NURSING LEADERSHIP AND MANAGEMENT FOR PATIENT SAFETY AND QUALITY CARE

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NURSING LEADERSHIP AND MANAGEMENT FOR PATIENT SAFETY AND QUALITY CARE. NURSING LEADERSHIP AND MANAGEMENT FOR PATIENT SAFETY AND QUALITY CARE

Elizabeth Murray, PhD, RN, CNE Program Director, MSN Nurse Educator

Assistant Professor Florida Gulf Coast University

School of Nursing Fort Myers, Florida

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F. A. Davis Company 1915 Arch Street Philadelphia, PA 19103 www.fadavis.com

Copyright © 2017 by F. A. Davis Company

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Library of Congress Cataloging-in-Publication Data

Names: Murray, Elizabeth J., author. Title: Nursing leadership and management for patient safety and quality care

/ Elizabeth J. Murray. Description: Philadelphia : F.A. Davis Company, [2017] | Includes

bibliographical references and index. Identifiers: LCCN 2016052944 | ISBN 9780803630215 (alk. paper) Subjects: | MESH: Nursing Care—standards | Nursing Care—organization &

administration | Patient Safety—standards | Quality Assurance, Health Care—methods | Leadership | Nurse’s Role

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Dedication

This book is dedicated to my husband, Don, and my daughter, Angel, whose patience and encouragement are unending. Thank you for always supporting me in my professional endeavors and for understanding when I locked myself in “my cave.”

This book is also dedicated to Marydelle Polk, my mentor and friend, who shared so much with me and who had a great influence on my development as a faculty member and whom I miss dearly. NURSING LEADERSHIP AND MANAGEMENT FOR PATIENT SAFETY AND QUALITY CARE

Finally, this bo ok is dedicated to the hundreds of nurses and nursing students I have taught over the years for inspiring me to actualize my passion for nursing, quality, and patient safety through writing this book.

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Epigraph

“It may seem a strange principle to enunciate as the very first requirement in a Hospital that it should do the sick no harm. It is quite necessary nevertheless to lay down such a principle.”

Florence Nightingale, 1863 Notes on Hospitals

“The world, more specifically the Hospital world, is in such a hurry, is moving so fast, that it is too easy to slide into bad habits before we are aware.”

Florence Nightingale, 1914 Florence Nightingale to Her Nurses

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Preface

In 2000, the Institute of Medicine shocked the health-care community when they reported, in their landmark report, To Err is Human, that approximately 98,000 Americans die each year as a result of preventable adverse events. In response, many patient safety and quality initiatives were launched to make health care safer in the United States and globally. More recently, James (2013) identified evidence suggesting that a more accurate estimate of deaths from preventable errors is 200,000 to 400,000 per year. There is no question that the health-care delivery system is undergoing major changes related to safety and quality. Nurses at all levels and in all settings have been identified as key to transforming health care to a safer, higher-quality, and more effective system. Front-line nurses are being charged with taking leadership and management roles in transforming care at the bedside. Nurse educators must prepare a new generation of nurses to step into these roles as well as manage safe and effective patient care. To that end, this book was written to provide a comprehensive approach to preparing nurses in the critical knowledge, skills, and attitudes in leadership and management needed for the current and future health-care environment. NURSING LEADERSHIP AND MANAGEMENT FOR PATIENT SAFETY AND QUALITY CARE

This book is built on the premise that all nurses are leaders and managers re- gardless of their position or setting in which they work. First-level or front-line nursing leaders and managers are those leading and managing care of a patient or groups of patients at the bedside and clients or groups in the community. This level may also include charge nurses, patient care managers, and supervisors. Second-level nursing leaders and managers are those holding a formal position in the system such as unit manager. Their responsibilities include leading and managing material, economic, and human resources necessary for the care of a group of patients, as well as clients or groups in the community. The third-level nursing leaders and managers are those holding a formal position in the organi- zation such as a director over several units and whose responsibilities are similar to those of the second level manager but encompass a broader scope. The fourth level or executive level includes nursing leaders and managers in positions such as chief nursing officer (CNO) or Vice President of Nursing Services. Their re- sponsibilities include administering nursing units within the mission and goals of the organization. Finally, many nurse leaders and managers hold positions outside direct care delivery such as nurses in academic settings, labor unions, political action groups, health-care coalitions, and consumer advocacy groups. This book provides an evidence-based approach to attaining the necessary knowl- edge, skills, and attitudes for nursing practice in today’s dynamic health-care environment. It will be beneficial to prelicensure nursing students, RNs returning

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to school, new nurse leaders and managers, and nurses in any type of leadership and management position that impacts health care and health-care recipients.

The underpinnings of this book are evidence-based practice, safety, quality, and effective nursing care. The book will assist students to understand a current per- spective of nursing leadership and management theories, concepts, and principles. Evidence-based content is presented on topics relevant in today’s ever-changing health-care environment, such as contemporary leadership and management theories, managing ethical and legal issues, leading and managing effectively in a culture of safety, improving and managing quality care, building and managing a sustainable workforce, leading change and managing conflict, creating and sustaining a healthy work environment, and managing resources.

The safety and quality of care depend greatly on our future nurses. I believe this book will help future nurses to attain leadership and management knowledge, skills, and attitudes critically needed to lead, manage, and provide safe, high-quality, and effective nursing care. NURSING LEADERSHIP AND MANAGEMENT FOR PATIENT SAFETY AND QUALITY CARE

ELIZABETH J. MURRAY Fort Myers, Florida

x Preface

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Contributors

Brett L. Andreasen, MS, RN-BC Clinical Applications Analyst Informatics Nurse Specialist University of Washington Medicine IT Seattle, Washington

Rebecca Coey, MSN, RN, FNP Family Nurse Practitioner Fort Myers, Florida

Paula M. Davis-Huffman, DNP, ANP-BC, PPCNP-BC, Emeritus CCRN Assistant Professor Florida Gulf Coast University School of Nursing Fort Myers, Florida

Sara Jo Foley, RN, MSN, FNP Family Nurse Practitioner Fort Myers, Florida

Linda K. Hays-Gallego, MN, RN Lead Clinical Informatics Analyst, ORCA Clinical Informatics and Support University of Washington Medicine IT Seattle, Washington

Judith Walters, DNP, RN, PMHCNS-BC Assistant Professor Florida Gulf Coast University School of Nursing Fort Myers, Florida

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Reviewers

Suzanne Barsness, MSN, RN, CCRC Associate Professor Northwest University School of Nursing Kirkland, Washington

Jennifer D. M. Cook, PhD, MBA, RN, CNS Professor Emeritus Adjunct Professor University of the Incarnate Word San Antonio, Texas

Laura Crouch, EdD, RN, CPAN, CNE Associate Clinical Professor Northern Arizona University Flagstaff, Arizona

Cheryl A. Crowe, MS, RN Instructor Saint Francis College of Nursing Peoria, Illinois

Holly J. Diesel, PhD, RN Associate Professor Goldfarb School of Nursing at Barnes-Jewish College St. Louis, Missouri

Laura Dulski, RNC, CNE, MSN Assistant Professor Resurrection University Chicago, Illinois

Karen M. Estridge, DNP, RN Assistant Professor College of Nursing and Health Sciences Ashland University Mansfield, Ohio

Michelle Ficca, PhD, RN Chair and Professor Bloomsburg University of Pennsylvania Bloomsburg, Pennsylvania

Debbie Fischer, MS, RN Assistant Teaching Professor Montana State University Billings, Montana

Eileen P. Geraci, MA, PhD, ANP-C Professor Western Connecticut State University Danbury, Connecticut

Pamela G. Harrison, EdD, RN, CNE Professor Pre-Licensure Nursing Indiana Wesleyan University Marion, Indiana

Mary B. Killeen, RN, PhD, NEA-BC Associate Professor, Adjunct University of Michigan-Flint Flint, Michigan

Anita H. King, DNP, MA, FNP-BC, CDE, FAADE Professor College of Nursing University of South Alabama Mobile, Alabama

Mary Kovarna, EdD, RN Department Chair and Professor Morningside College Sioux City, Iowa

Rebecca Krepper, PhD, MBA, RN Professor Texas Woman’s University Houston, Texas

Susan Lynch, MSN, RN, CNE RN-BSN Coordinator University of North Carolina Charlotte Charlotte, North Carolina. NURSING LEADERSHIP AND MANAGEMENT FOR PATIENT SAFETY AND QUALITY CARE

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David Martin, MN, RN Program Director RN-BSN Program Clinical Associate Professor University of Kansas School of Nursing Kansas City, Kansas

Carrie A. McCoy, PhD, MSPH, RN, CEN, CNE Professor of Nursing Northern Kentucky University Highland Heights, Kentucky

Tammie McCoy, RN, PhD Professor and Chair BSN Program Mississippi University for Women Columbus, Mississippi

Kerry A. Milner, DNSc, RN Assistant Professor of Nursing Sacred Heart University Fairfield, Connecticut

Beatriz C. Nieto, PhD, RN Associate Professor The University of Texas–Pan American Edinburg, Texas

Elinor Nugent, PhD, APN-BC Professor Emeritus Curry College Milton, Massachusetts

Lauren E. O’Hare, EdD, RN Associate Professor of Nursing The Evelyn Spiro School of Nursing

at Wagner College Wagner College Staten Island, New York

Mary Ovitt, RN, MSN Assistant Professor Idaho State University Pocatello, Idaho

Aroha Page, PhD, RN Associate Professor Nipissing University North Bay, Ontario, Canada

Verna C. Pangman, RN, MEd, MN Senior Instructor College of Nursing University of Manitoba Winnipeg, Manitoba, Canada

Maria Rosen, PhD, APRN-BC Assistant Dean Associate Professor Massachusetts College of Pharmacy and Health

Sciences University Worcester, Massachusetts

Kevin Dean Tipton, PhD, MN, BSN, RN Associate Professor Southern Utah University Cedar City, Utah

Paulina Van, PhD, RN, CNE Associate Professor School of Nursing Samuel Merritt University Oakland, California

Laura Pruitt Walker, DHEd, MSN, RN, COI Assistant Professor of Nursing Certified Online Instructor College of Nursing Jacksonville State University Jacksonville, Alabama

Janet R. Webber, RN, BSN, MSN, EdD Professor of Nursing Director of RN-BSN Online Program Southeast Missouri State University Cape Girardeau, Missouri

Danielle White, MSN, RN Associate Professor Austin Peay State University Clarksville, Tennessee

xiv Reviewers

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Acknowledgments

I would like to thank Joanne DaCunha for helping me see that my ideas for this book could be a reality. I would also like to thank Echo Gerhart and Amy Reeve for their assistance with the editing and publishing of this project and for their encouragement throughout the entire process.

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Contents in Brief

xvii

P a r t I Foundations and Background

C h a p t e r 1 Core Competencies for Safe and Quality Nursing Care 2

C h a p t e r 2 Health-Care Environment and Policy 27

C h a p t e r 3 Theories and Principles of Nursing Leadership and Management 45

C h a p t e r 4 Ethical and Legal Aspects 61

C h a p t e r 5 Critical Thinking and Decision Making 102

C h a p t e r 6 Effective Communication 118

P a r t I I Promotion of Patient Safety and Quality Care

C h a p t e r 7 Improving and Managing Safe and Quality Care 142

C h a p t e r 8 Health-Care Organizations 174

C h a p t e r 9 Information Technology for Safe and Quality Patient Care 195

P a r t I I I Leadership and Management Functions

C h a p t e r 10 Creating and Managing a Sustainable Workforce 212

C h a p t e r 11 Organizing Patient Care 229

C h a p t e r 12 Delegating Effectively 254

C h a p t e r 13 Creating and Sustaining a Healthy Work Environment 271

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C h a p t e r 14 Leading Change and Managing Conflict 294

C h a p t e r 15 Building and Managing Teams 313

C h a p t e r 16 Budgeting Concepts 327

P a r t I V Managing Your Future in Nursing

C h a p t e r 17 Transitioning From Student to Professional Nurse 346

Index 367

xviii Contents in Brief

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Contents

P a r t I Foundations and Background

C h a p t e r 1 Core Competencies for Safe and Quality Nursing Care 2 INSTITUTE OF MEDICINE REPORTS 3 QUALITY AND SAFETY EDUCATION FOR NURSES CORE COMPETENCIES 7

Patient-Centered Care 7 Advocacy 8 Empowerment 8 Self-Management 8 Health Literacy 9 Cultural Competence 9

OPTIMAL HEALING ENVIRONMENT 10 Teamwork and Collaboration 10

Care Coordination 12 Communication 13

Evidence-Based Practice 13 Nursing Research 15 Relationship With Quality Improvement 16 Clinical Practice Guidelines 16 Evidence-Based Management 16

Quality Improvement 17 Structure or Care Environment 18 Care Process 18 Outcomes of Care 18

Informatics 19 Information Management 19 Documentation 20

Safety 20 Human Errors and Factors 21 Standardized Protocols and Practice 22 Safety Culture 22 High-Reliability Organizations 23

CURRENT STATE OF SAFETY AND QUALITY 23

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C h a p t e r 2 Health-Care Environment and Policy 27 SYSTEMS WITHIN THE HEALTH-CARE ENVIRONMENT 28 CURRENT STATUS OF HEALTH CARE IN THE UNITED STATES 30

Access to Health Care 30 The Cost of Health Care 31 Quality of Care 33 Lack of Providers and Services 35 Lack of Health Insurance and Insurance With Limited Income 36

THE PATIENT PROTECTION AND AFFORDABLE CARE ACT 37 MEDICARE AND MEDICAID 38 HEALTH POLICY 40

C h a p t e r 3 Theories and Principles of Nursing Leadership and Management 45 HISTORICAL DEVELOPMENT OF LEADERSHIP 46

Trait Theories 46 Leadership Styles 47 Situational and Contingency Leadership Theories 47

CONTEMPORARY THEORIES OF LEADERSHIP 47 Relational Leadership Theories 48

Quantum Leadership 48 Transactional Leadership 48 Transformational Leadership 49 Connective Leadership 49

Attribution Leadership Theories 50 EMERGING LEADERSHIP THEORIES 50 PROFESSIONAL COMPETENCE IN NURSING LEADERSHIP 51 LEADERSHIP CHARACTERISTICS 51 FOLLOWERSHIP 54 MENTORSHIP 57

C h a p t e r 4 Ethical and Legal Aspects 61 ETHICAL ASPECTS OF NURSING PRACTICE 62

Morals 63 Moral Integrity 63 Moral Obligation 63

Values 64 Values Clarification 64 Core Professional Values for Nurses 64

Principles 65 Autonomy 65 Beneficence 66 Nonmaleficence 66 Justice 67 Fidelity 68 Veracity 68 Privacy 68 Confidentiality 68

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Theories 69 Utilitarianism 69 Deontology 70 Principlism 70

Codes of Ethics 70 International Council of Nurses Code of Ethics for Nurses 71 Canadian Nurses Association Code of Ethics for Registered Nurses 72 American Nurses Association Code of Ethics for Nurses With Interpretive Statements 72

Ethical Dilemmas 73 Ethical Decision Making 76 Ethics Committees 76

LEGAL ASPECTS OF NURSING PRACTICE 77 Standards for Clinical Practice 78

Nursing’s Social Policy Statement: The Essence of the Profession 78 Nursing: Scope and Standards of Practice 79

Licensure and Regulation of Nursing Practice 79 Licensure 79 Regulation 80

STATE NURSE PRACTICE ACTS 80 NATIONAL COUNCIL OF STATE BOARDS OF NURSING 80 STATE BOARDS OF NURSING 81

Federal and/or State Legislation 81 Health Insurance Portability and Accountability Act 81 Patient Self-Determination Act 82 Safe Medical Devices Act 83 Good Samaritan Laws 83 Disclosure Statutes 83 Employment Laws 84

Classifications of Law That Relate to Nursing Practice 85 Negligence and Malpractice 85

Elements of Malpractice 86 DUTY OWED THE PATIENT 87 BREACH OF THE DUTY OWED THE PATIENT 87 FORESEEABILITY OF HARM 87 CAUSATION 87 INJURY OR HARM 87

Major Categories of Malpractice 88 FAILURE TO ASSESS AND MONITOR 88 FAILURE TO FOLLOW STANDARDS OF CARE 88 FAILURE TO COMMUNICATE 89 FAILURE TO DOCUMENT 90 FAILURE TO ACT AS A PATIENT ADVOCATE 90 FAILURE TO USE EQUIPMENT IN A RESPONSIBLE MANNER 90

Contents xxi

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Expert Witnesses 90 Liability 90

Professional Liability Insurance 93 ETHICAL AND LEGAL ISSUES 93

Advance Directives 93 Living Will 94 Do Not Resuscitate 94 Durable Power of Attorney for Health Care 95

Confidentiality and Information Security 96 Informed Consent 97 Disruptive Behavior, Incivility, and Bullying 97 Unsafe or Questionable Practice 98

C h a p t e r 5 Critical Thinking and Decision Making 102 CRITICAL THINKING 103

Elements of and Cognitive Skills for Critical Thinking 103 Reactive, Reflective, and Intuitive Thinking 105 Modeling Critical Thinking 107

DECISION MAKING 107 Decision Making and the Nursing Process 108 Tools for Decision Making 109

DECIDE Model 110 Decision-Making Grid Analysis 110 SWOT Analysis 111

Shared Decision Making 112 Appreciative Inquiry 112

C h a p t e r 6 Effective Communication 118 WHY EFFECTIVE COMMUNICATION IS CRITICAL 119 BASICS OF COMMUNICATION 120

The Communication Process 120 Verbal and Nonverbal Communication 121

Verbal Communication 121 Nonverbal Communication 122

Active Listening 123 FACTORS THAT IMPACT COMMUNICATION 124

Gender 124 Generation 124 Culture 124 Values and Perceptions 124 Personal Space 125 Environment 125 Roles and Relationships 125

FORMAL AND INFORMAL COMMUNICATION 126 TYPES OF COMMUNICATION IN A HEALTH-CARE ENVIRONMENT 127

Organizational Communication 127 Interprofessional Communication 128

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Interprofessional Team Rounding 129 TeamSTEPPS 130 SBAR 130

Intraprofessional Communication 133 Nurse-to-Nurse Transitions in Care 134

P a r t I I Promotion of Patient Safety and Quality Care

C h a p t e r 7 Improving and Managing Safe and Quality Care 142 MEDICAL ERRORS 144 CREATING A CULTURE OF SAFETY 148 PATIENT SAFETY INITIATIVES 150

Agency for Healthcare Research and Quality 150 American Nurses Association 151 National Quality Forum 151 Institute for Healthcare Improvement 152 The Joint Commission 154 World Health Organization 155

PRINCIPLES OF QUALITY IMPROVEMENT 155 MODELS FOR QUALITY IMPROVEMENT 159

Donabedian Model 159 Lean Model 160 Six Sigma Model 161 Institute for Healthcare Improvement Model of Improvement 161 Failure Modes and Effects Analysis 161 Root Cause Analysis 162

QUALITY IMPROVEMENT TOOLS 164 Run Chart 164 Bar Chart 165 Histogram 165 Fishbone Diagram 165 Flow Chart 167 Pareto Chart 167

C h a p t e r 8 Health-Care Organizations 174 BASIC ELEMENTS OF A HEALTH-CARE ORGANIZATION 175

For-Profit Versus Not-for-Profit Organizations 175 Types of Health-Care Organizations 176 Levels of Service 176

ORGANIZATIONAL STRUCTURE AND CULTURE, AND STRATEGIC PLANNING 177

Organizational Structure 177 Organizational Culture 179 Strategic Planning 179

Contents xxiii

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REGULATION AND ACCREDITATION 182 Regulation 182 Accreditation 182

The Joint Commission 183 DNV GL 183 Magnet Recognition Program 183

ORGANIZATIONAL THEORIES 188 Classical Organization Theories 189 Contemporary Organizational Theories 190

General Systems Theory 190 Complexity Theory 191 Learning Organization Theory 192

C h a p t e r 9 Information Technology for Safe and Quality Patient Care 195 UNDERSTANDING NURSING INFORMATICS 196

Basic Elements of Informatics 196 Technical Aspects of Informatics 198

Network 199 Data 199 Database 199 Data Mining 199 Interfaces 199 Decision Support Systems 200 Rules and Alerts 200 Standardized Languages 200

HOW INFORMATICS CONTRIBUTES TO PATIENT SAFETY 201 LEGISLATIVE AND REGULATORY IMPACTS ON INFORMATICS 202

Health Insurance Portability and Accountability Act 203 American Recovery and Reinvestment Act of 2009 203 Regulatory Requirements 203

INFORMATICS DEPARTMENTS 204 USE OF DATA IN INFORMATICS 204

Data Set 204 Coding 204 Data Security 205

INFORMATION SYSTEMS USED IN HEALTH CARE 205 Electronic Medication Administration Record 206 Computerized Provider Order Entry 206 Barcode Medication Administration 206 Patient Portals 206 Telehealth 206 Online Health Information 207

IMPLEMENTATION OF AN INFORMATICS PROJECT 207 Conversion Strategy and Conversion Planning 207 Implementation Support Model 208 Maintenance 208 System Downtime 208

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P a r t I I I Leadership and Management Functions

C h a p t e r 10 Creating and Managing a Sustainable Workforce 212 CREATING A SUSTAINABLE WORKFORCE 213

Recruiting 213 Interviewing 214 Orienting 216 Retaining 217

MANAGING THE WORKFORCE 218 Managing Generational Differences 218 Coaching Staff Members 220 Appraising Performance 221 Using Corrective Action 223

C h a p t e r 11 Organizing Patient Care 229 CARE DELIVERY MODELS 230

Traditional Models 231 Total Patient Care 231 Functional Nursing 231 Team Nursing 232 Primary Nursing 232 Nursing Case Management 232

Nontraditional Models 233 Patient-Focused Care 233 Partnership Models 233 Nonclinical Models 234 Integrated Models 234

Contemporary Models 234 Professional Nursing Practice Model 234 Differentiated Nursing Practice Model 235 Clinical Nurse Leader Model 235 Synergy Model for Patient Care 236 Transforming Care at the Bedside 236 Patient- and Family-Centered Care Model 238

STAFFING FOR PATIENT SAFETY 239 Shortage of Nurses 240 Core Concepts of Staffing 241

Full-Time Equivalent 241 Productive Time 242 Average Daily Census 242 Staffing Mix 242 Workload and Units of Service 242 Unit Intensity 243 Patient Acuity 243 Skill Mix 243

RN SCOPE OF PRACTICE 243

Contents xxv

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LPN/LVN SCOPE OF PRACTICE 245 UAP SCOPE OF PRACTICE 245

Staffing Approaches 245 Patient Classification Systems 246 American Association of Nurses Principles for Safe Staffing 246 Agency for Healthcare Research and Quality Nurse Staffing Model 247 National Database of Nursing Quality Indicators Staffing Benchmarks 247

Developing and Implementing a Staffing Plan 249 Monitoring Productivity 250 Evaluating Staffing Effectiveness 251

C h a p t e r 12 Delegating Effectively 254 KEY PRINCIPLES OF DELEGATION 255

What Can and Cannot Be Delegated 257 Who Can and Cannot Delegate 258

THE FIVE RIGHTS OF DELEGATION 259 Right Task 259 Right Circumstances 260 Right Person 260 Right Direction or Communication 260 Right Supervision or Evaluation 261

THE DELEGATION PROCESS 261 BARRIERS TO EFFECIVE DELEGATION 265

Delegator-Related Barriers 266 Delegatee-Related Barriers 267 Leadership- and Management-Related Barriers 267 Breaking Down Barriers 269

C h a p t e r 13 Creating and Sustaining a Healthy Work Environment 271 GUIDELINES FOR BUILDING A HEALTHY WORK ENVIRONMENT 272 SAFETY ISSUES IN A HEALTH-CARE ENVIRONMENT 275

Safe Patient Handling and Mobility 276 Nurse Fatigue 278 Workplace Violence 280

Types of Violence 282 NURSE-TO-NURSE VIOLENCE 282 THIRD-PARTY VIOLENCE 284 NURSE-TO-PATIENT VIOLENCE 284 PATIENT-TO-NURSE VIOLENCE 284 ORGANIZATIONAL VIOLENCE 284 EXTERNAL VIOLENCE 285 SEXUAL HARASSMENT 285 MASS TRAUMA OR NATURAL DISASTERS 285

Contributing and Risk Factors 286 Consequences 286 Strategies to Prevent Workplace Violence 287

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C h a p t e r 14 Leading Change and Managing Conflict 294 CHANGE THEORIES 295

Traditional Change Theories and Models 296 Lewin’s Force-Field Model (1951) 296 Lippitt’s Phases of Change Model (1958) 297 Rogers’ Innovation-Decision Process (1995) 298 Kotter’s Eight-Stage Process of Creating Major Change (1996) 299

Emerging Change Theories 301 Chaos Theory 302 Learning Organization Theory 302

MANAGING CHANGE AND INNOVATION 303 Becoming a Change Agent 304 Responding to Change 304 Adopting Change 305 Dealing With Barriers to Change 306

MANAGING CONFLICT 307 Types of Conflict 308

Intrapersonal Conflict 308 Interpersonal Conflict 308 Intergroup Conflict 309 Organizational Conflict 309

Conflict Management Strategies 309 Role of Nurse Leaders and Managers in Addressing Conflict 310

C h a p t e r 15 Building and Managing Teams 313 TEAMWORK AND COLLABORATION 314 TEAM BUILDING 317

Stages of Team Development 318 Creating Synergy 319

CHARACTERISTICS OF EFFECTIVE TEAMS 320 LEADING AND MANAGING TEAMS 321

C h a p t e r 16 Budgeting Concepts 327 BUDGETING AS A CORE COMPETENCY 328 COST CONTAINMENT AND EFFECTIVENESS 329 THE BUDGET PROCESS 330

Assessment 331 Diagnosis 331 Planning 331 Implementation 332 Evaluation 332

Productivity 333 NECESSARY CARE ACTIVITIES 334 VALUE-ADDED CARE ACTIVITIES 334 NON–VALUE-ADDED CARE ACTIVITIES 334

TYPES OF BUDGETS 336

Contents xxvii

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Operating Budget 336 Expenses 336 Revenues 337

Personnel Budget 337 Capital Budget 340

BUDGETING METHODS 340 Incremental Budgeting 340 Performance Budgeting 341 Zero-Based Budgeting 341

P a r t I V Managing Your Future in Nursing

C h a p t e r 17 Transitioning From Student to Professional Nurse 346 CAREER PLANNING AND DEVELOPMENT 347

Preparing a Strategic Career Plan 347 Developing a Resume 349 Interviewing 351

TRANSITION TO PRACTICE 353 PRECEPTORS AND MENTORS 354 STRATEGIES FOR PROFESSIONAL GROWTH 355

Becoming a Lifelong Learner 355 Continuing Education 356 Specialty Certification 357 Advanced Degrees 359

Contributing to the Nursing Profession 359 BALANCING PERSONAL AND PROFESSIONAL LIFE 360 FUTURE DIRECTIONS 363

Index 367

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Introduction

This book reflects the notion that all nurses at all levels and in all health-care set- tings are leaders and managers. The purpose of this book is to provide an evidence- based approach to nursing leadership and management as well as practical applications to real-life situations that reflect today’s dynamic health-care environ- ment. By integrating content from the National Council of Boards of Nursing Licensure Examination (NCLEX) blueprint, the American Association of Colleges of Nurses (AACN) Baccalaureate Essentials, the American Association of Nurses (ANA) foundational documents for nursing practice, Quality and Safety Education for Nurses (QSEN), the American Organization of Nurse Educators (AONE) stan- dards, and various quality and safety initiatives, students will be introduced to leadership and management theories, concepts, and principles.

This book offers a comprehensive approach to prepare nursing students in the knowledge, skills, and attitudes needed to provide safe, quality, and effective nurs- ing care. It is divided into four parts that organize evidence-based information and relevant topics for effective nursing leadership and management at various levels and settings.

Part I: Foundations and Background provides foundational information about health-care safety and quality, ethics and legal aspects, and nursing lead- ership and management. Students are introduced to historical perspectives of the quality and safety movement and the core competencies for safe, quality, and effective nursing care. Health-care policy and the health-care environment are addressed, and theories of nursing leadership and management are presented. Next, an overview of critical thinking and decision making is presented along with various tools that effective nurse leaders and managers can use for decision making at various levels in the health-care system. Finally, effective communi- cation is reviewed, and types of communication in a health-care environment are discussed.

Part II: Promotion of Patient Safety and Quality Care focuses on patient safety and quality and includes models and tools for quality improvement, how informatics contributes to patient safety, and an overview of health-care organizations.

Part III: Leadership and Management Functions presents specific roles and functions that effective nurse leaders and managers must understand and develop to be able to create, manage, and sustain a healthy work environment that fosters a workforce that delivers safe, quality, and effective nursing care.

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Part IV: Managing Your Future in Nursing provides guidelines for new nurses transitioning to practice and guidelines for career planning and development.

Each chapter in this book provides learning activities and evidence that reflect current nursing research. This book is an excellent resource for nursing students, new nurses, new nursing managers, and nurses in leadership and management at any stage of their career.

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P a r t I

Foundations and Background

Chapter 1 Core Competencies for Safe and Quality Nursing Care

Chapter 2 Health-Care Environment and Policy

Chapter 3 Theories and Principles of Nursing Leadership and Management

Chapter 4 Ethical and Legal Aspects

Chapter 5 Critical Thinking and Decision Making

Chapter 6 Effective Communication

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2

C h a p t e r 1 Core Competencies for Safe and Quality Nursing Care Elizabeth J. Murray, PhD, RN, CNE

K E Y T E R M S

Advocacy Care coordination Care process Clinical practice guidelines Communication Cultural competence Disparity Diversity Documentation Empowerment Evidence-based management Evidence-based practice Health literacy High-reliability organizations Human errors Human factors engineering Informatics Information management Interdisciplinary Interprofessional Multidisciplinary Nursing research Optimal healing environment Outcomes of care Patient-centered care Quality Quality improvement Reliability science

L E A R N I N G O B J E C T I V E S

● Describe the impact of the Institute of Medicine (IOM) reports on the qual- ity of health care in the United States.

● Define the IOM competencies, outline the IOM’s six aims for health care, and analyze the IOM’s 10 rules for health care in the 21st century.

● Compare and contrast the IOM competencies and the Quality and Safety Education for Nurses (QSEN) Core competencies.

● Identify and describe fundamental elements for each core competency for nursing.

● Discuss the importance of effective nursing leadership and management in providing safe and quality patient-centered care.

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Chapter 1 Core Competencies for Safe and Quality Nursing Care 3

Nurses at all levels are leaders in the patient safety movement. Every nurse mustbe educated to deliver patient-centered care as a member of an interprofes- sional team, emphasizing evidence-based practice, quality improvement ap- proaches, informatics, and safety (Cronenwett et al., 2007; Greiner & Knebel, 2003). The modern patient safety movement began in 2000 when the Institute of Medicine (IOM) published its landmark report, To Err Is Human: Building a Safer Health System (Kohn, Corrigan, & Donaldson, 2000). With that publication, a quest for quality and safety in health care was launched that continues today. In 2003, the IOM published Health Professions Education: A Bridge to Quality (Greiner & Knebel, 2003), which identified five core competencies for all health-care professions. In response to the IOM report, the Quality and Safety Education for Nurses (QSEN) initiative was launched in 2005 with the primary goal of establishing a set of core competencies specific to the nursing profession.

This chapter provides a foundation for the entire book and discusses the core competencies for health-care professionals identified by the IOM and adapted by the QSEN faculty for nursing to be integrated into basic nursing education. Because the QSEN core competencies are now being translated into practice, the fundamental elements of each competency are discussed to help nurse leaders and managers operationalize them in their work settings.

INSTITUTE OF MEDICINE REPORTS

Established in 1970 as the health arm of the National Academies, the IOM is an independent nonprofit organization that works outside the federal government to provide unbiased and authoritative advice on health and health care to decision makers and the public. The IOM brings together experts and stakeholders to pro- vide the nation with unbiased, evidence-based guidance on health-related issues. Since 2000, the IOM has published a number of reports related to the state of quality in the U.S. health-care system. Box 1-1 provides a list of the reports most relevant to the content of this book; select elements of the various reports are discussed here as well as in other chapters.

The IOM’s first report, To Err Is Human, was groundbreaking in that it identified medical errors as the leading cause of injury and unexpected death in health-care settings in the United States. The purpose of the report was to present a strategy to improve health-care quality over the following 10 years. Contending that prevent- able adverse events result in up to 98,000 deaths annually, the IOM identified three domains of quality: patient safety, practice consistent with current medical knowl- edge, and meeting customer-specific values and expectations. Additionally, the

Safety Safety culture Self-management Standardized practice

Standardized protocols Structure or care environment Teamwork and collaboration

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IOM determined that patient safety is a critical component of quality. The IOM out- lined the following four-tiered approach to quality improvement (Kohn, Corrigan, & Donaldson, 2000):

1. “Establishing a national focus to create leadership, research, tools, and protocols to enhance the knowledge base about safety” (p. 3)

2. “Identifying and learning from errors by developing a nationwide public mandatory reporting system and by encouraging health care organizations and practitioners to develop and participate in voluntary reporting systems” (p. 3)

3. “Raising performance standards and expectations for improvements in safety through the actions of oversight organizations, professional groups, and group purchasers of health care” (p. 4)

4. “Implementing safety systems in health care organizations to ensure safe prac- tices at the delivery level” (p. 4)

Before the publication of To Err Is Human, in 1997, President Bill Clinton ap- pointed the Advisory Commission on Consumer Protection and Quality in the Health Care Industry to advise him on changes occurring in the health-care system and to make recommendations on how to promote and ensure health-care quality as well as protect consumers and professionals in the health-care system. In re- sponse, the Commission drafted a consumer bill of rights, adopting the following eight areas of consumer rights and responsibilities (Advisory Commission on Consumer Protection and Quality in the Health Care Industry, 1997):

1. Information disclosure 2. Choice of providers and plans 3. Choice of health-care providers that is sufficient to ensure access to appropriate

high-quality care 4. Access to emergency services

4 PART I FOUNDATIONS AND BACKGROUND

BOX 1-1BOX 1-1 Institute of Medicine ReportsInstitute of Medicine Reports

1990

Medicare: A Strategy for Quality Assurance: Executive Summary, Volume 1

2000

To Err Is Human: Building a Safer Health System

2001

Crossing the Quality Chasm: A New Health System for the 21st Century

2002

Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care

2003

Health Professions Education: A Bridge to Quality Priority Areas for National Action: Transforming Health

Care Quality

2004

Keeping Patients Safe: Transforming the Work Environment of Nurses

Patient Safety: Achieving a New Standard for Care Health Literacy: A Prescription to End Confusion

2011

The Future of Nursing: Leading Change, Advancing Health

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5. Participation in treatment decisions 6. Respect and nondiscrimination; confidentiality of health information 7. Complaints and appeals 8. Consumer responsibilities

Endorsing the eight recommendations for consumer rights and responsibilities adopted by the Commission, the IOM (2001) challenged all health-care organiza- tions and professionals to work continually to reduce the burden of illness, injury, and disability of the people of the United States. Although health-care professionals were—and continue to be—dedicated to providing quality care, a gap remained. Asserting that the U.S. health-care system was in need of major restructuring, the IOM called for an overhaul by outlining six aims for health-care improvement in the 21st century in its 2001 report, Crossing the Quality Chasm: A New Health System for the 21st Century: that health care should be safe, effective, patient-centered, timely, efficient, and equitable. The IOM believed that addressing these perform- ance characteristics would lead to narrowing the quality gap. Table 1-1 lists the descriptions of these six aims.

In addition to the six aims, the IOM (2001) identified 10 rules to redesign and improve health-care delivery in the 21st century. Emphasizing that part of the quality gap reflects a lack of support of well-designed systems and the absence of an environment that fosters innovation and excellence, the IOM contended that these 10 specific rules are necessary to achieve significant improvement in quality (IOM, 2001). These rules were implemented to have an impact on the health-care workforce and, in turn, require change in accountabilities, standards of care, and relationships between patients and health-care professionals (IOM, 2001). Box 1-2 compares the historical approach with the 10 rules for health care in the 21st century.

Building on the six aims for health-care improvement and the rules for health care in the 21st century, the IOM recognized health professions education as the primary tactic to narrow the quality gap. Thus, its report Health Professions

Chapter 1 Core Competencies for Safe and Quality Nursing Care 5

Health Care Should Be: Description

Safe Avoiding injuries to patients from the care that is intended to help them Effective Providing services based on scientific knowledge to all who could benefit and

refraining from providing services to those not likely to benefit; avoiding overuse, underuse, and misuse of care

Patient-centered Providing care that is respectful of and responsive to individual patients’ preferences, needs, and values, and ensuring that patients’ values guide all decisions

Timely Reducing waits and sometimes harmful delays for both those who receive and those who give care

Efficient Avoiding waste, in particular of equipment, supplies, ideas, and energy Equitable Providing care that does not vary in quality because of personal characteristics

such as gender, ethnicity, geographic location, and socioeconomic status

Table 1–1 Institute of Medicine’s Six Aims for Health Care in the 21st Century

Adapted from IOM, 2001, pp. 39–40.

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Education: A Bridge to Quality (Greiner & Knebel, 2003) outlined five essential competencies necessary for all future graduates of health professions education programs, regardless of discipline (pp. 45–46):

1. Provide patient-centered care. 2. Work in interdisciplinary teams. 3. Employ evidence-based practice. 4. Apply quality improvement. 5. Use informatics.

The competencies are interrelated and applied together. However, the IOM stresses that skills related to the competencies are not discipline-specific and that each profession may put them into practice differently (Greiner & Knebel, 2003). In response, the QSEN faculty adapted the IOM competencies for the nursing pro- fession and identified the knowledge, skills, and attitudes for each competency that should be developed in prelicensure nursing education (Cronenwett et al., 2007).

6 PART I FOUNDATIONS AND BACKGROUND

BOX 1-2BOX 1-2 Ten Rules for Health-care Delivery in the 21st CenturyTen Rules for Health-care Delivery in the 21st Century

1. Care is based on a continuous healing relationship, rather than periodic individual face-to-face visits.

2. Care is based on patients’ values and needs, rather than variations of care provided by health-care pro- fessionals based on different local and individual styles of practice and/or training.

3. The patient is the source of control over care, rather than health-care professionals.

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4. Knowledge is shared, and information flows freely, rather than requiring the patient to obtain permission. The patient has access to information without restriction, delay, or the need to request permission.

5. Decision making is evidence based, rather than based on the education and experience of the health-care professionals.

6. Safety is a system property, in that procedures, job designs, equipment, communication, and information technology should be configured to respect human factors, make errors less com- mon, and make errors less harmful when they do occur, rather than safety being an individual person’s responsibility.

7. There is a need for transparency, rather than a need for secrecy.

8. Health-care professionals predict and anticipate needs, rather than reacting to problems and underinvesting in prevention.

9. Waste is continuously decreased, rather than resorting to budget cuts and rationing services.

10. Collaboration and teamwork are the norm, rather than professional prerogatives and roles.

Adapted from IOM, 2001, pp. 66–83.

LEARNING

ACTIVITY 1-1 Apply the 10 Rules for Health Care

Think about a health-care experience you or your family have encountered. Apply the 10 rules for health care in the 21st century listed in Box 1-2 to various aspects of your experience. Can you identify examples of care that reflect the historical approach? Can you identify examples of care that reflect the 21st-century approach?

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QUALITY AND SAFETY EDUCATION FOR NURSES CORE COMPETENCIES