Leadership Management by Kelly

NOTE-TAKING
AND BULLETS
<Insert Picture Here>
Nursing Leadership and Mana
gement
The Health Care Environment
Organizational Behavior and M
agnet Hospitals
Basic Clinical Health Care Econ
omics
Evidence-Based Health Care
Nursing and Health Care Inform
atics
Population-Based Health Care P
ractice
Personal and Consumer Partner
ships
Politics and Consumer Partne
rships
Strategic Planning and Organ
izing Patient Care
Effective Team Building
Power
Change, Innovation, and Con
flict Management
Budget Concepts for Patient
Care
Effective Staffing
Delegation of Patient Care
Organizational of Patient Care

Time Management and Setting Pati
ent Care Priorities
Managing Outcomes Utilizing an
Organizational Quality Improvem
ent Model
Evidence-Based Strategies to Im
prove Patient Care Outcomes
Decision Making and Critical Thin
king
Culture, Generational, Differences
, and Spirituality
Collective Bargaining
Career Planning
Emerging Opportunities
Nursing Leadership and

Management
Definition of Management
A process of coordinating
actions
and
allocating
resources
to
achieve
organizational goals
An art of accomplishing
things through people
Managerial Roles
Role includes behaviors, expectations,
and recurrent activities within a
pattern
that
is
part
of
the
organizations structure
Information-processing role: used
to manage information people need
Interpersonal
role:
figurehead,
leader, liaison
Decision-making role: entrepreneur,
disturbance handler, allocator of
resources
Management Functions
Managing the work

Managing relationships
Managing the Work

Planning
Informing
Organizing
Monitoring
Problem
Consulting
solving
Delegating
Clarifying roles
and objectives
Managing Relationships
Networking
Supporting
Developing and mentoring
Managing conflict and team
building
Motivating and inspiring
Recognizing and rewarding
Scientific Management
Focus
is
on
goals
and
productivity
Organization
viewed
as
machine to run efficiently to
increase production
Workers must have proper
tools and equipment
Time and motion studies
Bureaucratic Management
Focus
on
superior
subordinate communication
Top down approach
Uses
explicit
rules
and
regulations for governing
activities
Uses merit and skill as basis
for promotion/reward
Concern
for
economic
efficiency
Administrative Management
Focus is on science of
management
Commonly referred to as the
management process
Identifies need for Planning,
Organizing,
Supervising,
Directing,
Controlling,
Reviewing, and Budget =
POSDCORB
Human Relations
Focuses on the empowerment of the
individual worker as source of control
Hawthorne effect
Phenomena of being observed or
studied results in changes in
behavior
Participatory
decision
increases worker autonomy
making
Provides training to improve work
First-Level Manager Roles
Nurse manager
clinical bedside
at
the
Manages patient care and

supervision
of
others
delivering care
Plans for care
Middle-Level Nurse Manager

Unit manager or director
Spends
most
time
coordinating and planning
on
Executive-Level Manager
Expanded role of planning

and being generalist
May have title of Chief
Nurse Executive or Vice
President of Patient Care
Services
Administrative Principles
General principles of management relevant to
any organization
Unity of command and direction
Worker
gets
supervisor
orders
from
only
one
Acceptance theory of authority
People have free will and choose to comply

with the orders they are given
Organizations have naturally forming social
groups that can become strong and powerful
Human Relations
The effect of being watched
and
receiving
special
attention may alter a persons
behavior
People benefit and are more
productive and satisfied when
they participate in decisions
about their work environment
Motivation Theories
Belief that worker output greater when workers
treated humanistically
Motivation
Whatever influences our choices and creates
direction
Process that occurs internally to influence and
direct our behavior in order to satisfy needs
Helpful because they explain why people act the
way they do and how a manager can relate to
workers as human beings and workers
Selected Motivation Theories

Maslow: Hierarchy of Needs
Motivation occurs when needs are not
met
Must satisfy one need to move on to
next
Herzberg:
Job
dissatisfaction
occurs
when
adequate
salary,
safe
working
conditions and relationships are not
met
Motivation occurs with meaningful
work and advancement opportunities

McGregor: Theory X
Leaders must direct and control

Employees prefer security, direction,
and minimal responsibility to get the
job done
McGregor: Theory Y
Leaders remove obstacles as workers

have self-control and self-discipline
The
workers
reward
is
their
involvement in their work

Ouchi: Theory Z
Collaborative decision making

Long-term employment
Mentoring
Holistic concern
Leadership
A process influence by which the
leader influences others toward
goal achievement
Leaders inspire, enliven, and
engage others to participate
Reciprocal relationship
Nurses are leaders
Formal and informal leaders
Formal and Informal

Leaders
Formal
Person
in
authority
has
sanctioned role in organization
Informal
An individual who has emerged
as a leader outside the scope of a
formal leadership role
Perceived to have influence
Leadership Characteristics
Guiding vision
Provides
direction
preferred future
toward
Passion
Passion expressed
inspires others
by
the
leader
Integrity
Knowledge
maturity
of
self,
honesty,
and
Leadership Traits
Intelligence
Self-confidence
Determination
Integrity
Sociability
Visionary
Enthusiastic
Have high
standards
Value education
Value professional
development
Demonstrate
power in the
organization
Active in a
professional
organization
Differences in Leaders versus Nonleaders

Drive
Desire to lead
Honesty and integrity
Self-confidence
Cognitive ability
Knowledge of the business
Behavioral Theories
Autocratic
Centralized decision making

Leader makes decisions and has power to
command others
Democratic
Participatory leader
Delegates authority to others
Expert power
Laissez-faire
Passive and permissive

Defers decision making
Behavioral Leadership
Employee-centered leadership
Focus is on human needs of
subordinates
Job-centered leadership
Focus
is
on
costs
efficiency
and
Leader Behavior
Initiating structure
Emphasis on work to be done
Focus on task and production
Focus on how work is organized
Focus on achievement of goals
Planning, directing others, and
establishing deadlines
Focus on details of how work is to
be done
Leader Behavior
Consideration
Focus on employee
Emphasizes
relating
and
getting along with others
Focus on well-being of others
Fosters
communication
and
trust
Contingency Approaches
Acknowledges that other factors
in the environment influence
outcomes as much as leadership
style
Leader
effectiveness
is
contingent upon or depends upon
something
other
than
the
leaders behavior
Different
patterns
leader
behavior
will be effective in
Fielders Contingency Theory

Belief that a leaders behavior is
dependent upon the interaction of
the personality of the leader and the
needs of the situation
The needs of the situation, or how
favorable the situation is, toward the
leader involves:
Leader-member relationships
The degree of task structure
The attitudes of the followers
Leader-Member Relations
Feelings and attitudes of followers regarding
acceptance,
leader
trust,
and
credibility
of
the
Good leader-member relationships
Followers
respect,
trust
confidence in the leader
and
have
Poor leader-member relations
Reflect distrust
Reflect a lack of confidence and respect
Dissatisfaction with the leader by the
followers
Task Structure
The degree to which work is
defined, with specific procedures,
explicit directions, and goals
High
task
structure
routine,
predictable,
defined work tasks
involves
clearly
Low task structure involves work

that is not routine, predictable, or
clearly defined
Position Power
The degree of formal authority
and influence associated with the
leader
High position power
Favorable to the leader
Low position power
Not favorable to the leader
Hersey and Blanchards Situational

Theory
Addresses follower characteristics in
relation to effective leader beliefs
Considers follower readiness as a factor
in determining leadership style
Uses
behavior
and
relationship
behavior
Types
Telling leadership style
Selling leadership style
Participating leadership style
Delegating leadership style
Path-Goal Theory
Leader
works to motivate
followers and influence goal
accomplishment
Leadership style is:
Directive
Supportive
Motivating
Path-Goal Theory
Provides
structure
through
direction and authority, with
leader focusing on task and
getting job done
Leadership style is matched to
the situational characteristics of

the followers and situational
factors in the environment
Contemporary Approaches
Charismatic theory
Charismatic
leaders
have
selfconfidence and strength in their
convictions and communicate high
expectations
and
confidence
in
others
Transformational theory
Seeks to empower others to engage
in pursuing a collective purpose by
working together
Types of Leaders
Transactional
Concerned
operations
with
day-day
Transformational
Committed to a vision that
empowers others
Change agents
Communities of Practice
Forming informal groups

Using
group
process
of
organizing
Using principles of learning
Sharing information
Form by self-organization
They
come
together
naturally
The Knowledge Age

Rapid,
instant
access
to
information
Organizations
have
expert,
specialized knowledge workers
Will be influenced by three
trends
Mobility
Virtuality
User-driven practices
Key Trends
Mobility
The ability to change skill sets as well as

the work being dispersed
Virtuality
Working through virtual means using digital

networks
User-driven practices
Individual acts more independently and is

increasingly accountable for choices and
actions
BACK
The Health Care

Environment
History of Health Care

Advances
in health care science and

technology continually change what health
care can accomplish
Many
problems in health care remain a

challenge
Preventing the spread of disease
Structuring organizations to benefit both
clinicians and patients
Collecting and using data and information
to encourage improvement
Understanding
how
external
forces
influence care delivery
Structuring Hospitals around

Nursing Care
Nightingale
described the importance

structuring hospitals around nursing care
of
The physical environment of hospitals can
create stress for patients, their families, and

clinical staff
Designs of hospitals lead to improvements in:
Patient outcomes
Patient safety
Patient and staff satisfaction
Collecting Data
Data can be collected through patient
records,
systems
surveys,
and
administrative
Many reports are developed from this
data that provide valuable information

Data
is displayed with charts and

pictures to emphasize the successes and
failures of health care throughout the
nation
Influence of External Forces on

Health
Care
Health care is the largest sector of
our economy
Employers,
clinicians, managers,
and patients all have a vested
interest in the proposed changes to
health care financing, organization,
and the responsibilities and scope
of practice for clinicians
Organization of Health Care

Structure
Resources or structures needed to deliver

quality care
(doctors, nurses, buildings,
medical records, pharmaceuticals)
Process
Quality activities, procedures, tasks, and

processes performed within the health care
structure (hospital admissions, surgery, nursing
care)
Outcome
The results of good care delivery
Goals of Good Health Care

Ensure
that the health status of

everyone is the best that is possible
across the life span
Health care must respond to patients
expectations of respectful treatment,

and there must be a patient focus by
health care clinicians
Health
care must provide financial

protection for everyone regardless of
their ability to pay
Absence of a Universal Health Care

System
United States is only one of a few
large countries without a universal
health care system
Health
care is tied directly

having health insurance
to
Leaves serious gap in health care
payment coverage for millions
Emphasis on Hospital Care

The
emphasis on acute health care

services has driven health care costs
higher, but has not necessarily improved
the quality of care or outcomes
Only eight out of one thousand people
will benefit from hospitalization

Majority of people benefit from primary
health care delivery
Need for Primary Health Care

Primary
care provides
accessible health care
integrated,
Clinicians are accountable for:
Addressing a large majority of

personal health needs
Developing
a
sustained
partnership with patients
Practicing in the context of family
and community
Primary Care
Emphasizes seven features
Continuous
Comprehensive
Coordinated
Community oriented
Family centered
Culturally competent
Begun at first contact with the
patient
Foundations of Primary Care

First contact
Conduct the initial evaluation and define the

health dysfunction, treatment options, and goals
Longitudinality
Sustain a patient-clinician relationship over time

Comprehensiveness
Manage the wide range of health care needs

Coordination
Care through referrals and other providers is

integrated
The Federal Government

Agency
for
Healthcare Research
and Quality (AHRQ)
Centers for Disease
Control
and
Prevention (CDC)
Centers for Medicare
and
Medicaid
Services (CMS)
Food
and
Drug
Administration
(FDA)
Health Resources and

Services
Administration (HRSA)
Indian Health Service
(IHS)
National Institutes of
Health (NIH)
Substance Abuse and
Mental Health Services
Administration
(SAMHSA)
State and Local Levels

Include the boards of health
and state and

departments
Efforts
local
health
for bioterrorism and

disaster preparedness funding
have left little money focused
on public health needs
Home Health Care

Fastest growing segment
of the health care delivery

system
Almost as many persons
receive care in the home

as in acute care settings
Health Care Disparities

Enabling
factors affect ones

ability to have access to health
care
Income
Type of insurance coverage
Gender
Race or ethnicity
Geographic proximity
System characteristics
Health Care Spending

In the United States, health insurance is
generally based on employment
This leaves gaps between those with high
incomes and employment and those with

low income or no employment
Providers of health care deliver service to
patients and bill third-party payers
Health insurance distributes health care
funds from the healthy to the sick
Rising Health Care Costs

By making health care more affordable, health
insurance has contributed to rising health

care costs
Health care costs grow faster than wages
Employees are bearing more of the financial
burden for their cost

Underinsurance and cost sharing items reduce
health service utilization for both appropriate

and inappropriate medical services
Medicare and Other Health Care

Costs
The elderly have virtually universal
health
care
Medicare
coverage
through
This universal health care coverage
indicates the United States will

likely experience very rapid growth
in overall health expenditures in
coming years as the population
continues to age
Health Care Insurance

People
are not covered because the

cost is too great
As health care costs increase and rising
costs
cut
into
business
profits,
employers are choosing to offer fewer
insurance options
Factors contributing to high numbers of
uninsured are people between jobs and

not being eligible for public programs
Medicare and Medicaid

Public health programs are intended to fill the gap of
coverage
insurance
for
those
without
employer-based
The Social Security Act of 1965 provided needed
services to uninsured populations

XVIII Medicare
Provides public insurance based on age 65 or

above
XIX Medicaid
Provides insurance for low income and/or disability
Other Public Programs

American
Heritage
Indian
and
Alaska
Native
The Indian Self-Determination Act of 1975
gave
tribal
organizations
the
responsibility for the provision of health
care services
The Department of Defense
Tricare
Champus
Department of Veteran Affairs
State Regulation of Health

Insurance
Three
key
pieces
of
federal
legislation
set
forth
national
standards for individual states to
regulate health insurance
Employee
Retirement
Income
Security Act (ERISA) 1974
Consolidated
Omnibus
Budget
Reconciliation Act (COBRA) 1985
Health Insurance Portability and
Accountability Act (HIPAA) 1996
The Rising Cost of Health Care

16%
of the Gross Domestic

Product (GDP) is spent on health
care
Health care spending continues
to increase faster than the

overall U.S. economy
It is growing at an annual rate
of 9.9%
Factors Contributing to Rising Health

Care Costs
Aging population
Average life expectancy is increasing
Elderly are becoming the largest
group of the population
Increased
utilization
of
pharmaceuticals
Increased
utilizations,
cost
of
research, and increased insurance
coverage

Care Costs
Technological advances
Greater availability of new technology drive

per capita expenditures higher
Rising hospital costs
A large proportion of health care dollars are

devoted to hospital care
Physician behavior
Diagnostic tests and procedures may be done

which are not medically necessary

Care Costs
Cost shifting
Health care providers raise prices for
the privately insured to offset the
lower health care payments from both
Medicare and Medicaid and non
payment
Administrative costs
Information
technology
(IT)
has
played a role in improving quality, but
increasing costs
Forces that Affect Overall Health Care

Utilization
Financial incentives that reward practitioners
Increased accountability for performance
Technological advances in the biological and
clinical sciences
Increase in chronic illness
Increased ethnic and cultural diversity
Forces that Affect Overall Health Care

Utilization
Increased
population
ethnic
and
cultural
diversity
of
the
Changes
in the supply and education of health

professionals
Social morbidity
Access to patient information
Globalization and expansion of the world economy
Cost control and competition for limited resources
Cost Containment Strategies

Cost
containment
strategies
have
targeted the financing and reimbursement
of health care
Reimbursement
containment strategies
use regulatory and competitive price and
utilization controls
Capitation
Patient cost sharing
Utilization management
Prospective payment
Capitation
The
payment of a fixed dollar

amount, per person, for the
provision of health services to a
patient population for a specified
period of time
Under
capitation, health care

organizations benefit from using
their financial resources to keep
people well
Prospective Payment
The
Tax
Equity
and
Fiscal
Responsibility
Act
(TEFRA)
1982
mandated the Prospective Payment
System (PPS) to control health care
costs
A method of reimbursement in which
Medicare payment is made based on

predetermined, fixed amount for
reimbursement to acute inpatient
hospitals and other health care
organizations
Health Care Quality

Several
large
studies
have
produced information about the
poor quality of health care
attributable to misuse, overuse,
and underuse of resources and
procedures
To Err Is Human 1999
Crossing the Quality Chasm
2001
Health Care Dimensions Needing

Improvement
Health care should be:
Effective
Patient centered
Timely
Efficient
Safe
Equitable
Health Care Variations

Significant variations in health care
have been found to be associated

with:
Geographic location
Provider preferences and training
Types of insurance
Age, gender, and race
Availability
of
services
and
technology
Patient adherence
Improvements in the Process of

Care
Evidence-based care changes
lower health care dollars and
save lives
These changes in the process
of care delivery can improve

the cost of health care and
reduce mortality rates
Performance and Quality

Measurement
Measured to:
Determine resource allocation

Organize care delivery
Assess clinician competency
Improve health care delivery processes
When
the quality of care is measured, it

improves
Reliable methods and measures need to be
developed and tested to be able to measure

quality care
Public Reporting of
Performance
Information can be used to determine where
there are health care deficiencies and poor

quality of care
Can be used by major health care payers as a
condition
of
organization
Used
doing
to influence
utilization behavior
business
clinician
with
and
an
patient
Moves health care towards a population-based
approach
Institute of Medicine Health Care

Reports
Institute of Medicine (IOM) 1996 launched
an effort to assess and improve the nations

quality of care
Established
misuse,
services
the problems
and underuse of
as overuse,
health care
Sets
vision for how to close the gap

between good quality care and what
actually exists
Defined ten rules for care delivery redesign
Other National Quality Reports

AHRQ National Healthcare Quality Report
(2005)
AHRQ
National
Report (2205)
Healthcare
Disparities
Healthy People 2010

Health Grades for Hospitals and Physicians
Leapfrog
Disease Management
A
systematic population-based
approach to identifying persons
at risk, intervening with specific
programs of care, and measuring
clinical and other outcomes
Many
patients
with
chronic
diseases have multiple chronic
conditions
Evidence-Based Practice
Supplements clinical expertise with the
judicious
and
conscientious
implementation of the most current
and best evidence along with patient
values and preferences to guide health
care decision making
Even when evidence-based quality care
guidelines are available, they are not

fully implemented in actual patient
care
Improvement of Health Care

Quality
Patients need to participate in shared decision
making
Care is customized according to patients needs
and values
Care is patient centered

Clinicians and patients communicate effectively
and share information
Decision making is based on evidence

Improved patient safety
Impact of Accreditation
A
mechanism
organizations
standards
Accreditation
is
used
meet
to
ensure
that
certain
national
provided
by
The
Joint
Commission
Accreditation is linked to:
The ability to serve Medicare beneficiaries

Meeting patient safety goals
Hospital regulations by the Centers for
Medicare and Medicaid Services
The Magnet Program

Provided by The Magnet Recognition Program
of the American Nurse Credentialing Center

Recognizes excellence in nursing services as
a health care system

Positive nursing outcomes are:
Increased job satisfaction

Improved retention
Prevention of job burnout
Improvement in perceived quality of care
Improving Quality through Health Professions

Education
Needs an overhaul of curriculum to
transform current skills and knowledge

Curriculum
includes training clinicians
to:
Effectively work in interdisciplinary
teams
Have an educational foundation in
informatics
Deliver patient-centered care with an
evidence base
Current Practices
Limited by the use of external
oversights of credentialing,
certification, and licensure
These oversight processes are
generally
oversight
clinicians
not part of the

of
individual
Keeping Patients Safe

Critical factors in patient safety
Organizational
management
practices
Strong nursing leadership
Adequate nurse staffing
The nursing shortage is affected by:
The aging nursing workforce

Lack of qualified faculty
Lower nursing wages
Doctorate of Nursing Practice

Relatively new
May
supplant current masters

level
nurse
practitioner
programs
challenge
is
to
clearly
establish the scope of work and
reimbursement for DNPs
Organizational Behavior
and Magnet Hospitals
Definition of Organization
A
coordinated
and
deliberately
structured social entity
Consists of two or more people
Functions on a relatively continuous
basis to achieve a predetermined set
of goals
An
organizations
long-term
effectiveness may be determined by
its ability to anticipate, manage, and
respond to changes in its environment
Changes Affecting
Organizations
External forces
Influences originating outside the
organization (labor force, economy)
Stakeholders
People or groups with an interest

in the organizations performance
(customers, competitors, suppliers,
government
and
regulatory
agencies)
Organizational Behavior
Concerned with work-related behavior
Addresses:
Individuals and groups

Interpersonal processes
Organizational dynamics and systems
Emphasizes people skills in addition to technical
skills
Involves the systematic study of the actions and
attitudes people exhibit within organizations
Attitudes of Interest
Job satisfaction
How organizational members feel

about their job
Organizational commitment
How
committed
or
loyal
employees feel to the goals of the
organization
Determinants of Employee
ProductivityPerformance
Quantity and quality of output an
employee generates
Absenteeism
Rate of employee absences from work

Turnover
Number of employees resigned divided

by the total number of employees
during the same time period
Importance of Organizational
Behavior members to
Enables organizational
better understand their own behavior

as well as those of peers, superiors,
and/or other subordinates
Helps
individuals
effective employees
Employees
become
more
with
high
levels
of
organizational
commitment
are
generally more satisfied with their jobs
Organizational Effectiveness
An
organizations
sustainable
high
performance to ultimately meet the needs
of the organization, its members, and
society
The ability to survive and thrive under
conditions of uncertainty
Important contributors to the effectiveness
of an organization are the quality of the

workforce and their commitment to the
goals and success of the organization
Knowledge Economy
United States has shifted from industrial
focus and assembly line mentality in the

1900s to a knowledge economy in the
2000s
Requires highly educated employees for a
more technologic information age
Health care workers view themselves as
knowledge workers
Requires organizations to be supportive
and cultivate employees talents
Models of Organizational
Autocratic Behavior
Custodial
Supportive
Collegial
High Performance Organizations

Value people as human assets, respect diversity,
and empower individuals to use their talents to

advance personal and organizational performance
Mobilize
teams that
talents of its members
build synergy from the
Successfully bring people and technology together

Thrive on learning
Are achievement-oriented
Magnet Hospital
Voluntary credentialing process
Health care organization that has
met
the
rigorous
nursing
excellence requirement of the
American Nurses Credentialing
Center (ANCC), a division of the
American
Nurses
Association
(ANA)
Goals of Magnet Recognition

Promote
quality in a milieu that

supports
professional
nursing
practice
Identify excellence in the delivery of
nursing services to patients

Provide
a
mechanism
for
the
dissemination of best practices in
nursing services
Characteristics of Magnet
Nursing
Services
High-quality
patient
care
Clinical autonomy and responsibility
Participatory decision making
Strong nurse leaders
Two-way communication with staff
Characteristics
Community involvement
Opportunity and encouragement
of professional development
Effective use of staff resources
High levels of job satisfaction
Benefits of Magnet Designation

Improved patient quality outcomes
Enhanced organizational culture
Improved
nurse
recruitment
retention
Enhanced safety outcomes
Enhanced competitive advantage
and
Essentials of Magnetism
Opportunities to work with other nurses who are
clinically competent
Good
nursephysician
communication
relationships
and
Nurse autonomy and accountability

Supportive nurse manager-supervisor
Control
over
environment
nursing
Support for education

Adequate nurse staffing
practice
and
practice
Forces of Magnetism
Quality nursing leadership
Organizational structure
Management style
Personnel polices and programs
Professional models of care
Quality of care
Quality improvement
Forces of Magnetism
Consultation and resources
Autonomy
Community and the hospital
Nurses as teachers
Image of nursing
Interdisciplinary relationships
Professional development
Magnet Appraisal Process

Establish database to collect data on nursing-
sensitive indicators (measures that reflect the

outcome of nursing actions)
Benchmark
Conduct gap analysis
Receive written application
Visit site
Award decision
BACK
Basic Clinical Health

Care Economics
Principles of Economics
Scarcity
Resources exist in finite quantities, and

consumption demand is typically greater than
resource supply
Choice
Decisions are made about which resources to

produce and consume among many options
Preference
Individual and societal values and preferences

influence the decisions that are made
Health Care Difference

In a typical market, the buyer is also the
payer
In health care, the payer is not the provider
or the buyer
The
actual payer is the third-party

reimburser (the insurance company or
government)
The end result is a skewed financial picture
Traditional Perspective on Cost of

Health Care
Health care as altruism
Altruism: the unselfish concern for

the welfare of others
Ethics: the doctrine that the
general welfare of society is the
proper goal of an individuals
actions
Early nursing generally focused on
altruistic service, which evolved
from early charitable institutions

Health Care
Need
for health care determined by

provider
Paternalistic model of governance and
control
Health professionals controlled medical
knowledge and skill
Knowledge and skill required extensive
and expensive education not shared with
outsiders
Health care professionals determined
what health care was needed and what to
charge for it

Health Care
Right to health care at any cost
Prior
to
1960s,
Americans
considered health care a right
American government established
Titles XVIII (Medicare) and XIX
(Medicaid) of the Social Security
Act, to control spiraling health
care costs
Private insurers established their
own requirements, beginning the
overall budgeting of health care

Health Care
Cost plus
Includes actual cost incurred

by
provider
plus
profit
incentive
Incentive was the more you
spend the more you get
rather than how can this be
accomplished
more
economically?
Contemporary Perspective on Cost of

Health Care
Health care as a business
HCFA and TEFRA, which established

government payments at flat rates
(prospective payment)
Emphasis
among
providers
on
providing
care
for
less
than
prospective
payment,
thereby
making profit
Cost became the focus of managers,
administrators, and employees at all
levels of health care

Health Care
Need for care determined by the consumer
Emphasis on cost has led to concerns

that safety and quality have suffered
Total quality improvement (TQI) and
continuous quality improvement (CQI)
were initiated to assure society that cost
management was not compromising
safety or quality
Emphasis on involvement of patients,
health care consumers, and allied health
care providers

Health Care
Right
to
health
care
at
reasonable cost
Insurers
determine
reasonable cost
Lack of consensus on what
constitutes reasonable cost
is
at
the
heart
of
contemporary controversy

Health Care
Managed care
Integrates financial and clinical care

delivery functions into a single
organized system by contracting to
be responsible for the clinical
outcomes of an enrolled population
for a fixed fee
Emphasizes delivery of a coordinated
continuum of services across the
care spectrum from wellness to
death, using financial incentives to
achieve cost efficiency

Health Care
Managed care
The only health services program generated

from a market response, rather than from a
formal
federal
government
legislative
initiative
Is not about providing healthcare; it is
about being a for-profit brokerage business
Care is rationed through requirements such
as preapproval, physician choice, and
copayment
Coordinated
care is replacing the term
managed care

Health Care
Socialized health care
In theory, socialized medicine

provides complete medical
and hospital care to all the
citizens in a community,
district, or nation (universal
access)
Funding
usually
comes
through taxation of citizens
Future Perspective on Cost of

Health Care
Future costs may be affected
by
expensive
technologies,
new
diseases,
and
an
increasingly aged population
Changes in demographics and
cost may affect the way health

care is provided
The Cost Equation: Money = Mission =

Money
There must be cohesion and consistency
across the mission, vision, and strategic

plan for the business
The health care facility must determine
what is the cost in achieving its mission

The health care facility must decide if
providing health care services not

directly related to the mission is a viable
option
Business Profit
Revenue (income) minus cost (expense) equals
profit
Every
business must generate more income

than it spends in order to remain in business
For-profit business
The profit is distributed to stockholders and

to maintain and grow the organization
Not-for-profit business
All monies are fed back into the business

All profit is referred to as margin
Fundamental Costs
Direct cost
Directly related to patient care

(wages and supplies)
Indirect cost
Not explicitly related to care, but
are necessary to support care
(utilities, maintenance)
Fundamental Costs
Fixed cost
One that exists irrespective of the

number of patients for whom care is
provided
Variable cost
Varies with the volume of patients

Can increase or decrease with
volume of patients or costs of
supplies
Cost Analysis
Budget
A plan for how much will need to be spent in the

ensuing time period (generally one year)
It is based on:
What is known about how much was spent in the

past
How that will inevitably change in the coming
year
A cost prediction is a tool for developing a budget
High-low cost analysis

Regression analysis
Break-even analysis
High-Low Cost Analysis

Not extremely accurate, but provides
good enough estimate

Examines both fixed and variable cost
information from the most recent five

years for each category of expense
Both fixed and variable dollars must
be adjusted upward to account for

inflation
Regression Analysis
More precise than high-low analysis
Examines
all
available
past
cost
information over a specific time period
Only one dependent variable: cost

Only one independent variable: volume,
which causes change in cost
All cost information plotted on a vertical
axis
Regression Analysis
All
volume information
horizontal axis
plotted
on
Scatter diagram results

Straight
line through scatter diagram

best approximating all the points is used
to predict cost at a specific volume of use
Analysis is carried out for each item for
which cost needs to be predicted
Break-Even Analysis
Projecting whether and when profitability
will be achieved is necessary for both

proposed and well-established programs
and services
Break-even analysis assists the provider in
predicting the volume of services that

must be provided (and for which payment
must be received) in order for the cost of
providing the services to be equally
matched by the payment received, yielding
neither a profit nor a loss
Diagnostic, Therapeutic, and Information

Technology Cost
The most expensive items on the total
budget are diagnostic, therapeutic, and

information technologies
Managed
care programs have begun

requiring
justification
for
and
preapproval
of
use
of
complex,
expensive technology
Concerns
have arisen about rationing

technology to those who can afford to
pay
Nursing Cost
Fiscally, nursing is viewed as a cost center that
does not independently generate revenue

Ongoing efforts to measure and establish the
cost of the various components of nursing care

are disappointing
Nursing cost is associated with budgeted and
actual nursing care hours per patient day

A measure of time rather than a measure of
type or level of care
Patient Classification System

(PCS)
The
tool most broadly used to identify

nursing cost
A system for distinguishing patients
based on their acuity, functional ability,
or resource needs
Patients with similar requirements for care
are assigned to five progressively weighted

categories of acuity
The higher the acuity of the patients, the
more nursing resources the PCS assigns
Relative Value Unit (RVU)

An
index number assigned to

various health care services based
on the amount of resources used
This
approach
provides
a
reasonably accurate per patient
costing approach
It does not account for the
differences in costs based on the
type of health care worker
Quality Measurement
An evidence-based concept of quality
Grounded on scientific evidence that a diagnostic

or therapeutic approach to care improves patient
outcomes
Four core components
A mechanism that establishes consensus about

what constitutes best practices
Strong feasible processes to accomplish such
practices
A disease prevention and health promotion
component
A system to review actual performance and
outcomes
Regulatory Oversight
The quality industry measures and
tracks organizational performance

The primary accrediting body is
The Joint Commission
Accreditation signifies that the
organization meets the standard
of practice and influences market
perception
Customer Satisfaction
No matter how superior providers
feel their product is, if customers

perceive it not to be needed or
wanted, the product will fail
Commercial surveys measure how
satisfied customers are with their

care,
environment,
and
interactions with the staff
Health Care Site Economics

Economics focuses on how choices
are made to overcome a scarcity of

resources
Requires:
Redesigning
Restructuring
Reengineering
Health Care Provider

Economics
Economic risk is borne by individuals, as well
as by organizations
Individual providers receiving direct payment
from insurers bear risk when they must lower

their usual fees to a flat rate in order to be
included for payment by the HMO
Patients bear the risk of being unable to
access services they regard as either optimal

or as minimal, jeopardizing their health
Evidence-Based
Health Care
History of Evidence-Based Care

Initially began in Canada
Evidence-based care
The process of providing clinically

competent care that is based on
the
best
scientific
evidence
available
Includes all health disciplines
Implementation of Evidence
Practice
Find a source of evidence-based content
that is developed using good research

techniques
The evidence-based content itself must
be efficient for clinicians to use at the

bedside
Integrate
the evidence-based content

into order sets, plans of care, and
documentation forms
The ACE Star Model of Knowledge

Transformation
Provides
a
framework
for
systematically putting evidence-based
practice into operation
Star points
Knowledge discovery
Evidence summary
Translation
into
recommendations
Integration into practice
Evaluation
practice
Research Terminology
Absolute benefit
increase
Best practice
Case-control
study
Clinical practice
guidelines
Cohort study
Control group
Correlational
research
Dependent variable
Descriptive
research
Evidence-based
health care
Follow-up study
Health outcomes
Independent
variable
Integrative review
Longitudinal study
Prospective study
Qualitative
analysis
Quantitative
analysis
Nonexperimental
Quasi-experiment
research
Number needed to Randomized
clinical trial
treat
Relative risk
Outcomes
research
Research
utilization
Matching
Meta-analysis
Retrospective design
Systematic review
Time series design
Translation
Treatment effect
Variable
Importance of EBC
There is a lack of agreed-upon standards or
processes that are based on evidence

EBC
is a process approach to collecting,

reviewing,
interpreting,
critiquing,
and
evaluating research
Leads
to a state-of-the-art integration of
knowledge and evidence that can be
evaluated and measured through outcomes
Should be viewed as the highest level of care
Nursing and EBC

The
agency for Healthcare Research

and Quality (AHRQ) launched twelve
evidence-based practice centers
The initiative partnered with public and
private organizations to improve the

quality,
effectiveness,
and
appropriateness of care
Nurses work with patients in deciding
treatment options
Attributes of EBC
Need to define the meaning of evidence in
each health care agency

Use the term in daily practice
Look for best evidence when evaluating
new goals and programs
Fundamental principles in EBC
Evidence alone is never sufficient to

make a clinical decision
Evidence-based care involves a hierarchy
of evidence to guide decision making
Challenges for Nurses

Rapidly growing body of scientific
literature
No unaided human being can
read, recall, and act effectively on
the volume of material
Literature is not in a form that is
suitable for application to practice

Needs to be evaluated and
transformed in order to be useful
Conducting Evidence Reports in

Nursing
Select problem
Review the evidence
Summarize the evidence
Report results
Make
recommendations
for
potential clinical applications
Implement
agreed-upon
practice changes
Promoting Evidence-Based Best

Practices
The
U.S. health care system

does
not
have
uniform
definitions of what constitutes
efficient,
effective,
quality
health care
It is difficult to get all clinical
health care providers to apply

EBC processes at the unit level
Promoting Evidence-Based Best

Practices
EBC processes must be uniform
enough to be valid, but also

adaptable to specific needs of
institutions
EBC
requires involvement of
and
collaboration
between
clinical practitioners and health
care researchers
Nursing and Health

Care Informatics
Nursing Informatics
Recognized specialty group who function
to integrate nursing, its information, and

information
management
with
information
processing
and
communication technology to support
the health of people worldwide
The use of information technology by
nurses carrying out their duties in

relation to any function in the purview of
nursing
Focus of Nursing Informatics

Technology focused
Conceptually focused
Role oriented
E-health
Multiple functions
Health
care
and
information
delivered or enhanced through
the Internet
Involves
medical
informatics,
public health, and business
Commitment
for
networked,
global thinking to improve health
care
locally,
regionally,
and
worldwide
Telehealth
Delivery
of
health-related
services and information via
telecommunications
technology
May be simple or complex
Elements of Nursing
Informatics
Computerized order entry
Electronic health record
Patient decision tools
Laboratory and x-ray results
Electronic
prescribing and order

entry including barcoding
Community and population health
management and information
Elements of Nursing
Informatics
Communication,
administrative systems
staffing,
Evidenced-based
knowledge
information retrieval systems
and
and
Quality improvement data collection/data
summary systems
Documentation and care planning

Patient monitoring and problem alerts
Implementation of Health Information

Technologies
Standards needed so all health care
providers
can
share
patient
information which is timely, patientcentered, and portable
Office of the National Coordinator for
Health Information Technology (ONC)

established 2004
The
Joint Commission established

National Patient Safety Goals
Recommended Changes
Care based on continuous healing
relationships
Customized care based on patient needs
and values
The patient as the source of control
Shared knowledge and the free flow of
information
Evidenced-based decision making
Safety as a system property
The need for transparency
Anticipation of needs
Continuous decrease in waste
Core Competencies
Provide patient-centered care
Work in interdisciplinary teams
Employ evidenced-based practice
Apply quality improvement
Utilize informatics
Specialty of Nursing
Informatics
Use decision-making systems or artificial intelligence
to support the nursing process

Use
software
organizations
application
to
support
health
care
Integrate IT into patient education

Use computer-aided learning for nursing education
Develop and use nursing databases
Use
research
related
to
nurses
management and communication
information
Clinical Information System

A computer-based system
Used to inform clinicians about

tests, procedures, and treatment
Used to improve the quality of
care through real-time assistance
in decision making
Used to increase the efficiency
and effectiveness of care delivery
Can
be
patient
focused
or
department focused
Computerized Patient Records

Replacement for the paper record
Permits health information to be used
to
support
the
generation
communication of knowledge
and
Multiple functions and requirements
Capture data
Store data
Process and retrieve data
Information Communication
Interoperability
of systems and
linkages for exchange of data
across disparate systems
Must be secure
Security
functions
must
be
designed to ensure compliance
with applicable laws, regulations,
and standards
Security
Privacy
The right of individuals to keep information

about themselves from being disclosed to
anyone
Confidentiality
Limiting disclosure of private matters

Security
The means to control access and protect

information from accidental or intentional
disclosure to unauthorized persons
Trends in Computing
Computer literacy
The knowledge and understanding

of computers combined with the
ability to use them effectively
Information literacy
The
understanding
of
the
architecture of information
The ability to navigate among
print and electronic tools
Virtual Reality
Allows a person to see, move through,
and react to computer-simulated items

or environments
Has
allowed surgeons to develop

minimally invasive surgical techniques
PDA
software has the potential to

bring evidence-based care to the
bedside
Using the Internet for Clinical

Practice
Information can be presented in
different forms and different
languages
Provides
different organization
structures
for
information
storage
and
access
to
accommodate users preference
and need
The P-F-A Assessment

Purpose-Focus-Approach
Determine your purpose (why are you doing
the search?)
Focus of the search may be:
Broad or general
Lay oriented
Narrow and technical
The
purpose combined with the focus will

determine the approach to the search
Strategies for Internet

Searches
Use Web sites published by governmental or
professional organization
Use
consumer health sites organized by

medical librarians
Use precise terms

Draw on search engines
Refine your Internet searches with filters
Evaluating Internet Material

Use critical-thinking skills
Evaluate with PLEASED
Purpose
Links
Editorial
Author
Site navigation
Ethical Disclosure
Date last updated
BACK
Population-Based
Health Care Practice
182
Population-Based Health Care

Practice
The
development, provision, and

evaluation of multidisciplinary health
care services to population groups
experiencing increased health care
risks or disparities
It involves partnership with health
care consumers and the community

in order to improve the health of the
community and its population groups

Practice
Vulnerable population groups
Subgroups of a community
that
are
powerless,
marginalized,
and
disenfranchised
and
are
experiencing
health
disparities

Practice
Health
risk factors are variables that

increase or decrease the probability of
illness or death
Health determinants are variables that may
cause changes in the health status of

individuals or groups and include:
Biological factors
Psychosocial factors
Environmental factors (physical and social)
Health systems factors or etiologies
Goals of Population-Based Health

Care
Improvement of access to health care
services
Improvement of quality of health care
services
Reduction of health disparities among
different population groups

Reduction of health care delivery costs
Outcomes Measurement
Population health status
Quality of life
Functional health status
Health Status
Health status
The level of health of an individual, family,

group, population, or community
Quality of life
The level of satisfaction one has with the

actual conditions of ones life
Health-related quality of life
Refers to ones level of satisfaction with

those aspects of life that are influenced by
ones health status and health risk factors
Functional Health Status

Functional health status
The ability to care for oneself and meet ones

human needs
Activities of daily life
Activities
related
to
toileting,
bathing,
grooming, dressing, feeding, mobility, and
verbal and written personal communication
Instrumental activities of daily living
Related to
home management, financial
management,
seeking
health
care,
and
meeting spiritual needs
Health Determinant Models

Provide
conceptual tools to use in

assessing and addressing the priority
health needs of at-risk population groups
Healthy
People 2010 emphasizes four

key
elements
to
achieve
health
improvement
Goals
Objectives
Determinants of health
Health status
Health Disparities
Differences in health risks and health
status measures that reflect the poorer

health
status
that
is
found
disproportionately
in
certain
population groups
Leads to unequal burdens in disease
morbidity and mortality rates borne by

racial and ethnic groups in comparison
to the dominant racial or ethnic group
in society
Health Care Systems

Disparities
Differences in health care system
access and quality of care for

different
racial,
ethnic,
and
socioeconomic population groups
that persist across settings, clinical
areas, age, gender, geography, and
health needs and disabilities
Result
in
outcomes
poorer
health
care
Major Health Indicators

Physical activity
Overweight/obesity
Tobacco use
Substance abuse
Responsible sexual behavior
Mental health
Injury and violence
Environmental quality
Immunizations
care
and
access
to
health
Culturally Inclusive Health Care

U.S. population is becoming more diverse
Ethnic minorities in the United States who
have been marginalized from mainstream

society experience more health care
disparities
and
increased
rates
of
morbidity, mortality, and burden of disease
The proportion of ethnic minorities in the
registered
nurse
workforce
in
2004
continues to lag behind the proportion of
ethnic minorities in the U.S. population
Barriers in the Workplace

Lack of awareness of differences
Lack of time
Ethnocentrism
Bias and prejudice
Lack of skills to address differences
Lack of organizational support
Culturally Inclusive Health Care

System
One
in which health care is

population based
Requires significant change in
the current health care system

Will require increased diversity
in the health care workforce
Population-Focused Nursing
Practice
Nursing activities that focus on all
of
the
people
and
reflect
responsibility to and for the people
Focus is on:
Maximizing health status

Maximizing functional abilities
Improving the quality of life of
groups of health care consumers
Population-Based Nursing
Practice
The practice of nursing in which the focus of
care is to improve the health status of

vulnerable or at-risk population groups
within the community by employing health
promotion
and
disease
prevention
interventions across the health continuum
Holistic in nature
Seeks
to empower population groups by

enhancing their protective factors and
resiliency
Protective Factors
Client
strengths and resources are

used to combat health threats that
compromise core human functions
Resilience
The social and psychosocial capacity

of individuals and groups to adapt,
succeed, and persevere over time in
face
of
recurring
threats
to
psychosocial and physiologic integrity
Population-Based Nursing Practice

Model
Population-based
interventions
three levels:
Community
Systems
community
Individuals,
groups
encompass
within
the
families,
and
Population-Based Nursing Practice

Interventions
Initiate
a
assessment
community
health
Provide nursing interventions in a
culturally sensitive and appropriate

manner
Apply the nursing process in working
with
communities,
organizations,
and population groups
Nontraditional Model of Population-Based Nursing

Practice
Vulnerable
or at-risk populations are

identified before community assessment
Subsequent
community
assessment
focuses on health determinants related
to the at-risk groups
Traditional
model
assesses
community needs first, and
population needs second
overall
at-risk
Nursing Process Applied to Population-Based Nursing

Practice
Assessment
Diagnosis
Planning and implementation
Evaluation
Assessment
Community level
Physical environment
Social environment
Policies and interventions
Health systems level
Access to quality health care

Behavioral
Data analysis
Diagnosis
Identify
North
American
Nursing Diagnosis Association
(NANDA) category
Identify etiology and list key
evidence supporting diagnostic

category
Planning and Implementation

Select
based
model
and employ populationnursing

intervention
Examples
of population-based
nursing intervention models:
Minnesota model
Virginia model
Evaluation
Program
evaluation is integral part of

evaluation process
Justification of resources and budget is
necessary
Cost benefit analysis is appropriate
Evaluate access, quality, cost, and equity
Collect data and develop statistics
Share
results
with
multidisciplinary
teams, health consumers, and community
partnerships
Identify
unmet
needs
and
further
interventions
BACK
ersonal and Interdisciplina

Communication
Trends in Society that Impact

Communication
Increasing social diversity

Changing/differing beliefs
Aging population
Shift to computerized
communication
Elements of the Communication

Process
Communication is an interactive
process that occurs when a
person (the sender) sends a
verbal or nonverbal message to
another person (the receiver) and
receives feedback
Influenced by emotions, needs,
perceptions, values, education,
culture, goals, literacy, cognitive
ability, and the communication
mode
Health Insurance Portability and

Accountability Act
Became law 1996

Privacy Rule enacted 2003
Protects
all
individually
identifiable health information
held or transmitted by a
covered entity or business
associate, in any form or
media,
whether
electronic,
paper, or oral
Law lists 18 personal health
Modes of Communication
Verbal
Spoken
Nonverbal
Facial expressions, posture, gait, body
movements, position, gestures, and
touch
Electronic
Uses electronic media that do not have
characteristics of the other modes
Electronic Communication
Plays an increasing dominant role in health care
Accurate
spelling,
correct
grammar,
and
organization
of
thought
assume
greater
importance in the absence of verbal and
nonverbal cues that are given in face-to-face
encounters
Always
proofread correspondence prior to

sending it
Keep the message brief and use standard font
Levels of Communication
Public
Communication with a group
people with a common interest
of
Intrapersonal
Internal communication within an
individual
Interpersonal
Communication between individuals,
person to person, or in small groups
Organizational
Communication
Avenues of communication are
often defined by an organizations
formal structure
Downward:
communication
originates at top or upper levels
of
organization
and
works
downward
Upward:
communication
originates at some level below
the top of the structure and
moves upward
Organizational Communication
Lateral:
communication occurs among

people at similar levels within the
organization
Diagonal:
communication occurs when

people who may be on different levels of
the organizational chart communicate
with each other
Grapevine: an informal and unstructured
avenue of communication; major benefit

is speed, but its major drawback is its
unreliability
Communication Skills
Attending: active listening
Responding: verbal and nonverbal
acknowledgment of the senders
message
Clarifying:
communicating
as
specifically as possible to help the
message become clear
Confronting: working jointly with
others to resolve a problem or
conflict
Barriers to Communication
Gender
Men and women may process information
differently
Culture
Different cultures may have different
beliefs, practices, and assumptions
Anger
An irrational response that arises from
irrational ideas: awfulizing, cant-stand-ititis
,
shoulding
and
musting,
and
undeservingness and damnation
Incongruent responses
When words and actions in a
communication do not match the inner
experience
of
self
and/or
are
inappropriate to the context
Conflict
Arises when
opposed
ideas
or
beliefs
are
Offering false reassurance

Promising something that cannot be
delivered
Being defensive
Acting as
attacked
though
someone
has
been
Stereotyping
Unfairly categorizing someone based on his

or her traits
Interrupting
Speaking before other has completed his

or her message
Inattention
Not paying attention

Stress
A state of tension that gets in the way of

reasoning
Unclear expectations
Ill-defined tasks or duties that make

successful
completion
of
the
communication unlikely
Overcoming Communication
Barriers
Understand the receiver
Communicate assertively
Use two-way communication
Unite with a common vocabulary
Elicit verbal and nonverbal feedback
Overcoming Communication
Barriers
Enhance listening skills
Be sensitive to cultural
differences
Be sensitive to gender differences
Engage in meta-communication
Use of Language in the

Workplace
Oral language is used to verbally communicate
with patients and other health care professionals

Great diversity in spoken languages
Title VI of the Civil Rights Act of 1964 entitles an
individual seeking health care who has limited

English proficiency to have an interpreter
available to facilitate communication
Language assistance needs to be comprehensive
Generational Differences in
Communication
Can
create
tensions
among
workers because of the divergent
outlooks on life
Generations working together
Matures, veterans
Baby boomers
Generation X
Generation Y
Literacy
Health
literacy represents the cognitive

and social skills that determine the
motivation and ability of individuals to gain
access to, understand, and use information
in ways that promote and maintain good
health
It is an outcome of health promotion and
health education efforts
Most health care materials are written at
the 10th grade level; most adults read

between an 8th and 9th grade level
Workplace Communication
Superiors
Observe professional courtesies
Dress professionally
Arrive for the appointment on time
Be prepared to state the concern
clearly and accurately
Provide supporting evidence and
anticipate resistance to any requests
Separate your need from your desires
State a willingness to cooperate in
finding a solution and then match
behaviors to words and persist in the
pursuit of a solution
Coworkers
Report
patient
information
accurately,
informatively,
and
succinctly
Remember professional courtesies
Be mindful of an appropriate time
and place to share your concerns
Do unto others as you would have
them do unto you
Delegate clearly and effectively
Offer positive feedback
Physicians, nurse practitioners, and other
health care professionals
Strive for collaboration, keeping the
patient goal central to the discussion
Present
information
in
a
straightforward manner
Remain calm and objective even if the
physician does not cooperate
Follow the institutions procedure for
getting the patient treated and then
document the actions taken
Patients and families
Use
touch
as
a
way
to
communicate caring and concern
Occasionally, language barriers
will limit communication to the
nonverbal mode
Be
open
and
honest
while
respecting patients and families
Honor
and
protect
patients
privacy with both actions and
words
Between mentor and prodigy
Mentors wisdom shared through
counseling,
encouraging
and
seeking the novice out
Mentor can anticipate challenges
for novice and make suggestions
for how to manage them
Use
role-playing,
where
the
mentor describes a theoretical
situation and allows the novice to
practice her response
BACK
Politics and Consumer

Partnerships
Politics
Predominantly a process by which
people use a variety of methods to

achieve their goals
Methods
inherently involve some

level of competition, negotiation,
and/or collaboration
Politics exist because resources can
be limited and some people control

more resources than others
Stakeholders and Health Care

Stakeholders
Vested interest groups who control

health care resources
All
these stakeholders tend to exert

political pressure on health policy makers
in an effort to make the health care system
work to their economic advantage
Nurses can garner consumer support for
professional nursing positions to help

patients and help the profession of nursing
by tapping into strong consumer support
Stakeholder Groups
Insurance companies
Consumer groups
Professional organizations
Health care groups
Educational groups
Why Should the Professional Nurse Be Involved in

Politics?
All nurses and patients are affected on a
daily basis by public policy, as well as by

the political actions of other stakeholders
in the health care system
By
understanding the influence of both

internal and outside pressures on nursing
practice and patients, nurses are more able
to support what is most important to them
To be able to advocate for health care for
those who have little or no voice
The Politics and Economics of Human

Services
All
health care is inextricably linked to

politics and economics, as well as to the
availability and services of providers
Health care in the United States depends
heavily on a continual supply of resources

from both public and private sectors
If nurses fail to exert political pressure on
the health policy makers, nursing will lose

ground to others who are more politically
active
Health Policy
Formulated,
enacted, and enforced through

political processes at the local, state, or federal
level
Local
level
policies
are
established
and
implemented by an individual hospital board or
directors of a hospital system
State policy governs nurses by defining nursing
practice, education, and licensure
Federal policies include the rules and regulations
governing Medicare and Medicaid funding
Cultural Dimensions of Partnerships and

Consumerism
If nurses intend to form partnerships with
consumer groups distinguished by cultural

heritage, racial makeup, and/or ethnic
background, they must understand and
value diversity
Nurses
can work with the consumer

movement to combine traditional consumer
concerns with a wider sense of civic rights
and responsibilities, and move culturally
related health care issues to the forefront
of politics
Politics and Demographic

Changes
The fastest growing consumer group is the
elderly
Many seniors are joining consumer groups to
have a greater political voice, to influence

health policy decisions, and to ensure that
they receive the health care services they
will need for years to come
AARP
constitutes
a
growing
political
powerhouse and an ideal consumer partner
for nursing in many ways
Nurses as Political Activists

Nurses
who are politically active have a

definitive voice in their work environments
for
patient
welfare,
as
well
as
for
themselves
As nurses develop politically, they come to
understand the need for political strategy

Nurses join professional organizations and
actively participate to ensure a more

collective, unified voice supporting health
care issues
Political Roles for Nurses

Nurse individual
Sets goals to strengthen nursing as a profession

Nurse citizen
Votes and writes members of Congress and state

legislators on issues of interest
Nurse activist
Active member of professional organization

Nurse politician
Runs for political office
Advocacy and Consumer

Partnerships
Nurses must understand the political
forces that define their relationships

with consumers
Nurses
can
work
with
their
professional organizations to promote
the role of the nurses as consumer
advocates in health policy arenas
The concept of patient advocacy is a
fundamental aspect of nursing
The Nurse as Political Activist

To be most effective politically, nurses
must be able to clearly articulate at

least four dimensions of nursing to any
audience or stakeholder:
What nursing is
What distinctive services nurses
provide to consumers
How nursing benefits consumers
What nursing services cost in
relation to other health care services
Essential Dimensions of
Nursing
Establishing a caring relationship that
enhances healing and health
Focusing
on
the
full
range
of
experiences and human responses to
illness and health within both the
physical and social environment
Appreciating the subjective experience
and the integration of such experience

with objective data
Essential Dimensions of
Nursing
Diagnosing and intervening in care
by using scientific knowledge,

judgment, and critical thinking
Advancing
nursing
knowledge
through scholarly inquiry
Influencing social and public policy
to promote social justice

Partnerships
Consumers expect the best people to be
health care providers, but are confused

about what the roles and responsibilities
of professional nurses entail
Nurses are responsible for ensuring that
consumers understand the critical role

nurses play as consumer advocates and
political activists in health care politics,
as well as what nurses do as direct care
providers

Partnerships
Working
through
their
professional organizations, nurses
can collaborate with consumer
groups
by
creating
formal
partnerships,
which
serve
to
promote the role of nurses as
consumer advocates in health
policy
arenas,
as
well
as
strengthen the political position of
both partners
Making Health Care More ServiceOriented

As
recipients of health care are

required to pay a larger portion of the
cost
for
health
care
services,
consumers are demanding to be
treated as something more than
passive recipients of health care
Nurses, working through professional
organizations, have been strong, early

supporters
for
patient
rights,
regardless of the patients ability to
pay
Making Health Care More ServiceOriented

Any
political vision to make

health care more consumerfriendly and service-oriented
must address cost, access,
choice, and quality
Turning a Consumer-Oriented Vision into

Reality
Nurses have opportunities to be more
than
supporters
of
a
consumeroriented vision for health care; they
can be co-creators of it
Nurses must have a clear image of the
vision, develop a sound philosophy,

demonstrate intelligent and strategic
thinking, and wield more political
influence
Turning a Consumer-Oriented Vision into

Reality
Health
care operates in a
political context of rapid change
and high financial risks
Stakeholders who are willing to
take the greatest risks are

afforded the most opportunities,
pending
good
timing
and
appropriate political action
The Consumer Demand for

Accountability
People who will own the future of
health care must address the
growing problem of accountability
Most people comprehend that being
accountable requires being held

responsible for ones behavior,
decisions,
and
affiliations
with
others
The Consumer Demand for

Accountability
Health
care professionals, including

nurses, depend upon each other to
ensure the quality, consistency, and
overall effectiveness of health care
within their work environments
The practice of nursing is based on a
social contract with society that gives

nurses
certain
rights
and
responsibilities
and
requires
that
nursing is accountable to the public
Credibility and Politics

To
have
credibility,
nurses
must
demonstrate professional competence and
a degree of professional accountability that
exceeds consumer expectations
Nurses
gain credibility through more

education, higher level functioning, and
greater accountability
As
consumer
advocates,
nurses
are
accountable
to
the
public
and
the
profession beyond a particular employment
setting
Helping Consumers Make Better Health Care

Choices
Nurses have a professional responsibility to
help consumers make better health care

choices and not fall victim to misleading
information, quick cures, or dangerous
practices
Beyond advocacy for an individual patient or
a patient group, nurses can work to create a

more supportive health care environment
that encourages input and feedback among
the various stakeholders or constituencies
Helping Consumers Make Better Health Care

Choices
If nurses believe that what they
do for consumers is essential or

highly
valuable, nurses
must
manifest
strategic
political
behaviors
and
take
political
actions for consumers of health
care services
New Challenges and Better

Opportunities
Nurses strengthen their political position by
sharing accountability for health care problems

with other health care providers
Effective
dialogue among professionals and

individuals being served by those professionals
takes time and considerable effort to build
An understanding of the perspectives of the
people being served is vital for real social

change to occur
New Challenges and Better

Opportunities
When a consumer group forms a
political
coalition
with
other
groups such as nurses in a given
community, the political influence
of both is strengthened
Consumer
partnerships
will
become more critical for all
stakeholders in health care
BACK
Strategic Planning
and Organizing
Patient Care
Organizational Purpose, Mission, Philosophy,

Values
Mission statement
A formal expression of the purpose or

reason for existence of the organization
Philosophy
A value statement of the principles and

beliefs that direct the organizations
behavior
Values
May be formally stated and explicit, or

may
be
implicit
and
part
of
the
organizational culture
Strategic Planning
A strategic plan is the sum total or outcome
of the processes by which an organization

engages in environmental analysis, goal
formulation, and strategy development with
the purpose of organizational growth and
renewal
Provides unified vision and goals for the
organization
Helps ensure that the needed resources are
available to carry out initiatives
Steps in Strategic Planning

Process
Perform environmental assessment
Conduct stakeholder analysis
Review literature for evidence-based best practices
Determine congruence with organizational mission
Identify planning goals and objectives
Estimate resources required for the plan
Prioritize according to available resources
Identify timelines and responsibilities
Develop marketing plan
Write and communicate business plan/strategic plan
Evaluation
Environmental Assessment
A situational assessment requiring a broad
view
of
the
environment
organizations
current
An external assessment
Is broadly based and attempts to view

trends and future issues and needs that
could impact the organization
An internal assessment
Seeks to inventory
assets and liabilities
the
organizations
SWOT Analysis
Tool
for
assessments
conducting
environmental
Identifies both strengths and weaknesses in
the internal environment and opportunities

and threats in the external environment
Stands for
S Strengths
W Weaknesses
O Opportunities
T Threats
Community and Stakeholder

Assessment
A
stakeholder is any person, group, or

organization that has a vested interest in the
program or project under review
A systematic consideration of all potential
stakeholders to ensure that the needs of

each of these stakeholders are incorporated
in the planning phase
When stakeholders are not involved in the
project planning, they do not get a sense of

ownership
Other Methods of Assessment

Surveys/questionnaires
Used when large numbers of stakeholders

and general idea of the options are available
Focus groups/interviews
Focus groups: small groups of individuals

with a common characteristic who meet in a
group and respond to questions about a topic
Time-consuming and expensive to conduct
Work best when the topic is broad and the
options are not as clear

Advisory board
Benefits large projects

Board members come from various
constituencies affected by project
Has no formal authority, but reviews
plan and makes recommendations

Review
of
literature
on
similar
programs
Should
be
completed
prior
to
strategic planning or beginning any
new project or program
Allows project team to identify similar
programs,
their
structures
and
organization, potential problems and
pitfalls, and successes
Ongoing process

Best practices
Identify best practices or evidencebased innovations that have been

adopted with success by other
organizations
Nurses planning to develop a new
program need to carefully examine
the existing evidence and practices
prior to beginning the planning
Other Assessments
Planning goals and objectives
Prioritize according to strategic importance,

resources required, and time and effort
involved
Set timeline
Develop a marketing plan
Communicate
the
plan,
the
goals,
and
objectives
Design, implement, train, and evaluate the new
program
Assures that all stakeholders have the needed
information
Organizational Structure
Organizations are structured or
organized
to
facilitate
the
execution
of
their
mission,
strategic plans, reporting lines,
and communication within the
organization
Functions on a continuum with
levels of authority
Types of Organizational
Structures
Communicated
by the use of an
organizational chart
Types
Matrix
Flat versus tall
Decentralized versus centralized
Other Characteristics to Use as a

Framework
Division of labor
Roles and responsibilities
Reporting relationships
Basis for division of labor
Functional division of labor
Geographic area
Product or service
Primary nursing
Factors Influencing Organizational

Structures
Environmental changes
New programs, services, or product

lines
Change in leadership
Technology
Socio-cultural environment
Size
The larger an organization, the more
complex the structures needed
Factors Influencing Organizational Structures

Repetitiveness of tasks
If there is a great deal of differentiation

among
tasks,
more
levels
of
management are usually needed
Trends in organizations
There is a need for leadership that
promotes sound ethical values and
quality assurance
Transformational nurse leaders are
needed to assist nurses to strive for
quality outcomes and personal mastery
BACK
Effective Team
Building
Definition of a Team
A
small number of people with

complementary
skills
who
are
committed to a common purpose,
performance goals, and approach
for
which
they
are
mutually
accountable
Teams exist for specific purposes
Types of Teams
Multidisciplinary or interdisciplinary
Comprised
of
varied
disciplines
contributing to an individual patients care
Team works closely and communicates
frequently
Allows the disciplines to work together
collaboratively
Committees
Teams serve on several types of
committees, which are created for specific
goals or tasks
The goal is to improve patient care
Advantages of Teamwork
Promotes safe and efficient patient care
delivery
Creates
effective
interprofessional
communication
Equalizes
power
through
shared
governance
Improves interpersonal relationships and
job satisfaction
Promotes free exchange of ideas, team
cohesion, trust, and mutual respect
Improves stability in employee satisfaction
Disadvantages of Teamwork
May take longer to achieve a goal
than one individual

Team
members
may
have
disagreements on the best course of
action
Teams
develop
through
timeconsuming predictable stages of
selecting the right members for the
team, organizing team goals and
manpower, and team collaboration
Some
team members may lack
interest, motivation, or skills to
participate in the team process
Informal Teams
Can
influence the organization

either positively or negatively
Are not directly established or
sanctioned by the organization,
but often form naturally
Can become very powerful
Often responsible for facilitating
improvements in the working
conditions
Stages of Group and Team

Process
Forming stage
Storming phase
Norming phase
Performing stage
Adjourning phase
Forming Stage
Occurs when the group is created and
they meet as a team for the first time

They
explore the purpose of the

team, why they are called to be part
of a team, and what contribution they
can bring to the table
Proceed to establishing team goals
and expectations
Storming Stage
As
the group relaxes into a more

comfortable team setting, interpersonal
issues or opposing opinions may arise to
cause conflict between the members
Conflict is healthy and a natural process

Must openly confront issues and conflict
Real teams dont emerge unless individuals
on them take risks involving conflict, trust,

interdependence, and hard work
Norming Stage
A feeling of group cohesion develops
Team members master the ability to
resolve conflict
Team
members learn to respect

differences of opinion and work
together
Overcoming barriers to performance is
how groups become teams
Performing Stage
Group
cohesion, collaboration,
solidarity are evident
and
Personal opinions are set aside in order
to achieve group goals

Team
members
are
openly
communicating, know each others roles
and responsibilities, are taking risks,
and trusting and relying on each other
Adjourning Stage
Termination
and consolidation occur in this
stage
The team reviews their activities and evaluates
their progress
The
team leader summarizes the groups

accomplishments and the roles each member
played in achieving these goals
It
is important to provide closure so each

member leaves with a sense of accomplishment
A Winning Team
Achieved when there is synergy
Things
work
together
harmoniously
The whole is greater than the
sum of the parts
The needs and characteristics
of a patient, clinical unit, or
system are matched with the
nurses competencies
Conducive Teamwork
Environment
Requires ongoing time and effort
Facility design allows for collaboration and
interaction
Social factors
Clear identification and ownership of the

team goal
Clear definition and acceptance of each
persons roles and responsibilities
Clear delineation of team processes
Clear opportunities to build trust
Team Communication
Ambassador activities
Communicate with those in the hierarchy

Used to protect the team from outside
pressures
Task coordinator activities
Communicate with lateral levels in the

organization
Scout activities
Occur in general ideas

Scanning in the external environment
Team Size
Team size affects performance in that
too few or too many affect performance

Communication
and
coordination
problems increase with large teams
Smaller teams have lower incidence
of social loafing
Individuals in large teams are able to
maintain anonymity and gain from
the work of the group without making
a suitable contribution
Status Differences
Status is the measure of worth conferred on
an individual by a group
High-status
members
initiate
communication
more
often
and
are
provided more opportunities to participate
A lower-status member may be ignored or
intimidated
Status differences have significant impacts
on patient outcomes
Need to build a trust-sensitive environment
Psychological Safety
Describes
individuals perceptions
about
the
consequences
of
interpersonal risks in their work
environment
Created by mutual respect and trust
among team members
Describes
climate that fosters

productive
discussion
and
nonpunitive action
Qualities of Effective Team

Members
Proactive
Motivated
Take
responsibility
for
ones
actions, decisions, and behavior
Seize initiatives to do whatever is
necessary to get the job done

consistent with correct principles

Leaders and manage
Will organize, facilitate,
the
entire team
Must understand how various learning
styles, cultural diversity, and personality

differences play into the dynamics of
teamwork
Have good communication skills, conflict
resolution skills, and leadership skills

Leaders
Focus the team
on outcome
improvement
Track reports
Recognize contributing members
Guidelines for Meetings

Set a time frame for the meetings and stick to it
Review the progress
Help group members feel comfortable with one
another
Establish ground rules
Get a report from each member
Sustain the flow of the meetings
Manage the discussion
Work to avoid groupthink
Close
the
meetings
by
summarizing
accomplishments
Identify a time frame for future meetings
Avoiding Groupthink
Occurs when the desire for harmony and
consensus overrides members rational

efforts to appraise the situation
The consequences of groupthink are that
teams may limit themselves to one

possible solution and fail to conduct a
comprehensive analysis of a problem
Team leaders can help avoid groupthink
Symptoms of Groupthink
The illusion of invulnerability
Collective rationalization
Belief in the inherent morality of the team
Stereotyping others
Pressures to conform
The use of mindguards
Self-censorship
Illusion of unanimity
BACK
Power
Definitions of Power
The
ability to create, get, and/or

resources to achieve ones goals
use
Power can be defined at various levels
Personal,
cultural,
organizational
professional,
or
Power at the personal level is closely linked
to how an individual perceives power, how

others perceive the individual, and the
extent to which an individual can influence
events
Levels of Power
Personal
Derives from characteristics of the individual

Professional
Conferred on members of the profession by

one another and the larger society to which
they belong
Organizational
Ones position in an organizational hierarchy

Being authorized to function powerfully
within an organizational culture
Power and Accountability

Accountability is considered one of the major
hallmarks of the health care professions

Nurses
have accountability and direct

responsibility for decisions made and actions
rendered
Effective nurses see power as positive and
view their ability to understand and use

power as a significant part of their
responsibilities to patients, coworkers, the
nursing profession, and themselves
Sources of Power
Diverse,
and
vary
situation to another
from
one
combination of conscious and

unconscious factors that allow an
individual to influence others to do
as the individual wants
Multiple types of power
Expert Power
Derived from the knowledge and skills a
nurse possesses
The less acknowledged that experts are
in a group, the less effective their expert

powers become
Visible
reciprocal acknowledgment of
expertise
among
group
members
balances
power
and
enhances
productivity
Legitimate Power
Power that is derived from a position a
nurse holds in a group, and it indicates

the nurses degree of authority
The more comfortable nurses are with
their legitimate power as nurses, the

easier it is for them to fulfill their role
Nurses in authority are expected to
use what authority they have and may

be punished for not doing so
Referent Power
Power
derived from how much

others respect and like any
individual, group, or organization
Nurses
who are identified with

respected,
trustworthy
individuals or groups will benefit
from referent power by virtue of
such identification
Reward Power
The ability to reward or punish others, as
well as to create fear in others to

influence them to change their behavior
Also referred to as coercive power

Rewards are not likely to permanently
change attitudes
Withholding rewards or achieving a goal
by instilling fear in others often results in

resentment
Connection Power
The
extent
to
which
connected with others
others
are
Leaders can dramatically increase their
influence by understanding that people

are attracted to those with power and
their associates
Nurses should work to resolve issues at
the appropriate level before they take

their concerns to a higher level of
authority
Information Power
The ability to influence others with the
information they provide to the group

Nurses must share knowledge that is
both accurate and useful

Information sharing can improve patient
care, increase collegiality, enhance

organizational
effectiveness,
and
strengthen
ones
professional
connections
Positive Personal Orientation to

Power
A persons desire for power takes
one of two forms

An orientation toward achieving
personal
gain
and
selfglorification
An orientation for achieving gain
for others or the common good
Empowerment
A
process of power sharing by

involvement in the decision-making
process
A process of personal growth and
development
Something positive, or highly desirable
to be aspired to, advocated for, or
attained
Nurses disempower themselves if they
see nurses or nursing as powerless
Power and the Media

There
is a relationship between
power and perception
The media can be used to create or
change perceptions
The way the media present nursing
to the public will empower or
disempower nursing
Nurses must work to consistently
use the media as effectively as
other more powerful occupational
groups
Power Development
Understanding power from a variety of
perspectives is not just important for

nurses professionally, it is important for
them personally as well
It allows nurses to gain control of their
work and personal lives
Three ways to imagine the future
What is possible
What is probable
What is preferred
Power and the Limits of

Information
To make good decisions, nurses must
be able to gather enough information

and realistically interpret its value, as
well as share and apply information in
a safe competent manner
Effective
nurses understand time

constraints and set priorities to
ensure that what is most important
receives the most attention
A Framework for Becoming

Empowered
Personal
Find a mentor
Introduce yourself to powerful people in
your personal and professional life
Find and maintain evidenced-based
sources of ongoing information
Seek answers to questions
Notice who holds power in your
personal,
professional,
and
organizational life
Make and evaluate a plan

Empowered
Professional
Assess patients condition using relevant

objective measurements
Collaborate with administrators, other
nurses, physicians, and other health care
workers involved in the care of your
patients
Join
your
professional
nursing
organization
Collaborate
with
significant
others,
friends, and members of the patients
family

Empowered
Organizational
Actively monitor and improve patient

care quality
Volunteer for committee assignments
that will challenge you to learn and
experience
more
than
what
is
expected of you in a staff nurse role
Evaluate your plans
Volunteer to be involved with health
care at the local, state, and national
levels
Power and Decision Making

Power and decision making are intricately
connected
Emphasis on cost containment in health
care has created opportunities for nurses
Nurses
knowledge
allows
them
to
participate in health care and costcontainment discussions, giving them
more opportunities for decision making
This, in turn, gives nurses greater power
The Power of Critical Thinking

Critical thinking enables nurses to
understand more and to find better

information
Effective nurses can take information
they have acquired in the past and

apply it to their present situation
Power
is
associated
with
transforming thought into action
BACK
Change,
nnovation, and Conflic
Management
Definition of Change
Change
Making something different than it

was
In
many instances, the outcome

remains the same, but the process is
changed
Living
organisms must constantly

adapt to changes in the environment
in order to thrive
The Changing Health Care

Environment
Access to information
has transformed
the relationship between the patient

and health care providers
Evidence-based practice is changing the
way decisions are made regarding

health care treatment and how nursing
care is delivered
Changing
demographics within the

population have resulted in a diversity
of cultures and languages
The Changing Health Care

The aging Environment
of the baby boomers
The
rising costs of health care

services
The underinsured/noninsured
Patient safety
Types of Change
Personal change
Voluntary change with the goal of

self-improvement
Professional change
Deliberate change with the goal of

improving professional ability/status
Organizational change
A planned change in an organization

to improve efficiency
Traditional Change Theories

Lewins force-field model
Lippitts phases of change
Havelocks six-step change model
Rogers diffusion of innovations
theory
Lewins Force-Field Model

Unfreezing
The current or old

something is flawed
way
of
doing
Moving
The intervention or change is introduced

and explained
Refreezing
The new way of doing is incorporated

into the routines or habits of the people
affected
Lippitts Phases of Change

Diagnosis of the problem
Assessment of the motivation and capacity for change
Assessment of the change agents motivation and
resources
The selection of progressive change objectives

Choosing an appropriate role for the change agent
Maintenance of the change once it has been started
Termination of the helping relationship
Havelocks Six-Step Change

Model
Planning stage
Build a relationship, diagnose the

problem, and acquire resources
Moving stage
Choose
the
acceptance
solution
and
Refreezing stage
Stabilization and self-renewal
gain
Rogers Diffusion of Innovations

Theory
Five-step
innovation/decision-making
process
Awareness, interest, evaluation, trial,
adoption
Believes change can be rejected initially
and adopted at a later time

Believes change is reversible and initial
rejection does not mean the change will

never be adopted
Commonalities among the Change

Models
All the theories relate to the process
of unfreezing, moving, freezing
Many of the theories describe linear
processes that move in a step-bystep manner
Differences among the Change

Models
Some theories do not work well
in
complex
situations
or
nonlinear
Some theories work better for
one type
another
of
change
than
Chaos Theory
Belief that chaos is not random, but
may have order

Order emerges through fluctuations
and chaos
Nurses and organizations must be
able to organize and implement

change quickly and forcefully
Does not work well for linear change
Learning Organization Theory

Emphasis is on interrelationships of
all parts of the organization

Organizations respond to changes
by using a learning approach

Focus
on
communication,
education, and cooperation among
all parts of organization
The Change Process

Planned change in the work environment is
similar to planned change on a personal level

Basic reasons to introduce change
To solve a problem
To improve efficiency
To reduce the unnecessary workload for
some group
To plan change, one has to know what has to
be changed
Steps in the Change Process

Assessment
Planning
Implementation
Evaluation
Assessment
Identify
the
problem
or
the
opportunity
for
change
Collect and analyze data
Data collection and analysis should come from
different sources
Structural (physical space or configuration)
Technological (lack of wall outlets, poorly
situated computer locations, lack of computers)
People
(commitment of
staff,
levels
of
education, and interest in the project)
Planning
Identify
the who,
when of change
how,
and
Identify the target date

Goals
and outcomes clearly

determined
and
stated
in
measurable terms
Implementation
Plan goes live
Provide information
Competency-based education
The
benefits stated
outcomes
actually
materialize
as positive
begin
to
Evaluation
The
effectiveness of the change is

evaluated according to the outcomes
identified during the planning and
implementation steps
The most overlooked step

Time intervals for evaluation should be
identified and allowed to elapse before

modifications and declarations of failure
are asserted
Responses to Change
The more the relationships or social
mores are challenged,

resistance to change
the
more
Factors affecting resistance to change
Trust
The ability to cope with change
Evaluation
of
the
immediate
situation
Anticipated consequences of change
Individuals stake
Responses to Change
Innovator
Change embracer; enjoys the challenge;

often leads change
Early adopter
Open and receptive, but not obsessed

with change
Early majority
Enjoy and prefer the status quo, but do

not want to be left behind
Responses to Change
Late majority
Followers; often skeptics

Laggards
Last group to adopt change; prefer

tradition
Rejectors
Openly oppose and reject the change
The Change Agent

Leads the change process
Manages
the
change
process
and
group
dynamics
Understands the feelings of the group
Maintains momentum and enthusiasm
Maintains vision of change
Communicates change, progress, and feelings
Knowledgeable about the organization
Trustworthy
Respected
Intuitive
Innovation
The process of creating new services
or products
Change and innovations are different
Change deals with any modification

Innovation is restricted to new
modifications in ideas and practices
Innovation is a team event
Types of Change Strategies

Power-coercive
Uses authority and threat of job loss to

gain compliance with change
Normative-reeducative
Uses social orientation and the need to

have satisfactory relationships in the
workplace as a method of inducing
support for change
Focuses on the relationship needs of
workers
Types of Change Strategies

Rational-empirical
Uses knowledge as power base

Assumes that once workers
understand the organizational
need or the meaning of the
change they will change
Conflict
Two or more parties holding differing
views about a situation

Disagreement
about something of
importance to each person involved
Ability
to resolve conflict is an
important part of change management
Conflict is not necessarily bad
Sources of Conflict
Allocation/availability of resources
Personality differences
Differences in values
Internal/external pressures
Cultural differences
Competition
Differences in goals
Issues
control
of
personal/professional
Types of Conflict
Intrapersonal
Disagreement in philosophy
values, policy or procedure
Interpersonal
Personality conflict
Organizational
Competition for resources
or
The Conflict Process

Antecedent conditions
Perceived and/or felt conflict
Manifest behavior
Conflict resolution or suppression
Resolution aftermath
Meaning of Conflict
Individuals form an idea or concept
of what the conflict is about

Four aspects of conflict
Facts
Goals
Methods of goal achievement
Values or standards used
select the goals or methods
to
Conflict Management
Avoiding
Ignoring the conflict

Accommodating
Smoothing or cooperating
One side gives in to the other side
Competing
Forcing
The two or three sides are forced to
compete for the goal
Conflict Management
Compromising
Each side gives up something and gains something

Negotiating
High-level discussion that seeks agreement

Not necessarily consensus
Collaborating
Both sides work together to develop optimal

outcome
Confronting
Immediate and obvious movement to stop conflict
at the very start
Strategies to Facilitate Conflict

Management
Open, honest communication
Private,
relaxed,
setting for discussion
Expectation
comfortable
of
compliance
results by both sides
to
Leadership and Management

Roles
Model conflict resolution behaviors
Lessen perceptual differences of parties
Assist
parties
techniques
to
identify
resolution
Create environment conducive to conflict
resolution
If conflict cannot be resolved, minimize or
lessen perceptions of conflicting parties
BACK
Budget Concepts for

Patient Care
Types of Budgets
Operational budget
Account for the income and expenses

associated with day-to-day activity within a
department or organization
Capital budget
Account for the purchase of major new or

replacement equipment
Construction budget
Developed
when
renovation
structures are planned
or
new
Budget Overview
Operational budget
A financial tool that outlines anticipated

revenue and expenses over a specified period
Accounting
An activity that managers engage in to record

and report financial transactions and data
Profit
Determined by the relationship of income to

expenses
Budget Overview
Dashboard
A documentation tool providing a

snapshot image of pertinent
information
and
activity
reflecting a point in time
Variance
The difference between what was

budgeted and the actual result
Budget Preparation
Budgets are generally developed for a
12-month period, or yearly cycle
The yearly cycle can be based on a
fiscal
year
determined
by
organization or a calendar year
the
Prior to the beginning of the budget
year,
most
organizations
devote
approximately 6 months to preparing
and developing an operational budget
Budget Preparation: Demographic

Information
Identifies
unique
market
characteristics
Determines
client characteristics
and health care needs
Determines capture rate
Budget Preparation: Competitive

Analysis
Probes into how the competition is
performing as compared
health care organizations
to
other
Examines other hospitals or practices
strengths or weaknesses
This
information
can
influence
decisions regarding implementation
of new programs, hiring of specialty
staff, and purchasing equipment
Budget Preparation: Regulatory

Influences
Centers for Medicare and Medicaid Services
Federal control over quality assurance, and

fraud and abuse prevention
Department of Health and Human Services
Coordinates health care policy and legislation

Food and Drug Administration
Regulates the use of drugs and medical devices

The Joint Commission
Ensures organizations meet specific standards
Strategic Plans
Maps
out the direction for

organization over several years
the
Guides the staff at all levels so that
the entire organization can have a

shared mission and vision with clearly
defined steps to meet the goals
Each
department
develops
unitspecific plans to help the organization
follow its overall strategic plan
Scope of Service and Goals

Hospital
systems are frequently divided into

subsections or units, commonly called cost
centers
Each cost center defines its own scope of
service
Departmental
goals
may
include
the
introduction of new technology, facilities, or
services
The manager is responsible for identifying the
expenses associated with patient care up front
so they will be covered by the charge
Charge
The dollar amount the patient is responsible

for paying as a result of service
Budget History
History or past performance is typically used
as a baseline of experience and data to better

understand activity in a department or unit
Buying
contracts are negotiated so that

predetermined reduced rates can be realized
when organizations purchase large quantities
of supplies
Knowledge about historical volume provides a
perspective as to how a department has grown

or declined over time
Revenue
Income generated through a variety of means
Billable patient services

Investments
Donations to the organization
Reimbursement
rates of third-party payers

affect revenue and continue to change from
year to year
The
reimbursement
rates
or
payments
received by hospitals often do not equal the
actual unit charges for the services rendered
Revenue
Payer mix
Third-party
payer
reimbursement rates
Diagnosis-related
groups
(DRGs)
Partial or nonpayment from
uninsured
Expenses
Determined
by identifying the cost

associated with the delivery of service
Expenditures are resources used by an
organization to deliver services

Labor
Supplies
Equipment
Space
Utilities
Supplies
Expenses are commonly broken down into
line items
Line items
Represent
specific
categories
that
contribute to the cost of the procedure
or activity, e.g., paper supplies, medical
supplies, drugs, etc.
Zero-based budgeting
Details every supply item and quantity

of items typically used
Labor
Health care services are very labor
intensive
Salaries and benefits account for
approximately 50%
operational costs
to
60%
of
Staffing Models
The amount and types of staff are
often accounted for in a staffing

model
Market wages and benefit costs
Types of staff (RN, LPN, CAN, etc.)
Staff-to-patient ratio
Recruitment and training costs
Unproductive time usually includes
sick, vacation, personal, holiday,
and education time
Direct and Indirect Expenses

Direct expenses
Those expenses that are directly

associated
with
the
patient
(medical and surgical supplies and
drugs)
Indirect expenses
Items such as utilities (gas,

electric, phones) that are not
directly related to patient care
Fixed and Variable Costs

Fixed costs
Those expenses that are constant and

are not related to productivity or
volume
(building
and
equipment
depreciation, utilities, fringe benefits,
and administrative salaries)
Variable costs
Fluctuate depending upon the volume

or census and types of care required
Budget Approval and

Monitoring
Approval process
Budgets are submitted to administration
for review and final approval

May take several months
Control of budget
Responsibility
of
unit
or
department
manager
Budget monitoring is generally carried out
on a monthly basis
Budget analysis is conducted to determine
if expenses are kept within the budget
allotted amount
Variance Reports
A budget variance report is a tool
used to identify when budget

categories are out of line and what
corrective action can be taken
Some
institutions request that

budget dashboards be developed
reflecting departmental activity at
a glance
BACK
Effective Staffing
Determination of Staffing
Needs
Patient
census was historically

used to determine staffing needs
Has proven to be inaccurate, since
patient care needs vary greatly
Better matching of patient needs to
nursing resources is now an

important financial quest in health
care institutions
Core Concepts
Full-time
equivalent (FTE) is a
measure of the work commitment of
an employee who works 5 days a
week or 40 hours per week for 52
weeks per year; some agencies
consider 36 hours (three 12-hour
shifts)
full time
FTE hours are a total of all paid time
Core Concepts
Productive hours
Hours worked and available for patient care

Nonproductive hours
Benefit time such as vacation, sick time, and

education time
Direct care
Time spent with hands-on care to patients

Indirect care
Time spent with activities that support patient

care
Units of Service
A
variety of volume measures

used to reflect different types of
patient encounters as indicators
of nursing workload
Used
in budget negotiations to
project nursing needs of patients
and to assure adequate resources
for safe patient care
Nursing Hours per Patient Day

(NHPPD)
A standard measure that quantifies the
nursing time available to each patient

by available nursing staff
NHPPD reflects only productive nursing
time available based on:

Midnight census
Past unit needs
Expected practice trends
National benchmarks
Budget negotiations
Patient Classification Systems

Patient classification system (PCS)
A
measurement
tool
used
to
determine the nursing workload for a
specific patient or group of patients
over a specific period of time
Patient acuity
The measure of nursing workload that

is generated for each patient
Patient Classification Systems

Nurse intensity
A measure of the amount and

complexity
of
nursing
care
needed by a patient
Patient turnover
A measure
admission,
discharge
reflecting
transfer,
patient
and
Factor Classification Systems

Use units of measure that equate to
nursing time
Attempt
to
capture
assessment,
planning, intervention, and evaluation
of patient outcomes along with
written documentation processes
Are
the most popular

classification system
type
of
Factor Classification Systems

Advantages
Data readily available for day-to-day operations

Provide information against which one can justify
changes in staffing requirements
Disadvantages
Create an ongoing workload for the nurse in

classifying patients every day
Problems with classification creep
Do not capture patient needs for psychosocial,
environmental, and health management support
Calculate nursing time based on a typical
nurse
Prototype Systems
Allocate nursing time to large patient groups
based on an average of similar patients
Advantage
Reduction of work for the nurse by not

classifying patients daily
Disadvantages
No ongoing measure of the actual nursing

work required by individual patients
No ongoing data to monitor the accuracy of
the preassigned nursing care requirements
Utilization of Classification System

Data
Can
be utilized by staff and managers

planning nursing care over the next 24 hours
for
Essential for preparing month-end justification
for variances in staff utilization

Used to cost out nursing services for specific
patient populations and global patient types

Information useful in negotiating payment rates
with third-party payers

Used in preparing the budget
Considerations in Developing a
Staffing Plan
Benchmarking
A
tool
used
to
compare
productivity across facilities to
establish performance goals
Does not always reflect quality of
care indicators that can link
quality patient care outcomes to
productivity measures
Can be helpful in establishing a
starting point for a staffing
pattern
Staffing Plan
Regulatory requirements
One controversial issue is nurse

staffing levels
Mandated nurse staffing plans are
enacted by law
The Joint Commission does not regulate
staffing levels
Does assess staffing effectiveness
Requires organizations to monitor
four of twenty-one specified indicators
Staffing Plan
Skill mix
The percentage of RN staff to other direct

care staff
Should vary according to the care that is
required and the care delivery model utilized
Staff support
The supports in place for the operation of

the unit or department (a systematic
process to deliver medications, patient
transport services, secretarial services, etc.)
Establishing a Staffing Plan

Articulates how many and what kind of staff
are needed by shift and day to staff a unit or

department
Two ways of development
Determine the ratio of staff to patients;

nursing hours and total FTEs are then
calculated
Determine the nursing care hours needed
for a specific patient or patients and then
generating
the
staff-to-patient
ratio
needed to provide the care
Inpatient Unit
An inpatient unit is a hospital unit that is able
to provide care to patients 24 hours a day, 7

days a week
Using data from all your sources, you can build
a staffing pattern that will meet the needs of

the patients, the staff, and the organization
Average daily census
The total numbers of patients at census time,

usually midnight, over a period of time, e.g.,
weekly, monthly or yearly, and dividing by the
number of days in the time period
Determining the FTEs Needed to Staff an

Episodic Unit
Episodic care units
Units that see patients for defined

episodes of care
Examples
are
dialysis
and
ambulatory care units
Start with an assessment of the hours
of care required by the patients
Add FTEs to cover days off and benefit
time
Scheduling
Scheduling
responsibility
manager
of
staff
is
the
of
the
nurse
The manager must ensure that
the
schedule
places
the
appropriate staff on each day
and shift for safe, effective care
Considerations for Staffing

The patient type and acuity
The higher the patient acuity, the more

consistent the staffing needs are across
shifts
The experience of the staff
Novice nurses take longer to accomplish the

same task than an experienced nurse
An experienced RN can handle more
workload and higher acuity patients
Good staffing requires putting the patient first
Scheduling
Volume
Patient volume numbers reviewed for

peaks and valleys in the census and
patient acuity
Scheduling adjustments are necessary
Experience and capability of staff
Different
degrees
of
knowledge,
experience, and critical thinking skills
Number of inexperienced staff (add hours)
Number of experienced staff
Need for staff with special skills
Shift Variations
Traditional staffing patterns
Generally 8-hour shifts

Start
times
may
vary
organization or nursing unit
by
Shift variations occur to meet the
needs of patients and the staff

12-hour shifts
Weekend programs
Concerns for Scheduling

Impact on patient care
Possible disruption of continuity of care

Weekend staff should be familiar with
patients and recent care events
Financial implications
Weekend programs are more expensive

than traditional staffing patterns
They are a recruitment and retention
tool for nursing leadership
Self-Scheduling
A
process in which unit staff take

leadership in creating and monitoring
the work schedule while working within
defined guidelines
Increasing
staff control over their

schedule is a major factor in nurse job
satisfaction and retention
Has
been associated with sick time

usage
Implementing Self-Scheduling
Form a committee made up of unit staff
who report to the manager
Define the roles
and responsibilities of
each committee member
Establish generic boundaries regarding
fairness, fiscal responsibility, evaluation

of the self-scheduling process, and the
approval process
Educate the staff
Evaluation of Staffing
Effectiveness
Patient
outcomes
and
nurse
staffing
Studies have found consistent
significant
relationships
between nurse staffing and
some patient outcomes
Certain outcomes are affected
negatively when nurse staffing
or skill mix is inadequate
Evaluation of Staffing
Effectiveness
Nurse staffing and nurse outcomes
Effect
of
staffing
on
nurse
performance
should
also
be
considered
Track staffs perception of staffing
adequacy
Provide
ability
for
staff
to
communicate concerns in written and
verbal form
Track recommended staffing versus
actual staffing
Models of Care Delivery

Care delivery models
Organize
patients
the
work
of
caring
for
The
decision for which care delivery

model is used is based on the needs of
the
patients
and
availability
of
competent staff
Managers
have the responsibility to

implement models and evaluate the
outcomes in their areas
Total Patient Care

Total patient care
The nurse is responsible for

the total care for his or her
patient assignment for the
shift he or she is working
Total Patient Care

Advantages
Consistency of one individual caring for

patients an entire shift
Enables development of patient and family
trust
Provides a higher number of RN hours of care
than other models
The nurse has more opportunity to monitor
progress of the patient
Disadvantages
Utilizes a high number of RN staffing

More costly than other models
Functional Nursing
Divides
nursing work into functional

roles that are then assigned to one of
the team members
In
this model, each care provider is

responsible for specific duties or tasks
Technical
rather
than
nursing care often results
professional
Decision making usually at the level of
the charge nurse
Functional Nursing
Advantages
Care can be delivered to a large

number of patients
Uses other types of health care
workers when there is a shortage of
RNs
Disadvantages
Lack of continuity of care

Patient may feel that care is disjointed
Team Nursing
A care delivery model that assigns staff to
teams that are then responsible for a

group of patients
A unit is divided into two or more teams,
each led by a registered nurse
The
team
leader
supervises
and
coordinates all of the care provided by
those on the team
Care
is
divided
into
the
simplest
components and then assigned to the care
provider with the appropriate level of skills
Team Nursing
Modular nursing delivery system
A kind of team nursing that

divides a geographic space into
modules of patients, with each
module having a team of staff
led by an RN to care for them
Useful
with
decentralized
nursing stations
Team Nursing
Advantages
Maximizes the role of the registered nurse

Nurse is able to get work done through
others
Disadvantages
Patients
often
receive
fragmented,
depersonalized care
Communication is complex
Shared responsibility and accountability
can
cause
confusion
and
lack
of
accountability
Primary Nursing
Clearly delineates the responsibility and
accountability of the RN
Places the RN as the primary provider of
care to patients
Patients are assigned a primary nurse
The primary nurse is responsible for
developing with the patient a plan of
care
Other nurses caring for the patient
follow this plan of care
Patients are assigned to their primary
nurse
regardless
of
geographic
location
Primary Nursing
Advantages
Patients and families are able to

develop a trusting relationship with
the nurse
Accountability and responsibility of
the nurse developing a plan of care
with the patient and family are
defined
Facilitates continuity of care
Authority for decision making is given
to the nurse at the bedside
Primary Nursing
Disadvantages
Cost is high due to the higher RN skill mix

The person making assignments needs to
be knowledgeable about all the patients
and staff to ensure appropriate matching
of nurse to patient
Lack of geographical boundaries within
the unit may require nursing staff to
travel long distances at the unit level to
care for their primary patients
Nursing time is often used in functions
that could be completed by other staff
Nurse-to-patient ratios must be realistic
Patient-Centered or Patient-Focused
Care
Designed
to focus on patient needs

rather than staff needs
All patient services are decentralized to
the patient area
Care teams are established for a group
of patients
The care team includes all disciplines
Disciplines collaborate to ensure that
patients receive the care they need
Patient-Centered or PatientFocused Care

Advantages
Most convenient for patients

Expedites services to patients
Disadvantages
Can be extremely costly to decentralize

major services in an organization
Some perceive model as a way of
reducing RNs and cutting costs in
hospitals
Patient Care Redesign

Initiative that developed in the 1990s to
redesign how patient care was delivered

Motivated by need to reduce costs
Goals
are to make care more patientcentered and not caregiver-centered
Reduces
the number of caregivers a

patient has to interface with, thus
increasing patient satisfaction
Care Delivery Management

Tools
Work flow analysis
A tool used to determine what activities

are value- added
Determines how to streamline or eliminate
those activities that do not contribute to
improved patient outcomes
Value-added
The customer is willing to pay for this
activity
Activity must be done right the first time
Activity
must
somehow
change
the
product or service in some desirable
manner
Care Delivery Management

Tools
In diagnosis-related groups (DRGs) the
national average length of stay (LOS) for

a specific patient type was used to
determine payment for that grouping of
patients
Hospitals
looked to
reduce hospital costs
reduce
LOS
and
Clinical pathways and case management
surfaced as significant strategies
Clinical Pathways
Clinical pathways
Care management tools that outline

the expected clinical course and
outcomes for a specific patient type
Should be evidence-based
Pathways
include expected outcomes

specified for each day of care
Patient progress is measured against
the expected outcomes
Clinical Pathways
Advantages
Very instructive to new staff

Save a significant amount of time
in the process of care
In most cases, improved care and
shortened lengths of stay for the
population on the pathway are
the results
Allow for data collection of
variances to the pathway
Clinical Pathways
Disadvantages
Some physicians perceive pathways to be

cookbook medicine and are reluctant to
participate in their development
Development
requires
a
significant
amount of work to gain consensus from
the various disciplines on the expected
plan of care
Pathways are less effective for patient
populations that are nonstandard, since
they are constantly being modified to
reflect individual patient needs
Case Management
A
strategy to improve patient care and

reduce hospital costs through coordination of
care
Typically a case manager:
Is responsible for coordinating care and
establishing
goals
from
preadmission
through discharge
Evaluates the patients outcomes daily and
compares them to the predicted outcomes
articulated in the clinical pathway
Works with all the disciplines to facilitate
care
Case Management
In other models, the case management
function is provided by the staff nurse at

the bedside
The case manager also collects data on
patient variances from the clinical pathway
Shares this data with the responsible
physicians and other disciplines that
participate in the clinical pathway
This data is then used to explore
opportunities for improvement in the
pathway or in hospital systems
BACK
Delegation of
Patient Care
Perspectives on Delegation
Delegation
in nursing has been

emphasized and deemphasized at
different periods in history
Delegation
has not always been

emphasized in nursing education
Current staffing practices require a
greater amount of delegation from

the nurse
Delegation
The transfer to a competent individual of the
authority to perform a selected nursing task in a

selected situation
The
nurse
delegation
retains
accountability
for
the
All delegation involves at least two individuals as
well as specifying duties to be accomplished

Successful
delegation addresses the personal

needs of the patient and the nurses professional
goals
Accountability
Being
responsible and answerable for

actions and inactions of self or others in
the context of delegation
Involves
compliance
with
legal
requirements
as
set
forth
in
the
jurisdictions law and rules governing
nursing
Involves the preparedness and obligation
to explain or justify to relevant others

(including the regulatory authority) ones
judgments, intentions, decisions, actions,
and omissions and their consequences
Responsibility
Involves
reliability,
responsibility,
obligation
Involves each person providing patient
care to perform at an acceptable level for

which they have been educated
The
nurse transfers responsibility and

authority for a delegated task, but
retains accountability for the delegation
process
Authority
Occurs when a person has been given the right
to delegate
Practice Act
as
defined
by
the
state
Nurse
Occurs when the nurse has the official power
from an agency to delegate

The right to delegate duties and give directions
to unlicensed assistive personnel places the RN

in a position of authority
Authority given by an agency legitimizes the
right of the nurse to give direction to others
Assignment versus Delegation

Significant
difference
between
assigning care to another RN and
delegating to an LPN/LVN or nursing
assistant
Assign: a verb, describes the
process of working through others
Assignment: a noun, describes
what a person is directed to do
Competence
The ability of the nurse to act and integrate
the knowledge, skills, values, attitudes,

abilities, and professional judgment that
underpin effective and quality nursing
Required to practice safely and ethically in a
designated role and setting
Built upon knowledge gained in a nursing
education program
Requires
the application
interpersonal
decision
psychomotor skills
of knowledge,
making,
and
Supervision
The
provision of guidance or direction,

evaluation, and follow up by the licensed nurse
for accomplishment of nursing tasks delegate
to the unlicensed assistive personnel (UAP)
Direct supervision
The presence of a licensed nurse working

with other nurses and/or UAP to observe and
direct
Indirect supervision
Licensed nurse is not present
Levels of Supervision
Unsupervised
Occurs when one RN works with another RN

Initial direction and periodic inspection
RN supervises licensed or unlicensed staff

of whom the RN knows their training and
competency levels
Continuous supervision
RN determines that the delegate needs

frequent
to
continuous
support
and
assistance
Assignment Making
The education, skill, knowledge, and
judgment levels of the personnel

being assigned to a task must be
relative to the assignment
The
expected
outcome
of
the
assignment,
time
frame
for
completion, and any limitations on
the assignment should be specified
when the assignment is made
Considerations for Delegation

Potential for harm
Complexity of the task
Amount
of problem
innovation required
solving
Unpredictability of outcomes
Level of patient interaction
and
Delegation Suggestions for RN

Consider
the
qualifications
of
all
personnel
Assess what is to be delegated and
who could best complete the task
Communicate
the
duty
to
be
performed
Avoid changing duties once assigned
Evaluate the effectiveness of the
delegation of duties
Accept minor variations in style
Responsibilities of the RN
RN
New graduates should focus on

duties for which they are directly
responsible
Responsible and accountable for
the provision of nursing care
Always responsible for patient
assessment,
diagnosis,
care
planning, and evaluation
Responsibilities of the LVN/LPN and Unlicensed

Assistive Personnel
LPN/LVN
Usually assigned to stable patients with

predictable outcomes
Does not complete the initial patient
assessment
UAP
Skills gained through training program

Cannot
complete
assessments
or
patient
potential
responses
to
treatment
Rights of Delegation
Right task
Right circumstance
Right person
Right direction/communication
Right supervision
Direct versus Indirect Patient

Care
Direct care
Activities that include assisting the
patient
Involves reporting and documenting
Indirect care
Activities necessary to support the

patient and their environment
Assists in providing clean, efficient,
and safe patient care milieu
Overdelegation
Leads to delegating duties to personnel
who are not educated for the tasks

Can
overwork
some
underwork others
personnel
and
Can place the patient at risk

Personnel
may
feel
uncomfortable
performing duties that are unfamiliar to
them, so they depend too much on others
Underdelegation
Personnel in new job roles tend to
underdelegate
May occur due to personnel avoidance
New
nurses may be reluctant to

delegate because they do not know or
trust individuals or the team or are not
clear on their scope of duties
Obstacles to Delegation
Fear of being disliked
Inability to give up
control
of
the
situation
Inability to determine what to delegate
and to whom
Past experience with delegation that did
not turn out well
Lack of confidence to move beyond being
a novice nurse
Tendency to isolate ones self and
choosing to complete all tasks alone
Obstacles to Delegation
Lack of confidence to delegate to staff
who was previously ones peers

Inability to prioritize using Maslows
Hierarchy of Needs and the Nursing
Process
Thinking of oneself as the only one who
can complete a task the way it is
supposed to be
Inability to communicate effectively
Inability to develop working relationships
Lack of knowledge of staff capability
Organizational Responsibility for

Delegation
Follow
professional
standards
for
education, licensure, and competency in
all hiring decisions
Have clear job descriptions
Facilitate
clinical
and
educational
specialty certification
Provide standards for ongoing evaluation
Provide access to professional health
care standards and policies

Delegation
Facilitate regular
evidence-based review
of critical standards and policies and
procedures
Have clear policies and procedures for
delegation and chain of command
Provide administrative support
Clarify
health
care
provider
accountability
Provide
standards
for
regular
RN
evaluation of NAP and LVN/LPN
Develop safe transfer policies

Delegation
Develop physical, mental, and verbal
No Abuse policy
Consider applying for Magnet status
Monitor patient outcomes
Maintain
ongoing
monitoring
of
patient incident reports
Develop
systematic,
error-proof
systems for medication administration
Attain The Joint Commission Patient
Safety Goals
Chain of Command
All members of the organization are
accountable for their actions to the

patients and communities they serve
All employees are accountable to
someone in a higher position
The RN is responsible to the charge
nurse
The charge nurse is responsible to
the manager
The manager is responsible to the
chief nurse executive
Delegation of the Nursing

Process
Some professional activities
can never be delegated
Patient assessment
Triage
Making a nursing diagnosis
Establishing a nursing plan of care
Teaching or counseling
Telephone advice
Evaluating outcomes
Discharging patients
Delegation of the Nursing

Process
Delegated tasks:
Typically those tasks that occur

frequently
Considered technical
Considered standard and unchanging
Have predictable results
Have minimal potential for risks
Delegated
tasks
fall
within
the
implementation phase of the nursing
process
Delegation Decision Making

Tree
Developed by the
NCSBN
Steps
Assessment and planning

Communication
Surveillance and supervision
Evaluation and feedback
Transcultural Delegation
The
process of having personnel

perform duties with the diversities
of culture taken into consideration
Cultural phenomena to consider:
Communication
Space
Social organization
Time
Environmental control
Biological variations
BACK
Organization of
Patient Care
Strategic Planning
A process designed to achieve
goals in dynamic, competitive

environments
through
the
allocation of resources
Unit Strategic Planning

Unit or departmental strategic planning
begins
with
examining
the
organizations mission, vision, strategic
plan, and annual operating plans
Unit
strategic
plans
should
be
congruent with and support the
mission
and
vision
of
the
organizational system of which they
are a part
Philosophy Development
Philosophy
A statement of beliefs based on

core valuesinner forces that give
us purpose
A units mission and vision are most
authentic they are developed based
on the philosophy or core beliefs of
the work team
A units core beliefs or values should
be incorporated into the units
mission and vision statements
Mission Statement
Mission
A call to live out something that matters or is

meaningful
An organizations mission reflects the purpose
and direction of the health care agency or a
department within it
A mission statement has three elements:
Reflects what the unit seeks to do and become
A view of what the unit is trying to accomplish
Indicates what is unique about the care that is
provided
Vision Statement
A unit vision statement describes how the
mission of the unit within an organization will

be actualized
A vision statement includes four elements:
A vision statement is written down

It is written in present tense, using action
words, as if it were already accomplished
It covers a variety of activities and spans
broad time frames
It addresses the needs of providers,
patients, and environment in a balanced
manner that anchors it to reality
Goals and Objectives

The work unit develops broad strategies that
span the next three to five years, and then

develops annual goals and objectives to meet
each of these strategies
Goals
Are written as specific aims or targets that the

unit wishes to attain within the time span of
one year
Objectives
Are the measurable steps to be taken to reach

each goal
Structure of Professional
Practice
In
an
organization
where
professional nursing practice is
valued,
development
and
implementation
of
strategic
initiatives is most effectively carried
out through a structure of shared
governance and shared decision
making between management and
clinicians
Shared Governance
An organizational framework based on
the idea of decentralized leadership that

fosters autonomous decision making and
professional nursing practice
It
implies the allocation of control,

power, or authority (governance) among
mutually (shared) interested vested
parties
Shared
governance
council models
structures
are
Shared Governance
In
most health care settings, vested

parties in nursing fall into two distinct
categories:
Nurses practicing direct patient care,
such as staff nurses
Nurses managing or administering the
provision of that care, such as
managers
In
shared governance, management

relinquishes control over issues related
to clinical practice
Clinical Practice Council

The
purpose is to establish the

practice standards for the work group
A unit level committee that works in
conjunction with the organizational

committee
accountable
for
determining policy and procedures
related to clinical practice
Develops
standards
evidence-based
practice
Quality Council
Has two purposes:
The credentialing of staff

Oversee
the
unit
management initiatives
quality
Can make recommendations for hiring
and promotions
Reviews
indicators for the

overall clinical performance
units
Education Council
Purpose is to assess the learning needs
of the unit staff
Develop
and implement programs to

meet learning needs
Learning organizations
Promote professional practice through

the
encouragement
of
personal
mastery, an awareness of our mental
models, and team learning
Research Council
Advances evidence-based practice with
the
intent
of
staff
incorporating
research-based findings into the clinical
standards of unit practice
Staff
critiques research literature and

make recommendations to the clinical
practice council for changes based on
evidence
May coordinate research projects
Management Council
Ensures that the standards of
practice
and
governance
agreed upon by unit staff are
upheld
Ensures
that
there
are
adequate resources to deliver
patient care
Coordinating Council
Facilitates and integrates the activities of
the other councils

Composed
managers
councils
of
and
first-line
patient care
chairpersons of other
Facilitates the annual review of the unit
mission and vision

Develops the annual operational plan
Competency
A
possession of the required skill,

knowledge, qualification, or capacity
Competency of professional staff can be
ensured through credentialing processes

developed around a clinical or career
ladder staff promotion framework
Career ladder
Acknowledges that staff have varying

skill sets based on education and
experience
Benners Novice to Expert

Model
Facilitates
professional
staff
development by building on the skill
sets
and
experience
of
each
practitioner
Acknowledges that there are tasks,
competencies, and outcomes that

practitioners can be expected to
have acquired based on five levels
of experience
Benner's Novice to Expert Model

There are five progressive stages of Benners
model of nursing practice:

Novice (task-oriented and focused)
Advanced beginner (demonstrates marginally
acceptable independent performance)
Competent (has been in the same role for one
to three years; demonstrates conscious,
deliberative planning)
Proficient (perceives the whole situation
rather than a series of tasks)
Expert (intuitively knows what is going on
with patients)
The Process of Professional

Practice
Ongoing
professional
staff
development is part of the regular
performance feedback staff can
expect
from
the
patient
care
manager or credentialing committee
Ongoing
professional development
determines the staff members
readiness
for
leadership
development and advancement
Situational Leadership
Maintains that there is no one best
leadership style
Effective
leadership lies in matching

the appropriate leadership style to the
individuals or groups level of taskrelevant readiness
The leader should help staff grow in
their readiness to perform new tasks as

far as they are able and willing to go
Situational Leadership
Accomplished through four styles of
leadership:
Directing
Coaching
Supporting
Delegating
Each
style is used with different

leadership readiness of the nursing
staff
Accountability-Based Care
Delivery
Focuses on roles,
their relationship
to
the work to be done, and the outcomes
they are intended to achieve
Includes the activities inherent in a role
and not legitimately controlled outside

the role
Competence is evidenced not by what a
person brings to the work, but instead

by the results of the application of the
persons skills to the work
Elements of Accountability-Based
Care is
Delivery
Accountability
about outcomes,
not processes
Accountability is individually defined

Accountability
is inherent
role, not delegated
in
the
Accountability is the foundation for
evaluation
Measurable Quality Outcomes

Regular evaluation of a work units
performance to ensure that the

outcomes of care delivery are meeting
the objectives of professional practice
The
development
of
process
improvement measures is driven by
The
Joint
Commission
and
the
National Council for Quality Assurance
Unit-Based Performance
Outcomes Improvement
from four domains must
be
measured:
Access
Service
Cost
Clinical quality
Quality must be measured in four domains:
Functional status
Clinical outcomes
Cost and utilization
Patient satisfaction
BACK
Time Management and

Setting Patient Care Prioriti
General Time Management

Concepts
Time management
A set of related commonsense skills that

helps you use your time in the most
effective and productive way possible
There
are
three
time
management
concepts to master:
The relative effectiveness of the effort
The importance of outcome versus
process orientation
The value of organizing how time is
currently being used
The Pareto Principle

States
that 20 percent of focused

effort results in 80 percent outcome
results, or conversely 80 percent of
unfocused efforts results in 20
percent results
strategy for balancing life and

work through prioritization of effort
Outcome Orientation
More
is achieved through an outcome

orientation than an emphasis on task
completion
Determine
long-term goals, then break

them down into achievable outcomes that
are the steps toward those goals
Write down long-term goals and outcomes

Flexibility
orientation
should
be
part
of
outcome
Time Analysis
Analyze how time is currently used
Understand the value of nursing
time
Consider
what
tasks
can
be
delegated
to
personnel
who
receive less compensation than
nurses
Prioritizing the Use of Time

Understand the big picture
No nurse works in isolation

Less likely to be frustrated when asked to
assist others
Decide on optimal outcomes
At the beginning of their shift nurses need to

decide what outcomes can be achieved
They also should decide what outcomes can be
achieved
given
less-than-optimal
circumstances
Do first things first
Establishing Priorities
First priority
Life threatening or potentially life

threatening
Second priority
Activities essential to safety

Third priority
Activities essential to the plan of

care
Environment
If
possible,
arrange
the
environment to provide nurses
with efficient access to supplies,
equipment, and patient areas
Stock
supplies
available
to
make
them
Have specialty carts available
Shift Report
The shift handoff report can best lead to
an efficient, effective, and safe start to

the shift
The
Joint
Commission
included
a
standardized report approach to shift
handoff as a 2006 patient safety goal
Shift report can be accomplished by a
face-to-face meeting,
walking rounds
audiotaping,
or
Formulating the Shift Action

Plan
A written plan that
sets the priorities for
the accomplishment of shift outcomes
that are both optimal and reasonable
Should
be written so that
members are aware of it
all
team
Must be based clearly on priorities set at
the beginning of the shift with built-in

flexibility
Making Assignments
Nurses
cannot accomplish patient

objectives completely by themselves,
requiring them to delegate
The assignment sheet should identify
who will perform the intervention

Assignments
should be part of the

planning process
Timing the Actions

The shift action plan should identify
by what time an intervention should

be completed
It is important to remember that
plans are just plans

They have to be flexible, based on
ever-changing patient care needs
At the
Evaluating Outcome
Achievement
end of
the shift, reexamine the
shift
action plan
Did you achieve the optimal outcomes? If
not, why not?
Were there staffing problems or patient
crises?
Did you achieve the realistic outcomes? If
not, why not?
Were the activities necessary for outcome
achievement carried out? If not, why not?
What did you learn from this for future
shifts?
Strategies to Enhance Personal

Productivity
Schedule activities that take focus and
creativity at high-energy times and dull,

repetitive tasks at low-energy times
Create more personal time
Delegate work to others

Eliminate chores or tasks that have
no value
Get up earlier in the day
Use downtime
Control unwanted distractions
Avoiding Priority Traps

Traps that nurses should avoid
Doing whatever hits first

Taking
the
path
of
least
resistance
Responding to the squeaky wheel
Completing tasks by default
Relying on misguided inspiration
Strategies for Avoiding Personal Time

Distraction
Clear your work area of clutter and
keep it clean
Organize your work area
Open your mail over your garbage
can; respond, delegate, or throw it out
Break a task down into manageable
segments; return to it again and again
until it is complete
Become a pursuer of excellence, not a
perfectionist
Behaviors of Perfectionists
Hate criticism
Are devastated by failure
Get depressed and give up
Reach for impossible goals
Value themselves for what they do
Have to win to maintain high self-
esteem
Can only live with being number one
Remember mistakes and dwell on
them
Pursuers of Excellence
Welcome criticism
Learn from failure
Experience disappointment, but keep going
Enjoy meeting high standards within reach
Value themselves for who they are
Do not have to win to maintain high self-
esteem
Are pleased with knowing they did their
best
Correct mistakes, then learn from them
Returning to School
Let
your employer know of your

intentions
Develop computer skills
Find a flexible educational program
Do not be surprised by the demands
of school
Solicit support from family and
friends
Utilize all available resources
Returning to School
Focus on the outcome
Be careful of the sacrifice
Manage time
Take care of yourself and your
responsibilities
If you need a break, take one
Study on the run
BACK
Managing Outcomes
Utilizing an Organizationa
Quality Improvement Mode
502
History of Quality Assurance

Quality assurance (QA)
Emerged in health care in the 1950s

as an inspection approach to ensure
that minimum standards of care
existed in health care institution
Because of its emphasis on doing it
right, some thought that QA was
very punitive and did little to sustain
change
or
proactively
identify
problems before they occurred
Total Quality Management

Began in the (TQM)
manufacturing industry
when
W. Edwards Deming and Joseph Juran
consulted with Japanese corporations in
the 1950s
Also referred to as quality improvement
(QI) and performance improvement (PI)
This approach became integrated in the
health care industry in the 1980s
A
proactive
approach
emphasizing
doing the right thing for customers
Quality Improvement (QI)

A
systematic
approach
of
organization-wide
participation
and partnership in planning and
implementing
continuous
improvement
methods
to
understand and meet customer
needs and expectations and
improve patient outcomes
General Principles of Performance

Improvement
The priority is to benefit patients and all
other internal and external customers
Quality
is
achieved
through
the
participation
of
everyone
in
the
organization
Improvement
opportunities
are
developed by focusing on the work
process
Decisions to change or improve a
system or process are based on data
Improvement of the quality of service is
a continuous process
Focus of Quality Assurance (Doing It

Right)
Assessing
or
measuring
performance retrospectively
Reviewing
chart audits and
incident reports
Determining
whether
performance
conforms
to
standards
Improving
performance when
standards are not met
Focus of Quality Improvement(Doing the Right Thing)

Meeting
the needs of the customer

proactively
Building quality performance into the
work process
Assessing the work process to identify
opportunities for improved performance
Employing a scientific approach and using
data for assessment and problem solving
Improving health care performance and
changing
the
health
care
system
continuously as a management strategy,
not just when standards are not met
Who Are the Customers in Health

A customer is anyone
Care?
who receives the output
of your efforts
Customers
can
be
internal,
within
the
outside
the
organization
Employees
Health care staff
Customers
can
be
organization
Patients
Accrediting bodies
external,
Empowerment of Everyone in the

Organization
Each
person
participates
must
feel
that
he
or
she
Each takes responsibility for the success or
failure of an organization
Each takes an active part in developing new
ways of doing business and securing new

customers
Each trusts that his or her efforts are valued
Who Participates in the Improvement

Process?
All staff members should be encouraged to
participate
All those involved with or affected by a goal or
process should participate

Staff
can participate
organizational level
on
individual,
unit,
or
Participants should include point-of-service staff
Those workers on the front line who do the

direct work involved in the process being
changed
Improvement of the Health Care

Process
Process
A set of causes and conditions that

repeatedly come together in a series of
steps to transfer inputs into outcomes
All processes have inputs, steps, and
outputs
All the steps of the work process can be
measured
Improvement of the System

System
An interdependent group of items,

people, or processes with a common
purpose
By
examining the
relationships, you
outcome
work process
can improve
and
the
In a system, each step of the process
affects the following step
Continuous Improvement
The cycle of continuous improvement
Developed by Shewhart in the 1920s

Suggests products and services are
designed
and
made
based
on
knowledge about the customer
These
products
or
services
are
marketed to and judged by the
customer
The process of QI becomes continuous
because it is linked to changing customer

needs and judgments
Improvement Based on Data

Decisions to change or improve a
work system or work process are

made based on data
Data should be used for learning, not
for judging
It is critical to look at work processes
rather than people for improvement

opportunities
Implications for Client Care

Quality improvement for patient care can be
measured by the overall value of care

Value is determined by outcomes and cost
Outcomes can be clinical or functional
Outcomes can be related to patient
satisfaction
Cost can be direct or indirect
The cost of care decreases when

standardized care delivery of the work
process is joined with evidence-based
practice
Methodologies for Quality

Improvement
Plan-do-study-act
(PDSA) cycle
Asks three questions:
What are we trying to accomplish?

How will we know that a change is an
improvement?
What changes can we make that will result
in improvement?
The goal is to increase the ability to predict
the effect that one or more changes would

have if they were implemented
Methodologies for Quality

Improvement
FOCUS Methodology
Describes a stepwise process how to move
through the improvement process

F: focus on an improvement idea
O: organize a team that knows the work
process
C: clarify what is happening in the
current work process
U: understand the degree of change
needed
S: select a solution for improvement
Other Improvement Strategies

Benchmarking
A continual and collaborative discipline of

measuring and comparing the work of key
work processes with those of the best
performers
Focuses on key services or work processes
Regulatory requirements
Sentinel event review
An unexpected occurrence involving death

or serious physical or psychological harm
Other Improvement Strategies

Measurements
Dashboard
Balanced scorecard
Report cards
Clinical value compass
Storyboard
Placed in a high traffic area

Outlines the progress of
improvement process
Patient satisfaction data
the
quality
Using Data
Time series data
Allows the QI team to see change in

quality over time
Allows you to see how a process is
behaving
Charts
Pareto diagrams
Pie charts
Flowcharts
Histograms
Principles in Action in an
Organization
Organizational
structure
Encourage accountability
Maximize communication
Communicate
and
priorities at all levels
focus
Outcomes Monitoring
Outcomes
A measurement of the patient

response to structure and process
Measure actual clinical process
Can be short term or long term
Outcome
data
identifying
improvement
causes
can be helpful in
opportunities
for
by determining root
BACK
Evidence-Based Strategies
to Improve Patient Care
Outcomes
Evidence-Based Practice (EBP)

The
conscientious,
explicit,
and
judicious use of current best evidence
in making decisions about the care of
individual patients
Is also referred to as outcomes research
It is a total process:
Know what clinical questions to ask
Know how to find the best practice
Know how to critically appraise the
evidence
Apply the evidence
100,000 Lives Campaign

Deploy rapid response teams
Deliver
reliable
evidence-based
care
for
acute
myocardial
infarction
Prevent
adverse
drug
events
through medication reconciliation
Prevent central line infections
Prevent surgical site infections
Prevent
ventilator-assisted
pneumonia
Role of the ANA

Active
advocate
evaluation
Outcomes
of
outcomes
emphasized
measure of quality care
as
Developed indicators for patient-
focused outcomes, structures of

care, and care processes
Evolution of EBP
Practice guideline
A
descriptive
tool
specification of care
or
standardized
Evidence-based nursing practice
The conscientious, explicit, and judicious use

of theory-derived, research-based information
in making decisions about making nursing care
delivery to individuals or groups of individuals
EBP has a medical focus, whereas evidencebased nursing practice considers the patients
needs and preferences
Evidence-Based Multidisciplinary Practice Improvement

Models
The
University of Colorado Hospital

model
Presents a framework for thinking
about how you use different sources
of information to change or support
your practice
Depicts nine sources of evidence that
are linked to the research core
Provides a way for the nurse to
organize information and data for care
of a patient and to evaluate the care
Practice Improvement Models

The Model for Improvement
Begins with three essential

questions
Forms the foundation for the
plan-do-study-act cycle
Improvement Models
Plan-do-study-act cycle (PDSA)
The cycle begins with a plan and ends
with action based on the learning gained

during the cycle
Plan: develop a plan to change or test a
process
Do: implement the plan
Study: summarize what was learned
Act: determine what actual changes to
make
BACK
Decision Making and

Critical Thinking
Critical Thinking
Rapid
changes in the health care

environment
have expanded the
decision-making role of the nurse
Stringent budgets
Patient care is more complex
Patients are being discharged earlier
Critical
thinking is essential when

making decisions and solving problems
Decision Making
Considering and selecting interventions
from a repertoire of actions that

facilitate the achievement of the
desired outcome
Process consists of five steps
Identify the need for a decision

Determine the goal
Identify actions
Determine which action to implement
Evaluate the decision
Critical Thinking
Purposeful, outcome-directed thinking that
is based on a body of scientific knowledge

derived from research and other courses of
evidence
A good critical thinker
Examines decisions from all sides and

takes into account varying points of view
Generates new ideas and alternatives
when making decisions
Asks why questions about a situation in
order to arrive at the best decision
Critical Thinking Skills

Critical reading
Critical listening
Critical writing
Critical speaking
Reflective Thinking
Watching or observing oneself as
one performs a task or makes a

decision about a certain situation
Two selves
Reflective: acts as an observer

and offers suggestions
Active: active participation
Problem Solving
An active process that starts with a
problem and ends with a solution
The problem-solving process consists of
five steps
Identify the problem
Gather and analyze data
Generate alternatives and select an
action
Implement the selected action
Evaluate the action
Decision Making
A behavior exhibited in making a
selection and implementing a course

of action from alternatives
Decision making is not necessarily
related to solving a problem
Problem Solving and Decision Making: Tools for Viewing

Choices
Decision grid
Useful when
choices
making a decision
between
two
PERT chart
Useful in making time line decisions

Decision tree
Useful in making the alternatives visible

Gantt chart
Useful for illustrating a project from beginning to

end
Group Decision Making

Group decision making may be necessary
in some situations
People affected by a decision often will be
involved in the decision

Involve
people
with
information
or
resources that contribute to the decision
Consider the size of the group and the
personalities of group members
Group Decision Making:

group canAdvantages
generate more ideas,
thus
allowing for more choices and an
increased chance of higher quality
outcomes
When
members participate in the

decision-making process, the decision is
more likely to be accepted
Groups may be used as a medium for
communication
Group Decision Making:

Disadvantages
Time consuming
Can be wasteful and unproductive
if not managed effectively

Can be costly
Can generate conflict
Techniques for Group Decision

Making
Nominal group
technique
Group
members
write
ideas,
without discussion
Each idea is presented with
advantages and disadvantages
Group discusses, clarifies, and
evaluates ideas
Group votes privately on ideas

Making
Delphi technique
Group members do not meet face
to face
Questionnaires
are
distributed
seeking
opinions
from
group
members
Summaries are disseminated to
group members
Process continues until group
members reach a consensus

Making
Consensus building
Means that all group members can live
with and fully support the decision
regardless of whether they totally
agree
Useful because all group members
participate
and
realize
the
contributions of each member to the
group
Requires more time
Should be reserved for important
decisions that need strong support

Making
Groupthink
Different from consensus building
Goal is for everyone to be in 100
percent agreement
Discourages questions and divergent
thinking
Hinders creativity
Groups can reach a decision early
without exploring all options
Can cause stereotyping and challenges
of disagreement
Obstacles to Effective Decision

Making
Past experiences,
values, personal bias
Jumping
to
conclusions
without
examining the situation thoroughly
Failing to obtain all of the necessary
information
Choosing decisions that are too broad,
too complicated, or lack definition
Failing to choose and communicate a
rational solution
Failing to intervene and evaluate the
decision or solution appropriately
Use of Technology in Decision

Making
Technology can support, but not take
over, the decision-making process
Clinical practitioners should evaluate
technology before adopting it

Other staff on which technology will
have an impact should have input

into decisions on its adoption
Strategies to Strengthen Patient Decision

Making
Consumers
of
health
care
are
knowledgeable and cost conscious
more
Nurses must be aware of patients rights in
making decisions about their treatments and

must assist patients in their decision making
Ask
why,
questions
what
else,
and
what
if
Anticipate questions and outcomes
BACK
Culture, Generational
ifferences, and Spiritual
Cultural Competence
Culturally competent care
A
complex
integration
of
knowledge,
attitudes, and skills that enhance crosscultural communication and appropriate and
effective interactions
A process that includes:
Awareness
Cultural knowledge
Cultural skills
Cultural encounters
Cultural desire
Cultural Nursing Theories and

Models
Leininger
Transcultural Nursing
Purnell
Model for Cultural Competence
Campinha-Bacote
The Process of Cultural
Competence in the Delivery of
Health Care Service
Giger and Davidhizar
Transcultural Assessment Model
Levels of Response
Greet
Accept
Help
Background
Advocate
Transcultural Assessment
Determine
communication
conversational style
Understand
differences
that beliefs about personal
space vary
Eye contact may vary from cultural groups
Subject matter and conversation length
vary from cultural groups
Organizational Culture
The system of shared values and
beliefs that actively influences the

behavior of organization members
Shared
values
are
important
because many people are guided by
the same values and they interpret
them in the same way
Values
develop over time and
reflect an organizations history
and traditions
Dimensions of Organizational
Culture
Values
Relative diversity
Resource
allocation
reward
Degree of change
Strength of the culture
and
Organizational Behavior Styles

Greetings
Determined by casual or business acquaintance
Titles
Introduce yourself by your first and last name
Time
Punctuality is important
Body language
Use of direct eye contact is expected in all work

situations
Dress
Ask what traditional dress is used in your department
Workplace Behavior Guidelines

Adapt to your organizations culture
Good
communication
requires
listening and clarifying

Go
to
the
source
of
the
communication
Observe for cultural differences in
the workplace
Realize that health care is a 24/7
business; make arrangements early
with your manager for time off for
religious or cultural holidays
Nursing Cultural Variations

Staff nurses from different cultures have
different perceptions of staff responsibilities
Collectivism
Emphasizes the importance of group

decisions and places the rights of the
group as a whole above the rights of any
individual in the group
Individualism
Emphasizes the importance of individual

rights and rewards
Different Perceptions of the

Nurses
Role
Nurses from different cultures have
different perceptions of the nurses
role and nursing care values
Obligation to care
Prevails
in
the
Philippine
American nurses values
Not as strong in the American
nurses values
Locus of Control
The degree of control that individuals feel they
have over events

People who feel in control of their environment
have an internal locus of control

Health care workers trained in the United States
generally have an internal locus of control
People who believe that luck, fate, or chance
controls their lives have an external locus of

control
Believe they cannot control matters of life and
death
Differences in Time Orientation

Cultural groups are either past,
present, or future oriented

Ways in which cultural groups
value time create challenges in

the health care workplace
Educational Differences
Generally,
nurses educated outside the

United States have less theory and more
clinical skills
A cultural difference in the education of
nurses revolves around who provides the

majority of the care: the nurse, the patients
family, or the patient
Nurses taught under a system of socialized
medicine may find it difficult to adapt to the

health care in the United States
Language Differences
Language differences, more than any
other barrier, raise the potential for

serious miscommunication
Nonverbal
communication
mistaken as well as verbal
Language
can
be
differences can be a
source of friction between foreign
and American nurses
Improving Communication on the

Recognize
that Team
your coworker has an
educational background different from yours
Acknowledge
that the coworkers value

system and perception of what constitutes
good patient care may differ from your own
Try to assess your coworkers understanding

Avoid the use of slang terms and regional
expressions
Improving Communication on the

Team with resources
Provide your coworker
Praise
your coworkers competency in

technical skills
Appreciate the knowledge that you can
gain by working alongside a skilled nurse

from another country
Try
to use I statements instead of

you
statements
when
offering
constructive criticism
Communication with Others

Do not take verbal orders from a
foreign physician whose language

is difficult to understand
Use
caution when supervising

unlicensed
assistive
personnel
who have difficulty understanding
and speaking English
Managerial Responsibility
Determine
which cultural groups are

represented on staff
Understand the organizations values and
goals
Decide what is best for the future of the
organization
Analyze present conditions within the
organization
Plan ways to reach the desired future state
and decide how to manage transitions
Evaluate the results
Techniques to Reduce Cultural

Plan informal Tension
meetings for nurse to
discuss their cultural values

Provide cultural workshops
Provide classes in English as a second
language
Establish a program for orienting
foreign nurses to the hospital or agency
Plan potluck dinners and socialize
Confer with specialists in transcultural
communication
Generational Perceptions
Generation
A group that shares birth

years,
age,
location,
and
significant life events
Approximately 15 to 20 years
in length
Has a different value system
from the preceding generation
and later generations
Generations in the Workplace

Traditional
Born before 1940

Baby Boomers
Born between 1940 and 1960

Generation X (GenXers)
Born between 1960 and 1980

Generation Y (Echo Boomers or Millennials)
Born after 1980
Traditional Generation
Came
of age
Depression
after
the
Great
Raised to be disciplined and obey
their elders
Feel obligated to conform
Believe that work is ones duty
Baby Boomers
Came of age when there was much available
education and economic expansion

Work
for the challenge of work and career

advancement
Characterized
as
workaholic,
strong-willed
individuals
working
for
material
gain,
promotions, recognition, job security, and corner
offices
Largest
impact
generation
with
dramatic
financial
Generation X
Latch-key kids
Have
learned to be self-reliant and

independent
Look for career security, not job security
Willing to change jobs and have little
loyalty to their employers
Not
workaholics;
seek
a
balance
between work and leisure
Want a work environment that is
technologically current
Generation Y
Primarily children of the baby
boomers
Grew up at the end of the Cold
War, the Internet, and speak-yourmind philosophy
Just beginning to make their mark
in the workforce
Focusing on early retirement
Change is their mantra
Expect countless options
Effect on the Workplace

Generations
have different goals
and needs
Generations are working alongside
each other
Requires a different management
style and increased flexibility
Each
generation
has
different
needs for orientation, training, and
opportunities for advancement and
benefits
Spirituality
Spirituality
is a component
healing in nearly every culture
of
There
is increasing amount of
research and thought on spirituality
to provide holistic care
Spirituality is a multifaceted concept
specific to the spiritually

experience of an individual
lived
Spiritual Assessment
To provide spiritual care, an understanding of the
patients beliefs can be used to plan appropriate

care
Nurses
need to understand more than the

patients labels of religion or religious needs
Nurses need to ask patients if they would like to
see
their
spiritual
leader
or
understanding that not all patients will
advisor,
Pastoral care departments can provide prayer,
visits, and
donation
bereavement
and
discuss
organ
Spiritual Distress
A
North American Nursing Diagnosis

Association (NANDA) term used to identify
when an individual has an impaired ability
to integrate meaning and purpose in life
through the individuals connectedness
with self, others, art, music, literature,
nature, or a power greater than oneself
To connect with these elements, patients
will use meditation, prayer, participating

in
religious
services
or
rituals,
communicating with nature, and sharing
of self
Barriers to Spiritual Care

Personal beliefs of the nurse
Nurse
may be uncomfortable and

embarrassed
by
their
own
spirituality
Does not believe spirituality is a
nursing responsibility
Lack of knowledge regarding the
specific beliefs of the patients
religion
Insufficient nursing time or privacy
Spiritual Nursing Interventions

Open a dialogue with the patient
regarding the meaning and purpose

of life
Allow the patient to describe their
spiritual life
Ask the patient if prayer plays a role
in their life
Offer to seek the spiritual or
religious leader of their choice
Be physically present
Spiritual Nursing Interventions

Use therapeutic touch
Seek
an answer to how you can

provide support to the individual
patient
Support patient-directed spiritual
activities
Focus on spiritual relationships and
how the nurse might provide
support for patients with spiritual
needs
Championing Spirituality
The
nurse leader who champions

spirituality for all staff ensures that
this component of holistic care is
not forgotten or marginalized
Develop
an
understanding and
empathetic approach to nurses
needs for religious holidays and
celebrations that have spiritual
significance
Developing Spiritual Leadership

Use compassion, caring, and nurturing to create
an environment that reflects the values and

beliefs of the leaders, patients, and staff
Spiritual leaders develop trust and connect with
their staff on both a personal and a professional

level
This connection is the basis for change and
growth
Provides
a cohesive and positive workplace

environment
BACK
Collective Bargaining
586
Definitions
Collective action
Acting as a group with a single

voice
Collective bargaining
The practice of bargaining with

reference to wages, work practice,
and other benefits by employees in
a
collective
group
with
management
Collective Action Models

Workplace advocacy
Activities nurses undertake to

address
problems
in
their
workplace
Most common type of collective
bargaining in nursing
Can be demonstrated through
committee work and patient
advocacy
Collective Action Models

Collective bargaining
The
group
bargains
with
management for what the
group desires
If the group cannot achieve the
desired
goals
through
collective bargaining, they may
decide to form a union
Factors Affecting Nurses Impetus to

Unionize
Nurses feel powerless

Job stress
Physical demands
Need to be able to communicate needs
to
management
without
fear
of
reprisal
Poor wages and job security
Unsafe staffing and health and safety
issues
Mandatory overtime and poor quality
of care
Unions
A formal and legal group that
works through a collective

bargaining agent to present
desires
to
management
formally
Whistle-Blowing
The
act in which an individual

discloses information regarding a
violation of a law, rule, or
regulation or a substantial and
specific danger to public health or
safety
The employer does not know who
attempted to blow the whistle
Proper Steps for WhistleBlowing

File a qui tam lawsuit
in secret with the court
Do not let the agency or hospital know you
filed the suit
Serve a copy of the complaint to the Department
of Justice with a written disclosure of all the

information you have concerning the fraud
If the government decides to go forward with
the lawsuit, the government will bear the

responsibility for litigating the lawsuit, and pay
for it
Process of Unionization
Obtain a collective bargaining agent
An agent that works with employees to

formalize collective bargaining through
unionization
Obtaining a collective bargaining agent and
negotiating a contract may take 3 months to

3 years
The American Nurses Association provides
steps to organize a collective bargaining unit
Managers Role
The National Labor Relations Board has
deemed eight collective bargaining

units for the health care industry
Managers who work in a union setting
must have at least eight different

contracts for the various employees
Unionization may result in increased
costs for the hospital
Employees Role
Nurses
must
follow
the
pertaining to unionization
laws
Choose
bargaining
a collective
agent carefully
Network
with other nurses who

have unions to determine issues
and problems
Striking
A collective bargaining agent cannot make
the decision to strike

The decision to strike can be made only by
a majority of union members
Most nursing collective bargaining agents
put a no-strike clause in the contract
The 1974 Health Care Amendments to the
National
Labor
Relations
Act
contain
provisions that guarantee the continuation
of adequate patient care in a strike situation
Collective Bargaining Agents

Different
organizations
act
as
collective bargaining agent
Teamsters Union
General Service Employees Union
United American Nurses AFL-CIO
American Nurses Association and
state nurses associations
National Union of Hospital and
Health Care Employees
Professionalism and
Unionization
Characteristics
of a profession include:
Requiring a long period of specialized
education
Having a service orientation
Having autonomy
Many
nurses believe that autonomy

precludes involvement in a union
Others
believe unionization is the only

way to achieve autonomy
Definition of Supervisor
Supervisor
Defined as any individual having authority, in

the interest of the employer, to hire, transfer,
suspend, lay off, recall, promise, discharge,
assign, reward, or discipline other employees
Defined in The National Labor Relations Act
(1994)
Only nurses defined as employees can unionize
The ambiguity of the terms employee and

supervisor has led to legal disputes as to
who can unionize
Physician Unionization
In some health care settings, physicians
are seen as employees, not supervisors

This means they have the ability to
join unions
Factors
influencing
physicians
to
unionize
Loss of autonomy
Low wages
The
American
Medical
Association
supports doctors rights to collective
bargaining, but does not support
unionization
Unionization of University
Professors
The unionization
of kindergarten
through twelfth grade teachers
is established in this country
Increases
in university faculty
unionization seen due to:
Wages and work environment
Ages of faculty
Managing in a Union
Environment
Nursing management
may not be
part of
the union, but nurse managers must work
with the union to manage within the rules
and context of contract agreements
Grievance
Where a union member feels that
management has failed to meet the
terms
of
the
contract
or
labor
agreement and communicates this to
management
All union contracts specify grievance
proceedings for their members
Collective Bargaining:
Advantages
Contract to guide
standards
Participation in decision-making process

All union members and management
must conform to terms of contract

without exception
Process exists to question managers
authority if member feels something
was done unjustly
Union dues are required to make the
union work
Gives collective voice to employees
Employees can voice concerns without
fear of reprisal
Collective Bargaining:
There
isDisadvantages
reduced
allowance
for
individually
Other union members may outvote your
decisions
All union members and management
must conform to the terms of the
contract
Less room for personal judgment
Union dues must be paid even if
individuals do not support unionization
Employee may not disagree with the
collective voice
Unions may not be seen as professional
BACK
Career Planning
Career Planning
An ongoing process
Involves:
A personal and professional selfassessment

Setting goals
Searching for a job
Preparing a cover letter and rsum
Participating
in
an
interview,
including
follow-up
Strategic Career Planning

Similar to the nursing process
Requires:
Assessment and clarification of

your values, interests, and the job
market
Determining your vision and goals
Planning and implementing a job
search
Ongoing
evaluation
to
assure
alignment
with
your
strategic
planning vision and goals
Strategic Planning Process

Take into consideration your values,
interest, and the job market

Assess your resilience in nursing
The ability to recover from or

adjust
to
a
misfortune
or
significant change
Many changes have occurred in the
nursing workforce, testing the
resilience of nurses
Determining Your Goals

S = specific
M = measurable
A = achievable
R = realistic
T = timely
Putting
your goals in writing

permits you to analyze the current
situation and make the necessary
changes to achieve your goals
Planning and Implementing a Job

Search
Network
Look at advertised positions
Attend a job fair
Review
any organizations you are

considering
Consider obtaining a residency
Determine if there is a multistate
license compact
Make an appointment with the nurse
recruiter
Preparation of a Cover Letter and

Rsum
A form of marketing strategy to

market yourself
Highlights your credentials and skills
The cover letter is a brief commercial
about yourself
Address your cover letter to a person
rather than a company
Keep them brief and specific
Make sure all dates are accurate
Proofreading is essential
Rsum
Chronological
Lists jobs in reverse chronological order

Good for those with little or no gaps in work
history
Serves to highlight a progression of work
experiences
Functional
Can illustrate experience in multiple

careers
Emphasizes skills and abilities rather than a
sequence of job experiences
Personal Information on the

Rsum
Include personal
attributes on the
rsum that portray you as a

continuous learner
Pay attention to detail
Take responsibility for own learning
Seek out learning opportunities
Demonstrate resilience in solving
conflict
Demonstrate
reliability
in
attendance and punctuality
Preparation for the Interview

Learn more about the agency
Develop possible questions to ask
Arrive shortly before the interview to
demonstrate time management skills

The
nurse
manager
or
human
resources representative will:
Verify your license and credentials
Complete
background
and
employment references
Types of interviews can vary
The Interview Process

Introductory phase
Employer will outline the

conditions of employment
job
and
Working phase
Employer will ask you questions that

reflect your cover letter and rsum
Highlight
specific
personal
and
professional accomplishments
Respond in a calm, problem-solving
fashion to all questions
Dressing for the Interview

Women
Solid-color, conservative suit

Limited jewelry
Neat, professional hairstyle
Men
Conservative suit and tie

Limited jewelry
Neat hairstyle
Termination Phase of the

Interview
The employer
will close an interview
by asking if you have any questions
Seek clarification for any concerns

Conclude by asking when you can
expect to hear from them

Wait to ask salary questions
Obtaining References
Seek
permission to use your

references
prior
to
your
interview
May
use faculty, past job

experiences,
character
references, or volunteer service
Interview Follow-up
Within 24 hours, follow up your interview with a
simple thank-you note

Reflect objectively upon the event with a colleague
or friend
Consider each interview a good learning experience
Call the employer with a phone call if you do not
hear from them from the specified time

If the job is offered, you may suggest a follow-up
meeting to clarify any needed information
Evaluation
Carry
out every step in your

strategic planning for your career
Career planning means thriving
rather than surviving

Share a mutual goal of providing
safe and competent care

BACK
Emerging
Opportunities
Case Manager
This new delivery of care method includes
providing and coordinating care across the

continuum of prevention, wellness, acute
care, rehabilitation, long-term, hospice,
and respite care
The nurse case manager should have at
least a baccalaureate degree and expert
clinical skills
Should possess knowledge of the health
care system, health care finances, and
legal issues
Should be an effective communicator
Nurse Entrepreneur
Many
nurses
are
becoming
entrepreneurs
in
a
variety
of
consultative,
educational,
and
technical areas
Advantages:
Independence
Job satisfaction
Flexibility
Choice
Nurse Entrepreneur
Disadvantages:
Competition
Volatility
Lack of provided benefits
Must learn to develop
follow a business plan
and
Characteristics of Nurse
Entrepreneurs
Visionary, self-motivated,
and a risk taker
Have common sense

Good
decision
makers
and
problem
solvers
Self-confident, assertive, autonomous,
creative
Responsive to perceived need
Market-driven,
with
good
financial
foresight
Recognize the possibility of success as
well as failure
Advanced Practice Nursing

An advanced practice nurse:
Conducts comprehensive health

assessments
Demonstrates a high level of
autonomy
Possesses expert skills in the
diagnosis
and
treatment
of
complex responses of individuals,
families, and communities to actual
or potential health problems
Examples of Advanced Practice

Nursing
Certified
Registered
Nurse
Anesthetist (CRNA)
Requires a masters degree
Takes care of the patients
anesthesia
needs
before,
during, and after surgery
Requires a BSN and at least 1
year of acute care nursing for
entry into the program

Nursing
Certified Nurse-Midwife (CNM)
Requires a masters degree
Practice in a variety of settings
Can
provide
well
woman
gynecological
and
low-risk
obstetrical
care,
including
prenatal, labor and delivery,
and postpartum care

Nursing
Nurse Practitioner
(NP)
Requires graduate level education
Practices throughout the continuum of care
in a multitude of settings and patient
populations
Clinical Nurse Specialist
Primarily hospital based

Clinical expert in evidence-based nursing
practice within a specialty area
Provides direct patient care, is an educator,
consultant, and researcher
BACK

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NOTE-TAKING

Nursing Leadership and Mana

Politics and Consumer Partne

Organizational of Patient Care

Nursing Leadership and

Managing the work

Managing the Work

Provides training to improve work

First-Level Manager Roles

Manages patient care and

Middle-Level Nurse Manager

Expanded role of planning

Unity of command and direction

Acceptance theory of authority

People have free will and choose to comply

groups that can become strong and powerful

Selected Motivation Theories

Selected Motivation Theories

Leaders must direct and control

Leaders remove obstacles as workers

Selected Motivation Theories

Collaborative decision making

Formal and Informal

Differences in Leaders versus Nonleaders

Centralized decision making

Passive and permissive

Fielders Contingency Theory

Good leader-member relationships

Poor leader-member relations

Low task structure involves work

Hersey and Blanchards Situational

Leadership style is:

Leadership style is matched to

the situational characteristics of

Forming informal groups

The Knowledge Age

The ability to change skill sets as well as

Working through virtual means using digital

Individual acts more independently and is

The Health Care

History of Health Care

in health care science and

problems in health care remain a

Structuring Hospitals around

described the importance

The physical environment of hospitals can

create stress for patients, their families, and

Many reports are developed from this

data that provide valuable information

is displayed with charts and

Influence of External Forces on

Organization of Health Care

Resources or structures needed to deliver

Quality activities, procedures, tasks, and

The results of good care delivery

Goals of Good Health Care

that the health status of

Health care must respond to patients

expectations of respectful treatment,

care must provide financial

Absence of a Universal Health Care

care is tied directly

Leaves serious gap in health care

payment coverage for millions