want the policy. Politics is “the process in a committee, it might be sent directly to the full
of influencing the authoritative allocation of scarce House or Senate.
resources” (Kalisch & Kalisch, 1982, p. 31). Typically, When the bill gets to the full House, it first
nurses participate in the policy-making process by goes to the rules committee. There, decisions are
using or participating in the political process. Public made about debate on the bill, such as the length
policy should meet the needs of the public, but in of debate. These decisions can have an impact on
the successful passage of the bill. The Senate does This decision typically is an important political
not have a rules committee, and senators can add dialogue. In such a case, Congress may decide
amendments and filibuster or delay a vote on the not to pursue the bill any further or Congress may
bill. There is more flexibility in the Senate than decide to bring the bill back for another vote to
in the House. The leader in the Senate (majority try to override the president’s veto. This effort may
leader) and the House leader have a great deal of or may not be successful, but it often is a highly
power over the legislative process. A bill cannot politicized situation. Depending on the number
be passed only in the House or only in the Senate of votes, at this point the bill could either become
and become law; rather, both the House and the law or die.
Senate must pass the bill. Sometimes a bill is intro- If the president signs the bill or if Congress
duced at the same time in both the House and the overrides a presidential veto, the bill goes to the
Senate, allowing the approval process to proceed regulatory agency that would have jurisdiction
in both simultaneously. Decisions may then need over that particular law. For example, a health law
to be made to reconcile differences in the two would typically go to the HHS. If the law relates to
bills. If this is the case, a conference committee Medicare, it would go to the Centers for Medicare
composed of both representatives and senators and Medicaid Services (CMS), an agency within
work to make those decisions. The altered bill the HHS. It is at this point that a very important
must then go back for votes in both the House and step in the process occurs: Rules or regulations
the Senate. Funding allocation is a critical aspect are written for the law that state specifically how
of legislation and associated regulations. If both the law will be implemented, and their content
houses of Congress pass the bill, then the bill goes and implementation make a significant difference
to the president for signature. At this time, the bill in the effectiveness of the law. At specific steps in
moves from the legislative branch of government the regulatory development process, the public,
to the executive branch. Figure 5-3 identifies the including healthcare professionals such as nurses,
branches of government. can participate by providing input. It is important
The president has 10 days to decide whether to that this input be given. Once the final rules are
sign the bill into law. If the president waits longer approved, the law is implemented. There may be
than 10 days or Congress is no longer in session, a date that the law ends, or “sunsets.” If so, the law
the bill automatically becomes law just as if the may expire, or it may be reintroduced into the
president had signed it. In some cases, it is made legislative process.
public, either before the bill comes to the president Not all interested parties accept a policy, and
or soon after, that the president is vetoing a bill. efforts may be made to defeat a policy. Because of
the various viewpoints on the same issue, there
are often competing interests (Abood, 2007).
Legislative Executive Judicial In addition, partisan issues—that is, Democrat
branch branch branch
versus Republican—may affect the policy devel-
opment process. “Decision-makers rely mainly
on the political process as a way to find a course
of action that is acceptable to the various indi-
Government viduals with conflicting proposals, demands, and
values. . . . Throughout our daily lives, politics
determines who gets what, when, and how”
Figure 5-3 The Branches of the U.S. Federal
Government (Abood, 2007, p. 3).
makes it difficult for nurses to speak with one voice

Nurses’ Role in the Political
for nursing.
Process: Impact on Nurses need to develop political competence.
Healthcare Policy Political competence involves the ability to use
As healthcare professionals, nurses bring a unique opportunities, including networking, highlighting
perspective to healthcare policy development because nursing expertise, using powerful persuasion,
of their education, clinical expertise, professional demonstrating a commitment to working with
values and ethics, advocacy skills, experience with others, thinking strategically, and persevering. It
the interprofessional healthcare team, and under- means being aware of the rules of the game and
standing of health and healthcare delivery. Signif- recognizing that the other side needs something.
icant progress has occurred over the years toward Sometimes giving up or modifying one viewpoint
advancing nursing’s presence, role, and influence or action may lead to more effective results. Collec-
in the development of healthcare policy. However, tive strength can be powerful, so finding partners
more nurses need to learn how to identify issues makes a difference. Nurses can network to find
strategically; work with decision makers; understand those partners. Sometimes partners may be found
who holds the power in the workplace, commu- in the least likely groups.
nities, and state- and federal-level organizations A policy is a tool for change, and nurses are
and government; and understand who controls very adept at working with change—something
the resources for healthcare services (Ferguson, they do in practice on a daily basis. This capability
2001). Many schools of nursing offer courses on should help nurses develop political competence.
health policy particularly graduate courses, or “Successful advocacy depends on having the power,
health policy content is integrated in courses such the will, the time, and the energy, along with the
as a course that uses this text. Nursing publications, political skills needed to ‘play the game’ in the leg-
textbooks, and journals also focus on health policy. islative area” (Abood, 2007, p. 3). How can nurses
These courses or content help to prepare all nurses have an impact on healthcare policy? This is what
to better understand policy and how they might be needs to be emphasized.
involved in health policy at multiple levels.
Although the nursing profession has gained Getting into the Political
political power, it is still weaker than it should be. System and Making It Work
Put simply, given the large number of nurses in
for Nursing
the United States, the profession should have more
influential power. Each nurse is a potential voter Lobbying is a critical part of the U.S. political process,
and, therefore, has potential influence over who and nurses are involved in lobbying. A lobbyist is a
will be elected and which legislative decisions are person who represents a specific interest or interest
made. However, nursing as a profession has strug- group that tries to influence policy making. The First
gled with organizing, and this weakness has diluted Amendment to the U.S. Constitution gives citizens
the political power of nurses in the United States. the right to lobby—to assemble and to petition the
At the most basic level, nurses have experienced government for redress of grievances. Lobbyists try
serious problems defining the profession. The use to influence legislators—the decision makers—as
of multiple entry levels, licensure issues, and mul- well as public opinion. They often collaborate via
tiple titles confuse the public and other healthcare coalitions and work with other interest groups to
professionals. Policy makers may not understand gain more support for a specific interest. Lobbyists
the various nursing roles and titles, which in turn particularly want to make contact with legislative
staff. The legislative staff assume a major role in passage of the bill. An example is a recent bill that
getting data about an issue; formulating solutions addresses registered nurse staffing (S.1132), from
that may become bills, writing bills, and, if those the 114th Congress (2015–2016) (Congress.gov,
bills are passed, become laws; and communicating 2017). This bill was sent to the Committee on Fi-
with elected representatives, their bosses, to accept nance and has not moved forward. The bill focuses
a particular approach or solution. Nurses who visit on requiring hospital-wide staffing plans to meet
state and federal representatives typically meet with needs of patients and delivery of quality care. This
legislative staff. This is a form of lobbying. bill, at this time, will not pass and is dead. This type
Professional organizations hire staff to be lob- of result indicates an inability to gain support for a
byists at both state and federal levels. The ANA, the bill; reasons may vary, such as the bill’s policy issue,
National League for Nursing (NLN), the American content of the bill, other bills that may conflict or be
Association of Colleges of Nursing (AACN), and more important, disagreement among stakeholders,
other nursing organizations, for example, have lob- and more. There are committees on both sides of the
byists in Washington, DC. Lobbyists may be nurses federal legislative body, the House and the Senate.
or persons who are informed about nursing and Some of the healthcare-related committees in the
work with nurses to provide the best information U.S. Congress are identified in Exhibit 5-3.
to move an issue forward that supports nursing. Within the House and the Senate, committees
Exhibit 5-2 identifies the federal government agen- have representatives from both major parties, Dem-
cies monitored by the ANA so that the organization ocrat and Republican. The party with the majority in
is aware of legislative and regulatory activities and the House and in the Senate decides who will chair
can impact policy. committees and who will serve on each committee.
At both the state and federal levels of govern- To effectively influence legislation, it is important
ment, the legislative branches are highly dependent to understand which committee will be involved in
on committees. Legislative work occurs mainly the legislation and who is on the committee. What
within committees. If legislation (a bill) gets “stuck” are the chair’s and the committee members’ views
in a committee, this can be the critical barrier to on the issue? How can they be persuaded? Knowing
Exhibit 5-2 Important Federal Government Departments

and Agencies
U.S. Department of Health and Human Services (HHS): http://www.hhs.gov

Agency for Healthcare Research and Quality (AHRQ): http://www.ahrq.gov
Centers for Medicare and Medicaid Services (CMS): http://www.cms.hhs.gov
Centers for Disease Control and Prevention (CDC): http://www.cdc.gov
U.S. Consumer Product Safety Commission (CPSC): http://www.cpsc.gov
U.S. Food and Drug Administration (FDA): http://www.fda.gov
National Institute for Occupational Safety and Health (NIOSH): http://www.cdc.gov/NIOSH
National Institutes of Health (NIH): http://www.nih.gov
Occupational Safety and Health Administration (OSHA): http://www.osha.gov
Department of Veterans Affairs (VA): http://www.va.gov
Exhibit 5-3 U.S. Congressional Committees with Jurisdiction over

Health Matters
U.S. House of Representatives U.S. Senate

●● House Appropriations Committee ●● Senate Appropriations Committee
●● House Commerce Committee ●● Health, Education, Labor and Pensions
●● House Commerce Committee Committee
Subcommittee on Health and ●● Health, Education, Labor and Pensions
Environment Committee Subcommittee on Public Health
●● House Ways and Means Committee ●● Senate Finance Committee
●● House Ways and Means Committee ●● Senate Finance Committee Subcommittee
Subcommittee on Health on Health Care
this information can help develop a more effective but rather on whether the candidate supports issues
strategy to influence the policy content and chance important to nursing. In the end, this empowers the
of success, maybe identifying approaches to gain PAC members—in this case, nurses. The ANA PAC’s
more support from stakeholders. There may need overall goal is to improve the healthcare system in
to be some compromises and negotiating. the United States. Any nurse can join this PAC by
Political action committees (PACs) are making a contribution to support the PAC’s can-
very important in the political process. A PAC is a didate choice and participate in determining who
private group, whose size can vary, that works to get will be supported.
someone elected or defeated. PACs represent a specific Nurses need to work to get their message across
issue or group. The Federal Election Campaign Act using grassroots advocacy. Many nurses communi-
of 1971 covers PACs and how organizations may cate directly with legislators about specific issues of
use them. The law defines a PAC as an organization concern. One method of doing so is through written
that receives contributions or makes expenditures communication. In the past, this was primarily
of at least $1,000 for the purpose of influencing an done through letter writing, but now it is easier,
election. Other rules about PAC operations are also and preferred by legislators, to use email for this
identified. PACs do not force organization members purpose. Email is more efficient, and it allows nurses
to vote on certain candidates—this is always an in- to respond quickly to a request to communicate
dividual choice even if a PAC supports a candidate. their views. This request may come from a nursing
Why would nurses need to know about PACs? organization, as a result of a personal recognition
The nursing profession has its own PACs, such as that something is going on that affects health care
the ANA PAC. The ANA considers political action and nursing, or from a colleague.
to be a core mission activity, and its PAC is critical In written communication to legislators, even
to its success on Capitol Hill (ANA, 2016). The PAC if through electronic means, it is important to state
is a form of political advocacy that focuses on sup- what the issue is, provide the bill number (if the cor-
porting candidates who support nursing issues. This respondence is related to a pending bill), succinctly
organization endorses candidates, makes minimal state one’s position, and provide a brief rationale.
campaign donations based on legal requirements, and The communication should include one’s full name,
campaigns for candidates. The decision to support credentials, employment location, contact informa-
a candidate is not based on the candidate’s party, tion, and voting district. To be more effective, the best
contact is the nurse’s elected representatives. Another activities of the representative—legislation and other
method of communication is to call elected repre- interests. Provide specific information and stories that
sentatives’ offices. Before making the call, the nurse support facts, avoid generalities, and information should
should prepare a brief statement that addresses the be useful. Present your information concisely—staff
specific issue. A third method of communication is to and legislators are busy. Students who visit legislators
visit elected representatives’ offices. This could be an or their staff, for example, might discuss the need
elected official’s local office, office in the state capital, for scholarships and financial aid monies, providing
or in Washington, DC. The nurse probably will meet examples of how this support helps students to meet
with the legislative staff, preferably staff responsible career goals and provides more nurses. Follow-up is
for health issues. This is not a step down because staff important; send a thank-you note with a reminder
members play a major role in the process. Make an of the discussion.
appointment if possible and be on time. The meeting All these examples related to policy demon-
may be short or long. Be engaging, and let the staff or strate leadership by nurses who participate in these
representative/senator know what you do as a nurse, efforts to advocate for health care. Exhibit 5-4
where you work, and relevant nursing and healthcare summarizes some tips for making such grassroots
concerns. Be prepared to discuss both the topic and the efforts more effective.
Exhibit 5-4 Grassroots Tips
Letter or E-Mail Communication with ●● Be sure to communicate up front the focus

Legislators or Staff of your contact—why you are contacting
●● Make sure your topic is clear. the legislator.
●● Do not assume anything.
●● Get the facts and share them as need. Visiting Members of Congress or State
●● Be brief and concise. Legislature
●● Find a local focus—what is important to ●● You can visit when a representative is in
your city, county, state and so on. the home district, state capitol office if
●● Make it personal. state legislator, or in Washington, DC.
●● Identify that you are a nurse and include ●● You should make an appointment.
your credentials—for example, “I am a ●● Follow all guides mentioned for other
registered nurse who works at Hospital Y in methods of contact. Time will be short, so
Middletown, Missouri.” you need to be on time, prepared, and also
●● Include your contact information. be prepared to wait.
●● Do not be disappointed if you meet with
Contact with Legislators or Staff a staff person. Staff members are very
●● State: Call the state legislative body, get a important and give the representative or
directory, or visit your state government’s senator information to make decisions
website. and, in some cases, are very involved in the
●● Federal: Visit senator or representative decision making.
websites (For federal representatives: http://
●● Be ready to answer questions; prepare for
www.house.gov; http://www.senate.gov). this possibility.
●● Prepare what you will say before you make
●● Dress professionally.
contact; consider the comments made
●● Enjoy yourself and be proud that you are a
earlier about written communication. professional nurse and an expert.
Nursing organizations are involved in policy of nurses in these positions. Running for office at
development through lobbying, members and any level requires political support, finances, and
officers serving as expert witnesses to government guidance from those experienced in the world of
groups and agencies, and publishing information politics and campaigning. If you choose to pursue
about issues in both professional and nonprofes- this path, be aware that it takes time to build up
sional literature. Radio and television journalists support for a campaign.
may interview nurses. These activities place There are also government staff who may
nurses directly in the policy-making process and be nurses in many levels of government. These
also improve nurses’ public image as experts and positions provide great opportunities for nurses
consumer advocates. to use their expertise and to participate in health
The AACN holds student policy summits to policy development and implementation. Nurses
inform students, such as graduate students, about have served in high-level government positions.
involvement in Capitol Hill visits and policy work. For example, in 2013, Marilyn Tavenner, MHA,
Student participants then make visits to Capitol Hill BSN, RN, was confirmed as the administrator of
with school of nursing deans and directors. Informa- the Centers for Medicare and Medicaid Services,
tion is provided for all who make these visits so that which is part of the HHS. This is a very import-
they are prepared with the facts. The AACN faculty ant position providing oversight for the federal
and dean conferences in W ashington, DC, typically government’s (and the nation’s) largest entitle-
include visits to Congress and/or conduct sessions ment program. In 2015, she left this government
in which representatives and senators are invited position and assumed a high level position at
to speak with attendees about nursing education the American Health Insurance Plans (AHIP)
and the profession in general and implications for (Matthews, 2015).
healthcare delivery.
There are numerous opportunities for nurses
to gain some experience in the area of government Stop and Consider #5
You can participate in the political process to advo-
practice. For example, fellowships—many of which cate for health care and for the nursing profession.
are short term—at the federal and state levels pro-
vide opportunities for nurses to learn more about
politics and the legislative process and interact
with people who work in government. This is a Patient Protection and
great way to learn more about health policy and the Affordable Care Act of 2010
potential government job opportunities. Graduate
programs that focus on health policy provide formal Over the years, there have been many attempts to
academic experiences that can lead to a career in reform the U.S. healthcare delivery system. Most
the health policy field. of these efforts have failed. Political issues have
Some nurses seek election to government typically limited progress in this area—healthcare
positions at local, state, and federal levels. Others delivery is a critical political issue because it affects
serve as staff in health-related government agencies. taxes and is a very expensive business. The 2008
Nurses who serve in government positions use their presidential election brought healthcare reform
nursing expertise, and this provides many opportu- to the forefront again. As was true with other
nities for nurses to be more visible at all levels of the efforts, nursing organizations got involved and
government—legislative, administrative, and judicial. spoke out about proposed changes. It was very
However, there needs to be greater representation important that nursing do this because healthcare
reform would definitely have an impact on nurs- communities. Access is more than just the ability
ing, and it has proven to have an impact during to get an appointment; it involves the availability
its implementation. of services at times convenient for the patient
In 2010, Congress passed significant legislation, (time of day and day of week); transportation
known as the Patient Protection and Affordable to and from the care facility; reimbursement for
Care Act (ACA); it was signed into law by P resident care; and receipt of the right type of care, such as
Obama. The purpose of the law was to reform from a specialist. An increase in U.S. citizens with
some aspects of healthcare insurance coverage in insurance coverage, such as what occurred with
the United States. Although universal healthcare the ACA, has an impact on these services and the
coverage was not included in the final bill owing ability to cover costs.
to a lack of political support, more people in the Healthcare reform continues to have an impact
United States obtained health insurance coverage on nursing education, nursing practice, regulation
under this law. It did not change the traditional of nursing, and professional roles. There are pro-
employer-based approach to U.S. health insurance. visions in the ACA that relate to issues other than
The healthcare delivery system has experienced reimbursement, such as quality care, funding for
changes as a result of the various reform efforts. healthcare provider education, workforce issues,
Nurses are assuming new roles and changing old and more. The provisions did not all go into effect
ones—for example, APRNs, nurse managers, clin- at one time, which means the final results will not be
ical nurse leaders, and clinical nurse specialists. determined for some time, and now with potential
Their roles may vary, and more opportunities are changes due to the new administration, this may
opening up. In some cases, nurses with these ad- have an effect, too.
vanced degrees are eligible for admitting privileges, Since the passage of the ACA, there have
meaning that they can admit their patients to the been efforts made through the court system to
hospital from private practice or clinics. This is diminish the effects of the ACA, and part of the
not the norm, but it does occur. Healthcare reform ACA has been declared unconstitutional, so the
and other critical sources such as the report, The long-term impact of the 2010 healthcare reform
future of nursing emphasize the need to expand remains unknown due to court issues and to a new
use of APRNs in primary care (IOM, 2010). The administration—changes in the ACA or repeal of
United States is experiencing a lack of primary the law and a new law. It is important for nurses to
care providers, and with the changes in healthcare engage in the process that might bring changes to
reform increasing the number of people who have this law and be informed of the changes because
health insurance coverage, there is even greater they will not only affect the number of persons
demand for these providers. insured, but as noted, there are ACA provisions that
The large number of patients who cannot focus on quality care and also nursing education,
pay for services and have no insurance coverage particularly funding. In the future, these provisions
causes major financial problems for hospitals. In could be deleted or changed.
some situations, this may lead to the closing of
units and fewer beds (decreasing the size of the
hospital); termination of staff; and, in extreme Stop and Consider #6
The Patient Protection and Affordable Care Act of
cases, the closing of hospitals. Patient access 2010 is a law that is changing.
to care has become a major problem in some
CHAPTER HIGHLIGHTS
1. Healthcare policy directly affects nurses care, and immigration and the nursing
and nursing. workforce.
2. Nurses participate in policy making 6. The policy-making process and the political
by sharing their expertise, serving on process are connected, and it is important
policy-making committees, working with that nurses understand these processes in
consumers to get their needs known, and their advocacy efforts on behalf of consumers
serving in elected offices. and for better health care.
3. A policy is a course of action that affects a 7. Methods that nurses use when involved in
large number of people inspired by a specific the policy-making and political processes
need to achieve certain outcomes. are lobbying, interacting with legislative
4. Policies are associated with roles and stan- committees, serving on PACs, participat-
dards; specific laws and related programs, ing in grassroots advocacy, working with
such as Medicare and Medicaid; delineation elected officials who are nurses, and serving
of reimbursement requirements for services; as elected officials.
staffing levels; access to care; policies and 8. In 2010, the U.S. Congress passed, and President
procedures; and nursing education. Obama signed, significant healthcare legislation
5. Examples of critical healthcare policy issues that has led to increasing the number of citizens
relevant to nursing are variable nursing with health insurance, but the final result is
shortage and staffing, the cost of health still not full universal healthcare coverage.
care, healthcare quality and disparities, This reform (Affordable Care Act of 2010
consumer issues, commercialization of or ACA) has an impact nursing education,
health care, reimbursement for nursing practice, regulation, and roles nurses assume.
1. Why is policy important to nursing? 4. Why is advocacy a critical part of policy
2. Describe the relationship between the policy- making?
making process and the political process. 5. Discuss the methods nurses use to get
3. Discuss the roles of nurses in the policy- involved in the policy-making process and
making process. the political process.
1. Select one of the following topics and search the Toolkit. Here you will find a list of current
the Internet to learn more about the issue. legislative/policy. What are they? Select one
Why would this issue be of interest to nursing? and examine the issue. Discuss your findings
Why would this be a healthcare policy issue with your classmates.
for a state or nationally, or both? Has anything 3. Form a debate team to address the following
been done recently to initiate legislation on questions: How would you support or not
this issue? Teams of students can work on support universal health care in the United
an issue and then share their work. States? How does the ACA affect this problem?
a. Rural health care The team should base its viewpoint on facts
b. Mental health parity and relevant resources. Present the debate
c. Aging and long-term care in class or online. Viewers (students who are
d. Healthcare unions not on the debate team) should vote for the
e. Home care viewpoint that they think is most persuasive.
f. Emergency room diversions 4. The AHRQ provides several modules and a
2. Visit the ANA’s Health Care Reform Head- toolkit on informed consent. The toolkit on
quarters webpage (http://www.rnaction informed consent can be viewed at https://
.org/site/PageServer?pagename=nstat_take www.ahrq.gov/funding/policies/informed
_action_healthcare_reform) and review consent/index.html and the modules at
the content provided on healthcare reform https://www.ahrq.gov/professionals/systems
and other policy issues. Look at the list of /hospital/informedchoice/index.html. Review
resources and select one to review. What the information, and identify three facts you
does this resource provide nurses? Look at did not know about informed consent.

Describe your personal view of nurses getting involved in politics. Would you get
involved? Why or why not?
CASE STUDIES
Case 1
A nurse works in community health in a very large urban neighborhood of mostly African
Americans and Hispanics. The socioeconomic level of the area is low, with most people
eligible for or covered by Medicaid and Medicare. The nurse is concerned about the level
of care that community members’ children receive. Clinic services are inadequate, and the
hours of the clinics that are available often make it difficult for working parents to access
services for their children and for themselves. The teens in the area are involved in a lot
of drug activity and have little to do after school. The neighborhood has one high school,
one middle school, and one elementary school. There are two small daycare centers for
preschoolers run by the city. The nurse is motivated to tackle some of these problems, but
she is not sure how to go about it.
Case Questions
1. Identify critical problems the nurse might identify.
2. Do these problems have health policy relevance? Why or why not?
3. What steps do you think the nurse should take in light of what you have learned about
health policy in this chapter? Be specific regarding stakeholders, strategies, and political
issues to consider.
Case 2
You have joined a nursing specialty organization. After you join, you decide you want to be
active by volunteering for the Legislative Committee. At the first meeting you attend, the
major topic is the upcoming state elections.
Case Questions
1. How should the committee prepare for the elections?
2. If you are going to visit a candidate, what might you do to prepare, and what type of
questions might you ask?
3. What types of election activities might the committee recommend to the organization
membership?

questions.
1. A nurse comments, “Why should we get involved?”
2. The discussion leads to a question, “What is important to us?”
3. How might we use our elected officials?
REFERENCES
Abood, S. (2007). Influencing healthcare in the legislative American Nurses Association. (2015). APRNs and
arena. Online Journal of Issues in Nursing, 12(1), 3. DME. Retrieved from http://www.rnaction.org/site
American Nurses Association. (2005). ANA’s health care /PageServer?pagename=nstat_take_action_dme.html
agenda—2005. Silver Spring, MD: Author.
American Nurses Association. (2016). ANA political action Kalisch, B., & Kalisch, P. (1982). Politics of nursing. Philadelphia,
committee. Retrieved from http://www.rnaction PA: Lippincott.
.org/site/PageNavigator/NSTAT/nstat_ana_pac Matthews, M. (2015, July 17). Tavenner is the perfect
American Nurses Association. (2017). Take action. fit for AHIP as big insurers become public utili-
Retrieved from http://www.rnaction.org/site ties. Retrieved from http://www.forbes.com/sites
/PageServer?pagename=nstat_issues /merrillmatthews/2015/07/17/tavenner-is-the-per
Block, L. (2008). Health policy: What it is and how it works. In fect-pick-for-ahip-as-big-insurers-become-public-
C. Harrington & C. Estes (Eds.), Health policy (5th ed., utilities/#47e27e29419b
pp. 4–14). Burlington, MA: Jones & Bartlett Learning. Shi, L., & Singh, D. (2015). Delivering health care in America
Coffey, J. (2001). Universal health coverage. American Journal (6th ed.). Gaithersburg, MD: Aspen.
of Nursing, 101(2), 11. Sullivan, L. (2004). Missing persons: Minorities in the health
Congress.gov. (2017). S.1132 Registered Nurse Safe Staffing professions. A report of the Sullivan Commission on
Act of 2015. Retrieved from https://www.congress diversity in the healthcare workforce. Retrieved from
.gov/bill/114th-congress/senate-bill/1132 http://www.aacn.nche.edu/Media/pdf/SullivanReport.pdf
Ferguson, S. (2001). An activist looks at nursing’s role in U.S. Department of Health and Human Services, & Agency
health policy development. Journal of Obstetric, Gy- for Healthcare Research and Quality. (2017a). About
necologic, and Neonatal Nursing, 30, 546–551. the national quality strategy. Retrieved from https://
Institute of Medicine. (2002). Unequal treatment: Confronting www.ahrq.gov/workingforquality/about.htm
racial and ethnic disparities in health care. Washington, U.S. Department of Health and Human Services, & Agency
DC: The National Academies Press. for Healthcare Research and Quality. (2017b).
Institute of Medicine. (2004). Health literacy: A prescription National healthcare quality and disparities report.
to end confusion. Washington, DC: The National Retrieved from https://www.ahrq.gov/research
Academies Press. /findings/nhqrdr/index.html
Institute of Medicine. (2010). The future of nursing: Lead-
ing change, advancing health. Washington, DC: The
National Academies Press.
Chapter
6
Ethics and Legal Issues
CHAPTER OBJECTIVES
■■ Apply ethical principles to decision making ■■ Discuss the relevance of legal issues such as
with consideration of the importance of ethics malpractice to nursing practice.
to the nursing profession. ■■ Discuss examples of ethical and legal issues in
■■ Examine the implications of healthcare fraud healthcare delivery.
and abuse, research ethics, and organizational
ethics.
CHAPTER OUTLINE
●● Introduction ●● Research: Risk of Social and

●● Ethics and Ethical Principles Economic Harm
●● Definitions ●● Organizational Ethics
●● Ethical Principles ●● Legal Issues: An Overview
●● Ethical Decision Making ●● Critical Terminology
●● Professional Ethics and Nursing Practice ●● Malpractice: Why Should This
●● American Nurses Association Code of Concern You?
Ethics ●● Examples of Issues with Ethical and Legal
●● Reporting Incompetent, Unethical, or Implications
Illegal Practices ●● Privacy, Confidentiality, and Informed
●● Critical Ethical Issues in Healthcare Delivery Consent
●● Healthcare Fraud and Abuse ●● Rationing Care: Who Can Access Care
●● Ethics and Research when Needed
●● Research: Informed Consent ●● Advance Directives, Living Wills,
●● Research: Risk of Physical Harm Medical Powers of Attorney, and
●● Research: Risk of Psychological Do-Not-Resuscitate Orders
Harm ●● Organ Transplantation
169
●● Assisted Suicide ●● Critical Thinking Activities

●● Social Media and Ethical and Legal ●● Electronic Reflection Journal
Issues: A New Concern ●● Case Studies
●● Chapter Highlights ●● Working Backward to Develop a Case
●● Engaging in the Content ●● References
●● Discussion Questions
KEY TERMS
Advance directives EthicsFraud Morals

Breach of confidentiality Informed consent Negligence
Breach of duty Invasion of privacy Organizational ethics
Confidentiality Living will Professional ethics
Ethical decision making Malpractice Whistleblowing
Ethical dilemma Medical power of attorney
Ethical principles Moral disengagement
that drive healthcare decisions and the nursing

Introduction profession as a whole.
The content in this chapter addresses ethics and

legal issues in nursing. As a profession, nursing Definitions
has ethical responsibilities, which in some cases The first question that could be asked in this type
are connected to legal issues and in others are not of content is what is ethics? It is easy to confuse
related. In the practice of nursing, ethical and legal ethics with morals. Morals refer to an individual’s
issues often arise, and the nurse must understand code of acceptable behavior, and they shape one’s
them and take appropriate steps to address them. values that are influenced by cultural factors and
These issues involve professionalism, practice con- experiences. Ethics refers to a standardized code
cerns, health policy, reimbursement issues, and the or guide to behaviors. Morals are learned through
organizations that provide health care. growth and development, whereas application of
ethics typically is learned through a more organized
system, such as a standardized ethics code developed
Ethics and Ethical by a professional group. Ethics deals with the right-
Principles ness and wrongness of behavior. Bioethics relates
to decisions and behavior related to life-and-death
All healthcare professionals consider ethics in their issues. The latter sometimes comes in conflict with
practice whether they recognize it or not. Nurses a patient’s morals, values, and ethics and a nurse’s
need to understand ethics and the ethical principles personal morals, values, and ethics. There may also
Chapter 6: Ethics and Legal Issues 171
be conflict between a nurse’s and an organization’s inform the patient, and then to support the
approach to morals, values, and ethics. Health policy patient’s decision. Supporting the patient’s
also involves ethical decision making, particularly decision is not always easy because the nurse
when cost–benefit analysis is used. may think that the patient is making the
wrong decision. It is not the role of the nurse
Ethical Principles to argue with the patient, but rather to act as
the patient’s advocate, respecting the patient’s
Four ethical principles are used in nursing and choice. The nurse can discuss the decision
healthcare delivery; they are highlighted in Figure 6-1. with the patient and ensure that the patient
Ethics is a difficult area, and these principles help recognizes the potential consequences of
guide nurses when confronted with ethical issues. decisions. This principle is directly related
Throughout this chapter, the term patient will be to patient-centered care.
used, but in the case of a minor or a person who ■■ Beneficence relates to doing something good
is under legal guardianship or power of attorney, and caring for the patient. This principle
patient refers to the family or the guardian, who encompasses more than just physical care—it
makes the decisions in such cases. The four principles involves awareness of the patient’s situation
are autonomy, beneficence, justice, and veracity: and needs. In the case of nurses, this also
■■ Autonomy focuses on the patient’s right to means doing no harm and safeguarding the
make decisions about matters that affect patient, or non-maleficence.
the patient. This means that if the patient ■■ Justice is about treating people fairly—for
wants to be involved in treatment decisions, example, when deciding which patients receive
the patient makes the final decisions about treatment and which patients do not. There
treatment. To do so, patients need complete are more concerns about justice in health care
and open information or informed consent. today because of problems with disparity (for
The nurse’s role is to provide information to example, some people are not getting care
better ensure that others, such as the physician, when they need it). Lack of justice can lead
to disparities in health care, and then it can
also have an impact on quality care.
■■ Veracity means truth. For example, which
Autonomy information is the patient given during the
informed consent process? Trust plays a
major role in this principle. Veracity can
be a difficult principle to apply because,
ETHICAL sometimes, a family member may request
DECISION-
Veracity Justice
MAKING that the patient not be fully informed. Such
PRINCIPLES
a request is in direct conflict with ethical
practices and patient-centered care. Some
believe that if another principle is involved,
Beneficence it might be considered first, before veracity
comes into play. For example, if it is believed
that the truth would cause more harm, does
beneficence outweigh veracity? In any ethical
Figure 6-1 Ethical Decision-Making Principles dilemma, it is important to remember that
no two situations are the same. Trust is also at the choices, goals, and parties involved. Options
related to the requirements for informed con- need to be prioritized.
sent and patient privacy and confidentiality. Key to all of this is patient involvement, if
Other principles have been suggested that are the patient is able and willing to participate in the
applicable in today’s healthcare delivery system—for decision-making process. The decision must be one
instance, advocacy, caring, stewardship (manage- that the patient accepts. During implementation,
ment of finite resources), respect, honesty, and the nurse must be the patient’s advocate, even if the
confidentiality (Koloroutis & Thorstenson, 1999). nurse does not agree with the patient’s final decision.
Ethical Decision Making Professional Ethics

and Nursing Practice
Ethical decision making is about ethical dilem-
mas. An ethical dilemma occurs when a person is Ethics is a part of any profession, and in nursing,
forced to choose between two or more alternatives, professional ethics is part of daily practice. Benner,
none of which is ideal. Typically, strong emotions Sutphen, Leonard, and Day (2010) emphasize that
are tied to the issue and the alternative solutions, nursing education needs to focus more on ethical
and it is not possible to say that one is better than conduct. Students need to develop skills to respond
the other. If an ethical dilemma arises and the nurse ethically when making ethical decisions, which may
is involved in the care, the nurse should participate involve responding to situations in which errors
in the decision making. If the nurse is not involved occurred. “Nurses need the skill of ethical reflection
in the issue, then the nurse should not step in unless to discern moral dilemmas and injustices created by
the situation is critical. inept or incompetent health care, by an inequitable
Once the ethical dilemma is recognized, the healthcare delivery system, or by the competing
next step is assessment to get facts. What are the claims of family members or other members of the
medical facts, including information about treat- healthcare team” (Benner et al., 2010, p. 28). It is
ment? What are the psychosocial facts? What does not easy to find the “right” perspective on ethics in
the patient want? Which values are involved, and professional roles and in the care provided. Each
what is the conflict? Getting this information requires nurse works to find this perspective and determine
talking to others, including the patient and—if the how it meshes with the nurse’s personal views. This
patient approves—the family, significant others, is the potential dilemma between the nurse’s view
and other healthcare providers. Neither the nurse of ethical behavior and the patient’s.
nor the physician makes the decision about sharing With the increased emphasis on quality
information with family or significant others, nor improvement it is important to recognize that
do they make the final decision about treatment ethical and legal issues are related to quality care,
unless the patient is in an emergency situation and particularly when errors occur. There is discussion
cannot speak for himself or herself. The treatment in other chapters about staff stress and how this
team provides recommendations to the patient. impacts care. Involvement in an error can cause
Sometimes it may be the nurse who thinks that the stress or stress may have been a factor in causing
treatment team does not recognize the presence of the error. Moral disengagement is “the process
an ethical dilemma; in this case, the nurse discusses that involves justifying one’s unethical actions by
this observation with the team. After the assessment altering one’s moral perception of those actions”
is concluded, the information is used to develop a (Hyatt, 2016, p. 15, as cited from Bandura, 1999).
plan to address the dilemma. This requires looking A common response is displacement of responsibility
or shifting of blame—it was not my responsibility; it Self-reflection, or the ability to look at a variety of
was someone else’s. Why does this happen to staff? possibilities and consider pros and cons, is also
One reason may be the work environment is not important. It is part of critical thinking and is par-
healthy and staff members withdraw from taking ticularly important when there does not seem to be
responsibility. Another reason may be the staff wants one right answer, which is the case when an ethical
to do what is expected (an ethical action), but there dilemma is experienced. The ANA Code of Ethics
are barriers in the organization to achieving this, provisions are described in Exhibit 6-1.
such as rules, time issues, and so on. This leads to
moral distress, which can lead to anger, hopelessness, Reporting Incompetent,
depression, and compassion fatigue. This works
in a cyclic fashion in that moral distress may result in
Unethical, or Illegal Practices
more moral distress for the organization, resulting in Every nurse, regardless of degree preparation or
a hostile work environment, staff and management position, has a responsibility to report incompetent,
passive-aggressive behavior, increased problems with unethical, or illegal practices to the nurse’s state
errors, working around the system (discussed in board of nursing (ANA, 2015; Burman & Dunphy,
more detail in content about quality improvement), 2011; National Council of State Boards of Nursing
and retention of staff (Hyatt, 2016). It is important [NCSBN], 2011), there is, however, variation from
that nurses and healthcare organizations support a state to state as to requirements for reporting. Others
healthy work environment to prevent or reduce these can also report nurses, such as employers, consumers,
problems that negatively affect care improvement. and family members. Each state’s nurse practice act
(law) serves as the guide for the nurses in the state.
American Nurses Association This law should be familiar to all licensed nurses.
Nurse practice acts vary from state to state because
Code of Ethics
each act is considered part of a state’s laws and is
Professional organizations such as the American not administered at the federal level.
Nurses Association (ANA) developed a code of State boards of nursing have specific processes
ethics with interpretative statements to help nurses and procedures that must be followed regarding
understand the intent of the guiding principles. The making and handling complaints. The source of
Guide to the code of ethics for nurses: Interpretation a complaint remains private. This confidentiality
and application (ANA, 2015) is the primary source is intended to protect the person who reports the
or guide for nurses when ethical issues are encoun- complaint as well as to eliminate fear of reprisal
tered. A nursing code of ethics was first discussed that would limit reporting of complaints. Among
in the United States in 1896. Several editions of this the common complaints brought to a state board
code have been issued to ensure that the content of nursing are using illicit drugs or alcohol while
and expectations stay current with practice and practicing, stealing drugs from a healthcare orga-
healthcare issues and analysis of the code (Fowler, nization, committing a serious error that might
2015). The Code of Ethics may change over time, demonstrate incompetence, and falsifying records.
but it also has consistent elements that have been It is important to remember that a complaint or an
retained. initiative by the board to investigate a nurse does
Obtaining a registered nurse (RN) license and not mean that the nurse is guilty. The legal process
entering the profession requires that nurses meet that must be followed by the state board provides
the professional roles and responsibilities identi- rights for the nurse, rights that can be used to
fied by nursing. Ethics is a part of professionalism. defend one self.
Exhibit 6-1 American Nurses Association Code of Ethics for Nurses
Provision 1 and continue personal and professional

The nurse practices compassion and respect growth.
for the inherent dignity, worth, and unique Provision 6
attributes of every person.
The nurse, through individual and collective
Provision 2 effort, establishes, maintains, and improves the
ethical environment of the work setting and
The nurse’s primary commitment is to the
conditions of employment that are conducive
patient, whether an individual, family, group,
to safe, quality health care.
community, or population.
Provision 7
Provision 3
The nurse, in all roles and settings, advances
The nurse promotes, advocates for, and
the profession through research and scholarly
protects and rights, health, and safety of the
inquiry, professional standards development, and
patient.
the generation of both nursing and health policy.
Provision 4 Provision 8
The nurse has authority, accountability, and
The nurse collaborates with other health
responsibility for nursing practice; makes
professionals and the public to protect human
decisions; and takes action consistent with the
rights, promote health diplomacy, and reduce
obligation to promote health and to provide
health disparities.
optimal care.
Provision 9
Provision 5
The profession of nursing, collectively through
The nurse owes the same duties to self as to its professional organizations, must articulate
others, including the responsibility to promote nursing values, maintain the integrity of the
health and safety, preserve wholeness of profession, and integrate principles of social
character and integrity, maintain competence, justice into nursing and health policy.
Reproduced from American Nurses Association. (2015). Code of Ethics for Nurses with Interpretive Statements.
Silver Spring, MD: Author. © 2015 by American Nurses Association. Reprinted with permission. All rights reserved.
Any nurse who is informed of a board of nurs- the public and protecting the individual nurse’s right
ing complaint or recognizes that such a complaint to practice and the nurse’s right to due process.
might be filed should consult with an attorney. This In some situations, such as when a nurse is ac-
legal advisor should not be the same attorney who cused of drug abuse, the state board of nursing may
represents the nurse’s employer; rather, the nurse offer the option of entering an alternative program.
should retain the services of a personal attorney. These programs are not treatment programs, but
Dealing with disciplinary actions is a major rather monitoring programs. However, they do give
responsibility of boards of nursing. The media, nurses who meet specified criteria the opportunity
legislators, and policy makers are interested in to maintain their licensure and to practice. The nurse
disciplinary actions that the boards take. A board must agree to enter a nondisciplinary program that
of nursing has to find a balance between protecting provides identification and treatment support; agree
to monitoring upon return to practice; and often In 2014, the federal government recovered more
agree to submit to regular drug testing. The risk than $5.7 billion from fraud-associated federal health-
of public knowledge about a drug problem may care programs, representing an increase of $1.9 billion
compel a nurse to accept the alternative program. from 2013 (Pawderly, 2015). In 2016, the Department
Compliance with treatment and aftercare recom- of Justice brought charges against 301 individuals
mendations is also required. Return to practice or for false billing totaling approximately $900 million
continuation of practice is not guaranteed, and the (DOJ, 2016). Both of these cases of fraud involve large
nurse is carefully monitored to ensure public safety. sums of money that could have been used to provide
health care. Recovering the funds is a positive step;
however, the magnitude of the collections makes a sad
Stop and Consider #1 statement about the level of healthcare fraud in the
RNs are required to report incompetent, unethical, United States. Such actions have led to many legal cases
or illegal practice. and convictions, all of which are expensive to conduct.
Because of this ongoing major loss of monies,
the Affordable Care Act of 2010 (ACA) includes
Critical Ethical Issues provisions to increase monitoring and enforcement
of laws to prevent fraud (U.S. Department of Health
in Healthcare Delivery
and Human Services & Office of the Inspector Gen-
Critical ethical issues change over time due to eral, 2011). In March 2011, the Centers for Medicare
current issues in healthcare delivery. Three issues and Medicaid Services (CMS) began an ambitious
that are important today are healthcare fraud and project to revalidate all 1.5 million Medicare-enrolled
abuse, research ethics, and organizational ethics. providers and suppliers under the new screening
requirements. As of September 2013, more than
535,000 providers were subject to the new screening
Healthcare Fraud and Abuse
requirements, and more than 225,000 lost the ability
Healthcare fraud and abuse are especially common. to bill Medicare due to the new requirements and
Fraud is a legal term that means a person delib- other proactive initiatives. This screening continues to
erately deceived another for personal gain. Fraud ensure that providers meet Medicare practice require-
also has a non-legal definition, but the focus here ments to receive reimbursement from CMS. Since the
is on fraud that involves breaking the law. In health passage of the ACA, the CMS has also revoked 14,663
care, it usually involves money and reimbursement. providers’ and suppliers’ ability to bill the Medicare
For example, a patient may be charged for care that program. These providers were removed from the
the patient did not receive or may be charged more program because they had felony convictions, were
than the usual fee. In 2009, the U.S. Department not operational at the address CMS had on file, and
of Health and Human Services (HHS) and the were not in compliance with CMS rules (HHS, 2014).
U.S. Department of Justice (DOJ) established the Fraud may be committed by physicians, phar-
Healthcare Fraud Prevention and Enforcement macists, nurses, and other healthcare providers;
Action Team (HEAT). Its mission is to prevent and medical equipment companies; and healthcare
reduce healthcare fraud. Since 2007, more than 2,300 organizations. Exhibit 6-2 identifies examples of
defendants have been charged with Medicare fraud. Medicaid fraud schemes, which continue to be used.
In 2011, HEAT initiated an effort to attack federal Areas of health care in which fraud is most preva-
healthcare fraud, which involved $530 million in lent include psychiatric care, home care, long-term
billing fraud (HHS, 2016). care, and large corporate healthcare organizations.
Exhibit 6-2 Examples of Medicaid Fraud Schemes
●● Billing for “phantom patients” ●● Concealing ownership in a related

●● Billing for medical goods or services that company
were not provided ●● Using false credentials
●● Billing for more hours than there are in a day ●● Double-billing for healthcare goods
●● Paying a “kickback” in exchange for a or services not provided
referral for medical goods or services
Modified from Department of Health and Human Services, Centers for Medicare and Medicaid Services. (2015).
About fraud. Retrieved from http://www.stopmedicarefraud.gov/aboutfraud/index.html
about consent. Some of the information that must

Ethics and Research
be revealed includes the nature and purpose of a
Research is an area in which complex concerns research intervention; potential risks, discomforts,
about ethical and legal issues arise. Research has and benefits to the patient; alternative treatments;
a history of ethical problems. Some key examples compensation if injury occurs; compensation for
of situations in which research participants were participating in a study (if offered by the study); and a
abused include the Nazi medical experiments in clear statement how the participant may withdraw at
World War II; the Tuskegee Syphilis Study, in which any time without any negative impact on the patient.
African American men with syphilis were not treated The institutional review board (IRB) is an or-
so that researchers could observe the course of the ganization’s committee or department that ensures
disease (1932–1972); and the Willowbrook Study, that the research process meets ethical and legal
in which residents of an institution for mentally requirements in protecting participants in biomed-
retarded children were deliberately infected with ical or behavioral research. Hospitals, universities,
hepatitis (mid-1950s to the early 1970s). In the and other organizations that conduct research have
late 1970s, recognition of these major abuses led IRBs. The following passage describes the differ-
to reforms and the creation of legal guidelines that ences between patient care and research, which can
now must be followed by all healthcare researchers. sometimes be confused: “While recognizing that the
The Belmont Report (National Commission for the distinction between research and therapy is often
Protection of Human Subjects of Biomedical and blurred, practice is described as interventions that
Behavioral Research, 1978) identified the key con- are designed solely to enhance the well-being of an
cerns and the need for greater attention to ethical individual patient or client and that have a reasonable
principles in conducting and reporting research. expectation of success. The purpose of medical or
Exhibit 6-3 contains an excerpt from the Belmont behavioral practice is to provide diagnosis, preventive
Report’s introduction. treatment, or therapy to particular individuals. The
Commission distinguishes research as designating
Research: Informed Consent an activity designed to test a hypothesis, permit
Participation in research must include informed conclusions to be drawn, and thereby to develop or
consent, and there are rules regarding how this contribute to generalizable knowledge (expressed,
consent must be obtained. The National Institutes for example, in theories, principles, and statements
of Health (NIH) is a key resource for information of relationships). Research is usually described in
Exhibit 6-3 The Belmont Report
On September 30, 1978, the National ●● Beneficence entails an obligation to

Commission for the Protection of Human protect persons from harm by maximizing
Subjects of Biomedical and Behavioral anticipated benefits and minimizing
Research submitted its report entitled “The possible risks of harm.
Belmont Report: Ethical Principles and ●● Justice requires that the benefits and
Guidelines for the Protection of Human burdens of research be distributed fairly.
Subjects of Research.” The Report, named
The Report also describes how these
after the Belmont Conference Center at the
principles apply to the conduct of research.
Smithsonian Institution where the discussions
Specifically, the principle of respect for
that resulted in its formulation were begun,
persons underlies the need to obtain informed
sets forth the basic ethical principles
consent; the principle of beneficence underlies
underlying the acceptable conduct of research
the need to engage in a risk–benefit analysis
involving human subjects. Those principles—
and to minimize risks; and the principle of
respect for persons, beneficence, and justice—
justice requires that subjects be fairly selected.
are now accepted as the three quintessential
As was mandated by the congressional charge
requirements for the ethical conduct of
to the Commission, the Report also provides a
research involving human subjects.
distinction between “practice” and “research.”
●● Respect for persons involves recognition The text of the Belmont Report is thus divided
of the personal dignity and autonomy of into two sections: (1) boundaries between
individuals, and special protection of those practice and research, and (2) basic ethical
persons with diminished autonomy. principles.
Reproduced from U.S. Department of Health and Human Services. (1979). The Belmont report. Retrieved from
https://www.hhs.gov/ohrp/regulations-and-policy/belmont-report/
a formal protocol that sets forth an objective and a were approved focusing on the procedural needs
set of procedures designed to reach that objective. for submitting research sample registration and
The report recognizes that ‘experimental’ procedures summary study results information, including
do not necessarily constitute research, and that adverse event information, from clinical trials of
research and practice may occur simultaneously. drug products and device products (U.S. Depart-
It suggests that the safety and effectiveness of such ment of Health and Human Services & National
‘experimental’ procedures should be investigated Institutes of Health, 2016). These regulations were
early, and that institutional oversight mechanisms, effective January 2017. This initiative is directed at
such as medical practice committees, can ensure protecting patients in trials and to ensure rapid,
that this need is met by requiring that ‘major inaccurate sharing of information about studies,
novation[s] be incorporated into a formal research improving public access to information. The reg-
project’ ” (HHS, 1993). ulations are complicated and require institutions
In healthcare research, participants or subjects and researchers to be more vigilant about sharing
may be exposed to multiple risks, typically classified information. If this is not done, there will be penalty
as physical, psychological, social, and economic fees, and organizations and researchers may lose
risks (HHS, 1993). In 2016, new federal regulations research funding.
Research: Risk of Physical Harm behavioral research that involves an element of de-
ception, particularly if the deception includes false
Some medical research is designed only to measure
feedback to the research participants or subjects
more carefully the effects of therapeutic or diagnostic
about their own performance.
procedures applied in the course of caring for an
Invasion of privacy is a risk of a somewhat
illness. This research may not involve any significant
different character. In the research context, it usually
risks beyond those presented by medically indicated
involves either covert observation or participant
interventions. Research designed to evaluate new
observation of behavior that the participants or
drugs or procedures, however, might present more
subjects consider private. The IRB must decide
than minimal risk and sometimes can cause serious
the following about the study: (1) Is the invasion
or disabling injuries. These types of studies may
of privacy acceptable in light of the participants’
lead to participant physical risk and thus would be
reasonable expectations of privacy in the situation
reviewed in the IRB review and via the informed
under study? (2) Is the research question of sufficient
consent. Some of the adverse effects that result from
importance to justify the intrusion? The IRB should
medical procedures or drugs may be permanent,
also consider whether the research design could be
but most are transient. Procedures commonly used
modified so that the study can be conducted without
in medical research usually result in no more than
invading privacy.
minor discomfort (for example, temporary dizziness,
Breach of confidentiality is sometimes con-
the pain associated with venipuncture).
fused with invasion of privacy, but it is a different
Research: Risk of Psychological problem. Invasion of privacy concerns access
Harm to a person’s body or behavior without consent;
breach of confidentiality concerns safeguarding
Participation in research may result in undesired
information that has been given voluntarily by one
changes in thought processes and emotion (for ex-
person to another. Some research requires the use of
ample, episodes of depression, confusion, or other
a subject’s hospital, school, or employment records.
cognitive effects resulting from the drugs used;
Access to such records for legitimate research pur-
feelings of stress, guilt, and loss of self-esteem). These
poses is generally acceptable, as long as the researcher
changes may be transitory, recurrent, or permanent.
protects the confidentiality of that information and
Most psychological risks are minimal or transitory,
the subject is informed of this access. The IRB must
but IRBs should be aware that some research has
be aware, however, that a breach of confidentiality
the potential for causing serious psychological harm
may result in psychological harm to individuals
and should be part of informed consent. Stress
(in the form of embarrassment, guilt, stress, and
and feelings of guilt or embarrassment may occur
so forth) or in social harm.
simply from thinking or talking about one’s own
behavior or attitudes on sensitive topics such as drug
use, sexual preferences, selfishness, and violence. Research: Risk of Social
These feelings may be aroused when the subject and Economic Harm
is interviewed or filling out a questionnaire. Stress Some invasions of privacy and breaches of con-
may also be induced when researchers manipulate fidentiality may result in embarrassment within
the subjects’ environment—such as if emergencies one’s business or social group, loss of employment,
or fake assaults are staged to observe how passersby or criminal prosecution—all representing risk of
respond, lighting is changed or noise is used, and social and/or economic harm. Areas of particular
so on. More frequently, however, IRBs assess the sensitivity are information regarding alcohol or drug
possibility of psychological harm when reviewing abuse, mental illness, illegal activities, and sexual
behavior and identity. Some social and behavioral understand the patient’s care experience—both
research may yield information about individuals aspects related to care and to the research study.
that could label or stigmatize the participants (for Some student projects are also reviewed to see
example, as actual or potential delinquents or a per- whether an IRB review is needed for the project.
son with schizophrenia). Confidentiality safeguards Faculty are responsible for guiding students to
must be effective in these instances. The fact that a determine if the school’s (college, university) IRB
person has participated in HIV-related drug trials or Committee should make the decision about the
has been hospitalized for treatment of mental illness need to complete the IRB written requirements
could adversely affect the person’s present or future or if a clinical site is used for the project must the
employment, political campaigns, and standing healthcare organization’s IRB be involved.
in the community. A researcher’s plans to contact Knowledge and application of the ethical prin-
these individuals for follow-up studies should be ciples related to research need to be part of practice
reviewed with care. Participation in research may whenever nurses are directly or indirectly involved
result in additional actual costs to individuals. Any in research. Exhibit 6-4 identifies key points of the
anticipated costs to research participants should be Code of Federal Regulations related to research that
described to prospective participants during the might affect nurses and nursing care.
consent process.
Nurses should be concerned about these issues
Organizational Ethics
for two reasons. First, nurses conduct research, and
they must follow the same rules as anyone else who In the late 1990s and early 2000s, there were seri-
uses human participants or even animals used in ous breaches of organizational ethics. A major
a study. Secondly, nurses may assist in getting in- stimulus to address this problem occurred in 1994,
formed consent, data collection, and other aspects when it was recognized that the federal govern-
of a research study. Nurses also work in areas where ment lost 10% of its total healthcare expenditures
clinical research is ongoing. In these situations, the to fraud, equivalent to $100 billion (U.S. House
nurse must continue to act as the patient advocate; of Representatives, 1994). Because of increasing
ensure that the patient’s rights are upheld; and corporate healthcare fraud and abuse of patients,
should be aware of the study, which should provide the CMS, through legislation, now requires that any
as much information as is possible to help the nurse healthcare organization that is reimbursed through
Exhibit 6-4 Code of Federal Regulations
●● Risks to subjects [participants] are ●● Informed consent must be properly

minimized. documented.
●● The risks to subjects are reasonable in ●● When appropriate, research plans monitor
relation to anticipated benefits. data collection to ensure subject safety.
●● The selection of subjects is equitable. ●● When appropriate, privacy of subjects and
●● Informed consent must be sought confidentiality of data are maintained.
from potential subjects or their legal ●● Safeguards must be in place when subjects
guardians. are vulnerable to coercion.
Reproduced from Schmidt, N., & Brown, J. (2015). Evidence-based practice for nurses: Appraisal and applications
of research. Burlington, MA: Jones & Bartlett Learning.
for Medicare and/or Medicaid services meet certain the whistleblower (Beckers Hospital Review, 2016).
compliance conditions to better ensure the organi- The hospital was not following standard procedure
zation maintains appropriate organizational ethics. to ensure that steps were taken to sterilize equip-
Because it is rare that a hospital does not receive ment used for bronchoscopy and may have led to
this type of reimbursement to cover care provided infections in 100 patients. This also had an impact
to Medicare or Medicaid enrollees, this mandate on monitoring of quality improvement. The nurse
applies to the majority of hospitals. Organizations tried to get hospital staff to address the problem
must identify a compliance officer, who audits and but was unsuccessful. The nurse then went to an
monitors actions taken to detect, correct, and pre- attorney, and the result was a whistleblower civil
vent fraud. Staff must know how to report concerns suit. This case contains many ethical and legal
related to ethical behavior and potential fraud, and aspects such as a coverup, lack of response to staff
they must be provided with education about these feedback about quality care, lack of concern about
critical issues. Reporting methods should ensure quality care, and subsequent legal ramifications.
privacy for staff, and they should not be penalized It also demonstrates that nurses do take steps to
for reporting. The federal government established ensure quality and advocate for patients—ethical
these requirements because it does not want patients and legal issues are interconnected in this example.
abused. In addition, the government is concerned
about the major loss of funds that has occurred
because of fraud, such as paying for care that was Stop and Consider #2
not given, paying more than the typical rate, paying Nurses and other healthcare professionals have
participated in unethical and illegal practices.
for patients who did not receive care, and so forth.
Whistleblowing can be part of fraud and abuse
situations. This action occurs when a person who
works for an organization that is committing fraud Legal Issues: An Overview
and abuse reports these activities to legal authorities,
sharing extensive information that would be difficult Legal issues are a part of each nurse’s practice. Each
for the authorities to obtain on their own. The False state board of nursing identifies situations for which
Claims Act, a very old law, protects whistleblow- licensure could be denied. You can search your state
ers. This law was passed during the Civil War and board of nursing’s website for this information.
amended in 1982 to further shield whistleblowers. Licensure itself is a legal issue that is implemented
Whistleblowers are protected from being sued and through the legal system. The nurse practice act
from being fired or otherwise penalized by their in each state is a state law. Legal concerns are also
employer for reporting the organization or staff directly related to practice. The following are some
within the organization. If the federal government examples of nursing-related legal issues:
pursues the case and recovers funds, the whis- ■■ When the nurse administers a narcotic med-
tleblower is given a portion of the funds. Anyone ication, specific procedures must be followed
can be a whistleblower, but the person must have to ensure that patients receive medications
information that could not be obtained otherwise per healthcare provider orders and that the
or information that was not public knowledge (such narcotic drug supply is monitored (counted)
as that reported in a newspaper). This type of legal to make sure the amounts are correct. If there
action is complicated and very difficult to resolve. are errors, it could mean that a criminal act
One example of whistleblowing occurred in an occurred—someone took a narcotic or con-
academic health center in 2016 involving an RN as trolled drug with no right to do so.
■■ Restraining a patient without a physician’s ■■ Doctrine of res ipsa loquitur: A doctrine

order or not in accordance with the require- of law in which a person is presumed to
ments in the order or healthcare organization be negligent if he, she, or an organization/
policy can be considered assault and battery. employer had exclusive control of whatever
■■ Falsifying medical records can have adverse caused the injury, even though there is no
legal consequences. specific evidence of an act of negligence, and
■■ Accessing an electronic medical record for without negligence, the accident would not
a patient who is not in a specific nurse’s care have happened.
can be questioned. ■■ Emancipation: A child is a minor, and there-
■■ Inadequate supervision of patients that fore under the control of his or her parent(s)/
leads to serious patient outcomes such as guardian(s), until the child attains the age
falls with injury or a suicide may have legal of majority (18 years), at which point he or
consequences. she is considered to be an adult. In special
circumstances, a minor can be freed from
Critical Terminology control by the minor’s parent/guardian and
given the rights of an adult before turning 18.
The nurse may encounter the following legal terms In most states, the three circumstances un-
as part of his or her practice: der which a minor becomes emancipated
■■ Assault: The threat or use of force on another are (1) enlisting in the military (requires
individual that causes the person to feel parent/guardian consent), (2) marrying
reasonable apprehension about imminent (requires parent/guardian consent), and
harmful or offensive contact. An example (3) obtaining a court order from a judge
is threatening to medicate a patient if the (parent/guardian consent not required). A
patient does not comply with treatment. This minor can also petition the court for this
type of threat is not uncommon in behavioral status if financial independence can be
or psychiatric care but should not be made. proven and the parents or guardian agree.
■■ Battery: The actual intentional striking of An emancipated minor is legally able to do
someone, with intent to harm, or in a rude everything an adult can do, with the exception
and insolent manner even if the injury is of actions that are specifically prohibited if
slight. An example of battery is conducting one has not reached the age of 18 (such as
a procedure, such as starting an intravenous buying tobacco). From a healthcare perspec-
line, without asking the patient. If this is an tive, emancipated minors can sue and be sued
emergency situation and the patient’s life is in their own name, enter into contracts, and
at risk, or if there is risk of serious damage seek or decline medical care.
and the patient is not able to provide consent, ■■ Expert witness: This is person with specific
the event would not be considered battery. expertise and knowledge who can provide
■■ Civil law: This type of statute (law) focuses testimony to prove or disprove the standard
on private rights. of care that is used to support a case. A nurse
■■ Criminal law: This type of statute deals with may serve as an expert witness for nursing
crimes against the public and members of the care but not for medical care issues. Typically,
public, with penalties and all the procedures the nurse is also a specialist in the specific
connected with charging, trying, sentencing, and area of care addressed in the legal case. For
imprisoning defendants convicted of crimes. example, for a case involving the death of a
newborn in a neonatal intensive care unit, the ensuring that the nurse received the education,
expert witness should be a neonatal nurse. and/or for not providing proper supervision.
■■ False imprisonment: Confinement of a person Typically, in such legal actions, multiple persons
against his or her will is against the law. This and organizations may be sued.
can happen in health care—for example, when ■■ Standards of practice: Minimum guidelines
a patient wants to leave the hospital and is identified by the profession (local, state, na-
retained (an exception is when a patient is tional) and healthcare organization policies
legally committed for medical reasons or and procedures. Expert opinion, literature,
held for legal reasons by law enforcement or and research may also be used as standards.
courts); when a patient is threatened or his Standards are used in legal situations to assess
or her clothes are taken away to prevent the negligence malpractice actions. (See other
patient from leaving; or when restraints are chapters in this text that include additional
used without written consent, appropriate information on standards.)
physician order, or a sufficient emergency ■■ Tort: A civil wrong for which a remedy may be
reason. obtained in the form of damages. An example
■■ Good Samaritan laws: Laws that protect a of a tort that is most relevant to nurses and
healthcare professional from being sued other healthcare providers is negligence, an
when providing emergency care outside a unintentional tort.
healthcare setting. The provider must provide
the care in the same manner that an ordinary, Malpractice: Why Should This
reasonable, and prudent professional would
Concern You?
do in similar circumstances, including fol-
lowing practice standards. An example is a Negligence does occur in nursing—for example,
nurse stopping on the highway to assist an medication errors, not adequately providing for
accident victim and following the expected patient access to a call light when the patient needs
standard for providing care to a victim with help, a lack of assessment of risk for falls and failure
a severe burn to maintain respiratory status to prevent falls, and failure to implement appropri-
under emergency conditions. ate interventions when required. Another example
■■ Respondent superior: A principal (employer) of negligence would be failure to communicate
responsible for the actions of his, her, or its information that affects care, which encompasses
agent (employee) in the course of employment. situations such as not documenting care provided
This doctrine allows someone—for example, a or response to care; not contacting the physician
patient—to sue the employee who is accused with information that would inform the physician
of making an error that resulted in harm. of the need for a change in treatment; and failing
The patient also may sue the employer, the to document, such as monitoring data, changes in
hospital, because the employer is responsible status, assessment of wound sites or skin status, or
for supervising the staff member. For example, malfunctioning intravenous equipment. Negligence
if a nurse administers the wrong medication, may also include inadequate patient teaching, in-
and the patient experiences complications, adequate monitoring and maintenance of medical
the nurse may be sued for the action, and the equipment, lack of identification of an allergy or
hospital also may be sued for not providing not following known information about allergies,
the appropriate education regarding medica- failure to obtain informed consent, and failure to
tions and medication administration, for not report another staff member to supervisory staff
for negligence or problems with practice. All these 4. Damages or injury to the patient must have
examples can lead to malpractice suits. occurred. What were the damages or injury?
Malpractice is an act or continuing conduct Are they temporary or permanent? What
of a professional that does not meet the standard impact do they have on the patient’s life?
of professional competence and results in provable These questions and many more will be asked
damages to the patient. Anyone can sue if an attorney about the damages and injury. If the lawsuit
can be found to support the suit; however, winning is won, this information is also used to assist
a lawsuit is not so easy. Often, lawsuits are settled in determining the amount of damages that
outside of court to reduce costs and prevent negative will be awarded, although the plaintiff (person
publicity; in such a case, even if the patient would suing) will identify an amount when the suit
not have been able to win the lawsuit, the patient is brought.
may still receive payment of damages. These four malpractice elements are illustrated
For a patient or family to be successful with in Figure 6-2.
a malpractice lawsuit, all of the following criteria The plaintiff ’s attorney must prove that each
must be met: of these elements exists for the judge or the jury to
1. The nurse (as person being sued) must have agree to the plaintiff ’s case, and the plaintiff should
a duty to the patient or a patient–nurse pro- be awarded damages. The nurse’s attorney will defend
fessional relationship. The nurse must have the nurse by proving that one or more elements do
provided care to the patient or been involved not exist. If even one element is lacking, malpractice
in the patient’s care. cannot be proved.
2. The duty must have been breached. This is Medical malpractice lawsuits have affected
called negligence, or the failure to exercise the healthcare practice and costs. The cases are very
care toward others that a reasonable or prudent expensive to defend, and when the case is won by
person would under similar circumstances. the plaintiff, awards are often very high. As men-
Any of the following could be used as proof: tioned earlier, even if the healthcare provider does
a nurse practice act, professional standards,
healthcare organization policies and procedures,
expert witnesses (RNs, preferably in same
specialty as the nurse sued), accreditation and
licensure standards, professional literature, and
research.
3. The breach of duty must be the proximate Duty to
(foreseeable) cause or the cause that is legally the
patient
sufficient to result in liability harm to the pa-
tient. There must be evidence that the breach
of duty (what the nurse is accused of having Duty is
done or not done, based on what a reasonable breached
or prudent person would do given the circum-
stances, such as what other nurses would have Proximate Damages
done in a similar situation) led directly to the cause or injury
harm that the patient is claiming. There might
be other causes of the harm to the patient that
have nothing do with the breach of duty. Figure 6-2 Elements of Malpractice
not win the case in a court decision by judge or jury, attorneys to provide a defense; instead, the nurse
a settlement may still be made, though typically needs an attorney who represents only the interests
settlements occur earlier. Collectively, these issues of the nurse. Professional liability insurance covers
have prompted many healthcare providers to practice these fees. There are also differences in the types of
“defensive medicine,” in which physicians prescribe malpractice insurance that can be obtained. Two of
excessive diagnostic testing and other procedures to the most common types are (1) claims-made coverage,
protect themselves. This approach increases the costs which covers only those incidents that occur and
of care, and if testing or procedures are invasive, it reported during the policy’s effective period, and
can increase patient risk. Malpractice concerns also (2) occurrence coverage, which provides protection
increase medical costs because physicians, other for an incident that took place while the policy was
healthcare providers, and healthcare organizations in effect even if the claim was not filed until after
must carry malpractice insurance to help cover po- the policy terminated. When accepting a job, the
tential legal costs for malpractice suits; these costs nurse should explore the pros and cons of carrying
are then passed on to consumers through patient personal professional malpractice/liability insurance.
service charges, increasing overall healthcare costs. As soon as a nurse learns of a possible lawsuit,
Nurses do get sued. A review of closed 516 the nurse should contact an attorney for advice. If the
claims from 2006 to 2010 identified the average nurse has liability insurance, the nurse would contact
total incurred claim was $204,594, with 11 different the insurer for legal advice, and the insurer may assign
nursing specialties represented in the cases (Benton, an attorney to the case. In addition, the nurse should
Arm, & Flynn, 2013). The largest number of claims recognize that at the conclusion of a lawsuit in which the
was found in adult medical-surgical care (40.1%), nurse and the nurse’s employer are sued, the employer
gerontology (18.0%), and obstetrics (10.3%). The cases might then sue the nurse to reclaim damages to cover
included 84.5% RNs and 15.5% licensed practical or the nurse’s employer’s expenses for the lawsuit. Nurses
vocational nurses. The following problems were the must make informed decisions about whether they
focus of these cases: treatment/care (59.6%); medication would rather have their employer’s attorney defend
administration (14.7%); assessment (12.6%); moni- them or seek out the services of an attorney who is
toring (6.8%); patient rights, abuse, and professional covered under their own policy, which is required for
conduct (5.4%); and scope of practice (1.7%). These some malpractice policies, or a personal attorney. In
examples of categories of lawsuit focus areas provide some instances, if the nurse has a personal attorney
an overview of the high-risk concerns that require or an attorney from the nurse’s malpractice policy,
special attention by nurses in their practice. the institutional legal team will not assist the nurse.
There are pros and cons to nurses carrying Nursing students are responsible for their own
professional liability insurance. Such policies are actions and can be held liable for them. Students are
not expensive for nurses, but the nurse needs to be not practicing under the license of their faculty (Guido,
clear about what the policy offers. A question that 2001). Because of this, students must never accept
could be asked is why nurses would be sued when, assignments or do procedures for which they are not
typically, they do not have high levels of personal prepared. It is also critical that students discuss these
funds. Nurses, however, are sued. Often, the nurse situations with faculty or staff if faculty if family are
is included in a group that is being sued—for not available rather than acting without guidance.
example, the physician(s), the hospital, specific
staff in the hospital (or other type of healthcare
organization), and others. When a nurse is sued,
Nurses may be sued.
the nurse should not rely on the nurse’s employer’s
communicate in the care process and with team

Examples of Issues members. Patient-centered care also implies that
with Ethical and Legal patients have the right to determine who sees their
information, and this decision must be honored. It
Implications
is important to remember that patient information
Ethics and legal issues are often interrelated. The should not be discussed in public areas (for example,
following section highlights some of these issues elevators, cafeteria, hallways) or any place where
such as privacy, confidentiality, informed consent, the information might be overheard by persons
rationing care, various patient legal decisions and who have no right to hear the information. You
documents, organ transplants, assisted suicide, and will encounter patients and family members who
use of social media. All of them relate to nurses and are part of your personal life; however, you must
nursing care. remember that what is known about the patient is
private. Nurses who work in the community and
Privacy, Confidentiality, make phone calls to and about patients using mobile
phones in public places can easily forget that their
and Informed Consent
conversations may be overheard.
Patients have the right to privacy, and this affects It is important to remember that patients drive
multiple situations that might occur during the patient privacy. For example, nurses should not assume
care process. The obvious is during assessment and that patients want family members to have access to
examinations. When patients are told about their the patient’s health information. Instead, patients
condition, this should be done in a private area. have to be explicitly asked who can be told about any
Rounds are discussed in this text, and privacy is health information. As a student and as a nurse, you
difficult to maintain, particularly when the patient will have access to patient information for only those
shares a patient room with another patient(s), patients to whom you are directly providing care. You
but we need do what we can to maintain it, such must have a reason related to healthcare provision to
as using curtains to separate the patient area and access patient information. If you do not adhere to
speaking in lower tones. Privacy is associated with these rules, then you are in violation of HIPAA. Be
confidentiality and informed consent. aware that patients may and do make HIPAA-related
Confidentiality is an issue that is relevant complaints to state boards and to educational institu-
to practice every day; we need to ensure, when tions, in the case of students, about staff or students
possible, that patient information is shared only who do not uphold privacy rules/HIPAA.
with those the patient approves or as required for Another ethical and legal concern related to confi-
treatment such as the treatment team. The Health dentiality is consent. Patient care consent occurs when
Insurance Portability and Accountability Act of 1996 the patient agrees to treatment, and it may be given
(HIPAA) has had a major impact on information either orally or in written form. Whenever possible,
technology and patient information (HHS, 2017). consent should be informed consent and documented
Nurses are required to follow this law to protect in writing. The patient’s physician or other independent
patient privacy and confidentiality. Patients are healthcare practitioner is required by law to explain or
informed about HIPAA when they enter a hospital, disclose information about the medical problem and
visit another type of healthcare facility for care, or treatment or procedure so that the patient can have
receive outpatient care. informed choice. The patient has the right to refuse
Nurses have the responsibility to keep patient the treatment. Failure to obtain informed consent
information confidential except as required to puts the practitioner at risk for negligence.
The requirement to obtain informed consent cover all care; instead, they determine which care
applies to many nurses. An advanced practice registered will be provided based on criteria that they identify.
nurse (APRN), for instance, needs to get informed Other forms of healthcare rationing also ex-
consent from his or her patients or ensure prior to ist. For example, organ transplantation is a form
performing treatments and procedures following of rationing—in both the allocation of funds to
required policy. By comparison, the nurse who is not perform transplants and the allocation of limited
an APRN does not have to get informed consent for organs. Patients are put into a database to receive
every nursing intervention, such as administering organ donations, and the order in which patients
a medication. Moreover, this nurse would not be receive a transplant depends on specified criteria.
the staff member who obtains patient consent for Oregon developed a rationing system for
treatment or procedures. In some cases, the nurse Medicaid by identifying the types of treatment
may ask a patient to sign a written consent form, that the state would cover, but this approach was
but in doing so, it is assumed that the patient’s phy- not successful. This is an example of a situation
sician or other healthcare provider has explained the in which the ethical principle of justice might
information to the patient. If the patient indicates be applied because rationing, or allocation of
that this conversation has not occurred, the nurse resources, is related to equity. It appears to be
must talk with the physician or other healthcare more acceptable to say “resource allocation” than
provider involved and cannot have the patient sign “rationing,” but in the end, resource allocation and
the form until the patient and the physician have rationing are similar.
discussed the specific treatment or procedure. If a
nurse is required to get informed consent and fails Advance Directives,
to do so, the nurse is at risk for negligence. Living Wills, Medical
A second type of consent is consent implied by Powers of Attorney, and
law. This consent is applicable only in emergency
Do-Not-Resuscitate Orders
situations, when a patient may not be able to give
informed consent. If the patient’s life is at risk or Advance directives are now part of the healthcare
if major damage or injury to the patient is likely, system. This type of legal document allows a person
healthcare providers can provide care. In this case, to describe personal medical care preferences. Of-
the assumption is that the patient would most likely ten, these documents describe the person’s wishes
give consent if the patient could, based on what a related to end-of-life needs ahead of time, in which
reasonable person would do. Nurses who work in case the document is called a living will. Patients
the emergency department encounter this type of have the right to develop this plan, and healthcare
consent situation. providers must follow it. Because state requirements
vary, it is advised that patients ask physicians if they
Rationing Care: Who Can will uphold the patient’s decisions about health
care. Any advance directives should be part of the
Access Care when Needed
patient’s medical record and easily accessible to the
The United States rations care, albeit not formally. healthcare provider. Be aware that end-of-life issues
Rationing is the systematic allocation of resources, are never simple but should be a critical part of care
typically limited resources. In this case, the limited for these patients.
resources are funds to pay for care. Some people A medical power of attorney document, a
receive care, and others do not. Insurers do not type of advance directive, designates an individual
who has the right to speak for another person if that staff and patients encounter and may make recom-
person cannot do so in matters related to health mendations but not final decisions.
care. Another name for this document is durable Palliative care is now an important healthcare
power of attorney for health care or a healthcare issue, and nurses are involved in this care. Ensuring
agent or proxy. If a person does not designate a that patients receive the type of care they want re-
medical power of attorney and the person is mar- quires nurses to understand the patient’s needs and
ried, the spouse can make the decisions if the sick goals and then advocate for them. The decision not
spouse is unable to do so. If there were no spouse, to receive “aggressive medical treatment” is not the
the decision would be made by adult children or same as withholding all medical care. A patient may
parents. People should determine the types of care still receive antibiotics, nutrition, pain medication,
they prefer and how aggressive that care should radiation therapy, and other interventions when
be with those who will be their medical powers of the goal of treatment becomes comfort rather than
attorney. The proxy or agent is not forced to follow cure. This is called palliative care, and its primary
the patient’s instructions if they are not written in focus is helping the patient remain as comfortable
a legal document; if there is no written document, as possible. Patients can change their minds and ask
a sick person should trust that the proxy or agent to resume more aggressive treatment. If the type of
would follow the guide discussed. treatment a patient would like to receive changes,
Interventions that are typically covered in ad- however, it is important to be aware that such a
vance directives include (1) use of life-sustaining decision may raise insurance issues that will need to
equipment, such as a ventilator, respirator, or dialysis; be explored with the patient’s healthcare plan. Any
(2) artificial hydration and nutrition (tube feeding); changes in the type of treatment a patient wants to
(3) do-not-resuscitate (DNR) or allow-a-natural- receive should be reflected in the patient’s living
death (AND) orders; (4) withholding of food and will (National Cancer Institute, 2000).
fluids; (5) palliative care; and (6) organ or tissue
donation. The DNR and the AND directives either
Organ Transplantation
are forms of advance directives or may be part
of an extensive advance directive. Such an order As mentioned earlier, organ transplantation is a form
means that there should be no resuscitation if the of resource allocation. Specific criteria are developed
patient’s condition indicates need for resuscitation. for each type of organ donation, and potential
A physician may write a DNR/AND order without recipients are categorized according to the criteria
an advance directive, but the physician must follow to determine who might receive a donation and in
hospital policy and procedures regarding this type what order. Organ transplantation registries are a
of decision. It is highly advisable that this situation critical component of this process. Nevertheless, it
be discussed with the patient, if the patient is able to is not always so clear as to who should get a trans-
comprehend, and with the family. The nurse may be plant. Many patient factors are considered—such as
present for this discussion but would not make this age, other medical or psychological illnesses, what
type of decision. If there are concerns about how it the person might be able to contribute to society,
should be handled, the nurse needs to consult the whether the person is single or married, whether the
nursing supervisor/manager. If the organization has person has children, comorbidities (other illnesses)
an ethics committee, the nurse may consult with the such as substance abuse, and ability to comply with
committee, which is typically an interprofessional follow-up treatment—and some of these factors
committee that is prepared to discuss ethical issues complicate the decision-making process. Organ
transplantation is expensive and may not be covered, of lethal medications prescribed by a physician
or only partially covered, by health insurance. The for this purpose. The law describes who can be
patient will need lifetime specialized care, which involved and the procedure or steps that must be
is also costly. taken. Two physicians must be involved in the de-
Of course, organ donation must occur first so cision. As of 2016, five states (Oregon, California,
that organ transplantation is possible. Some people Vermont, Colorado, and Washington) have legalized
designate their willingness to be organ donors while physician-assisted suicide by passing legislation, and
they are healthy—for example, on their driver’s one state (Montana) has legalized physician-assisted
license. However, when the time comes to actually suicide based on a court ruling (ProCon.org, 2016).
honor this request, family members may be reluctant In other states, this act is considered to be illegal.
to consent to it at an emotional time when a loved There has also been an increase in countries that
one has died. Other people may not have identified now allow assisted suicides.
themselves as organ donors when healthy, but then The ANA believes that the nurse should not
something happens that makes them eligible to be participate in assisted suicide. The organization
organ donors, such as an accident. This situation bases this position on its Code of Ethics for Nurses
is even more complex, ethically and procedurally. with Interpretive Statements (2015). Nurses, individ-
Healthcare providers do ask for organ donations, ually and collectively, have an obligation to provide
and hospitals have policies and procedures that comprehensive and compassionate end-of-life care,
describe what needs to be done. It is difficult to which includes the promotion of comfort and the
approach family members and say that loved ones relief of pain, and at times, forgoing life-sustaining
are no longer able to sustain themselves and then treatments (ANA, 2013). In a related topic, the ANA
to ask for an organ donation at the same time. With also issued a position statement on the withdrawal of
organ donations and transplants, time is a critical nutrition and hydration (ANA, 2011). This statement
element to maintain organ viability, and this com- indicates that the patient or the patient’s surrogate
plicates the decisions and procedures, occurring should make this decision, and the nurse should
when people (patient, donor, family) are stressed provide expert end-of-life nursing care.
and emotional, but also staff are stressed trying to
ensure the timelines are met to allow for a healthy Social Media and Ethical and
transplantation. Nurses do not ask for the donation
Legal Issues: A New Concern
but may assist the physician in this most difficult
discussion with all involved. Later, family members Social media or the use of networking web-based
or the patient (if responsive) may want to discuss instruments or sites such as Facebook, LinkedIn,
it further with the nurse. Instagram, Google+, Flickr, and Twitter has presented
nurses with new ethical and legal issues. A critical
issue is that social media may lead to problems
Assisted Suicide
associated with our professional obligations to
Assisted suicide is a complex ethical and legal issue, protect patient privacy and confidentiality. Nurses
but the nurse’s role is very clear: The nurse cannot should not share information about patients or
participate in helping a person end his or her life. In families, including images. It is not sufficient to
1997, Oregon passed the first state law pertaining to limit access using privacy settings. The basic rule is
assisted suicide, the Death with Dignity Act, which simple: Share no information or image. An example
allowed terminally ill citizens of Oregon to end is provided in a recent article on social media and
their lives through voluntary self-administration nurses, which offers comments that nurses should
be very careful about what they post (Barry, 2017). should be shared. This should also apply to staff and
This can be a slippery slope when we are attached healthcare organizations—sharing information that
to a patient and then share personal information can identify a staff person may not be something that
and thoughts about the patient. staff person would want done—for example, critiquing
This topic has become very important and a staff member or even a healthcare organization.
organizations such as the NCSBN (2014) have This chapter presented introductory infor-
published information on the topic with guidelines mation about ethical and legal issues in nursing.
for nurses. Many healthcare organizations have Nurses must deal with ethical concerns about their
also established their own policies on the use of patients and encounter numerous issues that could
social media that must be followed by students lead to potential legal concerns on a daily basis. A
and staff. NCSBN social media guidelines, which healthcare professional cannot avoid either ethics
support the ANA’s principles for using social or legal issues. A nurse cares for patients, families,
media, are provided on the organization’s website and communities, and in doing so, must consider
(NCSBN, 2014; Spector, 2012). how that care affects the feelings and rights of oth-
The ANA Code of Ethics emphasizes the pro- ers. From the time a nurse achieves licensure, he
tection of confidentiality of patient information by or she operates under a legal system through the
nurses. HIPAA also protects patient information, nurse practice act and other laws and regulations.
and educational and healthcare institutional poli-
cies outline the legal issues related to discussion or
sharing of protected information. With expansion
in use of online courses, it is important to remember Stop and Consider #4
Families of patients do not have the right to be given
that when patients are discussed in online forums, information about their family member.
the same guidelines apply—no specific identifiers
CHAPTER HIGHLIGHTS
1. Ethics is concerned with a code of behaviors, 6. Reporting unethical, immoral, and unsafe
whereas bioethics relates to life-and-death actions is part of a nurse’s ethical respon-
decisions. sibility to protect the public from harm.
2. Ethical dilemmas arise when there is conflict 7. Healthcare fraud and abuse involve deliberate
among the nurse’s, profession’s, organization’s, deceptive activities to steal funds; both have
and patient’s codes for decision making. ethical and legal implications.
3. Principles of ethical behavior fall into four 8. Research activities require stringent con-
areas: autonomy, beneficence, justice, and siderations of ethical principles—such as
veracity. protection of the public from physical, psy-
4. A professional code of ethics guides an chological, social, and economic harm—and
entire discipline and is generally set at the informed consent for the research protocol
national level. offered in language that the research subject
5. State boards of nursing outline the expec- understands.
tations of nurses within their jurisdiction.
(Continues)
CHAPTER HIGHLIGHTS (CONTINUED)
9. Organizational ethics refers to an insti- 11. Patient privacy and confidentiality are both
tution’s ethical expectations of itself as an ethical and legal issues; HIPAA is the federal
organization and its employees and the law that addresses patient protection of
patient’s rights. privacy and confidentiality.
10. Malpractice and negligence charges can 12. No information or image related to a pa-
be filed against a nurse. The nurse must tient or patient’s family should be shared
understand both of these concepts. on social media.
1. Describe malpractice and how it applies to 4. How does ethical decision making apply to
nursing care. nursing students?
2. What is the IRB? 5. Explain how the profession of nursing incorpo-
3. Explain the potential harms in research that rates ethics into practice and the profession.
IRBs are concerned about.
1. Visit your state board of nursing website and directives, living wills, DNR orders, or organ
find information about making complaints donation. Explain what it is in language
to the board. Review the information. What that consumers could understand. What
is your opinion of this process? makes the issue you selected an ethical
2. Visit https://www.ncsbn.org/3771.htm, the and/or legal issue?
website for the NCSBN, and select one of 4. NCSBN on Social Media Use: https://www
the topics. Summarize the topic, and discuss .ncsbn.org/347.htm. View the short video
why it is relevant to you as a student and and learn more about guidelines for use of
would be relevant you as a nurse. social media by nurses.
3. Select one of the following topics: confi-
dentiality and informed consent, advance

Describe an experience you have had in your clinical sessions that was an ethical
dilemma for you. Why was it difficult for you? What did you do to cope with it? What
will you do if you experience a similar situation in the future?
CASE STUDIES
Case 1
A 5-day-old premature baby was believed to require a blood transfusion because of
increasing anemia. The parents were Jehovah’s Witnesses and did not wish to have
blood or blood products given to the baby. A court order was obtained with the parents’
knowledge, and the blood was given. The physician on call the next night did not think he
needed to obtain the court’s consent for an additional blood transfusion because it had
been granted for the earlier transfusion. The blood was ordered, and the nurse was asked
to administer the blood. The nurse refused for ethical and legal reasons.
Case Questions
1. What might be the ethical and legal reasons for the nurse to refuse to follow the
physician’s orders?
2. Which steps should the nurse take?
3. How do you think the nurse should respond to the parents?
Case 2
Following the death of a patient who had received the wrong medication, the patient’s
family sued the hospital, the physician who ordered the medication, and the nurse
who administered the medication. The nurse is very concerned and agrees to legal
representation from the hospital attorneys. Weeks go by before she hears from the
attorney. The nurse has malpractice insurance, but she is unsure what to do about it. She
is frustrated and talks to a friend who is also a nurse. She tells her friend that she feels she
should call the patient’s family. The following are questions that come up.
Case Questions
1. Is it wise for the nurse to not have her own legal representation? If not, why?
2. What should the nurse do about her malpractice coverage?
3. What does the plaintiff (patient’s family) have to prove?
4. Should the nurse call the family? Why or why not?

questions.
1. I don’t understand why we need to discuss this situation as potential fraud.
2. Why would nurses be involved in this issue? We just provide care.
3. Who is the researcher?
REFERENCES
American Nurses Association. (2011). Position statement: National Commission for the Protection of Human Subjects
Forgoing nutrition and hydration. Retrieved from of Biomedical and Behavioral Research. (1978). The
http://www.nursingworld.org/MainMenuCategories Belmont report: Ethical principles and guidelines for the
/Policy-Advocacy/Positions-and-Resolutions/ANA protection of human subjects of research. Washington,
PositionStatements/Position-Statements-Alphabetically DC: Author.
/prtetnutr14451.pdf National Council of State Boards of Nursing. (2011). Filing
American Nurses Association. (2013). Position statement: a complaint. Retrieved from https://www.ncsbn.org
Assisted suicide. Retrieved from http://www.nursing /filing-a-complaint.htm
world.org/euthanasiaanddying National Council of State Boards of Nursing. (2014). Social
American Nurses Association. (2015). Code of ethics for nurses media guidelines for nurses. Retrieved from https://
with interpretive statements. Silver Spring, MD: Author. www.ncsbn.org/347.htm
Bandura, A. (1999). Moral disengagement in the perpetration Pawderly, H. (2015, December 7). Biggest healthcare
of inhumanities. Personality and Social Psychology fraud in 2015: Running list. Retrieved from http://
Review, 3, 193–209. www.healthcarefinancenews.com/slideshow/biggest
Barry, M. (2017, January 11). Social media. Proceed with -healthcare-frauds-2015-running-list
caution. The American Nurse. Retrieved from http:// ProCon.org. (2016). State-by-state guide to physician-assisted
www.theamericannurse.org/2014/01/02/social suicide. Retrieved from http://euthanasia.procon.org
-media-proceed-with-caution/ /view.resource.php?resourceID=000132
Beckers Hospital Review. (2016). UC health nurse sues Spector, N. (2012). What nurse educators should consider
health system for covering up scope-related outbreak. when developing social media policies. Dean’s Notes,
Retrieved from http://www.beckershospitalreview.com 34(1), 1–2. Retrieved from https://www.ncsbn.org
/quality/uc-health-nurse-sues-health-system-for /sep12.pdfc
-covering-up-scope-related-outbreak.html U.S. Department of Health and Human Services. (1993).
Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Protecting human research subjects: Institutional
Educating nurses: A call for radical transformation. Review Board guidebook. Retrieved from http://www
San Francisco, CA: Jossey-Bass. .hhs.gov/ohrp/archive/irb/irb_guidebook.htm
Benton, J., Arm, D., & Flynn, J. (2013). Identifying and U.S. Department of Health and Human Services. (2014,
minimizing risk exposures affecting nursing practice to January 26). Departments of Justice and Health and
enhance patient safety. Journal of Nursing Regulation, Human Services announce record-breaking recov-
3(4), 5–9. eries resulting from joint efforts to combat health
Burman, M., & Dunphy, L. (2011). Reporting colleague care fraud. Retrieved from http://www.hhs.gov/news
misconduct in advanced practice nursing. Journal of /press/2014pres/02/20140226a.html
Nursing Regulation, 1(4), 26–31. U.S. Department of Health and Human Services. (2016).
Fowler, M. (2015). Guide to the code of ethics for nurses with HEAT task force. Retrieved from https://www.stop
interpretive statements. Development, interpretation, and medicarefraud.gov/aboutfraud/heattaskforce/index
application. (2nd. ed.). Silver Spring, MD: American .html
Nurses Association. U.S. Department of Health and Human Services. (2017).
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Hyatt, J. (2016). Recognizing moral disengagement and its No. 104-191, 110 Stat. 1998 (1996). Retrieved from
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Judiciary House of Representatives, 103rd Congress,
Chapter
7
Health Promotion, Disease
Prevention, and Illness:
A Community Perspective
CHAPTER OBJECTIVES
■■ Discuss the Healthy People 2020 national medical home model; self-management; and
initiative to improve U.S. health. health literacy.
■■ Describe public/community health, expansion ■■ Discuss examples of public/health services:
of the U.S. healthcare system, and healthcare community emergency preparedness,
reform. managing population health, migrant and
■■ Discuss the continuum of care and continuity immigrant issues, home health care, school
of care and its relationship to the individual, health, rehabilitation, extended care, long-
family, and community across the life span, as term care, end-of-life and palliative care,
well as health promotion, disease prevention, case management, occupational health care,
and healthcare disparities. complementary and alternative medicine, and
■■ Explain the importance of concepts related genetics.
to public/community health such as patient- ■■ Discuss current public/community health
centered care; vulnerable populations; stress, problems.
coping, and resilience; aspects of acute illness ■■ Critique critical global healthcare concerns
and population health; chronic illness; the and nursing’s role in improving global health.
CHAPTER OUTLINE
●● Introduction ●● Individual, Family, and Community

●● A National Initiative to Improve the Health
Nation’s Health: Healthy People 2020 ●● Access to Care
●● Public/Community Healthcare Delivery ●● Across the Life Span
System ●● Health Disparities
●● Structure and Function of the Public/ ●● Health Promotion and Disease
Community Healthcare Delivery System Prevention
●● Continuum of Care ●● Health Promotion
●● Continuity of Care ●● Disease Prevention
195
●● Important Concepts ●● Extended Care, Long-Term Care,

●● Patient as Focus of Care and Member and Elder Care
of the Healthcare Team ●● End-of-Life and Palliative Care
●● Vulnerable Populations ●● Case Management
●● Health and Illness ●● Occupational Health Care
●● Stress, Coping, Adaptation, and ●● Complementary and Alternative
Resilience: A Public/Community Therapies or Integrative Medicine
Perspective ●● Genetics
●● Acute Illness ●● The Changing Nature of Public/
●● Greater Emphasis on Chronic Disease Community Health Problems
●● Medical Home Model ●● Violence in Communities
●● Self-Management ●● Opioid Epidemic
●● Health Literacy ●● Global Healthcare Concerns
●● Multiple Perspectives of Public/Community and International Nursing
Health Services ●● Chapter Highlights
●● Community Emergency Preparedness ●● Engaging in the Content
●● Managing Population Health ●● Discussion Questions
●● Migrant and Immigrant Issues ●● Critical Thinking Activities
●● Home Health Care ●● Electronic Reflection Journal
●● School Health ●● Case Studies
●● Rehabilitation ●● Working Backward to Develop a Case
●● References
KEY TERMS
Acute care Extended care Primary care provider

Acute illness Family Primary prevention
Caregiver Health Rehabilitation
Care coordination Health disparity Resilience
Case management Health promotion Secondary caregiver
Chronic disease Healthy community Secondary prevention
Collaboration Home care Self-management
Community Hospice care Stress
Continuity of care Illness Stress management
Continuum of care Long-term care Tertiary prevention
Coping Occupational health care Vulnerable population
Disease management Palliative care
Disease prevention Population
Introduction delivery of care in a variety of settings in the commu-

nity. Nursing programs provide clinical experiences
This chapter provides an introduction to a variety for students in many of the settings and situations
of public/community health issues, such as health discussed in this chapter, and students also learn
promotion and disease prevention, the continuum about public/community health in more depth in
of care, healthcare disparities, chronic disease, and public/community health courses. In this chapter,
Chapter 7: Health Promotion, Disease Prevention, and Illness 197
public/community health is introduced as an import- and prevent disease and illness and provide data to
ant component of healthcare delivery and nursing. evaluate outcomes. The ultimate measure of success
Where do patients receive care? Who are the patients? of this health improvement initiative is the health
How are health and illness viewed by patients and status of the target population. To meet this goal
by nurses, and what impact does this view have on the Healthy People 2020 (HHS, 2017) is designated
healthcare delivery? Nurses need an understanding as a national prevention initiative that focuses on
of these critical public/community health issues. improving the health of Americans by providing
“Although the United States spends more on health a comprehensive set of disease health promotion
care than any country in the world, its citizens as a and disease prevention goals and objectives with
whole are the least healthy in the developed world. target dates describing a timeline for evaluation
Nearly 45% of Americans have at least one chronic of outcomes.
condition, and chronic conditions are responsible There have been five editions of Healthy People
for 70% of the Nation’s deaths and 75% of health care (1979, 1990, 2000, 2010, and 2020) (HHS, 2017).
spending. Many illnesses associated with chronic Its vision and major goals that should be reached
conditions are related to unhealthy lifestyle behaviors by 2020 include the following:
and can be prevented by increasing access to effective Vision
clinical preventive services and promoting community A society in which all people live long healthy lives
interventions that advance public health. Public health
spending has been shown to be particularly effective Mission
for lower income, and often higher need, communi- Healthy People 2020 strives to:
ties, with 21% to 44% greater health and economic ■■ Identify nationwide health improvement
effects in low-income communities compared with priorities.
the average-income community. Increasing public ■■ Increase public awareness and understanding
health spending and improving access to preventive of the determinants of health, disease, and
care thus holds promise as a cost-efficient way to disability and the opportunities for progress.
create healthier communities, reduce the personal ■■ Provide measurable objectives and goals
and economic burden of chronic illnesses, and that are applicable at the national, state, and
improve quality of life while reducing disparities local levels.
throughout the United States” (U.S. Department of ■■ Engage multiple sectors to take actions to
Health and Human Services [HHS], & Agency for strengthen policies and improve practices
Healthcare Research and Quality [AHRQ], 2016). that are driven by the best available evidence
This description indicates that much needs to be done and knowledge.
in public/community health and improvement can ■■ Identify critical research, evaluation, and
impact many people. data collection needs.
Overarching Goals
Attain high-quality, longer lives free of
A National Initiative
■■
preventable disease, disability, injury, and

to Improve the Nation’s Health: premature death.
Healthy People 2020 Achieve health equity, eliminate disparities,
■■
and improve the health of all groups.

The HHS, its agencies, and other government de- Create social and physical environments that
■■
partments that have responsibilities related to health promote good health for all.
and healthcare services (federal, state, and local) are Promote quality of life, healthy development,
■■
charged to develop programs that promote health and healthy behaviors across all life stages.
Overarching goals:
Determ • Attain high quality, longer
inants
lives free of preventable
Physical disease, disability, injury,
environment and premature death.
• Achieve health equity,
Social Health Health eliminate disparities, and
environment services outcomes improve the health of all
groups.
Biology • Create social and physical
and environments that promote
Individual
genetics good health for all.
behavior
• Promote quality of life,
healthy development, and
healthy behaviors across
all life stages.
Figure 7-1 Healthy People 2020

Reproduced from U.S. Department of Health and Human Services. (2017). Healthy People 2020. Washington, DC:
U.S. Government Printing Office. Retrieved from http://www.healthypeople.gov
Figure 7-1 presents the Healthy People 2020 and the unavailability or inaccessibility of quality
model, which emphasizes the critical determinants health services.
for a society in which all people live long, healthy Healthy People 2020 focuses on topics that
lives. These determinants are the physical environ- are tracked and monitored to assess outcomes.
ment, the social environment, individual behavior, Exhibit 7-1 describes major topics and identifies
biology and genetics, and health services. All of their related indicators and objectives, which may
the determinants affect health outcomes, and the change based on monitoring data and outcomes.
determinants of health interact with one another. This plan relates to the annual National Quality
The determinants need to be monitored and eval- and Disparities Report and also to the new National
uated to improve the health status of individuals, Quality Strategy (NQS). Both of these are discussed
families, and communities. According to Healthy in other chapters in this text. The Healthy People
People, health status is determined by measuring 2020 data indicate that from 2010 to 2014, 14 of
birth and death rates, life expectancy, quality of life, the 26 indicators (53.9%) either met their target or
morbidity from specific diseases, risk factors, use of have shown improvement (HHS, 2014). Data are
ambulatory care and inpatient care, accessibility of typically not up-to-date with the current year as it
health providers and facilities, financing of health takes time to collect and analyze the data.
care, health insurance coverage, and other factors. A community is defined as “people and the
Access to health care is critical. This is a complex relationships that emerge among them as they develop
healthcare issue that affects the health status of in- and use in common some agencies and institutions
dividuals and communities. For example, when the and share a physical environment” (Williams, 2006,
causes of death in the United States are examined, p. 3). The Healthy People 2020 initiative describes
there typically is not one single factor or behavior a healthy community as one that embraces the
that determines outcomes, but rather multiple belief that health is more than merely an absence
factors—such as genetics, lifestyle, gender, and of disease; a healthy community includes those ele-
race/ethnic factors; poverty level, education, injury, ments that enable people to maintain a high quality
violence, and other factors in the environment; of life and productivity. A healthy community has
Exhibit 7-1 Healthy People 2020 Topics and Leading Health Indicators
Topic Leading Health Indicators

Access to health ●● Persons with medical insurance (percent, <65 years)
services ●● Persons with a usual primary care provider (percent)
Clinical ●● Adults receiving colorectal cancer screening on most recent guidelines
preventive (age adjusted, percent, 50–75 years)
services ●● Adults with hypertension whose blood pressure is under control (age
adjusted, percent, 18+ years)
●● Persons with diagnosed diabetes whose A1c value is >9% (age adjusted,
percent, 18+ years)
●● Children receiving the recommended doses of DTaP, polio, MMR, Hib,
hepatitis B, varicella, and PCV vaccines (percent, aged 19–35 months)
Environmental ●● Air quality index (AQI) exceeding 100 (number of billion person days,
quality weighted by population and AQI value)
●● Children exposed to secondhand smoke (percent, nonsmokers, 3–11 years)
Injury and ●● Injury deaths
violence ●● Homicides
Maternal, infant, ●● Infant deaths (per 1,000 live births, <1 year)
and child health ●● Total preterm live births (percent, <37 weeks’ gestation)
Mental health ●● Suicide (age adjusted, per 100,000 population)
●● Adolescents with major depressive episodes (percent, 12–17 years)
Nutrition, ●● Adults meeting aerobic physical activity and muscle-strengthening federal
physical activity, guidelines (age adjusted, percent, 18+ years)
and obesity ●● Obesity among adults (age adjusted, percent, 20+ years)
●● Obesity among children and adolescents (age adjusted, percent,
2–19 years)
●● Mean daily intake of total vegetables (age adjusted, cup equivalents per
1,000 calories, 2+ years)
Oral health ●● Persons who visited the dentist in the past year (age adjusted,
percent 2+ years)
Reproductive ●● Sexually experienced females receiving reproductive health services in the
and past 12 months (percent, 15–44 years)
sexual health ●● Knowledge of serostatus among HIV-positive persons (percent, 13+ years)
Social ●● Students awarded a high school diploma 4 years after starting 9th grade
determinants (percent)
Substance ●● Adolescents using alcohol or illicit drugs in past 30 days (percent, 12–17 years)
abuse ●● Adult binge drinking in past 30 days (percent, 18+ years)
Tobacco ●● Adult cigarette smoking (age adjusted, percent, 18+ years)
●● Adolescent cigarette smoking in past 30 days (percent, grades 9–12)
Modified from U.S. Department of Health and Human Services. (2017). Healthy People 2020. Leading Health
Indicators. Retrieved from https://www.healthypeople.gov/2020/Leading-Health-Indicators
the following characteristics: It is safe; provides both The Healthy People 2020 initiative not only
treatment and prevention services to all community provides a 10-year plan to improve health care in
members; has the infrastructure (roads, schools, the United States, but also monitors and reports on
playgrounds, and other services) to meet needs; progress periodically to determine if the goals and
and is a healthy environment (regarding issues of objectives are being met. Data on current outcomes
pollution, for example, air and water). Educational can be found on the Healthy People website. When
and community-based programs need to focus the 10-year time period is completed, all leading
on preventing disease and injury, promoting and indicators are evaluated, and the analysis of the
improving health, and enhancing the quality of outcome data is then used to develop the goals,
life. According to Healthy People 2020, to provide objectives, and leading indicators for the next 10
broad access, programs and their services should be years version 2013 is in preparation.
located in schools, workplaces, healthcare facilities,
and community sites. These programs might offer
services for prevention, monitoring, treatment, and Stop and Consider #1
Healthy People 2020 is a national initiative that has
rehabilitation focused on the following: implications for nursing care.
■■ Chronic diseases
■■ Injury and violence
Mental illness
Public/Community
■■
■■ Oral health
■■ Tobacco use Healthcare Delivery System
■■ Substance abuse
The public/community healthcare delivery system is
■■ Nutrition, physical activity, and obesity
complex and varied. We have a national system and
One method that a community might use to also state and local systems. This section examines
develop a healthy community is called “MAP-IT,” the system and its differences from the acute care
which is an approach recommended by Healthy system and how they relate to provide an overall
People to work with community members to plan health system for members of the community.
what needs to be done to improve the community’s
health. The MAP-IT steps are (HHS, 2010):
Structure and Function
■■ Mobilize individuals and organizations that of the Public/Community
care about the health of the community into
Healthcare Delivery System
a coalition.
■■ Assess the areas of greatest need in the Public/community health plays a critical role in
community, as well as the resources and improving and maintaining the health of individuals,
other strengths that planners can tap into families, and communities. Public health focuses
to address those areas. on issues related to the public health workforce,
■■ Plan the approach. Community leaders/members financing and economics, structure and perfor-
start with a vision of where they want to be mance, and information and technology. It is a
as a community; they then add strategies and complicated endeavor, requiring multiple services
action steps to help them achieve that vision. to meet needs of populations and communities
■■ Implement a plan using concrete action steps (Robert Wood Johnson Foundation [RWJF], 2012).
that can be monitored and will make a difference. There is a great need to address multiple complex
■■ Track progress over time. health problems in communities, such as violence,
including domestic, child, and elder abuse; substance environmental health issues (water, air, sanitation),
abuse and alcohol dependency; tobacco use; injuries; transportation safety, food safety, maintenance of
automobile accidents; environmental factors such licensure for healthcare providers (such as physi-
as air and water quality; food safety and consequent cians, nurses, hospitals, long-term care facilities,
health issues; chronic illnesses; and communicable and others), clinic systems, disaster emergency
diseases. Public health has recently become more planning, school health through public schools,
important with the increasing concern about disaster and much more. Each state has a public health
emergency management, terrorism, and now the department or division, and typically counties
growing opioid epidemic. Communities need to and other local entities also have their own public/
develop effective plans to provide healthcare ser- community health services. It is important that all
vices in major crisis situations. All these concerns three levels of government public health services
require more than just care for individuals who collaborate and communicate to ensure effective
are experiencing these problems; we need to look services; however, this is not always the case.
at populations and communities. Public health Although the Affordable Care Act of 2010 (ACA)
incorporates three functions: focuses primarily on healthcare reimbursement,
which has a direct impact on public/community
■■ Assessment: Assess and diagnose the status
health, it does have some provisions that relate to
of the community’s health and identify the
public/community health, such as health screening
needs for services using epidemiology, sur-
options in insurance plans. Changes in this law may
veillance, research, and evaluation.
have an effect on these provisions.
■■ Policy development: Some problems require
Nurses are very active in all types of public/
changes in laws, programs for prevention
community services, serving in administrative and
and treatment, and reimbursement for these
planning roles at the federal, state, and local levels;
services. There is a great need for strategic
assessing service needs; providing services in clinics
plans and interventions, and appropriate
and other state and local healthcare facilities; pro-
evaluation of outcomes needs to be developed
viding immunizations; working toward tuberculosis
through the government and its agencies at
control and control of other communicable diseases,
all levels (local, state, and federal).
particularly during times of epidemics or unexpected
■■ Assurance: Ensure universal access to care
communicable diseases (most recently, for example,
when it is needed and to health promotion
the Ebola virus and Zika virus outbreaks; providing
and prevention of disease and illness through
human immunodeficiency virus (HIV)/acquired
community-wide health services.
immunodeficiency syndrome (AIDS) care and
The public/community healthcare delivery prevention; developing and implementing health
system is complex and can be viewed from the promotion and disease prevention; providing home
perspectives of the federal, state, and local levels. care and hospice care; working as school nurses and
The HHS, the Centers for Disease Control and occupational health nurses; conducting research in
Prevention (CDC), Food and Drug Administration areas of public/community health; and participating
(FDA), and the Public Health Service (PHS) have in epidemiology activities). The role of the public
major responsibilities in ensuring the health of the health nurse has evolved and includes greater focus
nation. States and local areas vary as to how their on population-based health promotion and preven-
public/community healthcare delivery systems are tion (Kulbok, Thatcher, Park, & Meszaros, 2012).
organized and the types of services they provide; This role requires much more collaboration with a
however, services typically include immunizations, variety of organizations, healthcare professionals,
and others in the community—community par- Some hospitals are evolving into community
ticipation is critical to effective public/community health networks (Seegert, 2016). This is happening
health and nursing within the community. Nurses as hospitals are trying to determine how best to
who work in this area need to be able to collect and deal with a changing payment system, increasing
analyze data, develop plans and interventions, use costs, and the need to optimize patient outcomes
a variety of interventions such as typical nursing and improve population health. Collaborating with
interventions (for example, health assessment, others in the community—some who provide care
immunizations) and use different interventions (for and others who provide support services, funding,
example, implementing health education focused government structure and functions—may make the
on population groups, involvement in planning a difference in meeting goals. Working in isolation
health fair, working with the city council to develop from others will not meet the goals. These hospitals
plans for disasters and other situations, school are using nurses to help with making greater con-
nursing, work in clinics or even establish nurse nection with the community. “Rethinking health
managed clinics collaborate with acute care, and care requires a shift in the mindsets and skill sets
so on) (Pilon et al., 2015). Cultural competence is of all who care for patients. It’s less about episodes
even more important in public/community heath of care and more about an entire continuum of
nursing than in acute care. Nurses need greater pro- services” (Seegert, 2016, p. 19). Critical aspects of
gram planning skills, which requires coordination, the continuum include the need for coordination,
communication, and collaboration. When students collaboration, and effective healthcare teams. These
take public/community health courses, they learn topics are discussed in other chapters of this text.
more about this critical area of health care and the
roles of nurses and other members of the public/ Continuity of Care
community health team.
“Continuity of care is the degree to which a
series of discrete events is experienced as coherent
Continuum of Care and connected and consistent with the patient’s
The continuum of care is an important concept medical needs and personal context” (Haggerty,
in nursing and health care. In 2004, The Joint Reid, Freeman, Starfield, Adair, & McKendry, 2003,
Commission (then called the Joint Commission on p. 1219). This definition was developed after a mul-
Accreditation of Healthcare Organizations) defined tidisciplinary review of continuity of care literature
the continuum of care as “matching an individual’s to determine how different healthcare professionals
ongoing needs with the appropriate level and type viewed the concept. It was noted that continuity of
of medical, psychological, health, or social care or care is different from other views of care because it
service within an organization or across multiple focuses on care over time and on individual patients
organizations” (p. 317). The goal of the continuum to ensure connection of treatment to needs as they
of care is to decrease fragmented care and costs. change. Three types of continuity are important,
The continuum includes health promotion, disease and they arise at different times, dependent on the
and illness prevention, ambulatory care, acute care, care setting.
tertiary care, home health care, long-term care, and ■■ Informational continuity: Information is very
hospice and palliative care. The continuum is a view important in health care, across the continuum
of health care that describes a range of services in of care and to continuity of care. This type
a variety of settings so that a patient might receive of continuity focuses on information that is
care at different stages of health and illness. needed to link care from one provider and
setting to another—for example, medical Nurses are very involved in continuity of care
information, the patient’s preferences, values, when they transfer and coordinate care over time
and context. As noted in this text, healthcare and focus on consistency of care. Typically, this is
information technology has become more done through discharge planning. Nurses who work
and more important and now offers greater in the community need to recognize the importance
and faster accessibility to information. In of continuity of care and integrate this into planning
addition, the Internet offers the same to the for individuals, families, and populations within the
consumer. community. They need to recognize that care is a
■■ Management continuity: When patients have continuum and acute care is part of the continuum.
complex and chronic problems, management
of multiple providers ensures that all providers Individual, Family,
are aware of what each is doing and all are
and Community Health
working toward the same outcomes. This
requires sharing information and plans and The usual assumption is to consider the patient as
demonstrating flexibility to ensure quality an individual, and most patients are individuals.
care. A common problem that occurs in There are, however, other views of the patient. The
these situations is that one provider does family, the community, and specific populations,
not know the medications another provider such as patients with specific chronic diseases, may
has prescribed. Often, a home health nurse also be viewed as patients. In public/community
discovers a lack of coordination when the health, there is greater emphasis on the health of
nurse reviews all the medications (medication families, populations, and communities.
reconciliation) a patient is taking that may A family is defined as “two or more individuals
have been prescribed by different physicians who depend on one another for emotional, physical,
or other providers. Serious medication errors and/or financial support. Members of a family are
can result from this problem. As more care self-defined” (Kaakinen, Hanson, & Birenbaum,
is provided in the community, there will be 2006, p. 322). Functional families are considered
increased risk associated with managing clinical healthy families in which there is a state of bio/
problems unless there is improved structure psycho/socio/cultural/spiritual well-being. A healthy
and communication within the community. family provides autonomy and is responsive to
■■ Relational continuity: This type of continuity individual members within the family. In contrast,
concerns the need for patients to develop dysfunctional families have poor communication
relationships with providers, particularly in and relationships with one another and do not
the community. The primary care provider provide support to family members.
often serves as the entry point into the Nurses work with families in many ways along
healthcare system, and if used by the patient, the continuum of care. The family itself may be the
should coordinate the patient’s overall care and patient, or the nurse may be involved with a family
make referrals to specialists when necessary. because of one family member’s illness. For example,
Relational continuity emphasizes the need a home health nurse caring for a patient who has un-
for providers to be familiar with the patient controlled diabetes, who is recovering from surgery,
and the patient’s history so that when the and who lives with her daughter and family must be
patient becomes ill, there is someone who aware of family dynamics, needs, caregiver strain,
has a relationship with the patient and can and other health issues that can impact the identified
easily access past medical information. patient’s care and outcomes such as dietary changes.
Family members may also be caregivers. A school health, assess needs of the elderly in the home,
caregiver is someone who provides care to another develop programs to screen for diabetes in people
person. He or she is a nonprofessional healthcare in the community who might be at risk, manage a
provider. Because many insurance plans provide clinic for the homeless, or develop and implement a
limited or no coverage for home care, families community disaster emergency preparedness plan.
often need to serve as caregivers for short-term or There are many other ways that a nurse might assist
long-term needs of family members. This is not different populations within a community.
easy to do when family members work and have
other obligations. Serving as a caregiver for a family Access to Care
member on a long-term basis can lead to caregiver
psychological, physical, social, and financial prob- Access to care is, of course, the first step in receiving
lems. The majority of caregivers are women; men are care, and it is not a simple process for many people;
more likely to be cared for by their wives than the for some, there are major barriers. Access to care is
reverse because men have a shorter life expectancy a critical public/community health issue at federal,
(Schumacher, Beck, & Marren, 2006). Caregiver state, and local levels. Many people think of access
strain is something that the nurse needs to assess as solely the ability to physically get to a destination,
periodically to ensure that the caregiver(s), and but access to care actually involves many factors:
therefore the family, receive the support needed. ■■ Ability to pay for care, either by insurance
Primary caregivers provide the majority of daily or personally
aspects of care, and secondary caregivers help ■■ Transportation to get to care
with intermittent activities (shopping, transpor- ■■ Hours of operation at the clinical site
tation, home repairs, getting bills paid, emergency ■■ Waiting time to get an appointment
support, and so on). Both types of caregiving can ■■ Long waits at the time of appointment to
put a strain on the caregiver, but primary caregivers see a physician or other healthcare provider
are at greater risk. There has been more focus on ■■ Ability to get an appointment
helping caregivers with information and support. In ■■ Availability of type of healthcare provider
2017, Marrelli, a home care nurse expert, developed needed
an Internet-based resource for caregivers. Access to ■■ Ability of the patient and provider to com-
this in depth guide for caregivers will be offered by municate and make use of accommodations
healthcare providers and insurers to patients and for language, hearing, and sight
enrollees. This demonstrates the roles that nurses ■■ Timeliness of laboratory tests
may assume in creating new tools for patients and ■■ Handicap provisions at the healthcare site
then collaborating with technology experts to de- ■■ Childcare provisions so that family members
velop the tools (Marrelli, 2017). can go to appointments
Nurses offer many services in communities, ■■ Cultural barriers
and they may focus on an entire community or a ■■ Inadequate information or lack of information
specific population that lives in the community. A ■■ Lack of provider time (rushed)
population is “a collection of people who share one ■■ Insurer not covering specific treatment or
or more personal or environmental characteristics” medications
(Williams, 2006, p. 4). Examples of populations within ■■ Provider not accepting patient’s insurance
a community include children, the elderly, those coverage
with a chronic disease such as diabetes or respiratory ■■ Inadequate transportation choices, schedules,
disease, and the homeless. A nurse might work in and cost
As this list suggests, access is a complex issue, par- all citizens will have insurance. The overall goal for
ticularly for vulnerable populations. the ACA was to reduce the number of people without
Access to care has a major impact on the con- health insurance in the United States. Using data from
tinuum of care. Can the patient get the care that is the Current Population Survey (CPS), 9.1% of the
needed when it is needed? Where is the best loca- U.S. population, or 29 million people, were uninsured
tion for care? When patients experience barriers to in 2015, down from 13.3% in 2013 (Kaiser Family
access, they may neglect routine care and put off Foundation [KFF], 2016). Enrollment is increasing,
getting care when it is needed. These patients may reducing the number of the uninsured. It is important
then need more complex care and use the safety that the people who enroll in the ACA insurance options
net, which are services that cover patients who represent balanced needs, ideally with a lot of young,
cannot pay for care or who have other access barrier healthy people to offset the costs attributable to older,
problems. Examples of safety net sites include free sicker enrollees who require more care. Insurers that
clinics, academic health centers, and emergency are burdened with sicker enrollees without healthier
rooms. This type of care may (or may not) meet the enrollees will have financial problems. This law does
patient’s immediate need, and it does not typically not establish a universal healthcare system. If people
support an effective continuum of care and continuity do not obtain insurance—which is now easier to get,
of care. Patients who fall into the safety net often especially given that the law provides some financial
get lost in the system, and their outcomes may not support to help some people cover the costs—this
be positive. A Healthy People 2020 goal focuses on law requires persons without health insurance to pay
this concern (HHS, 2017). The goal is to achieve penalties. This carrot-and-stick strategy represents a
health equity, eliminate disparities, and improve complex approach to the problem, and this approach
the health of all groups. may be changed due to the Trump administration’s
One approach to improving access to healthcare efforts to repeal and replace the ACA. The results of
services is to offer comprehensive and wraparound these potential changes will be better known later in
services. Comprehensive services are best described the administration. Due to the potential for major
as “one-stop shopping,” in which the patient can go changes in the ACA, it is important for nurses to
to one place and receive multiple services. These keep up-to-date on changes and consider the impact
services are typically offered in convenient locations the changes might have on nurses, nursing care, and
such as neighborhoods, schools, or work sites. Health health care in general.
promotion and illness prevention can also be built Accountable care organizations (ACOs) are rec-
into these services. Recognizing that social and eco- ommended in ACA provisions. These organizations
nomic problems have a major impact on a person’s attempt to contain healthcare costs by fostering care
health and access to needed services, wraparound coordination across disciplines and providing for
services can be combined with comprehensive integrated care delivery. An example of one such
health services when the healthcare sites also offer ACO is Kaiser Permanente, in which the insurer,
social and economic services (for example, access physician groups, and healthcare institutions work
to a social worker to assist patients with getting together to provide integrated services from acute
food and housing, job issues, and assistance with care to community-based care (Accountable Care
healthcare reimbursement problems). Facts, 2014). It is important to note that Kaiser Per-
Another critical factor that has a major impact on manente is not a new organization; it existed before
access to care is the ability to pay for care, typically with the passage of the ACA and it is unclear what affect
some type of insurance. The ACA primarily addresses changes in the ACA might have on such provisions
this issue, although its implementation does not mean as the one that establishes ACOs.
Across the Life Span Health Disparities

Patients may enter the healthcare system for a va- Health disparities have become even more important
riety of needs and services, and they may enter at in the last 10 years. The Institute of Medicine, now
any point in the life span from: known as the National Academy of Medicine (NAM),
■■ Conception issued reports in its Quality Chasm series of reports
■■ Birth with supporting data demonstrating that the U.S.
■■ Infancy healthcare system has severe problems with health/
■■ Childhood healthcare disparities (Institute of Medicine [IOM],
■■ Adolescence 2002). A health disparity is an inequality or gap that
■■ Young adulthood exists between two or more groups. Health disparities
■■ Middle adulthood are believed to be the result of the complex interaction
■■ Older adulthood of personal, economic, societal, and environmental
■■ End of life factors. Healthy People 2020 considers measures of
race/ethnicity, gender, physical and mental ability,
Each of these life-span periods includes specific
and geography to be among these factors (HHS,
health concerns and needs, as well as potential
2017). The national healthcare disparities report is
disease and illness risks. In addition, social and
now combined with the quality report and called the
psychological experiences affect health and well-
National Healthcare Quality and Disparities Report
ness. These experiences include situations such as
(QDR). Healthcare quality is affected by race, ethnicity,
the death of a loved one, change in or loss of a job,
socioeconomic status, age, sex, disability status, sexual
beginning school, moving, marriage, birth of a child,
orientation, gender identity, and residential location
divorce, the need to care for a family member who
(HHS, & AHRQ, 2015). The 2015 report provides data
is ill, retirement, and other stressful situations. The
about disparities related to race and socioeconomic
federal government collects data about health and
status, for example (HHS, & AHRQ, 2015):
illness across the life span. Exhibit 7-2 provides a
list of the leading causes of death that impact public/ ■■ People in poor households received worse
community health status. The data are updated care than people in high-income households
periodically by the CDC on its website. for about 60% of quality measures.
Exhibit 7-2 Leading Causes of Death in the United States, 2014 Data
(most frequent to least frequent)
●● Heart diseases ●● Alzheimer’s disease

●● Cancer ●● Diabetes
●● Chronic lower respiratory diseases ●● Influenza and pneumonia
●● Accidents (unintentional injuries) ●● Nephritis, nephrotic syndrome, and nephrosis
●● Stroke (cerebrovascular diseases) ●● Intentional self-harm (suicide)
Reproduced from National Center for Health Statistics. (2016). Health United States, 2015: With special features
on racial and ethnic health disparities. Retrieved from https://www.cdc.gov/nchs/data/hus/hus15.pdf
Blacks, Hispanics, and American Indians

■■
Health Promotion
and Alaska Natives received worse care than
Whites for about 40% of quality measures.
and Disease Prevention
■■ Asians received worse care than Whites for The United States spends more on health care;
about 20% of quality measures. however, its citizens as a whole are least healthy
■■ For each group, disparities in quality of care compared to other developed countries (HHS,
are similar to disparities in access to care, AHRQ, 2016). Chronic illness is a major factor that
although disparities in access tend to be affects this outcome; chronic illness also often leads
more common than disparities in quality. to unhealthier lifestyle behaviors. The American
■■ Disparities also varied across NQS priorities: Hospital Association (AHA) developed an initiative
■■ Disparities were more common among that describes a road map for improving America’s
measures of person-centered care and healthcare system. It focuses on wellness rather
care coordination, involving about 60% than acute care. The goals of this initiative (Health
of comparisons (data not shown). for Life: Better Health. Better Healthcare) are as
■■ Disparities were less common among mea- follows (AHA, 201l):
sures of patient safety, effective treatment, ■■ Focus on wellness
and healthy living, involving about 30% of ■■ Most efficient, affordable care
comparisons (data not shown). ■■ The highest quality care
■■ Through 2013, about 40% of disparities at ■■ Best information
baseline for Blacks, Hispanics, and people ■■ Health coverage for all; paid by all
in poor households were getting smaller.
In addition, the National Quality Strategy promotes
Nearly one-third of disparities for Asians
health and well-being of communities by promoting
were getting smaller.
healthy living and well-being through (1) commu-
■■ About 20% of disparities at baseline for
nity interventions that result in improvement of
American Indians and Alaska Natives were
social, economic, and environmental factors; (2)
getting smaller.
interventions that result in adoption of the most
■■ Disparities that were getting smaller included
important healthy lifestyle behaviors across the life
24 measures in which a disparity at baseline
span; and (3) receipt of effective clinical preventive
was eliminated (9% of disparities at baseline),
services across the life span in clinical and commu-
primarily affecting Blacks and Hispanics.
nity settings (HHS, AHRQ, 2016).
■■ There were also 16 measures in which a disparity
was not present at baseline but developed over
time (4% of contrasts in which there was not Health Promotion
a disparity at baseline), primarily affecting Health promotion focuses on changing lifestyle
Asians (data not shown). to maximize health and is an important part of
■■ Change in disparities over time also varied primary prevention. This is very difficult for most
across NQS priorities. people to accomplish. An example of efforts to better
■■ About 45% of disparities related to care understand and address health promotion was the
coordination and effective treatment were 2006 National Prevention Summit, which focused
getting smaller (data not shown). on disease prevention, health preparedness, and
■■ Only about 30% of disparities related to pa- health promotion and featured innovative programs
tient safety, person-centered care, and healthy that are making a difference in communities across
living were getting smaller (data not shown). the country to build a healthier country (HHS, &
Office of Disease Prevention and Health Promo- ■■ Perceived benefits of action: Whether a person
tion [ODPHP], 2006). These programs examined will be active in participating in changing
healthy lifestyle choices—eating a nutritious diet, behavior is highly dependent on whether
being physically active, making healthy choices, and the person sees any benefit in doing so—that
getting preventive screenings—to help prevent major is, whether there are perceived benefits. It is
health threats and burdens such as diabetes, asthma, important to determine whether perceived
cancer, heart disease, and stroke. A special emphasis barriers are real. If perceived barriers to
was the prevention of overweight children and obe- success are felt by a person, it is much more
sity, which have become major problems since 2006 difficult for that person to change a behavior
and can lead to long-term chronic diseases such as to a health-promoting behavior.
diabetes (HHS, & CDC, 2011). Another emphasis ■■ Perceived self-efficacy: Self-efficacy relates
was on preparing for public health emergencies, to whether a person feels that it is possible
such as influenza, biochemical hazards, and natural to do what is needed. It does not mean that
disasters. The need for this preparation continues in the person has the competency to do this,
all communities and is discussed later in this chapter. but rather centers on whether the person
Many models describe how health promotion feels that he or she could actually do what
might be effective. Pender’s health promotion model needs to be done.
is a nursing model that has been used in many stud- ■■ Activity-related affect: Emotions tied to
ies about health promotion (Pender, Murdaugh, & actions are important to recognize, because
Parsons, 2006). This model does not include fear or they can determine whether a person repeats
threat as a motivator to make people change their a behavior. Did the person feel good about
behaviors, and it can be used across the life span. what he or she did? Did it make the person
Pender’s health promotion model includes individual anxious?
characteristics and experiences; that is, it emphasizes ■■ Interpersonal influences: A person is influ-
that each person is unique. The following aspects enced by others, family, friends, co-workers,
of health promotion have an impact on health and peers, healthcare providers, and so on. This
should be considered: influence—what it might be and how it might
be felt—may or may not be reality based,
■■ Prior related behavior: The frequency of the but it still can influence a person’s behavior
same or similar behavior in the past is the and the person’s ability to change to health-
best predictor of behavior. promoting behavior.
■■ Personal factors: Biological (age, weight, pubertal ■■ Situational influences: A situation or context
status, and strength), psychological (self- can influence a person’s behavior. If a person
esteem, coping style, and self-motivation), smokes and is told that all smoking must take
and sociocultural (race, ethnicity, education, place outside the building in a designated area
and socioeconomic status) factors may in- regardless of the weather, this situation or
fluence the cognitions, affects, and health context may influence a change in behavior.
behavior that are the focus. ■■ Commitment to a plan of action: Is a person
■■ Behavior-specific cognitions and affects: These committed to a specific plan to change to
cognitions and affects are very important health-promoting behavior? Commitment is
because nursing interventions can change not enough; strategies must be laid out that
them, which can in turn move a person will enable the person to reach the desired
toward health-promoting behaviors. outcomes.
■■ Immediate competing demands and preferences: occurs. Health promotion is a critical com-
What might interfere with a person changing ponent of primary prevention. Examples are
to health-promoting behavior? Will the family teaching people (children and adults) about
be supportive? Are there other actions that healthy diets before they become obese and
must take precedence (for example, work encouraging adequate exercise (education
over exercise)? Each person has alternative about health and healthy lifestyles is an
behaviors that compete with what the person important intervention at this level).
needs to do to change to a healthier lifestyle. ■■ Secondary prevention occurs when a
■■ Health-promoting behavior: This is the out- person is asymptomatic after disease has
come, and from this, a person reaches positive begun. The focus here is on preventing further
health outcomes. complications. Examples are breast cancer
screening using mammography and blood
In any context, the social determinants, or the pressure screening to diagnose hypertension.
conditions in the environments in which people ■■ Tertiary prevention occurs when there is
live, affect an individual’s health status. The World disability and the need to maintain or, if pos-
Health Organization (WHO, 2011) describes the sible, improve functioning. Examples would
social determinants of health as geographic region be teaching a person with diabetes how to
and condition of birth and life, work environment, administer insulin and manage the disease
age, and the health care that is available and accessi- or referring a stroke patient for rehabilitation
ble. Health is always influenced by access to care—a or providing long-term home care.
factor that may be related to an understanding of
healthy habits or how to use available health re- The ACA mostly focuses on reimbursement
sources, socioeconomic status, and resources that are for health care, but the law also includes some pro-
allocated by governments for the populace (WHO, visions related to the need for greater services to
2011). When we consider these determinants, we promote health and prevent disease (though this is
are looking at social policies, cultural and social not the strength of the legislation). An example is the
norms, political issues and systems, diversity, and requirement that insurers pay for certain healthcare
disparities. We need to use partnerships to address screening as part of their covered services; some of these
the social determinants—they cross many areas and screening services must not be charged to the patient.
concerns of society—and we also need to be more However, this provision is easy to misunderstand. If
prepared—offering more on the determinants in the screening is for diagnosis purposes, then it is not
academic health professional programs and to health- free. For example, if a woman notices she has a lump
care staff as part of lifelong learning (NAM, 2016). in her breast and has a mammogram to determine if
Disease Prevention there is a problem, this test would not be covered; in
contrast, if she were having a routine annual mam-
Disease prevention is concerned with i nterventions
mogram (with no notice of a potential problem), then
to stop the development of disease, but it also includes
the screening would be free. Over the long term, this
treatment to prevent disease from progressing fur-
change in health plan services will increase the quality
ther and leading to complications. The major levels
of life for many and reduce healthcare costs, but how
of prevention are primary, secondary, and tertiary
much improvement and what will improve remain to
(Leavell & Clark, 1965).
be determined. In addition, any changes in the law,
■■ Primary prevention includes interventions repeal or replacement, may have an impact on these
that are used to maintain health before illness provisions focused on prevention.
In 2011, the Office of the Surgeon General initi-

ated the National Prevention Strategy, which aims to Important Concepts
guide the United States in improving the health and
Public/community health care includes a number
well being of its population. The strategy prioritizes
of concepts that may not be found in acute health
prevention by integrating recommendations and
care or may be viewed differently. For example, the
actions across multiple settings to improve health
healthcare team may include different members
and save lives (HHS, Office of the Surgeon General,
from acute care such as government officials and
2013). The initiative includes actions that public and
agencies. The patient may be viewed as more than an
private partners can take to help Americans stay
individual or family. The following sections discuss
healthy and fit and improve the nation’s prosperity.
some of these concepts.
It outlines four strategic directions that, collectively,
are fundamental to improving the nation’s health:
1. Building healthy and safe community environments: Patient as Focus of Care
Prevention of disease starts in communities
and Member of the
and at home, not just in the physician’s office.
2. Expanding quality preventive services in both
Healthcare Team
clinical and community settings: When people The patient is always the focus of care, even when the
receive preventive care, such as immunizations larger community is considered. Patients should be
and cancer screenings, they have better health viewed as members of the healthcare team and should
and lower healthcare costs. be involved in decision making about their own care.
3. Empowering people to make healthy choices: Patient-centered care means that the patient is the
When people have access to actionable and center of that care—receiving the care—and must be
easy-to-understand information and resources, involved in care decisions. This point does not just
they are empowered to make healthier choices. apply to individual patients. In public or community
4. Eliminating health disparities: By eliminating dis- health, the patient may be an individual, family, pop-
parities in achieving and maintaining health, the ulation, or the community and involve government
goal is to improve quality of life for all Americans. officials and agencies as well as multiple different types
Several initiatives related to health promotion and of healthcare delivery services, including the private
disease prevention are identified in this chapter, and healthcare sector. All should be part of assessment,
they are all connected. For example, Healthy People, planning, and decision making. If this does not
the ACA, and the National Prevention Strategy all happen, the public/community health efforts are at
focus on both individuals and their communities. risk for failure. Public/community health initiatives
Another theme that runs through these initiatives are most successful when community members
is the need to decrease health disparities—an participate in planning and evaluation of programs
issue noted in the Surgeon General’s strategy, the and their services. This is demonstrated regularly,
Quality Chasm series of reports on health care, the for example, in local communities—in their health
ACA, Healthy People 2020, and the need to provide departments, city and county government meetings
p
atient-centered care. that might be discussing pollution, health needs, cost
of school nurses, and so on. Community members
as elected officials and as taxpayers and voters speak
Stop and Consider #2 out about issues that relate to health and services in
Nurses can make a positive impact on public/
community health.
their communities. Patient-centered care is discussed
in other chapters in this text.
updated annually, though the published poverty

Vulnerable Populations
rate is typically a few years behind the date reported.
A vulnerable population is a group of persons Poverty guidelines are important because financial
who are at risk for developing health problems. These eligibility for certain federal programs is based on
populations often have problems accessing care when poverty levels; to receive specific services, a person
they need it, for example, vulnerable populations are must not have an income higher than the poverty
children, the elderly, people with chronic disease, level. An example of current poverty guidelines is
immigrants, illegal aliens, migrant workers, people found in Table 7-1.
who live in rural areas, homeless people, the serious
mentally ill, victims of abuse and violence, pregnant
adolescents, and people who are HIV positive. Health and Illness
They need careful assessment and monitoring to Health and wellness are terms that tend to be used
identify problems early so that complications can interchangeably. But what does health mean? There is
be prevented. Typically, complex factors increase no simple response to this question. A simple definition
risk, such as physiological, psychological, economic, of health, albeit one that is not complete, is to be
ethnic, religious, social, cultural, and communica- structurally and functionally whole. Absence of this
tion factors. There may also be problems related to state is illness. Disease and illness are terms that are
diet, housing, safety, education, and transportation. often used interchangeably. Disease is an indication of
Poverty is an important concern, which has a a physiological dysfunction or pathological reaction.
significant impact on individual and public/com- The WHO defines health as “a state of complete
munity health, as described by the following data well-being, physical, social, and mental, and not
(U.S. Census Bureau, 2016a): merely the absence of disease or infirmity” (WHO,
■■ The official poverty rate in 2015 was 13.5%, 2006). This is a common definition and one that is
down 1.2 percentage points from 14.8% in 2014. often quoted. The WHO addresses health and illness
■■ In 2015, there were 43.1 million people in from a global perspective and identifies the following
poverty, 3.5 million less than in 2014. principles to guide its work:
■■ The 2015 poverty rate was 1.0 percentage ■■ Health is not merely the absence of disease
point higher than in 2007, the year before or infirmity.
the most recent recession. ■■ The enjoyment of the highest attainable stan-
■■ For most demographic groups, 2015 poverty dard of health is one of the fundamental rights
rates and estimates of the number of people of every human being without distinction of
in poverty decreased from 2014. race, religion, political belief, or economic
■■ Between 2014 and 2015, poverty rates decreased or social condition.
for all three major age groups. The poverty rate ■■ The health of all peoples is fundamental to
for children under age 18 dropped 1.4 percentage the attainment of peace and security and is
points, from 21.1% to 19.7%. Rates for people dependent upon the fullest cooperation of
aged 18 to 64 dropped 1.1 percentage points, individuals and states.
from 13.5% to 12.4%. Poverty rates for people ■■ The achievement of any state in the promotion
aged 65 and older decreased 1.1 percentage and protection of health is of value to all.
points, from 10.0% to 8.8%. ■■ Unequal development in different countries
The poverty rate has been rising since 2000, but in the promotion of health and control of
dropped by about 2 million people from 2012 to disease, especially communicable disease,
2015 (U.S. Census Bureau, 2016a). The data are is a common danger.
Table 7-1 2017 Department of Health and Human Services Poverty

Guidelines
48 Contiguous States
Persons in Family and Washington, DC Alaska Hawaii
2 $16,240 $20,290 $18,670
3 $20,420 $25,520 $23,480
4 $24,600 $30,750 $28,290
5 $28,780 $35,980 $33,100
6 $32,960 $41,210 $37,910
7 $37,140 $46,440 $42,720
8 $41,320 $51,670 $47,530
For families/households with Add $4,180 for each Add $5,230 for Add $4,810 for
more than 8 persons, add this additional person. each additional each additional
amount per person person person.
Reproduced from U.S. Department of Health and Human Services. (2016, January 25). Annual update of the
HHS poverty guidelines. Federal Register, 81(15), 4036–4037. Retrieved from https://www.federalregister.gov
/documents/2016/01/25/2016-01450/annual-update-of-the-hhs-poverty-guidelines. The poverty guidelines are
updated periodically in the Federal Register by the U.S. Department of Health and Human Services under the
authority of 42 U.S.C. 9902(2).
■■ Healthy development of the child is of basic or genetic impairments that result in a chronic dis-
importance; the ability to live harmoniously ease or disability. The definition has to be applied
in a changing total environment is essential to individuals, families, communities, and nations
to such development. (RWJF, 2000). The determinants of health or factors
■■ The extension to all peoples of the benefits of that have an impact on health are physical, mental,
medical, psychological, and related knowledge social, and spiritual. Stress and socioeconomic factors
is essential to the fullest attainment of health. are also very important.
■■ Informed opinion and active cooperation According to the Organization for Economic
on the part of the public are of the utmost Cooperation and Development (OECD), life expec-
importance in the improvement of the health tancy for Americans compared to 33 other countries
of the people. mostly falls in the lower third performance category
■■ Governments have a responsibility for the with some instances in middle third such as death
health of their peoples that can be fulfilled from cardiovascular disease (OECD, 2015). The
only by the provision of adequate health and United States has long ranked lower in health and
social measures. healthcare issues when compared by OECD with
other countries. Access to care is defined, as avail-
Definitions of health should be applicable to ability of healthcare coverage, is also a problem for
all—to those who are well; to those with illness or the United States when OECD compares the United
disease that can be treated; and to those with acquired States with other countries. Of the 34 countries, only
five countries do not have coverage at the 95% to health problems—for example, a patient with a
100% level, and the United States is one of the five cardiac problem can experience more symptoms
countries. The ACA or possible changes in the law when experiencing high levels of stress; patients
may or may not improve this ranking. However, who have socioeconomic problems may not have an
many other countries have universal health cover- adequate diet because of lack of money, or they may
age, but this is not the case for the United States, experience sleep problems because they work two
so improvement will be limited. jobs—all factors that increase stress. Not all persons
The U.S. Census Bureau publishes data about who experience stress experience negative outcomes.
health statistics specific for the United States. Life Communities may also experience stress—for ex-
expectancy for the total population is 78.8 years: ample, stress caused by economic problems such
76.4 years for men and 81.2 years for women (CDC as lack of employment and high poverty level, lack
used 2014 data). Differences in mortality between of critical healthcare services, increase in violence,
the Black and White populations persist in the or inadequate education for children. Weather can
United States, though the gap in life expectancy even increase stress in communities; for example,
was reduced to a 3.4-year gap, and the Hispanic in summer when temperatures may be very high,
population life expectancy increased by 0.2 to a some urban communities experience more violence
total of 82.8 years. White women have the highest among adolescents and young adults and people
life expectancy. Between 2004 and 2014, the infant who may be outside more due to heat experience
mortality rate decreased by 14%, from 6.79 to 5.82 more risk for violence.
deaths per 1,000 live births. The neonatal mortality The most effective intervention for stress is
rate (among infants under age 28 days) decreased by stress management. Eliminating stress completely
13%, from 4.52 to 3.94 per 1,000 live births. Between is not possible, but helping individuals, families,
2004 and 2014, the post-neonatal mortality rate vulnerable populations, and communities better
(among infants aged 28 days through 11 months) cope with stress is an important goal in improving
decreased 17%, from 2.27 to 1.88 (HHS, & CDC, health and developing health-promoting behaviors.
2015; U.S. Census Bureau, 2016b). This type of data Effective coping can reduce the negative impact of
is used in public/community health to assess status stress and, in many cases, prevent a person, family,
of health in communities and to determine need for or community from experiencing stress. This might
health promotion, disease prevention, and treatment be done through identifying stressors or stimuli that
services. It also affects other types of services such cause a person (family, community) to experience
as projecting housing, education, and employment stress. Stressors can be biological, sociological,
needs (for example, a community of older persons psychological, spiritual, or environmental. Self-
would require different community services versus assessment to identify stressors is critical to improve
a community composed of young families). coping. Stress management interventions might
include education to better understand stress and
Stress, Coping, Adaptation, application of interventions, relaxation techniques,
and Resilience: A Public/ better sleep, healthy diet, exercise, music, and use of
assertiveness—community education programs can
Community Perspective
offer residents information about these methods to
Stress is a complex experience, which is felt in- reduce stress. Community-oriented interventions
ternally. It makes a person feel a loss or threat of a might include reducing violence by providing places
loss. Stress is present in all parts of life. Stress has for teen after-school activities, increasing access
an effect on current health status and can lead to to community clinics, increasing jobs, improving
transportation to areas where healthcare services are always possible. Moreover, with the increase in
available, providing parenting classes, or increasing the number of people with chronic diseases and
exercise classes and social activities in community the growing elderly population, cure is becoming
centers. Resilience, or the ability to cope with stress, less important from the patient’s daily perspective.
is an important factor. Communities can develop There is more focus on functioning at the best
resilience—sometimes you hear on the news some- possible level. The curative model focuses more
one interviewed after a disaster such as a tornado on the biological approach, which relies on a
and they talk about how the community is coming hierarchical system of decision making in which
together, helping one another and they will survive. physicians make diagnoses and order treatment.
This is resilience. Adaptation to situations is also Nursing is more involved in other functions,
important to stress prevention and management. The although the nurse certainly participates in pro-
same principles of stress apply to everyone, including viding nursing care that is directed at cure, such as
patients—individuals, families, and communities. assisting in surgery to repair a fractured hip. The
hip can be repaired, but the patient typically has
other needs after this surgery that are tied to the
Acute Illness other functions. The patient will need help gain-
ing functional capacity, and he or she may never
Acute illness is typically self-limiting and occurs
regain full capacity. The patient may require help
over a short period of time—cure is the focus of
with health promotion if the cause of the fracture
acute care, though some acute illnesses may not be
was osteoporosis (for example, lifestyle changes
cured and then result in a chronic illness or death.
related to diet, vitamins, and exercise). These factors
Some of the care for acute illness takes place in the
need to be taken into account in follow-up care in
hospital, commonly referred to as the acute care
the community.
setting, but today, more care is taking place in the
patient’s home in the community through primary
care and ambulatory services or other community Greater Emphasis on Chronic
services and facilities that are not acute care. Exam- Disease
ples of acute illnesses are an infectious disease such
as the flu or pneumonia, a broken leg, appendicitis, Another factor supporting implications for patient-
and a urinary tract infection. centered care in public/community health is the
The curative model has long been viewed as the growing number of patients with chronic diseases
best approach to health; however, this model has come who need patient-centered care. In the United
under criticism (RWJF, 2000). Yes, cure is a good goal, States, the total number of persons with chronic
but is this the only view that can be applied to the diseases has increased, as has the number of people
complex area of health? There are other important with more than one chronic disease. Many of these
other goals, as noted by the RWJF: diseases are preventable. The following data related
■■ Restoring functional capacity to this problem support the need for more focus on
■■ Relieving suffering chronic disease, which increase healthcare costs
■■ Preventing illness, injury, and untimely death and impact quality of life (HHS, & CDC, 2016a).
■■ Promoting health ■■ As of 2012, about half of all adults—117 mil-
■■ Caring for those who cannot be cured lion people—had one or more chronic health
These additional goals expand what can be conditions. One of four adults had two or more
done to help those who need it because cure is not chronic health conditions.
■■ Seven of the top 10 causes of death in 2010 our primary care providers to better coordinate care,
were chronic diseases. Two of these chronic might help us to improve our performance. More
diseases—heart disease and cancer—together importantly, it might result in better outcomes for
accounted for nearly 48% of all deaths. a vulnerable group of patients” (Bindman, 2016).
■■ Obesity is a serious health concern. During Healthcare providers need to understand that
2009–2010, more than one-third of adults, or care for patients with chronic diseases is different
about 78 million people, were obese (defined from acute care. In order to ensure that these complex
as body mass index [BMI] ≥ 30 kg/m2). care needs are met, integration of new knowledge
Nearly one of five youths aged 2–19 years and treatment may be required. If a nurse typically
was obese (BMI ≥ 95th percentile). cares for patients with sudden-onset illnesses or
■■ Arthritis is the most common cause of dis- with injuries for which the cure model is the focus,
ability. Of the 53 million adults with a medical it may be difficult for the nurse to appreciate the
diagnosis of arthritis, more than 22 million say differences in care for chronic diseases and needs
they have trouble with their usual activities of these patients. Chronic diseases are diseases
because of arthritis. for which there is no effective cure; in turn, their
■■ Diabetes is the leading cause of kidney failure, treatment focuses on control of symptoms, support,
lower-limb amputations other than those psychosocial issues, and if possible, prevention of
caused by injury, and new cases of blindness deterioration and improved quality of life. Examples
among adults. of chronic diseases include heart disease, diabetes,
stroke, hypertension, rheumatoid arthritis, obesity,
Data reported in 2013 indicated that approximately and even cancer (cancer survivors live with the
133 million Americans (45% of the total population) long-term effects of the cancer and/or the treat-
have chronic illnesses. By 2020, this number is pro- ment). Chronic diseases are the leading cause of
jected to increase to 157 million, with 81 million death worldwide, namely, cardiovascular disease
having multiple conditions (National Health and chronic respiratory disease.
Council, 2013). As with adults, chronic illness and disease
One reason that the United States has problems prevention in children are major health consid-
with increasing chronic disease is that there is better erations. According to the CDC (CDC used 2015
treatment today, so people with chronic diseases data), more than 6 million children (under age of 18)
live longer; consequently, there are more people had asthma, and it was more common in children
with chronic disease. A second reason is that the in poor families; 8% of all U.S. children aged 3–17
United States still needs to improve care provided had a learning disability, which affected more boys
for chronic disease, particularly for patients with and children in poor families, and 13% of children
multiple chronic illnesses. Chronic disease is a seri- had taken a prescription for at least three months.
ous problem not only in the United States, but also Childhood obesity is also on the rise, increasing
worldwide. “We have much to learn about how to the incidence of diabetes, hypertension, and other
structure and furnish health care services for indi- related complications. Obesity rates have doubled
viduals with multiple chronic conditions. And, we in children and quadrupled in adolescents in the
need to recognize that countries that perform better past 30 years (HHS, & CDC, 2011). Obesity has
in coordinating care invest a higher proportion of long-term effects on the health and well-being of
their resources than we do in primary care. However, children, affecting them throughout their lives.
clinical guidelines focused on treating the whole These effects include cardiovascular disease, di-
patient, combined with improving the capacity of abetes, and bone and joint problems in addition
to self-esteem issues that may lead to social and (breast cancer, colorectal cancer, prostate cancer,
psychological problems. diabetes, hypertension, hearing, vision, cholesterol,
Because of the increased recognition of chronic and so on), and immunizations. Prevention is not
disease, innovations in interventions and services always successful. Some of the barriers to its success
for patients with chronic diseases have increased. are related to availability and use of previous services
Examples from the government payment perspective (Peters & Elster, 2002):
are important to consider, such as the Centers for ■■ Lack of reimbursement for these services
Medicare and Medicaid Services (CMS) innovative ■■ Lack of time for services
trial models of care to promote care coordination— ■■ Lack of access for populations who need
for example, medical homes. Under this model, these services
patients receive transitional care, care coordination, ■■ Inadequate consumer education to support
and comprehensive care management services. Self- need
management and health literacy are also important ■■ Uncertainty as to effectiveness (from both
to consider when planning services for patients with consumer and provider perspectives)
chronic illness to ensure a comprehensive public/ ■■ Failure to assure empowerment of patients,
community health program. Methods for delivering which leads to effective self-management
care for chronic disease have improved, though much
Patients with chronic illness need support, as
more needs to be done (for example, greater use of
well as information, to become effective managers of
disease management, which is another systematic
their own health. To meet these needs, it is essential
approach to managing a chronic disease). Typically,
for them to have the following resources:
interventions used in disease management have
been tested with large groups; thus they may be ■■ Basic information about their disease and
more effective than interventions tested in studies an understanding of self-management skills
with a narrower scope. Disease management ■■ Ongoing support from members of the practice
emphasizes use of interprofessional teams with ex- team, family, friends, and community as part
pertise in the specific disease, use of evidence-based of the self-management process
clinical guidelines, clear descriptions of interventions ■■ Providers who are sensitive to the roles that
and procedures and application of recommended families, caregivers, and communities assume
timelines, patient support and education, and mea- in different cultures
surement of outcomes. Nurses assume important In general, better patient outcomes are achieved
roles in disease management; specifically, they may through use of evidence-based techniques that
be on the team or lead the team. Insurers, hospitals, emphasize patient activation or empowerment,
and other healthcare providers develop and sponsor collaborative goal setting, and problem-solving skills.
disease management programs. The major goals are The provider team may use standardized assessments
to assist patients in maintaining the best quality of of patient self-management needs and activities to
life possible and preventing complications that might enhance their ability to support patients. Such as-
lead to deterioration and increased costs of care. sessments include questions about self-management
Disease management programs also emphasize knowledge, skills, confidence, supports, and barriers
prevention, although it is important to emphasize (Institute for Healthcare Improvement [IHI], 2011).
prevention throughout the healthcare system and A major report titled Living Well with Chronic
particularly in community care—not just in special Illness: A Call for Public Action indicates that there
focused programs. Examples of prevention services is greater interest in chronic illness and meeting the
include tobacco cessation counseling, screening needs of people with these illnesses (IOM, 2012). The
report describes this issue as a major public health needs to have healthcare organizations that support
problem: “Chronic disease is a public health as well self-management and recognize that the patient is the
as a clinical problem. Therefore, a population health source of control; support a delivery system design
perspective for developing strategies, interventions, that identifies clear roles for staff in relation to chronic
and policies to combat it is critical. A population disease care; supply decision support, integration of
perspective considers how individuals’ genes, biology, evidence-based guidelines into daily practice; and
and behaviors interact with the social, cultural, and use of clinical information systems to ensure effective
physical environment around them to influence exchange of information and reminder and feedback
health outcomes for the entire population” (IOM, systems (Wagner, 1998). If all of these elements are in
2012, p. 3). Community-based interventions are place and effective, the results should be productive
an important part of care for chronic illness, with interactions with an informed, active patient and a
prevention being the first intervention. Communities prepared, proactive care team. The ultimate result
have many options they use for prevention such as should then be improved outcomes. The Joint Com-
health fairs, immunizations in locations that are mission includes use of advanced practice registered
easy to access, walking groups in malls, enforcing nurses (APRN) in its standards for ambulatory care/
smoking bans, offering educational opportunities medical homes. This is a significant change, although
about health, smoking cessation groups, and exercise, there is still disagreement among healthcare profes-
as well as screening for diseases, substance abuse, sionals over the role of the advanced practice nurse in
stress, and so on. Establishing places for exercise in medical homes (ANA, 2011). Other nurses also have
parks, walking paths, bike lanes, ensuring healthy roles in medical homes that should not be ignored.
diets in school lunches, and so on, help to increase
exercise. A new intervention used in some locations
Self-Management
is requiring restaurants to post calories for menu
items. Community health departments might offer Self-management is a concept of care that focuses
disease management programs and self-help options on the patient and the patient’s role in managing
to benefit citizens. Working closely with an acute his or her care with resources provided as needed.
care system is critical for all of these efforts. It requires that the patient have access to health
information (IOM, 2003). Electronic personal health
records are useful in facilitating self-management
Medical Home Model
(Mitchell & Begoray, 2010). For example, this
The medical home model, a model supported by the record can be used to help patients manage their
ACA, is a multidimensional solution for planned, health through individualized care plans, graphing
clinically integrated care to meet the complex care and recording of symptoms, passive biofeedback,
needs of people with chronic disease; its elements individualized instructive or motivational feedback,
include organizing care around patients, working in aids to assist in decision making about health care,
teams, and coordinating and tracking care over time and reminders. Security, privacy, and confidenti-
(National Committee for Quality Assurance [NCQA], ality are all critical factors in the use of electronic
2017). The focus is on interprofessional primary care personal health records. It is important that when
teams. A common chronic care model, which is ap- these systems are used, the system is able to adjust or
plied in many healthcare organizations, describes two meet the health literacy needs of the patient. Public/
major delivery focus areas: (1) The community needs community health can utilize self-management to
to have resources and health policies that support support members of the community more support,
care for chronic diseases, and (2) the health system particularly patients with chronic diseases.
these services are interrelated and are also needed

Health Literacy
for effective collaboration and coordination in
Health literacy is a factor that has implications in acute care services.
all healthcare settings and for all patients (IOM,
2004). As mentioned elsewhere in this text, diver-
sity is a key element of patient-centered care, but Community Emergency
it is important to explicitly recognize it in terms of Preparedness
its relevance to public/community health as well.
Communities may be confronted with numerous
Patient education—whether from the perspective
challenges—natural disasters (for example, fires,
of individual patients, families, populations, or
floods, severe winter weather, hurricanes, and tor-
communities—is influenced by the relevant patient’s
nados), infectious diseases, excessive violence, and
health literacy. One definition of health literacy is
potential attacks such as bioterrorism or other types
“the extent to which an individual is able to access
of terrorism—that could lead to major community
and accurately interpret and evaluate health infor-
health needs and safety concerns. The AHRQ has
mation,” which correlates with the earlier definition
developed resources for public health emergency
in a critical report on health literacy (Mitchell &
preparedness; more on this topic can be found at
Begoray, 2010). Effective health literacy improves
the agency’s website. Community planning for such
self-management and engages the patient (individuals,
events is critical to better ensure the health and
families, populations, communities) in the process.
safety of the community.
Three key supporting interventions to better ensure
In the last few years, there have been major
health literacy are as follows (Sand-Jecklin, Murray,
weather-related disasters in the United States, such
Summers, & Watson, 2010):
as in New Orleans, Oklahoma, and the East Coast,
■■ Identify patients at risk for lack of understand- as well as tragic violence and terrorism that have
ing and not acting on health information. harmed a large number of children and adults.
■■ Communicate health information and in- Communities are now more alert to the need to plan
structions in a way that promotes patient for these situations. Nurses are involved both in this
understanding. planning and in working during the crisis period to
■■ Check for patient understanding. help others, either in their regular positions or on
specific disaster teams that respond to the imme-
Stop and Consider #3 diate and long-term disaster needs. For example,
Nurses who practice in public/community health school nurses should participate in planning as part
need to view the patient as an individual who is part of emergency preparation. Exhibit 7-3 identifies
of a family, population, or the community.
some critical links that provide more information
on this important topic.
There are also community situations that can lead
Multiple Perspectives to disasters requiring extensive healthcare services
of Public/Community Health as well as prevention of these problems. A problem
Services that occurred recently is lead in the water system in
Flint, Michigan. This is a complex problem that will
The following sections discuss examples of affect the community, particularly its children, for
public/community health services that need to a lifetime. It requires multiple responses, including
be considered and provided to ensure the health provision of immediate water needs, short- and long-
of communities and their populations. Many of term assessment of potential victims, improvement
Exhibit 7-3 Sources for Information about Emergency Preparedness
●● http://www.ready.gov/
●● http://www.fema.gov/
●● http://emergency.cdc.gov/preparedness/
●● http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN
/TableofContents/Volume112006/No3Sept06/Overview.htmlhttp://nursingworld.org/MainMenu
Categories/HealthcareandPolicyIssues/DPR.aspx
of the water system, health education, short- and homes and community-based transition grant
long-term treatment, collaboration with education programs, incentives to reduce readmission rates,
experts to help children who might have disabili- outcome measures for chronic diseases and wellness
ties, family support and guidance, mental health and prevention programs, development of employer
services for those suffering from the stress of the wellness programs, and requiring nonprofit hospitals
experience, and much more. All of this is costly and to conduct comprehensive needs assessments every
requires expert healthcare services and guidance. three years and report to the Internal Revenue Service
Nurses should be involved at all levels—assessment, the activities they pursue to address the identified
prevention, treatment, and follow-up—in multiple needs. These provisions have been enacted, though
settings such as public/community health services, if there are changes in ACA funding, some of these
clinics, schools, and other services. provisions may be at risk. To support communities
in improving population health, the National Quality
Managing Population Health Forum (NQF) published a guide, which emphasizes
10 elements (NQF, 2016):
There is greater emphasis today on learning how
to effectively manage population health to reduce ■■ Collaborative self-assessment
costs and improve outcomes. The first step is to ■■ Leadership across the region and within
identify the target population (Larkin, 2010). The organizations
second step is to assess the health status and needs ■■ Audience-specific strategic communication
of the population and then apply prevention and ■■ A community health needs assessment and
interventions to improve the population’s health. This asset mapping process
approach can have an impact on overall health care. ■■ An organizational planning and priority-
What might represent a population? With the setting process
increase in number of persons with chronic diseases, ■■ An agreed-upon, prioritized set of health
focusing on a population with a specific chronic improvement activities
disease, such as arthritis or diabetes, can be useful. ■■ Selection and use of measures and perfor-
Coordinating services across a continuum of care mance targets
and tracking data about outcomes are important ■■ Joint reporting on progress toward achieving
aspects of managing population health within a intended results
community. The ACA includes many provisions ■■ Indications of scalability
that emphasize community and population health. ■■ A plan for sustainability
For example, the law calls for increased funding for The guide is supportive of the NQS, which is discussed
community health centers, development of medical in other chapters. The NQS is focused on action to
foster healthier people and communities, better patients are not fully recovered or ready to care for
health care, and more affordable care. Communities themselves. Home care provides healthcare services
need to use this as a guide for their planning and in the home. These services vary as to the type of
initiatives to improve overall health. services, the amount of time that the care provider
is in the home, the number of visits per week, and
Migrant and Immigrant the length of services (for example, provided for a
week, three months, and so on). In addition, there is
Issues
variation in the type of healthcare provider needed:
In 2011, the American Nurses Association (ANA) a home health aide who provides assistance with
published a policy brief on immigrant health care, activities of daily living services (bathing, ambulation,
Nursing Beyond Borders: Access to Health Care for simple care, light housekeeping, food preparation);
Documented and Undocumented Immigrants Living a registered nurse who assesses the patient, develops
in the United States (Trossman, 2011). Access to the care plan, monitors progress, assesses the home
healthcare services for these two populations is environment for safety, and provides more complex
weak. Even though this is a complex political issue, care; a physical therapist who helps the patient with
it is still important for nurses to understand the exercises to gain strength; or a social worker who
needs of these two populations and provide care assists with obtaining other services that the patient
to them. In health care, they represent a diverse may need, such as Meals on Wheels, payment for
population—representing multiple cultures and healthcare services, and so on. Telehealth is used
languages. This population does not typically in some home care situations, using technology to
increase healthcare expenditures. In fact, its communicate with the patient, assess status, and so
expenditures are lower than care for most adult on. With this service, health information is sent from
citizens, and they visit the emergency department one site to another by electronic communication.
less often than U.S. citizens. Based on 2010 data, Given the growing number of persons with chronic
low-income immigrant children, even those in- disease and the aging population, it is expected
sured, are less likely to see a doctor than children that home health care will continue to grow as a
born in United States (Ku & Jewers, 2013). Many community health service.
of them are employed, but they may not have
health insurance coverage. However, they often School Health
work in hazardous jobs, such as agriculture and
construction, increasing their risk for injuries and School health has changed and expanded in many
illness. There have been increased efforts on the communities over the years. A critical concern is that
federal level to pass new immigration legislation it is not uncommon for school health services to be
and need for health insurance coverage, and these limited due to budget cuts for schools and public/
issues may become more important and complex community health services. Typically, decreasing
with the Trump administration. the number of registered nurses in the schools
or having school nurses cover several schools are
methods used to reduce costs for school health.
Home Health Care
In some communities, school health services have
The amount of care provided in the home has expanded to full clinics, often covered by pediat-
increased in the United States. As part of efforts ric APRNs. This can be particularly important in
to control costs, patients are discharged earlier urban communities that may have limited access
and earlier from the hospital. At this point, many to services for children with limited or no health
insurance and limited family financial resources that focuses on care of the elder population in all
or in rural areas that may have limited pediatric settings; however, the most important extended care
services. School nurses can make a major difference settings involve care in the home. Other services are
in the heath of children and, consequently, their offered in skilled nursing or intermediate-care and
long-term health as adolescents and adults through long-term care, in which patients receive a range
active use of prevention and appropriate, timely of services from housing, meals, and activities to
treatment when needed. routine personal care, rehabilitation, and specialized
treatment. There is great need within the community
Rehabilitation for more eldercare services, such as adult day care
(a facility where elders may go during the day for
Rehabilitation is part of tertiary prevention. The socializing and activities), home health care, senior
goal of rehabilitation interventions is to attain and centers, and retirement and assisted-living facilities
retain the best possible level of functioning for a (these can vary from single rooms to independent
person who has an illness or disability that is perma- living situations with support services as needed).
nent and irreversible. Rehabilitation can take place Older adults can experience health problems in
in the hospital, in an extended care or long-term all body systems and psychologically. They may also
care facility, in an ambulatory care facility, or in the experience social problems, such as loss of spouse
home. Rehabilitation therapists assist the patient. and friends and lessened ability to be mobile, and
The nurse may be the healthcare provider who they may become isolated. Financial problems are
identifies the need for rehabilitation, or the nurse not uncommon, and these problems affect food,
may be involved by following the rehabilitation plan. housing, social activities, transportation, and access
A patient may require a specialized therapist, such to medical care. Community health services for
as a physical therapist, an occupational therapist, a this population must consider multiple factors that
speech-language pathologist, or a vocational ther- impact quality of life.
apist. Patients may need to learn how to complete
activities of daily living, such as taking care of End-of-Life Care
personal hygiene and dressing; ambulating safely
and Palliative Care
with or without assistive devices such as a walker,
cane, or wheelchair; learning basic life skills, such Hospice care is a philosophy of care for the ter-
as cooking or driving with a disability; and learning minally ill that involves supporting the quality of
new job skills. Some patients recover more fully one’s life as long as possible (end-of-life care). It is
than others. Examples of patients who may require not required to be a place, though it can be—for
rehabilitation are those who have suffered a stroke, example, a freestanding building in which hospice
severe burns, or major injuries from an automobile service is provided. Hospice care can also be pro-
accident or a work-related accident, such as a serious vided in the patient’s home or in a special unit in an
fall or being cut, impaled, or crushed by equipment. acute care hospital. This philosophy of care includes
active participation of the patient and family in all
Extended Care, Long-Term care decisions. Specially trained staff—including
physicians, nurses, social workers, and often spiritual
Care, and Elder Care
professionals, as well as other healthcare providers
The U.S. population is aging, and the need for as needed—support the patient and family during
services to meet this population’s needs is growing. the critical last stages of life. Palliative care focuses
Gerontological nursing is an important specialty on alleviating symptoms and meeting the special
needs of the terminally ill patient and the family. their families in the provision of palliative
There is strong support for more nursing leadership care services.
and provision of palliative care by nurses. The Future 5. Educate and communicate effectively and com-
of Nursing report (IOM, 2010) identifies nurses as passionately with the patient, family, healthcare
the ideal providers of palliative care. The National team members, and the public about palliative
Institute of Nursing Research (NINR) provides sev- care issues.
eral resources about palliative care (NINR, 2016). 6. Collaborate with members of the interprofes-
The director of NINR, Dr. Grady, notes “offering sional team to improve palliative care for patients
interventions and translating our science related to and their families and to ensure coordinated
hospice and palliative care can enhance the quality of and efficient palliative care for the benefit of
life for those most in need of symptom management communities.
and emotional support” (NINR, 2016). The National 7. Elicit and demonstrate respect for the patient
Institutes of Health (NIH) collaborates with NINR and family values, preferences, goals of care,
to expand resources for these critical needs, support- and shared decision making during serious
ing a partnership among the various institutes and illness and at end of life.
other federal government agencies (NINR, 2017). 8. Apply ethical principles in the care of patients
Recognizing the growing need to ensure that with serious illness and their families.
nurses are prepared to care for patients with palliative 9. Know, apply, and effectively communicate cur-
care and end-of-life needs, the American Association rent state and federal legal guidelines relevant
of Colleges of Nursing (AACN) developed Palliative to the care of patients with serious illness and
CARES: Competencies and Recommendations for their families.
Educating Undergraduate Nursing Students to sup- 10. Perform a comprehensive assessment of pain
port nursing education to ensure this care includes and symptoms common in serious illness, using
assessment, management of complicated illnesses, valid, standardized assessment tools and strong
monitoring, and providing culturally sensitive care interviewing and clinical examination skills.
with an interprofessional team approach (AACN, 11. Analyze and communicate with the interpro-
2016a, 2016b). The competencies include the fol- fessional team in planning and intervening
lowing (AACN, 2016c): in pain and symptom management, using
evidence-based pharmacologic and non-
1. Promote the need for palliative care for seriously pharmacologic approaches.
ill patients and their families, from the time of 12. Assess, plan, and treat patients’ physical, psy-
diagnosis, as essential to quality care and an chological, social, and spiritual needs to improve
integral component of nursing care. quality of life for patients with serious illness
2. Identify the dynamic changes in population and their families.
demographics, healthcare economics, service 13. Evaluate patient and family outcomes from
delivery, caregiving demands, and financial palliative care within the context of patient goals
impact of serious illness on the patient and of care, national quality standards, and value.
family that necessitates improved profession 14. Provide competent, compassionate and culturally
preparation for palliative care. sensitive care for patients and their families at
3. Recognize one’s own ethical, cultural, and the time of diagnosis of a serious illness through
spiritual values and beliefs about serious illness the end of life.
and death. 15. Implement self-care strategies to support
4. Demonstrate respect for cultural, spiritual, coping with suffering, loss, moral distress, and
and others forms of diversity for patients and compassion fatigue.
16. Assist the patient, family, informal caregivers, Typically, care protocols or pathways guide the
and professional colleagues to cope with and case manager in making decisions about best care
build resilience for dealing with suffering, for specific health needs, which are adapted to
grief, loss, and bereavement associated with meet individual patient needs. Hospitals may also
serious illness. use case managers to assist with complex patient
17. Recognize the need to seek consultation (that needs and plan best care post hospitalization. Case
is, from advanced practice nursing specialists, management is a growing area of care delivery that
specialty palliative care teams, ethics consultants, has proved effective in helping patients to get the
and so on) for complex patient and family needs.* care they need in an often complex and confusing
healthcare system.
Case Management
Case management is a system that aims to get
Occupational Health Care
the right services to the patient at the right time and Occupational health care may seem a strange
avoid fragmented and unnecessary care that can be topic, but nurses are very active in this setting,
costly (Finkelman, 2011). It facilitates effective care providing health promotion; disease and illness
delivery and outcomes for patients. Case management prevention; and treatment services, including
requires collaboration or cooperative effort among assessment of risks of illness and injury associ-
healthcare providers and other sources of resources ated with the work environment. This healthcare
that the patient may require. Coordination is re- service is considered part of public/community
quired to organize care so that it is available when health. Providing these services at the work site
needed. Communication is also critical because makes it easier for employees to obtain services
the case manager must work with many people to with less concern about getting to appointments
ensure the patient gets required care. Case managers during work hours. Many employers have found
frequently do all their work on the telephone and it to be beneficial to provide these services on site
never actually see the patient or family. They are for employees, often reducing their potential health
typically employees of an insurance company, a risks and providing prompt treatment. All of this
government agency, or a healthcare organization can reduce employer health insurance costs and
(particularly acute care settings [hospitals]), but increase work productivity; however, employee
they may also work for agencies within the public/ privacy continues to be an issue.
community health system. Because one of the em- Employers may provide a variety of health
ployer concerns is cost-effective care delivery, case promotion and prevention services, such as exer-
managers need to have extensive knowledge about cise classes or even gym access, stress management
reimbursement and understand how to manage the resources and classes, diet and weight-loss classes,
care services in a manner that controls costs. Case smoking cessation programs, immunizations, weight
managers—who may be nurses, social workers, and management services, and other types of opportu-
other staff who work directly with patients (clients) nities for employees to maintain a healthy lifestyle.
and their families to assess needs—direct the pa- Employers may also consider factors such as the
tient to care when needed and monitor progress. food, and related nutritional factors, served in the
cafeteria; environmental health issues; walking areas
*Reproduced with permission from American Association of for employees during breaks; equipment to prevent
Colleges of Nursing (AACN). (2016c). CARES: Competencies back injuries while moving patients; air quality at
and recommendations for educating undergraduate nursing
students. Retrieved from http://www.aacn.nche.edu/elnec work; noise levels; staff use of ergonomic chairs and
/New-Palliative-Care-Competencies.pdf desks and other equipment and protective devices
related to lifting; exercise and yoga options on site light energy, botanical treatment, Reiki, tai chi, and
or external to the work site; and so on. use of a variety of herbs and other supplements,
such as garlic, shark cartilage, and ginseng. With
the creation of NCCAM, there is now an organized
Complementary system for clinical trials to gather data about the use
and Alternative Therapies of CAM and related outcomes. Nurses may provide
or Integrative Medicine some CAM interventions in their practice, and some
insurers cover these services, but this is not typical
The National Center for Complementary and in the United States. As more data are obtained to
Alternative Medicine (NCCAM, 2016), which is support their efficacy, there will probably be more
part of the National Institutes of Health, describes inclusion of these interventions in care, and they
complementary and alternative medicine (CAM) as will gain greater reimbursement coverage.
a group of diverse medical and healthcare systems,
practices, and products that are not presently con-
sidered part of conventional medicine. Conventional Genetics
medicine is medicine typically practiced by holders
Genetics has become more of a focus in health
of medical doctor or doctor of osteopathy degrees
care, and it will have a long-term effect on public/
and by other health professionals, such as registered
community services. The U.S. Department of Energy
nurses, physical therapists, and psychologists.
and the National Institutes of Health have funded and
Some healthcare providers practice both CAM and
led the Human Genome Project, which began in 1990
conventional medicine. Although there is some sci-
and was completed in 2003. This project focused on
entific evidence supporting use of CAM therapies,
mapping all the loci of the 20,000 to 25,000 genes that
for most, there are still key questions that have yet
make up the human body. The implications of this
to be answered through well-designed scientific
project are many. We have learned that the interac-
studies—questions such as whether these therapies
tion of the genetic makeup of an individual and the
are safe and whether they work for the diseases or
environment (genomics) often determines whether
medical conditions for which they are used. The list
the person will be healthy or ill for the majority of
of what is considered CAM changes continually as
his or her life. The benefits of this research include
therapies that are proved to be safe and effective
the following (U.S. Department of Energy, 2015):
are adopted by conventional health care and new
approaches to health care emerge. Countries in ■■ Improved diagnosis of disease
Europe and Asia and in the Middle East, such as ■■ Earlier detection of genetic predispositions
Israel, actively use CAM, and these interventions to disease
are covered by their universal healthcare plans. ■■ Rational drug design
Patients typically seek out these interventions in ■■ Gene therapy and control systems for drugs
their communities. For example, in San Francisco, ■■ Pharmacogenomics/custom drugs
California, groups of senior citizens participate in When this information is used in combination
tai chi in the parks. with a family history tool to gather information
Many of these interventions are not new, but their about diseases in the family, a very thorough risk
use in modern healthcare delivery has increased in assessment can be completed (HHS, 2007). If this
recent years. However, many of the CAM interven- risk assessment is used in health promotion, the
tions still have a long way to go before they become health professional can explain to patients and fam-
part of conventional medicine. Examples of these ilies not only their risk of a disease because of their
interventions are acupuncture, acupressure, massage, genetic profile, but also the interactions between the
environment and the person’s genomic risk. With Violence in Communities

the knowledge of how a person’s genes interact with
drugs, better pain medications may be designed to An example of the changing nature of public/
address individuals. We now have the ability in some community health is increasing violence in some
cases to fix a bad gene because we know its location. communities, such as Chicago. This type of violence
The technology to diagnose diseases and conditions is not new, but we have times of greater and lesser
even prenatally is becoming available, giving us the violence and some communities experience major
tools to allow a fetus to continue to grow normally crises with violence. The National Academy of Med-
instead of having major anomalies at birth. The icine published a report on a roundtable it held that
possibilities are endless for disease prevention and examined violence (NAM, 2017). Violence is a social
management. We are just at the beginning of a new determinant of health and important to consider in
frontier of health care and related nursing care. The public/community health systems and is viewed as
essentials for genetics competencies have already a chronic, recurrent disease. Some refer to violence
been written for nursing curricula (ANA Consensus as a contagious disease. This report describes serious
Panel, 2008). These are just as critical as the other problems that result from community violence, even
competencies regarding nursing processes that lead using the descriptor of a “war zone.”
to better patient outcomes and safe care. We know that violence affects acute care,
particularly emergency services, but it also affects
other services, police, ambulance, and even (in
Stop and Consider #4 some cases) the fire department. However, it also
Public/community health services are expanding,
affects many other community organizations and
and this affects the roles of nurses.
groups—schools, transportation, businesses, housing,
and community centers and other gathering places
such as playgrounds. It even affects home care—for
The Changing Nature example, how safe nurses feel going into a neighbor-
of Public/Community Health hood or a home. We cannot deny that ethnic issues—
Problems culture, language, and so on are factors that influence
what is happening and how we respond.
Public/community health changes more than acute Violence is an action but also a reaction to situ-
care, even with all the advancements in medical ations in which people, often the young people, feel
treatment. It is affected by many factors that are they are trapped, and so they respond with violence
broader—socioeconomic, culture, travel, weather, and risky behaviors such as using drugs. Domestic
communicable diseases, community safety, law violence may also be influenced by the same factors and
enforcement and other similar services, education, living environment. The NAM, 2017 report provides
religion, and much more. The following sections a comprehensive analysis of community violence as a
provide a few examples of problems that are primar- population health concern—background, causes, and
ily focused on the community and for which much community interventions. This is a topic that nurses
of the response must come from the community. need to understand not only in communities with
This does not mean that acute care is not relevant high levels of violence, but also in any community.
for many of the problems communities confront. Interventions that might be considered are focused on
The ideal is to have a system of care that incorpo- safety first and then prevention. Because violence is
rates both acute care and public/community care such a highly complex issue, it requires understanding
supporting effective coordination, communication, multiple variables and the use of interventions cov-
and collaboration. ering a broad perspective—safety in housing areas,
eliminating empty houses and buildings where gangs an understanding of benefits and consequences and
can hang out, health services and law enforcement to use methods with the least risk of harm.
collaborating in planning and implementing inter- This epidemic has led to multiple approaches
ventions, better gun control enforcement, dealing directed at prevention, treatment, and rehabilitation.
with substance abuse (drugs and alcohol), working in Prevention focuses on communication with members of
schools to help students—support, safety education, the community about the dangers of abuse and options
and so on; monitoring areas where children might be for getting help. Opioid abuse not only affects the addict,
at risk such as playgrounds; ensuring the elderly can but also families and close associates, employers who
get needs met when they may be fearful about going must deal with employees who cannot be productive, and
out; lighting in public places; and so on. Community criminal activity in a community, and there is a heavy
members may experience high levels of stress, anxiety, burden on the healthcare delivery system. Education
depression, and anger. All of this affects short- and also must be provided to children and adults about
long-term mental health—services are needed for the dangers of using this drug. Healthcare providers
these problems, prevention, and treatment. must also be educated about the risk of prescribing
this type of medication. The CDC and the Office of
the Surgeon General have developed information and
Opioid Epidemic
materials to assist in communicating this message and
The opioid epidemic is not a common story in our provide approaches to avoid abuse—this initiative is
news. Stories such as this one: A city experiences two called “Turn the Tide” (HHS, & CDC, 2016b). This
calls for assistance per hour for overdose patients information is directed at prescribers; however, all
for 32 hours. The number of overdose calls in 2015 nurses should review this material. The key message
was 4,642; in 2016, it was 6,879 (Hauser, 2017). Data is: Do not prescribe opioids as first-line treatment for
identify five states with the highest rates of death as- chronic pain—excluding active cancer, palliative, or
sociated to drug overdose—the range is from 28.2 per end-of-life care. On August 24, 2016, the Surgeon
100,000 to 41.5 per 100,000—with the CDC reporting General’s information about “Turn the Tide” was sent
91 deaths due to opioid overdose every day. Many in a letter and a pocket card for easy use to 2.3 million
communities across the United States are dealing doctors, nurses, dentists, and other clinicians, asking
with this epidemic that is hitting all sectors of society. for their help (Murthy, 2016). This is an example of
Narcan is recommended for response to an overdose a broad education effort. In addition, editorials and
and can save lives. Emergency services now carry articles were published in the fall of 2016 in multiple
this drug, but getting enough is a problem, as is cost. medical journals, supporting the need for greater
In the last few years as concern grew about attention to this problem.
opioid abuse, several major reports have addressed Communities with this problem are working
pain management and also opioid abuse. Relieving on providing more treatment and rehabilitation
Pain in America noted that an estimated 100,000 options. What is complex about this problem is
people experienced chronic pain and, as a result, once someone is addicted, the person has a chronic
cost $630 billion each year (IOM, 2011). Since this health problem that can also lead to other health
report was published in 2011, the data have changed problems. This treatment is costly, and if a person
with opioid use increasing, but the report served as does not have insurance, the situation is even more
an alert to a growing problem and provided evidence complex. This may also lead to many other problems
that the United States needed to respond quickly. The such as employment, difficulty with school, prob-
message is not that we should not provide treatment lems during pregnancies and for newborns, mental
for pain, but rather we need to do this carefully, with health issues, loss of one’s home due to insufficient
income, domestic and child abuse, divorce, crime, ■■ Increasing access to quality, safe, efficacious,
and much more. These are all major concerns for and affordable medical products (medicines,
a community, particularly if they involve many vaccines, diagnostics, and other health
members of the community. technologies).
Nurses need to be involved in the plan and re- ■■ Addressing the social, economic, and envi-
sponses to the problem along with an interprofessional ronmental determinants of health as means to
team that also includes other community leaders such promote health outcomes and reduce health
as government officials, law enforcement, religious inequalities within and between countries.
leaders, education leaders, business owners, and so
on. It will take a multipronged approach to improve Global healthcare concerns change, and some
the health of the community and its residents. have become significant both in their impact and
their costs. Emerging infections represent a major
global health concern, with particular concern about
Stop and Consider #5 bacteria that are antibiotic-resistant (Cleeson, 2016).
The problems of violence and opioid use affect all Other recent examples of infectious diseases are the
nurses in their practice.
Ebola virus and concern about it spreading globally;
the Zika virus and concern about long-term impact
on infants born when mothers are infected; and war
Global Healthcare and refugees who need medical care and support
services such as housing, food, and so on. All of
Concerns and International these situations become complex political situations
Nursing and problems related to coordination and speed in
meeting the needs. The refugee situation is much
WHO is the major international health organization more complex and will last a long time—affecting
that focuses on “building a better, healthier future multiple countries and a large number of people
for people all over the world”, and its priorities of all ages.
include (2016, pp. 2–3): The International Council of Nurses (ICN) is
■■ Advancing universal health coverage: enabling also involved in global health by providing a voice
countries to sustain or expand access to all for nursing throughout the world. Its stated mission
needed health services and financial protection, is “to represent nursing worldwide, advancing the
and promoting universal health coverage. profession and influencing health policy. The ICN’s
■■ Achieving health-related development goals: Strategic Intent is to enhance the health of individ-
addressing unfinished and future challenges uals, populations, and societies by: championing
relating to maternal and child health; com- the contribution and image of nurses worldwide;
bating HIV, malaria, and TB; and completing advocating for nurses at all levels; advancing the
the eradication of polio and a number of nursing profession; and influencing health, social,
neglected tropical diseases. economic and education policy” (ICN, 2014). The
■■ Addressing the challenge of noncommuni- ICN and WHO focus on the health of individuals,
cable diseases and mental health, violence, families, and communities.
and injuries and disabilities.
Ensuring that all countries can detect and
■■
respond to acute pubic health threats under Health and healthcare are global concerns.
the International Health Regulations.
CHAPTER HIGHLIGHTS
1. Healthy People 2020, coupled with other 6. Important concepts to consider in public/
major reports on the quality of health care, community health care are disease preven-
require health professionals to understand the tion, health promotion, life span, vulnerable
concepts of quality of care, health outcomes, populations, health and illness, acute illness,
and health indices, as well as to address health chronic disease, self-management, health liter-
disparities in everyday care in the community. acy, continuity of care, and continuum of care.
2. The focus of health care is changing to 7. Critical public/community services include
patient-centered care, with the patient in community emergency preparedness, managing
the key d ecision-making position. This also population health, migrant and immigrant care,
applies to all types of healthcare settings home care occupational health care, hospice
in the community, across the life span and and palliative care, rehabilitation, extended care,
the continuum of care, to meet healthcare long-term care, elder care, case management,
needs within the community and ensure occupational health care, complementary and
continuity of care. alternative care, and genetics.
3. Stress, coping, and resilience have an impact 8. Public/community health problems change,
on health promotion, disease prevention, probably more than acute care. Two current
and illness within communities. problems are community violence and the
4. Continuum of care means that nursing care opioid epidemic.
must be provided in acute care settings, the 9. The World Health Organization focuses its
home, and the community. attention on global health issues, health issues
5. Vulnerable populations are groups of peo- that may have a major impact on multiple
ple who are at risk for developing health countries and a large number of people.
problems. Examples include children, the The International Council of Nurses is an
elderly, people with chronic diseases, the example of an organization that represents
homeless, and others. the nursing profession’s global interests.
1. What are proposed changes for Healthy 5. How does the life span impact the continuum
People 2030? (See https://www.healthy of care in the community?
people.gov/2020/About-Healthy-People 6. Compare and contrast acute illness and
/Development-Healthy-People-2030) chronic disease related to public/community
2. Why is Healthy People 2020 an important care.
national health initiative? 7. Why are global health issues important
3. Why is public/community health a critical considerations for healthcare providers in
concern today? the United States?
4. Discuss the various views of health and illness
presented in this chapter.
1. Go to the Take the First Step to Prevention 4. Visit this WHO site: Global Health Estimates
page at the Centers for Disease Control and http://www.who.int/healthinfo/global_burden
Prevention’s website (http://wonder.cdc.gov _disease/en/index.html
/data2010/HU.htm). Search for your state, What can you learn about global life expec-
and review the most current data. Select tancy, mortality, and the burden of disease?
a specific health indicator, and look at the How does the United States compare with
national data and then data from your own other countries?
state. How do they compare? Search for data 5. Select one of the vulnerable populations, and
focused on a specific population. discuss issues that would have an impact on
2. Visit the National Center for Health Statistics’ the health and illness for that population.
website (http://www.cdc.gov/nchs/). Search Consider issues such as health promotion,
for current data related to births/natality, disease prevention, and access to care.
infant health, child health, adolescent health, 6. Analyze the chronic disease model and
men’s health, women’s health, and older its relevance to nursing in the community.
people’s health. Institute of Medicine Report: Living Well with
3. Visit http://www.ahrq.gov/clinic/pocketgd Chronic Illness: A Call for Action. https://www
.htm to review the current version of the .nationalacademies.org/hmd/~/media/Files
U.S. Guide to Clinical Preventive Services. /Report%20Files/2012/Living-Well-with-Chronic
How might you use this information if you -Illness/livingwell_chronicillness_reportbrief.pdf
were planning services for a community What are the critical elements in coping
health center? with chronic illness?

Use your journal to describe your own perspective on health and illness, and explain
how this has influenced you as a nursing student compared to your views before
becoming a nursing student.
CASE STUDIES
Case 1
Imagine that you are a member of an interprofessional team in a rural county in your state.
The team is looking into improving the health status of the community. The community
has a high rate of cancer (particularly breast and lung); accidents (farm related); alcohol
abuse, particularly among teens; and obesity (adults, but with increasing weight gain in
children). The interprofessional team is composed of two registered nurses (one who works
in the local hospital, and you, the only school nurse in the area), one physician in private
practice, the local hospital administrator, the mayor of the largest town in the area, a
psychologist in practice, and a clergyman.
Case Questions
1. Identify the problems that need to be considered by the community.
2. Describe how you think the team should approach these problems based on what you
have learned in this chapter.
3. How might you apply information about Healthy People 2020 in this case?
Case 2
Health literacy has been a long-time problem in health care. Data from a recent
community survey completed for your moderate-size city indicate that health literacy
problems are increasing and that minority populations have increased in the last five
years. Chronic illnesses in these populations have also increased, such as diabetes and
hypertension. Clinics and home health agencies have reported an increase in medication
errors for patients who are taking medications at home. Many of these errors appear to be
due to poor understanding of medication directions and ability to read these directions
either in written patient directions or reading medication containers.
Case Questions
1. Consider the following links to get additional information:
Community Guide: http://www.thecommunityguide.org
If you were on a task force to improve your community’s health, how might you use this
website?
2. Given the data provided, identify the key problems and related settings.
3. Research additional information on health literacy and its impact on quality of care.
4. Describe three interventions to address the issues in this community.

questions.
1. What is the rate of obesity in our community?
2. Why should the school nurses in the county be at our meetings?
3. Do these children receive any health education in school, and if so, what is included in
the content?
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Chapter
8
The Healthcare Delivery
System: Focus on Acute Care
CHAPTER OBJECTIVES
■■ Discuss the corporatization of healthcare ■■ Discuss critical elements related to healthcare
delivery by comparing and contrasting financial issues and reimbursement.
for-profit and not-for-profit systems. ■■ Examine how nursing fits into the overall
■■ Compare and contrast healthcare organization hospital organization.
structure and processes. ■■ Explain the importance of organizational
■■ Describe the healthcare provider team and its culture.
relationship to nursing. ■■ Discuss examples of changes in the healthcare
delivery system.
CHAPTER OUTLINE
●● Introduction ●● Government Reimbursement of

●● Corporatization of Health Care: How Did Healthcare Services
We Get Here? ●● The Uninsured and the Underinsured
●● The Healthcare Organization ●● The Nursing Organization within the
●● Structure and Process Hospital
●● Classification of Hospitals ●● Organizational Culture
●● Typical Departments in a Hospital ●● Changes in Healthcare Delivery
●● Healthcare Providers: Who Is on the Team? ●● Chapter Highlights
●● Healthcare Financial Issues ●● Engaging in the Content
●● The Nation’s Health Care: Financial ●● Discussion Questions
Status (Macro View) ●● Critical Thinking Activities
●● The Individual Healthcare Organization ●● Electronic Reflection Journal
and Its Financial Needs (Micro View) ●● Case Studies
●● Reimbursement: Who Pays for Health ●● Working Backward to Develop a Case
Care? ●● References
●● The Third-Party Payer System
235
KEY TERMS
Annual limit For-profit Organizational culture

Copayment Indirect care provider Process
Corporatization Medicaid Reimbursement
Deductible Medicare Structure
Direct care provider Not-for-profit
Uninsured and underinsured patients who

Introduction
■■
are unable to pay for their care

■■ Compromised access to care for some in-
Healthcare delivery is a complex process and system.
dividuals, leading to healthcare disparities
The system includes many types of healthcare pro- ■■ Advances in medical technology that can
vider organizations, such as acute care organizations
improve care but may be costly and require
(hospitals), ambulatory care centers (clinics), private
special staff training and may not be accessible
provider offices, public/community health facilities,
to those who cannot pay for them
home care agencies, hospice agencies, extended care ■■ Impact of quality improvement data and
facilities, and so on. This chapter focuses on the
requirements that may lead to changes
largest type of healthcare organization (HCO): the ■■ Greater use of informatics in documentation
acute care hospital. This does not mean that other
and for other healthcare informational purposes
types of HCOs are not important; however, nursing ■■ Growing diversity in patients and the healthcare
students typically spend more of their clinical time
workforce—for example, increasing need for
in hospitals. Many of the organizational elements
interpreter services and greater representation
of a hospital are similar to those of other HCOs
of ethnic groups in the healthcare workforce
but may vary depending on the organization and ■■ Increasing consumerism—more knowledge-
purpose. The content in this chapter explores current
able patients who demand more information
issues related to hospitals, hospital organization
and participation
and function, and the hospital provider team, and ■■ Hospital mergers and closings, altering access
provides an introduction to healthcare financial
to services
issues and nursing organization and functions ■■ Changing number of available beds; changing
within the hospital.
specialty services (for example, increasing the
Many factors affect hospitals, leading them to
number of intensive care beds, eliminating
change their services, collaborate with others in
obstetric services, offering home health services)
their communities, realign their organization with ■■ Changes in patient demographics that require
other organizations, close because of financial issues,
reassessment of which services to offer and
meet quality improvement requirements, and so
how those services are provided (for example,
forth. Examples of factors that influence hospitals
increasing services for the elderly, immigrants,
today:
and single parents; expanding clinic hours
■■ Increase in healthcare costs to facilitate access; and so on)
■■ Shortage of healthcare providers (may be ■■ Legislation such as the Affordable Care Act
geographic or HCO specific) of 2010 and possible changes to this law
Chapter 8: The Healthcare Delivery System 237
Examples of key influences on health care are

highlighted in Figure 8-1. Exhibit 8-1 identifies Corporatization of Health
examples of organizations that influence healthcare Care: How Did We Get Here?
delivery.
Using the term corporatization or business when
referring to a hospital may seem strange; however,
Economics
icies
Pat
ien health care is a business—a very large business. It
pol tp
provides services to most of the population at some
re
op
ca
time during a person’s life, from birth to death.
ula
lth
Hea
tion
Hospitals have a very large employee pool, with
nurses representing the largest percentage. Hospitals
Gove
lthcare needs
provide jobs for many people—both professionals
rnment regulat
and nonprofessionals; thus, they represent one of the
largest employment sectors. Within a community,
Hea
HCOs also usually own or lease a large amount of

ion
property, purchase a great number of supplies and

s
H ea
equipment, and pay taxes—all activities that bring

rc h
lt h c
e
income into a community. Typically, healthcare
ar
ea
p ro s
vid
er Re
n a leaders hold significant positions in the business
l
H ea
lth care profe s sio
e d u c a ti o n
sector and the community. Health care consumes
the largest amount of federal and state dollars
Figure 8-1 Influences on Healthcare Delivery through healthcare reimbursement programs such
Exhibit 8-1 Examples of Organizations Important to the Healthcare

Delivery System
●● National Association of Children’s Hospitals and Related Institutions: http://www

.childrenshospitals.org
●● American Academy of Hospice and Palliative Medicine: http://www.aahpm.org
●● American Association of Homes and Services for the Aging: http://www.leadingage.org
●● American Association of Retired Persons: http://www.aarp.org
●● American Health Care Association: http://www.ahcancal.org/Pages/Default.aspx
●● American Hospital Association: http://www.aha.org/aha/about
●● American Nurses Association: http://www.nursingworld.org
●● Nursing Specialty Organizations: http://www.nursingcenter.com/library/JournalArticle
.asp?Article_ID=623779
●● American Public Health Association: http://www.apha.org
●● Arthritis Foundation: http://www.arthritis.org
●● American Diabetes Association: http://www.diabetes.org/?loc=404page
●● The Joint Commission: http://www.jointcommission.org
●● National Association of Public Hospitals: https://essentialshospitals.org
●● National Committee on Quality Assurance: http://www.ncqa.org
●● National Health Council: http://nationalhealthcouncil.org
as Medicare and Medicaid, as discussed in other on the availability of money for other purposes that
chapters. affect nurses and nursing.
It is not uncommon to refer to hospitals as
for-profit or not-for-profit. The terms for-profit
and not-for-profit can be confusing. The first Stop and Consider #1
critical point is that every hospital needs to Healthcare delivery is a business.
make a profit, which means the HCO needs to
have money left over after expenses are paid. The
distinguishing characteristic between for-profit
and not-for-profit organizations is what the or- The Healthcare
ganization does with its profit. The assumption Organization
by most is that all hospitals are not-for-profit
organizations, but this is not correct. Many large Hospitals are one type of HCO, and the largest. Other
HCOs are for-profit corporations. Some of their types of HCOs are identified in Exhibit 8-2.
profit must go to their stockholders/shareholders Descriptions of HCO should include information
or to their owners. However, even for-profit orga- about the organization’s structure, processes, staff,
nizations must cover their operation costs and and organizational culture. Although the majority
reinvest money in the hospital for maintenance, of registered nurses (RNs) work in hospitals, many
expand space and renovate, develop new services, work in other types of HCOs, with the percentage
purchase equipment and supplies, and so on. Not- RNs working in hospitals decreasing over recent
for-profit organizations do not have stockholders/ years. Nurses work in all of the healthcare settings
shareholders, but these hospitals still need to identified in Exhibit 8-2. Data from 2015, and still
make a profit for the same reasons that for-profit most current data available at the end of 2016,
organizations need a profit. indicated that 61% of RNs worked in state, local,
Knowing whether the hospital you work for and private hospitals; 7% in nursing and residential
is a for-profit or not-for-profit organization can care facilities; 7% in physician offices; 6% in home
help you understand why and how decisions are healthcare services; and 6% in government healthcare
made. For example, if a hospital is burdened with services (U.S. Department of Labor, 2015).
a high number of nonpaying patients, the hospital The organization of hospitals varies, but there are
may eventually spend more than it is making and some standard types of organization. In the past, it
thus be “in the red” when its debt increases. When was more common for hospitals to operate as single
this happens, the hospital may cut staff, limit new organizations. Now, more hospitals have formed
equipment purchases, control use of supplies, fail complex organizations consisting of multiple hos-
to maintain equipment effectively, neglect facility pitals. In some cases, these systems also include
maintenance needs and renovation, attempt to re- other healthcare entities such as home care agencies,
configure services to attract paying patients, decrease rehabilitation centers, long-term care facilities, and
staff education, and make other changes to improve freestanding ambulatory care centers. Most of the
the hospital’s financial condition. All HCOs have reasons for this change in organization structure
to be concerned with cost containment, but when are related to financial issues and the survival of
the financial situation is weak, the organization will the organization—to keep patients in the system,
need to use cost containment more. A for-profit increase services, and expand the continuum of care.
HCO must always have funds to pay stockholders or Some communities have seen multiple changes in
owners, and this consideration can have an impact their local hospitals, with hospitals merging with
Exhibit 8-2 Types of Healthcare Organizations
●● Substance abuse treatment/rehabilitation ●● Specialty hospitals (for example, pediatric,

centers (inpatient and outpatient) psychiatry-mental health)
●● School health clinics ●● Long-term care hospitals (for example,
●● Diagnostic centers psychiatric)
●● Ambulatory care surgical centers ●● Urgent care centers
●● Dental offices and clinics ●● Home health agencies
●● Long-term care facilities ●● Hospice care
●● Skilled nursing facilities ●● Ambulatory care/clinics
●● Occupational health clinics ●● Clinical practices, such as family practice,
●● Rehabilitation centers specialty (for example, orthopedics,
●● Acute care hospitals dermatology)
●● Physician offices ●● Retail clinics
●● Medical homes
●● Advanced practice registered nurses practice
sites, such as nurse-managed clinics
other hospitals or others trying to go it alone. The distance education to facilitate the nursing programs,
critical message is hospitals are changing their making it easier for students and reducing student
overall organization, and it is not clear what the travel time to campus.
future holds. The U.S. healthcare delivery system has an
Small hospitals with 100 or fewer beds and hos- estimated $750 billion in wasted resources in the
pitals in rural areas are particularly vulnerable. They system. This money is lost, so it cannot be spent on
often have difficulty getting enough admissions, and improving healthcare outcomes. A recent report on
therefore, they often lose money. In addition, they healthcare in the United States indicates that there is
must keep costly equipment current by purchasing need to focus on the best care at a lower cost, not a
new equipment and maintaining their equipment higher cost (Institute of Medicine [IOM], 2013). The
and physical facilities. Hospitals have to maintain report Best Care at Lower Cost: The Path to Continu-
a certain level of staff: This is not a business that ously Learning Health Care in America describes the
can easily flex staffing numbers and use a lot of system in this way: “Health care in America presents
temporary staff, and it takes time to orient new staff. a fundamental paradox. The past 50 years have seen
These vulnerable hospitals may also have problems an explosion in biomedical knowledge, dramatic
recruiting RNs for their workforces because many innovation in therapies and surgical procedures,
RNs prefer to work in urban centers and in large, and management of conditions that previously were
up-to-date hospitals. Schools of nursing in states fatal, with ever more exciting clinical capabilities on
with large rural areas are increasingly partnering the horizon. Yet, American health care is falling short
with rural hospitals to improve student enrollment on basic dimensions of quality, outcomes, costs, and
from these areas and, they hope, increase the RN equity” (IOM, 2013, p. 1).
pool in the workforce for these geographic regions. Compared to other countries, the United States
Such partnerships provide courses and clinical ex- is paying more for less, resulting in poorer healthcare
periences in rural healthcare settings and may use outcomes than are found in other industrialized
nations. The complex U.S. healthcare delivery system ■■ Detailed rules and regulations: greater emphasis
must manage costs while simultaneously ensuring on policies and procedures; expectation that
quality, evidence-based care. Trying to achieve this these will be followed and guide decision
balance will lead to more changes in the healthcare making
delivery system and impact nursing. ■■ Impersonal relationships: expectation that
staff will do their jobs and supervisors will
ensure that jobs are done as expected
Structure and Process
Hospitals typically have hierarchical manage-
One way to describe a hospital is to consider its ment levels. The top level consists of the board of
structure and process. A hospital’s structure is trustees or board of directors. This board typically
based on how the organization is configured, and includes members of the community and com-
the best source for a view of a hospital’s structure is munity leaders who are not directly involved in
its organizational chart. Figure 8-2 is an example of health care. The board is responsible for developing
a hospital organizational chart, which displays the the overall direction of the hospital and ensuring
components of the hospital in a vertical structure. that the goals of the organization are met. The
The chart identifies to whom staff report, or rather, board hires the hospital’s chief executive officer
who is a staff member’s manager or supervisor. Or- (CEO—also sometimes called the organization’s
ganizations that focus more on this type of structure president), and this person reports to the board.
tend to be more bureaucratic and highly centralized The CEO then hires the other major leaders for the
with key persons in the organization making de- hospital, such as the chief financial officer (CFO)
cisions. Bureaucratic organizations typically have and the nursing leader. The nursing leader may
the following characteristics: be called the chief nursing executive (CNE), the
■■ Division of labor: descriptions of jobs that chief nursing officer (CNO), or in some cases, the
include clearly defined tasks vice president for nursing or patient services. This
■■ Defined hierarchy: clear description of the last title may also reflect the person’s oversight of
reporting relationships nursing and other disciplines or ancillary services,
Board of directors
President, chief
executive officer (CEO)
Sr. vice president, chief

operating officer (COO)
Vice president,
Vice
Vice president, Vice president, professional Vice president,
president, Vice president,
chief information quality and practice, chief chief financial
human medical affairs
officer (CIO) patient safety nursing officer officer (CFO)
resources
(CNO)
Figure 8-2 Example of a Hospital Organizational Chart

such as occupational therapy, physical therapy, or would a staff member gain an understanding of a
nutrition. Often, the board approves these hires. hospital’s process? The hospital’s vision, mission
Because the board has ultimate responsibility for statement, and goals are a good place to begin to
the budget, it has significant influence over mat- find out what is important to the organization and
ters that impact nurses, such as staffing and other how the hospital describes itself and its functions.
resources important to nursing. Other sources of information relevant to process
Although bureaucratic organizations are less include policies and procedures, communica-
common today, many hospitals still use this approach, tion systems and expectations, decision-making
emphasizing a vertical structure that includes these processes, delegation process, implementation of
elements but is less rigid than the structure of past coordination (teams), informatics, and evaluation
formal bureaucratic organizations. Line authority, methods (quality improvement [QI]). The key
or chain of command, is very important, in that question is how does the work get done?
each staff member knows to whom to report,
and it is expected that this order will be followed. Classification of Hospitals
A true bureaucratic organization does not expect or
want much staff input regarding decisions, but this Hospitals can be classified using a variety of descrip-
does not apply in most organizations today, with tors. The following are some of these descriptors:
administration encouraging more staff commitment ■■ Ownership: Is the hospital for-profit (investor
and thus engagement in the organization. Another owned), not-for-profit, part of a corporate
element of organizational structure is span of control, system, faith based, or governmental (state,
or the number of staff managed by each supervisor federal)? Government hospitals include Vet-
or manager. The more staff a manager supervises erans Administration (VA) hospitals, military
the more complex that supervision becomes. hospitals, state mental health hospitals, the
A horizontal structure is decentralized, with National Institutes of Health Clinical Center,
emphasis placed on departments or divisions; and Indian Health Service hospitals.
decisions are made closer to where work is done. ■■ Number of beds: Bed size or the number of
Departments or divisions focus on special func- beds can vary widely from hospital to hospital.
tions such as those related to nursing, laboratory, ■■ Licensure: State health departments are re-
pharmacy, and dietary/patient food services. This sponsible for hospital licensure, which ensures
is referred to as departmentalization. Later in this hospitals in the state meet state standards.
chapter, examples of common hospital departments Licensure and accreditation are not the same,
or services are discussed. though they both are concerned with quality.
The matrix organization structure is newer and Licensure comes from a government agency.
less clear than the traditional bureaucratic organi- Accreditation is a process to determine
zation that is centered on departments. In a matrix whether a hospital meets certain minimal
organization, staff might be part of a functional de- standards; this process is voluntary and pro-
partment, such as nursing services, but if the nurse vided by a nongovernmental organization. For
works in surgery, the nurse may also be considered hospitals to receive Medicare and Medicaid
a staff member in the surgical services/department. reimbursement—and this is an important
This type of organization is considered flatter because source of income for hospitals—they must
decisions do not flow clearly from the top down. be certified or given authority by the Centers
Process, the other dimension of organizations, for Medicare and Medicaid Services (CMS)
focuses on how the organization functions. How to provide services to Medicare and Medicaid
recipients. Meeting all these requirements and include multiple hospitals. These systems often
participating in the surveys take staff time, provide more than just acute care services;
which is costly, but it is very important for for example, they may offer ambulatory care
the overall financial status of an institution. (clinics, surgery), hospice care, home care, long-
In addition, hospitals that do not meet these term care, and other services. This partnering
requirements cannot be used as sites for provides the hospitals with a continuum of
healthcare professional students’ clinical services, from acute care to long-term care, to
practice experiences (nursing, medicine, and meet the needs of their patients. In a sense, the
others). Professional licensure and related system does not lose the patient; the patient
regulation are discussed in other chapters. just goes on to a different part of the system
■■ Teaching: A hospital is classified as a teaching for additional care needs and may return to
hospital if it offers residency programs for the system for other services if needs change.
physicians. The expansion of nurse residency For example, suppose a patient has been in a
programs may also become a method for hospital intensive care unit for complications
classifying hospitals in the future, although related to chronic obstructive pulmonary
this is not certain at this time and few hospi- disorder. The patient returns home after
tals have such programs. Some hospitals are discharge and receives home care from the
referred to as academic health centers (AHCs). hospital’s home care agency. One week after
These hospitals are associated with academic discharge, the home care nurse assesses the
institutions that offer healthcare profession patient and decides that the patient needs to
education, primarily medicine, but typically if be rehospitalized because of pneumonia. The
the university has a nursing program or other patient is then admitted to the same hospital.
programs such as pharmacy, they will also be
associated with the AHC. In these hospitals Typical Departments
there may be cross-administration—for in a Hospital
example, the Dean of Medicine and Dean of
Nursing might have positions in the hospital As was discussed in relation to the structure of or-
as well as some of the faculty. This is a more ganizations, hospitals are made up of departments,
formal arrangement than referring to a hos- divisions, and/or services. This structure has existed
pital as a teaching hospital where students for a long time. Students need to be familiar with
come for clinical experience. these departments because nurses interact with all
■■ Length of stay: Length of stay refers to how of them at some point in their practice, and they
long patients typically stay in a hospital, a need to know how to coordinate care by using
measure given as a range or average length services from a variety of departments and collab-
of stay. Fewer than 30 days is referred to as orate with interprofessional staff. What are some of
short stay, and more than 30 days is long term. the departments found in an acute care hospital?
Length of stay has been decreasing in the last Titles may vary from hospital to hospital, but the
15 years because of decreasing reimbursement functions described here are typical and part of
for hospital care and a greater push to provide daily hospital operations:
more healthcare services outside the hospital. ■■ Administration: This is the leadership for the hos-
■■ Multihospital system: Since 1991, there has pital, the central decision-making source—for
been growth in large hospital systems that example, the CEO or administrator; assistant
administrators; financial services and budget ■■ Information management: This department

staff; the CNO, CNE, or vice president for ensures that required information is collected,
nursing or patient services; department analyzed, monitored, and summarized—
heads; and others. typically administrative and clinical data. Its
■■ Nursing: This is the largest department in function is directly related to medical records
terms of employee numbers. Often it is called and documentation. Another area in which
patient services, which is a title used by many information management is important today
hospitals since the early 1990s. This does not is for QI efforts. Staff need ongoing training
mean that patients receive only nursing care; to ensure effective use of digital information
many other departments are directly involved systems (electronic medical/health records).
in patient care, such as laboratory, dietetic Health information technology (HIT) is
services, respiratory services, pharmacy, and a rapidly expanding area in healthcare
others. However, nursing service is the 24/7 organizations.
coordinator of patient care and provides the ■■ Quality improvement: This department is
largest percentage of direct care to patients. charged with ensuring that the hospital has
■■ Medical staff: Physicians who practice in a a QI program, implements active QI efforts,
hospital, if not part of a training program evaluates its outcomes, and makes changes to
such as a residency or fellowship, must be improve care. Nurses often are part of the staff
members of the medical staff. Their cre- in this department because they have much to
dentials are reviewed, and they are given offer with their experience and knowledge in
admitting privileges. This is done to ensure providing and assessing quality care. Nurses
that standards are met. A director or chief of should be actively involved in these activities
medical staff leads the medical staff. Medical throughout the hospital and in their daily
staff may or may not be employees of the practice. Additional discussion on QI is found
hospital. If a college of medicine is partnered in other chapters.
with the hospital, the organization may be ■■ Infection control: This function has become
more complex, as noted earlier with AHCs. increasingly important, influenced by a
■■ Admission and discharge: This department greater need to provide services that decrease
manages all aspects of admission and disinfection risk for patients and staff. Nurses
charge for patients, including paperwork, are typically active staff members in this
reimbursement, patient room assignments, department; they develop and implement
and in some cases, assignment of physicians. policies and procedures, monitor infection
Case management may be part of this depart- rates, and train staff.
ment or part of patient services. ■■ Research and evidence-based practice (EBP):
■■ Medical records: Documentation is a critical Many hospitals, particularly AHCs, have
part of all aspects of care. The medical records research departments. The department’s
department provides oversight of documen- purpose is to conduct research studies and
tation, whether paper documentation or review and approve studies prior to their
information in a computerized system. This implementation through the institutional
complex function requires nursing input to review board (IRB). Typically, professionals
ensure that nursing documentation is recog- in medicine lead this department, although
nized and nursing care information is included. nurses often participate in research studies
and may lead their own nursing studies. The surgery, and dialysis. Clinical areas may also be
nursing department may have its own desig- specific to a specialty, such as medical units for
nated nurse researchers. In some healthcare the post-cardiac care unit may be referred to as
organizations, research and EBP are combined, step-down units, oncology units, or other internal
or there may be a separate EBP service or medicine subspecialties; surgical units might focus
department. The EBP department is one of on orthopedics, urology, and so on.
the newest in hospitals, and not all hospitals
have this department. Some hospitals are Stop and Consider #2
incorporating the management of EBP— Organization structure and process affect healthcare
both medicine and nursing—into other de- organizations.
partments. The EBP functions may be part of
nursing or patient services, QI, or evidence-
based medicine related to medical staff orga- Healthcare Providers:
nization. Additional information on research Who Is on the Team?
and EBP is found in other chapters.
■■ In-service or staff development: This is the The hospital healthcare team providing care is
department that implements orientation and composed of a variety of healthcare providers, both
ongoing education for staff. professional and nonprofessional. All are important
■■ Environmental services (housekeeping): Staff in the care process. In addition, many other staff are
from this department interacts with nurses critical to the overall operation of a hospital, such as
in the patient care areas to ensure that areas office support staff, dietary staff, housekeeping staff,
are clean for patients. facilities management and maintenance staff, patient
■■ Dietary: This department is responsible for transportation staff, medical records staff, commu-
ensuring patients’ nutritional needs are met nications (HIT) staff, equipment maintenance and
through meals that conform to individual repair staff, and many others. For our purposes, the
patient dietary requirements and offer other focus is on staff that provides care, either direct or
dietary interventions. indirect patient care. A staff member who provides
direct care, such as a nurse, comes in contact with
Other departments focus on specific health the patient. An indirect care provider might be
needs, such as pharmacy, respiratory therapy, clinical someone who works in the lab to complete a lab
laboratory, infusion therapy, occupational therapy, test, but this provider may never actually see the
radiology, physical therapy, and social services. patient. However, the work done in the lab is very
Nurses get involved in all these services. Hospi- important to the patient’s care.
tals are typically organized around clinical areas The group of staff who provide care to a patient is
(units, services, and in some cases, departments) referred to as a team. They have a common purpose:
such as medicine, surgery, intensive care (medical providing patient care. Interprofessional teamwork
intensive care unit [MICU], surgical intensive care is one of the five recommended core competencies
unit [SICU], cardiac care unit [CCU], and neonatal for all healthcare professionals and is discussed in
intensive care unit [NICU]), post-anesthesia unit other chapters. Nurses work together with other
(PACU), labor and delivery (L&D), postpartum, nursing staff (licensed vocational nurses [LVNs]/
nursery, gynecology, pediatrics, emergency depart- licensed practical nurses [LPNs] and nursing/patient
ment (ED), urgent care, psychiatric or behavioral/ care assistants on teams) to provide care; however,
mental health, ambulatory care, ambulatory care today there is also greater emphasis on the need for
interprofessional teams in which nurses collaborate LPNs/LVNs and are important members of
and coordinate with members of multiple disciplines, the team.
such as physicians, pharmacists, social workers, and ■■ Advanced practice registered nurse (APRN):
many other members. A nurse practitioner is an RN with a master’s
The following are some of the major team degree in a specialty. In some states, APRNs
members and their functions. Not all patients require may provide some services independent of
services from all these healthcare professionals; in- physician orders, such as prescribing certain
stead, services are based on individual patient needs. medications and treatment procedures.
APRNs may work in clinics and typically do
■■ Registered nurse (RN): Nurses are the back- not work in acute care units, although this
bone of any acute care hospital. They work situation is changing. In some states, APRNs
in a variety of positions and departments, may have admitting privileges along with
not just the nursing department; for ex- their prescriptive authority (that is, the right
ample, they work in medical records, QI, to prescribe medication). As discussed in
infusion therapy, case management, staff content on nursing education, the future plan
development, radiology, ambulatory care, is APRNs will get a doctor of nursing practice
and other departments. Some nurses are in (DNP) degree instead of a master’s degree.
management positions and do not provide ■■ Clinical nurse specialist (CNS): A CNS is an
direct care. RN with a master’s degree. This nurse is pre-
■■ Licensed practical/vocational nurse (LPN/ pared to provide care in acute care settings
LVN): An LPN/LVN is a member of the and guides the care provided by other RNs.
nursing staff who has completed a 1-year Examples of CNS specialties are cardiac care
nursing program, successfully passed the and behavioral health (psychiatry), where
LPN/LVN licensing exam, and licensed they would work with staff to improve care
by state in which they practice. They are and assist in educating staff and focusing
supervised by RNs and are important team more on EBP.
members. The state board of nursing deter- ■■ Clinical nurse leader (CNL): This nurse has a
mines what care they may provide, although master’s degree and is a provider and a man-
not all states use the LPN/LVN designations. ager of care at the point of care to individuals
It is important for RNs to know what LPNs/ and cohorts (groups of patients) but is not in
LVNs are allowed to do including familiarity an administrative or manager position. The
with their position descriptions and provide CNL may be involved in team leadership
supervision for this care. RNs can delegate by improving information management;
to LPNs/LVNs, but the reverse is not true. determining patient risk; collecting outcomes
■■ Patient care assistant or nursing assistant: data for QI; providing clinical leadership;
Patient care assistants or certified nursing applying EBP; advocating for patients, the
assistants may have a variety of titles. They community, and the care team; and providing
are nonprofessional nursing staff who have a other related activities (American Associa-
short training period (typically a few months) tion of Colleges of Nursing [AACN], 2013).
that prepares them to provide direct care, The CNL is involved in care planning and
such as assisting with activities of daily living coordination and working with the nursing
(bathing, taking vital signs, and so on). They team and interprofessional teams to better
are supervised by RNs or, in some cases, by ensure quality care and outcomes.
■■ Certified nurse–midwife (CNM): A nurse– patient care and have oversight of overall
midwife has a master’s degree and is pre- care requirements.
pared to provide women’s health services ■■ Physician’s assistant (PA): A PA is prepared to
and services to obstetric patients (L&D, practice some aspects of medicine under the
postpartum, and obstetric clinics). In some supervision of a physician. The PA conducts
states, CNMs have admitting privileges. Their physical examinations, performs diagnostic
scope of practice may be regulated under workups, makes diagnoses, prevents and
either the medical or nursing practice act, treats diseases, assists with procedures,
depending on the state. and may have some prescribing privileges.
■■ Certified registered nurse anesthetist (CRNA): ■■ Pharmacist: The pharmacist has completed
This nurse anesthetist has a master’s degree professional education and ensures that
and is prepared to provide services to patients pharmaceutical care is appropriate for patient
requiring anesthesia, which is done in many needs. Given the growing concern about
hospitals today for inpatient and ambulatory medication errors, pharmacists are important
care surgery or for procedures that require members of the team, and nurses should
anesthesia. As discussed in other chapters, work closely with them. Some hospitals have
the CRNA is transitioning to a DNP degree a centralized pharmacy department with
rather than a master’s degree. all pharmaceutical services coming from a
■■ Doctor of nursing practice (DNP): An RN central unit. Others have moved to include
with a DNP has a terminal doctoral practice pharmacists as direct team members on
degree. This nurse is prepared to carry out units, providing an invaluable service and
roles similar to the traditional APRN and staff education about pharmaceutical agents
CNS, in addition to focusing at the systems at the point of care.
level on EBP, QI, leadership, and financing ■■ Occupational therapist (OT): OTs are not present
expertise. These nurses may hold a variety in every hospital, but they provide important
of positions in a hospital. services for patients with rehabilitation needs
■■ Physician: A physician has a medical degree because of impaired functioning, such as
and typically has a specialty such as surgery, patients who have had a stroke or patients
medicine, pediatrics, or obstetrics and gy- who have experienced a serious automobile
necology; some physicians may even have accident. Another type of a therapist, who
a subspecialty. For example, a physician might be used especially for patients who have
with a specialty in internal medicine may had a stroke, is a speech-language pathologist.
subspecialize in rheumatology, dermatology, These types of therapists are commonly found
oncology, or neurology. A surgeon may in rehabilitation services, but these services
subspecialize in orthopedics, oncology (and can also be provided in all types of settings,
even more specifically in breast surgery), such as in hospitals, long-term care facilities,
and so on. In a teaching hospital, which and home care.
has medical students and residents, and in ■■ Physical therapist (PT): PTs provide mus-
AHCs, the typical team includes faculty/ culoskeletal care to patients, such as
attending physician, the chief resident, res- assisting with teaching patients how to
idents, interns, and medical students. They walk (for example, stroke patients or post-
are responsible for the medical aspects of hip replacement), use crutches, or use of
other assistive devices. They also help design in some hospitals. The hospitalist is a generalist who
exercises to ensure or increase patient mobility coordinates the patient’s care, serving as the primary
and may train nurses to assist in providing provider while the patient is in the hospital. In this
physical therapy for patients as they provide case, the patient’s primary provider outside the
daily patient care. hospital is not involved in the inpatient care, and
■■ Registered dietitian: Dietitians work with pa- the patient returns to that provider in the commu-
tients to help resolve dietary and nutritional nity after discharge. This reduces the time that the
needs. Nurses work with dietitians as patient primary care provider (internist, family practitioner,
dietary needs are identified and implemented. pediatrician) needs to devote to inpatient care. Thus,
■■ Respiratory therapist: Respiratory therapists the primary care provider (PCP) has more time to
provide care to patients who have a variety focus on patient outpatient needs. In addition, the
of respiratory problems. They are trained to hospitalist is more current with acute care and the
provide specific types of treatments, such as treatment required. The intensivist is similar to
oxygen therapy, inhalation therapy, inter- the hospitalist, but because this MD focuses on care
mittent positive-pressure ventilators, and of patients in intensive care, he or she is providing
artificial mechanical ventilators. Respiratory more specialized patient care, care that requires
therapists go to the patient’s bedside for these physicians who are up-to-date on critical informa-
treatments, and some respiratory therapists tion and intensive care procedures. The hospitalist
may be assigned to work solely in intensive and intensivist positions were developed to increase
care units, where there is great need for these coordination and continuity of care in the hospital.
treatments. Respiratory therapists are also part Both of these providers are paid by the hospital as
of the team that responds to codes when pa- hospital employees. A major disadvantage of this
tients experience cardiac or respiratory arrests. model of medical care is that the patient has no
■■ Social worker: Social workers have professional relationship with the hospitalist or the intensivist
degrees and assist patients and their families prior to hospitalization and will not have any con-
with such issues as reimbursement, discharge tact after hospitalization. Some patients may not be
concerns, housing, transportation, discharge satisfied with a nurse in this role. Patient choice is
plans, and other social services. Nurses work always an important factor to consider as this has
with social workers to identify patient issues a direct impact on patient satisfaction.
that need to be resolved in order to decrease
stress on patients and families. Social workers
(and nurses) may serve as case managers, and Stop and Consider #3
Nurses need to understand the roles of the multiple
they may be important resources in providing healthcare providers.
effective discharge plans.
Medical care in acute care has been examined

over the last few years with several problem areas Healthcare Financial
noted that have led to changes in some hospitals. Issues
Two of the newest members of the healthcare team
are the hospitalist and the intensivist. The hospital- Healthcare financial issues can be viewed from three
ist position usually is a doctor of medicine (MD), perspectives. The first perspective is the macro view,
although APRNs and CNSs may hold this position or the status of healthcare finances viewed from a
national or a state perspective. The second is the Medicare benefit payments by type of service for
micro view, which focuses on a specific HCO and 2012. These expenditures are changing, and they
its budget. A third perspective is reimbursement are increasing.
for healthcare services. The National Quality Strategy (NQS), discussed
in more detail in other chapters, includes long-term
goals related to affordability of healthcare, recogniz-
The Nation’s Health Care: ing that cost is associated with quality care (HHS,
Financial Status (Macro View) AHRQ, 2016b):
The macro view is important because it encompasses 1. Ensure affordable and accessible high-quality
the major financial support for the U.S. healthcare health care for people, families, employers, and
system. The United States spends a lot of money on governments.
health care, yet not everyone has been covered by 2. Support and enable communalities to ensure
healthcare insurance. In 2016, national spending accessible, high-quality care while reducing
for health care averaged more than $10,000 per waste and fraud.
person. By 2025, health care spending is expected The goals apply to health care across the continuum
to be 20% of the total economy; in 2015, it was of care from acute care to public/community health
17.8%. Medicare enrollment is also increasing, and services. The NQS now tracks outcomes related
and by 2025, one of every five Americans will be to these goals by using data from the National
enrolled in Medicare, spending an average of nearly Quality and Disparities Report (QDR) and other
$18,000 a year per Medicare enrollee; in 2015, this sources. It is clear that costs are rising. The QDR
amount was $15,000 (Pear, 2016). Looking into report describes the status of affordability. These
the future, further national healthcare spending is reports usually represent data that are at least 1 year
expected to increase from 2016 through 2025 by behind the current year.
5.6% per year, with a projection of $5.5 trillion in
2025 (Ellison, 2017). This is a projected vision of the
future of healthcare financial status, and changes in The Individual Healthcare
healthcare delivery and reimbursement that might Organization and Its Financial
be made by the Trump administration will have
Needs (Micro View)
an impact on these projections. As discussed in other
content on QI, it is noted that efforts to improve The hospital budget is used by hospitals to manage
care may reduce costs; for example, national efforts their financial issues—to plan, monitor expenses
to reduce hospital-acquired conditions resulted and revenue, and then make adjustments to ensure
in 125,000 fewer deaths and saved more than $28 financial stability. The budget is prepared for a specific
billion from 2010 to 2015 (U.S. Department of time period, usually a year. In addition, a longer-term
Health and Human Services [HHS], Agency for plan covering several years is prepared, although this
Healthcare Research and Quality [AHRQ], 2016a). plan must be adjusted over time because of changes
This is a good example of the critical importance of in the organization’s financial status and other factors
QI for better patient outcomes and reducing costs. that affect the organization and its services. The
Reimbursement issues impact the status of health budget describes expected expenses, such as staff
care and coverage of these expenses. Figure 8-3 salaries and benefits, equipment, supplies, utilities,
describes the nation’s healthcare dollar—how much pharmaceutical needs, facility maintenance, dietary
Medicare and Medicaid spent on different categories needs, administrative services, clinical care, HIT,
of services. Figure 8-4 provides information on QI, staff education, legal fees, insurance coverage,
THE NATION’S HEALTH DOLLAR ($3.2 TRILLION), CALENDAR YEAR 2015:

WHERE IT CAME FROM
Out of pocket2,
11%
Government Private health

public health insurance,
activities, Health insurance, Medicare, 33%
3% 74% 20%
Other third
Medicaid
party payers
(Title XIX)
and
Federal,
programs1,
11%
8% Investment,
VA, DOD, and CHIP Medicaid (Title XIX)
5%
(Titles XIX and Title XXI), State and Local,
4% 6%
1
Includes worksite health care, other private revenues, Indian Health Service, workers’ compensation,
general assistance, maternal and child health, vocational rehabilitation, Substance Abuse and Mental
Health Services Administration, school health, and other federal and state local programs.
2
Includes co-payments, deductibles, and any amounts not covered by health insurance.
Note: Sum of pieces may not equal 100% due to rounding.
THE NATION'S HEALTH DOLLAR ($3.2 TRILLION), CALENDAR YEAR 2015,

WHERE IT WENT
Nursing care facilities and

continuing care retirement communities,
5%
Other Prescription Government
professional drugs,
administration Durable medical
services, 10% and net cost of equipment,
3% Other health
Dental health insurance, 2% residential and
services, 8%
personal care2,
4% 5%
Investment1,
5%
Physician Other non-durable
and clinical medical products,
services, Other,
2% Home health
20% 14%
care, Public
3% health
Hospital care, activities,
32% 3%
1
Includes Noncommercial Research (2%) and Structures and Equipment (3%).
2
Includes expenditures for residential care facilities, ambulance providers, medical care delivered in
non-traditional settings (such as community centers, senior citizens centers, schools, and military field
stations), and expenditures for Home and Community Waiver programs under Medicaid.
Note: Sum of pieces may not equal 100% due to rounding.
Figure 8-3 The Nation’s Health Dollar, Calendar Year 2015, Where It Went
Reproduced from Centers for Medicare & Medicaid Services, Office of the Actuary, National Health Statistics Group. (n.d.).
The nation’s health dollar ($3.2 trillion), calendar year 2015: Where it came from. Retrieved from https://www.cms
.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads
/PieChartSourcesExpenditures2015.pdf
Home
organization should be actively involved in cost
health Other containment decisions because these decisions af-
3% services*
Skilled 13% Medicare
fect answers to these questions. Nurses should also
nursing
facilities advantage work collaboratively with interprofessional leaders
5% 27%
and staff because financial decisions are not limited
Hospital
outpatient to one specific profession or service. This, however,
services requires that nurses be prepared to effectively consider
7%
Physician
payments
Hospital
inpatient
financial issues. More content on health economics
11%
Part D
services
23%
is needed in nursing education programs to develop
prescription
drugs
competencies not only for graduate programs, but
12% also for baccalaureate students (Platt, Kwasky, & Spetz,
2015). Nurse managers and administrators have the
most responsibility for financial decisions; however,
Figure 8-4 Medicare Benefit Payments by Type
of Service for staff nurses to actively engage and be effective in
Reproduced from Kaiser Family Foundation. (2016). the organization, they too need to have some under-
An overview of Medicare. Retrieved from http://kff.org standing of this area and provide input when needed.
/medicare/issue-brief/an-overview-of-medicare/. Reprinted
with permission. Data from Congressional Budget Office, Nurses are not usually directly involved in
2016 Medicare Baseline (March 2016). the development of budgets unless they are in a
management position; however, it is important
parking and security, and so on, and also includes
for nurses to understand what a budget is and why
any major expenses outside of operating expenses
it is important. Nurse managers need to ask their
such as expansion or renovation. The budget also
nursing staff for input when unit budgets are de-
includes projected revenue or money coming into
veloped and need to share budget outcomes with
the organization.
staff. The nurse leader of the nursing department
It is very important that nursing management
should consult with department nurse managers as
participate in the budget process because the budget
budgets are developed and monitored.
has a major impact on nurses and nursing care. Reim-
The hospital board of directors approves the
bursement and other aspects of healthcare finance affect
final budget. After a budget is approved and im-
nursing care and responses to questions such as these:
plemented, it is important that budgetary data are
1. Are there enough nursing staff? monitored on a regular basis, and this information
2. Are there sufficient and effective support services should be shared with the healthcare organization’s
for nurses so that they are free to provide care managers throughout the year. This monitoring is
and not do nonpatient duties? done to better ensure that the budget goals are met
3. Are the most up-to-date supplies and equip- and facilitate early recognition of budget issues
ment available? that may require adjustment in the budget and in
4. Is there an efficient computerized documen- the workplace.
tation system?
5. Is orientation sufficient for new staff?
6. Do nursing staff receive the training they need?
Reimbursement: Who Pays
7. Are nurse managers provided with effective for Health Care?
training and education? Reimbursement is a critical, complex topic in
All of these are critical questions, and more, are health care. It represents the third perspective on
of interest to nursing staff. Nursing leaders in an healthcare financial issues. Nursing students may
wonder why this topic is relevant to them or even 45% of uninsured stays, and 43% of all mental
to nurses in general. Basically, reimbursement health-related stays (HHS, AHRQ, HCUP, 2016).
pays the patient’s bill for services provided, and Often, these hospitals are teaching hospitals and
this payment in turn covers costs of care, such as AHCs. This does not mean these hospitals do not
staff salaries and benefits, drugs, medical supplies, or could not serve patients with excellent reim-
physician fees, facility maintenance and upgrades, bursement; however, it is typically the case that the
equipment, general supplies, and much more. These majority of their patients cannot provide sufficient
monies then provide healthcare providers with funds reimbursement and in some cases potential patients
to pay their bills and cover their services. So, for with insurance do not want to go to these hospitals.
example, reimbursement dollars eventually become Patients with limited or no reimbursement also
the dollars that pay staff salaries in hospitals, clinics, tend to be more complex in terms of their care: low
physician practices, homecare agencies, and so on. income, medically vulnerable, with complex social
Hospitals that do not bring in enough money needs, and have had limited preventive care. Some
to pay their bills are said to be operating “in the have chronic medical conditions that have not been
red,” and this is not a good position for a hospital. treated. Other complications include socioeconomic
It means the hospital cannot pay all its bills. Most problems, language issues, and immigrant status, all of
hospitals are operating in the red, but how far in which contribute to the need for complex healthcare
the red can make the difference between modern- treatment. The safety net hospital system struggles
izing or filling staff positions or not doing so—and to operate effectively to meet the complex medical
whether the hospital stays open for business. Some and social services for vulnerable populations, but
hospitals in this country have closed. Particularly they need sufficient reimbursement for services to
hard hit have been hospitals in rural areas and cover their operating costs (Dewan & Sack, 2008).
small hospitals that are not able to compete for “As providers of last resort, safety net systems offer
patients. Their closing may have a major impact on services that are expected by their communities and
access to care. Some patients may not have access required by state and local governments, regardless
to a local hospital for needed services, or even for of whether adequate revenue streams exits to sup-
emergency services, or people may have to travel port these services” (VanDeusen et al., 2015, p.1).
long distances for obstetric care or specialized care These systems require changes to meet the needs
for children (pediatrics, neonatal care for newborns), of patients, provide quality care, and also to remain
mental health services, oncology (diagnosis and financially stable.
treatment), complex surgical procedures, and many It is important for nurses to understand basic
other services. information about reimbursement. Patients today
The United States is experiencing a serious frequently worry about payment for care. Questions
crisis in its safety net hospitals, which are hospitals that arise are: Do patients have insurance coverage?
that serve populations with limited or no resources How much of their care will be covered by insur-
to pay for service. The government defines safety ance? Will they get the treatment they need from
net hospitals as hospitals with the highest number the providers they prefer? Experiencing an illness
of inpatient stays that are paid by Medicaid or is difficult for any patient and the patient’s family,
for which there is no insurance coverage (HHS, and to add worry about payment for services adds
AHRQ, 2016b). Healthcare Cost and Utilization to this stress and can have an impact on a patient’s
Project (HCUP) data for 2014 indicate that one health as well as the patient’s response to the health
quarter of these hospitals accounted for 33% of all problem. This stress can affect whether patients
inpatient stays, 50% of stays covered by Medicaid, can follow treatment recommendations. Can the
patient afford needed medications, or would the for people who have to buy insurance through the
costs compromise the patient’s ability to buy food exchanges, but they must meet certain criteria to
or pay rent? Can the patient afford to take a bus or obtain this support. The launch of this system was
taxicab to a doctor’s appointment? Can the patient accompanied by numerous problems—particularly
afford to take off work for an appointment? None technological problems, but also issues related to the
of this is simple. insurance plans and some people having to change
coverage, which in some cases was more costly or
The Third-Party Payer System required a change in providers. It is unclear what
The U.S. healthcare delivery system is funded primar- the long-term results of these changes will be be-
ily through a third-party payer system (insurance) cause the Trump administration plans on making
that is primarily employer based, with healthcare changes; details are not yet known.
services paid by someone other (insurer) than the Fee-for-service is the most common reimburse-
patient and services provided mostly in private sector ment model in the United States. In this model,
healthcare organizations, but also in some public or physicians or other providers, such as hospitals, bill
government healthcare organizations. This means if separately for each patient encounter or service that
your employer does not offer an insurance benefit, they provide, rather than receiving a salary or a set
you must purchase your own insurance, apply for payment per patient enrolled. The third-party payer
Medicaid if you are eligible, apply for Medicare if actually pays the bills, but the enrollee usually has
you are eligible, or go without insurance. Under the some payment responsibilities that vary from one
Affordable Care Act, going without insurance means policy to another. This is a complex area, so nurses, as
you have to pay a penalty; however, this penalty consumers of health care and as healthcare providers,
may change with Trump administration initiatives. need to understand the basics. Enrollees (patients)
Examples of third-party payers include Blue Cross may pay any or all of the following:
and Humana. Medicare and Medicaid, though
■■ Deductible: The deductible is the part of
government programs and not employer based,
the bill that the patient must pay before the
are also third-party payers. The patient pays for
insurer will pay the bill for the services. If the
part of the care, but the payment for most patients
patient reaches the total amount allowed per
goes through another party, the insurer (the third-
year, the patient pays no additional deductible
party payer). Typically, the patient or enrollee in the
for that year.
insurance policy is covered as part of a group, most
■■ Copayment and coinsurance: The copayment
likely through the enrollee’s employer healthcare
is the fixed amount that a patient may be
policies as an employee benefit. Some employers
required to pay per service (physician visit,
allow employees to choose from certain policy plans
lab test, prescription, and so on), and this
of varying cost and covered services.
amount can vary among insurance policies.
The Patient Protection and Affordable Care Act
For example, for a physician visit, the patient
(ACA) established insurance exchanges (at the fed-
may pay a small amount at the time of the
eral level and in some states as well). An individual
visit or be billed by the physician. The insurer
can buy personal health insurance through these
pays the rest of the bill. Health plans vary
exchanges when he or she does not have access to
as to the amount of this copay per service.
employer healthcare insurance (for example, some-
one who is self-employed or whose employer does Both the deductible and the copayment rep-
not provide insurance). The new legislation also resent the patient’s annual out-of-pocket expenses,
provides some financial support and reduced costs in addition to the annual fee or premium, that the
employee pays for the coverage. These expenses medical condition that a person developed before
have been steadily increasing for consumers, some the person applies for a particular health insurance
years more than others: “In 2016, the average annual policy; this condition could affect the person’s (enrollee
workplace family health premiums rose a modest 3% or employee) ability to get coverage or how much
to $18,142; more workers enrolled in high-deductible the enrollee has to pay for it. What is considered a
plans with savings options over the past 2 years; preexisting condition? Differences in how policies
average deductible rose 12% to $1,478 annually” answer this question have long been a problem; how-
(Kaiser Family Foundation [KFF], 2016a). These ever, the ACA has had an impact on the preexisting
costs are expected to increase. Employers also pay a condition requirement in that insurers are no longer
portion of the annual insurance fee. Fees vary from able to use a preexisting condition as a reason to
policy to policy and from one employer to another. deny insurance coverage. This is an important part
There has long been no requirement in the United of ACA that most Americans like, and it may or may
States that every employer provide healthcare in- not be maintained at current level due to potential
surance coverage, although this changed with the changes in healthcare reimbursement legislation.
ACA in that there are other insurance options. The
ACA also increases the number of employers who Government Reimbursement
offer insurance to employees by basing requirement to of Healthcare Services
offer insurance on how many employees the employer State and federal governments cover a large portion
has, but if the law is repealed and new legislation of the healthcare costs in the United States, but there
passed, this may or may not be the case in the future. is no universal coverage, meaning that not all citizens
Annual limits are also important as they define have healthcare coverage. The United States is one
the maximum amount that enrollees have to pay; of the few industrialized countries that do not have
after that level is reached, they no longer have to universal coverage. The ACA does not support full
contribute to the payment. For example, suppose the universal healthcare coverage, although more people
employee or enrollee has bills exceeding $5,000, and are now able to get coverage and all are required to
the annual limit is $5,000. This enrollee or patient have coverage or pay a penalty, but the government
would not have to pay any more for care that year does not cover insurance for everyone. The Trump
after paying $5,000; the patient is 100% covered for administration does not plan on implementing
care for the remainder of that year. universal healthcare coverage.
Employees may include their families on their There are several types of government-sponsored
employer insurance coverage. The ACA now makes reimbursement. The largest programs are Medicare
it a requirement that insurers allow families to and Medicaid, which are managed by the CMS as
include uninsured adult children up to age 26 on part of HHS. In 1965, Title XVIII, an amendment
their insurance, even if the adult child is no longer to the Social Security Act, established Medicare.
dependent on the parents. This has been very pop- Medicare is the federal health insurance program for
ular and may or may not continue with changes people aged 65 and older, persons with disabilities,
the Trump administration may make. Typically, and people with end-stage renal disease. Medicare
employees have to pay more per year for family had 55,504,005 beneficiaries in 2015, and this num-
insurance, and there may be different requirements ber increases each year (KFF, 2016b). The need for
for the family (for example, a higher annual out- Medicare coverage is growing because of the increase
of-pocket limit) than for an individual employee. in the population older than age 65. There are several
Another critical element of reimbursement is parts to Medicare: Part A covers hospital services;
preexisting conditions. A preexisting condition is a Part B covers physician and outpatient care; Part C,
referred to as Medicare Advantage, offers Medicare Illnesschapter), which establish the annual income
approved private insurance plans that cover Part A level for poverty defined by the federal government,
and B services, but Medicare enrollees may choose are important in identifying people who meet coverage
one of these plan—the plans may charge different criteria for Medicaid reimbursement.
fees; and Part D provides coverage for prescriptions. Covered Medicaid services include inpatient
Enrollees have to pay a portion of costs for Part B care (excluding psychiatric or behavioral health);
and prescriptions (Part D). Medicare does not pay for outpatient care with certain stipulations; laboratory
long-term care but does cover some skilled nursing and radiology services; care provided by certified
and home health care for specific conditions. pediatric and family nurse practitioners when li-
The CMS sets standards and monitors Medicare censed to practice under state law; nursing facility
services and payment. Medicare covers many patients services (long-term care) for beneficiaries aged 21
in acute care today. It is a very important part of the and older; early and periodic screening, diagnosis,
U.S. healthcare delivery system that supports older and treatment for children younger than age 21;
citizens and other populations; however, there is family planning services and supplies; physician
concern about financing this program in the future services; medical and surgical care; dental ser-
because of the increase in the number of citizens vices; home health care for beneficiaries who are
who will be 65 and older, and this will increase costs. entitled to nursing facility services under the state’s
The CMS is also concerned about quality care, as Medicaid plan; certified nurse–midwifery services;
discussed in other chapters in this text. pregnancy-related services and services for other
Medicaid, established in 1965 by Title XIX conditions that might complicate pregnancy; and
of the Social Security Act, is the federal/state pro- 60 days’ postpartum pregnancy-related services.
gram for certain categories of low-income people. A second group of persons is also eligible for
Medicaid covers health and long-term care services Medicaid: the medically needy. These are persons
for more than 51 million Americans, including who have too much money (which may be in sav-
children, the aged, the blind, disabled persons, and ings) to be eligible categorically for Medicaid but
people who are eligible to receive federally assisted who require extensive care that would consume all
income maintenance payments. The number of their resources. Each state must include the following
people enrolled in Medicaid is increasing, and this populations in this group: pregnant women through
has been influenced by the ACA, as more people a 60-day postpartum period; children younger than
are now eligible for Medicaid due to changes in the the age of 18; certain newborns for 1 year; and certain
program made by the ACA to increase insurance protected blind persons. States may add others to
coverage for many. Pre-ACA average monthly en- this list. The federal government requires that each
rollment was 56,392,477, and in 2016, total monthly state cover, at a minimum, persons who qualify for
Medicaid/CHIP enrollment was 74,369,888 (KFF, Aid to Families with Dependent Children, all needy
2016b). Government data are typically 1–2 years children younger than age 21, those who qualify
behind the current year. This program may also for old-age assistance, those who qualify for Aid to
experience major changes in the Trump adminis- the Blind, persons who are permanently or totally
tration healthcare initiatives. disabled, and those older than 65 who are on welfare.
The Medicaid program is funded by both federal The government also reimburses care through
funds and state funds, but at this time, each state sets the following organizations and methods:
its own guidelines and administers the state’s Medicaid
program. The federal poverty guidelines (described ■■ Military health care: In this system, the
in the Health Promotion, Disease Prevention, and government not only pays for the care for
all in military service, but also is the care and continues to do so. “The current enrollment
provider through military hospitals and numbers (as of February 2016) are roughly: 12.7 mil-
other healthcare services. The military also lion in the marketplace, and very roughly 20 million
covers care of dependents whose care may total between the ACA between the Marketplace,
or may not be provided at a military facility. Medicaid expansion, young adults staying on their
■■ U.S. Department of Veterans Affairs: The VA parents plan, and other coverage provisions. The 2016
provides services to veterans at VA facilities and uninsured rate remains at an all time low with the
covers the cost of these services. VA hospitals uninsured rate at 11.9% for Americans 18–64 and
are found across the country and provide acute 8.6% for all Americans. 8.6% is down from 9.1% as
care; ambulatory care; and pharmaceutical, of 4th quarter 2015, and 15.7% before the Affordable
rehabilitation, and specialty services. In some Care Act was signed into law” (Obamacare Facts,
cases, the VA provides care at long-term care 2016). The uninsured rate is dropping and now is
facilities. The VA does not cover healthcare under 10%. Data such as the number of uninsured
services for families of veterans. are always a few years behind the current year with
■■ Federal Employees Health Benefit Program: current data found at the U.S. Census Bureau website.
Federal law mandates federal employee health Data change as more Americans move in and out
insurance. More than 21,995,000 federal of the health insurance pool, and changes in ACA
employees, retirees, and their dependents will affect the number of uninsured.
are covered (Jeffrey, 2015). Enrollees choose The uninsured and underinsured are in great
from a variety of healthcare insurance plans need of healthcare services—preventive, ongoing,
as part of the Federal Employees Health Ben- acute, and chronic care. They also have complex
efit Program. This is just a reimbursement needs related to employment, housing, finances,
or insurance program; it does not provide food, transportation, and education. Discharge
healthcare services. planning to meet these needs should include a
■■ State insurance programs: States offer health thorough assessment of the patient’s needs at home
insurance to their state employees. Typically, and a plan to ensure that patients receive the care
the state government is the largest employer they need post-hospitalization. Complex and vul-
in a state, and therefore, the state’s largest in- nerable populations need care and are at serious
surer. State employees choose from a variety risk for not being able to access the care and other
of plans and contribute to the coverage in the services they need.
same way that non–state employees pay into
their employer health programs.
The United States does not have a universal healthcare
The Uninsured and the reimbursement system.
Underinsured
The United States has a large population of people
who are not insured or who are underinsured (that The Nursing Organization
is, they do not have enough insurance coverage to Within the Hospital
pay for their needs). As more Americans register for
insurance as required by the ACA, the number of RNs are members of the nation’s largest healthcare
uninsured decreases, but the problem of uninsured profession, and they practice wherever people need
will not be eliminated. The ACA has had an impact nursing care. There has been a serious shortage of all
types of nurses in the United States in recent years. just focused on nursing, and the DON had little, if
Although this trend slowed down somewhat, it is any, input into the functioning of the hospital as a
expected to increase again as more nurses retire whole and no input into the budget. Today, even if
and the population ages requiring more care. The the nurse leader is called a DON, the DON has
shortage of nursing faculty continues to be a major, much more input into all aspects of the hospital
long-term problem, as discussed in content on administration and the budget. This is an important
nursing education in this text, and this affects the change. Given that nurses account for the largest
number of students nursing programs may admit. percentage of hospital staff and provide most of the
Nurses assume critical roles in a variety of direct care, it is critical that a nurse leader represents
healthcare settings—a topic explored throughout the nurses in the organization. This nurse leader
this text. The focus in this chapter is on hospitals needs to be recognized in the organization as an
as one example of a HCO. Nursing services may be important HCO leader and participate in major
organized differently in hospitals. The traditional HCO decision making.
nursing organization—which is still the most In the 1970s and 1980s, directors of nursing
common type—is a nursing department. In this began to gain more power, and their titles changed
model, nursing staff (RNs, LPNs/LVNs, patient to vice president for nursing or patient services in
care/nursing assistants) are part of the nursing recognition of their organization leadership role—
department, which includes unit support staff or but the focus was still on nursing. During this time,
a unit clerk (secretary and other titles) and other increasing numbers of nursing leaders began to
support administrative staff as well. The title for the complete graduate degrees. It was recognized that
unit clerk position varies, but this is the person or they were running large, complex departments
persons who help with clinical unit administrative that represented a significant portion of the overall
issues such as records, supplies, reception at the hospital budget. Gradually, the vice president of
central desk area, and so on. nursing (VPN) was included in the hospital’s budget
The second and newer organization model process as an equal partner. The next change was the
is a patient services department. In this case, the evolution of the vice president of patient services
department focuses on the function of multiple position, in which the nurse leader is responsible for
patient services, not just nursing. Other patient care more than just nursing services. This was a major
services might include medical records, respiratory shift, but the idea that a nurse could manage other
therapy, infusion therapy, infection control, and so healthcare disciplines changed very slowly. As is
on. The configuration varies widely from one hospital true for all such information about hospitals, there
to another. Figures 8-5 and 8-6 provide examples is great variation from one hospital to another. The
of this type of organization. Figure 8-7 describes size of the hospital has an impact on how the nursing
a hospital unit structure. services are organized.
An RN is the designated leader as noted in More nurses today are also taking positions in
Figures 8-5 through 8-7, which illustrate depart- hospital administration that are not related to just
ment models. An RN must be the overall leader nursing; for example, a nurse could be the chief
of nursing services to meet The Joint Commission operating officer or CEO. This is a major shift, but
accreditation standards. The nurse leader title has there are not many nurses in these positions. Nurses
changed over time. Director of nursing (DON) was are also serving on boards of directors for a variety
the title most commonly used in the past, and some of healthcare organizations in acute care and in com-
hospitals still use this title today. The traditional DON munity organizations. Today, any nurse who serves
Chief nursing
officer
Director Director staff

nursing research development
Director
evidence-based
practice
Director Director Director Director Director

medical surgical intensive ambulatory women’s
nursing nursing care nursing care health
Medical Surgical Gynecology

ICU Clinics
unit A unit A unit
Medical Surgical Labor and

CCU ED
unit B unit B delivery
Medical Step-down Urgent

OR Postpartum
unit C units care
Post-anesthesia
NICU
recovery
Ambulatory
care surgery
Figure 8-5 An Example: Nursing Department Organizational Chart

VP patient services Chief nursing

officer
Director of
Director of Director of medical nursing
nursing pharmacy
Nurse manager Area
unit A coordinators
Nursing Director of
services dietary services
RN team leader RN team leader RN team leader
team A team B team C
Nursing Director of
research medical records
LPNs/LVNs LPNs/LVNs LPNs/LVNs
Director Nursing Nursing Nursing

EBP of quality assistant assistant assistant
improvement
Figure 8-7 An Example: Medical Nursing Unit
Organizational Chart
Staff
development
and education
Figure 8-6 An Example: Patient Services types of services—director of women’s health,

Organizational Chart director of surgical services, director of be-
havioral health, and so on. These directors
supervise multiple units that have a common
in a nursing leadership position in a HCO needs function or specialty, such as women’s health
to be competent in administrative responsibilities (for example, gynecology, obstetrics).
such as planning, budgeting, staffing, QI, effective ■■ First level: Managers who provide the day-to-
decision making, communicating, coordinating, and day or operational direction for the nursing
public speaking, and he or she must also demonstrate service and units. This group is composed
leadership. The nurse administrator must involve of supervisors and managers. Titles for
others in decision making, support teamwork, and these managers vary. Some examples are
work with other healthcare professionals to support nurse manager, head nurse (not used much
effective interprofessional teamwork to ensure quality today), nursing unit manager, and nursing
care and a healthy work environment. or nurse coordinator. These managers are
The nursing organization or department includes critical to the effectiveness of any hospital
a variety of nursing management staff. Typically, because they deal with the daily functioning
there are three levels of management: of patient care areas, quality care and safety
■■ Upper level: Responsible for establishing for patients and staff, budget implementation
goals, objectives, and strategic plans for the and use of resources, staffing, staff issues
organization. The highest-level nurse leader and morale, teamwork, coordination, and
(DON, VPN, vice president of patient services communication. They work with multiple
positions) is in upper-level management. disciplines to ensure that patients get the care
■■ Middle level: Supervise first-level managers. they need. Nurse managers do not typically
For example, there may be directors of specific provide direct care.
Participation in nursing committees and inter- organizational cultural issues in the units where
professional committees provides opportunities for they have clinical experiences.
nurses to be directly involved in decision making Two terms are often used to describe organi-
and have an impact on care delivery. Some of the zational culture: dissonant and consonant. Hospital
committees typically found in hospitals focus on leaders need to be aware of which label applies to
policies and procedures, QI, staffing, staff develop- their organization’s culture. A dissonant culture
ment/education, medical records and documentation, means that the organization is not functioning
pharmacy, EBP, and research. Some committees are effectively. Such organizations have the following
special task forces that address specific issues—for characteristics (Jones & Redman, 2000, p. 605):
example, preparing for change to a new computerized ■■ Unclear individual staff and department
documentation system. expectations. (Staff do not know what they
should be doing and how they should be
working.)
Stop and Consider #5 ■■ Lack of consistent measurement of quality of
The organization of nursing services has an impact
on its staff.
service. (Data from monitoring quality may
lead to improvement, but a dysfunctional
organization is not as interested in improve-
ment or may not have effective processes to
Organizational Culture monitor quality.)
■■ Organized to serve the staff (providers of care)
Typically, culture refers to an individual person’s culture, instead of serving the consumers (patients).
the culture of a group in a country, or a country’s (Consumers are less important, and thus
culture, but there is also organizational culture. services will not focus on consumer needs.)
Curtin described organizational culture in this ■■ Limited concern for employee welfare. (Em-
way: “There is in each institution an implicit, ployees are viewed only as workers and not
invisible, intrinsic, informal, and yet instantly as part of the team and not valued.)
recognizable weltanschauung that is best described ■■ Limited education and training of staff.
as ‘corporate culture.’ Like most important things, (Educated staff members lead to better care
it is difficult to define or even describe. It is not and improvement, but the dysfunctional or-
‘corporate climate,’ ‘organizational climate,’ or ganization is not interested in improvement
‘corporate identity.’ The corporate culture em- and better patient outcomes or has difficulty
bodies the organizational values that implicitly providing education that is of benefit to the
and explicitly specify norms, shape attitudes, staff.)
and guide the behaviors of the members of the ■■ Frequent disagreements among staff that
organization” (2001, p. 219). relate to control (turf battles). (This situation
Organizational culture has an impact on nurs- indicates a high stress level among staff and
ing staff and their practice. The overall HCO has a thus affects effective staff functioning and
culture. Nursing within an organization also has a can impact quality of care—for example,
culture; the nursing department and even separate increase in errors.)
divisions or units may have different cultures. New ■■ Lack of patient involvement in decision
staff members need to get to know the culture of making. (Lack of interest in consumers af-
the organizations that they are considering for fects the care provided, patient satisfaction,
employment. Students may be able to identify and quality; this in turn may have financial
implications if patients do not want to receive culture takes the form of a gut feeling that a patient
care in the HCO.) has when the patient enters the hospital and ob-
■■ Limited recognition of staff accomplishment. serves its physical appearance, how staff respond,
(The organization does not value staff.) the ease of finding one’s way around, services set
up for the consumer, and so on. The following are
Today, there is growing concern about staff other considerations that staff should recognize as
incivility and bullying with one another—nurse to important to the organization culture:
nurse and nurse to other healthcare staff. This is a
■■ The organization’s structure and process
symptom of a dissonant culture. Additional infor-
■■ Communication (types, effectiveness, who
mation on incivility is discussed in other chapters
is included in communication, level of se-
in this text. Healthcare organizations are taking
crecy, information overload, timeliness of
strong stands against this type of behavior.
communication, and so on)
The goal is to develop and maintain a con-
■■ Acceptance of new staff (who become mem-
sonant culture, or a functional and effective
bers of the organization)
organization—one that would have the opposite of
■■ Willingness of staff to listen to new ideas
each of the characteristics of a dissonant organiza-
■■ Inclusion of staff in decision making
tion. People do not like to go to work in stressful
■■ Morale
environments and want to work in organizations
■■ Vacancies and turnover
that are effective, creative, and productive. How
■■ Acceptance of students (all types of healthcare
does an organization attain these characteristics?
professions)
The hospital’s formal framework lays the ground-
■■ Positive feelings by patients about their care
work for an effective, healthy workplace. This
experiences
includes the hospital’s structure and functions,
■■ Welcome feeling by visitors
chain of command, rules and regulations, and
policies and procedures. The hospital’s vision Nurses usually know which hospitals are functional
and mission statements are important. The vision (consonant) organizations in the communities
statement describes the hospital’s values and its in which they live and practice. They share this
view of the future and provides direction for the information with colleagues, and this can have an
organization. The mission statement describes impact on recruitment of new staff.
the hospital’s purpose. The mission describes the Workforce diversity and patient diversity both
current state of the organization, and the vision influence the hospital’s culture. All the people who
is what the organization aspires to be. Hospitals work in the organization and all the people who
also identify goals and objectives that flow from interact with the organization, such as the patients
the vision and mission statements. These state- and their families, public/community healthcare
ments are part of the organization’s process and organizations, and community members and rep-
are very important to the organization’s culture. resentatives, affect organization culture. Workforce
The vision, mission, goals, and objectives should diversity has become a critical issue in health care—
not be documents that are filed away, but rather specifically, there is need for greater diversity in all
their messages should be implemented in the of the healthcare professions. Labor laws affect this
hospital’s processes and in its structure. diversity. Title VII of the Civil Rights Act of 1964
It is not always easy to describe an organiza- and Executive Order 11246 prohibit employer dis-
tion’s culture. The first response to an organization’s crimination on the basis of race, color, religion, sex,
or national origin. The Americans with Disabilities environment include physical environment—use
Act of 1990 prohibits discrimination as a result of of color, sameness or variety, sense of warmth in
disability, including mental illness, if the person furnishings, type of artwork on the walls, and so
can complete the job requirements. These federal on. Some colors are more peaceful than others.
laws apply to any hospital (or any type of HCO) Put simply, is the architecture and furnishings pa-
that receives any federal funds such as Medicare tient-centered and safe? More attention needs to be
or Medicaid reimbursement. On a practical level, paid to the physical environment and consideration
this means nearly all hospitals are subject to these of changes that improve the environment—leading
requirements because few do not provide services to a healing environment.
to patients covered by these two payment systems Planetree is a nonprofit organization concerned
or receive other types of federal funding/payment. with the environmental impact of the delivery
Language is another issue that is related to diver- system on health care. It is one example of a model
sity. Hospitals need to have access to interpreters of healing in healthcare environments. The focus
to communicate with patients if staff cannot do so. in this model is on body, mind, and spirit, with
Another critical aspect of the hospital’s cul- active patient and family involvement. Hospitals
ture is its effectiveness. Since 2001, there has been that meet specific criteria can be designated as
more interest in whether or not the environment Planetree hospitals. This patient-centered heal-
is a healing environment. This is just as difficult to ing environment model emphasizes the need to
define or describe as organizational culture. Some of consider the healthcare organization’s cultural
the factors considered when assessing the environ- transformation, patient activation, leadership de-
ment are (1) privacy, (2) air quality, (3) noise levels, velopment, and performance improvement with a
(4) views from windows, and (5) visual character- focus on “patient-centered care is the right thing
istics. The needs of patients can vary and, in turn, to do” (Planetree, 2014). Many hospitals are now
affect the type of healing environment needed. The designated as Planetree hospitals when they meet
elderly may require more safety measures to prevent criteria that emphasize a healing environment as
falls, but if restraining patients is used to accomplish proposed by Planetree.
this, the person’s (patient, family) may then have a
negative view of the environment and healthcare
delivery. Restraining a patient may prevent injury, but Stop and Consider #6
An organization’s culture has an impact on every
the patient may also feel imprisoned and punished nurse on the staff, and nurses have an impact on
or abused. Its use should be based on assessment the organization’s culture.
and identification of the best intervention—but
at no time should restraining be a long-term in-
tervention without routine assessment as to the
patient’s status and continuing need. Older adults Changes in Healthcare
may have problems hearing and can tolerate more Delivery
noise. Others may not be able to tolerate a lot of
noise and may complain that they cannot sleep in Historically, hospitals have experienced many
the hospital. From a historical perspective, Florence changes. In the past, hospitals had a significant
Nightingale’s view of care was associated with heal- role in nursing education, but their most important
ing and the patient’s need for fresh air, cleanliness, role—then and now—is the provision of healthcare
quiet, diet, and light. Other aspects of a healing services in their communities. What has been the
history of hospitals? The reengineering of health change a form in the medical record, it will be more
care—that is, the redesigning of how care is pro- difficult to train them in the use of the form, and it
vided and how the organization functions—has may be difficult to get them to even use the form
led to major changes in healthcare organizations. or to use it correctly. The complexity of the change
Many healthcare organizations have undergone and how frequently changes are made can lead to
some level of reengineering in the last decade. overload for staff. The goal is to have staff behind
This might include restructuring, developing new the change and committed to it; they will then be
services, improving processes and systems, or per- facilitators of change. Understanding resistance to
haps decreasing services. A common response to change can help in preparing for the change and
periods of healthcare worker shortages has been in developing any training that might be required.
to redesign how work is done and by whom. If When changes are planned within a hospital, plan-
there are not enough providers, the organization ners need to consider the impact that the changes
needs to consider how staff and management are may have on policies and procedures; accreditation
working and how work processes and resources and regulation requirements; financial issues; the
can be improved to be more effective. As hospi- structure of the organization; the ways in which
tals change, many factors influence the need for staff do their work; patients, visitors, and students
change and how it occurs. Some of these factors (for example, nursing, medical, other); and much
were highlighted earlier in Figure 8-1. more. Other chapters in this text discuss change
Change is inevitable in any type of organization and its implications, such as QI, which often iden-
today, but particularly in health care. Science and tifies change needs.
knowledge have driven some of this change, such This chapter focused on healthcare organi-
as development of technology that has affected zations, with acute care hospitals as the major
diagnosis and treatment options and increased dig- example of a HCO. Understanding how hospitals
ital options, but there are other factors to consider. are structured and their processes (functions) helps
Change is a process that is driven by forces that the nurse practice in this setting. The departments
motivate a person or an organization to consider and team members assume important roles in how
what needs altering. The key is to be clear about the organization functions. The U.S. healthcare
this need and understand the why before taking system has been undergoing many changes. This
the next steps. It is also important to consider will continue due to important legislation such
whether staff are ready for the change. Staff can as the ACA and any subsequent legislation that
act as either barriers to or facilitators of change. may be initiated. Nurses are very much involved
Staff members are typically tired of changes and in these changes and should participate in the
feel that there are too many. They often also feel left change process.
out of the decision process that leads to changes.
In such a case, they may become critical of the
change or feel no commitment to the success of
change. This attitude, in turn, becomes a major Stop and Consider #7
Healthcare delivery is not static; there are frequent
barrier to successful change; for example, if staff factors that change and then impact health care.
do not understand the need behind a decision to
CHAPTER HIGHLIGHTS
1. Healthcare delivery is a complex process 11. Hospitalists and intensivists are generally
and system that includes multiple delivery physicians who specialize in acute in-hospital
sites: acute care organizations (hospitals), care, although some hospitals use APRNs
ambulatory care clinics, private provider and CNSs in these roles.
offices, community health facilities, home 12. Healthcare finances can be viewed from a
care agencies, hospice agencies, extended macro, micro, or reimbursement perspective.
care facilities, and so on. 13. The 1965 Title XVIII established Medicare,
2. Many factors affect hospitals and cause changes which is an amendment to the Social Secu-
in their services and how they collaborate rity Act. It is the federal health insurance
with others, realign their organization with program for people aged 65 and older,
the external environment, or even close persons with disabilities, and people with
because of financial issues. end-stage renal disease.
3. Health care is a business; it provides services 14. The 1965 Title XIX of the Social Security
to a population. Act established Medicaid, which is the
4. Healthcare entities may be for-profit or federal–state program for certain categories
not-for-profit organizations, depending on of low-income people, children, the disabled,
what they do with their revenues. blind persons, and so forth.
5. Healthcare organizations may differ depending 15. The number of uninsured and underinsured
on their structure and process. For example, individuals has been growing in the United
a bureaucratic structure receives little input States, but implementation of the Affordable
from staff as part of its decision-making Care Act of 2010 (ACA) should reduce this
processes. number—although changes in this law may
6. Horizontal structure is decentralized, with have a negative impact on this outcome.
an emphasis on departments or divisions; (This may change based on possible future
decisions are made closer to where staff changes in the legislation or new legislation.)
members do the work. 16. Nursing within an organization is a critical
7. The matrix organization structure is newer component of healthcare delivery.
and less clear than the traditional bureau- 17. Organizational culture reflects the mission,
cratic organization centered on departments. core values, and vision of the entity—the
A matrix organization is flatter (that is, goal is consonant cultures.
decisions do not flow from the top down). 18. Healthcare delivery systems may be viewed
8. The process of an organization focuses on as a healing environment.
how it functions. 19. Changes in healthcare delivery have an
9. Classification of hospitals varies greatly and impact on hospitals, and staff members
may reflect the hospital’s mission focused need to understand and participate in the
on teaching or research, length of stay, change process.
ownership, and so on.
10. The hospital healthcare team is composed
of a variety of healthcare providers, both
professional and nonprofessional.
1. What is the difference between organizational 4. Describe ways to organize nursing services
structure and process? Identify examples in a hospital, key roles of nursing services,
for each. and nursing services’ relationship to other
2. If you were not a nursing student, what departments.
other healthcare team member would you 5. What does organizational culture mean, and
want to be and why? Does this healthcare why is it important?
team member have something in common 6. What is your opinion of the healing envi-
with nursing? ronment model? How do you think the
3. Compare and contrast the three finan- designation of a Planetree hospital might
cial p
erspectives—macro, micro, and affect nursing care?
reimbursement.
1. What is your reaction to the corporatization learned about the issue? Student teams
of health care? Discuss with a student team. should select different issues to review and
2. Search the Internet for a hospital website. See then share what they learned. Consider the
if you can find information on that hospital’s implications for nursing.
vision, mission, goals, and objectives. Many 4. Search the Internet for information about
hospital websites include this information. one type of healthcare team member to
After you find an example, review the infor- learn more about the profession.
mation. How does this information apply to 5. Visit the consumer site for Medicare (http://
nursing? Discussion team members could medicare.gov). If you were a Medicare bene-
select different HCO websites, and then ficiary, how helpful would this site be? What
compare and contrast the information information can you find? Click on Com-
they gather. pare Hospitals in Your Area (www.hospital
3. Visit the website for the American Hospital compare.hhs.gov/) and review hospitals in
Association (http://www.aha.org). What is your area from the perspective of a consumer
the American Hospital Association? Click who is 70 years old and needs to have a hip
on “Advocacy Issues” and select one of the replacement.
key initiatives to explore. What have you

Write a description of a healthcare organization where you have had a clinical
experience. Consider the information in this chapter as you describe the organization.
Reflect on its culture and how you felt while being in the organization. How do you think staff,
patients, and families might feel? What could be improved in the organization based your
experience? When you first entered the hospital and one of its units, what did you feel like?
Consider all your senses in your response.
CASE STUDIES
Case 1
It is time to interview for you first hospital job. You are not sure what you should do in the
interview and what questions you should ask. You are having lunch with fellow students,
and all of you are focused on this issue.
Case Questions
1. How should we prepare for our interviews?
2. Tell me what questions you think are critical to ask?
3. Why is it important to talk to several nurses who work in the hospital?
Case 2
You are a staff nurse on a surgical unit. The nurse manager has formed a task force to
provide input on the budget for the unit. She asks you to serve on the task force. You tell
her you do not feel competent because you have been a nurse for only 1 year, but she
says she wants fresh input. Now, you find yourself at the first meeting. The chair opens the
meeting with some questions. How would you respond to them?
Case Questions
1. What type of budget do we have for our unit?
2. What types of expenses do we have? If we find that some of these expenses have been
increasing, what interventions and/or changes might we suggest to lower the expenses
(cost containment)? Why should staff get involved in unit budget planning?

questions and comments.
1. What is the status of our unit and organization culture?
2. What needs to be improved? What is effective?
3. How does the culture impact nurses and nursing in the organization?
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American Association of Colleges of Nursing. (2013). Com- etrieved from https://www.nytimes.com/2016/07/14

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www.aacn.nche.edu/publications/white-papers/cnl Planetree. (2014). The formula. Retrieved from http://
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Section 3
Core Healthcare
Professional
Competencies
In its 2003 report, Health
Professions Education, the
Institute of Medicine (IOM)
identified core competencies for
all healthcare professionals. These
are not the only competencies,
but rather they form the core
competencies that should be
addressed in all healthcare
professionals’ education: nurses,
physicians, pharmacists, allied
health professionals, and
healthcare administrators.
These competencies are based
on the need to improve the
quality of health care and the
recognition that healthcare
professional education was
not effectively including these
five critical competencies. The
five core competencies are
summarized here:
■■ Provide patient-centered care:
Identify, respect, and care
about patients’ differences,
values, preferences, and
expressed needs; relieve pain
and suffering; coordinate
continuous care; listen to,
clearly inform, communicate
with, and educate patients; of structure, process, and

share decision making outcomes in relation to patient
and management; and and community needs; and
continuously advocate design and test interventions
disease prevention, wellness, to change processes and
and promotion of healthy systems of care, with the
lifestyles, including a focus on objective of improving quality.
population health. ■■ Utilize informatics:
■■ Work in interprofessional Communicate, manage
teams: Cooperate, collaborate, knowledge, mitigate error, and
communicate, and integrate support decision making using
care in teams to ensure that information technology.
care is continuous and reliable.
These competencies
■■ Employ evidence-based
are interrelated, and all
practice: Integrate best
should be applied in most
research with clinical expertise
clinical interactions. This
and patient values for
competency-based approach
optimal care and participate
to healthcare education should
in learning and research
lead to improved quality because
activities to the extent feasible.
educators should be able to
■■ Apply quality improvement:
gather data about learning
Identify errors and hazards
outcomes that could then be
in care; understand and
associated with better patient
implement basic safety
care, the desired goal.
design principles, such
as standardization and Source: Institute of Medicine. (2003).
simplification; continually Health professions education (p. 4).
understand and measure Washington, DC: The National
quality of care in terms Academies Press.
Chapter
9
Provide Patient-Centered Care
CHAPTER OBJECTIVES
■■ Describe the competency: Provide ■■ Support the need for patient advocacy.
patient-centered care and its relationship ■■ Summarize processes that nurses use to
to nursing. ensure better care coordination.
■■ Discuss the importance of consumerism in ■■ Apply critical thinking/clinical reasoning and
health care. judgment to patient-centered care.
■■ Explain the relationship of culture, diversity, ■■ Explain the need for self-management of care.
and disparities to health and healthcare ■■ Discuss the impact of the therapeutic use of
delivery. self on the nurse–patient relationship.
CHAPTER OUTLINE
●● Introduction ●● Culture, Diversity, and Disparities

●● The Competency: Provide Patient- in Health Care
Centered Care ●● Culture
●● Support of Patient-Centered Care ●● Cultural Competence
●● Levels of Patient-Centered Care ●● Disparities in Health Care
●● Does a Patient-Centered Healthcare ●● Disparities: Examples and Importance
System Exist in the United States? ●● Diversity in the Healthcare Workforce
●● Related Nursing Theories ●● Patient Advocacy
●● Consumerism: How Does It Affect Health ●● Care Coordination: A Plan of Care
Care and Nursing? ●● Application of Critical Thinking and Clinical
●● Who Are the Consumers or Customers? Reasoning and Judgment
●● Patient Rights ●● Nursing Process
●● Information Resources and Consumers ●● Assessment
●● Patient Satisfaction ●● Diagnosis
269
270 Section 3: Core Healthcare Professional Competencies
●● Planning ●● Chapter Highlights

●● Implementation ●● Engaging in the Content
●● Evaluation ●● Discussion Questions
●● Care/Concept Mapping ●● Critical Thinking Activities
●● Self-Management of Care ●● Electronic Reflection Journal
●● Health Literacy: A Barrier ●● Case Studies
●● Patient/Family Education: Inclusion ●● Working Backward to Develop a Case
in the Plan of Care ●● References
●● Therapeutic Use of Self in the Nurse–
Patient Relationship
KEY TERMS
Bias Diversity Patient advocacy

Care coordination Ethnicity Patient-centered care
Concept/care map Ethnocentrism Prejudice
Consumer/customer Health literacy Race
Culture Macro consumer Stereotyping
Discrimination Micro consumer Therapeutic use of self
Disparities Nursing process
reasoning and judgment to ensure that care is

Introduction coordinated and the implementation process
focuses on patient-centered care. This all must
This chapter begins the discussion of the five
be done during a time of many changes in health
healthcare profession core competencies for all
care. As a reminder, some of the changes related
healthcare professionals. The first core competency
to patient-centered care are as follows:
focuses on patient-centered care. The U.S.
healthcare system is patient centered, but it is not ■■ The U.S. population is becoming older and
at the level it should be. This content describes more diverse.
patient-centered care, relevant nursing theories, ■■ Preventive care and chronic care are increas-
consumerism in health care, diversity and dispar- ingly joining curative and acute primary care
ities, patient advocacy, care coordination to meet as the focus of health care.
patient-centered care needs, self-management ■■ Chronic disease management is more prom-
of care, and therapeutic use of self in the nurse– inent in many medical practices.
patient relationship. As you enter your nursing ■■ More patients want active involvement in
education program, it is assumed that you are in their health care.
a nursing program because of your concern about ■■ The financial mechanisms that support health
patients; however, providing patient-centered care care are changing.
does not come naturally. It requires knowledge ■■ There is greater concern about the interrela-
and caring, time, critical thinking, and clinical tionship of access, cost, quality, and outcomes.
Chapter 9: Provide Patient-Centered Care 271
center of care and an active decision maker, if the

The Competency: Provide patient chooses to be active. The content in this
Patient-Centered Care chapter focuses on the key elements of the core
competency as illustrated in Figure 9-1.
In 2003, five key core competencies were identified for
all healthcare professionals. This chapter focuses on Support of Patient-
the first core competency: provide patient-centered
Centered Care
care: “Identify, respect, and care about patients’ dif-
ferences, values, preferences, and expressed needs; Why is patient-centered care included in the core
relieve pain and suffering; coordinate continuous competencies? What is the basis for emphasizing
care; listen to, clearly inform, communicate with, patient-centered care? All of the core competencies
and educate patients; share decision making and are interrelated, as seen in Figure 9-2. The central
management; and continuously advocate disease focus in this figure is on providing patient-centered
prevention, wellness, and promotion of healthy care. Evidence-based practice, quality improvement,
lifestyles, including a focus on population health” and use of informatics all affect patient-centered
(Institute of Medicine [IOM], 2003a, p. 4). On the care, and interprofessional teams encircle all and
surface, this definition may seem simple, but it is bring care to the patient.
not; patient-centered care includes multiple factors Crossing the quality chasm: A new health
and activities—all aimed at making the patient the system for the 21st century (IOM, 2001) describes
Self-management
of care, health
Patient advocacy
literacy, patient and
family education
Core competency:
Providing patient-centered care
Nurse–patient
Culture, diversity,
communication
and disparities
and interaction
Core coordination:
Plan of care, critical thinking,
clinical reasoning and
judgment, delegation
Figure 9-1 Providing Patient-Centered Care: Key Elements

Provide
Utilize
patient-centered
informatics
care
Work in
interprofessional
Teams → Core
competencies
Employ Apply
evidence-based quality
practice improvement
Figure 9-2 IOM Relationship Core Competencies

Reproduced from Interprofessional Education Collaborative Expert Panel. (2011). Core competencies for interprofessional
collaborative practice: Report of an expert panel. Washington, D.C.: Interprofessional Education Collaborative.
10 rules for redesigning patient care and pres- health care requires improved competencies
ents a vision for the U.S. healthcare delivery in all healthcare professionals, beginning with
system. The first four rules specifically apply to providing patient-centered care.
patient-centered care, supporting the need to Patient-centered care is a critical part of the
include patient-centered care in the core com- six domains of quality. A description of the skills
petencies and focus on the need for continuous required to provide patient-centered care expand
health relationships, individualized care, patient on the meaning of patient-centered care (IOM,
engagement in decision making, and sharing of 2003a, pp. 52–53):
information. The other six rules are not directly
related to patient-centered care. They are, how- ■■ Share power and responsibility with patients
ever, a major part of the framework to improve and caregivers (family, significant others) (for
the quality of care and are discussed in the quality example, involve the patient in care, make
improvement content in this text. Improving the patient the center of care and decision
making; work to increase patient understand in line to provide added value and service to
standing, acceptance, and cooperation; help that fact” (2003, p. 204). However, it is important to
caregivers as they provide care to a family recognize that patients should not be passive in the
member [education for patient and family]; care process but rather need to be active, engaged,
support self-management; provide comfort and empowered to speak out and participate in
and emotional support; manage pain and decision making. Nursing has long supported this
suffering; relieve anxiety; provide expert view of patients (Pelletier & Stichler, 2013).
care to manage symptoms).
■■ Communicate with patients in a shared and Levels of Patient-
fully open manner (for example, patients have
Centered Care
access to information, communication with
healthcare providers [including nurses], and There are three levels of concern when discussing
use of technology to communicate). patient-centered care. The first relates directly to the
■■ Take into account patients’ individuality, emo- identification of patient-centered care as the core
tional needs, values, and life issues (for example, healthcare professional competency, focusing on the
culture, religion, family, language, profession). care provided by an individual healthcare professional.
■■ Implement strategies to reach those who do The necessary knowledge base for each healthcare
not present for care on their own, including professional, such as a nurse, in order to provide
care strategies that support the broader com- patient-centered care is discussed in this chapter.
munity (for example, underserved members The second level focuses on the organizational level
of the community, vulnerable populations). and the ways in which healthcare organizations
■■ Enhance prevention and health promotion situate themselves to be patient-centered organiza-
(for example, population focus, risk factors, tions. The third level is the macro focus—how the
health promotion, and prevention strategies). healthcare system, as viewed from the local, state,
and national perspectives, ensures that it is patient
As hospitals focus more on patient-centered care,
centered. Strategies to ensure the third level are
the inevitable question is, how do we accomplish
primarily healthcare policy concerns.
effective patient- and family-centered care? Three
There is consensus about the key attributes
key elements in a hospital organization make a ma-
describing patient-centered care at the healthcare
jor difference in reaching this goal (Balik, Conway,
system level. In an analysis of nine models and
Zipperer, & Watson, 2011):
frameworks used to define patient-centered care,
■■ Emphasis on an integrated system the following six core elements were identified most
■■ Effective leadership at the executive, middle, frequently (Shaller, 2007):
and front-line levels ■■ Education; shared knowledge
■■ Effective, engaged teams ■■ Family and friends involvement
Patient-centered or person-centered care is the ■■ Collaboration and team management
key focus for all nurses and the care they provide. ■■ Sensitivity to nonmedical, spiritual dimen-
Hagenow comments, “This care alleviates vulnerability sions of care
in all of its forms. That care should and must then be ■■ Respect for patient needs and preferences
delivered at the right time, at the right level, in the ■■ Accessibility of information
right place, and so on. If care were on a compass, it Shallar also identifies the following factors as
would be true north and all other functions would contributing to the six core elements, which has
an impact on patient-centered care at the organi- though 70% of hospitals continue to have restrictive
zational level (2007): visiting policies (Gasparini, Champagne, Stephany,
■■ Leadership, chief executive officer and board Hudson, & Fuchs, 2015). Some hospitals are now
of directors, committed, engaged in a com- allowing families to be present during resuscitation.
mon mission Nurses have mixed reactions to this change. Typical
■■ A strategic vision communicated to all staff concerns from healthcare providers are: (1) The family
members will see and hear things that may be disturbing to
■■ Involvement of patients and families at them; (2) there is concern the team will not function
multiple levels throughout the organization well, and the family will see this; and (3) the family
■■ A supportive work environment for caregivers may become disruptive and interfere with treatment
■■ Systematic, continuous measurement and (Twibell et al., 2008). Despite these concerns, there
feedback has been movement toward changes to allow more
■■ A supportive, nurturing physical space and family presence—all require careful thought and
design for patients, families, and employees planning with nursing input and preparation of staff.
■■ Supportive technology engaging patients and An example of an approach to improve patient-
families directly in the care process; facilitat- centered care within healthcare organizations is the
ing information access and communication Planetree model, discussed in other chapters in this
with their caregivers text (Planetree, 2014). The Planetree Institute is a
nonprofit membership organization that partners
The Agency for Healthcare Research and
with hospitals and health centers to develop and
uality (AHRQ) now offers resources for healthcare
Q
implement patient-centered care in healing environ-
organizations and providers on using patient- and
ments. These healthcare organizations meet certain
family-centered innovations to improve care (U.S.
criteria to be designated as a Planetree institution,
Department of Health and Human Services [HHS] &
demonstrating effective healing environments.
Agency for Health Research and Quality [AHRQ],
2016a). This website provides multiple examples of
innovations such as redesigning bedside change-of- Does a Patient-Centered
shift reporting, using a patient and family advisor Healthcare System Exist
rounding program, and improving outpatient
in the United States?
rehabilitation with better patient education and
resources, for example AHRQ toolkits (for example, Throughout the Quality Chasm reports, patient-
a patient-centered improvement guide, recom- centered care is emphasized by the IOM, now known
mendations for including patients and families on the National Academy of Medicine. “Research shows
committees and task forces, engaging patients and that orienting health care around the preferences
families in quality improvement, and so on). There and needs of patients has the potential to improve
is a clear message that healthcare organizations and patients’ satisfaction with care as well as their clinical
providers can makes changes to improve patient- outcomes. Yet, one of five American adults reports
centered care. An example of a more commonly used that they have trouble communicating with their
method by healthcare organizations is to include doctors and one of 10 says that they were treated
families in rounds, if the patient agrees. Some hos- with disrespect during a healthcare visit. Patients
pitals have also expanded visiting hours and even often report that test results or medical records were
moved to 24/7 family presence in patient rooms. A not available at the time of a scheduled appointment
recent study indicates that increased opportunity or that they received conflicting information from
for family presence improves patient satisfaction, their providers” (Commonwealth Fund, 2008).
Patients want to be partners in their care, but why? A serious difficulty in developing and main-
This approach offers benefits in the following areas: taining a patient-centered healthcare system is
■■ Provider–patient communication insufficient insurance reimbursement for patient-
■■ Patient educational materials about health centered care. For example, insurers do not cover care
concerns coordination; it is just considered a natural part of
■■ Self-management tools to help patients care delivery. However, this really does not account
manage their illness or condition and health for the time that staff must spend on coordinating
and make informed decisions care, communicating with team members, and so
■■ Access to care (timely appointments, off-hours on. In addition, alternative communication methods
services, and so on) and use of information are not typically covered, such as communication
technology (for example, automated patient with patients over the Internet or telephone. To really
reminders and patient access to electronic change the system, this critical issue of reimbursement
medical records) must be addressed. Insurers, however, are telling
■■ Continuity of care providers they need to be more productive and yet
■■ Post-hospital follow-up and support they have less time to spend with patients; less time
■■ Management of drug regimens and chronic to be patient-centered. Meeting the latter demand
conditions requires more—not less—time with patients. When
■■ Access to reliable information about the quality there is a nursing shortage (which has fluctuated
of physicians and healthcare organizations, over the last few years and may occur in certain
with the opportunity to give feedback geographic regions or individual healthcare orga-
nizations), this affects providing patient-centered
“Ensuring that all patients have a medical home
care. Nurses may feel overburdened with work if
would be an important first step toward creating
staffing is not at the level it should be, and this may
a patient-centered care system” (Commonwealth
then have an impact on nurses’ ability to provide
Fund, 2008). People need a regular place to receive
this care—less time, more stress, more acutely ill
care and the opportunity to develop a relationship
patients requiring more time, increase in risk of
with healthcare providers. The benefits noted above
errors, and so on. This may also lead to staff conflict
have a greater chance of occurring when a patient
and frustration and a poor working environment.
has a regular source of care.
How can this goal of patient-centered care be
Throughout this text quality improvement is
reached at the same time that insurance coverage,
discussed, and we need to consider it with patient-
access to care, and quality of care need to be improved
centered care. It is, however, not easy to measure.
in the United States? To better ensure patience-centered
The National Database of Nursing Quality Indicators
care, all healthcare professionals need to be competent
(NDNQI), the only monitor of nursing-sensitive
and also understand how to support patient-centered
indicators, which is discussed in other chapters,
care. The following attributes of patient-centered care
needs more inclusion of a performance measure on
indicate what needs to be done to reach this goal
patient and family engagement (Pelletier & Stichler,
(Davis, Schoenbaur, & Audet, 2005, p. 954), with
2013). Having data about outcomes on this mea-
examples as to how they might be described:
sure would be very helpful in improving care. The
National Healthcare Quality and Disparities Report ■■ Improved access to care (for example, patients
(QDR) does include person- and family-centered can easily make appointments; wait times
care measures (HHS & AHRQ, 2015a). Data for 2014 for appointments are reasonable; off-hours
indicate person-centered care is improving. Current service is available or patients know whom
report data can be obtained at the AHRQ website. to contact)
■■ Greater patient engagement in care (for Entwistle, Zwarenstein, & Dick, 2001; Pew Health
example, patients have the option of being Professions Commission, 1995; Stewart, 2001).
informed and engaged partners in their care; To reach, the goal of significantly improved
patients participate in treatment planning patient-centered care within a healthcare organiza-
and are updated; self-care and counseling tion requires redesigning care processes to improve
assistance are provided) care delivery. It necessitates partnerships among
■■ Clinical information systems that support practitioners, patients, and patients’ families as
high-quality care, practice-based learning, and appropriate. We also need stronger partnerships
quality improvement (for example, healthcare between schools of nursing and clinical organizations
organizations maintain patient databases and to enable students to gain more experience and better
monitor adherence to treatment; patients understanding of the complexity of p atient-centered
receive decision support and information care and the impact of care processes (Finkelman &
on recommended treatments) Kenner, 2012). The Quality Chasm reports indicate
■■ Care coordination (for example, coordinated that it is more common for the patient to have to adapt
care across the continuum and settings; to the healthcare delivery system than the system
monitor and prevent errors that occur when adapting to the patient’s needs and preferences. This
multiple healthcare providers are involved; approach needs to change. Patients who are involved
provide post-hospital follow-up and support) in their own care tend to have better outcomes.
■■ Integrated and comprehensive team care (for Important methods that should be used to change
example, free flow of communication among the system to a more patient-centered approach are
physicians, nurses, and other health professionals) greater use of rounds, care at the bedside, services
■■ Routine patient feedback to physician/health- in one location at a clinic rather than asking the
care providers (for example, Internet-based patient to go to other locations for tests, and so on.
patient surveys used to obtain patient feed- There is greater and greater access to infor-
back and ensure patient input into treatment mation among healthcare providers, which in turn
plans; there is follow-up if patients provide means patients also have more potential access to
negative feedback) information. Information provides more power
■■ Publicly available information (for example, and control—not just for healthcare providers,
patients have access to accurate, standard- but for patients as well. It is, however, important
ized information about healthcare providers to recognize that just providing information is not
[physicians, hospitals] to help them choose enough for effective shared decision making with
where they will get their care) patients (Hargraves, LeBlanc, Shah, & Montori,
2016). We need to talk with patients, not just give
The following is a summary of strategies from information—that is, have a conversation. For
experts and researchers that emphasizes the key points example, if patient rounds are conducted with
in improving and maintaining patient-centered care: conversation “over the patient” rather than with the
(1) share power and responsibility with patients and patient, then this cannot be called patient-centered
caregivers and (2) engage in an ongoing discussion care. We also need to include expected outcomes
with patients to increase understanding, acceptance, in treatment planning that the patient identifies
cooperation, and identification of common goals (Lavalleel et al., 2016). These methods lead to a greater
and related care plans (Gerteis, Edgman-Levitan, patient empowerment, a topic discussed further in
Daley, & Delbanco, 1993; Halpern, Lee, Boulter, & this chapter in the sections on consumerism and
Phillips, 2001; IOM, 2001, 2003a; Lewin, Skea, self-management.
There is a great need to develop patient-centered ■■ Leininger’s cultural diversity theory: This theory
models that focus on particular populations, such focuses on cultural issues and their impor-
as persons with chronic illness, rural and urban tance in health and healthcare delivery. The
populations, minority groups, women, children, definition of patient-centered care includes
the elderly, persons with special needs, and patients cultural aspects of care, and as discussed in
at the end of life. Focusing on certain populations early Quality Chasm reports, disparities in
better ensures that unique patient-centered needs health care are a critical concern now mon-
will be met. Nurses assume major roles in these new itored by the annual National Healthcare
models and will continue to be active as additional Quality and Disparities Report.
models are developed for hospitals and in public/ ■■ Peplau’s interpersonal relations theory: This
community health settings. Despite barriers mentioned theory emphasizes the importance of the
in this chapter and in healthcare literature, Davis, nurse–patient relationship and communi-
Schoenbaum, and Audet comment, “The concept cation. It is difficult to discuss or provide
of patient-centered health care is beginning to take patient-centered care without considering
hold. Increasingly, patients expect physicians to be the patient–provider relationship and
responsive to their needs and preferences, to provide communication.
them with access to their medical information, and to ■■ Learning theories: Knowles’s adult learning
treat them as partners in care decisions. But despite and the health belief model: These two theo-
being named one of the key components of quality ries particularly relate to a patient-centered
health care by the IOM, ‘patient-centeredness’ has approach and patient education. Patient and
yet to become the norm in primary care” (2005, family education about health and illness is
pp. 953–954). a critical part of patient-centered care. This
education emphasizes the active role of the
patient in the care delivery process and the
Related Nursing Theories patient as a decision maker, with greater
Nursing theories are discussed in other content in emphasis on self-management. If a patient
this text, but in this chapter, we examine theories does not have adequate information and/or
that are particularly relevant to patient-centered necessary skill to care for self, this diminishes
care. Examples include Watson’s theory on caring, patient-centered care. Adult learning theory
Orem’s self-care theory, Leininger’s cultural theory, emphasizes adult learners are different from
Peplau’s interpersonal theory, and some theories younger learners—a factor that must be
related to learning. considered in any educational endeavor with
adults (Knowles, 1972). Patient education
■■ Watson’s theory on caring: This theory focuses certainly includes children; however, there
on caring. Patient-centered care includes an are more adult patients who have complex
emphasis on caring—how the patient receives needs. Often, adult education is approached
care, how the patient perceives care, and how in a paternalistic manner in which patients
nurses and other healthcare providers perceive are not treated as adult learners, and this is
their roles and implement care. ineffective patient education.
■■ Orem’s self-care theory: This theory focuses on
providing support and guidance to patients Another view to consider with patient-centered
so that they can be actively involved in their care is the health belief model, which is also referred
own care, or self-management of care. to as the theory of reasoned action and focuses on
health promotion (Hochbaum, 1958). This model the patient as an integral part of the nursing pro-
was developed to predict if a person would follow cess. What does this really mean, and has nursing
medical recommendations and to gain a better grasped the concept of consumerism so that it is
understanding of patient motivation. According not only spoken about but also incorporated as a
to this model, Masters comments that a person’s critical part of the implementation of nursing care?
response to a health threat is based on the following With the growing number of advanced practice
factors (2009, p. 173): registered nurses, many may be in their own prac-
■■ The person’s perception of the severity of tices or hold roles where consumerism is even more
the illness relevant to them.
■■ The person’s perception of susceptibility to Patients expect more and more to be active in
illness and its consequences their own care at all levels. They do not like it when
■■ The value of the treatment benefits (for exam- they are ignored and left out of decision making.
ple, do the cost and side effect of treatment Families are also becoming much more assertive.
outweigh the consequences of the disease?) Both patients and families are more concerned
■■ Barriers to treatment (for example, expense, about quality and costs. A Quality Chasm report
complexity of treatment, access to care) on safety led to greater recognition of the major
■■ Costs of treatment in physical and emotional safety problem in health care in the United States
terms (IOM, 1999). When this report was published, the
■■ Cues that stimulate taking action toward media widely shared the report’s information via
treatment of illness (for example, mass-media newspapers, radio, television, and the Internet. The
campaigns, pamphlets, advice from family statistics in the report about the high level of errors
or friends, and postcard reminders from were frightening to consumers and, consequently,
healthcare providers) alerted the public (consumers) to the need to be
more vigilant.
By assessing these factors, nurses can develop
The U.S. Department of Health and Human
more effective patient education plans that are
Services (HHS) also now provides more resources
patient-centered.
to engage consumers. One example is the AHRQ
initiative to develop and test a healthcare safety ho-
Stop and Consider #1 tline (HHS & AHRQ, 2016b). There has been extensive
Patient-centered care is the central concern today work done to get data from healthcare providers
in healthcare delivery.
about adverse events, errors, and unsafe conditions
in healthcare settings, and now there is more effort
being made to include patient data—from patients.
Consumerism: How Does This would be done on a secure website or toll-
It Affect Health Care free phone number. This AHRQ report discusses
and Nursing? how this could be done. There are other national
opportunities for patients to provide input on specific
Consumerism might seem a strange term to use in a healthcare issues. Patients can report healthcare
nursing text. It is commonly encountered in business, providers (individuals and organizations), insurers,
particularly in advertising. However, consumerism or any other related healthcare entity for failure to
in health care has become a very important concept, meet HIPAA requirements, which are violations
and it relates directly to patient-centered care. As far of the law (HHS, 2017). This can be done online
as nursing is concerned, nursing has long viewed or in writing via the HHS website. Both of these
approaches empower patients beyond filling out a ■■ Making sure caring comes across: It is easy to
patient satisfaction survey; however, it is important wonder why caring should even be discussed
that consumers know they can make these reports in relation to nursing because caring is so
and how to report concerns. much a part of nursing and its image. Key
questions, however, we need to ask: Does the
Who Are the Consumers patient perceive the caring? Do nurses say
or Customers? and do things that do not support caring?
■■ Paying quality attention: Focusing on quantity
There are two major types of consumers/customers improvement requires engagement of staff
in health care. Macro consumers are the major who understand how to participate in quality
purchasers of care: the government and insurers. improvement, but we are not yet clear on how
They pay for care, and therefore, are consumers we measure staff attention and impact it might
in that they have expectations of the product (the have on the patient. The skill of presence or
care delivered) and can influence that care. The mindfulness involves controlling attention.
micro consumer is the patient. Patient families This allows the persons (patient, family,
and significant others, when the patient agrees others) who are on the receiving end of the
that the family may have a role in the patient’s care care to feel like the center at that moment.
and/or decision-making process, are also micro The nurse is not distracted, and the patient
consumers. Patients are turning more to nurses connects; the result should be better quality
and asking questions about their health care and care that is focused on the patient.
the healthcare delivery process. In the past, nurses ■■ Reducing patient anxiety: This is a major part
knew little about reimbursement and the delivery of daily nursing practice in any setting. One
process, but today’s nurses need to be prepared to can view this goal differently from what might
answer patient questions or to direct patients to occur with typical customers. For example,
resources for answers. retail store sales staff want to make customers
Customer-centered health care means that the happy, but nurses and other healthcare staff
nurse must be more aware of customer/consumer/ want to reduce patient anxiety and support
patient needs, but this is not a simple process. them. Making patients feel happy is not a bad
Typically in retail and business, one thinks of the result, but it may not actually reduce anxiety
statement, “The customer is always right”; however, or provide support; may not be the critical
in health care, this may not always be the case. The outcome, but it is important.
patient may not have all the information necessary ■■ Your personal calling: Are you committed to
to make an informed decision and may require the improvement and caring, and how do you
expertise of healthcare professionals to meet his or demonstrate this in your practice?
her needs. Nurses need to find a balance—meeting
patient needs, including the patient, respecting the It is important to understand what patients want
patient’s opinion, and applying their professional and what they think their care outcomes should
nursing expertise. Leebov identifies customer service be. In the face of increasing out-of-pocket patient
goals that are important in the healthcare system expenses, patients are compelled to know more
and related to nursing (2008, pp. 21–23): about their needs and care and want to influence
■■ Caring with compassion: This is not an unusual care decisions. If one compares this to shopping for
concept for nurses; it is part of the traditional a product such as an automobile, the buyer (cus-
view of nursing. tomer) typically wants the best quality for the best
price. Consumers are expressing concerns about health plan decisions, ensuring health coverage for
the limits in their healthcare choices (for example, young adults, and protections under “grandfathered
employers offering fewer choices of health plans, plans.” If the Trump administration makes changes
offering plans with restricted or limited services, in reimbursement and healthcare delivery, these
or placing restrictions on provider use). Although rights may also change. The Centers for Medicare
healthcare consumers may have changed over the and Medicaid Services support these rights for its
years, quality of care and access to services remain beneficiaries (U.S. Department of Health and Human
important consumer issues. When managed care was Services & Centers for Medicare and Medicaid Ser-
the major approach used in healthcare reimburse- vices, 2017). Many national organizations (such as
ment, it actually became a stimulus for increasing the American Cancer Society, National Institutes of
consumer engagement with the healthcare system. Health clinical trials) provide their own bill of rights.
Consumers became more active in their complaints The Patient Self-Determination Act of 1990 is
about the changes made by managed care healthcare a law that significantly affects patient information
reimbursement. Over time, this had an impact on the and process and relates to patient rights. It applies
system, adjusting use of managed care strategies— to all healthcare organizations that receive Medicare
for example, consumers insisting on more patient or Medicaid reimbursement; thus, because few
choice in healthcare providers. Today we see increased healthcare organizations do not receive this form of
consumer activism as changes are considered in the reimbursement, this law applies to most healthcare
Affordable Care Act (ACA). organizations. It requires that all these organizations
or providers give their patients certain information
that relates to confidentiality; consent; the right to
Patient Rights make medical decisions, be informed about diagnosis
and treatment, and refuse treatment; and supports
Healthcare providers and many consumers com-
use of advance directives. As yet, no federal legis-
monly understand patient rights, but we do not have
lation has been passed that specifically addresses a
a clear statement of patient rights that is applied in
general statement of patients’ rights, although several
all situations (American Organization of Nurse
attempts have been made. Individual healthcare
Executives & National Alliance for Quality Care,
organizations publish a list of patient rights that are
2012). The American Hospital Association (2017)
shared with their patients and that staff are expected
first published a Patient Bill of Rights in the 1970s;
to follow. However, patient-centered care can best
it was updated in its “Patient Care Partnership”
be actualized with the patient–healthcare provider
brochure. The U.S. Congress has considered multiple
(nurse) relationship, and patient rights must be part
versions of national patient rights legislation, with
of this relationship.
none approved. The U.S. Advisory Commission
on Consumer Protection and Quality published
a version in 1998, which is often referenced. The Information Resources
ACA provides a new version in is provisions, which
and Consumers
focuses on rights to treatment and reimbursement
(FamiliesUSA, 2011). The rights noted are ensuring Today, technology provides easy access to informa-
coverage for people with preexisting conditions, tion not only for healthcare providers, but also for
ensuring the right to choose a doctor, ensuring the consumers. The chapter on informatics discusses
right to fair treatment of emergency care, making this trend in more detail, but it is mentioned in
sure insurance policies cannot be canceled unfairly, this chapter because healthcare informatics and
ending annual and lifetime limits, enhancing access technology also relate to patient-centered care.
to preventive services, ensuring the right to appeal Through the use of new technologies, providers
have multiple ways to communicate with current healthcare organizations, such as Press Ganey,
customers/consumers/patients, such as email, may assist in data collection and analysis. Patient
Internet, and cell phones, and extensive methods satisfaction data can be helpful, but this information
to collect, manage, and use healthcare information. must be viewed carefully and should be used as one
Patients use such information to self-manage their source of data to assist in assessment of quality care.
health and care, expanding their knowledge of Zimmerman identifies the following as examples of
self-care and wellness. They seek medical advice, myths related to satisfaction data that are important
learn about their treatment options, and obtain to consider, with additional comments provided
information about reimbursement. Patients also as to the validity of the myth (2001, pp. 255–256):
increasingly obtain information to help them ■■ Patient satisfaction is objective and straight-
evaluate providers (physicians, hospitals, and so forward. This is not true. Patient surveys
on), such as “report cards” about healthcare or- are difficult to develop, and they are often
ganizations and outcomes, which are now more poorly designed.
widely available to the public. ■■ Patient satisfaction is easily measured. Satis-
faction is complex and not easily measured.
Patient expectations influence the process,
Patient Satisfaction and many factors can affect patient responses
Kennedy comments, “When the subject of patient that are not always easy to identify.
satisfaction surveys is raised among RNs working ■■ Patient satisfaction is accurately and precisely
in hospitals, most will argue that the findings are measured. This is not possible at this time;
either inapplicable or skewed. They’ll say that attitudes are difficult to measure.
patients’ expectations of care are unrealistic and ■■ It is obvious who is the customer. A healthcare
not achievable. They’ll say that such surveys, organization actually has many different
especially follow-up surveys, don’t accurately re- types of customers—more than just patients.
flect the quality of care because they don’t ask the For example, families, physicians, insurers,
right questions and don’t take into account myriad and internal staff are also customers (staff
of other issues that might have affected patients’ within the organization become customers
experiences” (2015, p. 7). Nurses think that patients to other staff; for example, the laboratory
are often more concerned with issues that do not provides services to the units and thus nursing
really affect quality. Hospitals are focusing more on staff on the units are also the laboratory’s
patient ratings—but not necessarily in a positive customers).
way—mostly to make their overall ratings higher A complete customer satisfaction analysis
rather than care better. When hospitals receive should include multiple types of customers in the
low patient satisfaction scores, the response is healthcare organization. Exhibit 9-1 identifies
often to look for easy fixes and not really address examples of key consumer or patient tips to better
problems. Patient satisfaction is heavily associated ensure safe health care and outcomes and influence
with nurses and nursing care. What is patient sat- patient satisfaction.
isfaction, and how do we measure it effectively? Healthcare organizations are making more
Or can we measure it, and how does it relate to efforts to engage patients in their care and in quality
patient-centered care? improvement to implement strategies to improve the
Patient satisfaction is a critical topic in most patient’s healthcare experience. One method that
healthcare organizations. Hospitals expend a great healthcare organizations are using more to improve
deal of energy and monies to assess how patients patient satisfaction is structured hourly rounds.
feel about their services. Companies external to Nursing staff routinely go to patients every hour to
Exhibit 9-1 Consumer Tips for Safe Health Care
●● Ask questions if you have doubts or ●● Talk to your doctor about which hospital is
concerns. best for your health needs.
●● Keep and bring a list of all medications ●● Make sure you understand what will
you take. happen if you need surgery.
●● Get the results of any test or procedure.
Data from U.S. Department of Health and Human Services. Agency for Health Resources and Quality. (2014). Five
Steps for Safer Care. Patient Fact Sheet. Retrieved from https://archive.ahrq.gov/patients-consumers/care-planning
/errors/5steps/index.html
check on a variety of factors—for example, “pain one view. It is important to not assume that when
level, need for toileting or elimination, assessment of a healthcare provider has a positive view of care
the environment including temperature, proximity quality and patient satisfaction the patient will
of personal items, safety hazards, and positioning of agree. For example, patients receiving ambulatory
the patient or need to change the patient’s position” care usually express different views of quality than
(Brosey & March, 2015, p. 153). Hospitals that use do hospitalized patients. In examining the issues
this type of rounds find that patient satisfaction in this example, ambulatory care patients may be
is higher—patients do not have to ask for help as concerned with access to care, accessible and safe
much when staff assess routinely. This increases parking, wait time for appointments, amount of time
patient trust in staff to be there when the patient the provider spends with the patient, interaction
needs help. Another benefit of this rounding is to with the provider, response from office or clinic
prevent errors and improve patient outcomes—for staff, follow-up, access to information, or patient
example, identify a safety hazard in the room before outcomes while the healthcare provider in the clinic
a patient falls; assist the patient to the bathroom so may focus only on patient outcomes. Assumptions
that the patient does not get frustrated calling for should also not be made about what patients want
help and gets out of bed without assistance; ensure or who they want to know about their health care.
pain medication is given in the most effective time A hospitalized patient may have different views of
period to reduce patient pain level. quality, such as how many times the doctor visits
When it comes to quality of care, there is no clear them, noise level, food quality, staff routinely use
universal definition of quality of care. Patient-centered hand washing, getting pain medication when need,
care implies that not only is the patient the focus call light answered in a timely manner, sharing of
of care, but also is the focus of evaluation of that information, staff attitudes, whether they feel bet-
care. Patient-centered care implies a contract and ter or worse, and much more, and again hospital
partnership between the patient and all healthcare healthcare providers may focus on patient outcomes.
providers (individuals and organizations). This means Over time, a variety of data collection methods
we are required to include the patient in the assess- will undoubtedly emerge, but right now there are
ment of the care process and outcomes. A patient only a few reliable sources of data, such as Hospital
often sees quality of care and services differently Consumer Assessment of Healthcare Providers and
than a nurse or physician might view care quality. Systems (HCAHPS): “survey is the first national,
The insurer also has a different view—mostly from standardized, publicly reported survey of patients’
a cost perspective. This makes it difficult to analyze perspectives of hospital care. HCAHPS (pronounced
satisfaction data objectively—you get a snapshot of ‘H-caps’), also known as the CAHPS Hospital
Survey, is a survey instrument and data collection goal also indicates that providers throughout the
methodology for measuring patients’ perceptions healthcare system, including nurses, need to know
of their hospital experience. While many hospitals more about culture and its impact on healthcare
have collected information on patient satisfaction needs and delivery of care. The definition of patient-
for their own internal use, until HCAHPS there centered care includes culture as one of its elements.
was no national standard for collecting and publicly
reporting information about patient experience of Culture
care that allowed valid comparisons to be made across
hospitals locally, regionally and nationally” (U.S. Culture is “the accumulated store of shared values,
Department of Health and Human Services [HHS], ideas (attitudes, beliefs, values, and norms), under-
Centers for Medicare and Medicaid Services [CMS], & standings, symbols, material products, and practices
Hospital Consumer Assessment of Healthcare Pro- of a group of people” (IOM, 2003b, p. 522). Nurses
viders and Systems [HCAHPS], 2013). This survey view patients through their personal experiences
is an important resource for data about hospitals and with culture and their personal histories. This may
patients and includes 21 patient perspectives on care lead to problems, such as misinterpretation of com-
and patient rating items—for example, communication munication and behavior that result in limitations
with doctors, communication with nurses, respon- in planning and implementing patient-centered care
siveness of hospital staff, pain management, commu- that meets the patient’s needs. Culture and language
nication about medications, discharge information, may influence the following aspects of care (U.S.
cleanliness of the hospital environment, noise level Department of Health and Human Services [HHS] &
in the hospital environment, and transition of care The Office of Minority Health [OMH], 2008):
(HHS, CMS, & HCAHPS, 2017). Current information ■■ Health, healing, and wellness belief systems
about the survey is found on the HCAHPS website. ■■ Patient/consumer perception of causes of
illness and disease
■■ Patients/consumer behaviors and their atti-
Stop and Consider #2 tudes toward healthcare providers
A patient is a consumer.
■■ Provider perceptions and values
In the United States, the diversity of racial and
ethnic communities and linguistic groups is growing.
Culture, Diversity, Each of these subpopulations, with its own cultural
and Disparities in Health Care traits and health profiles, presents a challenge to the
healthcare delivery system and providers. The pro-
The growing diversity of patients also demands vider and the patient bring their individual learned
more patient-centered care. Diversity is a key driver patterns of language and culture to the healthcare
of change in healthcare delivery today. Along with experience, which in turn affects the care process
the changes in diversity is the grave concern about and may further increase healthcare disparities.
disparities in health care, with some populations Demographic data indicate that more nurses are
receiving different care than others; as noted by the caring for patients from different cultural, racial,
Quality Chasm reports on diversity, treatment is and ethnic backgrounds. In some areas, there are
all too often unequal (IOM, 2003a). Healthy People clusters of specific cultural populations, such as
2020 identifies four major goals for the health of U.S. Blacks, Hispanics/Latinos, Native Americans, and
citizens, one of which emphasizes cultural diversity: Asians. In 2015, data indicate the following about the
“Achieve health equity, eliminate disparities, and total U.S population: White 61%, Hispanic/Latino
improve the health of all groups” (HHS, 2010). This Americans 18%, Blacks 12%, Asian American 6%,
and American Indian/Alaska Native 1% (Kaiser (IOM, 2003b, pp. 3–4). The IOM examined two
Family Foundation, 2015, according to March 2016 issues when determining the existence of disparities
U.S. Census Bureau). Areas of the United States that in health care. The first is how the U.S. healthcare
typically have the highest diversity (in order of size) are system functions and which legal and regulatory
the South, the West, the Northeast, and the Midwest. The issues may make it difficult for patients to get equal
presence of such diversity requires greater emphasis on care. The second issue relates to discrimination at the
providing care that is respectful of, and responsive to, patient–provider level. Discrimination is defined as
the health beliefs, practices, and cultural and linguistic “differences in care that result from bias, prejudices,
needs of the various patient populations. stereotyping and uncertainty in clinical commu-
nication and decision-making” (IOM, 2002, p. 4).
Cultural Competence What are some of the key terms related to diversity?
■■ Bias: Predisposed to a point of view
Schools of nursing and healthcare organizations
■■ Ethnicity: Shared feeling of belonging to a
are working to improve students, faculty, and staff
group—peoplehood
cultural competence. This trend has been driven
■■ Ethnocentrism: Belief that one’s group or
by the Quality Chasm reports, which discuss the
culture is superior to others
presence of significant healthcare disparities in the
■■ Prejudice: Making assumptions or judg-
healthcare delivery system. Competence “implies
ments about the beliefs, behaviors, needs, and
having the capacity to function effectively as an
expectations of patients or other healthcare
individual and as an organization within the context
staff of a different cultural background than
of the cultural beliefs, behaviors, and needs presented
one’s own because of emotional beliefs about
by consumers and their communities” (Anderson,
the population; involves negative attitudes
Scrimshaw, Fullilove, Fielding, & N ormand, 2003,
toward the different group
pp. 68–69). There are three conceptual approaches
■■ Race: A biological designation of a group;
to cross-cultural education: (1) focus on attitudes
belonging to the group based on biological
(cultural sensitivity/awareness approach), (2) knowl-
factor(s)
edge (multicultural/categorical approach), and
■■ Stereotyping: A “process by which people
(3) skills (cross-cultural approach) (IOM, 2003b,
use social groups (such as sex and race) to
p. 19). Implementation of all three approaches is
gather, process, and recall information about
necessary for improvement. As discussed in other
other people . . . these are labels” (IOM, 2002,
chapters of this text, schools of nursing include
p. 475) (It is natural for people to organize
content on culture, diversity, and disparities to
information, and organizing information
ensure that pre-licensure and graduate students
about people is part of this. This process,
meet cultural competencies (National League for
however, can be negative if it involves un-
Nursing, 2016; American Association of Colleges
fairly classifying people or using incorrect
of Nursing [AACN], 2006, 2008, 2011).
information about an individual who may
or may not meet the characteristics.)
Disparities in Health Care
After the Quality Chasm report on healthcare
Disparities in health care are defined as “racial or disparities indicated there were problems in the
ethnic differences in the quality of healthcare that United States, it was recognized that it is necessary
are not due to access-related factors or clinical needs, to have more effective monitoring of diversity and
preferences, and appropriateness of intervention” disparities in health care. In 2001, the National
Healthcare Disparities Report was created. This ■■ Increase the reach and usefulness of the
annual report, which was later combined with the AHRQ’s family of report-related products.
National Quality Report, focused on five critical ■■ Revamp the presentation of the reports to tell
areas of measurement (IOM, 2002, p. 2): a more complete quality improvement story.
■■ Analyze and present data in ways that inform
■■ Socioeconomic status in disparities research
policy and promote best-in-class achievement
■■ Disparities in healthcare services and quality
for all actors.
■■ Disparities in healthcare access
■■ Identify measure and data needs to set a
■■ Geographic units in disparities research
research and data collection agenda.
■■ Subnational data sets
This is a good example of how an initiative such
Critical issues of socioeconomic status, service as the original recommendation for national mon-
and quality, and access, as well as geographic issues, itoring of healthcare quality and disparities can be
are covered in this annual report. Healthcare dispar- expanded and must be reviewed periodically to see
ities occur consistently across a variety of illnesses if the process needs to be improved. The first annual
and delivery services and are associated not with disparities report was completed in 2003, but now
specific types of illnesses but with a broad spectrum due to this review, subsequent annual reports are
of characteristics. combined with the annual quality report (National
In 2010, the AHRQ, which serves as the ad- Healthcare Quality and Disparities Report [QDR])—
ministrator for the national annual the healthcare recognizing that healthcare disparities have a major
quality and disparities report, asked the IOM to impact on quality care. The 2015 report’s content
review past national quality and disparity reports related to patient-centered care comments on the
and provide a vision to improve the annual reports. following (HHS & AHRQ, 2015b, p. 1).
A committee was formed, the Committee on Future
■■ Access to care has improved dramatically.
Directions for the National Healthcare Quality and
■■ Quality of care continues to improve, but
Disparities Reports, to address this task. Through
wide variation exists across the National
research and deliberations, the committee con-
Quality Strategy (NQS) priorities:
cluded that while the disparity reports alone will
■■Effective treatment measures indicate
not improve the quality of health care, the report
improvements in overall performance and
results assist in better understanding of issues to
reductions in disparities.
close the gap between current performance levels
■■Care coordination measures have
and recommended standards of care. The committee
lagged behind other priorities in overall
recommended that the AHRQ take the following
performance.
steps (HHS & AHRQ, 2010):
■■Patient safety, person-centered care, and
■■ Align the content of the reports with na- healthy living measures have improved
tionally recognized priority areas for quality overall, but many disparities remain.
improvement to help drive national action. ■■ Despite progress in some areas, disparities
■■ Select measures that reflect healthcare attri- related to race and socioeconomic status
butes or processes that are deemed to have persist among measures of access and all
the greatest impact on population health. NQS priorities.
■■ Affirm through the contents of the reports ■■ Improvements in access were led by sustained
that achieving equity is an essential part of reductions in the number of Americans
quality improvement. without health insurance and increases in
the number of Americans with a usual source The HHS developed a disparities action plan
of medical care. that focuses on reducing racial and ethnic health
■■ Care affordability measures are limited for disparities: “With the HHS Disparities Action Plan,
summarizing performance and disparities. the Department commits to continuously assessing
■■ Disparities in access tend to be more common the impact of all policies and programs on racial
than disparities in quality. and ethnic health disparities. It will promote inte-
The QDR is always a few years behind the current grated approaches, evidence-based programs and
year because it takes time to collect and analyze best practices to reduce these disparities. The HHS
the data. Action Plan builds on the strong foundation of the
The HHS publishes information on its web- Affordable Care Act and is aligned with programs
site about culture and health care. It describes and initiatives such as Healthy People 2020, the
health disparities as the persistent gaps between First Lady’s Let’s Move initiative, and the President’s
the health status of minorities and non-minorities National HIV/AIDS Strategy” (HHS & OMH,
in the United States (HHS, 2008). Health services 2016). The goals of the plan are to (1) transform
involve “providing care that does not vary in quality health care; (2) strengthen the nation’s health and
because of personal characteristics such as gender, human services infrastructure and workforce; and
ethnicity, geographic location and socioeconomic (3) advance the health, safety, and well-being of the
status” (IOM, 2001, p. 6). Despite ongoing advances American people, advance scientific knowledge and
in health care and technology, racial and ethnic innovation, and increase the efficiency, transparency,
minorities continue to experience more disease, and accountability of HHS programs. This is an
disability, and premature death than non-minorities. example of the connection between legislation (for
African Americans, Hispanics/Latinos, American example, ACA) and changes (the HHS Disparities
Indians and Alaska Natives, Asian Americans, Native Action Plan), but it may also be something that
Hawaiians, and Pacific Islanders have higher rates would change if there were changes in or repeal
of infant mortality, cardiovascular disease, diabetes, of legislation.
human immunodeficiency virus infection/acquired
immunodeficiency syndrome, and cancer, as well as
lower rates of immunizations and cancer screening.
Disparities: Examples
Two major factors influence these results: and Importance
■■ Inadequate access to care: Barriers to care can The QDR identifies some of the current major
result from economic, geographic, linguistic, quality and disparities issues. Data provided in the
cultural, and healthcare financing issues. 2015 report indicate that overall quality and access
■■ Substandard quality of care: Even when mi- are improving, but disparities related to race and
norities have similar levels of access to care, socioeconomic status continue to be a problem
health insurance, and education, the quality (HHS & AHRQ, 2015b). This report was completed
and intensity of health care they receive are prior to implementation of the first major changes
often poor. Lower-quality care has many causes, dictated by the ACA, which were initiated in late
including patient–provider miscommunica- 2013 and early 2014. These changes—particularly
tion, provider discrimination, stereotyping, the expansion of insurance coverage among the
and prejudice. Quality of care is now usually U.S. population—made some difference in reducing
rated using the IOM-recommended measures: disparities. The QDR correlates with Healthy People
safe, timely, effective, equitable, efficient, and 2020, the National Partnership for Action, and the
patient-centered (STEEEP). NQS to end health disparities.
It is not possible to totally eliminate disparities in in 2012 reported that ethnic and racial minori-
health care; however, much can be done to improve ties accounted for approximately 37% of the U.S.
care for all persons and better ensure equity in health population. In 2013, the National Council of State
care. Ensuring access is critical. Can patients get Boards of Nursing (NCSBN) and the Forum of State
the care they need from experts in a timely manner? Nursing Workforce Centers reported that only 19%
Access involves multiple factors, such as appoint- of all U.S. registered nurses (RNs) were members
ments, transportation to appointments, availability of an ethnic or racial minority (2013 data) (AACN,
of qualified staff, wait times, service hours, and 2015). Data from AACN also indicate that 48.4% of
so on. Disparity issues require that all healthcare White RNs complete nursing degrees beyond the
professionals actively consider patient values and associate degree level, but the number is significantly
preferences (a critical component of patient-centered higher or equivalent for minority nurses: African
care). These values and preferences can vary between American (52.5%), Hispanic (51.5%), and Asian
groups and within groups. It is easy to stereotype (75.6%) nurses. RNs from minority backgrounds
and assume that everyone in a specific ethnic group recognize the importance of higher levels of nursing
is the same, but this is not the case. Monitoring data education beyond the entry level.
on disparities is important to assist in identifying The AACN and the Robert Wood Johnson
current status and to develop and improve effective Foundation (RWJF) partnered together to launch
interventions to reach desired outcomes. an initiative entitled Doctoral Advancement in
Nursing. The project aims to attract more minority
students to PhD and DNP programs. These orga-
Diversity in the Healthcare nizations also support another joint initiative, the
Workforce RWJF New Careers in Nursing Scholarship Program,
which focuses on providing monies for minority
The Sullivan Commission report, which is discussed
students in accelerated programs. The Campaign
in other chapters, examined disparities in health care
for the Minority Nurse Faculty Scholars Program,
from a different perspective (Sullivan, 2004). This
co-sponsored by the AACN and Johnson & Johnson,
commission concluded that a key contributor to the
focuses on preparing minority nurses for faculty
growing healthcare disparity problem is disparities
roles (AACN, 2017). These are just a few of the
in the U.S. health professional workforce. This is one
initiatives that are directed at the ongoing shortage
factor that limits minorities’ access to health care and
of minority nurses and nursing faculty.
to healthcare providers who understand their needs.
The American Organization of Nurse Exec-
The commission suggested that there should be an
utives is an important organization for nurses in
increase in the number of minority health professionals.
leadership and management positions. This orga-
This recommendation came at a time when there was
nization’s principles include diversity: “the success
a shortage of nurses and other healthcare providers.
of nursing leadership is dependent on reflecting
There is a continuing need to increase minority
the diversity of the communities nurses serve . . .
admissions to nursing programs and retain minority
diversity is one of the essential building blocks
students. The federal government provides grants to
of a healthful practice/work environment,” and a
encourage schools of nursing to increase minority
belief that healthcare organizations should apply
enrollment, develop student support services, and
these principles (American Organization of Nurse
also increase minority enrollment in graduate school
Executives, 2011, pp. 1–2):
to increase the number of minority nursing faculty.
It will take time to improve the level of minority 1. Strive to develop internal and external resources
participation in nursing. The U.S. Census Bureau that support patient-centered care and meet
the needs of the diverse patient and workforce means that the nurse must know about the patient’s
populations served. values and preferences—for example, cultural issues
2. Establish a healthful practice/work environ- and how they might affect the patient. This should
ment that is reflective of diversity through lead to an improved collaborative relationship with
a commitment to inclusivity, tolerance, and the patient. Collaboration is working with others to
governance structures. arrive at the best outcome. When the nurse acts as
3. Partner with universities, schools of nursing, the patient advocate, the nurse remembers that the
and other organizations that educate healthcare patient must be involved. Advocacy does not mean
workers to support development and implemen- that the nurse makes the patient dependent on the
tation of policies, procedures, programs, and nurse. The nurse must also be persuasive with other
learning environments that foster recruitment healthcare team members to ensure better care for
and retention of a student population that reflects the patient that meets the patient’s needs to reach
the diversity of the United States. the desired outcomes. Advocacy means that the
4. Collect and disseminate diversity-related re- nurse respects the patient and the patient’s rights
sources and information. and ensures the patient has the necessary informa-
tion to understand treatment and care needs and
is informed about patient rights. Support is also
Stop and Consider #3 given to the patient and family. When the patient
We do not provide equal care in the United States. makes a treatment decision, the nurse does not
judge the patient’s decision, even though the nurse
may disagree with that decision.
Patient Advocacy
Patient advocacy has always been a major aspect As a nurse, you are a patient advocate.
of the nursing role, and effective advocacy requires
leadership skills. Nursing standards developed by
the American Nurses Association, nursing specialty
organizations, and healthcare organizations, as well Care Coordination:
as those developed by accrediting organizations A Plan of Care
and other healthcare professional organizations,
support advocacy and consumerism. Throughout Care coordination is recognized as an important
the care delivery process, nurses participate in and part of the care process. The purpose of care coor-
support actions that emphasize patient advocacy. dination is “to establish and support a continuous
The standards support patient and family education, healing relationship, enabled by an integrated clinical
patient satisfaction, the complaint process, efforts to environment and characterized by a proactive delivery
improve care, and increasing patient participation of evidence-based care and follow-up” (IOM, 2003a,
in healthcare decision making. p. 49). To accomplish this, healthcare providers, in-
As each nurse provides care, he or she has cluding nurses, need to provide patient-centered care.
numerous opportunities to serve as the patient’s The goal is care coordinated across people, functions,
advocate. The nurse coordinates care and, in doing activities, and sites (including the community and
so, represents the patient, but the nurse needs to home) so that the patient receives effective care. A
recognize the patient’s values and preferences in this critical issue today is the need to improve interpro-
process, thereby supporting patient-centered care. This fessional teamwork in the care planning process for
patients, and care coordination is a part of effective important to recognize in this chapter that the
teamwork and quality care. This particular content processes of critical thinking and clinical reasoning
is discussed in other chapters. and judgment relate to planning, implementing, and
The NQS includes care coordination in its pri- evaluating patient-centered care. Critical thinking
orities: Promote communication and coordination and clinical reasoning and judgment should be used
of care. As a result of this inclusion in NQS, care throughout the nursing process. These competencies
coordination is now monitored in the QDR, focused are important to effective nursing practice, but it
on three long-term goals (HHS & AHRQ, 2016c, p. 2): takes time and experience to develop them and to
1. Improve the quality of care transitions and use them effectively.
communications across care settings.
2. Improve the quality of life for patients with Nursing Process
chronic illness and disability by following a
The nursing process is a systematic method for
current care plan that anticipates and addresses
thinking about and communicating how nurses
pain and symptom management, psychosocial
provide patient care. It is a step-by-step tool that
needs, and functional status.
guides nurses as they plan and provide care in a
3. Establish shared accountability and integra-
variety of clinical settings. Students are asked to
tion of communities and healthcare systems
use this process often by developing extensive care
to improve quality of care and reduce health
plans for patients and applying critical thinking
disparities.
and clinical reasoning and judgment. As students
These goals are also important for healthcare or- become RNs and move into practice, this process
ganizations and nurses who want to improve care is adapted for daily use with multiple patients. The
coordination for all patients. The measures that nursing process is similar to the problem-solving
are used to determine care coordination typically process in that there is a concern that requires more
focus on transitions of care, preventable emergency information to determine the best approach to solve
department visits, potentially avoidable hospitaliza- it. In the nursing process, there are five steps, as
tions, integration of medication information, and described in Figure 9-3.
use of electronic medical records (HHS & AHRQ,
2016c, p. 3).

1. Assessment
Patient-centered care requires care coordination.
2. Diagnosis
Application of Critical Re-evaluation

Thinking and Clinical Reasoning 3. Planning
and Judgment
4. Implementation
For a long time, nurse educators have included
critical thinking in curricula; however, the content 5. Evaluation
itself and the means by which it is taught need to be
revised to include clinical reasoning and j udgment,
as discussed in other chapters in this text. It is Figure 9-3 Nursing Care Process
Assessment have been more successful than others in controlling

unnecessary repetition.
Information or data about the patient is required
It is important during assessment to communi-
to describe the patient’s health status and needs.
cate to patients that they are the center of concern.
This information is collected during assessment
Achieving this goal requires attention on the part of
by multiple methods, such as a description of the
the nurse. Patient rights—for example, maintaining
patient’s health history, interviews, observation,
privacy during the assessment, ensuring confiden-
physical examination, and review of medical records.
tiality of information obtained, and explaining to
The nursing process is not linear; it is ongoing,
the patient the process and the patient’s rights—are
and one step leads to the next step and then the
also important.
process begins again. Assessment is the initial step
in the process; however, assessment is also ongoing
Diagnosis
because a patient’s health status and needs change,
which may require a change in diagnosis, in plan, Diagnosis occurs as the nurse analyzes and interprets
and in how a plan is implemented. This also affects the information/data to determine the patient’s nursing
outcomes and evaluation. During assessment, the problems and needs—actual and potential. Nursing
nurse must evaluate the quality of the information diagnoses have been identified and categorized
to determine if additional information is needed through a system referred to as the North American
and the best method to obtain the information. It Nursing Diagnosis Association (2017). Patient prob-
is during this step that the nurse begins to establish lems and needs change throughout the care process
the nurse–patient relationship. and thus lead to changes in the plan.
Patient-centered care means that the patient’s
values, preferences, needs, culture, and history are Planning
important factors to consider in the care plan. The The care plan directs the care that will be given, pro-
nurse needs to document the assessment in a man- motes communication and sharing of information,
ner that is clear and informs other staff. In today’s and provides a record of the plan. The plan identifies
healthcare settings, interprofessional teams typically the interventions or actions that the nurse may
deliver more effective care. This means that the nurs- take to manage or resolve problems, monitor the
ing plan of care should not be separate from other patient, decrease risks of injury or illness, promote
aspects of the patient’s care needs. The team needs to health or prevent injury or illness, support patient
consider all aspects of care and collaborate. A patient self-management, and provide patient-centered
plan of care rather than a plan focused on a specific care. Interventions may be direct or indirect care.
profession’s plan of care, such as the nursing care plan Examples of direct care are administering medica-
or medical care plan, is more effective. Regardless tion, helping the patient get out of bed, changing
of the focus, the care planning process is the same. a dressing, teaching the patient, and assessing or
Patients often complain that many staff from monitoring patient status—all interventions or
different healthcare disciplines or the same staff actions that include the patient and the nurse.
members ask them the same questions. Some health- Examples of indirect care are documenting in the
care organizations are trying to address this problem medical record; preparing medications; giving a
by eliminating repetition in assessment forms—for report to other staff on a patient’s status; talking to
example, making sure that the assessment forms the physician about the patient; reviewing medical
physicians use and the nursing assessment forms orders; and delegating care to unlicensed assistive
are not repetitive unless a sufficient rationale exists personnel, such as explaining what needs to be done
for the repetition. Some healthcare organizations for the patient during daily care—all interventions or
actions in which the patient is not directly involved should be included in decision making. It is possible
in the process. Classification of nursing care and that as the plan is implemented, the patient’s status
interventions includes the following categories: might change, or perhaps an intervention might not
(1) dependent care—most nurses cannot legally be effective. Many factors affect implementation,
prescribe medications or act without a physician such as the nurse’s competency, the strategy used
order (after the physician orders the medical infor delegation, staffing levels, acuity levels of all the
tervention, the nurse follows the orders unless the patients whom the nurse is caring for at the time,
nurse assesses the situation and determines the availability of supplies and resources, the number
physician needs to be consulted before implementing of interruptions, the needs of the patient’s family,
the orders); (2) independent care—the nurse may patient cooperation and acceptance of the plan,
make decisions about use of nursing interventions time management and priorities, and much more.
to prevent, reduce, or alleviate a problem; and Throughout the implementation step, it is critical
(3) interdependent care—includes care in which that the nurse coordinates, collaborates, and com-
both the nurse and the physician collaborate. State municates with the interprofessional team and other
nurse practice acts identify the types of care that are nursing staff. Delegation is part of implementation,
independent, dependent, and interdependent within which is discussed in content about teams.
each state. There is now greater interest in using
interprofessional care plans; in such cases, nursing Evaluation
plans would be part of the treatment team’s plan. Evaluation focuses on each of the nursing care
Planning takes time and must be connected to process steps. The following questions are asked
assessment data and diagnoses/problems identified (the applicable nursing process step or steps follow
for the patient. The patient needs to be part of the each question in parentheses):
planning and the identification of care needs, which ■■ Was the assessment adequate? (assessment)
should include an explanation of the care plan. This ■■ Are there changes in the patient’s status that
approach supports patient-centered care. The final de- require attention? (assessment)
cision about treatment is really up to the patient, unless ■■ Are there new diagnoses/problems? Incorrect
the patient is not physically able to make decisions. identification of problem(s)? (diagnosis)
The plan identifies interventions, responsibility ■■ What are the outcomes for the identified
for implementing interventions, a timeline, and ex- nursing diagnoses/problems? (diagnosis,
pected outcomes, and the plan should be based on evaluation)
best evidence. Outcomes are particularly important ■■ Were the interventions completed, and what
in evaluation. Some schools of nursing and some were the outcomes? (planning, implementa-
hospitals may use standardized nursing intervention, evaluation)
tions and outcomes. The common source for this is ■■ Are new interventions required? (planning,
the Nursing Intervention Classification (University implementation, evaluation)
of Iowa, College of Nursing, Center for Nursing
Reevaluation takes place throughout the process
Classification and Clinical Effectiveness, 2017).
as the patient’s health status changes. This may
require that the nurse return to a previous step in
Implementation the nursing process.
The plan is developed so that the patient can receive Getting patients involved in their own care
the care required, which is achieved through im- can be challenging. Most patients want to be in-
plementation of the plan. Change may be required volved, and nurses must use strategies to support
at any time during this process, and the patient patient-centered care. It is important to be aware of
Exhibit 9-2 Strategies to Help Healthcare Providers Encourage

Patient Participation in the Critical Thinking/Clinical Reasoning
and Judgment Process
●● Stay in the room. Don’t talk to patients ●● Use phrases that let the patient know that
from the doorway. the patient’s situation is not so unusual that
●● Pay attention to your body language and the patient cannot discuss it. For example,
to the patient’s body language. “Some people feel anxious when . . .”
●● Sit down so that you are at eye level with ●● Address patients respectfully. Find
the patient. out if they prefer Mr. or Mrs., Doctor,
●● Use open questions and comments such Professor, Reverend, and so on. Do not use
as “Tell me about . . .” instead of closed affectionate terms to address the patient,
questions that imply you expect a short such as “sweetheart,” “dear,” and so on.
answer. ●● Do not look at your watch, no matter how
●● Touch patients, but be respectful of their busy you are.
space and cultural norms. ●● Be direct and honest. For example, tell
●● Use collaborative thinking language, such patients when the schedule is backed up
as “We should think this through,” “Let’s and why.
look at some possible conclusions,” and ●● If you feel like avoiding a patient, reflect on
“Can we analyze this together?” why you feel that way.
Reproduced from Rubenfeld, M., & Scheffer, B. (2015). Critical thinking tactics for nurses. Burlington, MA: Jones &
Bartlett Learning.
your attitude and tone of voice when you speak with been used for a long time; however, it has been
adult patients. Some nurses approach all patients the subject of some criticism. Its length is an issue,
as if they were children, which is not helpful in particularly with students. This approach may also
engaging adult patients in their care. For example, limit student critical thinking and clinical reasoning,
when patients are recovering from anesthesia, the and judgment because of its rigid format. Another
nurse speaks to the patient in “baby tones”; this is approach to care planning is the concept/care map,
not appropriate. defined by Schuster as follows: “The concept map
Exhibit 9-2 provides some examples of strategies care plan is an innovative approach to planning
to help encourage patient participation in the critical and organizing nursing care. In essence, a concept
thinking/clinical reasoning and judgment process. A map care plan is a diagram of patient problems and
new concern today is use of electronic devices with interventions. Your ideas (concepts) about patient
patients—the staff member may be documenting problems and treatments are the ‘concept’ that will be
in the computer and not paying attention to the diagrammed” (2007, p. 2). Using concept mapping
patient, missing important observations and acting for care plans develops your critical thinking and
as a barrier to patient-centered care. clinical reasoning. Follow these steps to develop a
concept map plan:
Care/Concept Mapping ■■ Develop the basic skeleton diagram. Begin with
The traditional format for the nursing care plan, the patient’s reason for care (often the medical
which focuses on the five steps just outlined, has diagnosis), putting it in the center of the page
or diagram. Around this central point, identify

general problems (nursing problems). This Self-Management of Care
represents the first concept map.
Regardless of whether healthcare providers accept
■■ Analyze and categorize data. In this step, the
it, patients are very active in managing their own
focus is on the information (assessment data)
care, as discussed in public/community health con-
that is known; categorization provides evidence
tent. Even if they choose not to receive health care,
for the medical and nursing diagnoses. The
they have made a decision about their health and
information is obtained from history, assess-
what they want to do about it. In some cases, the
ment, medical records, and interviews with the
patient is pushed into greater personal responsi-
patient. This information is added to the care
bility for care; for example, the patient may have
map—problems/diagnoses with related data.
inadequate reimbursement or no reimbursement
■■ Analyze nursing diagnoses relationships.
at all or may not have support from family and
Using the data map with the problems and
others. It is recognized that critical strategies in
related data assists in making connections by
preventing health problems and reducing healthcare
analyzing relationships among the diagnoses,
costs are self-management, health promotion, and
drawing lines to identify the relationships,
disease and illness prevention. When patients use
and numbering each problem/diagnosis. The
self-management effectively and are supported by
goal is to achieve a holistic view of the patient.
healthcare providers to use it, the outcomes are
■■ Identify goals, outcomes, and interventions.
(1) greater collaboration with healthcare providers,
On a separate page, identify the patient’s goals
(2) better understanding of treatment choices and
and outcomes. Next, identify interventions
patient and healthcare provider responsibilities,
to meet these goals and outcomes for each
and (3) improved follow-up to treatment. Patients
of the problems/diagnoses numbered on the
who are involved in their healthcare decisions are
care map. This step is similar to the planning
more satisfied with their health care and health
process in the nursing care process.
status. Self-management of care is “the systematic
■■ Evaluate the patient’s responses. On the page
provision of education and supportive interven-
with the goals, outcomes, and interventions
tions to increase patients’ skills and confidence in
for each of the problems, add the patient’s
managing their health problems, including regular
outcomes to each intervention after it has
assessment of progress and problems, goal setting,
been implemented and evaluated. This in-
and problem-solving approach” (IOM, 2003b, p. 52).
formation is then used in documentation.
The Institute for Health Improvement website pro-
When using a concept map, you create a diagram vides many self-management resources for healthcare
describing the care and can add to it as needed. This providers and organizations to assist patients who
document is similar to the traditional nursing care might use self-management.
plan format in that all the components of care are
included. The concept map, however, allows for more
creative thinking as you create a visual depiction of
Health Literacy: A Barrier
the patient’s status, care needs, and the plan for care. Health literacy is important to effective self-
It also may serve as student study tool. management and for healthcare in general as noted
in other chapters, as well as to reducing healthcare
disparities (IOM, 2004). Nearly 90 million Americans
The nursing process guides nursing practice.
(almost half of all adults) have difficulty understanding
and using health information. This serious problem
has increased the rate of hospitalizations and the use access services in healthcare organizations, offers a
of emergency services, and it increases healthcare practical and basic step-by-step approach to imple-
costs. If a patient cannot understand directions menting language services (HHS & OMH, 2005).
or does not follow recommended directions, the In 2011, the AHRQ announced that low health
patient may need more intensive care, including literacy in older Americans is linked to poorer health
hospitalization. A patient who does not understand status and a higher risk of death, more emergency
the diabetic diet or know how to use insulin cor- room visits, and more hospitalizations. The agency
rectly will have more health problems; that person noted that more than 75 million English-speaking
may then seek out help in the emergency room and adults in the United States have limited health
consequently need to be hospitalized. literacy. In 2016, the AHRQ published the second
Healthcare literacy includes reading, writing, edition of its Health literacy universal precautions
and arithmetic skills; listening and speaking abil- toolkit; its goals are (HHS & AHRQ, 2016):
ities; and conceptual knowledge—how patients ■■ Simplify communication with and confirm-
get information, analyze it, and then understand
ing comprehension for all patients so that the
it so they can use it. Even educated people can
risk of miscommunication is minimized.
find themselves with a health literacy problem and ■■ Make the office environment and healthcare
not understand medical information. The Joint
system easier to navigate.
Commission (2008) notes that communication ■■ Support patients’ efforts to improve their
problems are the most common root cause of
health.
healthcare errors. Safety and errors are discussed
in more detail in other content in this text, but it The toolkit offers a variety of resources that can be
is important in this discussion to recognize the used by healthcare providers and organizations. To
connection between patient-centered care and improve health literacy jargon needs to be reduced and
healthcare literacy, self-management, and errors. information needs to be provided in easy-to-understand
With the increase in the number of patients written information, clear forms, and straightforward
from diverse backgrounds, healthcare organizations information on websites. Verbal communication with
are seeking more language interpreters, particularly all patients also needs to improve.
those who speak Spanish, but also other languages. Nurses are in direct contact with patients daily
Families are not the best interpreters because they and encounter many patients who are experiencing
are not trained in medical terminology and they may health literacy problems. This has an impact on how
influence the communication and decision-making effective nurses can be in providing care; assisting
processes due to their personal connection to the patients with self-management of their care; and
patient. An interpreter interprets only the language teaching patients what they need to understand about
or words and is not involved in how the patient their health, illness, and care needs. Nurses should
should respond. Some healthcare organizations be involved in healthcare organization efforts to
have bilingual staff that can be a useful source of address health literacy throughout the organization.
interpreting services if they are easily accessible and
still able to complete their usual work. Patient/Family Education:
The HHS Office of Minority Health offers a
Inclusion in the Plan of Care
guide to help healthcare organizations implement
effective language access services and improve care Patient and family education has long been a part
for patients with limited English skills. This report, of nursing, but it is not easy to provide such educa-
A patient-centered guide to implementing language tion effectively. If we expect patients to be engaged
in their care, then they need to be prepared to do Given the realities of the healthcare workplace
this. One can look at patient education from two today, it is difficult to plan and implement education
perspectives: (1) helping the patient understand the for patients and their families. This can be very frus-
illness experience and how to cope with it effectively trating for both the nurse and the patient. Patients
and (2) providing information and direction for are discharged earlier today, but they are often still
self-management of care. sick. While in the hospital, they may not be able to
One of the major nursing interventions is concentrate on what they need to learn, and then
patient education. It is not an intervention that the they are sent home and feel at a loss. Home care is
nurse can delegate unless the learning need is best one solution, but most home care is not provided
addressed by another healthcare professional—RNs around the clock, and patients still need to know
cannot delegate patient education to non-RN nursing about their illness or injury and treatment. Home
staff such as a licensed practical nurse or a nursing health nurses provide patient education, but patient
assistant. It is not easy to provide effective patient education needs to be provided in the hospital as
education. The barriers to meeting patient education well—and not all patients receive homecare services.
needs may include the following: Caregivers need a lot of information and support,
but also we need more guidance for nurses who
■■ Inadequate assessment of the patient’s ed- work in home care, an expanding area of practice
ucation needs (Marrelli, 2016).
■■ Inadequate patient education plan When nurses are rushed, the typical scenario is
■■ Impact of patient factors such as medical to hand the patient and/or family written informa-
status, cognitive status, and language tion. The nurse may ask if there are questions. This
■■ Lack of time to provide the education required is not effective patient education. Effective education
■■ Interruptions that limit concentration includes the patient in the entire process, a process
■■ Medical status of the patient (inability of the that includes the following:
patient to adequately participate)
■■ Unclear assessment of the role of the family/ ■■ The nurse assesses the patient’s education
significant others (whether the patient wants status and needs. What does the patient need
the family to participate in the education as to know? How much does the patient know?
this is the patient’s decision) ■■ The nurse identifies (diagnosis) learning
■■ Patient education in settings such as am- needs. For example, the patient may need
bulatory care typically not reimbursed; less to know how to administer insulin and how
emphasis placed on education as a result (not to plan a diet.
reimbursed in acute care either but there is ■■ The nurse develops a patient education plan
more emphasis placed on it, mostly to get with specific interventions. These interventions
the patient ready for discharge) are based on expected outcomes. The nurse
■■ Confusion regarding who is responsible for identifies who is responsible for providing
patient education the learning intervention and creates the
■■ Lack of effective learning strategies and tools timeline. Here, the nurse must consider the
to meet individual patient education needs patient’s values and preferences, age, family
■■ Lack of nursing staff (nurses view other as- support, religion, cultural background and
pects of their job nursing as more important) issues, and health literacy. For example, the
■■ Lack of follow-up and evaluation of patient nurse teaches the diabetic patient about
outcomes related to the education provided equipment and where to get it; how to draw
up insulin, including checking dosage and For nursing care to be patient centered, with each
so on; how to prepare the skin; and how to patient developing effective self-management for their
administer the medication. The nurse talks health and care needs, the patient needs information
with the patient about complications and and skills to meet his or her individual needs.
aftercare needs and how to track insulin
administered and store insulin. The nurse
plans several sessions with the patient and Stop and Consider #7
uses a variety of teaching–learning strategies, Effective self-management requires health literacy.
such as discussion, visual aids, equipment,
demonstration, and return demonstration;
today, more technology is used so that
patients can easily access information. The Therapeutic Use
family is included as appropriate and with of Self in the Nurse–Patient
permission of the patient. The patient needs Relationship
time to ask questions and express concerns.
Rushing patient education is the greatest When you are a nurse and begin to care for pa-
barrier to its success. tients, eventually you realize that the relationship
■■ The nurse implements the plan. Typically, is different from other relationships that you have
this responsibility is not delegated unless experienced. It is not a parent–child relationship, a
assigned to another RN. Many of the barriers teacher–student relationship, or a personal or friend
mentioned earlier come into play when im- relationship. As you progress in the nursing program
plementing the plan. It takes planned effort and then become an RN, this difference becomes
to make sure the patient gets the education even more evident. In the beginning, students often
that is needed at the proper time. try to make the nurse–patient relationship into
■■ The nurse evaluates the plan/interventions something it is not (for example, in many cases, the
and documents. Were the expected outcomes student tries to be friends with the patient). The key
met? This should not be done in a threat- difference between the nurse–patient relationship
ening way, as if it was a test. Evaluation is and a friendship is that in a friendship, there is an
commonly a weak link in the process, often expectation, on both sides, that friends will help
because the patient goes on to another each other, listen to each other, and be there for
healthcare setting or home. It is important, each other. This is not the case in a nurse–patient
whenever possible, to assess outcomes, such relationship. There should not be any expectation
as through questions, return demonstrations, that the patient will listen to the nurse’s concerns,
teach-back (the nurse asks the patient to feelings, or problems, nor is the patient there to
repeat information included in the patient support the nurse. The nurse is expected to listen
education experience), and so on, and also to to the patient, work with the patient (even if the
ask the patient how he or she feels about the nurse does not really like the patient), and meet the
process and outcomes. Often, however, the patient’s care needs. This is difficult to learn, but it
patient is discharged, preventing complete does come with experience.
evaluation of patient education. In some The nurse–patient relationship has been
situations, the patient may be called after described as therapeutic. Therapeutic means
discharge, but this should be done only with treatment. Using this term to describe this special
the patient’s permission. relationship emphasizes that this relationship is
part of the care process. Therapeutic use of self, a about boundaries in the nurse–patient relation-
concept that was developed in the past to describe ship. A professional boundary is an invisible line
the nurse–patient relationship, “requires the nurse that provides limits to a nurse’s behavior and fo-
to use his/her personality consciously and in full cuses professional nurse–patient behavior so that
awareness in an attempt to establish relatedness and the patient is the center. The patient expects that
to structure nursing intervention. . . . This requires the nurse will act for the patient and respect his
self-insight, self-understanding, an understanding or her values and preferences. There should be no
of the dynamics of human behavior, ability to in- personal gain for the nurse. The NCSBN identifies
terpret one’s own behavior, as well as the behavior the guiding principles with additional comments
of others, and the ability to intervene effectively in added (2014, p. 6):
nursing situations” (Travelbee, 1971, p. 19). The
importance of this relationship should not be min- ■■ The nurse’s responsibility is to delineate and
imized. Parker notes that “Professional successes, maintain boundaries. (It is not the patient’s
especially at the bedside, are most often measured responsibility to know the boundaries or
objectively through such sources as patient outcome enforce them.)
data, length of stay, response to treatment, patient ■■ The nurse should work within the zone of
satisfaction, and the like. But other measurements, helpfulness. (The zone of helpfulness falls be-
which are often therapeutic but less tangible, cannot tween under involvement or over involvement
be discounted as measures of success. These patient with the patient. The most common boundary
outcomes may take the form of relief in a troubled issue involves over involvement.)
countenance, tears of joy, or a peaceful, pain-free ■■ The nurse should examine any boundary
sleep” (2006, p. 28). crossing, be aware of its potential implications,
In this relationship, the patient expects the nurse and avoid repeated crossings. (For example,
to be competent and have expertise in nursing care. if a patient offers the nurse a gift, the nurse
There is no such expectation of the patient. The nurse should not accept the gift. The nurse should
plans and initiates care for the patient with the patient. analyze the situation and may consider dis-
The center of the nurse–patient relationship is the cussing this situation with a supervisor, mentor,
patient. Even when a patient asks about the nurse’s or colleague to get feedback and assistance in
personal reactions, the patient is still more focused best response.)
on self. Through the nurse–patient relationship, the ■■ Variables such as the care setting, commu-
patient is given support and guidance in coping nity influences, patient needs, and nature of
with the illness experience and/or health wellness therapy affect the delineation of boundaries.
process. Patients with acute illness recover, but they (For example, patients in mental health set-
still need help with coping during their illness, and tings are particularly vulnerable to boundary
they may need time to reflect on their illness after issues, and nurses have to be clear about the
recovery. As has been discussed, more and more boundaries.)
people have chronic illnesses that are not resolved. ■■ Actions that overstep established boundaries
These patients need to receive support and learn to meet the needs of the nurse are bound-
coping skills that can help them during the ups and ary violations. (For example, the nurse does
downs of their illness process, and the therapeutic not describe his or her personal problems to
relationships supports this process. patients, does not accept money or individual
The National Council of State Boards of gifts from patients, and does not give money
Nursing (NCSBN, 2014) identifies key information or gifts to patients.)
The nurse should avoid situations where ■■ Engaging in behaviors that could reasonably
the nurse has a personal or business rela- be interpreted as flirting
tionship, as well as a professional one. (For ■■ Believing you are the only one who truly
example, the nurse should not date a patient, understands or can help the patient
develop a friendship outside the nurse–patient ■■ Spending more time than is necessary with
relationship, or have a business transaction a particular patient
with a patient.) ■■ Speaking poorly about colleagues or your
■■ Post-termination relationships are complex employer with the patient and/or family
because the patient may need additional ■■ Meeting a patient in settings besides those
services and it may be difficult to determine used to provide direct patient care or when
when the nurse–patient relationship is truly you are not at work
terminated. (Post-care personal relationships All nurses need to watch for these situations of
with patients are not recommended.) potential boundary violations and respond to them
Figure 9-4 illustrates a continuum of professional by altering communication and behavior.
behavior described in the NCSBN guide (2014). Communication is a critical component of the
How does a nurse know that there may be a nurse–patient relationship. The nurse needs to be
boundary violation with a patient (NCSBN, 2014, p. 9)? clear and consistent with the patient and provide
■■ Discussing intimate or personal issues with explanations about the care. Both verbal and non-
a patient verbal communication are integrated throughout
the communication process. Nurses need to be
aware of their own communication patterns and
UNDER- THERAPEUTIC OVER-
nonverbal messages, as well as those of the patient
INVOLVED RELATIONSHIP INVOLVED and people around the patient (family, friends, and
other members of the healthcare team). Exhibit 9-3
identifies some examples of therapeutic communi-
cation responses.
Exhibit 9-4 identifies examples of validation
Figure 9-4 Continuum of Professional Behavior remarks that promote patient participation in
Exhibit 9-3 Therapeutic Communication Responses
●● Using silence ●● Reflecting

●● Accepting others for who they are ●● Focusing
●● Giving recognition ●● Exploring more fully
●● Offering self ●● Seeking clarification
●● Using broad openings ●● Presenting reality
●● Offering general leads ●● Voicing doubt
●● Placing an event in time or sequence ●● Verbalizing the implied, then asking for
●● Making observations validation
●● Encouraging description or perceptions ●● Attempting to translate words into feelings
●● Encouraging comparison ●● Formulating a verbal contract
●● Restating ●● Assessing, evaluating with the patient
Exhibit 9-4 Validation Remarks to Promote Patient

Participation in Decisions
●● Here’s what I think; do you agree? ●● Let me explain my thinking to you.

●● What would you say is going on here? ●● What do you think?
●● How is all of this affecting you? ●● Does this feel okay?
●● Does it seem that way to you? It does ●● Do you agree with this?
to me. ●● This is what I’m thinking; what do you think?
●● Let’s think about this together for a minute. ●● I’m interested in your take on all of this.
●● Only you know your daily living situation, so ●● If you could change this, what would be
how do you think it might affect the care different?
plan after you are discharged? ●● If you had a magic wand, what would you
●● Can we find a way through this together? have it do?
Reproduced from Rubenfeld, M., & Scheffer, B. (2015). Critical thinking tactics for nurses. Burlington, MA: Jones &
Bartlett Learning.
decisions. These communication examples illustrate ■■ Poor communication with doctors and nurses
how communication, the nurse–patient relationship, in hospitals
and patient-centered care are interrelated. ■■ Provider–patient communication among
The AHRQ data on person- and family-centered adults receiving home health care, by language
care include communication with providers. In the and by race/ethnicity
2017 review of the QDR data, the AHRQ reported ■■ Providers asking patients to assist in making
that poor communication between adult patients treatment decisions, by insurance, education,
and healthcare providers decreased significantly for number of chronic conditions, and ethnicity
all ethnic groups from 2002–2013 (HHS & AHRQ,
2017). The measures used to collect the data are:
■■ Poor communication with adult and child A nurse is not a patient’s friend.
healthcare providers in offices/clinics
CHAPTER HIGHLIGHTS
1. The competency—provide patient-centered 2. Four rules underpin patient-centered care:

care—refers to considering the patient’s (1) care is based on continuous health
needs, cultural values, preferences, and relationships, (2) care customization is
unique situation instead of centering on based on patient needs and preferences,
the provider’s prospective. (3) patients are the source of control, and
(Continues)
(4) there is shared knowledge and free flow 11. Care coordination is an important part of
of information. high-quality, patient-centered care, but it
3. Patients who are involved in their care have is an aspect of care that is not generally
better outcomes. reimbursable. Effective interprofessional
4. Examples of four nursing theories related to teamwork includes coordination.
patient-centered care are Watson’s theory on 12. Clinical reasoning and judgment is differ-
caring, Orem’s self-care theory, Leininger’s ent from critical thinking. It focuses on
cultural diversity theory, and Peplau’s in- putting the care needs within the context
terpersonal relations theory. that the patient presents—environment,
5. Macro consumers of health care are gov- values, and preferences—as gathered in
ernment and insurers. the assessment.
6. Micro consumers of health care are the 13. The nursing process is a systematic method
patient and family. for thinking about and communicating how
7. Patient satisfaction is a key factor that many nurses provide patient care.
healthcare institutions measure as a part of 14. A concept map care plan is a diagram of
their delivery of care, although it is difficult patient problems and interventions that
to effectively quantify satisfaction. offers a more interactive plan than the
8. The health disparities problem includes traditional care plan.
issues related to access to care, level of care, 15. Healthcare literacy includes reading, writing,
and equality of care across races and ethnic and arithmetic skills; listening and speaking
groups. ability; and conceptual knowledge. Lack of
9. Strategies to overcome disparities include healthcare literacy can present a barrier to
addressing access-to-care issues—such as care because patients may not understand
wait times, appointment availability, and aspects of their care.
hours of service—to better meet the needs 16. Nurses provide patient and family education
of the population served. Another strategy to allow patients to more actively partici-
is to include patient values and preferences pate in their care and care decisions and
in the delivery of care. to encourage effective self-management of
10. Patient advocacy means the nurse is active health and illness.
in respecting patient rights and ensuring 17. A professional boundary is an invisible
that the patient has the knowledge nec- line that places limits on a nurse’s behavior.
essary to understand his or her treatment 18. Effective communication is an important
and care needs. component of patient-centered care.
1. What does patient-centered care mean, 5. Describe healthcare disparity and its
and why is it relevant to nursing? importance.
2. Describe a nursing theory that relates to 6. What is health literacy?
patient-centered care. 7. Why is patient advocacy important?
3. How is diversity related to patient-centered 8. What is self-management of care?
care? 9. Discuss the importance of patient education.
4. Explain consumerism in health care and its
relevance to nursing.
1. The National Healthcare Quality and Dis- 3. Review the material on health literacy found
parities Report monitors our health care at the following site: http://nnlm.gov/outreach
(https://www.ahrq.gov/research/findings /consumer/hlthlit.html. In a team discussion,
/nhqrdr/index.html). Go to the site. What consider the identified vulnerable popula-
can you learn about current disparities in tions and their relevance to health literacy.
health care? What measurements are used? 4. Visit The Joint Commission website to
2. Watch an episode of a favorite TV show, review the report on diversity in hospitals
including the commercials. This program (http://www.jointcommission.org/assets/1/6
does not have to be a health-related TV /ARoadmapforHospitalsfinalversion727
show. As you watch the show, keep notes .pdf). Visit http://www.crculturevision.com
describing ethnic, racial, and culture issues /commissionupdate.aspxlearn. What does
that arise. Who is playing which types of this organization emphasize about diversity
the roles? Also note the communication, in health care and its cultural competency
clothing, attitudes, values, and any other standards? What can you learn that might
factors related to diversity. Do the same for help you be more culturally competent?
the commercials. Share your findings in an How might this type of information improve
online course discussion forum, and relate health care?
your findings to the content in this chapter
about diversity and disparities.

Consider the following in your journal by clearly and briefly responding to the
following questions:
■■ How would you describe yourself ethnically/racially/culturally? Has your view of ethnicity/race/
culture changed over time? If so, how?
■■ Do you think people are treated differently because of race or ethnicity? If so, describe an
example.
■■ Have you been treated differently because of your own ethnicity or race? If so, how?
■■ When did you first become aware that people were different ethnically or racially?
■■ If you were or are a member of a minority group, would you want to have a healthcare
professional who is a member of that minority group care for you? Why?
CASE STUDIES
Case 1
A 45-year-old woman fell during an ice storm. She went to the emergency department
because she thought she might have broken one or more ribs. When the X-ray results
came back, the physician told the patient and her husband that they showed a carcinoid
tumor in one lung. The patient had never smoked and was healthy. There was no history of
lung cancer in her family. The couple left devastated, with a list of specialists for follow-up.
They spent 3 weeks in testing. Both the patient and her husband assumed from the term
carcinoid that she had malignant lung cancer. The patient and her husband had college
degrees and held management positions. The physician in the emergency department
did not discuss what “carcinoid” meant. The couple’s anxiety rose with each passing day. At
a later appointment, it became evident that the couple was not clear on what “carcinoid”
meant and that the couple’s interpretation included more life-threatening implications
than necessary.
What does carcinoid mean? The National Cancer Institute (NCI) in the National
Institutes of Health (NIH) defines “carcinoid” as a slow-growing type of tumor usually found
in the gastrointestinal system (most often in the appendix) and sometimes in the lungs or
other sites. Carcinoid tumors may spread to the liver or other sites in the body, and they
may secrete substances such as serotonin or prostaglandins, causing carcinoid syndrome.
This patient’s tumor was localized, and it was removed.
Case Questions
1. What do you think could have been done differently?
2. What role might a nurse have assumed, and what specifically might the nurse have done?
3. Is this an example of health literacy? If so, how is it an example?

4. How might patient-centered care be applied to this case? Be specific.
Case 2
A nurse on a medical unit was caring for an elderly woman. The patient’s family visited
frequently. The nurse, patient, and family spent a lot of time together, and the nurse was
very helpful to the family. The nurse shared with the patient and family that her husband
was out of work and her family was experiencing a difficult time. Her husband had applied
for a job at many businesses, and in the course of the conversation, the nurse realized that
her husband had applied to the patient’s son-in-law’s business. He had never been called
for an interview.
After the patient left the hospital, the family sent flowers to hospital unit for the nurse.
The nurse was surprised and happy to receive the flowers, which she took home. A week
later, her husband received a call for an interview at the business owned by the patient’s
son-in-law; he received a job offer one week later. The couple was very happy.
Case Questions
1. How were professional boundaries crossed in this case?
2. Describe how this case relates to nurse–patient (and family) relationships as described
in this chapter.
3. What should the nurse have done when she experienced issues related to professional
boundaries?

questions.
1. Why does management expect us as nurses to contribute to plans for the redesign
of the lobby of the hospital and the admissions office?
2. I think we should ask our patients about the unit.
3. What should be the main focus of the design of our unit?
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Chapter
10
Work in Interprofessional
Teams
CHAPTER OBJECTIVES
■■ Discuss the core competency: Work in ■■ Explain how coordination relates to patient
interprofessional teams. care and teams.
■■ Examine team leadership, teamwork, types ■■ Examine the problem of incivility in the
of teams, relationship to effective team healthcare work environment and approaches
functioning, and improving teams by using to resolving the problem.
TeamSTEPPS®. ■■ Apply the delegation process.
■■ Discuss communication and its relationship to ■■ Analyze the change process and implications
patient care and teams. for health care and teams.
■■ Examine the knowledge and competencies ■■ Explain conflict and conflict resolution and
needed for effective team functioning. implications for nursing.
■■ Discuss effective team decision making. ■■ Discuss power and empowerment in the
■■ Examine collaboration and its relationship to healthcare delivery system.
patient care and teams.
CHAPTER OUTLINE
●● Introduction ●● Debriefing
●● The Core Competency: Work in ●● Assertiveness
Interprofessional Teams ●● Listening
●● Teamwork ●● Mindful Communication
●● Clarification of Terms ●● SBAR
●● Microsystem ●● Checklists
●● Team Leadership ●● Healthcare Team Members: Which
●● Development of Effective Teams Knowledge and Competencies Do They
●● Improving Team Communication Need?
●● Overview of Communication ●● Teams and Decision Making
●● Formal Meetings ●● Collaboration
307
●● Coordination ●● Conflict and Conflict Resolution

●● Barriers and Competencies Related ●● Power and Empowerment
to Coordination ●● Chapter Highlights
●● Tools to Improve Coordination ●● Engaging in the Content
●● Incivility in Healthcare Work Environment ●● Discussion Questions
●● Delegation ●● Critical Thinking Activities
●● Importance of Delegation ●● Electronic Reflection Journal
●● Five Delegation Rights ●● Case Studies
●● Delegation Principles ●● Working Backward to Develop a Case
●● Evaluation of Effective Delegation ●● References
●● Change
KEY TERMS
Assertiveness Delegation Power

Call-out Delegator Situation–background–
Check-back Empowerment assessment–
Checklist Followers recommendations (SBAR)
Clinical protocol/pathway Interprofessional Team
Collaboration team-based care Team leader
Communication Interprofessional teamwork Teamwork
Conflict Microsystem Types of power
Conflict resolution Mindful communication Unlicensed assistive
Coordination Plan–do–study–act (PDSA) personnel (UAP)
Delegatee cycle
communication, collaboration, and coordination.

Introduction Incivility is a problem that many healthcare organi-
zations and staff are experiencing, and this behavior
This chapter focuses on working in teams—both leads to ineffective teamwork. In addition, delega-
nursing teams and interprofessional teams. Through- tion is a part of the daily work for every nurse and
out this content, when the term team is used, it is part of planning care and teamwork or how a
applies to both interprofessional teams and nursing team functions. Teams must cope with change and
staff teams. Nurses are members of interprofessional learn to make effective change decisions. Conflict
teams and also members of nursing teams (nursing and conflict resolution are issues that all teams face.
teams include nursing staff such as registered nurses Power and empowerment are also discussed in this
(RNs), licensed practical/vocational nurses, and chapter as they relate to staff and teams.
unlicensed assistive personnel (UAP). Through its assessment of the U.S. healthcare
This is a critical competency for every nurse. system, the IOM (2001) described the healthcare
The content includes an explanation of the health- system as a system “in need of fundamental change.
care professions core competency, teams and team- Many patients, doctors, nurses and healthcare leaders
work, and critical components of effective teams: are concerned that the care delivered is not, essentially,
Chapter 10: Work in Interprofessional Teams 309
Teamwork
Communication
Conflict
resolution
Core competency:
Working in
interprofessional
teams Collaboration
Change
Coordination
Delegation
Figure 10-1 Working Interprofessional Teams: Key Elements
the care we should receive. The frustration levels of chapter covers the second core competency, “work
both patients and clinicians have probably never been in interprofessional teams.” The competency is de-
higher. Yet the problems remain. Healthcare today scribed as: “cooperate, collaborate, communicate,
harms too frequently and routinely fails to deliver its and integrate care in teams to ensure that care is
potential benefits” (p. 1). This description continues continuous and reliable” (IOM, 2003, p. 4). As a re-
to be relevant today. Technology, new drugs, and minder, these core competencies were developed for
many other care advances can improve health and all healthcare professions, not just nursing; however,
health care, but something is wrong with the care this chapter focuses on nurses who are members
delivery models. This set of problems is what drove of interprofessional teams and also members of
the need to it identify the five healthcare professions nursing teams.
core competencies. This chapter examines the core One has to ask why there is such emphasis on
competency that most directly addresses the need this core competency. After all, it makes sense that
for changes in the care delivery models: Work in teams are important—why would anyone question
interprofessional teams. Figure 10-1 highlights the this? The critical issue is whether healthcare pro-
key elements for this competency. fessionals are prepared to participate effectively in
teams, particularly interprofessional teams, but the
conclusion is they are not. Healthcare professional
The Core Competency: education takes place in isolation; each healthcare
Work in Interprofessional Teams profession provides its own education, with limited
reference to other healthcare professionals. The re-
The first of the healthcare professions core com- sult is that nursing, medicine, pharmacy, and allied
petencies is “provide patient-centered care.” This health students (for example, physical therapists,
occupational therapists, and so on) have limited, if description of the core competencies: (1) The in-
any, contact with one another in their educational terprofessional collaborative domain is a domain
programs. As a consequence, they have limited in and of itself to assist in integrating population
knowledge of roles of the other professions and the health competencies, and (2) there is emphasis on
ways in which they must collaborate and coordinate the Triple Aim (improve patient experience—quality
care to provide patient-centered care. This is a seri- and satisfaction, improve health of populations, and
ous problem because when healthcare professionals reduce costs). Additional content on the IPEC and
graduate and meet licensure requirements, they are its competencies is found in this text’s content on
expected to work together. nursing education, for example, as described in an
In 2009, the Interprofessional Education Col- earlier figure, Figure 3-2. The 2016 IPEC update
laborative (IPEC) was formed to address the need of the interprofessional collaborative practice core
for competencies that were not profession-specific competency domains continue to support the World
(IPEC, 2011). The collaborative emphasizes that Health Organization (WHO) perspective on the need
all healthcare organizations need to develop ef- for and the impact of interprofessional education
fective interprofessional teamwork and maintain leading to effective interprofessional teams.
these efforts. In 2016, IPEC published an update In addition, nurses need to know how to work
of its work (IPEC, 2016). Since 2009, recognizing on nursing teams whose focus is nursing care. In
the importance of interprofessional teams more most cases, this, too, leads to isolation and limited
education accreditors for different healthcare recognition of the need for greater reaching out to
professions are including the IPEC competencies other healthcare disciplines. Nurses tend to focus
in their accreditation requirements. The American on the nursing care plan to the detriment of the
Association of Colleges of Nursing (AACN) is a total plan of care for the patient—a nursing care
founding member of IPEC and supports its ap- plan, as opposed to a patient-centered care plan.
proaches in AACN accreditation. Endorsement of Nursing education reinforces this perspective by
IPEC content, standards, model, and so on from emphasizing the nursing care plan. This is not to
many healthcare professional accreditation bodies say that the same scenario does not exist in other
ensures greater integration in healthcare profession healthcare professions because it does. Nursing
education and inclusion in professional literature, students need a broader view of health care along
including textbooks and other professional liter- with the nursing perspective (Barnsteiner, Disch,
ature to share with students. The 2016 update of Hall, Mayer, & Moore, 2007). Nurses also work
the 2011 report on interprofessional competencies together on teams related to service and healthcare
also included significant changes in health care, delivery in general, such as committees and task
such as greater inclusion of quality improvement forces. These teams require the same competencies
and references to changes related to the Affordable as teams focused on patient care.
Care Act of 2010 (ACA), with greater emphasis All healthcare providers should be focused on
on population health at the local, state, national, delivering patient-centered care—care that “ alleviates
and global levels. Since 2011, there are more in- vulnerability in all of its forms. That care should and
terprofessional education activities—for example, must be delivered at the right time, at the right level,
in 2011, 76% of schools of medicine offered these in the right place, and so on. If care were on a compass
activities, and in 2014, 92% included these learning it would be true north and all other functions would
activities (IPEC, 2016). stand in line to provide added value and service to
IPEC also now offers a website to provide that focus” (Hagenow, 2003, p. 204). Because one
resources for faculty. Changes were made in the individual healthcare profession cannot do it all
alone, interprofessional teams are best suited to is further supported in recent work that examined
achieve this patient-centered care. the need for greater interprofessional education and
identified two key definitions (IPEC, 2011, p. 2):
Interprofessional teamwork: The levels
■■
All nurses should be competent in serving on inter- of cooperation, coordination, and collabora-
professional teams. tion characterizing the relationship between
professions in delivering patient-centered care.
■■ Interprofessional team-based care: Care
delivered by intentionally created, usually
Teamwork relatively small work groups in health care,
who are recognized by others as well as by
With the increasing complexity of care and concerns themselves as having a collective identity and
about the fragmented healthcare system, inter shared responsibility for a patient or a group
professional teams are even more important. In of patients—for example, rapid response
addition, the complex needs of patients with chronic team, palliative care team, primary care team,
illness, providing critical acute care, geriatric care, operating room team.
and care at the end of life require effective planning
The key difference between these two descrip-
to ensure improved outcomes. Patients who require
tors for teams is that multidisciplinary focuses on
such care have multiple, complex needs. The types
how individual team members do their work and
and complexity of settings, multiple types of health-
encourages sharing of information with others who
care providers, and need to share information and
are providing care. For example, nurses share infor-
planning across settings require more teamwork.
mation about the nursing care plan with physicians
Use of interprofessional teams tends to result in
and social workers, and vice versa. This typically
improved quality care and a decrease in healthcare
is what has been done in health care, but it is not
costs (IOM, 2003a).
what is recommended in this core competency.
The descriptor interprofessional is much more in-
Clarification of Terms volved, emphasizing collective action and in-depth
The term interdisciplinary is used in the core com- collaboration in planning and implementing care.
petency (IOM, 2003), although recently the more Less emphasis is placed on what individual team
widely accepted term has been interprofessional. In members do, and more emphasis is placed on what
the literature and in practice, nurses encounter other individual members can do together to contribute
terms that seem similar, such as multidisciplinary. to the joint team plan and initiatives. Use of in-
Multidisciplinary refers to “a team or collaborative terprofessional teams improves care delivery, for
process where members of different disciplines example, these teams may:
assess or treat patients independently and then ■■ Decrease fragmentation in a complex care
share information with each other” (McCallin, system.
2001, p. 420). The core competency recognizes ■■ Provide effective use of multiple types of
that “team members integrate their observations, expertise (for example, medicine, nursing,
bodies of expertise, and spheres of decision making pharmacy, allied health, social work, and
to coordinate, collaborate, and communicate with so on).
one another in order to optimize care for a patient or ■■ Decrease utilization of repetitive or duplicate
group of patients” (IOM, 2003, p. 54). This description services.
■■ Increase creative or innovative solutions to teams may have different leaders, and in some cases,
complex problems. the leader may be a nurse. Regardless of who is the
■■ Increase learning for team members about leader, all team members are critical to the success
different roles and responsibilities, com- of a team. To be effective, a team leader must first
munication and coordination, and ways to recognize that it is the work of the team that is critical.
better plan care. The leader should not focus on personal success as
■■ Improve motivation and increased self-esteem a leader or on the success of any individual team
in team and individual performance. member. Effective team leadership is demonstrated
■■ Allow for greater sharing of responsibility. through the effectiveness of the entire team.
■■ Empower team members to speak up. Leaders need to know when to guide, when
to let the team function, and when to be directive.
If the team is on task as planned, direction is not
Microsystem
as critical. In contrast, if the team is floundering
Another way to describe the clinical team is to and not able to get work done, the leader needs to
refer to its role as a microsystem (Nelson et al., be more active in directing the team, engaging the
2008). A microsystem in a healthcare system has team to assume more responsibility. Leaders need to
been described as follows: “[A] small group of encourage and accept members’ ideas and actively
people who work together on a regular basis to seek information and ideas from team members.
provide care to discrete subpopulations including Some of the responsibilities of team leaders are as
the patients. It has clinical and business aims, linked follows:
processes, [and a] shared information environment ■■ Lead the team—at meetings and in the
and produces performance outcomes. [Microsys- team’s work. Represent the team when the
tems] evolve over time and are (often) embedded organization requires someone from the team
in larger organizations. As a type of complex to speak for the team and its activities—for
adaptive system, they must: (1) do the work, (2) example, with management, committee
meet staff needs, and (3) maintain themselves as a meetings, and so on.
clinical unit” (Dartmouth College, 2010). Clinical ■■ Determine or clarify the team’s purpose and
microsystems serve as direct care or front-line units operating rules or guidelines. Some of this
where there is interaction among patients, families, may be predetermined by the organization.
and care teams. Clinical staff, support staff, processes, ■■ Select team members. In many cases, someone
technology, communication and information, staff other than the team leader or the organization’s
behavior and attitudes, and outcomes are factors that policies determine who will serve on a team;
influence microsystems, which should be patient for example, team members may be assigned
centered. The major focus is to provide care and as to a unit or a particular patient.
care is provided and work is done the team needs ■■ Orient team members to the team, including
to consider the elements of quality, safety, reliability, coaching and training new members.
efficiency and innovation, patient satisfaction, and ■■ Determine the plan of action with team
staff morale. members’ participation. After the team
reviews information, discusses issues, and
arrives at team decisions, the team leader
Team Leadership
ensures that there is an effective plan of
Teams typically have designated team leaders. For action. If it is a clinical team, keep the focus
a nursing team, the leader is an RN. Interprofessional on the patient(s).
■■ Determine how to make the team more collaborate and communicate. Unfortunately, this
effective given the time constraints. pattern leads to problems and errors, which may
■■ Provide resources and information to the then affect team functioning. The development of
team as needed. an effective team is critical to the success of new
■■ Update the team as necessary. and innovative methods such as briefings before
■■ Ensure that the team’s plan of action is im- handoffs, checklists, and time-outs before surgery,
plemented as designed. such as the Situation–background–assessment–
■■ Recognize the team’s work as well as the work recommendations (SBAR; a standardized communi-
of individuals. cation method), TeamSTEPPS®, and others. Organi-
■■ Resolve conflict when it occurs. zations that just use these methods without working
■■ Evaluate the team’s outcomes; include input on developing effective teams to be effective will not
from all team members; strive for improve- be as successful, but using them in combination
ment. This information then feeds into the with teamwork creates a more effective organization
organization’s quality improvement program. and improved care outcomes. These methods are
■■ Encourage team learning to improve described in this chapter and other chapters.
effectiveness. TeamSTEPPS is an evidence-based teamwork
■■ Ensure that required information about system aimed at optimizing patient outcomes by
team functioning, decisions, and actions improving communication and teamwork skills
implemented is documented. among healthcare professionals. It was developed by
■■ Accept feedback from team members and the Department of Defense, and now the Agency for
others who may be involved. Healthcare Research and Quality (AHRQ) assists in
■■ Provide feedback to team members and the making this resource available to healthcare orga-
team as a whole. nizations (HHS, AHRQ, 2017). The system and its
■■ Ensure that the team effectively uses col- resources include a comprehensive set of ready-to-use
laboration, coordination, communication, materials and a training curriculum to successfully
and delegation. integrate teamwork principles into any healthcare
system (HHS, AHRQ, 2016). Figure 10-2 describes
the TeamSTEPPS model, and Figure 10-3 provides
Development of Effective an overview of the TeamSTEPPS action planning.
Teams Within a team, members have informal and for-
The word team implies there is a group of people, mal roles, and some members may assume multiple
but how do they develop into a team? To just say, roles at different times as team members interact.
“Today this group of staff is a team,” does not mean Heller (1999, p. 42) defines some of these roles:
that the group is actually functioning as a team. It ■■ Coordinator: Pulls together the work of the
takes time to develop a team. The term team does team
not include the letter I, and this is important to ■■ Critic: Keeps an eye on the team’s effectiveness
note. Teams are about groups of people who work ■■ Idea person: Encourages the team to be innovative
collaboratively, not about individuals. However, it ■■ Implementer: Ensures that the team’s func-
takes effort and time to move a team to a state where tioning is effective
it is truly functioning as a team and not as a group of ■■ External contact: Looks after the team’s ex-
individuals (Weinstock, 2010). The most common ternal contacts and relationships
scenario is that team members work in “silos” most ■■ Inspector: Ensures that standards are met
of the time and then come together periodically to ■■ Team builder: Develops the team spirit
PERFORMANCE
Leadership
Situation
Communication monitoring
Mutual
support
SKILLS
KNOWLEDGE ATTITUDES
PAT I N
IE N T CARE TRA
The TeamSTEPPS triangle logo is a visual model that represents some basic but critical concepts
related to teamwork training as explained below.
Individuals can learn four primary trainable teamwork skills. These are:
1. Leadership.
2. Communication.
3. Situation monitoring.
4. Mutual support.
If a team has tools and strategies it can leverage to build a fundamental level of competency in each
of those skills, research has shown that the team can enhance three types of teamwork outcomes:
1. Performance.
2. Knowledge.
3. Attitudes.
Figure 10-2 TeamSTEPPS®
Reproduced from U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality (AHRQ).
(2016). Pocket Guide to TeamSTEPPS® 2.0. Retrieved from https://www.ahrq.gov/teamstepps/instructor/index.html
1 Create a Change Team
Define the Problem, Challenge or

2
Opportunity for Improvement
Define the Aim(s) of your

3
TeamSTEPPS Intervention
Identify
Priority
Define the TeamSTEPPS Problem,
4
Intervention Challenge or
Opportunity
from Step 2
Develop the Plan for Testing the Effectiveness
5
of Your TeamSTEPPS Intervention
6 Develop Implementation Plan
Develop a Plan for Sustained Continuous

7
Improvement
8 Develop a Communication Plan
Putting it All Together: Writing the

9
Incorporate TeamSTEPPS Action Plan
Feedback
from Key
Personnel Review Your TeamSTEPPS Action Plan
10
with Key Personnel
Figure 10-3 TeamSTEPPS®: Action Planning At-a-Glance

Reproduced from Agency for Healthcare Research and Quality (AHRQ). (October 2014). The quick reference guide to
TeamSTEPPS® action planning. Retrieved from http://www.ahrq.gov/professionals/education/curriculum-tools/teamstepps
/instructor/essentials/implguide3.html
The four areas of particular concern that need ■■ Misinterpretation of cues

to be considered when evaluating team effectiveness ■■ Lack of role clarity
are (IOM, 2001, p. 132): Because there is more focus on quality improve-
1. Team makeup, such as having the appropriate ment (QI) teams need to be concerned with QI,
team size and composition of members and the on a continuous basis. TeamSTEPPS recommends
ability to reduce status differences (for example, that team structure can be used to support patient
between the nurse manager and staff nurses or safety, particularly in the following areas (HHS,
between nurses and physicians). AHRQ, 2014a):
2. Team processes, such as communication ■■ Communication: Structured process by
structure, conflict management, leadership which information is clearly and accurately
that emphasizes excellence, and clear goals exchanged among team members.
and expectations. ■■ Leadership: Ability to maximize the activities
3. Nature of team tasks, such as matching roles or team members by ensuring that team
with knowledge and experience and pro- actions and are understood, changes in
moting cohesiveness when work is highly information are shared, and team members
interdependent. have the necessary resources.
4. Environment context, such as obtaining needed ■■ Situation monitoring: Process of actively
resources and establishing appropriate rewards. scanning and assessing situational elements
“Effective teams have a culture that fosters to gain information or understanding, or
openness, collaboration, teamwork, and learning to maintain awareness to support team
from mistakes” (IOM, 2001, p. 132). Healthcare functioning.
delivery tends to overemphasize personal account- ■■ Mutual support: Ability to anticipate and
ability of healthcare professionals such as nurses support team members’ needs through ac-
and physicians, and this may negatively affect curate knowledge about their responsibilities
teamwork. Teams often resort to uncoordinated or and workload.
sequential action rather than collaborative work,
which is required for effective teams. TeamSTEPPS
identifies the following barriers to effective to team Stop and Consider #2
Teamwork makes a difference in effective teams.
performance. These barriers can be used to identify
areas to assess and improve team performance
(HHS, AHRQ, 2014a):
■■ Inconsistency in team membership Improving Team
■■ Lack of time Communication
■■ Lack of information sharing
■■ Hierarchy Communication is important throughout the
■■ Defensiveness healthcare system, but it is critical for teams. They
■■ Conventional thinking cannot function without communication, and
■■ Varying communication styles effective communication makes a difference in team
■■ Conflict functioning. An important role for team leaders
■■ Lack of coordination and follow-up is to lead the team’s activities, and much of this is
■■ Fatigue done through team discussion and also discussion
■■ Workload with non–team members. The process of leading
discussions can be informal or formal. When the Communication is the sharing of a message
team leader seeks out individual team members between one person or group and another. It is
to discuss team issues and the team’s work, this is important to know if the message was received as
informal discussion. In this situation, the leader is sent. Interpretation has a major impact on effective
seeking an open discussion of issues and sharing communication, and sometimes interpretation
of ideas. Such an exchange can help the leader to confuses or changes the original message. Non-
better understand team members and identify verbal communication also has an impact on the
issues that are important to the team’s functioning message sent. If a team member verbally affirms
and activities. Informal discussion can also be used commitment to an action but the team member’s
for the team members to get to know the leader on facial expression shows a lack of interest (such as
a different level. Formal communication typically no eye contact or a hurried manner), the message
takes place in meetings and through written com- of commitment may be viewed as noncommitment.
munication methods. As team members get to know one another, they
learn each other’s communication styles, includ-
ing nonverbal methods. This knowledge confers
Overview of Communication
an advantage in that it can improve and speed up
All nurses communicate—with other nurses, other communication. Nevertheless, in some cases, team
staff, patients, families, and others who impact members may jump to conclusions, and communi-
patient care. The assumption is that individuals cation may not be clear. The same could be applied
know how to communicate effectively, and this is to student communication in the classroom or in
not always true. Nurses have an ethical mandate team discussions.
to become skilled communicators; doing so is an The Joint Commission analyzed data related to
essential standard of practice (O’Keefe & Saver, healthcare quality from 2004 to 2012 and concluded
2014; Kuppeschmidt, Kientz, Ward, & Reinholz, that communication issues were the major reasons
2010). What is important is the effectiveness of for deaths related to a delay in treatment. Data from
this communication. Teams must communicate, 2010 to 2012 indicated that communication was the
too. The effectiveness of team communication may third highest root cause of sentinel events (The Joint
also vary, but it is clear that communication makes a Commission, 2013; O’Keeffe & Saver, 2014). Not
difference in results, decreases errors, and improves communicating is the major issue in communica-
the work environment. tion breakdown. Situations that are most at risk for
Individuals have communication styles, and communication breakdown include those involving
understanding one’s style is important. Some people broken rules or taking shortcuts (workarounds),
are more passive; others use more nonverbal commu- mistakes or use of poor clinical judgment, lack of
nication; others prefer to see important information support, incompetence, poor teamwork, disrespect, and
in writing; and so on. Using professional jargon micromanagement when someone abuses authority
often creates a barrier, limiting clear communica- (Maxfield, Grenny, McMillan, Patterson, & Switzler,
tion. This is why using structured communication 2005). Clearly, effective communication is critical
practices such as SBAR, call-out, and check-back for delivery of quality health care and something
is important in reducing communication barriers. that must be frequently monitored and improved.
Within these methods, all healthcare providers use The relationships and communication between
the same terminology and process so that they do nurses and physicians have long been important
not have to take time to figure out the process or healthcare issues because they have an impact on
what someone else means. the quality of care and work satisfaction. One small
study that included 20 medical and surgical residents communication in healthcare settings—for exam-
examined their attitudes toward nurses (Weinberg, ple, nurse to nurse, nurse to unlicensed personnel,
Miner, & Rivlin, 2009). In this study, 19 of the 20 nurse to other healthcare professionals, and nurse to
residents shared examples of poor communication administrators/managers. All of these communication
or problematic relationships with nurses, but the processes are critical to effective functioning of the
important result was the residents did not feel such healthcare delivery systems, yet problems occur in
issues presented a problem for patient care because all of these interaction combinations.
the nurse’s role was to follow orders and nothing Another recent study that focused on quality
more. The residents did say that when nurses were care reached an interesting conclusion related to
knowledgeable and collaborative, such qualities the issue of interprofessional teamwork (Curry
had positive effects on the residents and on patient et al., 2011). This study examined factors that may
care—which, of course, contradicts their view of be related to better performance in care of patients
the importance of nurses’ contribution to health with an acute myocardial infarction diagnosis, which
care. Knowledgeable and collaborative nurses were the study measured by assessing risk-standardized
able to anticipate and respond to needs of and then mortality rates. The sample included 11 hospitals
work with residents to identify patient needs and and 158 staff members. The high-performing hos-
interventions. This working relationship was part pitals demonstrated organizational cultures that
of the residents’ positive comments; however, this supported improved care for this patient population.
was not the common experience. This type of re- The conclusion was that evidence-based protocols
sult indicates that residents view nurses with more and processes are important but not sufficient to
education and experience in a more positive light, reach high hospital performance. These hospitals
suggesting there might be a more collaborative had clear organizational values and goals, senior
relationship formed in this circumstance. Because management was involved, communication and
this study focused on residents, transferring these coordination were evident in broad staff presence
results to experienced physicians is not possible; and expertise, and problem solving and learning
they represent a different sample. This study also did were important. These are all elements of effective
not examine nurses’ views of the medical residents. teamwork, which does make a difference in patient
In reality, this is not a one-sided perspective, and outcomes, and depending on the effectiveness of
blame for poor communication with nurses cannot the team, it can be negative or positive.
just be placed on nurses, medical residents, or any
other specific type of staff. Nurses have responsi-
Formal Meetings
bilities in the communication process, and their
role in this partnership is complicated, too. There Formal meetings are an important part of team-
is more of a power struggle today because of the work, and the team leader or someone designated
increased number of female physicians, increased by the leader usually leads these meetings. Besides
number of nurse practitioners, increased nursing participating in team meetings, team members and
autonomy, and decreased perception of physician leaders may participate in a variety of meetings: staff
esteem due to accessibility of information online meetings, committees, task forces, staff education
(Nair, Fitzpatrick, McNulty, Click, & Glembocki, sessions, and so on.
2012). It is easy to stereotype and to frequently Formal meetings can be held in a variety of
complain about doctors; however, this is not helpful. settings. The most common site is a conference
Researchers tend to focus on physician– room in the healthcare setting. The setting should be
nurse communication, but there is much more to private and conducive to fostering communication.
Space should be provided for team members to sit becomes volatile, the leader needs to guide
and take notes. In clinical settings, telephone access the discussion back to the topic and away
is important, although members should be encour- from personal reactions. Decisions should
aged to keep interruptions to a minimum—with the be clearly identified. The minutes should
increasing use of cell phones this can be a challenge. reflect action items, persons responsible for
Another method for conducting meetings today those items who may or may not be team
is virtual conferencing, including conference calls, members, and timelines for completion.
video conferencing, and Internet conferencing. Planning and conducting a meeting in an
These methods also require planning and equipment. orderly fashion indicates that a team member’s
Members must be informed about access require- time is valued and accountability for actions
ments, and technological support may be needed is an expectation.
to assist with possible connection problems. The ■■ After the meeting: Minutes are finalized.
following guide recommends steps for conducting The leader and members complete actions
formal team meetings: that require follow-up or as designated in
the team’s decision plan timeline. A report
■■ Planning the meeting: Planning before the of these actions should be addressed at the
meeting is important. Avoid scheduling next meeting or may be sent to members to
meetings just to have a meeting. Time is too report progress as needed.
limited. Staff will be reluctant to attend and ■■ Evaluation of meetings: Consider these
may not be productive in meetings they feel questions: (1) Did the meeting have a
are not worthwhile. Before completing the clearly defined purpose (agenda)? (2) Were
final agenda, the leader might survey mem- there measurable outcomes (do the minutes
bers via email for additional agenda items. provide data, and were they met)? (3) What
■■ Steps before the meeting: Arrange for meeting was the attendance level? (4) Did members
space and any technology required. Send out participate in the meeting(s), or was the
the agenda, any necessary handouts, and leader doing all of the talking? (5) Is it easy
minutes from the last meeting. Allow time to identify actions taken?
for this material to be reviewed. Typically,
these items are now sent electronically. If Another type of meeting that is common
there is no designated “minutes taker” or among clinical teams is the patient care planning
secretary, the leader may ask a member to meeting. Such meetings may take place daily, each
assume this role. shift, or several times a week. The purpose of these
■■ Meeting time: Meetings should begin and end meetings is to assess patient care and determine
on time. All members should make an effort the patient plan of care. This type of meeting is
to be on time, come prepared, and follow the typically less structured than the formal meeting
agenda. The leader should guide the meet- (for example, no structured agenda or minutes).
ing to ensure the agenda is followed. At the However, the team leader does need to plan the topics
beginning of the meeting, minutes should for discussion. The team may develop a common
be reviewed and approved—the minutes order in which patient issues are discussed. Notes
are the team’s documentation. The leader should be kept, although they need not be formal
is responsible for making sure all members minutes. The team may add changes to the patient’s
have the opportunity to participate. If the plan of care or other standard clinical documents.
discussion digresses from the agenda or The responsibilities noted earlier for team leaders
remain the same for the clinical planning team as 3. Application: This phase focuses on summariz-
for other types of teams. In this type of meeting ing the key points learned so that they can be
staff are typically anxious to get to their work so a applied as needed.
focused meeting is critical. Effective debriefing demonstrates clear communi-
In many hospitals, patient rounds are also cation, clear and known roles and responsibilities,
used for planning. Staff members as a team go to understanding of the context of the problem or
the patient’s bedside to talk with the patient and situation, sharing of workload, and continuous
assess needs. The patient should be an active par- monitoring.
ticipant in the rounds, although this is not always
the case. Rounds may be interprofessional (the
Assertiveness
ideal method) or focused on a specific profession
(such as nursing rounds or physician rounds). Assertiveness is a communication style that is
Patient rounds are discussed in this text in quality often confused with aggression and, therefore, may
improvement content. be viewed negatively. Assertiveness, however, is
important, though many nurses have to learn how
Debriefing to use it effectively. Using assertiveness, a person
stands up for what he or she believes in but does
Effective teams need to incorporate debriefing as not push or control others. The assertive nurse
one of their routine communication methods. It can uses I statements when communicating thoughts
improve team and individual provider performance. and feelings and you statements when persuading
Debriefing is defined as “a dialogue between two or others (Fabre, 2005).
more people; its goals are to discuss the actions and Fabre also recommends that nurses need to
thought processes involved in a particular patient approach situations calmly, reducing emotional
care situation, encourage reflection on those actions responses. When problems occur, delaying response
and thought processes, and incorporate improvement usually is not helpful; however, if emotions are high
into future performance. The function of debriefing a “cool down” period may be advised. As discussed
is to identify aspects of team performance that in other content in the text on communication
went well, and those that did not. The discussion we need to consider our audience and use termi-
then focuses on determining opportunities for nology that others can understand.
improvement at the individual, team, and system Nurses need to break the code of silence (Fabre,
level” (HHS, AHRQ, PSNet, 2016). It is important 2005). Nurses are often silent, keeping their opin-
that debriefing is used as a learning tool and not ions to themselves rather than being open with the
to take punitive steps to identify individuals who treatment team and management. This pattern of
may have made an error. There are three common not communicating most likely reflects low self-
phases to debriefing. esteem of the profession as a whole, which has a very
1. Description or reactions: The leader asks team negative impact—namely, loss of valuable nursing
members for their perspectives. input. Speaking up may be risky, but the results can
2. Analysis: The analysis phase prioritizes concerns be worthwhile. It may take time for team members
and rationales discussed. This phase, as is true to value one another’s opinions and expertise. If
for all phases, requires an environment in which done in a professional manner with the goal of col-
staff feel comfortable in being direct with one laboration and coordination, over time most team
another and respect other perspectives. members begin to respect and trust one another;
they see value in the team’s diversity of multiple ■■ Listening jump-starts the solution process
healthcare professionals and variety in experience. because answers may pop up during candid
conversations.
Listening relieves stress. Bottling up thoughts
Listening
■■
and feelings simply depletes our energy.

Listening is an important skill to develop. Most
■■ Active listening is more than hearing; it re-
people think they listen when they really do not quires communicating to the other person
do so effectively. Effective listening is important that you are listening.
when delivering care—to the patient and family, in
■■ Just saying “yes” and “no” is not active listening.
working in teams, and with colleagues. Most people
■■ Paraphrasing communicates that you have
probably would say that they listen, but listening listened.
takes practice. There are also a number of barriers Nurse–physician communication has long been
to effective listening: an important topic, probably more so in nursing than
■■ Anxiety and stress in medicine. In addition to the studies mentioned
■■ Distractions and interruptions earlier, other studies have examined this issue and
■■ Too many tasks to do the impact of collaboration on care (Baggs et al.,
■■ Fatigue and hunger 1999; Fairchild, Hogan, Smith, Portnow, & Bates,
■■ Lack of self-esteem 2002; Higgins, 1999; Thomas, Sexton, & Helmreich,
■■ Anger 2003). These studies indicate communication prob-
■■ Overwork lems can affect collaboration and, consequently,
■■ Reaction from the past patient outcomes. In one study, two nurses and one
■■ Confusing message physician conducted a study using focus groups of
In addition, the team member may not think indi- nurses and physicians. They identified methods to
vidual team members’ opinions are valued, leading improve nurse–physician communication (Burke,
the member to tune out or exhibit a lack of concern Boal, & Mitchell, 2004). The researchers noted that
or respect for the communicator. The opposite can some communication problems require major or-
also occur with the team member thinking he or ganizational changes—system changes. Suggested
she knows enough and thus does not need to listen. methods that are not as system focused but rather
When you recognize that you are not listening, are steps individual nurses could take to improve are:
you should think about what is interfering with your ■■ Develop a personal connection, which helps
listening. What is the barrier(s) at the moment? to increase colleagueship.
Through this self-examination, you can learn more ■■ Use humor.
about the listening process and improve your lis- ■■ Make the assumption that you are on the
tening skills—and, in turn, your communication same team.
skills. Fabre (2005, p. 80) identifies why listening ■■ Recognize that team members are equal in
is important beyond generally improving commu- their expertise, which can be important to
nication; it is critical to effective identification and patient care.
description of problems: ■■ If you speak frequently to a physician over
■■ Listening exposes feelings—those invaluable, the phone, arrange to meet in person; a face-
but sometimes inconvenient, traits that make to-face interaction may improve your com-
us truly human. munication over the phone.
■■ Report good news about patients—improvements, on, all impact communication—staff to staff, staff
not just problems. to patients and families, and others. Use of mindful,
■■ Recognize that conflict will occur, but this more conscious communication can make a differ-
does not mean that communication and ence in clear communication, sent and received in
collaboration cannot be maintained. a timely manner. Consider emails—how often do
■■ Discuss preferred methods of communication we quickly write an email without thinking about
(telephone, email, pager, in person, voice the content or tone and hit the send button only to
message) and under which circumstances realize then or later that we could have done better.
they should be used. This applies to all forms of communication—oral,
■■ Ask for parameters regarding when the written, and electronic. Mindfulness is discussed
physician wants to be called. in other chapters in this text.
■■ Plan ahead for meetings or times of contact
so that you are prepared with information SBAR
and know what you want to communicate.
Provide clinically pertinent information. The situation–background–assessment–
■■ Work with the physician to determine the recommendations (SBAR) is a structured
best methods for communicating with the communication method that is used to improve
family, and determine who should contact team communication (typically, interprofessional,
whom and for what purposes. such as physician to nurse, but also other types of
teams, such as nursing teams). It focuses on critical
information about a patient that requires immedi-
Mindful Communication ate attention and action. To ensure more effective
Mindful communication is a process by communication, a consistent process is used that
which actively aware individuals engage in commu- includes the following steps (IHI, 2011a):
nication that is meaningful, is timely, and responds ■■ Situation: What is going on with the patient?
continually as events unfold (Anthony & Vidal, 2010; ■■ Background: What is the clinical background
O’Keefe & Saver, 2014, p. 9). It is easy to assume or context?
that one is communicating and participating in an ■■ Assessment: What do I think the problem is?
active way by talking—but more needs to be done ■■ Recommendation: What would I do to
about how we communicate, verbally and nonver- correct it?
bally, and why. Then we consider what needs to be This process includes use of the call-out and the
communicated and, finally, whether we really did check-back. The call-out is used to communicate
communicate the message we wanted to send. This important or critical information that lets all team
all requires us to consider the receiver of the mes- members hear the information at the same time
sage. Many factors affect how our message will be and clarifies responsibilities. The check-back
received and even if it will be received as intended. provides assurance that the team members heard
In healthcare settings, these factors are even more and understood the information from the sender.
complex. Patients are sick, and their communication Exhibit 10-1 offers an example of SBAR in action.
may not be at the patient’s usual level. The same can
be said for families and significant others. Many
Checklists
factors in the work setting, such as stress, miscom-
munication, power, past problems and current ones, Dr. Atul Gawande (2009) wrote The Checklist
supervisory inadequacies, policies and procedures, Manifesto to address safety in the surgical arena.
understaffing, staff not prepared, workload, and so His document mandates that all staff working in
Exhibit 10-1 SBAR Example
This is an example of how SBAR might be Background: What is the clinical background
used to focus the message in a telephone or context?
call between a nurse and a physician. The “The patient is a 75-year-old woman who was
nurse would not wait for the physician to ask admitted for pneumonia yesterday. She did
these questions, but rather would routinely not complain of hip pain before being found
provide the information in clear statements as on the floor.”
indicated by SBAR.
Assessment: What do I think the problem is?
Situation: What is going on with the patient? “I think the fall may have caused an injury. Her
A nurse finds a patient on the floor. She calls pain is level 7 out of 10. Vital signs are normal.”
the doctor: “I am the charge nurse on the night
Recommendation: What would I do to correct
shift on 5 West. I am calling about Mrs. Jones.
it or respond to it?
She was found on the floor and is complaining
“I think we need to get an X-ray immediately
of pain in her hip.”
and have her seen by the orthopedic resident.”
the surgical arena should follow a checklist. This

checklist itemizes a list of activities that should be Healthcare Team
examined by the team before surgery takes place to Members: Which Knowledge
ensure clear communication and certainty about
and Competencies Do They
actions to be taken. Gawande based his work on the
checklist approach used by pilots to ensure safety Need?
during takeoff, landing, and during other critical
Team members may be viewed as followers. This
points in a flight. We now see checklists used in
is not a negative term. If there were no members
different areas of health care to ensure processes
or followers, there would be no team. There may
are followed and identify potential risks or near
be times when a follower, leader of a subgroup, or
misses before they lead to harm and improve care.
another member must assume the leadership role,
Checklists are not just associated with improving
such as in the absence of the team leader; however,
care—reducing errors, but effective use of check-
in most cases, team members are followers. The
lists is connected to how a team might function. A
follower role should not be a passive one, but rather
study examined whether perceptions of teamwork
a very active one. Each member needs to feel a
predicted use of checklist (Singer et al., 2016). In
responsibility to participate actively in the work of
this study, the checklist was used in surgery in only
the team and feel that the members have the right
3% of the surgical cases. When it was used, the
to help the team determine its rules, structure, and
team leader, the surgeon, had a significant impact
activities.
on this use—the leader believed in the use of the
Effective teams need members who engage
checklist and provided clinical leadership, clear
with one another as the team works. This requires
communication, and effective teamwork.
ability to effectively communicate, negotiate, and
delegate. Team members need to assess their own
dynamics and use time management to get their
Improving your communication is an ongoing process.
work done, which requires sharing information in
timely manner with staff who need it. Sometimes
team members are not in the same site, and in this

case, the team needs to determine how they will Teams and Decision
work together to communicate and coordinate so Making
that outcomes can be met. It is inevitable that teams
may experience conflict, either within the team or Teams make decisions about the work that they
with persons or teams external to the team. This need to do and use problem solving as they make
requires use of conflict resolution, which is discussed decisions. The amount and quality of information
later in this chapter. Effective teamwork takes time that is required and the number of possible solutions
and effort, but the results can be much better than for a problem affect decisions. The schedule is very
individual’s functioning alone. important; for example, is an immediate decision
Recent work that has sought to clarify ways required, or can time be taken to consider options
to ensure interprofessional team education has carefully? Many clinical teams must act quickly in
identified key competencies for all healthcare pro- response to clinical problems. These teams need to
fessions related to teamwork (IPEC, 2011, pp. 19, develop quick thinking and analytic skills (depending
21, 23, 25). The following competencies might look on the expertise of team members), trust one another,
like they form a to-do list. In a way they do because weigh benefits and risks, and move to a decision.
these are the expected actions/competencies of the At other times, teams may have more time to fully
healthcare team: analyze an issue or problem, brainstorm possible
■■ Work with individuals of other professions solutions, and develop a consensus regarding the
to maintain a climate of mutual respect and best decision—for example, a decision made by a
shared values. committee. Teams must recognize that there may
■■ Use the knowledge of one’s own role and the not be a perfect solution (there rarely is) and that
roles of other professions to appropriately there is risk, but decisions need to be made. Not
assess and address the healthcare needs of making a decision is really making a decision—to
patients and populations served. do nothing is a decision. Several decision-making
■■ Communicate with patients, families, com- styles may be used (Milgram, Spector, & Treger,
munities, and other health professionals in 1999, p. 42):
a responsive and responsible manner that ■■ Decisive decision making depends on minimal
supports a team approach to the maintenance data to arrive at a single solution or decision.
of health and treatment of disease. ■■ The integrative style uses as much data as
■■ Apply relationship-building values and the possible to arrive at several reasonable solu-
principles of team dynamics to perform tions or decisions.
effectively in different team roles to plan ■■ The hierarchic style uses a large amount of
and deliver patient/population-centered data and organizes the data to arrive at one
care that is safe, timely, efficient, effective, optimal decision.
and equitable. ■■ The flexible style relies on minimal data but
Accomplishing these competencies requires greater generates several different options or will
emphasis on interprofessional education for all shift focus as the data are interpreted.
healthcare profession students. A team leader and the team typically use more than
one decision-making style, depending on the issue
or problem. It is important to understand styles
used by team members and the team leader, who
Followers are as important to teams as are leaders.
is also a team member.
Key questions that are asked during decision-

making are: (1) What is the issue, problem, or task
to be done and the desired outcome? (2) What
type of data do we need? (3) How complicated and
substantial is the issue, problem, or task? (4) How
Discussion
many possible solutions or approaches are there, and Dialogue
what are they? (5) Can the desired outcome(s) be
met with acceptable cost–benefit standards? (Note
that cost is more than financial; it could refer to the
patient’s health status if an outcome is not achieved
or risk of an error due to a decision-making problem, Improved Patient Care
Decreased Costs
and so on.) Figure 10-4 illustrates team thinking. Decreased Redundancy
Increased Job Satisfaction
Exhibit 10-2 provides an example of a team-thinking Increased Patient Satisfaction
inventory that teams can use to assess their thinking. Maximum Use of Resources
Figure 10-4 Interprofessional Team Thinking

Stop and Consider #5 Reproduced from Rubenfeld, M. & Scheffer, B. (2015).
Team decision making never stops. Critical thinking tactics for nurses. Burlington, MA:
Jones & Bartlett Learning.
Exhibit 10-2 Team-Thinking Inventory
●● Which strategies are used to help team ●● Which other sources of gratification,
members think about the big picture as besides interprofessional teamwork, are
well as the parts? available for team members to socialize,
●● Which strategies are used to help team obtain recognition, and interact?
members see the situation from different ●● How were the interprofessional team
perspectives? members prepared for their thinking roles?
●● Which strategies are used to help ●● How does the team deal with ambiguity?
team members see their biases and How long can team members tolerate not
assumptions? having a solution?
●● Which strategies help team members ●● How does the team examine its own think-
think about patterns and interrelationships ing processes (for example, how it works,
of issues and parts of problems? not what it is doing), and who is doing it?
●● Which strategies are used to help team From Rubenfeld, M. & Scheffer, B. (2015).
members think beyond cause-and-effect Critical thinking tactics for nurses.
consequences? Burlington, MA: Jones & Bartlett Learning.
●● Does the thinking that occurs in the team Data adapted from Senge, P. (1998). The
fifth discipline: The art and practice of
resemble simple sharing of information or
the learning organization. New York, NY:
discussion/dialogue? Why? How can you Doubleday; Bensimon, E. & Neumann, A.
move in the direction of discussion/dialogue? (1993). Redesigning collegiate leadership:
●● What is done to encourage team members Teams and teamwork in higher education
to share their thinking or feel comfortable Baltimore, MD: Johns Hopkins University
Press; and Brookfield, S. & Peskill, S. (1999).
enough to talk about it?
Discussion as a way of teaching: Tools and
●● How is conflict managed in the team to techniques for democratic classrooms. San
promote thinking instead of discouraging it? Francisco, CA: Jossey-Bass.
space should not focus on one profession. This is

Collaboration changing but is still a problem in some healthcare
organizations. Teams need space in which they can
Collaboration is an integral part of patient-centered
collaborate, discuss issues and patients, plan, and so
care and safe, quality care. When staff or team
on. This then means the space needs to be conducive
members work in a collaborative environment, it is
to privacy and quiet, with limited interruptions.
a satisfying work experience with limited conflict.
The station as described here does not usually meet
Collaboration means that all the people involved
these criteria—it is noisy, offers little privacy, and
are listened to and decisions are developed together.
is often crowded and stressful. Nurses and others
Views are respected; however, at some point, deci-
need to consider the space in which they work and
sions must be made, and not all views or opinions
collaborate.
will be part of the final decision. Compromise is
Collaboration requires that open communica-
part of effective collaboration. The goal is to arrive
tion take place and team members feel comfortable
at the best possible decision. Working with others
expressing their opinions even when they disagree.
increases the possibility of having the best deci-
Team members of different healthcare professions
sion because there is greater availability of ideas
must work across professional boundaries to develop
and dialogue about ideas and solutions. Though
a team culture of working together. The goal is not
diversity may cause barriers, it can also improve
to make an individual’s profession look good, but
decision-making by providing different viewpoints
rather to focus on the team as a whole. Even when
to better understand an issue.
the team is composed of members from the same
The American Nurses Association (ANA)
healthcare profession, such as a nursing team, the
standard on collaboration states, “the registered
focus is on the team, not individuals. This does not
nurse collaborates with the healthcare consumer
mean that conflicts will not occur, but some can be
and other key stakeholders in the conduct of
prevented. When conflict does occur, the team uses
nursing practice” (2015a, p. 73). The standard
effective methods for coping to reach a common goal.
supports patient-centered care. It requires nurses
to communicate, collaborate with the plan of care,
promote conflict management, build consensus, Stop and Consider #6
engage in teamwork, cooperate, and partner with Healthcare delivery requires more and more
others to effect change and produce positive out- collaboration.
comes while adhering to professional standards and

codes of conduct. Effective collaboration requires
understanding who are the potential stakeholders Coordination
or partners; their expertise, level of power and
influence and common goals. Nurses coordinate patient care through planning and
Another factor that influences collaboration that implementing care, and they have been involved in
is not always considered is space and environment the development of care coordination throughout its
(Gum, Prideaux, Sweet, & Greenhill, 2012). What evolution (Lamb, 2013). “Care coordination involves
does this mean? In most clinical units, there is a deliberately organizing patient care activities and
space that is central to coordinating work. In many sharing information among all of the participants
hospitals, this space is called the nurses’ station; concerned with a patient’s care to achieve safer and
however, this title may act as a barrier to improving more effective care. This means that the patient’s
interprofessional collaboration. The title for the needs and preferences are known ahead of time and
communicated at the right time to the right people, prescriptions, and clearer advice about the best
and that this information is used to provide safe, course of treatment” (HHS, 2013).
appropriate, and effective care to the patient” (HHS, Patients often complain about the number of
AHRQ, 2014b). Effective coordination needs to be care providers that interact with them. They may
interprofessional. Coordination and collaboration not know who is responsible for which aspects of
should be interconnected. Care is complex, and their care, and they receive confusing and often
patients require healthcare providers with different conflicting communication and information. The
expertise to meet these needs. With this type of sit- patient needs to have an anchor—a healthcare
uation, the different providers need to collaborate to provider to whom the patient can turn for support
reach a plan and then implement care in a manner and knowledge of the plan. Basically, patients are
that makes sense—meeting the timeline required, saying that they are not the center of care and their
with minimal conflict and confusion. care is fragmented. This leads to an increased risk
Although the need for care coordination is of errors and decreases the quality of care. Care is
clear, there are obstacles within the U.S. healthcare coordinated through the implementation of the
system that must be overcome to provide this type care plan, documentation of care, and teamwork.
of care. Redesigning a healthcare system in order to Healthcare teams that recognize these concerns can
better coordinate patients’ care is important for the help patients more, engaging patients in the care and
following reasons (HHS, AHRQ, 2014b): as a member of the care team. All of this increases
■■ Current healthcare systems are often dis- opportunities to improve care and reach outcomes.
jointed, and processes vary among and
between primary care sites and specialty sites. Barriers and Competencies
■■ Patients are often unclear about why they Related to Coordination
are being referred from primary care to a
specialist, how to make appointments, and Coordination is not easy to achieve even when team
what to do after seeing a specialist. members want to achieve it. Some of the barriers
■■ Specialists do not consistently receive to effective coordination are listed here:
clear reasons for the referral or adequate ■■ Failure of team members to understand
information on tests that have already been the roles and responsibilities of other team
done. Primary care physicians do not often members, particularly members from different
receive information about what happened healthcare professions
in a referral visit. ■■ Lack of a clear interprofessional plan of care
■■ Referral staff deal with many different pro- ■■ Limited leadership
cesses and lost information, which means ■■ Overwork and excessive burden of team
that care is less efficient. member responsibilities
Coordination through team effort—working ■■ Ineffective communication, both oral and
to see that the pieces and activities fit together and written
flow as they should—can help to meet patient out- ■■ Lack of inclusion of the patient and family/
comes. “Conscious patient-centered coordination significant others in the care process
of care not only improves the patient experience, ■■ Competition among team members to con-
it also leads to better long-term health outcomes, trol decisions
as demonstrated by fewer unnecessary trips to the Despite these barriers, coordination can be
hospital, fewer repeated tests, fewer conflicting achieved through use of effective interventions.
First, the team must recognize that coordination Assessment

is critical and strive to ensure that it is used. The data
team needs to understand the purpose and goals
of coordination and work to achieve them. To do Actual and Delineate
so, the team must evaluate its work and be willing potential problems responsibilities
to identify weaknesses and figure out methods to
improve coordination. Team members need to
communicate openly and in a timely manner.
Timeline and
Teams that effectively solve problems together will Interventions
outcomes
improve their coordination. Delegation, discussed
elsewhere in this chapter, is an important part of
Figure 10-5 Categories of Information Found in
coordination. One person cannot do everything Clinical Pathways
(and that one person may not even be the best per-
son for the task or activity). Coordination requires
team members who understand the different roles a patient who is severely depressed and suicidal. An
and expertise of the members, determine the best interprofessional team of experts then develops the
member to deliver care to meet the timeline, and pathway describing expected care and outcomes.
then evaluate the outcomes. Current literature and evidence from research should
be used when developing pathways, and examples
Tools to Improve from other hospitals or examples found in profes-
sional literature may be used. In other situations,
Coordination
the healthcare organization may decide to use a
Health care has developed a variety of tools and published clinical pathway rather than develop one
methods to increase coordination. From a chronic for the organization. After the clinical pathway is
illness perspective, disease management is a process developed or selected, staff members need training
used to improve coordination and collaboration, about the pathway and its use. Pathways can be
typically using practice guidelines and clinical used to evaluate care and outcomes by collecting
protocols or pathways. A clinical protocol or data about their use and the patients’ outcomes.
pathway is a written guide to provide direction The question to be addressed during evaluation is
for specific clinical problems. The pathway content simple: Does the pathway, or specific interventions
includes interventions, timeline, and resources within a pathway, make a difference? Are expected
needed; identifies expected outcomes; and pro- outcomes met?
vides a sequencing of interventions to reach the There are a number of advantages to using
outcomes. Figure 10-5 provides examples of clinical protocols or pathways. First, this type of
information categories that might be found in a tool improves team coordination and increases the
clinical pathway. likelihood of meeting outcomes. Because clinical
Pathways are developed in a number of ways. protocols or pathways are written and based on
In some situations, healthcare organizations may evidence, there is a care standard and greater con-
create them by identifying focus areas based on sistency in care provided, which should enhance
needs commonly found in their patients—for ex- quality of care and facilitate evidence-based practice.
ample, pathways that focus on the care of a diabetic However, whenever a pathway is used, the team must
patient who has been hospitalized, a patient who review the standard pathway to ensure that it meets
needs a hip replacement and then rehabilitation, or the individual needs of the patient and then adapt
it accordingly. Other advantages of using clinical feel traumatized, powerless, or stressed; lose sleep;
protocols or pathways include more effective use and develop anxiety and depression. People may try
of expertise and resources, better management to avoid one another for fear of another negative
of healthcare costs, improved collaboration and encounter leading to distrust. When students and
communication, decreased errors, improved patient faculty are in situations where evaluation occurs,
satisfaction (because patients feel that their care is distrust on both sides may prevent objective fac-
organized and they are more informed), improved ulty evaluation of students and student evaluation
care documentation (because it follows a consistent of faculty. This behavior can be disruptive in the
plan), improved identification of responsibilities, classroom and in clinical experiences, interfering
and a clear statement of interventions. with student learning both for the students directly
involved and for the students on the sidelines. The
community of learning then becomes a place where
no one wants to be.
Coordination is a major responsibility of teams.
Incivility demonstrates disrespect. When this
type of behavior occurs, decreasing the escalation of
the behavior is critical. Many times, incivility occurs
Incivility in Healthcare from misunderstanding, so trying to talk about the
Work Environment issue—in a calm manner—is important. Students may
feel that they have no power. If the issue cannot be
Nurses work closely with physicians, and this worked out directly with those involved, all schools
relationship has a long history of conflict. Often should have a process for discussing difficult issues,
it is stereotyped as “us versus them,” which is an and these guidelines should be followed.
unhealthy approach. With the greater emphasis on Before you go to talk to the person (another
teamwork, nurses and physicians are slowly being student or faculty member) about the situation that
forced into improving their work relationships. This you found unacceptable, think about what you will
change in attitude really needs to begin at the student say and even practice before the discussion. Doing so
level. Organizations need to stand behind efforts will help you cope with your emotions because you
to improve team collaboration, coordination, and do not want to have a repeat of the uncivil behavior.
communication. One area that has received special Another method for dealing with verbal abuse is
attention is abuse—usually verbal—from physician to try to remove the emotion from the situation—
to nurse. Unfortunately, this is also a problem from step back for a breather and then discuss the issue
nurse to nurse—incivility or bullying among nurses or problem on a factual basis. This strategy may
is now found in healthcare organizations as well as require a third party to act as a neutral mediator in
in schools of nursing. the discussion. This is not easy to do when parties
In schools of nursing, incivility is found among are emotional and often tired and stressed, but it
students and faculty, in both student–faculty and does make a difference. Such an approach provides
student–student interactions. Students may also time to gain more objective perspective.
experience bullying with nurses during their clinical When students observe or are involved in un-
experiences or observe it. In 2008, the National Stu- civil encounters in clinical experiences, this has a
dent Nurses Association published an article about negative impact on their professional socialization
incivility in its journal (Luparell, 2008). Involvement and learning. Such behaviors are all connected to
in this type of behavior may lead to physical and communication, ability to compromise and listen,
emotional responses, even causing the victim to and respect and trust, which in turn affect the ability
to work collaboratively as a team member. Students of rage (Lower, 2007). One study sought to explore
begin to learn about healthy interactions with others the impact of work relationships on clinical outcomes
when they are students, lessons that should then (Rosenstein & O’Daniel, 2005). This research was pub-
be carried into their practice to reduce incivility lished in a nursing journal, although a physician and a
in the workplace. healthcare administrator conducted the study. This was
Organizations associated with health care have a follow-up to an earlier study that examined the
made statements about the problem of incivility. impact of disruptive behavior on job satisfaction and
In 2008, The Joint Commission issued a sentinel retention (Rosenstein, 2002). In the 2005 study, 1,500
alert on incivility for its accredited healthcare surveys from nurses and physicians were evaluated.
organizations. As the problem increased, the Nurses were reported to exhibit disruptive behavior
Commission now requires that these healthcare as frequently as physicians. Both groups felt that
organizations have standards in place to address disruptive behavior (which included verbal abuse)
this type of behavior. The American Association of negatively affected relationships and created stress,
Critical Care Nurses also issued a statement about leading to frustration, lack of concentration, poor
healthy work environments (American Association communication, and inability to effectively collab-
of Critical Care Nurses, 2005; Dixon, 2008). The orate and provide effective information transfer in
ANA published a position statement on incivility the workplace. Given that this chapter discusses the
in the workplace. It emphasizes the ANA Code need for greater use of effective interprofessional
of Ethics as a base for preventing and resolving teams to provide quality, patient-centered care, it
incivility so that the workplace is one in which is easy to see how these results may be perceived as
healthcare organizations can “create an ethical disturbing. The participants also felt that disruptive
environment and culture of civility and kindness, behavior was adversely affecting patient safety, patient
treating colleagues, coworkers, employees, students, mortality, the quality of care, and patient satisfac-
and others with dignity and respect” (ANA, 2015b, tion. These concerns further emphasize the need to
p. 4). The position statement examines incivility, improve teamwork and professional relationships.
bullying, and violence in the workplace (ANA, The researchers recommended that organizations
2015c). All of this affects nursing practice. It also should take the following steps to improve work-
has financial ramifications because incivility reduces place relationships beginning with an assessment
productivity and may have a negative influence on to determine the extent of the problem and sharing
staff retention as well as recruitment. This all can results with staff (Rosenstein & O’Daniel, 2005). The
lead to health problems for nurses and interfere HCO needs to support open, safe communication
with career development. among all staff members. To ensure this occurs staff
Concern has also emerged about the impact of require education about the problem of disruptive
verbal abuse and disruptive behaviors among team behavior and how to respect and communicate with
members on patient care. Examples of disruptive one another even during stressful situations. HCOs
behaviors include verbal abuse, negative behavior, must ensure that collaboration, communication,
and physical abuse (for example, profanity, innu- teams and teamwork, and conflict management are
endo, demeaning comments); reprimanding or part of the culture and also included in staff ongoing
insulting another person in public and inappro- education. To augment these strategies policies and
priately; threatening; telling racial or ethnic jokes; procedures need to be developed and effectively
undermining team cohesion; scapegoating; silence implemented to guide staff in their actions.
(not speaking to a team member); and assaulting All of these organization strategies should
another person, throwing objects, and outbursts promote better patient care and clinical outcomes.
There are also strategies that individual staff fault when, in fact, they are not. Many nurses enter the
should consider to respond or reduce incivility. profession with a negative attitude toward physicians
Gessler, Rosenstein, and Ferron identify examples and feel that they do not want to be controlled by
of these strategies (2012, p. 11): physicians. The better approach is for new nurses to
enter the profession with a positive attitude toward
■■ Be assertive and confront the person(s) who
nursing as a profession, be knowledgeable about
is involved in the uncivil behavior.
the nursing role and responsibilities, be compe-
■■ Use “I” language when talking to the involved
tent, and possess a reasonable level of self-esteem.
person(s).
Nurse–nurse incivility is all too prevalent and a
■■ If direct conversation about the situation
serious problem; thus the problem involves more
does not work, then staff should report the
than just nurse–physician incivility. What is needed
occurrence as expected in the organization
to prevent incivility is someone who wants to work
process. Identify critical information such
with others, not against others, and someone who
as date, time, who was involved, and what
approaches issues and problems with an open mind
occurred.
and who is not tied to an “I know better” mindset.
Many organizations now have zero-tolerance If all healthcare professionals approached practice
policies related to this type of abuse. Some healthcare in this manner, then collaboration, coordination,
organizations, as well as schools of nursing, have and communication would improve. There would
identified codes of conduct that staff or, in the case also be less incidence of verbal abuse, and the work
of a school of nursing, faculty, students, and staff environment would be positive and healthy for all
are expected to follow (Lewis & Malecha, 2011). team members.
However, the existence of a written policy does not
guarantee on its own that attitudes and behaviors
will automatically improve. Staff need to know about Stop and Consider #8
Incivility in the healthcare workplace is a major problem.
the policy content and the consequences of violating
the policy, and these consequences must be applied
when necessary. Some healthcare organizations
are using the term “Code Pink” (Trossman, 2014). Delegation
Nurses who are experiencing incivility use the code
to alert others to these negative experiences and Delegation is part of daily work of nurses. Care is
ask for support. It is important for staff to have a planned and coordinated to meet patient needs, but
structured method to ask for help. Nursing leaders at some point the registered nurse (RN) may need to
as well as other leaders in the organization need delegate work to others. Much of the work is done in
to commit to reducing these problems (Lewis & a team model, in which it is not cost-effective for all
Malecha, 2011). In addition, as noted earlier, this care to be provided by the RN. Delegation involves
is not just an issue for the workforce. As noted in giving another staff member the responsibility and
this content, students experience incivility, and they authority to complete a task or activity. Before an
also need to know how to cope with it when they RN can delegate, the RN needs to have responsibility
enter the workforce. Given these concerns, the ANA and authority, or the power over the activity or task.
has resources for nurses and students on its website An RN cannot delegate something that is outside
(ANA, 2014). approved nursing practice as determined by the nurse
In summary, it is very easy to say that poor at- practice act in the state where the nurse practices.
titudes and abusive behaviors are all the physicians’ An extreme example is that an RN cannot delegate
prescriptive authority (prescribing of medications) for the actual action or activity, whereas the person
because an RN typically cannot do this activity. who made the assignment is responsible for the
An advanced practice registered nurse may have assignment decision.
prescriptive authority because this nurse has met
special requirements and the state allows it, but even
Importance of Delegation
this nurse cannot delegate prescriptive authority.
When an RN delegates to another staff member, Why is delegation important, and why is it part of
such as unlicensed assistive personnel (UAP) care coordination and teamwork? One RN or one
or a licensed practical nurse/licensed vocational team member cannot always do everything that is
nurse (LPN/LVN), the RN is not avoiding work required for a patient. There must be effective use
and is still held accountable for the outcomes, but of staff resources—expertise and time. Delegation
the care is provided in a more efficient manner. is a critical part of providing cost-effective, quality
Accountability is “being responsible and answer- care. In some situations, it is more cost-effective if
able for actions or inactions of self or others in the care can safely be provided by a UAP or a licensed
context of delegation” (ANA, NCSBN, 2006). The practical nurse, whose salary is lower than that of
UAP is an unlicensed staff member who is trained an RN, with the RN providing overall supervision.
to function in an assistive role to the licensed nurse Quality care requires that patient outcomes be
in the provision of patient activities as delegated by achieved with no harm to the patient. Through
the nurse. The UAP may have several different titles, delegation, the RN determines the tasks that should
such as nursing assistant or nurse’s aide. There is no be done, by whom, when, and how.
national standard that is accepted and enforced in Communication and information are critical
every state as to employment requirements, training, elements of delegation. If communication is not
or position descriptions for the UAP. The RN (the effective or there is inadequate information, dele-
delegator) is still responsible for supervising the gation may then be ineffective. This can in turn lead
work (activity, task) that the other staff member to problems for the patient and interfere with the
(the delegatee) is to do. team’s ability to achieve the desired patient outcomes.
Supervision and assignment may be confused It is often difficult to provide clear communication
with delegation; however, they are related to one in rushed, stressful healthcare environments, but
another. When a nurse is monitoring patient care doing so has never been more important if care
and work performance, this is supervision. The nurse is to be improved. Mindfulness—staying alert to
may be in a formal management position, such as a key information and evaluating and updating that
nurse manager, a team leader, or an RN staff nurse information as necessary—is an active process that
who has delegated work and then ensures that a can improve communication during delegation,
task is done effectively. Assignment is the process as discussed earlier. The goal is not to share as
that moves an activity from one person to another, much information as possible, but rather to share
including the responsibility and accountability. For the critical information—that is, information that
example, the nurse manager might assign an RN has meaning in the situation. Anthony and Vidal
to lead a team or to administer medications to the (2010) comment, “When mindful communication
patients. An assignment can be given only to staff is integrated as a principle of delegation, it involves
that have the required qualifications to complete the more than knowing the facts regarding the care plan.
task and can assume the responsibility and account- Mindful communication practice is recognizing
ability; however, the accountability is still shared. the significance of the facts and how they pertain
The person doing the activity has the accountability to the patient situation. When nurses engage in
mindful communication, information processing complete a task. In some cases, the RN may
is redirected, resulting in a unique set of decisions decide that because of the critical status of the
and actions. Historically, RNs have relied on job patient and the need for intensive interaction
descriptions and delegated skills lists to guide dele- and assessment, the RN should complete the
gation practices . . . hospitals value standardization bed bath; alternatively, the RN may decide that
as a means to improve safety through consistent the UAP is best suited to handling this task.)
practices. Paradoxically, however, overreliance on ■■ The delegatee must then do something—this
standards that results in routine interpretations action is specific and attached to a specific
and behaviors may jeopardize patient safety when situation. (For example, the UAP completes
nurses do not engage in mindful communication the bed bath for a patient, documents the care
about the task at hand.” if required, and informs the RN that there
The National Council of State Boards of Nursing was nothing unusual to report.)
(NCSBN) has identified delegation standards and
described the delegation process. The NCSBN defines Five Delegation Rights
delegation as “transferring to a competent individual
authority to perform a selected nursing task in a se- It is natural to wonder who is responsible for the
lected situation. The nurse retains the accountability care in delegation. The delegatee is responsible for
for the delegation” (ANA, NCSBN, 2006). the care that the delegatee provides or the delegatee
This definition really says the following: performance, and the delegator is responsible for
the delegation process. This process is not a simple
■■ Transferring means the RN can do something one and requires experience. The RN must consider
that will be passed on to someone else to do. the five rights of delegation (ANA, NCSBN, 2006).
The RN has the right to do transfer tasks; ■■ Right task: The task must be delegatable for
however, the RN cannot delegate something a specific patient or situation. If the RN or
that the RN has no right to do as an RN. (For delegator is not clear about what the task is,
example, suppose a patient needs a bed bath. the RN will not be able to clearly identify
The RN can do the bed bath, but it is more what needs to be done and by whom.
efficient to have the UAP complete the bed ■■ Right circumstances: The appropriate setting,
bath while the RN assesses the patient’s overall available resources, and other relevant factors
status at the beginning of a shift.) need to be considered. Perhaps the RN needs
■■ The RN transfers this activity to a competent to tell the delegatee where to complete the
person—someone who can complete the task and identify which supplies, equipment,
task because that person has the skills and and other resources are needed to complete
experience to do so. (For example, the UAP the task effectively.
has been trained to give bed baths and report ■■ Right person: The right person delegates the
to the nurse any problems encountered.) right task to the right person, to be performed
■■ In the delegation process, the delegator or by the right person. The RN must consider
RN is giving the delegatee the authority or the best staff member to complete the task
power to do the act or task. (For example, (type of staff, experience and skills, availability
RNs have overall responsibility and authority of time to complete task without negatively
for all nursing care—from basic care, such as impacting other work, and so on).
a bed bath, to complex care needs. The RN ■■ Right direction/communication: Providing a
determines who is the best staff member is to clear, concise description of the task, including
its objective, limits, and expectations, is part Right task

of effective delegation. The delegator must
explain to the delegatee what is to be done,
how to do it (if that is not already clear), the Right supervision/ Right
evaluation circumstances
time frame, outcomes, and so on. The delegatee
needs to feel comfortable asking questions for
clarification or expressing concern about the
delegatee’s inability to complete the task. The
delegator must be an effective communicator Right directions/ Right
and must be sensitive to concerns and issues communications person
to establish a communication environment

that allows for open discussion. This is crit-
ical to ensure patient-centered care that is Figure 10-6 Five Rights for Effective Delegation
focused on quality. If the delegatee is afraid
of speaking up and saying, “I do not know in delegating and how well the delegator knows the
how to do something” or “Would you explain delegatee. New RNs may be very nervous about
more about what you want done?” then this delegating; trusting another person to complete
is an ineffective delegation process that may a task can be risky. Some new RNs may be overly
harm the patient. The delegatee may need concerned because they feel that they could per-
help in organizing work and setting priorities, form the task better. In both situations, the result
or the delegatee may need to be told what to could be excessive hovering or overmonitoring; the
report to the RN and when. The delegator delegatee may interpret the delegator’s behavior
needs to ask directly if there are questions or attitude as indicating a lack of confidence in
or concerns and be open to the response. All the delegatee. This message can have a negative
of this is part of providing clear directions impact on team relationships. Finding the right
and guidance. balance takes experience. New RNs need time to
■■ Right supervision: Appropriate monitoring, learn how to delegate effectively and need to seek
evaluation, intervention (as needed), and guidance from their own supervisors or mentors to
feedback are part of delegation. The RN as assess their delegation competencies. Figure 10-6
a delegator does not just delegate a task and highlights the five delegation rights that all who
then forget about it. Instead, the RN needs to delegate need to apply.
supervise as required. Monitoring methods
include observation, verbal feedback, written
Delegation Principles
feedback, and review of records in which
the delegatee documents what was done. The American Nurses Association (ANA) and the
In some situations, supervision is minimal; NCSBN collaborated to identify the key delegation
in other situations, there may be a greater principles that should be applied by every RN (ANA,
need for monitoring. Factors such as the NCSBN, 2006, pp. 2–3):
expertise of the delegatee, the patient’s status,
the complexity of the task, and timing may ■■ The RN takes responsibility and accountability
all affect the monitoring process. for the provision of nursing practice.
■■ The RN directs care and determines the ap-
Another factor that cannot be ignored during propriate utilization of any assistant involved
delegation is how comfortable the delegator feels in providing direct patient care.
■■ The RN may delegate components of care It is important for the RN, as the delegator, to
but does not delegate the nursing process thank the delegatee and recognize the work that the
itself. Nursing judgment cannot be delegated. delegatee has done. The RN should provide positive
■■ The decision of whether to delegate or assign feedback when work is done well and constructive
is based on the RN’s judgment concerning feedback as needed; the RN should not criticize work
the condition of the patient, the competence negatively, but rather discuss the work and outcomes
of all members of the nursing team, and the and make recommendations for improvement. It is
degree of supervision that will be required easy to take things for granted and not recognize the
of the RN if a task is delegated. work of team members. It really takes little time to
■■ The RN delegates only those tasks that the RN give positive feedback and a “thank you,” and this
believes the other healthcare worker has the step can go a long way toward building teams and
knowledge and skill to perform, taking into individual staff competence.
consideration training, cultural competence, Will there be times when the RN as delegator must
experience, and facility/agency policies and change a decision about delegation? If so, why would
procedures. this occur? In the monitoring process, the delegatee
■■ The RN individualizes communication may ask for help. The RN needs to listen to this request
regarding the delegation to the nursing and intervene. There may be times when the patient’s
assistive personnel and patient situation, condition changes, and someone else, including the
and the communication is clear, concise, RN, may be better suited to complete the task. The RN
correct, and complete. The RN verifies may recognize that the delegatee is not as qualified to
comprehension with the nursing assistive complete the task as originally thought. The RN must
personnel and ensures that the assistant be aware of the need to avoid being negative, hurting
accepts the delegation and the responsibility the delegatee’s self-confidence, or embarrassing the
that accompanies it. delegatee in front of others. How the RN communi-
■■ Communication must be a two-way process. cates and intervenes can make the situation a positive
Nursing assistive personnel should have the learning experience for the delegatee. In addition, the
opportunity to ask questions and clarify RN must recognize the impact on the patient—how
expectations. the patient views the change of assignment and if the
■■ The RN uses critical thinking and professional patient wonders what is going on.
judgment when following the five rights of Supervision is a critical part of delegation. The ANA
delegation. and the NCSBN have similar definitions of supervision.
■■ Chief nursing officers are accountable for The ANA defines supervision as the “active process
establishing systems to assess, monitor, ver- of directing, guiding, and influencing the outcome
ify, and communicate ongoing competence of an individual’s performance of a task” whereas the
requirements in areas related to delegation. NCSBN defines it as “the provision of guidance or
■■ There are both individual accountability and direction, oversight, evaluation and follow-up by the
organizational accountability for delegation. licensed nurse for the accomplishment of a delegated
Organizational accountability for delegation nursing task by assistive personnel” (ANA, NCSBN,
relates to providing sufficient resources.* 2006). It is important to note that supervision does
not necessarily mean that the RN is in a management
position. RNs who are not in management positions
must also supervise when they delegate. Figure 10-7
*© American Nurses Association (ANA) and National Council
of State Boards of Nursing (NCSBN). Reprinted with permission. describes the decision tree for delegation that should
All rights reserved. be applied by staff when using delegation.
Step One — Assessment and Planning
If not in the licensed nurse’s scope of practice, then

Are there laws and rules in place that support No cannot delegate to the nursing assistive personnel
the delegation? (NAP). Authority to delegate varies, so licensed nurses
must check the jurisdiction’s statutes and regulations.
Yes
No
Is the task within the scope of the delegation nurse? Do not delegate.
Yes
Has there been assessment of the client’s No Assess client needs and then proceed to a
needs? consideration of delegation.
Yes
Is the delegating nurse competent to make No Do not delegate until you can provide and document
delegation decisions? additional education, then reconsider delegation;
otherwise do not delegate.
Yes
Is the task consistent with the recommended criteria

for delegation to Nursing Assistive Personnel (NAP)?
Must meet all the following criteria:
• Is within the NAP range of function
• Frequently recurs in the daily care of a client or
group of clients;
• Is performed according to an established sequence No
of steps; Do not delegate.
• Involves little or no modification from one client-care
situation to another;
• May be performed with a predictable outcome;
• Does not inherently involve ongoing assessment,
interpretation, or decision-making which cannot be
logically separated from the procedure(s) itself; and
• Does not endanger a client’s life or well-being
Yes
Does the nursing assistive personnel have the appropriate Do not delegate until evidence of additional
No education and validation of competency
knowledge, skills, and abilities (KSA) to accept the delegation?
available, then reconsider delegations;
Does the ability of the NAP match the care needs of the client? otherwise do not delegate.
Yes
Are there agency policies, procedures, and/or No Do not proceed without evaluation of need for policy,
protocols in place for this task/activity? procedures, and/or protocol or determination that it is
in the best interest of the client to proceed to delegation.
Yes
No
Is appropriate supervision available? Do not delegate.
Yes
Proceed with delegation
Figure 10-7 National Council of State Boards of Nursing Decision Tree for Delegation to Nursing Assistive
Personnel
Reproduced from American Nurses Association and National Council of State Boards of Nursing. (2006). Joint statement
on delegation. Retrieved from https://www.ncsbn.org/Delegation_joint_statement_NCSBN-ANA.pdf
336
Establish what needs to be done, and then

Evaluation of Effective ■■
provide support to the employee so that

Delegation the employee can decide how to effectively
How does the RN evaluate delegation? The first fo- accomplish the activity or task.
cus is the role of the delegator. Were the right tasks
The focus of this discussion thus far has been
delegated, and why were they delegated? The second
on RNs delegating to other nursing staff—staff that
concern is the directions. Were the directions clear?
are not RNs. It is important to recognize that RNs
The RN should consider to whom the task was del-
may assign work or tasks to other RNs. A team may
egated and the delegatee’s strengths and limitations.
include several RNs, and one may be the team leader.
Did the delegatee have the resources to complete the
The nurse manager or nurse coordinator of a unit
task? Did the delegatee have the time to complete
assigns work to RN staff routinely.
the task? What impact did performing the specific
Effective delegation takes practice; it does not “just
task have on other responsibilities that the delegatee
happen.” There are barriers to delegation. Staff may
may have had? Did the delegatee have the authority
be uncomfortable with delegating and with criticism,
to complete the task? Were the expected outcomes
depending on whether they are the delegator or the
met? Was the delegator available to the delegatee if
delegatee. This can interfere with effective delega-
questions arose or problems occurred? This avail-
tion and positive outcomes. RNs typically delegate
ability is more than just physical; it concerns not only
to UAPs. Consequently, RNs need to know about
whether the delegatee is able to reach the delegator,
UAP roles and job responsibilities. UAPs cannot do
but also whether the delegator is able to listen and
the following or be delegated these activities: health
hear the delegatee and then respond effectively.
counseling, teaching, and activities that require
RNs want to be effective delegators, and all new
independent, specialized nursing knowledge, skills,
RNs struggle with how to delegate. The following
or judgment. The ANA (1997) identified the UAP
are some characteristics of effective delegation
direct and indirect patient care activities as follows:
(Milgram, Spector, & Treger, 1999, p. 245):
■■ Do not give employees just menial tasks; ■■ Direct patient care activities assist the patient
include tasks that offer opportunities for in meeting basic human needs (settings
learning and growth. may be hospitals, home, long-term care,
■■ Distribute tasks with an understanding of and other). Activities include assisting with
each employee’s position description and job feeding, drinking, ambulation, grooming,
status, abilities, and total workload. toileting, dressing, and socializing. Collection,
■■ Delegate when there is someone skilled avail- reporting, and documentation of data related
able or when the task can be completed by to these activities are important. UAPs need
a subordinate whose time is less expensive. to report data to RNs; data then are used to
■■ Use benchmarks to monitor progress along make clinical judgments about patient care.
the way; having only a final deadline can be ■■ Indirect patient care activities support the
overwhelming. (This applies to activities or patient and the patient’s environment, such as
tasks that take a longer time to complete.) providing a clean, efficient, and safe patient care
■■ Do not micromanage subordinates. Expe- milieu. Activities might include companion
rienced employees usually have the skills care; simple meal preparation; housekeeping;
necessary for managing complex tasks on providing transportation; and clerical, stocking,
their own (particularly if the tasks are typi- and maintenance tasks. Many of these activ-
cally done by them). ities would take place in the patient’s home,
where UAPs may be working one-on-one

with patients through a home health agency Stop and Consider #9
Effective delegation is not easy to learn.
or some type of community agency.
Generally, tasks that can be delegated are those
that have the following characteristics (ANA,
NCSBN, 2006): Change
■■ Frequently occur
■■ Are considered technical by nature Change can be discussed in relation to changes in
■■ Are considered standard and unchanging the healthcare delivery system, but change is also a
■■ Have predictable results part of collaboration and coordination, which are
■■ Have minimal potential for risks difficult to accomplish without some change; change
may be required from an individual team member,
Figure 10-8 illustrates the key to delegation and
the entire team, a unit, or the organization. Patients
highlights the key aspects of delegation.
are asked to change all the time. Why do team mem-
bers often not like change? They may be fearful of
the results, particularly of the unknown; they may
fear losing something of value, such as control, job
KNOW YOUR WORLD
• Practice responsibility, and so on; or they may have a belief
• Organization that change will not make things better. The other
KNOW YOURSELF view of change is its potential as an opportunity for
• Barriers
• Benefits improvement. Sometimes, however, change does not
lead to positive outcomes. This situation has to be
KNOW WHAT NEEDS dealt with, but not changing means stagnation and
TO BE DONE lack of improvement. The change process includes
• Professional
• Technical the following steps:
• Amenity ■■ Identify the issue or problem/need for change
• Based on outcomes
and factors that influence the need for change.
■■ Engage staff when possible in the planning
process.
■■ Gather information to better understand the
KNOW YOUR COMMUNICATE need and possible solutions.
DELEGATE • Initial direction
• Competency • Parameters for ■■ Identify stakeholders and barriers to and
• Motivation follow-up support for the change.
■■ Describe solutions to solve a problem or to
improve one.
FEEDBACK/ RESOLVE ■■ Select the solution to implement.
EVALUATE CONFLICT
• Who • Where • Collaboration ■■ Prepare staff for the change (inform them
• What • When • Resolution about the change, the reasons for the change,
the timeline, planning and implementation,
and training staff if needed; engage them in
Figure 10-8 The Key to Delegation the implementation).
Reproduced from Hansten, R., & Jackson, M. (2004).
Clinical delegation skills: A handbook for professional
■■ Implement the change (the solution).
practice. Burlington, MA: Jones & Bartlett Learning. ■■ Evaluate the results (including staff feedback).
■■ Determine whether any adjustments are

needed (ongoing); ideally, include relevant Stop and Consider #10
Change can be positive or negative.
staff early in the process to enhance staff
commitment.
The plan–do–study–act (PDSA) cycle is
used more today by healthcare professionals and Conflict and Conflict
teams to assist in decision-making, make changes, Resolution
and ensure better coordinated care (IHI, 2011b).
This cycle is used to test changes. During the first Conflict is inevitable; however, what is important
step (plan), the team identifies the objective(s) is how it is handled. In many cases, conflict can be
and discusses predictions as to what might prevented. It is natural for misunderstandings to
happen and why; the team then develops a plan occur among people who work together, such as in
to implement the change. In the next step (do), teams. Often, causes of conflict relate to whether
the team institutes the change and collects and resources are shared equitably, insufficient explana-
analyzes outcome data. In the third step (study), tion of expectations, questioning someone’s perfor-
there is more in-depth analysis of the outcome mance, unexplained changes that disturb routines
data and relationship to the problem. In the last and process and for which team members are not
step (act), the change may be modified and then prepared, and stress resulting from changes that
fully initiated. team members do not understand and may see as
What methods can be used to decrease bar- threatening or ineffective. Each of these causes can
riers to change and increase team involvement in be prevented from developing into conflict. Engag-
change? Explanation and education about the issue ing in clear, timely communication and including
or problem and the need for change is the first step. team members in the process can reduce conflict.
Including team members in the discussion about There is another cause of conflict that is more
the need for change and possible solutions allows difficult to manage: an individual’s personal responses
members to buy into the change process. They and behavior that may increase team conflict. Ex-
will participate more fully and be more invested amples include the team members who do not do
in the results. Change is stressful; this stress needs expected work, are late to meetings, do not listen to
to be recognized, and when possible, implement others, complain, are overly critical of others, do not
interventions to reduce stress. Experiencing too know how to communicate effectively, want to be the
many changes at one time or too quickly can make star and take all the credit, and so on. Figure 10-9
effective change difficult. Sometimes there are describes a conflict flowchart that can be applied to
situations in which change is dictated. When this better understand what happens during a conflict.
occurs, team members still need an explanation and Conflict resolution requires leadership and
should be included in the change process. Asking participation from team members. When difficult
for feedback and listening are important. Change issues or problems arise, it is best to deal with them
is risky—and sometimes it will fail. Teams need to rather than postpone decisions (which usually means
learn from their errors and ineffective decisions that the problem has time to get worse). Using
and then move on. Effective collaborative teams threats and negativity with little positive feedback
do not place blame on individuals; rather, they can lead to more conflict, so these approaches need
look at results in an objective manner and realize to be avoided. Listening can go a long way toward
that the team works together and sometimes can preventing conflict, and if conflict does occur, re-
make mistakes. solving it. When team members treat one another
SOURCES OF CONFLICT
• Ambiguous jurisdiction
• Conflict of interest
• Communication barriers
• Dependence of one party
• Association of the parties
• Behavior regulations
• Unresolved prior conflicts
CONFLICT
Resolution Resolution
INAPPROPRIATE COLLABORATIVE
Techniques Techniques
NEGATIVE OUTCOMES BENEFICIAL OUTCOMES

• Destructive behaviors • Better patient care
• Hostility • More open relationships
• Professional stereotyping • Personal growth
• Negative gossip • Improved communication
• Burnout • Improved and innovative systems
• Lack of professional growth • Staff satisfaction
• Frequent job changes • Professional growth
• Lack of collaboration among • Collaboration
professionals, increasing use of • Patient satisfaction
resources and suboptimal care • Better use of resources
• Length-of-stay (LOS)
Figure 10-9 Conflict Flowchart

Reproduced from Hansten, R., & Jackson, M. (2004). Clinical delegation skills: A handbook for professional practice.
Burlington, MA: Jones & Bartlett Learning.
with respect and communicate clearly, conflict can to temper their emotional reactions. However,
be decreased. Respect means to recognize another’s the issue needs to be resolved, so this time period
right to have opinions and listen and discuss these needs to be monitored—it should not go on too
opinions. Nonverbal communication can give im- long. Sometimes one or two members need to be
portant clues as to when conflict is increasing. When persuaded to reexamine the issue. This effort may
teams or individual members experience stress, the or may not be successful. Teams need to understand
risk of conflict increases. Open communication is key that individual team members do not always get
to resolution of conflict, and it is key to preventing their viewpoint accepted by all. Compromise is
conflict when possible. required; however, when this occurs, it must be
When conflict occurs, it is important to provide done in a manner that respects divergent opinions
opportunities to identify the facts, determine the and does not use negativity or reduce self-esteem.
purpose of the actions or activities at the time, and All of these facets of conflict resolution require
review team member perspectives. When members leadership—on the part of the designated team
are emotional, this factor can interfere with effective leader and from the members who commit to the
resolution, so sometimes the best first approach is to team and its effectiveness. Figure 10-10 describes
step back and allow some time for all parties involved a collaborative resolution method.
Use of describe–express–suggest–consequences
(DESC) is an example of a structured approach to Power and Empowerment
address a conflict (O’Keefe & Saver, 2014, p. 12).
As people work together, the issue of power arises.
The goal is to arrive at consensus and keep the
Simply put, power can be described as when health-
discussion on track. The DESC script includes the
care provider A wants something that healthcare
following elements:
provider B has and may or may not need or want as
■■ Describe the specific conflict situation or much; healthcare provider B then has more power
behavior using concrete data. in the relationship. Typically, there is not a balance
■■ Express how the situation made you feel or of power in a team, particularly when it is first
identify your concerns. formed. This is most commonly seen with nurses
■■ Suggest alternatives and seek agreement. and physicians; physicians typically have more power
■■ State consequences in terms of effects on because of their profession, experience, and history.
team goals; strive for consensus. This balance, however, can shift and should change
as the team develops, with members recognizing
one another’s value and experience. Nevertheless, an
Stop and Consider #11 imbalance can be difficult to overcome and makes
Nurses encounter conflict in the workplace.
the work situation stressful.
How a person feels about his or her work and
job has an impact on how that person functions
on a team. Herzberg’s theory, as described in
SHIFT YOUR FOCUS.
What is good about this issue?
Figure 10-11, identifies job maintenance factors
Separate the person from the problem.
Determine exactly what you want.
Job maintenance factors

CREATE A POSITIVE OPEN ATTITUDE.
(extrinsic factors)
Listen and restate what the other party
• Job security
wants.
• Salary and benefits
Be certain he or she feels heard.
• Supervision
Reflect and respect feelings expressed.
• Status
• Working conditions
STATE YOUR PERCEPTION. • Policies and administrative
Use assertive language. practices
Express what it is you want from a
factual viewpoint. Satisfactory level 5 Unsatisfactory level 5
Determine what you are willing to do, or Hygiene factors Dissatisfied
give up, to get what you want. Work gets done and Work does not get
improves done or improve
ESTABLISH MUTUAL GOALS.
Determine what the other party is willing to Motivators to improve
do, or give up, to get what he or she wants. performance
Propose a solution that reflects your (intrinsic factors)
understanding of both parties’ needs/desires. • Responsibility
Summarize each party’s agreed-on actions. • Advancement
• Recognition
• Achievement
Figure 10-10 Hansten & Washburn’s • Growth
Collaborative Resolution Method
Reproduced from Hansten, R., & Jackson, M. (2004).
Clinical delegation skills: A handbook for professional Figure 10-11 Herzberg’s Theory on Job
practice. Burlington, MA: Jones & Bartlett Learning. Satisfaction
Exhibit 10-3 Types of Power
Type of Power Description

Legitimate/formal power Power that originates from serving in a formal position (for
example, a team leader, nurse manager, or chief nursing officer).
Referent/informal power Power that originates from others’ recognizing that an individual
has leadership qualities and choosing to follow that person.
Informational power Power that originates from information a person has and others
need.
Expert power Power that originates from a person’s expertise, which can be
useful to others and enable the person to provide guidance (for
example, a nurse clinical specialist).
Reward power Power that originates from a person’s ability to reward others (for
example, the ability to grant a salary increase, promotion, or assign
an interesting project) if they agree to do something.
Coercive power Power that originates from a person’s ability to punish others (for
example, the ability to assign an unpleasant task or project, or
deny a promotion) if they do not do what is asked.
or extrinsic factors that influence job satisfaction; and the nursing process” (pp. 54–55). Exhibit 10-3
however, there is more to job satisfaction than these describes the types of power.
hygiene factors, as Herzberg calls them. The motivator Empowering teams means that the leader
factors (intrinsic factors) must also be considered. of the team needs to be less assertive over time
Herzberg suggested that because of these factors, and gradually allow the team to lead itself. The
organizations that increase accountability, create team needs to find the best solutions by using the
teams, remove controls, provide feedback, introduce expertise of all the members and then assuming
new tasks, allocate special assignments, and grant more leadership. This actually strengthens the team
additional authority might increase staff motivation leader’s leadership—with the result of better team
(Michalopoulos & Michalopoulos, 2006). Staff may outcomes. Power and empowerment are discussed
then feel increased personal achievement and more in other content in this text, particularly in content
empowerment. The same authors noted that the related to nursing leadership.
factors to increase staff motivation are part of the
need for nurses to “increase responsibility, control
over their work, and the opportunity to use their own Empowerment allows you to practice fully as a nurse.
initiative, all of which are offered in team nursing
CHAPTER HIGHLIGHTS
1. The essential features of the interprofes- 11. A clinical protocol or pathway is a written
sional team include examination of self as it guide that provides direction for specific
relates to the team effort, interprofessional clinical problems; considers the interven-
communication and conflict resolution, and tions, timeline, and resources needed; and
the impact of the team’s efforts on quality, identifies expected outcomes—improving
safety, patient-centered care, and overall care coordination.
delivery of care. 12. Incivility in the healthcare workplace is a
2. Healthcare professional education takes place growing problem.
in isolation, with each healthcare profession 13. Delegation refers to the process of trans-
providing its own education with limited ferring responsibility for a task to another
regard to other healthcare professionals. person. The person delegating must have
This has limited the development of effective the authority to transfer this task; the task
interprofessional teams. must then be handed off to someone whose
3. A team leader must first recognize that it is scope of responsibilities includes this work.
the work of the team that is critical and avoid There are five rights of delegation: right task,
focusing on personal success as a leader. right circumstances, right person, right
4. Communication is the sharing of a message direction, and right supervision.
between one person or team/group and an- 14. Change is part of collaboration, coordination,
other. It is important to know if the message and teamwork, which are difficult to accom-
was received as sent. Interpretation plays plish without some change; change may be
a major role in effective communication, required from an individual team member,
and sometimes interpretation confuses or the entire team, a unit, or the organization.
changes the original message sent. Practices The plan–do–study–act (PDSA) cycle is one
such as SBAR and checklists help to reduce method for planning and implementing
communication problems. change that a team might use.
5. Formal meetings are an important part of 15. Causes of conflicts may relate to inequitable
teamwork. sharing of resources, insufficient explanation
6. Listening is critical to effective communication. of expectations leading to performance
7. Team members need knowledge and com- being questioned, unexplained changes
petence that assist them in being effective that disturb routines and process and for
team members. which team members are not prepared,
8. Teams participate in decision making. and stress resulting from changes that team
9. Collaboration means that all people involved members do not understand and may see
are listened to and that decisions are devel- as threatening. Resolving conflict requires
oped together—interprofessionally. Effective leadership and participation from team
teams value openness and collaboration. members.
10. Coordination—working to see that the 16. Empowering teams means that the leader
pieces/activities fit together and flow as they of the team must be less assertive over time
should—can help to meet desired patient out- and allow the team to lead.
comes and is part of interprofessional teams.
1. Explain the healthcare core competency 4. Why is coordination a key activity of a clinical
“work in interprofessional teams.” Why is interprofessional team? Of a nursing team?
this issue important to address in healthcare 5. Explain the communication process.
education? What is its impact on practice? 6. Discuss the five delegation rights. How
2. What is a team? How does it function? would you apply them in clinical?
Would a nursing team and an interprofes- 7. What is conflict resolution? How can conflict
sional team function differently? If so, how? be prevented?
3. How does collaboration influence team
effectiveness?
1. For a week, keep a log of your critical com- 4. Have you been a member of a team/group
munications. Note who was involved in the or in a work situation in which there was
communication, the context or situation in conflict? Describe the situation (does not
which it occurred, the time of day and day have to be a clinical situation), the events
of the week, the message, the effectiveness that occurred, your role in the situation, and
of the communication, and what could have the resolution. How did you feel about the
been done to improve communication. experience? Could something have been
Compare four communication examples done to prevent the conflict? Were you sat-
from your log. Identify examples of team isfied with the resolution? If not, what could
coordination and collaboration. have improved it?
2. Make a list of what you want to improve in 5. View the video on incivility in the workplace:
your communication. What strategies might http://www.youtube.com/watch?v=NujWmw8z7sg
you use to improve your communication? Then identify three things you learned from
3. Why do you think delegation might be easy the video that you found helpful. Discuss
or difficult for you as an individual? in teams.

Describe your opinion of incivility in the healthcare workplace. Have you observed it or
experienced it? What was your reaction?
CASE STUDIES
Case 1
A 70-year-old man in very good health experiences a syncopal episode after standing
unsupported for 20 minutes. His pulse was 46 and color ashen with circumoral cyanosis.
Paramedics were called, and he was taken to the nearest emergency department. After
extensive tests and 3 weeks of home monitoring, it was determined that the patient
needed a pacemaker. Following the pacemaker insertion, it was determined that his
cholesterol was elevated, and he was started on medication. The patient stated that he had
been put on statins once before by his primary care physician and was not able to tolerate
them. This time, the medication was to be closely monitored.
One month following his pacemaker insertion and the start of this medication, the
patient saw his primary care physician. The physician went over his lab tests, for which
samples were drawn before the visit. When the patient asked about his cholesterol, he was
told that no lipid levels had been measured. When the patient further asked about the
report on his pacemaker surgery, the physician replied that he had no report.
This case presents a lack of care coordination, a lack of effective communication
among team members, and potential for error, resulting in patient safety and quality-of-
care issues.
Case Questions
1. What could have been done to prevent the confusion that this patient experienced?
2. Where and when might errors have occurred?
3. How does this case reflect the need for interprofessional teamwork?
4. Have you or a family member experienced similar situations when receiving health care?
What happened? Now that you know more about teamwork and quality care, what is
your perspective of your experience?
Case 2
Examine the important topic of care coordination at the AHRQ website: https://www.ahrq
.gov/professionals/prevention-chronic-care/improve/coordination/index.html. Content and
presentations on the topic are provided on the site. You are preparing a presentation for
your unit’s next staff meeting.
Case Questions
Outline your presentation using the information from the website and information for this
chapter.
1. What are some examples of effective care coordination you have seen in your clinical
experiences that you might include in your presentation?
2. What are examples from your clinical experiences when you thought care coordination
should have been used that you might include in your presentation?

questions.
1. Why do we need to work together?
2. We work in teams all the time as nurses. You need to work in interprofessional teams, so
what do we need to do to accomplish this?
3. What are the 3 Cs we need to address?
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Chapter
11
Employ Evidence-Based
Practice
CHAPTER OBJECTIVES
■■ Discuss the core competency: Employ ■■ Compare and contrast evidence-based
evidence-based practice. practice, research, and quality improvement.
■■ Discuss the relevance of nursing research. ■■ Discuss importance of evidence-based practice
■■ Discuss the relevance of evidence-based for the nursing profession.
practice and its process. ■■ Examine the impact that evidence-based
■■ Compare and contrast evidence-based practice has had over the last decade on
practice and evidence-based management. nursing practice and management, nursing
■■ Discuss the need to improve implementation education, government initiatives, and nursing
of evidence-based practice. students.
■■ Describe tools used to ensure use of ■■ Discuss the role of student application
evidence-based practice. of evidence-based practice.
CHAPTER OUTLINE
●● Introduction ●● Evidence-Based Practice

●● The Core Competency: Employ ●● Definitions
Evidence-Based Practice ●● Types of EBP Literature
●● Nursing Research ●● Searching for EBP Literature: Evidence
●● Historical Background ●● The Roles of Staff Nurses Related to
●● National Institute of Nursing Research Systematic Reviews
●● The Research Process ●● Evidence-Based Management
●● Types of Research Design ●● Improving EBP Implementation
●● Research Funding ●● Tools to Ensure a Higher Level of Use of EBP
●● Ethics and Legal Issues ●● Policies and Procedures Based on EBP
●● Barriers to and Facilitators of Research ●● Clinical Guidelines Based on EBP
●● Other Influential Organizations: Impact ●● Confusion: Difference in Research, EBP,
on Research and Quality Improvement
349
●● Importance of EBP to the Nursing ●● Chapter Highlights

Profession ●● Engaging in the Content
●● Impact of Evidence-Based Practice over ●● Discussion Questions
the Last Decade ●● Critical Thinking Activities
●● Nursing Practice and Management ●● Electronic Reflection Journal
●● Nursing Education ●● Case Studies
●● Government Initiatives: Research ●● Working Backward to Develop a Case
and EBP ●● References
●● Applying EBP as a Student
KEY TERMS
Applied research Institutional review board Research

Basic research Outcomes research Research analysis
Continuous quality PICOT (patient–intervention– Research design
improvement (CQI) comparison–outcome– Research problem
Evidence-based time) statement
management (EBM) Qualitative study Research proposal
Evidence-based practice Quality improvement (QI) Research purpose
(EBP) Quantitative study Research question
Experimental study Randomized controlled trial Systematic review
Hypothesis (RCT) Translational research
Introduction The Competency: Employ

This chapter focuses on the third healthcare profes- Evidence-Based Practice
sions core competency, the need for all healthcare The Institute of Medicine (IOM, 2003) definition
professionals, including nurses, to use evidence-based of EBP is to “integrate best research with clinical
practice (EBP). Evidence-based management (EBM) expertise and patient values for optimum care,
is also critical for effective healthcare delivery in and participate in learning and research activities
all settings. The content provided in this chapter to the extent feasible” (p. 4). EBP is connected to
explores this core competency. Because research providing patient-centered care and improving
is an important component in understanding and quality care. Teams need to use EBP and EBM in
using EBP and is a part of nursing content in nursing making decisions and to ensure the most effective
education programs, a brief introduction to nursing patient-centered care. Nurse managers and other
research is offered as well. EBP and EBM and their nursing leaders also need to actively apply EBM.
impact on nursing care and the nursing profession There is too long a time lag between conclusions
are described. of studies and then, if the results are significant,
Chapter 11: Employ Evidence-Based Practice 351
applying them in care delivery. Clearly, there is a great of discovery as a natural outgrowth of patient care,
need to get research results to the patient sooner. and to ensure innovation, quality, safety, and value in
Increasing use of evidence can improve the quality health care. Our vision is for a healthcare system that
of care and avoid underuse, misuse, and overuse draws on the best evidence to provide the care most
of care (Chassin, 1998). To the nurse, this means appropriate to each patient, emphasizes prevention
the ability to access the evidence, know what the and health promotion, delivers the most value, adds to
evidence is and apply it, as appropriate for need, at learning throughout the delivery of care, and leads to
the point of care. Using EBP affects comparison of improvements in the nation’s health. By the year 2020,
alternatives and interventions such as prevention, 90 percent of clinical decisions will be supported by
diagnostic tests, or therapy; and, in some cases, accurate, timely, and up-to-date clinical information,
leads to the decision that no intervention is the and will reflect the best available evidence. We feel
best choice. Figure 11-1 illustrates the key elements that this presents a tangible focus for progress toward
related to this core competency. our vision, that Americans ought to expect at least
In 2011, the IOM published additional infor- this level of performance, that it should be feasible
mation about the relevance of EBP to health care: with existing resources and emerging tools, and that
“We seek the development of a learning health sys- measures can be developed to track and stimulate
tem that is designed to generate and apply the best progress” (IOM, 2011a, p. xi). This is a clear mandate to
evidence for the collaborative healthcare choices support EBP as a critical component of all healthcare
of each patient and provider; to drive the process delivery, regardless of healthcare provider or setting.
Evidence-based
management
EBP process Nursing

models research
Core competency:
Employ EBP
EBP and the EBP and quality

students improvement
Tools for EBP success:

Clinical guidelines,
policies, and procedures
Figure 11-1 Employ EBP: Key Elements

Research results that can make a difference in

health care in general, and in nursing in particular, Nursing Research
need to be implemented in nursing practice. EBP is
The first step in using EBP effectively is to understand
the major initiative used to increase the use of best
research. Research is a systematic investigation
practice or evidence in making clinical decisions. It
that includes research development, testing, and
is important to note that EBP includes more than just
evaluation. It is designed to develop or contribute to
research results (IOM, 2003). Best practice clinical
generalizable knowledge. One of the major sources
decisions also require healthcare provider expertise
of best evidence for practice comes from research
and patient assessment, as well as inclusion of the
results. Nursing is considered a science discipline
patient’s perspective (patient preferences and values).
in that much of the knowledge base for nursing
It is easy to confuse research utilization and EBP. Re-
practice includes theoretical and evidence-based
search utilization usually involves using knowledge
knowledge (ANA, 2015a).
gained from one study, with limited regard to provider
Two major types of research approaches are:
expertise, patient assessment, and patient preferences
basic and applied. Basic research is designed to
and values. EBP, by comparison, is a much more
broaden the base of knowledge, rather than solve
organized approach to getting research into practice—
an immediate problem, and is typically done in a
tailored to individual patient needs and should
laboratory setting. Results from basic research may
be based on evidence from more than one study.
be used to develop applied research, which is
A critical question is: How much evidence
designed to find a solution to a practical problem.
from research is actually applied? Research done
It is often referred to as clinical research and is usu-
for research’s sake, without ever influencing clinical
ally carried out in a non-laboratory setting. Nurses
research or making it into practice, has limited value.
typically are more involved in applied research,
There are growing efforts to change this by increas-
although some nurses are involved in basic research.
ing EBP content—not just research content—in all
Outcomes research is a newer approach. This type
levels of nursing education, undergraduate through
of research focuses on determining the effectiveness
graduate. Efforts are also being made to improve
of healthcare services and patient outcomes.
staff education about EBP so that nurses in practice
can gain and maintain essential competencies to
Historical Background
increase EBP in clinical settings. In this chapter, it
is important to recognize that research cannot be How has the nursing profession developed nursing
discussed without considering EBP; research and research (American Nurses Association [ANA],
EBP should be interconnected. As part of this rela- 2015a)? Florence Nightingale did have some interested
tionship, science must be accessible. EBP provides in clinical research. Although Nightingale used the
methods for making science more accessible to the data she collected to measure some patient outcomes
practitioner who does not have a lot of time to pore and improve care, the nursing community really did
over research study reports to determine what works not pay much attention to research early in its history.
and what does not work and compare one study with When nurses began to earn advanced degrees,
another in detail. this trend resulted in some studies about nurses
and nursing education, but research was still not an
important part of nursing. In the 1920s and 1930s,
Stop and Consider #1 a few very early studies focused more on nursing
EBP is an important competency due to its affect
on quality health care.
care. Some of these studies were published in the
American Journal of Nursing, making them the first
studies to be published in a nursing journal, although individuals, families, and communities; their
the conduct of nursing studies was not common. research takes a biobehavioral, interdisciplinary
It took time for more studies to be done, and time (interprofessional), and translational approach
to develop nursing researchers. to science. The priorities for nursing research
In the 1950s, greater interest in nursing research reflect nursing’s commitment to the promotion
emerged, and the journal Nursing Research was of health and healthy lifestyles, the advancement
launched. In the 1970s and 1980s, more nurses con- of quality and excellence in health care, and the
ducted studies and more nurses obtained graduate critical importance of basing professional nursing
degrees (including doctoral degrees); thus, nursing practice on research.”
researchers were more qualified. Master’s programs The AACN position statement also identifies
in nursing typically required courses on research and major research focus areas. The first area, clin-
completion of an extensive master’s thesis based on ical research, includes interventions that might
a study conducted by the student; however, this was be used, from acute to chronic care experiences
eliminated as the PhD in nursing became available. across the entire life span; health promotion and
Nursing theorists were very active in the 1960s and preventive care to end-of-life care; and care for
1970s, adding to the scholarly work, as discussed individuals, families, and communities in diverse
in other chapters. settings. The second area is health systems and
Nursing organizations in the United States outcomes research, which focuses on identifying
and internationally support nursing research and ways that the organization and delivery of health
have described their views of research; for example, care influence quality, cost, and the experience of
the International Council of Nurses (ICN, 2010) patients and their families. The third focus is on
is “committed to supporting nursing research as a nursing education—research that explores more
powerful tool for generating new knowledge and effective and efficient educational processes and new
evidence to underpin nursing practice. Nursing teaching–learning practices to incorporate tech-
has an obligation to society to provide care that nology in the learning process, intergenerational
is continually researched and evaluated. Nurses learning differences and their impact on education,
working singly or in multidisciplinary research and the development of methods to improve lifelong
teams can offer new insights and unique perspec- learning and commitment to leadership.
tives to the research process. Nursing research
provides opportunities for linkages between those National Institute
involved in the research process, practicing nurses,
of Nursing Research
other health professionals, policy makers, and the
public. With the rapid advances in knowledge and The National Institute of Nursing Research (NINR),
technology, nursing research serves as a framework established in 1985, is part of the National Institutes
for organizing facts and evidence into a coherent of Health (NIH). It is important that nursing have a
and usable format. A research network provides presence in the most prestigious national research
a vehicle for continual exchange of knowledge system in the United States. As discussed in other
and experience.” This effort allows for greater chapters about scholarly work, the NINR conducts
global sharing of research information and ex- research that has an impact for the nursing profes-
pertise. The American Association of Colleges sion and also allocates funding for nursing studies
of Nursing (AACN, 2006) statement on research that may be conducted in other institutions such as
includes the following principles: “Nursing re- universities and clinical organizations. Interprofes-
searchers bring a holistic perspective to studying sional research is also encouraged and funded by
the NINR, which describes how nursing research ■■ Improve palliative and end-of-life care.
develops knowledge for the following purposes (2014): ■■ Enhance innovation in science and practice.
■■ Build the scientific foundation for clinical ■■ Develop the next generation of nurse scientists.
practice. In comparing the ICN and AACN statements with
■■ Prevent disease and disability. the NINR purposes and strategic plan goals, there
■■ Manage and eliminate symptoms caused are clear similarities, and thus, these organizations
by illness. provide a more consistent statement about nursing
■■ Enhance end-of-life and palliative care. research and the profession’s overarching view of
The NINR is physically located at the NIH cam- research.
pus in Rockville, Maryland. When funded research
is conducted at the NINR campus, it is referred to The Research Process
as an intramural or internal study. Grants are also The research process is similar to the nursing pro-
awarded for outside, or extramural, studies that cess; it is a problem-solving method. Exhibit 11-1
are conducted at the researcher’s home institution describes the steps of the quantitative experimental
or in collaboration with several institutions. The research process. The specific plan for conducting
NINR’s current strategic plan identifies its goals to the study is the research design and methods. In
invest in research focusing on the following areas the proposal, the researcher describes what will
(NINR, 2016): be done, and in the research report or published
■■ Enhance health promotion and disease article, poster, or presentation after the study is
prevention. completed, the researcher describes what was done.
■■ Improve quality of life by managing symptoms First, the researcher develops a plan or proposal
of acute and chronic illness. for the study. This written document describes recent
Exhibit 11-1 Steps in the Quantitative Experimental Research Process
I. Description of problem statement, VI. Ethical considerations: Description

including background and significance of informed consent for participants/
II. Identification of research question(s) and subjects and the institution review board
hypothesis process
III. Identification of the purpose(s) of the VII. Research design and methods
study: Explain how the findings might A. Research design
be used 1. Identify the research design. Is
IV. Review of literature: Summary of critical the study a quantitative study
literature (theoretical and research or a qualitative study? Identify
literature) that applies to the study. the specific sub-design (for
V. Theoretical framework: Theories and example, experimental, quasi-
conceptual models organize research experimental, and descriptive).
findings into a broader conceptual 2. Provide an adequate rationale
context and include conceptual and for choosing the research
operational definitions of the variables design.
(independent and dependent) in the 3. Identify independent and
framework. (This step is not done for dependent variables (if required
all studies.) for the study design).
B. Sample and sample selection chronologically and clearly

1. Describe the sample population. enough to allow for replication
2. Provide sample criteria (inclusion (describe them in sufficient
and exclusion criteria). detail so that a stranger could
3. Describe sample size using use this procedure and collect
power analysis. the data as intended).
4. Describe how participants/ 2. Identify who will collect the
subjects who meet the criteria data, and describe the training
will be selected as study required. Provide data collection
subjects: sampling method. forms as needed.
5. If applicable, describe how 3. Discuss control features for study
groups or treatments/ procedures.
interventions will be assigned F. Data analysis (This step is completed
in the sample. after the previous steps are
C. Setting completed, but the proposal plan
1. Briefly describe the setting for needs to describe the data analysis
the study. plan that will be used.)
2. Describe how access to the 1. Describe specific data analysis
study setting will be obtained. plan for each hypothesis
D. Measurement and instrumentation or study question. Identify
1. Discuss the origin and type of appropriate statistical tests and
measurement instruments. the rationale for their use in
2. Describe why the instrument(s) analyzing each study question
is (are) appropriate to study or hypothesis and participant
the problem (that is, why demographic data. Include the
the instrument can produce level of measurement of each
data that to answer the study variable and selected level of
question). significance. (This proposal is a
3. If an instrument is developed for plan for the study, as data are
the study, describe how it will not analyzed until after collected
be developed and how it will and then included in the final
be tested for reliability/validity; report.)
pilot-test it before using it in the 2. Specify and justify the level of
study. significance (that is, 0.05, 0.01)
4. Describe the reliability and for statistical results and findings.
validity of the instrument (if G. Limitations
used). Evaluate and report 1. Ensure that limitations
relevant reliability and validity are clearly identified and
data from previous research appropriate.
or a pilot conducted for the VIII. Development of budget for the study
study.
Details about analysis of results and conclusions
E. Data collection
are not included in the proposal, but rather in
1. Describe the data collection
the final report when the study is complete.
process and procedures
relevant literature on the problem area, describes the investigate patient education about diabetes, Orem’s
research topic or problem, and defines the processes theory on self-care might be used as the framework
or steps that will be followed to answer the research for the study. Nursing research studies that use a
question(s). The research proposal is used to conceptual framework may or may not rely on a
plan the research and also may be used to apply for nursing theory, some may use a non-nursing theory.
research funding. It is the critical document used to It is important that the framework represents the
obtain approval for a study and institutional review phenomenon of interest and guides the research
board (IRB). The proposal is written in the future question and the measurement of the variable(s).
tense because the research has not yet been done. For example, if the nurse is studying blood pressure
There must be an assessment to identify in a premature infant, the study would most likely
and describe the problem, formulating the use a scientific, physiologically based framework
research problem statement. The researcher to support factors that influence blood pressure.
does this assessment using the researcher’s individ- This all sets the stage for the actual research, which
ual expertise, reviewing the literature, and possibly requires that problem assessment and identification
interviewing other experts. The review of literature are clear. These steps are similar to the assessment
and any other sources is included in the research and nursing diagnosis phases in the nursing process.
proposal and in the subsequent research report of The research design and methods are com-
results. The researcher (or researchers) primarily plex. They include the details related to type of study
examines previous studies by reading their pub- (research approach and design), the sample and the
lished reports of results to consider relevance to means by which the sample is selected, the setting
the researcher’s proposed study. for the study, measurement and data collection in-
The researcher then identifies the study ques- struments, the data collection process (what exactly
tion(s) and hypothesis(ses). The research question will be done to collect the data), data analysis, and a
is concise, developed before the research is conducted description of potential limitations. The plan should
and stated in the research proposal. The hypothesis be clear and detailed. This information, or the plan,
is the formal statement of the expected relationship is called a proposal until the research is conducted.
or relationships between two or more variables in The study is conducted after funding is received.
a specified population, which is the sample. The Most research requires funding, and some studies
hypothesis is stated before the research is conducted are very expensive to conduct. This step could be
and included in the proposal. Some studies do compared to implementing a care plan.
not have hypotheses, such as qualitative studies in The last part of the research process is the
which the emphasis is on describing a situation or research analysis and description of the results
perception rather than on measuring the variable of and conclusions. The proposal describes how the data
interest. The question and hypothesis flow from the will be analyzed, but the actual analysis of data cannot
description of the research problem statement and occur until the study has been conducted. What did the
the research question(s). The researcher also needs analysis of data demonstrate, and what are the impli-
to consider the research purpose—describing cations of the data? The researcher needs to consider
the potential uses of the results. the proposal—what was planned, how the study was
In nursing research, particularly qualitative implemented, and the plan for data analysis—so that
studies, the researcher may identify a theory or a the outcomes are identified, just as would be done in
conceptual model to organize the findings. The theory the nursing process. This can be compared to the eval-
or model is described and related to the research uation that determines whether patient outcome goals
question. For example, if a study was developed to were met based on the nursing process or care plan.
Data collection in qualitative studies is less struc-

Types of Research Design
tured than in a quantitative study. A qualitative study
The research design describes the plan for the study might use focus groups, diaries, logs, observation,
in detail and explains how the study will be con- and open-ended interviews. Analysis of data does
ducted. Research study designs are categorized into not rely on statistics or mathematical equations. The
two broad categories: quantitative or qualitative. In researcher is less detached and may interact actively
quantitative studies, the research question focuses with the participants/subjects to obtain the best data
on how many or how much; in qualitative studies, possible. In fact, the researcher is often considered
the research question focuses on feelings or expe- the instrument of the qualitative research because
riences. Not all quantitative research studies are of the researcher’s involvement. Data are analyzed
experimental studies. To be experimental, a as the study progresses and may lead the researcher
study must meet three criteria: in a different direction or to collect additional data.
■■ Manipulation of intervention: The researcher However, data that are not covered in the informed
administers an intervention to the partici- consent cannot be collected without IRB approval
pants/subjects (sample). This intervention for the change. The goal is to understand the issue
represents the independent variable(s). The deeply, not to intervene, and also to see results or
researcher wants to identify the effect of compare groups.
the independent variable on the dependent
variable or determine if the independent Research Funding
variable causes the dependent variable(s).
■■ Control: The researcher controls some of the Funding is a critical part of any research because
experimental situation and uses a control group it provides the resources to conduct the research,
from the sample, which does not experience such as researcher salary, staff pay, space (office,
the intervention (independent variable). Total lab) supplies, animal costs, and so on. Funding
control is not usually possible, but efforts sources vary widely: universities, private donations,
must be made to have as much control of the foundations and organizations, local and state gov-
situation as possible. This is easier to do in ernments, and the federal government. The federal
a laboratory setting as compared to applied government is the largest source of grant monies,
or clinical research where there are many but private sector organizations also fund research
factors, many of them unknown, that affect at high levels such as the specialty organizations (for
the patient or the sample. example, American Cancer Society) and healthcare
■■ Randomization: The researcher assigns professional organizations. Funding sources determine
participants/subjects in the sample to the the amount of the funding and length of time it is
experimental and to the control group using awarded. The research proposal includes a budget
systematic methods, ideally randomization. that should be realistic but also should consider the
funding amounts the funding source(s) is providing.
Data collection in a quantitative study is highly
There are three approaches a researcher may take
structured. Examples of data collection methods
to obtain funding:
include structured interviews; collection of biophys-
iological data, such as blood pressure, blood, urine, 1. Identify a problem and develop a proposal. This
and other physiological parameters; questionnaires proposal is sent to funding sources that might
or surveys; rating scales; structured observation; have an interest in the particular problem.
and many other methods. In quantitative studies, 2. Develop a research proposal that specifically
data analysis involves the use of statistics. addresses a problem area that a funding source
has identified as a critical need area. This is in healthcare professions education or education
called a request for proposals or request for opportunities that would not otherwise be tried
applications, and in this case, the researcher due to financial barriers.
must carefully follow all the requirements
for the proposal.
3. Sometimes funding sources require the re- Ethics and Legal Issues
searcher to conduct a pilot study or have data When ethics and legal issues are considered in re-
that indicate greater need for research about lation to research, the first concern is to protect the
a particular problem. Indeed, in many cases, rights of human participants/subjects. A second area
having some data to support the research is that the researcher considers is how best to balance
critical to getting funding for a study. benefits and risks/harm in the studies. Ethics and
Once the written proposal is completed and legal issues are discussed in other chapters, but
submitted, it is scrutinized to see whether it meets a here we focus on their implications for research.
set of very specific requirements. These requirements There are many studies in which participants might
can vary from one funding source to another, and potentially be harmed. Research ethics emphasizes
deadlines differ. The proposal then goes through the need to be clear about participant/subject risks
the grant review process, which can take months. whenever possible. The third ethical and legal issue
Typically, peer groups identified by the funding is informed consent, which is also important in
source review grant proposals. healthcare service delivery. The last concern is in-
It is extremely difficult to get funding. The federal stitutional review—that is, review of the proposal to
government grants are highly competitive, and the ensure that participant/subject rights are protected
major source of such funds is the NIH. Congress and the study is planned in an effective manner that
sets the NIH’s budget. Nursing research is funded by meets the sponsoring organization’s standards. This
similar sources, as is other healthcare research. Funds topic is discussed in text content focused on ethical
are also available to support training programs and and legal issues.
service programs, which are typically not considered Today, because of past concern about research
research studies—for example, for schools of nursing ethics and standards, there is greater control to
to develop a new nurse practitioner or doctor of prevent problems with research and ethics. An
nursing practice program, offer a nurse residency example demonstrating recognition of ethics is the
program, implement programs to increase student ANA’s Code of ethics with interpretive statements,
retention, or establish a nurse managed clinic. which focuses on multiple rights related to clinical
There are also grants for healthcare organizations to practice but also to research: Provision 3, “the nurse
develop new services such as in public/community promotes, advocates for, and protects the rights,
health. Funding for these types of projects and pro- health, and safety of patients,” and Provision 8,
grams typically comes from the Health Resources which notes that nurses in collaboration with “other
and Services Administration, which is part of the health professionals and the public protects human
U.S. Department of Health and Human Services rights, promotes health diplomacy, and reduces
(HHS), but other government sources may also health disparities” (ANA, 2015b, pp. 9, 31).
offer these grant opportunities. These funds are After many major experiences of abuse in re-
not research grants, but rather program grants, search, discussed in this text, efforts were instituted
but they still require a detailed proposal. Program to prevent further problems. One of the strategies
grants are very important as they provide monies to was the creation of the institutional research
try new practice or delivery approaches or changes board. This committee reviews research before it
is conducted to ensure that the study is conducted

Barriers to and Facilitators
ethically. Any study that involves human subjects
should obtain approval from their institution’s IRB
of Research
(for example, university, healthcare organization). Research is not easy to accomplish. Barriers need to
IRBs are mandated to review all research that in- be turned into facilitators for research to be successful.
volves human subjects in institutions that receive Barriers could include any of these issues; suggested
federal funds. The purpose is to protect participants/ methods for removing the barrier are noted here:
subjects from unnecessary risk or from risks that ■■ Lack of funding: Researchers need to plan for
outweigh potential benefits. Particularly vulnerable and obtain adequate funding; most research
populations include the following groups: is costly to implement. As the research is
■■Neonates (newborns) conducted, the researcher needs to manage
■■Children the budget.
■■Pregnant women and fetuses ■■ Lack of sufficient time: Good research takes
■■Persons with mental illness planning and time to accomplish. The re-
■■Persons with cognitive impairment searcher needs blocks of time to work on a
■■Terminally ill persons study, so this requires a schedule that makes
■■Persons confined to institutions (for example, sense for the researcher’s required workload
prisons, long-term care hospitals) and other staff involved in the study. Some
Examples of questions that might be considered investigators are involved in research on a
by an IRB prior to approval of a proposed study full-time basis.
include the following: ■■ Lack of research competencies: Research ex-
■■Will the participant/subject be deceived, pertise is developed over a period of years.
and if so, is it necessary for the integrity of Finding a mentor or mentors is important;
the research? working with researchers who have been
■■Does the participant/subject understand successful can assist a novice researcher.
the purpose of the project and completely ■■ Lack of participants/subjects for the sample: If
understand his or her role in the project and the study includes participants/subjects, it is
potential risk of harm and benefits? (informed not always easy to find them in the number
consent process; who will conduct and what required or for the required circumstances.
will the participant/subject be told) This takes time and creativity, and at all
■■Are there obvious costs or hidden costs to times, ethical principles must be considered.
people if they participate? Can they withdraw The researcher needs to be realistic when
at any time? Are there any incentives such planning the study. Participants/subjects
as cost of transportation? may also leave a study at any time, and this
■■What are the benefits, if any, to the participant/ loss of sample size can result in a negative
subject? result for the study.
■■What are the risks, immediate and long term ■■ Inability to find the right setting: Finding and
(if known), to the participant/subject? securing a setting that agrees to participate
■■How will the researcher protect the partici- in the study can be problematic because it
pant’s/subject’s right to confidentiality? requires contacts and communication. The
■■Whom should the participants/subjects setting also must consider how the study
contact with questions? will impact its patients, staff, functioning,
■■What will be done with the results of the study? and so on.
■■ Lack of statistical expertise: Researchers and improve quality (Jennings & Loan, 2001). An
should find a statistical expert to consult; EBP nursing review is not nursing research. This
researchers work in teams and need to work review involves identifying evidence to answer an
with different experts. EBP question.
How do you get from EBP to research? You might
not. At the conclusion of an EBP review, reviewers
Other Influential
might find that there is not sufficient evidence to
Organizations: Impact answer the clinical question. The review is referred
on Research to as a systematic review. If an EBP review indicates
The ANA identifies research as an important issue that evidence is already available, there is no need
for professional nursing. “Nurses use research to to perform additional research. Thus, an EBP re-
provide evidence-based care that promotes quality view does not mean that research is conducted or
health outcomes for individuals, families, com- that it must be conducted. In most cases, however,
munities and health care systems. Nurses also use sufficient nursing research is not available to settle
research to shape health policy in direct care, within most nursing questions. This means that research
an organization, and at the local, state and federal conducted by nurses prepared in research may be
levels. Nurses conduct research, use research in needed to fill the gap in the knowledge base, though
practice, and teach about research. The ANA supports most nurses would not conduct this research because
nursing research with a variety of resources such they are not prepared to do so.
as the Research Toolkit” (ANA, 2016). Its website
offers research news, information about research Definitions
needs, and resources, and the ANA research agenda
“Decisions about the care of individual patients
focuses on (2016):
should be based on the conscientious, explicit, and
■■ The value of nursing contributions to safety, judicious use of current best evidence. This means
reliability, quality, and efficiency that individual clinical expertise should be integrated
■■ Factors that increase the impact of nurses with the best information from scientifically based,
on quality and efficiency systematic research and applied in light of the pa-
■■ Use of National Database of Nursing Quality tient’s values and circumstances” (IOM, 2008, p. 2).
Indicators to enhance patient safety, quality This does not mean that all patient care decisions
care, and efficiency are based on research evidence or only research
■■ Nurse workforce issues evidence as there are other types of evidence. Other
■■ Population health issues sources of knowledge or evidence exist, including
the following (Melnyk & Fineout-Overholt, 2014):
Stop and Consider #2 ■■ Best research evidence.

Nursing research needs to improve and expand. ■■ Clinical expertise: The clinician’s knowledge
and experience or what the nurse, physician,
and others on the healthcare team contribute
Evidence-Based Practice to the care process.
■■ Patient values and preferences/circumstances:
What is the purpose of EBP? The use of EBP in This represents the individual patient’s own
nursing leads to more effective decision making to concerns, preferences, expectations, and social
guide the use of limited resources, control costs, and financial resources that affect health and
health care. These factors can change over 4. Integrate the evidence with the other parts
time and with each unique healthcare need of EBP: patient preferences and values, your
and encounter. clinical expertise, assessment information about
■■ Clinical data (assessment) and history: A patient’s the patient and the patient’s history.
assessment includes important evidence that 5. Evaluate the practice decision or change.
should be considered in treatment decisions.
As nursing students soon discover when they Types of EBP Literature
search for nursing EBP literature, there is a problem
in this field: The nursing and allied health profes- EBP literature is different from typical clinical litera-
sions are not as far along in implementing EBP as ture and research literature (that is, published articles
medicine. The amount of nursing research must about studies). The key component of EBP literature
increase—not just in quantity, but also in quality is a systematic review. A systematic review is a “the
and relevance to nursing practice. Also, nursing consolidation of research evidence that incorporates
health interventions are not captured effectively a critical assessment and evaluation of the research
in medical records, which affects the quantity and (not simply a summary) and addresses a focused
quality of nursing data that might be found in these clinical question using methods designed to reduce
records, if this is the an important source for data the likelihood of bias” (DiCenso, Guyatt, & Ciliska,
(IOM, 2003). Examples of nursing data include 2005, p. 570). The key characteristic of systematic
those related to patient pain, dehydration, skin reviews that identifies their value is their critique
breakdown, lifestyle change, patient knowledge of multiple studies related to the same research
deficiencies, and nonadherence with treatment. Fur- question to determine best evidence available. There
thermore, nursing interventions often are evaluated are several types of systematic reviews, but all types
in descriptive or qualitative studies rather than in (1) include clear criteria for conducting the review
quantitative studies. Quantitative studies are ranked process and (2) review not only of research reports,
higher than qualitative studies when evaluating or but also may review data from large databases and
ranking EBP evidence from research studies, but include published articles that are opinion or essay
they are still considered sources of evidence. with the goal of finding as much available evidence
The PICOT (patient–intervention– as possible that meet the question and related crite-
comparison–outcome–time) or EBP question ria (Brown, 2009). During the assessment process,
should be part of every search for evidence to im- when evidence is reviewed, a standard hierarchy or
prove practice. The goal is to ask a searchable and rating system is used.
answerable question to identify the best evidence The increasing interest in EBP and need to better
to answer the question. The acronym stands for understand implications for healthcare delivery led
the patient/population, intervention, comparison, to the publication of in-depth analysis of research
outcome, and time (Melnyk & Stillwater, 2010). EBP issues and EBP. Some of these reports are briefly
questions must be specific—describing each of the described here:
elements so that the search for evidence will reach ■■ Knowing what works in health care: a roadmap
the best conclusions. for the nation (IOM, 2008): This report em-
How is the PICOT question used? The following phasizes the need to use EBP and to identify
describes the process (Melnyk & Stillwater, 2010): diagnostic, treatment, and prevention services
1. Identify a burning clinical issue or question. based on what works effectively. Cost must
2. Collect the best evidence relevant to the question. also be considered in clinical decisions,
3. Critically appraise that evidence before it is used. and it impacts quality care. Critical factors
that need to be considered are constraining (independent variable). The results of an RCT
healthcare costs, reducing geographic variation provide the strongest support for a cause-and-effect
in the use of healthcare services, improving relationship. Not all studies meet these criteria.
quality, empowering healthcare consumers, Two important EBP literature databases are
and making healthcare coverage decisions. the Cochrane Database of Systematic Reviews and
■■ Clinical practice guidelines we can trust (IOM, the Joanna Briggs Institute EBP Database. A third
2011b): This report discusses the importance source is the Agency for Healthcare Research and
of developing effective clinical guidelines Quality (AHRQ) and its collection of evidence-
based on best evidence and then applying based national clinical guidelines (NCGs). A brief
those guidelines when appropriate. The description of each of these databases follows:
guidelines should be based on systematic ■■ The Cochrane Database of Systematic Reviews:
reviews, developed by knowledgeable mul- This center develops, maintains, and updates
tidisciplinary experts, consider important systematic reviews of healthcare interventions
patient subgroups and patient preferences, to allow practitioners to make informed
provide clear explanations of the logical re- decisions. It is located in London.
lationships between alternative care options ■■ Joanna Briggs Institute EBP Database: This
and health outcomes, and revise as needed. organization represents an international col-
■■ Finding what works in health care: stan- laboration among nursing and allied health
dards for systematic reviews (IOM, 2011c): centers. It is located in Australia. Its main
This report focuses on research and EBP and purpose is to train professionals to conduct
emphasizes the importance of systematic systematic reviews.
reviews. Standards to ensure quality care ■■ NCGs: This source is U.S. government based,
should be based on systematic reviews that through the AHRQ, although the guidelines
include assessment of individual studies and come from many different sources. Guide-
synthesis of the evidence. This information lines are discussed within other sections of
should then be shared through publication so this chapter.
that it can be applied in healthcare delivery.
Sigma Theta Tau International, the nursing honor
society, is also active in supporting and developing
Searching for EBP Literature: EBP through its online publication, Online Journal of
Evidence Knowledge Synthesis for Nursing. This journal provides
full-text systematic reviews to guide nursing practice.
The first step in finding evidence is to look for a It is available by subscription. University libraries
systematic review that addresses the identified may have access via a university subscription, so
PICOT question. If these reviews cannot be students may be able to access the journal through
found, published articles describing random- their university library.
ized controlled trials/studies should be sought.
Randomized controlled trials (RCTs) are often The Roles of Staff Nurses
referred to as the gold standard in research design. Related to Systematic
They involve a true experiment; there is control
Reviews
over variables, randomization of the sample, use
of a control group and an experimental group, and Nurses may be involved in developing systematic
manipulation of an intervention or interventions reviews by reviewing studies based on specific
criteria, but this is not common for most nurses.

Formulating the Question
Reviewing studies using systematic review procedures
takes special expertise and in-depth knowledge of
statistics, so this would not be something every Acquiring Research Evidence
nurse could do. It should not be an expectation that
staff nurses will do these reviews. The staff nurse’s
most important role is that of consumer: applying Assessing the Quality of Evidence
knowledge from systematic reviews. Using the
PICOT method to guide them, nurses search for
the systematic reviews through databases (for ex- Presenting the Evidence
ample, Cochrane, Joanna Briggs, Clinical Guideline
Clearinghouse, and other professional literature
Applying the Evidence to the Decision
review). After evidence is found, nurses examine
the validity of the evidence, its relevance, and its
applicability to the EBP question and may then Figure 11-2 The EBM Process
apply the evidence in their practice. Data from Kovner, A., Fine, D., & D’Aquila, R. (2009).
Evidence-based management in healthcare. Chicago, IL:
Health Administration Press.

EBP depends on more than just research evidence.
management and leadership is needed. The results

of these studies may then be considered evidence
Evidence-Based and incorporated into leadership and management
decisions. Figure 11-2 describes the EBM process.
Management
Most nurse managers and non-nurse managers, such Stop and Consider #4
as someone on a committee making decisions that Nurses need to apply more EBM.
relate to management of services, do not typically use
evidence from research to actively assist in making
management decisions. Many use the professional
literature, which does not always describe research,
Improving EBP
but rather provides more content and descriptions of Implementation
practice. Included in one of the American Organiza-
It has not been easy to incorporate EBP into prac-
tion of Nurse Executives’ (2017) goals is facilitation
tice. Some healthcare organizations have been more
and support of research and development to advance
successful than others. Over time, greater use of
nursing administrative practice and quality patient
EBP will occur, but some barriers still need to be
care. EBM is “systematic application of the best
overcome by most organizations:
available evidence to the evaluation of managerial
strategies for improving the performance of health ■■ Lack of knowledge about EBP and its value:
services organizations” (Kovner & Rundall, 2009, EBP has been added to nursing curricula
p. 56). The definitions for EBM and EBP are not in the last 5 to 10 years, so many practicing
that different. More research that focuses on nursing nurses have limited knowledge of EBP.
This gap in the knowledge base requires ■■ Search for the relevant answers to the questions
healthcare organizations to play catch-up from the best possible sources of evidence,
to improve staff knowledge of EBP. There including those that evaluate or appraise the
are now greater numbers of resources for evidence for its validity and usefulness with
faculty and students through the increased respect to a particular patient or population.
number of EBP textbooks and inclusion of ■■ Determine when and how to integrate these
EBP content in research textbooks. new findings into practice.
■■ Limited time in practice settings: Staff are Nursing services within a healthcare organiza-
rushed and often just able to keep up with tion (or any type of healthcare organization) need to
providing required care, so adding more plan carefully so that staff have knowledge of EBP
responsibilities is difficult. and time to ensure staff can effectively apply EBP
■■ Nursing shortage: Some healthcare organi- and evaluate the outcomes. The first step is staff
zations may have insufficient staff to allow preparation. Some staff members are not ready to
nurses time to consider EBP effectively. engage in EBP. Given that most staff did not graduate
■■ Greater need to emphasize both knowledge and from nursing education programs within the last
practical approaches: This barrier applies to few years (the average age of nurses is older than
both nursing education and practice settings. 45 years), staff may not have had EBP content in
■■ Concern that EBP represents a cookbook their nursing programs or limited content. This is
approach to care: EBP may be considered a major hurdle for healthcare organizations. In an
a cookbook approach if it is used without effort to remedy potential staff knowledge deficit,
assessment and clinical reasoning and judg- many healthcare organizations have integrated EBP
ment. Every patient must be viewed as an content into their staff education programs. EBP is
individual (patient-centered care). now standard content in pre-licensure and graduate
■■ Lack of knowledge about EBP resources: To nursing programs, which is reducing the problem
make evidence available and usable, more of staff that might have limited knowledge of EBP.
information is needed regarding searching Table 11-1 describes strategies individual nurses
for resources, accessing resources, and ana- and healthcare organizations may use to overcome
lyzing resources. barriers to EBP.
■■ Lack of resources to find information: For
example, staff may not have easy access to
the Internet, access to appropriate databases, Stop and Consider #5
and library support. There are many barriers to effective EBP.
■■ Limited recognition by employers regarding
the value of EBP: Nurses are not given time
to find EBP evidence and then apply it—even
though the healthcare organizations says they Tools to Ensure a Higher
want care to be evidence-based.
Level of Use of EBP
The recommendation is that EBP needs to be used
more effectively; healthcare professionals should EBP evidence should be incorporated into standards
have these abilities to (IOM, 2003, pp. 57–58): of care that guide nursing practice and education.
■■ Know where and how to find the best possible This can reduce practice variation and provide greater
sources of evidence. consistency based on evidence to improve quality
■■ Formulate clear clinical questions. and safety (Newhouse, 2006, 2007). In practice, two
Table 11-1 Strategies to Overcome Barriers to Adopting EBP
Barrier Strategy
Lack of time Devote 15 minutes a day to reading evidence related to a clinical
problem.
Sign up for emails that offer summaries of research studies in your area
of interest.
Use a team approach when considering policy changes to distribute the
workload among members.
Bookmark websites having clinical guidelines to promote faster retrieval
of information.
Evaluate available technologies (that is, personal digital assistant) to
create time-saving systems that allow quick and convenient retrieval of
information at the bedside.
Negotiate release time from patient care duties to collect, read, and
share information about relevant clinical problems.
Search for established clinical guidelines because they provide synthesis
of existing research.
Lack of value placed Make a list of reasons healthcare providers should value research,
on research in and use this list as a springboard for discussions with colleagues.
practice Invite nurse researchers to share why they are passionate about their
work.
When disagreements arise about a policy or protocol, find an article that
supports your position and share it with others.
When selecting a work environment, ask about the organizational
commitment to EBP.
Link measurement of quality indicators to EBP.
Participate in EBP activities to demonstrate professionalism that can be
rewarded through promotions or merit raises.
Provide recognition during National Nurses Week for individuals involved
in EBP [and EBM] projects.
Lack of knowledge Take a course or attend a continuing education offering on EBP.
about EBP and Invite a faculty member to a unit meeting to discuss EBP.
research Consult with advanced practice nurses.
Attend conferences where clinical research is presented, and talk with
presenters about their studies.
Volunteer to serve on committees that set policies and protocols.
Create a mentoring program to bring novice and experienced nurses
together.
Lack of technological Consult with a librarian about how to access databases and retrieve
skills to find evidence articles.
Learn to bookmark important websites that are sources of clinical
guidelines.
Commit to acquiring computer skills.
(Continues)
Table 11-1 (continued)
Barrier Strategy
Lack of resources to Write a proposal for funds to support access to online databases
access evidence and journals.
Collaborate with a nursing program for access to resources.
Investigate funding possibilities from others (that is, pharmaceutical
companies, grants).
Lack of ability to read Organize a journal club where nurses meet regularly to discuss the
research evidence about a specific clinical problem.
Write down questions about an article, and ask an advanced practice
nurse to read the article and assist in answering the questions.
Clarify unfamiliar terms by looking them up in a dictionary or research
textbook.
Use one familiar critique format when reading research.
Identify clinical problems and share them with nurse researchers.
Participate in ongoing unit-based studies.
Subscribe to journals that provide uncomplicated explanations
of research studies.
Resistance to change Listen to people’s concerns about change.
When considering an EBP project, select one that interests the staff,
has a high priority, is likely to be successful, and has baseline data.
Mobilize talented individuals to act as change agents.
Create a means to reward individuals who provide leadership during
change.
Lack of Link organizational priorities with EBP to reduce cost and increase
organizational efficiency.
support for EBP Recruit administrators who value EBP.
Form coalitions with other healthcare providers to increase the base
of support for EBP.
Use EBP to meet accreditation standards or gain recognition (that is,
Magnet recognition).
Reproduced from Schmidt, N., & Brown, J. (2015). Evidence-based practice for nurses: Appraisal and
applications of research. Burlington, MA: Jones & Bartlett Learning.
major tools are commonly used to ensure a higher guides for care within healthcare settings. Organi-
level use of EBP: (1) healthcare organization policies zations develop these written guides to inform staff
and procedures and (2) clinical guidelines. about expectations related to care and management.
Policies and procedures are not new to health care,
Policies and Procedures and in reviewing resources such as research results
and systematic reviews, this may lead to revision
Based on EBP
of policies and procedures or development of new
Much of the care in healthcare organizations is defined policies and procedures. What is the evidence to
by policies and procedures, which are important support a policy or procedure? The difficulty in
nursing is there may not yet be evidence such as not discussed in detail in this chapter, it is important
from research, but policies and procedures should to clarify the differences in these three terms and
state the research evidence used (if it exists) to processes for the purposes of this discussion. Research
support the content. Many healthcare organizations is systematic investigation of a problem, question,
are now trying to improve their policies and proce- issue, or topic that uses a specific scientific process
dures by reviewing them from an EBP perspective. to gain new knowledge. Results from studies can
Unfortunately, this is a time-consuming process. be used as evidence to support clinical decisions,
although not all research concerns clinical problems
Clinical Guidelines and related decisions or has an impact on quality
Based on EBP care. An example of research that is clinically focused
and would have an impact on quality is a nurse who
An evidence-based guideline is one of the strongest questions the best method for preventing patient falls
sources for EBP, along with systematic reviews. in a long-term care facility and wants to consider new
Clinical guidelines are described as follows (U.S. interventions. This nurse might develop a research
Department of Health and Human Services [HHS] & study to gather data to examine how two different
Agency for Healthcare Research and Quality [AHRQ], groups of patients respond to a new intervention to
2016): “A guideline that provides a purposeful and prevent falls. In doing so, the nurse would follow the
clear evaluation of the effectiveness of therapeutic research process described elsewhere in this chapter.
modalities. Effectiveness is defined as a measure of By comparison, EBP focuses on systematic
the benefit resulting from an intervention for a given review and appraisal of evidence, including not only
health problem under average conditions of use. This research results, but also the patient’s assessment
form of evaluation considers both the efficacy of an and history data, the clinician’s expertise, and the
intervention and its acceptance by those to whom it patient’s preferences and values. In this case, the
is offered. It answers the question: Does the practice same nurse who wondered about factors related
do more harm than good to people to whom it is to falls might take a different approach, the EBP
offered?” Expert panels or professional organiza- approach. The nurse would pose a PICOT question,
tions develop clinical practice guidelines, and these such as “Which factors influence patient falls in a
guidelines should be evidence based. An important long-term care facility?” The nurse would look for
source for guidelines is the National Guideline systematic reviews to answer this question and would
Clearinghouse, which is sponsored by the AHRQ
use systematic reviews, if found, to guide practice;
providing a commonly used searchable database of
doing so would impact quality care.
guidelines that are used to improve patient outcomes.
QI, which now focuses more on continuous
quality improvement (CQI), is the process that
Stop and Consider #6 aims to ensure patients receive the best care when
Using clinical guidelines may better ensure effective EBP.
they need it and outcomes are met on an ongoing
basis (Finkelman, 2018). CQI is “a structured organi-
zational process for involving personnel in planning
Confusion: Difference and executing a continuous flow of improvements
in Research, EBP, and Quality to provide quality healthcare that meets or exceeds
Improvement expectation” (Sollecito & Johnson, 2013, p. 4).
Healthcare organizations are involved in CQI on a
Research, EBP, and quality improvement (QI) are not daily basis as the healthcare organization staff tries
the same, but they are interrelated. Although QI is to understand outcomes and improve them. In the
same example noted with falls, a CQI project might ■■ Will the evidence help me provide quality care?
include monthly collection of HCO data related ■■ Were all clinically relevant outcomes considered?
to the number of falls and specific information ■■ Are the benefits worth the potential harm
about the falls (that is, factors related to the falls). and costs?
The HCO would examine the seriousness of the
Changing how care is delivered is a major
problem by using root-cause analysis and might
undertaking because there are always barriers to
then institute a change in practice or management,
change. It takes an organized approach to implement
such as requiring identification of patients at risk
EBP in a healthcare delivery system. Reimbursement
for falls in medical records and putting labels in the
for services—medical and nursing—is increasingly
patient areas. The HCO would then track data to
based on whether the guidelines for care are evi-
see if there is any change in the number of falls for
dence-based. As the financial incentive to implement
at-risk patients—what are the outcomes of using
EBP grows, so will integration of EBP. Exhibit 11-2
these interventions, though many factors could im-
describes role criteria that support EBP functions
pact the outcomes since this is not an experimental
for the staff nurse, nurse manager, advanced practice
study with controls.
registered nurse, and nurse executive.
Stop and Consider #7 Stop and Consider #8

Research, EBP, and QI are different but related.
Every nurse is responsible for using EBP.
Importance of EBP Impact of Evidence-Based

to the Nursing Profession Practice over the Last Decade
As noted in a number of expert reports, EBP can Since the publication of the Quality Chasm reports,
improve care. Nursing care should be supported by covering the last decade, and the publication of The
evidence, but it is not uncommon for nursing care future of nursing report (IOM, 2010), there have
to be provided in a manner that is best described been many changes in the delivery of care by nurses.
as “we have always done it this way.” This type of Notably, EBP has influenced many of these changes
approach may not always lead to quality care that in nursing practice, nursing models and frameworks,
best meets patient outcomes, and it may not be education, and nursing research. The following
the most cost-effective approach. “Evidence-based content discusses some of the impact on nursing.
practice is a problem-solving approach to making
clinical, educational, and administrative decisions Nursing Practice
that combines the best available scientific evidence
and Management
with the best practical evidence” (Newhouse, 2006,
p. 337). In this process, EBP increases nurses’ It was recognized early on that integrating EBP
clinical knowledge; this in turn, leads to greater in the healthcare delivery system, nurses as in-
freedom to act, increasing nurses’ autonomy and dividual care providers, microsystem and system
feeling of empowerment. The following are the leaders, and policy makers at all levels of govern-
critical questions for each nurse to ask (Kramer & ment would have to implement EBP. The Magnet
Schmalenberg, 2005, p. 278): Recognition Program® includes EBP as one of its
Exhibit 11-2 Sample EBP Performance Criteria for Nursing Roles
Staff Nurse ●● Uses evidence to write/modify practice

●● Questions current practices. standards.
●● Participates in implementing changes in
●● Role models use of evidence in practice.
practice based on evidence.
●● Facilitates system changes to support use
●● Participates as a member of an EBP of EBPs.
project team. Nurse Executive
●● Reads evidence related to the nurse’s
●● Ensures the governance reflects EBP if
practice.
initiated in councils and committees.
●● Participates in QI initiatives.
●● Assigns accountability for EBP.
●● Suggests resolutions for clinical issues
●● Ensures explicit articulation of
based on evidence.
organizational and department
Nurse Manager commitment to EBP.
●● Creates a microsystem that fosters critical
●● Modifies the mission and vision to include
thinking. EBP language.
●● Challenges staff to seek out evidence to
●● Provides resources to support EBP by
resolve clinical issues and improve care. direct care providers.
●● Role-models EBP.
●● Articulates the value of EBP to the
●● Uses evidence to guide operations and chief executive officer and governing
management decisions. board.
●● Uses performance criteria about EBP in
●● Role-models EBP in administrative
evaluation of staff. decision making.
●● Hires and retains nurse managers and
Advanced Practice Registered Nurse advanced practice nurses with knowledge
●● Serves as a coach and mentor in EBP. and skills in EBP.
●● Facilitates locating evidence. ●● Provides a learning environment for EBP.
●● Synthesizes evidence for practice. ●● Uses evidence in leadership decisions.
Reproduced from Schmidt, N., & Brown, J. (2015). Evidence-based practice for nurses: Appraisal and applications
of research. Burlington, MA: Jones & Bartlett Learning. Modified from Titler, M. (2014). Developing an evidence-based
practice. In G. LoBiondo-Wood & J. Haber (Eds.), Nursing research: Methods and critical appraisal for evidence-
based practice (8th ed., pp. 418–440). St Louis, MO: Mosby Elsevier.
recognition elements—a factor that has encouraged evidence to do so. Both of the programs noted here
an increasing number of healthcare organizations are discussed in other chapters.
to adopt nursing EBP and actively pursue staff
knowledge of EBP so that EBP can be effectively
Nursing Education
implemented. Evidence has also been used more
extensively to support new practice initiatives such EBP is included in the five healthcare professions core
as TeamSTEPPS®. However, even when a program competencies, which in turn provides more support
is based on evidence and is well developed, it is not for the call to include EBP in nursing education (IOM,
easy to implement and sustain an EBP program. 2003). Nursing education accreditation standards
Much more is needed to improve practice and use also now include EBP. To prepare students in these
core competencies, schools of nursing EBP content

is provided at both the undergraduate and graduate Applying EBP
levels. Healthcare organizations also include more as a Student
content on EBP in their staff education. Professional
literature, textbooks, and journals are available to Nursing curricula are including more content on
support nursing EBP preparation. EBP for both undergraduate and graduate students.
The location of this content in the curriculum
Government Initiatives can vary from school to school, but typically it is
associated with nursing research content and then
Supporting Research
emphasized throughout the curriculum. This con-
and EBP tent is not something that should be presented in
There is increasing recognition that a critical need isolation from other nursing content and clinical
exists for evidence to support strategies employed to experiences. Instead, students need to actively pursue
improve care. Examples of two initiatives that have understanding of EBP and use of evidence in their
been developed to meet this need are the Clinical practice. When you are assigned or select patients
and Translational Science Awards (CTSA) and the for clinical experiences, part of the preparation
Patient-Centered Outcomes Research Institute should be to search for current research evidence
(PCORI). The CTSA’s goal is to decrease the time found in professional literature and then incorporate
taken to move research into practice; as a consequence, this evidence in the care plan and practice. This
this initiative has driven translational research. search should extend beyond the patient diagnosis
Translational research had been described in two to nursing problems. Students typically use certain
ways: (1) the application of discoveries generated types of EBP data—for example, patient values and
in the laboratory and in preclinical studies to the preferences, patient history, and assessment data—
development of trials and studies in humans and but they also need to include research evidence and
(2) research aimed at enhancing the adoption of often do not consider their own clinical expertise
best practices in the community. Determining com- level as evidence for practice.
parative effectiveness of prevention and treatment The more you examine and use EBP, the more
strategies, for example, is part of translational science it will become an integral part of your practice as
(National Institutes of Health, 2010). PCORI (2014) a student, as well as your practice after graduation.
focuses on research that addresses patient-centered Merely completing a few assignments on EBP or
outcomes. The federal government also supports taking an exam on EBP will not cause you to develop
comparative effectiveness research and provides the core competency to use EBP. Instead, you need to
resources so that state-of-the-science information make a commitment to practice at the best possible
is available (HHS & AHRQ, 2017). level; to get there takes practice, and that practice
should include EBP.

EBP is now part of nursing education and practice Stop and Consider #10
and several important government programs. You need to use EBP as a student.
CHAPTER HIGHLIGHTS
■■ EBP as a core competency is connected to of ensuring that a research participant/

providing patient-centered care, QI, and subject’s rights are protected and that the
interprofessional teams. study is planned in an effective manner
■■ Application of EBP has increased because that meets scientific standards, particularly
of the recognition of the large translation theory and informed consent.
gap between bench (scientific) research and ■■ EBP uses evidence from research results,
its impact (that is, its use in practice). patient assessment and other sources,
■■ Research is a systematic investigation of a clinical expertise, and information about
specific problem. patient preferences and values.
■■ The relationship between research and EBP ■■ The key component of EBP literature is
centers on the fact that the best evidence systematic reviews.
comes from research findings. ■■ The involvement of staff nurses in the EBP
■■ Basic research is designed to broaden the process is critical to its eventual integration
base of knowledge rather than to solve an in a healthcare organization’s culture of care
immediate problem. delivery.
■■ Applied research is designed to find a ■■ EBM is critical for effective management of
solution to a practical problem. care in all types of settings.
■■ Nursing research is inextricably linked ■■ Research, EBP, and QI are not the same.
to the profession’s mandate to protect Research focuses on the scientific method
the public and promote the best possible to deduce answers to questions; EBP
patient outcomes. focuses on the use of supporting data to
■■ The NINR was established in 1985, support interventions; and QI focuses
providing nursing with representation at on a system or process to measure and
the NIH. systematically examine quality of care at
■■ The research process, like the nursing a macro (or system) level or a micro (or
process, is based on problem solving. patient) level.
■■ Research can be either quantitative or ■■ Nursing education has begun to shift
qualitative design; some studies include from pure research content with additive
both. In quantitative studies, the research information on EBP to a focus on EBP
question(s) focus on how many or how while teaching how research underlies
much; in the qualitative design, the much of EBP.
research question(s) focus on feelings or ■■ Government initiatives such as PCORI
experiences. support research and EBP.
■■ IRBs focus on participant/subject rights. ■■ Students need to apply EBP in their clinical
The IRB is charged with the responsibility experiences.
1. What does the core competency “employ 5. Why is EBP important to nursing practice?
evidence-based practice” mean? 6. What are the barriers to implementing
2. What is the research process? EBP, and how might some of them be
3. How does research relate to EBP? overcome?
4. What is a systematic review? How do sys- 7. Why is EBM important to healthcare delivery?
tematic reviews relate to EBP? What is their 8. Which factors would you consider when
value to practice? implementing EBP in a nursing unit?
1. In an EBP review, you begin by describing 3. Visit the NINR website and review the cur-
the clinical problem or scenario. At the rent strategic plan (https://www.ninr.nih.gov
University of Washington’s website (http:// /aboutninr/ninr-mission-and-strategic-plan).
libguides.hsl.washington.edu/content.php What examples are given on the site to
?pid=231619&sid=1931590), you will find demonstrate how nursing research is mak-
examples of clinical problems and scenar- ing a difference? Do any of these examples
ios. The PICOT method is used to clearly surprise you (nursing involvement, type of
define a specific clinical problem. This site study, results)? What is your own school doing
shows you how to move from the clinical in the area of nursing research?
problem/scenario to a clinical question 4. Visit the National Institute of Health ethics
using a PICOT question. How would you program website (http://ethics.od.nih.gov
summarize this process? /default.htm). Review one of the posted topics.
2. Write a PICOT question. After you have writ- Why did you select this topic? Summarize
ten your PICOT question, compare it with what you have learned from this site.
questions developed by other students (this 5. If you are interested in learning more about
can be done in a small group). Ask members the Tuskegee study as an example of need for
of the group to identify the P, I, C, O, and T research ethics, visit The National Academics
in your question, and do the same with the online ethics center (https://www.cdc.gov/tuskegee
other questions. Select one PICOT question /timeline.htm). What happened in this study?
and see if the group can find a systematic What were the ethical issues that should have
review dealing with it. If you cannot find a been considered? Does your school have an
systematic review, then discuss what this IRB office? If so, visit its website and review the
means. Identify PICOT questions for your informed consent forms and Health Insurance
clinical patients. Portability and Accountability Act forms.
Electronic Reflection
Consider how you might improve your practice first as a student and then as a nurse.
Develop the steps you will take to work to improve, and then track your results annually.
CASE STUDIES
Case 1
Health professionals noticed that ventilator-dependent adults often developed
pneumonia. They started questioning what might be going on. They reviewed the literature
and found that there was little evidence to support this phenomenon, although a few
studies had addressed the topic. Subsequently, more and more institutions examined
ventilator-associated pneumonia (VAP). Based on these reviews, guidelines or best
practices were developed to decrease the incidence of VAP in adults. Now, research and
EBP studies examine VAP as a measure of quality of care, consider costs associated with
VAP versus preventive costs, and use VAP as a benchmarking tool for quality care and
patient safety (Ruffell & Adamcova, 2008; Uckay, Ahmed, Sax, & Pittet, 2008).
Case Questions
1. Can you find one published article describing a single study and also a systematic review
focusing on VAP and related care issues? If so, what evidence does it provide? How is a
single study different from a systematic review?
2. Can you find a clinical guideline on VAP? What evidence is provided?
3. What care approach is used in a clinical setting in which you have practicum? How does
it relate to what you have learned from the systematic review and/or clinical guideline?
Case 2
You have just taken a new position in a cardiac care unit. A month after you start the job,
you have a question about a procedure and the rationale for its use. You go to your staff
mentor, and she tells you to just follow the procedure as written, as it makes work easier.
This is not what you expected.
Case Questions
1. What might be your response to your mentor?
2. How might this interaction affect your view of your mentor?
3. At your next monthly meeting with the nurse manager, what might you say about this issue?
4. What does this tell you about EBP on the unit?
5. What might be improved in this unit’s practice?

questions.
1. What do we need to do to increase use of EBP?
2. Why is this important to us? We are all very busy.
3. Why is the documentation of EBP something we should consider?
REFERENCES
American Association of Colleges of Nursing. (2006). AACN Melnyk, B., & Fineout-Overholt, E. (2014). Evidence-based
position statement on nursing research. Washington, practice in nursing and healthcare. Philadelphia, PA:
DC: Author. Lippincott Williams & Wilkins.
American Nurses Association. (2015a). Scope and standards Melnyk, B., & Stillwater, S. (2010). Asking compelling,
of practice. Silver Spring, MD: Author. Appendix: Code clinical questions. In B. Melynik & E. Fineout-Over-
of ethics with interpretive statements. holt (Eds.), Evidence-based practice in nursing and
American Nurses Association. (2015b). Code of ethics with healthcare (pp. 25–39). Philadelphia, PA: Lippincott
interpretive statements. Silver Spring, MD: Author. Williams & Wilkins.
American Nurses Association. (2016). Nursing research. National Institute of Nursing Research. (2016, September).
Retrieved from http://www.nursingworld.org The NINR strategic plan: Advancing science, improving
/EspeciallyForYou/Nurse-Researchers lives. Retrieved from https://www.ninr.nih.gov/sites
American Organization of Nurse Executives. (2017). American /www.ninr.nih.gov/files/NINR_StratPlan2016
organization of nurse executives. Retrieved from http:// _reduced.pdf
www.aone.org/about/overview.shtml National Institute of Nursing Research. (2014). What is nursing
Brown, S. (2009). Evidence-based nursing. Burlington, MA: research? Retrieved from http://www.ninr.nih.gov/
Jones & Bartlett Learning. National Institutes of Health. (2010). Institutional clinical
Chassin, M. (1998). Is healthcare ready for Six Sigma quality? and translational science award (US4). Retrieved from
Milbank Quarterly, 76, 565–591. http://grants.nih.gov/grants/guide/rfa-files/RFA-RM
DiCenso, A., Guyatt, G., & Ciliska, D. (2005). Evidence-based -10-001 .html#SectionI
nursing: A guide to clinical practice. St. Louis, MO: Newhouse, R. (2006). Examining the support for evi-
Elsevier Mosby. dence-based nursing practice. Journal of Nursing
Finkelman, A. (2018). Quality improvement: A guide for integration Administration, 36, 337–340.
in nursing. Burlington, MA: Jones & Bartlett Learning. Newhouse, R. (2007). Diffusing confusion among evidence-based
Institute of Medicine. (2003). Health professions education: practice, quality improvement, and research. Journal
A bridge to quality. Washington, DC: The National of Nursing Administration, 37(10), 432–435.
Academies Press. Patient-Centered Outcomes Research Institute. (2014).
Institute of Medicine. (2008). Knowing what works in health About us. Retrieved from http://www.pcori.org/about
care: A roadmap for the nation. Washington, DC: The -us/landing/
National Academies Press. Ruffell, A., & Adamcova, L. (2008). Ventilator-associated
Institute of Medicine. (2010). The future of nursing: Lead- pneumonia: Prevention is better than care. Nursing
ing change, advancing health. Washington, DC: The Critical Care, 13(1), 44–53.
National Academies Press. Sollecito, W., & Johnson, J. (2013). The global evolution of
Institute of Medicine. (2011a). Clinical data as the basic staple continuous quality improvement: From Japanese man-
for health learning: Workshop summary. Washington, ufacturing to global health services. In W. Sollecito &
DC: The National Academies Press. J. Johnson (Eds.) McLaughlin and Kaluzny’s continuous
Institute of Medicine. (2011b). Clinical guidelines we can quality improvement in healthcare (4th ed., pp. 1–48).
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Institute of Medicine. (2011c). Finding what works: Standards Uckay, I., Ahmed, Q., Sax, H., & Pittet, D. (2008). Ventilator-
for systematic reviews. Washington, DC: The National associated pneumonia as a quality indicator for patient
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Nursing Administration Quarterly, 29, 275–287.
Chapter
12 Apply Quality Improvement
CHAPTER OBJECTIVES
■■ Discuss the relevance of the core competency: ■■ Explain two new major federal initiatives to
Apply quality improvement. improve care and control costs: hospital-acquired
■■ Describe the current status of healthcare conditions and 30-day unplanned readmissions.
quality. ■■ Examine examples of high-risk healthcare
■■ Explain the need for a blame-free culture activities.
of safety and critical concerns of healthcare ■■ Describe examples of tools and methods used
safety. to monitor and improve health care.
■■ Discuss the integration of quality improvement ■■ Describe quality improvement measurement
in healthcare delivery. and analysis.
■■ Describe examples of safety initiatives. ■■ Discuss the roles of nurses and nursing as a
■■ Examine the National Quality Strategy. profession in improving health care.
CHAPTER OUTLINE
●● Introduction ●● A Culture of Safety and a Blame-Free

●● The Competency: Apply Quality Work Environment
Improvement ●● Staff Safety
●● Quality Health Care ●● Quality Improvement
●● To Err Is Human: Impact on Safety ●● Examples of Safety Initiatives
●● Crossing the Quality Chasm: Impact on ●● The Joint Commission
Quality Care ●● Healthcare Report Cards
●● Envisioning the National Healthcare ●● National Quality Strategy
Quality Report: Need for Monitoring ●● Federal Initiatives to Improve Care:
●● Defining Quality Health Care Hospital-Acquired Conditions and 30-Day
●● Safety in Health Care Unplanned Readmissions
●● Critical Safety Terms
375
●● Examples of High-Risk Healthcare ●● Incident Reports

Activities ●● Sentinel Events
●● Medication Administration ●● Measurement and Analysis
●● Care Transitions and Handoffs ●● Data Collection
●● Failure to Rescue ●● Analysis
●● Alarm/Alert Fatigue ●● Patient Outcomes and Nursing Care:
●● Missed Nursing Care Do We Make a Difference in Quality
●● Tools and Methods to Monitor and Improve Improvement?
Healthcare Delivery ●● Chapter Highlights
●● Utilization Review/Management ●● Engaging in the Content
●● Benchmarking ●● Discussion Questions
●● Assessment of Access to Healthcare ●● Critical Thinking Activities
Services ●● Electronic Reflection Journal
●● Medication Reconciliation ●● Case Studies
●● Standardized Communication Methods ●● Working Backward to Develop a Case
●● Rounds ●● References
KEY TERMS
Accreditation Hospital-acquired Quality improvement (QI)

Adverse event complication (HAC) Rapid response team (RRT)
Alarm or alert fatigue Incident report Root-cause analysis (RCA)
Benchmarking Indicator Rounds
Blame-free environment The Joint Commission Safe care
Care transition Measure Safety
Continuous quality Medication error Sentinel event
improvement (CQI) Medication reconciliation STEEEP®
Culture of safety Missed nursing care Structure
Effective care Misuse Surveillance
Efficient care National Quality Strategy Timely care
Equitable care (NQS) Transforming Care at the
Error Near miss Bedside (TCAB)
Failure to rescue Outcomes Triple Aim
Healthcare quality Overuse Underuse
Healthcare report Patient-centered care Utilization review/
card Process management (UR/UM)
of healthcare organizations (HCOs) is also related to

Introduction the need to improve care. Nurses and nursing as a
profession assume major roles in ensuring that care
This chapter discusses the fourth healthcare core
is safe and outcomes are reached, resulting in quality
competency: Apply quality improvement (QI). The
care. Appendix A is an important resource for this
content includes information about the key quality
content, providing additional content and terminology
and associated safety reports (Quality Chasm series)
to assist in greater understanding of quality health care.
and their recommendations. The role of accreditation
Chapter 12: Apply Quality Improvement 377
United States is about average. In addition to deaths

The Competency: Apply and injuries, medical errors also cost billions of
Quality Improvement dollars. One study conducted in 2011 put the figure
at $17 billion a year. Counting indirect costs like
The fourth healthcare profession core competency is lost productivity due to missed workdays, medical
to apply QI. The description of this core competency errors may cost nearly $1 trillion each year. . .” (U.S.
follows: “Identify errors and hazards in care; understand Congress, Subcommittee on Primary Health and
and implement basic safety design principles, such Aging, 2014). Experts comment on healthcare quality
as standardization and simplification; continually by noting recent studies supporting the comments
understand and measure quality of care in terms to congress—if we identified errors as a disease,
of structure, process, and outcomes in relation to then when tracking death rates per disease errors
patient and community needs; and design and test would be the third leading cause of death in the U.S.
interventions to change processes and systems of (Makary, 2016). This is a strong statement, and it
care, with the objective of improving quality” (In- should drive us to greater efforts to improve. The
stitute of Medicine [IOM], 2003, p. 4). Figure 12-1 picture is not all bleak as there has been improve-
identifies the key elements of this competency. ment since the report, To err is human, but there
Current data indicate that there are serious has not been enough. The examples provided in this
problems with health care in the United States—its chapter content and in Exhibit 12-1 indicate major
safety, its quality, and waste and inefficiency. In problems still exist 18 years after the publication of
2014, the U.S. Congressional Subcommittee on Pri- To err is human (IOM, 1999).
mary Health and Aging held a meeting to examine
healthcare errors: “Preventable medical errors in
hospitals are the third leading cause of death in the Stop and Consider #1
United States, a Senate panel was told today. Only Every nurse is expected to meet the QI competency.
heart disease and cancer kill more Americans . . .
Medical harm is a major cause of suffering, disability,
and death—as well as a huge financial cost to our
nation,” Senator Bernie Sanders commented (I-Vt.).
Quality Health Care
The press release went on to state, “each year as many
as 440,000 people die due to a preventable medical Since the late 1990s, there has been considerable
error in hospitals. Compared with other nations, the growing examination of healthcare quality. The
Institute of Medicine (IOM), now known as the
Academy of Medicine, is a leader in this effort, con-
sulting with experts, collecting and analyzing data,
Safety in
health care
Quality
health care
and publishing reports with recommendations on
a variety of topics related to healthcare quality. Its
Core competency:
Apply QI series of reports is often referred to as the Quality
Quality in
Chasm reports.
Patient
nursing delivery role in QI
systems
Critical tools To Err Is Human: Impact
on Safety
to improve
care (QI)
The first report in the Quality Chasm series was

Figure 12-1 Apply QIs: Key Elements To err is human: Building a safer health system
Exhibit 12-1 Examples of Quality Care Issues
The following represent several examples of and then limiting use of standard checking
problems that have occurred in last few years of equipment routinely used in procedures
in healthcare organizations that have had a to ensure sterility (Beckers Hospital Review,
serious impact on patients and their health 2016). If equipment is not checked then,
outcomes. Some have been resolved, and data collected would not identify problems
some are ongoing. and performance would appear to be better
than it might be. The nurse asked that
National Institutes of Health
this not be done and an external audit be
Clinical Center
conducted. This was rejected. The nurse is
The NIH Clinical Center has long been thought suing under the whistleblower law, which
of as an exemplar healthcare setting that offers allows a person to report and file a lawsuit.
care for unique problems and clinical trials for Employers cannot retaliate for this type of
research studies; however, in 2016, there was employee action.
significant criticism of the center and its care.
Leadership at the center disputed the claims of Lost Newborn Body
poor quality (Kaiser, 2016). The report identifies An academic medical center loses the body
several recommendations for improvement: of a newborn after death during delivery.
(1) Fortify a culture and practice of safety and This is an unusual situation and is a sentinel
quality; (2) strengthen leadership for clinical event. There are procedures and policies that
quality, oversight, and compliance; and (3) should be applied when a death occurs in a
address sterile processing of all injectables and healthcare organization, including care of the
the specifics of the sentinel event that set this body. This did not happen in this case when
review in operation (NIH, ACD, 2016). a woman delivered twins; one was stillborn
and the second lived an hour (CBS News, 2015;
Veterans Health Administration
Fieldstadt, 2015). The hospital even searched
In 2014, there was extensive reporting of abuse the city dump but did not find the body (Butts,
with the Veterans Health Administration 2015).
focused on patients put on wait lists for long
periods of time or never seen. This in itself is Whistleblower: Visiting Nurse
poor care, but added to this were changes Service Fraud
made in documentation indicating that there At one of the largest nonprofit home
were not problems with getting appointments. healthcare agencies in the United States, a
This is fraud and unethical and has been senior manager filed a whistleblower lawsuit
investigated by the Inspector General for the for fraud that resulted in hundreds of millions
VA. In 2016, problems continued in some VA of dollars taken from Medicare and Medicaid.
medical centers—for example, the Inspector The fraud included falsified and improper
General investigating care and misconduct billings. This resulted in many patients
(Krause, 2016). Other problems have been receiving a fifth or less of their prescribed
identified in other VA medical centers, such care. Patients were not told about changes
as environment concerns in the operating in the service level nor were physicians
rooms and fraud and cover-ups with nurses’ notified. An example of fraud was a nurse
involvement (Rebelo & Santora, 2016). who claimed to have made 20 patient visits
for 9 patients in one day. Other nurses made
A Nurse as a Whistleblower
similar claims of visits that could not have
A nurse in an academic health center sues been made in the timeframe identified.
the health center for covering up infections
Sources: Center. Retrieved from http://www.nbcnews

Beckers Hospital Review (2016). UC health .com/news/us-news/body-newborn-baby
nurse sues health system for covering up -goes-missing-university-cincinnati-medical
scope-related outbreak. Retrieved from http:// -center-n435696; Kaiser, J. (2016, June 3). NIH
www.beckershospitalreview.com/quality in uproar over report slamming clinical center,
/uc-health-nurse-sues-health-system-for leadership shake up. Retrieved from http://
-covering-up-scope-related-outbreak.html; www.sciencemag.org/news/2016/06/nih
Bernstein, N. (2016, September 24). Whistle- -uproar-over-report-slamming-clinical-center
blower suit accuses visiting nurse service of -leadership-shakeup; Krause, B. (February 15,
fraud. Retrieved from http://www.nytimes 2016). Cincinnati VA at center of misconduct
.com/2016/09/24/nyregion/whistle-blower investigation. Retrieved from http://www
-suit-accueses-visiting-nurse-service-of-fraud .disabledveterans.org/2016/02/15/cincinnati-va
.html; Butts, R. (2015, September 29). Search -at-center-of-misconduct-investigation/;
of landfill fails to find newborn. Retrieved National Institutes of Health (NIH), & Advisory
from http://www.usatoday.com/story/news Committee to the Director (ACD). (2016).
/nation/2015/09/29/newborn-boy-body Reducing risk and promoting patient safety
-landfill/73017012/; CBS News (2015, for NIH intramural clinical research. Final
September 29). Cincinnati hospital report. Retrieved from https://acd.od.nih.gov
apologizes for lost remains of baby. Retrieved /Red_Team_final_report_4262016.pdf;
from http://www.cbsnews.com/news Rubelo, K., & Santora, M. (2016, September 19).
/university-of-cincinnati-medical-center Deaths, fraud allegation, and an inquiry
-apologizes-for-lost-remains-of-baby/; into a Long Island VA hospital. Retrieved
Fieldstadt, E. (2015). Body of newborn baby from https://www.nytimes.com/2016/09/20
goes miss at University of Cincinnati Medical /nyregion/inquiry-into-northport-va-hospital
-long-island.html?_r=1
(IOM, 1999). This report explored the status of safety Health and Human Services [HHS] & Agency for
in the U.S. healthcare delivery system. The results were Healthcare Research and Quality [AHRQ], 2013b).
dramatic, with data indicating serious safety problems As is discussed in this chapter, effective understand-
in hospitals. This examination did not include other ing or quality requires clear data that are useful for
types of healthcare settings, such as ambulatory care, monitoring and measuring healthcare outcomes.
home care, long-term care, and many other types of Some of the data from the initial Quality Chasm
sites. More research was needed to provide data about report that disturbed the public and healthcare
the quality of care and safety in these settings. A recent providers included the following and set the stage
example of such research is the report published by for the drive to improve care (IOM, 1999, pp. 1–2):
the Agency for Health Research and Quality (AHRQ): ■■ When data from one study were extrapo-
AHRQ health information technology, ambulatory lated, the result suggested that at least 44,000
safety and quality. Findings and lessons from the Americans die each year as a result of a
AHRQ ambulatory safety and quality program. This medication error. Another study indicated
report describes studies about ambulatory care, but the number of deaths from this cause could
the report notes that more information is needed be as high as 98,000 (American Hospital
to support strong conclusions (U.S. Department of Association, 1999).
■■ More people die in a given year as a result this problem. Changing the status of quality care
of medical errors than from motor vehicle requires multiple planned strategies in practice and
accidents (43,458), breast cancer (42,297), management and an increase in QI education in
or acquired immunodeficiency syndrome professional healthcare programs such as nursing
(AIDS) (16,516) (U.S. Department of Health education and staff training.
and Human Services, Centers for Disease
Control and Prevention, & National Center
for Health Statistics, 1998).
Crossing the Quality Chasm:
■■ Healthcare delivery costs represent over more Impact on Quality Care
than half of total healthcare national costs, Crossing the quality chasm (IOM, 2001a) is the report
which includes lost income, lost household that followed To err is human (IOM, 1999) in the
production, disability and the actual healthcare Quality Chasm series. This report’s major message
delivery costs (Thomas et al., 1999). is that the U.S. healthcare system is in need of fun-
The data described here are no longer current but are damental improvement. Although the healthcare
important in understanding the significance of this delivery system has undergone many changes—
report. Later in this chapter, HCO accreditation is such as the development of new drugs, medical
discussed in detail; however, it is important to note technology, and informatics that have improved care
here that accreditation, focusing on evaluating the and care options—more needs to be done. The 2001
quality of care in HCOs, has long been a driving report provides valuable information to help nurses
force in health care. It is clear from To err is human better understand quality issues in the healthcare
that this has not been enough to improve care at system; however, if this information is not applied
the level needed. to improve care, it serves little purpose. The report
The media took note of To err is human and identifies six aims or goals for improvement. These
its recommendations, and soon worrisome stories aims state that care should have the following char-
appeared on the evening news and in newspapers; acteristics: safe, timely, effective, efficient, equitable,
special in-depth news reports asked, “How safe are and patient-centered care (STEEEP®) (IOM, 2001a,
you when you go in for health care?” Consumers pp. 5–6). This care ensures that patients receive the care
began to ask questions. Healthcare errors experienced they need, when they need, in the most cost-effective
by patients and errors reported in the media reduce manner and that efforts are made to prevent problems
the public’s trust in the healthcare system. The result that might occur due to the care such as an error. As
is that patients and families now question their care noted in other Quality Chasm reports, care must also
more. Some patients now want a family member or recognize diversity and ensure that disparities are
friend with them when they are in the hospital, not just limited. The critical element that connects all of this
for support but also to act as a protector from errors. is the care is focused on the patient with the patient
When a patient experiences an error, the patient’s participating in the care process. All of the healthcare
trust level drops, and this has an impact on how the professions’ core competencies relate to STEEEP,
patient approaches future care. There is a positive and these aims are now considered to be critical
side to this situation: More patients are demanding elements for all healthcare delivery (IOM, 2003).
to be informed about their care and, therefore, are The Quality Chasm series is unique in that each
becoming more involved in the care process. report does not stand alone, but rather expands on
The first important issue when trying to do previous reports in the series. This interconnected-
something to prevent errors and improve care is ness makes it important that readers understand
to recognize there is not a specific single answer to the general information in each report, the ways
in which the reports relate to one another, and the 4. Shared knowledge and the free flow of information.
recommendations and joint implications for nursing Patients need access to their medical information,
and health care. For example, STEEEP is related to and clinicians also need access. This rule relates
all of the reports and now is a central feature in HCO to all the core competencies, and particularly
QI programs and in national QI initiatives to better to the fifth competency—applying informatics.
ensure continuous quality improvement (CQI). Consider these factors and examples: informatics,
To ensure an improved healthcare system meets interprofessional teams, sharing information in
the six aims identified in the Crossing the quality the nursing care process, patient-centered care,
chasm report, new rules for the 21st century were privacy and confidentiality, patient education,
developed to guide care delivery describing a vision computerized documentation, professional
of health care, though we are not there yet. The rules ethics, and standards.
are included here with additional comments about 5. Evidence-based decision making. Patients need
their relationship to nursing (IOM, 2001a, p. 67). care that is based on the best possible evidence
1. Care based on continuous healing relationships. available. Care should not vary illogically
Patients should receive care whenever they need from clinician to clinician or from place to
it—access is critical. Health needs are not static, place. Consider these factors and examples:
and care must change to meet the needs. Consider patient-centered care, nursing research and
these factors and examples: the nurse–patient other areas of research, research informed
relationship, continuum of care, collaboration consent, and plan of care.
and coordination, HCO services and systems, 6. Safety as a system property. Patients need to
diversity, interprofessional teams, communi- be safe from harm that may occur within the
cation, and nursing standards. healthcare system. There needs to be more
2. Customization based on patient needs and values. attention placed on system errors rather than
This rule relates directly to patient-centered care. just individual errors. Consider these factors and
Patient needs and values also constitute one of the examples: patient-centered care, CQI, nursing
sources of evidence for evidence-based practice care provided in a safe manner, inclusion of
(EBP). Consider these factors and examples: safety in the plan of care, patient safety and
nursing care and planning, interprofessional errors, staff safety, culture of safety, and reim-
teams, patient-centered care, collaboration bursement (for example, Medicare rules limit
and coordination, diversity, patient rights, and reimbursement if a patient experiences a fall).
patient education, all of which relate to nursing 7. The need for transparency. The healthcare system
standards and to the nursing code of ethics. should make information available to patients
3. The patient as the source of control. Patients need and their families that allow them to make in-
information to make decisions about their own formed decisions when selecting a health plan,
care—this is essential to patient-centered care. hospital, or clinical practice or when choosing
Healthcare systems and professionals need to among alternative treatments. This should include
share information with patients and bring patients information that describes the system’s perfor-
into the decision-making process. Consider these mance on quality, EBP, and patient satisfaction.
factors and examples: plan of care, interprofes- Consider these factors and examples: interpro-
sional care, informed consent provides patient fessional teams, informatics, privacy and con-
information to the decision maker, privacy and fidentiality, informed consent, research, patient
confidentiality, patient education, patient rights education, report cards, ethics and standards,
and professional ethics, and informatics. and national reports on quality and disparity.
8. Anticipation of needs. Healthcare providers healthcare quality, which is made available on the
and the health system should not just react Internet. This report should “serve as a yardstick
to events that may occur with patients, but or the barometer by which to gauge progress in
should anticipate patient needs and provide care improving the performance of the healthcare de-
needed. Consider these factors and examples: livery system in consistently providing high-quality
assessment, interprofessional teams, nursing care” (IOM, 2001b, p. 2). Elsewhere in this chapter,
care process, plan of care, collaboration and healthcare report cards are discussed. An annual
coordination, HCO services, patient satisfaction, national report card does not replace the need for
diversity, outcomes. individual HCOs to monitor their own quality.
9. Continuous decrease in waste. Resources should The information from the national annual report
not be wasted—including patient time. Consider card can be used by HCOs in comparing their QI
these factors and examples: use of resources data with national data and developing services.
for care delivery, costs of care, access to care Healthcare professionals (providers), insurers, and
and services, staff communication, and issues health policy makers may use the information to
of misuse, overuse, and underuse. better understand current healthcare quality and
10. Cooperation among clinicians. Collaboration and consider strategies to improve. Nurse educators
communication are critical among healthcare should use this information in planning curricula
professionals and systems (interprofessional and teaching–learning strategies to ensure that
teamwork). Consider these factors and examples: students are prepared to practice effectively based
interprofessional team, plan of care requires on current needs.
team collaboration and coordination. Because the quality report and the national
These rules provide a vision of what healthcare de- disparities report were interrelated, in 2010 they
livery should be if we are to ensure quality care for were merged into one report, the National Quality
all. They provide nurses with a guide in developing and Disparities Report (QDR) (HHS & AHRQ,
improvement initiatives and strategies. 2010). This report is designed to meet the following
needs: use measurement based on best methods;
Envisioning the National identify issues that improve or act as barriers to
Healthcare Quality Report: quality care; collect data about care quality; educate
the public, healthcare professionals, organizations,
Need for Monitoring
and so on, about quality care; assist policy makers in
Envisioning the national healthcare quality report improving care; identify key benchmarks; compare
(IOM, 2001b) is the follow-up report to the Cross- U.S. health care with other countries; continue to
ing the quality chasm (IOM, 2001a). Up until this improve measurement so that data are available
time, the United States did not have a structured and useful; examine healthcare issues that might
method to monitor and measure healthcare quality. affect quality of care; and report data and results.
This report addresses this problem and describes a The annual report tracks outcomes for the priority
framework for collecting annual national data about areas of care and the adjusted priorities based on
healthcare quality and focusing on how the U.S. annual results.
healthcare delivery system performs in providing We now have more than 10 years of data from
personal health care. The Agency for Healthcare these monitoring reports, and the reports influence
Research and Quality (AHRQ) is mandated to decisions made about health policy and QI. Because
collect data using this framework and then publish it takes time to collect and analyze data, the published
an annual report describing current status of U.S. reports are typically 2 years behind the current year.
Safety in Health Care

Structure
Safety is a critical component of quality care. It is

Process Outcomes important to recognize the relationship of safety
and quality because it is easy to assume that safety is
Figure 12-2 Three Elements of Quality something different from quality care rather than to
view it as an integral component of QI. An effective
The monitoring methods used to collect and analyze HCO QI program monitors all aspects of quality so
the data are reviewed periodically to ensure their safety for patients and staff would be included. There
usefulness and quality of the data, and changes have is no question that healthcare providers, including
been made as needed. The current National Health- nurses, have long been concerned about providing safe
care QDR can be accessed at the AHRQ’s website. care for their patients. If one interviewed healthcare
providers, they would say that they want to keep their
Defining Quality Health Care patients safe. This belief was somewhat shattered when
the U.S. Congress and President’s Clinton’s Advisory
There is no universal definition of healthcare quality—a
on Consumer and Quality in the Healthcare Industry
fact that has made it difficult to assess quality. For
requested that the IOM initiate an examination of
this discussion, the following definition will be used
healthcare safety and make recommendations based
in this chapter and is applied in other chapters:
on its findings. Here we explore the topic of safety in
“degree to which health services for individuals
healthcare quality: what it is and what can be done
and populations increase the likelihood of desired
to better ensure safe care for all. As will be discussed,
health outcomes and are consistent with current
this examination expanded to something more than
professional knowledge” (IOM, 1990, p. 4). Quality is
a focus on healthcare safety.
a complex concept, and who is defining it can make
a difference; for example, a nurse, a physician, and a
patient may all have different definitions of quality. Critical Safety Terms
This definition of quality includes three ele-
Through the IOM’s emphasis on healthcare quality,
ments, which usually are included in the discussion
this organization expanded knowledge about safety
of quality care and monitoring care and described
and errors, in part by undertaking identification
in Figure 12-2 (Donabedian, 1980):
and definition of key terms. This development of
1. Structure: The environment in which services a common terminology is an important step in
are provided; inputs into the system, such as addressing the issue. To effectively collect and ana-
patients, staff, and environments. lyze data nationally requires a shared terminology.
2. Process: The manner in which services are Appendix A provides a summary of definitions for
provided; the interactions between clinicians some critical terms. The following terms are part
and patients. of this effort, and they have relevance to nurses
3. Outcomes: The results of services; evidence who need to be directly involved in initiatives to
about changes in patients’ health status in re- improve care in HCOs, at the individual healthcare
lation to patient and community needs. professional level, and in health policy (Chassin &
Galvin, 1998; IOM, 1999).
■■ Safety: Freedom from accidental injury.
It is not easy to define quality health care.
Example: The patient leaves the hospital after
surgery and a 3-day stay with no complications multiple medications, and the patient’s
with expected outcomes reached. multiple healthcare providers do not know
■■ Error: The failure of a planned action to be the medications that have been prescribed
completed as intended or the use of the wrong by different healthcare providers.
plan to achieve an aim. Errors are directly ■■ Underuse: Failure to provide a service that
related to outcomes. There are two general would have produced a favorable outcome for
types of errors: error of planning and error of the patient. Example: The patient is not able
execution. Errors harm the patient, and some, to get a specialty service needed for cancer
not all, errors may be preventable. Example: because of distance from resources, or the
The patient is given the wrong medication. patient’s insurer will not cover a medication
■■ Adverse event: An injury resulting from a for arthritis that could make the patient
medical intervention; in other words, an injury more mobile.
that is not a result of the patient’s underlying ■■ Near miss: Recognition that an event
condition. Not all adverse events are caused by occurred that might have led to an ad-
errors, and not all are preventable. It requires verse event. This does not mean an error
greater examination and analysis to determine occurred, but that it almost occurred. It
the possible relationship between an error and is important to understand these errors
an adverse event. When an adverse event is because they provide valuable information
the result of an error, it is considered a pre- for preventing future actual errors. Example:
ventable adverse event. Example: A patient is The surgical team is preparing for surgery
given the wrong medication and experiences to repair a patient’s knee. The right knee is
a seizure. If the patient does not have a seizure prepped, but soon after, the team checks
disorder, this is more likely an adverse event, the records and goes through a safety check
but much more needs to be known about the list prior to beginning surgery, the call-out,
cause(s). How did the error that led to the and check-back, to ensure that the correct
adverse event happen? The following factors knee is exposed—only to find out that it
are expected to increase the risk of medication is the left knee that requires surgery. The
adverse events in the future: development of team stops and replans the surgery. If there
new medications, discovery of new uses for is no consideration of why this error almost
older medications, aging of the U.S. population, happened, then the team cannot learn from
and greater use of medications for disease it and hopefully prevent future errors. One
prevention (U.S. Department of Health and model for understanding near misses and
Human Services [HHS] & Centers for Disease prevention of an error is the Endhoven model
Control and Prevention [CDC], 2012). (van der Schaaf, 1992), which was adapted
■■ Misuse: Avoidable complications that prevent by nursing to identify three sources of errors
patients from receiving the full potential Henneman and Gawlinski (2004, p. 196):
benefit of a service. Example: The patient 1. Technical failure (system error): Physical
receives a medication that is not prescribed items such as software, equipment, or other
and that conflicts with the patient’s allergies; materials are not designed correctly, are
the patient experiences anaphylaxis. working incorrectly, or are not available
■■ Overuse: Potential for harm from the when needed.
provision of a service exceeds the possible 2. Organizational failure (system error): Such
benefit. Example: An elderly patient is on errors relate to complex factors that affect
how work is carried out in the healthcare another example that illustrates how the reports, data,
setting, such as staff orientation, staff ex- recommendations, and methods to monitor change
pertise, protocols, policies and procedures, are all interconnected. They are clearly interwoven
clinical pathways, management priorities, with the need to develop core competencies so that
budget, and organizational culture. healthcare providers can meet the need to improve
3. Human failure: This failure results from care. As discussed later and in other chapters, there
behaviors related to skills, rules, and are now major initiatives that respond to the concerns
knowledge. Safety mechanisms should noted in the Quality Chasm reports.
include reliable system defenses and the
availability of adequate human recovery.
A Culture of Safety
Human intervention such as from nurses
can prevent adverse outcomes even when and a Blame-Free Work
high-risk incidents develop into error Environment
incidents. The typical HCO approach to errors in health care
Sentinel event: This type of event has a
has been to identify the staff member who made
■■
serious negative patient outcome (unexpected the error, supported by requiring staff to complete
death, serious physical or psychological incident reports that describe errors. This type of
injury, or serious risk). Example: A patient approach is punitive in nature and has not been
commits suicide while in the hospital for effective in reducing errors, as noted in the 1999
treatment of diabetes. report (IOM). It has not been effective because most
If the examination of healthcare quality had errors are not made by an individual, but rather are
concluded with the To err is human report, the complex and most likely system errors. When an
major impact of the report and its recommenda- error occurs, the question should not be “Who is
tions would most likely have been diluted (IOM, at fault?” but rather “Why did our defenses fail?”
1999). This, however, did not happen. In 2004, due (Reason, 2000). Communication, collaboration,
to recognition that much more needed to be known and coordination (interprofessional teamwork);
about the quality of health care, follow-up reports staffing levels and expertise; staff knowledge; patient
were published. The approach of the Quality Chasm acuity level; equipment; delivery processes; the
series has been (1) to describe a problem using data role of the patient in care; and many other factors
and expert knowledge, (2) identify recommenda- affect actions taken or not taken in health care. The
tions to respond to the problem(s), and (3) identify healthcare system has focused on the blame game
monitoring methods and possible interventions or and not on designing and using structured methods
solutions. Patient safety: Achieving a new standard for to find out more about all the factors related to an
care (IOM, 2004a) focuses on the need to establish error. Staff members need to feel comfortable—not
a national information infrastructure and the need fearful—in reporting errors. The goal now should be
for data standards. These elements help healthcare a blame-free environment or a culture of safety
providers and payers improve monitoring outcomes. in which staff can practice and openly discuss
Having a common language/terminology to use potential errors or near misses and actual errors.
in discussions about safety and errors is critical in If staff members worry about implications such
meeting the goal to develop a national information as impact on their position or performance, they
infrastructure to support monitoring of care. It may not report an error. This can have serious
also addresses the fifth healthcare professions core consequences for patients and prevent the system
competency, which focuses on informatics. This is from improving. This type of fear may also prevent
staff from communicating near misses, from which It is particularly important to have effective HCO
much can be learned about potential errors. In the leadership to guide and support the development of a
past, if a nurse made a medication error, the nurse culture of safety (Anderson, 2006). Trust is important
might have been routinely required to take a med- in this type of culture—staff must trust management
ication review course and an exam on medication and vice versa. A topic that comes up often from all
administration with no consideration of analyzing types of healthcare professionals is concern about
the causes of the error. The following are examples revealing errors and near misses. This is based on
of questions that are important to consider for this past experiences. Moving away from blame means
situation in a culture of safety, demonstrating the that staff members must trust that they will not be
complexity of an error: automatically blamed or punished for errors that are
out of their individual control. Another aspect of
■■ What are the key questions we should consider?
this issue is related to individual staff expectations;
■■ Was the prescription transcribed correctly?
nurses feel that they should not make mistakes, that
■■ Was the order not the best choice for the
the care they provide should be perfect. This is not
patient and patient’s problem?
a reality-based perspective. Errors will inevitably be
■■ Was an error made in what the physician
made that are caused by many factors. Improvement
intended to order or what the team agreed
is, of course, critical, but to think that errors will
would be the best approach?
never be made is not realistic. There is no doubt that
■■ Was the correct medication sent by phar-
the number of errors needs to decrease. Moreover,
macy? Correct dose? Correct method of
there is no doubt that what has been done to address
administration? Correct time?
errors has not yet been fully effective. To be truly
■■ Did the error involve placing a patient medi-
effective, disclosure must be present with maximum
cation in the wrong patient medication box?
transparency. Ensuring transparency and involving
■■ Was there an equipment malfunction (for
patients are the most difficult aspects of ensuring a
example, intravenous equipment, monitoring
culture of safety (Anderson, 2006). “A fundamental
equipment)? Was there a computer error?
principle of the systems approach to error reduction
■■ What were the distractions and interruptions
is the recognition that all humans make mistakes
when the medication was prepared and
and that errors are to be expected, even in the best
administered?
organizations” (Reason, 2000, p. 768).
■■ Were monitoring guidelines followed (for
It is important to note that a no-blame culture
example, vital signs checked)? If data indi-
of patient safety does not mean a lack of individual
cated certain actions should be taken, were
accountability (Wachter & Pronovost, 2009). There
they taken? If not, why?
is greater emphasis on the recognition of the impact
Did the nurse check the patient’s identification of the system on errors, but nurses and other health-
correctly? To accomplish the goal to move to a culture care providers still have accountability for their own
of safety, there must be (1) greater understanding practice. When an individual fails to adhere to a safety
of its essential elements, (2) a decrease in barriers standard that one would be expected to know and
to creating the culture, (3) development and imple- apply, and there are no system issues for this failure,
mentation of strategies to create the safety culture, then an individual staff member may be accountable
and (4) evaluation of outcomes (IOM, 2004a). Hos- for the error. Reporting is an important component
pitals and other HCOs are moving toward cultures of professional accountability. This means healthcare
of safety, but it will take time and effort to change professionals recognize the importance of QI and are
staff and administration attitudes and behaviors. committed to active participation in the QI process.
Despite all of these reports, data, and initiatives 2011, a neonatal nurse with 24 years’ experience was
to improve care and respond to errors—for example, involved in medication error that led to the death
with checklists to ensure that the correct side or body of an 8-month-old baby, though at the time it was
part is operated on in surgery—major problems per- not clear the error was the actual cause of the death.
sist. The Joint Commission reports that wrong site, Immediately after the incident, the nurse was escorted
wrong patient, and wrong procedure continue to be from the hospital, put on administrative leave, and
major problems, representing the most frequently then fired several weeks later. Seven months later, the
reported sentinel event—for example 1,196 events nurse committed suicide. The hospital in which this
reported for first 9 months of 2015 (Joint Commission, event occurred had been following a “just culture”
2015). Such errors are increasing, not decreasing. approach for more than 3 years, but this example
For example, consider what happened with a patient does not demonstrate this type of culture (Aleccia,
who was scheduled to have cardiac bypass surgery. 2011). Does this incident send a message not to
When a nurse asks the patient to sign the consent mention mistakes? How effective was the organiza-
form, it listed a different procedure. The patient, who tion’s “just culture”? How can employers help staff so
was a physician, pointed out the error and refused that staff do not become secondary victims if they
to sign. A half-an-hour later, another nurse brought cannot cope with the result of an error? Emotional
the patient another consent form to sign, but it was distress after an event is not uncommon for staff.
also incorrect. The third consent form was correct In a survey of 3,000 physicians in the United States
and signed by the patient. This should never happen. and Canada, 92% reported experiencing an adverse
What if the patient had not noticed or did not have the event, and of those physicians, 81% reported some
background to understand that the surgical procedure job-related stress associated with the adverse event
described was not what was agreed upon between (U.S. Department of Health and Human Services
the physician and the patient? This experience also [HHS], Agency for Healthcare Research and Quality
took staff time and increased stress for the patient [AHRQ], & Patient Safety network [PSNet], 2016a).
and family just prior to surgery. Patient trust in staff Recovery requires time, but it is critical that HCOs
was significantly reduced, and as the patient left the maintain an environment of support and offer the
hospital, he said, “What has happened to nurses? I provider assistance. Getting support from peers
have worked with them for years, but their practice is also important, as is having a break from work
has gone downhill. I could have been killed in there.” responsibilities immediately after the adverse event
This same patient experienced several critical near and having some time to talk about the event in an
misses with intravenous medications that could environment that is not threatening.
have led to cardiac arrest if the patient had not no- The establishment and maintenance of an
ticed the errors and told the nurse to stop giving the effective culture of safety requires leadership. This
medication immediately; an error that was repeated is so critical that The Joint Commission published
the next day. It highlights the fact that much more a sentinel event alert entitled: The essential role of
needs to be done to improve care and that changing leadership in developing a safety culture (2017a). It
the culture is much more complicated than thought. recognizes that when leaders in HCOs do not create
It is important to recognize that some HCOs an effective culture of safety, this results in adverse
continue to have blame cultures, and more attention events. The sentinel alert notes that leadership is
should be given to the personal reaction of staff needed for effective support of event reporting and to
involved in errors, particularly errors that lead provide feedback to staff and others who are reporting
to the death of a patient. How much debriefing safety concerns, promote an environment in which
occurs, and are staff blamed and in what way? In staff who report events are not intimidated, use the
Inst i tut i onal safety in this report does not mean staff safety is not
Hosp i ta l important—it is very important. Another report, Keep-
pa r t me n t a l Fa c
t
ing patients safe: Transforming the work environment
D e k E nv i r o nm or s of nurses (IOM, 2004b), includes content related to
or en
W t
am F a c t o staff safety, particularly nurses. Nursing staff is not
Te al P r s
u r ov
v id immune to workplace injuries. The Occupational
k Fac
i
ide
I nd
Safety and Health Administration (OSHA) is the

Tas
tors
r
federal agency that is responsible for monitoring
safe workplaces and provides guidance and resources
to ensure workplace safety. The American Nurses
Association (ANA) is a strong advocate for safety
for nurses in all types of healthcare settings. Its po-
sition statements on staff safety provide guidelines
Patient
Characteristics for healthy work environments. Examples of some
of the position statements are available at the ANA
Figure 12-3 System-Level Factors That Affect Safety website, such as Personnel policies and HIV in the
Reproduced from Agency for Healthcare Research and workplace, HIV infection and nursing students, HIV
Quality. (2015, June). Collaborative unit-based safety
program (CUSP) toolkit. Understand the science of
testing, and others. Some of the key safety issues
safety: Presentation slides. Retrieved from http://www.ahrq for nursing staff other than those mentioned are
.gov/professionals/education/curriculum-tools/cusptoolkit
highlighted here. These statements can be accessed
/index.html
via the ANA website.
reporting data to improve, and alert management ■■ Needlesticks: Hospital-based healthcare
to staff burnout. This type of leader supports a just workers experience approximately 385,000
culture, a reporting culture, and a learning culture needlesticks and other sharps injuries
at all levels of the organization. annually, with 5.6 million at risk for expo-
It is important for students who are involved sure (HHS & CDC, 2015; U.S. Department
in a near miss or an error to discuss the experience of Labor & Occupational Safety and Health
openly with faculty and ask for support. Faculty Administration, 2016). These exposures can
need to provide support to students when these lead to hepatitis B, hepatitis C, and human
situations occur or get qualified persons to assist immunodeficiency virus, the virus that causes
the student. If this is not done, it reinforces a blame AIDS. At least 1,000 healthcare workers are
culture—schools of nursing need to establish cultures estimated to contract serious infections an-
of safety or just cultures (Penn, 2014). As we move nually from needlestick and sharps injuries.
toward a system view of errors, factors described Registered nurses (RNs) working at the bedside
Figure 12-3 support a culture of safety. experience the majority of these exposures.
More than 80% of needlestick injuries can be
prevented with the use of safer needle devices,
Staff Safety
but HCOs must provide them—and nurses
To err is human focused on patient safety, not staff need to demand that they are available.
safety, but the report did state that “creating a safe ■■ Infections: As noted, healthcare workers are
environment for patients will go a long way in often exposed to communicable diseases via
addressing issues of worker safety as well” (IOM, needlesticks. Other examples of infections
1999, p. 20). This lack of information about staff staff may be exposed to include tuberculosis,
Staphylococcus, cytomegalovirus, influenza, safe patient handling and the prevention of

and bacteria. Influenza spread has been musculoskeletal disorders among nurses in the
linked to suboptimal vaccination levels of United States. Through a variety of activities,
healthcare workers (Polygreen et al., 2008). the campaign seeks to advocate, educate, and
Bacterial infections have sometimes been facilitate change from traditional practices
linked to glove contamination (Diaz et al. of manual patient handling to emerging
2008). A recent infectious disease is the Ebola technology-oriented methods. Nursing ed-
virus that spread from Africa and also the ucation and staff education needs to include
Zika virus, transmitted by mosquitos but content and experiences to facilitate the use
not contagious in the work environment, of the most effective handling methods. In
unless the nurse is working in an area where addition, more emphasis should be placed
the infected mosquitos exist. Both of these on assistive patient handling equipment and
situations are examples of the global impact devices. Students need to learn how to use
of infectious diseases today; people travel this equipment, too. In 2013, the ANA ex-
globally, and healthcare providers go to assist panded its initiative on safe patient handling
other countries in providing health care for by publishing Patient handling and mobility:
emergencies and on a routine basis. Interprofessional national standards, in col-
■■ Ergonomic safety: Nurses experience a significant laboration with an interprofessional group
number of work-related back injuries and other to establish safe environments for nurses and
musculoskeletal disorders. Because of these patients (ANA, 2013).
injuries, nurses may transfer to other units or Standard 1. Establish a culture of safety.
other healthcare settings, and sometimes they Standard 2. Implement and sustain a safe
may leave nursing. Typical injuries are to the patient handling and mobility (SPHM)
neck, shoulder, and back. Nursing practice program.
requires a lot of patient handling, and factors Standard 3. Incorporate ergonomic design
such as the patient’s weight, height, body principles to provide a safe environment
shape, age, dependency, and medical status of care.
are important to consider as ergonomic issues. Standard 4. Select, install, and maintain
There has been an increase in weight in the SPHM technology.
U.S. adult population in general, and this has Standard 5. Establish a system for education,
increased the risk of injury. The physical setting training and maintaining competence.
also is a factor in increasing risk. There should Standard 6. Integrate patient-centered SPHM
be enough space to provide care and when assessment, plan of care, and use of SPHM
moving the patient. Nurses should consider technology.
the types of equipment available to assist with Standard 7. Include SPHM in reasonable
moving patients, request assistance, and discuss accommodation and post-injury return
their work needs with management, noting to work.
the importance of these factors to quality care Standard 8. Establish a comprehensive eval-
and staff and patient safety. The ANA’s “Handle uation system.
with Care” campaign addresses work-related ■■ Violence: Violence may not be a typical
musculoskeletal disorders (Castro, 2004). Its staff safety concern that a student would
goal is to develop and implement a proactive, first think of when asked about safety in
multifaceted plan to promote the issue of the healthcare workplace, but it may be a
problem. There is greater risk for violence remove their guns). Additional content on
in emergency departments, psychiatric/ workplace violence is discussed in other
substance abuse departments, and long-term content in this text.
care facilities; however, such incidents may ■■ Chemical exposure: OSHA offers information
occur anywhere. Patients and families may on preventing workplace injuries caused by
not be able to control their anger appropri- exposure to chemicals, which is something
ately. The nurse may also be in a situation nurses may encounter during the course of
in which violence that is not directly related their work. The Environmental Working
to the nurse or health care occurs, such as Group and Healthcare Without Harm,
providing home care in a community in which in collaboration with the ANA and the
there is often violence. Staff members need Environmental Health Education Center
training so that they can prevent violence of the University of Maryland’s School
when possible—particularly training on how of Nursing and supported by numerous
to identify signs of escalation and how to state and specialty nursing organizations,
de-escalate a situation when possible. They conducted an online survey of workplace
need to know how to protect themselves exposures and disease conditions among
when violence cannot be prevented. In 1,500 nurses. This comprehensive survey
areas such as psychiatry, this training is indicated that participating nurses who were
more common. Signs of escalation include a exposed frequently to sterilizing chemicals,
sudden change in behavior, clenched jaws or housekeeping cleaners, residue from drug
fists, threats, pacing, increased movement, preparation, radiation, and other hazard-
shouting, use of profanity, increased respi- ous substances reported increased rates of
rations, and staring or pointing. These signs asthma, miscarriage, and certain cancers and
do not mean that the person will become an increase in birth defects (in particular,
violent, but rather that the nurse should musculoskeletal defects) in their children.
be more aware of the person’s behavior There are limited workplace safety standards
and communication to determine if the for the hundreds of hazardous substances to
person is escalating. Protecting oneself is which nurses are exposed on the job (En-
very important: The nurse may decide it is vironmental Working Group, 2007). Other
safer to leave the room stay near the door reviews of nurses’ workplace safety identifies
or keep the door open, but not appear to concerns such as anesthetic gases, hand
be blocking the door; ask other staff to and skin disinfection, latex (for example,
be present; or call for security assistance. gloves), medications such as antiretroviral
It is also important when any weapon is medications and chemotherapeutic agents,
noted in patient belongings to secure the mercury-containing devices, personal care
weapon and call for professional assistance products, and sterilization and disinfectant
such as the HCO’s security and the police. agents such as ethylene oxide and glutar-
HCOs should have a policy and procedure aldehyde. The ANA continues to monitor
describing expected staff response to this risks for nurses (Trossman, 2017). Nurses
type of situation. This information should need to be aware of past and current data
also include requirements for police who that indicate specific potential problems in
are carrying weapons (for example, when order to protect themselves and their col-
entering a mental health unit they must leagues from exposure and prevent injuries
and health problems. In addition, nurses You will observe and may be involved in is-
need to be alert to developing symptoms sues of quality care as a student and as a nurse in
of allergies to drugs and products, which practice. Entering the healthcare system and the
can directly affect their health and practice. nursing profession, you may have doubts that QI is
an important topic, particularly if you have found
the health system to be effective for you and your
Stop and Consider #3 family. In this case, this might demonstrate that the
Safety is a component of quality health care.
healthcare system or HCO in which you received
care had an effective QI program that you might not
know about. There are, however, serious problems
Quality Improvement that have been reported routinely in major reports,
by the government, and by consumers. The content
Healthcare QI focuses on the healthcare system. The in this chapter is critical for you as a nurse who must
system is fragmented and in need of improvement. engage in efforts to improve care on a daily basis for
Plsek defines a system as “the coming together of parts, your individual patients and the healthcare system.
interconnections, and purpose. While systems can QI needs to be viewed as a continuous process
be broken down into parts, which are interesting in so it is often referred to as CQI. When QI is discussed,
and of themselves, the real power lies in the way the there are several perspectives to consider. The first
parts come together and are interconnected to fulfill and most critical is your individual practice, the
some purpose. The healthcare system in the United practice of all healthcare professionals. What you do
States consists of various parts (e.g., clinics, hospitals, as a nurse has a direct impact on patient outcomes
pharmacies, laboratories) that are interconnected and quality. This chapter and other content in this
(via flows of patients and information) to fulfill a text guide you in understanding your responsibilities
purpose (e.g., maintaining and improving health)” and need to engage in CQI. There is no end point to
(2001, p. 309). This does not mean that meeting QI, so it is continuous or referred to as CQI. There
individual patient needs and individual patient care are two other perspectives that affect individual
improvement are not important. Each patient’s care is healthcare professionals and in total the quality of
part of the overall emphasis on healthcare improve- healthcare. One of the perspectives is the HCO QI
ment and is integrated in the system. Ultimately, program that is designed to support the HCO’s efforts
the goal is that each patient’s outcomes will be met. to maintain and improve care quality. The second
The Institute for Healthcare Improvement view is the health policy perspective—QI initiatives
(IHI) suggests that new designs can and must be from the local, state, and national levels. All of these
developed to simultaneously accomplish three crit- perspectives should be in sync to provide effective
ical objectives—that is, the Triple Aim, which is health care for patients, families, and communities.
now integrated in most efforts, both by HCOs and Implementing QI “requires that health pro-
in health policy, to improve care on a continuous fessionals be clear about what they are trying to
basis (CQI). The aims are (Institute for Healthcare accomplish, what changes they can make that will
Improvement [IHI], 2007): result in an improvement, and how they will know
1. Improve the health of the population. that the improvement occurred” (IOM, 2003, p. 59).
2. Enhance the patient experience of care (including Healthcare complexity is mentioned many times as
quality, access, and reliability). a barrier to understanding quality and improving
3. Reduce, or at least control, the per capita cost healthcare delivery. Its consumers are very diverse
of care. in their needs, diagnoses, ethnic and cultural
backgrounds, and overall health status, including 2. How will the HCO know whether a change is
genetic background, socioeconomic factors, patient an improvement?
preferences for health care, community differences, 3. What change can the HCO try that it believes
and healthcare coverage/reimbursement. Health will result in improvement?
care cannot be viewed in the same manner as other For an HCO to have an effective QI program,
businesses (such as the automobile industry) that nurses and other health professionals need to be
might manufacture or sell one product or a series knowledgeable and competent in a number of areas
of highly related products. Healthcare products/ (IOM, 2003). All aspects of the healthcare environ-
services vary based on the medical problem and ment are important to consider such as patients and
the patient; the setting; the expertise of clinical staff and their interactions; patient and healthcare
staff; the desires of the patient; treatment options; outcomes; and changes in science, technology, and
patient prognosis; the expertise of the healthcare needs of individuals and communities. HCOs need to
providers and HCOs; health policy and legislation; consider and compare factors with other HCOs and
and advances in science, medical technology, and similar healthcare systems to determine best current
health informatics technology (HIT). In specialty practices and then develop and apply interventions
areas such as obstetrics, psychiatry, emergency to improve care. This all requires an understanding
care, intensive care, home care, and long-term care, of quality issues—errors, risks, human factors—that
there is great variation within services—in their affect quality care for patients and staff safety, mon-
interventions, roles of the patient and family, patient itoring, and measurement. Surrounding all of this is
education needs, prognosis and outcomes, and so the need to integrate interprofessional teamwork in
on. It is expensive to develop and maintain effective CQI and also in care practice. Figure 12-4 illustrates
QI programs, but The Joint Commission requires the importance of quality in the healthcare system,
such programs for all its accredited organizations. emphasizing critical thinking and teams focused on
QI programs should guide HCOs to improve care safe, effective, and efficient care delivery.
(Finkelman, 2018).
Because of the complex nature of quality,
developing an HCO QI program that addresses
QI is a continuous process.
monitoring and improving healthcare quality is
in and of itself a complex process. HCOs typically
have a department with staff that focus on CQI.
This requires a budget for these efforts, and the Examples of Safety Initiatives
program must plan, implement its plans, monitor, A number of important safety initiatives have been
measure quality, and then identify interventions and stimulated by the Quality Chasm series. The IHI,
solutions to maintain quality or improve quality. for example, was established in 1991. It describes
Effective appraisal of the scientific facts suggests itself as “a reliable source of energy, knowledge, and
that health care can be improved by closing the support for a never-ending campaign to improve
wide gaps between prevailing practices and the healthcare worldwide. The IHI helps accelerate change
best-known approaches to care and by developing in healthcare by cultivating promising concepts
new forms of care. This requires planning and careful for improving patient care and turning those ideas
evaluation of results. One model for improvement into action” (IHI, 2014). The IHI also focuses on
focuses on three key questions (Berwick & Nolan, STEEEP. The 5 Million Lives campaign is one exam-
1998, p. 209): ple of an IHI safety initiative. This voluntary global
1. What is the HCO trying to accomplish? initiative sought to protect patients from 5 million
Reflecting
g
lyzin
Co spec
Co
pe
g
nte tiv
s
nd g
in
Ana
r
nfid
at
ard
Sta plyin
in
xtu e
Cr
enc
ea rim
al
Ap
tiv sc -
Di n
e
ity tio
Fle o r ma
g
Inqu xib Inf ekin
isiti ility se
ven
e ss Team al
Intellectu Logic ning
al e a s o
Integrity r
Safe
Intuition Predicting
Effective Efficient
-
Open Trans
d n e ss fo
know rming
inde
ng
m iti ledge
Cr
ki
ca in
e l Th
ranc
rs eve
Pe
d
Desir sire
hea d
e De alth
outco lth he mes
co
mes out
Figure 12-4 Medallion of Quality Health Care through Critical Thinking

Reproduced from Rubenfeld, M., & Scheffer, B. (2015). Critical thinking tactics for nurses. Burlington, MA: Jones & Bartlett
Learning.
incidents of medical harm over 2 years (December guides pilot studies to improve care, and QI studies
2006–December 2008). This initiative led the IHI to are developed at the point-of-care by staff in practice,
further develop its resources to improve healthcare which offers many opportunities for improvement.
quality, such as an improvement map designed to The Joint Commission’s annual safety goals,
help hospitals deal with the multiple requirements which were first introduced in 2003, is a safety
they face and to focus on high-leverage changes to initiative that has an impact on many HCOs. Each
transform health care (IHI, 2011). year, The Joint Commission identifies safety goals
Another initiative, a collaborative effort that should be the focus of every Joint Commis-
between the IHI and the Robert Wood Johnson sion–accredited HCO. These goals are based on
Foundation, focuses mostly on nursing— the critical, current safety concerns based on data
Transforming Care at the Bedside (TCAB). TCAB The Joint Commission collects and analyzes from
is a “unique innovation initiative that aims to create, its accredited HCOs, as well as other sources of
test, and implement changes that will dramatically information about healthcare safety. Their surveyors
improve care on medical/surgical units, and improve also emphasize the safety goals during accredita-
staff satisfaction as well” (IHI, 2017). This program tion visits. HCOs typically provide staff education
related to the goals and monitor goal progress. accreditation standards at all times, not just at the time
Nursing students need to know the current safety of a survey. In the past, great emphasis was placed
goals and integrate them into their clinical learning on getting ready for The Joint Commission visit and
experiences. The current annual goals are available surviving it; afterward, the HCO was less vigilant
on The Joint Commission website. until it came time to prepare for the next visit. This
approach of just focusing on the survey eventually
changed, and now accredited HCOs must submit
The Joint Commission reports on certain data to The Joint Commission
Accreditation is the process by which organizations annually, with a plan of action for areas noted in
are evaluated on their quality, based on established the self-assessment that may require improvement
minimum standards. The major organization that (periodic performance review); in addition, HCOs
accredits HCOs is The Joint Commission, a must be prepared for possible unscheduled visits.
nonprofit organization accrediting more than 20,500 Nurses are very active in preparing for the survey
HCOs, including hospitals, long-term care organi- and during the survey visit. The Joint Commission
zations, home care agencies, clinical laboratories, survey now involves more direct care staff in the visits
ambulatory care organizations, behavioral health by including them in meetings to discuss care in the
organizations, and healthcare networks or managed HCO and asking individual staff questions during
care organizations. It has accredited HCOs since the survey visit. If students are present during the
1951, and over that time, the accreditation require- visit, surveyors may ask them questions. The goal
ments and process have changed. Participating in is to find out if patients are achieving the expected
a Joint Commission survey is time consuming and outcomes, and if not, why. Examples of outcomes
costly, but it is necessary for HCOs. For example, that The Joint Commission assesses include mor-
nursing education programs need to use HCOs tality rates, length of stay, sentinel events, adverse
with current Joint Commission accreditation for incidents, complications, readmission rates, patient/
student practicum/clinical experiences. As The Joint family satisfaction, referrals to specialists, patient
Commission has changed, its emphasis on quality adherence to discharge plans or treatment plans,
care has also changed. CQI is now the major focus achievement of safety goals, prevention adherence
of the accreditation process, which includes safety. services (for example, mammograms, Pap smears,
Nurses serve on the Joint Commission Nursing immunizations), and more.
Advisory Council, which advises its parent organiza- The Joint Commission standards have been
tion about nursing concerns and care issues related developed, evaluated, and revised over the years
to quality. Nurses who work in HCOs eventually to meet the changing needs of healthcare delivery.
experience a Joint Commission survey. After initial These standards form the framework for accredi-
accreditation is received, The Joint Commission tation. The accreditation of hospitals focuses on a
makes a visit to the HCO every 3 years to complete number of areas and issues, for example (The Joint
its intensive survey for accreditation renewal, and it Commission, 2017b, 2017c):
may even make unscheduled visits. For the sched- ■■ Environment of care
uled visits, the HCO is given a date and has 9–12 ■■ Emergency medicine
months to prepare for the visit. Preparing for the ■■ Human resources
visit involves gathering information and data for ■■ Infection prevention and control
The Joint Commission, educating staff about the ■■ Information management
standards, conducting mock surveys to prepare ■■ Leadership
staff, and so on. The HCO should meet the expected ■■ Life safety
■■ Medication management other similar HCOs. Some of these report cards are
■■ Medical staff now accessible on the Internet and can also be used
■■ National patient safety goals by consumers (patients, families). Nurses use them
■■ Nursing when searching for new jobs to obtain evaluation
■■ Provision of care, treatment, and services data about a specific HCO. In some cases, insurers
■■ Performance improvement use healthcare report cards to assess an HCO and
■■ Record of care, treatment, and services compare it with similar HCOs. The goal is to exam-
■■ Rights and responsibilities of the individual ine performance based on clearly defined criteria.
■■ Transplant safety Examples of other changes in QI focus on
Because The Joint Commission accredits a broad sharing information with patients and rewards for
range of HCOs, there are differences in the minimum QI performance. Today, public reporting is more
standards and in how the various healthcare settings common, so report cards may be made public. This
might monitor care and outcomes. Consider home sharing of predetermined quality and efficiency mea-
care agencies: These agencies may use other national sures with performance data informs patients and
evaluation approaches that are not related to or led by stakeholders about provider performance (Dunton,
The Joint Commission. The home care outcome-based Gonnerman, Montalvo, & Shumann, 2011).
approach to QI, known as the Outcome and As- Value-based purchasing is also used today.
sessment Information Set (OASIS), was developed Value-based purchasing is a payment system that
in the 1990s by the U.S. Department of Health and provides financial rewards for performance. Such
Human Services. It offers a database for collecting a system, in addition to public reporting, may in-
and organizing home care data so that outcomes can centivize providers to improve outcomes. There is,
be analyzed (U.S. Department of Health and Human however, a risk that pay-for-performance may act as
Services [HHS] & Centers for Medicare and Medicaid an incentive to “cut corners,” to take steps to ensure
Services [CMS], 2012). This database focuses on a data “looks positive” when it is not. An example is
group of data elements that represent core items of found in Exhibit 12-1 describing how the Veteran’s
a comprehensive assessment of home care patients. Administration medical system changed records
The key question is: Did the patient benefit from the that provided data on appointments and wait times
home care services? In this type of system, home in order to improve performance.
care agencies from all over the country input their In 1994, the ANA began an investigation of the
QI data. The OASIS is managed through the CMS impact of workforce restructuring and redesign on
and offers a national view of home healthcare quality. the safety and quality of patient care in acute care
settings. This investigation led to the development
of a nursing report card in 1998, the National Da-
Healthcare Report Cards
tabase of Nursing Quality Indicators® (NDNQI®)
Healthcare report cards provide specific per- (ANA, 2014). This occurred around the time that
formance data about an HCO at specific intervals, the Quality Chasm series began to address healthcare
with a focus on quality. The report can be used quality. The ANA wanted to “explore the nature and
by the HCO to compare its outcomes with report strength of the linkages between nursing care and
cards published by other similar HCOs or with a patient outcomes by identifying nursing quality
large state or national database (benchmarking). indicators” (Pollard, Mitra, & Mendelson, 1996,
This information can be helpful in improving care p. 1). This initiative also provides a framework for
in the HCO by identifying what the HCO is doing educating nurses, consumers, and policy makers
well and what needs improvement as compared with to evaluate the contributions of nursing within the
acute care setting by tracking the quality of nursing NQF Strategic Plan for 2016–2019 focuses on four
care provided in such settings. The NDNQI made purposes (2017a):
it clear that data on nursing and outcomes were 1. Accelerate development of needed measures.
lacking—that is, the methods of HCO used to 2. Reduce, select, and endorse measures.
collect data at that time were not nursing specific. 3. Drive measure implementation of prioritized
Patients come into the acute care setting primarily measures.
because they need around-the-clock care, which is 4. Facilitate feedback on what works and what
the focus of nursing care, and yet data on this care does not work.
were lacking.
The NQF examines some of the critical care
The NDNQI was initially managed by the Uni-
issues that need to be considered to meet these
versity of Kansas School of Nursing, under contract
purposes. Currently, the NQF endorses about 300
to ANA; it is now part of Press Ganey, a company
measures, which are used in more than 20 federal
that offers HCOs services to evaluate quality and
public reporting, pay-for-performance programs;
patient satisfaction (Press Ganey, 2014, 2017). As
state programs; and the private sector, but it does
of early 2017, there were more than 2,000 hospitals
not develop measures (NQF, 2017b). The NQF also
participating in this database. Ninety-five percent of
identifies areas where more measures are needed
Magnet® recognized facilities participate in NDNQI.
to reduce gaps and attempts to ensure measures
This initiative “provides each nurse the opportunity
are effective.
to review the evidence, evaluate their practice,
The National QDR, discussed earlier in the
and determine what improvements can be made”
chapter, also serves as another report card. It now
(Montalvo & Dunton, 2007, p. 3). The participating
represents the major national annual report on the
institutions submit their nursing-sensitive indicator
status of care in the United States.
data to the electronic database, which allows for the
collection of a large amount of data for evaluation
and for research. The NDNQI database indicators Stop and Consider #5
focus on the characteristics of the nursing workforce, Healthcare accreditation supports QI, but it cannot
nursing processes, and patient outcomes. To assist ensure it.
with more effective comparisons, reports are pro-
vided to hospitals with information about patient
population, unit type, and hospital bed size. The National Quality Strategy
result is the nursing profession’s quality report card.
With the exception of Magnet hospitals, participa- A provision in the Affordable Care Act of 2010 requires the
tion in the NDNQI process is voluntary; therefore, HHS to develop the National Quality Strategy (NQS).
only participating HCOs are reflected in the data. The AHRQ led the development of the strategy
Some of the nursing-sensitive indicators are and now administers the NQS. An evidence-based
now included in other public reporting such as approach along with a collaborative effort was
data collected by the National Quality Forum used, including feedback from more than 300
(NQF), but there needs to be more representation of stakeholders representing the federal government,
nursing-sensitive indicators in public reporting on especially the HHS; the states; the private sector; and
the status of healthcare quality (Dunton et al. 2011). multi-stakeholder groups such as healthcare profes-
The NQF is an important national quality initiative, sional organizations (Finkelman, 2018). The NQS
and one with which the NDNQI collaborates. The is a groundbreaking initiative supporting national
measurement and QI at multiple levels: community, ■■ Promoting the most effective prevention
practice settings, and individual physicians (HHS, and treatment practices for leading causes
2011). As the strategy was developed, a critical of mortality
problem was noted. There were too many measures ■■ Working with communities to promote wide
and no control or evaluation of measures, causing use of best practice to enable healthy living
measurement redundancies and overlap that may ■■ Making quality care more affordable for indi-
negatively affect the value of results. viduals, families, employers, and government
The NQS priorities are patient safety, person- by developing and spreading new healthcare
centered care, care coordination, effective treatment, delivery models
healthy living, and care affordability and, as noted, Figure 12-5 provides an overview describing
are also monitored as part of the annual QDR and how NQS works. It is important to consider the
correlate with other initiatives such as Healthy entire healthcare delivery system rather than just
People 2020. The NQS establishes priorities, and focus on the hospital setting. For example, there are
this information about outcomes related to the an estimated 1 billion ambulatory care visits per
priorities is then included in the annual NQS report year and 35 million hospital admissions, and 1 in
to Congress (HHS, 2015; HHS & AHRQ, 2015b). 10 patients develop a healthcare-acquired condition
Thus, data for the NQS annual report originates (National Patient Safety Foundation, 2015). The
from multiple HCOs and government agencies. plan applies to all types of healthcare settings and
Patient-centered care is a core factor in the NQS, is intended to address the entire continuum of care.
supporting earlier work emphasizing patient-centered It is recommended that other healthcare pro-
care. The major purpose of the NQS is to provide grams, private and public, adopt the NQS; however,
a national approach to measure quality and ensure it is not required—though more healthcare programs
higher quality care for all, which correlates with the and quality initiatives do correlate with the NQS.
Triple Aim and STEEEP. The NQS recommends that The AHRQ provides tools and resources to sup-
all HCOs adopt the Triple Aim and STEEEP, and port implementation of the NQS (HHS & AHRQ,
many are meeting this recommendation. 2015). The NQS annual reports to Congress are
More systematic measurement methods are posted on the AHRQ website. The 2015 congres-
needed to effectively assess quality and maintain sional report states “across the nation the National
CQI. The NQS now provides a framework for better Strategy for Quality Improvement in Health Care
development and coordination across the HHS to (NQS) brings together federal agencies, healthcare
establish core sets of measures to improve mea- payers, purchasers, providers, consumers, and
surement for multiple populations and healthcare other partners in pursuit of improved health and
services. It is clear we need to have better control health care for all Americans. The NQS serves as a
and coordination of measurement—confusion does framework for aligning stakeholders across private
not support effective CQI. The six strategy priorities and public sectors at the federal, state, and local
are (HHS & AHRQ, 2015b): levels” (U.S. Department of Health and Human
■■ Making care safer by reducing harm caused Services [HHS], 2015).
in the delivery of care
■■ Ensuring that each person and family is
engaged as partners in their care Stop and Consider #6
The NQS should be integrated into our view of nursing
■■ Promoting effective communication and practice to ensure QI.
coordination of care
Figure 12-5 NQS: How It Works

Reproduced from Agency for Healthcare Quality and Research. (2015, July). National Quality Strategy: Overview
(PowerPoint presentation). Retrieved from http://www.ahrq.gov/workingforquality/toolkit.htm
its reimbursement policy. It will no longer pay for

Federal Initiatives to care for complications that occur in the hospital
Improve Care: Hospital- that could have been prevented, now referred to
as hospital-acquired complications (HACs).
Acquired Conditions and 30-Day
Examples of types of complications that are no longer
Unplanned Readmissions covered include falls, hospital-acquired decubiti,
performing the wrong procedure, and administering
In an effort to improve care and reduce costs in
the wrong blood type. This policy has major impli-
2007–2008, the Centers for Medicare and Medic-
cations: Who will now pay for the care for HACs?
aid Services (CMS) introduced a major change in
Ultimately, the HCO may hold the bill and have to and why they are important. The targets for HACs
cover the costs. HCOs are limited in what they can are (1) high volume and cost; (2) identified as a
charge a Medicare patient personally. This issue is complication, comorbidity, or major complication
complex and serious, but the major message from as connected with CMS diagnosis-related groups;
the CMS and other insurers is that when errors are and (3) reasonably preventable using evidence-based
made, there are costs involved, and performance is guidelines (HHS & CMS, 2016, p. 3). In the past, the
associated with cost. For many reasons, HCOs have CMS identified problems that are now called HACs
problems maintaining a stable budget, and this change as care quality problems (such as for air embolism,
in reimbursement practice has a major impact on pressure ulcers, catheter-associated urinary tract
the financial status of hospitals. This CMS decision infection, foreign object retained after surgery, and
has a potential major impact on HCO finances. others), and they were not associated with limited
For example, suppose a patient who is covered by reimbursement for care and thus were covered. Now
Medicare falls in the hospital and incurs an injury. the attention turns to evidence-based guidelines
Treatment for that injury may not be charged to to improve care focused on the HACs and need
Medicare and may not be charged to the patient. for HCOs to provide care that will prevent these
The hospital must provide care but will receive no problems.
payment for doing so. It is uncertain how hospitals For each HAC, several associated EBP guidelines
will respond to this change long-term though they are available that should be used to prevent these
are developing methods to prevent HACs, some problems. This emphasizes the importance of EBP
more successful than others. and need for CQI. The CMS’s goal is to stimulate
In addition, in 2011, Medicaid issued its list of hospitals to improve care—to decrease preventable
HACs that might occur in hospitals. In July 2012, hospital-acquired conditions—and this has begun
Medicaid implemented a policy of not paying for to happen. A second goal is to decrease care costs.
these HACs if they occurred in hospitalized patients Asking HCOs to improve care did not seem to
covered by Medicaid. Examples of some of these work, so the CMS turned to incentivizing by lim-
events, similar to Medicare’s list, are blood incom- iting payment if care performance was not at the
patibility, falls and trauma, hypoglycemic coma, expected level. In spring 2014, the HHS announced:
and surgery on the wrong patient or wrong body “New preliminary data show an overall 9% decrease
part (Galewitz, 2011). The list of HACs for Medi- in hospital-acquired conditions nationally during
care and Medicaid may change over time based on 2011 and 2012. National reductions in adverse drug
data related to common complications and errors, events, falls, infections, and other forms of hospi-
and the CMS website maintains an updated list of tal-induced harm are estimated to have prevented
HACs. In early 2008, some of the major insurers nearly 15,000 deaths in hospitals, avoided 560,000
came out in support of this approach, announcing patient injuries, and [avoided] approximately $4 billion
zero tolerance for HACs and identifying their own in health spending over the same period. Hospital
list of such events. Hospitals are now required to be readmissions fall by 8% for Medicare beneficiaries.
aware of all HACs regardless of insurer, and as noted In 2010 there were 145 HACs per 1,000 discharges
here, they do not all include the same HACs on their and in 2012 132 HACs per 1,000 discharges” (HHS,
lists. Nurses can make a difference in preventing 2014). Data from the 2015 National Scorecard on
HACs, and they need to be involved in determining Rates of Hospital-Acquired Conditions “shows
interventions to prevent these conditions or other that about 125,000 fewer patients died and more
“never” events, as they are sometimes called. To be than $28 billion in health care costs were saved
more involved, nurses need to understand HACs from 2010 through 2015 due to a 21 percent drop
in hospital-acquired conditions (HACs). In total, above information, set aims and objectives
hospital patients experienced more than 3 million and then identify strategies that will be part
fewer HACs from 2010 through 2015. HACs include of the program. Examples of strategies are
adverse drug events, catheter-associated urinary use of checklists, arrange for post-discharge
tract infections, central line associated bloodstream follow-up, flag discharge more than 30-days
infections, pressure ulcers and surgical site infec- in chart, develop transitional plans, engage
tions, among others” (HHS & AHRQ, 2016). The the patient and when appropriate the family
current data indicate significant improvement. This with the patient’s permission, and identify
improvement supports partnerships to improve care high-risk patients.
and structured initiatives to monitor and respond ■■ Expand and strengthen cross-setting part-
to problems, and it may demonstrate that we do nerships: Implement strategies to increase
need to motivate healthcare providers to improve collaboration with cross-setting partners.
performance by including a financial incentive. ■■ Provide enhanced services to patients at high-
Along with the development of the initiative risk of readmission: Implement strategies for
to reduce HACs, unplanned readmissions for any high-risk patients.
cause to an acute care hospital within 30 days Nurses are directly involved in this problem
of discharge have come under CMS scrutiny to because discharge planning and patient education are
improve care and reduce costs. This initiative now critical elements in preparing patients for discharge
requires that hospitals do the following (HHS & and establishing an effective post-discharge trajec-
AHRQ, 2014a, p. 5): tory so that patients do not need to be readmitted
■■ Analyze the root causes of readmissions: Un- within 30 days of discharge. Teach-back, asking
derstand patterns and trends for the HCO patients to repeat information they have learned, is
and the local community for comparison; used by many nurses to better ensure that patients
understand the patient’s perspective, for and families understand the information they need
example, effectiveness of communication post-discharge (Peter, Robinson, & Jordan, 2015).
and coordination. Data should be tracked Patients and families should also be involved in dis-
routinely. charge planning to ensure that the plan would work
■■ Inventory and align the current readmission post-discharge for the patient and the environment
reduction efforts to meet the needs of the in which the patient will be living. Consideration
HCO’s targeted patients: This should be an in needs to be given to support services that might be
depth inventory; the AHRQ guide provides required such as home health care, follow-up phone
several tools (Hospital Inventory, Cross- calls and other communication with healthcare
Continuum Team Inventory, and Conditions providers, and support for caregivers. We cannot
of Participation Checklist) so that the HCO control all aspects of the patient’s life and condition,
can understand what it currently does to but we need to do as much as we can to ensure their
prevent and/or respond to the problem to success post-discharge.
better plan changes.
■■ Examine the extent to which the current re-
admission reduction efforts meet the needs of
the HCO targeted patients: Combine previous Stop and Consider #7
information about methods HCOs may use. The CMS decided that care was not improving for its
beneficiaries, so it began to incentivize improvement
■■ Improve hospital-based processes to better target
with threat of loss of payment for services.
and serve targeted patients’ needs: With the
improvement in academic professional education,

Examples of High-Risk but also lifelong learning. Figure 12-6 provides an
Healthcare Activities overview of the five drivers of clinical quality and
safety. This description highlights risk areas, or fac-
As has been stated, we cannot eliminate all errors tors that may affect risk, and the same factors can be
and healthcare quality concerns; however, we can used to guide decisions and interventions to reduce
reduce them—and we need to do this much more. risk and improve care. This section discusses several
There are some healthcare activities (for example, examples of high-risk healthcare activities for nurses.
nursing interventions, procedures, treatment) that
are of higher risk for errors and quality problems than Medication Administration
others. The Joint Commission’s annual safety goals
identify high-risk concerns in health care—and the Medication administration via any route or for any
goals change annually. There are factors that increase medication is a high-risk treatment intervention.
risk, and these should guide us in developing plans A medication error is a “preventable event that
to reduce risk. We know that poor communication may cause or led to inappropriate medication use
is a critical factor to consider. Today, with increasing or patient harm while the medication in control of
use of and development of technology—both for the healthcare professional, patient, or consumer”
communication and use in in treatment methods—we (U.S. Department of Health and Human Services
have opportunity for positive outcomes, but this also & Food and Drug Administration, 2015). The
increases risk (Finkelman, 2018). We also know that medication use process includes documenting,
staff need to be competent, and this requires not only dispensing, administering, and monitoring.
Information Management
People
Numbers Correct measures

Knowledge
Data integrity
Skills
Working conditions
Interpretation
Teamwork
Communication Decision support
Patient with Desired
an Illness/Problem Outcome
Physical plant Process capability Leadership
Equipment
Shared vision and need
Information systems Process improvement
Support services methodology
Stakeholder analysis
Roles Making change last
Infrastructure Processes Culture
Five Drivers of Clinical Quality and Patient Safety
Figure 12-6 Five Drivers of Clinical Quality and Patient Safety

Reproduced from Ettenberg, W. (2006). Basic tools for quality improvement. In D. Nash & N. Goldfarb, The quality solution,
(pp. 115–132). Burlington, MA: Jones & Bartlett Learning.
Table 12-1 Common Sources of Medication Error
Ambiguous orders Incorrect drug selected

Drug device use Incorrect patient
Environmental stress Insufficient drug information
Errors in communication/ Insufficient information about other drugs patient
miscommunication of drug orders is on (therapeutic duplication)
Error-prone abbreviation Insufficient laboratory information
Illegible handwriting Known allergy
Improper dose Limited patient education
Incomplete orders Limited staff education
Incomplete/insufficient monitoring Look-alike or sound-alike drugs
Incomplete patient information/patient Poor communication
information unavailable
Reproduced from Youngberg, B. (2013). Patient safety handbook (2nd ed.). Burlington, MA: Jones & Bartlett
Learning.
Common sources of medication errors are iden- administration: right patient, right medication,
tified in Table 12-1. Students and staff must apply right dose, right time, and right route. The goal in
methods to reduce medication errors. Some of applying the five rights is to reduce errors; how-
these methods include the following: know and ever, they also are the common areas for errors
respond when high-alert medications are admin- and when nurses need to be alert. Other rights
istered (drugs that are of higher risk for patient have been identified that are not included in the
harm); report and analyze near misses; ask for help long-recognized five rights: right documentation,
when needed; avoid distractions and interruptions right to refuse medication, and right to evaluation
during the medication administration procedure; and monitoring (Anderson and Townsend, 2010).
if in doubt, ask for help (for example, other nurses, Another right that is suggested is to identify the
pharmacist, physician); double check and verify; right indication or reason for using the medica-
listen to the patient and family when they question tion (Walton, 2014). An example of how these
something; do not use workarounds; be alert to rights impact care and QI, which relates to HIT, is
allergies; apply sterile technique when required; administering the medication at the right time or
follow policies and procedures; document in a time ordered. This has been a potential problem
timely manner; do not document medications for some time, particularly as more HCOs use elec-
you have not administered; provide appropriate tronic medical records and bar codes. A common
patient education about medications; and routinely accepted policy that was supported by the CMS was
apply the five rights of medication administration. that medications should be administered within
Much time is spent in nursing education on 30 minutes of the ordered time. The Institute for Safe
medication administration. Such content and l earning Medication Practice (ISMP, 2011) expressed concern
activities focus on the five rights of medication about what happens when nurses cannot meet this
administration, which emphasize safe medication standard. The typical response is to use workarounds
or shortcuts because nurses do not want this to be

Failure to Rescue
considered an error. The ISMP conducted a survey
of 17,500 nurses. The majority of the nurses believed Failure to rescue is a time of potential critical risk
that trying to meet the 30-minute deadline leads for patients; it is a time when staff miss something
to problems and errors. With electronic methods about the patient’s condition and then do not intervene
(medical records and use of bar codes), more data as needed. There are many reasons this may occur
are now available regarding the actual times medica- such as inadequate staffing levels, staff competency
tions are administered, and this has led to negative and ineffective use of critical thinking and clinical
views, with late administration being considered an reasoning/clinical judgment, ineffective response
error. This viewpoint does not consider that most to alarms or alerts or malfunction of alarm equip-
nurses are capable of making commonsense clinical ment, distractions and emergencies, lack of routine
decisions and are aware of medications for which monitoring such as rounds and other methods/
administration time is a critical element and the surveillance, and ineffective communication from
need to consider individual patient status issues. one staff to another (for example, during handoffs).
This example demonstrates how analysis of a quality A common method used to reduce failure to rescue
problem may lead to change and improvement, but is use of rapid response teams (RRTs). These
it also demonstrates that many factors and many teams of experts in care of the critically ill respond
stakeholders may be involved. to a call to the bedside to assess the patient and
determine best treatment, which may mean trans-
ferring the patient to intensive care. A systematic
Care Transitions and Handoffs
review of studies on the use of RRTs indicates that
Care transition is a time of change for the patient, 20% of the patients in the sample seen by the RRT
family, and staff. It occurs when a patient’s care is had experienced an adverse event, and 80% of these
transferred from one staff member to another, one events were preventable (Amaral et al., 2015). Most
unit to another, one HCO to another, and from an of the events were not reported through the expected
HCO to the patient’s home—it also occurs between reporting system. The recommendation from the
students and staff and vice versa. Communication review is that calling for RRT assistance should be
is the key issue: the key cause of problems if it is a trigger to investigate if an adverse event occurred.
ineffective and the key strategy to improve handoffs
when it is effective. There are also other factors that
Alarm/Alert Fatigue
interfere with effective handoffs, such as stressful
work environment, staffing levels, interruptions, With the growing use of technology, there is recogni-
problems with sharing digital information (as dis- tion that technology provides many advantages and
cussed in chapter on informatics), HIT equipment improves care, but also may lead to more problems.
problems, leadership and management concerns, Alarm or alert fatigue occurs when staff do not
lack of staff preparation and understanding of the respond or are slow to respond to an alarm from a
transition process, multitasking, and ineffective device such as a cardiac monitor, bedside physio-
teamwork (Finkelman, 2018). It is important for logical monitor, infusion pump, or ventilator. Why
staff to ask questions and expect to receive required does this happen when the alarms are supposed to
information so that the patient’s care can continue direct us to immediate assessment and response?
as needed and in a safe manner. Use of standardized In some cases, on a single unit such as an intensive
communication methods can help reduce problems care unit there can be several hundred alarms per
and are discussed later in this chapter. patient in a day. If you multiply this number by the
number of patients on a unit, it is easy to see how with effective teams and team members who help
these alarms can, over time, stress staff; added to one another plus a culture of safety with an emphasis
this is the problem that between 85% and 99% of the on CQI support nurses to work more effectively and
alarms are false, requiring no clinical intervention improve patient care. Nurses also need to work in
(Finkelman, 2018; Joint Commission, 2013). When environments in which work needs are met, not
there are many alarms for multiple patients, the just appropriate staffing levels, but also access to
risk of a poor response increases. This problem has clinical supplies, equipment, medications, and HIT.
increased so much that The Joint Commission issued Having these resources reduces missed nursing
a sentinel event alert for medical device alarm safety care—care cannot get done if the nurse does not
in hospitals (Joint Commission, 2013), and in 2016, have the resources to provide the care.
improving response to alarms was included in The
Joint Commission’s annual safety goals.
There are many care situations that are times of high
Missed Nursing Care risk for errors.
Missed nursing care is considered to be an issue

that nurses need to attend to more in their practice
and in their CQI responsibilities. It is a type of error Tools and Methods
of omission, representing “needed nursing care that to Monitor and Improve
is delayed, partially completed, or not completed Healthcare Delivery
at all” (HHS, AHRQ, & PSNet, 2016b). Due to the
increased concern about this type of error—which Other chapters include content about some of the
has a negative impact on care coordination, im- methods used by HCOs to monitor and improve
plementation of care, and patient outcomes, thus healthcare delivery. Some of these are related to
increasing risk that the patient will not get care nursing professional issues such as standards of
required or other errors may occur—the AHRQ care; HCO policies and procedures; clinical path-
has developed a patient safety primer on missed ways and protocols; licensure and credentialing to
nursing care (HHS, AHRQ, & PSNet, 2016b). In a better ensure competency for practice; application
systematic review of 42 studies, 55% to 98% of the of evidence-based care; interprofessional teams and
nurses in the samples reported that they had missed teamwork; HCO risk management focused on pos-
one or more items required for assessment; most of sible legal concerns, which also affect quality care;
this occurred during the last shift (Jones, Hamilton, and healthcare regulation and legislation. In this
& Murry, 2015). This review also noted that missed section, we discuss other, more specific CQI tools
nursing care is associated with decreased patient and methods used by HCOs. Nurses are involved in
satisfaction and higher rates of adverse events. The the use of these tools and methods. This discussion
major predictors of missed nursing care are staffing does not include all possible tools and methods.
levels, the work environment, and teamwork. This Appendix A augments this content.
is then where nursing should focus its strategies to
prevent missed nursing care. When nurses feel time Utilization Review/
pressure and competing demands during a shift,
Management
there is increased risk that something that should be
done is not done or not done completely. We know Utilization review/management (UR/UM) is the
that efforts to develop a positive work environment process of evaluating the necessity, appropriateness,
and efficiency of healthcare services for specific

Assessment of Access to
patients or patient populations. HCOs use uti-
lization review data in a number of ways—for
Healthcare Services
example, to determine access and usage of ser- Access to healthcare services is important to monitor
vices, if a service is no longer needed, whether and improve as part of the QI process. Communities
or not a new service is needed, and to review the are concerned about whether their citizens have access
relationship of data to patient outcomes. Data to care. The Healthy People 2020 initiative considers
are primarily obtained from medical records to access to be a critical issue across the United States
determine necessity, appropriateness, and time- for all types of healthcare needs (HHS, 2017). The
liness of healthcare services. Utilization review QDR also monitors access to care. When a patient
data are connected to financial concerns for the does not have access, the patient’s health status is at
HCO and its budget (for example, whether the risk, and further complications may occur.
HCO is serving enough patients to meet its budget,
types of procedures and their reimbursement, Medication Reconciliation
and so on). Utilization review is administered by
the HCO administration, although nurses may Patients often take many medications, and a key
participate as data collectors and in the analysis concern is how these medications interact with one
process. Nurses should participate in decisions another. Medication reconciliation is “creating
about changes that might be made in clinical the most accurate list possible of all medications
services. The QI program may use some of the a patient is taking, including drug name, dosage,
UR data. frequency, and route, and comparing that list
against the physician’s admission, transfer, and/or
discharge orders with the goal of providing correct
Benchmarking
medications to the patient at all transition points
Many hospitals and other types of HCOs use within the hospital (could be throughout contin-
benchmarking. Benchmarking is the process of uum of care)” (Ketchum, Grass, & Padwojski, 2005,
comparing performance to an external standard. It pp. 78–79). Responsibility for completing the medi-
can help staff members and management under- cation reconciliation procedure needs to be clarified
stand how their performance compares to other in a policy and procedure. Use of routine tracking is
HCOs, and this may then motivate them to engage important. HCOs should have a standardized form
in improvement. “Benchmarking can stimulate on which to record the information. If the patient
healthy competition, as well as help members of takes a lot of medications and cannot remember
a practice reflect more effectively on their own all the information, medication reconciliation can
performance” (HHS & AHRQ, 2013a). take time to complete and may be inaccurate. The
One popular benchmarking approach is Six Joint Commission now requires that its accredited
Sigma. This rigorous and systematic methodology HCOs use medication reconciliation routinely. If
utilizes information (management by facts) and problems arise in reconciling medications, then
statistical analysis to measure and improve an errors can result in omitted medications, incorrect
HCO’s operational performance, practices, and dosage, incorrect route, incorrect timing, use of the
systems by identifying and preventing defects in same medications that are different formulations,
processes. The goal is to anticipate and exceed use of drugs that do not interact effectively with one
stakeholder expectations and increase effectiveness. another, and failure to discontinue contraindicated
(Six Sigma, 2017). medications (Rozich et al. 2004).
2012). Checklists support team vigilance. The most

Standardized
common area of use is in surgery—prior to surgery
Communication Methods and/or after surgery. When checklists are used, any staff
HCOs are now using more standardized communication member may interrupt and question—for example, a
methods. This is mostly due to the recognition that errors step was missed or something was done that should
are often associated with ineffective communication. not have been done according to the checklist. This
There are many methods now used or incorporated method may be used in many situations, but the HCO
with other methods to address QI problems. An should have clear checklists that staff understand. Staff
example of the latter is that during handoffs, HCOs need to be involved in the development of checklists,
may require that specific information be shared. Staff provide feedback for improvement, and use the
members are trained in using the structured script to checklists as a checklist that is not used is then not
provide critical information and thus make sure this effective. Use of checklists not only acts as a method
information is not forgotten. In a study of standardized to prevent QI problems, but may also provide QI data.
communication used during handoffs, recurrent types
of content covered in various standardized methods
Rounds
are identified as introduction, patient/administrative
data/necessary patient information, danger or risk(s), Rounds have been used in healthcare for a long
background/history, situation/story/framework, time. The types of rounds, however, have changed
follow-up care needs, awareness of error risk to prevent over time. Rounds provide opportunity to gain
errors, dialogue, questions, ownership/custody, doc- information through observation and communi-
ument, and thank you (Nasarwanji, Badir, & Gurses, cation. They may be used by an individual staff
2016, p. 241). Two standardized communication member checking on his or her patients or by teams,
methods discussed here are SBAR and checklists. which may be profession specific (such as a nursing
The SBAR, or situation–background– team or physicians/residents/medical students) or
assessment–recommendation, is discussed in more interprofessional. All units should use some form
detail in content about teams, but it is important of interprofessional rounds to ensure consistent
to recognize that this method is part of CQI. It assessment, clearer communication, and planning
is used to prevent QI problems by ensuring clear for patient care. Rounds do not always focus on the
communication during times when important patient directly. There may be administrative rounds
information is required. It is easy to get off track in when the nurse manager goes through the unit and
communication, but during communication from is focused on many issues such as safety, cleanliness,
one healthcare provider to another, such as a nurse and work environment and may also observe patient
calling a physician about a patient, it is important to care in process or talk to patients and families. Safety
stay on track. The SBAR and other similar methods rounds may be used when certain staff—often man-
help to focus the conversation. agers, but also clinical staff—go through the unit
Checklists are also discussed in content about focusing on risks for staff and patient safety. Clinical
teams. They have become a common tool used to rounds focus on the patient and should be patient
guide staff during certain aspects of care with the centered—with patient engagement. This may seem
goal of ensuring that critical steps are taken. Teams strange, but it is important. In the past, rounds were
provide a collective vigilance to identify potential often done around the patient with little effort made
risk of errors or to quickly identify when an error to include the patient. It is also important to recognize
has occurred, shifting from individual accountability that rounds disturb the patients—patients’ rest and
and thus providing a better chance to catch a new quiet, concerns about privacy, and concerns that
miss (potential error) (Jeffs, Lingard, Berta, & Baker, others may be making decisions in which they have
no input or limited input. Rounds may be routine or negative outcomes, such as unexpected death or
unscheduled, such as the nurse decides to check on critical physical or psychological complications that
assigned patients. Routine rounds happen at scheduled can lead to major alteration in the patient’s health”
times, specific staff are involved, and the purpose is (Finkelman, 2018, p. 221). These are events that re-
clear. Documentation may be part of rounds, either quire immediate response—for example, a suicide in
during the rounds, which is typical, or immedi- the hospital, wrong-site surgery, or a life-threatening
ately after rounds. QI concerns may be identified post-operative complication. Staff responsible for
during rounds. If so, they require follow-up. HCOs QI must analyze the event (use root-cause analysis
should have policies and procedures about rounds [RCA], discussed in the next section) and collaborate
and also about how they relate to the QI program. with other staff to respond. The Joint Commission
publishes sentinel event alerts on its website based
Incident Reports on information it receives from its accredited HCOs.
This information is provided so that others can be
Incident reports have long been used by HCOs
alert to potential risks. Not all errors are sentinel
as a method for staff to report errors or problems events, and HCOs need to determine if the event is
with care. HCOs have policies and procedures to to be classified as sentinel. Often, sentinel events are
guide staff in the use of incident reports. This is an unique or happen rarely but response is required,
HCO standardized form that is completed by staff including steps to prevent reoccurrence.
involved in an event. The HCO identifies the types of
events that require reporting. These forms are used
by the QI program to track events such as infections, Stop and Consider #9
There are many methods and tools used to prevent
medication errors, treatment and procedure errors,
or resolve quality care concerns.
patient complaints, falls, security issues, harm to staff,
sentinel events, and regulatory compliance (U.S.
Department of Health and Human Services [HHS]
& Office of the Inspector General [OIG], 2012). Measurement and Analysis
Management, including nursing management, review
Measures/indicators provide performance data to
the reports to provide up-to-date information on QI
better understand actual practice, identify problems,
and to assist in identifying situations that require
and assist in best practice changes for improvement by
an immediate response. Incident reports have been
identifying topics that will be monitored to determine
used in blame cultures to identify staff involved and
performance and expected outcomes. A measure is
then take steps to resolve problems focused on staff
a “standard used as a basis for comparison, a reference
actions and the staff member—often leading to pu-
point against which other things can be evaluated”
nitive responses. Over time, this has had a negative
(HHS & AHRQ, 2014b). Indicators are aggregate
impact on staff completion of reports, which is not
measures for broader application. Data provide in-
helpful because valuable information is lost (HHS &
formation about potential quality concerns and areas
OIG, 2012). There is more effort now in cultures of
that need more examination and also help to track
safety to reduce this focus—to view incident reports
changes over time. Why is this done? “We cannot
as a source of data to be used in HCO QI efforts to
really measure ‘quality care’ per se so we use measures
assess care processes from a system perspective.
as an ‘indicator’ of quality—although they are not
a direct measure of quality care” (HHS & AHRQ,
Sentinel Events
2004). “Measuring a health system’s inputs, processes,
As described earlier, sentinel events are “unexpected and outcomes is a proactive, systematic approach
events that happen to patients resulting in major to practice-level decisions for patient care and the
delivery systems that support it. Data management purpose of this record is documentation of patient
also includes ongoing measurement and monitoring. care for clinical purposes—sharing information;
It enables an organization’s CQI team to identify and documenting what will be done and what was done;
implement opportunities for improvements of its records of testing, procedures, and medication admin-
current care delivery systems and to monitor progress istration; monitoring, such as vital signs; and so on.
as changes are applied. Managing data also helps a This, however, is also valuable data for CQI. When
CQI team to understand how outcomes are achieved, using data from methods that were not primarily
such as, improved patient satisfaction with care, staff designed for CQI data collection, there is some risk
satisfaction with working in the organization, or an that the data will not be what is needed; data may be
organization’s costs and revenues associated with missing or not understood; and data may be difficult
patient care” (U.S. Department Health and Human to retrieve. The QI program must plan carefully what
Services & Health Resources and Services Admin- data will be collected and the best source for the data.
istration, 2011a, 2011b). It is important to recognize The focus above is on HCO data collection; how-
that once something is identified as a measure, this ever, CQI data are also collected for broader purposes.
puts that situation or action in the list of important The government collects data, as has been discussed in
activities—it draws attention to the issue and typically this text for Healthy People 2020, the QDR, NQS, CMS
means staff will pay more attention to the issue, and programs, and many other initiatives. The NDNQI®
more resources may be directed at interventions to is an example of a health profession database that
prevent or resolve a problem. This may or may not be requires data collection. The Joint Commission and
a positive result—for example, if the measure is not the Magnet Recognition Program® also collect data
that important, something that is more important is from HCOs that are accredited or recognized by these
ignored. “Nurses function as the gatekeepers of health organizations. Data collection and measurement has
care, and nursing systems serve as important leverage become a complex process and, at times, is confusing
points” (VanFosson, Jones, & Yoder, 2016, p. 126). with multiple measures and indicators.
Measurement must be planned, evaluated, and
revised as needed. The HCO QI program is responsible
for the measurement plan and then its implementation. Analysis
“It is critical that an HCO’s QI program and plans Analysis of data or review of performance is a complex
identify clear steps to be taken to ensure that the CQI process conducted by an HCO’s QI program. The
activities have direction. This direction is provided goal is better understanding of the data. The data
by overall goals, which typically are fairly universal may be analyzed from a broad perspective, such
and often focus on the six aims (STEEEP®); however, as all data about medication errors; from a more
more specific direction is required. Measures/indi- focused perspective, such as intensive care unit med-
cators provide this direction to assist in reaching the ication errors or the HCO’s intravenous medication
overarching goals” (Finkelman, 2018, pp. 329–330). errors; may compare data using benchmarking, for
example, comparisons with other, similar HCOs or
comparing clinical units within the HCO; and the
Data Collection
analysis may be focused on specific incidents using
The HCO QI program collects data to monitor and RCA to understand an incident or event.
assess its QI status. There are many sources of data. RCA is now used by most HCOs, particularly
Some of the sources are designed specifically to collect hospitals. It is an error analysis system that recognizes
QI data. Other sources, such as the electronic medical system factors are more important than individuals
record, are used primarily for other purposes and when an error occurs. The RCA process includes the
then may also be used as a source of CQI data. The following steps (Finkelman, 2018; U.S. Department
of Health and Human Services, Agency for Research ■■ Organizational factors (for example, staffing
and Healthcare Quality, & Health Information levels/mix, staff availability and roles, support
Technology, 2013): staff, clear policies, administrative support,
effective leadership, access to equipment and
1. Select the team to complete the RCA. The team supplies, documentation, use of rounds and
should include experts related to the event. For other communication methods, attitudes toward
example, if the error occurred in surgery, team
patients and families/patient-centered care)
members should include representatives from ■■ Staff/team (for example, supervision of staff,
the surgical staff from the operating room, communication, team membership, quality of
anesthesiology, other relevant healthcare profes- teamwork, team leadership and functioning,
sionals such as surgeons and nurses, laboratory availability of expertise)
technicians, radiologist, infusion team, pharmacy, ■■ Individual staff factors (for example, level of
infection control (depending on the error), and knowledge, competency, and experience,
management. Staff educators may also participate. fatigue, stress, expectations, position de-
2. As the team analyzes the situation and error, scription, staff safety)
it creates a flow chart to describe the situation. ■■ Task factors (for example, clear protocols and/
3. The team then examines the flow chart for or guidelines, use of checklists, lab tests and
areas of failure. other procedures, description of tasks, policies)
4. The team uses CQI tools to consider data col- ■■ Patient factors (for example, stress, com-
lected and possible root causes. munication, accessible patient information,
5. The team redesigns the process for improvement diversity factors, comorbidities, status on
(if required) based on the analysis results. admission, past history, 30-day unplanned
6. The HCO implements the changes, ideally first readmission, discharge plans)
through a pilot, and then spread to other areas
as appropriate for the improvement strategy/ Work in healthcare environments is complex,
intervention. and many factors affect how staff perform (Roth,
Wieck, Fountain, & Hass, 2015). Common human
Key questions the RCA team asks during RCA are: factors that affect staff performance, and thus quality
■■ What happened? care, are fatigue and sleep problems, stress, hunger,
■■ Who was involved? illness, unfamiliarity with a task, inexperience,
■■ When did it happen? shortage of time, inadequate checking, interruptions,
■■ Where did it happen? noise, poor procedures to follow, unwillingness or
■■ What is the severity of the actual or potential inability to ask for help, and language and culture
harm? factors (Finkelman, 2018). These factors can be used
■■ What is the likelihood of reoccurrence? to develop strategies to improve care by preventing
■■ What are the consequences? these factors or reducing them.
The analysis must lead to clear views of issues
The team analyzing the problem or error usually so that it can be used to plan for interventions to
uses brainstorming, flow charts, and cause-effect prevent problems or to solve problems. Gap anal-
diagrams to clearly describe the problem and fac- ysis may be part of the process—identification of
tors related to it. Typical contributing factors are where you want to be and comparison with current
categorized as (Finkelman, 2018, p. 363):
status. Staff members need to be informed about the
■■ Environmental factors (for example, work analysis and results. If they are not informed, it is
environment, staff safety, safety culture-type, very difficult to engage them in QI. Nurses should
ethical-legal concerns) be involved in all phases of analysis.
the healthcare work environment, an ongoing need.

Stop and Consider #10 This critical report identifies six major concerns for
Nurses should be involved in QI measurement and
analysis.
direct care in nursing (IOM, 2004b):
1. Monitoring patient status or surveillance: This

is different from assessment. Surveillance is
Patient Outcomes defined as “purposeful and ongoing acquisition,
and Nursing Care: Do We interpretation, and synthesis of patient data
for clinical decision-making” (McCloskey &
Make a Difference in Quality Bulechek, 2000, p. 629). If surveillance is not
Improvement? effective, the result may be termed failure to
rescue—missing an opportunity to prevent
Keeping Patients Safe: Transforming the Work
complications.
Environment of Nurses (IOM, 2004b) is an early
2. Physiologic therapy: This is the most common
Quality Chasm report that focuses on acute care or
visible intervention performed by nurses.
care provided in the hospital setting; however, it is
3. Helping patients compensate for loss of function:
relevant here because much of the content can also
Teamwork is important to accomplish this—for
be applied to nursing in other types of settings and
example, nursing, physical therapy, medicine,
even to current nursing practice. This report also has
and so on.
a different focus from the later report The Future of
4. Providing emotional support, which is critical
Nursing, Leading Change, Advancing Health (IOM,
for patients and their families.
2010).The earlier report states, “When we are hos-
5. Education for patients and families: This has
pitalized, in a nursing home, or managing a chronic
become more difficult to accomplish due to
condition in our own homes—at some of our most
work conditions, staffing levels, patient acuity,
vulnerable moments—nurses are the healthcare
and shorter lengths of stay.
providers we are most likely to encounter, spend the
6. Integration and coordination of care: Patients’
greatest amount of time with, and be dependent upon
needs are complex, and care is complex, often
for our recovery” (IOM, 2004b, p. ix). The report
resulting in multiple forms of care provided by
emphasizes designs for a work environment in which
multiple providers.
nurses can provide safer, higher quality patient care.
The content discusses changes in nursing shortage This report recommends (1) adopting transfor-
and staffing, healthcare errors, patient safety risk mational leadership and evidence-based management,
factors, central role of the nurse in patient safety, (2) maximizing the capability of the workforce,
and work environment threats to patient safety. (3) understanding work processes so that they can be
In discussing errors, the focus moves away from a improved, and (4) creating and sustaining cultures
punitive, blaming environment and emphasizes the of safety (IOM, 2004b). Nursing leadership must
need to view errors more from a system perspective, be very active throughout the HCO. Nurse leaders
supporting the major message from To Err Is Human must represent staff, support the need for effective
(IOM, 1999). Some of the factors that influence change, facilitate input from direct care nursing
errors from a system perspective are highlighted in staff, and expand communication and collabora-
this report, including equipment failures, inadequate tion. Leadership is a reoccurring theme throughout
staff training, lack of clear supervision and direc- this text. The HCO needs to support ongoing staff
tion, and inadequate staffing levels—these have not learning—for example, through effective orientation
become major issues in QI programs. The central for an appropriate length of time, ongoing train-
message in the report is that we need to transform ing; nurse residency programs, funding support
for nurses to return to school to complete higher collection, analysis, measurement and measuring
degrees, establishing partnerships with schools of resulting changes” (Kovner, Brewer, Yingrengreung,
nursing, providing opportunities for interprofes- & Fairchild, 2010, p. 29). The authors of this study
sional educational experiences, and so on. All this indicate that more needs to be done in nursing ed-
requires resources that management must ensure are ucation on this critical content to help students see
available—for example, adequate staffing is critical. All the connection between QI concepts and practice.
HCOs struggle with the challenges of how best to fill Subsequently, a second study was done that
positions and retain staff. Excessive documentation compared the 2004–2005 graduates with graduates
can lead to less time for patients, which can affect from 2007–2008 (539 RNs who worked in 15 states).
safety and quality. There is need for computerized Not much difference was apparent in their responses,
documentation with decision-making support, which indicating little had changed in nursing education to
many HCOs have today. Work design is discussed better prepare new nurses for QI (Djukic, Kovner,
in depth in the Keeping Patients Safe report (IOM, Brewer, & Bernstein, 2013). Although more hospitals
2004b); physical space and design—for example, are providing staff education for new graduates,
lighting, size of the unit, and the ability to get to hospitals in general need to collaborate more with
equipment easily and quickly—and how these may schools of nursing so that nursing graduates are
affect safety are also addressed (IOM, 1999). The better prepared and then require less staff education,
Future of Nursing report also emphasizes nursing which is costly for the hospitals.
leadership and the need for nurses to be leaders in A 2015 publication discusses education gaps and
HCOs and in CQI (IOM, 2010). solutions for early-career, front-line nurse managers’
Woven throughout all of the recommendations education and participation in QI (Djukic, Kovner,
is the need for EBP and the need to base decisions Brewer, Fatehi, & Jun, 2015). These are key concerns
on evidence. “As nurses are the largest component if we want care to improve. We need leaders at all
of the healthcare workforce and are also strongly levels in QI, but unit managers have a major impact
involved in the commission, detection, and pre- on QI and in increasing staff nurse engagement—but
vention of errors and adverse events, they and their are these managers prepared for this need? A sample
work environment are critical elements of stronger of 42 early-career, front-line nurse managers was part
patient safety defenses” (IOM, 2004b, p. 31). of study to examine this issue. The results indicate
Based on what is known about QI and its that about 30% of the sample thought they were very
importance, it is natural to assume that nurses are prepared based on 12 QI indicators. Did they indi-
very active in QI and have assumed leadership in cate that the sample was engaged in specific clinical
improving care, but this is not necessarily the case, efforts to improve care on their unit more than once a
particularly with new nurses. When a 2008 survey on month? Thirty-five percent noted that they had been
this topic was sent to nurses who graduated between involved in this manner. More than 50% indicated
2004 and 2005, 436 responded (a rate of 69.4%). Ac- that they received good organizational support for
cording to the researchers, “Overall, 159 (38.6%) of QI efforts, with 30% receiving reward for their QI
new nurses thought that they were ‘poorly’ or ‘very contributions. This study then demonstrates that
poorly’ prepared about or had ‘never heard of ’ QI. some nurse managers are prepared and participate,
Their perceptions of preparation varied widely by though the sample for the study was small.
the specific topic. Baccalaureate (BSN) graduates Nurses need to participate actively in the NQS
reported significantly higher levels of preparation although historically nurses have provided weak QI
than associate degree (ADN) graduates in EBP; as- leadership. Means by which nurses can participate
sessing gaps in practice, teamwork, and collaboration; include the National Priorities Partnership, Measures
and many of the research-type skills such as data Application Partnership, and the NDNQI (Kennedy,
Murphy, & Roberts, 2013). Nurses need to actively to verbal persuasion: data dumps, lectures, sermons,
engage in the national quality agenda. and rants” (Maxwell et al. 2011, p. 10). Thus, it is
The American Association of Critical-Care important to get staff to share stories of near misses,
Nurses conducted a study to examine calculated patient injuries, or examples of when they discuss
decisions of nurses to not speak up when nurses have error prevention and harm to a patient. Staff can
knowledge of errors (Maxwell, Grenny, Lavandero, & relate more to stories, and they will remember them.
Groah, 2011). One aspect of the study examined the use Nurses also must be engaged in error recovery.
of four common survey safety tools (universal protocol We know that not all errors can be prevented, though
checklist, World Health Organization checklist, SBAR we are making efforts to reduce errors. Error recovery
when used with a handoff protocol, and drug-interaction “includes identifying, interrupting, and correcting
warning systems). In the study, the nurses were asked medical errors in a timely fashion” (Gaffney, Hatcher,
how often they had been in situations where one of & Milligan, 2016, p. 906). This nursing role is invisible
these tools was effective, warning them of a problem for the most part when a near miss occurs. Gaffney
that might have been missed and harmed a patient et al. systematic review of studies on error recovery
if a tool had not been used. The results indicated that notes that nurses typically used strategies to identify,
85% (2,020) of the nurses said they had been in this interrupt, and correct errors that included knowledge
situation at least once, and 29% (693) said they were of the patient and the patient’s problems, knowledge
in this situation at least a few times a month. This of the environment, and awareness of the plan of care.
would indicate that these tools do make a difference Nurses gain this knowledge, which may affect error
and lead to improved care. recovery, through collection of data, surveillance,
Other data from the same study, however, were communicating with others (team), continuity of
not so positive. Maxwell and colleagues (2011) also care, asking questions and sharing information.
examined the effectiveness of these safety tools, “When these strategies were not effective, being
which may be undercut by “undiscussables” as noted physically present was key in verbally interrupting
in their sample: 58% (1,403) of the nurses said they or creating delays to correct potential errors” (2016,
had been in situations where it was either unsafe to p. 914). Development of clinical judgment comes
speak up or they were unable to get others to listen. with experience, and this assists in error recovery.
Seventeen percent (409 of the 1,403) said they were in Other ways that more nurses can participate
this situation at least a few times a month. This type in the quality agenda is through development and
of data attests to the complexity of QI. Understand- implementation of standards; involvement in shared
ing data requires consideration of the problems; the governance and decision making about QI; serving
challenges in identifying, monitoring, and measuring on QI committees in HCOs and for professional
the problems; and the influence of human factors. organizations; engaging in health policy development
Findings reported in this “Silent Treatment” study at the local, state, and national levels; undertaking
show that only a small minority of nonsupervisory research and using evidence to improve practice;
nurses spoke up when they had a concern related to and engaging in active discussions with colleagues
dangerous shortcuts, incompetence, or disrespect. and other healthcare professions about QI. There is
Only 9% spoke up in all three of these situations, and need for change in the healthcare system, and the
only 14% spoke up in two of the three. “The goal is to following is critical: “The 21st century healthcare
connect to people’s existing values to stimulate their system envisioned by the committee—providing
passion for keeping patients safe. The most effective care that is evidence based, patient centered, and
way to make this connection is through sharing per- systems oriented—also implies new roles and re-
sonal experiences. The least effective way is to resort sponsibilities for patients and their families, who
must become more aware, more participative, and nursing care performance illustrating how nursing
more demanding in a care system that should be care intersects with QI.
meeting their needs. And all involved must be united
by the overarching purpose of reducing the burden
of illness, injury, and disability in our nation” (IOM,
2001a, p. 20). Figure 12-7 describes a framework of
Nursing care environment legislation, regulation, professional systems, social and

economic issues, culture, educational systems
Nursing care system
Acquiring, deploying and maintaining resources Transforming resources into services
• Management of • Practice • Nursing • Patient

• Nursing staff working environment processes
supply conditions
Autonomy Assessment,
Quantity Physical, material Collaboration planning &
Patient and Technological Decentralized evaluation
Types
profiles resources decision- Problems &
Skill-mix
Employment making symptoms
conditions Support from management
(e.g. workload, co-workers Promotion /
schedule, status) and managers Prevention
Hospital-
community
integration
• Nursing staff maintenance • Professional
Scope of
Health and quality of life at work satisfaction
practice
Satisfaction with working conditions
Retention
Absenteeism
• Economic sustainability
Costs
Cost per case-mix
Producing changes in patients' conditions
Nursing sensitive outcomes Joint contribution of nursing and other systems
Patient comfort and Patient

quality of life empowerment
• Health status
• Readmission
Risk outcomes and Patient functional • Length of stay
safety status • Complications
• Mortality
Patient satisfaction
Other organizational systems

CHAPTER HIGHLIGHTS
1. The IOM published a number of critical and to the healthcare professions core

reports related to quality health care in the competencies.
United States—the Quality Chasm series. 12. The United States now collects national
2. QI is aimed at processes that critically ex- quality and disparities data and publishes
amine the level of care, any problems with an annual report: the National QDR.
care, and how to make patient outcomes 13. The Joint Commission’s standards for QI
better. It is a continuous process (CQI). focus on patient-focused functions, organi-
3. Safety is a critical component of quality care zational functions, and structural functions.
and improved patient outcomes. 14. Healthcare report cards provide specific
4. Critical terms that require consistent defini- performance data about an organization at
tions related to safety and are important to specific intervals, with a focus on quality
understand and use in the practice setting and safety.
include the following: safety, error, adverse 15. The NQS is now the major improvement
event, misuse, overuse, underuse, near miss, guide for framework for U.S. health care.
sentinel event, and RCA. 16. In 2007, the Centers for Medicare and
5. Errors are generally systems errors, not Medicaid Services introduced a major change
individual problems. in its reimbursement policy, stating that
6. There is a strong recommendation to move the CMS will not pay Medicare benefits for
to a culture of safety rather than a culture certain patient complications that occur in
of blame. the hospital that could have been prevented.
7. Some of the key safety issues for nursing In 2011, new regulations added Medicaid
staff are needlesticks, infections, ergonomic patients to this requirement (HACs).
safety, violence, and chemical exposures. 17. The CMS added another quality initiative
8. Examples of safety initiatives include the that is focused on reducing 30-day unplanned
IHI’s 5 Million Lives campaign, the IHI readmissions.
and Robert Wood Johnson Foundation’s 18. Nursing’s report card (NDNQI) provides
TCAB initiative, and The Joint Commission’s a framework for educating nurses, con-
annual safety goals. sumers, and policy makers about nursing’s
9. Quality of care is usually measured by contributions within the acute care setting
structure, process, and outcomes. by tracking the quality of nursing care
10. The six aims or goals for improvement state provided in acute care settings. Data are
that care should be safety, timely, effective, collected for nursing-sensitive indicators
efficient, equitable, and patient-centered that reflect the nursing workforce, nursing
STEEEP. process, and patient outcomes.
11. The IOM developed new rules for the 19. Examples of high-risk care activities are
21st century to guide care delivery. These medication administration, care transitions
rules provide a vision for healthcare qual- and handoffs, failure to rescue, and alarm
ity and are directly related to the six aims /alert fatigue.
(Continues)
20. Examples of methods used to measure and of the workforce, (3) understanding work
monitor safety and quality include utilization processes so that they can be improved,
review, benchmarking, assessment of access to and (4) creating and sustaining cultures
care, medication reconciliation, standardized of safety.
communication, rounds, incident reports, 22. The Future of Nursing (IOM, 2010) em-
and sentinel reports. phasizes nursing leadership and need for
21. Keeping Patients Safe (IOM, 2004b) recom- nursing engagement in QI.
mended the following: (1) adopting trans- 23. Much more needs to be done to prepare
formational leadership and evidence-based nurses for CQI and to assume leadership
management, (2) maximizing the capability in CQI.
1. How do the six aims (STEEEP) to improve 3. What is accreditation? Who is the major
quality relate to the rules for the 21st century provider of accreditation for HCOs?
(IOM) and the healthcare professions core 4. Discuss the definition of quality.
competencies (IOM)? 5. Describe four examples of tools and methods
2. Describe the culture of safety. How does this used to improve care.
compare to the blame culture?
1. Divide up into teams, with each team taking monitored and summarize key issues. Share
one of the rules for the 21st century. Develop this with others who have reviewed different
a defense for this rule and share with the clinical conditions.
other teams. 3. In student teams, examine the website for
2. Visit the National Healthcare QDRs website to the Toolkit for Using the AHRQ Quality In-
review the current reports on healthcare quality dicators (https://www.ahrq.gov/professionals
and disparities (https://www.ahrq.gov/research /systems/hospital/qitoolkit/index.html). Each
/findings/nhqrdr/index.html). After reviewing team should review the information and
data on the dimensions of quality, what summarize the key points that they would
have you learned? Select one of the areas
(Continues)
use to explain the purpose of the toolkit and 5. Select one of the common quality care issues,
value to nursing practice. such as hand washing, decubiti, and so on,
4. Visit the OSHA Workplace Violence website, and search for information about the topic
https://www.osha.gov/SLTC/healthcarefacilities and how care can be improved.
/violence.html, to learn about this important 6. Select two of the online patient safety
staff safety problem and possible solutions. resources found at National Patient Safety
Review the guidelines for healthcare workplace Foundation website (http://www.npsf
violence. What solutions are recommended, .org/?page=professionals). How might nurses
and what is your opinion of the solutions? use this resource?

In your journal, describe an example of a QI problem that you have observed or were
directly involved in while in clinical practice. Remember to follow the Health Insurance
Portability and Accountability Act rules when recording your information.
CASE STUDIES
Case 1
A 21-year-old woman presented to the emergency department of an urban hospital with a
history of systemic lupus. Her complaint was dehydration, dizziness, and feeling faint. The
woman also had a recent history of being dehydrated, complicated by renal involvement
from lupus and having to receive bolus fluids. She was on multiple medications, including
steroids and methotrexate. An intravenous (IV) line was started, and blood was drawn for
labs. The emergency department physician returned to report that the lab values were
within normal limits, yet the young woman felt no better. She stated that she still felt
dehydrated, her blood pressure felt low, and she normally received more IV fluids and a
steroid injection when she felt this way. The physician indicated that he felt no need for
this treatment, but when the patient insisted on more fluids, he agreed to continue them
for a while and to give her an injection of steroids. The patient asked, “Do you want to give
me anti-nausea medication first?” The physician stated that there was no indication. The
patient told him that she was always nauseated following steroids and had sometimes
vomited if no antiemetic were administered first. The physician argued but finally grew
tired and walked away. The steroid injection was given, and nausea ensued. When the
patient got home a few hours later, the patient called her rheumatologist and urologist
(neither had been available when the illness occurred because of the late hour). They
repeated her labs the next day, only to find that she was severely dehydrated, and many
values, including renal panel, were outside normal limits.
Case Questions
1. What are the critical issues in this case description?
2. Consider the six aims (STEEEP) to better ensure quality care. How might they apply to
this patient?
3. Is this patient-centered care? Why or why not?
4. If you were the nurse assigned to this patient in emergency department, what could
you have done?
Case 2
A patient has been admitted to an ambulatory surgical unit for a hernia repair. He is a
physician, and his wife is a nurse. After his surgery, his wife is taken to the post-anesthesia
care unit (also known as recovery) to see her husband. The unit is configured with cubicles
divided with curtains. In the patient area, there is the stretcher with the patient, monitors,
and a computer with a stool in front of it. The patient is recovering from anesthesia but
can communicate. The nurse is “glued to” the computer, rarely looking at the patient
when speaking to him. The patient has a history of atrial fibrillation and takes a number
of cardiac medications. The nurse says that he is going to put a medication into the IV;
he indicates the medication name, and begins to do so. At the same time, the patient
becomes alert and says, “No.” Just at that time, the curtain opens and the anesthesiology
resident says loudly, “Stop that order.” Both physicians knew (the patient and the resident,
although the resident should not have made the order) that there was a contraindication
for mixing certain drugs.
A few hours later, the patient is getting ready for discharge in the ambulatory surgical
unit, and his wife is present. During the admission process, the nurse was also “glued to”
computer when assessing the patient, rarely looking at the patient and more concerned
with typing in information rather than assessment. At the time of discharge, the nurse
comes in and reads through a list of discharge directions, strongly emphasizing that the
patient should take all of his routine medications when he gets home. The patient says, “All
of them?” (He is testing the nurse, as he knows the answer to this question.) The nurse says,
“Yes.” The patient says, “I don’t think so. Aspirin should not be taken right after surgery, and
I take it daily as routine medication.” The nurse did not seem to understand what he said
and did not respond.
In this situation, the doctor should not have written an order for all medications
after discharge; however, in both incidents the nurse had responsibilities and provided
ineffective, unsafe care that was stopped by the patient before a serious problem occurred.
The patient and his wife left the hospital fed up with the quality of care. Both incidents were
described in the patient satisfaction survey the patient received, but the patient never heard
from the hospital. This was an academic health center with a medical school and nursing
school attached to the university. The patient will not return to this hospital for surgery.
Case Questions
In this example of a case that actually occurred, it is clear that physician errors led to near
misses, but it is also clear that nursing actions led to near misses.
1. What is a “near miss”?
2. Describe each of the near misses and the roles of the physicians and the nurses in each
incident.
3. Which system issues might have been involved?
4. What could have been done to prevent these near misses?
5. What do you think hospitals should do when patients describe incidents like these in
patient satisfaction surveys?
6. What was the impact of technology in this case?

questions.
1. Can you provide us with comparison data for the last 5 years?
2. Was the procedure followed as described and based on best evidence?
3. What role should staff nurses assume?
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Chapter
13
Utilize Informatics
CHAPTER OBJECTIVES
■■ Discuss the core competency: Utilize ■■ Explain systems and terminologies as they
informatics. relate to health informatics.
■■ Discuss the relevance of the two recent federal ■■ Examine informatics types and methods used
reports on health information technology. in healthcare delivery.
■■ Describe health informatics and its ■■ Describe new and expanding future
relationship to nursing. approaches for applying informatics and
■■ Explain the purpose of documentation technology in health care.
and key issues related to informatics and ■■ Explain the importance of HIPAA.
documentation. ■■ Compare and contrast high-touch care with
■■ Explain the importance of meaningful use. high-tech care.
■■ Critique the need for standardized ■■ Discuss the need for nursing leadership in
terminologies in healthcare delivery. health informatics technology.
CHAPTER OUTLINE
●● Introduction ●● Documentation
●● The Core Competency: Utilize Informatics ●● Meaningful Use
●● The Federal Health Informatics Reports ●● Standardized Terminology
●● Informatics ●● Systems and Terminologies
●● Description and Definitions ●● Informatics: Types and Methods
●● Nursing Standards: Scope and ●● Automated Dispensing of Medications
Standards of Nursing Informatics and Bar Coding
●● Certification in Informatics Nursing ●● Computerized Monitoring of Adverse
●● Informatics: Impact on Care Events
●● Implications for Nursing Education and ●● Electronic Medical/Health Records
Nursing Research ●● Clinical Provider Order-Entry System
423
●● Clinical Decision Support Systems ●● Telehealth and Remote Telemetry

●● Tablets and Smartphones Monitoring
●● Computer-Based Reminder Systems ●● Robotics
●● Access to Patient Records at the Point ●● Genetics and Genomics
of Care ●● Medical Devices
●● Internet Prescriptions ●● HIPAA: Ensuring Confidentiality
●● Nurse Call Systems ●● High-Touch Care versus High-Tech Care
●● Voice Mail and Texting ●● Nursing Leadership in Health Informatics
●● Telephone for Advice and Other Services ●● Chapter Highlights
●● Internet or Virtual Appointments ●● Engaging in the Content
●● Online Support Groups for Patients and ●● Discussion Questions
Families ●● Critical Thinking Activities
●● The Future of Health Informatics and ●● Electronic Reflection Journal
Medical Technology ●● Case Studies
●● Nanotechnology ●● Working Backward to Develop a Case
●● Wearable Computing ●● References
KEY TERMS
Clinical data repository Electronic medical/health Knowledge

Clinical decision support record (EMR/EHR) Meaningful use
systems Email list Minimum data set
Clinical information system E-measurement Nomenclature
Clinical provider order-entry Encryption Nursing informatics (NI)
system (CPOES) Health Insurance Portability Personal health record (PHR)
Coding system and Accountability Act of Scorecard
Computer literacy 1996 (HIPAA) Security protections
Dashboard Informatics Software
Data Information Standardized terminology
Data analysis software Information (cognition) Telehealth
Data bank overload Telenursing
Data mining Information literacy Wisdom
Database Interoperability
Introduction communication and sharing of knowledge. The impact

of health informatics technology (HIT) on nursing
This chapter concludes the section that focuses on care is explored here. Other issues that need to be
the healthcare profession core competencies with a addressed are documentation; confidentiality and
discussion of the fifth core competency: utilize infor- privacy of information; and technology and informatics
matics. Informatics technology (IT) is an important methods used in practice, education, and research.
topic in all areas of life today; with the explosion This chapter also includes content about biomedical
of technology, there are many opportunities for equipment or medical devices, an expanding area in
Chapter 13: Utilize Informatics 425
Documentation Regulations: HIPAA
Informatics
High-tech use
description
high touch
standards Core competency:
Utilize informatics
Biomedical
Informatics and
and patient
communication
care equipment
Telehealth
Figure 13-1 Utilize Informatics: Key Elements
healthcare technology that affects nurses and nursing It also includes how that technology is used to
care. Some of this equipment also uses IT. Nurses prevent errors and improve care, particularly in
today cannot avoid technology, whether it is used in the measurement of care. From the initial use of
communication, care provision, or monitoring the computers to share information, to management of
quality of care. The chapter concludes with a discus- financial records, to the current use of informatics
sion about the potential conflict between high-touch with more emphasis on patient care, there has been
care versus high-tech care and the need for nursing a major move toward HIT application in health care.
leadership in health informatics—important issues Some examples are greater use of informatics to
for nurses to consider. Figure 13-1 identifies key find evidence to implement evidence-based prac-
elements in this competency. tice (EBP); use of informatics in research; greater
consumer access to information via the Internet;
and more specific clinical applications, such as
The Core Competency: reminder and decision systems, telehealth, online
prescribing, and use of email for provider–provider
Utilize Informatics communication and patient–provider communi-
cation. The Quality Chasm report on healthcare
The fifth healthcare profession core competency is
professions core competencies concludes that every
“communicate, manage knowledge, mitigate error,
healthcare professional should meet the following
and support decision making using information
informatics competencies (IOM, 2003, p. 63):
technology” (Institute of Medicine [IOM], 2003,
p. 4). Informatics entails more than just under- ■■ Employ word processing, presentation, and
standing what is HIT and its clinical implications. data analysis software.
■■ Search, retrieve, manage, and make decisions The statement also indicates that nurses play a
using electronic data from internal informa- critical role in HIT and there are expanded roles for
tion databases and external online databases nurses—there is strong support for nursing leader-
and the Internet. ship in HIT. “Nurses are key leaders in developing
■■ Communicate using email, instant messaging, the infrastructure for effective and efficient health
email lists, and file transfers. information technology that transforms the delivery
■■ Understand security protections such as access of care. Nurse informaticists play a crucial role in
control, data security, and data encryption, advocating both for patients and fellow nurses who
and directly address ethical and legal issues are often the key stakeholders and recipients of these
related to the use of IT [HIT] in practice. evolving solutions. Nursing informatics profession-
■■ Enhance education and access to reliable als are the liaisons to successful interactions with
health information for patients. technology in healthcare” (HIMSS, 2011).
A position statement from the Healthcare Infor-
mation and Management Systems Society (HIMSS, Stop and Consider #1
2011) addresses The future of nursing (IOM, 2010) Every nurse applies the informatics competency.
report from the perspective of informatics. The
following HIMSS recommendations were made
and align with The Future report on the key points
of nursing leadership, education, and practice The Federal Health
(HIMSS, 2011): Informatics Reports
■■ Partner with nurse executives to lead tech-
The federal government increased its involvement
nology changes that advance health and the
in HIT, particularly through the U.S. Department
delivery of health care.
of Health and Human Services (HHS), Office of
■■ Support the development of informatics
the National Coordinator for Health Information
departments.
Technology (ONC). This office published Health
■■ Foster the evolution of the chief nursing
information technology: Patient safety action &
informatics (NI) officer role.
surveillance plan, which identifies advantages for
■■ Transform nursing education to include
greater use of the electronic medical record (EMR), a
informatics competencies and demon-
key HIT example found in healthcare organizations
strable behaviors at all levels of academic
(HCOs) (HHS & ONC, 2013, pp. 5–6):
preparation.
■■ Promote the continuing education of all ■■ Increase clinicians’ awareness of potential
levels of nursing, particularly in the areas of medication errors and adverse interactions.
electronic health records (EHRs) and HIT. ■■ Improvement of the availability and timeliness
■■ Ensure that data, information, knowledge, of information to support treatment decisions,
and wisdom form the basis of 21st-century care coordination, and care planning.
nursing practice by incorporating informatics ■■ Make it easier for clinicians to report safety
competencies into practice standards in all issues and hazards.
healthcare settings. ■■ Give patients the opportunity to more effi-
■■ Facilitate the collection and analysis of in- ciently provide input on data accuracy than
terprofessional healthcare workforce data what paper records would allow.
by ensuring data collected from existing IT These continue to be advantages in linking EMRs
systems. to quality improvement. The increased use of
electronic records was initially driven and still is

driven by important federal legislation, the Health VISION
Information Technology for Economic and Clinical High-quality care, lower costs, healthy
population, and engaged people
Health Act of 2009, known as HITECH. All of this
set the stage for greater federal involvement in HIT. MISSION
In 2015, the HHS published a report, Connecting Improve the health and well-being of
individuals and communities through the use
health and care for the nation: A shared nationwide of technology and health information that is
interoperability roadmap, draft version 1.0. The accessible when and where it matters most
purpose of this extensive report is to describe a road-
map supporting interoperability or “the ability of
a system to exchange electronic health information Goal 1
Advance person-
with and use electronic health information from centered and self-
other systems without special effort on the part of the managed health
user” (HHS & ONC, 2015a, p. 18). This is a critical

element in making HIT more accessible and sharing Goal 2 Goal 3
Transform health Foster research,
information across systems and providers. A second care delivery and scientific
report describes the federal health IT strategic plan community knowledge and
health innovation
for 2015–2020. Figure 13-2 describes the frame-
work for this strategic plan, including the vision, Goal 4
mission, and four goals. The key issue is access to Enhance nation's
health IT infrastructure
information when needed by people. Figure 13-3
highlights the vision that guides the strategic plan,
focusing on high-quality care, lower costs, a healthier
Figure 13-2 Federal Health IT Strategic Plan:
population, and engaged individuals—thus providing
Vision, Mission, and Goals
patient-centered care. This is a good example of how Reproduced from U.S. Department of Health and Human
HIT is not just about computers and software. There Services. The Office of National Coordinator for Health
needs to be a relationship between the technology Information Technology. (2015). Federal health IT strate-
gic plan. 2015–2020. p. 6. Retrieved from https://www
and care delivery—needs and outcomes. Important .healthit.gov/sites/default/files/9-5-federalhealthitstratplan
principles should be followed when HIT plans are final_0.pdf
developed (HHS & ONC, 2015b, pp. 20–21).

■■ Build upon the existing health IT infrastructure.
■■ Recognize that one size does not fit all. ■■ Protect privacy and security in all aspects of
■■ Empower individuals giving them more interoperability.
access to information. ■■ Include scalability and universal access.
■■ Leverage the market—greater need now for These two reports—the strategic plan and follow-up
seamless flow of electronic clinical health initiatives—demonstrate the importance of HIT and
information. the need for better standards and consistency, as
■■ Simplify. well as the important role of the federal government
■■ Maintain modularity and provide flexibility through the work done by HHS and its agencies.
to the system as change will be ongoing. Undoubtedly, there has been major expansion
■■ Consider the current environment and support in the use of HIT. The HHS through the ONC must
multiple levels of advancement. now report annually to Congress on the status of HIT.
■■ Focus on value. The 2016 report indicated that prior to 2009, most
Individuals care is patient centered, accessible, and safe, and
High-Quality
interventions address behavioral, social, and environmental
determinants of health (National Quality Strategy)
Individuals benefit from improvement and innovation, and
Care new knowledge is captured as part of care experience

(Health and Medicine Division of the National Academies of
Sciences, Engineering, and Medicine)
Individuals, families, employers, and governments benefit
Lower Costs from more affordable quality care through new delivery
models (National Quality Strategy)
Healthier Individuals, families, clinicians, and communities focus on
Population
prevention and wellness (National Prevention Strategy)
Engaged Individuals are active in managing their health and partnering
Individuals
in their health care (ONC Person at the Center)
Figure 13-3 The Vision to Guide the Federal Health IT Strategic Plan 2015–2020
Reproduced from U.S. Department of Health and Human Services. The Office of National Coordinator for Health
Information Technology. (2015). Federal health IT strategic plan. 2015–2020. p. 13. Retrieved from https://www.healthit
.gov/sites/default/files/9-5-federalhealthitstratplanfinal_0.pdf
HCOs—including hospitals, physician practices,

clinics, and so on—used paper documentation. Informatics
Sharing was done using fax machines. Indicating
Informatics is complex, and the fact that it is changing
major improvement, the ONC notes that seven
daily makes it even more difficult to keep current
years later, 78% of physician practices and 96% of
with this field. Healthcare delivery has been strongly
hospitals use a certified electronic medical/health
influenced by the changes in informatics, but what is
record (EMR/EHR; HHS & ONC, 2016a, 2016b).
informatics? “Technology is revolutionizing the way
Now there is more emphasis placed on creating a
that healthcare is delivered with a steady infusion
better seamless and secure system that considers
of new solutions into clinical environments. At the
interoperability.
same time, outside of healthcare, both clinicians and
consumers are learning to incorporate technolog-
ical solutions into their daily lives with tools like
Stop and Consider #2 high-speed data networks, smart phones, handheld
The federal government is very involved in ensuring
effective health information technology.
devices, and various forms of patient engagement
in social media exchanges. Bringing these types of
technologies into the healthcare marketplace will performance. The use of HIT has a major impact
transform the time and place for how care is provided. on quality improvement (Finkelman, 2018). Today,
Having individuals who understand the unique it is much easier to collect, store, and analyze large
complexities of healthcare practices along with how amounts of data that, in the past, were collected
to best develop technological tools that positively by hand. Insurers rely heavily on informatics as
affect safe patient care is essential. Nurses integrating they provide insurance coverage, manage data, and
informatics solutions into clinical encounters are analyze performance, which has a direct impact on
critical for the transition to an automated health- whether care is covered for reimbursement. Infor-
care environment that promotes the continuum of matics allows governments at all levels—local, state,
care across time and place, in addition to wellness national, and international—to collect and use data
and health maintenance activities” (HIMSS, 2011). for policy decision making and evaluation.
Some nurses may hold health informatics Informatics has its own language and is a highly
positions, as discussed later in this chapter, but all specialized area. Nurses do not have to be informatics
nurses use HIT in their positions—it is not an area experts, but they do need to understand the basics.
that only concerns a specific nursing specialty. HIT Some common IT terms that most people know are
is now a critical element throughout the healthcare Internet and e-mail. Other terms that nurses should
delivery system. “It is a foundational tool to change know are highlighted here (Glassman & Rosenfeld,
the healthcare industry; however, it is not an instant 2015; American Nurses Association [ANA], 2008):
fix. Rather, it is one tool in the arsenal of health re- ■■ Clinical data repository: This is a physical
form. Health IT impacts quality by providing users or logical compendium of patient data per-
the unique ability and opportunity to truly capture taining to health; an information warehouse
and derive the benefits from data. This allows users used to store data longitudinally, in multiple
to translate seemingly independent pieces of data forms (text, voice, images, and so on).
into meaningful conclusions that, if applied and ■■ Clinical decision support systems: These
implemented correctly, can improve the health of systems are computer applications designed
individuals and populations; lower costs; and help to facilitate human decision making. Decision
tailor healthcare to individual patient needs. Health support systems are typically rule based,
IT can be implemented and employed in such a way using a knowledge base with a set of rules
as to support the National Quality Strategy and help to analyze data and information to reach
achieve the 3-part aim of better care, better health, recommendations.
and lower cost” (Kennedy, Murphy, & Roberts, 2013). ■■ Clinical information system: This is an
information system that supports the acquisi-
tion, storage, manipulation, and distribution
Description and Definitions
of clinical information throughout an HCO,
Informatics has opened doors to many innovative with a focus on electronic communication,
methods of communication with patients and using HIT applied at the point of clinical
among providers, individuals, and HCOs of all care. Typical clinical information system
types, some of them discussed in this chapter. HIT components include EMRs/EHRs, clinical
often saves time but can also lead to information data repositories, decision support programs
overload. With these changes comes greater risk (such as application of clinical guidelines
of inappropriate access to information through and checking drug interaction), handheld
hacking and other means. Informatics is also used devices for collecting data and viewing
to evaluate HCO and individual healthcare provider reference material, imaging modalities, and
communication tools such as electronic ■■ Information literacy: This is the ability to

messaging systems. recognize when information is needed and
■■ Coding system: This is a set of agreed-upon then to locate, evaluate, and effectively use
symbols (frequently numeric or alphanumeric) that information.
associated with a concept representation or ■■ Minimum data set: This describes the
terms to allow exchange of meaning. Exam- minimum categories of data with uniform
ples are the SYNTEGRITY Perioperative definitions and categories; concerns a spe-
Nursing Data Set (PNDS) and the Clinical cific aspect or dimension of the healthcare
Care Classification System. system that meets the basic needs of multiple
■■ Computer literacy: Specific knowledge data users.
and skills are required to use basic computer ■■ Nomenclature: This is a system of designa-
applications and computer technology. tions (terms) that is elaborated on according
■■ Data: These are discrete entities described to preestablished rules. Examples include
objectively without interpretation. Systematized Nomenclature of Medicine—
■■ Dashboard: A method to provide a quick Clinical Terms International and International
view of data using key elements of concern. Classification for Nursing Practice.
■■ Data analysis software: Computer software ■■ Scorecard: This is a metric method used by
used to analyze data; used in health care to management to assess and track performance,
meet regulatory requirements, performance typically related to the HCO’s agenda (or unit,
assessment and quality improvement, ac- service, department); it can focus on clinical,
creditation, and research. financial, and other indicators. Another
■■ Data bank: A method used to store a large term that may be used is report card.
amount of information; may include several ■■ Security protections (access control, data
databases. security, and data encryption): Methods
■■ Database: A collection of interrelated data used to ensure that information is not read
organized according to a scheme to serve one or taken by unauthorized persons.
or more applications with data stored so that The role of HIT in e-measurement and quality
several programs can use the data without care has become increasingly more important in recent
concern for data structures or organization. years (Dykes & Collins, 2013). E-measurement is
An example is the National Database of the secondary use of electronic data to populate
Nursing Quality Indicators, discussed in standardized performance measures (National
other content in this text. Quality Forum [NQF], 2017). The NQF is engaged
■■ Data mining: This is a method used to in ensuring effective e-measures are available so
locate and identify unknown patterns and that data can be used for clinical documentation
relationships within data. and reused to measure patient outcomes that are
■■ Email list: A list of email addresses can be clear and consistent. This endeavor, which is very
used to send an email to many addresses complex, remains far from complete at this time.
simultaneously. A current problem in our everyday lives and in our
■■ Encryption: A method used to change professional lives is information (cognitive) overload,
information into a code, usually for security which is an “interpretation that people make in
reasons so as to limit access to that information. response to breakdowns, interruptions, interrup-
■■ Information: This represents data that have tions of ongoing projects, or imbalances between
been interpreted, organized, or structured. demand and capacity” (Weick, 2009, p. 76). We
are so overwhelmed with information that we may

experience it as a barrier in using the information
and, in some cases, it may interfere with our decision Wisdom
making and work that must be done. Interruptions, Knowledge
attention issues, and not having enough time can
Information
also influence information overload, making it a
greater problem. The bottom line is this problem
Data
can lead to other problems (Sitterding, 2015).
We are attached to our devices personally and
now more and more in our work in health care.
Figure 13-4 From Data to Wisdom
Managing the use of devices and information is a
critical requirement for success. Information and
accessibility to information has a positive impact Data alone are not useful—understanding
on quality care; however, we are learning that this the data and then using this knowledge is what
can also have a negative impact, which may prevent is important. This view is important to include in
us from reaching outcomes—we have too much discussions with students. The steps in moving from
information or we cannot manage the information data to wisdom can be described as data naming,
effectively. collecting, and organizing, following this pattern: (1)
information—organizing and interpreting; (2) knowl-
Nursing Standards: Scope edge—interpreting, integrating, and understanding;
and Standards of Nursing and (3) wisdom—understanding, applying, and
applying with compassion. Figure 13-4 illustrates
Informatics
this process. Nelson and Joos define wisdom as “the
NI is a specialty that integrates nursing science, appropriate use of knowledge to manage and solve
computer science, and information science to human problems. It is knowing when and how to
manage and communicate data, information, apply knowledge to deal with complex problems
knowledge, and wisdom in nursing practice. NI or specific human needs” (1989, p. 6). Knowledge
supports consumers, patients, nurses, and other and wisdom are related: “While knowledge focuses
providers in their decision making in all roles and on what is known, wisdom focuses on the appro-
settings. This support is accomplished through the priate application of that knowledge. For example,
use of information structures, information pro- a knowledge base may include several options for
cesses, and HIT. The goal of NI is to “improve the managing an anxious family, while wisdom would
health of populations, communities, families, and help decide which option is most appropriate for
individuals by optimizing information management a specific family” (ANA, 2008, p. 5). Data are
and communication” (ANA, 2008, p. 1). important to the delivery of nursing care, but
Undergraduate nursing programs may include without effective analysis, it is not useful to us. In
HIT in the curriculum, sometimes as a course hospitals, data can be used to evaluate outcomes,
on informatics, but not all programs include this identify problems for a specific group of patients,
content. This omission from nursing education and assist in making plans for change to improve
programs is a problem because of the greater em- care. In the community, aggregated data are often
phasis on informatics as a healthcare professions collected to better understand the health issues
core competency. Some schools of nursing offer in a population or community and to formulate
master’s degrees in NI. a plan of action.
information handling in nursing, such as the de-

Certification in Informatics
velopment, support, and evaluation of applications,
Nursing tools, processes, and structures that help nurses to
Nurses who practice in the area of informatics can manage data in direct care of patients as well as in
be certified if they meet the eligibility criteria and nursing education and research. Informatics nurses
satisfactorily complete the certification examination. can be involved in a variety of information systems,
The following list identifies the application eligibility including theory formulation, design, development,
criteria required for the informatics certification exam marketing, selection, testing, implementation,
sponsored by the American Nurses Credentialing training, maintenance, and evaluation. They may
Center (ANCC). The nurse must (ANCC, 2016): hold positions in HCOs, such as in clinical practice,
■■ Hold a current, active registered nurse license management, or education; serve as an HIT con-
in a state or territory of the United States or sultant; and hold positions that support research. It
the professional, legally recognized equivalent is clear that a nurse who wants to function in this
in another country. specialty area must have excellent computer skills,
■■ Have practiced the equivalent of 2 years understand practice needs for information, and
full-time as a registered nurse. know how best to apply HIT to nursing practice.
■■ Hold a bachelor’s or higher degree in nursing The nurse must also be able to work collaboratively
or a baccalaureate degree in relevant field. in interprofessional teams and demonstrate leader-
■■ Have completed 30 hours of continuing ed- ship. By advocating for the needs of the practicing
ucation in informatics within the last 3 years nurse, the informatics nurse represents all nurses
■■ Meet one of the following practice hour in practice—clinical, education, and research—as
requirements: applies to the specific situation.
a. The nurse must have practiced a minimum
Informatics: Impact on Care
of 2,000 hours in informatics nursing
within the last 3 years. Effective use of informatics can lead to safe, quality
b. The nurse must have practiced a minimum care. Application of informatics, however, does not
of 1,000 hours in informatics nursing in guarantee perfection. It is commonly thought that
the last 3 years and must have completed work processes will be better if using IT; however,
a minimum of 12 semester hours of aca- potential glitches need to be considered so that
demic credit in informatics courses that problems will be prevented. Examples include the
are a part of a graduate-level informatics following: clear expectations for staff HIT use and
nursing program. outcomes, ease of use, staff time for HIT training,
c. The nurse must have completed a graduate quality of HIT training, staff time required to use
program in NI containing a minimum of HIT, monitoring of errors and methods used to
200 hours of faculty-supervised practicum address problems, accessibility to HIT such as
in informatics.* access to a computer or device that supports the
These are not simple eligibility criteria; they take task, acceptance of HIT by staff, methods used to
time to meet. They also provide a good overview introduce HIT changes and communication of these
of the need for expertise in this area. changes, HIT tech support, and so on. Introducing
The informatics nurse is involved in activities and maintaining HIT requires careful planning with
that focus on the methods and technologies of input from staff that will use HIT.
Nurses need to assume an active role in the
*© American Nurses Credentialing Center (ANCC) 2016. development of HIT for patient care and not wait to
Reprinted with permission. be asked to participate. When an HCO is choosing
an EMR system, nurses need to be involved to ensure consultation. In many situations, such communi-
that the system meets nursing care documentation cation eliminates the need to see the patient. The
requirements and that relevant data can be collected specialist reviews information such as lab reports,
to assist nurses in providing and improving care. surgical reports, and so on, and the specialist can
Nurses may serve in key HIT roles to guide devel- share opinion and treatment recommendations with
opment and implementation. Nurses may also serve the other healthcare provider. It is critical that reim-
as resources in identifying needs and testing systems bursement be provided for this type of service, or it
to ensure that the systems are nurse–user friendly. will not be used. Health Insurance Portability and
Many nurses who provide feedback about systems Accountability Act of 1996 (HIPAA) requirements
do not have special HIT training; they review the must also be considered, with all parties working
system to determine if it is user friendly for nurses together to ensure patient privacy. Timely information
who have limited informatics knowledge and help flow from the hospital to post-hospital care should
to determine if the system meets documentation improve patient coordination. Not having this is a
needs and standards. All nurses need to be skilled major drawback; even though the technology to
in managing and communicating information, improve it is available, it is not freely used.
but most nurses are primarily concerned with the
content of that information and getting it when
Implications for Nursing
they need it.
In today’s dynamic healthcare environment, Education and Nursing
coordination of care is very important. One of the Research
barriers to seamless coordination is the lack of in- Informatics is important not only for practice, but
teroperable computerized records with hospitals and also for nursing education and nursing research.
also office-based physicians (Bodenheimer, 2008). Today, there is greater use of IT in nursing education
Interoperability is receiving more attention on the than was the case in the past. The increased use of
national level, as discussed earlier in this chapter. online courses throughout the nursing curriculum,
A problem that is not yet fully solved is the need at both the undergraduate and graduate levels, has
to share information from one system to another, revolutionized nursing education. This has led to
which is a limitation that needs to be resolved for the need for faculty to consider use of more inter-
better coordination of care. For example, it should active learning methods. Moreover, as students use
be possible to share current information among more technology in their personal lives, they expect
healthcare providers in private practice, clinics, correspondingly greater use of IT in education.
and hospitals when it is needed. All of this requires Such tools as tablets and smartphones and Internet
greater use of standardized definitions related to tools and apps such as Facebook, Instagram, and
data and measurement to ensure objectivity and Twitter provide instant information and can be
reliability of data, allow for comparisons, consistently very interactive. These methods can also be used
track data over time, and increase opportunity to to increase student–faculty communication and
provide/observe empirical evidence of outcomes have the potential to provide different means of
(Glassman & Rosenfeld, 2015). student–faculty supervision in the clinical area.
Innovative methods to improve coordination This is particularly true in areas such as public/
that focus on informatics have been developed. One community health when students visit multiple sites
method is to use electronic referral (e-referral.) and faculty move from site to site to spend time
This approach allows a healthcare provider to send with students. Informatics also affects simulation
an email to another provider, such as a specialist, experiences for students, allowing faculty to create
with information about the patient and ask for complex learning scenarios that use the computer
and computerized equipment and, in many cases, The format and content of nursing docu-
provide opportunity for students to use an EMR mentation have also changed. It is a professional
system in a simulated environment. responsibility to document planning, actual care
Nursing research uses informatics in data col- provided, and outcomes. Care coordination and
lection and analysis; it saves time and improves the continuity are supported by documentation. With
quality of data collection and analysis. Researchers many different staff caring for patients around
have greater access to tools that can make their work the clock and use of interprofessional teams, it is
easier and organize and save data for later use. It is critical that a clear communication mechanism
then easier to analyze the data to determine research exists, and the key mechanism is documentation.
results. Nurse researchers and their staff do some of Verbal communication is important, but a written
this work, and specialists such as statisticians may document must be available. Staff can refer to such
assist in using technology. documentation when other care providers are not
available. Through documentation, outcomes and
evaluation of patient care are made clear.
Stop and Consider #3 The medical record is a legal document, and
Health informatics is now integrated in practice,
as such, rules must be followed when creating and
management, education, and research.
amending it. Once documentation has been created,
changes to it must be accompanied by a note indi-
cating who made the change(s) and when (date and
time), following HCO policy and procedure. Only
Documentation certain staff may document; they must note the date
Over time, clinical documentation has increased in and time on the documentation and include their
terms of its relevance to nurses and to other healthcare name and credentials. If there are questions about
professionals, thus increasing its impact on patient care or a legal action, such as a malpractice suit,
care and patient outcomes. Today it is expected that the medical record is the most important source
documentation should be accurate and accessible of evidence. Consequently, medical records must
to those who need and should have access given be saved. A nurse can say that he or she provided
confidentiality and privacy law requirements, as has certain care, but if it is not documented, then it is
been the case for a long time. Many different staff as if that care did not occur.
document in the medical record. Documentation The following provides a list of the advantages
must describe nursing practice, which should be of using EMRs (U.S. Department of Health and
evidence based. Both nurse managers and nurses Human Services [HHS] & HealthIT.gov, 2015):
involved in direct care are accountable for ensuring ■■ Quick access to patient information from
that documentation meets the expected standards. multiple locations to assist in providing
Nurse educators in academic and HCO settings are coordinated, efficient care
also involved in ensuring effective documentation. ■■ Decision support, clinical alerts, reminders,
Documentation meets many needs, such as clear and medical information
communication for the team and others who need ■■ Performance-improving tools, real-time
the information to provide care and meet legal and quality reporting
ethical, accreditation, documentation, and reim- ■■ Legible, complete documentation that facil-
bursement and budget requirements. We now place itates accurate coding and billing
greater emphasis on documentation as a source for ■■ Interfaces with labs and other sources of
quality improvement and research data. information
■■ Safer, more reliable prescribing ■■ Transcribe orders carefully; double-check

■■ Reduction in errors when multiple caregivers and ask questions if an order is not clear. In
are involved in the care—care coordination computerized systems, orders do not need to
■■ Improvement of care transitions (handoffs) be transcribed; however, this does not mean
between settings that there is no risk of an error. All orders
■■ Up-to-date information for emergency need careful review, and if they are not clear,
care—care coordination they may require follow-up.
The summary of the following guidelines should also ■■ Document omitted care.
be considered in documentation (Iyer & Camp, 1999): ■■ Document medications and outcomes.
■■ Document patient noncompliance/nonad-
■■ Do not include opinion, but only objective
herence and the reason(s) for it.
information in documentation. The nurse
■■ Document allergies, and use this information
does not make subjective comments (for
to prevent errors and complications.
example, comments about the patient being
■■ Document sites of injections and other
uncooperative, lazy, or impolite). Nurses
procedures.
document only what they have done and
■■ Record all required information about intra-
objective data. A nurse does not document
venous therapy and blood administration.
another staff member’s actions. Supervision
■■ Report abnormal laboratory results.
of care, however, can be documented.
■■ Document as soon as possible after care is
■■ Write neatly and legibly. Many HCOs now
delivered. If documentation is done late,
use computerized documentation, although
note this in the record. The nurse should not
not all HCOs have moved to an EMR system.
leave blank areas to come back to for later
If a computerized system is used, typos (ty-
documentation.
pographical errors) may be a problem. Other
■■ When quoting, use quotation marks and
issues may arise in electronic systems that
note the person who made the statement.
use a checklist for a particular section of the
■■ When documentation is corrected because of
EMR but do not allow for narrative notes.
a mistake, follow the HCO policies regarding
Nurses and others may be frustrated when
corrections as per a hard-copy record or
they cannot add a narrative note.
electronic record. Medical records are never
■■ Use of copy and paste feature in an EMR/
rewritten or destroyed by staff.
EHR increases risk of errors, particularly
■■ Document patient status change.
perpetuating an error (Yadav et al., 2016).
■■ When contacting the physician, document
■■ Use correct spelling, grammar, and medical
the time, date, name of physician, reason for
terminology.
the call, content, physician response, and
■■ Use authorized abbreviations. Using unapproved
steps taken after the call. This note should
abbreviations increases the risk of errors.
not include subjective analysis of the response
■■ Use graphic records to record specified pa-
such as the physician’s attitude.
tient data, such as vital signs and medication
administration. The Joint Commission does not provide
■■ Record the patient’s name on every page (for details as to what must be in a medical record
hard-copy medical records); this should be (the term used by The Joint Commission for
part of the EMR. this document is record of care/treatment and
■■ Follow HCO policies and procedures about services), but it does provide some guidelines
verbal and telephone orders. that are required for accreditation as follows
with additional comments (Clark, 2011; Joint

Commission, 2011, 2016): Stop and Consider #4
Documentation is a critical communication method
■■ The minimum content that should be included for the care team.
is the patient’s name, address, date of birth,
name of any legally authorized representative,
assessment, diagnosis, clinician notes and
actions, signatures and countersignatures
Meaningful Use
as required, dates, details of procedures Meaningful use focuses on use of certified EHR
performed, laboratory reports, medications technology for the following purposes (HHS &
administered, and treatment plans. Other HealthIT.gov, 2014):
data may be included.
■■ Improve quality, safety, efficiency, and reduce
■■ The record should be clear and understandable.
health disparities.
■■ The record provides a system of communi-
■■ Engage patients and family.
cation and in doing so is a source of data for
■■ Improve care coordination, and population
quality improvement monitoring.
and public health.
■■ Storage of documents must be secure and
■■ Maintain privacy and security of patient
reasonable. For example, security requirements
health information.
need to identify who has access to records
and prevent casual viewing by non-staff. All The American Recovery and Reinvestment Act of
Medicare storage rules must be followed. 2009 specifies the following three components of
Today, with increased risk of problems with meaningful use (HHS & CMS, 2014):
computer systems or hacking, HCOs need a ■■ Use of certified EHR in a meaningful manner
policies and procedures to assist staff when (for example, e-prescribing)
there may be problems with the EMR and ■■ Use of certified EHR technology for electronic
access. exchange of health information to improve
■■ HIPAA requirements must be followed— quality of health care
ensuring patient privacy and confidentiality. ■■ Use of certified EHR technology to submit
HCOs should have policies and procedures clinical quality measures and other such
that support HIPAA and staff must adhere measures selected by the Secretary of HHS
to them. Meaningful use identifies specific objectives
■■ Use acceptable abbreviations identified by that eligible professionals and hospitals must achieve
the HCO. to qualify for Centers for Medicare and Medicaid
These guidelines apply to hospital medical Services (CMS) reimbursement. Given that most
records. The content is somewhat different for hospitals receive CMS reimbursement, most hospitals
medical records in other types of settings, such as have a strong incentive to follow these requirements.
ambulatory care, long-term care, and home care, Nurses are also required to consider meaningful
although some information and guidelines are the use, particularly if they are in leadership positions
same. It is important for all HCOs to have clear where decisions about HIT are made. Ultimately, it
documentation policies and procedures and ensure is hoped that meaningful use compliance will result
that staff are aware of them and follow them. When in the following benefits:
changes occur, staff must be informed so that the ■■ Better clinical outcomes
new requirements will be met. ■■ Improved population health outcomes
■■ Increased transparency and efficiency of terms with definitions for use in information
■■ Empowered individuals systems, databases. This enables comparisons to
■■ More robust research data on health systems be made because the same term is used to denote
the same condition, and it is necessary for effective
All of the meaningful use purposes are in line
documentation in EMRs/EHRs.
with the Quality Chasm reports on quality and are
It is recognized that we need a common lan-
associated with continuous quality improvement.
guage across health professions supporting the
five core healthcare professions competencies.
Accomplishing this requires that healthcare pro-
Stop and Consider #5 fessionals are willing to actively work together to
Meaningful use relates to nursing practice.
achieve this goal. The HHS has been tasked with
meeting this goal, though it is a difficult goal to
reach—getting different healthcare professionals
Standardized Terminology to accept a universal terminology. This will require
compromises and has yet to be fully accomplished.
Health care has expanded in multiple directions The ANA notes that: “The data element sets and
and includes the services of many different health- terminologies are foundational to standardization
care providers. Ensuring effective communication of nursing documentation and verbal communica-
among these myriad providers is not always easy. tion that will lead to a reduction in errors and an
Certainly, there are issues regarding willingness to increase in the quality and continuity of care. It is
communicate, lack of time to communicate, and through standardization of nurse documentation
so on, but a critical problem is the lack of a com- and communication of a patient’s care that the
mon professional language/terminology. For those many nurses caring for a patient develop a shared
entering healthcare profession, such as nursing understanding of that care” (2006). These statements
students, this is probably a surprising comment. are an example of why developing and accepting
Each healthcare professional area has its own ter- a universal language is difficult but necessary,
minology. There are some common medical terms, but they also illustrate how it is easy to approach
but each profession has specific terminology that is this from silos—focused on individual healthcare
often not known or understood by other healthcare professions. Such statements are nursing focused,
professionals. “Creating a common language is no but all healthcare professions need to address this
small task. Developing and adhering to distinct issue using interprofessional collaboration.
profession-specific terms may be a manifestation of Determining how best to move from a specific
professionals’ desire to preserve identity, status or profession approach to a collaborative approach
control” (IOM, 2003, p. 123). This problem affects to solve this problem is the challenge. The Library
all the core competencies and the ability to develop of Medicine (NLM), serving as the coordinating
educational experiences that meet the competen- body for clinical terminology standards within
cies across healthcare professions, such as nursing, HHS, offers products and services for HCOs and
medicine, pharmacy, and allied health. The issue healthcare professionals that support interoper-
of shared terminology is even more important in ability and the unambiguous exchange of health
HIT because informatics is dependent on language, data (National Institutes of Health [NIH] & U.S.
requiring a shared terminology. We now recognize National Library of Medicine [NLM], 2016a). The
its effect on practice and interprofessional teams. website for NLM provides a current overview of
A standardized terminology is a collection activities focused on standardized terminologies.
diagnosis codes and 3,700 procedure codes

Stop and Consider #6 (U.S. Department of Health and Human
Standardized terminologies are needed, but it will be
difficult to reach consensus among the healthcare
Services, Centers for Disease Control and
professionals. Prevention, & National Institute for Occu-
pational Safety and Health, 2016).
■■ Nursing Intervention Classification and
Systems and Nursing Outcome Classification: The North
American Nursing Diagnosis Association
Terminologies (NANDA) focuses on nursing diagnoses,
Informatics is not as simple as email and the Inter- Nursing Intervention Classification (NIC)
net. Informatics in general and HIT include many on nursing interventions, and Nursing
database systems, terms, and other factors that Outcome Classification (NOC) on nursing
make this a complex area. The following provides outcomes (NANDA, 2017; University of
examples illustrating the complexity of HIT: Iowa, Center for Nursing Classification and
Effectiveness, 2017).
Systematic Collection of Nursing Care Data ■■ Omaha System: The Omaha System is a com-
or Data Element Sets
prehensive, standardized taxonomy designed
■■Nursing Minimum Data Set: This data set
to improve practice, documentation, and
describes patient problems across healthcare
information management. It includes three
settings, different populations, geographic
components: the problem classification scheme,
areas, and time. It provides clinical data
the intervention scheme, and the problem
to assist in identifying nursing diagnoses,
rating scale for outcomes. When the three
nursing interventions, and nursing-sensitive
components are used together, the Omaha
patient outcomes. In addition, the Nursing
System offers a way to link clinical data to
Minimum Data Set is useful in assessing re-
demographic, financial, administrative, and
sources used in the provision of nursing care.
staffing data (Omaha System, 2011). The
The goal is to link data between HCOs and
Omaha System is used in home health care,
providers. Data can also be used for research
community health, and public health services.
and healthcare policy. ■■ PNDS: The PNDS is a standardized nursing
■■Nursing Management Minimum Data Set: This
vocabulary that addresses the perioperative
data set focuses on nursing administrative
patient experience from preadmission until
data elements in all types of settings.
discharge, including nursing diagnoses,
Interface Terminologies interventions, and outcomes. This set was
■■Clinical Care Classification: The clinical developed by a specialty organization, the
classifications software for the International Association of periOperative Registered
classification of diseases, 10th revision, Clinical Nurses (2017) and recognized by the ANA
Modification (ICD-10-CM), is a diagnosis as a data set useful for perioperative nursing
and procedure categorization scheme that practice. This standardized system is now
can be used in many types of projects to called SYNTEGRITY PNDS. It is an IT tool
analyze data on diagnoses and procedures. that can be personalized by HCOs to meet
The software is based on ICD-10-CM, a individual organization needs. The frame-
uniform and standardized coding system. work supports electronic documentation,
ICD-10-CM includes more than 13,600 patient quality and EBP, a common language/
terminology, and a method to collect and technologies. The results indicate that most nurses
compare data. It connects nursing diagnoses, do not have much knowledge of or experience with
care implementation, and assessment to standardized nursing technologies, such as the NIC,
measure outcomes. NOC, and NANDA. They may have used these
Examples of Multiprofessional Terminologies technologies in their nursing education, but not
■■Logical Observation Identifiers Names and in practice after graduation. Given the increasing
Codes: This clinical terminology classification use of informatics in healthcare settings, such a lack
is used for laboratory test orders and results. of knowledge and experience may hamper nurses’
It is a system designated for use in U.S. federal ability to participate actively in HIT development
government systems for the electronic ex- and evaluation and better ensure that nursing
change of clinical health information (NIH & practice is supported.
NLM, 2008). This system can be used to
collect data about assessments and outcomes Stop and Consider #7
for nursing and other healthcare services. Nursing is more involved in approaches to develop
■■Current Procedural Terminology: This code is and improve health information technology.
used for reimbursement (American Medical
Association, 2016).
■■Systematized Nomenclature of Medicine— Informatics: Types
Clinical Terms: This comprehensive clinical and Methods
terminology is one of several standards
approved for use in U.S. federal government For informatics to be effective, three concerns must
systems for the electronic exchange of clinical be addressed. First, the HCO must have effective
health information (NIH & NLM, 2016b). and easily accessible HIT support services. Staff
The system is applicable to nursing and other must be able to pick up the telephone and get this
healthcare services and focuses on diagnoses, support. Failure of the information system has major
interventions, and outcomes. implications for patient care and increases staff stress,
so backup systems are critical. The second critical
With the increased use of technology for docu-
concern is staff training. This requires resources:
mentation, nursing has been more concerned about
financial resources, trainers, and time. Time is
two issues (Schwiran & Thede, 2011):
needed for staff to attend training, and there must be
■■ How to differentiate nursing’s contributions recognition that it takes time for staff to learn how
to patient care from those of medicine to use a system—and during this time, there is an
■■ How to incorporate descriptions of nursing impact on care and work processes. Incorporation
care into the health record in a manner that of informatics with any of the methods described
is commensurate with its importance to next (and others that are not included here) requires
patients’ welfare a major change in care delivery. Change is stressful
This requires systems that can meet these needs; for staff, and it needs to be planned, representing
therefore, nurses need to engage in HIT so that the third concern. Trying to implement too many
nursing can be better represented in decisions changes at one time may increase staff stress, affect
about EMRs. the success of using more informatics in the future,
In a study conducted by Schwiran and Thede decrease staff motivation to participate, and increase
(2011), the researchers examined nurses’ knowl- the risk of errors that might affect patient outcomes.
edge of and experience with standardized nursing Change is discussed in several chapters in this text.
It is not difficult to find nurses who will com- to us and to our patients, but also to others who
plain about a hospital’s attempt to increase the use may not have the same goals. We must be careful
of informatics, particularly if it has been badly and use appropriate passwords and procedures to
planned. Often, in these complaints, staff members protect data. We see an increasing use of emails as
note that the system selected was not effective and a method to communicate with patients—sharing
they had no part in the decision and implementation important personal information. Is this wise? Pa-
process. Equipment and software is very costly, tients are often asked and encouraged to provide
and decisions regarding them are critical—getting their email—but it is their choice to make, and in
an ineffective system or bad fit for what is needed all cases, it should be their decision. We need to
only increases costs and management and staff take care with what we put in emails or what we
stress. Time must be taken to evaluate equipment ask patients to send in an email, for example, social
and software to make sure they meet the needs security numbers should never be sent in an email.
and demands of the organization and users such When we keep data for healthcare, we have ethical
as nurses. Examples of current activities in this and legal responsibilities to ensure the information
area are automated dispensing of medications and is accurate and safe.
bar coding; computerized monitoring of adverse
events; the use of EMRs/EHRs, provider order-entry Automated Dispensing of
systems, clinical decision support systems, use of
Medications and Bar Coding
devices such as tablets and smartphones, computer-
based and reminder systems; access to patient Pharmacies in all types of HCOs are using or mov-
records at the point of care; prescribing via the ing toward expanding use of automatic medication
Internet; using nurse call systems, voice mail, and dispensing systems with bar coding. These systems
the telephone for advice and other services; use of select the medication based on the order and prepare
Internet or virtual appointments; and online support it in single doses for the patient. The bar code is on
groups for patients and families. These methods are the packaged dose. This code can then be compared
discussed in this section. with the bar code on the patient’s identification
It is important to note that there is now a band using a handheld device. This type of system
serious risk with the use of electronic methods for can decrease errors, and it supports all five rights
documentation and communication today. Hack- of medication administration, as discussed in other
ing has become more common with IT in general, content in this text. Bar coding can also be used
and there have been incidents of hacking health to collect data about prescribed and administered
records. Why would this be done? One reason is drugs. Data then may be used for monitoring quality
health records often include personal identification improvement and for research. Bar coding systems
information that might be used for illegal purposes, are expensive to install and maintain, but they can
such as to obtain addresses, telephone, email ad- make a difference in reducing errors and can reduce
dresses, credit card information, and social security time required for all medication administration steps.
numbers (McCain, 2014; Pagliery, 2014; Peterson,
2015). Another experience that some HCOs have Computerized Monitoring
had is hacking data or control of data and then the
of Adverse Events
hacker(s) demand a ransom for the HCO to regain
access to the system (Conn, 2014). This can happen Computerized systems that monitor adverse events
to small or large HCOs. All of this emphasizes that assist in identifying and monitoring adverse events.
the data we have are important—valuable—not only Developing and using a database of these events
facilitates analysis of data and the development of ■■ Race

interventions to decrease adverse events. A major ■■ Ethnicity
problem with data collection, such as for adverse ■■ Preferred language
events, is not using structured collection—overdoing ■■ Smoking status
collection and ending up with data that are not ■■ Problems
needed or not in a format that could be used. Care- ■■ Medications
ful planning is required to identify information or ■■ Medication allergies
data needed and how it will be accessed and used ■■ Vital signs
to prevent this from occurring. ■■ Care plan field(s), including goals and
instructions
Electronic Medical/Health ■■ Procedures
Records ■■ Care team members
■■ Immunizations
EMRs/EHRs are slowly replacing the written medical ■■ Unique device identifier(s) for the patient’s
record for an individual patient while the patient implantable device(s)
receives care within a specific healthcare system. A ■■ Notes/narrative
second type of electronic documentation system Care plans are included. It should be easy to
is the personal health record (PHR). The PHR input, search, and review information, and it should
is less common than the EMR, but the goal is for be possible to print reports. Electronic data can
it to become standard in the future. The PHR is a be stored over the long term, which is harder to
computer-based health record for which data are do with written records. Written records require
collected over the long term—for a lifetime. With significant storage space, and they may not be easy
the patient’s permission, the healthcare provider to find once archived. In addition, written records
can access this record easily to obtain information. can be less readable over time. The hard-copy record
To reach this point, there must be agreement on a is not always easy to access when it is needed in a
minimum data set—uniform definitions of data hospital unit. If one person is using the record, others
(that is, standardized language/terminology) that cannot use it. With the EMR, this is not a problem
would enable all healthcare providers to understand as long as staff can access the computerized record
and use the information. There is still much to be system. EMR systems do require security and backup
done to make this a reality in every HCO, including systems to ensure that data are not lost in the event
clinics and medical offices, but the technology is of a power outage, natural disaster, or other event
already available. that may make access difficult.
The EMR/EHR is a record of the patient’s Electronic documentation has many advantages
history and assessment, orders, laboratory results, such as timeliness of care. Staff can document as care
description of medical tests and procedures, and is provided or soon after, providing a system for all
documentation of care provided and outcomes. members of the team to view the care process when
Current requirements for electronic records referred needed. Documentation may take place at the unit
to as the Common Clinical Data Set guides EMR workstation, at a hallway computer station, at the
content. The following are the minimum require- bedside in the hospital, or in an examining room
ments identified by the HHS (HHS & ONC, 2015a): in a clinic. Bedside systems are better because they
■■ Patient name are easy to access when the nurse or other healthcare
■■ Sex professional needs information, and point-of-care
■■ Date of birth documentation is enhanced. This all improves
documentation and communication. Other ad- physician/provider orders into a form in which the
vantages are legibility; greater access to records for orders can be used. During this process, the risk
multiple users; increase in efficiency and effective- of transcription errors increases. Typing orders
ness in the work environment; less opportunity to into a computer can also lead to typos, but this
change records inappropriately; inclusion of safety is less of a problem than errors with handwrit-
elements, such as alerts for allergies or incompatible ten orders. A systematic review of 34 studies on
drug orders, and reminders to do certain tasks or CPOES used identified key areas of the EMR and
add certain information to the record; ability to its CPOES that may be associated with CPOES
print records when need; and more accurate and errors: computer screen display, drop-down menus
accessible data for reimbursement, budget, and and auto-population, wording, default settings,
quality improvement. nonintuitive or inflexible ordering, repeat pre-
It is important to recognize that when HCOs scriptions and automated processes, users’ work
change to electronic documentation or make changes processes, and clinical decision support systems
in a current electronic system, this is a time of (Brown et al., 2016). The studies reviewed iden-
great disruption in clinical practice and workflow tified examples of how an EMR and its CPOES
processes, typically with negative staff responses to might have weaknesses in these areas—such as
the change process and/or the change itself (Ford, incomplete medication lists that led to prescrip-
Silvera, Kazley, Diana, & Huerta, 2016). A study tion error, misinterpretation of text, and lack of
conducted by Barnett, Mehrotra, Jena, and New- flexibility in the CPOES so the staff member uses
house (2016) also refer to the disruption in work a workaround—increasing the risk of an error.
processes during transition to electronic records, Drop-down menus need to include safeguards to
particularly noting the negative impact on patient prevent selection errors. Another study examined
outcomes. In this study of 17 hospitals transitioning alerts of automated identification of antibiotic
to electronic methods, the hospitals demonstrated overdoses and adverse drug events via a CPOES
more problems with adverse patient outcomes than (Kirkendall et al., 2016). This study highlights alert
hospitals that were not transitioning to electronic fatigue, which is discussed in this text. If providers
records. All of this affects the culture of safety. HCOs get a number of alerts, there is increased chance
and their providers must have time to adjust to the they will override the alert because of too many
change and to recognize the benefits and, during alerts—viewing them as irritants to getting work
change, be alert to prevent errors. done. Alert systems need to be carefully reviewed
and revised to reduce alerts that are not critical.
Clinical Provider Clinical decision support systems can be in-
cluded with the CPOES. The Brown and colleagues
Order-Entry System
systematic review concludes that development of
A clinical provider order-entry system (CPOES) better clinical decision support systems may reduce
may be included in an EMR, although it may also errors and improve workflow (2016). Combining the
be a stand-alone system. The healthcare provider CPOES with the decision support system enhances
inputs orders into this system rather than using a the provider order-entry system and can lead to
hard-copy record. This is an expensive system to improved care and a decrease in errors as noted in
implement. One clear advantage of the CPOES is the Brown study.
legibility; written orders are often very difficult CPOES is not only a clinical tool to assist in
to read because handwriting varies, and this may providing effective care, but it also offers a source of
cause errors. It also takes time to transcribe written information about quality improvement—data that
may be used by the QI program. Analysis of medi- system will catch all potential errors, which is not
cation order voiding provides critical information always the case.
for why providers who write the orders void them More research is needed to fully understand
or why the system voids them (Kannampallil et. al., the impact of clinical decision support systems on
2017). Kannampallil and colleagues examined 6 years patient outcomes. Romano and Stafford’s (2011)
of CPOES data, looking at void and not void orders study indicated that there was no consistent associ-
and reasons for the voiding. In the sample, 0.49% ation between such systems and the quality of care
of the all orders were voided, with most voiding in an investigation that included 3 billion patient
due to medication ordering errors. The use of a visits. Only one of 20 indicators—diet counseling
voiding provides the HCO with an easy method for high-risk adults—demonstrated significantly
for self-reporting of near-miss medication ordering better performance when clinical decision support
errors, and the data should be used to assess the systems were utilized. In contrast, earlier studies
current status within the HCO and develop strategies had shown that use of the clinical decision support
to reduce need for voiding orders. systems improved outcomes. A critique of the 2011
study questions whether the results were influenced
Clinical Decision Support by the following factors: (1) Clinical decision sup-
port system rules may have been different in the
Systems
systems studied; (2) the study focused on medi-
Clinical decision support systems have led to major cation management, whereas earlier studies were
changes in healthcare delivery. These systems provide broader; and (3) the study looked at the outcome
immediate information that can influence clinical of a single visit rather than the cumulative effect.
decisions. Some of the systems actually intervene More research is needed to understand use of this
when an error is about to be made. For example, method and better determine the effectiveness of
when an order for a medication is put in a patient’s using clinical decision support systems, which is a
EMR, the computerized system might indicate the complex research area.
patient is allergic to that medication by immediately
sending an alert, stopping the order. The nurse can
Tablets and Smartphones
also get alerts for a variety of potential problems such
as the patient at risk for falls or decubiti. Tablet computers are very popular with the general
In the past, nurses depended on textbooks or public and also in the workplace. Most mobile
journals that the unit or hospital library might have telephones now have Internet capability, such as
available to find information, and such searches were access to the Internet and storage of information.
often not done effectively. Easy electronic access to These phones give users quick access to informa-
current information eliminates many problems related tion, Internet, email, and text messaging, and of
to obtaining information when needed. This, too, course, telephone service. Such handheld devices
can improve the quality of care. EBP relies heavily can hold a significant amount of information, serve
on access to EBP literature, which is most easily as a calendar, keep contact information, monitor
accessible via the Internet and databases. As is true tasks, and so on, and are an effective method for
for all electronic methods, healthcare professional transmission of information.
critical thinking, as well as clinical reasoning and Nurses who use tablets and/or smartphones
judgment, must still be applied. Errors can still be carry information with them and can look up side
made with technology. When HIT is used, staff may effects of a medication or any other type of medical
go on “automatic pilot,” assuming the electronic information necessary as they provide care. In some
cases, the nurse can access EMRs to get to patient defined, only the patient should have access to the
information through the tablet. Some textbooks can information unless the patient wants the information
now be uploaded into tablets, such as pharmacology shared. An example of concern about privacy is
and clinical laboratory resources. This is useful using a patient’s work email or work mobile phone.
information for the nurse to have available—it is Employers have the right to view employee emails
accessible in seconds at the point of care. Nurses and phones, and thus private health information
working outside a structured setting, such as in public/ may be shared if the employer does view employee
community health or in home care, may also find information and devices.
this type of system useful for support information
and documentation needs (patient information,
visit data, and so on); however, they must be very
Access to Patient Records
careful to maintain HIPAA regulations. Tablets at the Point of Care
are used in public/community health to collect Many hospitals are moving toward providing access
data such as health assessments; data are stored to the patient records either in the patient’s room
locally on the tablet and then uploaded to a secure or in the hallway via computers. In the future,
cloud server (that is, a server that is encrypted to more nurses will carry small laptops or tablets that
protect personal health information) when the user allow access to the EMR when needed for work
is back in network/wireless range. Any time such requirements. This reduces time spent returning to
technology is used, the data must be protected to the workstation to get information and allows for
keep information secure and confidential. It is not more timely documentation—it can be completed
only the concern about security of information, but as soon as care is provided. This reduces errors and
also the devices, which can be lost and should be improves quality because all care providers know
used with security codes. HCOs should have clear when care has been provided in a timely manner.
policies and procedures for actions staff should Point-of-care access decreases the chance that de-
take if a device is lost or a person(s) who should tails may be forgotten, documented incorrectly, or
not have access to the information gains access to not documented at all. In addition, it saves nurses
the device. If the healthcare provider is using these time and eliminates the need to delay documen-
devices for oral communication in any location, he tation. For example, if they do not have this type
or she must be careful to ensure privacy. of immediate access, nurses may document at
certain times during the shift such as midmorning
or near the end of a shift, requiring them to find a
Computer-Based Reminder
block of time to complete documentation without
Systems interruptions. This is an approach that can lead to
Computer-based reminder systems are used to com- errors, incomplete data in the record if the nurse
municate with patients via email or text messages forgets information, and situations in which other
to remind them of appointments and screenings providers need current patient information that has
and to discuss other health issues. In the future, not yet been documented.
these methods will most likely take the place of
telephone calls to remind patients of appointments. Internet Prescriptions
Any reminder system must also maintain HIPAA
regulations. For example, the healthcare provider There has been rapid growth in consumer access
must ensure that only authorized parties have access to prescribed medications via the Internet. The
to the computer and email data. More narrowly medications are then mailed to the patient. The
consumer must be careful and check the legitimacy insurers develop standard protocols or clinical
of the source to prevent errors. pathways that the nurses use to respond to common
questions, but nurses must still use professional
Nurse Call Systems judgment when providing advice. This type of service
should not become “cookbook” care in which there
Nurse call systems are a form of informatics that is is no consideration of assessment and individual
very important in communication within a health- patient needs. Assessment is the key to successful
care system. They allow for improved and efficient telephone nursing because it enables providers to
communication and are a great improvement on the identify the caller’s problems and interventions
old method of yelling out for a staff member or a required that may or may not be found in the
unit speaker system calling for staff. Many types of guidelines. Some physician offices have telephone
nurse call systems exist, such as pagers, light signals, advice services that are manned by a physician in
buzzers, methods that allow patients to talk directly the practice or by a nurse. Pediatric practices are the
to nurses through an easily accessible direct audio most common type of practice using this system.
system, smartphones, miniature label microphones, Patient advice systems via telephone require clear
and locator badges. The goal is to get a message to the documentation policies and guidelines that include
right person as soon as possible while maintaining content related to who called, when, and for what
privacy and confidentiality. Doing so can improve reason; the required assessment data; problem(s);
care, improve patient satisfaction, reduce errors, and recommended interventions—as well as any
and make staff more efficient, thus preventing the follow-up taken, such as a return call by the service
unnecessary work of trying to obtain and share to check on the patient. Telephone advice systems are
information. typically used to answer questions, remind patients
of appointments or follow-up needs, and check in
Voice Mail and Texting on how a patient is doing.
Many hospitals now use the telephone to begin
Computer-based messaging systems are found in
the admission process for patients with scheduled
all healthcare settings today so that staff and others
admissions, procedures, and testing. Patients are
can leave and receive voice and text messages; for
called before the scheduled date, asked questions
example, staff and patients can use these systems,
related to required information, and told what to
often reducing the need for callbacks. Complicated
expect and any required preparation. Pretesting
systems may annoy consumers, however, and there is
may also be scheduled prior to hospital admission.
an impersonal quality to this form of communication,
This saves the hospital time, is more cost-effective,
though it is part of everyday life today. One has to
and may be more convenient for the patient. This
be very careful about leaving voice mails and even
method can also identify problems that may affect
text messages. Clearly, others may listen to or view
patient care so that they can be addressed early on.
messages, and this may lead to a HIPAA violation.
Telephone for Advice Internet or Virtual

and Other Services Appointments
Mostly, insurers use patient advice systems, although The Internet may be used as a means for increasing
some HCOs and providers provide these services accessibility to physicians, advanced practice reg-
as well. In such systems, staff determine the caller’s istered nurses, or other healthcare professionals or
problem or questions and provide advice. Typically, making appointments. The Internet is used today
to obtain advice from health professionals. Portable including health and medical information. When the
family histories can be maintained in this fashion and Internet is used as a source of health information, it
passed on to a new primary care provider. Patients is important to evaluate the websites because they are
and families who have limited resources—financial, not all of the same quality. A nurse needs to consider
transportation, or insurance—can more easily receive the following factors when evaluating a website:
medical advice in this format if they have Internet ■■ The source or sponsor of the website: The
access. It also keeps some patients from missing government, academic institutions, health-
work or taking a child or other family member to an care professional organizations, and HCOs
appointment. Some virtual methods allow the patient sponsor the most reliable websites.
and the healthcare provider to see each other, which ■■ Current status of the information: When was
may provide more effective communication between it posted or revised?
the patient and provider. Many of these sites link to ■■ Accessibility of the information on the site:
cellular devices to send an alert of high importance Can one find what one needs?
to whoever is on call for virtual hours. These types of ■■ References provided for content when appro-
services have increased, providing quick connection priate: Sources should be cited, and data
with health professionals to get answers to questions, should be current.
provide patient monitoring data, and/or make deci-
As is true with all methods such as the ones dis-
sions about next steps such as an appointment or to
cussed in this section, patient confidentiality must
go in for emergency services. Mental health services
be maintained. Notably, the risk of confidentiality
may also be provided in this format.
problems increases with use of technology. There
are many ways that privacy can be violated, such
Online Support Groups as viewing data, overhearing conversations, and
for Patients and Families obtaining actual documents. It is the responsibility of
healthcare providers, HCOs, insurers, and consumers
Online support groups can focus on any problem (patients, families) to consider privacy a critical issue
or disease. Patients and their families may use whenever technology is used and to ensure as much
chat rooms, email, and websites for information as possible that information is safe—available only
sharing. Consumers gain information, education to those who need the information and for whom
about their health and health needs, and support the patient wants the information shared.
from others with similar problems. A healthcare
provider may or may not be involved. Privacy
issues must be discussed with participants, along Stop and Consider #8
During a single shift, a nurse will interact and use
with the risk of lack of privacy. Blogging has also
multiple types and methods of informatics.
become very popular and can be done by anyone
with some basic technology information. This can
make information from consumers more available
to other consumers; however, as is true with any The Future of Health
information available on the Internet, the accuracy Informatics and Medical
of that information is important. Blogging can lend Technology
support and let consumers know they are not alone
with their problems. The future will continue to bring about expansion in
Many of these methods use the Internet. It can the use of technology, informatics, and medical devices.
be an excellent source for all types of information, This expansion is already in process. C utting-edge
computer and remote monitoring systems may
depend on the user’s activity so that the technology
becomes transparent. Sensors and devices can gather
data during the patient’s daily routine, providing
healthcare providers or researchers with periodic
or continuous data on the person’s health while he
or she is at work, at school, exercising, or sleeping,
rather than the current snapshot captured during a
Two-way interactive video is the most effective surgical procedures. Hand-assist devices help patients
telehealth method. Telenursing refers to the use regain strength after a stroke (Science Daily, 2016).
of telecommunications technology used to provide Robots may provide a remote presence to allow
nursing care. This may be done with audio and/or physicians to virtually examine patients by manip-
visual—it is a virtual method of care. ulating remote cameras (Thomas, 2015). They are
Issues that arise with telehealth include the cost also used for microscopic, minimally invasive sur-
of equipment and its use; training for staff and for gical procedures. For example, the da Vinci surgical
patients if they need to actively use the equipment; system helps surgeons perform such procedures as
limited or no insurance coverage for telehealth mitral valve repairs, hysterectomies, and prostate
services; the need for clear policies, procedures, surgeries (Intuitive Surgical, 2017). This type of
and protocols; privacy and confidentiality of infor- surgery has increased, decreasing some of the past
mation; and regulatory issues (for example, a nurse surgical risks, decreasing the need for long hospital
who is located and licensed in one state providing stays, and supporting more rapid overall recovery. In
telenursing for a patient in another state where the the future, robots may also be used in direct patient
nurse is not licensed). care—for instance, to help lift obese patients.
A systematic review of 58 studies on telehealth
concluded that “the most consistent benefit has been
reported when telehealth is used for communication Genetics and Genomics
and counseling or remote monitoring in chronic The use of genomics has expanded as knowledge
conditions such as cardiovascular and respiratory about genetics has become more accessible, as dis-
disease, with improvements in outcomes such as cussed in other content in this text. Healthy People
mortality, quality of life, and reductions in hospital 2020 added a goal related to this expanding area:
admissions as well as for psychotherapy as part of “improve health and prevent harm through valid and
behavioral health” (U.S. Department of Health and useful genomic tools in clinical and public health
Human Services & Agency for Healthcare Quality practices (Healthy People 2020, 2016). Genetic data,
and Research, 2016, pp. vi–vii). The report discusses especially once data are integrated into EMR/EHR/
the need for research about expanding implemen- PHR, are expected to advance customized patient
tation of telehealth and elimination of barriers to care and medications targeted to individual responses
use areas such as consultation in maternal and child to medications—precision medicine is recognized
health, use for triage in urgent care, and new delivery as a critical aspect of future health care. This is
models. Future applications will arise, and nurses leading to more precise customization of treatment
need to consider how this might be used more in and medication based on the patient’s unique DNA
nursing practice. Telehealth also has implications profile and how the patient responded to medica-
for international health care because it provides a tions and other interventions in the past. This will
method for connecting expertise to patients who dramatically change how patients are managed for
may need care that is not accessible in their home specific diseases and conditions and will extend
country—for example, during disasters. into the prevention of some diseases. The inherent
complexity of customized patient care will demand
computerized clinical decision support that reflects
Robotics
individual needs and health history. Predictive
Robots have been used for many years to deliver sup- disease models based on patients’ DNA profiles
plies to patient care areas, and its use has expanded. are emerging as clinicians better understand DNA
Robotics enables remote surgeries and virtual reality mapping. These advances have implications for a
new model of care and for informatics and nursing

care. Nurses’ participation in the development of Stop and Consider #9
The nursing profession needs to be up-to-date with
genomic HIT solutions is important. Nurses are changes in technology because many will affect
beginning to collaborate more with bioengineers nursing practice.
and informatics experts to develop new products,
participate in research using these products, and
help to develop implementation and evaluation
plans to use with these products. More than ever, HIPAA: Ensuring
patients will need to be partners in this development
Confidentiality
as part of patient-centered care.
The HIPAA has had a major impact on healthcare
delivery systems and healthcare communication.
Medical Devices
Privacy and confidentiality have long been problem-
Development of medical devices has improved atic issues in health care. Because HIPAA focuses
medical care. Some of these devices assist with on the issue of information and confidentiality, it
diagnosis and others with treatment, rehabilitation, applies to HIT. The law also requires data security and
and ongoing health maintenance. Nurses use medical electronic transaction standards. With the growth of
equipment everyday, some of which is associated information sharing, it became increasingly evident
with informatics. The HCO is responsible for en- that existing means of transactions and systems
suring that the equipment functions effectively and were not ensuring privacy and confidentiality—key
responding when questions are asked about its use elements that had long been part of the healthcare
or repair is required. Nurses also have responsibili- delivery system.
ties for reporting problems to appropriate persons Privacy is the right of a person to have personal
in the organization. As use of medical devices has information kept private. As discussed in this text,
expanded, so has adverse events associated with this relates to professional ethics and also has legal
devices. One concern is incident reporting is not implications. Privacy restrictions even apply to all
yet clear on reporting of medical device concerns, family members, unless the adult patient specifically
resulting in underreporting of these incidents communicates that it is acceptable for family members
(Polisena, Gagliardi, Urbach, Clifford, & Fiander, to be given information. This cannot be assumed.
2015). The U.S. Food and Drug Administration HIPAA requires that only necessary information be
(FDA) Med-Watch adverse event reporting program shared among providers, including insurers. Patients
focuses on reporting medical device concerns, noting may also access their medical records.
examples of medical devices that should be reported Health information cannot be openly shared
when adverse events occur. The following is a list of by healthcare providers—for example, discussing
examples (Simone, Brumbaugh, & Ricketts, 2014; patient information in public places, calling a pa-
U.S. Department of Health and Human Services & tient’s work or home and leaving a message that
Food and Drug Administration, 2017): electric beds reveals information about health or health services,
such as electric shock or patient entrapment, patient and so on—must not be done. Carrying documents
lifts resulting in falls, peritoneal dialysis machines outside an HCO with patient identifier informa-
(for example, increased intraperitoneal pressure), tion is prohibited; this constraint has implications
foley catheters (for example, infections, breakage), for students who may take notes or have written
and so on. The FDA provides updated information assignments that include this information. How
on medical device problems on its website. information is carried such as in tablets, laptops,
or smartphones is also of concern. For example, this technology when possible, and they must be
taking pictures on smartphones in clinical settings involved in the implementation of the technology.
is a privacy violation. Many institutions have But there are concerns. When we “talk” through
implemented strict policies about taking patient machines, do we lose information and the personal
photos, even if they are de-identified. As a nurse, relationship? How can this be prevented so that we
you should make sure you know your employer’s are not disconnected from our patients? How can we
policies on smartphone and email use in a clinical ensure that the information we are getting is correct
setting and follow them. and complete? Are people able to communicate
Development of new technology has been mov- fully through some of these other means? It is clear
ing so fast that critical prior issues have not always that over time, the public has become increasingly
been addressed effectively. The 1996 law, however, comfortable with informatics, which they are using
requires that staff know the key elements of HIPAA more and more in their everyday lives, but when
and apply them. As a result, HCOs and healthcare it comes to their health care, they may want more
profession schools, such as nursing programs, personal communication. As nursing increasingly
are required to provide information and training adopts informatics, nurses need to keep in mind
about HIPAA. Patients are informed about HIPAA the potential for isolation and the continuing need
when they enter the health system; they are given for effective patient communication throughout the
written information and asked to sign documents care process. Nurses, also, must not forget the need
to indicate that they have been informed. Ensuring for touch and face-to-face communication. When
that the requirements are met must be incorporated a nurse uses a computer or some type of handheld
into HIT. It is easy for patients and staff to report device while asking the patient questions and does
HIPAA violations to HHS via its website. Violations not look at the patient, this does not engage the
are examined, and the provider may have to pay a patient in the process.
fee for not following HIPAA regulations. The future will include many more new uses
of technology; change is ongoing. For example, the
e-intensive care unit (eICU) is used to monitor pa-
Stop and Consider #10 tients from afar to improve patient outcomes (Rouse,
There is high risk of problems with privacy and con- 2017). In this example, a system is attached to four
fidentiality when using HIT.
hospitals in Iowa and their ICUs. This system allows
intensivists at a remote monitoring center to view
patients’ vital statistics, electrocardiograms, venti-
lators, and X-ray and lab results. The eICU includes
High-Touch Care versus two-way conference video capability so that patients
High-Tech Care and staff can interact when required. This type of
system has advantages; for example, experts can be
High-touch care is why most people become nurses, located in one place and then consult with multiple
but nursing is much more than this today. This locations and staff that may not have the required
chapter describes the growing influence of technol- experts. This is particularly useful in providing ex-
ogy on all segments of health care. This influence pert medical care for residents in rural and remote
will not decrease, but rather increase in the future. areas. There is no reason that this type of system is
Nurses need to understand and know how to use limited to physician consultation because nurses
technology that is applied to their practice areas. use it, too. For example, a nurse clinical specialist
They need to be involved in the development of might view patient data and consult on patient care
with nurses in an ICU in an external location from 2010 led to further changes in healthcare delivery
where the nurse specialist is located. There is potential and more dependence on informatics, and nurse
for increased access to information and expertise. informaticists should be part of the structure that
The other side of this innovation coin is the effect develops and implements greater use of informatics
on the touch side of care when the provider is not (HIMSS, 2011).
actually in the room with the patient. It is not clear The report titled Health IT and patient safety:
how this might affect care because these types of Building safer systems for better care (IOM, 2012)
systems are very new. makes a strong statement that HIT is not some-
thing separated from care delivery or the providers
of care. “We are at a unique time in health care.
Stop and Consider #11 Technology—which has the potential to improve
A computer can stand in the way of relating to patients.
quality and safety of care as well as reduce costs—
is rapidly evolving, changing the way we deliver
health care. At the same time, health care reform is
reshaping the health care landscape” (IOM, 2012,
Nursing Leadership p. ix). This report highlights patient and family
in Health Informatics concerns about safety and shared responsibility.
These same themes have also been emphasized
We are currently at a critical junction for nurses throughout this text.
and the informatics competency, with all nurses
called upon to assume more leadership in the
expansion of informatics in health care. This call Stop and Consider #12
With the expansion of health informatics in all sectors
to action corresponds to the recommendations in
of health care nurses need to be leaders by partic-
The future of nursing report (IOM, 2010). Ongo- ipating in this expansion and providing feedback.
ing implementation of the Affordable Care Act of
CHAPTER HIGHLIGHTS
1. The fifth healthcare profession core com- 4. Health informatics is used to evaluate
petency is to utilize informatics. the performance of HCOs and individual
2. The federal government published two re- healthcare providers and has a major im-
ports on HIT, indicating increasing interest pact on quality improvement. Today, it is
in this topic; the reports include a federal much easier to collect, store, and analyze
strategic HIT plan. large amounts of data than were collected
3. Health informatics is more than just looking by hand in the past.
at IT; it also involves understanding how 5. Insurers rely heavily on informatics to
that technology is used in providing care, provide insurance coverage, manage data,
preventing errors and improving care, and analyze performance, which has a
research, and more.
(Continues)
direct impact on whether care is covered 14. Interface terminologies include, but are not
for reimbursement. limited to, the Clinical Care Classification,
6. Informatics provides opportunities for the International Classification of Nursing
government at all levels—local, state, na- Practice, NANDA, NIC, NOC, the Omaha
tional, and international—to collect data System, and the SYNTEGRITY PNDS.
and use them for policy decision making 15. Multidisciplinary terminologies include,
and evaluation. but are not limited to, the Logical Ob-
7. A clinical information system is a method servation Identifiers Names and Codes
of data storage that is generally used at the and the Systematized Nomenclature of
point of care. It includes such elements as M
edicine—Clinical Terms.
clinical guidelines, patient information, and 16. Examples of use of informatics in healthcare
pharmacopeias to check for drug interactions. delivery include the automated dispensing
8. Computer literacy requires knowledge of of medications and bar coding for identifi-
basic computer technology. cation; computerized monitoring of adverse
9. Standardized language is a collection of terms events; use of EMRs, provider order-entry
with definitions for use in informational systems, and clinical decision support sys-
systems databases. Standardized language tems; use of tablets and smartphones; access
is necessary for documentation in EHRs. to patient records at the point of care; and
10. NI is a nursing specialty that integrates Internet prescriptions, nurse call systems,
nursing science, computer science, and voice mail, telephone for advice and other
information science to manage and com- services, online support groups for patients,
municate data, information, knowledge, and Internet or virtual appointments.
and wisdom in nursing practice. This 17. HIPAA requires that patient data are kept
specialty has its own sets of standards, secure and private.
scope of practice, and national certification. 18. Current and future uses of HIT and tech-
11. Informatics can directly affect care by nology include such methods as telehealth,
providing data in a retrievable form for the robotics, genomics, and others.
purpose of assisting with clinical decision 19. Technology may have an impact on the
making. However, the data are only as patient–provider relationship—leading
reliable as the information entered in the to a conflict between high-tech and high
computer. touch-care.
12. In today’s HCOs, documentation is often 20. As health informatics expands, nursing
implemented in an electronic format. must be proactive in increasing its role in
13. Standardized terminology assists in pro- informatics and assume more leadership
moting clearer communication across to improve health care through better
disciplines. informatics.
1. Explain how the core competency “utilize 5. Why is documentation important?
informatics” relates to the other four core 6. Explain how the EMR and PHR can increase
competencies. quality of care and decrease errors. Provide
2. What is informatics? Why is it important in examples.
health care and nursing? 7. Discuss issues related to confidentiality and
3. Describe the certification requirements for informatics.
the role of the informatics nurse.
4. Describe four examples of healthcare infor-
matics and implications for nursing.
1. Divide into teams. Identify an HCO (hospital 3. Speak to a registered nurse who works in
or other type) in your local community and staff development/education in an HCO.
try to find out how it uses informatics and Discuss the training that staff members
applies meaningful use. You can focus on receive for using informatics (for example,
the entire organization or select a depart- type of content, cost and time commitment,
ment or a unit. Are there any future plans challenges). Share this information with
to increase the use of informatics? Teams classmates.
should then compare and contrast their 4. If you have used an EMR in clinical practice,
information. what was it like for you? Did you get sufficient
2. In a team, develop six questions to ask a orientation? If not, what was missing? If you
nurse who works in a hospital that uses have not yet done this, interview a senior
an EMR. Each student on the team then student and ask about the experience.
interviews one registered nurse. After the 5. Which biomedical equipment have you
interviews, combine your data and analyze used or seen used? How does the use of this
the results. equipment impact care?

What is your opinion of the potential conflict between high-touch care and high-tech
care? Describe some examples where you thought technology interfered with patient
care, either for you or for something you observed. What could have been done to prevent this?
CASE STUDIES
Case 1
A 6-year-old has come to the attention of the child welfare department as a possible
victim of sexual abuse. The child’s school nurse reported the situation as required by law.
The child lives in a very rural part of a western state. Rather than have the child travel a
distance to experts, she was taken to the nearest clinic with sexual assault nurse examiners
and a knowledgeable pediatrician skilled in sexual abuse examinations. At the time of
the examination, pictures were taken of the child’s body, including the genital area. These
pictures were crucial if charges were to be filed. To ensure that an accurate diagnosis
was made, local experts sought a second opinion because the results of the physical
examination were not believed to be completely definitive. The experts for the second
opinion were linked via the Internet and Internet videoconferencing equipment so that the
two teams could talk and view de-identified (because the information was going across
unsecure Internet channels) photos. Within 15 minutes, it was determined that the hymen
was intact and no penetration had occurred. Other markers indicated that there was
evidence of child abuse, but none that supported a claim of sexual assault. This case used
an EMR, digitized photos, school records, and Internet consultation to arrive at a diagnosis
that had both medical and legal implications.
Case Questions
1. Discuss the impact of the use of these methods in the case on the nurse–patient rela-
tionship and on patient confidentiality, including HIPAA requirements.
2. How else might this technology be used?
3. What is your opinion of the human, caring part of the care process in relation to this
case description?
Case 2
The hospital where you work is assessing its EMR system, which has been in use for 1 year.
You volunteered to be on the task force that is leading the review. The team meets to
discuss critical issues that need to be addressed. Some of the issues are staff acceptance
of the new system, errors, and information that is not easy to access in the EMR. The
representative from the hospital finance team asks, “What about meaningful use?”
Case Questions
1. What is meaningful use?
2. Why is the team member’s question important?
3. How might meaningful use affect what the task force does?

questions.
1. What should we tell them about our documentation concerns?
2. Why are we discussing quality improvement when we are talking about documentation?
3. The timeline—why do we need to consider it?
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Drug Administration. (2017). Medical device reporting. .healthit.gov/sites/default/files/briefs/2015_hospital
Retrieved from https://www.fda.gov/medicaldevices _adoption_db_v17.pdf
/safety/reportaproblem/default.htm Weick, K. (2009). Making sense of the organization. New
U.S. Health and Human Services, & HealthIt.Gov. (2014). York, NY: John Wiley & Sons.
Meaningful use definition and objectives. Retrieved Yadav, S., Kazanji, N., Narayan, K., Paudel, S., Falatko, J.,
from http://www.healthit.gov/providers-professionals Shoichet, S., . . . Barnes, M. (2016). Comparison of
/meaningful-use-definition-objectives accuracy of physical examination findings in initial
U.S. Department of Health and Human Services, & HealthIT. progress notes between paper charts and a newly
gov. (2015). What is an electronic medical record implemented electronic health record. Journal of
(EMR)? Retrieved from http://www.healthit.gov American Medical Informatics Association, 24(1),
/providers-professionals/electronic-medical-records-emr 140–144.
Section 4
The Practice of
Nursing Today and
in the Future
Section 4 concludes this text.
It summarizes key concerns
focusing on the future of
nursing and the importance of
nursing leadership. Change in
the healthcare delivery system
provides many opportunities for
nursing, if nursing is ready for
them.
Chapter
14
The Future: Transformation
of Nursing Practice through
Leadership
CHAPTER OBJECTIVES
■■ Discuss the relevance of leadership in nursing ■■ Discuss the impact of the work environment
and management and the impact of shared on the nursing profession and the delivery of
governance. effective quality care.
■■ Examine the factors that influence nursing ■■ Explain why it is important for nurses to
leadership and management. assume active leadership roles in quality
■■ Examine the various healthcare settings, roles, improvement.
and specialties for nurses and possible future ■■ Discuss how the Forces of Magnetism and
changes in scope of practice. the Magnet Recognition Program® are used
■■ Critique examples of past and current to support effective, healthy nursing work
professional practice models. environments and nursing leadership.
■■ Discuss the impact of legislation, regulation, ■■ Examine the future of nursing leadership to
and policy on nursing leadership and practice. move the profession forward.
■■ Explain the importance of economic value to
the nursing profession.
CHAPTER OUTLINE
●● Introduction ●● Factors that Influence

●● Leadership and Management in Nursing Leadership
●● Leadership Models and Theories ●● Generational Issues in Nursing:
●● Shared Governance: Empowering Impact on Image
Nursing Staff ●● Power and Empowerment
●● Leadership versus Management ●● Assertiveness
●● Nursing Management Positions ●● Advocacy in Leadership
461
462 Section 4: The Practice of Nursing Today and in the Future
●● Scope of Practice: A Profession of Multiple ●● Quality Improvement and Nursing

Settings, Positions, and Specialties Leadership
●● Multiple Settings and Positions ●● Transforming Care at the Bedside
●● Nursing Specialties ●● Magnet Recognition Program®
●● Advanced Practice Registered Nurse: ●● Moving the Profession Forward: Students
Changing Scope of Practice Are the Future of Nursing
●● Professional Practice ●● The Future of Nursing: Leading Change,
●● Differentiated Nursing Practice Advancing Health
●● Examples of Professional Practice Models ●● Progress Report on The Future of Nursing:
●● Impact of Legislation/Regulation/Policy on Leading Change, Advancing Health
Nursing Leadership and Practice ●● Student Leadership
●● Economic Value and the Nursing ●● Chapter Highlights
Profession ●● Engaging in the Content
●● The Nursing Work Environment ●● Discussion Questions
●● The Work Environment and Leadership ●● Critical Thinking Activities
●● Workforce Issues and Effective Staffing ●● Electronic Reflection Journal
●● Interprofessional Teams and the Work ●● Case Studies
Environment ●● Working Backward to Develop a Case
●● Improving the Work Environment ●● References
●● Finding the Right Workplace for You
KEY TERMS
Accountability Leader Peter Principle

Accreditation Leadership Practice models
Autonomy Magnet Recognition Responsibility
Differentiated nursing Program® Shared governance
practice Management Transformational leadership
Forces of Magnetism Manager
coordination and collaboration, communication, in-

Introduction terprofessional teams, delegation, conflict resolution,
evidence-based practice (EBP) and research, and the
This is the concluding chapter in this text, but in
five healthcare core competencies. This discussion
another sense, it is the beginning of your professional
does not end with this text or in a course that intro-
journey. Leadership is key to the success of the pro-
duces the critical elements of the nursing profession.
fession, so we end with discussion about leadership
Instead, this chapter marks a beginning because it
and tie together content found in this text. Content
highlights key concerns introduced elsewhere in
related to leadership is found throughout this text,
the text, and the content focuses on the future of
such as in discussions about the development of the
nursing and the need for greater leadership—both
profession, nursing education, healthcare policy, legal
for the profession and for individual nurses. You
and ethical issues, healthcare organizations (HCOs),
Chapter 14: The Future: Transformation of Nursing Practice through Leadership 463
are the future of nursing. This content also explores the model assumes staff are not able and not
some of the emerging issues, trends, and initiatives interested in participating in decision making.
important to the nursing profession and the need ■■ Bureaucratic : The focus is on structure,
for greater nursing leadership. More changes are rules, and policies, with decision making
predicted for the future, but most are unknown. placed in the hands of the formal leader
(manager/administrator). Staff members
receive directions. This approach is related
Leadership and to the autocratic approach.
Laissez-faire: The formal leader (manager/
Management in Nursing
■■
administrator) turns over decision making

Leadership is important for every nurse, whether to the staff; steps back from participation;
the nurse is in a formal administrative/management and lets things happen with little, if any,
position or not. Leadership characteristics and direction. This can lead to problems because
competencies are required to ensure that patients it often means the organization or process
receive the care they need. These characteristics may be leaderless; it is a difficult balance to
and competencies are also important in ensuring provide some leadership but to do so in the
that the nursing profession is an active participant background.
in the healthcare delivery system and in the devel- These models and theories have long been
opment and implementation of healthcare policy. used in health care. Indeed, some HCOs still use
The future of nursing report supports this perspec- them or some adaptation of them. Nevertheless,
tive by emphasizing the need for nurses to assume these approaches are not effective in today’s rap-
more leadership in health care, and to accomplish idly changing environment where staff want to
this, nurses need greater leadership competency participate more and seek recognition for their
(Institute of Medicine [IOM], 2010). performance and expertise, but they still expect
leaders to guide the overall process. Over time,
Leadership Models new models and theories that built on one another
and Theories were developed. Often, these changes began in
other industries and then were adopted by HCOs.
A good place to begin to better understand lead- Some of these newer theories are highlighted here:
ership in nursing is with an overview of leader- ■■ Deming’s theory: Effective organizations are
ship models and theories, critical issues, and a dependent on group or team interaction.
comparison of leadership and management. ■■ Drucker’s theory: This theory, which is re-
Leadership and management are not the same, ferred to as modern management, builds on
although effective managers need to demonstrate Deming’s recognition of the importance of
leadership. In general, earlier leadership models staff team participation in the organization
and theories emphasized control and getting the and yet also maintains the importance of
job done with little, if any, emphasis on creativity individual autonomy.
and innovation or staff participation in decision ■■ Contingency theory: Multiple variables affect
making. The following is a brief summary of some situations, which in turn affect leader–member
of the key models and theories to illustrate how relationships, tasks, and position power.
they have changed over time. ■■ Connective leadership theory: The focus is on
■■ Autocratic : The formal leader (manager/ caring and connecting to others—individuals,
administrator) makes decisions for the staff; groups, and organizations.
■■ Emotional intelligence theory: The focus is the work of the organization. This leader is described
on leader–follower relationships, feelings, as honest, energetic, loyal, confident, self-directed,
and self-awareness. flexible, and committed. Staff members are able to
■■ Chaos or quantum theory: A more current the- see these characteristics in a transformational leader
ory, this model emphasizes interdependency, and want to work for and with this leader. Some
sensitivity to change, avoidance of predicting studies indicate that there is a connection between
too far into the future, and accountability in staff perceiving their nursing leaders as transfor-
the hands of those who do the work. mational leaders and staff perceptions of a positive
■■ Knowledge management theory: This theory work environment; there is less staff burnout and
turns attention to knowledge—the knowledge more staff engagement in the work environment and
worker, knowledge-intense organizations, processes (Lewis & Cunningham, 2016). This type of
interprofessional collaboration, and ac- study further supports the need for transformational
countability. It recognizes the importance of leadership and also more nursing research to better
technology and information today. Although understand this type of leadership.
this is a new theory, it, too, has historical
roots. For example, Drucker’s theory used the
term knowledge worker to describe a person
Shared Governance:
who works with his or her hands and with Empowering Nursing Staff
theoretical knowledge. Knowledge workers With the changing environment and changes in lead-
are assets for HCOs—for example, nurses ership and management models or theories, there is
should focus on knowledge and application greater need to focus more on team efforts. This led to
of knowledge rather than being overly con- development and greater use of shared governance
cerned with staff titles and positions. (shared decision making), which “can be viewed as
As changes were made in leadership models and a management philosophy, a professional practice
theories in the last 20 years, there has been a move- model, and an accountability model that focuses on
ment toward greater staff participation, recognition staff involvement in decision-making, particularly
of staff performance, staff and staff–manager rela- in decisions that affect their practice” (Finkelman,
tionships, and collaboration. This is very different 2016, p. 115). Through shared governance, nurses
from autocratic, bureaucratic, or even laissez-faire in an organization can (Hess, 2004):
leadership approaches.
1. Control their professional practice.
As a result of these changes, a newer leadership
2. Influence organizational resources that support
theory stands out today—a theory that has connec-
practice.
tions to the theories previously described. In early
3. Gain formal authority, which is granted by the
Quality Chasm reports, experts recommended that the
organization.
best leadership style today for healthcare delivery is
4. Participate in decision making through com-
transformational leadership (IOM, 2003a). This
mittee structure.
approach emphasizes a positive work environment,
5. Access information about the organization.
recognition of the importance of change and using
6. Set goals and negotiate conflict.
change effectively, rewarding staff for expertise and
performance, and development of staff awareness In this type of organization, nurses assume an
of work processes so that they can engage in quality active role in the management of the patient care
improvement (QI). Transformational leaders create services and thus have more control over their
vision and mission statements with the staff to guide practice (Murray et al., 2016). Shared governance
is a management model, emphasizing the need for such as staffing, scheduling, education, salaries and
nurses to share accountability and responsibility, benefits, promotion structure, and so on. Typically,
and this typically leads to more staff commitment hospitals that use a shared governance model find
to the HCO. Nurses have the authority to make sure that staff members are more satisfied and turnover
the right decisions are made about the work they is lower. Staff like working in the organization.
do. Accountability means that the nurse accepts Not all hospitals use shared governance, and its
responsibility for outcomes or is answerable for what implementation and effectiveness can vary widely.
is done. Responsibility is to be “entrusted with a
particular function” (Ritter-Teitel, 2002, p. 34). These Leadership versus
aspects of management are connected to autonomy,
Management
or the right to make decisions and control actions. The
best situation occurs when the nurse who provides It is easy to confuse leadership and management.
care is also the staff member who works to resolve A leader can be a leader and not a manager, just
issues and ensure that patient outcomes are achieved as a manager can be a manager and not a leader.
at the point of care, limiting the number or layers of A leader provides overall guidance and supports
staff who must be involved. This approach is more staff engagement at all levels of the organization. A
effective in ensuring quality care than someone far manager holds a formal management or adminis-
above the direct care situation telling staff what they trative position and, in that position, focuses on four
must do to improve. Shared governance is dependent major functions: planning, organizing, leading, and
on effective collaboration, communication, and controlling. Today, effective nurse managers need
teamwork and spreads departmental and organiza- to be able to collaborate, communicate, coordinate,
tional decision making over a large number of staff, delegate, recognize importance of data and outcomes,
providing for opportunities for more decentralized manage resources (budget, staff, equipment, sup-
decision making. This approach, however, does not plies, and so on), improve staff performance, build
mean that managers can ignore their managerial teams, and evaluate effectiveness and efficiency. In
and leadership responsibilities or that all decisions their position, they must actively support and apply
are made by the staff. If the process blocks decision EBP, evidence-based management (EBM), and QI.
making—for example, by taking too long to make They use critical thinking and clinical reasoning and
a decision—then this model will not be effective. judgment, and they need to be flexible and able to
This approach means managers must do their jobs adjust to change, using the planning process. This
differently with inclusion of staff. Shared governance role has changed over time, particularly due to the
is not easy to develop, and sometimes it can become changing healthcare environment and changes in
a barrier to delivery of efficient, high-quality care. It leadership and management models. Currently,
takes time to develop an effective shared governance managers need more leadership and management
structure and culture. competencies.
HCOs may vary in how they structure shared Someone who is described as a leader is viewed
governance, but the principles are typically the as such due to the person’s ability to influence
same—as described here. For example, a hospital may others; however, it does not necessarily mean that
have a nursing council with different nursing staff this person is in a formal management position. In
represented, and the council makes certain decisions contrast, managers have power because they hold a
for operation of nursing services with committees formal management position such as team leader,
and task forces working on various aspects to ensure nurse manager, or chief nursing office. Ideally, all
effective nursing care and meet staff work needs, managers should also be leaders and viewed this
way by their staff, but this does not always happen. There are many myths about leadership that
Bennis and Goldsmith describe one viewpoint of are important to address, and three of them are
the difference between leaders and managers (1997, key for nursing leaders to consider as they develop
p. 4): “There is a profound difference—a chasm— their own leadership or develop other nurses for
between leaders and managers. A good manager leadership (Goffee & Jones, 2000).
does things right. A leader does the right thing.” ■■ Everyone can be a leader. This is not true.
A problem in organizations and in nursing is the Everyone may have potential to be a leader;
Peter Principle, which occurs when someone is however, it is important to recognize that
promoted beyond their leadership and manage- leadership competencies can and must be
ment competencies required for a new position. developed for a person to actually be a leader.
This is a particular problem in nursing as it is not ■■ People who get to the top are leaders. This is
uncommon to promote a very competent clinical not true. There are many people in high-level
nurse to a management position and assume that administrative positions who would not be
this will lead to success. In many cases, it does not. described as leaders; in some cases, they
Major changes in healthcare delivery have would not even be described as managers
led to the need for changes in leadership and in by their staff.
management. The following aspects of leadership ■■ Leaders deliver business results. This is not
have become more important, and they also have an true. Leaders do not always meet expected
impact on management (Porter-O’Grady, 1999, p. 40): outcomes; sometimes they are not effective
■■ Change focus from process to outcomes. managers.
■■ Align role to the information infrastructure HCOs need to work on developing leadership in
rather than to functional performance. nursing staff, and nurses need to work on developing
■■ Focus on team results rather than individual their own leadership. Leaders do not just happen;
performance. they need education, guidance and support, men-
■■ Manage data complexes rather than indi- toring, and so on.
vidual events.
Facilitate resources that then direct work.
Nursing Management
■■
Transfer skill sets rather than make decisions

Positions
■■
for staff.
■■ Develop staff self-direction rather than Nurse managers today carry much more respon-
giving direction. sibility than in the past. The main purpose of
■■ Focus on obtaining value rather than simply management is to get the job done and make sure
finding costs. the job is done effectively. There are three common
■■ Focus on consumer-driven structure rather levels of management. The first level includes
than provider-based system. managers who work with staff daily to complete
■■ Construct horizontal relationships rather required work. The typical title at this level is
than maintain vertical control mechanisms. nurse manager, though titles may vary by HCO.
■■ Facilitate equity-based partnerships rather This person guides and supervises a unit’s staff,
than control individual behaviors. both professional and nonprofessional, to ensure
Consideration of these factors provides greater that quality patient care is delivered focused at the
opportunity to develop and implement transfor- clinical unit level. The second level in an organi-
mational leadership; an effective nurse manager zation consists of middle managers who supervise
should demonstrate transformational leadership. multiple first-level managers. Such managers might
include a nursing director who supervises all the ability to ask for guidance, effective use of problem
unit nurse managers in the medical division or solving, ability to develop and communicate a vision,
all the nurse managers in ambulatory care clinics ability to engage others in the work process, and so
and the emergency department. The upper level on. The following sections include a discussion of
is the chief nursing officer. This nurse manager some factors that should be considered in developing
is responsible for the overall work of the nursing leadership at organizational and individual staff levels.
service and, in some cases, may be responsible
for other services. Middle-level managers report
to upper-level managers. Regardless of level, the Generational Issues in
manager must be able to perform management Nursing: Impact on Image
functions and ideally demonstrate leadership. Generational issues are important because multiple
This description is the most common structure generations are part of the image of nursing and
for nursing management in HCOs such as hospitals; have an impact on nursing practice and manage-
however, there are variations from organization ment and, consequently, on leadership. When a
to organization. In addition, some staff may hold person thinks of a nurse, which generation or age
non-managerial positions, but they also need to be groups are considered? Most people probably do
effective leaders and demonstrate some management not realize that there is not one age group, but
functions such as planning. These individuals do rather several represented in nursing. Today, nurs-
not have supervisory responsibilities because they ing staff include representation from three active
do not always direct staff, but they must influence generations: (1) Baby Boomers, (2) Generation X,
staff. For example, a clinical nurse specialist (CNS), and (3) Generation Y. The so-called Traditional
advanced practice registered nurse (APRN), clinical generation is no longer in practice, but it had a
nurse leader (CNL), or nurse informaticist may hold significant impact on the nursing profession and
this type of position. current practice. Exhibit 14-1 identifies the time
frames for these nursing generations.
Stop and Consider #1 Nurses in the four generations are different from
Leadership and management are part of shared one another. How does this affect the image of nursing?
governance. It means that the image of nursing is one of multiple
age groups with different historical backgrounds and
viewpoints. How nurses from each generation view
Factors that Influence nursing can be quite different, and their educational
Leadership backgrounds vary a great deal, from nurses who en-
tered nursing through diploma programs to nurses
Many factors influence the development of leadership who entered through baccalaureate programs and
competencies and the practice of effective leadership. on to graduate degrees. Some of these nurses have
Some of the factors are organization-based such as seen great changes in health care, and others see the
administrative support of effective leadership devel- current status as the way it has always been. Technol-
opment, clear communication and processes, recog- ogy, for example, is frequently taken for granted by
nition and empowerment, and so on. Other factors some nurses, whereas others are overwhelmed with
are focused more on individuals who are leaders or technological advances. Some nurses have seen great
aspire to improve and be leaders. Examples of factors changes in the roles of nurses, whereas other nurses
are education (academic, staff education, continuing now take the roles for granted—for example, the APRN
education [CE]), self-esteem, ability to communicate, role. If one asked a nurse in each generation for the
Exhibit 14-1 Current Generations in Nursing
Traditional generation Born 1930–1940

Baby Boomers Born 1941–1964
Generation X Born 1965–1980
Generation Y (also called Millennials) Born 1981–present
Reproduced from American Nurses Association. (2009). Nursing administration: Scope and standards of
practice (pp. 16–18). Silver Springs, MD: Author. © 2009 by American Nurses Association. Reprinted with
permission. All rights reserved.
nurse’s view of nursing, the answers might be quite on how nursing services were organized and
different—for example, how nurses practice, settings nurses’ expectations of management. Some
in which nurses practice, management responsibil- of this impact has been negative, such as the
ities, and so on. If these nurses then tried to explain emphasis on bureaucratic structure, and it
their views to the public, the perception of nursing has been difficult to change in some HCOs.
would most likely consist of multiple images. ■■ Baby Boomers, born 1940–1964: This gen-
The situation of multiple generations in one eration, which is currently the largest in the
profession provides opportunities to enhance the work arena, is the group moving into the
profession through the diversity of the age groups retirement process. This trend is predicted
and their experiences, but it has also caused problems to lead to greater nursing shortage problems
in the workplace. What are the characteristics of the in the future. The Baby Boomer generation
various groups? How well do they mesh with the grew up in a time of major changes, including
healthcare environment? How well do they work the women’s liberation movement, the civil
together? The following list summarizes some of rights movement, and the Vietnam War. They
the characteristics of each generation, including had fewer professional opportunities than
the traditional generation and its impact (American are available to nurses today because the
Hospital Association, 2002; Bertholf & Loveless, typical career choices for women were either
2001; Finkelman, 2016; Gerke, 2001; Santos & Cox, teaching or nursing. This began to change
2002; Ulrich, 2001; Wieck, Prydun, & Walsh, 2002). as the women’s liberation movement grew,
■■ The Traditional (Silent or Mature) generation, for example, opening up other opportunities,
born 1930–1940: This generation is important medicine, law, business, and so on. Within
because of its historical impact on nursing, but this generation, fewer men went into nursing,
members of this group are no longer in prac- as was true of the previous generation. This
tice. This group of nurses was hard working, group’s characteristics include indepen-
loyal, and family focused, and they felt that dence, acceptance of authority, loyalty to the
duty to work was important. Many served in employer, workaholic tendencies, and less
the military in World War II and the Korean experience with technology, although many
War. This period occurred prior to the women’s in this group led the drive for adoption of
liberation movement. The characteristics of more technology in nursing. This generation
the traditional generation had a major impact is often more materialistic and competitive
and appreciates consensus leadership. It is a are more loyal to their employer, stay in the
generation whose members chose a career job longer, are more willing to work overtime
and then stuck to it, even if they were not (although they are not happy about it), and
very happy with that choice. have greater long-term commitment. These
■■ Generation X (Gen-X), born 1965–1980: The differences may cause problems between the
presence of Generation X, along with Gen- two generations, with Baby Boomers often
eration Y, is growing in nursing. Members occupying supervisory positions or senior
of this group are assuming more nursing faculty positions and Gen-Xers found in staff
leadership roles as the Baby Boomers retire. positions or beginning faculty positions, but
Gen-Xers are more accomplished in tech- moving into more leadership positions. It
nology and very involved with computers is a critical time of leadership transition in
and other advances in communication and the profession.
information (social media), both in their ■■ Generation Y (Nexters, Millennials, Gener-
personal lives and in healthcare delivery. ation Next, Gen-Y), born 1980–present: The
They have experienced many changes in Millennial generation is the newest gener-
these areas in their lifetimes. These nurses ation in nursing, although second-career
want to be led, not managed, and they students and older students are also entering
usually have not yet developed high levels the profession who might be older and thus
of self-confidence and empowerment. What may represent an earlier generation. Key
do they want in leaders? They look for characteristics of this generation are opti-
leaders who are motivational, demonstrate mism, civic duty, confidence, achievement,
positive communication, appreciate team social ability, morality, and diversity. In work
players, and exhibit good people skills— situations, they demonstrate collective action,
leaders who are approachable and supportive. optimism, tenacity, multitasking, and a high
Baby Boomers, in contrast, would not look level of technology skill, and they are also
for these characteristics in a leader. Gen- more trusting of centralized authority than
Xers typically do not join organizations Generation X. Typically, they handle change
(which has implications for nursing or- better, take risks, and want to be challenged.
ganizations that need more members and This generation is connected to cell phones
active members), do not feel they must stay and personal tablets and use various social
in the same job for a long time (which has networking methods. They are tech savvy
implications for employers that experience and expect to multitask. Sometimes, how-
staff turnover and related costs), and want ever, this makes it difficult for them to focus
a good balance between work and personal on one task.
life (which means that they are less willing In a profession that includes representatives
to bring work home). Compared with earlier from multiple generations, it is necessary to recog-
generations of nurses, members of Generation nize that age diversity means variations in positive
X are more informal, pragmatic, technolit- and negative characteristics among staff. Some will
erate, independent, creative, intimidated by pull the profession backward if allowed, and some
authority, and loyal to those they know; they will push the profession forward. “In the workplace,
also appreciate diversity. By contrast, the Baby differing work ethics, communication preferences,
Boomers with whom the Gen-Xers work manners, and attitudes toward authority are key
often see things very differently. Baby Boomers areas of conflict” (Siela, 2006, p. 47). This also has
an impact on the nursing profession’s image. As what a nurse is or make decisions for nurses. This
discussed here, nursing is not a profession that failure to be proactive merely worsens their image
encompasses just one type of person or one age and diminishes professional self-esteem; both
group, and people in different age groups are now reduce leadership.
entering nursing. We are long past the time when What nurses want and need is power—to be
mostly 18-year-olds entered nursing education able to influence decisions and have an impact on
programs. As one generation moves toward re- issues that matter. It is clear that power can be used
tirement, the next generation will undoubtedly constructively or destructively, but the concern
have a greater impact on the image of nursing. It here with the nursing profession is using power
is critical to avoid gender role stereotyping, and constructively. Power and influence are related.
we need to increase the strength of nurses as one Power is about gaining control to reach a goal. There
group of professionals, while still recognizing that is more than one type of power, as described earlier
these differences exist and appreciating how they in this text in content about teams and teamwork:
might affect the profession. informational, referent, expert, coercive, reward, and
persuasive. The type of power a person possesses
has an impact on how it can be used to reach goals
Power and Empowerment
or outcomes.
Power and empowerment are connected to the Empowerment is also an important issue for
image of nursing and the ability to assume lead- nurses today and is connected to leadership. Leaders
ership. How one is viewed can affect whether the who empower staff enable staff to act—a critical
person is considered to have power—power to need in the nursing profession. Shared governance
influence, to say what the profession is or is not, emphasizes empowerment. Basically, empower-
and to influence decision making. Nurses typically ment is more than just saying you can participate
do not like to talk about power; they find it to be in decision making; staff need more than words.
philosophically different from their view of nursing Empowerment is needed in day-to-day practice
(Malone, 2001). This belief—that is, viewing power as nurses meet the needs of patients in hospitals,
only in the negative—acts as a barrier to success as the community, and home settings. Empowerment
a healthcare professional and also affects teamwork, also implies that some individuals may lose their
as discussed in other chapters. But what are power, power while others gain power. This can lead to
powerlessness, and empowerment? They are critical conflict, which needs to be resolved so that it does
elements influencing leadership. not negatively affect the work environment and
To feel as if one is not listened to or not viewed patient care.
positively can make a person feel powerless; this Staff members who experience empowerment
remains a longstanding problem for nurses. Many feel that they are respected and trusted to be active
nurses believe that they cannot make an impact participants. This also helps them demonstrate a
in clinical settings, and they are not listened to or positive image to other healthcare team members,
sought out for their opinions. This powerlessness patients and their families, and the public. Nurses
can result in nurses feeling like victims. The result who do not feel empowered will not be effective in
may be resentment that is expressed as incivility, as conveying a positive image because they will not
discussed in other chapters in this text. This feeling be able to communicate that nurses are profession-
of powerlessness can act against nurses when they do als with much to offer. Empowerment that is not
not actively address issues such as a negative image clear to staff or not supported by management is
of nurses and when they allow others to describe just as problematic as lack of staff empowerment.
Empowered teams feel a responsibility for the verbal and nonverbal communication become
team’s performance and activities, which in turn congruent, making the message clearer. Assertive
can improve care and reduce errors. and aggressive communications are not the same.
Control over the nursing profession is a critical Assertive persons are better able to confront prob-
issue that is also related to the profession’s image. lems in a constructive manner and do not remain
Who should control the nursing profession, and silent. The problems that the nursing profession has
who does? This is related to independence and with its image have been influenced by nursing’s
autonomy—key characteristics of any profession. silence caused by the inability to be assertive, but
But a key question persists: What should be the assertiveness is a critical leadership competency.
image of nursing? As a profession, nursing does not Smith (1975) identified some critical rules
appear to have a consensus about its image, given related to assertive behavior that can easily be
that the types of advertising and responses to these applied to the difficulties that nursing experiences
advertising initiatives vary. This topic is discussed with its image and the need to increase its visibility
in other chapters, and here it is mentioned again as and develop leadership. A summary of examples of
one considers nursing leadership and what nurses these rules includes:
need to do to become more effective leaders in a ■■ Avoid over-apologizing.
complex healthcare delivery system. Nursing needs ■■ Avoid defensive, adverse reactions, such as
to control the image and visibility of the profession, aggression, temper tantrums, backbiting,
and in doing so, may exert more control over the revenge, slander, sarcasm, and threats.
solutions for the following four issues: ■■ Use body language—such as eye contact, body
1. If nurses have a more realistic image, it is easier posture, gestures, and facial expressions—
to support the types of services that nurses that is appropriate to and that matches the
offer to the public. verbal message.
2. If nurses have a more realistic image, it is easier ■■ Accept manipulative criticism while main-
to support an entry-level baccalaureate degree taining responsibility for your decision.
to provide the type of education needed. ■■ Repeat a negative reply calmly without
3. If nurses have a more realistic image, it is easier justifying it.
to support the need for reimbursement for ■■ Be honest about feelings, needs, and ideas.
nursing services, which involves much more ■■ Accept and/or acknowledge your faults calmly
than patient hand holding. and without apology.
4. If nurses have a more realistic image, it is easier Katz identifies other examples of assertive behavior
to participate in the healthcare dialogue on the (2009, p. 267):
local, state, national, and international levels ■■ Express feelings without being nasty or
to influence policy.
overbearing.
Acknowledge emotions but remain open to
Assertiveness
■■
discussion.
Earlier content in this text discussed assertiveness ■■ Express self and give others the chance to
from the point of view of teams, but here we focus on express themselves equally.
nursing assertiveness and leadership. Assertiveness is ■■ Use I statements to defuse arguments.
demonstrated in a person’s communication—direct ■■ Ask for and give reasons.
and open with appropriate respect of others. When This information provides a guide to improve and
a person communicates in an assertive manner, maintain effective assertiveness.
specialties based on interest and jobs that they want

Advocacy in Leadership
to pursue during their career. Some examples of
Advocacy is speaking on behalf of something import- the many different nursing settings and positions
ant, and it is one of the major nursing roles. Other are provided here, and some are discussed in other
content discussed advocacy for patients, but now chapters.
we turn to advocacy as applied to the nursing pro-
fession and the need for nursing leaders to advocate ■■ Hospital-based or acute care nursing: This is
for staff. To do this successfully, nurses need to feel the area that most students think of first when
empowered and be assertive. All nurses represent considering nursing positions. It is what is
nursing—acting as advocates in their daily work and most frequently illustrated in the media (films,
in their personal lives. When someone asks a nurse, television, and so on). Within this setting are
“What do you do?” the nurse’s response is a form of multiple specialty opportunities and clinical/
advocacy for the profession. The goal is to provide a management/education/research positions.
positive, informative, and accurate response. ■■ Ambulatory care: This is a growing area for
nurses, and these venues are considered to
be community-based settings. Many types of
Stop and Consider #2 ambulatory care settings exist, such as clinics,
Power and empowerment should be part of the
image of nursing.
private practice offices, ambulatory surgical
centers (both freestanding and associated
with hospitals), and diagnostic centers (both
freestanding and associated with hospitals).
Scope of Practice: There is greater expansion in this area today
A Profession of Multiple Settings, with more focus on public-/community-based
Positions, and Specialties care. Nurses hold clinical and management
positions in ambulatory care facilities.
Healthcare delivery requires nurses with multi- ■■ Public/community health: This area, which is
ple competencies and specialties to fulfill many growing rapidly, is an important clinical site
different roles in a variety of healthcare settings. for nursing students, and within this setting
Healthcare delivery is never static. For example, are multiple opportunities. Examples include
there is greater interest today in public/community clinical/management/education positions
health and thus more need for nurses to enter this in public/community health departments,
area and hold a variety of positions. The following clinics, school health facilities, tuberculosis
discussion considers some of the issues related to control centers, immunization clinics, home
the variety of healthcare delivery settings and roles health, substance abuse treatment, mental
and implications for nursing leadership. health, occupational health, and more. Nurses
may also be involved in development and
Multiple Settings and implementation of public policy at the local,
state, and federal levels to improve health
Positions
and healthcare quality.
The practice of nursing takes place in multiple ■■ Home care: This setting is very broad, in
settings, thus offering multiple job possibilities for that numerous home care agencies exist
an individual nurse over the nurse’s career span. across the United States. Some are owned
Many nurses change their settings, positions, and and managed by government agencies,
such as city health departments; others are now have palliative care teams that provide
owned and managed by other HCOs, such support to the patient, family, and the staff
as a hospital or may be part of national who care for these patients on a daily a basis.
healthcare corporations, for-profit HCOs, or ■■ Nurse-managed health clinics (NMHCs):
not-for-profit HCOs. Nurses in this specialty NMHCs have increased due to the increased
practice in the patient’s home. They may also healthcare insurance coverage provided through
hold management positions within the home the Affordable Care Act of 2010 (ACA); if the
care agency, and some nurses may even own ACA continues in the same form, then this
home care agencies. We typically think only increase will likely increase. These clinics
about nurses and home care aides as working are community-based, primary healthcare
in home care, but there are some physicians services that operate under the leadership
who make home visits (Wasik, 2016)—though of an APRN and focus on health education,
this is not common. Could home medical health promotion, and disease prevention. The
care reduce healthcare costs? “Aging in place” population targeted by NMHCs is usually the
is a new focus to help older adults stay in underserved. NMHCs are not-for-profit orga-
their homes as long as possible, but getting nizations and typically use a sliding scale for
healthcare services acts a barrier for many payments. They may be classified as Federally
older adults. With new technology, we can do Qualified Health Centers (FQHCs) (Kovner
much more in the home and communicate & Walni, 2010). Since 2010, the number of
better with patients to monitor their status, FQHCs has grown. In 2012, the National
as discussed in the chapter on informatics Nurse-led Care Consortium, a nonprofit
and technology. Physician home visits require member association representing more than
more time due to travel and other factors, and 200 NMHCs throughout the United States,
one might question if this is the best use of was formed (2016). These clinics focus on
resources—additional experience and data delivering care at the neighborhood level,
are needed to determine if expanding this connecting social service delivery needs and
approach is best. APRNs also may practice in resources, and partnering with the community
the home setting, providing more expanded to advance health equity.
nursing services. ■■ Retail clinics: A healthcare delivery growth
■■ Hospice and palliative care: This type of area is retail clinics. These are clinics located
setting may be partnered with home care, in retail areas, such in a pharmacy, a large
or it may be a freestanding service. Hospice grocery store, or a mall. The goal is to provide
and palliative care can also be associated easy access to the consumer. Most of these
with an inpatient unit that is either part of clinics use APRNs as their primary care
a hospital system or a freestanding facility. provider. Sometimes a for-profit corpora-
Hospice care has a special mission: to include tion owns them, and others may be owned
patients, families, and significant others in by academic health centers . It was thought
the dying process and make the patient as that these clinics would reduce emergency
comfortable as possible while meeting the department visits for low-acuity conditions;
patient’s wishes. Palliative care or comfort however, a recent study indicates that this is
care is also used when a life-threatening not necessarily true—there is a slight decrease
condition is present that may or may not of emergency department visits for patients
result in death. Many acute care hospitals with private insurance (Martsolf et al., 2016).
The researchers attribute the latter result to own practices. Depending on their level of
the fact that most retail clinics are located in education, these nurses provide assessment
higher-income, suburban areas. These clinics and direct services, assist the physician,
may also serve as a source of referrals to a monitor and follow-up with patients, and
medical center. We need more data over time teach patients and families. APRNs provide
to understand the outcomes from this type more advanced nursing care in this setting.
of ambulatory care setting. ■■ Extended care and long-term care: Many nurses
■■ School nursing: This setting is part of public/ work in this area. With the aging population
community health nursing. The focus is on increasing, nursing staff needs will increase.
the provision of healthcare services within Positions may be located in residential or
schools. The role of the school nurse is changing community-based centers. Nurses provide
dramatically. Some schools have very active assessment, direct care, and support to pa-
clinics where nurses provide a broad range tients and support and education to families.
of healthcare services to students. Pediatric ■■ Management positions: Nurse managers are
APRNs have become more involved in school found in all HCOs. The key responsibilities
clinics that provide more expanded services. of this functional position are staffing, re-
■■ Occupational health: This is a unique setting cruitment, and retention of staff; planning,
for nursing practice. Nurses who work in budgeting, and staffing; supervising; QI;
this area provide healthcare services in oc- supporting EBP; staff education; and ensuring
cupational or work settings. They provide overall functioning of the nurse manager’s
emergency care; direct care, including assess- assigned unit, division, or department.
ment, screenings, and preventive care; and ■■ Nursing education (academic and staff educa-
health and safety education, and they may tion): This is a functional position. Academic
work with employer management to ensure faculty teach in nursing education programs.
a safer work environment. They also initiate Nurses may also hold positions in staff de-
referrals for additional care. Some schools of velopment or staff education within HCOs,
nursing offer graduate degrees in this area. focusing on staff orientation, ongoing staff
■■ Telehealth/telemedicine: Nurses work in education, and maintenance of continued
telehealth by monitoring patients, providing competencies.
patient and family education, and directing ■■ Nursing research: Nurses are involved in
care changes. Home health may also use this research in HCOs, academic institutions,
method; although it is still not common, it is and in the public/community arena. They
considered a care service area that will increase. fill many research roles, including serving
■■ Parish nursing: Parish nursing takes place in a as the primary investigator designing and
faith-based setting, such as a church or other leading research studies, collecting data, and
religiously affiliated institution. The nurse is analyzing data. Some healthcare institutions
often a member of the faith-based institution. refer to this role as a nurse scientist. Nurses
Healthcare services might include screenings are not just conducting nursing research;
and prevention, health education, and referral they are also responsible for helping other
services for the members of the institution. interprofessional team members conduct
■■ Office-based nursing: Nurses work in physician research. In addition, because research
practices. Some of the nursing staff may be provides important evidence for EBP, they
APRNs, and some APRNs may have their contribute to the expansion and use of EBP.
■■ Informatics: Nurses are active in the area of medical records and other documents, and
informatics as a specialty and as a part of their assists with planning legal responses. Some
other responsibilities. A nurse might serve on nurse legal consultants are hired by HCOs
the informatics committee or participate in to assist their attorneys and participate in
planning for implementation of an electronic risk management functions. Nurses may be
medical record; if the nurse has advanced expert witnesses providing expert testimony
informatics expertise, the nurse may lead or for cases. Some nurses are also attorneys and
help with major organizational informatics thus function in a dual role in the area of
planning, implementation, and evaluation. healthcare legal issues.
Additional content explaining this role and It is unknown what the future holds for new
preparation is discussed in this text’s content healthcare settings or new roles, but nursing his-
about health informatics technology (HIT). It tory demonstrates that the likelihood of new roles
is an important new role for nurses and HCOs. emerging is high. In an interview with nursing
■■ Nurse entrepreneurship: Nurses may serve leaders, Porter-O’Grady commented that mobility
as consultants or own a healthcare-related and portability would become very important in
business. Some may be involved in developing technotherapeutic interventions (Saver, 2006).
new healthcare products or in technology Technology is extending into patients’ lives, and the
development, including computer products. settings in which care is received will be less con-
This is an area that most nursing students nected to hospitals. Others suggest that as patients
do not know much about because it is a less demand more control as consumers, there will be
common role for nurses; however, it is likely more self-diagnostic tests (Saver, 2006). Examples
that this area will expand in the future. might be apps that are used to monitor and identify
■■ Nurse navigator: This nurse helps a patient medical problems or monitor diet or exercise. New
and family navigate the healthcare system. roles for nurses, in turn, will emerge to support
HCOs may use different titles for a nurse changes. For example, nurses will assume more active
who fulfills these functions. The nurse may roles in positions concerned with healthcare quality,
coordinate care among several professions in pharmaceutical companies, as nurse practitioners
or provide a bridge between transitional in clinics located in retail stores, managing research
care settings. For example, the patient who and development departments associated with
has cancer and has been discharged home equipment or biomedical companies, working in or
may require care coordination between leading medical homes, and in counseling (Saver,
the acute care facility and oncology and 2006). All of this change is occurring now, with
radiology services. The patient may also more expected in the future, and requires greater
need home visits. The nurse navigator helps nursing leadership competency.
find services and coordinates the care. Some
HCOs use case managers for this purpose,
Nursing Specialties
as do insurers.
■■ Legal nurse consultant: This nurse usually has Nursing specialties are part of the profession and
completed additional coursework related to expand professionalism. There are numerous
legal issues and health care, and the nurse general specialties in nursing, such as maternal–
may even be certified in this area. The legal child (obstetrics)/women’s health, neonatal, pedi-
nurse consultant works with attorneys and atrics, emergency, critical care, ambulatory care,
provides advice about health issues, reviews public/community health, home health, hospice,
surgical/perioperative, psychiatric/mental health/ neonatal care, and psychiatric–mental health. A

behavioral health, nurse–midwifery, management, CNL does not typically focus on a specific clin-
legal nurse consulting, nursing consulting, and ical group in the CNL degree program; instead,
many more. There are also subspecialties such this is a functional role that may be used in any
as diabetic care, wound care, and renal dialysis. type of specialty area. For example, a CNL may
The most important reason specialties develop is hold a position in a medical unit, a pediatric unit,
to meet the need for focused practice experience or a women’s health unit. The CNS title is also a
and ensure that nurses receive the necessary ed- broader term, but the CNS master’s degree focuses
ucation to provide specialized nursing. Nurses on a specific clinical area—it is not a common title
may also become interested in a type of patient today, with increased use of APRNs and CNLs.
or care setting and want to learn more about it, Specialty education at the graduate level and cer-
gain more experience, and work in that area. All tification support professionalism in nursing and
specialty nursing is based on the core general help to ensure that nursing remains a profession.
nursing knowledge and competencies. The same As discussed in education content, many of these
specialty might be offered in multiple settings—for positions are transitioning to an entry-level doctor
example, a certified nurse–midwife (CNM) might of nursing practice (DNP) degree.
work in a hospital in labor and delivery, a private Nurse leaders must continually support staff
practice with obstetricians, a clinic, a freestanding and the need for professionalism within the work
delivery center, patients’ homes, or a nurse’s (APRN) setting. They do this by recognizing education and
private practice. degrees through differentiated practice, encouraging
There are two ways to view a specialty. One ongoing staff education (CE and academic), ensuring
view is based on the nurse who works in a specialty that standards are maintained, working to increase
area and thus claims it as his or her specialty (for staff participation in decision making, helping staff
example, the nurse works in a behavioral health unit who want to move into a management position
and is then considered a psychiatric nurse). A second accomplish this goal (for example, by directing staff
view, combined with the first, is that the nurse has to management-focused education to prepare for
additional education and possibly certification in the role), and mentoring staff who want to pursue
a specialty. For example, the psychiatric nurse may the management track. Nurse leaders also need
have a master’s degree in psychiatric–mental health to encourage staff to participate in professional
nursing and may be certified in this specialty. The key organizations; publish in professional journals;
to truly functioning as a specialty nurse is making attend professional conferences; submit abstracts for
a commitment to gain additional education in the presentations; participate in EBP, QI, and research;
specialty. This also includes CE and may include and then recognize these staff accomplishments
certification. throughout the organization.
There are many titles in nursing, but they
all do not necessarily indicate a nurse’s specialty.
These titles are APRN, CNS, and CNL. The titles Advanced Practice
for CNM and certified registered nurse anesthetists Registered Nurse: Changing
(CRNA) make their specialties clear in their titles Scope of Practice
(midwifery and anesthesia, respectively). An APRN
may focus on one or more multiple specialties, such There has been increasing development in the role
as families, pediatric acute care, adult–gerontology of the APRN. “Nurses’ role in primary care has re-
primary care or acute care, pediatric primary care, cently received substantial scrutiny, as demand for
primary care has increased and nurse practitioners action to move forward, and most likely will not.
have gained traction with the public. Evidence from This is an example of how legislation gets “frozen
many studies indicates that primary care services, in committee,” and this is not an uncommon result
such as wellness and prevention services, diagnosis for proposed legislation. Sometimes the legislation
and management of many common uncomplicated is re-introduced in a different form. Legislation and
acute illnesses, and management of chronic dis- nursing may be connected—for example, The future
eases such as diabetes can be provided by nurse of nursing report highlights many new position
practitioners at least as safely and effectively as by opportunities for APRNs such as in community
physicians” (Fairman, Rowe, Hassmiller, & Shalala, health centers, nurse-managed health centers,
2010, p. 280). medical/health homes, and accountable care or-
The report The future of nursing recommends ganizations—but most if not all of these would
increased expansion of nurses’ scope of practice in never exist without health policy changes or new
primary care focused on advanced practice (IOM, health policy. Some of the ACA provisions support
2010). The critical factor that limits nurse practi- these new care settings, illustrating how important
tioners’ scope of practice is state-based regulations. healthcare legislation may be to nursing and why
The website for the Center to Champion Nursing it is important to monitor changes in legislation as
in America provides resources about nursing and they may mean changes for nursing; however, not
about nurse practitioners and their scope of practice. all may be positive.
Data are provided describing how specific states A number of barriers exist to expansion of
regulate nurse practitioner practice. the role of nurse practitioners in primary care,
Other changes are occurring due to legislation particularly state laws that limit scope of practice;
that are important to the APRN scope of practice. reimbursement policies; and may increase profes-
One example is the movement allowing APRNs to sional tensions among nurse practitioners, phy-
sign home health plans of care and certify Medicare sicians, and physician assistants. Policy solutions
patients for home health benefits. This change re- need to (1) remove unwarranted restrictions on
quired legislation, and in 2013, bills were introduced scope of practice, (2) equalize payment and rec-
in both the U.S. House of Representatives (H.R. ognize nurse practitioners as eligible providers,
2504) and the Senate (S. 1332) Home Healthcare (3) increase nurses’ accountability, (4) expand
Planning Improvement Act, endorsed by the nurse-managed centers, (5) address professional
American Nurses Association (ANA) and others. tensions and focus more on interprofessional teams,
This legislation would allow payment for home (6) fund education for the primary care work-
health services to Medicare beneficiaries when these force, and (7) fund research to examine outcomes
services are delivered by (1) a nurse practitioner, (Naylor & Kurtzman, 2010, p. 898).
(2) a CNS working in collaboration with a physician
in accordance with state law, (3) a CNM, or (4) a
physician assistant under a physician’s supervision. There are new nursing positions for not only APRNs,
This change would facilitate providing greater but for all nurses.
home care services to the rural and underserved
areas. Because this is federal legislation, it must
be passed by both the House and the Senate and Professional Practice
signed by the president to become law; however,
this legislation was referred to a committee in 2013 Today, professional practice models are described
and now sits in committees waiting for committee as having an impact both on the nursing profession
and on quality care. A model describes the view Blegen, Goode, Park, Vaughn, & Spetz, 2013; Friese,
of professional nursing for a group or a HCO—it Lake, Aiken, Silber, & Sochalski, 2008; McHugh
may be a verbal description, visual, or both. The et al., 2012) indicate that there is a positive impact
American Nurses Credentialing Center defines a on patient care when more RNs have a BSN degree.
professional practice model as the “driving force of We are seeing more students in BSN programs, and
nursing care; a schematic description of a theory, more nurses returning to complete a BSN degree.
phenomenon, or system that depicts how nurses Graduates from all types of nursing programs
practice, collaborate, communicate, and develop take the same licensure exam, and this compli-
professionally to provide the highest-quality care cates the differentiated practice. RN licensure is
for those served by the organization (e.g., patients, the same for all nursing graduates regardless of
families communities)” (American Nurses Association the type of degree earned, which complicates the
[ANA] & American Nurses Credentialing Center understanding of differentiated practice. Boston
[ANCC], 2013a, p. 74). Some HCOs are developing, defined differentiated nursing practice as “a
or have developed, their own professional practice philosophy that focuses on the structuring of roles
models, but all should include the description of its and functions of nurses according to education,
“mission, vision, and values; how the organization experience, and competence” (1990, p. 1). This
manages and governs; how the organization cares does not mean that a graduate from one program
for its patients; how various professions relate to is necessarily better than another because many
one another; and how the organization develops individual factors determine effectiveness; rather,
and recognizes employees” (Robert & Finlayson, it indicates that graduates from each program enter
2015, p. 26). Elements of a successful professional practice having completed a curriculum associated
practice model should support expected nursing with a level of education and related competencies.
profession standards, differentiated practice, shared Differentiated practice needs to be more ev-
governance, collaboration, leadership, EBP, teams, ident in nursing and relates to professional prac-
and ongoing staff education. All of these elements tice models, which may identify required levels
are important topics and discussed in this text. of education and competency. Many employers
do not formally recognize a nurse’s degree. It
is rarely noted on employee identification badges,
Differentiated Nursing and if noted, the degree designation is difficult to
Practice read on small name badges. Patients, and many
Differentiated nursing practice is part of devel- other staff, do not know about nursing degrees
oping a professional practice model. The subject and roles—they group all nurses together into the
of desired degree for entry into nursing practice RN group. Another issue is that salaries are often
continues to be an issue in the nursing profession. not based on the education level of the nurse,
As discussed in content on education, a decision although they should be. Much needs to be done
was made in 1965 to establish the baccalaureate in by the profession to address this area of concern,
nursing (BSN) as the nursing entry-level degree. The and this requires professional leadership.
emphasis on the BSN degree in hospitals as part of
the Magnet Recognition Program® has made a Examples of Professional
difference. These HCOs usually have more registered
Practice Models
nurses (RNs) with BSN degrees (59% compared to
34% in non-Magnet hospitals) (ANA & AACN, 2017). Why does an HCO need a professional practice
Studies (Aiken, Clarke, Sloane, Lake, & Cheney, 2008; model for nursing? The description of the Magnet
forces and the Magnet model provide some reasons The American Association of Critical-Care
for the need: “Conceptual models provide an infra- Nurses’ Synergy Model for Patient Care is an ex-
structure that decreases variation among nurses, ample of a current nursing model (Kerfoot et al.,
the interventions they will choose, and, ultimately, 2006). This model’s core premise is closely related to
patient outcomes. Conceptual frameworks also the five healthcare professions core competencies,
differentiate forward thinking organizations from particularly patient-centered care, by describing
those where nursing has less of a voice” (Kerfoot
et al., 2006, p. 20). These forward-thinking HCOs
also tend to have a professional rather than technical FUNCTIONAL NURSING STRUCTURE
view of nursing. A model offers nurses “a consistent RN medication
nurse
way of framing the care they deliver to patients and
their families” (Kerfoot et al., 2006, p. 21).
Examples of professional practice models are found RN treatment
nurse
in Figures 14-1, 14-2, 14-3, 14-4, and 14-5. Some of Charge Patients–
these models are not used today, but it is important nurse clients
Nursing assistants
to understand their evolution; sometimes they are hygienic care
used again or are revised. Notably, the functional
model is used less today, although total care may be Clerical
used in critical care. Primary care was very popular housekeeping
in the 1980s, but it is less so now because it requires

a greater number of RNs. However, some HCOs still
use the primary care model, usually as an adaptation Figure 14-2 Functional Nursing Model
of the original model. The Forces of Magnetism for Reproduced from Hansten, R. I., & Jackson, M. (2004).
Magnet hospitals emphasizes the need for HCOs to practice. Sudbury, MA: Jones & Bartlett Learning.
implement a professional practice model. The Magnet
Recognition Program, which is a nursing practice
model, is discussed later in this chapter. TOTAL CARE NURSING STRUCTURE
Nursing Patients–
staff clients
TEAM NURSING STRUCTURE

Team Nursing Patients–
leader staff clients Charge Nursing Patients–
nurse staff clients
Charge Team Nursing Patients–

nurse leader staff clients
Nursing Patients–
Team Nursing Patients– staff clients
leader staff clients
Figure 14-1 Team Nursing Model Figure 14-3 Total Patient Care Model
Reproduced from Hansten, R. I., & Jackson, M. (2004). Reproduced from Hansten, R. I., & Jackson, M. (2004).
Clinical delegation skills: A handbook for professional Clinical delegation skills: A handbook for professional
practice. Sudbury, MA: Jones & Bartlett Learning. practice. Sudbury, MA: Jones & Bartlett Learning.
PRIMARY NURSING STRUCTURE the needs of patients and families as the drivers of
Physician Charge Hospital the characteristics and competencies of the nurse
nurse resources (American Association of Critical Care Nurses,
2017). The Synergy Model focuses on patient
characteristics (resiliency, vulnerability, stability,
complexity, resource availability, participation in
Patient– Primary care, participation in decision, and predictabil-
client nurse ity) and nurse competencies (clinical judgment,
advocacy, caring practices, collaboration, systems
thinking, response to diversity, clinical inquiry,
facilitation of learning, and clinical inquiry
Associate Associate Associate nurse(s) [innovator/evaluator]) (Harden & Kaplow, 2016).
nurse (evenings) nurse (nights) as needed (nights) This model can be applied to all types of units, not
just critical care.
Innovative new professional practice models
Figure 14-4 Primary Care Model have common elements (Kimball, Cherner, Joynt,
Reproduced from Hansten, R. I., & Jackson, M. (2004). & O’Neil, 2007). Specifically, they include an ele-
practice. Sudbury, MA: Jones & Bartlett Learning. vated RN role; greater focus on the patient; efforts
CASE MANAGEMENT MODEL
Multidisciplinary
team
LPN
Nurse Case
Patient
manager manager
Associate
personnel
RN
Figure 14-5 Case Management Model

Reproduced from Hansten, R. I., & Jackson, M. (2004). Clinical delegation skills: A handbook for professional practice.
to improve patient transitions and handoffs to particularly as changes are considered by the Trump
decrease errors and make the patient more com- administration. Changes that might be made due
fortable; leveraging of technology to enable care to change in administration are not known at this
model design, such as electronic medical records, time but require nursing input as health policy is
robots, bar coding, cell phone communication, and reviewed and revised or maintained. We need to
more; and greater emphasis on results or outcomes. recognize that even though the focus of ACA is on
The five healthcare professions core competencies healthcare reimbursement, the legislation has had an
also provide an effective start for a professional impact on many areas of healthcare delivery; some
practice model (IOM, 2003b). may then be altered if ACA is repealed or changed.
Over the last decade, many agencies, through
the establishment of state workforce centers, have
examined the issue of the nursing supply and de-
Differentiated practice has an impact on every mand related to state legislation and regulation.
nurse. State workforce centers focus on maintaining an
adequate supply of qualified nurses within a state to
meet healthcare needs (demand), providing analysis
and strategies to address unmet needs (National
Impact of Legislation/ Forum of State Nursing Workforce Centers, 2014).
This initiative has been more successful on the
Regulation/Policy on Nursing
state level than the federal/national level, though
Leadership and Practice we need both perspectives to better prepare for
supply and demand to meet staffing needs for all
Legislation, regulations, and policies emphasize the
healthcare professionals. At the national level, a
need for nurses to work collaboratively with other
provision in the ACA established the National
stakeholders in shaping health policy through legis-
Health Care Workforce Commission. Its purposes
lation and regulation. Nurses are involved and will
are fivefold:
continue to be involved at the local, state, national,
and international levels. The current critical health 1. Serve as a resource for Congress, the president,
policy issue is the Patient Protection and ACA. and localities.
The increasing cost of health care, the increasing 2. Coordinate activities of the Departments of
number of uninsured and underinsured individu- Health and Human Services, Labor, Veterans
als, and the growing aging population (along with Affairs, Homeland Security, and Education.
concerns about the long-term ability of Medicare 3. Develop and evaluate education and training
funds to cover all of their care) are all forces that activities.
helped to propel healthcare reform forward. The 4. Identify barriers to improved federal, state,
ACA, which focuses primarily on reimbursement/ and local coordination and recommend ways
insurance, affects nurses and nursing care, and now to address barriers.
the implementation phase requires active nursing 5. Encourage innovation.
participation to further develop this important The commission was designed to include 15 members
policy. It will take time to evaluate the results of (each serving a 3-year term), and the commission
this initiative with regard to individual consumer as a whole to report to Congress. Membership
satisfaction, access to care, quality of care, and of must include no less than one representative from
course, cost of care. These health policy issues have the following categories: healthcare workforce and
been and continue to be intense political battles, health professions, employers, third-party payers,
experts in healthcare services and health economics need to be involved in these initiatives because they
research, consumer representatives, labor unions, directly affect patient care every day in multiple
state or local workforce investment boards, and settings. Healthcare legislation at the state level is
educational institutions. Although this commission also important to nurses. For example, many states
was established and the Obama administration are trying to pass legislation related to mandatory
requested $3 million for the commission, this was overtime and staff–patient ratios—and some states
not allocated; thus the commission has not been have already enacted these types of laws.
operational (Buerhaus & Retchin, 2013). This is There is a nurses’ caucus in Congress made
described here as an example of how legislation up of nurses who serve in Congress. It serves as
might initiate a change, but if there is limited or no an important resource for nursing. More nurses
funding, the initiative can be blocked. With potential are needed to run for office at the local, state, and
changes in ACA under the Trump administration, national levels. Nurses who have an interest in pol-
it is unclear if this ACA provision will ever be fully itics and health policy have to plan for this activity,
activated, though it is needed. particularly if they want to run for office in the fu-
The American Academy of Nursing recently ture. This requires a career plan with a time frame,
held a technology conference to examine work mentoring, and experience in political activities.
redesign and the use of technology as a means to Regulation is also an important issue today as
transform nursing care. As this initiative evolved, change occurs both within the healthcare system
a commission on the workforce was formed, led by and within nursing. One example is an initiative to
representatives from both practice and education. change regulations related to APRNs, focusing on
It was quickly recognized that responses to nurs- changes to allow APRNs to practice independently
ing shortage problems must address the pipeline of physicians, when appropriate. Most states have
issue—that is, the faculty shortage, which in turn not enacted such changes. There is often greater
reflects on educational preparation of the workforce. emphasis on the need for changes related to such
A subcommittee addressing this issue included issues as expansion of reimbursement for APRNs
regulators from the National Council of Boards of on the federal level. Reimbursement for APRNs
Nursing, nursing education accreditation services represents a major change, and it will not be easy
such as from the National League for Nursing and to accomplish.
the American Association of Colleges of Nursing,
and officials from higher education and practice.
The focus of this work is to identify barriers to Stop and Consider #5
To improve health care, we need more nursing lead-
increasing school of nursing enrollment and rede- ership in health policy.
signing education at all levels. To make sweeping
changes in this area, regulatory bodies also need to
be included in the conversations to shape the new
nursing educational models of the future. Quality Economic Value
of education to meet required competencies and and the Nursing Profession
differences in roles and responsibilities must also be
considered. Work, such as done with this initiative, Salaries and benefits have long been a concern of
may then be used to support future legislation (state nurses, which vary across the United States. Some
or federal) to address issues. nurses have unionized to get better salaries and
There is no doubt that quality care is a major benefits and to have more say in the decision-making
issue addressed by healthcare legislation. Nurses process in the work setting. The nursing profession
as a whole has yet to develop effective methods to areas and demonstrate that they can have a major
determine their value in the reimbursement process impact on the quality of care and cost of care by
and implications for HCO budgets, and it is important developing effective interventions to assess risk and
to solve this problem. How do nurses describe the prevent these complications and prepare for more
value of nursing services? How do nurses identify effective transitions to discharge.
costs of nursing services? Some efforts have been
made to accomplish this, but there is much more
to do. Within the fragmented healthcare system, Stop and Consider #6
We still do not have consistent and effective recog-
nursing contributions are even more difficult to
nition of the economic value of nursing practice.
identify. Most HCOs’ accounting systems are not
able to capture or differentiate economic value
provided by nurses (IOM, 2010).
APRNs have brought the issue of payment for The Nursing Work
nursing services to the forefront. Some examples of Environment
issues that have arisen relate to reimbursement. The
Federal Employee Compensation Act—a law that The nursing work environment is critical for quality
provides healthcare services to federal employees care, patient satisfaction, staff satisfaction, recruitment
who are injured on the job—has become important to and retention, HCO financial stability (for example,
APRNs. It is one of the last major federal healthcare if an HCO has high staff turnover, the HCO will have
programs to deny patient access to APRNs. APRNs higher expenses associated with recruitment and
are now covered medical providers in Medicare, orientation), development of leadership and effective
Medicaid, Tri-Care, and some private insurance plans, management, and effective use of interprofessional
and they serve as medical providers in the Veterans teams. This section discusses some issues relevant
Administration, the U.S. Department of Defense, to healthy work environments.
and the Indian Health Service. If they choose, most
federal employees have access to APRNs through The Work Environment
their federal employee health benefit plan.
and Leadership
Because greater emphasis has been placed on
healthcare quality, there is now more focus on a Quality care is best provided in a healthy, func-
pay-for-performance model—third-party payers and tional work environment. Key issues are staff
government determine payment for services based safety; communication; collaborative, positive
on performance or quality care (Saver, 2006). This work relationships; work design (space/facility);
change is exemplified by the Centers for Medicare work processes; infrastructure that support staff
and Medicaid Services’ (CMS) and other insurers’ participation in decision making; and an emphasis
refusal to pay for certain complications experienced on positive work environments that support staff
by patients (hospital-acquired complications) or for and reduce staff stress/burnout and high turnover
30-day post-discharge unplanned readmissions, rates and seek to develop staff. This requires an
as discussed in content on QI. In turn, this policy environment in which staff members respect one
has an impact on nursing care and on budgetary another and incivility is controlled, as discussed
decisions related to nursing. Because nurses are in other content in this text. Nurse managers need
involved in most of the care associated with these to develop and maintain a work environment that
complications and with discharge planning, nurses engages staff in work processes, decision making,
have an opportunity to exhibit leadership in these and continuous quality improvement (CQI). Job
resources, interpersonal relationships, job perfor- 222,000 in 2014” (American Association of Nurse
mance, and proactive work behavior are factors Practitioners, 2016). The CRNA accounts for ap-
that influence the work environment (Warshawsky, proximately 20% of total APRNs (NCSBN, 2017,
Havens, & Knafl, 2012). p. 4). Staffing in all types of healthcare settings
The future of nursing report highlights the unique has an impact on staff morale, staff retention, the
needs of new graduates and recommends nurse budget, and quality care. Staffing is also a power
residency programs as a means to increase reten- issue—scheduling affects staff directly and their
tion of staff, guiding transition into the workplace ability to engage in decision making. Fairness in
and affecting the quality of care (IOM, 2010). The patient assignments and staff scheduling has a
nursing profession is currently focusing much of its positive impact on the manager–staff relationship
attention on APRNs; however, most nurses are not (Cathro, 2013). All aspects of staffing are critical in
APRNs, but rather staff nurses who have complex the workplace environment. The fact that staffing
staff needs and work in a complex environment. If needs are not static, even changing throughout the
these needs are not addressed, this omission will day, makes this a very complex workforce issue as
have a major negative impact on patient care—more noted in the following discussion.
significantly, it will affect quality as well as nursing We have a large number of RNs and will need
practice. We need to know more about the problems, more. Staffing is a critical concern in providing
but more importantly, the nursing profession needs quality care, and multiple factors need to be con-
to actively address the problems for all nurses and sidered: patient acuity and changes in status, staff
not just focus on APRNs. expertise, mix of staff, supervision, budget, staff
fatigue and stress, staff behaviors that may lead
Workforce Issues and negativity such as incivility, physical environment,
admissions and discharges, presence of students (any
Effective Staffing
type of healthcare profession student), presence and
RNs represent a large number of healthcare profes- quality of medical staff, access to resources such as
sional healthcare providers in the United States: As a pharmacist, need and methods used to transport
of September 2016, there are a total of 3,880,565 RNs patients, use of electronic documentation, position
and 913,453 licensed practical nurses and licensed descriptions, standards, policies and procedures,
vocational nurses (LPN/LVNs) in the United States access to EBP resources, presence of family members
(National Council for State Boards of Nursing or significant others, leadership within the HCO,
[NCSBN], 2016a). Of this number, 2,687,310 RNs budget, staff orientation and education, and more.
and 695,610 LPN/LVNs were employed as of May These factors demonstrate that staffing is more than
2015. Compared to 10 years ago, RN employment just the number of staff. There is increased interest
increased and LPN/LVN employment decreased. from nursing leadership to better address these factors
There are also now many more APRNs in a variety in the workplace. An example is staff fatigue from
of healthcare roles and settings. “More than 250,000 long hours and shift work. In 2016, the ANA held a
APRNs are in the United States, categorized into webinar focused on helping nurse leaders deal with
four distinct roles: the certified nurse practitioner, staff fatigue, emphasizing the need to implement
the certified registered nurse anesthetist (CRNA), evidence-based strategies to proactively address
the certified nurse midwife (CNM), and the clinical this problem—“to promote the health, safety, and
nurse specialist. Certified nurse practitioners con- wellness of registered nurses and ensure optimal
stitute nearly 70% of the total number of APRNs, patient outcomes” (ANA, 2016). The ANA also offers
with nurse practitioners reportedly numbered at resources on nurse fatigue on its website.
A topic that has long caused concern for the more problems in this area leading to staff dis-
nursing profession is potential and real nursing satisfaction, burnout, turnover, and a decrease in
shortages (American Association of Colleges of productivity. All of this may lead to a reputation
Nursing [AACN], 2014). There have been periods of of a poor place to work, and this drives employee
time when there were national shortages and regional applicants away. HCOs need to continually assess
shortages. In addition, individual HCOs may expe- these issues and institute changes to reduce stress in
rience shortages, which may be due to budget cuts, the workplace, and staffing is one of these factors.
recruitment problems, and poor HCO ratings, thus “Ensuring adequate staffing levels has been shown
reducing applications for positions and/or leading to to (ANA, 2014):
staff retention problems, and so on. A nursing shortage ■■ Reduce medical and medication errors
is expected as more nurses retire due to the number ■■ Decrease patient complications
of nurses approaching retirement age. This is coupled ■■ Decrease mortality
with a growing need for more nurses with expansion ■■ Improve patient satisfaction
of care services. According to the Bureau of Labor ■■ Reduce nurse fatigue
Statistics’ employment projections for 2012–2022, ■■ Decrease nurse burnout
released in December 2013, “Registered nursing (RN) ■■ Improve nurse retention and job satisfaction”
is listed among the top occupations in terms of job
growth through 2022. The RN workforce is expected Staff scheduling approaches should consider
to grow from 2.71 million in 2012 to 3.24 million in patient acuity; strategies for using unlicensed assis-
2022, an increase of 526,800 or 19%. The Bureau tive personnel; staff skills and competencies (skill
also projects the need for 525,000 replacements mix), education, and training required for specific
nurses in the workforce bringing the total number of settings; and effective use of delegation. Staffing
job openings for nurses due to growth and replace- levels are related to quality care and to meeting
ments to 1.05 million by 2022” (U.S. Department patient outcomes, as well as staff satisfaction and a
of Labor & Bureau of Labor Statistics, 2013). healthy work environment. For example, a recent
Staffing and related workforce issues are directly study reported that staffing in 71 acute care hospitals
related to nursing education. To meet demands, there in two states indicated that work schedules are sig-
must be sufficient graduates from nursing programs, nificantly related to patient mortality when staffing
and this means there must be sufficient qualified levels and characteristics were controlled (Trinkoff
applicants in nursing program admission pools. A et al., 2011). This study relates to earlier work done
shortage of nursing faculty has led to nursing programs led by Dr. Aiken about the impact of nurse staffing
turning away qualified students, as discussed in other on patient mortality and quality care (Aiken, Clarke,
chapters. Efforts have been made to provide funding Sloane, Sochalski, & Silber, 2002). “The safety of
for graduate education to increase the faculty pool. We nurses from workplace-induced injuries and illnesses
will also need more nurses who are competent to care is important to nurses themselves as well as to the
for the growing aging population. This will require patients they serve. The presence of healthy and
both pertinent clinical content and experiences with well-rested nurses is critical to providing vigilant
this population in nursing programs (pre-licensure monitoring, empathic patient care, and vigorous
and graduate levels) and staff education to increase advocacy” (Trinkoff et al., 2008, p. 2473). The HCO
staff competencies in this area. needs to commit to developing and maintaining a
The work environment is an important factor culture of safety, and this must include staff safety
in recruiting and retaining nurses. The environ- issues. The level of staffing impacts staff safety—for
ment is high stress; however, some HCOs have example, if there are too few staff, this may lead to
more staff stress and staff injuries—for example, ■■ Interprofessional teams work collaboratively
when lifting patients without considering the most to set and achieve goals directed toward
effective interventions and/or asking for help. innovative and effective care and efficient
Appendix B provides some guidelines about organizational systems.
staffing that are important for students to review ■■ Nurses on the team represent the voice of
to better understand staffing and scheduling. The nursing as a discipline responsible for the
guidelines also provide important information that holistic care of patients.
should be considered when searching for first nursing ■■ Positive relationships with physicians benefit
positions—staffing should be an important topic in the patient and enhance the work environ-
job interviews, and applicants need to be prepared ment for nurses.
with questions addressing this topic. ■■ Nurses must develop the skills to work col-
laboratively as professional members of the
Interprofessional Teams interprofessional team.
and the Work Environment As has been discussed in this text, teams are
a critical component of healthcare and interpro-
Interprofessional teams are critical in today’s fessional teams have become more important.
healthcare workplace, as discussed throughout Nurses, however, are also members of nursing
this text. One of the healthcare professions core teams. For both types of teams, team function-
competencies is the ability to use interprofessional ing is the same—the same teamwork principles
teams effectively as teams have a major impact on apply. A study examined whether there was a
the work environment. Despite this well-known relationship between nursing teamwork and the
need, an effective approach to preparing nursing presence of nurse-sensitive outcomes (for ex-
students and other healthcare profession students ample, pressure ulcers, falls, catheter-associated
to work on teams is still lacking. The assumption urinary tract infections) (Rahn, 2016). Rahn’s
is these individual healthcare professionals will study indicates there is a significant relationship,
be able to work on teams after they graduate—but and improving teamwork can have a positive im-
that outcome does not necessarily happen. New- pact on reducing the occurrence of preventable
house and Mills (2002, pp. 64–69) identified key adverse outcomes. Nursing needs to understand
points related to nurse–physician relationships this in order to develop education (content and
that are important in the development of effective learning experience), leadership, and practice
interprofessional teams: solutions to reduce adverse patient outcomes.
■■ All teams are not created equal, but careful This is a critical part of QI. Another factor that
development of working relationships and is important to consider with any type of team
clear goals can make all the difference. (nursing or interprofessional) is changing team
■■ Successful teams are composed of competent membership, a problem for most healthcare
team members with the necessary skills, teams. Leaders need to monitor this factor and its
abilities, and personalities to achieve the impact on team functioning. Lack of long-term
desired objectives. team membership may be a problem as well as
■■ Teams composed of many professions/ increasing the need for team orientation, which
disciplines are able to expand the number is not often a routine requirement. If a nurse
and quality of actions to improve healthcare leader can improve teamwork, this may have a
systems. direct impact on performance, improving care.
healthy work environment need to consider the

Improving the Work
five healthcare professions core competencies and
Environment critical elements in the work culture. Exhibits 14-2
Nurses need to take the lead in HCOs to improve and 14-3 describe examples of improvement
the work environment—by identifying concerns, strategies.
helping to identify supporting data and analyzing The March 2014 issue of Charting nursing’s
the data, understanding retention of staff, assisting future, a newsletter that was created following the
in the development of strategies to resolve prob- publication of The future of nursing report, describes
lems, and tracking outcomes to improve the work an emerging blueprint to transform the nurses’ work
environment and level of care. It has been noted environment that recommends providers, policy
that staff are using workarounds more, which makers, and educators use the following strategies
increases risk of errors in a work environment. (Robert Wood Johnson Foundation, 2014, p. 8):
A workaround is an effort to get something done ■■ Monitor nurse staffing and ensure that all
without following the expected process, standards, healthcare settings are adequately staffed
policy, or procedure. This situation means staff with appropriately educated, licensed, and
do not recognize or understand a potential risk certified personnel.
for error so that it is difficult to correct and im- ■■ Create institutional cultures that foster pro-
prove. Efforts to improve and develop an effective, fessionalism and curb disruptions.
Exhibit 14-2 Transition Policy and Strategies
Goal: Anticipate and prepare the nurse labor market for impending shortages, thereby reducing
their duration and impact and lowering the economic and noneconomic costs to patients,
nurses, and hospitals.
Strategies Transition Policy

Demand strategies ●● Speed up development and adoption of technology and use
nonprofessional nursing personnel more effectively
●● Remove barriers to efficiency and redesign the work content and
organization of nursing care
●● Strengthen management decision making
●● Avoid regulating nurse staffing
Supply strategies ●● Accommodate an older RN workforce
●● Accelerate improvements in working conditions
●● Expand the capacity of nursing education programs
●● Continue to inform the public about opportunities in nursing
Wage strategies ●● Assist hospitals and other healthcare employers in financing needed
RN wage increases
●● Avoid imposing controls on RN wages
Reproduced from Buerhaus, P. I., Staiger, D. O., & Auerbach, D. I. (2009). The future of the nursing workforce in
the United States: Data, trends, and implications. Sudbury, MA: Jones & Bartlett Learning.
Exhibit 14-3 Long-Run Policy and Strategies
Goal: Expand employment of RNs in the long run by eliminating barriers that lead to an
inadequate supply of RNs and by appropriately valuing the contributions of RNs.
Strategies Long-Run Policy

Supply strategies ●● Remove barriers to hiring foreign-educated RNs
●● Remove stigmas and barriers facing men and Hispanics
Demand strategies ●● Reinforce development of pay-for-performance systems
●● Increase the number of nursing-sensitive outcomes included in pay-
for-performance systems
Reproduced from Buerhaus, P. I., Staiger, D. O., & Auerbach, D. I. (2009). The future of the nursing workforce in
the United States: Data, trends, and implications. Sudbury, MA: Jones & Bartlett Learning.
■■ Harness nurse leadership at all levels of

administration and governance. Stop and Consider #7
You need to be involved in improving the healthcare
■■ Educate the current and future workforce work environment.
to work in teams and communicate better
across the health professions.
All of these strategies relate directly to the healthcare
professions core competencies discussed through- Quality Improvement
out this text. and Nursing Leadership
Finding the Right There is no question that all nurses need to be more
active in CQI. The American Organization of Nurse
Workplace for You
Executives supports nursing leadership in HCOs and
Students begin the process of finding the right work describes key principles that need to be considered
environment for themselves when their clinical courses to guide the role of the nurse in future patient care
begin. You begin to consciously or unconsciously delivery, including in CQI. This is described in
assess each work environment you encounter by Figure 14-6. Nurse managers and administrators
asking, “Would I want to work here?” In doing so, need to be leaders in the HCO in setting QI direc-
you also begin to integrate your ideas about nursing, tion and determining strategies to improve care at
“What is a nurse?” and “Is this profession right for all levels and engaging nursing staff in the process.
me?” Socialization into the profession begins at this Some nurses should serve in key QI positions. At
stage. By the time senior year arrives, you are actively the health policy level, nurses should be active at the
beginning to consider positions after graduation. local, state, and federal levels in the development
Along with your review of Appendix B to gain a of QI health policy; they may assume many roles
better understanding of staffing, which is a critical to provide leadership in the health policy-making
issue to consider when assessing positions, review process. Nursing faculty provide QI leadership by
Appendix C, which provides tips related to finding ensuring that students, both undergraduate and
the right workplace for you. graduate, are prepared to practice, understand
Figure 14-6 AONE Guiding Principles for the Role of the Nurse in Future Patient Care Delivery
Reproduced with permission from AONE. (2010). AONE guiding principles for the role of the nurse in future patient
care delivery. Retrieved from http://www.aone.org/resources/leadership%20tools/guideprinciples.shtml. © American
Organization of Nurse Executives. All rights reserved.
and know how to apply information about CQI, ■■ Making care safer by reducing harm caused
utilize EBP and EBM, and engage in CQI during in the delivery of care
clinical experiences. The following sections discuss ■■ Ensuring that each person and family is
examples of some new initiatives that relate to CQI engaged as partners in their care
and nursing leadership focused on improving care. ■■ Promoting effective communication and
The National Quality Strategy (NQS) is discussed coordination of care
in this text; however, in this chapter it is important ■■ Promoting the most effective prevention and
to emphasize that the NQS is relevant to nurses treatment practices for the leading causes
and nursing care (Kennedy, Murphy, & Roberts, of mortality, starting with cardiovascular
2013). Nurses need to understand the strategy disease
and integrate it into nursing education, practice, ■■ Working with communities to promote wide
and research. The NQS has at its center the Triple use of best practices to enable healthy living
Aim (better care, healthy people, affordable cost). ■■ Making quality care more affordable for
Its priorities are (U.S. Department of Health and individuals, families, employers, and gov-
Human Services & Agency for Healthcare Quality ernments by developing and spreading new
and Research, 2017): health care delivery models
After reviewing each of the priorities, it is clear improve? Was care monitored using indicators such
that nurses and nursing care are involved in all of as injury from falls, adverse events, readmission,
the priorities, but nurses must step up and engage voluntary turnover of RNs, patient satisfaction,
as HCOs turn to integrating the NQS in their QI and percentage of nurses’ time in providing direct
programs, as is recommended by the NQS and the patient care? Examples of some of the innovative
HHS. In addition, we need more nursing leadership ideas that have been tested are (IHI, 2017):
in all levels of health policy, and a critical example ■■ Use of rapid response teams to rescue patients
is the Trump administration’s potential changes in before a crisis occurs
healthcare delivery and reimbursement. Nurses ■■ Specific communication models that support
need to advocate for quality care for all people; consistent and clear communication among
there should be no disparities in quality care. This caregivers
requires knowledge of issues, keeping up-to-date ■■ Professional support programs such as pre-
with potential changes, providing professional input, ceptorships and educational opportunities
and monitoring progress. ■■ Liberalized diet plans and meal schedules
for patients
Transforming Care ■■ Redesigned workspace that enhances efficiency
at the Bedside and reduces waste
TCAB has an impact on care delivery and
The creation of Transforming Care at the Bedside
nursing practice by introducing effective, innovative
(TCAB) is a result of the Quality Chasm reports
changes that can then be used in many hospitals.
(IOM, 2001). The development of this initiative
This initiative provides many opportunities for
began in 2003 through the Institute for Healthcare
nurses to assume leadership in improving health-
Improvement (IHI) in conjunction with the Robert
care delivery—leadership can occur at the level of
Wood Johnson Foundation. The IHI is an effective
the staff nurse, the nurse manager, or other nurse
initiative that provides multiple strategies for im-
administrative positions. The TCAB website provides
proving health care—its website provides excellent
information on the TCAB framework and current
QI resources. “The goal is to make fundamental
TCAB projects.
improvements in the healthcare delivery system
that will result in safe and reliable care, vitality and
teamwork, patient-centered care, and value-added Magnet Recognition
care processes” (Martin et al., 2007, p. 445). In
Program®
2008, the TCAB program was implemented in
10 hospitals, starting in a hospital unit and then It is important that nurses assume active roles in
spreading throughout the hospital. The approach determining the quality of care and the nurse’s role in
that was taken was to establish pilots in hospitals at the process. Nurses run the risk of taking the blame
the level of direct care, which could, after testing, for some of the problems that are found in acute
have a greater impact on the entire organization. care today. “Politics in healthcare may not end at
The current focus areas are safe and reliable care, the bedside, but it certainly begins there. It would
vitality and teamwork, patient-centered care, and be a tragedy if patients and family members blamed
value-added care processes (Institute for Healthcare nurses for system failures. But the more nurses detach
Improvement [IHI], 2017). from their patients, the easier it becomes for the
TCAB looks not only at innovative change, rest of us (consumers) to lose sympathy” (Kaplan,
but also at the outcomes from the change. Did care 2000, p. 25). The Magnet program, which offers a
nursing professional practice model, is one way to an approval body meet established continuing
address this issue. It is the “highest credential for education standards. Recognition is a process
nursing excellence and the leading source of suc- used to evaluate an organization’s adherence to
cessful nursing practices and strategies worldwide” excellence-focused standards” (Urden & Monarch,
(Robert & Finlayson, 2015, p. 8). 2002, pp. 102–103). The Magnet program is a rec-
In 1981, researchers conducted a study that ognition program, not an accreditation program.
explored the issue of attracting and retaining nurses Magnet HCOs must also successfully receive and
(McClure, Poulin, Sovie, & Wandelt, 1983). This maintain accreditation from The Joint Commission.
study played a significant role in attempts to address The first step for an HCO that wants to apply
the shortage at that time because it identified some for Magnet status recognition is to complete a
methods for improving recruitment and retention of self-assessment using materials provided by the
nurses. The researchers sought to identify factors or program. The HCO then has a better idea about
variables that have an impact on acute care hospitals where it stands and what needs to be improved
in their staff recruitment and retention success. before completing the application to achieve
Stimulated by these results, the Magnet program recognition. The recognition process does not
was established in 1993 to be administered by the focus solely on management; staff nurses must be
American Nurses Credentialing Center’s (ANCC) involved in all steps of the process. After extensive
Commission on the Magnet Recognition Program® sharing of information, an onsite survey is com-
(ANA & ANCC, 2014). Recognition is awarded to pleted by the Magnet surveyors. Once recognition
acute care hospitals and long-term care facilities. is obtained—and not all HCOs that apply receive
The program provides a “roadmap to achieve nurs- Magnet status—the organization must maintain
ing excellence using the five model components the expected standards, participate in the National
and sources of evidence to drive organizational Database of Nursing Quality Indicators® (NDNQI)
performance focused on improving the quality (Press Ganey, 2017), and provide certain annual
of patient care while lowering costs” (Robert & monitoring reports to ensure that the requirements
Finlayson, 2015, p. 12). The five model components for Magnet recognition continue to be met over
are: (1) collaborative care practice; (2) transforma- time. Studies indicate that achieving recognition
tional leadership; (3) culture; (4) evidence, research, has a positive impact on Magnet HCOs, such as
and innovation; and (5) professional growth and improving professional practice, clinical compe-
development (ANA & ANCC, 2013a, 2013b, tence, and job experience—all of which influence
2013c, 2013d, 2013e). The model and its components staff retention rates (Aiken et al., 2008; Havens,
support the five healthcare professions core compe- 2001; Stone et al., 2006; Ulrich, Buerhaus, Done-
tencies, the Quality and Safety Education for Nurses lan, Norman, & Dittus, 2007). Recognition is not
(QSEN) competencies, and national initiatives to permanent, however, and the HCO must apply
improve care such as the Quality Chasm reports, for renewal. A website is maintained with current
including The future of nursing report, Healthy People information about the Magnet program.
2020, the NQS, and CMS QI efforts. A hospital that has Magnet status also demon-
It is not an easy process to be awarded Magnet strates a different form of management, focusing
status. It requires commitment and time from more on participative management in which staff
HCO leadership, nursing leadership, and staff. members have input into decisions, with managers
Any size HCO that meets the standards may apply listening to staff, and typically using a decentral-
for Magnet status. “Accreditation as a voluntary ized structure, such as shared governance. This
process used to validate that an organization and difference in management is evident in the role
of the nurse executive and throughout all levels 1. Working with other nurses who are clinically
of nursing management, as well as in the overall competent
organizational leadership’s support of nursing. 2. Good nurse–physician relationships
Effective leadership is present. Staff members feel 3. Nurse autonomy and accountability
the HCO nursing leaders understand their needs 4. Supportive nurse manager–supervisor
and provide resources and support for the work that 5. Control over nursing practice and practice
staff perform daily—that is, the managers demon- environment
strate transformational leadership. These hospitals 6. Support for education
have more nurses with BSN degrees because this 7. Adequacy of nurse staffing
is a Magnet requirement. Nurses are very active in 8. Paramount concern for patients
committees, projects, and so on. EBP is actively
There are now significant research results that
pursued, and the hospitals are involved in nursing
indicate that Magnet HCOs tend to provide quality
research. Clearly, staffing is of critical concern, and
care that leads to positive outcomes for patients
Magnet hospitals use innovative methods to respond
and better work environments for nurses (Aiken,
to recruitment and retention issues and provide
2002). As a result of the research on the Magnet
appropriate mix and levels of staffing per shift.
program, 14 Forces of Magnetism were identi-
Staff education is valued: There are opportunities
fied. These forces relate to the five components of
for quality staff development, and staff members
the model and are used to evaluate an HCO and
who want to pursue additional academic degrees
determine whether it can be designated as a Mag-
are encouraged to do so. Promotion can occur
net HCO (ANA & ANCC, 2013a, 2013b, 2013c,
through the management track, which is the most
2013d, 2013e). Nurses who are considering new
common method, but it also should occur through
positions might use these variables or the forces
the clinical track. These HCOs typically demonstrate
to guide their job search, as the variables assist
higher levels of quality of care, autonomy, a nursing
nurses in learning more about the HCO and help to
model, mentoring, professional recognition, staff
assess whether the HCO has a positive workplace.
education and support for career development such
If the HCO already has Magnet status, the forces
as completing baccalaureate degree or a graduate
should be present, but if not, the nurse applicant
degree, and respect of staff. They enable staff to
can still use the forces as a personal checklist. Less
practice nursing as it should be practiced.
than 8% of HCOs reach Magnet recognition, but
Research in this area did not stop with the
many more have Magnet-like characteristics that
original 1981 study. Multiple studies that support
support quality care (Robert & Finlayson, 2015).
the positive impact of Magnet recognition have been
The Magnet Program is not prescriptive and allows
conducted. These HCOs have better outcomes—lower
its recognized HCOs to be innovative as long as the
burnout rates, higher levels of job satisfaction, and
expected criteria are met. The Forces of Magnetism
higher quality of care—than non-Magnet HCOs
represent the organizational elements of excellence
(Laschinger, Shamian, & Thomson, 2001). Kramer
in nursing care (ANA & ANCC, 2017):
and Schmalenberg, reexamined 14 Magnet hospitals
and identified variables that are important in pro- 1. Quality of nursing leadership
viding quality care (2002). These variables relate to 2. Organizational structure
nursing leadership demonstrated by formal leaders 3. Management style
in management positions and by staff leaders, em- 4. Personnel policies and programs
phasizing transformational leadership and continue 5. Professional models of care
to be relevant today (pp. 53–55): 6. Quality of care
7. QI Related to THe future of nursing report, the

8. Consultation and resources Robert Wood Johnson Foundation conducted a
9. Autonomy Gallup poll in 2010 entitled “Nursing Leadership
10. Community and the HCO from Bedside to Boardroom” (Blizzard, Khoury, &
11. Nurses as teachers McMurray, 2010). The purpose of the poll was to
12. Image of nursing ask opinion leaders about their views of nursing
13. Interdisciplinary (interprofessional) relationships leadership, particularly nurses’ role and future and
14. Professional development potential barriers. Past and current Gallop Polls on
the image of nursing, as discussed in other content,
typically indicate that the public views nurses as
highly ethical and honest; however, this 2010 poll
Every nurse needs to be a leader in QI.
questioned why nurses continued to lag behind
as leaders in the healthcare delivery system. The
following were the key findings of this opinion poll
Moving the Profession about healthcare leadership and nursing (Blizzard,
Khoury, & McMurray, 2010):
Forward: Students Are the
Future of Nursing ■■ Respondents rated doctors and nurses
first and second out of a list of options for
In conclusion, we turn to the nursing report, trusted information about health and health
The future of nursing: Leading change, advancing care.
health (IOM, 2010) and assess the status of its ■■ Government and insurance executives will
recommendations. It is also important to empha- have a great deal of influence in health reform
size that nursing leadership and development of in the next 5 to 10 years.
leadership does not just apply to nurses but also ■■ Respondents perceived patients and nurses
to nursing students. as having the least amount of influence in
health reform in the next 5 to 10 years.
The Future of Nursing: ■■ Reducing medical errors and increasing the
Leading Change, quality of care are two areas where nurses
now have a great deal of influence in policy
Advancing Health
and management.
The future of nursing: Leading change, advancing ■■ Relatively few opinion leaders say nurses
health is a landmark report that addresses the need currently have a great deal of influence in
for nursing leadership. “By virtue of its numbers increasing access to care, including primary
and adaptive capacity, the nursing profession has care.
the potential to effect wide-ranging changes in the ■■ Reducing medical errors, increasing quality
healthcare system. Nurses’ regular, close proximity of care, and promoting wellness top the list
to patients and scientific understanding of care of areas in which large majorities of opin-
processes across the continuum of care give them ion leaders would like nurses to have more
a unique ability to act as partners with other health influence.
professionals and to lead in the improvement and ■■ Major barriers to nurses’ increased influence
redesign of the health care system and its many and leadership were identified as not being
practice environments” (IOM, 2010, p. S-3). perceived as important decision makers or
revenue generators compared with doctors, Susan Hassmiller, a nursing advisor to the
nurses’ focus on primary care rather than Robert Wood Johnson Foundation, identified her
preventive care, and nursing not having a vision for a 21st-century nursing workforce, which
single voice in speaking on national issues. is related to the recommendations in The future of
■■ Suggestions for nurses to take on more of a nursing report. This vision includes the following
leadership role included making their voices interconnected processes (Hassmiller, 2011):
heard and having higher expectations. ■■ Develop nurse-led innovations
These results, which were identified in 2010 just ■■ Generate evidence
as the ACA became law and THe future of nursing ■■ Redesign education
report was completed, do not paint a positive picture ■■ Embrace technology
of nursing leadership, but do identify some areas ■■ Diversify our workforce
that require active nursing strategies to improve ■■ Expand scope of practice
and develop leadership. Some of these elements ■■ Foster interprofessional relationships
have improved since 2010, but much more work is ■■ Develop leadership at every level
needed to develop nursing leadership. ■■ Be at the table
The future of nursing report focuses on three These are critical points that provide a guide for
nursing areas that need transformation: practice, improving nursing leadership and engaging nurses
education, and leadership (IOM, 2010). The leadership in the healthcare delivery process. Furthermore,
approach discussed is transformational leadership, these points also apply to nursing leadership in
with its emphasis on collaborative management. healthcare policy development and implementation
The report supports the leadership competencies to improve health and health care.
discussed throughout this text. In particular, it
supports interprofessional collaboration and QI Progress Report on The
by noting that it is important to learn “to be a full Future of Nursing: Leading
partner in a health team in which members from
Change, Advancing Health
various professions hold each other accountable
for improving quality and decreasing preventable In 2016, a critical progress report was published as-
adverse events and medication errors” (IOM, 2010, sessing the status of the recommendations from The
pp. 5–4). Leadership is needed among nurses who future of nursing: Leading change, advancing health
hold any position, and this need even extends to (IOM, 2010; National Academy of Medicine [NAM],
nurses who assume more entrepreneurial and 2016). Just as it is important to evaluate health care,
business approaches. it is also important to evaluate what the nursing
In 2014, Sigma Theta Tau International (STTI) profession accomplishes; thus, we turn to examining
joined a global effort to improve nursing leadership. what has been done to reach the recommendations
It formed the Global Advisory Panel on the Future from the 2010 nursing report and how this affects
of Nursing (GAPFON), whose purpose is to serve nursing and its role in CQI (Pittman, Bass, & Har-
as a catalyst to stimulate partnerships and collabo- graves, 2015). During the time from 2011 to 2016,
rations to advance global health outcomes (STTI & including the passage of the ACA, there has been
GAPFON, 2016). This initiative is directly related greater emphasis on CQI throughout the healthcare
to the STTI theme, “Serve Locally, Transform Re- system. The Future of Nursing: Campaign for Action
gionally, Lead Globally” (STTI, 2014). The focus is (the Campaign), which is a partnership with the Robert
global nursing leadership, an important leadership Wood Johnson Foundation and AARP, supports the
for focus for the profession. recommendations of the 2010 report and provides
a source of information and resources to assist the what services and providers it will cover in its
profession in implementing strategies to meet the reimbursement payment system, but it cannot
recommendations (Campaign for Action, 2016). dictate state law. HCOs need to then ensure that
The following content summarizes some of the all healthcare professions follow the requirements
key issues in the progress report by commenting on to meet the standards.
each of the The future of nursing recommendations 2. Expand opportunities for nurses to lead and
and outcomes. As discussed in many chapters in diffuse collaborative improvement efforts:
this book, since 1999 and the first Quality Chasm “The ACA provisions include development
reports, we have moved to a greater concern of new models of care to accommodate the
about quality, diversity and disparities, teams and large numbers of people previously without
interprofessional teamwork, cost, collaboration, access to health insurance. These models
care coordination, patient-centered care, and focus on teamwork, care coordination, and
integration of the Triple Aim (better care, healthy prevention—models in which nurses can
people/healthy communities, affordable care) in contribute a great deal of knowledge and
our view of the healthcare delivery system. The skill” (NAM, 2016, p. 15). Some of these new
progress report recommendations are related to models are accountable care organizations,
all of these issues—even more so than in 2010 nurse-managed clinics, and others. These
because there is now greater understanding of new models support and assist in meeting this
the quality care problems and greater initiatives recommendation. Collaboration is a critical
to improve. The recommendations are noted in component of care today, and it is important
bold with commentary added and relevance to CQI to effective interprofessional teamwork, one
described in italics (Finkelman, 2018, pp. 459–463; of the healthcare professions core competen-
IOM, 2010): cies identified in the Quality Chasm reports
(IOM, 2003b). Effective CQI requires care
1. Remove scope of practice barriers: In 2010, 13 coordination and collaboration from many
states met the criteria for full practice authority, stakeholders—nonclinical and clinical, health-
and since then, 8 more states have been added. care professional organizations, professional
Some states have made some changes but still education programs, accrediting organizations,
do not fully meet the criteria. The CMS has ex- government agencies, and third-party payers.
panded the scope of practice for CMS payment; The new models provide new opportunities
however, medical staff membership and hospital for nurses, and in the future, it is hoped other
privileges for APRNs continue to be based on models will be developed—and nursing roles
state laws and business preferences rather than and responsibilities expanded.
federal law. This outcome is not met with only 3. Implement nurse residency programs: At the
13 states improving since 2010, and more than time of the publication of The future of nursing
50% of the states do not meet the recommen- report, there was concern about staff turnover
dation. How does scope of practice affect CQI? It and retention, and these continue to be concerns.
affects nursing practice—what nurses do. In the The use of residency programs is one method
case of this report, the focus was on APRNs. What that may reduce this problem, and the report
APRNs and also RNs can do in their practice is focused on these programs for post-licensure
directed by state nurse practice acts. Scope of RNs. The progress report notes that there is
practice is part of each state’s nurse practice act. also need for this type of program for nurses
The CMS as a federal program can determine transitioning to new settings and for APRNs.
In 2011, the National Council for State Boards meeting the healthcare core competency related
of Nursing engaged in research about transi- to QI (IOM, 2003b).
tion-to-practice programs (NCSBN, 2016b). 5. Double the number of nurses with a doctorate
Residency programs vary, but the progress report by 2020: The recommendation does not specify
notes that they do have value in helping nurses details as to type of doctorate and number per
develop competencies important to improving type (DNP, PhD in nursing, PhD in another
practice and self-confidence in practice. There field). Enrollment in total has increased 15% in
is also need for similar programs focused on 5 years. Major barriers are funding and number
nurses in outpatient settings. This result indi- of faculty and their experience for these degree
cates there has been some progress, although programs. This level of increase makes it diffi-
more programs are needed. These programs cult to meet this recommendation by 2020. QI
are costly to develop and implement. The content should be part of all doctoral programs
American Association of Colleges of Nursing in order to develop more nursing leadership
nurse residency accreditation provides a model that understands QI and applies it in practice,
and standards for nurse residency programs education, and research.
focused on baccalaureate graduates (BSN), 6. Ensure that nurses engage in lifelong learn-
although not all existing residency programs ing: “Continuing education and competence
are accredited (AACN, 2016). The programs can have not kept pace with the needs of the
be particularly helpful in developing nurses to increasingly complex, team-based health
participate in CQI by including EBP, CQI, and care system. Nurses and other providers will
EBM content and experiences. increasingly need to update skills for providing
4. Increase the proportion of nurses with a care in both hospital and community-based
baccalaureate degree to 80% by 2020: “Bac- settings” (NAM, 2016, p. 7). We need more
calaureate program enrollment has increased data about CE, particularly about its impact on
substantially since 2010: Entry-level baccalaureate patient outcomes. As noted in other chapters,
enrollment increased from 147,935 in 2010 to there have been greater efforts to understand
172,794 in 2014; accelerated baccalaureate en- and support interprofessional CE (IOM, 2009).
rollment increased from 13,605 to 16,935; and In addition, we need to better understand the
baccalaureate completion enrollment (so-called implications of the relationship between nurse
RN to bachelor of science in nursing [BSN]) certification and credentialing and lifelong
increased from 77,259 to 130,345” (NAM, 2016, learning and their impact on practice and
p. 6). There are other important improvements patient outcomes, as well as on collaboration
such as the number of 4-year nursing programs/ and leadership. Education, including lifelong
BSNs increased, and more employers require learning, is discussed in other chapters, and
their RNs to have minimum of a BSN degree. it is critical for maintaining and developing
However, the progress report indicates a need knowledge and competencies. Lifelong learning
to continue to focus on improving nursing should include content and experiences related
education programs. Funding for degrees to CQI because this is a rapidly changing
has been relatively flat, which is a barrier to area and one in which nurses must actively
increasing enrollment. Leaders are needed in participate. If we expect staff to engage in
all types of healthcare settings to improve care. interprofessional teams within the context of
Education is needed to prepare competent nurses CQI and practice, interprofessional initiatives
who can assume roles that include CQI activities, are particularly important.
7. Prepare and enable nurses to lead change Commission, which focused on all healthcare
to advance health: There has been progress professions, including nursing. This was to be
with the Campaign and development of the a resource for gathering workforce data and
Interprofessional Education Collaborative analysis. Many states have established their
supported by the Josiah Macy Jr. Foundation. own workforce commissions; however, we
In 2013, the Campaign noted that more work also need a national perspective and one that
needs to be done to increase interprofessional includes all healthcare professions, and this is
collaboration. Leadership continues to lag—for not yet sufficiently available. One workforce
example, the percentage of nurses who serve problem that The future of nursing report
on hospital boards. In a 2011 survey of 1,000 noted was nursing workforce diversity, and
hospitals, nurses held 6% of the positions and it continues to be a problem identified in the
physicians 20%, and in 2014, physicians held progress report. Some data about diversity in
the same percentage with nurse representation the nursing have been collected. The progress
decreasing by 5%. This is not a positive out- report, however, notes that a review of 5 years
come. There are, of course, many other types is not a sufficient time period to effectively
of leadership, and nurses are involved or need evaluate these outcomes. The progress report
to be more involved in a variety of leadership notes, “African Americans make up 13.6 percent
situations. Hospital boards direct the vision and of the general population aged 20 to 40, and
goals of hospitals, including CQI, and thus are 10.7 percent of the RN workforce, 10.3 percent
important to nursing; however, other types of of associate’s degree graduates, and 9.3 percent
boards in the community and for other types of baccalaureate graduates. The disparity is even
of HCOs are just as important (Walton, Lake, greater for Hispanics/Latinos, who make up
Mullinix, Allen, & Mooney, 2015). Commu- 20.3 percent of the general population aged
nicating the need for nursing leadership and 20 to 40, but only 5.6 percent of the RN
what nurses can offer has progressed, but this workforce, 8.8 percent of associate’s degree
effort has primarily focused on informing graduates, and 7.0 percent of baccalaureate
nurses. More needs to be done to inform other graduates. Men make up just 9.2 percent of
healthcare professionals, patients, families, the RN workforce, 11.7 percent of baccalau-
and so on about the roles of nurses, and not reate nursing students, and 11.6 percent of
just during the annual National Nurses’ Week. graduates” (NAM, 2016, p. 9). Important focus
Changes in health care and in roles require that points are recruitment, retention, and success
we consider QI implications and ensure that in nursing education programs. Diversity needs
standards are met. to be a workforce priority. The progress report
8. Build an infrastructure for the collection identifies barriers to data collection that need
and analysis of interprofessional health- to be addressed: lack of consistent national
care workforce data: This book discusses indicators to provide consistent state-to-state
measurement—how it works and barriers to data, lag time in data collection and reporting,
success. The progress report notes similar con- lack of standardized databases, and need to use
cerns in assessing the outcomes of The future proxy measures to assess progress in meeting
of nursing recommendations. Data must be The future of nursing recommendations. The
collected and analyzed to drive decisions. As lack of a national infrastructure (the commis-
discussed earlier, the ACA included a provision sion) to meet this recommendation continues
to establish the National Healthcare Workforce to be a major problem. Workforce data are also
important to CQI. This information provides communities” (Dzau, McClellan, & McGinnis,
greater understanding of the current status of 2017). The initiative goals are highlighted in content
problems related to staffing levels and mix and throughout this text.
competent staff (all healthcare professions, not
just nursing). This information can then be used Student Leadership
to develop strategies to address these problems, Students need to begin developing their leadership
address problems with recruitment and retention skills while in their nursing educational program.
as a component of ensuring quality care and This can be done by participation in student or-
reducing errors, and support funding for health ganizations, such as the National Student Nurses
professions education and identify improvements Association; working to be invited into STTI; or
that might be needed in health professions edu- assuming leadership roles in courses and in other
cation programs. on-campus and off-campus activities. Developing
The progress report concludes with: “Continued leadership takes time, and every nurse needs lead-
work is needed to remove scope-of practice barriers; ership competencies to practice in today’s complex
pathways to higher emphasis on increasing diver- healthcare system. Leadership development does
sity; avenues for continuing competence need to be not necessarily have to be done only in a nursing
strengthened; and data on a wide range of outcomes context—your involvement in campus activities
are needed—from the education and makeup of and other organizations are all opportunities to
the workforce to the services nurses provide and develop leadership and learn more about yourself,
ways in which they lead. A major and overarching communication, teamwork, handling conflict,
need is for the nursing community, including The and so on.
Campaign, to build and strengthen coalitions with Moving forward implies change. Many people
stakeholders outside of nursing. Nurses need to do not like change or do not feel comfortable with it.
practice collaboratively; continue to develop skills During an interview, the nurse leader Porter-O’Grady
and competencies in leadership and innovation; and stated, “Our work isn’t changing. Change is our
work with other professionals, as no one profession work.” He tells nurses, “If you looked at change
alone can meet the complex needs of the future of like that, it wouldn’t be an enemy” (Saver, 2006,
health care” (NAM, 2016, p. 16). Progress has been p. 24). Patton, another nurse leader who served as
made, but not enough. Assessing some of the original president of the ANA, advised: “See opportunities
report’s recommendations using a 5-year time span instead of challenges” (Saver, 2006, p. 24). Nurses
is not sufficient time to determine if recommenda- entering the profession have before them a healthcare
tions are met, but this is enough time to identify delivery system in need of repair, as has been noted
some weaknesses in reaching recommendations that by many experts and reports. This challenge can be
require more effort. seen as an impossible task or as an opportunity for
If we are to develop nursing leadership and nurses to step up and assume new roles and expand
be more engaged, then we need to get involved in old roles, if need be. Reforming the U.S. healthcare
all aspects of healthcare change. As an example delivery system requires that nurses are educated;
of change described by the National Academy of are competent in all five healthcare professions
Medicine in a recent article about its initiative Vital core competencies; provide quality nursing care;
directions for health and health care, the future will are able to communicate and collaborate effectively
be one of interaction: “policy and practice in the with others; use political skills; and advocate for
nation’s health, healthcare, and biomedical science patients, families, communities, and the nursing
profession. Nurses need to base their decisions on five core competencies (IOM, 2003b), but is not
EBP and EBM, whether they are in clinical practice, yet fully realized:
management, or education. They need to under- 1. Provide patient-centered care
stand the possibilities that come with technology, 2. Work in interdisciplinary/interprofessional teams
participate in determining how technology can be 3. Employ EBP
used, and then use it effectively. Change should be 4. Apply QI
based on data and analysis of data—for example, 5. Utilize informatics
from nursing research. Data are also associated
This text’s content is an introduction to nurs-
with CQI, another area in which nurses need to
ing as a profession; to the healthcare system; and,
step up and participate so that they are among the
most importantly, to patients, their families, and
healthcare professionals who drive QI, thereby,
communities. Nursing is a dynamic profession with
influencing how health care is provided. Last but
multiple possibilities. A nurse can participate in many
not least, nurses of the future need to recognize that
different nursing positions throughout the nurse’s
money drives most decisions. Understanding how
career. Some positions require additional education;
money flows and how to communicate the value
others do not. As described in this chapter, nurses
of nurses and nursing care are important nursing
practice in many different settings. The future holds
responsibilities.
more change that will lead to new possibilities. You
Linda Burns-Bolton, vice president and chief
will have the responsibility as a nurse to participate
nursing officer at Cedars-Sinai Medical Center,
actively in the profession to advocate for your patients
believes that in the future, “Nurses will get the evi-
(individuals, families, populations, communities)
dence they need when they need it, get information
and demonstrate leadership in your practice.
for patients when they need it, deliver safe care,
communicate with team members, engage with
family members, and leave work feeling satisfied” Stop and Consider #9
As a nursing student, you need to begin developing
(Saver, 2006, p. 25). Her view of the future really leadership competencies now.
covers the key elements found in this text and the
CHAPTER HIGHLIGHTS
1. There is much change occurring in nursing all the clinical, management, or education
and in health care today. positions that they may hold.
2. Transformational leadership is the most 5. Nursing practice occurs in multiple settings,
effective leadership style. Transformational positions, and specialties.
leaders are confident, self-directed, honest, 6. Differentiated practice, shared governance,
loyal, and committed, and they have the and collaboration are important elements
ability to develop and implement a vision. of a successful professional practice model.
3. A leader may or may not hold a formal 7. Legislation, regulation, and policy
management position. emphasize the need of nurses to work
4. Nurses should influence how the health- collaboratively with other stakeholders in
care delivery system works and be actively shaping health policy through legislation
involved in healthcare delivery changes in and regulation.
(Continues)
8. The economic value of nursing focuses on system focused on direct care—“at the
salaries and benefits, but it also needs to bedside.”
consider the value of nurses themselves 13. The future of nursing: Leading change,
and how the healthcare delivery system advancing health (IOM, 2010) report has
values nursing care. had a major impact on nursing education
9. Quality care requires a work environment and practice.
focused on the need for a healthy, functional 14. The progress report for The future of
work environment. nursing: Leading change, advancing health
10. Nurses need to assume active leadership (IOM, 2010; NAM, 2016) indicates we
roles in CQI. still have much to do to meet the original
11. The Magnet Recognition Program recognizes recommendations.
HCOs that provide quality nursing care or 15. Students have responsibility to develop
excellence in nursing care. leadership competency.
12. The goal of the TCAB program is to make
improvements in the healthcare delivery
1. Why is leadership important in nursing? Your classmates. How does the issue apply to
response should demonstrate knowledge leadership?
of the differences between leadership and 3. What is the Magnet Recognition Program?
management. Why is it important?
2. Consider one of the issues in this chapter 4. Why should you as a student begin to work
and conduct a literature review on an issue on your leadership competencies?
that interests you. Share your critique with
1. What is a nursing professional practice model? 2. Visit YouTube on the Internet, and search
Describe one type of model. Is one used in for “nursing” or “nurses.” What do you find?
a clinical site where you have been? If so, View one of the selections and critique the
what is it? How do the nurses demonstrate image portrayed. Discuss your findings in a
the model in their practice? What do you team with classmates.
think about the model?
(Continues)
3. In a team with your classmates, consider how 4. After completing Critical Thinking Activity 3,
the five core competencies might be used each team should review another team’s
as a framework for a professional practice vision and decide which education, regula-
model. Describe your model in narrative tory, and practice issues apply to the vision.
form and graphically on large paper your What is the role of leadership?
instructor provides. Post it in the classroom.
Each team should then explain its model.
Electronic Reflection journal

Develop your vision of the future of nursing. How does it compare with the “real
world”? Save this vision and review it every 6 months while in school to see if your
vision changes; then review it again after graduation as you enter into practice. You may find your
vision of the future of nursing changes.
CASE STUDIES
Case 1
The CNL functions as a care coordinator either at the unit level or in a practice. For
example, Ms. Apple heads up a busy practice in a cancer institute. As a CNL, she acts as
a mentor to novice nurses while coordinating care and helping patients navigate the
healthcare maze.
In one patient’s case, Ms. Apple identified the need for transportation to and from
radiation appointments. She also recognized financial counseling needs because the
patient was no longer able to work, and her husband was on disability. Treatment plans
needed to be explained, and teaching the patient about medications was necessary.
A referral had been made to a radiation interventionist. The family needed knowledge
about the problems and explanation about all aspects of care. The CNL pulled the
interprofessional team together to ensure clear communication and the creation of an
interprofessional plan of care.
In some institutions, these positions are called nurse navigators; in others, CNLs,
depending on the organization’s structure and needs. The CNL, having expertise in
interprofessional communication, financial management, and human relations, serves the
patient and family to protect and ensure quality patient-focused care and promote safety.
(Find out more about nurse navigators: Pruitt, Z., & Sportsman, S. (2013). The presence and
roles of nurse navigators in acute care hospitals. Journal of Nursing Administration, 43(11),
592–596.)
Case Questions
1. Search the Internet to find HCOs that have CNL and nurse navigator positions. What can
you learn about these positions?
2. Find nursing programs on the Internet that offer the CNL master’s degree. Compare
and contrast them.
3. How does these new positions apply or not apply to the five healthcare professions core
competencies?
Case 2
You have taken a new position as a head nurse for a 30-bed unit. You have been working
in the hospital for 7 years—for the first 4 years as a staff nurse and for the last 3 years as the
assistant nurse manager on a surgical unit. However, the new position means you have to
change units. The chief nursing officer arranged for you to have a mentor, another nurse
manager, to help you as you transition to the new role and new unit. Before you meet with
your mentor for the first time as a mentee, you consider the following questions.
Case Questions
1. What is your personal view of the transformational leadership style? Do you feel competent
in applying this style? Why or why not? How might the leadership style of the previous
nurse manager affect your transition to the position?
2. What should your unit assessment plan include as you assume your new role?
3. You have been told that the unit has an RN retention problem that has been increasing
over the last 2 years. What more do you need to know about the problem?
4. The nursing department uses shared governance. How might this affect you and your
new position?

Write a brief paragraph that describes a case related to the following questions.
1. But if we want to be better leaders what should we do?

2. If you are not in a management position, I do not understand why this is important.
3. How might we use The future of nursing report and the follow-up progress report?
REFERENCES
Aiken, L. (2002). Superior outcomes for Magnet hospitals: American Nurses Association, & American Nurses’ Credentialing
The evidence base. In M. McClure & A. Hinshaw (Eds.), Center. (2013e). Transformational leadership: Criteria for
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Appendix A
Quality Improvement Measurement
and Analysis Methods
This appendix presents examples of QI measurement and analysis methods and information related to
quality care. This information is applicable to your clinical experiences throughout your nursing program
as you develop QI competency and leadership.
Definitions: Errors ■■ Overuse: Potential for harm that exceeds the

possible benefit from a service.
■■ Error: Failure of a planned action to complete as ■■ Underuse: Failure to provide a service that would
intended or use of the wrong plan to achieve a have produced a favorable outcome for the patient.
goal. (Also search for this topic on the Institute ■■ Near miss: Recognition that an event occurred
for Healthcare Improvement website: http:// that might have led to an adverse event. An error
www.ihi.org.) almost happened, but staff or the patient/family
■■ Adverse event: An injury resulting from a medical caught it before it became an error.
intervention, not due to the patient’s underlying ■■ Active error: An error that results from noncom-
condition. It may or may not be due to an error pliance with a procedure.
and may or may not be preventable. If the ad- ■■ Omission: Missed care should also be considered
verse event is viewed as result of an error, then an error.
it is considered preventable. (Also search for this ■■ Common errors: Falls, medication errors, devel-
topic on the Institute for Healthcare Improvement opment of pressure ulcers due to inadequate skin
website: http://www.ihi.org.) care, surgical errors such as wrong site, diagnosis
■■ Misuse: An avoidable complication that prevents (wrong diagnosis, incomplete diagnosis, and so
patients from receiving the full potential benefit on), wrong patient identification, lack of timely
of services. response, development of nosocomial infections,
507
508 Appendix A: Quality Improvement Measurement and Analysis Methods
wound infections, not washing hands, equipment ■■ Health literacy: See the Provide Patient-Centered
failure, inappropriate use of restraints or used in Care chapter. Health literacy can affect errors—for
unsafe manner, documentation errors or inade- example, if the patient does not understand the
quate documentation, poor discharge planning discharge directions or cannot read them, an
or directions. error could occur.
■■ Sentinel event: Unexpected events that happen to
patients and that result in major negative outcomes
Examples of Typical Errors
such as an unexpected death or critical physical
or psychological complication that can lead to or Concerns of Inadequate
major alteration in the patient’s health. (Also Quality Care
search for this topic on the Institute for Health- ■■ Hospital-acquired conditions (HACs): See the
care Improvement website: http://www.ihi.org.) Healthcare Delivery System: Focus on Acute Care
chapter and the following websites:
Examples of High Risk for ■■Centers for Medicare & Medicaid Services,
Errors and/or Reduced Hospital-Acquired Infections: http://www.cms
.gov/Medicare/Medicare-Fee-for-Service-Payment
Quality Care
/HospitalAcqCond/Hospital-Acquired_Conditions
■■ Working in silos: Not working as a team or us- .html and http://www.cms.gov/Medicare
ing poor communication; individuals or pairs /Medicare-Fee-for-Service-Payment/Hospital
working with little consideration of others who AcqCond/index.html.
may be working on the same issue, with the same ■■ Agency for Healthcare Research and Quality in-
patient, and so on. patient quality indicators:
■■ The Joint Commission Annual Safety Goals: See ■■Volume indicators/measures are proxy, or
the annual goals posted on the website: http:// indirect, measures of quality based on counts
www.jointcommission.org/standards_information of admissions during which certain intensive,
/npsgs.aspx. high-technology, or highly complex procedures
■■ Handoffs: A handoff occurs when a patient expe- were performed. They are based on evidence,
riences a change in provider or setting and there suggesting hospitals that perform more of these
is a transfer of responsibility. (Also search for this procedures may have better outcomes for them.
topic on the Institute for Healthcare Improvement ■■Mortality indicators/measures for inpatient
website: http://www.ihi.org.) procedures include procedures for which
■■ Medication reconciliation: See the Apply Quality mortality has been shown to vary across
Improvement chapter. (Also search for this topic institutions and for which there is evidence
on the Institute for Healthcare Improvement that high mortality may be associated with
website: http://www.ihi.org.) poorer quality of care.
■■ Workaround: Occurs when staff use a shortcut ■■Mortality indicators/measures for inpatient pro-
to get something done so they do not complete cedures include conditions for which mortality
all the steps or substitute different steps in a pro- has been shown to vary substantially across
cess. This often happens when staff are behind; institutions and for which evidence suggests
rather than figure out the problem they are ex- that high mortality may be associated with
periencing, they use a workaround. (Also search deficiencies in the quality of care.
for this topic on the Institute for Healthcare ■■Utilization indicators/measures examine pro-
Improvement website: http://www.ihi.org.) cedures whose use varies significantly across
Appendix A: Quality Improvement Measurement and Analysis Methods 509
hospitals and for which questions have been ■■ Employee surveys: Written questionnaires used to
raised about overuse, underuse, or misuse. get information from employees on a particular
■■ Primary and secondary data: Primary data are data topic—for example, staff safety.
collected from firsthand experience; secondary ■■ Patient/family surveys: Written questionnaires
data are collected by others. used to get information from patients/families on
■■ Prevalence and incidence: Prevalence is the pro- a particular topic—for example, patient and/or
portion of the population that has a condition or family views of quality care and experience while
risk factor. Incidence is the rate of occurrence. hospitalized. A common standardized survey used
■■ Benchmarking: Measuring quality across healthcare by hospitals is offered by Press Ganey. (See the
organizations based on same standards. website: http://www.pressganey.com/index.aspx)
■■ Report cards: A published report that provides in- ■■ Flow charts and decision trees: Methods used to
formation about the quality of care for a healthcare describe a process so it can be clearly understood
organization or provider. (See examples at NCQA’s to improve the process or use to help identify when
website: http://reportcard.ncqa.org/portal/home a process is not effective. (Search “decision trees”
.aspx and http://www.ncqa.org/Directories.aspx.) on Yahoo Images or Google Images.)
■■ Incident reports: Healthcare organizations require ■■ Patient safety indicators (PSI): A set of indicators
that certain incidents, such as medication errors, providing information on potential in-hospital
are reported in written form using a standard complications and adverse events following
form. This provides a record and helps in tracking surgeries, procedures, and childbirth. The PSIs
errors for improvement. were developed after a comprehensive literature
■■ Root-cause analysis (RCA): A method used by many review, analysis of ICD-10-CM codes, review
healthcare organizations today to analyze errors, by a clinician panel, implementation of risk
supporting the recognition that most errors are adjustment, and empirical analyses. They can be
caused by system issues and not individual staff used to help hospitals identify potential adverse
issues. This in-depth analysis is intended to iden- events that might need further study, provide the
tify causes and then consider changes that might opportunity to assess the incidence of adverse
be required to reduce risk of reoccurrence. (Also events and HACs using administrative data
search for this topic on the Institute for Healthcare found in the typical discharge record, include
Improvement website: http://www .ihi.org.) indicators for complications occurring in hos-
■■ Failure mode and effects analysis (FMEA): A tool pitals that may represent patient safety events,
that “provides a systematic, proactive method for and design area-level analogs to detect patient
evaluating a process to identify where and how safety events on a regional level. (See the Agency
it might fail and to assess the relative impact of for Healthcare Research and Quality for more
different failures in order to identify the parts i nformation: http://qualityindicators.ahrq.gov
of the process that are in most need of change” /Modules/psi_overview.aspx.)
(Institute of Health Improvement, 2011). (Also ■■ Interviews: One-on-one collection of data that
search for this topic on the Institute for Health- can be done in person or on telephone.
care Improvement website: http://www.ihi.org.) ■■ Observation: Using staff or outside individuals to
■■ Plan–do–study–act (PDSA): A process that is watch a procedure or work process and collect
used in planning; four steps are followed to reach data on what occurs. This information is then
effective results. (Also search for this topic on the used to track errors, improvement, and so on. An
Institute for Healthcare Improvement website: example would be to have observers watching staff
http://www.ihi.org.) to determine compliance with hand washing.
510 Appendix A: Quality Improvement Measurement and Analysis Methods
■■ Quality measures: Tools that help measure or Institute for Healthcare Improvement website:
quantify healthcare processes, outcomes, patient http://www.ihi.org.)
perceptions, and organizational structure and/ ■■ Change of shift reports: Clinical reports are done
or systems that are associated with the ability routinely, particularly in hospitals units, for bringing
to provide high-quality health care and/or that new staff coming on up-to-date regarding patient
relate to one or more quality goals for health status. Such a report is also an opportunity to
care. These goals include safety, timely, efficient, discuss quality and safety concerns for individual
effective, equitable, patient-centered (STEEEP) patients or for the unit or team as a whole.
and timely care (Centers for Medicare and Med- ■■ Safety walkarounds: Staff (usually management
icaid Services [CMS]). (See more information at but can be other staff) walk through the unit or
http://www.cms.gov/Medicare/Quality-Initiatives area of the healthcare organization and identify
-Patient-Assessment-Instruments/QualityMeasures any safety concerns they may see that would apply
/index.html.) to patients, families and visitors, and staff. This
■■ Time-out: During a procedure, the team may use information is then used to plan improvement
a checklist to confirm the right patient, site, and including prevention measures.
procedure. If any staff member thinks there may ■■ Crew resource management (CRM): This is a
be an error, that staff member can call a stop to communication method used in aviation to
any actions so that the correct information can improve communication and decision making,
be determined—for example, if the wrong site is providing a clear structure for the process. (Also
identified and actions taken to ensure that care search for this topic on the Institute for Healthcare
provided meets required outcomes. Improvement website: http://www.ihi.org.)
■■ Checklist: A consistent method for ensuring that ■■ Surveillance: This is the ongoing assessment of
what needs to be done is done. The checklist is patient status to identify problems and/or preven-
simple and requires limited, if any, training to tion of potential problems; nurses are primarily
use it. (Also search for this topic on the Institute responsible for surveillance. Not doing surveillance
for Healthcare Improvement website: http:// may result in failure to rescue.
www.ihi.org.) ■■ Universal protocol for preventing wrong site, wrong
■■ Situation–background–assessment–recommendation procedure, or wrong person surgery: The Joint
(SBAR/ISBAR): SBAR is a structured method of Commission established a procedure to prevent
communication that is used to improve commu- wrong-site, wrong-procedure, and wrong-person
nication; commonly used with teams. See the surgery errors. This procedure requires staff to
Work in Interprofessional Teams chapter. (Also utilize the following steps: (1) preprocedure verifi-
search for this topic on the Institute for Health- cation, (2) site marking, and (3) use of time-outs.
care Improvement website: http://www.ihi.org.) Any staff member may call a time-out if the staff
■■ Rapid response team (RRT): A team of critical member thinks there is a problem at any point
care experts who can be called if there is concern during the procedure.
about failure to rescue so as to respond quickly ■■ Early warning aystem (EWS): A “physiolog-
to complex and critical needs of patients. (Also ical scoring system typically used in general
search for this topic on the Institute for Health- medical–surgical units before patients experi-
care Improvement website: http://www.ihi.org.) ence catastrophic medical events” (Duncan &
■■ Huddle: This is a means by which a team gets McMullan, 2012, p. 40). This is what triggers
together periodically during a shift to discuss the use of the rapid response team to prevent
critical issues. (Also search for this topic on the failure to rescue.
Appendix A: Quality Improvement Measurement and Analysis Methods 511
■■ Morbidity and mortality conferences: M&M in healthcare delivery has assisted in improving
conferences are held in many hospitals on a rou- timely communication that meets the need at the
tine basis to discuss patient care and outcomes. time. See the Utilize Informatics chapter.
■■ Trigger points: Clues that there may be an ad- ■■ Bar coding: Bar coding is used routinely in med-
verse reaction. Staff may use standardized lists ication administration and other times when
of trigger points. identification of patient and action need to be
■■ Electronic medical/health record: Documenta- ensured. See the Utilize Informatics chapter.
tion is now most commonly done via electronic ■■ Safety primers (AHRQ): See AHRQ’s patient
methods, which improve timely communication safety primers webpage (http://psnet.ahrq.gov
and usually have a positive impact on care. See /primerHome.aspx) for information on a variety
the Utilize Informatics chapter. of important safety concerns.
■■ Computerized physician/provider order-entry
system (CPOES): The CPOES is used to improve References
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■■ Computerized decision support (CDS): CDS offers
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making and is usually associated with electronic trieved from http://www.ihi.org/knowledge/Pages
medical records. See the Utilize Informatics chapter. /Tools/FailureModesandEffectsAnalysisTool.aspx
■■ Use of other technology (for example, smartphones, Institute of Medicine. (2004). Keeping patients safe.
handheld computers): Increased use of technology Washington, DC: National Academies Press.
Appendix B
Staffing and a Healthy Work

Environment
Staffing: What a New Nurse 2. Evaluation of any staffing system should include
quality of nurses’ work–life outcomes as well
Needs to Know as patients’ outcomes.
When you search for your first job as a new graduate, 3. Staffing should be based on achieving quality
it is critical that you inquire about staffing—who of patient care indices, meeting organizational
does the staffing plan, how far in advance is staffing outcomes, and ensuring that the quality of
done, which methods are used, how inadequate nurses’ work life is appropriate.
staffing areas are covered, and whether overtime is Developing staffing schedules and then main-
required. Nurses need information about staffing taining staffing as care is delivered are complex and
and the input they have in staffing. time-consuming management activities. Nursing
management uses different methods to determine
American Nurses Association the level of staff required, such as patient acuity
Staffing Principles assessment tools. Some states have legislated staff-
ing requirement criteria. The following are some
The American Nurses Association (ANA) staffing guides that nursing management uses to support
principles, which were reissued in 2010, support the staffing decisions:
need for adequate staffing to deliver quality patient ■■ Current Nursing: Scope and Standards of Nursing
care. Three underlying assumptions of these prin- (ANA)
ciples provide guidance for staffing decisions and ■■ Appropriate scope and standards of specialty
are the major ethical concerns related to staffing: nursing practice
1. Nurse staffing patterns and the level of care pro- ■■ Current state nurse practice act and scope of
vided should not be based on the type of payer. practice information (state board of nursing)
513
514 Appendix B: Staffing and a Healthy Work Environment
■■ Current Code of Ethics with Interpretive State- into account the heterogeneity of settings);
ments (ANA) variability of care; admissions, discharges, and
■■ Copies of relevant facility policies and procedures transfers; volume.
(for example, staffing, floating, temporary staffing 3. Context: Architecture (geographic arrangement
agency use) of patient areas, size and layout of individual
■■ Copies of the current collective bargaining agree- patient rooms, arrangement of entire patient
ment/contract (if applicable) care units, and so forth); technology (use of
■■ Copies of contracts with outside staffing agencies page systems, cellular phones, computers).
■■ Information on competencies of agency staff 4. Expertise: Learning curve for individuals and
■■ Bill of Rights for Registered Nurses (ANA) groups of nurses; staff consistency, continu-
ity, and cohesion; cross-training; control of
The ANA staffing standards are divided into
practice; involvement in quality improvement
three categories. First, the principles of the patient
activities; professional expectations; prepa-
care unit focus on the need for appropriate staffing
ration; experience; and interprofessional
levels at the unit level. These standards reflect
teamwork.
both the analysis of individual patient needs and
aggregate patient needs, and the unit functions
that are important in delivering care. The second Staffing Terminology
category focuses on staff-related principles, such Nurse staffing includes not only RNs but also licensed
as the type of nurse competencies needed to practical nurses (LPNs)/licensed vocational nurses
provide the required care as well as role responsi- (LVNs) and unlicensed assistive personnel (UAPs).
bilities. The third category involves institutional All of these staff members provide direct care. RNs
or organizational policies. These policies should and LPNs are licensed by the states in which they
indicate that nurses are respected, and they should are employed. The state board of nursing in each
state a commitment to meeting budget require- state regulates state licensure. RNs assess patient
ments to fill nursing positions. Competencies needs, develop patient care plans, and administer
for all nursing staff (employees, agency, and so medications and treatments, and they must meet the
on) should be documented. A clear plan should state’s nurse practice act requirements. LPNs carry
describe how float staff are used and the required out specified nursing duties under the direction of
cross-training for these staff so that they are prepared RNs. Nurses’ aides typically provide nonspecialized
to practice in multiple areas of care. Staff members duties and personal care activities. Some states re-
need to know if they may be switched from one quire that UAPs complete a certification program,
unit to another. There must be a clear designation at which point they are referred to as certified nurse
of the adequate number of staff needed to meet a assistants.
minimum level of quality care. The nursing model Hospitals and other healthcare organizations
that is used has an impact on staffing. (HCOs) have written position descriptions for
The principles identify four critical elements RNs, LPNs, and UAPs. These descriptions should
that need to be considered when making staffing be followed. They influence staffing because the
decisions (ANA, 2010, p. 23): descriptions identify what staff members may do,
1. Patients: Patient characteristics and number of which in turn affects the staff mix. Nurse staffing
patients receiving care. is measured in one of two basic ways:
2. Intensity of unit and care: Individual patient ■■ Nursing hours per patient per day
intensity; across-the-unit intensity (taking ■■ Nurse-to-patient ratio
Appendix B: Staffing and a Healthy Work Environment 515
Nursing hours may refer to RNs only; to RNs and errors (Geiger-Brown & Trinkoff, 2010; IOM, 2004;
LPNs; or to RNs, LPNs, and UAPs. It is important to Montgomery & Geiger-Brown, 2010; Trinkoff,
know which staff category is identified by the nurse Johantgen, Storr, Gurses, Liang, & Han, 2011).
staffing measurement. Nursing care hours refers to Trinkoff and colleagues (2011) examined the
the number of hours of patient care provided per independent effect of work schedules on patient
unit of time or over the course of a specified time. care outcomes. Their study surveyed 633 nurses
The term full-time equivalent is used to describe in 71 acute care hospitals in two states. The results
a position equal to 40 hours of work per week for indicate that work schedule related significantly to
52 weeks, or 2,080 hours per year. One full-time patient mortality when staffing levels and hospital
equivalent can represent one staff member or sev- characteristics were controlled. Other concerns are
eral members; that is, a full-time equivalent can increased risk of infections among staff who are
be divided (for example, two staff members each fatigued and ergonomic stressors, accidents that
working half a full-time equivalent). Many nursing result from driving home tired, and responsibili-
units employ part-time staff. ties at home that further increase nurses’ fatigue
The staffing mix describes the type of nursing (Geiger-Brown & Trinkoff, 2010; Worthington,
staff needed to provide care. This mix should be 2001). More research needs to be done to determine
determined by considering the type of care needed the impact of shifts on fatigue and errors.
and patient status, as well as the qualification and Split shifts are used to provide more staff at
competencies needed to provide the care. In some busy times of the day (such as 7:00–11:00 a.m. or
cases, the staff must be RNs; in other situations, a later in the day). Part-time staff usually fill in during
mix of RNs, LPNs, and UAPs is needed, with the split shifts, and this has implications for consistency
RN supervising. This issue is often a concern when of care and quality with increased risk of errors.
the proportion of RNs is compared with other types “Moving away from 12-hour shifts will require a
of nursing staffing. Another factor that needs to be real change in hospital culture” (Montgomery &
considered is the work level and work flow; for exam- Geiger-Brown, 2010, p. 148).
ple, the typical time for discharges and admissions The staffing schedule can contribute to many
or the surgical schedule can make a difference as negative results. Because staff usually do not get
to when more or fewer staff members are needed off on time, longer shifts can compound the prob-
(distribution of staff). lems associated with 12-hour shifts. For example,
when staff work 10- or 12-hour shifts instead of
Scheduling 8-hour shifts, staying 1 hour past the end of their
shifts can be very difficult. This is a frequent oc-
The shift, or typical pattern of time worked, is an currence because some staff may be arriving late
important factor in scheduling. Some areas of care or not coming at all, and temporary coverage is
use multiple types of shifts, whereas others have only needed until additional staff coverage is found.
one type. Typical shifts are 8, 10, and 12 hours in This makes a 10- or 12-hour shift much longer. In
length. More and more hospitals are using 12-hour some HCOs, staff are required to rotate shifts so
shifts, and some schools of nursing are using 12-hour that they may switch back and forth from the day
clinical rotations for students. Staff members often shift to the night shift. This can be hard for many
prefer the 12-hour shift because it allows for more nurses, although some like to work the night shift.
days off (40 hours can add up quickly). However, Scheduling is not easy and causes a lot of conflict
there has been concern about 12-hour shifts and among staff. Nurses invariably want more say in
the resulting fatigue level that may lead to more scheduling. Some organizations use computerized
request systems so that staff can input their special of the staffing and to work with one another to
staffing requests, and others do this in writing or come up with the most effective arrangement. It
orally. When staffing is posted is also of concern also reduces the time that the nurse manager or
because staff need to make their personal plans. another scheduler might spend on staffing. More
The procedures for schedule changes need to be staff input and control over staffing usually results
known by all staff. The trend is for HCOs to develop in greater staff satisfaction and less absenteeism,
staffing schedules centrally, although some may do which leads to greater staff empowerment.
it unit by unit. In addition, a non-nurse scheduler The schedule inevitably has holes—positions
is more common today (Cavouras, 2006). This on the schedule for which there is no staff member
model has disadvantages because it may leave out assigned. What does the HCO do? One method
or limit important input from nurse managers. HCOs use to fill holes in the schedule is to develop
However, “one of the most important reasons that a float pool. This is a group of staff (RNs, LPNs, or
people (nurse managers) leave hospital nursing is UAPs) who may be moved from unit to unit based
frustration with schedules and staffing” (Cavouras, on need. These staff members need to be competent
2006, p. 36), so it is important to find a balance. in the relevant area of care and should be flexible
Scheduling must consider patient needs; staff com- and able to adjust quickly to new environments.
petencies; individual staff issues such as days off, Float pool staff are HCO employees who are not
vacation time, sick leave, and so on; organization assigned to a specific unit. Staff members who float
needs; legislative and regulation requirements; union need orientation and training related to the types
requirements; shortage concerns; use of external of care that they are expected to provide.
sources for staff (for example, agencies); standards; When nursing shortages become a serious
and rising labor costs. problem, hospitals increase the number of staff
Patient classification systems may be used who are not permanent employees of the HCO but,
to assist with staffing levels. These computerized rather, temporary employees. Agency nurses are
systems are used to identify and quantify patient nurses hired by a nursing agency; the agency then
needs, which can then be matched with staffing contracts with an HCO for specific types of staff to
level and mix. It is thought that these systems are meet schedule requirements. Some hospitals contract
more objective because data related to patients and with one supplemental staffing agency, whereas
their needs are used to determine the number and others contract with multiple agencies to meet
type of staff required per shift. their staffing needs. An agency nurse is paid by the
Some organizations or patient care/clinical agency (typically more than regular HCO staff),
units use self-scheduling (Hung, 2002). With this must be licensed, and should meet employee com-
system, guidelines are developed for the schedule. petency qualifications or any other criteria required
Staff members are then given a certain amount of by the HCO. Work assignments can be for one shift,
time to fill in the schedule based on the guidelines. for several days, or for weeks or months.
Individual staff members do need to consider the Another method for responding to incomplete
schedules that other staff members have already schedules or lack of staff to fill all positions needed
posted. When the designated time period is com- is the use of travelers. Travelers are nurses who
pleted, the nurse manager (or a staff member who work for an agency, but not a local agency. They are
is responsible for completing the schedule) reviews hired by the agency and then assigned to work at an
it and makes any required changes or additions HCO for a block of time (more than a few days and
to ensure that staffing is adequate. This type of often several months). The nurse may come from
scheduling allows staff to feel more in control anywhere in the United States. The agency pays
Appendix B: Staffing and a Healthy Work Environment 517
the nurse’s salary and benefits, and often moving, moving on to other jobs. Both new nurses and
travel, and housing expenses are covered by the experienced nurses may change positions and
HCOs that use the travelers. Salaries are often very employers. Nurse turnover is very costly. What are
high for these nurses. Nurses can decline a specific some of the costs and benefits of turnover? The
assignment, and moving is required. Nurses might following describe some of these costs that con-
even be assigned a management position. Nurses tinue to be problems and related benefits (Jones &
who are employees of the HCO are often concerned Gates, 2007):
about the pay difference; traveling nurses, as well as
Nurse Turnover Costs
regular agency nurses, typically earn much more than
the full-time employees, which can cause conflict. ■■ Advertising and recruitment
Travelers must meet the requirements to practice ■■ Vacancy costs (for example, paying for agency
in the state and the HCO requirements. nurses, overtime, closed beds, and hospital di-
All these nurses need orientation and should versions when the emergency department must
not be expected to just “get to work.” It is not easy be closed)
to change from one HCO to another because HCOs ■■ Hiring (review and processing of applicants)
are not all the same. The nurse has to learn quickly ■■ Orientation and training
to work with a new team. More experienced nurses ■■ Decreased productivity (loss of staff who know
are better at making this transition, and many of routines)
the traveling nurse agencies hire only experienced ■■ Termination (processing of termination)
nurses. Although the fluctuations in the nursing ■■ Potential patient errors; compromised quality
shortage have decreased in some areas, when the of care
shortage begins to increase again, which will occur ■■ Poor work environment and culture; dissatisfac-
when more nurses retire, there will be greater need tion; distrust
again to use alternative staffing strategies. ■■ Loss of organizational knowledge (loss of staff
who know the history of the organization and
processes)
Recruitment
Recruitment in nursing involves the recruitment Nurse Turnover Benefits for the HCO
of both nurses and nursing students. Some im- ■■ Reductions in salaries and benefits for newly
provement has occurred in recruitment of nursing hired nurses versus departing nurses
students, increasing supply. Recruitment is a critical ■■ Savings from bonuses not paid to outgoing nurses
function of HCOs—they must maintain sufficient ■■ Replacement nurses bringing in new ideas, re-
staffing levels of competent staff. This requires a ality, and innovations, as well as knowledge of
recruitment plan that is revised based on needs and competitors
a plan that includes input from management and ■■ Elimination of poor performers (this is not guar-
staff. Clear position descriptions provide guidance anteed, it is merely hoped)
to the types of staff needed.
Creating a Healthy Work
Retention Environment: Retaining
Nurses
After new staff are recruited, they need to be re-
tained. HCOs want to avoid a situation in which Working in a healthcare environment can be a very
staff do not stay in their positions—for example, positive experience, particularly if the environment
is one in which staff are respected, communica- ■■ Staff–management conflict

tion is open, staff feel empowered and part of the ■■ Distrust of staff and staff distrust of management
decision-making process, staff safety and health
are considered important, and staff feel that they References
are making a contribution. This, however, is not
always the case. Staff experience stress, burnout, and American Nurses Association. (2010). Utilization guide
conflict in the workplace. Some signs that students for the ANA principles for nurse staffing (reissue).
and staff should watch for in themselves, in others, Silver Spring, MD: Author.
Cavouras, C. (2006). Scheduling and staffing: Innovations
and in organizations follow.
from the field. Nurse Leader, 4(4), 34–36.
Personal Signs Geiger-Brown, J., & Trinkoff, A. (2010). Is it time to pull
■■ Irritability the plug on 12-hour shifts? Part 1. The evidence.
Journal of Nursing Administration, 40(3), 100–102.
■■ Lack of sleep or too much sleep
Hung, R. (2002). A note on nurse self-scheduling. Nursing
■■ Complaining about many aspects of work
Economics, 20(1), 37–39.
■■ Unwillingness to help others Institute of Medicine. (2004). Keeping patients safe: Trans-
■■ Desire to just get the job done and leave forming the work environment of nurses. Washington,
■■ Less enjoyment during personal time DC: The National Academies Press.
■■ Dreading going to work Jones, C., & Gates, M. (2007). The costs and benefits
■■ High frustration with management of nurse turnover: A business case for nurse re-
■■ Angry outbursts tention. Online Journal of Issues in Nursing, 12(3).
■■ Gaining or losing weight Retrieved from http://www.nursingworld.org/Main
■■ Lack of energy MenuCategories/ANAMarketplace/ANAPeriodicals
/OJIN/TableofContents/Volume122007/No3Sept07
Attitude and behavior affect others, too—co-workers
/NurseRetention.aspx
and family. Burnout is contagious because of this Montgomery, K., & Geiger-Brown, J. (2010). Is it time to
impact. Morale can decrease as staff members try to pull the plug on 12-hour shifts? Part 2. Barriers to
cope with their own stress and burnout. This affects change and executive leadership strategies. Journal
productivity and the quality of care. of Nursing Administration, 40(4), 147–149.
Trinkoff, A., Johantgen, M., Storr, C., Gurses, A. P.,
Organizational Signs
Liang, Y., & Han, K. (2011). Nurses’ work schedule
■■ Inadequate or confused communication characteristics, nurse staffing, and patient mortality.
■■ Top-down decision making, leaving staff out Nursing Research, 60(1), 1–8.
■■ Poorly planned change that is unsuccessful Worthington, K. (2001). The health risks of mandatory
■■ Increase in staff complaints overtime. American Journal of Nursing, 101(5), 96.
Appendix C
Getting the Right Position

which to apply those rules and to expand clinical
Career Development—First
reasoning and judgment.
Step: First Nursing Position Getting your first job as an RN is a very im-
Career development is a responsibility of every portant step in your career development. Even
nurse. This process really begins before graduation before graduation, you should take some time to
from a nursing program and completion of licensure begin a career plan. The plan will change over time,
requirements. but having a plan provides a guide for personal
professional decisions.
From Student to Practice:
Reality Shock Tools and Strategies to Make
Reality shock has been identified in nursing as the Transition Easier
the shock-like reaction that occurs when initial Where to begin? You should begin by developing a
education comes in conflict with work-world résumé, composing a biosketch, and maintaining
values (Kramer, 1974). Another definition is “the a professional portfolio. A résumé is a one- or
incongruency of values and behaviors between two-page document that describes your career. It
the school subculture and the work subculture includes your name, contact information, credentials,
that leads to role deprivation or reality shock” education, goals and objectives, and employment
(Schmalenberg & Kramer, 1979, p. 2). Benner and relevant experience (a résumé should be kept
(1984) identified five stages of competence: novice, current and not be lengthy). The biosketch is a
advanced beginner, competent, proficient, and paragraph that provides a short summary of your
expert. The first three stages are affected by reality work history and accomplishments. It should
shock. Through the nursing education process, include your name, credentials, and education. It
the novice nurse learns the rules for performance is a narrative rather than a list. Later, curriculum
but has limited real-life clinical experience during vitae can be developed. This is a more detailed
519
520 Appendix C: Getting the Right Position
accounting of information found in the résumé and Make sure you know how to get to the interview,
includes publications, presentations, continuing and arrive early to allow yourself time to focus
education (CE), honors and awards, community on the interview. Delays can happen when you
activities, and grants. least expect it, so planning to arrive early helps to
The portfolio provides evidence of a person’s prevent lateness.
competency. It is not always required for job During the interview, focus on the questions.
applications, but sometimes it is, and in some Look the interviewer in the eye, take a moment to
positions, nurses are asked to maintain a portfolio respond, and ask for clarification if you are unsure
for performance review. A portfolio is a collection about the question. Share information about compe-
of information that demonstrates experiences tencies and experiences—successes and challenges,
and accomplishments, such as committee work, and how you handled them. Ask the interviewer
professional organization activities, presentations, about the organization and the position.
development of patient education material, awards, When the interview is completed, thank the
letters of recognition, projects and grants, and so interviewer. Follow-up to thank him or her (in a letter
on. The portfolio should include annual goals and or via email). Ask about the process—what comes
objectives and review of outcomes, which should next, when the decision will be made, and so on.
be updated annually. Exhibit C-1 suggests examples of questions to
A professional development plan, which is based ask at an interview.
on information found in your résumé and portfolio,
lays out the direction you want to take with your Determination of the Best Fit:
career over the next year, 2 years, and 5 years. It You and a New Position
should include a target time frame and strategies How does one choose a position and an organization
and activities to reach the goals. Self-assessment is for employment? It is not easy to know that the fit
a critical activity for any nurse, and this assessment is a good one. First, know which type of nursing
helps you to further develop the career plan. interests you and why. Second, based on what you
know about the HCOs in the location where you
Interviewing for a New Position want to work, focus on those organizations that
Interviewing for a new position as a nurse should most interest you. Today, the Internet is a resource
be taken seriously. The first step is setting up the for job hunting. Most HCOs, particularly hospitals,
interview. As the potential employee, you should have websites. Explore them to learn about specific
find out the time of the appointment, the location, HCOs. Talk to people who may know about the
and the length of the interview. Will there be more HCOs that interest you.
than one interview on the same day? Will additional Students often have clinical experiences in several
interviews take place later depending on whether HCOs, and they can use this opportunity to assess
the person is considered for the position? Will the each organization. Do staff members seem happy
interview be with one person or with a group and working there? Does the HCO differentiate degrees
with whom? Do your homework; find out as much in nursing and how? What is the quality of care? What
as possible about the healthcare organization (HCO) are some of the negative aspects of the organization?
and people who will be at the interview, and think Salary and benefits are always an important
about the types of questions might be asked and factor. Potential employees should also consider
how to respond to them. Wear business dress, look driving distance, parking, schedules, and general
neat, and be prepared. Bring a copy of your résumé work conditions. Asking about promotions and
to all interviews and any other required documents. use of career ladders can yield helpful information,
Appendix C: Getting the Right Position 521
Exhibit C-1 Examples of Questions to Ask during an Interview

for a Hospital RN Position
●● Do you have an opening on one of your ●● What is the turnover rate of RNs in the unit
___________ units in this hospital? For what and the healthcare organization?
shift? ●● What is the relationship of RNs and
●● Would you hire a new BSN-prepared nurse physicians on the unit?
to work in that unit? If not, why not? ●● Is a team concept practiced on the unit? If
●● What is the position description for the so, who are the members of the team?
job? (Ask to see it.) ●● Is the hospital a Magnet hospital? (Even
●● Which skills or knowledge (beyond basic if the HCO is not a Magnet hospital,
preparation) would I need? Magnet forces are a good guide for HCO
●● How can I obtain these skills or knowledge? characteristics to consider and to inquire
●● What are the opportunities for about.)
advancement in the unit? ●● What orientation is provided? Are
●● What is the culture of the unit? mentors provided for new staff (who
●● Is mandatory overtime; rotating shifts? (If and for how long)? What is the view of
so, ask more about this.) career development (staff education and
●● How is scheduling done? When is it done? academic)?
What kind of notification of scheduling is ●● What are the salary and benefits? (Typically
given? Is there staff input into scheduling? not asked at the initial interview, but later
●● Who is the nurse manager, and how long when the HCO indicates an interest in
has the manager been in the position? hiring an applicant.)
●● What is the leadership style of the ●● Does the HCO have a union? (If so, ask
manager of the unit? more about its function and membership.)
Reproduced from Milstead, J., & Furlong, E. (2008). Handbook of nursing leadership: Creative skills for a culture
of safety. Sudbury, MA: Jones & Bartlett Learning.
along with how much support is given to staff for having problems retaining nurses and developing
education (that is, orientation, staff development, strategies to cope with a nursing shortage. (Nursing
CE, and academic degrees). Regarding education, shortages vary and may be HCO specific, local, or
a potential new employee should ask if tuition national.)
reimbursement is available and for whom and Is the HCO used for clinical experiences for
at which level. Is it difficult to get release time to nursing students? This usually means that the orga-
attend classes, or is there flexible staffing to allow nization is interested in education, but it also means
for this? that staff members need to be willing to work with
Nurses should also ask about staff turnover, students. How is medical staff coverage handled? Are
use of supplemental staffing (agency, travelers), there medical students and residents? It is important
mandatory overtime, and change in nurse leaders. to know who covers for medical issues because this
Organizations that experience high turnover in has an impact on expectations of nursing staff and
staff and nurse managers are organizations that collaboration with others. Today hospitals are ranked
are experiencing problems. Overreliance on sup- locally, by state, and nationally. This information
plemental staff indicates that the organization is can be accessed through the Internet.
522 Appendix C: Getting the Right Position
The HCO’s top leadership, such as the chief I, II, III, and so on. The first level is entry level.
executive officer (CEO), is an important person. The levels describe the role and responsibilities,
The CEO signs off on the budget. If the CEO does as well as the educational requirements for that
not recognize the importance of nursing to the position or level. This type of system provides clear
organization and to outcomes, this can have a criteria for promotion and an increase in salary
negative impact on how nurses are treated, and that does not require moving to a management
it can affect such budget issues as the number of position, which in the past was the most common
nursing positions, salaries and benefits, and funds path for advancement. The career ladder structure
for education. recognizes that clinical work is important and
deserves recognition. Nurses have to demonstrate
that they meet the criteria for the level that they
Mentoring, Coaching,
are requesting. This is the point at which a nurse
and Networking might use a portfolio and mentor. In some HCOs,
Several methods are used in HCOs to support new portfolios are required for promotion. Along with
staff, and mentoring is one of them. The mentor is identified criteria, HCOs need clear procedures for
more experienced and usually is selected by the staff staff members who want to apply for a change in
nurse, but some HCOs assign new staff to mentors. level within the career ladder system.
The mentor acts as a role model and serves as a Encouraging staff to participate in the career
resource. Coaching is another method used for ladder offers positive outcomes for the organization,
support, encouragement, and career development such as motivating staff to improve their competen-
(for example, how to prepare for a promotion or cies and increase their education level, increasing
change of career ladder level or to go back to school efforts to improve care, serving as an attractive
for a higher degree). recruitment strategy, and increasing retention.
Networking is a less structured method. All Performance improvement should be an active part
nurses need to learn how to network or make of any nursing position. Through an active, positive
connections with nurses and others who can help performance improvement program, staff can use
them. Professional organizations are good places to self-assessment and assessment from supervisors
network and meet nurses who might provide guid- to further develop their career plans.
ance, support, and/or information. Nurses should
keep contact information of potential connections Going Back to School,
even when they may not have a specific reason to
Certification, and CE
make the contact; one never knows when this in-
formation may become important. Networking can Returning to school for another degree may not be
also be done in non-healthcare settings that include your first thought after graduation and licensure, but
people who may be helpful to know. when you develop a career plan, additional education
should be considered. This decision should be based
on your goals and timeline. You need to consider the
Career Ladder
best time to begin work on additional education.
Many HCOs today have developed career ladder Competency is an important issue. Do you need
programs for their nurses. The details of these more time to achieve competency and to further your
career ladders vary from organization to organi- development as a professional nurse before entering
zation. Typically, there are levels such as Clinician a graduate program or a specialty? Some specialties
Appendix C: Getting the Right Position 523
may require certain type of practice experience before CE programs, and some offer web-based programs.
entering a graduate program—for example, nurse Many CE programs are offered via the Internet. Some
anesthesia programs require practice experience in states require that RNs earn a certain number of
critical care. Entering into such specialties requires contact hours prior to relicensure. Certified nurses
serious thought and planning. Additional education must meet CE requirements to continue their cer-
is most productive when you are competent at your tification. CE is more effective if the content relates
current position level and practice effectively as a to the work that the nurse does and is in alignment
professional nurse. For many new graduates, achieving with the nurse’s professional goals. Nurses should
this level of competency takes time. keep a file of CE activities and update their records
Certification is another way to expand com- accordingly.
petencies and education; however, it does require
that you have a specified amount of experience
before taking the examination. Thus you need References
to plan when to apply and obtain the required
Benner, P. (1984). From novice to expert, excellence and
experience. power in clinical nursing practice. Menlo Park, CA:
CE is a professional responsibility. Employers Addison-Wesley Publishing Company.
may provide educational experiences that also allow Kramer, M. (1974). Reality shock: Why nurses leave nursing.
nurses to earn CE contact hours, or they may cover St. Louis, MO: Mosby.
expenses for staff to attend CE programs outside Schmalenberg, C., & Kramer, M. (1979). Coping with
the HCO. Many professional organizations offer reality shock. Wakefield, MA: Nursing Resources.
Glossary
Academic Health Center (AHC) A medical Advanced Practice Registered Nurse
center with acute care hospital and other services that (APRN) A registered nurse with advanced educa-
is directly associated with medical, nursing, and other tion in adult health, pediatrics, family health, women’s
healthcare profession education institutions. Academ- health, neonatal health, community health, or other
ic faculty usually serve in some of the key roles in the specialties.
center. An AHC may include several hospitals such as adverse event An injury resulting from a med-
acute care and pediatric. ical intervention (in other words, an injury that is not
academic nursing A college of nursing associ- caused by the patient’s underlying condition).
ated with an AHC. advocacy Speaking for something important (one
accelerated program A nursing degree that is of the major roles of a nurse).
offered for students who have a non-nursing degree advocate A nurse who speaks for the patient but
and want to obtain a nursing degree, which is typically does not take away the patient’s independence.
a baccalaureate degree in nursing or may be combined
Affordable Care Act of 2010 (ACA) This
with a master’s degree. The program is offered at a
law was passed to revise healthcare reimbursement
faster pace.
in the United States and to increase the number of
accountability An obligation or willingness to persons who have access to health insurance.
accept responsibility.
alarm or alert fatigue With the increasing
accreditation The process by which organiza- use of alarms on equipment in health care and the
tions are evaluated on their quality, based on estab- frequency in which they are set-off in healthcare set-
lished minimum standards. tings, staff may not respond to alarms as expected.
acute care Treatment of a severe medical condi- annual limit A defined maximum amount that
tion that is of short duration or at a crisis level. an employee/policy holder/patient would have to pay,
acute illness An illness of short duration with and after that level is reached, he or she no longer has
limited impact on the person. to contribute to the payment for care.
advance directive A legal document that allows applied (or clinical) research Research
a person to describe his or her medical care preferences. designed to find a solution to a practical problem.
525
526 Glossary
apprenticeship A nursing program developed integrated clinical environment and characterized

in England that provided on-the-job training and a by a proactive delivery of evidence-based care and
formal education component. follow-up.
articulation agreement A formal agreement care transition See also handoffs.
between two or more institutions that allows specif- caregiver Someone who provides care to another;
ic programs at one institution to be credited toward not a healthcare professional.
direct entry or advanced standing at another. caring Feeling and exhibiting concern and empa-
assertiveness Confronting problems in a con- thy for others.
structive manner and not remaining silent. case management A system of management
associate degree in nursing A degree offered that facilitates effective care delivery and outcomes for
as culmination of a 2-year program that includes some patients through structured care coordination.
liberal arts and sciences curriculum but focuses more certification A process by which a nongovernmen-
on nursing. tal agency validates, based on predetermined standards,
autonomy The quality or state of being self-gov- an individual nurse’s qualification and knowledge for
erning; the freedom to act on what you know. practice in a defined functional or clinical area of nursing.
baccalaureate degree in nursing A degree change agent Someone who engages deliberate-
from a 4-year nursing program in a higher education ly in, or whose behavior results in, social, cultural, or
institution. behavioral change.
basic research Research designed to broaden check-back See also call-out. In structured team
the base of knowledge rather than solve an immedi- communication, team members respond to call-out to
ate problem. ensure correct care is provided.
benchmarking Measurement of progress toward checklist A method used to ensure consistent
a goal, taken at intervals prior to the program’s com- steps are taken to ensure quality care is provided; the
pletion or the anticipated attainment of the final goal. list is provided by the HCO for staff use (for example,
bias A predisposition to a point of view. prior to surgery).
blame-free environment An environment chronic disease A disease that a person experi-
that encourages reporting of errors and focuses more ences long term that affects the person’s quality of life.
on a systematic view of errors rather than individual clinical data repository An information ware-
causation. house that stores data longitudinally and in multiple
breach of confidentiality Confidential forms, such as text, voice, and images.
information shared with others when it should not clinical decision support systems (CDSS)
be shared. Computerized system integrated into an electronic
breach of duty The proximate (foreseeable) medical record system to provide immediate infor-
cause or the cause that is legally sufficient to result in mation that can influence clinical decisions.
liability for harm to the patient; a breach of due care. clinical experience Practicum that occurs
burnout A deterioration of attitude in which a when students with faculty supervision provide care
person becomes tired, defensive, frustrated, cynical, to patients for learning experiences.
bored, and generally pessimistic about the job; exhaus- clinical information system A method of
tion of physical or emotional strength. data storage generally used at the point of care.
call-out In structured team communication, staff clinical judgment The process by which nurses
speak up and tell members of the team that something come to understand the problems, issues, and con-
does not appear to be correct and ask for checks by the cerns of patients; to attend to salient information;
team to ensure correct care is provided. and to respond to patient problems in concerned and
care coordination Establishment and support involved ways. It includes both conscious decision-
of a continuous healing relationship, enabled by an making and intuitive response.
Glossary 527
clinical protocols/pathways Written des conflict resolution A process of resolving a

criptions of how care is best provided for a specific dispute or disagreement.
patient population with specific problem(s). consumer/customer The ultimate user of a
clinical provider order-entry system product or service.
(CPOES) A data-entry system that allows health- continuing education (CE) Systematic pro-
care providers to input orders into a computer system fessional learning designed to augment knowledge,
rather than writing them. skills, and attitudes.
clinical reasoning The nurse’s ability to assess continuity of care “The degree to which a series
patient problems or needs and analyze data to accu- of discrete events is experienced as coherent and
rately identify and frame problems within the context connected and consistent with the patient’s medical
of the individual patient’s environment. See also clin- needs and personal context” (Haggerty, Reid, Freeman,
ical judgment. Starfield, Adair, & McKendry, 2003, p. 1219).
code of ethics A list of provisions that makes continuous quality improvement (CQI)
explicit the primary goals, values, and obligations of An organized approach to identify errors and hazards
the nursing profession; published by the American in care, and to improve care overall that emphasizes
Nurses Association. that this is an ongoing process.
coding system A set of agreed-upon symbols continuum of care Care services available to
(frequently numeric or alphanumeric) that is used to assist an individual throughout the course of his or
change information into another form so that it can her disease.
be better accessed and used.
coordination Proactive methods to optimize
collaboration Cooperative effort among health- health outcomes.
care providers, staff, and multiple organizations who copayment The fixed amount that a patient may
work together to accomplish a common mission. be required to pay per service (doctor’s visit, lab test,
colleagueship Workplace relationships with prescription, etc.).
common interests. coping The process of managing taxing
communication The exchange of thoughts, mes- circumstances.
sages, or information. corporatization Business; the business of health
community The people and their relationships care.
that use common services and share specific space counselor A person who gives guidance in a spe-
environment. cific area of expertise or knowledge.
compassion fatigue The feeling of emotion credentialing A process used to ensure that
that ensues when a person is moved by the distress practitioners are qualified to perform and to monitor
or suffering of another, leading to a state of psychic continued licensure.
exhaustion.
critical thinking Purposeful, informed, out-
competency A behavior of a student or staff come-focused (results-oriented) thinking that requires
member is expected to demonstrate. careful identification of key problems, issues, and risks.
computer literacy Knowledge of basic computer culture The knowledge and values shared by a
technology. society or a group/organization.
concept/care map An innovative approach to culture of safety A work environment that does
planning and organizing nursing care. not focus on individual actions as cause for errors but,
confidentiality The responsibility to keep patient rather, considers impact of system factors, emphasiz-
information private, except as required to communi- ing a blame-free culture or just culture.
cate in the care process and with team members. curriculum An integrated course of academic
conflict A state of opposition between persons, studies that describes the program’s philosophy, level,
ideas, or interests. and terminal competencies for students, or what they
528 Glossary
are expected to be able to accomplish by the end of discrimination “Differences in care that result
the program. from bias, prejudices, stereotyping and uncertainty in
dashboard A method, or part of electronic meth- clinical communication and decision-making” (IOM,
ods, to provide a quick view of data using key elements 2002, p. 4).
of concern. disease management An approach to man-
data Discrete entities that are described objectively agement of chronic diseases that emphasizes use of
without interpretation. interprofessional teams with expertise in the specif-
data analysis software Computer software ic disease, use of evidence-based clinical guidelines,
that can analyze data. clear descriptions of interventions and procedures and
application of recommended timelines, patient sup-
data bank A large store of information, which
port and education, and measurement of outcomes.
may include several databases.
disease prevention Focuses on interventions
data mining Locating and identifying unknown
to stop the development of disease, but also includes
patterns and relationships within data.
treatment to prevent disease from progressing further
database A collection of interrelated data, often and leading to complications. The major levels of pre-
with controlled redundancy, organized according to a vention are primary, secondary, and tertiary.
scheme to serve one or more applications.
disparity An inequality or a difference in some
debriefing A method used to review a situation, respect.
incident, or experience immediately following; assists
distance education A set of teaching and/
in identifying factors that support effective response
or learning strategies to meet the learning needs of
and those that limit response (for example, faculty–
students separate from the traditional classroom and
student debriefing after simulation, healthcare team
sometimes from traditional roles of faculty (for exam-
debriefs after a patient experiences a cardiac arrest).
ple, an online course).
deductible The part of the bill that the patient
diversity All the ways in which people differ,
must pay before the insurer begins to pay for services.
including innate characteristics (for example, age,
delegatee The person to whom someone dele- race, gender, ethnicity, mental and physical abili-
gates a task. ties, and sexual orientation) and acquired charac-
delegation The transfer of responsibility to com- teristics (for example, education, income, religion,
plete a task that is within the scope of the transferee’s work experience, language skills, and geographic
position. location).
delegator The person who assigns responsibility Doctor of Nursing Practice (DNP) A termi-
or authority. nal degree that provides a clinical doctorate in nursing.
dichotomous thinking Seeing situations as do not resuscitate (DNR) A form of advance
either good or bad, or black or white. directive that may be part of an extensive advance
differentiated nursing practice A philoso- directive. This order means that there should be no
phy that focuses on the structuring of roles and func- resuscitation if the patient’s condition indicates need
tions of nurses according to education, experience, for resuscitation.
and competence. educator A person who teaches others; typically
diploma schools of nursing Nursing pro- a professional such as a nurse or teacher.
grams associated with a hospital that offer a nursing effective care The provision of services based
degree that is not offered through a college or univer- on scientific knowledge (evidence-based practice) to
sity setting; typically 3 years in length. all who could benefit, and refraining from provid-
direct care provider A healthcare provider ing services to those not likely to benefit (avoiding
who delivers care to a patient(s). underuse and overuse).
direct entry program See also accelerated efficient care Care that avoids waste, including
program. waste of equipment, supplies, ideas, and energy.
Glossary 529
electronic health record (EHR) An elec executive branch The branch of the U.S. gov-
tronic record that provides a complete review of the ernment in charge of enforcing and executing the laws.
person’s health and medical care; person has access to experimental study A type of research design
it and can then be shared across healthcare providers. in which the conditions of a program or experience
electronic medical record (EMR) A medical (treatment) are controlled by the researcher and in
record in a digital format. which experimental subjects are randomly assigned
email list A list of email addresses that can be used to treatment conditions. This design must meet three
to send one email to all addresses at one time. criteria: manipulation, control, and randomization.
e-measurement The secondary use of electronic extended care The provision of inpatient skilled
data to populate standardized performance measures. nursing care and related services to patients who
empower To give power to another. require medical, nursing, or rehabilitative services.
empowerment Having power or authority. failure to rescue (FTR) The inability to recog-
nize a patient’s negative change in status in a timely
encryption Changing written information, espe-
manner in order to prevent patient complications and
cially patient information, into a code that protects the
to prevent major disability or death.
privacy of data for security purposes.
family Two or more individuals who depend on
entrepreneur An innovator who recogniz-
one another for emotional, physical, and/or financial
es opportunities to introduce a new process or an
support.
improved organization.
followers Members of a team.
equitable care The provision of care that does
not vary in quality because of personal characteris- for-profit An organization that must provide
tics such as gender, ethnicity, geographic location, and funds to pay stockholders or owners; this affects the
socioeconomic status. availability of money for other purposes that have an
error The failure of a planned action to be complet- impact on nurses and nursing.
ed as intended or the use of the wrong plan to achieve Forces of Magnetism The identified effective
an aim; errors are directly related to outcomes. descriptors of healthcare organizations that are des-
ethical decision making Ethical dilemmas ignated as Magnet organizations by the Magnet Rec-
that occur when a person is forced to choose between ognition Program®.
two or more alternatives, none of which is ideal. fraud A legal term that means a person deliberately
ethical dilemma Occurs when a person is forced deceived another for personal gain.
to choose between two or more alternatives, none of groupthink Occurs when all group or team mem-
which is ideal. bers think alike. While all of the team members might
ethical principles A standardized code or guide be working together smoothly, groupthink limits
to behaviors for the nursing profession. choices, discourages open discussion of possibilities,
and diminishes the ability to consider alternatives.
ethics A standardized code or guide to behaviors.
handoff A clinical situation (care transition) that
ethnicity A shared feeling of belonging to a group;
occurs when the patient is passed from one provider
peoplehood.
or setting to another; increasing the risk for errors.
ethnocentrism The belief that one’s group or
culture is superior to others. health The state of well-being; free from disease.
evidence-based management (EBM) Use health disparity An inequality or gap in health-
of evidence such as research to support management care services that exists between two or more groups.
decisions. health informatics technology (HIT)
evidence-based practice (EBP) The integra- Informatics that focuses on healthcare delivery.
tion of the best evidence into clinical practice, which Health Insurance Portability and Acc
includes research, the patient’s values and preferences, ountability Act of 1996 (HIPAA) A law
the patient’s history and exam data, and clinical expertise. that amended the Internal Revenue Code of 1986 to
530 Glossary
improve portability and continuity of healthcare infor- indicator A standard of aggregate performance
mation and ensure privacy of patient information. measures used to monitor quality improvement.
health literacy The ability to understand and use indirect care provider A provider who does
health information. not provide direct care to a patient (for example, a
health promotion Effort to stop the develop- laboratory technician who prepares a test but does not
ment of disease by emphasizing wellness; includes ever see the patient).
treatment to prevent a disease from progressing fur- informatics An integration of nursing science,
ther and causing complications. computer science, and information science to manage
healthcare quality “The degree to which health and communicate data, information, knowledge, and
services for individuals and populations increase the wisdom in nursing practice.
likelihood of desired health outcomes and are consistent information (cognition) overload An
with current professional knowledge” (IOM, 1990, p. 4). “interpretation that people make in response to break-
healthcare report cards A report that pro- downs, interruptions, interruptions of ongoing proj-
vides specific performance data for an organization ects, or imbalances between demand and capacity”
at specific intervals, with a focus on quality and safety. (Weick, 2009, p. 76).
healthy community A community that information Data that are interpreted, organized,
embraces the belief that health is more than merely or structured.
an absence of disease. information literacy The ability to recognize
Healthy People 2020 A federal initiative to when information is needed and to locate, evaluate,
improve the health of all citizens in the United States and effectively use that information.
by establishing goals and leading indicators for com- informed consent Permission required by law
munities to strive for; results are monitored and then to explain or disclose information about a medical
used to adjust the initiative (goals and indicators). problem and treatment or procedure so that a patient
home care The provision of healthcare services can make an informed choice or informed consent
in the home. with potential participants in a research study.
hospice care A philosophy of care for managing Institutional Review Board (IRB) An orga-
symptoms and supporting quality of life as long as nization’s (academic, healthcare) review of studies that
possible for the terminally ill. may be conducted by employees and/or conducted
in its organization to ensure that the study meets the
hospital-acquired complications (HACs) requirements (for example, participant privacy and
Identification of complications that occur in the confidentiality; this is done by the IRB).
hospital that could have been preventable and the
patient did not have on admission. The Centers for internship/externship A program that offers
Medicare and Medicaid Services and some insurers nursing students employment (typically during
have identified specific HACs that they will not cover the summer) and includes educational experiences
in reimbursement. such as seminars, special speakers, and simulation
experiences.
hypothesis A formal statement in a research
study describing the expected relationship or rela- interoperability “The ability of a system to
tionships between two or more variables in a specified exchange electronic health information with and use
population (the sample). electronic health information from other systems
without special effort on the part of the user” (HHS,
identity Sense of self as a professional nurse. ONC, 2015a, p. 18).
illness A sickness or disease of the mind or body. interprofessional team-based care Care
incident report A method for documenting delivered by intentionally created, usually relatively
details about an incident in a healthcare organization small work teams in health care, who are recognized by
such as a medication error, patient fall, and so on. Data others and by themselves as having a collective identity
are used to monitor quality care. and shared responsibility for a patient or a group of
Glossary 531
patients (for example, rapid response team, palliative living will A document that describes a person’s
care team, primary care team, operating room team). wishes related to his or her end-of-life care needs.
interprofessional teamwork The levels of lobbying Assembling and petitioning the govern-
cooperation, coordination, and collaboration char- ment for redress of grievances.
acterizing the relationship between professions in
lobbyist An individual paid to represent a special
delivering patient-centered care.
interest group, whose function is to urge support for
intuition Quick and ready insight. or opposition to legislative matters.
invasion of privacy Occurs when individual long-term care A continuum of broad-ranged
providers or HCOs do not maintain patient privacy maintenance and health services delivered to the
requirements (access to a person’s body or behavior chronically ill, disabled, and the elderly.
without consent) (for example, examining a patient macro consumer The major purchasers of care:
in an area that is not private). the government and insurers.
The Joint Commission A major nonprofit Magnet hospital A hospital that demonstrates
organization that accredits more than 20,500 health- high levels of quality of care, autonomy, primary nurs-
care organizations, including hospitals, long-term care ing care, mentoring, professional recognition, respect,
organizations, home care agencies, clinical laborato- and the ability to practice nursing; hospitals awarded
ries, ambulatory care organizations, behavioral health this status meet specific standards, as determined by
organizations, and healthcare networks or managed the Magnet Recognition Program®.
care organizations.
Magnet Recognition Program® A recog-
judicial branch The branch of the U.S. govern- nition program developed to support excellence in
ment that interprets and applies laws in specific cases. nursing services; program is administered by the
knowledge An awareness and understanding of American Nurses Credentialing Center’s (ANCC)
facts. Commission on the Magnet Recognition Program®.
knowledge management A method for gath- HCOs and their nursing services must meet certain
ering information and making it available to others. criteria, Forces of Magnetism, to be recognized as a
Magnet organization.
knowledge worker A person who is effective
in acquiring, analyzing, synthesizing, and applying malpractice An act or continuing conduct of a
evidence to guide practice decisions. professional that does not meet the standard of pro-
fessional competence and results in provable damages
leader One who has the ability to influence others;
to a patient.
a role that nurses assume, either formally by taking an
administrative position or informally as others recog- management A formal administrative position
nize that they have leadership characteristics. that focuses on four major functions: planning, orga-
nizing, leading, and controlling.
leadership The ability to influence others to
achieve a common goal or outcome. manager A person who holds a formal man-
agement or administrative position and who, in that
learning style A student’s preferences for differ- position, focuses on four major functions: planning,
ent types of learning and instructional activities; there organizing, leading, and controlling.
are a variety of learning styles.
master’s degree in nursing A graduate-level
legal issues Questions and problems concerning nursing degree of approximately 2 years with specialty
the protections that make laws (U.S. Congress). focus (for example, advanced practice registered nurse
legislative branch The law-making branch of or clinical nurse specialist).
the U.S. government; made up of the Senate, the House meaningful use This government requirement
of Representatives, and agencies that support Congress. focuses on use of certified electronic health record
lifelong learning The need for healthcare pro- technology for the following purposes (HHS, Health-
fessionals to continue with their professional learning IT, 2014): improve quality, safety, efficiency, and reduce
throughout their careers. health disparities; engage patients and family; improve
532 Glossary
care coordination and population and public health; one’s moral perception of those actions” (Hyatt, 2016,
and maintain privacy and security of patient health p. 15, as cited from Bandura, 1999).
information. morals An individual’s code of acceptable behav-
measure A “standard used as a basis for compar- ior, which shapes one’s values and is influenced by
ison, a reference point against which other things can cultural factors and experiences.
be evaluated” (HHS, AHRQ, 2014). National Database of Nursing Quality Indi-
Medicaid The federal healthcare reimbursement cators (NDNQI) A system in which nursing data
program that covers health and long-term care ser- are collected to evaluate outcomes and nursing care.
vices for children, the aged, blind persons, the dis- National Quality Strategy (NQS) A national
abled, and people who are eligible to receive federally initiative led by the U.S. Department of Health and
assisted income maintenance payments. Human Services to establish a national approach to
medical power of attorney The right of a per- healthcare quality with annual reports to Congress.
son given by another individual to speak for him or her The requirement to establish the NQS was part of the
if he or she cannot do so in matters related to health Affordable Care Act of 2010.
care. Also known as a durable power of attorney for near miss An event that occurred that could have
health care or a healthcare agent or proxy. led to an adverse event but did not.
Medicare The federal health insurance program negligence Failure to exercise the care toward
for people aged 65 and older, persons with disabilities, others that a reasonable or prudent person would have
and people with end-stage renal disease. under the same circumstances; an unintentional tort.
mentor A role model. networking The cultivation of productive rela-
mentoring Method used in healthcare organiza- tionships for employment or business.
tions to support new staff; the mentor acts as a role nomenclature A system of designations (terms)
model and serves as a resource. elaborated according to pre-established rules; an
micro consumer The patients, families, and sig- example would be the International Classification for
nificant others who play a role in patient care and in Nursing Practice.
the decision-making process.
not-for-profit An incorporated organiza-
microsystem In healthcare delivery, a small tion whose shareholders or trustees do not benefit
group of people who work together on a regular basis financially.
to provide care to discrete subpopulations including
nurse licensure compact An interstate
the patients.
licensure partnership that allows nurses to practice
mindful communication A process by which in adjacent states when licensed in one state. Clear
actively aware individuals engage in communication requirements must be met by the individual nurses
that is meaningful, is timely, and responds continually and the state boards of nursing in the compact.
as events unfold.
nurse migration The movement of nurses from
minimum data set The minimum categories one place to another, particularly globally; may affect
of data with uniform definitions and categories; an number of nurses available in a country if too many
example would be the Nursing Minimum Data Set. move to another country, typically for better pay and
missed nursing care A type of error of omis- working conditions.
sion when needed nursing care is delayed, partially nurse practice act The act (law) that governs
completed, or not completed at all. nursing practice in the state in which the nurse practices.
misuse An event that leads to avoidable compli- nurse residency A special employment program
cations that prevent a patient from receiving the full that helps new RN graduates transition to practice in a
potential benefit of a service. structured program that provides content and learn-
moral disengagement “The process that ing activities, precepted experiences, mentoring, and
involves justifying one’s unethical actions by altering gradual adjustment to higher levels of responsibility.
Glossary 533
nursing The profession of a nurse. PICOT (patient–intervention–comparison–

nursing informatics (NI) The specialty that outcome–time) To ask a searchable and answer-
integrates nursing science, computer science, and infor- able question. The P (patient population) is specific and
mation science to manage and communicate data, infor- describes the population in terms such as age, gender,
mation, knowledge, and wisdom in nursing practice. diagnosis, ethnicity, other. The I (intervention) relates
to prognostic factors, risk behaviors, exposure to dis-
nursing process A systematic method for think-
ease, clinical intervention or treatment, and so forth.
ing about and communicating how nurses provide
The C (comparison intervention) can pertain to anoth-
patient care; this includes assessment, diagnosis, plan-
er treatment, no treatment, or other. The O (outcome)
ning, intervention or implementation, and evaluation.
includes factors such as risk of disease, complications
occupational health care Health promotion, or side effects, or adverse outcomes. The T is the time,
disease and illness prevention, and treatment; includes meaning the time involved to demonstrate the outcome.
attention to the risks of illness and injury within the
plan–do–study–act (PDSA) cycle A system-
work environment.
atic approach to planning and decision making.
organizational culture The values, beliefs,
traditions, and communication processes that bring policy A set course of action that affects a large
a group of people together and characterize the group. number of people and is stimulated by a specific need
to achieve certain outcomes.
organizational ethics Organizational concerns
related to the beliefs, decision making, and behavior political action committee (PAC) A private
of the organization as an entity. group that represents a specific issue or group and
works to get someone elected or defeated.
outcomes Measurable benefits of patient care.
political competence An understanding of
outcomes research Research focused on deter-
the political process and how best to participate in
mining the effectiveness of healthcare services and
the process.
patient outcomes.
politics The process of influencing the authorita-
overuse The point at which the potential for harm
tive allocation of scarce resources.
from the provision of a service exceeds the possible
benefit. population Group of people with something in
common, such as a disease, age, ethnic group, where
palliative care Care focused on alleviating symp-
they live, and so on.
toms and meeting the special needs of the terminally
ill patient and the family. power The ability to influence decisions and have
an impact on issues that matter.
patient advocacy Respecting patient rights and
the patient and ensuring that the patient has the edu- practice model A framework used to guide
cation to understand treatment and care needs. practice.
patient-centered care (PCC) Identification practicum A course that includes clinical activi-
of, respect, and care for patient differences, values, ties and stresses the practical application of theory in
preferences, and needs; relief of pain; coordination a field of study; also referred to as a “clinical.”
of care; clear communication with and education of preceptor An experienced and competent staff
the patient; shared decision making; and continuous member (an RN or, for nurse practitioner students,
promotion of disease prevention and wellness. possibly a nurse practitioner or physician) who has
personal health record (PHR) Computer- received formal training to function as a preceptor and
based health records that collect data over a lifetime; with who serves as a role model to guide student learning,
permission of the patient, this record can be accessed serving as a resource for the nursing student.
easily by any provider who needs the information. prejudice Making assumptions or judgments
Peter Principle Occurs when someone is pro- about the beliefs, behaviors, needs, and expectations
moted beyond his or her leadership and management of other persons who are of a different cultural back-
competencies required for a new position. ground than oneself because of emotional beliefs about
534 Glossary
the population; involves negative attitudes toward the Public Health Act of 1944 This law consoli
different group. dated all existing public health legislation into one law.
prescriptive authority Legal authority granted public policy Policy created by the legislative,
to advanced practice nurses to prescribe medication. executive, and judicial branches of federal, state, and
primary care provider A healthcare provider local levels of government that affects individual and
who is the first contact for a patient at the entry point institutional behaviors under the government’s respec-
of care and who then may manage overall care for tive jurisdiction.
the patient; examples of providers are physicians and qualitative study A systematic, subjective,
advanced practice registered nurses. methodological research approach; analysis of data that
primary prevention Interventions used to does not rely on statistics or mathematical equations.
stop development of disease; includes interventions quality Requirements that maintain high stan-
that are used to maintain health before illness occurs. dards to meet expected outcomes.
Health promotion is a critical component of primary
quality improvement (QI) An organized
prevention. Examples are teaching people (children
approach to identify errors and hazards in care, and
and adults) about healthy diets before they become
to improve care overall.
obese and encouraging adequate exercise (education
about health and healthy lifestyles is an important quantitative study A formal, objective, syste
intervention at this level). matic research process that uses statistics for data
analysis.
private policy Policy created by nongovernmen-
tal organizations. race A biological designation of a group.
procedures A definite statement of step-by-step randomized controlled trial (RCT) Often
actions required for a specific result. referred to as the gold standard in research designs,
this is the true experiment in which there is control
process Particular course of action intended to
over variables, randomization of the sample with a
achieve a result.
control group and an experimental group, and an
professional ethics Generally accepted intervention(s) (independent variable).
standards of conduct and methods in the nursing
profession. rapid response team (RRT) A special team of
staff with specific expertise related to assisting patients
professional organization An organization in critical condition; team is called by staff to a patient
that represents a professional group, such as nurses area, or in some cases, family may request that staff
represented by the American Nurses Association. call for RRT support.
professional socialization “Transition into reality shock The reaction of students when they
professional practice is characterized by the acqui- discover that the clinical experience does not always
sition of the skills, knowledge, and behaviors need- match the values and ideals that they had anticipated.
ed to successfully function as a professional nurse.
This process involves the new nurse’s internalization recognition A process used to evaluate an organi-
of the values, attitudes, and goals that comprise his zation’s adherence to excellence-focused standards (for
or her occupational identity” (Young, Stuenkel, & example, the Magnet Hospital Recognition Program).
Bawel-Brinkley, 2008, p. 105). reflective thinking Creativity and conscious
professionalism The conduct, aims, or qualities self-evaluation over a period of time.
that characterize or mark a profession. regulation An official rule or order, based on
protocols Formal treatment plans focused on spe- laws, governing processes, practice, and procedures;
cific care needs and then applied to individual patients in nursing, legal regulation governs licensure.
with changes made to meet individual patient needs. rehabilitation The restoration of, or improve-
provider of care A healthcare staff member who ment of, an individual’s health and functionality.
provides care to patients. reimbursement Payment for healthcare services.
Glossary 535
research Investigation or experimentation aimed done for special purposes in nonroutine time frame,
at the discovery and interpretation of facts about a such as safety rounds to check for safety concerns.
particular subject. safety/safe care Freedom from accidental injury.
research analysis The process of using methods scholarship A fund for knowledge and learning.
to analyze and summarize results or data. scope of practice A statement that describes
research-based doctorate A terminal degree the who, what, where, when, why, and how of nurs-
that is focused on research (PhD). ing practice.
research design A specific plan for conducting scorecard A method used in quality improvement
a study. to document data and analysis providing a “rating or
research problem statement A description grade”; scorecards may be used internally or may be
of the topic or subject for a research study, which pro- used to compare healthcare organizations.
vides the context for the research study and typically secondary caregiver Assistant who helps home
generates questions that the research aims to answer. patients with intermittent activities such as shopping,
research proposal A written document that transportation, home repairs, getting bills paid, emer-
describes recent, relevant literature on the problem gency support, and so forth.
area; describes the research topic/problem; and defines secondary prevention Interventions used to
the processes or steps that will be followed to answer stop development of disease; includes interventions
the research question(s); proposal is written before the that are used to maintain health before illness occurs;
study is conducted. occurs when a person is asymptomatic but after disease
research purpose Identifies the potential uses has begun. The focus here is on preventing further
of research results. complications. Examples are breast cancer screening
research question The interrogative statement using mammography and blood pressure screening to
that directs a research study. diagnose hypertension.
researcher A person who systematically inves- security protections Methods used to ensure
tigates and studies materials and sources to establish that information is not read or taken by persons not
facts and reach conclusions. authorized to access it.
resilience The ability to cope with stress. self-directed learning A process in which indi-
viduals take the initiative, with or without the help of
responsibility Moral, legal, or mental accountability.
others, in diagnosing their learning needs, formulat-
risk management (RM) Maintaining a safe and ing learning goals, identifying human and material
effective healthcare environment and preventing or resources for learning, choosing and implementing
reducing financial loss to the healthcare organization. appropriate learning strategies, and evaluating learn-
RN-BSN A nursing educational program for ing outcomes.
licensed nurses (RNs) who want to meet the require- self-management (of care) The systematic
ments for a baccalaureate degree in nursing (BSN). provision of education and supportive interventions
role Behavior oriented to the patterned expectation to increase patients’ skills and confidence in man-
of others. aging their own health problems, including regular
role transition Gradual development in a new assessment of progress and problems, goal-setting, and
role. problem-solving approaches.
root-cause analysis (RCA) An in-depth anal- sensemaking Making sense of a problem; it is
ysis of an error to assess the event and identify causes part of using critical thinking and clinical reasoning
and possible solutions. and judgment.
rounds An organized method to observe and com- sentinel event An unexpected medical event
municate between staff and patients; typically is done that results in death or physical or psychological harm,
routinely, such as daily or per shift, but may also be or the risk thereof.
536 Glossary
shared governance A management philosophy, structure The environment in which services are
a professional practice model, and an accountability provided; inputs into the system, such as patients, staff,
model that focuses on staff involvement in decision and environments.
making, particularly in decisions that affect their surveillance Purposeful and ongoing acquisition,
practice. interpretation, and synthesis of patient data for clinical
simulation Replication of some or nearly all decision making.
essential aspects of a clinical situation as realistically system The coming together of parts, intercon-
as possible. nections, and purpose.
situation–background–assessment– systematic review (SR) A summary of
recommendations (SBAR) A systematic evidence typically conducted by an expert or a pan-
communication method that is used to improve com- el of experts on a particular topic; uses a rigorous
munication of critical information about a patient that process to minimize bias for identifying, appraising,
requires immediate attention and action. and synthesizing studies to answer a specific clini-
social policy statement A statement that cal question and draw conclusions about the data
describes the profession of nursing and its professional gathered; different methods may be used depending
framework and obligations to society; published by the on the type of review such as integrative review or
American Nurses Association. meta-analysis.
Social Security Act of 1935 The act that estab- team A number of persons associated in work or
lished the U.S. Medicare and Medicaid programs—two activity.
major reimbursement programs—and also provided team leader The person who leads the team.
funding for nursing education through amendments teamwork Work done by several associates, with
added to the law. each doing a part but all subordinating personal prom-
software Computer programs and applications. inence to the efficiency of the whole.
standard A reference point against which other telehealth The use of telecommunications
things can be evaluated and that serve as guides to equipment and communications networks to trans-
practice. fer healthcare information between participants at
standardized terminology A collection of different locations.
terms with definitions for use in informational sys- telenursing The use of telecommunications tech-
tems databases. nology in nursing to enhance patient care.
status A position in a social structure with rights tertiary prevention Interventions used to stop
and obligations. development of disease; includes interventions that are
STEEEP® Description of critical characteristics of used to maintain health before illness occurs; occurs
care delivery: safe, timely, effective, efficient, equitable, when there is disability and the need to maintain or,
and patient-centered care. if possible, improve functioning.
stereotype The process by which people use theory A body of rules, ideas, principles, and tech-
social groups (for example, gender and race) to gather, niques that applies to a particular subject.
process, and recall information about other people; therapeutic use of self The nurse’s use of his
also known as labeling. or her personality consciously and in full awareness
stress A complex experience felt internally that in an attempt to establish relatedness and to structure
makes a person feel a loss or threat of a loss; bodily a nursing intervention.
or mental tension. time management Strategies used to manage
stress management Strategies used to cope and control time productivity.
with stress to alter bodily or mental tension; reducing timely care Meeting the patient’s needs; provid-
the negative impact of stress, improving health, and ing high-quality experiences and improved healthcare
developing health-promoting behaviors. outcomes when needed.
Glossary 537
training Activities and instruction intended to unlicensed assistive personnel (UAP)

foster skilled behavior. Healthcare workers who are not licensed to perform
transformational leadership This approach nursing tasks but are trained and often certified.
emphasizes a positive work environment, recognition utilization review/management (UR/UM)
of the importance of change and using change effec- Evaluating necessity, appropriateness, and efficiency
tively, rewarding staff for expertise and performance, of healthcare services for specific patients or in patient
and development of staff awareness. Transformational populations.
leaders create vision and mission statements with the vulnerable population A population (group of
staff to guide the work of the organization and are people with something in common) at risk for medical
described as honest, energetic, loyal, confident, self- or other problems such as lack of funds, housing, and
directed, flexible, and committed. so on, who may not be able to effectively care for them-
translational research This research may be selves. Examples of these populations are children, the
(1) the application of discoveries generated in the labo- elderly, those with mental illness or other disabilities,
ratory and in preclinical studies to the development of and prisoners.
trials and studies in humans and (2) research aimed at whistleblowing This action occurs when
enhancing the adoption of best practices in the com- a person who works for an organization that is
munity. A common use is to determine comparative committing fraud and abuse reports these activi-
effectiveness of prevention and treatment strategies. ties to legal authorities, sharing extensive informa-
Triple Aim Major goals or aims of healthcare tion that would be difficult for the authorities to
delivery: Improve the health of the population; obtain on their own. The False Claims Act protects
enhance the patient experience of care (including whistleblowers.
quality, access, and reliability); and reduce, or at wisdom The appropriate use of knowledge to solve
least control, the per capita cost of care. human problems; understanding when and how to
types of power Legitimate (formal), referent apply knowledge.
(informal), informational, expert, reward, and coer- wraparound services Services that offer social
cive power. and economic interventions, preferably within the
underuse Failure to provide a service that would healthcare provider setting to better ensure that full
have produced a favorable outcome for the patient. services are provided for complex patient needs.
Index
Note: Page numbers followed by f and t denotes figures and tables respectively.
A Agency for Healthcare Research and Quality (AHRQ),

abuse, 175–176 274, 278
academic education, 134 alarm/alert fatigue, 403–404
Academic Health Center (AHC), 97 alternative therapies/integrative medicine, 224
academic nursing, 97 alternative to regulation, 99–100
accelerated programs, 84 ambulatory care, 472
access to care, 204–205 American Academy of Nursing (AAN), 25
access to clinical experiences, 95–96 American Association of Colleges of Nursing (AACN),
access to healthcare services, 405 8, 9, 26–27
access to patient records at point of care, 444 American Journal of Nursing (AJN), 7
accommodators, 116 American Nurses Association (ANA), 23, 25, 173
accountability, 20, 465 health policy issues, 154–155
accountable care organizations (ACOs), 204 immigrant health care, 220
accreditation, 77, 394, 491 American Nurses Credentialing Center (ANCC), 25–26
nursing education, 93–94 American Nurses Foundation (ANF), 25
program, 25–26 American Organization of Nurse Executives, 287–288
activists, 116 annual limits, 253
activity-related affect, 208 anticipation of needs, 382
acute care, 214 application, 50
adaptation, 214 applied research, 61, 352
administration, 242–243 apply quality improvement, 50, 377f. See also quality
admission, 243 improvement (QI)
advance directives, 186 apprenticeship, 76
Advanced Practice Registered Nurse (APRN), 84, 245, articulation agreement, 83
476–477 assault, 181
adverse event, 384 assertiveness, 320–321, 471
advocacy, 41, 150, 472 assessment, 201
goal, 27 assimilators, 116
patient, 288 assisted suicide, 188
aesthetic knowing, 42 associate degree in nursing (AD/ADN), 82–83
Affordable Care Act of 2010, 163–164 assurance, 201
539
540 Index
autocratic, 463 clinical expertise, 360

automated dispensing of medications, 440 clinical information system, 429
autonomy, 20, 465 clinical learning experiences, 130–132
ethical issues, 171 cooperative, 132
level of, 99 lab and simulation, 129–130
lifelong, 134–137
B nurse internships/externships, 133
Baby Boomers, 468–469 nurse residency programs, 133–134, 134f
baccalaureate degree in nursing (BSN), 83–84, 496 clinical nurse leader (CNL), 85, 245
bar coding, 440 clinical nurse specialist (CNS), 84, 245
basic research, 61, 352 clinical protocol/pathway, 328
battery, 181 clinical provider order-entry system (CPOES),
behavior-specific cognitions and affects, 208 442–443
benchmarking, 405 clinical quality and safety, 401f
beneficence, ethical issues, 171 clinical reasoning and judgment, 46
bias, 284 clinical research, 61
blame-free environment, 385 The Cochrane Database of Systematic Reviews, 362
breach of confidentiality, 178 code of ethics, 20, 21, 173–175
breach of duty, 183 Code Pink, 331
building healthy, 210 coding system, 430
bureaucratic, 463 coinsurance, 252
burnout, 138 collaboration, 27, 64, 223, 326
collaborator, 64
C colleagueship, 32
CAHPS Hospital Survey, 282–283 commercialization of health care, 153–154
call-out, 322 commitment to a plan of action, 208
care coordination, 216, 288–289 communication, 316–318
care transition, 403 assertiveness, 320–321
career development, 519–523 checklists, 322, 323
caregiver, 204 debriefing, 320
caring, 42, 47–49, 138–140, 139f formal meetings, 318–320
case management, 223 listening, 321–322
certification, 26, 137–138 mindful, 322
nursing informatics, 432 SBAR, 322, 323
certified nurse–midwife (CNM), 85, 246 community, 198
certified registered nurse anesthetist (CRNA), 84–85, 246 community emergency preparedness, 218–219
change agent, 64 compassion fatigue, 140
chaos/quantum theory, 464 competency, 49–50
check-back, 322 focus on, 89, 90t
checklists, 322, 323 complementary, 224
chemical exposure, 390–391 computer literacy, 430
Christman, Luther, 9 computer-based reminder systems, 444
chronic disease, 214–217 computerized monitoring of adverse events, 440–441
circumstances, 333 concept map care plan
civil law, 181 analyze and categorize data, 293
clinical care classification, 438 analyze nursing diagnoses relationships, 293
clinical data and history, 361 develop basic skeleton diagram, 292–293
clinical data repository, 429 evaluate the patient’s responses, 293
clinical decision support systems, 429, 443 identify goals, outcomes, and interventions, 293
clinical experience/practicum, 82 confidentiality, 449–450
curriculum, 91–92 conflict, 339, 340f
Index 541
conflict resolution, 339–341, 341f didactic/theory content, 90–91

connective leadership theory, 463 distance education, 92–93
consumer expectation, 99 customer service
consumerism caring with compassion, 279
consumers/customers, 279–280 making sure caring comes across, 279
Health and Human Services, 278 paying quality attention, 279
information resources, 280–281 personal calling, 279
patient rights, 280 reducing patient anxiety, 279
patient satisfaction, 281–283 customization based on patient needs and values, 381
consumers, 153
contingency theory, 463 D
continuing education (CE), 101, 135–136 dashboard, 430
continuity of care, 202–203 data, 430
continuous decrease in waste, 382 data analysis software, 430
continuous healing relationships, care based on, 381 data bank, 430
continuous quality improvement (CQI), 367, 391 data collection, 408
continuum of care, 202 data mining, 430
convergers, 116 database, 430
cooperation among clinicians, 382 debriefing, 130
cooperative experiences, 132 decisive decision making, 324
coordination, 326–327 deductible, 252
barriers and competencies related, 327–328 defensive medicine, 152
tools and methods, 328–329, 328f delegatee, 333
coordinator, 313 delegation, 331–332
copayment, 252 evaluation, 337–338, 338f
coping, 213 five rights, 333–334, 334f
corporatization, 237–238 importance, 332–333
cost of health care, 152–153 principles, 334–335, 336f
counselor, 64 delegator, 333
courage, intellectual, 43 Deming’s theory, 463
credentialing, 137–138 dichotomous thinking, 42, 43
criminal law, 181 didactic/theory content, 90–91
critic, team members, 313 dietary, 244
critical problems differentiated nursing practice, 478
access to clinical experiences, 95–96 differentiated practice, 80–81
faculty shortage, 95 diffuse collaborative improvement efforts, 495
laboratory and simulation experiences, 96 diploma schools of nursing, 82
critical terminology, 181–182 direct care, 244
critical thinking direct entry programs, 84
components, 43 direct patient care activities, 337
dichotomous, 42, 43 direction/communication, 333–334
intuition, 46 discharge, 243
reflective, 45 discovery, 50
skills, 43, 45 discrimination, 284
cross-cultural education, 284 disease management, 216
cultural competence, 284 disease prevention, 209–210
culture, 283–284 disparity
culture of safety, 385 in health care, 284–286
current procedural terminology, 439 importance, 286–287
curriculum, 89–90 distance education, 92–93
clinical experience/practicum, 91–92 divergers, 116
542 Index
diversity, 283, 287–288 illegal practices, 173–175

division of labor, 240 nursing practice, 172–173
Doctor of Nursing Practice (DNP), 84, 85–86, 246 principles, 171–172, 171f
doctrine of res ipsa loquitur, 181 professional, 172–173
documentation, 434–436 report incompetent, unethical, 173–175
double the number of nurses with a doctorate research evidence-based management, 358–359
by 2020, 496 social media, 188–189
Drucker’s theory, 463 ethnicity, 284
ethnocentrism, 284
E evidence-based decision making, 381
EBP. See evidence-based practice (EBP) evidence-based practice (EBP), 243–244
economic harm, risk of, 178–179 clinical guidelines based, 367
economic value, 482–483 definition, 350, 360–361
Educating nurses: A call for radical transformation, 78 impact
education goal, 27 government initiatives, 370
educator, 63 nursing education, 369–370
effective care, 380 nursing practice and management, 368, 369
effective staffing, 484–486 implementation, 363–364, 365–366t
efficient care, 380 key elements, 351f
elder care, 221 level of use, 364, 366
electronic medical/health record (EMR/EHR), 429, literature, 361–362
441–442 management, 363, 363f
eliminating health disparities, 210 nursing profession, 368, 369
email list, 430 policies and procedures, 366–367
emancipation, 181 vs. quality improvement, 367–368
E-measurement, 430 research, 352, 367
emotional intelligence theory, 464 barriers, 359–360
empathy, intellectual, 43 design, 357
empirical knowing, 42 ethics and legal issues, 358–359
employ evidence-based practice, 49 facilitators, 359–360
empowerment, 342, 470–471 funding, 357–358
encryption, 430 historical background, 352–353
end-of-life care, 221–223 impact on, 360
entrepreneur, 64 NINR, 353–354
entrepreneurship, 475 quantitative experimental process, 354–356
environmental factors, 409 students, to apply, 370
environmental services (housekeeping), 244 systematic reviews, 362–363
equitable care, 380 executive branch, 151
ergonomic safety, 389 expand opportunities for nurses to lead, 495
error, 384 expanding quality preventive services in, clinical and
essence of nursing, 18 community settings, 210
ethical knowing, 42 experimental studies, 357
ethics and legal issues expert witness, 181–182
American Nurses Association, 173 extended care, 221, 474
critical issues external contact, 313
fraud and abuse, 175–176
organizational, 179–180 F
research, 176–179 faculty shortage, 95
decision making, 172 failure to rescue, 403
definitions, 170–171 false imprisonment, 182
dilemma, 172 family, 203–204
Index 543
federal employees health benefit program, 255 life span, 206

federal health, informatics technology, 426–428, structure and function, 200–202
427f, 428f healthcare quality
financial status crossing quality chasm, 380–382
macro view, 248, 249f, 250f definition, 383
micro view, 248, 250 envisioning the national healthcare quality report,
first level, 258 382–383
flexible style, 324 err is human, 377, 379–380
followers, 323 outcomes, 383, 383f
forces of magnetism, 492 process, 383, 383f
foreign nursing graduates, 104–105 safety, 383
formal meetings, 318–320 critical, 383–385
for-profit, 238 culture of, 385–388, 388f
fraud, 175–176 healthcare report cards, 395–396
fund, 357–358 initiatives, 392–394, 393f
lack of, 359 The Joint Commission, 394–395
The future of nursing: Leading change, advancing health, staff, 388–391
78, 493–498 structure, 383, 383f
health disparity, 206–207
G Health Insurance Portability and Accountability Act
Generation X (Gen-X), 469 (HIPAAA), 449–450
Generation Y (Nexters, Millennials, Generation Next, health literacy, 218, 293–294
Gen-Y), 469 health policy
genetics, 224–225, 448–449 Affordable Care Act of 2010, 163–164
genomics, 448–449 critical issues, 151–152
global health regulatory issues, 105 commercialization of health care, 153–154
global healthcare, 227 consumers, 153
Goldmark Report, 77 cost of health care, 152–153
good samaritan laws, 182 disparities in health care, 153
government reimbursement, of healthcare services, healthcare quality, 153
253–255 immigration, 154
groupthink, 43 nursing workforce, 154
reimbursement for nursing care, 154
H definitions, 148–149
Hansten & Washburn’s Collaborative Resolution general descriptors of U.S., 150–151
Method, 341f importance, 148
health, 41, 211 nursing agenda, 154–155
Health and Human Services (HHS), 278 patient protection, 163–164
health belief model, 277–278 policy-making process, 155–157, 156f
health care political process, 157–163, 158f
commercialization of, 153–154 relevance to nation’s health, 149–150, 149f
cost of, 152–153 Health Professions Education, 89
disparities in, 153 health promotion, 207–209
quality, 153 Health Resources and Services Administration (HRSA), 29
health care delivery system healthcare delivery system
public/community health corporatization, 237–238
access to care, 204–205 financial issues, 247–250, 249f, 250f
continuity of care, 202–203 healthcare organization, 238–244
continuum of care, 202 hospital
family, 203–204 changes in, 261–262
health disparity, 206–207 classification, 241–242
544 Index
healthcare delivery system (continued) immediate competing demands and preferences, 209
nursing organization, 255–259 immigrant issues, 220
structure and process, 240–241, 240f immigration, 154
typical departments, 242–244 impersonal relationships, 240
influence factors, 236, 237f implement nurse residency programs, 495–496
organizational culture, 258–261 implementation, 363–364, 365–366t
providers, 244–247 implementer, 313
reimbursement, 250–252 inability to find right setting, 359
government, 253–255 incident reports, 407
third-party payer system, 252–253 incivility, 329–331
uninsured and underinsured, 255 indicators, 407
healthcare report cards, 395–396 indirect care provider, 244
health-promoting behavior, 209 indirect patient care activities, 337
healthy choices, empowering people to make, 210 individual staff factors, 409
healthy community, 198 Industrial Revolution, 6, 12
Healthy People 2020, 197–200, 283 infections, 388–389
Herzberg’s Theory on Job Satisfaction, 341f control, 243
hierarchic style, 324 informatics, 425, 475
hierarchy, defined, 240 informatics technology (IT), 428–429
high-risk healthcare activities confidentiality, 449–450
alarm/alert fatigue, 403–404 definitions, 429–431
care transition, 403 documentation, 434–436
clinical quality and safety, 401f federal health, 426–428, 427f, 428f
failure to rescue, 403 high-touch care, 450–451
medication administration, 401–403, 402t interface terminologies, 438–439
missed nursing care, 404 meaningful use, 436–437
high-touch care, 450–451 medical technology, 446–447
home care, 472–473 genetics and genomics, 448–449
home health care, 220 medical devices, 449
hospice care, 221, 473 nanotechnology, 447
hospital, 238–239 robotics, 448
changes in, 261–262 telehealth, 447
classification, 241–242 telenursing, 448
nursing organization, 255–259 wearable computing, 447
organizational chart, 240f multiprofessional terminologies, 439
structure and process, 240–241, 240f nursing informatics, 431
typical departments, 242–244 certification, 432
Hospital Consumer Assessment of Healthcare data to wisdom, 431f
Providers and Systems (HCAHPS), 282–283 education and research, 433–434
hospital-acquired complications (HACs), 398–400 impact on care, 432–433
hospital-based or acute care nursing, 472 nursing leadership, 451
human failure, 385 privacy, 449–450
humility, intellectual, 43 Quality Chasm report, 425–426
hypothesis, 356 standardized terminology, 437
systematic collection of nursing care data, 438
I types and methods, 439–440
idea person, 313 access to patient records at point of care, 444
identity, 63 automated dispensing of medications, 440
illness, 41, 211–213 bar coding, 440
acute, 214 clinical decision support systems, 443
prevention of, 41 clinical provider order-entry system, 442–443
image of nursing, 30–32 computer-based reminder systems, 444
Index 545
computerized monitoring of adverse events, management, 43

440–441 sensemaking, 46–47
electronic medical/health records, 441–442 workers skill, 43
internet, 444–445, 445–446 knowledge management theory, 464
nurse call systems, 445 Knowles’s adult learning theory, 277
online support groups, 446
tablets and smartphones, 443–444 L
telephone, 445 laboratory and simulation experiences, 96
virtual appointments, 445–446 lack of funding, 359
voice mail and texting, 445 laissez-faire, 463
information, 430 leader, 65, 465
information literacy, 430 leadership, 316, 462
information management, 243 Advanced Practice Registered Nurse, 476–477
information (cognitive) overload, 430 economic value and nursing profession, 482–483
informational continuity, 202–203 effective staffing, 484–486
informed consent, 185–186 The future of nursing: Leading change, advancing
injury, 41 health, 493–498
prevention of, 41 influence factors, 467
in-service, 244 advocacy, 472
inspector, 313 assertiveness, 471
institutional research board, 357 empowerment, 470–471
integration, 50 generational issues, 467–470
integrative style, 324 power, 470
integrity, intellectual, 43 interprofessional teams, 486
intellectual aspect, 48 legislation/regulation/policy, 481–482
interdisciplinary, 311 Magnet Recognition Program®, 490–493
interface terminologies, 438–439 multiple settings and positions, 472–475
International Council of Nurses (ICN), 27, 227 nursing management, 463, 465–466
internet, 125, 444–445, 445–446 models and theories, 463–464
internships/externships, 133 positions, 466–467
interoperability, 427 shared governance, 464–465
interpersonal influences, 208 nursing specialties, 475–476
interprofessional education collaborative professional practice, 477–478
(IPEC), 310 differentiated nursing practice, 478
interprofessional team, 486 models, 478–481, 479f, 480f
care, 311 quality improvement, 488–490, 489f
thinking, 325f students, 498–499
interprofessional teamwork, 311 teamwork, 312–313
intuition, 46 Transforming Care at the Bedside, 490
invasion of privacy, 178 work environment, 483–484, 486
improvement, 487–488
J workforce issues, 484–486
Joanna Briggs Institute EBP Database, 362 legal nurse consultant, 475
The Joint Commission, 394–395 legislation/regulation/policy, 481–482
judicial branch, 149 legislative branch, 149
justice, 171 Leininger’s cultural diversity theory, 277
length of stay, 242
K licensed practical/vocational nurse (LPN/LVN), 245
knowledge, 431 licensure, 241–242
clinical reasoning and clinical judgment, 46 licensure requirements, 101–102
critical thinking, 44–46 lifelong learning, 134–137
definition, 42 listening, 321–322
546 Index
Living Well with Chronic Illness: A Call for Public micro consumers, 279
Action, 216 microsystem, 312
living will, 186 middle ages, 5–6
lobbying, 159–161 middle level, 258
lobbyist, 159 migrant issues, 220
logical observation identifiers names and codes, 439 military health care, 254–255
long-term care, 221, 474 mindful communication, 322
minimum data set, 430
M missed nursing care, 404
macro consumers, 279 Missing Persons: Minorities in the Health Professions, 8
Magnet Recognition Program®, 26, 478, 490–493 misuse, 384
malpractice, 183–184, 183f moral disengagement, 172–173
management, 64 morals, 170
management continuity, 203 multidisciplinary, 311
management positions, 474 multihospital system, 242
manager, 64, 465 multiple settings and positions, 472–475
managing population health, 219–220 multiprofessional terminologies, 439
mandatory overtime, 104 mutual support, 316
manipulation of intervention, 357
MAP-IT, 200 N
master’s degree in a functional area, 85 nanotechnology, 447
master’s degree in nursing (MSN), 84–85 National Council Licensure Examination (NCLEX), 20,
meaningful use, 436–437 102–103
measure, 407 National Council of State Boards of Nursing (NCSBN),
medicaid, 254 101, 297–298
medical devices, 449 National Database of Nursing Quality Indicators
medical home model, 217 (NDNQI), 275
medical power of attorney, 186–187 National Institute of Nursing Research (NINR), 40
medical records, 243 National Institute of Occupational Safety and Health
medical staff, 243 (NIOSH), 138
medical technology, 446–447 National League for Nursing (NLN), 26, 86–87
genetics and genomics, 448–449 excellence, in nursing education, 88–89
medical devices, 449 national quality strategy (NQS), 396–397, 398f
nanotechnology, 447 National Student Nurses Association (NSNA), 27–28
robotics, 448 nation’s health care, 248, 249f, 250f
telehealth, 447 navigator, 475
telenursing, 448 NCGs, 362
wearable computing, 447 near miss, 384–385
medicare, 253 needlesticks, 388
medication administration, 401–403, 402t negligence, 182–183
medication error, 401–403, 402t networking, 128
medication reconciliation, 405 Nightingale, Florence, 10–16
meeting Nightingale Pledge, 10–11
evaluation, 319 nomenclature, 430
formal, 318–320 not-for-profit, 238
planning, 319 number of beds, 241
steps before, 319 nurse call systems, 445
time, 319 nurse licensure compact (NLC), 103–104
member of healthcare team, 210 nurse migration, 104
mentor, 128 nurse practice act, 100
mentoring, 128–129 nurse residency programs, 133–134, 134f
Index 547
nurse–managed health clinics (NMHCs), 473 experience/practicum, 130–132

nurse–patient relationship lab and simulation, 129–130
communication, 298–299 lifelong, 134–137
continuum of professional behavior, 298, 298f nurse internships/externships, 133
National Council of State Boards of Nursing, nurse residency programs, 133–134, 134f
297–298 credentialing, 137–138
therapeutic use of self, 296–297 critical problems
nursing, 243 access to clinical experiences, 95–96
accountability, 20 faculty shortage, 95
autonomy, 20 laboratory and simulation experiences, 96
code of ethics, 20 differentiated practice, 80–81
definition, 18, 19, 40–42 educators, 76
essence of, 18 entry into practice, 78–80
external and internal factors, 31 evidence-based management, impact, 369–370
image of, 30–32 experience to reach graduation and licensure, 114–115
knowledge center, 26 history, 76–77
leaders, 10–16 improving, 77–78
professional characteristics, 19–20 informatics, 433–434
research, 60–61 interprofessional, 97–98
responsibility, 20 levels of nursing programs, 75–76
roles, 63 National League for Nursing, 86–87
change agent, 64 Organization for Associate Degree Nursing, 87
collaborator, 64 to practice, 75f
counselor, 64 professional socialization, 115
educator, 63 quality and excellence
entrepreneur, 64 competencies focus, 89, 90t
leader, 65 curriculum, 89–93
manager, 64 NLN Hallmarks of Excellence©, 88–89
patient advocate, 65 standards, 88
provider of care, 63 regulation
researcher, 64 critical current, 103–105
scholarship, 50–55 future issues, 103–105
social contract with society, 20 licensure requirements, 101–102
theory, 55–60 National Council Licensure Examination,
workforce, 154 102–103
nursing agenda, 154–155 National Council of State Boards of Nursing, 101
nursing assistant, 245 nurse practice act, 100
nursing care process professional licensure criteria, 99–100
assessment, 290 state boards of nursing, 100–101
diagnosis, 290 students, 76
evaluation, 291–292 and faculty, 115–116
implementation, 291 learning styles, 116–117
planning, 290–291 tools for success, 117
steps, 289, 289f mentoring, 128–129
Nursing Department Organizational Chart, 257f networking, 128
nursing education, 74–75, 474 study skills, 121–128, 123f, 124f, 127f
accreditation, 93–94 time management, 117–121, 118f, 121f
American Association of Colleges of Nursing, 87 transforming, 97
certification, 137–138 types, 81–86
clinical learning associate degree, 82–83
cooperative experiences, 132 baccalaureate degree, 83–84
548 Index
nursing education (continued) patient care assistant, 245

diploma schools, 82 patient factors, 409
doctor of nursing practice, 85–86 patient protection, 163–164
master’s degree, 84–85 patient rights, 280
research-based doctoral degree, 85 patient satisfaction, 281–283
nursing informatics (NI), 431 Patient Services Organizational Chart, 258f
certification, 432 patient values and preferences/circumstances, 360–361
data to wisdom, 431f patient-centered care
education and research, 433–434 care coordination, 288–289
impact on care, 432–433 changes related to, 270
nursing intervention classification, 438 characteristics of, 48
nursing leadership, 451 consumerism
nursing management, 463, 465–466 consumers/customers, 279–280
models and theories, 463–464 Health and Human Services, 278
positions, 466–467 information resources, 280–281
shared governance, 464–465 patient rights, 280
nursing management minimum data set, 438 patient satisfaction, 281–283
nursing minimum data set, 438 critical thinking and clinical reasoning and
nursing outcome classification, 438 judgment, 289
nursing practice and management, 368, 369 concept/care map, 292–293
nursing specialties, 475–476 nursing process, 289–292, 289f
nursing theory, 55–60, 277–278 cultural competence, 284
culture, 283–284
O disparities
observers, 116 in health care, 284–286
occupational health care, 223–224, 474 importance, 286–287
occupational therapist (OT), 246 diversity, 283, 287–288
office-based nursing:, 474 goal, 275–276
Omaha System, 438 information provides, 276
online support groups, 446 levels, 273–274
opioid epidemic, 226–227 nursing theories, 277–278
Orem’s self-care theory, 277 patient advocacy, 288
organ transplantation, 187–188 Quality Chasm, 274–275
Organization for Associate Degree Nursing (OADN), quality improvement, 275
27, 87 self-management, 293
organizational culture, 258–261 health literacy, 293–294
organizational ethics, 179–180 nurse–patient relationship, 296–299, 298f
organizational factors, 409 patient and family education, 294–296
organizational failure, 384–385 support, 271–273, 272f
outcomes research, 352 Peplau’s interpersonal relations theory, 277
overuse, 384 perceived benefits of action, 208
ownership, 241 perceived self-efficacy, 208
Perioperative Nursing Data Set (PNDS), 438–439
P person, right, 333
palliative care, 187, 221–223, 473 personal factors, 208
Parish nursing, 474 personal health record (PHR), 441
participants/subjects for sample, lack of, 359 personal knowing, 42
patient advocacy, 288 Peter Principle, 466
patient advocate, 65 pharmacist, 246
patient and family education, 294–296 physical aspect, 48
patient as focus of care, 210 physical therapist (PT), 246–247
Index 549
physician, 246 colonization of America, 6–10

physician’s assistant (PA), 246 early history, 5
PICOT (patient–intervention– comparison– enlightenment, 6
outcome–time), 361 growth in United States, 6–10
plan–do–study–act (PDSA) cycle, 339 Industrial Revolution, 6
Planetree Institute, 274 middle ages, 5–6
policy, 148 Renaissance, 6
policy development, 201 rise of Christianity, 5–6
policy-making process, 155–157, 156f themes, 16–17
political action committees (PACs), 161–163 professional organization, 22
political competence, 159 major nursing associations, 23–28
political process, 157–158, 158f membership, 28
lobbying, 159–161 websites, 23–24
nurses’ role, 159 professional socialization, 115
political action committees, 161–163 professionalism
politics, 157 comparison of attitudes, 18t
population, 204 nursing
power, 341–342, 341f accountability, 20
leadership, influence factors, 470 autonomy, 20
types of, 342 code of ethics, 20
practice barriers, remove scope of, 495 definitions, 18, 19
practice models, 477–478 essence of nursing, 18
practicum, 82 professional characteristics, 19–20
curriculum, 91–92 responsibility, 20
nursing education, 130–132 social contract with society, 20
pragmatists, 117 professional organization, 22
preceptor, 92 major nursing associations, 23–28
prejudice, 284 membership, 28
prescriptive authority, 84 websites, 23–24
primary care provider, 203 sources of professional direction, 20–22
primary prevention, 209 workforce, 28–29
prior related behavior, 208 promotion of health, 41
privacy, 185, 449–450 provide patient-centered care, 49, 471. See also
private policy, 149 patient-centered care
professional characteristics, 19–20 provider of care, 63
professional development, 4–5 psychological aspect, 48
colonization of America, 6–10 Public Health Act of 1944, 155
early history, 5 public policy, 148
enlightenment, 6 public/community health care, 197, 472
growth in United States, 6–10 acute illness, 214
Industrial Revolution, 6 adaptation, 214
middle ages, 5–6 coping, 213
renaissance, 6 delivery system
rise of Christianity, 5–6 access to care, 204–205
professional ethics, 172 continuity of care, 202–203
professional literature, 61–62 continuum of care, 202
professional nursing family, 203–204
evidence-based management, 368, 369 health disparity, 206–207
history, 4 life span, 206
leaders, 10–16 structure and function, 200–202
professional development, 4–5 disease prevention, 209–210
550 Index
public/community health care (continued) quality care issues, 377, 378

greater emphasis on chronic disease, 214–217 tools and methods, 404
health and illness, 211–213 access to healthcare services, 405
health literacy, 218 benchmarking, 405
health promotion, 207–209 incident reports, 407
medical home model, 217 medication reconciliation, 405
member of healthcare team, 210 rounds, 406–407
patient as focus of care, 210 sentinel events, 407
problems, 225 standardized communication methods, 406
opioid epidemic, 226–227 utilization review/management, 404–405
violence in communities, 225–226 quantitative studies, 357
resilience, 214
self-management, 217 R
services race, 284
alternative therapies/integrative medicine, 224 randomization, 357
case management, 223 randomized controlled trials (RCTs), 362
community emergency preparedness, 218–219 rapid response teams (RRTs), 403
complementary, 224 rationing care, 186
elder care, 221 readmissions, root causes of, 400
end-of-life care, 221–223 reality shock, 65, 132
extended care, 221 reflective critical thinking, 45
genetics, 224–225 reflectors, 116
home health care, 220 registered dietitian, 247
immigrant issues, 220 registered nurse (RN), 9, 173, 245
long-term care, 221 registered nurse-baccalaureate degree in nursing
managing population health, 219–220 (RN-BSN), 82
migrant issues, 220 regulation
occupational health care, 223–224 critical current, 103–105
palliative care, 221–223 future issues, 103–105
rehabilitation, 221 licensure requirements, 101–102
school health, 220–221 National Council Licensure Examination,
stress, 213 102–103
vulnerable population, 211, 212t National Council of State Boards of Nursing, 101
nurse practice act, 100
Q professional licensure criteria, 99–100
qualitative studies, 357 state boards of nursing, 100–101
quality and disparities report (QDR), 285–286 rehabilitation, 221
Quality Chasm reimbursement, 250–252
cultural competence, 284 government, 253–255
disparities, 284–285 third-party payer system, 252–253
diversity, 283 reimbursement for nursing care, 154
impact on quality care, 380–382 relational continuity, 203
informatics technology, 425–426 renaissance, 6
patient-centered care, 274–275 research, 60, 243–244, 474
quality improvement (QI), 243, 367–368, 391–392 analysis, 356
leadership, 488–490, 489f design, 356
measurement, 407–408 ethics, critical issues
analysis, 408–409, 507–511 informed consent, 176–177
data collection, 408 physical harm, risk of, 178
patient outcomes and nursing care, 410–413, 413f psychological harm, risk of, 178
Index 551
evidence-based management (EBM), 352, 367 professional literature, 61–62

barriers, 359–360 school health, 220–221
design, 357 school nursing, 474
ethics and legal issues, 358–359 scope of practice, 21, 99
facilitators, 359–360 scorecard, 430
funding, 357–358 secondary caregivers, 204
historical background, 352–353 secondary prevention, 209
impact on, 360 security protections, 430
NINR, 353–354 self-directed learning, 93
quantitative experimental process, 354–356 self-management of care, 217, 293
informatics, 433–434 health literacy, 293–294
problem statement, 356 nurse–patient relationship, 296–299, 298f
proposal, 356 patient and family education, 294–296
purpose, 356 sensemaking, 46–47
research competencies, lack of, 359 sentinel events, 385, 407
research question, 356 shared governance, 464–465
research-based doctoral degree in nursing, 85 shared knowledge and free flow of information, 381
researcher, 64 Sigma Theta Tau International (STTI), 27
researcher controls, 357 simulation learning, 129–130
resilience, 214 situation monitoring, 316
respiratory therapist, 247 situational influences, 208
respondent superior, 182 situation–background–assessment–recommendations
responsibility, 20, 465 (SBAR), 322, 323
retail clinics, 473–474 skill and training, 99
rise of Christianity, 5–6 smartphones, 443–444
risk of harm for the consumer, 99 social contract with society, 20
Robert Wood Johnson Foundation (RWJF), 287 social harm, risk of, 178–179
robotics, 448 social media, 188–189
role transition, 63 social policy statement, 20–21
root-cause analysis (RCA), 408–409 Social Security Act of 1935, 155
rounds, 406–407 social worker, 247
rules and regulations, 240 source of control, 381
spiritual aspect, 48
S staff development, 244
safe community environments, 210 education, 135
safety, 383–384 staffing and healthy work environment, 513–518
critical, 383–385 staff safety, 388–391
culture of, 385–388, 388f staff/team, 409
healthcare report cards, 395–396 standardized communication methods, 406
initiatives, 392–394, 393f standardized terminology, 437
The Joint Commission, 394–395 standards, 21
staff, 388–391 nursing education, 88
system property, 381 of practice, 22, 182
SBAR. See situation–background–assessment– of professional performance, 22
recommendations (SBAR) state boards of nursing, 100–101
scholarship State Children’s Health Insurance Program
activities, 50 (S-CHIP), 151
definition, 50 state insurance programs, 255
milestones, 51–55 statistical expertise, lack of, 360
new modalities of, 62 status, 63
552 Index
STEEEP®, 380 transferring, 333

stereotyping, 284 transformational leadership, 464
stress, 138, 213 Transforming Care at the Bedside (TCAB), 393, 490
management, 139, 213 translational research, 370
model of job, 139f transparency, need for, 381
students, 76 treatment, 41
and faculty, 115–116 triple aim, 391
leadership, 498–499 types of power, 342
learning styles, 116–117
study skills, 121–122 U
class time effectively, 123–125 underuse, 384
internet, 125 uninsured and underinsured, 255
preparation, 122 unlicensed assistive personnel (UAP), 332
preparing written assignments and team projects, upper level, 258
125–126 U.S. Department of Veterans Affairs, 255
quizzes and exams, 126–128, 127f utilization review/management (UR/UM), 404–405
reading, 122–123, 123f, 124f utilize informatics, 50, 425f. See also informatics
team discussions, in classroom and online, 128 technology (IT)
sufficient time, lack of, 359
Sullivan Commission report, 287 V
supervision, 334 veracity, 171
surveillance, 410 violence, 389–390
synthesizing, 42 violence in communities, 225–226
systematic review, 361 virtual appointments, 445–446
Systematized Nomenclature of Medicine—Clinical voice mail and texting, 445
Terms, 439 vulnerable population, 211, 212t
T W
tablets, 443–444 Watson’s theory on caring, 277
task, 333 wearable computing, 447
task factors, 409 whistleblowing, 180
teaching, 50, 242 wisdom, 431
team, 308 work environment, 329–331, 483–484, 486
team builder, 313 improvement, 487–488
TeamSTEPPS®, 314–315f work in interdisciplinary, 49
teamwork, 308, 311 work in interprofessional teams, 309, 309f
clarification, 311–312 change process, 338–339
effective development, 313, 314f, 315f, 316 collaboration, 326
leadership, 312–313 communication, 316–318
microsystem, 312 assertiveness, 320–321
technical failure, 384 checklists, 322, 323
telehealth/telemedicine, 474 debriefing, 320
telenursing, 448 formal meetings, 318–320
telephone, 445 listening, 321–322
tertiary prevention, 209 mindful, 322
theorists, 117 SBAR, 322, 323
time management, 117–121, 118f, 121f conflict, 339, 340f
timely care, 380 conflict resolution, 339–341, 341f
tort, 182 coordination, 326–327
The Traditional (Silent or Mature) generation, 468 barriers and competencies related, 327–328
training, 76 tools and methods, 328–329, 328f
Index 553
decision making, 324–325 teamwork, 311

delegation, 331–332 clarification, 311–312
evaluation, 337–338, 338f effective development, 313, 314f, 315f, 316
five rights, 333–334, 334f leadership, 312–313
importance, 332–333 microsystem, 312
principles, 334–335, 336f thinking, 325f
empowerment, 342 work environment, 329–331
members, 323–324 workforce issues, 484–486
power, 341–342, 341f

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Anita Finkelman

Anita Finkelman, MSN, RN

Library of Congress Cataloging-in-Publication Data

Names: Finkelman, Anita, author.

Printed in the United States of America

9781284127959_FMxx_i_xviii.indd 4 27/09/17 9:54 AM

Nursing Theory 55 Quality and Excellence in Nursing

Ethics and Research 176 Across the Life Span 206

Chapter 8 The Healthcare Delivery The Competency: Provide Patient-Centered

Chapter 10 Work in Interprofessional Chapter 11 Employ Evidence-Based

Chapter 12 Apply Quality Measurement and Analysis 407

Internet or Virtual Appointments 445 Scope of Practice: A Profession of Multiple

in the Future Progress Report on The Future of Nursing:

Information up through June 2017 is accurate, but

●● Introduction ●● Nursing as a Profession

Accountability Nursing Scope of practice

The past portrayal of nurses as handmaidens and

Exhibit 1-1 The Original Nightingale Pledge

Exhibit 1-2 A Glimpse into the Contributions of Nurses in the

Exhibit 1-2 (continued)

Sophia Palmer (1900) nursing, housing reform, suffrage, world peace,

Mary Adelaide Nutting (1910) Virginia Avenel Henderson (1939)

Exhibit 1-2 (continued)

Exhibit 1-2 (continued)

Professionalism: Nursing as a Profession

Table 1-1 Comparison of Attitudes: Occupation Versus Career

Exhibit 1-3 Definitions of Nursing: Historical Perspective

Florence Nightingale American Nurses Association

board definitions. Commitment to providing a service that

In general, a profession—whether nursing or benefits individuals and the community

law—has certain characteristics (Finkelman, 2016; autonomy, responsibility, and accountability

Major Nursing Associations perspective of the many organizations representing

Exhibit 1-4 Specialty Nursing Organizations

Academy of Medical–Surgical Nurses: http://www.medsurgnurse.org

Exhibit 1-4 (continued)

Association for Nursing Professional Development: http://anpd.org

ENGAGING IN THE CONTENT

CRITICAL THINKING ACTIVITIES

CRITICAL THINKING ACTIVITIES (CONTINUED)

your data to identify any themes and un- www.nursingworld.org/MainMenuCatego

ELECTRONIC REFLECTION JOURNAL

Working Backward to Develop a Case

CASE STUDIES (CONTINUED)

Write a brief paragraph that describes a case related to the following

Advocate Dichotomous thinking Provider of care

must be present for quality nursing care. Content

Knowledge and Caring ■■ Promotion of health and wellness

■■ Adaptation to physiologic and pathophysi- ■■ Teamwork

Exhibit 2-1 A Brief History of Selected Nursing Scholarship Milestones

1850 Nightingale conducted first nursing research by collecting healthcare data

Exhibit 2-1 (continued)

Exhibit 2-1 (continued)

As a distinct discipline, nursing needed standards to guide practice and

Exhibit 2-1 (continued)

1954 The University of Pittsburgh started a PhD program in nursing (academic