Advanced Practice Nursing: Essential Knowledge for the Profession [4th Edition] 9781284205176, 1284205177, 9781284176124, 1284176126

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Contents Introduction About the Author Contributors

PART 1 Professional Roles for Advanced Practice Chapter 1 Introduction to the Role of Advanced Practice Nursing Susan M. DeNisco and Anne M. Barker Introduction Other Advanced Practice Nursing Roles and the Nursing Curriculum Supply and Demand for Nurses Conclusion Discussion Questions References

Chapter 2 Historical Perspectives: The Art and Science of Nurse Practitionering Julie G. Stewart Historical Perspective

Nurse Practitioner Education and Title Clarification The Master’s Essentials Nurse Practitioner Core Competencies Doctor of Nursing Program (DNP) Nurse Practitioners’ Approach to Patient Care Nurse Practitioners’ Unique Role Discussion Questions References

Chapter 3 Overview of the Doctor of Nursing Practice Degree Lisa Astalos Chism Doctor of Nursing Practice Degree Defined Research-Focused Doctorate and Practice-Focused Doctorate Defined Evolution of Doctoral Education in Nursing Why a Practice Doctorate in Nursing Now? What Is a DNP Degree Made Of? The Recipe for Curriculum Standards Role Transition Introduced Summary Discussion Questions References

Chapter 4 Emerging Roles for the DNP Nurse Educator Judith M. Pechacek Faculty Development Programs Nursing Education Practicum Graduate Teaching Assistant New Nurse Educator Mentoring Programs Online Learning Peer Review References Nurse Administrator Mary Jean Vickers

Change Theory Leadership Style Evidence-Based Management Practices Collaboration Conclusion References Public Health Nurse Carol Flaten and Jeanne Pfeiffer Public Health Nurse: A Definition History of Public Health Nursing Foundational Principles of Public Health Nursing Public Health Nursing National Organizational Framework National Public Health Performance Standards Program Theoretical Framework for Nursing Practice in Public Health Educational Preparation and Credentialing Roles of Advanced Practice PHNs Practice Sites Evidence-Based Practice in Population-Based Public Health Nursing The Doctor of Nursing Practice–Prepared Public Health Nurse as Leader References Nurse Entrepreneur Timothy F. Gardner Definitions Background The Relationship Between Entrepreneurship and the DNP Degree Business and Practice Management Practice Start-Up, Closure, and Credentialing Organizational Systems Leadership and Collaboration Healthcare Policy and Legislative Issues Relevance and Opportunities of DNP-Prepared Individuals in the Current Marketplace Current and Future Trends Biosketches of Select Successful DNP Entrepreneurs Margaret A. Fitzgerald, DNP, FNP-BC, NP-C, FAANP, CSP, FAAN, DCC, FNAP David G. Campbell-O’Dell, DNP, ARNP, FNP-BC, FAANP Carol Lisa Alexander, DNP, APRN, ACNS/NP-BC

References Integrative Practitioner Joy Elwell Nurses as Integrative Practitioners Types of Integrative Healing Modalities The DNP as Integrative Practitioner: Unique Aspects of DNP Preparation References Nurse Informaticist Sandra L. McPherson Curriculum/Preparation Certification Project Management Hybrid Health Records Theoretical Supports for Nursing Informatics Future References

Chapter 5 Influencing and Leading Change in the Complex Healthcare Environment: The Role of the Advanced Practice Nurse Anne M. Barker The Evolution of Theories of Organizational Change Complexity Science: A New Paradigm for Understanding Organizational Change A Change Model Informed by Complexity Science The Call for Action: Transformational Leadership The Evolution of Leadership Theories A Contemporary Leadership Model for Advanced Practice Nurses Discussion Questions References

Chapter 6 Interprofessional Collaboration for Improving Patient and Population Health Laurel Ash and Catherine Miller Background

Improving Health Outcomes Care Improvement Efforts Interprofessional Collaboration Barriers to and Drivers of Effective Collaboration in Interprofessional Healthcare Teams Necessities for Collaboration Models for Implementation: From Project to Practice Summary References

PART 2 Healthcare Delivery and Health Policy for Advanced Practice: Core Knowledge Chapter 7 An Overview of U.S. Healthcare Delivery Leiyu Shi and Douglas A. Singh Introduction An Overview of the Scope and Size of the System A Broad Description of the System Basic Components of a Healthcare Delivery System Insurance and Healthcare Reform Role of Managed Care Major Characteristics of the U.S. Healthcare System Trends and Directions Significance for Healthcare Practitioners Significance for Healthcare Managers Healthcare Systems of Other Countries Global Health Challenges and Reform The Systems Framework Summary Test Your Understanding Discussion Questions References

Chapter 8 Government Response: Regulation

Jacqueline M. Loversidge Introduction Regulation Versus Legislation Health Professions Regulation and Licensing The State Regulatory Process The Federal Regulatory Process Current Issues in Regulation and Licensure: Regulatory Responses Conclusion Discussion Questions References

Chapter 9 Healthcare Policy for Advocacy in Health Care Angela Mund Introduction Influencing the Health Policy Agenda Long-Standing Policy Goals Integration of Policy With Ethics, Research, and Education Phases of Policy Involvement Conclusion Discussion Questions References

Chapter 10 Healthcare Business Essentials: A Primer for Advanced Nurses Mary Beth Kingston and Patti Rager Zuzelo The Context of Nursing Practice: An Overview of the U.S. Healthcare System Budget Process Essentials Discussion Questions References

Chapter 11 Microeconomics in the Hospital Firm: Competition, Regulation, the Profit Motive, and Patient Care

J. Michael Leger and Mary Anne Schultz Microeconomics, Cost Accounting, and Nursing Competition Regulation and Managed Care Profit Motive and Patient Care Quality Patient Care Healthcare Policy: The Staffing Ratios Debate The Business Case: Electronic Health Record Systems in Hospitals Summary Discussion Questions References

PART 3 Quality, Safety, and Information Systems for Advanced Practice Nurses Chapter 12 Influencing Outcomes: Improving the Quality of Care Delivery Patti Rager Zuzelo What Is an Outcome? Outcomes Measures: Key Players and Driving Forces Systematically Examining and Managing Outcomes to Improve Quality Standardizing the Language of Nursing Conclusion Discussion Questions References

Chapter 13 Providing Patient Value While Achieving Quality, Safety, and Cost-Effectiveness J. Michael Leger, Sandy K. Diffenderfer, Janne Dunham-Taylor, Karen W. Snyder, and Dru Malcolm Introduction We Have a Long Way to Go to Fix Our Healthcare System Our Reality Is Changing—Ready or Not

Our First Priority: Discovering What the Patient Wants and Values The Quality Dimension Recognition of Value and Quality Performance Measurement Employee Issues Summary Discussion Questions References

Chapter 14 Health Information Technology Philip J. Kroth Chapter Overview Historical Overview Historical Challenges in Implementing Health Information Technology The Federal Government’s Response to Health Information Technology Implementation Challenges HIT Opportunities: Improving Healthcare Delivery Quality, Effectiveness, and Efficiency Health Information Exchanges The Veterans Administration Health Information System Electronic Health Record Adoption Progress in the United States Future Challenges Discussion Questions References

Chapter 15 The Electronic Health Record and Clinical Informatics Emily B. Barey, Kathleen Mastrian, and Dee McGonigle Introduction Setting the Stage Components of Electronic Health Records Advantages of Electronic Health Records Standardized Terminology and the EHR Ownership of Electronic Health Records Flexibility and Expandability

Accountable Care Organizations and the EHR The Future Summary Discussion Questions References

Chapter 16 The Impact of EHRs, Big Data, and EvidenceInformed Practice Toni Hebda Introduction Electronic Resources: Their Relationship to Health Care Big Data Implications for RNs, APRNs, and Other Healthcare Professionals References

Chapter 17 Utilize Informatics Anita Finkelman Introduction The Core Competency: Utilize Informatics The Federal Health Informatics Reports Informatics Documentation Meaningful Use Systems and Terminologies Informatics: Types and Methods The Future of Health Informatics and Medical Technology HIPAA: Ensuring Confidentiality High-Touch Care Versus High-Tech Care Nursing Leadership in Health Informatics Discussion Questions Critical Thinking Activities References

Theoretical Foundations, Research, and PART 4 Evidence-Based Practice Chapter 18 The Evolution of Nursing Science Beth L. Rodgers Introduction The Impact of the Doctor of Nursing Practice Degree Science and Knowledge Nursing as a Discipline The Education of Nurses Delineating the Discipline The Idea of a “Professional” Discipline The Emergence of Nursing Science The Theory Movement in Nursing The Importance of Evaluating Philosophical Ideology The Search for a Nursing Paradigm Conceptual Problems and Concept Development The Postmodern Turn Pragmatism and Neopragmatism Emerging Trends in Nursing Science The Future of Nursing Knowledge Development Summary Discussion Questions References

Chapter 19 Research: How Health Care Advances Harry A. Sultz and Kristina M. Young Focus of Different Types of Research Types of Research Agency for Healthcare Research and Quality Health Services Research and Health Policy Quality Improvement Medical Errors

Evidence-Based Medicine Outcomes Research and the Patient-Centered Outcomes Research Institute The Patient-Centered Outcomes Research Institute Patient Satisfaction Surveys Research Ethics and Conflicts of Interest Future Challenges Discussion Questions References

Chapter 20 Evidence-Based Practice Kerry Milner The History of Evidence-Based Practice Nursing and EBP Evidence-Based Competencies for Advanced Practice Nurses How to Translate EBP Into Practice Searching for Evidence What Counts as Evidence? Critical Appraisal of Evidence Evidence Synthesis and Recommendations Outcomes of the EBP Process Shared Decision Making: An Important but Often Missed Part of EBP Barriers to EBP Summary Discussion Questions References

Chapter 21 Clinical Scholarship and Evidence-Based Practice Catherine Tymkow What Is Clinical Scholarship? Evidence-Based Practice and Clinical Scholarship: Are They the Same? What Is the Role of the Doctor of Nursing Practice in Clinical Scholarship? Translating Research in Practice Quality Improvement and Patient-Centered Care

Evaluation of Practice Information Technology, Databases, and Evidence for Practice Participation in Collaborative Research Disseminating Findings From Evidence-Based Practice Preparing a Poster Presentation Summary References

Chapter 22 Writing for Professional Publication Elizabeth Johnston Taylor The Process of Writing for Publication Next Steps Summary Discussion Questions Suggested Group Activities References

PART 5 The Role of Race, Culture, Ethics, and Advocacy in Advanced Nursing Practice Chapter 23 Beliefs, Values, and Health Leiyu Shi and Douglas A. Singh Introduction Significance for Managers and Policy Makers Basic Concepts of Health Quality of Life Risk Factors and Disease Health Promotion and Disease Prevention Disease Prevention Under the Affordable Care Act Public Health Health Protection and Preparedness in the United States Determinants of Health Measures Related to Health

Anthro-Cultural Beliefs and Values Integration of Individual and Population Health Summary Discussion Questions References

Chapter 24 Cultural Sensitivity and Global Health Michelle A. Cole and Christina B. Gunther Introduction Global Diversity Cultural Competency and Clinical Education Cultural Awareness Cultural Humility Cultural Competence and the Clinician Cultural Immersion Experiences Demystifying the Cultural Competence Puzzle Language and Communication Community Partnerships Pulling It All Together Evaluation Discussion Questions References

Chapter 25 Health Services for Special Populations Leiyu Shi and Douglas A. Singh Introduction Framework to Study Vulnerable Populations Racial/Ethnic Minorities The Uninsured Children Women Rural Health Migrant Workers The Homeless

Mental Health The Chronically Ill HIV/AIDS Summary Discussion Questions References

Chapter 26 Advanced Practice Nursing: The Nurse–Patient Relationship and General Ethical Concerns Aimee Milliken, Eileen Amari-Vaught, and Pamela J. Grace Introduction Virtue Ethics: The Characteristics of Good APNs Informed Consent Decision-Making Capacity Veracity and Transparency Privacy and Confidentiality Social Media and Electronic Medical Records Summary References

Chapter 27 Ethical Leadership by Advanced Practice Nurses Nan Gaylord and Pamela J. Grace Introduction Characteristics of Effective Leadership The Goals of Nursing: Advanced Practice Leadership Enhancing APN Leadership Historical and Contemporary Nursing Leaders Special Conditions Requiring Leadership: Dual Loyalties Summary Discussion Questions References

Leadership and Role Transition for the PART 6 Advanced Practice Nurse Chapter 28 Strategic Career Planning: Professional and Personal Development Patti Rager Zuzelo Reflection and Self-Appraisal: Know Yourself Reflective Practice: Developing the Professional Self Professional Portfolios: Opportunities to Gather Personal and Professional Insights Publicizing Professional Experiences and Expertise: The Curriculum Vitae and Résumé Certification: A Value-Added Enhancement Discussion Questions References

Chapter 29 Developing Leadership Skills for the Advanced Practice Nurse Through Mentorship Dori Taylor Sullivan and Anne M. Barker Introduction Mentorship: The Barker–Sullivan Model Other Support Systems Paying It Forward Discussion Questions References

Chapter 30 Managing Personal Resources: Time and Stress Management Dori Taylor Sullivan and Anne M. Barker Introduction Time Management Stress Management Stress Management Techniques Reflective Practice and Resiliency

Discussion Questions References

Chapter 31 Entering the Job Market and Promoting Your Future Success Audrey Beauvais Introduction Transitioning Roles Strategies for a Successful Transition Entering the Job Market Finding Employment Opportunities Assessments to Prepare for the Job Market Portfolio Development Applying for the Job Fostering Development Lifelong Learning Summary Discussion Questions References Index

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Introduction Advanced practice nursing education has been rapidly evolving over the past decade, with much attention given to the unique differences between advance practice nursing and the four traditional advanced practice roles—that is, certified registered nurse anesthetists (CRNAs), certified nurse–midwives (CNMs), clinical specialists (CNSs), and nurse practitioners (NPs)—as direct care providers. The fourth edition of this book was conceived in response to several new national initiatives, including the evolution of the doctor of nursing practice (DNP) degree. The following position papers and task force recommendations were taken into account when selecting new content for this textbook: Defining Scholarship for Academic Nursing Task Force Consensus Position Statement (American Association of Colleges of Nursing [AACN], 2018) Diversity, Inclusion, & Equity in Academic Nursing AACN Position Statement (AACN, 2017) Common Advanced Practice Registered Nurse Doctoral-Level Competencies (AACN, 2017) Advancing Healthcare Transformation: A New Era for Academic Nursing (AACN, 2016) The Doctor of Nursing Practice: Current Issues and Clarifying Recommendations Report from the Task Force on the Implementation of the DNP (AACN, 2015) Re-envisioning the Clinical Education of Advanced Practice Registered Nurses (AACN, 2015)

These initiatives address the rapid changes in the healthcare arena and the need for advanced practice nurses to be responsive to a complex health system with an aging population with complex comorbid health conditions at the core. For example, the new common advanced practice core competencies for doctorally prepared advanced practice registered nurses (APRNs) are not intended to replace the master’s and doctoral essentials of education but to provide a framework for contemporary APRN practice across each of the aforementioned APRN roles. As academic and clinical partnerships continue to intensify, so does the intricacy of healthcare services. Advanced practice nurses are expected to engage in a high level of teamwork that is both intra- and interprofessional in nature. This calls for advanced practice nurses to participate in clinical scholarly activities to enhance best clinical practices, influence health policy, and educate the next generation of clinicians, scholars, and leaders. Content on business planning and economics, quality improvement, and the use of metrics to drive clinical decisions have been incorporated. Advanced practice nurses must have a broad overview of how big data, including cost, healthcare outcomes, and patient and provider satisfaction, facilitates decisions and affects outcomes in all arenas. The impending shortage of primary care providers, new healthcare reform legislation, the focus on patient safety, and cost-effective high-quality care have provided curricular guidance to master’s and doctoral programs preparing advanced practice nurses. As in previous editions, the content of this textbook has been cross-referenced with the Essentials of Doctoral Education for Advanced Nursing Practice (AACN, 2006). The task force that developed the doctoral essentials built their work on the former master’s essentials. Given the work of the American Association of Colleges of Nursing’s APRN Clinical Training Task Force, the content was also cross-referenced against the work of the APRN Competency-Based Education for Doctoral-Prepared APRNs Work Group. The development of common doctoral-level competencies that are observable, realistic, and measurable will help educators and APRNs providing direct patient care to have common, achievable goals for provision of high-quality health care. TABLE I-1 displays a comparison of the essential core curriculum content for both the master’s and the doctoral programs and the new

common advanced practice registered nurse doctoral-level competencies. The last column lists the chapters in this book that address this content. TABLE I-1 Comparison of Master’s Essentials, Doctoral Essentials, Doctoral-Level Competencies, and Book Content

The publisher, Jones & Bartlett Learning, under the guidance of editor Susan M. DeNisco, embarked on a quest to produce a fourth edition of an advanced practice textbook that would compile selected chapters from existing books in the Jones & Bartlett Learning collection. The strength of this approach is that experts in each of the content areas wrote each chapter in the book. The revision of this textbook comprehensively addresses the core curriculum content requirements of the master of science in nursing (MSN) and doctor of nursing practice (DNP) essentials, recognizing that broad content areas and role competencies cannot be covered in separate courses due to credit limitations. In addition, this book addresses the roles required, regardless of their specialty or functional

focus. This knowledge can then be built upon as graduate students proceed into their specialty foci. New to this edition are the following topic and content areas: Writing for publication and scholarship Ethical leadership Business essentials for advanced practice nurses The impact of big data on healthcare outcomes Phases of health policy development as it pertains to advanced practice nurses Patient value, quality, safety, and cost-effectiveness Economics in the hospital environment Strategic career planning Lifelong learning Content areas that have been strengthened for this textbook focus on: Both direct and indirect provider roles Role of the clinical doctorate in advanced practice nursing Reimbursement and credentialing issues for nurse practitioners Federal and state regulation of advanced practice nursing Budgeting and finances for advanced practice Electronic health records and clinical informatics Continuous quality improvement strategies to optimize clinical practice Evidence-based practice and clinical scholarship Global health, diversity, and healthcare disparities for special populations Role transition and professional development The content of this book has been carefully selected based on the editor’s 35 years of experience as a primary care provider, educator, and administrator. This content is crucial to all levels of graduate nursing preparation. With the recent revision and sophistication of the master’s essentials, there is closer application in each content area to the doctoral essentials. Thus, the book can be used in both master’s-level and postbaccalaureate doctoral programs in the beginning core courses to lay a foundation for advanced nursing practice. As with any textbook, additional scholarly readings, especially research and evidence-based articles, will enhance the content.

As previously mentioned, some confusion exists regarding the terminology advanced nursing practice versus advanced practice nursing. Over time, these terms have become commonly used to indicate master’s-prepared nurses who provide direct clinical care and include the roles of clinical nurse specialist, nurse practitioner, certified nurse– midwife, and certified registered nurse anesthetist, with the last three roles requiring a license beyond the basic registered nurse license to practice. This book has adopted a broader, more inclusive definition (AACN, 2004), which reflects the current thinking about advanced practice. Advanced practice nursing is defined as follows: Any form of nursing intervention that influences health care outcomes for individuals or populations, including direct care of individual patients, management of care for individuals and populations, administration of nursing and health care organizations, and the development and implementation of health policy. (p. 2) In this book, nurses in advanced practice are defined as any nurse who holds a master’s degree or higher in nursing and whose role is consistent with this definition. Advanced practice nursing, advanced practice nurses, and advanced nursing practice are used interchangeably throughout the book. Currently, several major professional forces are influencing graduate education in nursing and promise to have dramatic effects on nursing education both today and into at least the next decade: The 2010 Affordable Care Act represents the broadest healthcare overhaul legislation passed since the 1965 creation of the Medicare and Medicaid programs. The Institute of Medicine report The Future of Nursing: Leading Change, Advancing Health (2010) positions nurse regulators to provide leadership on the critically important challenge of assigning accountability for quality and patient safety at the state and local levels. The clinical doctorate, designated as a doctor of nursing practice, has been mandated as the entry to advanced nursing practice (see the introduction to Part 1 for more details).

A consensus model for advanced practice nurse regulations has been developed through work by the Advanced Practice Registered Nurse Consensus group (2008) and the National Council of State Boards of Nursing (NCSBN). A new role in nursing, the clinical nurse leader (CNL), has been introduced. This role is designed to address many of the problems currently evident in health care, including the nursing shortage, patient safety and medical errors, and fragmentation of the healthcare system. The AACN (2007) provides this definition of the CNL: The CNL functions within a microsystem and assumes accountability for healthcare outcomes for a specific group of clients within a unit or setting through the assimilation and application of research-based information to design, implement, and evaluate client plans of care. The CNL is a provider and a manager of care at the point of care to individuals and cohorts. The CNL designs, implements, and evaluates client care by coordinating, delegating, and supervising the care provided by the health care team, including licensed nurses, technicians, and other health professionals. (p. 6) CNLs are considered generalists who will be prepared at the master’s level and require the same core curriculum knowledge as do other master’s-prepared nurses. In both the master’s essentials and the doctoral essentials documents, the AACN lays out the foundation for core knowledge needed by all graduate nursing students. This book provides in one collection a foundation for this core knowledge. It does not address any of the specific content needed by the specialties. Moreover, this foundational content should be further integrated and applied throughout the rest of the curriculum.

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About the Author Susan M. DeNisco is the Director of the Post Baccalaureate, Doctor of Nursing Practice/Family Nurse Practitioner Program at Sacred Heart University. She has held a variety of leadership positions including Interim Director of the School of Nursing and Director of Graduate Nursing Programs. She coordinated the Family Nurse Practitioner Program there from 2000 - 2010. She led the development of the Doctor of Nursing Practice (DNP) Program which was implemented in 2010. Susan received a DNP degree in Clinical Leadership from Case Western Reserve University, an MS in the Family Nurse Practitioner Program from Pace University, and a BSN from Western Connecticut State University. Dr. DeNisco is the Executive Director of College of Health Professions, Center for Community Health & Wellness. She served on the Executive Board of the Connecticut Advanced Practice Registered Nurse Society in a variety of elected positions including President from 2005-2009. She is certified as a Childbirth Educator by the Council of Childbirth Education Specialists. Dr. DeNisco’s impressive career includes 30 years of clinical experience as a Family Nurse Practitioner in a variety of primary care settings. Her work has largely focused on medically underserved populations including disenfranchised groups such as migrant farm workers, refugees and the homeless. Dr. DeNisco’s current clinical practice areas include internal medicine at a large federally qualified health center for the medically underserved in Bridgeport, CT. Her scholarly interests include evidence-based treatment modalities for

alternative treatments for pain, depression and anxiety disorders. She has published several articles and book chapters on these topics. Her doctoral research focused on the relationship between resilience and diabetes outcomes in African American women. She was recently inducted as a Fellow in the American Association of Nurse Practitioners. She is the recipient of numerous state and national awards including the American Academy of Nurse Practitioner Connecticut State Award for Excellence, The National Nursing Center Consortium Primary Care Champion Award, the Connecticut Nurses Association, Diamond Jubilee Josephine Dolan Award for Outstanding Contributions to Nursing Education. Most recently she received the Connecticut League for Nursing, Jane E. Murdock “Life-Long” Learning Award for her contributions to nursing education. She has been awarded several grants by the Southwestern Connecticut Agency on Aging to implement health promotion programs for elderly Latinos residing in Bridgeport. Most recently, Dr. DeNisco received funding by the Department of Health and Human Services, Advanced Nursing Education Workforce grant. The project, entitled Alternatives to Opioids for Pain (ALTOP) will benefit patients who are at risk for misuse of opioids for non-cancer chronic pain. As a Family Nurse Practitioner, Dr. DeNisco feels she is able to combine her love for clinical practice with teaching since education provides the foundation for all health promotion and wellness activities.

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Contributors Eileen Amari-Vaught, RhD, RN, MSN, FNP-BC Clinical Assistant Professor School of Nursing and Health Studies University of Missouri Kansas City, Missouri Laurel Ash, DNP, APRN, FNP-BC Essential Health Proctor Proctor, Minnesota Emily B. Barey, MSN, RN Director of Nursing Informatics Epic Systems Corporation Madison, Wisconsin Anne M. Barker, EdD, RN Retired, Professor and Chair of Nursing Programs Sacred Heart University, College of Nursing Fairfield, Connecticut Audrey Beauvais, DNP, MSN, MBA Associate Dean, School of Nursing Fairfield University Fairfield, Connecticut Janie B. Butts, PhD, RN The University of Southern Mississippi School of Nursing Hattiesburg, Mississippi Lisa Astalos Chism, DNP, APRN, NCMP, FAANP Clinical Director, Women’s Wellness Clinic

Nurse Practitioner Certified Menopause Practitioner Sexual Health Counselor and Educator Karmanos Cancer Institute Detroit, Michigan Michelle A. Cole, DNP, MSN, RN, CNP Director of Undergraduate Nursing Assistant Professor Sacred Heart University, College of Nursing Fairfield, Connecticut Susan M. DeNisco, DNP, APRN, FNP-BC, FAANP Professor and Director, Doctor of Nursing Practice Program and Family Nurse Practitioner Program Sacred Heart University, College of Nursing, Fairfield, Connecticut Family Nurse Practitioner, Southwest Community Health Center, Bridgeport, Connecticut Sandy K. Diffenderfer, PhD, MSN, RN, CPHQ Assistant Professor, Graduate Program East Tennessee State University, College of Nursing Johnson City, Tennessee Janne Dunham-Taylor, PhD, RN Professor Emerita East Tennessee State University, College of Nursing Johnson City, Tennessee Joy Elwell, DNP, FNP-BC, APRN, CNE, FAAN, FAANP Associate Professor & Director DNP Program University of Connecticut Storrs, Connecticut Denise R. Felsenstein, DNP, RN, CRNP, WHNP-BC Consultant Continuing Education Department LWW/Wolters Kluwer Health Women’s Health Nurse Practitioner St. Agnes Nurses Center West Chester, Pennsylvania Anita Finkelman, MSN, RN Visiting Lecturer, Nursing Department Recanati School for Community Health Professions Faculty of the Health Sciences Ben-Gurion University of the Negev Beersheba, Israel

Carol Flaten, DNP, RN, PHN Clinical Professor University of Minnesota School of Nursing Minneapolis, Minnesota Timothy Gardner, DNP FNP - BC CEO and Family Primary Care Provider Count to Ten Holistic Health Center Gary, Indiana Nan M. Gaylord, PhD, RN, CPNP, FAAN Associate Professor William F. Connell School of Nursing Boston College Chestnut Hill, Massachusetts Pamela J. Grace, PhD, RN, FAAN Associate Professor Ethics and Adult Health William F. Connell School of Nursing Boston College Chestnut Hill, Massachusetts Christina B. Gunther, MA Director, Global Health Programs and Health Science Program Sacred Heart University, College of Health Professions Fairfield, Connecticut Toni Hebda, PhD, MSIS, RN-BC, CNE Professor Chamberlain College Columbus, Ohio Mary Beth Kingston, RN, MSN, NEA-BC Executive Vice President and Chief Nursing Officer Aurora Health Care Milwaukee, Wisconsin Philip J. Kroth, MD, MS Director, Biomedical Informatics Research, Training and Scholarship Health Sciences Library and Information Center Associate Professor and Section Chief for Clinical Informatics Division of Translation Informatics and General Internal Medicine University of New Mexico School of Medicine Albuquerque, New Mexico J.Michael Leger, PhD, MBA, RN

Director, Department of System Quality, Health Care Safety, and Accreditation Adjunct Professor, School of Nursing University of Texas Medical Branch Galveston, Texas Jacqueline M. Loversidge, PhD, RNC-AWHC, CNS Assistant Professor The Ohio State University, College of Nursing Columbus, Ohio Dru Malcolm, DNP, MSN, RN, NEA-BC, CPHRM Chief Nursing Officer and Assistant Administrator Johnston Memorial Hospital, a facility of Mountain States Health Alliance Abingdon, Virginia Kathleen Mastrian, PhD, RN, FAAN, CNE Professor, MSN-Online Program Chamberlain College of Nursing Columbus, Ohio Sr. Advisor, Online Journal of Nursing Informatics (OJN) Member, Informatics and Technology Expert Panel (ITEP) American Academy of Nursing Dee McGonigle, PhD, RN, CNE, FAAN, ANEF Associate Professor and Program Coordinator for Nursing Pennsylvania State University, Shenango Sr. Managing Editor, Online Journal of Nursing Informatics (OJN) Sandra McPherson, DNP, RN-BC, CPHIMS Director of Clinical Informatics Lawrence and Memorial Hospital New London, Connecticut Catherine Miller, EdD, RN, CNE Retired Dean of Academics, Mennonite College of Nursing Illinois State University Normal, Illinois Aimee Milliken, MSN, RN PhD Candidate William F. Connell School of Nursing Boston College Chestnut Hill, Massachusetts Kerry Milner, DNSc, RN Associate Professor Sacred Heart University, College of Nursing Fairfield, Connecticut

Jeri A. Milstead, PhD, RN, NEA-BC, FAAN Senior Nurse Consultant for Public Policy, Leadership, and Education Professor and Dean Emerita University of Toledo, College of Nursing Toledo, Ohio Angela Mund, DNP, CRNA Assistant Professor, Program Director Anesthesia for Nurses Medical University of South Carolina Charleston, South Carolina Judith M. Pechacek, DNP, RN, CENP Clinical Associate Professor and Director Doctor of Nursing Practice (DNP) Program Senior Quality Scholar Veterans Administration Quality Scholars Program (VAQS) University of Minnesota School of Nursing Minneapolis, Minnesota Garrett Peterson, DNP, CRNA, APRN Staff Nurse Anesthetist Minneapolis Veterans Affairs Health Care System Minneapolis, Minnesota Jeanne Pfeiffer, DNP, MPH, RN, CIC, FAAN Clinical Professor University of Minnesota Minneapolis, Minnesota Karen l. Rich, PhD, RN The University of Southern Mississippi School of Nursing Long Beach, Mississippi Deborah Ringdahl, DNP, RN, CNM Clinical Associate Professor School of Nursing University of Minnesota Minneapolis, Minnesota Beth L. Rodgers, PhD, RN, FAAN Professor and Chair, Department of Adult Health and Nursing Systems Nursing Alumni Endowed Professor Virginia Commonwealth University School of Nursing Richmond, Virginia

Melissa Saftner, PhD, CNM Clinical Associate Professor School of Nursing University of Minnesota Minneapolis, Minnesota Mary Anne Schultz, PhD, MBA, MSN, RN Former Faculty Member California State University, Los Angeles, Department of Nursing Los Angeles, California Leiyu Shi, DrPH, MBA, MPA Professor and Director Johns Hopkins University Baltimore, Maryland Nancy M. Short, DrPH, MBA, RN, FAAN Associate Professor Duke University Medical Center Durham, North Carolina Douglas A. Singh, PhD, MBA Associate Professor School of Public and Environmental Affairs Indiana University, South Bend South Bend, Indiana Karen W. Snyder, MSN, RN Quality Improvement Specialist Integrated Solutions Health Network Johnson City, Tennessee Julie G. Stewart, DNP, MPH, MSN, FNP-BC, FAANP Associate Professor, FNP and DNP Programs Sacred Heart University, College of Nursing Fairfield, Connecticut Dori Taylor Sullivan, PhD,RN-BC,CPHQ,FAAN Principal Consultant, Leadership/Education/Quality Consulting Stuart, Florida Harry A. Sultz, DDS, MPH Professor Emeritus, Social and Preventative Medicine, School of Medicine and Biomedical Sciences, State University of New York at Buffalo Dean Emeritus, School of Public Health and Health Professions, State University of New York at Buffalo Buffalo, New York Elizabeth Johnston Taylor, PhD, RN

Professor, School of Nursing Loma Linda University Loma Linda, California Catherine Tymkow, DNP, MS, APN, WHNP-BC CNE Associate Professor of Nursing and DNP Program Coordinator Department of Nursing College of Health and Human Services Governors State University University Park, Illinois Mary Jean Vickers, DNP, RN, APRN, ACNS-BC, NEA-BC Nurse Consultant for Nursing Practice, Leadership, and Education Roberta L. Huna Wagner Clinical Nurse Specialist Cardiovascular Units, IV Team, WOCN Abbott Northwestern Hospital, Part of Allina Health Minneapolis, Minnesota Kristina M. Young, MS Clinical Assistant Professor Emerita School of Public Health and Health Professions State University of New York at Buffalo Buffalo, New York President Kristina M. Young & Associates, Inc. Buffalo, New York Mary E. Zaccagnini, DNP, APRN, ACNS-BC Clinical Assistant Professor ad Honorem University of Minnesota, School of Nursing Minneapolis, Minnesota Patti Rager Zuzelo, EdD, RN, ACNS-BC, ANP-BC, CRNP, FAAN Clinical Professor Drexel University, College of Nursing and Health Professions Philadelphia, Pennsylvania

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PART 1 Professional Roles for Advanced Practice

T

he chapters in Part 1 of this book consider the role of the advanced practice nurse from historical, present-day, and future perspectives. This content is intended to serve as a general introduction to select issues in professional role development for the advanced practice of nursing. As students progress in the educational process and develop greater knowledge and expertise, role issues and role transition should be integrated into the entire educational program. In Chapter 1, DeNisco and Barker define advanced practice nursing from a traditional perspective and trace the history of the role. Traditionally, advanced practice has been limited to clinical roles that include the clinical nurse specialist, nurse practitioner, certified nurse– midwife, and certified registered nurse anesthetist; to practice, the last three roles require a license beyond the basic registered nurse (RN) license. This book, however, uses an expanded definition of advanced practice nursing that reflects current thinking. As you read this chapter, keep in mind this expanded definition and appreciate the development of the advanced clinical roles for nursing practice. This discussion lays the foundation for a deeper understanding of the historical development, current practice, and future opportunities for advanced practice in nursing. In Chapter 2, Stewart discusses the tipping point for nurse practitioners as we enter the age of healthcare reform and the role nurse practitioners will play in providing cost-effective, high-quality primary care to a demographically changing population. Stewart’s quantitative and qualitative research resulted in the Stewart model of nurse practitionering, which reflects key attributes that make nurse practitioners unique. Much has transpired related to the role and education of nurses

for advanced practice. Since the national call for the clinical doctorate to be the required degree for advanced clinical practice nursing by 2015 (American Association of Colleges of Nursing, 2004), there has been a proliferation of master’s programs that have transitioned to the doctoral level. The rationale for this position by the American Association of Colleges of Nursing (AACN) is based on several factors: The reality that current master’s degree programs often require credit loads equivalent to doctoral degrees in other healthcare professions The changing complexity of the healthcare environment The need for the highest level of scientific knowledge and practice expertise to ensure high-quality patient outcomes In an effort to clarify the standards, titling, and outcomes of clinical doctorates, the Commission on Collegiate Nursing Education (CCNE)— the accreditation arm of the AACN—has decided that only practice doctoral degrees awarding a doctor of nursing practice (DNP) will be eligible for accreditation. In addition, the AACN has published the Essentials of Doctoral Education for Advanced Nursing Practice, which sets forth the standards for the development, implementation, and program outcomes of DNP programs. Needless to say, this recommendation has not been fully supported by the entire profession. For instance, the American Organization of Nurse Executives (AONE, 2007) does not support requiring a doctorate for managerial or executive practice on the basis of expense, time commitment, and cost benefit of the degree. It also suggests that nurses may migrate toward a master’s degree in business, social sciences, and public health in lieu of a master’s degree in nursing. Further, the AONE suggests that there is a lack of evidence to support the need for doctoral education across all aspects of the care continuum. In contrast, doctoral and master’s-level education for nurse managers and executives is encouraged. For other advanced practice roles, including those of the clinical nurse leader, nurse educator, and nurse researcher, a different set of educational requirements exists. The clinical nurse leader as a generalist remains a master’s-level program. For nurse educators, the position of the AACN—although not universally accepted within the profession (as demonstrated by the existence of master’s programs in nursing

education)—is that didactic knowledge and practical experience in pedagogy are additive to advanced clinical knowledge. Nurse researchers will continue to be prepared in PhD programs. Thus, there will be only two doctoral programs in nursing, the DNP and the PhD. It is important for readers to keep abreast of this movement as the profession further develops and debates these issues because the outcomes have implications for their own practice and professional development within their own specialty. The best resources for this are the AACN website and the websites of specialty organizations. The next three chapters in Part 1 discuss the future of advanced practice nursing and the evolution of doctoral education—in particular, the practice doctorate. Within today’s rapidly changing and complex healthcare environment, members of the nursing profession are challenging themselves to expand the role of advanced practice nursing to include highly skilled practitioners, leaders, educators, researchers, and policy makers. In Chapter 3, Chism defines the DNP degree and compares and contrasts the research doctorate and the practice doctorate. The focus of the DNP degree is expertise in clinical practice. Additional foci include the Essentials of Doctoral Education for Advanced Nursing Practice as outlined by the AACN (2004), which include leadership, health policy and advocacy, and information technology. Role transitions for advanced practice nurses prepared at the doctoral level call for an integration of roles focused on the provision of high-quality, patient-centered care. In Chapter 4, Zaccagnini and Waud White discuss emerging roles of DNP graduates as nurse educators, nurse executives, and nurse entrepreneurs and advanced practice nurses’ increased involvement in public health programming and integrative and complementary health modalities. In Chapter 5, Barker sets the foundation for advanced practice nurses to recognize and embrace their role as leaders and influencers of practice changes in healthcare organizations. Complexity science, organizational change theory, and transformational leadership are used as a platform for advanced practice nurses to realize their leadership potential and their role as agents of change. Last, in Chapter 6, Ash, Miller, and Zaccagnini provide an in-depth look at interdisciplinary and interprofessional collaborative teams as a

means to effect positive health outcomes. They discuss barriers to successful collaborative teams and factors for successful team development. Advanced practice nurse leaders educated at both the master’s and the doctoral levels are uniquely positioned to overcome the workforce and regulatory issues that might otherwise diminish the success of collaborative teams—in particular, those involving participants from the nursing and medicine disciplines.

References American Association of Colleges of Nursing (AACN). (2004). AACN position statement on the doctorate in nursing. Retrieved from https://www.aacnnursing.org/Portals/42/News/PositionStatements/DNP.pdf American Organization of Nurse Executives (AONE). (2007). Consideration of the doctorate of nursing practice. Retrieved from http://www.aone.org/resources/doctorate-nursing-practice.pdf

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CHAPTER 1 Introduction to the Role of Advanced Practice Nursing Susan M. DeNisco and Anne M. Barker

CHAPTER OBJECTIVES 1. Describe the four roles used to define advanced practice nursing in the United States. 2. Identify the differences between the clinical nurse leader role and the traditional advanced practice nursing roles. 3. Recognize factors that currently influence the supply and demand of nurse educators. 4. Discuss the educational preparation and certification requirements for nurse administrators.

Introduction Considerable confusion exists regarding the terminology advanced nursing practice, advanced nurse practice, and advanced practice registered nurse. Based on the definition given by the American Association of Colleges of Nursing (AACN) and other widely accepted usages, the term advanced practice registered nurse (APRN) has been used to indicate master’s-prepared nurses who provide direct clinical care. This term encompasses the roles of nurse practitioner (NP), certified nurse–midwife (CNM), certified registered nurse anesthetist (CRNA), and clinical nurse specialist (CNS). The first three roles require a license beyond the basic registered nurse (RN) license. The role of the clinical nurse specialist requires a master’s degree but does not require separate licensing unless the CNS is applying for prescriptive authority. Complicating the titling and definition of roles, the AACN (2004) defined advanced practice nursing as follows: Any form of nursing intervention that influences health care outcomes for individuals or populations, including direct care of individual patients, management of care for individuals and populations, administration of nursing and health care organizations, and the development and implementation of health policy. (p. 2) The Consensus Model for APRN Regulation is a product of substantial work done by the APRN Consensus Work Group and the National Council of State Boards of Nursing (NCSBN) APRN Advisory Committee in an effort to address the irregularities in regulation of advanced practice registered nurses across states. As defined in the model for regulation, there are four roles: certified registered nurse anesthetist, certified nurse–midwife, clinical nurse specialist, and certified nurse practitioner (CNP). These four roles are given the title of advanced practice registered nurse (APRN). APRNs are educated in one of the four roles and in at least one of the following population foci: family/individual across the life span, adult–gerontology, pediatrics, neonatal, women’s

health/gender related, and psych/mental health (APRN Consensus Work Group & National Council of State Boards of Nursing APRN Advisory Committee, 2008). Advanced practice registered nurses are licensed independent practitioners who are expected to practice within standards established or recognized by a licensing body. The model further addresses licensure, accreditation, certification, and education of APRNs. FIGURE 1-1 depicts the APRN regulatory model.

FIGURE 1-1 APRN regulatory model. Reproduced from National Council of State Boards of Nursing: The APRN Consensus Model 2008.

Description

Other Advanced Practice Nursing Roles and the Nursing Curriculum Consequently, nurse administrators, public health nurses, and policy makers are considered advanced practice nurses albeit they do not provide direct care or obtain advanced practice licensure per the state they practice in. As this text goes to press, there is an initiative to expand and clarify the definition of and requirements for advanced practice nursing. No matter the final outcome of this deliberation, all nurses need the same set of essential knowledge. The Essentials Series outlines the necessary curriculum content and expected competencies of graduates of baccalaureate, master’s, and doctoral nursing practice programs and the clinical support needed for the full spectrum of academic nursing (AACN, 2006, 2011a, 2011b). Although the terms advanced practice nursing, advanced practice nurses, advanced nursing practice, and advanced practice registered nurses are used interchangeably throughout this text, the authors are addressing any students enrolled in master’s or doctoral programs that are designed, implemented, and evaluated by the AACN Essentials. Chapter 2 provides an overview of the master’s and doctoral essentials.

Clinical Nurse Leaders The clinical nurse leader (CNL) role was introduced in 2003 to address the Institute of Medicine’s quality and safety reports, which envisioned a nursing workforce who would provide direct clinical leadership at the point of care and work to ensure a safe patient care environment (AACN, 2013). Clinical nurse leaders were not considered in the definition of advanced practice because the CNL role did not exist when the aforementioned roles were defined. Some argue that the CNL is a generalist and thus CNL should not be considered an advanced practice role. We disagree. The clinical nurse leader role requires advanced knowledge and skill beyond that attained with the baccalaureate degree, and it requires a master’s degree for certification. The original white

paper on the education and role of the CNL provided the background, rationale, and description of the CNL role and education as well as the expected outcomes and competencies for all CNL graduates (AACN, 2007) There are currently 7,036 nurses who have earned the CNL since 2006 (Commission on Nurse Certification, 2018). According to the AACN (2007), the clinical nurse leader is responsible for patient care outcomes and integrates and applies evidence-based information to design, implement, and evaluate healthcare systems and models of care delivery. The CNL is a provider and manager of care at the point of care for individuals and cohorts of patients anywhere health care is delivered (AACN, 2007). In fact, as recommended in both the AACN white paper and the CNL Competencies and Curricular Expectations on the CNL role, all CNL curricula across the country require graduate-level content that builds on an undergraduate foundation in health assessment, pharmacology, and pathophysiology. In many master’s-level programs, NP and CNL students sit side by side to learn these advanced skills. Also, the inclusion of these three separate courses—health assessment, pharmacology, and pathophysiology—facilitates the transition of master’s program graduates into doctor of nursing practice degree programs (AACN, 2007, 2013). Moreover, the CNL program graduate has completed more than 400 clinical practice hours, similar to the number required of NP graduates, and is eligible to sit for the CNL Certification Examination developed by the American Association of Colleges of Nursing. In 2013, the CNL Expert Panel developed Competencies and Curricular Expectations for Clinical Nurse Leader Education and Practice to revise the competencies in the original white paper and strengthen the original curriculum framework and practice expectations to reflect changes in our healthcare environment. It is recommended that CNLs practice stewardship to leverage resources and use information systems and technologies to improve patient care outcomes (AACN, 2013). The clinical nurse leader, similar to the clinical nurse specialist (discussed next), has developed clinical and leadership skills and knowledge of statistical processes and data mining. The CNL brings evidence-based practice to the bedside, creates a culture of safety, and provides high-quality care. This aligns directly with the American Organization of Nurse Executives’ (AONE) guiding principles for the

nurse of the future (AONE, 2019a; Haase-Herrick & Herrin, 2007).

Clinical Nurse Specialists Clinical nurse specialists comprise a group of over 70,000 advanced practice registered nurses (National Association of Clinical Nurse Specialists [NACNS], 2018). Clinical nurse specialists have been providing care to patients with complex cases across healthcare settings since the 1960s. The CNS role originated largely to satisfy the societal need for nurses who could provide advanced care to psychiatric populations. Since the passage of the National Mental Health Act in 1946, the National League for Nursing (NLN) and the American Nurses Association have supported the CNS role. The first program at Rutgers University educated nurses for the role of psychiatric clinical specialist (McClelland, McCoy, & Burson, 2013). Following this implementation, the usefulness of the role became apparent, and schools of nursing began to educate nurses across specialties, including oncology, medical-surgical, pediatric, and critical care nursing. The literature of the 1980s and 1990s shows that care provided by clinical nurse specialists produced positive patient outcomes related to self-management and early hospital discharge (Fulton, 2014). More recently, studies show improvement in patient satisfaction and pain management as well as reduced medical complications in hospitalized patients (McClelland et al., 2013). The recent trend toward hospital and healthcare system mergers and the focus on cost containment has forced the CNS role into a precarious position. Hospital administrators have a difficult time showing that CNSs decrease hospital costs, and they cannot bill for specialty nursing services. The AACN states that there are significant differences between the CNS and CNL roles; however, few differences are clearly articulated by those being educated in or practicing in these roles. NACNS announced in 2015 its endorsement of proposals for the doctor of nursing practice (DNP) as the required degree for CNS entry into practice by 2030. This has created role confusion and uncertainty regarding the role these nurses should play in the inpatient hospital setting. TABLE 1-1 compares role competencies of the CNS and the CNL.

TABLE 1-1 Comparison of Select Role Competencies for the CNS and the CNL Clinical Nurse Specialist

Clinical Nurse Leader

■ Conducts a comprehensive health assessment in diverse care settings, including psychosocial, functional, physical, and environmental factors.

■ Conducts a holistic assessment and comprehensive physical examination of individuals across the life span.

■ Leads and participates in the process of selecting, integrating, managing, and evaluating technology and products to promote safety, quality, efficiency, and optimal health outcomes.

■ Uses information technology, analytics, and evaluation methods.

■ Leads and facilitates coordinated care and transitions in collaboration with the patient and interprofessional team.

■ Facilitates collaborative, interprofessional approaches and strategies in the design, coordination, and evaluation of patientcentered care.

■ Provides education and coaching to patients with complex learning needs and atypical responses.

■ Demonstrates coaching skills, including self-reflection, to support new and experienced interdisciplinary team members in exploring opportunities for improving care processes and outcomes.

■ Consults with healthcare team members to integrate the needs, preferences, and strengths of a population into the healthcare plan to optimize health outcomes and patient experience within a healthcare system.

■ Engages in partnerships at multiple levels of the health system to ensure effective coordination, delivery, and evaluation of clinical prevention and health promotion interventions and services across care environments.

■ Implements customized evidence-based advanced nursing interventions, including the provision of direct care.

■ Uses evidence to design and direct system improvements that address trends in safety and quality.

■ Analyzes the ethical impact of scientific advances, cost, clinical effectiveness on patient and family values, and preferences.

■ Advocates for policies that leverage social change, promote wellness, improve care outcomes, and reduce costs.

Reproduced from American Association of Colleges of Nursing. (2013). Competencies and curricular expectations for clinical nurse leaders education and practice. Retrieved from https://www.aacnnursing.org/Portals/42/News/White-Papers/CNL-Competencies-October2013.pdf; National CNS Competency Revision Task Force. (2018). Core clinical nurse

specialists competencies. Retrieved from http://nacns.org/wp-content/uploads/2018/05/CoreCompetencies-CNS-Table-2-2018-line-numbers.pdf

Description In addition, the APRN consensus model states that graduate nursing roles that do not focus on direct patient care will not be eligible for APRN licensure in the future (APRN Consensus Work Group & National Council of State Boards of Nursing APRN Advisory Committee, 2008). NACNS (2019) reports that in the past decade, eight states have granted clinical nurse specialists the authority to practice without a physician’s supervision and six have given CNSs independent authority to prescribe drugs and durable medical equipment. CNSs can now practice independently in 28 states and prescribe independently in 19. This represents strides that CNSs are making to maximize their education and clinical expertise. However, only 13 recognize CNSs as advanced practice registered nurses and require them to have a collaborative practice agreement with a physician. This creates further challenges for the CNS, such as variability in state title protection, inconsistency among states grandfathering in the CNS role, lack of a regulatory approach to accepting grandfathered CNSs to practice in other states, and job loss based on misperceptions of the model (NACNS, 2005).

Nurse Educators The role of nurse educators may be one of the most contentious issues in nursing education. Nursing education has transformed from an apprentice style of education to one that requires an education grounded in liberal arts and demands the development of critical thinking abilities. The evolution of nursing education has resulted in several approaches to initial preparation and the expansion of both master’s and doctoral programs to prepared nurses as critical partners in the healthcare setting. According to the National League for Nursing (2002), the nurse educator role requires specialized preparation, and every individual engaged in the academic enterprise must be prepared to implement that role successfully. Nurse educators are key resources in preparing the nursing workforce to provide high-quality care to meet the healthcare needs of a

rapidly aging and diverse population. Whether in academic or clinical settings, nurse educators must be competent clinicians. However, whereas being a good clinician is essential, some would say it is not sufficient for the educator role. Much of the debate in nursing education centers on the fact that the nurse educator student primarily needs advanced knowledge and skills in clinical practice in order to teach, and therefore graduate education should be directed toward enhancing clinical expertise. According to the AACN (2014), the master’s-level curriculum for the nurse educator builds on baccalaureate knowledge, and graduate-level content in the areas of health assessment, pathophysiology, and pharmacology strengthen the graduate’s scientific background and facilitate understanding of nursing and health-related information. In this model, students are required to take courses beyond the graduate core curriculum and that provide content expertise in the “3 Ps” (pharmacology, pathophysiology, and physical assessment), similar to the education of nurse practitioners and clinical nurse leaders. On the other side of the argument, many clinicians who become nurse educators are already clinical and content experts. The National League for Nursing advocates for advancing the science of nursing education to address new pedagogies and to prepare, develop, recruit, and retain faculty while applying innovative clinical teaching models, including the integration of new technology (NLN, 2007). Excellence in advanced nursing education and research will support teaching/learning theories and strategies, curriculum development, and student and programmatic assessment.

Supply and Demand for Nurses The relationship between nurse supply and demand in the United States has been cyclical, with periodic shortages of nurses where demand exceeds available supply, followed by periods of overproduction that lead to nursing surpluses. According to U.S. Department of Health and Human Services, Health Resources and Services Administration (USDHHS/HRSA), National Center for Health Workforce Analysis (2017), there is substantial projected variation across the United States for RNs in 2030 through the large differences between projected supply and demand. After an analysis of each state’s 2030 RN supply minus its 2030 demand, there will be both shortages and surpluses in the RN workforce in 2030 across the United States. For example, there are seven states that have estimated 2030 shortages, with four states projected to have shortages of more than 10,000 RN full-time equivalents (FTEs), including California, followed by Texas (15,900 fewer FTEs), New Jersey (11,400 fewer FTEs), and South Carolina (10,400 fewer FTEs). Meanwhile, three states predict a surplus of more than 20,000 RN FTEs, including Florida, followed by Ohio (with 49,100 more FTEs) and Virginia (with 22,700 FTEs) (HRSA, 2017). At the national level, the projected growth in RN supply (39% growth) is expected to exceed demand (28% demand), resulting in a projected excess of about 293,800 RN FTEs in 2030 (HRSA, 2017). This is in contrast to the AACN’s position that the United States is projected to experience a shortage of RNs that is expected to intensify as baby boomers age and the need for health care grows. Making matters worse is the fact that nursing schools across the country are struggling to expand capacity to meet the rising demand for care given the national need for healthcare reform. Nurse shortage or surplus appears to reflect local conditions, such as the number of new graduates in a given state, as nurses tend to practice in states where they have been educated. Future supply and demand will be affected by a myriad of factors, including population growth, the aging of the nation’s population, overall economic conditions and expanded health insurance coverage, changes in healthcare reimbursement, geographic location, and health workforce

availability. See TABLE 1-2. TABLE 1-2 Baseline and Projected Supply of and Demand for Registered Nurses by State: 2014 and 2030

Description Description Notes: The model assumes increased insurance coverage associated with Medicaid expansion and insurance marketplaces, together with year 2014 health care use and delivery patterns. Numbers may not sum to totals due to rounding. a

The projections assume that each state’s supply and demand are equal in 2014.

bDifference = 2030 projected supply – demand. d

Starting supply for Washington D.C. is based on small sample size in the American Community Survey so supply estimates might be unreliable. cAdequacy = 100 * (projected supply – projected demand)/(projected demand); a negative

adequacy indicates a shortage (i.e., supply is less than demand) while a positive adequacy indicates a surplus (i.e., supply is greater than demand); adequacies associated with 2030 projected shortages are highlighted in blue. Reproduced from U.S. Department of Health and Human Services, Health Resources and Services Administration, National Center for Health Workforce Analysis. 2017. National and regional supply and demand projections of the nursing workforce: 2014–2030. Rockville, Maryland.

Meeting this projected demand will require a significant increase in the number of nursing graduates, perhaps by as much as 40%, to fill new nursing positions as well as to account for attrition from an aging workforce. This corresponds to an increase in the demand for nursing faculty. Although the number of nurses enrolling in doctoral programs has increased in the past decade, the current demand for nurses prepared for advanced practice, clinical specialties, teaching, and research roles far outstrips the supply. Consequently, to increase the supply requires a major expansion of nursing faculty and other educational resources. With the “graying” of the current pool of nursing faculty, efforts we make must persuade more nurses and nursing students to pursue academic careers and to do so at

an earlier age. Careers in nursing education are typically marked by long periods of clinical practice prior to being educated for a faculty role. The idea of advanced practice nurses with clinical doctorates versus research doctorates working in academia has been supported by the National Organization of Nurse Practitioner Faculties, NLN, and AACN. The doctor of nursing practice degree may be the answer to imparting advanced knowledge in evidence-based practice, quality improvement, leadership, policy advocacy, informatics, and healthcare systems to clinicians, managers, and educators. The DNP-prepared educator is poised to educate a future nursing workforce that can influence patient care outcomes. The nursing faculty shortage contributes to the problem of nursing programs turning away qualified applicants across graduate and undergraduate programs. See FIGURE 1-2.

FIGURE 1-2 Faculty vacancies (full-time equivalents) by program. Reproduced from National League for Nursing. (2017). Faculty vacancies (full-time equivalents) by program, 2017.

Currently there is a growing need for nurses who are pursuing advanced degrees to learn to prepare to be nurse educators. Competence as an educator can be established, recognized, and expanded through master’s and doctoral education, postmaster’s

certificate programs, continuing professional development courses, mentoring activities, and professional certification as a faculty member. Each academic unit in nursing must include a cadre of experts in nursing education who provide the leadership needed to advance nursing education, conduct pedagogical research, and contribute to the ongoing development of the science of nursing education.

Nurse Practitioners Nurse practitioners have been providing care to vulnerable populations in rural and urban areas since the 1960s. The role was born out of the shortage of primary care physicians able to serve pediatric populations. Initial educational preparation ranged from 3 to 12 months, and as the role developed and expanded, so did educational requirements. By the 1990s, the master’s degree was endorsed as entry-level education for nurse practitioner specialties. In 2004, the AACN took a position recognizing the doctor of nursing practice as the entry-level degree for advanced practice nursing, stating the following: Advanced competencies for increasingly complex clinical, faculty and leadership roles . . . enhanced knowledge to improve nursing practice and patient outcomes . . . enhanced leadership skills . . . better match of program requirements . . . provision of an advanced educational credential . . . parity with other health care professionals . . . enhanced ability to attract individuals to nursing from non-nursing backgrounds; increased supply of faculty for clinical instruction; and improved image of nursing. (AACN, 2004, p. 7) Today, nurse practitioners are the largest group of advanced practice nurses. More than 248,000 NPs are licensed and practicing with some level of prescriptive authority in all 50 states and the District of Columbia (American Association of Nurse Practitioners, 2017). Nurse practitioners work, are educated, and hold board certification in a variety of specialty areas, including pediatrics, family, adult-gerontology, women’s health, and acute care, to name a few. See TABLE 1-3.

TABLE 1-3 Distribution, Top Practice Setting, and Clinical Focus Area by Area of NP Certification

Description * NPs may be certified in more than one area ^ Primary Care Focus Modified from American Association of Nurse Practitioners. (2018). NP fact sheet. Retrieved from https://www.aanp.org/all-about-nps/np-fact-sheet

A federal initiative continues to exist to increase the number of primary care providers in the United States. The 2010 consensus report titled the Future of Nursing developed by the Institute of Medicine (IOM) and the Robert Wood Johnson Foundation (RWJF) calls for a

transformative change in nursing education. It calls for nurses to “practice to the full extent of their education and training” and for “nurses to achieve higher levels of education and training through an improved education system” (IOM, 2010). This analysis and recommendation coincided with the passage of the legislation for the Patient Protection and Affordable Care Act of 2010, which is estimated to increase the need for qualified primary care providers to 241,200 by 2020. The growing demand for nurse practitioners nationwide is estimated to increase 36% between 2016 and 2026, substantially faster than the 7% growth rate expected for all occupations during the same time period (U.S. Bureau of Labor Statistics, 2018). This rapid increase in the demand for NPs, particularly family nurse practitioners (FNPs), is fueled in part by the predicted shortfall of more than 20,000 primary care physicians by 2025. Thirty-seven states are projected to have a shortage of primary care physicians in 2025, with 12 of these states having a deficit of 1,000 or more full-time positions, so the need for FNPs will help fill the gap (USDHHS/HRSA, National Center for Workforce Analysis, 2016). This, coupled with a demographically aging and ethnically diverse population, makes the demand for primary care providers—in particular, nurse practitioners—greater than ever. It is well known that nurse practitioners provide high-quality, safe, and cost-effective care. Excellent educational programs are needed to increase this pool of healthcare providers to improve access to care and strengthen care provided for elderly and other vulnerable populations.

Nurse–Midwives The first nurse–midwifery school was established in 1925 by Mary Breckenridge, who founded the Frontier Nursing Service (FNS) in Hyden, Kentucky, in response to the high maternal and child death rates in rural eastern Kentucky, an area isolated by geography and poverty. The midwives were educated to provide family health services, as well as childbearing and delivery care, at nursing centers in the Appalachian Mountains. As reported by the FNS (2014), by the late 1950s, the FNS nurse–midwives had attended more than 10,000 births, and maternal and infant outcome statistics in rural Kentucky were better than those for the whole country during the nurse–midwives first three decades of service.

The most significant differences were in maternal mortality rates (9.1 per 10,000 births for FNS compared with 34 per 10,000 births for the United States as a whole) and low birth weights (3.8% for FNS compared with 7.6% for the country). Today, all nurse–midwifery programs are housed in colleges and universities. There are multiple entry paths to midwifery education, but most nurse–midwives graduate at the master’s degree level, and several programs culminate in the DNP degree. These programs must be accredited by the American College of Nurse-Midwives (ACNM) for graduates to be eligible to take the national certification examination offered by the American Midwifery Certification Board (AMCB). Midwifery practice as conducted by certified nurse–midwives and certified midwives (CMs) is the autonomous primary care management of women’s health, focusing on pregnancy, childbirth, the postpartum period, care of the newborn, family planning, and gynecologic needs of women. CNMs are licensed, independent healthcare providers who have prescriptive authority in all 50 states, the District of Columbia, American Samoa, Guam, and Puerto Rico. CNMs are defined as primary care providers under federal law. Although midwives are well known for attending births, 53.3% of CNMs identify reproductive care and 33.1% identify primary care as their main responsibilities in their full-time positions (Fullerton, Schuiling, & Sipe, 2010). Examples include performing annual exams; writing prescriptions; providing basic nutrition counseling, parenting education, and patient education; and conducting reproductive health visits. According to the American Midwifery Certification Board, there are 11,826 CNMs and 101 CMs in practice in the United States. Since 1991, the number of midwife-attended births in the United States has nearly doubled. In 2014, CNMs or CMs attended 332,107 births—a slight increase despite a decrease in total U.S. births compared with births in 2011 (ACNM, 2016). In 2014, CNMs or CMs attended 94.2% of all midwife-attended births, 12.1% of all vaginal births, and 8.3% of total U.S. births (Hamilton, Martin, Osterman, Curtin, & Mathews, 2015). FIGURE 1-3 shows birth data from 2005 to 2014. Whereas the majority of midwife-attended births occur in hospitals, some occur at home and in freestanding birth centers. See FIGURE 1-4.

FIGURE 1-3 Percentage of births attended by nurse–midwives and certified midwives, 20052014. Data from Hamilton B., Martin, J., Osterman, M., Curtin, S., & Mathews, T. Births: Final data for 2014. National Vital Statistics Reports, 64(12). Hyattsville, MD: National Center for Health Statistics, 2015. Retrieved from http://www.midwife.org/Essential-Facts-about-Midwives

Description

FIGURE 1-4 Site of births attended by certified nurse–midwives and certified midwives, 2014. Reproduced from Martin, J., Hamilton, B., Osterman, M., Curtin, S., & Mathews, T. Births: Final data for 2014. National Vital Statistics Reports, 64(12). Hyattsville, MD: National Center for Health Statistics, 2015. Retrieved from: https://www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_12.pdf

Allowing CNMs to have hospital privileges as full, active members of the medical staff would promote continuity of care, and birth certificate data would more accurately reflect provider type and outcomes (Buppert, 2012). Medicaid reimbursement for midwifery care is mandatory in all states and is 100% of the physician fee schedule under the Medicare Part B fee schedule. The majority of states also mandates private insurance reimbursement for midwifery services. It is clear that nurse– midwives have improved primary healthcare services for women in rural and inner-city areas. It is imperative that nurse–midwives be given a

larger role in delivering women’s health care for the greater good of society.

Nurse Anesthetists According to the American Association of Nurse Anesthetists (AANA), nurses have been providing anesthesia services to patients in the United States for more than 150 years. The first anesthesia administered to patients was chloroform, used for the treatment of wounded soldiers during the American Civil War. The shortages of physicians qualified to administer anesthesia during wartimes continued, and nurse anesthetists were the main providers of anesthesia care for U.S. military personnel on the front lines for World War I, World War II, the Korean War, and the Vietnam War; nurse anesthetists also provide care in the current conflicts in the Middle East (Keeling, 2009). Historically, nurse anesthetists have been the primary providers of anesthesia care in rural America, enabling healthcare facilities in medically underserved areas to offer obstetrical, surgical, pain management, and trauma stabilization services. In some states, CRNAs are the sole providers in nearly 100% of rural hospitals. According to the U.S. Bureau of Labor Statistics (2016), there are 39,860 employed CRNAs in the United States, with the highest employment rates in the states of Texas, Ohio, North Carolina, Pennsylvania, and Florida, respectively. Nurse anesthetists enjoy a higher mean annual wage than their nurse practitioner and nurse–midwife counterparts of $164,030 versus $103,880 (NPs) versus $100,590 (CNMs) (U.S. Bureau of Labor Statistics, 2016). The credential CRNA came into existence in 1952 when the AANA established an accreditation program to monitor the quality and consistency of nurse anesthetist education (Keeling, 2009). Today, CRNAs safely administer 45 million anesthetics to patients each year in the United States (AANA, 2018a). The scope and standards of practice for CRNAs are similar to those for other advanced practice registered nurses. Nurse anesthetists are licensed as independent practitioners, and they provide care autonomously and in collaboration with surgeons, dentists, podiatrists, and anesthesiologists, among other healthcare professionals. CRNAs provide evidence-based anesthesia and pain care

services to patients at all acuity levels in a variety of settings for procedures, including, but not limited to, surgical, obstetrical, diagnostic, therapeutic, and pain management (AANA, 2018b). Currently, CRNAs are qualified and have the legal authority to administer anesthesia without anesthesiologist supervision in all 50 states, the District of Columbia, Puerto Rico, and the Virgin Islands; however, some states have put into place restrictions and supervisory requirements in some settings (Joel, 2013).

Nurse Administrators The term nurse administrators is being used to simplify the following discussion. This includes such roles as the nurse executive, supervisor, director, nurse manager, and so forth. Because individuals in these roles are responsible for leading a successful work environment, it is ironic that educational requirements for nurse administrators are not as demanding as those for other advanced practice roles. The knowledge, skills, and attitudes needed to be successful as a nurse administrator are not included in nursing baccalaureate programs, let alone associate degree/diploma programs, yet some of these exams are offered to experienced nurse managers without a baccalaureate and/or master’s degree, as noted in TABLE 1-4. TABLE 1-4 Educational Requirements for Nurse Administrator Certifying Organizations



American Nurses Credentialing Center

American Organization of Nurse Executives

Basic certification

Hold a bachelor’s or higher degree in nursing

Associate degree Diploma Bachelor’s degree

Advanced certification

Hold a master’s or higher degree in nursing or hold a bachelor’s degree in nursing and a master’s in another field

Master’s degree or higher

Data from American Nurses Credentialing Center (ANCC). (2019). ANCC certification center. Retrieved from https://www.nursingworld.org/our-certifications/; American Organization of Nurse Executives (AONE). (2019). About AONE credentialing center. Retrieved from http://www.aone.org/initiatives/certification.shtml

Description There are two organizations that certify nurse administrators: the American Nurses Credentialing Center and the American Organization of Nurse Executives. Both offer certification exams in basic and advanced/executive nursing administration. Table 1-4 includes the educational requirements for each organization. Years and levels of experience vary for each certification exam and can be accessed on their websites (ANCC, 2019; AONE, 2019b). Further complicating the preparation of nurse administrators are the following practices by many organizations: Promoting good “bedside” nurses to managerial positions without assessing or developing their leadership abilities Weak orientation/on-the-job training for new nurse administrators No requirements for an advanced degree for the position

Conclusion A national initiative exists to improve access to high-quality health care while reducing costs. This mandate will require the emergence of many new roles not yet imagined for nurses. Recently, new roles to serve as coordinators of care, such as nurse navigators and healthcare coaches, have been established. In the future, these roles may require advanced degrees and certification. Opportunities for nurses to coordinate care throughout the continuum of care are likely to abound. The aging population will require nurses to be chronic disease specialists and wellness coaches. Population health, gender-specific health care, and global health specialties will become the norm. An understanding of the healthcare delivery system, healthcare policy, and care transition will need to be incorporated into graduate curricula. As this book goes to press, there is a push to expand and clarify the definition of and requirements for advanced practice nursing. No matter the final outcome of this deliberation, all nurses need the same set of essential knowledge and the ability to think outside the box.

Discussion Questions 1. What are the differences between the terms advanced practice nursing and advanced practice registered nurse? 2. What emerging roles should be considered when describing advanced practice nursing? 3. Why was the APRN consensus model developed, and what does it hope to do for the provision of health care?

References American Association of Colleges of Nursing (AACN). (2004). AACN position statement on the practice doctorate in nursing. Retrieved from https://www.aacnnursing.org/Portals/42/News/Position-Statements/DNP.pdf American Association of Colleges of Nursing (AACN). (2006). The essentials of doctoral education for advanced nursing practice. Washington, DC: Author. American Association of Colleges of Nursing (AACN). (2007). White paper on the education and role of the clinical nurse leader. Washington, DC: Author. American Association of Colleges of Nursing (AACN). (2011a). The essentials of master’s education in nursing. Washington, DC: Author. American Association of Colleges of Nursing (AACN). (2011b). 2010–2011 enrollment and graduations in baccalaureate and graduate programs in nursing. Washington, DC: Author. American Association of Colleges of Nursing (AACN). (2013). Competencies and curricular expectations for clinical nurse leader education and practice. Retrieved from https://www.aacnnursing.org/Portals/42/AcademicNursing/CurriculumGuidelines/CNLCompetencies-October-2013.pdf American Association of Colleges of Nursing (AACN). (2014). Essentials series. Retrieved from https://www.aacnnursing.org/Education-Resources/AACN-Essentials American Association of Nurse Anesthetists (AANA). (2018a). Certified registered nurse anesthetists fact sheet. Retrieved from https://www.aana.com/membership/become-acrna/crna-fact-sheet American Association of Nurse Anesthetists (AANA). (2018b). Professional practice documents: Scope of nurse anesthesia practice. Retrieved from https://www.aana.com/docs/defaultsource/practice-aana-com-web-documents-(all)/scope-of-nurse-anesthesia-practice.pdf American Association of Nurse Practitioners (AANP). (2017). National NP Sample Survey: An overview. Austin, TX: Author. American Association of Nurse Practitioners (AANP). (2019). NP fact sheet. Retrieved from http://www.aanp.org/all-about-nps/np-fact-sheet American College of Nurse-Midwives (ACNM). (2016). Fact sheet: Essential facts about midwives. Retrieved from http://www.midwife.org/acnm/files/ccLibraryFiles/Filename/000000005948/EssentialFactsAboutMidwives021116FINAL.pdf American Nurses Credentialing Center (ANCC). (2019). ANCC certification center. Retrieved from https://www.nursingworld.org/our-certifications/ American Organization of Nurse Executives (AONE). (2019a). AONE guiding principles for nurse leaders. Retrieved from http://www.aone.org/resources/guiding-principles.shtml American Organization of Nurse Executives (AONE). (2019b). About AONE credentialing center. Retrieved from http://www.aone.org/initiatives/certification.shtml APRN Consensus Work Group & National Council of State Boards of Nursing APRN Advisory Committee. (2008, July 7). Consensus model for APRN regulation: Licensure, accreditation, certification and education. APRN Joint Dialogue Group Report. Retrieved from https://www.aacnnursing.org/Portals/42/AcademicNursing/pdf/APRNReport.pdf Buppert, C. (2012). Hospital privileges. In C. Buppert (Ed.), Nurse practitioner’s business practice and legal guide (pp. 247–253). Burlington, MA: Jones & Bartlett. Commission on Nurse Certification. (2018). American Association of Colleges of Nursing (AACN) institutional data. Retrieved from https://www.aacnnursing.org/Portals/42/CNL/CNLStats.pdf Frontier Nursing Service (FNS). (2014). A brief history of the Frontier Nursing Service. Retrieved

from https://www.frontiernursing.org/History/HowFNSbegan.shtm Fullerton, J., Schuiling, K., & Sipe, T. A. (2010). Findings from the analysis of the American College of Nurse-Midwives’ membership surveys: 2006–2008. Journal of Midwifery and Women’s Health, 55, 299–307. Fulton, J. S. (2014). Evolution of the clinical nurse specialist role and practice in the United States. In J. S. Fulton, B. L. Lyon, & K. A. Goudreau (Eds.), Foundations of clinical nurse specialist practice (2nd ed., pp. 1–16). New York, NY: Springer. Haase-Herrick, K., & Herrin, D. (2007). The American organization of nurse executives’ guiding principles and American Association of Colleges of Nursing’s clinical nurse leader. Journal of Nursing Administration, 37(2), 55–60. Hamilton, B., Martin, J. A., Osterman, M., Curtin, S., & Mathews, T. (2015). Births: Final data for 2014. National Vital Statistics Reports, 64(12). Hyattsville, MD: National Center for Health Statistics. Retrieved from https://www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_12.pdf Institute of Medicine. (2010). The future of nursing: Leading change, advancing health. Retrieved from http://nationalacademies.org/hmd/~/media/Files/Report%20Files/2010/The-Future-ofNursing/Future%20of%20Nursing%202010%20Report%20Brief.pdf Joel, L. (2013). Advanced practice nursing: Essentials of role development (3rd ed.). Philadelphia, PA: F. A. Davis. Keeling, A. W. (2009). A brief history of advanced practice nursing in the United States. In A. B. Hamric, J. A. Spross, & C. M. Hanson (Eds.), Advanced practice nursing: An integrative approach (4th ed., pp. 3–32). St. Louis, MO: Elsevier. McClelland, M., McCoy, M., & Burson, R. (2013). Clinical nurse specialists: Then, now, and the future of the profession. Clinical Nurse Specialist, 27(2), 96–102. National Association of Clinical Nurse Specialists (NACNS). (2005). Statement on clinical nurse specialist practice and education (2nd ed.). Harrisburg, PA: Author. National Association of Clinical Nurse Specialists (NACNS). (2018). Statement on clinical nurse specialist practice and education. (3rd ed.). Retrieved from http://nacns.org/wpcontent/uploads/2018/05/3rd-Edition-Statement-on-Clinical-Nurse-Specialist-Practice-andEducation-2018-line-numbers.pdf National Association of Clinical Nurse Specialists (NACNS). (2019). CNS scope of practice and prescriptive authority. Retrieved from http://nacns.org/wpcontent/uploads/2016/11/PractPrescAuthority1605.pdf National CNS Competency Revision Task Force. (2018). Core clinical nurse specialists competencies. Retrieved from http://nacns.org/wp-content/uploads/2018/05/CoreCompetencies-CNS-Table-2-2018-line-numbers.pdf National League for Nursing (NLN). (2002). Position statement: The preparation of nurse educators. Retrieved from http://www.nln.org/docs/default-source/about/archived-positionstatements/the-preparation-of-nurse-educators-pdf.pdf National League for Nursing (NLN). (2007). Position statement: The need for funding for nursing education research. Retrieved from http://www.nln.org/docs/default-source/about/archivedposition-statements/nursingedresearch_051807.pdf?sfvrsn=6 National League for Nursing. (2017). Faculty vacancies (full time equivalents) by program. NLN Faculty Census Survey. Retrieved from http://www.nln.org/docs/default-source/defaultdocument-library/faculty-vacancies-(full-time-equivalents)-by-program-2017.pdf?sfvrsn=0 U.S. Bureau of Labor Statistics, U.S. Department of Labor. (2016). Occupational employment and wages, 29-1151. Nurse anesthetists. Retrieved from https://www.bls.gov/oes/2016/may/oes291151.htm#nat U.S. Bureau of Labor Statistics, U.S. Department of Labor. (2018). Occupational outlook handbook: Nurse anesthetists, nurse midwives, and nurse practitioners. Retrieved from

https://www.bls.gov/ooh/healthcare/nurse-anesthetists-nurse-midwives-and-nursepractitioners.htm U.S. Department of Health and Human Services, Health Resources and Services Administration, National Center for Health Workforce Analysis. (2016). National and regional projections of supply and demand for primary care practitioners: 2013–2015. Rockville, MD: Author. Retrieved from https://bhw.hrsa.gov/sites/default/files/bhw/health-workforceanalysis/research/projections/primary-care-national-projections2013-2025.pdf U.S. Department of Health and Human Services, Health Resources and Services Administration, National Center for Health Workforce Analysis. (2017). Supply and demand projections of the nursing workforce: 2014–2030. Rockville, MD: Author. Retrieved from https://bhw.hrsa.gov/sites/default/files/bhw/nchwa/projections/NCHWA_HRSA_Nursing_Report.pdf

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CHAPTER 2 Historical Perspectives: The Art and Science of Nurse Practitionering Julie G. Stewart

CHAPTER OBJECTIVES 1. Identify factors that contributed to the evolution of the nurse practitioner role in the United States. 2. Describe the key attributes that make the nurse practitioner role unique. 3. Explore the different educational pathways that are shaping the curriculum in nurse practitioner programs.



U

.S. News and World Report (2017) lists nurse practitioner (NP) as the second top occupation for 2017. There were 23,000 new NP graduates in 2015 who joined the ranks of the nation’s roughly 270,000 NPs, a number that has almost doubled within 10 years (American Association of Nurse Practitioners [AANP], 2019). In 2010, the Institute of Medicine (IOM) released a report that identified the need for nurses to be placed at the forefront of health care. The report strongly recommended that advanced practice registered nurses—including nurse practitioners—be allowed to practice to the full scope of their abilities and that barriers be removed to enable moving forward. We have come a long way since 2010, but there are still

milestones to reach and barriers to break. Nurse practitioners reached a tipping point as a profession (Buerhaus, 2010). Malcolm Gladwell states that the “tipping point is that magic moment when an idea, trend, or social behavior crosses a threshold, tips, and spreads like wildfire” (Gladwell, 2000, p. 12). Nurse practitioners have been given the opportunity to shine and to experience growth professionally. Nurse practitioners provide a solution to some of the issues affecting health care in America today. The need for NPs is growing as we consider the IOM’s recommendation and the large population of aging baby boomers, which is anticipated to increase the use of the healthcare system (U.S. Department of Health & Human Services [USDHHS], 2011; Van Leuven, 2012). In addition, the Patient Protection and Affordable Care Act signed in 2010 instituted comprehensive health insurance reform and expanded healthcare insurance coverage to 32 million Americans (USDHHS, 2011). Researchers have validated the cost, quality, and competence of NPs’ role in providing primary care with outcomes that are similar to primary care physicians (Hamric, Spross, & Hanson, 2009; Laurant et al., 2005; Mundinger et al., 2000; Wilson et al., 2005). Medical economist and health futurist Jeffrey C. Bauer (2010) reviewed evidence-based data in an article to illustrate how NPs functioning independently can meet the cost-effective needs of healthcare reform while providing high-quality care for patients in multiple settings. Indeed, more than 1 billion patients visit NPs for health care annually (AANP, 2019). At least 87% of NPs are educated to provide primary care, and two out of three are educated as family NPs (AANP, 2019); however, in some states, many NPs are not working in primary care possibly because of the state’s restrictions on requiring collaborators and written agreements with physicians. Many states have recognized this barrier and have removed those requirements, and many insurance companies are including NPs in their provider networks. So, will we meet the near future needs for healthcare providers? The answer appears to be a resounding yes. In an age-cohort, regression-based model, RAND Health projected that the future workforce of NPs will grow to 244,000 by the year 2025 (Auerbach, 2012), and as previously mentioned, we are already more than 270,000 strong. Clearly, there is a need to fully understand the role of the NP in order to advance professionalism and unity of the NP

workforce. Seminar discussions regarding pertinent issues must be part of the education of student NPs and included in discussion among those already in practice.

Historical Perspective The role of the nurse practitioner was developed as a way to provide primary care for the underserved. The role is typically described as having emerged during the 1960s, yet Lillian Wald’s nurses of the late 1800s bear a striking resemblance to NPs of today. The nurses of Wald’s Henry Street Settlement House in New York City provided primary care for poverty-stricken immigrants and treated common illnesses and emergencies that did not require referral (Hamric et al., 2009). In 1965, the role of nurse practitioner was formally developed by Loretta Ford, EdD (nurse educator), and Henry Silver, MD (professor of medicine), both of whom were teaching at the University of Colorado (Sullivan-Marx, McGivern, Fairman, & Greenberg, 2010). This nurse practitioner program was developed not only to advance the nursing profession but also in response to the need for providers in rural, underserved areas. The program was initially funded by a $7,000 grant from the School of Medicine at the University of Colorado (Weiland, 2008). The first program was a pediatric NP program based on the nursing model, yet the program advanced the clinical practice of these students by teaching them how to provide primary care and how to make medical diagnoses. These early NP pioneers were focused on having a positive effect on advancing the profession, “making a difference,” and gaining autonomy (Weiland, 2008, p. 346). However, due to the socioeconomic and political climate of the times, the NP was viewed to be a cost-effective way to offer healthcare providers for the underserved. During the 1970s, federal funding helped to establish many NP programs to address a shortage of primary care physicians, particularly in underserved areas. Idaho was the first state to endorse nurse practitioners’ scope of practice to include diagnosis and treatment in 1971. NP programs doubled between 1992 and 1997. By the year 2000, there were 321 institutions that offered either a master’s level or a postmaster’s-level NP program (Health Resources and Services Administration [HRSA], 2004). By 2002, more than 30% of NPs were working with vulnerable populations, including the homeless, indigent, chronically ill, and elderly (Stewart, 2019). Today there are more than 400 institutions educating nurse practitioners and

270,000 licensed nurse practitioners in the United States (AANP, 2019).

Nurse Practitioner Education and Title Clarification In the 1960s, the role of the NP was not warmly welcomed by nurse educators; therefore, many educational programs to train nurses in the NP role were more often continuing education programs rather than university-housed programs (Pulcini, 2013). In the 1980s and 1990s, NP education moved into the university setting as master’s-level programs, although confusion arose when there were efforts to interchange the clinical nurse specialist (CNS) and NP roles. Today there are well over 330 graduate-level NP programs, and many have switched to offering only a clinical doctorate—the doctor of nursing practice (DNP)—for NP education in response to the American Association of Colleges of Nursing’s (AACN’s) recommendation that advanced practice nurses be educated at that level by 2015. In 2008, the Consensus Model for APRN Regulation: Licensure, Accreditation, Certification & Education was finalized through the collaborative efforts of the APRN [Advanced Practice Registered Nurse] Consensus Work Group and the National Council of State Boards of Nursing APRN Advisory Committee. To clarify who is an advanced practice registered nurse, the document included the following definition (APRN Consensus Work Group & National Council of State Boards of Nursing APRN Advisory Committee, 2008): An advanced practice registered nurse (APRN) is a nurse: 1. Who has completed an accredited graduate-level education program preparing him or her for one of the four recognized APRN roles; 2. Who has passed a national certification examination that measures APRN role and population-focused competencies, and who maintains continued competence as evidenced by recertification in the role and population through the national certification program;

3. Who has acquired advanced clinical knowledge and skills preparing him or her to provide direct care to patients, as well as a component of indirect care; however, the defining factor for all APRNs is that a significant component of the education and practice focuses on direct care of individuals; 4. Whose practice builds on the competencies of registered nurses (RNs) by demonstrating a greater depth and breadth of knowledge, a greater synthesis of data, increased complexity of skills and interventions, and greater role autonomy; 5. Who is educationally prepared to assume responsibility and accountability for health promotion and maintenance as well as the assessment, diagnosis, and management of patient problems, which includes the use and prescription of pharmacologic and nonpharmacologic interventions; 6. Who has clinical experience of sufficient depth and breadth to reflect the intended license; and 7. Who has obtained a license to practice as an APRN in one of the four APRN roles: certified registered nurse anesthetist (CRNA), certified nurse–midwife (CNM), clinical nurse specialist (CNS), or certified nurse practitioner (CNP).1 Clearly, NPs are one of the four roles that fall under the umbrella definition for APRN; however, using the title “APRN” does not clearly define which role and educational background the professional has. Each APRN role differs from the others, and state regulatory agencies vary in requirements for licensing in each state, and in many cases, for each APRN role.

The Master’s Essentials The American Association of Colleges of Nursing (2011) prepared the Essentials for Master’s Education in Nursing. There are nine essentials that focus on outcomes and are for all master’s-level programs. In addition, direct patient care provider (APRN) education must offer three separate courses on the “3 Ps,” which are advanced pharmacology, advanced pathophysiology, and advanced physical assessment. The nine essentials are (AACN, 2011): I. Background for practice from sciences and humanities II. Organizational and systems leadership III. Quality improvement and safety IV. Translating and integrating scholarship into practice V. Informatics and healthcare technologies VI. Health policy and advocacy VII. Interprofessional collaboration for improving patient and population health outcomes VIII. Clinical prevention and population health for improving health IX. Master’s-level nursing practice Essential IX, master’s-level nursing practice, recognizes that nursing practice, at the master’s level, is broadly defined as any form of nursing intervention that influences healthcare outcomes for individuals, populations, or systems. Master’s-level nursing graduates must have an advanced level of understanding of nursing and relevant sciences as well as the ability to integrate this knowledge into practice. Nursing practice interventions include both direct and indirect care components (AACN, 2011).

Nurse Practitioner Core Competencies In addition to the AACN, which strives to advance the education of nurses in general, the National Organization for Nurse Practitioner Faculties (NONPF) sets the standards for nurse practitioner programs. The NONPF has stated that there are core competencies for nurse practitioners in all tracks and specialties. These are listed here so that the NP student can review and understand how coursework reflects these competencies (NONPF, 2017).

Scientific Foundation Competencies 1. Critically analyzes data and evidence for improving advanced nursing practice. 2. Integrates knowledge from the humanities and sciences within the context of nursing science. 3. Translates research and other forms of knowledge to improve practice processes and outcomes. 4. Develops new practice approaches based on the integration of research, theory, and practice knowledge.

Leadership Competencies 1. Assumes complex and advanced leadership roles to initiate and guide change. 2. Provides leadership to foster collaboration with multiple stakeholders (e.g., patients, community, integrated healthcare teams, and policymakers) to improve health care. 3. Demonstrates leadership that uses critical and reflective thinking. 4. Advocates for improved access, quality, and cost-effective health care. 5. Advances practice through the development and implementation

of innovations incorporating principles of change. 6. Communicates practice knowledge effectively both orally and in writing. 7. Participates in professional organizations and activities that influence advanced practice nursing and/or health outcomes of a population focus.

Quality Competencies 1. Uses best available evidence to continuously improve quality of clinical practice. 2. Evaluates the relationships among access, cost, quality, and safety and their influence on health care. 3. Evaluates how organizational structure, care processes, financing, marketing, and policy decisions affect the quality of health care. 4. Applies skills in peer review to promote a culture of excellence. 5. Anticipates variations in practice and is proactive in implementing interventions to ensure quality.

Practice Inquiry Competencies 1. Provides leadership in the translation of new knowledge into practice. 2. Generates knowledge from clinical practice to improve practice and patient outcomes. 3. Applies clinical investigative skills to improve health outcomes. 4. Leads practice inquiry, individually or in partnership with others. 5. Disseminates evidence from inquiry to diverse audiences using multiple modalities. 6. Analyzes clinical guidelines for individualized application into practice.

Technology and Information Literacy Competencies

1. Integrates appropriate technologies for knowledge management to improve health care. 2. Translates technical and scientific health information appropriate for various users’ needs. a. Assesses the patient’s and caregiver’s educational needs to provide effective, personalized health care. b. Coaches the patient and caregiver for positive behavioral change. 3. Demonstrates information literacy skills in complex decision making. 4. Contributes to the design of clinical information systems that promote safe, high-quality, and cost-effective care. 5. Uses technology systems that capture data on variables for the evaluation of nursing care.

Policy Competencies 1. Demonstrates an understanding of the interdependence of policy and practice. 2. Advocates for ethical policies that promote access, equity, quality, and cost. 3. Analyzes ethical, legal, and social factors influencing policy development. 4. Contributes to the development of health policy. 5. Analyzes the implications of health policy across disciplines. 6. Evaluates the impact of globalization on healthcare policy development. 7. Advocates for policies for safe and healthy practice environments.

Health Delivery System Competencies 1. Applies knowledge of organizational practices and complex systems to improve healthcare delivery. 2. Effects healthcare change using broad-based skills, including negotiating, consensus building, and partnering. 3. Minimizes risk to patients and providers at the individual and systems level.

4. Facilitates the development of healthcare systems that address the needs of culturally diverse populations, providers, and other stakeholders. 5. Evaluates the impact of healthcare delivery on patients, providers, other stakeholders, and the environment. 6. Analyzes organizational structure, functions, and resources to improve the delivery of care. 7. Collaborates in planning for transitions across the continuum of care.

Ethics Competencies 1. Integrates ethical principles in decision making. 2. Evaluates the ethical consequences of decisions. 3. Applies ethically sound solutions to complex issues related to individuals, populations, and systems of care.

Independent Practice Competencies 1. Functions as a licensed independent practitioner. 2. Demonstrates the highest level of accountability for professional practice. 3. Practices independently, managing previously diagnosed and undiagnosed patients. a. Provides the full spectrum of healthcare services to include health promotion, disease prevention, health protection, anticipatory guidance, counseling, disease management, palliative care, and end-of-life care. b. Uses advanced health assessment skills to differentiate between normal, variations of normal, and abnormal findings. c. Employs screening and diagnostic strategies in the development of diagnoses. d. Prescribes medications within scope of practice. e. Manages the health or illness status of patients and families over time. 4. Provides patient-centered care recognizing cultural diversity and the patient or designee as a full partner in decision making.

a. Works to establish a relationship with the patient characterized by mutual respect, empathy, and collaboration. b. Creates a climate of patient-centered care to include confidentiality, privacy, comfort, emotional support, mutual trust, and respect. c. Incorporates the patient’s cultural and spiritual preferences, values, and beliefs into health care. d. Preserves the patient’s control over decision making by negotiating a mutually acceptable plan of care. e. Develops strategies to prevent one’s own personal biases from interfering with delivery of high-quality care. f. Addresses cultural, spiritual, and ethnic influences that potentially create conflict among individuals, families, staff and caregivers. 5. Educates professional and lay caregivers to provide culturally and spiritually sensitive, appropriate care. 6. Collaborates with both professional and other caregivers to achieve optimal care outcomes. 7. Coordinates transitional care services in and across care settings. 8. Participates in the development, use, and evaluation of professional standards and evidence-based care.2 The comprehensive components of the competencies that must be met for role development are necessary and useful for developing curricula and for evaluating the NP student during the educational training period as well as containing standards to which the practicing NP can be held accountable.

Doctor of Nursing Program (DNP) In response to the confusion arising from the variety of doctoral degrees that nurses seeking to advance their education were obtaining, the AACN developed a task force to address the issue in 1999 (Zaccagnini & White, 2011). Until this point, nurses had obtained doctorates in education (EdD), PhDs in nursing or other disciplines, doctorates in nursing science (DNS/DNSc), and doctorates in nursing (ND). In 2004, the AACN formally approved the doctor of nursing practice degree, which is focused on clinical practice in contrast to the research-focused doctoral degree obtained with a PhD. This degree is not only for NPs but also offers a clinical doctorate for all nurses who seek to improve healthcare delivery systems and patient outcomes. Although an original goal was to have the DNP as entry level for the NP by 2015, the complexities associated with the endeavor, particularly at the state licensure level, made this impossible to achieve. However, the AACN endorses the DNP as a goal for all APRNs (AACN, 2013). The DNP is recognized as the terminal practice degree (AACN, 2006). Why is there a need for a DNP when numerous studies have validated the excellent and cost-effective care provided by Master of Science in Nursing (MSN)-level NPs (AANP, 2010a, 2010b)? Owing to the ever-increasing complexity of health care and healthcare delivery systems, it is optimal to have clinicians who are well educated in the areas of health policy, quality improvement, evidence-based practice, and outcomes evaluation. Currently, MSN-level programs for NPs require 42 to 50 credits—much more than other MSN tracks that typically require approximately 30 credits for completion. In addition, most NP programs require at least 500 to 600 clinical hours to graduate and take certification examinations. The DNP offers the NP student additional education and preparation to meet the needs of the complex healthcare system of the near future. In addition, NPs work collaboratively with numerous other doctorally prepared clinicians whose doctorate is clinically focused, including pharmacists (PharmD), physical therapists (DPT), physicians (MD), doctors of osteopathy (DO), naturopaths (ND), and others. To achieve educational parity, the clinical doctorate (DNP) is recommended

for nurse practitioners. There are currently 303 DNP programs enrolling students in the United States, and there are at least another 124 DNP programs being developed (AACN, 2017). More than 25,200 nurses were enrolled in a DNP program in 2015–2016 (AACN, 2017). At this time, there are differences in the existing programs, particularly as they relate to the scholarship of the terminal project, the title of which in itself has sparked numerous passionate debates among leaders in doctoral-level nursing education. The AACN published The Essentials of Doctoral Education for Advanced Nursing Practice (2006) to shape the education for the DNP to meet quality indicator criteria. These essentials were developed to build upon the baccalaureate and master’s essentials and are aligned with recommendations from the IOM’s multiple reports emphasizing quality in education, evidence-based practice, and nurses practicing to the full extent of their scope of practice (Zaccagnini & White, 2011). The DNP essentials are listed here.

DNP Essentials I. Scientific underpinnings for practice II. Organizational and systems leadership for quality improvement and systems thinking III. Clinical scholarship and analytical methods for evidence-based practice IV. Information systems/technology and patient care technology for the improvement and transformation of health care V. Healthcare policy for advocacy in health care VI. Interprofessional collaboration for improving patient and population health outcomes VII. Clinical prevention and population health for improving the nation’s health VIII. Advanced nursing practice (AACN, 2006) In addition, the DNP essentials also contain language that reflects the need for the 3 Ps and the expertise required for advanced practice nurses (APNs) which is detailed here for ease of access during seminar discussions.

The AACN published a white paper—The Doctor of Nurse Practice: Current Issues and Clarifying Recommendations—which describes and clarifies the “characteristics of DNP graduate scholarship, the DNP project, efficient use of resources, program length, curriculum considerations, practice experiences, and collaborative partnership guidelines” (AACN, 2015, para 4). Of particular interest to the DNP educator and student are the components required for the DNP Scholarly Project, which must: a. Focus on a change that affects healthcare outcomes either through direct or indirect care. b. Have a systems (micro-, meso-, or macro-level) or population/aggregate focus. c. Demonstrate implementation in the appropriate arena or area of practice. d. Include a plan for sustainability (e.g., financial, systems or political realities, not only theoretical abstractions). e. Include an evaluation of processes and/or outcomes (formative or summative). DNP Projects should be designed so that processes and/or outcomes will be evaluated to guide practice and policy. Clinical significance is as important in guiding practice as statistical significance is in evaluating research. f. Provide a foundation for future practice scholarship. (AACN, 2015, p. 4)

Advanced Practice Nursing Focus The DNP graduate prepared for an advanced practice role must demonstrate practice expertise, specialized knowledge, and expanded responsibility and accountability in the care and management of individuals and families. By virtue of this direct care focus, APNs develop additional competencies in direct practice and in the guidance and coaching of individuals and families through developmental, health– illness, and situational transitions (Hamric et al., 2009). The direct practice of APNs is characterized by the use of a holistic perspective; the formation of therapeutic partnerships to facilitate informed decision making, positive lifestyle change, and appropriate self-care; advanced

practice thinking, judgment, and skillful performance; and use of diverse, evidence-based interventions in health and illness management (Brown, 2005). APNs assess, manage, and evaluate patients at the most independent level of clinical nursing practice. They are expected to use advanced, highly refined assessment skills and to employ a thorough understanding of pathophysiology and pharmacotherapeutics in making diagnostic and practice management decisions. To ensure sufficient depth and focus, it is mandatory that a separate course be required for each of these three content areas: advanced health/physical assessment, advanced physiology/pathophysiology, and advanced pharmacology. In addition to direct care, DNP graduates emphasizing care of individuals should be able to use their understanding of the practice context to document practice trends, identify potential systemic changes, and make improvements in the care of their particular patient populations in the systems within which they practice (AACN, 2006, p. 18). The National Organization of Nurse Practitioner Faculties provides further clarification related to competencies for the NP educated to the DNP level (NONPF, 2006). These areas include independent practice, scientific foundations, leadership, quality, practice inquiry, technology and information literacy, policy, ethics, and health delivery systems.

Nurse Practitioners’ Approach to Patient Care Sometimes I am asked why I did not become a physician instead of an NP. My response is that becoming a nurse practitioner gave me the best of both worlds, nursing and medicine. I support my answer by stating that nursing continues to be the top trusted profession in the United States (Gallup Politics, 2016). I also point out that NPs have extremely high patient satisfaction scores. Nurse practitioners have a unique approach to health care. This is not to say that there are no physicians who are amazing—because I personally have worked with and have been under the care of fantastic physicians—but a common theme I hear from my patient population is that “nurses listen to what I have to say.” One study found that only 50% of the patients seen by physicians reported that they felt that the physician “always” listened carefully, compared to more than 80% of NP patients (Creech, Filter, & Bowman, 2011). In a study of more than 1.5 million veterans, satisfaction levels were highest in primary care clinics when the healthcare provider was an NP (Budzi, Lurie, Singh, & Hooker, 2010). The authors state that the interpersonal skills of NPs in patient teaching, counseling, and patient-centered care contribute to positive health outcomes and patient satisfaction. Encouragement to hire more NPs to increase access to cost-effective quality care for the largest healthcare system in the United States was a conclusion reached by these researchers. Of course, it is important to review and analyze quantitative research regarding the cost-effectiveness and improved health outcomes when NPs are providing primary care, but it is also as important (in many cases, more important) to listen to what patients have to say about their experiences with NPs as healthcare providers.

STEPHANIE’S STORY

At the turn of my 25th birthday, life was going well for me. I had just completed my master’s degree in elementary education and secured my first job as a head teacher in a local private school. I enjoyed my time during the day with my students, excited to employ the learning strategies I had discovered in graduate school. After school hours and on the weekends, I spent my time exercising outside, traipsing around New York City, and socializing with my friends and family. All of this changed the day I visited my gynecologist seeking treatment for a yeast infection. Having no relief from an over-the-counter antifungal medication, I turned to my gynecologist—a highly regarded physician who studied at the Chicago School of Medicine. I found Dr. X to be warm, attentive, and funny; she did her best to make me feel comfortable despite the lay-on-your-back-feet-up-in-stirrups position. After confirming my self-diagnosis with a culture, Dr. X prescribed an antifungal suppository cream and sent me on my way home. At the end of treatment, I still had severe itching and called my gynecologist’s office. After discussing my situation with the nurse, we both assumed that I was fighting off a tough strain. Dr. X prescribed a stronger medication for me, and although I was itchy throughout this course of treatment, I held hope that my symptoms would abate soon after. Still plagued with itching, I visited Dr. X a week after I finished the latest medicine. She asked me to remind her if diabetes ran in my family. She asked me to have my primary care physician run some blood work to be certain that I had not developed type II. Throughout this, Dr. X and I still kept our humor about my condition. Although we were puzzled about why it lasted so long, we both assumed that it would clear up shortly. Unfortunately, we were wrong. For 3 more months, Dr. X examined me at least twice each month as I was still experiencing relentless itching and redness. At each visit, she swabbed my vagina; ran a culture; asked if I was certain that I was not diabetic; and then prescribed me a cream, suppository, or pills. Dr. X explained that I would always test positive for yeast, as it is normal for a small amount to live in the vagina. However, she was surprised that the small amount of cells that I had caused me to be so itchy and red, that I must be sensitive to yeast. Throughout my treatment with Dr. X, she maintained her warm demeanor; however, her nursing staff grew irritated with me. They became curt with me, sighing on the phone upon hearing my voice and rushing me through procedures at office visits. Through their lack of professionalism, they made it clear that I was not an important patient and that they were skeptical of my condition. I began to feel worn down, broken. A simple infection had turned into a chronic illness, causing my gregarious nature to fade. I no longer wished to go out with friends. I pushed prospective boyfriends away so that I would not have to contend with intimacy. I stopped exercising, as body heat and sweat further aggravated my symptoms. I was tired of being sick. Understanding my discomfort, which seemed to intensify after each round of medication, Dr. X decided to try something that was not a typical course of treatment: gentian violet. This antifungal dye was “painted” onto the outside of my vagina as well as inside the first third of the canal. As with the previous medications, my symptoms worsened. My skin felt raw and burned. And although I thought it impossible at this stage, the incessant itching intensified. Dr. X was all out of ideas and sent me to see a Candida specialist located 90 minutes away. Dr. Y was an older man who entered the exam room while laughing with his nurse. Immediately he acted as though we had known each other for years. He was overly familiar, touching my arm, and doing his best to assure me that there wasn’t a patient yet who presented a medical condition he couldn’t fix. I quickly regretted taking Dr. X’s recommendation to see him. After Dr. Y questioned me about my condition, he asked me to lie back and then made

sure to point out the strategically placed artwork in the room. Above my head on the ceiling was a painting by Georgia O’Keefe. O’Keefe is famous for her floral still lifes that strongly resemble parts of the female anatomy. Dr. Y thought this was not only comical considering his line of work but also believed the art helped distract his patients from why they were in the stirrups. Personally, I found this strange, and rather than diverting my attention away from the purpose of my visit, I was forced to stare at a visual reminder while lying down! Dr. Y separately swabbed the inside of my mouth, vagina, and anus, all the while sharing double-entendre jokes with his nurse. Half naked and vulnerable, I willed myself to go through with the exam, thinking that if I could get through these lousy 10 minutes, I could finally have an answer to my problem. Dr. Y sent the swabs off to a lab and then wrote me a prescription for an antidepressant. He told me that sometimes when a person has an illness as long as I have, it really is no longer a medical condition as much as a psychological one. He told me to take the antidepressant for at least 6 weeks and that it should help get my mind off dwelling on my problem and that he wouldn’t be surprised if my symptoms vanished by that time. The nurses at Dr. X’s office made me feel as though they didn’t believe that I had an actual medical issue, and now this “specialist” was saying the same thing. Desperate for relief and willing to consider the possibility that my illness was “all in my head,” I began the antidepressant. When Dr. X’s office called to say that my tests were negative for Candida, I continued the antidepressant, now hoping that it was a psychological issue, meaning there would be an end eventually. Although my mood had improved a bit, the itching and redness did not. During this time, I had scheduled an appointment with my dermatologist to check a questionable mole. Prior to her exam, Dr. Z asked how I was doing, what was new with me. I opened my mouth to say fine but broke down in tears. I had been uncomfortable and frustrated for so long that I couldn’t control my emotions. I explained my ordeal to Dr. Z, which by this point had been going on for over 6 months, and she replied, “I think I know what you have.” Dr. Z. suspected that I had acquired eczema from being overmedicated. A biopsy of my labia proved her correct, and I started a course of steroid treatment that lasted for several months. The relief was immediate! Although I was ecstatic that I was on my way back normal, I was also very angry. Initially, yes, I had a yeast infection. But at some point, the infection cleared and the itching and redness was from the medications. So having a small amount of yeast cells in the cultures should have been a clue to Dr. X that it was not an infection. Dr. Y could not correctly diagnose my condition either and could focus only on yeast. After my experiences with Drs. X and Y, I lost trust in their capabilities as diagnosticians. I stopped seeing Dr. X and missed a year between my annual exams. Months after I ended my steroid treatment, I developed what I was certain was a yeast infection. Scared to return to a gynecologist, I called my neighbor, a nurse practitioner, for a recommendation. She referred me to a fellow nurse practitioner who was working at the local Planned Parenthood. The NP was a friendly woman, who patiently listened as I told her my recent medical history. She examined me, found a high number of yeast cells in the culture, and then prescribed me an oral antifungal so as not to cause the eczema to return. Having experienced recurring yeast infections, she asked if I was diabetic. Unlike Drs. X and Y, and the nurses at their offices, the NP didn’t stop after my reply of no. She then asked if I had a lot of wheat and/or chocolate in my diet as some recent studies have shown a correlation between those foods and yeast infections. Not able to do a thorough evaluation of my diet on the spot, I told her that I didn’t think so. She told me to think about it and to give her a call to let her know how I fared with the medication. On my drive home from Planned Parenthood, I started thinking about what I ate that morning and noon for lunch and couldn’t believe how unaware I had been earlier with the NP. My breakfast had consisted of fruit and almond butter on two wheat waffles. Lunch was ham

and cheese on whole wheat bread. The more I thought about my eating habits, the more I realized that wheat was in heavy rotation in my daily diet, and chocolate did indeed play a role during my menstrual cycle. I drove past my house and directly to the supermarket to purchase both wheat-free waffles and bread. In the 8 years since spending those enlightening 30 minutes with the NP, I have had only two yeast infections, both successfully treated with over-the-counter medications. The NP shared invaluable information with me, information that has changed my life. To this day, if one is available, I prefer to see an NP to a doctor. I have found that NPs tend to think more outside the box to solve a problem. They seem to be more aware of current research and studies and are willing to share this with their patients. Thanks to my NP, I no longer have a chronic illness.

What Nurse Practitioners Do In an effort to articulate what a nurse practitioner actually does, it is easy to discuss the tasks involved with the daily work of the NP. These tasks involve reviewing laboratory tests, performing physical examinations, charting, writing prescriptions, and ordering radiologic procedures, yet this approach describes the profession or duties of the NP and not the actual art of nurse practitionering. Dr. Loretta Ford described holistically oriented goals for self-care as what sets NPs apart from physicians in primary care (Weiland, 2008). Nurse practitionering (as a unique verb) incorporates the vital elements of nursing and philosophical theories, communication skills, diagnostic skills, coaching and educating, and, most important, developing reciprocal relationships with patients. It is the foundation of nursing that forms the basis for taking a holistic approach to the interview, assessment, diagnosis, and mutually agreed-upon goals for patient care, which help NPs to engage patients as full partners in aspects of their health care. Florence Nightingale recognized the main difference between nursing and medicine by writing that whereas medicine focuses on disease, nursing focuses on illness and suffering with the goal(s) being to ease suffering and promote disease prevention (Nightingale, 2009). Physicians are trained in a different framework from NPs. In an interesting article, “The Total Package: A Skillful, Compassionate Doctor,” the theme was stated thusly: Traditionally, medical school curricula have focused on the pathophysiology of disease while neglecting the very real impact

of disease on the patient’s social and psychological experience, that is, their illness experience. It is in this intersection that humanism plays a profound role. (Indiana University, 2009) NPs, with their comprehensive, humanistic nursing background, formulate nurse practitionering in that intersection. The role of the nurse practitioner has the foundation of nursing and has integrated segments of the medical model to become the unique profession of nurse practitioner; therefore, differences in the role and practice of nurses and nurse practitioners exist (Haugsdal & Scherb, 2003; Kleinman, 2004; Nicoteri & Andrews, 2003; Roberts, Tabloski, & Bova, 1997). However, there remains confusion among the public and other members of the healthcare team, as well as among some NP students, as to what NP practice truly means. It is not surprising that defining nurse practitionering is difficult when one considers that it has historically been difficult to define nursing (Chitty & Black, 2007). Certainly today we have comprehensive definitions of nursing developed by the American Nurses Association, the Royal College of Nursing, and the International Council of Nurses; however, it seems that Florence Nightingale wrote the first definition of a holistic approach to patient-centered care: I use the word nursing for want of a better. It has been limited to signify little more than the administration of medicines and the application of poultices. It ought to signify the proper use of fresh air, light, warmth, cleanliness, quiet, and the proper selection and administration of diet—all at the least expense of vital power to the patient. (Nightingale, 2009)

Nursing Theories for Nurse Practitioners Many nursing philosophies, theories, and models exist today, and NPs can and should build upon these for their professional practice. For example, Henderson identified the 14 basic needs of the patient (BOX 2-1), which are common needs to all humankind.

BOX 2-1 The 14 Components of Virginia Henderson’s Need Theory 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.

Breathe normally. Eat and drink adequately. Eliminate body wastes. Move and maintain desirable postures. Sleep and rest. Select suitable clothes—dress and undress. Maintain body temperature within normal range by adjusting clothing and modifying environment. Keep the body clean and well groomed, and protect the integument. Avoid dangers in the environment and avoid injuring others. Communicate with others in expressing emotions, needs, fears, or opinions. Worship according to one’s faith. Work in such a way that there is a sense of accomplishment. Play or participate in various forms of recreation. Learn, discover, or satisfy the curiosity that leads to normal development and health, and use the available health facilities.

Reproduced from Henderson, V. A. (1991). The nature of nursing: Reflections after 25 years. New York, NY: National League for Nursing Press. Pp. 22-43. Reprinted by permission of National League for Nursing.

Jean Watson’s 10 Caritas Processes (BOX 2-2) exemplify the changing relationship between patient and nurse attending to the unification of body, mind, and soul to achieve optimal health. Watson has spent many years as director of the Center for Human Caring at the University of Colorado in Denver. Watson’s theory of human caring meets the criteria for Carper’s four fundamental ways of knowing, and Watson defines the metaparadigm of person, environment, nursing, and health in her theoretical base.

BOX 2-2 Ten Caritas Processes™ 1. 2. 3. 4. 5.

Embrace altruistic values, and practice loving kindness with self and others. Instill faith and hope, and honor others. Be sensitive to self and others by nurturing individual beliefs and practices. Develop helping, trusting, and caring relationships. Promote and accept positive and negative feelings as you authentically listen to another’s story. 6. Use creative scientific problem-solving methods for caring decision making. 7. Share teaching and learning that addresses the individual needs and comprehension styles.

8. Create a healing environment for the physical and spiritual self that respects human dignity. 9. Assist with basic physical, emotional, and spiritual human needs. 10. Open to mystery, and allow miracles to enter. Reproduced from Ten Caritas Processes™, Jean Watson 2007; 2008 www.watsoncaringscience.org; Watson, J. (2008). Nursing: The philosophy and science of caring. New revised edition. Boulder, CO: University Press of Colorado. Reprinted by permission of Jean Watson.

Hildegard Peplau (1952) focused as well on the relationship between patient and nurse during which the nurse takes on the role of counselor, resource, teacher, technical expert, surrogate, and leader, as needed. Whether one is practicing professionally in the United States or elsewhere in our global arena, to be successful in clinical practice, the NP must use transcultural nursing theory, which was founded by Leininger (1995). The NP must use culturally sensitive and aware skills to develop relationships and to assess, diagnose, and treat patients. King’s framework (1981) uses personal, interpersonal, and social interacting systems to form a theory for nursing. Interestingly, when one reviews the Calgary Cambridge guide to the medical interview for physicians in training (Kurtz, Silverman, & Draper, 1998), many of the concepts are the same. The focus is on the concerns of the patient for both of these methods for interacting with patients. King’s framework gives the NP the ability to see the patient holistically by including the family and community aspects. Both King’s framework and the Calgary Cambridge guide focus on mutual goal setting—taking the time during each step of the interview, assessment, and planning stages to truly understand the patient’s issues and perspectives. By frequently eliciting the patient’s input, it is easier to develop mutual understanding and to develop interventions and goals to reach a state of optimal health. The idea of forming a partnership with the patient is hardly new. Whitlock, Orleans, Pender, and Allan (2002) wrote about this concept in a U.S. Preventative Services Task Force recommendation, “Evaluating Primary Care Behavioral Counseling Interventions: An Evidence-Based Approach.” Developing mutually respectful relationships with patients is more likely to prevent patients’ resistance to advice on healthy living and behavior change suggestions by healthcare providers. Also detailed in this recommendation is an approach the National Cancer Institute

developed to guide physician intervention in smoking cessation known as the “5 As”: assess, advise, agree, assist, and arrange. Assess: Ask about and assess behavioral health risk(s) and factors affecting choice of behavior change goals/methods. Advise: Give clear, specific, and personalized behavior change advice, including information about personal health harms/benefits. Agree: Collaboratively select appropriate treatment goals and methods based on the patient’s interest in and willingness to change the behavior. Assist: Using behavior change techniques (self-help and/or counseling), aid the patient in achieving agreed-upon goals by acquiring the skills, confidence, and social/environmental supports for behavior change, supplemented with adjunctive medical treatments when appropriate (e.g., pharmacotherapy for tobacco dependence, contraceptive drugs/devices). Arrange: Schedule follow-up contacts (in person or by telephone) to provide ongoing assistance/support and to adjust the treatment plan as needed, including referral to more intensive or specialized treatment (Whitlock et al., 2002). All the approaches mentioned in this chapter focus on the need for the healthcare provider to be open to patients’ needs, to hear what they really have to say, to understand what they really believe is wrong or right, and to let them work with you to develop goals. The ability to be culturally sensitive—and to be flexible and willing to collaborate and compromise when needed and appropriate—will help to form the framework for a successful patient–NP relationship and, most important, to assist patients to reach a state of optimum health. This is not to say that becoming expert in these skills is easy or that it can be accomplished in one course; however, the student NP should start practicing these skills as soon as the educational program begins.

Nurse Practitioners’ Unique Role In a survey seeking to identify barriers for nurse practitioners to use standardized nursing language (SNL) for documenting nursing practice, the researchers found that NP survey participants identified that their role was a blending of the nursing and medical models, and most were not aware of what SNL consisted of (Conrad, Hanson, Hasenau, & StockerSchneider, 2012). Jacqueline Fawcett (in Cody, 2013) exhorts us to sever our “romance” with medical science and nonnursing professions—and in particular, with NPs being compared to physicians providing primary care. Instead, she advises that we integrate nursing science as nurse scholars. With this in mind while clarifying the professional practice of nurse practitioners, it is important to distinguish the profession from that of physicians and physician assistants. A qualitative study by Carryer, Gardner, Dunn, and Gardner (2007) was undertaken in Australia and New Zealand where NPs were interviewed to illustrate the core role of NPs. Three components were described: dynamic practice, professional efficacy, and clinical leadership. Dynamic practice described the clinical skills and expertise the NP uses in direct patient care, including physical assessment and treatment. Professional efficacy was what the researchers titled the aspects of NP practice that are highly autonomous and accountable. This level of practice does not exclude the need for collaboration; however, the NP acts as an integral member of the multidisciplinary team. The participants also described the overlap in role boundaries that occurs with NPs and physicians. Another aspect of professional efficacy was described as being an illustration of the NP–patient relationship. Being able to integrate the complex components of psychosocial aspects in addition to the concrete physical aspects means taking the time needed in a patient visit to do so—and to develop the therapeutic link for a significant relationship. Finally, the researchers described the advanced education and clinical experience that the NP brings to the advanced professional role. NPs understand the vital place that nurses need to occupy in healthcare delivery systems and how important it is to be a part of designing and implementing systems that can improve access to high-

quality care. Therefore, NP leadership occurs in both the direct practice environment and within the context of the larger healthcare system. This final theme was not recognized at the same level by all participants. Many were still developing in this portion of role identity. Nicoteri and Andrews (2003) sought to uncover any theory that was unique to NPs and associated attributes. This integrative review of the literature found that the role of the NP is influenced by many disciplines, especially medicine. The authors posited that an emergence of theory that is unique to NPs and grounded in nursing, medicine, and social science was discovered. The authors suggested developing the concept of “nurse practitionering” (p. 500). The concept of nurse practitionering as a unique phenomenon has been written about in only a few journal articles. The term itself is not one used in typical conversation between healthcare providers and patients, nor within the nursing community; thus, there may be confusion with the term. The goal for this endeavor is not to elevate or denigrate one profession or another but to better understand the components of nurse practitionering. Hagedorn (2004) posits that the difference between nurse practitioners and “biomedical practitioners” is related to nurse practitioners’ humanistic approach to patient care. According to many theorists, such as Jean Watson, Patricia Benner, and Boykin and Schoenhofer, nursing’s essence is that of caring (Zaccagnini & White, 2011). The interpersonal focus of nursing within a caring and nurturing framework is the building block of all nursing theories (Brunton & Beaman, 2000; Chinn & Kramer, 1999; Green, 2004; Nicoteri & Andrews, 2003; Visintainer, 1986). If one accepts this as a core element of being a nurse, it would be difficult to imagine one losing this essence when acquiring advanced education that contains skills and competencies associated with the practice of medicine. In fact, NPs should be familiarizing themselves with nursing theories in order to use nursing theory to guide their practice. By doing so, one is practicing beyond the medical model, offering a unique approach to the relationship, assessment, and treatment plan. In an effort to expand upon the concept of nurse practitionering, 90 NPs in Connecticut responded to an online survey about nurse practitionering and what they believed it encompassed. Fifty-nine (65.6%) respondents stated that nurse practitionering is a unique term that

describes what they do, which is different from solely the practice of nursing or medicine. Because many activities of practice overlap and are subjective, participants were not given definitions of nursing activities versus medical activities. Regarding how much time they perceived is spent in solely nursing activities, 36.7% of participants felt it was low, between 0% and 25%. In contrast, 34.4% of NP participants felt that the amount of time spent performing medical activities was greater, being between 36% and 50%. These results are included in TABLE 2-1. TABLE 2-1 Percentage of Clinical Practice Time in Nursing and Medical Activities (N = 90) Percentage of Time

Nursing Activities

Medical Activities

0–25%

36.7% (n = 33)*

13.3% (n = 12)

26–50%

30.0% (n = 27)

34.4% (n = 31)*

51–75%

25.6% (n = 23)

32.2% (n = 29)

75–100%

7.8% (n = 7)

20.0% (n = 18)

*Bold denotes highest value.

Description The respondents were requested to enter key terms and phrases that described what is encompassed when providing care to patients as a nurse practitioner. Participants were not given terms or phrases from which to choose; rather, this portion of the survey was open ended. Similar terms were grouped together where deemed appropriate. The most frequent key phrases in order of the number of times mentioned were nurture/care/empathy (f = 31), educate (f = 30), assess/diagnose/treat/prescribe (f = 30), holistic (f = 22), listener (f = 17), collaborate (f = 13), advocate (f = 11), and coach (f = 5). The majority of the key phrases and terms in this pilot study confirm that the core of nurse practitionering is based on the nursing model. Key phrases and terms relating to medical practice included diagnosing and

treating/prescribing, which were as frequent as the caring (nursing) category, but the nursing elements were mentioned most often. In an effort to expand upon the key phrases, invitations to participate in interviews to share their perceptions of nurse practitionering were sent to 150 NPs in Connecticut. A total of 14 individual interviews were held with a convenience sample of experienced NPs willing to participate and share their perceptions. The 14 interview participants were all female, between the ages of 31 and 70 years, and currently practicing as nurse practitioners.

Authentic Listening The NPs in this study were exemplars for authentic listening. According to Bryant (2009), listening well involves being present, interested, spending time, and showing respect. One NP explained: I think the biggest reason why people like to come here is they say, “You listen. The docs don’t listen to me.” It is probably what I do the most, and one of the nurses got very frustrated with me and said, “You nurse practitioners, when a patient comes in to see the doctor and their finger is the problem, the doctor just looks at the finger and the patient is out. You go and you guys talk about everything. You have to talk about everything!” Another NP described the time she spends teaching patients: I prescribed the medications, I go out, I get the inhaler, you know, the sample inhaler and the sample spacer, and I go right back in and I tell the patient, “This is what I am ordering, and this is how you use it,” versus the pediatrician or the pulmonologist who says, “Here are your medications. I’ll have the nurse come in to teach you how to use it.”

Empathy Empathy is the ability to relate to the patient’s thoughts and feelings and to develop an understanding of what the patient is experiencing (Baillie, 1996). The NPs in this study are genuinely concerned about the patient’s

psychosocial well-being, family matters, and future goals and aspirations: This woman this morning has lots of what I perceive as small complaints. She’s a relatively healthy 28-year-old woman, and I asked her, “Tiffany, are you working?” She said, “No.” I said, “When was the last time you worked?” She said, “Oh, 9 years ago, before my daughter was born.” Then she said, “It’s really hard to get a job.” I asked, “Do you have your high school diploma?” She said, “No.” So I recommended to her a local learning center program. I encouraged her, and that’s where I think the nurse practitioner is different. It was me listening first, caring about what she was telling me, and then offering her something and trying to be an advocate for her. Empathy enabled another NP to gain a deep understanding of what motivated the patient: She has a disabled child at home who needs total care. That’s something that I know about her and her situation. That’s an example of, I guess, advocating and coordinating and knowing that a lot of people don’t have transportation. Like if I want to send them to radiology, I’ll ask them, “What time of the day is good for you?” because a lot of these people are grandmothers raising grandkids, and they need to arrange their life. Some of them are pretty capable of making appointments for themselves, but others are not. They are scared to or they don’t think that they’re going to do it right. Maybe we are enabling them by doing it for them, but we will take the extra time and, you know, ask, “What’s the best day for you to go for that ultrasound? Morning or afternoon?”

Negotiating Authentic listening and empathy enabled the NPs in this study to communicate more effectively and to negotiate with patients when formulating treatment plans. An integrated literature review on

communication styles of NPs and the impact on patients (Charlton, Dearing, Berry, & Johnson, 2008) found that NPs who are trained to use a patient-centered communication style are most likely to have patients with better understanding of their health and treatment options and who are more likely to follow the treatment plan, thereby having better health outcomes. This was found in NPs in this study who involved patients in the decision-making process and actively negotiated with patients: One of the things here that we do well, I think, is negotiate with the patients. Part of when I see people I’m not going to be paternalistic and tell them you have to do this, this, and that. I have a woman I saw this morning; she came in for follow-up of her labs. She has hypertension, and the first time she had a hemoglobin A1C of 6, and she has a family history of diabetes, so we talked. She’s not a dummy; she is a registered nurse. She just became a registered nurse, just got out of school, and I said, “Let’s talk about this new thing that’s coming up. Do you have diabetes? Or are you prediabetic? Let’s discuss it.” So we negotiated what she was going to do next. I didn’t want to say to her, “You have to start on more meds today.” Her fasting sugars have been normal, the A1C was 6, and she is a woman who takes care of herself, pretty much. Now she may go on metformin in 3 months, but I know she doesn’t like to take pills. She cares about a healthy lifestyle, so we negotiated: try lifestyle changes for 3 months and check the A1C in 3 months; if it goes up, then we’ll talk about starting medication.

Going Above and Beyond NPs describe going beyond what is expected or required of the role of primary care provider. The NPs in our study were motivated to do more for their patients and to ensure that patients were satisfied with their care: My patient who came in this morning was status posthospitalization. When she was in the hospital, they did a big cardiac and neuro workup. I had sent her out by ambulance the week before, and they kept her for 4 days because they did a really good workup on her, but they didn’t do a stress test, so she needed to have that done. And so I coordinated today for her to

have a stress test, and I picked a Spanish-speaking cardiologist for her because I thought she would be more comfortable with that. And then they also recommended that she see a therapist because she’s on an antidepressant, so we talked about that today, and I coordinated that for her. Another NP describes her ability to take on a difficult patient and help to gain his trust, thereby improving his adherence to the treatment plan and reducing costs for overusing the emergency room: Treating marginalized patients with multiple comorbidities is challenging. This challenge is amplified by mental illness and substance abuse, combined with mistrust of the healthcare system. An example of this begins with the discharge of a difficult patient from a clinic for threatening front desk staff and a few nurses. He was belligerent, and when he felt he was not being respected, he threatened staff members, including his physician. He had been followed in the medical resident clinic for his chronic medical illnesses but was not addressing his anger management, cocaine abuse, obsessive compulsive disorder, and depression, and ultimately he was not adherent to medications or medical appointments either. The patient had been fired by multiple agencies in the town he lives in for the same behaviors and at this point was about to be fired from the only medical provider left within walking distance. He does not own a car and could not afford to travel by bus. Final discharge from the clinic and care would render this man with no primary care locally, except the emergency room. A final attempt was made to have the patient receive his care with a nurse practitioner, as she could at least provide continuity, if he showed up for the appointment, and she was not afraid. But really, the NP provided more than the same face in the clinic each visit. The NP provided this man with a milieu of empathy and teamwork between patient and care provider. Her approach to practice sparked a level of trust of the practitioner. The patient recognized the NP’s genuine interest in providing him individualized care and respect. She built upon this practitioner–

patient relationship. The NP helped the patient realize his control of his healthcare commitment and his role in his health outcome. This empowerment and trust led to successful engagement in following through for his routinely scheduled medical visits as well as medication adherence. When the patient was ready to address his mental health and addiction, he asked the NP to be his advocate. The NP’s commitment to holistic patient-centered care led to reinstatement of his mental health services. And today, this patient is significantly healthier, drug-free, treating his medical and mental illness, and is one less person sitting in the emergency room. Another NP describes the impact one can have when going the extra step for a patient: While at a precollege arts experience, a teen came to the clinic to ask for help with a sore throat. While assessing her, I began discussing her comfort with being away from home for the first time. She mentioned that she was really surprised that having three meals a day made her feel so comfortable. (Students eat in the college cafeteria during the program.) Further questioning revealed that she rarely ate except at school, as she qualified for free lunch, because “There is an empty refrigerator in my house.” When asked if her school had a breakfast program, she said that they did but her mom “was too busy to apply—says it is too complicated.” Her strep culture was positive, so I prescribed antibiotics and had the resident assistant pick them up from the pharmacy. Meanwhile, I asked the young lady if she would like to speak to the nurse practitioner at her school to contact social services for assistance with not only the breakfast program but also what else the assessment would allow. At that point, I learned that her mom was in rehab and unable to be reached—that this student had been assigned a foster care person—whom I contacted regarding care and treatment for the strep throat and confirmed the rest of the story. Activation of social services through contact with the NP at the school-based health center started the process in motion. Additional contact with her

throughout the 5 weeks proved to positively impact this child’s life. The NPs in this study expressed how much they love being nurse practitioners. They believe in the added value and unique contributions of the NP to health care and get a lot of gratification from putting in extra time and effort. This is supported by a similar study that showed NPs feel that their lives are enhanced and cite internal rewards and gratification from their interactions with patients: I think the most gratifying thing is when I sit down with them and explain their disease and really spend the time with them that they need. I feel like they really understand the necessity for the treatment plan that I recommend, and I really feel like if I spend the time with them that they are so grateful because they feel like you’ve really invested in them. . . . I think that most nurse practitioners will probably say something to this effect, but when they sit down with their patients, they try to treat them like they would want one of their family members treated. And so when people really see that you’re really doing that for them, and distinguish it from the way that they feel like they’ve been treated by other providers in the past or when they really recognize the amount of energy and the amount of giving—when they really see that—there’s nothing more gratifying than that. (Kleinman, 2004) The preceding studies validate similar components uncovered by Kleinman (2004) regarding nurse practitioners and their relationships with patients. Essential meanings in her phenomenological study included “openness, connection, concern, respect, reciprocity, competence, time, and professional identity” (p. 264). Based on research and formal and informal interviews, a concept map depicting nurse practitionering was developed (FIGURE 2-1). From that, the Stewart model of nurse practitionering was developed to depict this model of nurse practitioner practice (FIGURE 2-2). This model has as its core the nursing model—the foundation of NP practice. As the NP student evolves through the educational program, scientific knowledge and attributes of the medical model are incorporated in order to provide accurate assessment, medical diagnoses, and appropriate evidence-

based treatment modalities to patients needing health care. The circles within the larger circle represent unity and wholeness.

FIGURE 2-1 Model of nurse practitioner practice.

Description

FIGURE 2-2 The Stewart model of nurse practitionering.

It is evident that in order to function successfully within this model, the NP must retain the crucial interpersonal skills required to provide education surrounding health promotion and disease management. Brykczynski (2012), in an article discussing qualitative research that looked at how NP faculty keep the nurse in the NP student, suggests that holistically focused healthcare providers consider thinking of “patient diagnoses” instead of either medical versus nursing diagnoses (p. 558). Nurse practitioner students and novice NPs need to beware of minimizing

the importance of nursing as the core foundation from which excellence in practice develops. Rather, all NPs should emphasize the art and science of nursing philosophies and theories as the building blocks for providing health care to patients. It is these very qualities that make NPs unique—what it is that instills trust and confidence, as well as positive patient–NP relationships—which is the circle labeled in Figure 2-2 as “nurse practitionering.” In an opinion article in the New York Times (Rosenberg, 2012), it is clearly noted that nurse practitioners approach patient care differently than physicians do and that research has proven that it is as effective and “might be particularly useful for treating chronic disease, where so much depends on the patients’ behavioral choices” (para. 5). Sullivan-Marx et al. (2010) posit that the NP encompasses both the holistic nursing caring model and more than the physician’s curing model—that NPs have a paradigm flexible enough to be able to move between the two. Who better than NP/DNPs to tackle the inequities in health that have been tied to variations in socioeconomic status, racial and ethnic discrimination, and stressors as well as policies relating to social and economic justice?

Discussion Questions 1. What was the purpose for the initial role of the nurse practitioner, and does it differ from the role of the nurse practitioner in today’s healthcare system? 2. Who are advanced practice registered nurses (APRNs)? 3. What are the master’s and DNP essentials, and what are they used for? 4. Describe the NP core competencies as identified by the NONPF, and discuss how students can attain basic mastery of those competencies. 5. What are elements of role transition from RN to NP, and what are you currently experiencing in this process? 6. The concept of nurse practitionering has been introduced in this chapter. Comment on your responses to this idea.

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© Zen Rial/Moment/Getty Images.

CHAPTER 3 Overview of the Doctor of Nursing Practice Degree Lisa Astalos Chism

CHAPTER OBJECTIVES 1. Discuss differences between the practice doctorate in nursing versus the research doctorate. 2. Describe the evolution of the doctor of nursing practice curriculum and its potential impact on the future of nursing. 3. Identify different educational pathways to the doctor of nursing practice degree. 4. Analyze factors in our current healthcare delivery system that are driving the need for nurses prepared as expert clinicians.



W

hat exactly is a doctor of nursing practice (DNP) degree? As enrollment in this innovative practice doctorate program continues to increase, this question is frequently posed by nurses, patients, and other healthcare professionals both in and outside the healthcare setting. Providing an answer to this question requires not only defining the DNP degree but also reflecting on the rich history of doctoral education in nursing. Doctoral education in nursing is connected to our past and influences the directions we may take in the future (Carpenter & Hudacek, 1996). The development of the DNP degree is a tribute to where nursing has been and where we hope to be in the future of doctoral education in nursing. Understanding the DNP degree requires developing an awareness of

the rationale for a practice doctorate. This rationale illustrates the motivation behind the evolution of doctoral education in nursing and provides further explanation of this contemporary degree. The need for parity across the healthcare team, the Institute of Medicine’s call for safer healthcare practices, and the need for increased preparation of advanced practice registered nurses to meet the changing demands of health care are all contributing antecedents of the development of the practice doctorate in nursing (American Association of Colleges of Nursing [AACN], 2006a, 2006b; Apold, 2008; Dracup, Cronenwett, Meleis, & Benner, 2005; Roberts & Glod, 2005). Becoming familiar with the motivating factors behind the DNP degree will aid understanding of the development of this innovative degree. This chapter provides a definition of the DNP degree and a discussion of the evolution of doctoral education in nursing. The rationale for a practice doctorate is also described. The recipe for the DNP degree, which includes the Essentials of Doctoral Education for Advanced Nursing Practice by the AACN (2006b) and the Practice Doctorate Nurse Practitioner Entry-Level Competencies by the National Organization of Nurse Practitioner Faculties (NONPF, 2006), is also provided in this chapter. The pathway to the DNP degree is also addressed. Providing a discussion of these topics will equip one with the information necessary to become familiar with this innovative degree.

Doctor of Nursing Practice Degree Defined The DNP degree has been adopted as the terminal practice degree in nursing (AACN, 2004, 2006b). The AACN (2004) position statement specifically defines the DNP degree as a “practice-focused” doctorate degree, with nursing practice defined as any form of nursing intervention that influences health care outcomes for individuals or populations, including the direct care of individual patients, management of care for individuals and populations, administration of nursing and health care organizations, and the development and implementation of health policy. (p. 3) Preparation at the practice doctorate level is considered the highest level of preparation for nursing practice; hence, it is the terminal degree for nursing practice (AACN, 2004). The DNP degree curriculum is focused on, but not limited to, evidence-based practice, scholarship to advance the profession, organizational and systems leadership, information technology, healthcare policy and advocacy, interprofessional collaboration across disciplines of healthcare, and advanced nursing practice (AACN, 2006b). In 2015, it was projected that the DNP degree would be the terminal preparation for advanced practice nursing, and the current master’s degree options for advanced nursing practice would be replaced by the DNP degree (AACN, 2006a). A newly developed master’s degree, the clinical nurse leader (CNL) degree, will be offered for those who wish to provide healthcare services at the point of care to individuals and cohorts of clients within a healthcare unit or setting (AACN, 2007). This degree prepares the graduate as “a leader in the health care delivery system, not just in the acute care setting but in all settings in which health care is delivered” (AACN, 2007, p. 10). Details regarding the content of the DNP degree curriculum are provided later in this chapter.

Research-Focused Doctorate and Practice-Focused Doctorate Defined The question “What is a DNP degree?” is often followed by the question “What is the difference between a doctor of philosophy (PhD) and a DNP degree?” Nurses now can choose between a practice-focused or research-focused doctorate as a terminal degree. Although the academic or research degree, once the only terminal preparation in nursing, has traditionally been the PhD, the AACN now includes the doctor of nursing science (DNS, DNSc, DSN) as a research-focused degree (AACN, 2004). The AACN Task Force on the Practice Doctorate in Nursing has also recommended that the practice doctorate be the DNP degree, which will replace the traditional nursing doctorate (ND) degree (AACN, 2006a). Currently ND programs are taking the necessary steps to adjust their programs to fit the curriculum criteria of DNP degree programs. The practice- and research-focused doctorates in nursing share a common goal regarding a “scholarly approach to the discipline and a commitment to the advancement of the profession” (AACN, 2006b, p. 3). The differences in these programs include differences in preparation and expertise. The practice doctorate curriculum places more emphasis on practice and less on theory and research methodology (AACN, 2004, 2006b). The final scholarly project differs in that a dissertation required for a PhD degree should document development of new knowledge, and a final scholarly project, now referred to as the DNP Project, required for a DNP degree should be grounded in clinical practice and demonstrate ways in which research has an impact on practice. The focus of the DNP degree is expertise in clinical practice. Additional foci include the Essentials of Doctoral Education for Advanced Nursing Practice by the AACN (2006b), which include leadership, health policy and advocacy, and information technology. The focus of a research degree is the generation of new knowledge for the discipline and expertise as a principal investigator. Although the research degree prepares the expert researcher, it should be noted that DNP projects will

also contribute frequently to the discipline by generating new knowledge related to clinical practice and demonstrate the use of evidence-based practice. The American Association of Colleges of Nursing Task Force on the Implementation of the DNP Degree further expanded on the distinction of research-focused and practice-focused scholarship in their report published in 2015. This task force clarified that “graduates of both research- and practice-focused doctoral programs are prepared to generate new knowledge” (AACN, 2015, p. 2). Although “researchfocused graduates are prepared to generate knowledge through rigorous research . . . practice-focused graduates are prepared to generate new knowledge through innovation of practice change, the translation of evidence, and the implementation of quality improvement processes in specific practice settings, systems, or with specific populations to improve health or health outcomes” (AACN, 2015, p. 2). Refer to TABLE 3-1 for the AACN’s comparison of a DNP program with PhD, DNS, and DNSc programs. TABLE 3-1 AACN Contrast Grid of the Key Differences Between DNP and PhD, DNS, and DNSc Programs

DNP

PhD, DNS, and DNSc

Program of study

Objectives: Prepare nurse specialists at the highest level of advanced practice

Objectives: Prepare nurse researchers

Competencies: Based on Essentials of Doctoral Education for Advanced Nursing Practice (AACN, 2006b)*

Content: Based on Indicators of Quality in Research-Focused Doctoral Programs in Nursing (AACN, 2001)†

Students

Commitment to a practice career Oriented toward improving outcomes of care

Commitment to a research career Oriented toward developing new knowledge

Program faculty

Practice doctorate and/or experience in area in which teaching Leadership experience in area of specialty practice

Research doctorate in nursing or related field Leadership experience in area of sustained research funding High level of expertise in research

High level of expertise in specialty practice congruent with focus of academic program

congruent with focus of academic program

Resources

Mentors and/or preceptors in leadership positions across a variety of practice settings Access to diverse practice settings with appropriate resources for areas of practice Access to financial aid Access to information and patientcare technology resources congruent with areas of study

Mentors/preceptor in research settings Access to research settings with appropriate resources Access to dissertation support dollars Access to information and research technology resources congruent with program of research

Program assessment and evaluation

Program outcome: Healthcare improvements and contributions via practice, policy change, and practice scholarship Oversight by the institution’s authorized bodies (i.e., graduate school) and regional accreditors Receives accreditation by specialized nursing accreditor Graduates are eligible for national certification exam

Program outcome: Contributes to healthcare improvements via the development of new knowledge and other scholarly projects that provide the foundation for the advancement of nursing science Oversight by the institution’s authorized bodies (i.e., graduate school) and regional accreditor

*American Association of Colleges of Nursing. (2006b). Essentials of doctoral education for advanced nursing practice. Retrieved from https://www.aacnnursing.org/Portals/42/Publications/DNPEssentials.pdf †American Association of Colleges of Nursing. (2001). Indicators of quality in research-focused

doctoral programs in nursing. Retrieved from https://www.aacnnursing.org/Portals/42/DNP/roadmapreport.pdf Reprinted with permission from AACN DNP Roadmap Task Force Report, October 20, 2006.

Description Description

Evolution of Doctoral Education in Nursing To appreciate the development of doctoral education in nursing, one must understand where nursing has been with regard to education at the doctoral level. Indeed, nursing has been unique in its approach to doctoral preparation since nurses began to earn doctoral degrees. Even today nurses are prepared at the doctoral level through various degrees, including doctor of education (EdD), PhD, DNS, and now DNP. Prior to the development of the DNP degree, the ND was also offered as a choice for nursing doctoral education. Examining the chronological development of doctoral education in nursing is somewhat complicated because early doctorates were offered outside nursing. These included the EdD degree and the PhD degree in basic science fields, such as anatomy and physiology (Carpenter & Hudacek, 1996; Marriner-Tomey, 1990). The first nursing-related doctoral program was originated in 1924 at Teachers College, Columbia University, and was an EdD designed to prepare nurses to teach at the college level (Carpenter & Hudacek, 1996). Teachers College was unique in that its program was the first to combine both the “nursing and education needs of leaders in the profession” (Carpenter & Hudacek, 1996, p. 5). EdD degrees continued well into the 1960s to be the mainstay of doctoral education for nursing (Marriner-Tomey, 1990). The first PhD in nursing was offered in 1934 at New York University. Unfortunately, the next PhD in nursing was not offered until the 1950s at the University of Pittsburgh and focused on maternal and child nursing. Incidentally, this degree was the first to recognize the importance of clinical research for the development of the nursing discipline (Carpenter & Hudacek, 1996). The PhD degrees earned elsewhere continued to be in nursing-related fields, such as psychology, sociology, and anthropology. This trend continued until nursing PhD degrees became more popular in the 1970s (Grace, 1978). Grace (1978) summarized the progression of nursing education over time. Between 1924 and 1959, doctoral education in nursing focused on

preparing nurses for “functional specialty” (p. 22). In other words, nurses were prepared to fulfill functional roles as teachers and administrators to lead the field of nursing toward advancement as a profession. The problem with these programs was that they lacked the substantive content necessary to develop nursing as a discipline and a profession. The next shift in doctoral education attempted to fulfill this need and took place between 1960 and 1969. Within this time period, popularity increased for doctoral programs that were nursing related. This included doctorates (PhDs) that were related to such disciplines as sociology, psychology, and anthropology. Grace (1978) noted that the development of these types of programs provided the basic science and research input necessary for the development of future ND programs. Murphy (1981) concurred that this stage in the development of doctoral education in nursing led to pertinent questions for the discipline of nursing, such as “(1) What is the essential nature of professional nursing? (2) What is the substantive knowledge base of professional nursing? (3) What kind of research is important for nursing as a knowledge discipline? As a field of practice? (4) How can the scientific base of nursing knowledge be identified and expanded?” (p. 646). In response to these questions, nursing doctoral education again progressed in the 1970s to include doctorate degrees that are actually in nursing (Grace, 1978). This stage also supported the growth of nursing’s substantive structure, hence the growth of the discipline of nursing. This is where nursing’s history of doctoral education becomes more complex. In 1960, the DNS degree originated at Boston University and “focused on the development of nursing theory for a practice discipline” (MarrinerTomey, 1990, p. 135), hence the development of the first practice doctorate. The notion of a practice-focused doctorate in nursing is not new. Even as early as the 1970s, it was proposed that the research doctorate (PhD) should focus on preparing nurses to contribute to nursing science, and the practice (or professional) doctorate (DNS) should focus on expertise in clinical practice (Cleland, 1976). Newman (1975) also suggested a practice doctorate as the preparation of “professional practitioners” (p. 705) for entry into practice. Grace (1978) noted that it was not sufficient to have a core of nursing researchers building the knowledge base (discipline) without also giving attention to the clinical field. Grace also suggested that nurses prepared through a

practice doctorate be titled “social engineers” (p. 26). This seems appropriate given what expert clinicians in nursing are called upon to do. Although the DNS degree was initially proposed as a practice or professional doctorate, over time the curriculum requirements have become very similar to those for a PhD degree (AACN, 2006a; Apold, 2008; Marriner-Tomey, 1990). Research requirements for this degree have eventually become indistinguishable from that of a PhD in nursing. Because of this, it is not surprising that the AACN (2004) has characterized all DNS degrees as research degrees. With the DNS and PhD degrees so similar in content and focus, the challenge to develop a true practice doctorate remained. An attempt toward this was made in 1979 when the ND originated at Case Western Reserve University, followed by the University of Colorado, Rush University, and South Carolina University. The first ND program was developed by Rozella M. Schlotfeldt, PhD, RN. The ND was different in that the research component was not the general focus of the degree. This degree was designed to be a “pre-service nursing education which would orient nursing’s approach to preparing professionals toward competent, independent, accountable nursing practice” (Carpenter & Hudacek, 1996, p. 42). This general theme for a practice doctorate remains consistent even today. Unfortunately, this program did not share the same popularity of DNS or PhD degrees in nursing, and it was less common to find a clinician with this preparation. In addition, the curricula in these programs were varied and lacked a uniform approach toward a practice doctorate (Marion et al., 2003). In 2002, the AACN board of directors formed a task force to examine the current progress of practice doctorates in nursing. Their objective also included comparing proposed curriculum models and discussing recommendations for the future of a practice doctorate (AACN, 2004). To accomplish their mission, the AACN task force (2004) took part in the following activities: Reviewed the literature regarding practice doctorates in nursing and other disciplines. Established a collaborative relationship with the NONPF. Interviewed key informants (deans, program directors, graduates, and current students) at the eight current or planned practice-focused

doctoral programs in the United States. Held open discussions regarding issues surrounding practice-focused doctoral education at AACN’s Doctoral Education Conference (January 2003 and February 2004). Participated in an open discussion with the NONPF, along with representatives from key nursing organizations and schools of nursing that were offering or planning a practice doctorate. Invited an External Reaction Panel, which involved participation from 10 individuals from various disciplines outside nursing. This panel responded to the draft of the AACN Position Statement on the Practice Doctorate in Nursing. In 2004, the AACN published the AACN Position Statement on the Practice Doctorate in Nursing and recommended that the DNP degree be the terminal degree for nursing practice by 2015. According to the NONPF, the purpose of the DNP degree is to prepare nurses to meet the changing demands of health care today by becoming proficient at the following (Marion et al., 2003): Evaluating evidence-based practices for care Delivering care Developing healthcare policy Leading and managing clinical care and healthcare systems Developing interdisciplinary standards Solving healthcare dilemmas Reducing disparities in health care Not only is the development of the DNP degree a culmination of today’s emerging healthcare demands but also the degree provides a choice for nurses who wish to focus their doctoral education on nursing practice. Since the inception of this degree, the growth has been astonishing. The University of Kentucky’s College of Nursing was the pioneer for this innovative degree and admitted the first DNP class in 2001. In spring 2005, 8 DNP programs were offered and more than 60 were in development. By summer 2005, 80 DNP programs were being considered. In fall 2005, 20 programs offered DNP degrees and 140 programs were in development. Today there are 289 DNP programs in the United States (AACN, 2018).

It should also be mentioned that in 1999, Columbia University’s School of Nursing was formulating plans for a doctor of nursing practice (DrNP) degree that would build on a model of “full-scope, cross-site primary care that Columbia had developed and evaluated over the past ten years” (Goldenberg, 2004, p. 25). This degree was spearheaded by Mary O. Mundinger, DrPH, RN, dean of Columbia University’s School of Nursing. The curriculum of a DrNP program is clinically focused with advanced preparation designed to teach “cross-site, full-scope care with content in advanced differential diagnosis skills, advanced pathophysiology and microbiology, selected issues of compliance, management of health care delivery and reimbursement, advanced emergency triage and management, and professional role collaboration and referrals” (Goldenberg, 2004, p. 25). This expanded clinical component is what seems to differentiate a DrNP degree from a DNP degree. The first DrNP class graduated from Columbia University in 2003. Since the development of the DrNP degree, the Commission on Collegiate Nursing Education (CCNE), the autonomous accrediting body of the AACN, has decided that only practice ND degrees with the doctor of nursing practice title will be eligible for CCNE accreditation (AACN, 2005). This decision was reached unanimously by the CCNE board of directors on September 29, 2005, in an effort to develop a process for accrediting only clinically focused NDs (AACN, 2005). The CCNE’s decision is consistent with accrediting organizations for other healthcare professions and helps to ensure consistency with degree titling and criteria. Specific criteria for the DNP degree, including the AACN’s Essentials of Doctoral Education for Advanced Nursing Practice (2006b) and the Practice Doctorate Nurse Practitioner Entry-Level Competencies (NONPF, 2006), are discussed later in this chapter.

Why a Practice Doctorate in Nursing Now? It has already been mentioned that the notion of a practice doctorate is not new, so why the development of the DNP degree now? It has been noted that the development of the DNP is “more than a mere interruption but rather a response to the need within the healthcare system for expert clinical teachers and clinicians” (Marion, O’Sullivan, Crabtree, Price, & Fontana, 2005, para. 1). Healthcare needs are not new, yet the growth of this program has been escalating. The question posed therefore is “What are the drivers of this DNP degree, and why is there such urgency?”

The Institute of Medicine’s Report and Nursing’s Response In 2000, the Institute of Medicine (IOM) published a report titled To Err Is Human: Building a Safer Health System (Kohn, Corrigan, & Donaldson, 2000). This report summarized information regarding errors made in health care and offered recommendations to improve the overall quality of care. It was found that “preventable adverse events are a leading cause of death in the United States” (p. 26). In more than 33.6 million admissions to U.S. hospitals in 1997, 44,000 to 98,000 people died as a result of medical-related errors (American Hospital Association, 1999). It was estimated that deaths in hospitals by preventable adverse events exceed the amount attributable to the eighth leading cause of death in America (Centers for Disease Control and Prevention [CDC], 1999b). These numbers also exceed the number of deaths attributable to motor vehicle accidents (43,458), breast cancer (42,297), and AIDS (16,516) (CDC, 1999a). The total cost of health care is greatly affected by these errors as well, with estimated total national costs (lost income, lost household production, disability, healthcare costs) reported as being between $29 billion and $36 billion for adverse events and between $17 billion and $29 billion for preventable adverse events (Thomas et al., 1999).

As a follow-up to the To Err Is Human report, in 2001 the IOM published Crossing the Quality Chasm: A New Health System for the 21st Century. In an effort to improve health care in the 21st century, the IOM proposed six specific aims for improvement. According to the IOM (2001), these six aims deem that health care should be: 1. Safe in avoiding injuries to patients from the care they receive 2. Effective in providing services based on scientific knowledge to those who could benefit, but services should not be provided to those who may not benefit 3. Patient centered in that provided care is respectful and responsive to individual patient preferences, needs, and values; all patient values should guide all clinical decisions 4. Timely in that wait time and sometimes harmful delays are reduced for those who give and receive care 5. Efficient in that waste is avoided, particularly waste of equipment, supplies, ideas, and energy 6. Equitable in that high-quality care is provided to all regardless of personal characteristics, such as gender, ethnicity, geographic location, and socioeconomic status The IOM (2001) emphasized that to achieve these aims, additional skills may be required on the healthcare team. This includes all individuals who care for patients. The new skills needed to improve health care and reduce errors are, ironically, many skills that nurses have long been known to exemplify. Some examples of these skills include using electronic communications, synthesizing evidence-based practice information, communicating with patients in an open manner to enable their decision making, understanding the course of illness that specifically relates to the patient’s experience outside the hospital, working collaboratively in teams, and understanding the link between health care and healthy populations (IOM, 2001). Developing expertise in these areas required curriculum changes in healthcare education as well as addressing how healthcare education is approached, organized, and funded (IOM, 2001). In 2003, the Health Professions Education Committee responded to the IOM’s Crossing the Quality Chasm report (2001) by publishing Health Professions Education: A Bridge to Quality (Greiner & Knebel, 2003). The

committee recommended that “all health professionals should be educated to deliver patient-centered care as members of an interdisciplinary team, emphasizing evidence-based practice, quality improvement approaches, and informatics” (Greiner & Knebel, 2003, p. 45). To meet this goal, the committee proposed a set of competencies to be met by all healthcare clinicians, regardless of discipline. These competencies include the following: provide patient-centered care, function in interdisciplinary teams, employ evidence-based practice, integrate quality improvement standards, and utilize various information systems (Greiner & Knebel, 2003). As part of the continued effort to advance the education of healthcare professionals, the Robert Wood Johnson Foundation (RWJF) and the IOM specifically addressed advancing nursing education. In 2008, the RWJF and the IOM “launched a two-year initiative to respond to the need to access and transform the nursing profession” (IOM, 2010a, p. 1). The IOM appointed the Committee on the RWJF Initiative on the Future of Nursing. This committee published a report titled The Future of Nursing: Focus on Education (IOM, 2010a). In this report, the IOM (2010a) concluded that “the ways in which nurses were educated during the 20th century are no longer adequate for dealing with the realities of healthcare in the 21st century” (p. 2). The IOM reiterated the need for the aforementioned competencies, such as leadership, health policy, system improvement, research- and evidence-based practice, and teamwork and collaboration. In response to the increasing demands of a complex healthcare environment, the IOM recommended higher levels of education for nurses and new ways to educate nurses to meet the needs of this population better. The IOM included recommendations in the report that specifically address the number of nurses with doctorate degrees. It was noted that although 13% of nurses hold a graduate degree, fewer than 1% hold doctoral degrees (IOM, 2010a). The IOM (2010a) concluded that “nurses with doctorates are needed to teach future generations of nurses and to conduct research that becomes the basis for improvements in nursing science and practice” (p. 4). Therefore, recommendation number 5 states that “schools of nursing, with support from private and public funders, academic administrators and university trustees, and accreditation bodies, should double the number of nurses with a doctorate by 2020 to

add to the cadre of nurse faculty and researchers, with attention to increasing diversity” (IOM, 2010b, p. 4). The development of the DNP degree is one of the answers to the call proposed by both the IOM’s Health Professions Education Committee and the IOM’s and the RWJF’s Initiative on the Future of Nursing Committee to redefine how healthcare professionals are educated. Nursing has always had a vested interest in improving quality of care and patient outcomes. Since Florence Nightingale, “nursing education has been directed toward the individualized, personalized care of the patient, not the disease” (Newman, 1975, p. 704). To further illustrate nursing’s commitment to improving quality of care and patient outcomes, the competencies described by the Health Professions Education Committee are reflected in the AACN’s Essentials of Doctoral Education for Advanced Nursing Practice (2006b) and the NONPF’s Practice Doctorate Nurse Practitioner Entry-Level Competencies (2006). Preparing nurses at the practice doctorate level who are experts at using information technology, synthesizing and integrating evidence-based practices, and collaborating across healthcare disciplines will further enable nursing to meet the challenges of health care in the 21st century.

Additional Drivers for a Practice Doctorate in Nursing In a 2005 report titled Advancing the Nation’s Health Needs: NIH Research Training Programs, the National Academy of Sciences (2005) recommended that nursing develop a nonresearch doctorate. The rationale for this initiative included increasing the numbers of expert practitioners who could also fulfill clinical nursing faculty needs. The report specifically states that “the need for doctorally prepared practitioners and clinical faculty would be met if nursing could develop a new non-research clinical doctorate, similar to the MD and PharmD in Medicine and Pharmacy, respectively” (National Academy of Sciences, 2005, p. 74). The initiatives of the National Academy of Sciences regarding doctoral education in nursing are reflected in the AACN’s development of the DNP degree. An additional rationale for a practice doctorate is reflected in nursing’s educational history when the practice doctorate was first proposed.

Newman (1975) noted that “nursing lacked the recognition for what it has to offer and authority for putting that knowledge into practice” (p. 704). Starck, Duffy, and Vogler (1993) stated, “[F]or nursing to be accountable to the social mandate, the numbers as well as the type of doctorally prepared nurses need attention” (p. 214). The NONPF’s Practice Doctorate Task Force summarized the most frequently cited additional drivers for a practice doctorate in nursing (Marion et al., 2005): Parity with other professionals who are prepared with a practice doctorate. Such disciplines as audiology, dentistry, medicine, pharmacy, psychology, and physical therapy require a practice doctorate for entry into practice. A need for longer programs that both reflect the credit hours invested in master’s degrees and accommodate additional information needed to prepare nurses for the demands of health care. Most master’s degrees require a similar number of credit hours for completion as the number required for practice doctoral degrees. Remedy the current nursing faculty shortages. The development of a practice doctorate will help meet the needs for clinical teaching in schools of nursing. The increasing complexity of healthcare systems requires additional information to be included in current graduate nursing programs. Rather than further burden the amount of information needed to prepare nurses at the graduate level for a master’s degree, a practice doctorate allows for additional information to be provided and affords a practice doctorate to prepare nurses for the changing demands of society and health care.

What Is a DNP Degree Made Of? The Recipe for Curriculum Standards The standards of a DNP program have been formulated through a collaborative effort among various consensus-based standards. These standards reflect collaborative efforts among the AACN as the Essentials of Doctoral Education for Advanced Nursing Practice (2006b), the NONPF as the Practice Doctorate Nurse Practitioner Entry-Level Competencies (2006), and more recently the National Association of Clinical Nurse Specialists (NACNS) as Core Practice Doctorate Clinical Nurse Specialist Competencies (2009). These organizations’ strategies for setting the standards of a practice doctorate in nursing demonstrate interrelated criteria that are congruent with all rationales for a practice doctorate in nursing. It should be noted, however, that while maintaining these consensus-based standards, there may be some variability in content within DNP curricula.

AACN Essentials of Doctoral Education for Advanced Nursing Practice In 2006, the AACN published the Essentials of Doctoral Education for Advanced Nursing Practice. These essentials are the “foundational outcome competencies deemed essential for all graduates of a DNP program regardless of specialty or functional focus” (AACN, 2006b, p. 8). Nursing faculties have the freedom to design coursework creatively to meet these essentials, which are summarized in the following sections.

Essential I: Scientific Underpinnings for Practice This essential describes the scientific foundations of nursing practice, which are based on the natural and social sciences. These sciences may include human biology, physiology, and psychology. In addition, nursing science has provided nursing with a body of knowledge to contribute to the discipline of nursing. This body of knowledge or discipline is focused

on the following (adapted from AACN, 2006b; Donaldson & Crowley, 1978; Fawcett, 2005; Gortner, 1980): The principles and laws that govern the life process, well-being, and optimal functioning of human beings, sick or well The patterning of human behavior in interaction with the environment in normal life events and critical life situations The processes by which positive changes in health status are affected The wholeness of health of human beings, recognizing that they are in continuous interaction with their environments Nursing science has expanded the discipline of nursing and includes the development of middle-range nursing theories and concepts to guide practice. Understanding the practice of nursing includes developing an understanding of scientific underpinnings for practice (the science and discipline of nursing). Specifically, the DNP degree prepares the graduate to do the following (adapted from AACN, 2006b): Integrate nursing science with knowledge from the organizational, biophysical, psychological, and analytical sciences, as well as ethics, as the basis for the highest level of nursing practice. Develop and evaluate new practice approaches based on nursing theories and theories from other disciplines. Utilize science-based concepts and theories to determine the significance and nature of health and healthcare delivery phenomena, describe strategies used to enhance healthcare delivery, and evaluate outcomes.

Essential II: Organizational and Systems Leadership for Quality Improvement and Systems Thinking Preparation in organizational and systems leadership at every level is imperative for DNP graduates to have an impact on and improve healthcare delivery and patient-care outcomes. DNP graduates are distinguished by their ability to focus on new healthcare delivery methods that are based on nursing science. Preparation in this area will provide DNP graduates with expertise in “assessing organizations, identifying

systems’ issues, and facilitating organization-wide changes in practice delivery” (AACN, 2006b, p. 10). Specifically, DNP graduates will be prepared to do the following (adapted from AACN, 2006b): Utilize scientific findings in nursing and other disciplines to develop and evaluate care delivery approaches that meet the current and future needs of patient populations. Guarantee accountability for the safety and quality of care for the patients they care for. Manage ethical dilemmas within patient care, healthcare organizations, and research, including developing and evaluating appropriate strategies.

Essential III: Clinical Scholarship and Analytical Methods for Evidence-Based Practice DNP graduates are unique in that their contributions to nursing science involve the “translation of research into practice and the dissemination and integration of new knowledge” (AACN, 2006b, p. 11). Further, DNP graduates are in a distinctive position to merge nursing science, nursing practice, human needs, and human caring. Specifically, the DNP graduate is expected to be an expert in the evaluation, integration, translation, and application of evidence-based practices. In addition, DNP graduates are actively involved in nursing practice, which allows for practical, applicable research questions to arise from the practice environment. Working collaboratively with experts in research investigation, DNP graduates can also assist in the generation of new knowledge and affect evidence-based practice from the practice arena. To achieve these goals, the DNP program prepares the graduate to do the following (adapted from AACN, 2006b): Analytically and critically evaluate existing literature and other research to determine the best evidence for practice. Evaluate practice outcomes within populations in various arenas, such as healthcare organizations, communities, or practice settings. Design and evaluate methodologies that improve quality in an effort to promote “safe, effective, efficient, equitable, and patient-centered care” (AACN, 2006b, p. 12).

Develop practice guidelines that are based on relevant, best-practice findings. Utilize informatics and research methodologies to collect and analyze data, design databases, interpret findings to design evidence-based interventions, evaluate outcomes, and identify gaps within evidencebased practice, which will improve the practice environment. Work collaboratively with research specialists and act as a “practice consultant” (AACN, 2006b, p. 12).

Essential IV: Information Systems/Technology and Patient-Care Technology for the Improvement and Transformation of Health Care DNP graduates have cutting-edge abilities to use information technology to improve patient care and outcomes. Knowledge regarding the design and implementation of information systems to evaluate programs and outcomes of care is essential for preparation as a DNP graduate. Expertise is garnered in information technology, such as Web-based communications, telemedicine, online documentation, and other unique healthcare delivery methods. DNP graduates must also develop expertise in utilizing information technologies to support practice leadership and clinical decision making. Specific to information systems, DNP graduates are prepared to do the following (adapted from AACN, 2006b): Evaluate and monitor outcomes of care and quality-of-care improvement by designing, selecting, using, and evaluating programs related to information technologies. Become proficient in the skills necessary to evaluate data extraction from practice information systems and databases. Attend to ethical and legal issues related to information technologies within the healthcare setting by providing leadership to evaluate and resolve these issues. Communicate and evaluate the accuracy, timeliness, and appropriateness of healthcare consumer information.

Essential V: Healthcare Policy for Advocacy in Health Care Becoming involved in healthcare policy and advocacy has the potential to affect the delivery of health care across all settings. Thus, knowledge and skills related to healthcare policy are central to nursing practice and are therefore essential to the DNP graduate. Further, “health policy influences multiple care delivery issues, including health disparities, cultural sensitivity, ethics, the internalization of health care concerns, access to care, quality of care, health care financing, and issues of equity and social justice in the delivery of health care” (AACN, 2006b, p. 13). DNP graduates are uniquely positioned to be powerful advocates for healthcare policy through their practice experiences. These practice experiences provide rich influences for the development of policy. Nursing’s interest in social justice and equality requires that DNP graduates become involved and develop expertise in healthcare policy and advocacy. In addition, DNP graduates need to be prepared in leadership roles with regard to public policy. As leaders in the practice setting, DNP graduates frequently assimilate research, practice, and policy. Therefore, DNP preparation should include experience in recognizing the factors that influence the development of policy across various settings. The DNP graduate is prepared to do the following (adapted from AACN, 2006b): Analyze decisively health policies and proposals from the points of view of consumers, nurses, and other healthcare professionals. Provide leadership in the development and implementation of healthcare policy at the institutional, local, state, federal, and international levels. Participate actively on committees, boards, or task forces at the institutional, local, state, federal, and international levels. Participate in the education of other healthcare professionals, patients, or other stakeholders regarding healthcare policy issues. Act as an advocate for the nursing profession through activities related to healthcare policy. Influence healthcare financing, regulation, and delivery through the

development of leadership in healthcare policy. Act as an advocate for ethical, equitable, and social justice policies across all healthcare settings.

Essential VI: Interprofessional Collaboration for Improving Patient and Population Health Outcomes This essential specifically relates to the IOM’s mandate to provide safe, timely, equitable, effective, efficient, and patient-centered care. In a multitiered, complex healthcare environment, collaboration among all healthcare disciplines must exist to achieve the IOM’s and nursing’s goals. Nurses are experts at functioning as collaborators among multiple disciplines. Therefore, as nursing practice experts, DNP graduates must be prepared to facilitate collaboration and team building. This may include both participating in the work of the team and assuming leadership roles when necessary. With regard to interprofessional collaboration, the DNP graduate must be prepared to do the following (adapted from AACN, 2006b): Participate in effective communication and collaboration throughout the development of “practice models, peer review, practice guidelines, health policy, standards of care, and/or other scholarly products” (AACN, 2006b, p. 15). Analyze complex practice or organizational issues through leadership of interprofessional teams. Act as a consultant to interprofessional teams to implement change in healthcare delivery systems.

Essential VII: Clinical Prevention and Population Health for Improving the Nation’s Health Clinical prevention is defined as health promotion and risk reduction– illness prevention for individuals and families, and population health is defined as including all community, environmental, cultural, and socioeconomic aspects of health (AACN, 2006b; Allan et al., 2004). Nursing has foundations in health promotion and risk reduction and is

therefore positioned to have an impact on the health status of people in multiple settings. The further preparation included in the DNP curriculum will enable graduates to “analyze epidemiological, biostatistical, occupational, and environmental data in the development, implementation, and evaluation of clinical prevention and population health” (AACN, 2006b, p. 15). In other words, DNP graduates are in an ideal position to participate in health promotion and risk reduction activities from a nursing perspective with additional preparation in evaluating and interpreting data that are pertinent to improving the health status of individuals (adapted from AACN, 2006b).

Essential VIII: Advanced Nursing Practice Because one cannot become proficient in all areas of specialization, DNP degree programs “provide preparation within distinct specialties that require expertise, advanced knowledge, and mastery in one area of nursing practice” (AACN, 2006b, p. 16). This specialization is defined by a specialty practice area within the domain of nursing and is a requisite of the DNP degree. Although the DNP graduate may function in a variety of roles, role preparation within the practice specialty, including legal and regulatory issues, is part of every DNP curriculum. With regard to advanced nursing practice, the DNP graduate is prepared to do the following (adapted from AACN, 2006b): Assess comprehensively health and illness parameters while incorporating diverse and culturally sensitive approaches. Implement and evaluate therapeutic interventions based on nursing and other sciences. Participate in therapeutic relationships with patients and other healthcare professionals to ensure optimal patient care and improve patient outcomes. Utilize advanced clinical decision-making skills and critical thinking, and deliver and evaluate evidence-based care to improve patient outcomes. Serve as a mentor to others in the nursing profession in an effort to maintain excellence in nursing practice. Participate in the education of patients, especially those in complex health situations.

A Note About Specialty-Focused Competencies According to the AACN The purpose of specialty preparation within the DNP curricula is to prepare graduates to fulfill specific roles within health care. Specialty preparation and the eight DNP essentials equip DNP graduates to serve in roles within two different domains. The first domain includes specialization as advanced practice registered nurses who care for individuals (including, but not limited to, clinical nurse specialist [CNS], nurse practitioner, nurse anesthetist, nurse–midwife). The second domain includes specialization in advanced practice at an organizational or systems level. Because of this variability, specialization content within DNP programs may differ (AACN, 2006b). It should also be noted that postmaster’s degree DNP preparation includes doctoral-level content exclusively; however, postbaccalaureate DNP preparation includes both advanced practice specialty content that was previously covered in master’s preparation and doctoral-level content.

NONPF Practice Doctorate Nurse Practitioner Entry-Level Competencies The NONPF (2006) published Practice Doctorate Nurse Practitioner Entry-Level Competencies for nurse practitioner and DNP graduates. These competencies differ somewhat from the AACN’s essentials in that they are particular to nurse practitioner roles. However, these competencies are also reflective of the AACN’s essentials. The competencies are as follows: I. Competency Area: Independent Practice Practices independently by assessing, diagnosing, treating, and managing undifferentiated patients. Assumes full accountability for actions as a licensed practitioner. II. Competency Area: Scientific Foundation Critically analyzes data for practice by integrating knowledge from arts and sciences within the context of nursing’s philosophical framework and scientific foundation.

Translates research and data to anticipate, predict, and explain variations in practice. III. Competency Area: Leadership Assumes increasingly complex leadership roles. Provides leadership to foster intercollaboration. Demonstrates a leadership style that uses critical and reflective thinking. IV. Competency Area: Quality Uses best-available evidence to enhance quality in clinical practice. Evaluates how organizational, structural, financial, marketing, and policy decisions affect cost, quality, and accessibility of health care. Demonstrates skills in peer review that promote a culture of excellence. V. Competency Area: Practice Inquiry Applies clinical investigative skills for evaluation of health outcomes at the patient, family, population, clinical unit, systems, or community levels. Provides leadership in the translation of new knowledge into practice. Disseminates evidence from inquiry to diverse audiences using multiple methods. VI. Competency Area: Technology and Information Literacy Demonstrates information literacy in complex decision making. Translates technical and scientific health information appropriate for user need. VII. Competency Area: Policy Analyzes ethical, legal, and social factors in policy development. Influences health policy. Evaluates the impact of globalization on healthcare policy. VIII. Competency Area: Health Delivery System Applies knowledge of organizational behavior and systems. Demonstrates skills in negotiating, consensus building, and partnering. Manages risks to individuals, families, populations, and

healthcare systems. Facilitates development of culturally relevant healthcare systems. IX. Competency Area: Ethics Applies ethically sound solutions to complex issues.

NACNS Core Practice Doctorate Clinical Nurse Specialist Competencies In 2006, the NACNS consulted with various nursing organizations and nursing accrediting entities regarding the implications of the DNP degree for CNS practice and education (NACNS, 2009). A formal task force, including representatives from the NACNS and 19 other nursing organizations, was charged with developing competencies for the CNS at the doctoral level (NACNS, 2009). Because traditional CNS education has included a master’s degree, “the Core Practice Doctorate Clinical Nurse Specialist Competencies should be used with the National CNS Competency Task Force’s Organizing Framework and Core Competencies (2008) and the AACN Essentials of Doctoral Education for Advanced Nursing Practice (2006b) to inform educational programs and employer expectations” (NACNS, 2009, p. 10). The foci of the Core Practice Doctorate Clinical Nurse Specialist Competencies are congruent with the AACN’s Essentials of Doctoral Education for Advanced Nursing Practice and the NONPF’s Practice Doctorate Nurse Practitioner Entry-Level Competencies (FIGURE 3-1). Specifically, graduates of CNS-focused DNP programs should be prepared beyond traditional CNS competencies to “strengthen the already significant contribution that CNSs make in ensuring quality patient outcomes through establishing a practice foundation based on advanced scientific, theoretical, ethical, and economic principles” (NACNS, 2009, p. 11). These competencies ensure that doctoralprepared CNS graduates are ready to do the following (adapted from NACNS, 2009):

FIGURE 3-1 Relationship among the DNP essentials, the NONPF competencies, the NACNS competencies, and the core competencies needed for healthcare professionals per the Committee on Health Professions Education.

Generate and disseminate new knowledge. Evaluate and translate evidence into practice. Employ a broad range of theories from nursing and related disciplines. Design and evaluate innovative strategies to improve quality of care and safety in all settings. Improve systems of care. Provide leadership that promotes interprofessional collaboration. Influence and shape health policy.

Certified Registered Nurse Anesthetists As advanced practice nursing moves toward doctoral preparation for

entry into practice, certified registered nurse anesthetists (CRNAs) have debated if this progression is appropriate for this advanced practice specialty. In 2005, the American Association of Nurse Anesthetists (AANA) Summit on Doctoral Preparation for Nurse Anesthetists convened to discuss and identify potential implications of adopting doctoral preparation (Martin-Sheridan, Ouellette, & Horton, 2006). The summit participants concluded that in the future, CRNAs may need additional knowledge and skills that include doctoral preparation. Following the summit, the Task Force on Doctoral Preparation of Nurse Anesthetists was formed to develop recommendations regarding doctoral preparation for CRNAs. In 2007, a decision was made by AANA to transition from master’s level education to doctoral-level education by 2025 (AANA, 2007). To date, the Standards for Accreditation of Nurse Anesthesia Programs Practice Doctorate states that “students accepted into accredited entry-level programs on or after January 1, 2022, must graduate with doctoral degrees” (Council on Accreditation of Nurse Anesthesia Programs, 2018, p. 3). A recent development with regard to CRNAs obtaining doctoral degrees is the Doctorate of Nurse Anesthesia Practice (DNAP) degree (TheCRNA.com, 2017). The DNAP degree has been approved through the Nurse Anesthetists Council of Accreditation. The DNAP was developed “because many of the nurse anesthesia schools are not located within schools of nursing, and therefore these schools cannot offer a Doctor of Nursing Practice (DNP)” (TheCRNA.com, 2017). The DNAP is not offered through schools of nursing and is therefore not considered a nursing doctorate. Many CRNA programs are offered through schools of nursing, and therefore the DNP degree is conferred through these programs.

The Path to the DNP Degree: Follow the Academic Road The path to the DNP degree has evolved since the inception of the DNP degree. Previously DNP preparation included exclusively postmaster’s degree preparation. Many postmaster’s degree students will have already fulfilled several of the criteria listed in the Essentials of Doctoral Education for Advanced Nursing Practice and the Practice Doctorate Nurse Practitioner Entry-Level Competencies in their master’s degree

curricula. In addition, as mentioned earlier, the specialization content included in the DNP degree curriculum is currently being fulfilled within the master’s degree curriculum. In recent years, postbaccalaureate DNP preparation has been developed and adopted by many schools of nursing. Postbaccalaureate preparation includes both specialization advanced practice nursing content and doctoral-level content. This option presents many new challenges for both students and schools of nursing. Each individual’s path to the DNP degree may be unique. Prospective students’ program content may be individualized to include the learning experiences necessary to incorporate the described requirements for the DNP degree. Refer to FIGURE 3-2 for an illustration of the pathways to the DNP degree.

FIGURE 3-2 Pathways to the DNP degree.

Description

Role Transition Introduced As explained earlier in the chapter, the doctoral-level content of the DNP degree is not intended to provide specialization in nursing practice. The doctoral-level content instead builds on advanced nursing practice specialization and provides additional preparation in the formulation, interpretation, and utilization of evidence-based practices, health policy, information technology, and leadership. Although DNP graduates may function as evaluators and translators of research, health policy advocates, nursing leaders, educators, information specialists, or clinicians, it is entirely likely that these roles will be integrated as well. One DNP graduate may participate in research in addition to practicing as a nurse anesthetist. Another DNP graduate may be a nurse executive in addition to developing health policy. Nursing has always been a profession that involves juggling multiple roles (Dudley-Brown, 2006; Jennings & Rogers, 1988; Sperhac & Strodtbeck, 1997). Within these multiple roles, the fundamental goal of the DNP graduate remains the development of expertise in the delivery of high-quality, patient-centered care, and the graduate utilizes the necessary avenues to provide that care.

INTERVIEW WITH A DNP COFOUNDER: THEN AND NOW

Courtesy of Carolyn Williams Carolyn A. Williams, PhD, RN, FAAN, is professor and dean emeritus of the University of Kentucky. She was president of the American Association of Colleges of Nursing from 2000 to 2002 and scholar-in-residence at the Institute of Medicine from 2007 to 2008. At the time of this writing, Dr. Williams was named an Academy Living Legend, the highest honor achieved through the American Academy of Nursing. THEN . . . 2008 Dr. Williams, could you please describe your background and current position? I began my nursing career as a public health nurse at a public health department in a rural

area and practiced for 2 years before returning to graduate school. I then received my master’s degree in public health nursing. This was a joint master’s degree from both the School of Nursing and the School of Public Health from the University of North Carolina at Chapel Hill (UNC, CH). I then went on to earn a PhD in epidemiology from the School of Public Health at UNC, CH. This was met with some controversy in that I did not have a large amount of nursing experience before returning to graduate school. Interestingly, the School of Public Health was supportive of my doctoral studies, whereas the School of Nursing seemed to think I needed more nursing experience. This is what I call a “pernicious pattern” in nursing education. I actually had to talk faculty [in nursing] into supporting me to earn a doctorate. However, faculty from other disciplines—for example, medicine, psychology, and sociology in the School of Public Health—were very supportive. This is where nursing differs from medicine: We don’t build in the experience into our educational programs. Upon finishing my PhD in epidemiology, I took a faculty position at Emory University’s School of Nursing. From there, I was asked to return to Chapel Hill to participate in the development and evaluation of a family nurse practitioner program in the School of Nursing and to teach epidemiology in the School of Public Health. The program in the School of Nursing was one of the first six federally funded family nurse practitioner programs in the country. I remained at Chapel Hill for 13 years before accepting an appointment as dean of the College of Nursing at the University of Kentucky. Last year I retired as dean after 22 years in that position and remained as a faculty member. This year [2007 to 2008] I am a scholar-in-residence at the Institute of Medicine in Washington, DC. My role here includes development of a project, which happens to be interprofessional collaboration. This stems from the view that improvement in quality care depends on people working together in interprofessional teams. Interprofessional collaboration is happening around the margins of education for health care instead of in the mainstream, particularly core clinical components of undergraduate and graduate education for health care. It may be picked up in passing, but frequently it is not a formal part of the curriculum. Part of my project involves identifying the policy changes [that] are needed at the university level to integrate interprofessional collaboration as part [of] an integral component of education in the health professions. Interprofessional collaboration is a necessary part of practice and therefore needs to be integrated into the preparation of healthcare professionals. This leads me to an issue I have always struggled with: too few clinical faculty in nursing actually practice. This is a problem due to the fact that a practice culture is not as visible as I believe it needs to be in most schools of nursing. Some progress in having nursing faculty engaged in practice was achieved with the nurse practitioner movement that started in the 1970s, but it is still a struggle for nursing faculty to engage in practice as part of their faculty role in a manner similar to what happens in medical education. Some faculty attempt to practice on their own, not as a part of their faculty role, and usually faculty practice is not viewed as a priority in schools of nursing. I feel if we want nursing faculty to provide leadership in practice and develop leaders for practice, each school of nursing needs to have a core group of faculty who actually engage in practice as part of their faculty role. Dr. Williams, could you please describe how your vision for a doctor of nursing practice became a reality? While on the faculty at the University of North Carolina at Chapel Hill and consulting with a number of individuals in practice settings, I developed some ideas of what nursing education to prepare nurse leaders needs to be. Initially, I viewed the degree as what public health nurses could earn to prepare them to face the challenges of public health nursing. I didn’t feel that the master’s degrees in nursing offered at that time [1970s through early 1980s] were sufficient for the kind of leadership roles nurses were moving into. I felt a true practice degree

at the doctoral level was needed. When I went to the University of Kentucky as the dean of nursing, I was charged with developing a PhD in nursing program. While at Chapel Hill, I had been very involved in research activity, doctoral education in epidemiology, and was active nationally in research development and advocacy in nursing as chair of the American Nurses Association’s Commission on Nursing Research and as the president of the American Academy of Nursing. I proceeded to work with the faculty at the University of Kentucky, and we developed the PhD program in nursing. However, I was still interested in the concept of a practice doctorate and in promoting stronger partnerships between nursing practice and nursing education. As time went on, it became clearer and clearer to me that to prepare nurses for leadership in practice, something more in tune with preparing nurses to utilize knowledge, not necessarily generate new knowledge, which was expected in PhD programs, was needed. Thus, I began to talk and work with my faculty colleagues on the concept of a new practice degree for nurses to prepare for leadership in practice, not in education or research. I saw practice as the focus with this degree, not research. Working with my University of Kentucky faculty colleagues, particularly Dr. Marcia K. Stanhope and Dr. Julie G. Sebastian, we developed the initial conceptualization of the degree. These foci included four themes that I feel should be central to a practice doctorate in nursing: 1. Leadership in practice, which includes leadership at the point of care. This also includes leadership at the policy level to impact care. 2. A population approach and perspective. This involves a broader view of health care, which recognizes the importance of populations when planning and evaluating care processes. 3. Integration of evidence-based practice to make informed decisions regarding care. 4. The ability to understand change processes and to institute positive changes in health care. These four themes guided the development of the curriculum of the first DNP program at the University of Kentucky, which, when we instituted it, was the first in the United States. These themes also influenced and are incorporated into what became the AACN’s Essentials of Doctoral Education for Advanced Nursing Practice. To expand on the development of the DNP program at the University of Kentucky, the following is the timeline: 1994–1998: Informal conversations among faculty, people in practice, and others regarding a practice doctorate in nursing 1998: Professional Doctorate Task Force Committee formed May 1999: Approval of DNP program by total college faculty July 1999: Medical Center Academic Council approval January 2000: University of Kentucky Board of Trustees approved the program May 2000: Approval by the Kentucky Council of Postsecondary Education January 2001: The first national paper on the DNP degree at the AACN’s National Doctoral Education Conference (Williams, Stanhope, & Sebastian, 2001) Fall 2001: Students admitted to the first DNP program in the country. In 1998, when the University of Kentucky’s DNP task force was created, we decided we didn’t want this degree to look like anything else currently in nursing education. We also decided on the name of this degree in this committee. We wanted the degree and the name to focus on nursing practice, and we did not want the degree to be limited to preparing for only one particular type of nursing practice. We decided on the doctor of nursing practice because that describes what the degree is: a practice degree in nursing. One of the most important things that happened during my presidency of the American

Association of Colleges of Nursing was the appointment [of] a task force to look at the issue of a practice doctorate. The task force committee was carefully planned. I wanted to have a positive group of people as well as major stakeholders represented. These stakeholders were credible individuals who had an interest in the development of a practice doctorate. Members of the committee included representatives from Columbia University, the University of Kentucky, a representative from an ND program, as well as a representative from schools that did not have nursing doctoral programs. This committee was chaired by Dr. Elizabeth Lentz, who has written extensively on doctoral education in nursing. As this to task force began sorting out the issues, it became the goal that by 2015, the DNP would become the terminal degree for specialization in nursing. From this point, a group to develop both the essentials of doctoral education in nursing and a roadmap task force were formed. These committees worked together, and we presented together nationally in a series of regional forums. We invited others to engage in discourse regarding the essentials as well as to ask questions about the DNP degree. As our presentations across the country came to a conclusion, we noticed an obvious transformation. The DNP degree was beginning to gain more acceptance. By the time we were done, the argument of whether to adopt a practice doctorate in nursing had given rise to how to put this degree in place. Dr. Williams, are you surprised by the acceptance of the degree and the speed with which programs are being developed? Yes, I am surprised. I thought the DNP degree would be an important development for the field of nursing, and I thought some would adopt a practice doctorate. I certainly did not think things would move so fast. The idea of a DNP really struck a chord with many people. Dr. Williams, do you think the history of doctoral education in nursing has influenced the development of a practice doctorate in nursing? Well, we need to have scientists in our field. However, we also need to come to grips with the fact that we are a practice discipline. Over the years, since the late 1970s, many of the leading academic settings in nursing have become increasingly research intensive and [have] not spent as much effort on developing a complementary practice focus. I feel the development of a practice doctorate has more to do with our development as a discipline than with the history of doctoral nursing education. Attraction and credibility from the university setting stem from involvement in research. Therefore, it becomes a struggle when handling this practice piece. If nursing wants acceptance as a discipline, we must have research. But we are a practice discipline, and all practice disciplines struggle to some extent in research-intensive university environments. Dr. Williams, do you agree that nursing should have both a research- and a practice-focused doctorate? Of course. The ratio between research-focused and practice-focused doctorates may be tipped toward the practice focus due to the practice focus of our discipline. Dr. Williams, could you describe what you feel is the future of doctoral education in nursing? Down the pike, some people may move into DNP programs and then discover they want to be researchers and end up also getting a PhD. This would be very healthy for our profession. Essentially, we have lost talented folks due to offering only a research-focused terminal degree. The DNP allows us to accommodate those folks who don’t want a research-focused degree. I also feel we need a more intensive clinical component integrated into the degree. This may be in the form of residency programs integrated within nursing degrees or as a postdoctorate option.

Dr. Williams, could you expand on the grandfathering of advanced practice registered nurses (APRNs) who don’t wish to pursue a DNP degree? The DNP degree will not be required to practice anytime soon. It took a while to require a master’s degree to practice as an APRN. There will be a similar transition regarding the DNP degree. If someone is certified and successful as an APRN without a DNP, they should continue to be successful. Dr. Williams, do you believe the DNP will continue to flourish as a degree option for nursing? If so, what would your advice be regarding nurses earning a DNP degree? Yes, I do. My advice regarding nurses earning a DNP degree is that it depends on their career choice. Some have been looking for this option for a long time. This may be the right degree for some no matter where they are in practice. NOW . . . 2018 Dr. Williams, we discussed your nursing background and education the last time we spoke. Could you please describe your current position and what types of projects you are currently involved in? After I moved out of the deanship of the University of Kentucky’s College of Nursing, I continued my role as a professor of nursing with a focus on teaching, projects, and consultation related to graduate education in nursing at the doctoral level. I continue to teach both DNP and PhD students. One of the things that I have been working on this year is the development of a course in population health. Essential VII of the DNP essentials (AACN, 2006b) is “Clinical Prevention and Population Health for Improving the Nation’s Health.” My impression is that those of us who teach DNP students could and should focus more attention on this essential. Although there is a fairly clear idea among faculty about prevention and its importance, from my perspective there is considerable confusion among faculty about what population health means and how it should be incorporated into the DNP curriculum. I am working on this, and because I feel it is so important to prepare nursing leaders of the future with a firm grounding in this area, I am considering developing a book on population health. Dr. Williams, now that we are approximately 17 years since the inception of the DNP degree, how do you think today’s DNP degree compares to your original vision of the DNP degree? Our program at the University of Kentucky, the first DNP program in the United States, was originally conceptualized as a post-MSN program. Our vision was to create an advanced, clinically oriented program as an alternative to our PhD in nursing, which focused on preparing researchers. We created a program for applicants who had master’s preparation in nursing and offered two plans of study, one for those who were either nurse practitioners or clinical nurse specialists and another for those who wanted to focus on administrative/executive roles. Our original program, of course, was developed before the DNP essentials (AACN) had four major curricular pillars: evidence-based decision making, a population perspective, processes for planning and leading sustainable and meaningful practice changes, and leadership in practice, all of which made their way into the essentials document. With the emergence of post-BSN DNP programs and the effort to keep the length of such programs in check, an issue that needs much more attention is how to reconceptualize and implement preparation for nurse practitioners that incorporates a meaningful approach to utilizing a population perspective in decision making, planning, and leading change and other concepts outlined in the essentials. The reality I have witnessed is that many practitioner students are preoccupied with learning the basics of patient assessment and strategies for problem identification and management at the level of individual patients and trying to develop their “clinical legs” in a new role. Thus, creative curricular strategies are needed to guide students in incorporating such concepts into how they understand their practice and actually practice. My observations

suggest that this challenge is more apparent in programs with a practitioner focus, the majority of post-BSN programs, but it is a challenge for all post-BSN DNP programs. Dr. Williams, when I graduated in 2007, very few folks had heard of a DNP degree. Do you think the DNP degree is now more of a household name among nurses and healthcare professionals? I don’t have any solid data on the extent to which the general public, nurses, or other healthcare professionals know about the degree. On the other hand, I suspect that those who are in communities where DNP programs are located and/or receive care or work in setting where DNPs are either practicing in a provider role or serving in executive or other organizational leadership roles are aware of the DNP degree and have impressions of their contributions to patients and the settings in which they work. Dr. Williams, do you believe that the theory-research-practice gap has been influenced in any way from DNP graduates’ involvement in relevant clinical research and partnerships with PhD colleagues? I would hope that one of the outcomes of partnerships in which DNP graduates and PhD colleagues work together would be an understanding among all participants in the partnership that both types of graduates bring very important perspectives and expertise to the project and that, because of that, the results for patients are better than they would be without such a partnership. One way to speed up the development of such partnerships among graduates would be to encourage faculty teaching in DNP and PhD programs to model working with one another on projects directed to closing the theory-research-practice gap and include DNP and PhD students on the team. Those faculty members who teach in settings with both groups of students have an unusual opportunity to show the way and to create meaningful learning experiences for students and, most important, a better future for patients. I believe DNP students in schools without a PhD program could benefit greatly from working on a project with a partnership of DNP and PhD faculty. Dr. Williams, do you have any feedback regarding the 2015 recommendation for APRN education to transition to the DNP degree for entry into practice? What do you believe the current thinking is regarding this transition? From the beginning, the American Association of Colleges of Nursing’s 2015 recommendation was an aspirational goal, and to my knowledge, the goal of having advanced practice prepared at the DNP level remains in place. The basic idea underlying the goal is that those who have the benefit of attaining a DNP degree are more likely to fully actualize the role of an APRN. At the time, those of us who were in the vanguard of moving the DNP forward at the national level had our eye on the future and what it would take for nurses to provide leadership in the practice arena and all that entails. Yes, the goal was idealistic, and it continues to be. However, at that time we did not say that there was no place for master’s degrees in the preparation of APRNs. And some of us recognized that movement toward the 2015 goal was a process that needed to evolve in a positive way. Specifically, we understood that it would take time for DNP programs to restructure their resources and curriculums to prepare postbaccalaureate students as nurse practitioners, clinical specialists, and administrators. Meanwhile, there is a need to continue to prepare graduates at the master’s level while building the capacity of DNP programs to admit more postbaccalaureate students. Although master’s graduates will be able to enter practice for the near future, the momentum for DNPprepared graduates appears to be growing as more schools are offering post-BSN programs, and enrollments in such programs are increasing (information based on AACN enrollment and graduation data over time). Dr. Williams, are you noticing a transition of roles in nursing as more students graduate from

DNP degrees and begin their careers? Are there any additional roles you see evolving as more nurses earn their DNP degree? I do not have quantitative data on which to base a response to your question. From my personal observations, I have seen three patterns emerging, and these have been predominately among postmaster’s graduates. First, I have seen graduates show the confidence to change positions not long after graduation and to take on new responsibilities and risks. Some have taken on new administrative leadership roles. Another has moved from a successful role working as a clinician in a tertiary care setting to join a large national pharmaceutical company to work with an interprofessional team focused on developing materials and strategies to help patients and families understand and cope with managing complex drug regimens while living in the community. A second pattern I have noted is the movement of a number of graduates into clinical teaching roles, mostly at the baccalaureate level, while maintaining some engagement in clinical practice. As one undergraduate dean said to me, “They are knowledgeable and committed to practice and they know what is important for new graduates to know.” Dr. Williams, it is recognized that there are different considerations for post-MSN and postBSN graduates returning to school to earn a DNP degree. Do you have words of wisdom for MSN and BSN students regarding the DNP degree? Although there are some differences between the two groups, I think the most important factors to be assessed are shared by all considering entering a DNP program. Specifically, I suggest to each applicant that you give careful consideration to (1) what you aspire to do following completion of the degree; (2) an analysis of the resources of each potential DNP program, with particular attention to the expertise and experience of the faculty and the modalities for learning offered by the program; and (3) the match you see between your interests and learning needs, the faculty’s expertise and experience, and how you see each program challenging and assisting you in accomplishing your goals. With regard to faculty expertise, I think it is particularly important to find a program in which a significant number of faculty members have current or very recent experience in the areas in which they teach. This type of information may be difficult to find from looking at websites or recruitment material; therefore, an onsite or a virtual interview, even though it may not be required by the program, would be a good investment.

Summary The DNP degree is defined as a practice-focused doctorate that prepares graduates as experts in nursing practice. Nursing practice is defined by the AACN as “any form of nursing intervention that influences health care outcomes for individuals or populations, including direct care of individual patients, administration of nursing and health care organizations, and the implementation of health policy” (AACN, 2004, p. 3). According to the AACN’s (2004) position statement, it was recommended that the DNP degree be the terminal degree for nursing practice by 2015. A nursing PhD degree is a research-focused degree, and a DNP degree is a practice-focused degree. The evolution of doctoral education in nursing illustrates where we have been in doctoral education and the direction nursing is taking in the development of doctoral education. The concept of a practice doctorate is not new. The idea began in the 1970s with the development of the DNS degree. The AACN now designates the DNS and PhD degrees as researchfocused degrees, and the DNP and DrNP degrees are designated as practice-focused degrees. In 2002, the AACN board of directors formed a task force to examine the current progress of proposed doctorates in nursing. In 2000, the IOM published a report titled To Err Is Human: Building a Safer Health System, which summarized errors made in the healthcare system and proposed recommendations to improve the overall quality of care. In 2003, the Health Professions Education Committee published Health Professions Education: A Bridge to Quality, which outlined a specific set of competencies that should be met by all clinicians. In 2008, the IOM appointed the Committee on the RWJF Initiative on the Future of Nursing. This committee published a report in 2010 titled The Future of Nursing: Focus on Education, which concluded that “the

ways in which nurses were educated during the 20th century are no longer adequate for dealing with the realities of healthcare in the 21st century” (IOM, 2010a, p. 2). This committee also recommended doubling the number of nurses with doctorates by 2020. In 2005, the National Academy of Sciences recommended that a nonresearch ND be developed to meet nursing faculty needs. In 2006, the AACN described the Essentials of Doctoral Education for Advanced Nursing Practice, which represents the standards for DNP curricula. The NONPF outlined the Practice Doctorate Nurse Practitioner EntryLevel Competencies as standards for DNP curricula. In 2009, the NACNS developed Core Practice Doctorate Clinical Nurse Specialist Competencies. In 2007, the AANA stated that nurse anesthetist education would adopt doctoral education as preparation to enter into practice by 2025. The DNP degree includes postmaster’s degree programs and postbaccalaureate degree programs. Graduate students may follow an individualized path to the DNP degree, depending on their current degree preparation. DNP graduates may be involved in many different roles that may include, but are not limited to, research evaluator and translator, leader, healthcare policy advocate, educator, information technology specialist, and clinician.

Discussion Questions 1. How do you think nursing’s history has contributed to the development of the DNP degree? 2. How do you think the IOM report To Err Is Human: Building a Safer Health System, along with the follow-up report Crossing the Quality Chasm: A New Health System for the 21st Century, contributed to the development of the DNP degree? 3. Explain why you think the IOM and the RWJF concluded, in their report The Future of Nursing: Focus on Education, that nurses need improvement in their educational preparation. 4. Do you think a struggle still exists within nursing today regarding whether doctoral education should be research or practice focused? 5. Do you think nursing doctoral education should be research focused, practice focused, or both? 6. Do you think a DNP degree is the right degree for you?

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CHAPTER 4 Emerging Roles for the DNP Chapter Objectives After completing this chapter, the reader will be able to 1. Describe leadership roles that are emerging from the doctor of nursing practice (DNP) degree. 2. Explore the impact of the DNP on nursing education and healthcare outcomes. 3. Discuss the influence of the DNP on nursing administration and executive roles. 4. Define the characteristics of a nurse entrepreneur. 5. Distinguish between public health and community health nursing and the role of the DNP as program developer and evaluator. 6. Analyze complementary healthcare modalities and the DNP as an integrative practitioner. 7. Understand the role of the nurse informaticist as project manager and change agent.

NURSE EDUCATOR Judith M. Pechacek Advanced nursing practice demands the doctorally prepared nurse to be clinically competent in one area of specialized advanced nursing practice (American Association of Colleges of Nursing [AACN], 2006). The academic preparation, including the alignment of the pedagogy for doctor of nursing practice (DNP) programs and the AACN Essentials contribute to achievement of these applied practice competencies. However, the existing program of study for the DNP student (and the doctor of philosophy [PhD] student) is inadequate preparation for the role of nurse educator (AACN, 2006). Both the National League for Nursing (NLN, 2012) and the American Association of Colleges of Nursing posit advanced practice nursing faculty should have additional coursework in curriculum design and evaluation and teaching pedagogies. The NLN describes the role of nurse educator as its own distinct field of expertise with eight competencies that serve to do the following: Facilitate learning Facilitate learner development and socialization Use assessment and evaluation strategies Participate in curriculum design and evaluation of program outcomes Function as a change agent and leader Pursue continuous quality improvements in the nurse educator role Engage in scholarship Function within the educational environment According to Booth, Emerson, Hackney, and Souter (2016), the nurse educator needs formal nurse education preparation including, curriculum development, teaching strategies, and evaluation methods to be an effective in his or her role. The need for nurse educators continues, as this shortage limits the capacity of schools to expand to meet the demands for qualified students to enter the capacity of schools. The AACN reports baccalaureate and graduate nursing programs turned away over 64,000 qualified applicants due to the nurse educator

shortage. The impact to graduate nursing is substantial, with master’s programs rejecting 9,757 qualified applicants and doctoral programs turning away 2,102 qualified doctoral applicants (AACN, 2017). A recent AACN (2017) survey reported over 1,500 faculty vacancies in over 800 schools of nursing, with 60% of these schools reporting full-time nurse educator vacancies. In addition to these vacancies, nursing schools report the need to add educator positions to meet student interest in nursing education. Nationally, the vacancy rate for nurse educators is 7.9%, with 91% of these positions requiring doctoral preparation (AACN, 2017). The U.S. Department of Labor, Bureau of Labor Statistics (2015) reported 35% more nurse educators are needed by 2022 to meet the demand. Additionally, over 10,000 nurse educators plan to retire, resulting in a need of over 34,000 nurse educators by 2022 (U.S. Department of Labor, Bureau of Labor Statistics, 2015). Even though the DNP degree is an applied practice doctorate, more than 30% of graduates aspire to teach in nursing programs (National Advisory Council on Nurse Education and Practice, 2010). In the 2010 seminal report The Future of Nursing: Leading Change, Advancing Health, the Institute of Medicine (IOM) put out the challenge to “double the number of doctorally prepared nurses by the year 2020” (IOM, 2011). This challenge is intended to address the need for nurse educators to educate the nursing workforce. In March of 2008, AACN endorsed recommendations to guide academic institutions as they respond to the faculty shortage and need to expand teaching capacity. The AACN set forth the following as the “preferred vision of the nursing professoriate” (AACN, 2008, p. 1): Educational institutions vary in culture and policy. Qualifications and performance of nursing faculty will be congruent with accepted institutional standards. Consistent with academy expectations, faculty with primary responsibility for the oversight of courses in baccalaureate, master’s, and doctoral nursing programs will have doctoral preparation. Doctoral graduates who will be involved in an academic role will have preparation in educational methods and pedagogies. The nursing program faculty must balance its stature within the academy with its concurrent responsibility to prepare graduates for the

practice environment. Therefore, the mix of faculty expertise, roles, and responsibilities will vary according to the mission of the academic program. Courses in the nursing program will be taught by faculty with graduatelevel academic preparation and advanced expertise in the areas of content they teach. Nursing science is enriched by the knowledge and expertise of many disciplines. Selected nursing program courses and electives may be taught by either nurse or non-nurse faculty with appropriate educational and experiential preparation. Clinically focused graduate preparation is the minimal expectation for clinical instruction and the coordination and mentoring of preceptors. Preceptors from the practice environment working under the guidance of nursing faculty serve as role models for the design, organization, and implementation of patient care. Preceptors in entry-level prelicensure programs must, at minimum, hold a baccalaureate degree in nursing. The requirement for doctorally prepared graduates to have focused “preparation in educational methods and pedagogies” is further articulated in the AACN Essentials of Doctoral Education for Advanced Nursing Practice (2006, p. 7): In some instances, individuals who acquire the DNP [degree] will seek to fill roles as educators and will use their considerable practice expertise to educate the next generation of nurses. As in other disciplines (e.g., engineering, business, law), the major focus of the educational program must be on the area of practice specialization within the discipline, not the process of teaching. However, individuals who desire a role as an educator, whether that role is operationalized in a practice environment or the academy, should have additional preparation in the science of pedagogy to augment their ability to transmit the science of the profession they practice and teach. This additional preparation may occur in formal course work during the DNP program. Some teaching strategies and learning principles will be incorporated into the DNP curriculum as it relates to patient education. However, the basic DNP curriculum does not prepare

the graduate for a faculty teaching role any more than the PhD curriculum does. Graduates of either program planning a faculty career will need preparation in teaching methodologies, curriculum design and development, and program evaluation. This preparation is in addition to that required for their area of specialized nursing practice or research in the case of the PhD graduate. Clearly the DNP curriculum is insufficient to support the DNP-prepared nurse in the role of nurse educator. The following sections will offer suggestions and strategies to support the DNP-educated nurse planning to serve in the nurse educator role. The examples provide the start of a developmental plan for both the DNP-prepared nurse and academic administrators to pursue related to the DNP-prepared nurse serving in the emerging role of nurse educator.

Faculty Development Programs Faculty development is defined by Sheets and Schwenk (1990) as “any planned activity to improve an individual’s knowledge and skills in areas considered essential to the performance of a faculty member . . . for example teaching skills, administrative skills, research skills, clinical skills” (p. 141). The core competencies of faculty development programs are to ensure personal and professional development in the context of the academic institution and its mission. According to McLean, Cilliers, and Van Wyk (2008), the work of the academic institution is to ensure the faculty development program is sustainable and effective. The program needs to ensure new faculty have an individualized, realistic development plan that supports multiple learning activities including peer review, reflection, courses, and mentoring. The context of the faculty development is varied, but because the DNP degree is grounded in the application of best clinical practice, attention to quality, safety, and interprofessional practice are crucial. The new nurse educator needs to focus on quality and safety in nursing with with concrete pedagogical strategies. All nurse educators require relevant instruction and development related to quality improvement methods, tools, and specifically the Quality and Safety Education for Nurses (QSEN) competencies (Thornlow & McGuinn, 2010). Effective interprofessional education is critical for all health professions (World Health Organization [WHO], 2010), and because nurses are critical members of the interprofessional team it is imperative that nurse educators focus on the interprofessional competencies (Reeves, Perrier, Goldman, Freeth, & Swarenstein, 2013). The Interprofessional Education Collaborative (IPEC) developed four domains that are to be used to guide interprofessional pedagogical strategies across all health professions: values/ethics for interprofessional practice, roles/responsibilities, interprofessional communication, and teams and teamwork (IPEC, 2016). New faculty development programs offered at most academic institutions are effective in supporting faculty in the educator role. New faculty programs (NFPs) are intended to “help faculty build their capacities in research, teaching, community engagement, career

advancement, and leadership” (University of Minnesota, 2018a). Curriculum offerings include, but are not limited to, early-career teaching and learning, active classroom activities, online learning, and writing across the curriculum. The structure of NFPs can vary, but typically NFPs occur over 8 to 12 months, with monthly in-person meetings, seminars, and individual work between sessions. Additionally, the networking and relationship building with faculty from other schools, programs, and professions enhances the experience (University of Minnesota, 2018b).

Nursing Education Practicum Nursing education practicum experiences enable the graduate nurse to acquire basic experience as a nurse educator. Students work through online modules that expose the student to the curriculum design, implementation, and evaluation of evidence-based, scholarly teaching and learning in various nursing education contexts. Students are required to analyze nursing program accreditation standards and nursing program outcomes. Additionally students are required to spend 120 hours of supervised teaching with an experienced nurse educator. This course is leveled for graduate students who have little or no teaching experience in nursing. Students develop and implement a teaching plan and are observed and evaluated by expert educators (University of Minnesota, 2018b).

Graduate Teaching Assistant While enrolled in graduate school, the DNP student can gain teaching experience in the academic setting by serving as a graduate teaching assistant (GTA). Typically, GTA experience provides the DNP student with real-world exposure to teaching with a tuition offset, making graduate school much more affordable. The GTA program is typically led by the dean of academic programs and facilitated by expert doctorally prepared faculty who are accountable for courses. The faculty work together with the GTA to ensure the clinical teaching is consistent with the objectives of the course and the competencies expected of the student. Constant oversight and feedback ensures both the nursing student and the GTA have a good experience. Time and attention is paid to the focus of the curriculum, objectives of the course, student activities, and evaluation strategies. Each phase of teaching requires feedback and oversight by an accountable faculty member (Pressler & Kenner, 2014).

New Nurse Educator Mentoring Programs The positive impact a formalized mentoring program can have on the retention, productivity, and work–life balance of a new nurse educator is substantial (Allen, Eby, Poteet, Lentz, & Lima, 2004). The transition from practicing clinician to academician can be hastened by the support and guidance of an expert mentor. The NLN (2006) established a model for mentoring that included “four mentoring outcome pillars”: Orientation to the faculty role Socialization to the academic community Development of teaching, research, and service skills Facilitation of the growth of future leaders in nursing and nursing education Extending the work of the NLN, Nick et al. (2012) established six best practice themes that provide a supportive framework to the four mentoring outcome pillars: Achieve appropriately matched dyads Establish clear mentorship purpose and goals Solidify the dyad relationship Advocate for and guide the protégé Integrate the protégé into the academic culture Mobilize institutional resources The research of Nick et al. (2012) supports positive transition, improved self-confidence, higher morale, and enhanced academic production. Many mentors and mentees continue their professional working relationship through joint scholarship and teaching.

Online Learning In one private university, educator support is provided through the learning management system (LMS). The system provided new educators basic information regarding the university, school of nursing, nursing programs, and contact information. This LMS enabled live links to useful technology resources and collegial networking opportunities. The feedback from the new nurse educators is positive; however, planning to sustain and revise this LMS needs to be factored into the work effort of experienced faculty (Slade, Robb, Sherrod, & Hunker, 2017). As a result of the 2008 North Carolina nursing faculty legislation, the board of nursing revised criteria to require faculty to have preparation in teaching and learning, principles of adult education, and curriculum development, implementation, and evaluation. To meet this new legislation, the Northwest Area Health Education Center (NWAHEC) of Wake Forest School of Medicine, in conjunction with nursing program directors, developed a 60-hour, four-model online learning institute (Wake Forest School of Medicine, n.d.). The learning modules include socialization, teaching/learning methodologies, curriculum design, and improving performance. The nurse educator learner is also provided with a 142-page workbook to practice the skills as they work through the modules. Upon completion of the modules and successful post-test, the learner is awarded contact hours and a completion certificate. The feedback is positive, with 94% of participants responding that the activities improved their skills and 92% stating that the online format was useful; the “course content, teaching methods, handouts, and audiovisuals were rated as appropriate, useful, and consistent with the course objectives” (Reese & Ketner, 2017, p. 225). Nurse educators who also serve as direct practitioners are clinically suited to serve as clinical instructors. To support clinical instructors in the necessary pedagogy, an online clinical instructor program (CIP) can be useful (Weston, 2018). The CIP, delivered exclusively online, includes six modules covering the philosophy of teaching, student orientation, matching classroom and clinical content, making the clinical teaching assignment, strategies for successful teaching, and evaluation of the

student. This online platform also includes active learning strategies, video clips, and quizzes. This supportive structure demonstrated an increase in the instructor’s understanding of teaching in the clinical setting as well as pedagogical strategies, and is an effective and efficient mechanism for clinical instructors (Weston, 2018).

Peer Review New faculty can benefit greatly from the feedback of experienced nurse educators. Supportive feedback is intended to enhance the personal development plan of the new nurse educator. The critical aspects of peer review reside in the process used to conduct peer review, which include not only the tools used and faculty development but also the culture of trust and support within the academic institution. Research conducted by Blauvelt, Erickson, Davenport, and Spath (2012) support the three-stage model of peer review (Siddiqui, Jonas-Dwyer, & Carr, 2007), which includes the pre-observation, observation, and post-observation steps. During the pre-observation step, preparations are made to ensure both the observer and the faculty member are oriented to the process, tools, and role expectations. During the actual peer review, the reviewer observes the faculty member and ensures their presence does not cause a disruption within the teaching environment. During the post-observation step, the reviewer shares their observations and recommendations. It is critical that the peer-review structure follows accepted competencies, such as the NLN competencies of a nurse educator (described previously). The nurse faculty member can use the feedback to inform and share a personal development plan with their department chair for support (Blauvelt et al., 2012). The number of fully online and hybrid (blended online and in-person) nursing programs has expanded over the last decade, necessitating new nurse educator competencies on how to effectively use online platforms for teaching. One such tool that can be used to support faculty in the development and evaluation of online courses is the Quality Matters (QM) process/rubric. QM (Quality Matters, 2018) is a research-based peer-review system developed by faculty to assess the instructional design of an online course. Specifically, the QM rubric consists of 40 standards and recommendations deemed as indicators of best practice course design. For example, the course learning objectives need to be measurable and align to the module objectives, the required learning activities, and evaluation or assessment methods. Faculty can use the QM rubric to develop new courses and to make improvements in existing

courses. Many organizations use this peer-review process with faculty to conduct an informal, internal review of the online course. The internal reviewer peer provides the faculty with specific, measurable directed feedback that will guide them to make needed changes to the course. After improvements are made, the course is reviewed formally by an outside reviewer to ultimately achieve QM certification. This certification is widely accepted as an indicator of a “high quality course design that supports student learning” (Roehrs, Wang, & Kendrick, 2013, pp. 64). The current DNP academic preparation is not intended, nor is it sufficient, to ensure an effective nurse educator practice, yet 30% of DNP graduates intend to serve in this role. While national organizations, such as the AACN and the NLN, wrestle with this reality, nurses holding DNP degrees who intend to serve in an academic position need to secure additional development in curriculum design, teaching methodologies, and program evaluation. A concrete professional development plan needs to be in place, with adequate time to execute and evaluate this development. Mentors, formalized pedagogy, and faculty feedback are all strategies to support new nurse educators and need to be incorporated in a new nurse educator’s personal development plan.

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NURSE ADMINISTRATOR Mary Jean Vickers The DNP educational program prepares nurses to lead health care in today’s challenging reform atmosphere, which demands better access and quality while reducing costs. During this period of rapid change, there are many new opportunities for administrators with DNP preparation to excel. However, first these graduates must demonstrate the expertise to create meaningful change in complex organizations. Within the profession of nursing there is significant effort to focus on quality outcomes, which are impacted by nurse staffing, nursing education, and frontline nurse engagement in participative management. Within the broader healthcare environment there is significant focus on improving quality and access while reducing costs. The DNP-prepared administrator is well positioned to lead effectively with a comprehensive focus on competing market demands. It is critical for the administrator to have an appreciation of the many governmental and private influences on healthcare programming. Among these agencies are the Joint Commission, the Centers for Medicare and Medicaid Services (CMS), the Institutes of Health, the National Quality Forum (NQF), the Agency for Healthcare Research and Quality (AHRQ), insurance companies, private businesses, and, specifically for nursing, the American Nurses Association Magnet Certification program and the National Database for Nursing Quality Indicators (NDNQI). These groups are developing certification programs and/or quality improvement measures in which hospitals are encouraged and rewarded for participation. Sometimes the improvement projects are educational in nature, but often the projects are redesigns of past processes intended to embrace technology in order to improve efficiency and the metrics related to care delivery. Specific best practices are embedded into the care requirements of common diagnoses to promote standardized care and reduce readmissions. Embracing these best practices is often rewarded with higher reimbursement fees, also understood as pay-for-performance strategies. A DNP-prepared administrator has an appreciation of the

delicate balance between cost and quality. He or she has a keen understanding of the interdependencies between providing high-quality patient-centered care and achieving improved reimbursement and cash flow. Likewise, the DNP-prepared administrator values the unique practice of nursing as well as the scope of practice of nursing as defined within each state’s Practice Act. Future employment opportunities for the DNP-prepared administrator will be in clinical leadership positions such as nurse managers, directors of nursing, and chief nurse of operations. Other pathways for leadership positions include nonclinical areas, such as directors of nursing informatics and leaders of case management programs, or in education, as leaders of healthcare-based practice and educational programs in academia. The potential for DNP-prepared administrators is limitless throughout the continuum of care. Identifying the focus of your career path is assisted by strong mentoring, exploration of opportunities, and reflection upon your personal strengths and aptitude.

Change Theory A DNP-prepared administrator is well served by the study of the concepts explored in change theories and the knowledge gained through DNP coursework. There are many change models to explore, and each can be helpful in guiding our decisions and facilitating change assimilation into practice. The early work of social psychology researcher Kurt Lewin is seminal in understanding how groups process change (Smith, 2001). Kurt Lewin developed a simple theory with three phases: unfreezing, change, and freezing. This theory, in its simplest form, suggests that first you need to prepare those who will change through a process of unfreezing their current view of the issue. Next, you must implement the change and, finally, freeze the new process into place. Current business literature abounds with books on the subject of leading and managing change for large organizations. These publications offer a more comprehensive model from which to design project plans. The works of Kotter (1996, 2012) and Taylor (2006) are helpful to DNP graduates in administrative positions. These authors provide a useful approach to leading change and managing large projects effectively. A change theory that may be helpful is the model developed by Kotter (1996, 2012). John Kotter, professor at the Harvard Business School, first published Leading Change in 1996. His model consists of eight steps: 1. Establishing a sense of urgency 2. Creating a guiding coalition 3. Developing a vision and strategy 4. Communicating the change vision 5. Empowering employees for broad-based action 6. Generating short-term wins 7. Consolidating gains and producing more change 8. Anchoring new approaches in the culture This model has continued to be an excellent guide in leading both nursing and education departments through many large projects. Establishing the sense of urgency requires nurse managers, clinical

nurse specialists, staff nurses, and preceptors to become engaged in each project. Nursing executive leadership must also become engaged to help build a guiding coalition for each project. Developing the vision and a strategy is best served by actively embracing a collaborative effort among those involved. Ultimately, creating the vision for the implementation of any project often becomes the sole responsibility of the administrator. Empowering the team to follow the plan and implement the change is motivated by this vision. The last three steps in Kotter’s model are a key barrier to successful change. These are generating short-term wins, consolidating gains, and anchoring the new approaches into practice. This often occurs because these steps are not intentionally designed into the change project. Leaders are eager to implement the change but need to stay committed for a long period to ensure the change has become normalized into practice. Considering the culture of the organization is important in anchoring the change into practice. This requires a demonstration that the change actually works and fits within the values of the organization (Kotter, 1996). Identifying the metrics that will measure project assimilation into practice through auditing or electronic health record reports is critical to anchoring the new approach into the culture. Communication is constant in any change project. Repeating, reviewing, and reinforcing the processes and the messages is necessary to solidify the change. Refining the process during implementation is critical to the ultimate success of all projects. This refining process merges into the next step, empowering employees for broad-based action. One of the most difficult tasks of the project leader is relinquishing control over every element of the project. Letting others take ownership of the project and empowering them to help guide the decisions during implementation will serve the DNP-prepared nurse leader well during the implementation phase of each project undertaken. Measuring and reporting short-term gains and consolidating those gains is motivational for those employees involved in the project and fuels their enthusiasm. Consolidating gains, producing more change, and ultimately anchoring the change into practice require continued vigilance. Each model that a leader explores will have some areas of weakness. The one area in which Kotter’s (1996, 2012) theory is weak is the evaluation phase of the program. Exploring program evaluation methods

is a skill found in DNP-prepared administrators. A review of the literature to find the right evaluation tool for each project may be time consuming. Many projects will require staff education prior to implementation. Alignment of these training projects with the Bersin (2008) model of training, measurement, and evaluation promotes consistency in how each project outcome is measured. Kotter’s theory of change and Bersin’s model of training measurement provide useful theoretical frameworks to guide projects in the real world, with real people to motivate and lead. The goal of many projects is final assimilation into practice. This step takes time, requires diligence and discipline, and is often the most difficult to achieve. Collecting metrics to measure assimilation and communicating the results to those involved are important in achieving the desired outcome.

Leadership Style Exploring leadership models is a skill that the DNP-prepared administrator gains in the course of study. Exposure to leadership theories and models enhances understanding of the variety of approaches and techniques that can be employed to reach organizational goals. In nursing curriculums some of the first leadership styles explored may be authoritarian, laissez-faire, or democratic (Cherry, 2011). Authoritarian style may be necessary during emergencies, but may leave the staff nurse dissatisfied. Nurses experience the decisions of nursing leaders and other administrators daily. They often express the need to be involved in these decisions. Authoritarian leadership styles are autocratic and do not involve other participants in making the decision. This style of leadership is limited in relationship building and staff development of those who report to us. The Magnet Certification Program encourages more decision-making control by the staffs that are served by administrators. Participative management is a form of democratic leadership. This style of leading has always held an attraction for this author. Democratic leaders will allow for group discussion of a problem and the selection of an acceptable solution. This participative leadership style promotes shared responsibility and greater involvement of those who are charged with implementation of the solution. Partnerships form between the administrator and the employees. This bond creates a relationship based on mutual respect and collegiality. We should not underestimate the importance of dialogue in the workplace. The ability of staff to openly share their concerns, offer ideas for resolving problems, and participate in both the discussion and the selection of resolutions empowers staff toward greater personal engagement and professional satisfaction. This approach is also likely to improve the adoption of a change and its assimilation into practice. Ultimately, the goal of all change is to improve patient outcomes and patient satisfaction. In the past, when in an academic role as clinical faculty, the desire to intellectually stimulate students, mentor them toward the acquisition of

knowledge and skills, and develop their abilities improved this author’s leadership competencies. Developing a transformational and transactional leadership style, as suggested by Failla (2008), is a worthy professional goal for all administrators. This article effectively describes the importance of more contemporary leadership models. The five critical strategies of transformational leaders described by Failla are useful: Instill employee pride in the leader’s vision and mission. Use leader behaviors to demonstrate the values and mission to employees. Increase staff awareness and acceptance of the desired mission. Intellectually stimulate employees and others to think in new ways. Individualize consideration by mentoring and expressing appreciation when the mission and related goals are accomplished. Other well-regarded authors such as Marshall (2011) and PorterO’Grady and Malloch (2011) have continued to explore the importance of transformational leadership. The competencies of a transformational leader are “achievement orientation, analytical thinking, financial skills, information seeking, innovative thinking, and strategic orientation” (Marshall, 2011, p. 53). In today’s rapidly changing healthcare environment, becoming the visionary leader that seeks to transform the department by deploying sound, evidence-based strategies and innovative thinking will be highly valued. A publication related to improving the nursing work environment, Keeping Patients Safe: Transforming the Work Environment of Nurses (IOM, 2003), supports transformational nursing leadership style for nursing leaders. Administrators must examine the work environment where care is delivered and the critical role of nurses in providing safe patient care. This important publication described the key elements of the work environment impacting patient safety: organizational management practice, workforce deployment practices, work design, and organizational culture (IOM, 2003). Developing and maintaining trust between administrators and the healthcare employee is critical in creating the safe patient care environment of the future. The accountabilities of leaders discussed in Stefl (2008) are “communication and relationship management, professionalism, leadership, knowledge of the healthcare system, and business skills and

knowledge” (p. 360). Missing from this model are the skills needed to evaluate and improve the competency of followers. Holding others accountable and maintaining the clinical discipline required for the delivery of safe care is an important competency of managers in a healthcare environment. One area for skills growth among many administrators and managers is holding people accountable and motivating them to improve clinical performance. This can be done very effectively through positive feedback and investing in staff development. Too often it is thought that constructive but negative feedback is the only avenue and that if things are going well, there is no need to provide feedback. Chapman and White (2012) encourage more positive and frequent feedback to promote a more productive employee and team. Leaders who find time to actively observe their staff in care delivery can optimize the feedback staff receive about the care and compassion they demonstrate to our patients. Too often we value the tasks being completed on time over the quality of the relationship and the interpersonal skills the nurse deployed in the care of patients. It is beneficial as an administrator to have strong values and high expectations of those you lead and those with whom you need to collaborate. Many times, communicating your expectations clearly will lead to accomplishing these goals. Many employees have a strong desire to meet their manager’s expectations and even to exceed them. However, if the goals are not clearly communicated, it is not unusual to be disappointed when one’s team fails to meet expectations. Being a good coach by spending time with all employees to further develop skills and facilitate their performance at the level expected is a valuable approach. However, it is also wise to understand that the learning curve is steeper for some, and this can create some tension for both the leader and the team. As a leader it is important to maintain an objective professional approach to your staff that is consistently interpreted as being fair and open to staff concerns. Much has been published about the way nurses kill their young (Dellasega & Volpe, 2013). As a leader, it is important to be aware of the relationships among staff and to be attentive to any overt or covert signs of bullying. These interpersonal conflicts can undermine the desired culture and have detrimental effects on the quality of patient care. As a leader, it may be useful to assess one’s own leadership and

personality traits. Many organizations use the Myers-Briggs (The Myers & Briggs Foundation, n.d.), Insights (Adams, 2017), or other personality tools to assist leaders to gain insight into their individual strengths and challenges. Additionally, many authors encourage the examination of emotional intelligence as a factor in achieving personal excellence. Porter-O’Grady and Malloch (2011) identify the five elements of emotional intelligence: self-awareness, self-regulation, motivation, empathy, and social skill. Reflecting upon our personal leadership behaviors through self-awareness and considering how this impacts the workplace is valuable in developing effective leaders who are admired by their staff.

Evidence-Based Management Practices The DNP program will prepare graduates to embrace evidence-based practice (EBP). An administrator also needs to adopt evidence-based management practices. This is accomplished through exploring the literature or delegating this task to those working on projects with the administrator. A review of executive summaries and formal literature reviews, as well as local programs and processes, will provide the administrator with the clearest picture of the current situation. Discussions with the team regarding these findings and selection of the best management approaches to achieve the organization’s goals will result in improved outcomes. It is not unusual for administrators to set goals that might not be achievable and then try to force the team to achieve an unrealistic goal. This can be costly and should be avoided unless urgent situations require quick solutions. Consider setting shortterm achievable goals that will build momentum toward the larger goal desired. Balancing the objectives of many healthcare disciplines can often challenge the administrator. Physicians’ need for adequate bed capacity to provide for the care of patients in their specialty and those receiving specialized treatments can challenge the skills and abilities of the available nursing staff. Working in a collaborative manner with the physicians, educators, nurses, and specialists in other disciplines to promote the care needs of patients and provide for the education that nurses or others need requires patience and commitment. Approaching these situations in a manner that does not address the educational needs of the nurses may result in less than optimal outcomes for patients.

Collaboration One of the most important skills the DNP-prepared administrator needs is that of collaboration. In its simplest form, collaboration “implies collective action toward a common goal in a spirit of trust and harmony” (D’Amour, Ferrada-Videla, San Martin-Rodriguez, & Beaulieu, 2005, p. 116). Working well in teams to achieve the goals of the organization requires this level of collaboration. Barriers to achieving good collaborative relationships can be work-related boundary concerns (“It’s not my job”) and competition. Healthcare reform requires healthy work relationships that use limited resources to provide the best care possible. Working together in healthy teams that put the patient and organizational goals ahead of our own will serve us in reducing costs, managing limited resources, and transforming health care in an efficient and effective manner. Deliberate collaboration can strengthen colleagues of the same discipline as well as interdisciplinary teams. This approach can lead to improved patient safety and staff satisfaction. There is much activity in health care focused on making health care safer for our patients. Some attention has been devoted to the TeamSTEPPS program developed by the Department of Defense and AHRQ to enhance team performance, communication, efficiency, and safety in health care (Powell, 2011). Frequent comparisons of health care to the airline industry are made. Attention is directed at healthcare organizations to demonstrate the attributes of High-Reliability Organizations, or HROs (Gamble, 2013). An HRO is an organization with a low tolerance for error that designs for success and not shortcuts and listens to their frontline staff as the experts in addressing problems.

Conclusion DNP preparation provides an opportunity to explore leadership theories, project management and evaluation techniques, EBPs, and change theories. Lifelong learning and exploring the literature to improve leadership skills must be embraced. The challenge for the administrator is to integrate this academic preparation and lifelong learning into practice to promote innovative approaches to problems in our highly complex healthcare environments. Thinking outside the box, exploring technologies that allow for more efficiency, and embracing new ideas while consistently paying attention to patient safety, patient and staff satisfaction, and cost will promote both better patient care and the role of DNP-prepared administrators.

References Adams, R. (2017). Discover the power of you: How to cultivate change for positive and productive cultures. Retrieved from http://commercialistaonline.us/?p=270 Bersin, J. (2008). The training measurement book: Best practices, proven methodologies, and practical approaches. San Francisco, CA: Pfeiffer. Chapman, G., & White, P. (2012). The 5 languages of appreciation in the workplace. Empowering organizations by encouraging people. Chicago, IL: Northfield. Cherry, K. (2011). Lewin’s leadership styles. Retrieved from http://psychology.about.com/od/leadership/a/leadstyles.htm D’Amour, D., Ferrada-Videla, M., San Martin-Rodriguez, L., & Beaulieu, M. D. (2005). The conceptual basis for interprofessional collaboration: Core concepts and theoretical frameworks. Journal of Interprofessional Care, 19 (Suppl. 1), 116–131. Dellasega, C., & Volpe, R. (2013). Toxic nursing: Managing bullying, bad attitudes, and total turmoil. Indianapolis, IN: Sigma Theta Tau International. Failla, K. (2008). Manager and staff perceptions of the manager’s leadership style. Journal of Nursing Administration, 38(11), 480–487. Gamble, M. (2013, April 29). 5 traits of high reliability organizations: How to hardwire each in your organization. Becker’s Hospital Review. Retrieved from www.beckershospitalreview.com/hospital-management-administration/5-traits-of-highreliability-organizations-how-to-hardwire-each-in-your-organization.html Institute of Medicine (IOM). (2003). Keeping patients safe: Transforming the work environment of nurses. Washington, DC: National Academies Press. Kotter, J. (1996). Leading change. Boston, MA: Harvard Business School Press. Marshall, E. S. (2011). Transformational leadership in nursing. New York, NY: Springer. The Myers & Briggs Foundation. (n.d.). MBTI basics. Retrieved from https://www.myersbriggs.org/my-mbti-personality-type/mbti-basics/home.htm?bhcp=1 Porter-O’Grady, T., & Malloch, K. (2011). Quantum leadership: Advancing innovation, transforming health care (3rd ed.). Sudbury, MA: Jones & Bartlett Learning. Powell, J. (2011). TeamSTEPPS definition. Retrieved from www.scontrinopowell.com/2011/teamstepps-definition-and-history Smith, M. (2001). Kurt Lewin: Groups, experiential learning and action research. Retrieved from http://infed.org/mobi/kurt-lewin-groups-experiential-learning-and-action-research Stefl, M. (2008). Common competencies for all healthcare managers: The health-care leadership alliance model. Journal of Health Care Management, 53(6), 360–373. Taylor, J. (2006). A survival guide for project managers. New York, NY: Amacom Books.

PUBLIC HEALTH NURSE Carol Flaten and Jeanne Pfeiffer Dramatic effects on the health of populations have been the work of public health nurses (PHNs) who consider population-level assessment, intervention, and evaluation to impact the health of the communities they serve. This work has improved the quality and quantity of life of individuals and communities. In the 20th century, life expectancy increased from 47.3 years in 1900 to 78.7 years in 2010 (National Center for Health Statistics, 2013). The 10 great public health achievements of the 20th century can be credited with this dramatic change in life expectancy. These 10 achievements are (1) immunizations, (2) motor vehicle safety, (3) workplace safety, (4) control of infectious disease, (5) decline in deaths from heart disease and stroke, (6) safer and healthier foods, (7) healthier mothers and babies, (8) family planning, (9) fluoridation of water, and (10) identifying tobacco as a health hazard (Centers for Disease Control and Prevention, 2011). PHNs have played a part in all these areas. DNP-prepared PHNs bring a depth of knowledge and an advanced skill set to the healthcare arena, which is becoming ever more complex. These nurses focus their practice and expertise at the community and systems levels. The DNP-prepared PHN is pivotal in this multifaceted, interprofessional work to protect and promote health and prevent disease and disability in our communities. National initiatives such as the Affordable Care Act, which emphasizes prevention and wellness, and the Institute for Healthcare Improvement (IHI, 2018), which clearly identifies population health as one component of its framework known as the Triple Aim, are all in alignment with the work, education, and skill sets of PHNs. The IHI Triple Aim includes improving the patient experience of care (including quality and satisfaction), improving the health of populations, and reducing the per capita cost of health care. These shifts in perspective at a national level over the past decade speak to the core principles that embody public health nursing practice.

Public Health Nurse: A Definition Public health nursing practice is grounded in knowledge from nursing and social and public health sciences. Public health nursing practice is focused on the health of populations rather than the specific health needs of individuals. PHNs are involved in interventions that promote health, prevent disease and disability, and create conditions in which all people can be healthy (Quad Council Coalition of Public Health Nursing Organizations, 2018a; Stanhope & Lancaster, 2012). The American Public Health Association (APHA, 2013) PHN section defines public health nursing practice as “the practice of promoting and protecting the health of populations using knowledge from nursing, social, and public health sciences. Public health nursing is a specialty practice within nursing and public health. It focuses on improving population health by emphasizing prevention and attending to multiple determinants of health.” Public health nursing is often used interchangeably with community health nursing. Keller, Schaffer, Lia-Hoagberg, and Strohschein (2002) identify key characteristics of PHN practice to include (1) a focus on the health needs of an entire population, including inequities and the unique needs of subpopulations; (2) assessment of population health using a comprehensive, systematic approach; (3) attention to multiple determinants of health; (4) an emphasis on primary prevention; and (5) application of interventions at all levels—individuals, families, communities, and the systems that impact their health. The population may be based on geographic boundaries or characteristics of interest— such as the elderly or children receiving cancer treatment—or a combination of the two. The underlying ethical principle of public health nursing practice is the theory of utilitarianism, which states, “the greatest good for the greatest number” (Bayer, Gostin, Jennings, & Steinbock, 2007). In addition, the concept of social justice is considered a foundation of public health nursing (Stanhope & Lancaster, 2012). The terms community health nursing and public health nursing have historically caused confusion. Community based tends to focus on nursing care of individuals and families in the community, typically managing acute or chronic conditions in the community. As previously

introduced, the terms community health nurse and public health nurse have been used interchangeably. In this discussion, the term public health nurse will be used. The primary focus of care is on the population, with the goal of preventing disease and promoting health (Stanhope & Lancaster, 2012). The IOM published a report that defined public health as “what we, as a society, do collectively to assure the conditions in which people can be healthy” (IOM, 1988, p. 1). This definition demonstrates the broad scope of practice and interprofessional nature of public health work, within which PHNs play an important role based on scientific principles of public health and public health nursing. Along with these central definitions, the PHN is also a master at developing and maintaining relationships with individuals, communities, and systems. The ability to establish and maintain caring relationships is one of the cornerstones of public health nursing identified by the Minnesota Department of Health (2007).

History of Public Health Nursing Many nursing leaders have influenced the practice of public health nursing. Florence Nightingale (1820–1910) improved health outcomes of soldiers in Europe during the Crimean War by being aware of environmental conditions that affected health and using basic principles of epidemiology to document outcomes such as mortality rate (Nightingale, 1992). Epidemiology is a foundational science for public health nursing. Understanding this notion of population-based nursing and systematically collecting data to inform practice was a new methodology and provided nursing with another dimension to assess the health of a population. The life and work of Lillian Wald (1867–1940) carried the concept of population-based nursing even further in the late 1800s in the United States. Wald is credited with coining the term public health nursing. Wald’s impact on nursing and the community in which she practiced was revolutionary for the time. Wald noticed the impoverished conditions and lack of basic necessities among the residents on the Lower East Side of New York City. After seeing firsthand the poor living and health conditions of recent immigrants and their families, Wald, along with several colleagues, established the Visiting Nurse Service. The Visiting Nurse Service provided the beginning model for PHNs interacting with families in their homes and communities. The Henry Street Settlement followed a short time later, which provided a variety of services to this population. It is important to note that Wald believed in meeting the individual in the home or on the street and emphasized the importance of the environment surrounding the individual. However, it was Wald’s capacity to notice and act on behalf of individuals and families at the community and system levels, as well as at the individual level, that has left a legacy of work that many still attempt to achieve today. Wald was very effective as a community organizer, advocate, and leader and effected dramatic changes in the quality of life in the community. In public health nursing, a single intervention at the community or systems level has the potential to affect large numbers of individuals (Jewish Women’s Archive, 2019). At the population level, Wald’s work provides a variety of examples of

population-based public health nursing interventions, including (1) developing safe playground spaces for neighborhood children; (2) advocating for the role of school nurses to ensure that children had adequate nutrition and health care; (3) advocating for decent working conditions for women; (4) partnering with the Metropolitan Life Insurance Company to provide health care to policy holders; (5) advocating for safe industrial working conditions; (6) campaigning for the first federal Children’s Bureau to abolish child labor; (7) promoting children’s health; and (8) supporting children who had dropped out of school. All these examples addressed individual needs, yet the interventions were aimed at the systems level or at the community level to affect programs and develop policy. That the entire population benefited from these interventions ultimately improved the lives of individuals. These accomplishments at the state and federal levels were all made before women had a voice through voting in the United States. Lillian Wald was a reformer of her day who greatly influenced public health nursing as it is practiced today (Jewish Women’s Archive, 2019). Other PHNs include Margaret Sanger, who advocated for birth control and women’s health and started the first birth control clinic in 1916.

Foundational Principles of Public Health Nursing In light of the preceding definition and examples of public health and public health nursing, the core functions of public health in which the PHN practices are assessment, policy development, and assurance, along with the 10 essential services of public health (Centers for Disease Control and Prevention, Health Literacy for Public Health Professionals, n.d.). This is illustrated in FIGURE 4-1.

FIGURE 4-1 Action model to achieve Health People 2020’s overarching goals. Reproduced from U.S. Department of Health and Human Services. (2008). Phase I report: Recommendations for the framework and format of Healthy People 2020 (p. 7). Retrieved from http://www.healthypeople.gov/sites/default/files/PhaseI_0.pdf. Every 10 years, the Healthy People Promotion and Disease Prevention Objectives are reassessed. Healthy People 2030 is in development (retreived from https://www.healthypeople.gov/2020/About-HealthyPeople/Development-Healthy-People-2030).

Description

The three core functions that drive public health practice are (IOM, 1988; Stanhope & Lancaster, 2012, p. 7): Assessment: Population focused, systematic collection, monitoring, and dissemination of health status information. Policy Development: Provision of leadership in development of health related policies with the use of scientific knowledge. Assurance: Ensures competent, essential, personal health services and workforce for underserved populations are readily available. Specific to public health nursing practice, the intervention wheel is a model that identifies specific PHN interventions that support the work toward these core functions and 10 essential services (Keller & Strohschein, 2012).

Public Health Nursing National Organizational Framework The Quad Council Coalition of Public Health Nursing Organizations is the overarching entity that includes four national nursing organizations that address public health nursing issues: (1) the Association of Community Health Nurse Educators (ACHNE), (2) the American Nurses Association’s (ANA) Congress on Nursing Practice and Economics, (3) the American Public Health Association-Public Health Nursing Section (APHA), and (4) the Association of State and Territorial Directors of Nursing (ASTDN). The mission of the Quad Council (2017) is “to improve the health of communities through excellence in public health nursing education, practice, leadership, and research.” The Quad Council promotes and stimulates collaboration among the member groups. The Quad Council also includes PHN experts who advance the work of public health nursing practice and education at the national level. The Quad Council approved “Quad Council Coalition PHN Competencies.” This document distinguishes between characteristics of the entry-level BSN graduate and PHNs with additional education and practice. These competencies were intended to be a guide for practice and academic settings in order to facilitate the education of the PHN. The competencies were grouped in eight domains (Quad Council Coalition of Public Health Nursing Organizations, 2018b): 1. Analytic assessment skills 2. Policy development and program planning skills 3. Communication skills 4. Cultural competency skills 5. Community dimensions of practice 6. Basic public health sciences 7. Financial planning and management skills 8. Leadership and systems thinking skills At the advanced level of practice, for the most part, the PHN is expected to be “proficient” (rather than knowledgeable or aware) in each of the

domains. Each domain has specific criteria listed. The AACN supports doctoral education for community/public health nursing. This is noted in Essential VII of doctoral education. The Quad Council competencies and the AACN document complement each other. Both documents recognize the advanced level of practice that is needed in the PHN role and the complexities that this role embraces. Doctoral education is imperative to meet these demanding components of PHN practice in the context of an ever-changing healthcare environment; the PHN must seek doctoral education to practice to the fullest extent of his or her ability and license (Quad Council Coalition of Public Health Nursing Organizations, 2014). The National Advisory Council on Nursing Education and Practice (NACNEP, 2014) identifies the need for advanced practice registered nurse (APRN) roles in public health nursing. The NACNEP (2014) further notes that nursing should be in a leadership role in this collaborative work utilizing advanced degrees such as the DNP (and/or the PhD), and a dual degree with MPH. The NACNEP (2014) also states, “The care of populations hinges on collaboration and partnering and no one discipline or entity can be solely responsible for population health outcomes. While nursing should be capable of taking the leadership role, this collaborative emphasis mitigates the notion of role overburden and opens new opportunities for APRN roles including dual degrees such as the Doctor of Nursing Practice and Master of Public Health (DNP/MPH) and Doctor of Philosophy in Nursing with an emphasis on public health. These advanced practice roles are critically important and needed to lead interprofessional public health teams and efforts that address population health.” The American Academy of Nursing endorses the NACNEP report, reinforcing the need for advanced education for public health nursing leaders (Kub, Kulbok, Miner, & Merrill, 2017).

National Public Health Performance Standards Program The office of the Chief of Public Health Practice, Centers for Disease Control and Prevention (CDC), has led a partnership with national public health organizations to develop a program to “improve the practice of public health, the performance of public health systems, and the infrastructure supporting public health actions” (CDC, n.d.). These performance standards are key components of an accreditation process for government public health agencies similar to that used in acute care settings. The accreditation process is currently being carried out by the Public Health Accreditation Board (PHAB, 2013). The PHAB reports a total of “257 health departments (36 state, 218 local, and 3 tribal) as well as 1 statewide integrated local public health department system, have achieved five-year accreditation” as of March 2019 (PHAB, 2019). As the practice of public health moves toward standards for accreditation, the PHN must be educated at an appropriate level and be able to practice in an environment with high expectations to serve the population in an era of growing concern aimed at population-level assessment, interventions, and outcome measures. There is a need for DNP-prepared PHNs to fill roles in this type of environment. The vision, mission, and goals put forth by the National Public Health Performance Standards Program align with the education and practice of a PHN with a DNP degree. This initiative indicates the high standards expected of public health practitioners. The convergence of the PHAB accreditation standards and the emergence of DNP-prepared PHNs speaks to the importance of the level of education needed for PHNs to provide leadership and to guide public health nursing practice.

Theoretical Framework for Nursing Practice in Public Health There are multiple issues to consider in providing good quality care to populations. A strategy that encompasses the multifaceted nature of public health work is the ecological approach (Stanhope & Lancaster, 2012). As noted in the example of Wald’s work, multiple factors impact the health of individuals and populations. These multiple factors are termed determinants of health and include (1) health, social, economic, cultural, and environmental conditions; (2) family, social, and living conditions; and (3) individual traits and biological factors. It is the linkages among all these factors that are important to consider as interventions are developed to affect the health of populations. The ecological model provides a structure that incorporates these linkages (Quad Council Coalition of Public Health Nursing Organizations, 2018b). The diagram in FIGURE 4-2 incorporates the ecological approach at the center. This approach illustrates how the goals of the action model for Healthy People 2020 initiative converge with the work of PHNs (U.S. Department of Health and Human Services, 2008, p. 7).

FIGURE 4-2 Healthy People 2020 vision and mission statement. Reproduced from U.S. Department of Health and Human Services. (2008). Phase 1 report: Recommendations for the framework and format of Healthy People 2020, p. 5. Retrieved from

https://www.healthypeople.gov/sites/default/files/PhaseI_0.pdf

Description Two initiatives, one at the global level and one at the national level, highlight these concepts as PHNs work in population-based programs that incorporate the principles of the ecological approach. The Millennium Development Goals (MDGs) were established in 2002 from the Millennium Project (United Nations, 2002) commissioned by the United Nations Secretary-General. This initiative came to a close in 2015 and has now been followed by a new United Nations resolution adopted by the General Assembly on September 25, 2015, “Transforming Our World: The 2030 Agenda for Sustainable Development” (United Nations, 2016). The resolution identifies 17 Sustainable Development Goals (SDGs) stating, “These goals are designed to build on the Millennium Development Goals and complete what they did not achieve. They seek to realize the human rights of all and to achieve gender equality and the empowerment of all women and girls. They are integrated and indivisible and balance the three dimensions of sustainable development: the economic, social, and environmental. The Goals and targets will stimulate action over the next 15 years in areas of critical importance for humanity and the planet” (United Nations, 2016). The charge of the MDGs was to develop a concrete action plan to “reverse the grinding poverty, hunger, and disease affecting billions of people” (United Nations, 2002). There are eight MDGs, which range from reducing extreme poverty by 50% to enhancing environmental stability. All eight goals were associated with the determinants of health described earlier and operationalize the definitions of public health and public health nursing. The 2030 agenda continues to move this work forward toward the future. On a national level in the United States, the Healthy People initiative has driven public health programs and awareness over the past 40 years. There have been four previous initiatives, in 1979, 1990, 2000, and 2010. Healthy People 2020 is now providing goals and objectives to guide national health promotion and disease prevention strategies to improve the health of all people over the remainder of this decade. The overarching goals of Healthy People 2020 are the following (U.S. Department of Health and Human Services, 2008):

1. Attain high-quality, longer lives, free from preventable disease, disability, injury, and premature death. 2. Achieve health equity, eliminate disparities, and improve the health of all groups. 3. Create social and physical environments that promote good health for all. 4. Promote quality of life, healthy development, and healthy behaviors across all life stages. Healthy People 2030 is in development (U.S. Department of Health and Human Services, 2018).

Educational Preparation and Credentialing In today’s nursing education environment, baccalaureate programs that prepare beginning practitioners typically include public health nursing content, theory, and clinical practice. This allows the new nurse to practice as a beginning staff-level PHN. This is similar to the new graduate beginning a medical-surgical position in an acute care setting. Additional orientation time is likely required as the new graduate transitions from the student role to practice. Some states (e.g., Minnesota and California) also have PHN certification for baccalaureate graduates who apply to the state board of nursing. This certification acknowledges the PHN content in the curriculum and allows the individual to use the PHN credentials with his or her title. Specializing in public health nursing requires an advanced degree. A certification process obtained through the Quad Council Coalition using a portfolio is the current method to achieve American Nurses Credentialing Center (ANCC) advanced practice recognition for public health nursing (Quad Council Coalition of Public Health Nursing Organizations, 2018a). The 1984 Consensus Conference on the Essentials of Public Health Nursing Practice and Education sponsored by the U.S. Department of Health and Human Services Division of Nursing identified that minimal qualifications for a PHN include a baccalaureate degree in nursing and that specialists in the field hold either a master’s or doctoral degree that focuses on public health sciences and have the ability to work with populations to assess and intervene at the aggregate level (U.S. Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Professionals, Division of Nursing, 1984). ACHNE has affirmed this position, and the ANA has also supported this position in Public Health Nursing: Scope and Standards of Practice (ANA, 2013; Quad Council Coalition of Public Health Nursing Organizations, 2018a).

Roles of Advanced Practice PHNs The roles of advanced practice public and community health nurses have evolved over time. States have the authority to determine the scope of practice of a PHN. For instance, in Virginia, PHN roles reflect the essential elements of the National Association of County Health Officials contained within the Blueprint for a Healthy Community. The nine essential elements are (1) conducting community assessments; (2) preventing and controlling epidemics; (3) providing a safe and healthy environment; (4) measuring performance, effectiveness, and outcome of health services; (5) promoting healthy lifestyles; (6) providing targeted outreach and forming partnerships; (7) providing personal healthcare services; (8) conducting research and innovation; and (9) mobilizing the community for action. Within each of these essential elements, public health nursing specialists contribute their expertise and leadership to develop programs to promote health and prevent disease; tools to standardize case definitions, data collection, and analysis; indicators to monitor the health status of the population; regulatory guidelines for the prevention of targeted diseases; community partnerships and resources to promote informed decision making for the health of its citizens; direct services to patients for targeted diseases that threaten the health of a community; leadership and advocacy strategies through collaboration, coalition building, and public relations; and healthy community research projects with measurable outcomes (National Association of County Health Officials, 1994). PHNs with expertise in the field have traditionally been promoted to lead agency-related, population-based health programs as funding is allocated to administer and implement them. PHNs who take on administrative responsibilities write program proposals and testify for the support of these programs at jurisdictional board meetings and state and federal legislative committees. Programs routinely led by PHNs include immunizations; family, maternal, and child health; disease prevention and control; family planning; health promotion; emergency preparedness; school health; senior services; home care refugee health; healthcare services; children with disabilities; women, infants, and children (WIC);

chronic disease; adults with disabilities; and environmental health (Association of State and Territorial Directors of Nursing [ASTDN], 2008). Furthermore, advanced practice PHNs who work in the public policy and advocacy arenas serve as executive nurse leaders at departments of health in each state to (1) represent nursing issues within the health department; (2) ensure effectiveness, efficiency, and quality of programs and services delivered; (3) ensure a workforce prepared for the nursing needs of the state; and (4) collaborate with educational systems to ensure the quality of the future public health nursing workforce (ASTDN, 2008). The roles of advanced practice PHNs, who will benefit from the DNP preparation, continue to develop as the complexity of health care increases in proportion to the growth of the population, particularly in relation to the rate of growth of an aging population in the United States.

Practice Sites PHNs commonly enter practice within a local public health agency that may be governed by a city or county. Proficient public health nursing leaders discover satisfying careers in diverse practice settings. PHNs with expertise in the field are employed in jurisdictional levels that encompass federal, state, regional, county, and city public health agencies. The federal employer may be the U.S. Public Health Service, the CDC, or the American Public Health Association. Advanced PHN expertise is critical to the planning, piloting, and implementation of evidence-based population health programs initiated at the state or federal jurisdiction level. DNP-prepared PHNs are crucial in collaborating with partners across disciplines to bring their unique perspective of public health nursing that includes the determinants of health to the complex needs related to health promotion and disease prevention. Advanced practice PhD- and DNP-prepared PHNs are employed in academic settings to teach, direct programs, and conduct research. They are also working in acute and long-term care systems to manage populationbased infection prevention, safety, quality improvement, occupational health, and emergency preparedness programs (Stanhope & Lancaster, 2012). Within the last decade, public health nursing leaders have been hired by health systems that provide a continuum of care to their chronically ill or rehabilitating patients in the community to direct hospice, home care, palliative care, complex medical care, and advanced care directive programs. Insurance companies have also benefited from the skills of DNP-prepared PHNs (Stanhope & Lancaster, 2012). These health-integrated organizations are complex, and their operations need to be informed by practice-based evidence related to client outcomes within each specialty program (Melnyk & Fineout-Overholt, 2011). The DNPprepared PHN has the academic preparation to address these growing multifaceted demands in the marketplace.

Evidence-Based Practice in Population-Based Public Health Nursing EBP was introduced into medicine initially to guide professionals’ decision making using the best available evidence (Guyatt & Rennie, 2002). Sackett, Straus, and Richardson (2000) later developed the definition for evidence-based medicine that has become an industry standard. This approach seeks to answer a clinical question about an individual patient condition (Guyatt & Rennie, 2002; Sackett et al., 2000). EBP was a seven-step process initiated to make an accurate diagnosis and to prescribe the most appropriate treatment or outcome. When nursing began implementing EBP, the concentration tended to be related to a collection of patients (Leven, Keefe, & Marren, 2010; Melnyk & Fineout-Overholt, 2011). The application of EBP started in acute care and primary care. There is little in the literature about its application to community settings. Examples of EBP that surface in public health nursing when the literature is searched include (1) the Family Nurse Partnership program, which is designed to help teen mothers make healthy life choices, complete their education, and space future pregnancies (Olds et al., 1997); (2) public health nursing interventions with individuals, families, and the community and the systems that impact them as modeled by the public health “wheel” (Keller & Strohschein, 2012); (3) survey of the tasks and frequencies performed by PHN participants from local and state health departments in the United States (ASTDN, 2008); (4) mining aggregate electronic data in the public health record for health outcomes and indicators to inform practice (Monsen, 2005); and (5) public health nursing competencies as developed by the Quad Council Coalition of Public Health Nursing Organizations (2018b). These examples are instrumental in guiding and informing practice and form the basis for further PHN research, which is a key action of the Quad Council Coalition of Public Health Nursing Organizations. PHNinitiated research has traditionally been funded by government agencies,

such as the National Institutes of Health and the Health Resources and Services Administration, and private foundations, including the Robert Wood Johnson Foundation and the Bill and Melinda Gates Foundation.

The Doctor of Nursing Practice– Prepared Public Health Nurse as Leader The Association of Community Health Educators (formerly the Association of Graduate Faculty in Community Health Nursing/Public Health Nursing), established in 1978, has promoted the increase in graduate-level programs to prepare the public health nursing leaders of the future. In addition to holding traditional responsibilities, PHNs are assuming high-functioning roles in the complex planning and implementation of health promotion and maintenance programs in the community. The DNP-prepared PHN has the knowledge to contribute and lead initiatives related to current public health issues at the local, national, and global levels. Current issues include climate change, racism and health, health reform, and healthy housing, as well as many areas considered traditional such as family and child health, injury prevention, and immunization. The skill sets that DNP-prepared nurses bring to the multiagency planning groups involve knowledge about EBP related to population health programs, the science of nursing intervention, policy development, financial astuteness, informatics, patient-centered care, quality improvement, safety, and interprofessional teamwork and collaboration. DNP-prepared public health leaders will be influenced daily by information generated by professional associations and government and nongovernment agencies. These leaders will be expected to access and evaluate this information in relation to its role in advocacy for populationbased health programs. DNP-prepared nurses will advocate for population health initiatives in writing, in public testimony, and within interdepartmental and interagency planning groups. PHN nurses are customarily respected in the community by the clients they serve, but a DNP-prepared PHN is better equipped to articulate strategic population health positions effectively with nonnursing professionals, policy planners, and legislative bodies. The public recognizes the nurse as a

trusted professional who is now publicly advocating with confidence for the health of the nation (ANA, 2013; APHA, 2019).

References American Nurses Association (ANA). (2013). Public health nursing: Scope and standards of practice. Silver Spring, MD: Author. American Public Health Association (APHA). (2013). The definition and practice of public health nursing: A statement of the public health nursing section (pp. 2). Washington, DC: Author. American Public Health Association (APHA). (2019). Topics and issues. Retrieved from www.apha.org/topics-and-issues Association of State and Territorial Directors of Nursing (ASTDN). (2008). Report on a public health nurse to population ratio. Retrieved from https://dph.georgia.gov/sites/dph.georgia.gov/files/ASTHOReportPublicHealthNursetoPopRatio2008.pdf Bayer, R., Gostin, L., Jennings, S., & Steinbock, B. (2007). Public health ethics: Theory, policy and practice. New York, NY: Oxford University Press. Centers for Disease Control and Prevention (CDC). (n.d.). Local public health system performance assessment. Washington, DC: Department of Health and Human Services. Retrieved from www.cdc.gov/od/ocphp/nphpsp/documents/07_110300%20Local%20Booklet.pdf Centers for Disease Control and Prevention (CDC). (2011). Ten great public health achievements —worldwide, 2001–2010. Morbidity and Mortality Weekly Report, 60(24), 814–818. Retrieved from www.cdc.gov/mmwr/preview/mmwrhtml/mm6024a4.htm Centers for Disease Control and Prevention, Health Literacy for Public Health Professionals (n.d.). Core functions of public health: Assurance. Retrieved from www.cdc.gov/healthliteracy/training/page1299.html Guyatt, G., & Rennie, D. (2002). Users’ guides to the medical literature: A manual for evidencebased clinical practice. Chicago, IL: American Medical Association. Institute for Healthcare Improvement (IHI). (2018). Triple aim for populations. Retrieved from www.ihi.org/Topics/TripleAim/Pages/default.aspx Institute of Medicine (IOM). (1988). The future of public health. Washington, DC: National Academies Press. Jewish Women’s Archive. (2019). Lillian D. Wald. Retrieved from http://jwa.org/people/wald-lillian Keller, L., & Strohschein, S. (2012). Population-based public health nursing practice: The intervention wheel. In M. Stanhope & J. Lancaster (Eds.), Public health nursing: Populationcentered health care in the community (pp. 186–215). Philadelphia, PA: Elsevier. Keller, L. O., Schaffer, M., Lia-Hoagberg, B., & Strohschein, S. (2002). Assessment, program planning, and evaluation in population-based public health practice. Public Health Management Practice, 8(5), 31–32. Kub, J., Kulbok, P., Miner, S., & Merrill, J. (2017). Increasing the capacity of public health nursing to strengthen the public health infrastructure and promote and protect the health of communities and populations. Nursing Outlook, 65(5), 661–664. Retrieved from www.nursingoutlook.org/article/S0029-6554(17)30408-6/fulltext Leven, R., Keefe, J., & Marren, J. (2010). Evidence-based practice improvement: Merging 2 paradigms. Journal of Nursing Care Quality, 25(2), 117–126. Melnyk, B., & Fineout-Overholt, E. (2011). Evidence-based practice in nursing and healthcare: A guide to best practice. Philadelphia, PA: Lippincott Williams & Wilkins. Minnesota Department of Health. (2007). Cornerstones of public health nursing. Retrieved from https://www.health.state.mn.us/communities/practice/ta/phnconsultants/docs/0710phn_cornerstones.pdf Monsen, K. (2005). Use of the Omaha System in practice. In K. Martin (Ed.), The Omaha System: A key to practice, documentation, and information management (pp. 58–83). St. Louis, MO:

Elsevier. National Advisory Council on Nurse Education and Practice (NACNEP). (2014). National Advisory Council on Nurse Education and Practice (NACNEP) public health nursing: Key to our nation’s health. Retrieved from www.hrsa.gov/advisory-committees/nursing/reports.html National Association of County Health Officials. (1994). Blueprint for a healthy community: A guide for local health departments. Washington, DC: Author. National Center for Health Statistics. (2013). Health, United States, 2010—with special feature on death and dying. Hyattsville, MD: Centers for Disease Control and Prevention. Nightingale, F. (1992). Notes on nursing: What it is, and what it is not. Philadelphia, PA: Lippincott Williams & Wilkins. Olds, D., Eckenrode, J., Henderson, C., Kitzman, H., Powers, J., Cole, R., . . . Luckey, D. (1997). Long-term effects of home visitation on maternal life course and child abuse and neglect: Fifteen-year follow-up of a randomized trial. Journal of the American Medical Association, 278(8), 637–643 Public Health Accreditation Board (PHAB). (2013). Standards and measures. Retrieved from www.phaboard.org/wp-content/uploads/SM-Version-1.5-Board-adopted-FINAL-01-242014.docx.pdf Public Health Accreditation Board (PHAB). (2019). Who is accredited? Retrieved from https://www.phaboard.org/who-is-accredited Quad Council Coalition of Public Health Nursing Organizations. (2014). Invitational forum on the role and future of nurses in public health: Final report. Retrieved from www.quadcouncilphn.org/documents-3/qcc-invitational-forum-on-the-role-and-future-of-nursesin-public-health Quad Council Coalition of Public Health Nursing Organizations. (2018a). ANCC certification for PHNs. Retrieved from www.quadcouncilphn.org/ancc-certification-for-phns Quad Council Coalition of Public Health Nursing Organizations. (2018b). Competencies for public health nursing practice. Washington, DC: Association of State and Territorial Directors of Nursing. Retrieved from www.quadcouncilphn.org/documents-3/2018-qcc-competencies Sackett, D., Straus, S., & Richardson, W. (2000). Evidence-based medicine: How to practice and teach EBM. London, England: Livingstone. Stanhope, M., & Lancaster, J. (2012). Public health nursing: Population centered care in the community. Philadelphia, PA: Elsevier. United Nations. (2002). End poverty: 2015 Millennium Development Goals. Retrieved from www.un.org/millenniumgoals/bkgd.shtml United Nations. (2016). Transforming our world: The 2030 agenda for sustainable development. Retrieved from www.un.org/millenniumgoals/reports.shtml U.S. Department of Health and Human Services. (2008). Phase I report: Recommendations for the framework and format of Healthy People 2020. Retrieved from www.healthypeople.gov/sites/default/files/PhaseI_0.pdf U.S. Department of Health and Human Services. (2018). Development of the national health promotion and disease prevention objectives for 2030. Retrieved from www.healthypeople.gov/2020/About-Healthy-People/Development-Healthy-People-2030 U.S. Department of Health and Human Services Health Resources and Services Administration, Bureau of Health Professionals, Division of Nursing. (1984). Consensus conference on the essentials of public health nursing practice and education. Rockville, MD: Author.

NURSE ENTREPRENEUR Timothy F. Gardner

Definitions To aid in the comprehension of how the DNP prepares advanced practice nurses (APNs) to become entrepreneurs, one must begin by understanding the definition what entrepreneurship is, what an entrepreneur does, what the DNP course of study covers, and what all these have in common. Entrepreneurship as defined by Berglund and Holmgren (2013) “is a dynamic and social process, where individuals, alone or in cooperation, identify opportunities and do something with them to reshape ideas to practical or aimed activities in social, cultural, or economical contexts” (p. 18). An entrepreneur is “one who undertakes innovations, finance and business acumen in an effort to transform innovations into economic goods” (Shane, 2004, pp. 205). The attributes and abilities of a successful entrepreneur are self-motivation, autonomy, problem solving, leadership, decision making, risk-taking, selfconfidence, determination, and being ethical (Dayhoff & Moore, 2003). Comparatively, the DNP is the highest clinical degree that exists in the profession of nursing, and it is the terminal practice degree for the profession. The DNP is a practice-focused degree and is designed to prepare experts in a specialized advanced practice role (AACN, 2006). When envisioning the DNP, the AACN (2006) identified and developed eight core competencies that the DNP graduate will have mastered upon completing the doctoral course of study. To address these competencies, programs typically have coursework that covers the fields of epidemiology, economics, business management, organizational systems analysis, health policy, EBP, healthcare information technology, and leadership. The majority of programs require students to plan, develop, implement, and evaluate a scholarly project. The purpose of the scholarly project is for students to synthesize, apply, and demonstrate learned concepts (Sperhac & Clinton, 2008). Students are required to complete advanced didactic and clinical coursework in physical assessment, pathophysiology, and pharmacology as well as further study in the student’s area of specialization, such as acute care, family primary care, midwifery, clinical nurse specialist, nurse anesthetist, and so on (AACN, 2006). Throughout this section, these core

essential competencies will be identified as they relate to doctoral educational preparation and entrepreneurship. It should be noted that the DNP-prepared APN is an independently licensed healthcare professional who performs as an independent and interdependent member of an interdisciplinary healthcare team. As a result of professional licensure and educational preparation, the DNP APN is well positioned to independently own and operate a private business venture.

Background Embedded throughout the nursing educational process is a combination of the three fundamental specialized skills of problem solving, critical thinking, and decision making. This combination is known in the profession as the nursing process. This trifecta of fundamental skills forms the core entrepreneurial skill essentials of the DNP. Because of their educational underpinnings, DNP entrepreneurs are prepared to perform a needs assessment, identify a problem, develop a plan of action, implement evidence-based interventions, evaluate the plan, and start over if needed. These concepts are not unique to the nursing profession. Critical thinking, problem solving, and decision making are also core concepts of, and basic critical skills in, the business world. The procedural steps of the nursing process are very similar to those actions outlined in the business definition of entrepreneurship. Nursing today is, and has always been, an eclectic profession with a scope of practice that overlaps with other professional disciplines such as medicine, pharmacology, public health, psychology, sociology, and business in the effort to provide optimal health care. For example, advanced practice nursing combines the holistic perspective of nursing science with specialized knowledge and skill sets obtained from the biomedical sciences, medicine, and pharmacology to provide healthcare services (AACN Essentials I and II; AACN, 2006). Because of this acquired expanded knowledge, APNs are able to use clinical thinking and skills traditionally associated with medicine to obtain a health history and risk assessment, perform a physical examination, and formulate a diagnosis gleaned from the patient’s signs, symptoms, and results of ordered diagnostic/laboratory tests in order to develop a treatment plan, including prescribing pharmacotherapy. It should be noted that the expanded knowledge and skills needed to provide these services are now fundamental to the APN educational process and should no longer require medical delegation, protocols, supervision, or mandatory written collaboration (Wisconsin Nurses Association, 2015). Similarly, nursing has incorporated other expanded knowledge and specialized skills from the business profession, such as principles of management, elements of

accounting, budgeting, and contract negotiation. Given these overlapping scopes of practice, the DNP-prepared APN possesses great entrepreneurial potential.

The Relationship Between Entrepreneurship and the DNP Degree Doctoral-level education provides the nurse entrepreneur with expanded knowledge and specialized skill sets necessary to navigate and thrive in today’s complex healthcare environment, not simply to become a clinician with “the ability to design and deliver effective care to patients” (Hanson & Bennett, 2014, p. 505). In addition, the “enhanced leadership, policy making and collaboration skills” obtained during the course of study positions the DNP entrepreneur to “make changes at the system and practice setting level” (Hanson & Bennett, 2014, p. 505). This enables the DNP-prepared entrepreneur to function as an administrator, educator, consultant, and community leader and to operate as an agent of change in legislation and policy making (depending on his or her area of expertise). Doctoral-level education enhances the entrepreneur’s ability to analyze and bring evidence-based research from the laboratory and scientific literature to the clinical arena. This area addresses AACN Essential III (AACN, 2006). This is in line with the AACN’s position that requires the DNP educational process to be designed to prepare the graduate APN to gain competence in the application of research to practice, to be able to evaluate evidence and research findings for decision making, and to implement potential innovations to change current clinical practice. It is also the AACN’s position that during the course of study, significant consideration should be given to programmatic decision making and program evaluation using assessment data collected at the population or cohort level (AACN, 2006, p. 2). However, in the call for healthcare restructuring by institutions such as the IOM and the National Research Council of the National Academies (NRCNA), the consistent mantra has been “patient-centered care.” By definition, patient-centered care is “healthcare that establishes a partnership among practitioners, patients, and their families (when

appropriate) to ensure that decisions respect patients’ wants, needs, and preferences and that patients have the education and support they need to make decisions and participate in their own care” (American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, & American Osteopathic Association, 2010). In patient-centered care, the central theme is that a healthcare provider can provide care for only one individual at a time, and therefore the tenets of population-based care belong in the public health domain and should not be the guiding principles of an individual healthcare practitioner (Peraino, 2011). Herein lies a conundrum. How can a doctoral education process that focuses on the tenets of EBP with data obtained from population-based research studies effectively support the call for patient-centered care? The appropriate answer would be through individualizing the findings. However, EBP, as it is currently implemented in health care, does not individualize care; rather, it standardizes care through clinical guidelines, protocols, and best practices. It must be remembered that all research findings are not generalizable. Is it prudent for all healthcare decisions to be based on the cultural health beliefs, values, and behaviors of an individual patient’s racial and ethnic background? A question that could be posed is “Isn’t this racial profiling and cultural stereotyping?” Consequently, this does not constitute patient-centered care; it is providing care based on the patient’s culture and ethnicity (HasnainWynia, 2006). In answering these questions, the doctoral educational process assists in preparing the DNP graduate to obtain population-based information, individualize these findings based on the individual patient’s risk assessment, and use this information to provide high-quality, evidence-based, holistic, and patient-centered care (AACN Essential VII; AACN, 2006). Other provisions of the call for restructuring include providing care that is “safe, effective . . . timely, efficient, and equitable . . . as members of an interdisciplinary team, emphasizing evidence-based practice, quality improvement, and informatics,” and the report calls for nursing to have “the best prepared senior level nurses in key leadership positions and participating in executive decisions” (AACN, 2006, p. 6). Again, the doctoral education process assists in preparing the DNP graduate to meet these needs and provide care that addresses all these

provisions. DNP-prepared entrepreneurs must have these added competencies to enhance the development of their personal professional business and practice management.

Business and Practice Management Doctoral education will assist in preparing the nurse entrepreneur to plan, organize, finance, and operate his or her own business venture. DNP programs typically offer courses that address practice management, economics, management of the client in the healthcare system, healthcare information technology, and project planning and evaluation in order to strengthen business acumen and performance. The DNP core courses and advanced practice specialization provide the nurse entrepreneur with the scientific underpinning for practice and expert advanced clinical knowledge and skills to provide direct and indirect care in an area of role specialization (AACN Essentials I and VIII; AACN, 2006). Knowledge of direct and indirect care processes is vital for the successful management of healthcare systems, regardless of the organization’s size or capacity (Hanson & Bennett, 2014). Doctoral-level education enables the APN to participate in both direct and indirect care processes within the scope of the role. It prepares the nurse entrepreneur to design and develop healthcare services provided to clients. Providing direct care to clients/patients is a central competency of an APN regardless of the specific specialized role of the practitioner (Tracy, 2014). However, many tasks performed are the same across various specialty APN roles (Tracy, 2014). For example, role specialization assists in preparing the DNP-educated primary care nurse to participate in direct and indirect care processes, such as obtaining comprehensive medical histories; performing physical examinations; diagnosing, treating, and managing acute and chronic illnesses and diseases; and performing minor procedures such as suturing, incision and drainage, and intrauterine device insertion. Direct care processes also include providing services such as wound management, pain management, counseling, and education; providing health promotion and disease prevention services (AACN Essential VII; AACN, 2006); and using electronic medical records and e-prescribing (AACN Essential IV; AACN, 2006). Some of these tasks may fall under the role of clinical nurse specialist and other advanced practice nursing roles (Hanson & Bennett, 2014; Tracy, 2014).

Indirect processes of care include organizational, administrative, and operational systems. The DNP-educated entrepreneur, regardless of area of specialization, will incur control over, and responsibility for, an increased proportion of indirect processes of care within the specialty role. These may include administration, budgeting, management, inventory and purchasing, quality control, risk management, development of office policies and procedures, supervision of staff, mentoring, medical coding and billing, and reimbursement issues. Other important indirect processes include the assessment and acquisition of appropriate office computer systems and information technology software that requires knowledge of Certification Commission for Health Information Technology–certified electronic health record (EHR) programs (AACN Essential IV; AACN, 2006; Hanson & Bennett, 2014). The scholarly project that is undertaken and completed during the course of DNP study helps to prepare the entrepreneurial nurse with the specialized knowledge and skills of project management and evaluation. Knowledge of these principles enables the nurse to (1) identify a systems-based problem; (2) perform a scholarly literature review; (3) develop process and outcome objectives; (4) develop, plan, and implement evidence-based interventions to address the problem; and (5) develop, implement, manage, and evaluate program outcomes. This again demonstrates the eclectic nature of nursing and its overlapping scope of practice with other professional disciplines such as engineering and project management.

Practice Start-Up, Closure, and Credentialing Given that this is a discussion on nursing entrepreneurship, it is appropriate to highlight basic tenets of business, including start-up, merger, and closure procedures, and credentialing with governmental and commercial insurance carriers. Although specific rules and regulations for establishing a business may vary by state, these general guidelines are essential for nursing entrepreneurs. Independence in practice is the cornerstone of nursing entrepreneurship. In contemplation of the start of a new practice, it is necessary to review the state board of nursing statutes and the state medical association guidelines applicable to the location where the practice is to open. This review will provide thorough detail of regulatory requirements and outline scope-of-practice guidelines, licensure, and other necessary credentialing requirements, such as a collaborative agreement (in some states). Additionally, local rules and requirements pertaining to licensing and liability must be reviewed thoroughly before the start of practice. This portion of the review may include business name search. Another essential area for entrepreneurs deciding to open a new practice is a review of the business regulations set forth by the Internal Revenue Service (IRS), which can be accessed at www.irs.gov or by contacting your local IRS agency. This information is critical in establishing the new business as a federally recognized entity through obtaining a federal identification number, or FIN, which is separate from an individual taxpayer identification number, or TIN, used for annual tax reporting purposes. Here, the expertise of an IRS business professional or certified public accountant (CPA) is a sound investment in the future of your new practice. To begin the process of starting a new practice, start at the prospective state’s medical association. For example, the Indiana State Medical Association (ISMA) provides prospective business owners basic information on starting a practice. The ISMA has a packet of information on starting a practice that includes setting up the legal entity, obtaining

licensure, NPI numbers, payer contracts and malpractice insurance. The prospective owner is advised to contact the ISMA’s legal department for the full packet (ISMA, 2015). Additionally, ISMA also provides information concerning provider retirement, closing a practice, or leaving a practice. The information available on this site will answer specific questions pertaining to practice terminations including standard processes for giving patient notice, credentials management, and handling of medical records. This information may be used in conjunction with existing practice policies of the independent or group practice to ensure proper termination actions. Another area of concern for APNs or nurse practitioners (NPs) is credentialing. This is because each insurance company may reserve the right to adhere to its own business policies as they reflect current laws and practice guidelines. What this means is that within any given state, each insurance company within that state can have a different set of policies and operate under those policies so long as operations do not violate the law. So why credential? Although credentialing does not guarantee an insurance company contracting with APNs or NPs as primary care providers (PCP), whether individually, as specialists, or part of a group; credentialing is vital to independent practice recognition and most essential to enrollment with many health insurance companies for reimbursement purposes. This is often a tedious and time-consuming process, as each individual insurance or health organization may require different information for credentialing considerations. Many health insurance providers such as Anthem, United Healthcare, and Tricare require credentialing with Medicaid and Medicare for participation. To circumvent this dilemma, credentialing is best accomplished through completion of the online enrollment form from the Council for Affordable Quality Healthcare (CAQH) Universal Provider Data source (UPD) service. The UPD is the industry standard for collecting provider data used in credentialing. “The UPD is a unique streamlined electronic data collection system that enables physicians and other health professionals, participating health plans, hospitals, and healthcare organizations the ability to access, manage, revise, and verify professional credentials” (CAQH, 2015). Further, “the UPD online form meets the data-collection requirements of URAC, the National Committee

for Quality Assurance (NCQA) and the Joint Commission standards. Indiana, Kansas, Kentucky, Louisiana, Maryland, Missouri, New Jersey, New Mexico, Ohio, Rhode Island, Tennessee, Vermont and the District of Columbia have adopted the CAQH standard form as their mandated or designated provider credentialing application” (CAQH, 2015). Another resource to assist the DNP entrepreneur in obtaining insurance credentialing can be found through the National Nursing Centers Consortium (NNCC, 2015), a premier organization for the advocacy and support of nurse-managed clinics. The NNCC offers nurse entrepreneurs a managed care contracting toolkit with a “7-step process specifically designed to walk the APN through the insurance credentialing process for reimbursement and proper recognition as a primary care provider (PCP),” following its mission statement of “advancing nurse-led health care through policy, consultation, programs and applied research to reduce health disparities and to meet people’s primary care and wellness needs” (NNCC, 2015). It should be noted here that while there are many layers and levels of credentialing, the nurse entrepreneur must be cognizant of the distinct requirements for proper licensure, liability, and reimbursement and be prepared to take necessary actions to comply with federal, state, and local laws. To credential with Medicare, the CMS has established an internetbased Provider Enrollment, Chain and Ownership System (PECOS). This internet-based PECOS allows physicians, nonphysician practitioners, and provider and supplier organizations to enroll, make changes to their Medicare enrollment, view their enrollment information on file with Medicare, and check on the status of a Medicare enrollment application via the internet. For more information about the internet-based PECOS visit www.cms.gov/Medicare/Provider-Enrollment-andCertification/MedicareProviderSupEnroll/index.html (CMS, 2018). To enroll in a particular state’s Medicaid program as a nonphysician practitioner, the practitioner must apply through the state’s governmental site for Medicaid services.

Organizational Systems Leadership and Collaboration Doctoral education assists in preparing the nurse entrepreneur to assume leadership positions and understand the basic principles of strategic planning, organizational management, systems thinking, and interprofessional collaboration. The DNP-educated entrepreneur will have the knowledge necessary to develop the skills to become a successful and effective leader. As a leader, the entrepreneur must be visionary and creative. Doctoral education includes coursework on strategic planning that involves exercises on developing vision and vision statements. Consequently, these exercises instill in the nurse entrepreneur the concept that “any success achieved in life must begin with a vision” (Love, 2005). A vision is defined as forming a detailed mental picture of exactly what you intend to accomplish or produce. “The visionary entrepreneur is able to see exactly what his or her business is going to look like in every detail when it is finished . . . a visionary entrepreneur constantly thinks in terms of innovation, and continually searches for opportunities for innovation and implementation” (Love, 2005). Potential opportunities for “innovation come through the creation of a new process” (direct or indirect) or with the redesigning of an existing process to render it more cost effective, efficient, and profitable (Hanson & Bennett, 2014, p. 507). In the effort to be successful and maintain success, it is essential that DNP-educated entrepreneurs “develop, implement, and continuously analyze direct and indirect processes of care” they may use to meet healthcare outcomes for their clients (Hanson & Bennett, 2014, p. 506). More often than not, this will occur when “working within the constraints of available resources and reimbursement” (Hanson & Bennett, 2014, p. 506), especially during these unsettled economic times when healthcare dollars are very sparse. The DNP-educated entrepreneur exhibits transformational leadership and will be capable of clearly conveying the corporate vision to tap into the creativity of other members of the organization as potential sources of new ideas. This entrepreneur uses systems thinking and has an

understanding of the principles of systems theory, chaos theory, and the butterfly effect as they apply to an organization. The DNP-educated entrepreneur is apt in utilizing other principles of organizational systems thinking and leadership styles, such as team, situational, and participative leadership. Of the three, team leadership is most pertinent in health care today. This is in line with the AACN’s (2006) position stating that DNP graduates will “have preparation in methods of effective team leadership and are prepared to play a central role in establishing interprofessional teams, participating in the work of the team, and assuming leadership of the team when appropriate” (p. 14). The entrepreneur is often the major risk-taker in a business venture and at times may need to employ alternative leadership styles. The DNPprepared nurse entrepreneur understands that leadership is about accomplishing critical tasks for the organization, and in some business situations, an autocratic or paternalistic style of decision making may be required. On the other hand, DNP-educated nurse entrepreneurs understand that interprofessional collaboration is essential to practicing effectively (AACN Essential VI; AACN, 2006). According to the AACN’s position, “today’s highly complex multi-tiered health care environment depends on the contribution of highly skilled and knowledgeable individuals from multiple professions,” and “healthcare professionals must function as highly collaborative teams” (AACN, IOM, & O’Neil, as cited in AACN, 2006, p. 14). Doctoral education assists in preparing the entrepreneur to understand both the clinical microcosm and the macrocosm of health care, which define practice and directly influence their ability to provide care (AACN Essential II; AACN, 2006). The DNP-prepared nurse entrepreneur understands healthcare policies and legislative issues that “facilitate or impede the delivery of health care services or the ability of the provider to engage in practice to address health care needs” (AACN, 2006, p. 13).

Healthcare Policy and Legislative Issues Doctoral education provides the nurse entrepreneur with the essential skills to function in the arena of political activism. Courses and class activities provide the student with learning experiences that deal with healthcare policy and legislative issues. This addresses the AACN Essential V of the DNP educational process, which states that the graduate should possess the ability to “analyze the policy process and . . . to engage in politically competent action” (O’Grady, as cited in AACN, 2006, p. 13) and “design, influence, and implement health care policies that frame health care financing, practice regulation, access, safety, quality, and efficacy” (IOM, as cited in AACN, 2006, p. 13). Now more than ever, it is imperative that nurses, especially nurse entrepreneurs, be able to function competently in the political arena during these very volatile times in health care as critical decisions concerning nursing’s scope of practice are being pondered by legislative and judicial systems.

Relevance and Opportunities of DNPPrepared Individuals in the Current Marketplace Possessing a DNP has led to more job opportunities, improved positions, and increased professional respect. For those NPs who have spent their careers in clinical practice, and who do not have plans to pursue a research position, a clinical doctorate is most likely the appropriate professional degree choice. Regarding income, the median weekly earnings for individuals with doctoral degrees are on average over $200 or more higher than the earnings for those with less advanced degrees (Boland, Treston, & O’Sullivan, 2010). DNPs earn upward of $1,700 to $1,800 per week for possessing a professional doctoral degree according to the Bureau of Labor Statistics (U.S. Department of Labor, Bureau of Labor Statistics, 2018). Advocates of the DNP recognize the constructive aspects of this new academic degree choice on academia. Additionally, NPs educated at the doctoral level will help alleviate the expanding nursing faculty shortage as colleges and universities acquire and bring them into the system as nontenured and tenured faculty for their undergraduate and graduate programs of study, including DNP programs (Boland et al., 2010). This is important. More specifically with the proliferation of DNP programs there is a need for DNP-prepared faculty to educate NPs to assist with the looming primary care provider shortage, as schools continue to close their MSN programs. Part of the vision of the AACN was to have NPs prepared to practice at the most advanced level of nursing, calling on schools to transition their programs from master’sto doctoral-level preparation (AACN, 2006). Regarding the utilization of the clinical doctoral-prepared nurses in the current marketplace, early studies show that there is an interest and support in hiring them. For example, one of the studies was a market analysis survey of 111 top executives in acute, long-term, and public health settings to determine their interest in hiring a DNP graduate. The findings showed that most (61%; n = 68) of these respondents indicated

they would be interested in hiring DNP graduates. Additionally, these respondents stated that they would have positions available to potentially consider hiring these graduates (Nichols, O’Connor, & Dunn, 2014). These executives identified nine specific positions—“(a) vice president for clinical service, (b) program director, (c) vice president for patient care, (d) chief executive officer, (e) quality improvement director, (f) director of clinical service, (g) clinical information technology specialist, (h) direct care clinician, (i) faculty member”—where they projected they would have a need and consider a DNP candidate (Nichols et al., 2014).

Current and Future Trends In the current healthcare environment, DNP-prepared entrepreneurs and intrapreneurs (internal company entrepreneur) are standing on the threshold of playing key roles as leaders and agents of change at the decision-making tables and in the clinical setting as primary care providers. As stated in the IOM’s landmark report on the future of nursing, the DNP-prepared nurse must be capable of functioning “from the bedside to the board room” (IOM, 2011, p. 6). All this is a result of a perfect storm playing out in health care today as fewer medical students pursue careers in general practice, thus increasing the shortage in available primary care physicians. These factors, combined with the soaring costs of health care, an aging population that is living longer, chronic health problems, and the implementation of the Affordable Care Act as well as a dismal outlook for its future, indicate a growing need for high-quality, affordable, and available health services. As a result, there is an increased demand for primary care services such as those provided by the healthcare professional created to address this problem over 40 years ago: the APN (Robert Wood Johnson Foundation, 2011). These circumstances position the DNP-prepared APN entrepreneur and intrapreneur to be a viable complement to the traditional physician internist or primary care provider for the healthcare–seeking consumer. Other precipitating factors, such as lack of appreciation, subordination to physicians, role diminution, low wages, short staffing, poor working conditions, inflexible schedules, frequent schedule changes, and burnout, have reduced the number of experienced professional nurses in the United States, further ripening the field of opportunity for nurse entrepreneurs (American Society of Registered Nurses, 2008). Commercial opportunities abound for DNP-prepared entrepreneurs in private practice, foundations, retail clinics, legal and business consulting, journalism, education, information technology development, pharmaceuticals, and organizational management and administration (American Society of Registered Nurses, 2008). As barriers to practice are eliminated and the national move for true autonomous APN practice progresses, the future is very promising for DNP-prepared entrepreneurs

and intrapreneurs in the business world. This effort has been greatly bolstered by the findings of the IOM’s landmark report (IOM, 2011, p. 4), which calls for restructuring of the current healthcare system to allow “nurses to practice to the full extent of their education and training” by removing the scope of practice barriers that currently exist in the system. At present, the regulations defining APN scope of practice vary widely from state to state (IOM, 2011, p. 4). This is one major hurdle that we must continue to address. Since the publication of the last edition of this text, a few more states have expanded or lifted restraints off the scope of practice of APNs, including the Veterans Administration (VA), granting nurse practitioners and other APNs full practice authority (Office of Public and Intergovernmental Affairs, 2016). Another is the recognition and impaneling of APNs as primary care providers by government agencies outside of the VA, insurance companies, and third-party payers, whether APNs are part of a physicians group or in independent practice. These changes are destined to happen; there is no turning back at this point. Nursing at all levels will play significant supporting and defining roles in the restructuring of the healthcare system that is underway in the United States. The nursing profession must learn to speak in one voice to address professional issues. By speaking in one voice, the nursing profession, which includes over 3.1 million nurses (Health Resources and Services Administration, 2010), becomes a very formidable presence in the political arena and at the decision-making tables. The doctorally educated nurse entrepreneur and intrapreneur is prepared to accept the challenge of leading change. During the restructuring, as previously stated, it is imperative that the profession learn to speak in one strong voice. The profession must not sit idly at the sidelines and allow other professions, agencies, and entities to decide and define what these roles will be.

Biosketches of Select Successful DNP Entrepreneurs Margaret A. Fitzgerald, DNP, FNP-BC, NP-C, FAANP, CSP, FAAN, DCC, FNAP Dr. Margaret Fitzgerald is the founder, president, and principal lecturer with Fitzgerald Health Education Associates (FHEA), an international provider of nurse practitioner certification preparation and continuing education for healthcare providers. An internationally recognized presenter, Dr. Fitzgerald has provided thousands of programs for numerous professional organizations, universities, and national and state healthcare associations on a wide variety of topics including clinical pharmacology, clinical assessment, laboratory diagnosis, health care, and nurse practitioner practice. For more than 25 years, she has provided graduate-level pharmacology courses for NP students at a number of universities. In addition, she practices as a family nurse practitioner at the Greater Lawrence Family Health Center, Lawrence, Massachusetts. Dr. Fitzgerald also holds a DNP from Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH, where she received the Alumni Association Award for Clinical Excellence and is also an adjunct associate professor. Dr. Fitzgerald is a member of the Pharmacy and Therapeutics Committee for Neighborhood Health Plan in Boston, Massachusetts. Dr. Fitzgerald is the recipient of the National Organization of Nurse Practitioner Faculties’ Lifetime Achievement Award, given in recognition of vision and accomplishments in successfully developing and promoting the nurse practitioner role, the American College of Nurse Practitioner’s Sharp Cutting Edge Award, and the Outstanding Nurse Award for Clinical Practice by the Merrimack Valley Area Health Education Council. In addition, Dr. Fitzgerald received the Loretta C. Ford Lifetime Achievement Award from the National Nurse Practitioner Symposium for demonstrating longevity, integrity, professional achievement, and advocacy in advanced practice nursing. She is also a Fellow of the

American Academy of Nursing and a charter fellow in the Fellows of the American Association of Nurse Practitioners. Dr. Fitzgerald is a Professional Member of the National Speakers Association and is the first nurse practitioner to earn the Certified Speaking Professional (CSP) designation in recognition of excellence and integrity as a speaker. She is also certified by the American Board of Comprehensive Care as a Diplomate of Comprehensive Care (DCC), a designation available to DNP graduates who are licensed advanced practice registered nurses and nationally certified in an APRN specialty. Dr. Fitzgerald is an editorial board member of The Nurse Practitioner, American Nurse Today, Prescriber’s Letter, and Journal of Doctoral Nursing Practice. She is widely published, with more than 200 articles, book chapters, monographs, and audio and video programs to her credit. Her book, Nurse Practitioner Certification Examination and Practice Preparation (now in its 5th edition), received the American Journal of Nursing Book of the Year Award for advanced practice nursing and has been published in English and Korean. She has provided consultation to nursing organizations in the United States, Canada, the Dominican Republic, Japan, South Korea, Hong Kong, and the United Kingdom. Dr. Fitzgerald is an active member of numerous professional organizations at national and local levels (Biosketch provided by FHEA, April 11, 2018). In regard to her perspective on how the DNP degree has enhanced her current practice and/or business, Dr. Fitzgerald stated, The purpose of the doctor of nursing practice study is to provide rigorous education to prepare clinical scholars who translate science to improve population health through expert leadership that powers innovation in health care. I serve my profession in a number of roles: entrepreneur, scholar, and clinician. As part of my DNP studies at Case Western Reserve University, I developed a business plan for the expansion of Fitzgerald Health Education Associates, Inc., with the project’s focus being the NP certification preparation course. The process of developing the business plan afforded the opportunity to delve into areas that would be critical to the company’s success and helped me to realize the significant possibilities in this niche market. My capstone project focused on the NP certification marketplace. These products of my DNP

studies directly have influenced my business’s success. I also practice as a family NP and adjunct faculty to the Family Practice Residency at the Greater Lawrence Family Health Center (in Massachusetts). As a result of my DNP, my ability to critique healthcare literature has been further enhanced, reinforcing my role as a clinical scholar and teacher. (Personal communication, April 11, 2018) In sharing her thoughts on nurse entrepreneurship, Dr. Fitzgerald further stated, As a nurse entrepreneur, I quickly realized that nursing practice is business practice. The strong clinical assessment skills of the advanced practice nurse—the ability to analyze a problem, study options to work toward the problem’s resolution, develop a plan to address the problem, perform ongoing evaluation, and adjust intervention to ensure the desired outcome—serve the entrepreneur well. In addition, DNP studies prepare the nurse leader; leadership is critical to entrepreneurship. The successful entrepreneur must have expert intrapersonal skills, possess initiative, and be risk tolerant; again, these are skills that are developed as part of nursing education and critical to nursing practice. While not all nurses aspire to be entrepreneurs, nurse trailblazers can fulfill the role of the intrapreneur, applying the entrepreneur’s skill set within an organization. The nurse intrapreneur provides the forward-thinking mind set needed, focusing on creativity, innovation, and leadership. (Personal communication, April 11, 2018) David G. Campbell-O’Dell, DNP, ARNP, FNP-BC, FAANP Dr. David Campbell-O’Dell is a president of Doctors of Nursing Practice, Inc. (DNP Inc.), a nonprofit charitable service organization dedicated to improving outcomes by promoting and enhancing the doctorally prepared nursing professional. This organization was founded in 2006 by a team of colleagues while they were still students at the University of Tennessee Health Science Center in Memphis, which today has grown from a small website that shared static information about the DNP role to a robust site

with many components, features, and benefits. The DNP Inc. organization presents national conferences, provides a foundation to help DNP students expand and complete their scholarly practice projects, while also offering a repository of scholarly projects and a searchable listing of all DNP programs. Many other supportive services are offered. The online community sponsored by DNP Inc. provides forums, blogs, events, and groups to support and enhance doctorally prepared nursing practice and education. The DNP Inc. website and online community are instrumental in building a network of DNP-prepared nursing professionals. Dr. Campbell-O’Dell is also a site evaluator for the Commission on Collegiate Nursing Education, the nation’s top nursing school review body that evaluates baccalaureate, graduate, and residency programs in nursing to ensure that they meet the standards set forth by the AACN. He purports that the DNP degree has afforded him the opportunity to enhance his clinical, academic, and professional life. These opportunities would not have been possible without the DNP degree and resulting professional collaboration with colleagues nationally and internationally. The DNP degree, along with past and present professional experiences and interests, has allowed him to expand his academic role and continue to enhance efforts to grow the profession. He believes these are exciting times to be a nurse and a DNP-prepared professional. Dr. CampbellO’Dell shared that entrepreneurship has been a natural phenomenon for him. He formed a corporation many years ago recognizing that a business entity has more opportunities to augment and grow than an individual. He stated, “I’ve maintained and plan to always work within a self-created corporate structure.” As a result of past and current efforts within DNP Inc., many opportunities are evolving to support the nursing discipline through a collective effort to improve outcomes and enhance practice. The possible synergistic opportunities for growth and development of the discipline as a result of the collective contributions of professional colleagues cannot be underestimated. The creation of the DNP Inc. organization has evolved into the generation of other areas of service that support faculty, students, graduates, and healthcare systems to make the most of the DNP-prepared nursing professional to impact healthcare delivery. Regarding entrepreneurship, Dr. Campbell-O’Dell relayed, “We are all

business people in our own way. All professionals, regardless of the discipline, have something to contribute in whatever environment we choose to flourish. No matter where we are in our professional lives, we all contribute and attempt to enhance the flow and outcomes as a result of our individual and collective efforts. An entrepreneurial spirit can be satisfied both within and outside of an existing organization. Therefore, we are all in the same boat trying to move it forward together.” On a personal note, Dr. Campbell-O’Dell believes that his own entrepreneurial spirit has provided him great satisfaction as a business owner, a contributor, and collaborator within an organization designed to enhance the discipline of nursing through the facilitation of the growth of the professional DNP degree. He enjoys teaching in graduate and doctoral programs online while working part-time in an urgent care center in Key West, Florida. His doctoral education allowed for a neurology focus with a special interest in neurocognitive disorders and coordination of care in the context of altered family dynamics (Personal communication, April 8, 2018). Carol Lisa Alexander, DNP, APRN, ACNS/NP-BC Dr. Carol Lisa Alexander is cofounder, president, and chief administrative officer of Coalition of African American Nurses (CAAN) Academy of Nursing and is cofounder and president of the newly established Illinois South Suburban National Black Nurses Association (ISSNBNA). Dr. Alexander is a board-certified clinical nurse specialist presently serving in the role of NP at KAM Alliance Inc., a mental health outpatient clinic providing mental health medication management for greater than 1,000 clients. Over the past 40 years, Dr. Alexander has committed herself to caring for the medically underserved, economically disadvantaged, and at-risk populations. It was during this period of time that she actively advanced her educational background to accomplish her goals in becoming an entrepreneur. In 2009, Dr. Alexander went on to pursue her DNP degree with a concentration in administration. With this accomplishment she completed her dream of establishing and operating an adult and high school practical nursing (PN) program in the south suburbs of Illinois, which was cofounded with Ms. Rose Murry, MSN, ACNS, DNP(c).

Dr. Alexander’s vision is “to inspire, motivate, cultivate, and educate nurses woven in the moral fibers of care and compassion.” The vision became reality in 2008 when the academy was instituted in the Thornton Fractional High School District. Her DNP capstone project was in creating the infrastructure and foundation for the launch of the adult PN program, which was instituted in 2010. After 6 years of successfully graduating over 125 students, Dr. Alexander identified a need within the community for an LPN-RN, ASN degree program. Therefore, Dr. Alexander and her team actively pursued this challenge and received authorization from the Illinois Board of Higher Education (IBHE) on March 16, 2018, to institute an LPN-RN, ASN degree program in South Metro Illinois, which was opened in fall 2018. In regard to achieving the DNP degree Dr. Alexander’s sentiments are as follows: My DNP program with the concentration in administration was an essential aid in enhancing my character as a transformational leader. The DNP title is respectfully recognized by leadership within the regulatory agencies I work with to accomplish the academy’s goals. My coursework guided me in refining my leadership skills specifically in communicating the vision, my ideas, and the needs of the community and organization in our contract negotiations. The concept of communication infiltrated every course, redefining the essentials in negotiating, delegating, planning, and managing a business, including its financial resources, effectively and efficiently, which is a major component in business administration. The program augmented my ability to strategically plan and develop our business plans. The program provided me with an in-depth focus on how to more effectively utilize evidencebased research in academia utilizing a “right here” and “right now” approach. I attribute the success that I am experiencing in business administration to achieving my DNP. (Personal communication, April 19, 2018) The CAAN Academy of Nursing’s goals are as follows: 1. To decrease the national and regional nursing shortage

2. To increase diversity in the nursing workforce in order to assist with decreasing the existing healthcare disparity 3. To provide the traditionally underserved with career opportunities that can be realized immediately upon completion of the programs The academy’s mission is to provide comprehensive academic instruction on the highest level that promotes and facilitates personal and professional development in nursing. This centers upon the client, with dedication to community health awareness and education, career building, lifelong learning, and, most importantly, the administration of caring compassion within the healthcare profession. With these ambitious goals in mind for the academy, Dr. Alexander now envisions attaching a mental and family health clinic to the academy. Dr. Alexander believes that the DNP degree has equipped her with the knowledge, leadership preparation, and fortitude needed in order to accomplish these ambitious goals to move the CAAN Academy of Nursing into the future.

References

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Robert Wood Johnson Foundation. (2011). APRNs a “big part of the solution” to the primary care provider shortage. Retrieved from www.rwjf.org/en/library/articles-and-news/2011/08/aprns-abig-part-of-the-solution-to-the-primary-care-provider-sh.html?cid=xsh_rwjf_em Shane, S. (2004). A general theory of entrepreneurship: The individual opportunity nexus. Northampton, MA: Edward Elgar. Sperhac, A., & Clinton, P. (2008). Doctorate of nursing practice: Blueprint for excellence. Journal of Pediatric Health Care, 22(3), 146–151. Tracy, M. (2014). Direct clinical practice. In A. Hamric, J. Spross, & C. Hanson (Eds.), Advanced practice nursing: An integrative approach (5th ed., pp. 147–182). St. Louis, MO: SaundersElsevier. U.S. Department of Labor, Bureau of Labor Statistics. (2018). Employment projections. Retrieved from www.bls.gov/emp/ep_chart_001.htm Wisconsin Nurses Association. (2015). APRN Uniformity Act. Retrieved from www.wisconsinnurses.org/education/aprn-uniformity-act/

INTEGRATIVE PRACTITIONER Joy Elwell According to Dr. Andrew Weil, integrative medicine “is healing-oriented medicine that takes account of the whole person (body, mind, and spirit), including all aspects of lifestyle. It emphasizes the therapeutic relationship and makes use of appropriate therapies, both conventional and alternative” (Lemley, 2015). An example would be the use of ginger or peppermint to prevent nausea in oncology patients undergoing chemotherapy. Integrative health care continues to be a choice for Americans. The CDC’s National Health Statistics Report on Complementary and Alternative Medicine (CAM) Use Among Adults and Children (Barnes, Bloom, & Nahin, 2008) revealed that 38% of American adults and 12% of children use alternative or complementary therapies of some type. The skills gained in the DNP program will enhance the APN in integrative therapy in accordance with The Essentials of Doctoral Education for Advanced Nursing Practice. Essential III, for instance, states that the DNP program prepares APNs to “critically appraise existing literature and other evidence to implement the best evidence for practice” (AACN, 2006). Essential VI speaks to interprofessional collaboration, which is truly an essential for the practice of this specialty that reaches across many different healthcare fields (AACN, 2006). Essential VII describes clinical prevention and population health, all facilitated through integrative health care (AACN, 2006). The DNP-prepared integrative health practitioner will have much to offer patients. To address the DNP-prepared APN as an integrative practitioner, it is essential to explore integrative health as a specialty within health care. Integrative health, also known as holistic health, is described as “treating the whole person, helping the person to bring the mental, emotional, physical, social, and spiritual dimensions of his or her being into greater harmony, using the basic principles and elements of holistic healing and, as much as possible, placing reliance on treatment modalities that foster the self-regenerative and self-reparatory processes of natural healing”

(Otto & Knight, 1979, p. 3). Nursing is an approach to wellness from a holistic perspective and therefore makes nursing and integrative health perfect partners for the APN. An area where integrative therapies make a significantly positive difference is safety. A significant issue in treating illness with traditional pharmacologic measures is unwanted side effects, which can be dangerous and costly. According to Wantanabe, McGinnis, and Hirsch (2018), “the estimated annual cost of drug-related morbidity and mortality resulting from nonoptimized medication therapy was $528.4 billion, equivalent to 16% of total US health care expenditures in 2016” (pp. 829). Considering that integrative modalities can be useful adjuncts in treating a multitude of conditions, the DNP-prepared nurse can utilize these to help patients reduce symptoms, improve their sense of wellbeing, and possibly reduce the pharmacologic burden.

Nurses as Integrative Practitioners Historically, Florence Nightingale may be considered one of the first professional integrative health practitioners in nursing. Nightingale “was a mystic, visionary, healer, reformer, environmentalist, feminist, practitioner, scientist, politician and global citizen” (Dossey, Selanders, Beck, & Attewell, 2005, pp. 283). She looked beyond the era’s traditional medical and surgical treatment of disease and injury to include nutrition, sanitation, lighting, and activity. She addressed the mind, body, and spirit connection that would pave the way for modern professional integrative practitioners. Since Nightingale’s death in 1910, professional nursing has evolved in numerous ways, including the development of advanced practice nursing roles. Numerous nursing pioneers have explored integrative modalities to assist clients in achieving optimum levels of wellness, alleviating suffering, and facilitating healing. Founded in 1980, the American Holistic Nurses Association (AHNA) focuses on holistic nursing as “all nursing practice that has healing the whole person as its goal” (AHNA, 2019). That nurses practice integrative health is not a novel concept. Major nursing theorists incorporate holism into their theories. Dr. Jean Watson’s theory of human caring is one example. She identifies caring beliefs and behaviors that benefit not only the client but the nurse as well. New York University established the first holistic NP program, and others have followed. Within the United States, certain states (e.g., New York) identify holistic health as a specialty (New York State Office of the Professions, State Education Department, 2017). There are also clinical nurse specialists in integrative health. The ANA now recognizes holistic nursing as a specialty, and certification can be obtained through the American Holistic Nurses Credentialing Corporation (AHNCC, 2015). In addition, the AHNA has articulated standards of practice, core values, a certification curriculum, and requirements for endorsement of holistic nursing programs. It also is a provider of continuing education in holistic nursing, which now includes a section specific to advanced geriatric education and resources. A current listing of nursing programs endorsed by the AHNCC can be found at

http://ahncc.org/home/endorsedschools.html. Nurses can pursue educational programs for integrative or holistic modalities at all levels of postlicensure preparation. Certification through the AHNCC reflects the level of academic study in the board certification test administered and the credential conferred on the successful applicant. The general requirements for certification include active practice as a holistic nurse for 1 year (full time) or 2,000 hours in the past 5 years (part time) and 48 contact hours of continuing education in holistic nursing over the preceding 2 years (AHNCC, 2012). APNs who hold a master’s or doctoral degree may sit for the Advanced Holistic Nurse Board Certification (APHN-BC; AHNCC, 2015). Certain roles within the realm of integrative practitioners, such as chiropractors, acupuncturists, and massage therapists, are licensed and have educational requirements. Nurses who pursue these roles must fulfill those requirements in addition to any nursing curriculum. DNP-prepared advanced practice registered nurses are uniquely suited to incorporate integrative modalities into practice and beyond into healthcare systems. It is in this area that all eight DNP Essentials (AACN, 2006) can be viewed in action: Essential I: Scientific underpinnings for practice. This essential addresses the theoretical framework or conceptual model utilized in planning, delivering, and evaluating advanced practice nursing care. There are many nursing theories and conceptual models that APRNs incorporate into their practice. One example is Ida Jean Orlando’s nursing process theory that, when applied to the APRN as an integrative practitioner, utilizes her concepts of seeking out the patient’s needs, addressing those needs, and engaging in selfreflection (Liebla, 2018). Essential II: Organizational and systems leadership for quality improvement and systems thinking. In this essential, the DNPprepared APRN addresses quality improvement needs from a systems-wide viewpoint. Questions regarding gaps in practice from the larger perspective, beyond the individual patient or population, translating to the healthcare system at large are examined and solutions created. In applying this DNP essential to integrative practice, the DNP-prepared APRN can facilitate the

inclusion of integrative modalities into systems and evaluate change made by utilizing quality improvement principles and techniques. Essential III: Clinical scholarship and analytical methods for evidence-based practice. In this essential, the DNP-prepared APRN engages in research to establish the effectiveness of integrative modalities in managing health conditions and can utilize translational research to develop evidence-based practice guidelines. An example of this is the use of translational research of the literature to develop an evidence-based program for children, incorporating music, mindfulness, and yoga to reduce attention-deficit disorder and stress symptoms in children (Darcy, 2017). Essential IV: Information systems/technology and patient care technology for the improvement and transformation of health care. This essential addresses the use of data to evaluate outcomes. By developing expertise in the understanding of the use of data, the DNP-prepared APRN develops, implements, and evaluates programs that are safe and efficacious, interpreting research appropriately. An example of this application in integrative care is the concept of using yoga as an adjunct to medication-assisted therapy (MAT) for opioid use disorder. There is literature to support this concept, and practitioners would hail its use, as it is safe, and cost-effective, but a systematic review by Arias, Steinberg, Banga, and Trestman (2006) determined that yoga is a useful adjunct to MAT but is not a superior alternative. Therefore, it is education specific to this essential that provides the DNP-prepared APRN the knowledge to evaluate data. Essential V: Health care policy for advocacy in health care. Knowledge and expertise in the area of health policy and advocacy are crucial to make integrative healthcare modalities accessible and affordable to the healthcare consumer. The DNPprepared APRN can communicate effectively with legislators and regulators to inform them of the need to ensure that these treatments are covered by health insurance. An example of this is massage therapy. Confirmed in numerous studies to be safe and effective for the management of low back pain (Cherkin, Sherman,

Deyo, & Shekelle, 2003), massage therapy is not always covered by health insurance. The national average cost of massage therapy is $60 per hour (University of Minnesota, 2019a), which is cost-prohibitive for many healthcare consumers. Utilizing expertise in the area of health policy, the DNP-prepared APN is uniquely able, as both a practitioner and an advocate, to make legislative and regulatory change to reduce this barrier to access to healthcare. Essential VI: Interprofessional collaboration for improving patient and population health outcomes. This essential addresses the need for providers in different healthcare disciplines to collaborate, sharing expertise to improve healthcare outcomes. In the area of integrative health, the DNP-prepared APRN will consult with and refer to other practitioners. Essential VII: Clinical prevention and population health for improving the nation’s health. This essential addresses ways in which the DNP-prepared APRN can translate research and utilize knowledge and expertise to improve healthcare outcomes on a national scale. An example of this is preventing complications in high-risk pregnancies through the use of yoga. In their randomized controlled trial, Rakhshania et al. (2012) identified that high-risk pregnant women who practiced yoga were less likely to experience complications of pregnancy, including pregnancyinduced hypertension, preeclampsia, gestational diabetes, and intrauterine growth retardation, than those who did not practice yoga. Given the risks to both mother and baby from all these conditions, and the healthcare costs associated with hospitalizations, a clear benefit to the nation at large can be seen in utilizing integrative therapies in this instance. Essential VIII: Advanced nursing practice. This essential addresses the DNP-prepared APRN as a practitioner. There are different routes for the DNP-prepared APRN to become an integrative practitioner. There are holistic nurse practitioner programs. There are also certificate programs available in massage therapy, master’s degree programs in acupuncture, and continuing education programs in other integrative modalities. The DNP-prepared APRN who wishes to engage in integrative practice

has many opportunities.

Types of Integrative Healing Modalities Integrative health care includes many healing modalities. There are five different approaches to care as organized by the National Center for Complementary and Alternative Medicine (NCCAM): whole medical systems, manipulative and body-based practices, mind–body medicine, biologically based practices, and energy medicine (NCCAM, 2007). The modalities described here are not intended to be an exhaustive list of every integrative healing modality known. TABLE 4-1 lists websites where further information can be found. TABLE 4-1 Websites for Further Information on Integrative Health American Holistic Nurses Credentialing Corporation (AHNCC)

www.ahncc.org

Center for Spirituality and Healing at the University of Minnesota

www.csh.umn.edu

Life Sciences Foundation

http://lifesciencesfoundation.org

National Center for Complementary and Integrative Health

https://nccih.nih.gov/health/integrative-health

Academy of Integrative Health and Medicine (AIHM)

www.aihm.org

Description

Whole Medical Systems Homeopathy: A medical discipline that facilitates healing through the administration of substances prescribed according to three principles: (1) like cures like, also known as the law of similars; (2) the more a

remedy is diluted, the greater the potency; and (3) illness is specific to the individual. Homeopathy is based on the belief that symptoms are signs of the body’s effort to get rid of disease; treatment is based on the whole person rather than on the symptoms (NCCAM, 2009). Osteopathic medicine: A form of medicine focusing on the relationship between the structure of the body and its function, identifying that both structure and function are subject to a range of illnesses. In treating the client, osteopathic practitioners use various types of physical manipulation to stimulate the body’s self-healing ability as well as traditional allopathic medical modalities. Osteopathic physicians are licensed to diagnose, treat, and prescribe nationally.

Manipulative Modalities Acupressure: Pressure, by fingers and hands, over specific areas of the body, is used to alleviate pain and discomfort and to positively influence the function of internal organs and body systems. Various approaches are used to release tension and restore the natural flow of energy in the body. Acupuncture: Use of fine-gauged needles inserted into specific points on the body to stimulate or disperse the flow of energy. This ancient Asian technique is used to alleviate pain or increase immunity by balancing energy flow. Massage, herbal medicine, and nutritional counseling are often used in conjunction with acupuncture. Alexander technique: This technique, developed by Australian actor Frederick Matthias Alexander, involves learning a series of lessons in rebalancing the body through awareness, movement, and touch. As the student explores new ways of reorganizing neuromuscular function, the body is reintroduced to healthy posture and direct, efficient movement (Trivieri & Anderson, 2002). AMMA therapy: AMMA therapy is a form of Asian massage that focuses on the balance and movement of energy within the body. Applied kinesiology: Originated by chiropractic physician George Goodheart Jr. in the 1960s, applied kinesiology incorporates the principles of several holistic therapies, “including chiropractic, osteopathic medicine and acupuncture, and involves manual manipulation of the spine, extremities, and cranial bones in performing

its procedures” (Trivieri & Anderson, 2002, p. 71). Aromatherapy: Aromatherapy incorporates the use of essential oils extracted from plants and herbs to treat physical imbalances and to achieve psychological and spiritual well-being. The oils are inhaled, applied externally, or ingested. According to Dr. Kurt Schnaubelt, “the chemical makeup of essential oils gives them a host of desirable pharmacological properties, ranging from antibacterial, antiviral, and antispasmodic, to uses as diuretics, vasodilators, and vasoconstrictors. Essential oils also act on the adrenals, ovaries, and thyroid, and can energize, pacify or detoxify, and facilitate the digestive process” (Trivieri & Anderson, 2002, p. 76). Breema bodywork: Breema bodywork incorporates simple, playful bodywork sequences along with stretch and movement exercises that help create greater flexibility, a relaxed body, a clear mind, and calm, supportive feelings. Developed by chiropractic physician Jon Schraiber, Breema bodywork is based on nine principles: body comfortable, no extra, firmness and gentleness, full participation, mutual support, no judgment, single moment/single activity, no hurry/no pause, and no force (Mann, 2009). Chiropractic medicine: A healthcare system emphasizing structural alignment of the spine. Adjustments involve the manipulation of the spine and joints to reestablish and maintain normal nervous system functioning. Some chiropractors employ additional therapies, such as massage, nutrition, and specialized kinesiology. Cranial osteopathy: Gentle and almost imperceptible manipulation of the skull to reestablish its natural configuration and movement. Such correction can have a positive influence on disorders manifested throughout the body. Craniosacral therapy: Diagnosis and treatment of imbalances in the craniosacral system. Subtle adjustments are made to the system through light touch and gentle manipulations. Dance therapy: Dance therapy is a modality in which dance and music combine to allow the body, mind, soul, and spirit to be refreshed and uplifted and to experience the freedom that natural bodily movement allows. Feldenkrais method: The Feldenkrais method is a method of instruction, through movement and gentle manipulation, to enhance

self-image and restore mobility. Students are taught to notice how they are using their bodies and how to improve their posture and move more freely. Jin shin jyutsu: This is a bodywork technique that balances body energy as it travels along specific pathways. Specific combinations of healing points are held with the fingertips to restore balance and harmony. Lymphatic therapy: Lymphatic therapy is a vigorous form of massage that helps the body release toxins stored in the lymphatic system— excellent for the immune system and rebuilding the body. Massage: Massage involves the use of strokes and pressure on the body to dispel tension, increase circulation, and relieve muscular pain. Massage can provide comfort and increased body awareness and can facilitate the release of emotional as well as bodily tension. Movement therapy: This modality involves a guided series of movements and body work to open energy pathways and facilitate healing. Neuromuscular therapy: Neuromuscular therapy is a massage therapy in which moderate pressure over muscles and nerves, as well as on trigger points, is used to decrease pain and tension. Physical therapy: Physical therapy includes the treatment of physical conditions of body malfunction, damage, or injury using procedures designed to reduce swelling, relieve pain, strengthen muscles, restore range of motion, and return functioning to the patient. Shiatsu: Shiatsu is an energy-based system of bodywork that uses a firm sequence of rhythmic pressure held on specific pressure points on the body, designed to awaken acupressure meridians. Trigger point therapy: This is a method of compression of sensitive points in the muscle tissue, along with massage and passive stretches, for the relief of pain and tension. Treatment decreases swelling and stiffness and increases range of motion. Exercises may be assigned.

Mind–Body Medicine Art therapy: Art therapy incorporates the use of basic art materials to discover how to restore, maintain, or improve physical and mental

health. Through observation and analysis, the art therapist is able to formulate treatment plans specific to the individual. Color therapy: Color therapy involves the use of electronic instrumentation and color receptivity, according to the work of Jacob Lieberman (1993), to integrate the nervous system and body–mind. It increases well-being and can be helpful for many acute and chronic ailments. Counseling/psychotherapy: A broad category of therapies that treat individuals as a whole. Treatments and sessions are focused on integrated care on all levels for individuals, families, or groups. Eye movement desensitization and reprocessing (EMDR): EMDR is an accelerated information-processing method that uses alternating stimuli—either eye movements or sounds—to desensitize and reprocess emotional wounds and install a healthier belief system. EMDR is effective with posttraumatic stress syndrome, childhood trauma, depression, addictions, compulsions, unhealthy patterns, and future-oriented solutions. Guided imagery: A holistic modality that assists clients in connecting with their inner knowledge at the thinking, feeling, and sensing levels, thus promoting their innate healing abilities. Together, guide and client co-create an effective way to work with pain, symptoms, grief, and stress management; conflict resolution; and self-empowerment issues; and to prepare for medical or surgical interventions. Hypnotherapy: A state of focused attention, achieved through guided relaxation, hypnotherapy is used to access the unconscious mind. Hypnosis is used for memory recall, medical treatment, and skill enhancement or personal growth. Interactive imagery: Fostering active participation, disease prevention, and health promotion, interactive imagery returns the focus of wellness to the individual. Meditation: A method of relaxing and quieting the mind to relieve muscle tension and facilitate inner peace. There are numerous forms of meditation, taught individually or in group settings, and it is thought that prayer for the self might have an effect similar to meditation. The nonsectarian form of prayer, which is akin to meditation and used for stress reduction, has long been recognized by clinicians to improve one’s sense of well-being.

Music therapy: An expressive art form designed to help the individual move into harmony and balance. Through the use of music, individuals explore emotional, spiritual, and behavioral issues. Musical skill is not necessary because the process, rather than technique, is emphasized. Neurolinguistic programming: A systematic approach to changing behavior through changing patterns of thinking. Its originators, Dilts, Grinder, Delozier, and Bandler (1980), proposed theoretical connections between neurological processes (neuro), language (linguistic), and behavioral patterns that have been learned through experience (programming), which can be organized to achieve specific goals in life. Stress management: Any therapy or educational practice with the objective of decreasing stress and enhancing one’s response to the elements of life that cannot be changed. This broad category may include bodywork, energy work, visualization, and counseling. Tai chi (chuan): A movement practice and Chinese martial art that enhances coordination, balance, and breathing and promotes physical, emotional, and spiritual well-being. Tai chi is taught in classes or as private lessons and requires home practice to be effective. Yoga therapy: The use of yoga postures, controlled breathing, relaxation, meditation, and nutrition facilitates the release of muscular and emotional tension, improves concentration, increases oxygen levels in the blood, and assists the body in healing itself.

Biologically Based Practices Biofeedback: A relaxation technique involving careful monitoring of vital functions (such as breathing, heart rate, and blood pressure) to improve health. By conscious thought, visualization, movement, or relaxation, one can learn which actions result in desirable changes in these vital functions. Biofeedback is used for medical problems related to stress and for management of many health problems, including pain syndrome, migraine, and irritable bowel syndrome. Herbal therapy: The use of herbs and their chemical properties to alleviate specific conditions or to support the function of various body systems. Herbal formulas have three basic functions: elimination and

detoxification, health management and maintenance, and health building. The scope of herbal medicine is sometimes extended to include fungal and bee products as well as minerals, shells, and certain animal parts (Acharya & Shrivastava, 2008). Hydrotherapy: The use of water, ice, steam, and hot and cold temperatures to relieve pain, fever, and inflammation and to maintain and restore health. Treatments include full-body immersion, steam baths, saunas, and the application of hot and/or cold compresses. Nutritional counseling: Nutritional counseling is performed by a practitioner who uses diet and supplementation therapeutically as the primary or adjunctive treatment for illness and for maintaining good health. Nutritionists employ a variety of approaches, including food combining, macrobiotics, and orthomolecular theory.

Energy Medicine Chi kung healing touch: An Eastern method of healing involving breath and gentle movements that follows the Chinese five-element theory and works with the meridian system. Energy work: A broad category of healing influencing the seven major energy centers (chakras) and the flow of energy around and through this field. Healing touch: A therapeutic approach in which touch is used to influence energy systems. Healing touch is employed to affect physical, emotional, mental, and spiritual health and healing. Magnetic therapy: A modality using magnets to generate controlled magnetic fields. Magnetic therapy is used to improve the functioning of bodily systems and facilitate healing. Reiki: Using the hands and visualization, the Reiki practitioner directs energy to affected areas of the client’s body to facilitate healing and relaxation. Therapeutic touch: A technique for balancing energy flow in the body through human energy transfer.

The DNP as Integrative Practitioner: Unique Aspects of DNP Preparation The question will be asked, what advantage is there to having DNP preparation for an APN specializing in integrative health? Any professional registered nurse (RN) who takes a course in holistic nursing at the post-RN level should be able to function competently and therapeutically as an integrative practitioner. What, then, does the DNP bring to integrative health? And what is the advantage to seeking DNP preparation for this role? The AACN addresses the competencies of the doctorally prepared APN (AACN, 2006). The DNP, a practice-focused terminal degree, prepares the APN to serve as an expert in nursing practice. Compared with the PhD and DNS degrees, which are research-focused degrees, the DNP is unique in providing education in those components of advanced nursing practice that are essential to practice at the highest clinical level. The skills gained in the DNP course of study will not only prepare the nurse for clinical competence but also prepare him or her for establishing a successful practice or business. As DNP programs proliferate in colleges and universities across the nation, certain states (e.g., Alabama and New York) are mandating that the curricula include a significant percentage of clinical content; indeed, some DNP programs (e.g., Columbia University, University of Wisconsin, University of Washington) include a clinical residency in the curriculum. The AACN Essentials of Doctoral Education for Advanced Nursing Practice state that DNP programs should require a minimum of 1,000 supervised clinical hours of practice for the baccalaureate-to-DNP degree course of study in any specialty (AACN, 2006). Including clinical components in the DNP curriculum strengthens the DNP-prepared APN as a clinician. The University of Minnesota’s Doctor of Nursing Practice Integrative Health and Healing area of concentration “prepares graduates with skills necessary for working with individuals, families, communities and health systems in developing holistic approaches to health promotion, disease prevention and chronic disease management, with a special emphasis on

managing lifestyle changes and incorporating the use of complementary therapies” (University of Minnesota, 2019b). This program fully integrates the specialty courses relevant to integrative practice with those courses designed to meet the requirements of the AACN’s Essentials competencies. These courses uniquely position the DNP graduate to succeed on many different fronts of integrative health. DNP curricula are unique in other areas, in that they include coursework in business finance, health policy, human resources management, change, and leadership (Rush University, 2019). The APN engaging in integrative health practice benefits from understanding past, current, and future trends in health policy. Healthcare legislation and regulation undergo frequent change, affecting the right to practice; scope of practice; definition of specialty; and related rights, privileges, and responsibilities. Legislation and regulation are influenced by many factors, including political, socioeconomic, and cultural. Advanced coursework in public policy provides the DNP with a firm foundation to clearly view the nuanced political landscape. The number of APNs owning or directing solo practices remains small, due in part to the expensive and adventurous nature of being an entrepreneur. Because of the lack of research on APNs in private practice, it is not possible to quantify with any specificity the number of APNs who own their own businesses. However, one survey on NPs indicated that 3% are engaged in private practice (Rollet & Lebo, 2007/2008). Given the nature and challenges of integrative health care (e.g., that health insurers do not consistently pay for holistic health services, that clients may be more inclined to pay for these services with disposable income, and that educated healthcare consumers are becoming increasingly interested in modalities that are more wellness oriented), it is reasonable to speculate that the number of APNs starting integrative health practices will increase. DNP programs provide the APN with education in health economics, financial management, budget creation and management, human resources, practice management, and business models. In the case of the DNP as integrative or holistic practitioner, earning the DNP degree provides advantages in the areas of direct delivery of health care, practice development and management, and interpreting and synthesizing research. Although some will posit that enough is learned at

the baccalaureate or master’s level, the competencies needed to provide health care to increasingly complex populations while managing a practice autonomously, using research for evidence-based care, and advocating for patient access to all relevant forms of interventions that promote wellness are all presented comprehensively in a DNP curriculum and provide the APN with the most optimal level of preparation for practice.

References Acharya, D., & Shrivastava, A. (2008). Indigenous herbal medicines: Tribal formulations and traditional herbal practices. Jaipur, India: Aavishkar. American Association of Colleges of Nursing (AACN). (2006). The essentials of doctoral education for advanced nursing practice. Retrieved from www.aacnnursing.org/DNP/DNPEssentials American Holistic Nurses Association (AHNA). (2019). What is AHNA? Retrieved from www.ahna.org/About-Us American Holistic Nurses Credentialing Corporation (AHNCC). (2012). Eligibility criteria for advanced holistic nursing certification. Retrieved from www.ahncc.org/recertification American Holistic Nurses Credentialing Corporation (AHNCC). (2015). Certification overview. Retrieved from http://ahncc.org/certificationprocess.html Arias, A. J., Steinberg, K., Banga, A., & Trestman, R. L. (2006). Systematic review of the efficacy of meditation techniques as treatments for medical illness. The Journal of Alternative and Complementary Medicine, 12(8), 817–832. doi:10.1089/acm.2006.12.817 Barnes, P., Bloom, B., & Nahin, R. (2008). Complementary and alternative medicine use among adults and children: United States, 2007. National Health Statistics Report, 12, 1–23. Cherkin, D., Sherman, K., Deyo, R., & Shekelle, P. (2003). A review of the evidence for the effectiveness, safety, and cost of acupuncture, massage therapy, and spinal manipulation for back pain. Annals of Internal Medicine, 138(11), 898–906. Darcy, B. (2017). Mindfulness, movement, & music: Implementing a yoga program for children. DNP scholarly project, Augsburg College. Retrieved from https://idun.augsburg.edu/cgi/viewcontent.cgi? referer=https://scholar.google.com/&httpsredir=1&article=1036&context=etd Dilts, R., Grinder, J., Delozier, J., & Bandler, R. (1980). Neuro-linguistic programming (Vol. I). Cupertino, CA: Meta. Dossey, B., Selanders, L., Beck, D. M., & Attewell, A. (2005). Florence Nightingale today: Healing, leadership, global action. Washington, DC: Nursesbooks.org. Lemley, B. (2015). What is integrative medicine? Retrieved from www.drweil.com/healthwellness/balanced-living/meet-dr-weil/what-is-integrative-medicine Lieberman, J. (1993). Light: Medicine of the future—How we can use it to heal ourselves now. Santa Fe, NM: Inner Traditions/Bear & Company. Liebla, B. (2018). Yoga as an adjunct to therapy in opioid abuse treatment. DNP General Exam PowerPoint Slides. University of Connecticut. Mann, J. D. (2009, January–February). Practicing presence through Breema. Spirituality and Health, 1–2. National Center for Complementary and Alternative Medicine (NCCAM). (2007). Complimentary, alternative, or integrative health: What’s in a name? Retrieved from https://nccih.nih.gov/health/integrative-health National Center for Complementary and Alternative Medicine (NCCAM). (2009). Homeopathy. Retrieved from http://nccam.nih.gov/health/homeopathy New York State Office of the Professions, State Education Department. (2017). Certification requirements: Nurse practitioner. Retrieved from www.op.nysed.gov/prof/nurse/np.htm Otto, H. A., & Knight, J. W. (1979). Dimensions in wholistic healing: New frontiers in the treatment of the whole person. Chicago, IL: Burnham. Rakhshania, A., Nagarathnaa, R., Mhaskarb, R., Mhaskarb, A., Thomas, A., & Gunasheelac, S. (2012). The effects of yoga in prevention of pregnancy complications in high-risk pregnancies:

A randomized controlled trial. Preventive Medicine, 55(4), 333–340. Rollet, J., & Lebo, S. (2008). 2007 salary survey results: A decade of growth. Results of the 2007 national salary and workplace survey of nurse practitioners. Advance for Nurse Practitioners. Jan;16 (1):28-32, 34-5. Rush University. (2019). Education and training: DNP. Retrieved from www.rushu.rush.edu/education-and-training#filter:doctor%20of%20nursing%20practice Trivieri, L., & Anderson, J. W. (2002). Alternative medicine: The definitive guide. Berkeley, CA: Celestial Arts. University of Minnesota. (2019a). How much does massage therapy cost? Retrieved from www.takingcharge.csh.umn.edu/explore-healing-practices/massage-therapy/how-much-doesmassage-theraphy-cost University of Minnesota. (2019b). Integrative health and healing DNP. Retrieved from www.nursing.umn.edu/degrees-programs/doctor-nursing-practice/postbaccalaureate/integrative-health-and-healing Wantanabe, J., McGinnis, T., & Hirsch, J. (2018, March 26). Cost of prescription drug–related morbidity and mortality. Annals of Pharmacology. Retrieved from https://doi.org/10.1177/1060028018765159

NURSE INFORMATICIST Sandra L. McPherson Nursing informatics is defined by the ANA (2015) as “a specialty that integrates nursing science, with multiple information and analytical sciences to identify, define, manage and communicate data, information, knowledge and wisdom in nursing practice” (p. 1). The advanced practice nursing informaticist can guide practice in both hospitals and private practice settings to meet meaningful use criteria and contribute to the delivery of safer patient care. Recent developments in American health care have promoted the role of the nurse informaticist. Chief among those developments is the meaningful use incentive program developed by the CMS. This CMS program provides incentive payments to eligible professionals, eligible hospitals, and critical access hospitals (CAHs) as they adopt, implement, upgrade, or demonstrate meaningful use of certified EHR technology. The certification ensures “purchasers and other users that an EHR system or module offers the necessary technological capability, functionality, and security to help them meet the meaningful use criteria. Certification also helps providers and patients be confident that the electronic health IT products and systems they use are secure, can maintain data confidentially, and can work with other systems to share information” (CMS, 2015). The DNP-prepared nurse informaticist can help practitioners and facilities achieve meaningful use incentives from the CMS. The meaningful use criteria were developed and written by physicians, for physicians. Scherger (2010) mentioned that these physicians knew that criteria placed into certain software applications could help prevent some medical errors and possibly save lives. One motivator for this development was the IOM publication To Err Is Human (IOM, 1999). This IOM report brought to light that many deaths in the United States are due to medical errors. In fact, it states that more Americans die from preventable medical errors than from motor vehicle accidents, breast cancer, and AIDS (IOM, 1999). It encouraged

development of systems to reduce errors and improve communication between healthcare providers. In addition to the medical influence on meaningful use, nurses and other members of the interdisciplinary health team have made contributions to improve safety and reduce errors. Despite the good intent of the meaningful use criteria, many hospitals are struggling to meet the criteria and with the impact of an EHR system. Many physicians and providers struggle with EHR entries because the output of the electronic record does not resemble a progress note (Baron, 2010), and it is difficult to submit for reimbursement. Another struggle that hospitals are experiencing in meeting the meaningful use criteria involves achieving provider proficiency in navigating the EHR system and making accurate, timely entries into the EHRs across all specialties. Training of providers is crucial for the success of any software implementation such as EHRs. As clinical practice changes to an electronic, digital workflow, the manual, analog workflow is quickly departing from clinical care areas. Technology is appearing in the basic functions of the nursing role. In the past, supplies were stored on wire racks or in closets that were open to all providers—and visitors. Now they are stored in electronic cabinets that track utilization and control access. These computerized cabinets associate the patient name with the supplies being accessed. An additional interface sends charges to the patient account once the provider clicks on a button that decrements the inventory. Only authorized providers are allowed to access the cabinet. Intravenous (IV) pumps are another example of emerging technology. Newer IV pumps have a database that allows maximum drug doses to be programmed in order to prevent overdosing. Many of the pumps also have an interface that allows the data collected at the bedside to be automatically entered into the EHR. In addition, the clinical documentation of assessments, flow sheets, care plans, and orders are all electronic, and the hard-copy patient paper record is becoming a part of history. The emerging informatics DNP specialty role is a result of the changing demands in health care. The complexity of patient care and the concern from the public about quality and safety of care are catalysts for the rapid enrollment in these advanced degree programs. Nationwide, enrollment into DNP programs at both the post-master’s and postbaccalaureate level has been steady and competitive (AACN, 2012), including the DNP specialty focused on informatics.

Curriculum/Preparation The curriculum for the DNP degree builds on the master’s-level program and encompasses many areas of practice. Generally, the curriculum has a core set of courses that all DNP-level students, regardless of their nursing specialty, are required to complete. The specialty classes are based on the student’s field of practice. Colleges vary greatly with what specialties they offer, and this must be researched prior to enrollment. Additional courses for a DNP degree focused on informatics can include classes on project management, system development life cycle, nursing terminologies, database and technology, knowledge management, decision support systems, and other related technology courses, depending on the institution. These courses fulfill the requirements for the AACN’s Essential IV, Information Systems/Technology and Patient Care Technology for the Improvement and Transformation of Health Care, and expand the practitioner’s knowledge beyond the basics. DNP graduates may assist in the selection of health information technology (HIT) systems. They are also proficient in evaluating the use of HIT, decision support options, and evidence-based practice. Many of the ANA standard terminologies are incorporated into the DNP curriculum, with emphasis being on the most commonly used terminologies of SNOMED CT and LOINC.

Certification One can obtain many certifications within the field of informatics that complement the education received in the DNP degree course of study. The American Health Information Management Association (AHIMA), the ANCC, and the Health Information Management System Society (HIMSS) offer these specialty certifications. Certificate programs can be found through many colleges both on-site and online. The project management professional (PMP) is another certification that may be obtained in conjunction with the doctoral study of informatics.

Project Management Project management is often part of the nursing informatics role. The informaticist may work on or manage a range of projects, from simple customizations of a computer screen or minor upgrades, to an EHR program, to full systems implementation. Most of these projects include a needs assessment and the full system development life cycle (SDLC). The SDLC includes planning, analysis, design, implementation, and evaluation (Dennis & Wixom, 2003). The DNP program in informatics allows for a deep immersion in all phases of the project life cycle to achieve an organized method of delivering the project. Work plans, work breakdown structures, project schedules, and project reporting tools can all be part of the project management role for the nursing informaticist. Process improvement activities such as flow mapping can be beneficial to the overall project success when workflows are changed. Project reporting tools can vary depending on the project. The DNP-prepared nurse informaticist will use many tracking tools to facilitate delivery of projects on time and within budget. Pert and Gantt charts are the most commonly used and found on multiple sites online and are charts in project management to display a visual representation of the milestones for the project and the date associated with each milestone. The Gantt chart represents the timeline of the project with estimated task durations and sequences. At a quick glance, it displays the project status and the overall anticipated project duration. A disadvantage of Gantt charts is their inability to show relationships between items or display items that are on the critical path (Luecke, 2004). The critical path items determine the entire project length. Failure to complete critical path items will delay overall implementation of the project. The Pert chart shows both the critical path items and the relationships between tasks. This type of chart has a great amount of information. The disadvantage of this chart is that it is not as simplified as the Gantt. The chart does not lend itself to a quick, at-a-glance assessment of the status of the project.

Hybrid Health Records Because of the rapid pace of technology enhancements and rapidly changing requirements, the literature for EHRs can become out of date within a short period. A common theme that this author found is that many facilities were in a hybrid status with health records; some portions of the record were electronic, whereas others were on paper or possibly in a different electronic system, and the data were not shared. Studies identified the value of sharing documentation as much as possible and removing hybrid systems if feasible, though results of the search and path varied. Some authors have stated that hybrid systems do not work well (Borycki, Lemieux-Charles, Nagle, & Eysenbach, 2009; Dimick, 2008; Hall, 2008), whereas others have claimed that hybrid systems do work well (Hamilton, Round, Sharp, & Peters, 2003). Although the literature has conflicting opinions—both for and against—regarding the use of hybrid records, the overall literature supports the use of EHRs for increased access to previous health histories, to enhance patient safety and improve patient outcomes, to increase access to decision support tools, and to increase the speed and accuracy of order processing. This is a role for the DNP-educated informaticist: to bring the hybrid systems into the future of an all-inclusive EHR.

Theoretical Supports for Nursing Informatics The nursing informatics specialty covers a wide breadth of clinical care areas and offers the flexibility of pulling from many different theory domains: nursing theories, nursing care models, project management theories, systems theory, behavioral theory, information science, computer science, and education theories. All these theories from within and outside nursing may be applicable to nursing informatics. One theory that can easily be used to describe change in the clinical setting is Lewin’s change theory. Although Lewin’s theory has only three steps, it offers the most flexibility. Lewin’s theory consists of unfreezing, making changes, and then refreezing. According to Burnes (2004), Kurt Lewin believed that planned change and learning would enable individuals to resolve conflict and understand their world in order to restructure their perceptions. Stage 1 is unfreezing. This allows people to recognize the need for change from the original process/procedure and move to another by creating the right environment. In informatics, this may occur when frontline staff get involved with redesigning their workflow as technology changes it. Stage 2 involves the actual change to be made. In informatics, stage 2 might include customization of a computerized documentation system or the implementation of an EHR system. Stage 3 is the freezing or refreezing process that allows the new process or procedure to become the new standard and the change to be stabilized and integrated (Boyd, Luetje, & Eckert, 1992). Sometimes there are several iterations of an EHR functionality or a screen display before the final outcome is reached. Lewin’s theory is flexible enough to describe these iterations.

Future The future of the DNP-prepared informaticist can only expand. Requirements for data reporting within the healthcare organization, benchmarking, and documentation of quality measures and patient outcomes all continue to increase. Additionally, meaningful use requirements will continue to evolve. The Office of the National Coordinator for Health Information Technology (ONC) has articulated national goals to encourage the widespread adoption of EHR, to interconnect clinicians so that data and information can be more easily shared, to personalize care through the use of personal health records and telehealth, and improve public health though accessible information (NLN, 2008). Such national goals will secure the place of the doctorally prepared nurse informaticist for the future. In 2015, MACRA (Medicare Access and CHIP Reauthorization Act) was passed and this changed how reimbursements to providers are made. MIPS (Merit-Based Incentive Payment System), which is part of MACRA, reports quality metrics electronically. MIPS and MACRA replace the meaningful use requirements that healthcare informatics and quality were focused on for the past decade. It is uncertain what the next federal milestone will be for informatics.

References American Association of Colleges of Nursing (AACN). (2012). The essentials of doctoral education for advanced nursing practice. Retrieved from www.aacnnursing.org/DNP/DNPEssentials American Nurses Association (ANA). (2015). Nursing informatics: Scope and standards of nursing informatics practice (2nd ed.). Silver Spring, MD: Author. Baron, R. (2010). Meaningful use of health information technology is managing information. Journal of the American Medical Association, 304(1), 89–90. Borycki, E., Lemieux-Charles, L., Nagle, L., & Eysenbach, G. (2009). Evaluating the impact of hybrid electronic-paper environments upon novice nurse information seeking. Methods of Information in Medicine, 28(2), 137–143. Boyd, M., Luetje, V., & Eckert, A. (1992). Creating organizational change in an in-patient long-term care facility. Psychosocial Rehabilitation Journal, 15(3), 47–54. Burnes, B. (2004). Kurt Lewin and complexity theories: Back to the future? Journal of Change Management, 4(4), 309–325. Centers for Medicare and Medicaid Services (CMS). (2015). Regulations & guidance. Retrieved from www.cms.gov/Regulations-and-Guidance/Regulations-and-Guidance.html Dennis, A., & Wixom, B. (2003). System analysis and design (2nd ed.). New York, NY: Wiley. Dimick, C. (2008). Record limbo: Hybrid systems add burden and risk to data reporting. Journal of AHIMA, 79(11), 28–32. Hall, T. (2008). Minimizing hybrid records. Tips for reducing paper documentation as new systems come online. Journal of AHIMA, 79(11), 42–45. Hamilton, W., Round, A., Sharp, D., & Peters, T. (2003, December). The quality of record keeping in primary care: A comparison of computerized paper and hybrid systems. British Journal of General Practice, 53(497), 929–933. Institute of Medicine (IOM). (1999). To err is human: Building a safer health system. Washington, DC: National Academies Press. Luecke, R. (2004). Managing projects large and small. Boston, MA: Harvard Business School Press. National League for Nursing. (2008). Preparing the next generation of nurses to practice in a technology-rich environment: An informatics agenda. Retrieved from www.nln.org/docs/default-source/professional-development-programs/preparing-the-nextgeneration-of-nurses.pdf?sfvrsn=6 Scherger, J. (2010). Meaningful use of HIT saves lives. Modern Medicine, 87(9), 8–9.

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CHAPTER 5 Influencing and Leading Change in the Complex Healthcare Environment: The Role of the Advanced Practice Nurse Anne M. Barker

CHAPTER OBJECTIVES 1. Use a contemporary model to lead and influence practice changes in healthcare organizations. 2. Apply concepts from complexity science to better understand how to realize successful, sustained organizational change. 3. Integrate the concepts of transformational leadership theory to the role of the advanced practice nurse as a leader and influencer of change. 4. Reflect on one’s leadership skills and plans for professional development.



T

his chapter provides a foundation from which advanced practice nurses can recognize and embrace their role as leaders and influencers of practice changes in healthcare organizations. There are a myriad of opportunities for the advanced practice nurse to partner with members of the interprofessional team to increase the efficiency and effectiveness of health care, improve quality and safety, and reduce costs. This chapter focuses on changes at the level at which most advanced practice nurses function (the microsystem) versus major

organizational changes. The first part of this chapter presents an eight-step change model that is informed by both a traditional understanding of organizational change and a basic understanding of complexity science. In this model, change happens by appealing to the vision and values of others rather than by coaxing and manipulation. The second part of the chapter presents transformational leadership as a theory and strategy advanced practice nurses can apply to be leaders and influencers of change in healthcare systems. A model of leadership is presented to assist the reader in actualizing the characteristics of effective leadership, whether in a formal managerial role or in a staff position.

The Evolution of Theories of Organizational Change Theories and models of organizational change have evolved over the last 70 years. One of the earliest change theories was introduced in 1947 by Kurt Lewin. He proposed a three-step model for managing change that still can be applied today: 1. Unfreezing: Challenging the status quo to gain support that a change is needed 2. Freezing: Making a change 3. Refreezing: Solidifying the change into the culture Over time, other models (Barker, Sullivan, & Emery, 2005; Kanter, 1983; Kotter, 2012) have proposed a varying number of steps to implement change. However, all basically have four distinct phases: assessing the problem/need for change, setting change objectives, implementing change, and evaluating the outcomes of the change.

Complexity Science: A New Paradigm for Understanding Organizational Change Despite these traditional models and theories of change, Kotter (2012) suggested that more than 70% of all major change initiatives in organizations fail because managers do not see the change holistically and follow it through. I suggest that the reason organizational changes fail to be sustainable is that, compounding Kotter’s findings, change leaders fail to recognize how people behave and engage in contemporary, complex environments. A new view of how the world works—complexity science—can shed light on why organizational change initiatives often fail. Before considering complexity science, it is first important to understand its predecessor, the modern worldview. Based on neoclassical thought arising from the work of such scientists as Newton and Galileo, the underlying view of how the world functions is that it is mechanistic, assuming cause and effect, linear relationships, and predictability. Over the centuries, this worldview revolutionized the understanding of how the world works and has been responsible for many scientific advancements. Applied to organizations, the modern worldview has led to the establishment of organizational hierarchies with well-defined systems of control (policies, procedures, complex planning algorithms, and so forth) with the intent to regulate processes, systems, and people in the organization to achieve predictable outcomes. However, this modern worldview is now being replaced by a postmodern worldview as scientists, leaders, and individuals discover that the world, organizations, events, and people are not controllable and predictable. Understanding is growing that we do not know many things about how the world and humans work. In concert with the postmodern worldview, an emerging school of organizational thought suggests that leaders need to abandon the old ways of thinking about organizations and embrace new ones that use complexity science as a framework.

Complexity science, a broad term that embraces theories and concepts from the natural sciences, including chaos, complexity, and quantum theories, provides a new understanding. The basic element of complexity science is the complex adaptive system. Complex denotes that the world is composed of a diverse and vast number of elements that are multidimensional, interconnected, and interactive. These elements form systems, which are sets of related parts that are connected, work together, and self-regulate. Adaptive suggests that these systems can process information and adapt to changes in order to learn from experiences so as to survive and thrive. By definition, complex adaptive systems do not significantly differ from the traditional definition of organizational systems. However, the concept of complexity reformulates thinking to view systems as messy, disorganized, and unpredictable versus mechanistic, controllable, and predictable. Complexity science views systems holistically, recognizing that the elements in the systems cannot be separated and pulled apart. Complexity science focuses on the interconnection of the elements and recognizes that elements can change and grow based on these connections. Traditional systems theory places a system in an environment in which it interacts. Complexity science emphasizes that this environment is also a complex adaptive system. This principle is called embeddedness and offers further understanding of why organizations are unpredictable and people and events are not controllable. To illustrate, the department in which the advanced practice nurse works is a complex adaptive system composed of a large number of individuals representing different professions, levels of expertise, educational backgrounds, religions, genders, ages, races, and so forth. These individuals interact with and depend on one another to complete the work of the department. Further, the department is embedded in other complex adaptive systems, such as the healthcare organization, the community, the healthcare industry, society, and so forth.

A Change Model Informed by Complexity Science The model (TABLE 5-1) presented in this chapter is an eight-step model that combines lessons from traditional theories of change with those of complexity science. As with all models, each step is an iterative process, where moving through one step multiple times may inform the previous step or a later step. For example, a change implementation should not be decided on before the stakeholders are analyzed. However, once the implementation is decided on, new stakeholders may be identified and added to the analysis. TABLE 5-1 Eight Steps of the Change Process Step 1

Making Sense/Unfreezing

Step 2

Leading or Serving on an Interprofessional Change Team

Step 3

Developing a Team Vision and Charge

Step 4

Identifying and Analyzing Forces of Change

Step 5

Developing a Work Plan for Change Implementation

Step 6

Implementing Change

Step 7

Evaluating Outcomes and Refining as Needed

Step 8

Incorporating Changes Into the Culture/Refreezing

Description In this section, I suggest a general approach to change. Change is very complex, thus the guidance provided should be modified based on many factors, beginning from step 1.

Step 1: Making Sense/Unfreezing The source of change, which can be proposed by top management, direct care providers, and those in midlevel positions: The magnitude of the change, which can be small changes affecting one to several people at the departmental level to large transformational changes affecting the entire organization How many disciplines/staff are affected by the change If multiple change projects occur at the same time The urgency for making the change

Step 2: Leading or Serving on an Interprofessional Change Team Complexity science proposes that relationships and the connections among people in organizations are the most important elements for successful functioning of the system and for making sustained, positive change. Thus, changes should be planned and implemented by a change team, not by one or two people imposing their ideas and processes on others. The best change outcomes involve the ideas and expertise of many people, and the contributions of many can lead to the most successful, sustained change. A diverse representation of all key stakeholders, including staff members, clinical disciplines, shifts, levels of personnel, and informal leaders, should be included on a change team. Further, people with expertise in budgeting and program evaluation could be very valuable in some instances. Members of the change team need to be credible and able to build trust among themselves, and they need to be seen as trustworthy by those affected by the change.

Step 3: Developing a Team Vision and Charge One of the first activities in which the team engages is to develop a team vision and charter. A vision for the change project, similar to a departmental or organizational vision, helps the team appreciate the meaning and purpose of the work of the team, aligns the team toward a common goal, and commits the team to a desirable future.

To develop a vision, a simple visioning exercise can be used. Each member of the team should close their eyes and envision the desirable end result. Each person writes the vision on paper and then reads the statement to the group. After each member contributes, the team begins to identify themes, clarify what is being discussed, and identify areas of agreement and disagreement. One person should record themes. To avoid wasting time, one or two people should be asked to draft the vision statement and bring it back to the group for final revisions and approval. A sample team vision can be found in BOX 5-1.

BOX 5-1 Sample Team Charter Purpose The purpose of the team is to review the current specialization track in nursing administration to ensure that appropriate content is presented, that there is no duplication of content or assignments among the courses, and that the content is consistent with professional standards. Vision At the completion of the project, the nursing administration specialty track will prepare students to be prominent transformational leaders in their healthcare organizations. The curriculum will be contemporary, reflecting professional standards in nursing administration and the application of best practice in teaching and learning. Potential students will seek admission to our School of Nursing based on its reputation for preparing nurse leaders. Employers will prefer to employ our students with the firm knowledge that graduates are ready to assume leadership in the healthcare organization. Team Members Linda Morality, Team Leader Anita Baxter Anna Maria Sarvonovich Joan Pettie Team Process The leader will prepare a written agenda. The team will meet on the third Monday of every month from 11:00 a.m. to 1:00 p.m. A written work plan will be developed and reviewed at each meeting to note the status of each step. Meetings will start and end on time. If someone is unable to attend a meeting, that person must notify the team leader and is responsible for implementing what decisions and assignments were made. The recorder will rotate for each meeting. Team Expectations

Meeting will begin and end on time Everyone is expected to contribute, and no one person should monopolize the discussion. Members will come to each meeting fully prepared with any assignments completed. Cell phones will be on vibrate, facedown. Should members need to text or take a call, they should leave the room. No sidebars. One person speaks at a time. Deliverables The courses will be revised and implemented by September 2018.

Next, the team develops a team charter. Charters can range from simple one-page documents, such as the one shown in Box 5-1, to more complex documents that might also include how the team communicates outside meetings, the strengths of the team, each member’s developmental needs, details on the roles of each person, and so forth. In Box 5-1, the team charter documents the team purpose, vision, team processes, team expectations, and deliverables.

Step 4: Identifying and Analyzing Forces of Change The next step is to identify the forces (people, values, technology, and structures) that facilitate change and those that resist change. This strategy, called a force field analysis, was first introduced by Kurt Lewin (1947) and still has applicability today. During this step, the team assesses these forces and considers strategies to strengthen the facilitating forces and to decrease the resisting forces. The team can conduct this analysis by using poster paper or a whiteboard. No matter the medium, someone should be assigned to capture this analysis on paper, which can be referred to as the process progresses. TABLE 5-2 is an example of a force field analysis for the team presented in the previous step. In the middle of the table, the team has provided a brief description of the proposed change. On the left side of the table, the forces that drive a change are listed, and on the right side, those forces that resist the change are listed. TABLE 5-2 Force Field Analysis

Driving Forces



Faculty content experts Current courses No costs except time Past experience

The purpose of the team is to review the current specialization track in nursing administration to ensure that appropriate content is presented, that there is no duplication of content or assignments among the courses, and that the content is consistent with professional standards.

Restraining Forces Members are located at different sites Complex implementation Time commitments of team

Description To identify the source of change, ask the following questions: What data are available that either support or refute the need for the change? Who are the individuals and groups affected by the change? Of these, who might be supportive of the change? Who might resist the change? Who has influence and who does not? (This is called a stakeholder analysis.) Is the change congruent with the mission, vision, values, and strategic plans of the parent organization and the department? Is the organizational culture one that supports risk-taking and learning, or is it rigid and resistant to change? Is there enough time to plan and implement the change? Are there enough resources (space, money, human resources) to support the change? What are the costs of the change? Are these driving or resisting forces? Is the change easy to implement or complex? Will there be a need to develop the people affected by the change? Once the forces of change are analyzed, the team next assigns each force a relative number to signify its strength. In the example, the driving forces scored x points and the restraining forces also scored x points. This then suggests to the team that the restraining forces should be considered and that steps to reduce these forces should be taken. For instance, the new faculty members without curriculum expertise can be developed. This action can be part of the objectives of the next step.

Step 5: Developing a Work Plan for Change Implementation After completing the team charter and the force field analysis, the change team is prepared to develop an implementation plan. If there are no preimplementation data to support the change, the team can consider whether it is feasible or practical to collect data prior to the implementation. For instance, in the practice setting, this may be accomplished by a retrospective review of medical records. Another approach might be to make the change in one area and not in another and then to compare differences. (The reader will be introduced to these and other methods in research courses.) The team can use Table 5-2 as a template for documenting objectives, plans, timelines, responsible parties, and evaluation. As the team develops the implementation plan, several considerations can help make the change successful and sustainable: Consider plans that are flexible, with a few simple specifications as guidelines. This allows for better strategies and ways of doing things to emerge from many individuals during the implementation phase. It also allows for small successes to happen that can build confidence, energize people for more change, and calm the doubters. Paradoxically, it also allows for failures to happen, but when they do, they are small moments of learning rather than large setbacks. New actions and ideas emerge from the failures as well as from the successes. Consider taking multiple actions for one or more objectives. Although this can be at times confusing, and perhaps resource intensive, it also allows for the best solutions to emerge through trial and error. For example, the advanced practice nurse in a primary care clinic may want to set up a system to get information from clients about their satisfaction with services. Several initiatives can be taken at the same time, such as focus groups, written surveys, and informal conversations with patients and families. Consider pilot tests of the change to assess its practicality and to iron out problems. Consider evaluations of structures, processes, and outcomes.

Determining how the change will be evaluated before its actual implementation is important. Do not overlook the need for people to learn new behaviors and ways of doing the work. Although often this means offering workshops and seminars of varying lengths to introduce the change, learning while doing is a more effective approach.

Step 6: Implementing Change Next, the team rolls out the implementation plan. The responsibility of the change team during this phase is to be visible, seek feedback, provide encouragement, communicate, and resolve problems as they occur. The key to success is to listen to those involved in and affected by the change and to take their ideas and concerns seriously. These are the individuals with whom the change will succeed or fail. Further, they are the individuals who can best express successes and failures. For example, if the change project is to decrease noise, only the patient and family can assess if the change has been successful.

Step 7: Evaluating Outcomes and Refining as Needed The purpose of this step is to ask whether the objectives of the change project, as set out in the work plan, have been met. The decisions about what is to be evaluated, who is evaluating, and how to evaluate have already been made during step 5. At the predetermined time, data are collected to determine what has been successful and what has not been successful and why. Adjustments are made based on the findings of the evaluation and new actions taken. Once these actions are taken, evaluations are done again until the expected results are achieved.

Step 8: Incorporating Changes Into the Culture/Refreezing During this phase, providing positive feedback is the most powerful tool to sustain change. This feedback happens on two fronts: showing appreciation for the people who implemented the change and sharing

widely the successes attained. The evaluation data from the previous step are also shared.

The Call for Action: Transformational Leadership Advanced practice nurses are being called on and challenged to lead changes in healthcare organizations to improve quality, decrease adverse events, reduce costs, and enhance patient satisfaction. Transformational leadership is widely accepted in the healthcare industry, and nursing is the preferred leadership style to accomplish this goal. In 2004, the Institute of Medicine (IOM) devoted an entire chapter in the landmark report Keeping Patients Safe: Transforming the Work Environment of Nurses to the theory and evidence of transformational leadership. The report cited studies that suggest that transformational leadership is associated with better patient outcomes, fewer medical errors, and greater staff satisfaction. In a subsequent report (IOM, 2010), the IOM recommends that no matter their formal positions in organizations, “all nurses must be leaders in the design, implementation, and evaluation of, as well as advocacy for, the ongoing reforms to the system that will be needed” (p. 221). In addition, the Magnet Recognition Program model has five components, one of which is transformational leadership. The rationale for recommending transformational leadership is that the goal of leadership is not to keep organizations stable but rather to transform values, beliefs, and behaviors to meet the demands of healthcare reform (American Nurses Credentialing Center, 2014).

The Evolution of Leadership Theories Ancient scholars and philosophers, such as Plato and Confucius, observed and wrote about leadership, but it was not until the 1930s and the onset of World War II that one can find formal theories and empirical studies of organizational leadership. During the first half of the 20th century, several important themes emerged that still have relevance in today’s organizations. First, most theories purported that a democratic, participatory style with positive, supportive relationships between the manager and followers is generally more effective than are autocratic styles of leadership (Fielder, 1957; Likert, 1957; White & Lippit, 1950). Second, the leader must pay attention to organizational goals (Blake & Mouton, 1985; House, 1971). And last, as the theories maintained and research studies further supported, the behaviors and attitudes of the leader affect follower satisfaction and group performance (Fielder, 1957; White & Lippit, 1950). During the 1980s, the view of leadership theory underwent a major paradigm shift from a focus on tasks and systems of controls to one of building the organizational culture to provide an environment in which people are successful and organizational outcomes are positive. In 1978, James McGregor Burns proposed a new leadership theory that he called transformational leadership. In his foundational work, Leadership, Burns described the leadership style and strategies of famous political leaders, such as Mahatma Gandhi, Franklin Roosevelt, and John Kennedy. This work resonated with organizational scholars and practitioners, forming the basis for most of the contemporary writing about leadership. Burns (1978) defines transformational leadership as occurring “when two or more persons engage with others in such a way that the leader and followers raise one another to higher levels of motivation and morality” (p. 20). In other words, both the leader and the follower find meaning and purpose in their work, growing and developing as a result of the relationship.

A Contemporary Leadership Model for Advanced Practice Nurses Although transformational leadership has been an enduring and often preferred leadership style since the 1980s, it is still evolving. FIGURE 5-1 displays a model I developed as a result of working with advanced practice nursing students who lead, influence, and participate in practice changes in healthcare organizations. The foundation of the model is transformational leadership and trust. The four pillars of leadership are supported by this foundation, ultimately resulting in a desirable healthcare system as defined by the IOM (2004).

FIGURE 5-1 Leadership model.

Description

The Foundation People can be influenced by leaders in whom they believe and trust. A desirable vision of where the team is headed provides meaning and purpose to the work and aligns the team toward common goals. To best accomplish this, the advanced practice nurse can adopt strategies of transformational leadership and trust.

Transformational Leadership

To summarize, the important concepts of transformational leadership theory are as follows: The relationships between leaders and their colleagues are characterized by engagement versus passivity. Transformational leaders bring out the best in the team and performance beyond expectations. Transformational leadership is based on empowering the team to work together toward a common vision versus power over others and imposing one’s ideas and will. Transformational leadership is ethical and focuses on the goals of the organization and development of the whole team versus selfaggrandizement and personal gain at the expense of others (Barker et al., 2005).

Trust Trust was identified, based on Burns’s work, as a basic ingredient for successful transformational leadership (Bennis & Nanus, 1985). Recently, there has been a renewed interest in and appreciation for the importance of trust as the foundation for leadership and team effectiveness. The importance of organizational trust cannot be overstated. In the literature on this topic, the following positive organizational outcomes have been associated with high levels of organizational trust: Enhanced employee performance Improved organizational effectiveness Greater commitment to the organization Good communications and information sharing Less resistance to organizational change Improved team functioning Improved job satisfaction/retention Greater participation in decision making and problem solving (Barker et al., 2005) An important characteristic about trust is that trust begets trust, and mistrust begets mistrust. In other words, trusting behaviors can lead to

increased trust, and, in contrast, distrusting behaviors can decrease mutual trust (Zand, 1972). For example, open, honest communication is one of several trusting behaviors. If the advanced practice nurse communicates with another person openly and honestly, the other person will come to trust her; in turn, the other person will likewise communicate openly and honestly, leading to a cycle of trust. Covey (2019), who is currently the top expert in organizational trust, defines trust as “confidence born of two dimensions: character and competence.” Character is one’s integrity and intent. These are actualized in such behaviors as follows (Covey, 2005): Walking the talk—the congruency between what one says and does Looking out for the good of others as well as of oneself Doing the right thing, even if it is unpopular or difficult Keeping commitments to others Being consistent and dependable in what one does Engaging in honest, transparent communications Listening actively Being candid Displaying basic honesty and moral character Acting ethically and with good intentions and motives Fulfilling one’s fiduciary obligations by placing the concern of others above one’s own Competence is one’s talents, skills, knowledge to work with others, and proven ability to deliver results. Simply stated, leaders have no credibility if they do not produce deliverables that contribute to organizational success. Competence is demonstrated by the following behaviors (Covey, 2005): Influencing others by setting mutual goals and directions together versus control Empowering others by giving people the opportunity to take action, providing them with the resources to be successful, supporting their efforts, and providing the necessary information to get the work done Demonstrating good decision-making skills so that others develop a trust in the decisions that are made and the changes that occur

Pillars of Leadership The model includes four pillars of leadership that are supported by the foundation of transformational leadership and trust: I. Professionalism II. Inspirational motivation III. Interpersonal relationships IV. Business competency Each of these pillars is briefly discussed, and each topic deserves further understanding by the novice advanced practice nurse.

Pillar I: Professionalism At the core of being professional is being self-aware by reflecting on one’s experiences, skills, knowledge, values and attitudes, and feedback from others. To be self-aware, advanced practice nurses reflect on personal thoughts and actions to gain an understanding of their leadership skills, values, and knowledge and to identify their strengths and areas in need of further development as a leader. There are several models of self-reflection, but for the purpose of this chapter, two models specific to nursing and health care have been combined to assist advanced practice nurses to engage in self-reflection —Gibbs’s (1988) classic model and Johns’s (1994) model. Despite their age, these models are still widely used in nursing and provide a concrete framework for self-reflection. BOX 5-2 provides a framework and questions to consider for self-reflection on leadership skills.

BOX 5-2 Reflection on Leadership Skills Think about a recent situation in which you assumed a leadership role, whether it was formal or informal. Describe the situation, including the who, what, where, when, and how. Describe your role as leader. Be objective and factual. Write down how you felt about the situation. Include both your positive and your negative feelings. How do you think others felt in the situation? Using the model in Figure 5-1, evaluate how effective you were as the leader. Consider each

of the following elements: Did you engage the other individuals in the situation to move toward a desired goal? What was the level of trust among the involved individuals? How well did you manage conflict, communication, and collaboration? What professional skills did you exhibit? Which might have been better employed? What business skills were needed? Did you use them effectively? Overall, what can you conclude, and what did you learn? What were the results? What would you do differently the next time? What would you do the same? Write down one or two self-development goals for actions to take the next time you confront a similar situation.

Pillar II: Inspirational Motivation Transformational leaders motivate and inspire followers, generating excitement and sustaining a positive belief about the work to be accomplished, by doing the following: Articulating a credible vision for others Providing a work environment in which people find meaning and purpose in their work Setting realistic and achievable yet high expectations for themselves and others. This is known as the Pygmalion effect. Simply put, expectations drive behaviors, and on a subconscious level, people will live up to the standards set. For instance, when a team believes they are the “best team,” have the best patient outcomes, and relate to one another better than similar teams do, the team members will act to maintain and confirm this expectation. Demonstrating to others that their contributions to the work of the organization have meaning and purpose that result in positive outcomes for clients, their families, and the community Being optimistic and passionate Encouraging questioning and the challenging of assumptions, as well as outside-the-box thinking, and by fostering creativity, innovation, and risk-taking Engaging with and treating each person as unique

Pillar III: Interpersonal Relationships Transformational leaders build positive interpersonal relationships by

engaging with individuals and groups in a way that is characterized by open and honest communication. Communication has two elements: knowing what, when, how, and to whom to communicate and, equally important, knowing how to listen. Communications need to be open, accurate, and candid. At the same time, the advanced practice nurse needs to know when to keep information confidential and when to be discreet, avoiding gossip and harmful rumor spreading. In both the practice and the educational settings, evidence is growing that high-quality, patient-centered care requires the collaboration of the clinical disciplines. Collaboration is defined by these underlying concepts: sharing, partnership, power, and interdependency (D’Amour, FerradVidela, Rodriquez, & Beaulieu, 2005, pp. 119–120): Sharing includes shared responsibilities, decision making, values, data, planning, and intervention. Partnerships are two or more people of different disciplines working together for mutual patient outcomes. The relationship is characterized by trust and respect. These types of partnerships emerge through understanding and appreciating the roles of each discipline and their unique contributions to patient-centered care. Understanding begins in the educational setting in the preparation of health professionals. Power is shared among the group rather than one person being viewed as the most powerful team member. In other words, all team members are empowered to work toward the outcomes. Interdependency means that the team works together versus autonomously.

Pillar IV: Business Competency At the end of the day, the measure of competent leadership is whether healthcare practices were improved by working with others and by employing their skills and competence. Throughout their education and practice, advanced practice nurses are exposed to and can achieve a further depth of understanding of many of the following business competencies: Understanding the healthcare delivery system Policy

Healthcare economics Healthcare delivery system Current and future trends Understanding the organization Mission and vision Strategic plan Finance Quality Information systems Care delivery system Relationships with the community Marketing

Results The third part of the model, the roof, is the results. As stated previously, leaders have no credibility if they do not produce results that contribute to the organization’s success. In this model, the results are organized by the IOM’s (2001) recommendations for high-quality health care: Safe: Avoiding injuries to patients from the care that is intended to help them Effective: Providing services based on scientific knowledge to all who can benefit, and refraining from providing services to those not likely to benefit Patient centered: Providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions Timely: Reducing waits and sometimes harmful delays for both those who receive and those who give care Efficient: Avoiding waste, including waste 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

Discussion Questions 1. Describe a change you have either participated in or observed in your organization. Using the eight-step model of change, analyze which suggested strategies were employed and which were not. Was the change sustained successfully? If yes, why? If no, why not? What could have been done differently? 2. Complete the visioning exercise described in the text for yourself. Share this with other students in your class. 3. Using Box 5-2, reflect on your leadership skills. Develop an action plan for leadership development.

References American Nurses Credentialing Center. (2014). Magnet Recognition Program model. Retrieved from http://www.nursecredentialing.org/Magnet/ProgramOverview/New-Magnet-Model Barker, A. M., Sullivan, D. T., & Emery, M. J. (2005). Leadership competencies: The renaissance of transformational leadership. Sudbury, MA: Jones and Bartlett. Bennis, W. G., & Nanus, B. (1985). Leaders: The strategies for taking charge. New York, NY: Harper & Row. Blake, R. R., & Mouton, J. S. (1985). The managerial grid III. Houston, TX: Gulf. Burns, J. M. (1978). Leadership. New York, NY: Harper & Row. Covey, S. (2005). The speed of trust: The one thing that changes everything. New York, NY: Simon and Schuster. Covey, S. (2019). How the best leaders build trust. Retrieved from https://www.leadershipnow.com/CoveyOnTrust.html D’Amour, D., Ferrad-Videla, M., Rodriquez, L., & Beaulieu, M. D. (2005). The conceptual basis for interprofessional collaboration: Core concepts and theoretical frameworks. Journal of Interprofessional Care, 19(1), 115–131. Fielder, F. E. (1957). A theory of leadership effectiveness. New York, NY: McGraw-Hill. Gibbs, G. (1988). Learning by doing: A guide to teaching and learning methods. Oxford, England: Further Education Unit. House, R. J. (1971). A path goal theory of leadership effectiveness. Administrative Science Quarterly, 15, 321–338. Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academies Press. Retrieved from http://nationalacademies.org/hmd/reports/2001/crossing-the-quality-chasm-a-new-healthsystem-for-the-21st-century.aspx Institute of Medicine. (2004). Keeping patients safe: Transforming the work environment of nurses. Washington, DC: National Academies Press. Retrieved from https://www.nap.edu/catalog/10851/keeping-patients-safe-transforming-the-work-environmentof-nurses Institute of Medicine. (2010). The future of nursing: Leading change, advancing health. Washington, DC: National Academies Press. Retrieved from http://www.nationalacademies.org/hmd/Reports/2010/The-Future-of-Nursing-Leading-ChangeAdvancing-Health.aspx Johns, C. (1994). Nuances of reflection. Journal of Clinical Nursing, 3, 71–75. Kanter, R. M. (1983). The change masters. New York, NY: Simon & Schuster. Kotter, J. (2012). Leading change. Cambridge, MA: Harvard Business Review Press. Lewin, K. (1947). Frontiers in group dynamics: Concepts, method, and reality in social science, social equilibrium, and social change. Human Relations, 1(1), 5–41. Likert, R. (1957). The human organization: Its management and values. New York, NY: McGrawHill. White, R. K., & Lippit, R. (1950). Autocracy and democracy: An experimental inquiry. New York, NY: Harper & Brothers. Zand, D. E. (1972). Trust and managerial problem solving. Administrative Science Quarterly, 17(2), 229–239.

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CHAPTER 6 Interprofessional Collaboration for Improving Patient and Population Health Laurel Ash and Catherine Miller

CHAPTER OBJECTIVES After completing this chapter, the reader will be able to 1. Identify workforce and regulatory issues that affect interprofessional collaboration in the clinical setting. 2. Discuss barriers to and drivers of effective collaboration among interprofessional healthcare teams. 3. Discuss stages of effective team development. 4. Analyze components of a work culture that supports collaboration. 5. Review leadership theories and consider the roles that leaders play in improving population health.

Background The Consensus Model for APRN Regulation, prepared by the APRN Consensus Work Group and the National Council of State Boards of Nursing APRN Advisory Committee (National Council of State Boards of Nursing, 2008) and endorsed by numerous nursing organizations, defined advanced practice registered nursing as nurses practicing in one of four recognized roles: certified nurse practitioners, certified nurse– midwives, clinical nurse specialists, and certified registered nurse anesthetists. The primary focus of the practice of an advanced practice registered nurse (APRN) includes provision of direct patient or population care. Conventionally, APRNs are prepared in accredited programs, sit for national certification, and meet regulatory requirements authorizing license to practice as an APRN. Since 2004, the American Association of Colleges of Nursing (AACN) has promoted the doctor of nursing practice (DNP) as the entry into advanced practice nursing. This endorsement has not come without confusion or controversy. Many incorrectly assume the acronym DNP refers to “doctor of nurse practitioner.” The doctor of nursing practice is not a role; it is an academic degree. It is the terminal professional degree in nursing and is not exclusive to one of the four APRN roles. A number of nurses with advanced graduate preparation function in specialties that do not fall into these categories yet advance the health of an organization, population, or aggregate. Such specialties as administration, informatics, education, or public health may not require regulation with specific certification or licensure as would a certified nurse–midwife or nurse practitioner, yet are well suited to enhance the profession by completing a practice-focused doctoral program in nursing. This chapter will use the term APRN to reflect all advanced fields of doctoral nursing practice. Much research has well documented the impact that APRNs have on health outcomes, including the ability to deliver excellent quality, costeffective care with high levels of patient satisfaction (Cunningham, 2004; Dailey, 2005; Horrocks, Anderson, & Salisbury, 2002; Ingersoll, McIntosh, & Williams, 2000; Lambing, Adams, Fox, & Devine, 2004; Laurant et al.,

2004; Miller, Snyder, & Lindeke, 2005; Mundinger et al., 2000; Oliver, Pennington, Revelle, & Rantz, 2014). The world is changing, and APRNs must position themselves to be at the table with other disciplines and professionals in order to emphasize the influence of nursing care on the health of an individual or population. The complexity of the current healthcare delivery system, trends in patient demographics, epidemiologic changes of disease and chronic conditions, economic challenges, the need for improved patient safety, and the call for a redesign or reform of the healthcare delivery system will challenge all professionals to envision health care in new ways. Healthcare reform continues to be a prominent issue for health professionals, policy makers, and the public. During the 2008 presidential campaign, President Obama announced a comprehensive healthcare reform proposal (Kaiser Family Foundation [KFF], 2008). This proposal outlined key points regarding restructuring the healthcare system. As a foundation, all individuals and communities must be guaranteed a set of essential preventive care services. Reform must include measures to improve health outcomes and safeguard patients from preventable medical error. President Obama’s platform supported programs of collaborative teams as a means to deliver comprehensive, cost-effective, and safe care to persons with chronic conditions (KFF, 2008). The Patient Protection and Affordable Care Act (PPACA) (Public Law 111-148) was signed into law March 23, 2010, by President Barack Obama. This comprehensive set of enactments aims to control healthcare expenditures, enhance access to care, and improve patient care delivery and quality of health care (KFF, 2013; PPACA, 2010). The 2016 presidential election spurred heated rhetoric regarding the recently enacted PPACA. Then–Republican candidate and current president Donald J. Trump criticized the healthcare expansion and supported its repeal and replacement. While the future of the 2010 law remains uncertain, the majority of Americans continue to view the PPACA as favorable and prefer refining to dismantling (KFF, 2017; PoliticoHarvard, 2017). Access to safe, effective, and affordable health care is a concern shared by many and rated of significant importance by the American public (KFF, 2017; KFF/Harvard School of Public Health Survey, 2009). Nursing is highlighted throughout the PPACA as playing a key role in addressing multiple reforms. Shortages of primary care

physicians, particularly in certain geographic and underserved areas, contribute to access problems. Because the act intends to extend health coverage to many more millions of Americans, further burdens are placed on an already stressed system. This legislation recognizes advanced practice nurses, particularly nurse practitioners, as part of the solution to raise the number of primary care providers and to expand funding for nurse practitioner training and education. Additionally, a number of provisions specifically identify nurses as interprofessional team leaders and members. The Medical/HealthCare Home provision (KFF, 2013; PPACA Section 3502, 2010) explicitly identified interdisciplinary teams— to include nurses, nurse practitioners, physicians, pharmacists, social workers, and other allied health professionals—to provide coordinated, integrated, and evidence-based care to patients and families, particularly those with complex healthcare needs. The Public Health Services Act of PPACA was amended to support nurse-managed health centers (KFF, 2013; PPACA Section 5208, 2010). The grant appropriates funds and authorizes advanced practice nurses to coordinate and deliver comprehensive primary and wellness care to underserved, vulnerable populations. Nurses must be the major providers of services in a team led by an advanced practice nurse. Demonstration projects, such as Independence at Home (KFF, 2013; PPACA Section 3024, 2010), clearly designate nurse practitioners as leaders of and/or participants in healthcare teams aimed at improving health outcomes of and reducing costs to homebound Medicare beneficiaries. Additionally, clinical nurse specialists have been noted as leaders in measures that were proved to prevent hospital-acquired conditions in acute care settings. DNPs, at the highest level of clinical nursing practice, must fully participate as team leaders and members in innovative models of care delivery and document improved healthcare outcomes as a result of such collaboration and leadership. The professions of nursing and medicine each recognize the need to create organizational environments that promote interprofessional collaboration, however, in many practice arenas effective collaboration is far from reality. The American Nurses Association (ANA) report Nursing’s Agenda for Health Care Reform (2008) placed particular emphasis on the role of collaboration in chronic disease management and patient safety. The American College of Physicians (ACP, 2009) also acknowledged that

the future of healthcare delivery requires interprofessional teams that are prepared to meet the diverse, multifaceted health issues of the population. Despite the emphasis each discipline places on the value of collaborative work, the healthcare delivery system remains hierarchical and siloed, impeding true interprofessional collaboration. Providers, policy leaders, and health systems need to shift mind-sets from traditional models of linear, disease-focused care to new delivery approaches. In a redesigned model, the process is dynamic with functions and leadership fluid dependent upon the patient need or desired outcome. No one profession owns the process. Each discipline brings specialized skills and abilities, practices at the highest level of the individual provider’s scope, assumes new roles, and participates in a shared partnership with other professionals to provide high-quality, safe, cost-effective, patient-focused care. This call to action demands that APRNs perform at the highest level of clinical expertise, the DNP, and collaborate interprofessionally to improve patient and population health outcomes. In 2008, the Institute of Medicine (IOM), in partnership with the Robert Wood Johnson Foundation (RWJF), convened an 18-member panel of physicians, nurses, educators, policy makers, economists, and public health experts to examine, debate, and problem solve critical healthcare issues—in particular, the role that nurses play in transforming the healthcare system. In October 2010, the panel released its findings in an evidence-based report, The Future of Nursing: Leading Change, Advancing Health (IOM, 2011). This 500-plus-page document highlights nursing’s reputation for safe, high-quality care and provides specific recommendations to further advance skills and expertise of nurses to lead change. The report proposed that nurses attain higher educational levels to address increasingly complex health issues; that outdated organizational and regulatory barriers be removed to allow nurses to practice to the full extent of their education and training; and that nurses be provided opportunities to assume leadership positions and be full collaborative partners with physicians and other healthcare professionals in redesigning health care in the United States (IOM, 2011). To improve quality, maximize resources, and coordinate care, patients with complex health needs are best served by an interdisciplinary approach to care. To foster positive collaborative behaviors between professionals, reduce biases of other disciplines, and ultimately improve

patient outcomes, nursing education needs to expand to include competencies in interprofessional teamwork and collaboration in clinical environments (IOM, 2011). All nurses will benefit from enhanced leadership, political suaveness, advocacy, and health policy development skills, all of which are components of DNP programs. Although the IOM is a highly regarded institution, not all health professions embrace the report. Deeply entrenched hierarchical relationships and mistrust between nursing and medicine continue to persist. The American Medical Association issued a response to the Future of Nursing report that challenged nursing’s role, iterated that a “physician-led team approach to care helps ensure high quality patient care and value for health care spending,” and emphasized the differences in physician and nurse practitioner education, suggesting that nurses are less prepared to deliver primary care (Patchin, 2010). Full partnership is a work in progress; DNPs must embrace these challenges and practice to the highest level to design, collaborate, lead, and document results of innovative models of care and resultant improved healthcare outcomes. Little agreement exists between healthcare professionals as to the terminology used to describe interprofessional collaboration. MerriamWebster’s Collegiate Dictionary (2015) defined collaborate as “to work jointly with others or together especially in an intellectual endeavor.” Leaders in the business world further describe collaboration as a concept involving “strategic alliances” or “interpersonal networks” in an effort to accomplish a project (Ring, 2005). As healthcare professionals, we can learn from successful business and management practices and use the collaborative processes of communicating, cooperating, transferring knowledge, coordinating, problem solving, and negotiating to more effectively reach a healthcare goal or outcome. In her text, Collaboration: A Healthcare Imperative, Dr. Sullivan (1997) describes collaboration as a “dynamic, transforming process of creating a power sharing partnership” (p. 6). The ACP (2009) suggests that collaboration involves mutual acknowledgment, understanding, and respect for the complementary roles, skills, and abilities of the interprofessional team. The Robert Wood Johnson Foundation (RWJF, 2015) in its project Identifying and Spreading Practices to Enable Effective Interprofessional Collaboration described effective interprofessional collaboration as the active participation of each discipline, where all disciplines work together,

disciplinary contributions are respected, the patient and caregivers are engaged in the process, and leadership on the team adapts based upon the patient needs. Effective collaborative partnerships promote quality and cost-effective care through an intentional process that allows members to exchange pertinent knowledge and ideas and subsequently engage in a practice of shared decision making. The purpose of this chapter is to generate a better understanding of interprofessional collaboration, distinguish the elements that DNPs must possess to successfully collaborate with other professionals to improve the health status of persons or groups, and provide an overview of models of interprofessional collaboration in the real world.

Improving Health Outcomes The IOM’s 2001 report, Crossing the Quality Chasm: A New Health System for the 21st Century, identified four key issues contributing to poor quality of care and undesirable health outcomes: the complexity of the knowledge, skills, interventions, and treatments required to deliver care; the increase in chronic conditions; inefficient, disorganized delivery systems; and challenges to greater implementation of information technology. The report went on to outline 10 recommendations intended to improve health outcomes, one of which focuses on interprofessional collaboration. It emphasizes the need for providers and institutions to actively collaborate, exchange information, and make provisions for care coordination because the needs of any persons or population are beyond the expertise of any single health profession (IOM, 2001; Yeager, 2005). An earlier IOM report (1999), To Err Is Human: Building a Safer Health System, addressed issues related to patient safety and errors in health care. This report articulated interprofessional communication and collaboration as primary measures to improve quality and reduce errors. A newer IOM report focused on Measuring the Impact of Interprofessional Education (IPE) on Collaborative Practice and Patient Outcomes (2015).

Care Improvement Efforts In addition to implementation of the Patient Protection and Affordable Care Act, another influencing change in health care is the attention to the Triple Aim. Triple Aim, first conceptualized by Berwick, Nolan, and Whittington over 25 years ago, is a movement to improve health care quality and safety (Berwick, Nolan, & Whittington, 2008). In this quality improvement model, health systems are challenged to simultaneously focus on three goals: improving the health of a population, improving the experience of care, and reducing the per capita cost of providing that care. To accomplish the triple aim it is essential to (1) involve individuals and families through effective communication and shared decision making; (2) redesign primary care services and structures—care cannot be physician-centric but must be collaborative and utilize teams of practitioners that coordinate and share information among providers and patients alike; and (3) it must measure the actual costs of providing such care and the effectiveness of it. Effective collaborative care has been associated with better treatment outcomes, such as reduced patient complications, decreased lengths of stay, improved control of chronic disease outcomes, improved patient and provider satisfaction, and decreased costs of care (RWJF, 2015; World Health Organization [WHO], 2010). Accrediting and regulatory bodies, such as the Joint Commission (2015) recognize interprofessional collaboration as an essential component of the prevention of medical error. This organization’s mission is to continuously improve the safety and quality of care through the measure and evaluation of outcomes data. It has targeted improved communication and collaboration among providers, staff, and patients as a means to better protect patients from harm. Improved patient safety outcomes can be additionally facilitated through collaborative efforts such as development of interdisciplinary clinical guidelines and interprofessional curricula that incorporate proven strategies of team management and collaboration processes. Doctorally prepared APRNs are well positioned to participate in and lead interprofessional collaborative teams in efforts to improve health outcomes of the individual patient or target population (American Association of Colleges of Nursing

[AACN], 2006b).

Interprofessional Collaboration The terms interdisciplinary and interprofessional are often interchanged in the literature about collaborative teams, but each has a slightly different connotation. Interprofessional collaboration describes the interactions among individual professionals who may represent a particular discipline or branch of knowledge but who additionally bring their unique educational backgrounds, experiences, values, roles, and identities to the process. Each professional may possess some shared or overlapping knowledge, skills, abilities, and roles with other professionals with whom he or she collaborates. Hence, the term interprofessional offers a broader definition than interdisciplinary, which is more specific to the knowledge ascribed to a particular discipline. DNPs are suited to serve as effective collaborative team leaders and participants not only because of the scientific knowledge, skills, and abilities related to their distinctive advanced nursing practice disciplines but also because of their comprehension of organizational and systems improvements, outcome evaluation processes, healthcare policy, and leadership. This new skill set will be critical for DNPs leading teams in the complex and everchanging health arena. The AACN’s Essentials of Doctoral Education for Advanced Nursing Practice (2006b) added that collaborative teams must remain “fluid depending upon the needs of the patient (population) . . . and [DNPs] must be prepared to play a central role in establishing interprofessional teams, participating in the work of the team and assuming leadership of the team when appropriate” (p. 14). The concept of interprofessional collaborations to improve health outcomes is not new; it has been and continues to be the cornerstone of public health practice. Effective public health system collaborations are critical to protect populations from disease and injury and to promote health. Public health collaborations have involved not only vested professionals but also systems of communities, governmental agencies, nonprofit organizations, and private-sector groups to address a common goal or complex health outcome (WHO, 2016; Wilson & Bekemeir, 2004). DNPs can benefit from the experiences of public health colleagues and expand the definition of interprofessional panel collaboration. This is

particularly relevant when considering potential stakeholders and in assembling the team. Successful implementation of a system or organizational improvement may require collaborations outside the typical healthcare team. The purpose or outcome of the project may dictate the need to include patient or family representation in accordance with their ability and willingness to participate, as well as professionals from information and technology, health policy, administration, governing boards, and library science.

Interprofessional Healthcare Teams Many healthcare practitioners indicate that they practice within an interprofessional team. Often this involves each professional addressing a particular portion of patient or population care, working independently and in parallel or in sequence with one another, with the physician frequently assuming the role of team leader (RWJF, 2008). Drinka and Clark (2000) reinforced the need to function interdependently and engage in collaborative problem solving. All too often, competition exists between roles, with each discipline holding to the belief that it is the most qualified to manage the patient or problem, thus negatively influencing the functioning of the team. In effective interprofessional teams, members recognize and value dissimilar professional perspectives and overlapping roles, put the patient first, communicate effectively, and share decision making and leadership to best meet the needs of the patient or problem at hand (Drinka & Clark, 2000; Interprofessional Education Collaborative [IPEC], 2016; RWJF, 2015; WHO, 2016). To achieve optimal health outcomes, it is essential for DNPs and other health professionals to engage in true collaborative interprofessional practices. These types of collaborative practices will be most successful when (1) the complexity of the problem is high, (2) the team shares a common goal or vision for the outcome, (3) members have distinctive roles, (4) members recognize the value of each other’s positions, (5) each member offers unique contributions toward the improved patient or population outcome, and (6) systems provide mechanisms for continuous communication (ACP, 2009; Drinka & Clark, 2000; IPEC, 2016; RWJF, 2008, 2015; WHO, 2016). This model for interprofessional healthcare teams will require DNPs to have a thorough understanding of effective collaboration—in addition to a firm

grounding in effective communication, team processes, and leadership— to bring forth innovative strategies to improve health and health care.

Benefits of Collaboration The literature of the past 2 decades well documents the numerous benefits of collaborative practices, including reduced error, decreased length of stays, improved health, better pain management, improved quality of life, and higher satisfaction (Brita-Rossi et al., 1996; Chung & Nguyen, 2005; Cowan et al., 2006; D’Amour & Oandasan, 2005; Drinka & Clark, 2000; Grady & Wojner, 1996; Green & Johnson, 2015; IOM, 1999; Joint Commission, 2008; RWJF, 2015; WHO, 2016; Yeager, 2005). Nelson et al. (2002) and Sierchio (2003) noted the additional benefits to healthcare systems of cost savings and healthy work environments. High-performing collaborative teams promote job satisfaction (D’Amour & Oandasan, 2005; Hall, Weaver, Gravelle, & Thibault, 2007; Sierchio, 2003), support a positive workplace atmosphere, and provide a sense of accomplishment while valuing the unique work and contributions of team members. Additionally, Weller, Boyd, and Cumin (2014) noted that “interventions to improve teamwork in healthcare may be the next major advance in patient outcomes” (p. 149).

An Interprofessional Model Among Nurse Practitioners, Physician Assistants, and MDs Models have been recommended for integration of nurse practitioners/physician assistants (NPs/PAs) and doctors of medicine (MDs) in primary care to care for populations of patients with varying degrees of success (Dinh, 2012). One model utilized by Essentia Health assigns all patients to a duo of MD plus NP or PA provider—any of the three could be considered as their primary care provider. Three major components were vital to the process: working to capacity, optimal panel size, and physician/NP-PA Practice Model. In this model, the most complicated patients are to be seen by a physician while chronic disease and wellness care was shared by MDs and NP/PAs. Acute care was handled as follows: MD or assigned primary care provider sees patients who are high risk or following up after hospitalization.

Key team activities were weekly 30-minute face-to-face team meetings for the new teams and monthly for established teams. A daily huddle includes 5 to 10 minutes to discuss patients for the day. Establishing close proximity of office space was recommended for continuous communication, with sharing an office being the best option. Overall, the model has had varying degrees of implementation throughout the diverse primary care clinics within the region. Where utilized, it increased access in locations and led to satisfaction by providers. Where the model was not used, there was decreased satisfaction by the NP and PA providers who were scheduled with highly complex patients. One of the purported barriers has been a production model of compensation for physicians. Another is a lack of a sense of community in some settings where providers prefer to work independently. The model is currently being evaluated for future utilization (Bianco, Erickson, & Maughan, 2015). These issues are particularly relevant to nursing practice. Addressing concerns of nursing shortages, improving working environments, and promoting measures to increase job satisfaction all have been found to correlate with lower rates of nurse burnout (Vahey, Aiken, Sloane, Clarke, & Vargas, 2004) and in turn indirectly influence nurse retention and recruitment. The concept of value added has been discussed as an indirect benefit of effective collaboration (Dunevitz, 1997; Kleinpell et al., 2002). The term value added indicates the growth or improvement experienced in a group, project, or organization over a period, which yields an indirect value gained by a patient or population. Such valueadded contributions may be the improvement to patient care delivery over time due to the rich professional interactions and exchanges that occur within an interprofessional team meeting. This enhanced communication would be more beneficial than the communication required from professionals working independently of one another. Valueadded benefits may additionally be evident from the process itself, such as the creative problem solving that occurs during a brainstorming session designed to address a community health problem.

Barriers to and Drivers of Effective Collaboration in Interprofessional Healthcare Teams Barriers In spite of the mandates or recommendations by the IOM, the RWJF, the ANA, and the Joint Commission, effective interprofessional collaboration has yet to be adopted in any widespread form in the United States to improve patient or population outcomes (Goldsbery, 2018). Literature from both Canada and Britain also makes recommendations for interprofessional collaboration to improve care (D’Amour & Oandasan, 2005), along with current thinking as to why healthcare systems have not adopted interprofessional healthcare teams. Some of the barriers to interprofessional collaboration include (1) gender, power, socialization, education, status, and cultural differences between professions (Hall, 2005; Whitehead, 2007); (2) lack of a payment system and structures that reward interprofessional collaboration; (3) the misunderstanding of the scope and contribution of each profession; (4) turf protection (Patterson, Grenny, McMillan, & Switzler, 2002); and (5) the existence of individual discipline-based teams (Weller et al., 2014). The DNP will need a comprehensive understanding of these barriers to provide fresh, creative thinking and leadership for the healthy development and sustainment of collaboration. Nursing and medicine were and are often considered central players in healthcare teams; an examination of the issues related to these two professions is prudent. Nurse and physician role differences are easier to understand in light of the historical roles of gender (Price, Doucet, & McGillis Hall, 2014). In the 19th century, nurses cared for patients in hospitals while physicians cared for patients in their offices or patients’ homes. According to Lynnaugh and Reverby’s Ordered to Care: The Dilemma of American Nursing 1850–1945 (1990), whereas physicians were “welcome visitors,” hospitals were run by lay boards and often staffed by “live in” nurses (p.

26). That changed when medicine became more science oriented and doctors realized that hospitals were full of sick patients to whom they could apply their newly developed knowledge of science. Medicine soon controlled hospitals and defended this control with the argument that they owned “special knowledge” to diagnose and treat. Physicians were able to convince the public that nurses were not trustworthy enough to manage medications or capable of obtaining the special knowledge that physicians had (often because of the menstrual cycle). Nurses soon became handmaidens to physicians; they needed to be “self-less, knowledgeless and virtuous” (Gordon, 2005, p. 63). Nursing education in the 20th century was designed to provide cheap labor for hospitals while educating its new workforce. Nurses came to view themselves as working for doctors, not patients. Nurses were valued for their virtue, not for their knowledge (Buresh & Gordon, 2006). Most nurse leaders either accepted this subjugated role or were unable to change it. As nursing lost power, medicine increased its social status by high-tech innovations in acute care (along with reimbursement for them). Healthcare delivery became fragmented based on physician specialty care for patients with acute care needs. Indeed, medicine dominated health care in the 20th century. It can be argued that this physician-dominant, fragmented care has driven up healthcare costs, promoted polypharmacy, and encouraged “silo” practices. Wheatley (2005) compared organizations to the biological natural world. In the biological world, if a species becomes too dominant and loses its ability to work when the environment shifts, the entire system can collapse. According to Healthy People 2020 (U.S. Department of Health and Human Services, 2010), the nation’s healthcare system will be challenged to provide effective chronic disease prevention and treatment. The current system, which is based on episodic care, will not serve the needs of the population. To meet the needs of the early 21st century, DNPs will need to bring a full nursing perspective into the healthcare environment, along with the empowerment of other members of the team to improve the viability and strength of the healthcare system. Physicians have also been closely aligned with the financial success of healthcare organizations (often hospitals) and therefore have often been designated leaders for any clinically based team. Even today, the

ACP (2009) concluded that the “patient is best served by a multidisciplinary team where the clinical team is led by the physician” (p. 2). Although physicians may have the most training in diagnosis and treatment of disease, they may not always be the best choice to lead teams. Haas (1977) discussed the “cloak of competence” that is expected of physicians by society. Medical students are socialized to adopt this cloak or image of confidence and perceived competence to meet societal expectations and may bring this “decisiveness” to the interprofessional arena. This may lead the physician to believe that he or she must always make the final decision in the team, which may result in a professional power imbalance whereby physicians have more power than other members of the team. The issue of disruptive behavior in the workplace has been studied in light of the connection between poor communication and adverse events (Joint Commission, 2008). Rosenstein’s (2002) qualitative study of physician–nurse relations found that almost all nurses in the study experienced some sort of disruptive physician behavior, including verbal abuse. Rosenstein and O’Daniel (2008) repeated this work, expanded to include disruptive behavior by both nurses and physicians. This second report concluded that whereas “physician disruptive behavior is usually more direct and overt, nurse disruptive behaviors more frequently take the form of back-door undermining, clique formation, and other types of passive-aggressive behavior” (Rosenstein & O’Daniel, 2008, p. 467). In its Essentials of Doctoral Education for Advanced Nursing Practice, the AACN (2006b) discussed the need for interprofessional healthcare teams to function as high-performance teams. High-performance teams are those that emphasize the skills, abilities, and unique perspective of each team member. If the nurses (or other team members) remain invisible, the overall effectiveness of the team will be impaired. To work on interprofessional teams, nurses will need to articulate the role they play in improving patient care. The work that nurses perform is often not recognized by other healthcare professionals and reimbursement systems or found within the nomenclature of electronic health records. Many tasks that nurses perform are difficult to quantify, such as supporting a family through a crisis. A vital responsibility of the DNP (likely collaborating with other nursing PhD colleagues) is to articulate to the public, insurers, and policy makers the role that nurses

play in promoting positive patient and family outcomes. Another key factor in empowering nurses in interprofessional collaboration is the importance of role identification and clarity. In the United States, there is confusion about the education and titling of nurses. Although many states protect the title of “nurse,” the public (including other healthcare professionals) continues to be confused about just who nurses are. Nurses in administration may not identify themselves as nurses, whereas some medical assistants may call themselves “nurses.” Although the work that medical assistants do with patients is valuable, it is not nursing. The first step to getting our voices heard is to identify who we are and to call ourselves nurses at all levels. It is important that as nurses work to gain visibility and voice, they remain open to listening to other voices on the team.

Drivers Successful Team Development The Institute for Healthcare Improvement (2017) has identified two foundational domains of effective and safe care: culture and the learning system. The institute’s white paper describes the crucial role of psychological safety needed for promoting a culture of teamwork. They recommend that all team members feel safe enough to “ask the ‘stupid’ question, elicit feedback without looking incompetent, be respectfully critical without appearing negative, and suggest new ideas or innovations without appearing disruptive” (p. 11). What are the stages of development that transform groups of disparate professionals into high-performance teams? Tuckman and Jensen (1977) and many others believe that teams go through stages, including forming, storming, norming, performing, and adjourning. Amos, Hu, and Herrick (2005) recommended that nurses understand these developmental stages in order to promote the development of a successful team. Forming is the stage when the team first comes together to serve a specific purpose. Team members come into the group as individuals and get to know each other while determining the mission of the team, along with their roles and responsibilities. The development of trust is key in this stage. Davoli and Fine (2004) suggested incorporating activities that

are designed to show the human side of each team member, such as “icebreakers” or “member check-in” (p. 269). In an interdisciplinary team, it is likely that there are members from diverse professions, each with its own culture and language. An important first task of an interdisciplinary team is to discuss and understand the scope of each profession represented (Hall, 2005). It is likely there will be both overlap and diversity of function and skills among the professions. It is also important to develop a sense of shared language by reducing the use of professional jargon. Although it may be unintentional, jargon can prevent knowledge sharing, hinder communication, and promote power imbalances. Standardized tools such as SBAR (situation, background, assessment, and recommendation) developed and used by Kaiser Permanente, can be used by interprofessional teams for discussion and problem solving regarding patient situations (Leonard, Graham, & Bonacum, 2004). SBAR is a simple, easy-to-remember, and useful tool developed to promote patient safety. It can also be used for daily huddles, which are often used for interprofessional collaboration (Agency for Healthcare Research and Quality [AHRQ], 2013). In the storming stage, team members have not fully developed trust, and conflict inevitably arises. Within interprofessional teams, members come from diverse disciplines and worldviews. It is highly likely that there will be a wide range of opinions and thoughts related to the issues and work of the team. It is important to face this conflict directly, however, to move on to the next stage. During the storming stage, it is vital that members learn to listen to one another with tolerance and patience (Lee, 2008). If the team does not go through this stage successfully, differences between individuals will not be brought into the team process and outcome. Conflict resolution will be discussed at length later in this chapter. Norming is the stage in which team members begin to develop a team identity. It is still important for the team to elicit differences of opinion in order to prevent groupthink. During this phase, team members develop a comfort level at which they can express their ideas freely and begin to gain respect for others on the team. Constructive criticism is acceptable, and members begin to resolve problems. In the performing stage, team members work together to achieve

team goals. Individual and professional turf needs will be set aside for the team to be effective in its mission. At this stage, the team members also learn to be flexible in tasks and roles in order to achieve the team’s goals. There should now be a sense of commitment to the tasks and goals of the team. Finally, the stage of adjourning concludes the formation of a team. The team evaluates its performance and progress by reviewing whether outcomes were met. Occasionally team members may lose focus on the actual task. It can, however, be a time of celebration of accomplishments. The following factors assist teams to progress through the stages of team development: Shared purpose, goal, and buy-in of members Reciprocal trust in team members Recognition and value of the unique role or skills each brings Functioning at the highest level of skill, ability, or practice Clear understanding of roles and the responsibilities of team members to meet goals Work culture and environment that embrace the collaborative process Collective cognitive responsibility and shared decision making

Shared Purpose For a team to be effective, there must be a shared purpose or vision (Kouzes & Pozner, 2012). The purpose of the interprofessional healthcare team is based on improving some aspect of patient or population health outcomes. Competing needs of team members must be tabled in favor of the greater purpose. Turf wars and politicized thinking have no place in an effective interprofessional healthcare team. The leader must inspire this shared vision and elicit buy-in from each member. As Wheatley (2005) suggested, creativity is unleashed in people when they find meaning or purpose in “real” work. Meaningful teamwork can create synergistic solutions from members when the team has shared meaning or vision. Patterson et al. (2002) described how free-flowing dialogue helps “fill the pool” of shared meaning. By allowing dialogue to be safe, more people can add their meaning to the “shared pool,” giving the group a higher IQ. Learning to make dialogue safe is a skill that drives trust.

Team Members and Reciprocal Trust An effective team must include the development of reciprocal trust between members. According to Kouzes and Pozner (2012), members of a high-trust team must continue to work to maintain interpersonal relationships with one another. In addition to the group mission and goals, the work of the group must also include getting to know one another. The leader or facilitator who is willing to trust others in the group enough to show vulnerability and give up control often begins a culture of trust. The leader must have enough self-confidence to be the first to be transparent; because trust is contagious, others will likely follow. Team members and leaders need to listen intently and value the unique viewpoints of others in the group. If the group fails to develop trust or to listen to and value each other, it is likely that group members will resist and sabotage the group’s efforts (Wheatley, 2005). Many authors describe this aspect of team leadership as leading with the heart: looking at how the heart can help shape dialogue and goals (Kouzes & Pozner, 2012; Patterson et al., 2002). Because of growth in global businesses, along with economic and time constraints, many teams now meet in virtual formats. Virtual formats can unite team members from different cultural groups and social constructs. The question many have is: What components are necessary to build trust in virtual teams? Kouzes and Pozner (2012) proposed that a group will become a team only when they have met face-to-face four to five times. These authors suggested that “virtual trust, like virtual reality, is one step removed from the real thing” (Kouzes & Pozner, 2012, p. 241). Watkins (2013) believes that it is easier to build trust if the team meets physically early on. During this meeting, it would be imperative to build in social time in order for members to get to know each other. Watkins then suggested that there be occasional reconnection if possible. Other sources discussed the very real possibility of developing trust via virtual means (Grabowski & Roberts, 1999; Greenberg, Greenberg, & Antonucci, 2007; Kirkman, Rosen, Gibson, Tesluk, & McPherson, 2002). Mayer, Davis, and Schoorman (1995) proposed that trust consists of three dimensions: ability, benevolence, and integrity. There is some evidence that when teams meet face-to-face, they form trust based on benevolence, whereas virtual teams rely more on ability.

For example, in teams that meet in person, benevolence or interpersonal trust is enhanced by informal personal meetings that occur at lunch or in the copy room. Virtual groups tend to develop trust based on performance and ability of team members. Because of the lack of eye contact and body language in virtual interactions, communication patterns should be more deliberate. Greenberg et al. (2007) proposed that trust building in virtual teams intentionally includes activities that promote both cognitive and affective trust. Cognitive trust is implicated in the formation of “swift, but fragile trust” during the early development of the team (Greenberg et al., 2007, p. 325). For cognitive trust to develop, individual team members need to believe that group members have both ability (competence) and integrity. One action to promote a sense of competence in individual team members is to have the team leader introduce members, endorse their abilities, and note why they were chosen for the team. Another important asset for building the sense of integrity is for team members to keep deadlines and stay engaged in the process (no freeloading). Affective trust is essential during later stages of the team’s development and is vital to the functioning of team members to complete the task. Development of affective trust is based on benevolence and relies on team members seeing the humanity in one another, with development of true caring and concern. Holton (2001) recommended that virtual teams include time in “caring talk,” which she defined as “personal conversations and storytelling” (p. 36). G. Boehlhower recommended that virtual teams begin their meeting time with “check-in, story-telling, deep questioning and dialogue, and affirmation” (personal communication, April 10, 2009). He went on to state that he “sees the level of trust develop regularly” in online groups when the human side of individuals is shared. As discussed earlier in this chapter, this type of sharing may be started with icebreakers, check-ins, and checkouts. DNPs will likely have experience with online relationship and team building during their education process and can continue to experiment with team building in face-to-face and virtual formats based on the current evidence. The use of video conferencing (which includes visual and nonverbal cues) enhances the richness of communication and thus decreases ambiguity and increases trust. It may be that the

communication channel (face-to-face, video or audio conferencing, group chat, text, email, and so on) should be matched to the purpose of the communication (Clark, Clark, & Crossley, 2010).

Recognition and Value of Each Team Member According to Burkhardt and Alvita (2008), “Each person is a moral agent and must be recognized as worthy of dignity and respect” (p. 219). Without respect, the work of the group cannot move forward; dialogue is halted. Respect among team members is vital because, as Patterson et al. (2002) noted, “Respect is like air. If it goes away, it is all people can think about” (p. 71). Each member’s voice must be heard and respected regardless of whether he or she is the highest educated member. To do this, team members must recognize the moral agency of each member and his or her unique skills and abilities, often based on the individual’s professional skill set. Using structure in interprofessional team dialogue may be called for as a result of the entrenched perceived power and authority of individual members and the professions they represent. Such methods as the Indian talking stick and Johari window can be used proactively to be sure that all team members feel they have a voice, are understood, and are free to share their thoughts and feelings. The concept behind the talking stick is that only the person who is holding the stick may speak. When the person finishes speaking, the stick is passed to the next speaker. That next person may not argue or disagree with the former speaker but is to restate what has been said. This process allows for all team members to be and feel understood (Covey, 2004). The Johari window is a tool developed in 1955 by Joseph Luft and Harry Ingham (Chapman, 2008). It is used to help build trust among group members by encouraging appropriate self-disclosure. The Johari window has four quadrants: the open area, the blind area, the hidden area, and the unknown area. The goal is to increase the open area so that team members can be more productive because communication is not hampered by “distractions, mistrust, confusion, conflict and misunderstanding” (Chapman, 2008, p. 4). One team member (the subject) is given a list of 55 adjectives and is told to pick 5 or 6 that describe himself or herself. A team member is given the same list and

also picks out 5 or 6 words that describe the subject. The adjectives are then placed in the four quadrants: 1. Both team members know the open area. 2. Only the subject, not the other team member, knows the hidden area. 3. Only the team member, not the subject, knows the blind spot. 4. The unknown area includes adjectives picked by neither subject nor team member and may or may not be applicable to the subject (Chapman, 2008). The Johari tool can assist team members to learn about both themselves and each other. Appropriate and sensitive increases in the open area can be promoted by the use of team-building exercises and games, along with teams engaging in non-work-time activities.

Functioning at the Highest Level American health care is expensive but not always effective. There is pressure for innovative models of care that are cost-effective and improve outcomes for patients. Many clinical systems have begun to use episodic treatment groups (ETGs) to measure patient outcomes and provider performance (Fortham, Dove, & Wooster, 2000). Introduced in 1993, “ETGs have become the industry standard for episodic patient classification” (OPTUM, 2015). Examples of ETGs are those for chronic diseases such as diabetes, asthma, depression, and hypertension. Guideline development by such groups as the Institute for Clinical Systems Integration (ICSI) can provide evidence-based pathways of care for the various ETGs. In the past, physicians have felt the need to perform all the primary care tasks for patients. Given the current complexity and expense of health care, it is not possible for one group to do it all. This realization has led to the concept of having all healthcare providers work to the top of their licenses. This involves a shifting of tasks, often with each discipline giving up some tasks that can be done by another care provider more cost effectively. An example of working to the top of one’s license is for advanced practice nurses to take more responsibility for routine chronic and acute care and health maintenance while physicians

perform the diagnosing and treatment of more complex unstable patients, and registered nurses (RNs) assume the role of care coordinator (including pre- and post-visit planning), coach, and educator. In this example, all disciplines may need to give up some tasks to be costeffective. An exemplar of a program that utilizes healthcare providers at the top of their licenses is the DIAMOND (Depression Improvement Across Minnesota, Offering a New Direction) project (ICSI, 2014). At the center of the DIAMOND project is a case manager (typically an RN) who has 150 to 200 patients with depression in an outpatient setting. The case manager works with a consulting psychiatrist to review patients on a weekly basis (typically 2 hours per week). This has proved to be a costeffective model that provides better depression outcomes than standard care. The challenge is to provide a payment structure that rewards this type of innovative care.

Clear Understanding of Roles and Responsibilities During the forming stage of the team (and beyond), it is vital that each team member understand his or her role and responsibilities. Role uncertainty can lead to conflict among team members and decrease team functioning (Baker, Baker, & Campbell, 2003). The leader should be certain that each team member has a clear understanding of his or her role by having the members restate their role to the team. This type of candid discussion can occur only if the team feels that open communication is safe. A clear understanding of each team member’s role helps to prevent role overlap as well as tasks falling through the cracks (Lewis, 2007).

Work Culture That Embraces Collaboration Some of the components of a work culture that embraces collaboration are (1) providing psychological safety, (2) a flattened power differential (hierarchy), (3) administrative support and resultant resources allocated for collaboration (Kelly, 2008), and (4) physical space design that promotes collaboration, such as rooms for interdisciplinary interaction (Lindeke & Sieckert, 2005).

According to Gilbert (2006), organizations that support “upward voice” promote a culture of psychological safety. She went on to state that “upward voice is communication directed to someone higher in the organizational hierarchy with perceived power or authority to take action on the problem or suggestion” (p. 1). Some tangible evidence of this are leaders who walk around the organization and initiate conversation, suggestion boxes placed around the organization, and an open-door policy. Individuals must have the sense that they can readily ask questions, try out new ideas and innovations, and ask for support from others. Another way to promote psychological safety within an organization centers on employee confidence that there will not be a penalty for admitting to mistakes. Safety culture research is shifting from focusing on only the role of individuals in errors to the role of systems. Healthcare leaders have had to explore other industry successes that promote safety, such as aviation, where the focus of safety improvement is on the systems in which individuals operate (Feldman, 2008). Authors such as Snijders, Kollen, Van Lingen, Fetter, and Molendijik (2009) have recommended a nonpunitive incident reporting system to improve safety standards. A nonpunitive incident reporting system helps ensure that issues are brought to the forefront so that improvements can be made. The Agency for Healthcare Research and Quality (AHRQ, 2009) has developed evaluation tools for primary care offices, nursing homes, and hospitals with questions related to psychological safety and communication. However, in many institutions there remains the problem that individuals are discouraged from reporting adverse events. It should be recognized that this fear could cause a decrease in safety (AHRQ, 2009). DNPs will be required to provide leadership and recommend resources to champion the culture of both psychological and systems safety within the organizations they serve.

Collective Cognitive Responsibility and Shared Decision Making As fundamental as it is for each team member to have a clear understanding of individual roles and responsibilities, it is also essential for high-performance teams to have a culture of shared decision making

or collective cognitive responsibility. Scardamalia (2002) described collective cognitive responsibility in terms of team members having responsibility not only for the outcome of the group but also for staying cognitively involved in the process as things unfold. She described the functioning of a surgical team, in which members not only perform their assigned tasks but also stay involved in the entire process. The responsibility for the outcome lies not just with the leader of the surgical team but with the entire team as a whole. A key component of shared decision making is that it usually occurs at the point of service (Golanowski, Beaudry, Kurz, Laffey, & Hook, 2007; Porter-O’Grady, 1997). Porter-O’Grady stated that “the point of decision making in the clinical delivery system is the place where patients and providers meet” (p. 41), which has implications for including patients as collaborators on the interprofessional team. Healthcare systems, as complex adaptive systems, require flexibility and continuous participation, learning, and sharing (Begun, Zimmerman, & Dooley, 2003). All the interprofessional healthcare team members must stay engaged in the process at the point of service for the outcome of care to be successful.

Strong Leadership There is no dispute that redesigning health care will require strong leadership. As opposed to management, which seeks to control and manage, leaders seek to create and inspire change (Kotter, 1990). Leadership theories generally fall under the classifications of behavioral, contingency, contemporary, and Wheatley’s “new leadership” approaches (Kelly, 2008). Behavioral theories posit that leadership style or behavior is the most important factor in the outcome desired. Behavioral approaches include autocratic, democratic, and laissez-faire, based on where the power or decision making occurs and the type of worker or task involved. Contingency theories recognize that there is more to leadership than the leader’s behavior. One type of contingency theory is situational leadership, developed by Blanchard (2008), in which follower maturity is evaluated and determines the amount of direction, support, or delegation from the leader to the follower. Contemporary theories include transformational leadership, which the IOM (2003) deemed vital to the

achievement of the transformation of health care. Transformational Leadership. The IOM (2003) report recommended transformational leadership to make the necessary changes to improve patient safety. Transformational leadership, developed first by Burns (1978), is based on the concept of empowering all team members (including the leader) to work together to achieve a shared goal. This fits with Covey’s (2004) definition of leadership: “Leadership is communicating to people their worth and potential so clearly that they come to see it in themselves” (p. 98). The transformational leader need not be in a formal position of administration but can lead from any position within the organization and operates through an ethical and moral perspective. Transformational leaders lead with a clear vision and use coaching, inspiring, and mentoring to transform themselves, followers, and organizations (Burns, 1978; Kelly, 2008). Complexity Leadership or New Leadership. Complexity leadership is the name given to the new paradigm of thinking about leadership that unites science and management to solve problems. Complexity has contributions from chaos theory and similarities to the thinking of such nurse theorists as Rogers, Newman, and Watson (Crowell, 2011). Margaret Wheatley (2005) described this “new way” of leadership, which is contrary to the Western style of linear, hierarchical organizations. She bases her view of organizations on biology, which is self-organizing and complex. Instead of seeing change as negative, Wheatley views change as life itself. She stated, “Nothing alive, including us, resists creative motions. However, all of life resists control. All of life reacts to any process that inhibits its freedom to create itself” (p. 28). She recommended that teams self-organize to build communities that are no longer ruled by “command and control” (p. 68). Instead of viewing organizations and workers as machines, Wheatley suggested that organizations model themselves after living systems, which are adaptive, creative, and depend on one another for growth and sustainability. Leadership Versus Management. Whereas management is the coordination of resources to meet organizational goals, leadership is built

on relationships. Kouzes and Pozner (2012), in their seminal book The Leadership Challenge, examined leaders over 25 years and determined that leadership is a relationship in which leaders do five things: 1. Model the way. The leader must be aware of his or her own values and live a life that expresses those values. 2. Inspire a shared vision. The leader must be able to imagine the future and inspire others to share that vision. 3. Challenge the process. Leaders are engaged in the processes of the team and continually looking for innovations. They are willing to take risks and learn from experiences. 4. Enable others to act. Leaders help to build trust in relationships through collaboration and competence. 5. Encourage the heart. Leaders identify the contributions of each individual team member and encourage celebration when victories occur. Anyone can be a leader; a formal title is not necessary.

Effective Communication Remember not only to say the right thing in the right place, but far more difficult still, to leave unsaid the wrong thing at the tempting moment. —Benjamin Franklin

All the work of interprofessional collaborations involves communication. Success or failure of the team is dependent on the effectiveness of the communication processes. Communication is a complex process of transmitting a message between a sender and receiver. The sender must effectively deliver the content, and the receiver must in turn correctly interpret or decipher the message. Many sources of error can occur within this exchange, and skilled communicators must make a concerted effort to deliver clear, consistent messages to prevent misinterpretation and loss of meaning. Communication is more than the exchange of verbal information; in fact, the majority of communication is nonverbal. The DNP must be accomplished not only in the art of verbal and written communication but also in the interpretation and effective use of nonverbal communiqués

such as silence, gestures, facial expressions, body language, tone of voice, and space (Sullivan, 2004). In addition to sending congruent verbal and nonverbal messages, it is vital for DNPs to employ strategies that enhance communication within the interprofessional team setting. Determining the timing and best medium for what, how, and when to deliver a message is a necessary skill (Sullivan, 2004). Appropriate timing of key messages increases the likelihood that the message will have the desired impact on the recipient. The message may be phrased well but rejected if the intended audience is not receptive. Consider the availability and state of mind of the recipient. Is there adequate time for the discussion? Is the recipient distracted, emotionally or physically? Are other issues more pressing now? Such factors may contribute to misinterpretation or lack of objectivity regarding the communication. Reflect as to whether an alternative time, venue, or medium may provide a more appropriate means by which to deliver the message. For instance, if the message is of a sensitive, confidential matter, face-to-face communication would be preferable to an email, voicemail correspondence, or team discussion (Sullivan, 2004). In group settings, it is imperative to allow participants enough time to provide objective information and express thoughts, viewpoints, and opinions about the situation in order for meaningful collaboration to occur. Buresh and Gordon, in their book From Silence to Voice: What Nurses Know and Must Communicate to the Public (2006), suggested use of the “voice of agency” when communicating the role of nursing to others. Within the collaborative team, it is imperative that DNP members clearly communicate nursing’s involvement in a patient care scenario or clinical project and, more important, articulate the level of clinical judgment and rationale required for such actions. It is important and necessary to embrace the opportunity to communicate to the team the role of the DNP in enhanced care delivery. This voice of agency is not boastful nor an attempt to be superior but rather an accurate acknowledgment of the unique contributions, value added, and improved patient outcomes resulting from expert nursing care. Conversely, it may reflect the negative consequences or potential for error averted as a result of the expertise, skills, and knowledge of doctorally prepared nurses. Davoli and Fine (2004) offered a similar perspective and noted,

“Collaboration gives providers an opportunity to be introspective and solidify their role through the contributions they make. A successful collaborative process will enhance one’s professional identity” (p. 268). Draye, Acker, and Zimmer (2006), in their article on the practice doctorate in nursing, proposed that the educational preparation of DNPs include opportunity for the student to convene an interprofessional team. This experience allows the student to incorporate strategies to promote effective team functioning while communicating the unique contributions of nursing required for the improved health outcome. Buresh and Gordon (2006) went on to discuss the role that selfpresentation plays in communicating information regarding the competency and credibility of the DNP to team members, patients, or the public. Attire and manner of address influence the perceptions of others. What does dress communicate if Mary wears teddy bear scrubs rather than street clothes and a lab coat to a committee meeting? How might the DNP’s role be valued if she is introduced as Mary from pediatrics versus Dr. Mary Jones, pediatric nurse practitioner? How are physician colleagues addressed in similar workplace encounters? Introductions using one’s full name and credentials convey professionalism, respect, and credibility on par with other healthcare professional colleagues (Buresh & Gordon, 2006). Ineffective communication is a major obstacle in interprofessional collaboration, is directly related to quality of patient care, and contributes to adverse health outcomes (Clarin, 2007; IOM, 1999; RWJF, 2015). Some barriers that lead to communication breakdowns are specific to interactions between the sender and receiver, whereas others relate to the organizational system. Defensiveness on the part of either participant can hamper communications (Sullivan, 2004). These behaviors may result from lack of self-confidence, a fear of rejection, or perceived threat to self-image or status. Defensiveness impedes communication by displacing anger via verbal aggression or conflict avoidance. Awareness of this mechanism and developing an approach to manage it in the context of the collaborative team are necessary attributes of an effective DNP leader. As healthcare teams become more global and virtual, the potential for language and cultural communication barriers increases. Misreading body language or misinterpretation of the spoken or written message

often results from a lack of understanding regarding language (especially in translation) and cultural differences (Sullivan, 2004). What one group finds acceptable another may consider offensive, such as eye contact, physical touch, or the use of space. Room for misinterpretation exists in translation. Language used by Western cultures typically is direct and explicit, in which the background is not necessarily required to interpret the meaning of the message. This may differ from cultures that use indirect communication, in which the intent of the message often relies on the context in which it is used (Brett, Behfar, & Kern, 2006). DNPs and interprofessional colleagues have an obligation to increase their cultural competence and understanding of health issues and healthcare disparities to dispel any misconceptions, particularly if the team is composed of persons from diverse cultures or if the recipient of care is from another culture. Jargon is another “language” that can pose a barrier to understanding (Davoli & Fine, 2004; Sullivan, 2004). Unfamiliar terms can lead to confusion and error and should be avoided to prevent unfavorable outcomes. Although professional jargon may serve as a type of verbal shorthand among some group members, it can also be a form of intimidation or exclusion and contribute to an imbalance of knowledge or power within the team (Davoli & Fine, 2004). Lindeke and Block (2001) stressed that collaborative teams communicate with a shared, inclusive language (i.e., “we,” “our”) to prevent this imbalance and promote participation of all members. Many successful teams utilize the SBAR process as a common language means to convey critical information to be shared. It provides clear expectations as for what and how information is to be communicated among the team members and by its use promotes patient safety (Leonard et al., 2004; RWJF, 2015). Effective communication involves the use of a common, shared language that is understood by all members of the team. Preconceived assumptions and biases prevent the listener from tuning in and focusing on the content (Sullivan, 2004). This hinders the communication process because the receiver has formulated a predetermined judgment or drawn a conclusion before all the information is shared or facts validated. Effective communicators need to suspend judgments until all viewpoints are shared. Gender differences in style and approach to communication can also

pose obstacles (Sullivan, 2004). Subtle differences exist in how men and women perceive the same message. In collaborative teams, women may strive for consensus, whereas men may place emphasis on hierarchy and “leading the team.” Differences exist in the use of questions and interruptions in communications. An appreciation and understanding of these dissimilarities can prepare the DNP to function more effectively in teams of mixed gender. Organizations and systems may pose additional obstacles to effective interprofessional communications. Outdated, limited, or unavailable technologies, such as video conferencing, messaging, or paging systems, or lack of electronic health record interoperability between systems can significantly impair the ability of members to communicate on a timely basis. This can be of vital importance to patient safety when attempting to communicate critical changes in patient status, medications, or lab values. The system further contributes to communication problems when the roles and responsibilities of team members are unclear. Participants may be hesitant or resistant to engage in exchanges or knowledge sharing. Clear designation of roles is of particular importance in virtual organizations and teams (i.e., electronically linked providers). In these collaborative environments, risks can be mitigated if members have a clear understanding of what is expected of each other and have a preestablished path of communication (Grabowski & Roberts, 1999) (see BOX 6-1).

BOX 6-1 Measures to Improve Communication Maintain eye contact: Convey interest, attentiveness. (United States/Canada) Speak concisely: Avoid jargon. Use questions wisely: Clarify or elicit further information. Avoid qualifiers or tags (e.g., “sort of,” “kind of,” “I don’t know if you would be interested”): These reduce the effectiveness of one’s message. Be aware of gestures, facial expressions, posture: Send positive nonverbal signals (e.g., smiling conveys warmth, leaning forward indicates receptivity, and open-palm gestures suggest accessibility). Avoid defensiveness. Avoid responding emotionally: Never raise your voice, yell, or cry.

Conflict Resolution As both leaders and members of interprofessional teams, DNPs will need to develop and continue to refine skills related to conflict resolution. Conflicts are inevitable and are even vital for interprofessional team effectiveness. Conflict is defined in many ways but generally includes disagreement, interference, and negative emotion (Barki & Hartwick, 2001). If conflict is disruptive or dysfunctional, team efforts can decrease communication and thus team functioning. On the other hand, conflict that is constructive leads to superior results by including the “shared pool of meaning” of all team members. According to Patterson et al. (2002), the “larger the shared pool, the smarter the decisions” (p. 21). As stated earlier, nurses over the last century have often used passive-aggressive methods to resolve conflict, such as avoidance, withholding, smoothing over, and compromising (Feldman, 2008). These methods do not promote dialogue, the most central means to attain the shared pool of meaning of the entire team. DNPs need to lead nurses and other professionals in techniques that promote dialogue and thus collaboration between professionals. The purposes of collaborative conflict management are to promote win-win versus win-lose solutions. The skills for conflict resolution and improving dialogue can be learned. According to Patterson et al. (2002) in their book Crucial Conversations, conflict resolution includes such methods as starting with the heart, making conversation safe, staying in dialogue when emotions are high, using persuasion, and promoting positive actions. Most of the skills related to collaborative conflict management are intertwined with effective communication skills and the development of emotional intelligence (EI). Chinn (2008) offered suggestions that are foundational for the transformation of conflict into solidarity and diversity. These recommendations begin before there is any conflict in a group or team and include rotating leadership, practicing critical reflection, and adopting customs to value diversity. By rotating leadership, the team members all have a stake in the outcome of the team goals and processes. When a conflict arises, involved parties can step back while other members rise up to help lead the team. Critical reflection can be accomplished by incorporating a closing time at which all team members can share their thoughts and feelings about the team process. By practicing ways to

value diversity, such as developing team processes during meetings that show appreciation and value for each individual, conflict can move from violence to peaceful recognition of the diversity of alternative views.

Emotional Intelligence Emotional intelligence (EI) is yet another valuable attribute of successful interprofessional leadership. EI is the awareness of the role that emotion plays in personal relationships and the purposeful use of emotion to communicate, build rapport, and motivate self and others. These characteristics have been found to play a far greater role than cognitive abilities in the success or failure of a leader (Goleman, Boyzatsis, & McKee, 2002). Goleman et al. (2002) outlined five realms of EI: self-awareness, selfregulation, motivation, empathy, and social skills. Self-awareness involves recognizing your own emotions and the effect your mood and confidence level have on persons. Maintaining your composure in highemotion meetings or challenging clinical situations is an example of effectual self-regulation. Conflict is a natural process of interprofessional teamwork, which can lead to positive or negative group functioning, depending on leadership style. Emotionally intelligent leaders have the ability to adapt, withhold judgment, and exhibit self-control in emotionally charged situations. An optimistic attitude, passion, and commitment to pursuing the goals of the group and desire for excellence help provide the motivation factor of EI. Leaders who are sensitive and empathetic to the needs and perspectives of others encourage the group to carry on and perform to its best ability. Drinka and Clark (2000) talked about the role of reflective practice in interprofessional team practice. This concept builds on the selfawareness and empathy qualities of EI: the understanding of how our professional cultures, preparations, and experiences shape how we function in teams as well as the ability to appreciate the similar and dissimilar perspectives of other interprofessional team members. A fifth element is that of social skill: the ability to build rapport, network, communicate, and facilitate change. As an effective leader, it is imperative to foster a system of open, timely communication—whether by face-to-face communication, phone, or electronic means—to meet the

desired outcomes for the project, patient, or population successfully. Regularly practicing calming relaxation techniques and rehearsing responses before anticipated stressful encounters allows one to manage reactions in an emotionally intelligent manner. DNPs can develop these skills with regular practice, self-reflection, coaching, and feedback from colleagues and can use EQ (emotional intelligence quotient) as a tool to gauge their performance as leaders. McCallin and Bamford (2007) suggested that EI is integral to effective interdisciplinary team functioning. Healthcare providers may be highly skilled in practicing emotionally intelligent interactions with their patients and families but may receive little preparation in promoting emotionally intelligent, healthy communication and functioning between professionals. Miller et al. (2008) specifically explored the role of EI in nursing practice as it relates to interprofessional team functioning. In this qualitative study, the ability of the nurse to effectively collaborate on interprofessional teams was influenced by his or her degree of EI. Nurses who engaged in esprit de corps (significant role embracing, to the exclusion of other professionals) were considerably less able to function successfully on the team, less able to have other members appreciate nursing’s contribution to patient care, and generally less engaged in team processes. These researchers support the need to address not only the cognitive aspects of interprofessional teamwork but also the emotional aspects of optimal team functioning. DNP leaders versed in EI work are well suited to recognize individual and personality differences among team members and can build on them, mentor colleagues, and use EI to influence the effectiveness of the team and improve patient outcomes and satisfaction among interprofessional team members.

Necessities for Collaboration Change Agent: Lewin’s Model The objective of interprofessional collaboration is, of course, to generate a practice or systems enhancement to improve the health of an individual or population. Whether implementing an evidence-based practice effort or a quality improvement initiative, some sort of change is required. Even what many group members view as a desirable change will inevitably encounter some reluctance or resistance. The ability to facilitate change or serve as an agent of change is a key function required for successful collaboration. DNPs must be versed in one or more theories of change to effectively motivate and move the collaborative team to the optimal goal. Lewin’s force field analysis model (1951) is a classic framework for understanding the process of change within a group, system, or health initiative. Lewin’s theory recognizes change as a constant factor of life ensuing from a dynamic balance of driving and opposing forces. The desired change results from the addition of driving forces or the diminishing of opposing forces and progresses over a series of three stages: unfreezing, moving, and refreezing. Unfreezing necessitates assessing the need and preparing members to move from the status quo to an improved level of practice, whereas the movement phase involves the addition of driving forces to motivate and empower members to adopt the improved perspective while simultaneously minimizing restraining forces that pose barriers to the desired change (Lewin, 1951; Miller, 2008). Driving forces must outweigh opposing forces to shift the equilibrium in the direction of the desired change. The improvements must then be secured, or allowed to refreeze, in order to maintain the desired change (Lewin, 1951; Miller, 2008).

Continuous Reflective Learning The drivers of effective interprofessional teams discussed in this chapter will evolve in teams over time. Knowing the drivers is the first step in the development of both personal and team skills, but individual team

members and the team as a whole will need continuous reflection. Each leader and follower should develop habits that build in time for personal reflection and growth. Many find that reading sacred texts or poetry, listening to music, practicing yoga, praying, meditating, exercising, connecting with spiritual leaders, or being in nature allows for deep reflective thinking and learning. Covey (1991) called this “sharpening the saw” (p. 38) and recommended that people proactively plan for daily time to renew themselves. The wholeness of each team member is vital for the best functioning of the entire team. Teams within healthcare organizations in the 21st century will need to practice continuous reflective learning (developed by Senge, 1990) to adapt to the rapid changes taking place. Interprofessional teams can utilize the vast organizational behavior research on the significance of continuous reflective learning. Edmonson (1999) defined team learning as “the activities carried out by team members through which a team obtains and processes data that allow it to adapt and change” (p. 352). Spending some time on reflection regarding team functioning will be vital to learning. Structural practices that foster team learning include providing time during each meeting for reflection, leaving the worksite for retreats, conducting critical incident evaluations, discussing errors and failures, using patient satisfaction surveys and interviews, and celebrating successes.

The Patient and Family as Interprofessional Team Members As health care reorganizes into interprofessional teams in which primary care is the hub of the system, central team members will be patients and their families. Patients and their families will need to be invited into and supported in the interprofessional collaboration process through actions that promote meaningful dialogue, patient empowerment, self-efficacy, and activation (Hibbard, Stockard, Mahoney, & Tusler, 2004; RWJF, 2015). Some tools the DNP may want to recommend include patient or family focus groups, satisfaction surveys, personal health records, decisional guides such as the Ottawa Personal Decision Guide (O’Connor, 2018), and advance directives, along with ongoing patient education regarding the patients’ and families’ role in health care.

Models for Implementation: From Project to Practice Value of Incorporating Collaborative Work Into Educational Preparation Curricula Although there is a growing body of evidence regarding the benefits of collaboration among disciplines in the delivery of optimal patient care, few healthcare professionals have received any formal training in this concept during their educational preparation. Students in health professional programs often are taught in both the classroom and clinical setting by faculty from the same professional background. They have little opportunity to learn about the work of other disciplines or participate in any shared learning experience. Brewer (2005) described this pattern of education as “silo” preparation, in which each discipline believes it is best qualified to care for the patient. Without a formal structure and support for learning and practicing a team approach to care delivery in the educational setting, negative attitudes, prejudices, and misunderstanding of roles can occur. This contributes to an inability to collaborate effectively and consult with other providers as practicing professionals and may lead to discipline overlap and competition rather than collaboration for delivery of care. The World Health Organization has been a leader in promoting interprofessional collaborative educational efforts. In 2010, a WHO study group was formed to develop a framework for interprofessional education and collaborative practice This framework highlights the current status of interprofessional collaboration worldwide, identifies key elements of effective teams, and formulates strategies for educating future healthcare professionals in interprofessional work in an effort to build successful collaborative practices in their respective communities. Educational efforts in interprofessional collaboration have flourished in the United States over the past decade. In 2009, educational leaders in medicine, nursing, dentistry, public health, and osteopathic medicine convened and formed the Interprofessional Education Collaborative. The purpose of

IPEC is to move beyond the silos of linear profession-specific education to that of learning alongside other healthcare disciplines. The IPEC developed a set of core educational competencies refined in 2016 to engage health professional students across disciplines to learn together with the vision to enter the workforce collaborative practice ready, ultimately improving healthcare delivery. Since its initial release, the IPEC has expanded to include disciplines of physical therapy, occupational therapy, psychology, podiatry, optometry, social work, and physician assistants. The competencies are widely endorsed by accrediting bodies and have spawned a number of interprofessional practice demonstration projects (IPEC, 2016). A Cochrane systematic review of interprofessional education interventions (Reeves et al., 2008) examined six studies—four randomized controlled and two controlled before-and-after designs in a variety of settings. Interprofessional education was defined as any type of educational experience or learning opportunity in which interactive learning occurred between two or more health-related disciplines. Although a number of positive outcomes were noted, further rigorous studies are needed to draw conclusive evidence supporting core elements of interprofessional education and the subsequent impact of interprofessional collaborative education on health outcomes. In an effort to increase the ability of health professional teams to deliver optimal patient care, the RWJF funded educational programs (Partnerships for Quality Education [PQE]) designed to improve interprofessional collaboration, chronic disease management, systemsbased care, and quality (RWJF, 2008). These initiatives were developed to provide nurse practitioners, physicians, and other allied healthcare providers with educational experiences, skills, and attitudes to deliver better quality care than could be provided by any single discipline. One funded model was Collaborative Interprofessional Team Education (CITE); the objective of this program was to design collaborative clinical and educational interventions for health professional students from medicine, nursing, social work, and pharmacy (RWJF, 2008). The program did make some strides toward improvement in participants’ understanding of and attitudes toward other professions. Whitehead (2007) offered some insight into the challenges of engaging medical students in interprofessional educational programs.

Real and perceived power, high degree of status, professional socialization, and decision-making responsibility can limit the ability of physicians to collaborate with other members of the healthcare team unless efforts to change the culture, flatten hierarchy, and share responsibility are promoted. A number of additional obstacles prevented full implementation of the CITE initiative, including differing academic schedules and a lack of faculty practicing in teams to effectively mentor and model for students (RWJF, 2008). The primary objective of Achieving Competence Today (ACT), another PQE initiative, was to promote interprofessional collaboration and quality improvement in the curriculum of healthcare professionals within two academic health centers (Ladden, Bednash, Stevens, & Moore, 2006; RWJF, 2008). Four disciplines worked jointly to plan and implement a quality improvement project. As a result, core competencies necessary (IPEC, 2016) for successful interprofessional teams were identified, and researchers suggested measures for incorporating these competencies into the educational preparation of future students as a means to improve quality and safety in health care. DNP programs can build on concepts of interprofessional education by allowing and encouraging programs to use faculty from a variety of disciplines to prepare DNP students. Interprofessional faculty can add a depth and richness to the DNP curriculum by bringing and sharing skills, knowledge, and the highest level of expertise in areas of clinical practice —whether it be business and management, pharmacy, public policy, psychology, medicine, or informatics (AACN, 2006a). Educational experience related to interprofessional collaboration as a means to improve quality or promote safety should be highly visible within the scholarly DNP project.

Role of the Scholarly Project: Real Interdisciplinary Collaboration The Essentials of Doctoral Education for Advanced Nursing Practice (AACN, 2006b) refers to the final DNP scholarly project or capstone as a culminating immersion experience that affords the opportunity to integrate and synthesize all elements of doctoral education competencies within an interprofessional work environment. DNP-led scholarly projects

provide a venue for students to assume leadership roles for effective interprofessional collaboration in order to improve health care, patient outcomes, and healthcare systems. The DNP project “Optimal Use of Individualized Asthma Action Plans in an Electronic Health Record” (Miller, 2008) involved a number of opportunities for interprofessional collaboration. This process improvement project involved a systems change designed to improve pediatric asthma care delivery in a regional health system. An asthma action plan tool built into the electronic health record of a multispecialty regional health system served as a vehicle for the delivery of evidencebased practice. Distinct DNP-led interprofessional teams collaborated during various stages of program planning, implementation, and evaluation. Collaboration with nursing professionals and professionals in the fields of informatics, information technology, statisticians, and management was active throughout the project, particularly during tool development and in the implementation phase. Key to ensuring effective communication within this group was the use of a common language and developing a clear understanding of each other’s roles and contributions. A second opportunity for interprofessional collaboration occurred during the implementation phase. Each member of the pediatric asthma team—the DNP, clinical nurse specialist, and physician—came to the project with his or her own agenda and perspective. Frequent revisiting of desired project outcomes, goals, and objectives was necessary early on to develop a cohesive, unified collaboration. A third DNP-led collaboration took place at the pilot project site, a regional primary care clinic. This collaboration, which initially presented many challenges, involved physicians, nurses, administrative management, and administrative support. This site had recently been acquired by the parent organization. Previous quality improvement initiatives had been attempted and, because of a variety of factors, were not successfully implemented. Several A number of barriers to collaboration were anticipated at this site, including a sense of mistrust and resistance to change. Building trusting, nonthreatening relationships with staff and providers was a much-needed starting point. Issues of power were foreseeable between the physicians and the project manager. Initially, this group expressed hesitancy with the concept of anyone other than the physician being responsible for the optimal

delivery of pediatric asthma care. It is important to acknowledge that providers might experience competing loyalties as they struggle to prioritize and balance the additional time needed to implement a project along with time required to see other patients or perform other duties. Avoiding these barriers requires mutual respect for each other’s role, purpose, and workload. It is vital to continually clarify and communicate the shared vision of the collaborative project—in this case, improved asthma care for children. Building relationships, seeking team member input, and developing a shared vision play critical roles in negotiating hurdles for interprofessional collaboration and for effective project implementation and evaluation. In the DNP project “Developing a Population-Focused Student Health Service” (Ash, 2005), interprofessional collaboration morphed from providers within the student health services (SHS) to a broad range of professionals. The ecologic approach (National Association of Student Personnel Administrators, 2004) was used in the final stages of the student DNP project, which broadened the stakeholders and thus the collaborating professionals. The ecologic perspective views the connections between health and learning within the campus setting (Sacher et al., 2005). The initial task force led by the DNP student included a project mentor who was an expert in group work as a result of his education and experience as a master of social work (MSW). His skills in the so-called softer side of team development molded the experience by bringing all the team members into the process. He was also continually willing to try new approaches and then evaluate the outcomes. He had direct access to the vice president of student affairs, who was also known to be innovative and skilled in human relationships because of his background in counseling. A current DNP student project, which is an offshoot of the former project, is preventing chronic disease through screening, nonpharmacologic and pharmacologic interventions, and healthcare coaching. This project will include nonhealth-care team members (coaches) to facilitate the attainment of healthcare goals. Unlike many healthcare-related projects, there were no physicians on the interprofessional team. This may have changed the leadership and political issues that have plagued nurse–physician relationships in the past. The DNP student may have struggled to lead a team that included a physician. If, however, a physician was part of the team, increased efforts

could have been made to develop reciprocal trust and to recognize and value each profession. Having a physician from outside the college may have afforded an opportunity for increased networking of the interprofessional team within the community in which the college is situated. Some of the drivers of interprofessional team functioning, such as trust, recognition and value of team members, and a shared purpose, were already present on this team at some level. Team members knew each other and had passion for the team purpose: developing a culture that embraces health and well-being. The team members worked within a college that espouses “Benedictine values” since its inception in 1912 (College of St. Scholastica, 2018), which include community, hospitality, and stewardship. This emphasis on Benedictine values provided a work culture that embraced collaboration, which is a driver of interprofessional teams. One of the barriers that plagued the team was that there was no clear understanding of roles and responsibilities. The team met and formed ideas that the team leader and mentor needed to follow through on. This team structure has changed since the end of the DNP project and now comprises four separate working groups focused on student health, faculty and staff health, marketing, and academic integration. The project, now entitled Well U, has continued to be integral to the college’s culture. The use of Wheatley’s (2005) new leadership approach helps account for the success of this project. The college campus, in relationship to health, could be seen as chaotic; once the relationships were formed between team members, however, information and ideas flowed. The team came to understand that all connections were vital to the development of a college-wide culture that embraced health and wellbeing. A long-term approach to building cultural change continues in this project. TABLE 6-1 shows interprofessional team members in the DNP project. TABLE 6-1 Interprofessional Team Members Initial Task Force

Final Multi-Interprofessional Team

DNP student

DNP student

MSW mentor

MSW mentor

RN from SHS

RN from SHS

Student

Student Director of Institutional Research and Assessment VP for Enrollment Management Registrar Manager, Wellness Center International Student Adviser Department Chair, Physical Therapy

Description Interprofessional collaboration is not limited to efforts in the United States. In two reports to the Minister of Health in Canada, the Health Provisions Regulatory Advisory Council (2008, 2009) reviewed the scope of practice of nurse practitioners and the need for interprofessional collaboration as a means to address primary care provider shortages and comprehensive, quality care. As a result, the Minister of Health supported initiatives for innovative practice models to improve access and quality of care for underserved Canadian residents. In the DNP-led project, “A Nurse Practitioner-Led Clinic in Thunder Bay” (Thibeault, 2011), a team of nurse practitioners, RNs, a social worker, a dietitian, a pharmacist, an administrator, and a community representative designed and implemented a comprehensive primary care clinic that opened its doors to Thunder Bay residents in November 2010. The clinic’s primary focus is comprehensive care across the life span, with a focus on health promotion, disease prevention, and chronic care delivery. The clinic has exceeded initial goals of increasing access for unattached patients and reducing costly emergency department visits.

Summary Given their advanced preparation, DNPs are well positioned to participate and lead interprofessional teams. Recognizing obstacles and developing strategies to reduce such barriers are key functions of interprofessional team leadership. All members of the interprofessional team need to have preparation and opportunities to rehearse this new approach to patient care delivery. Incorporating shared interdisciplinary learning experiences into the educational preparation of healthcare professionals provides the foundation for forming partnerships rather than competition for patient care delivery. Further study is needed to demonstrate the most effective educational interventions to prepare healthcare providers for successful collaborative work. Workforce and regulatory issues may present both challenges and opportunities for interprofessional collaborations. Shortages of physician primary care providers, particularly in rural settings, are likely to influence both the configuration and function of the interprofessional team (ACP, 2009; Minnesota Department of Health [MDH], 2009). DNP-prepared primary care providers can help to fill this gap but must be allowed to practice at the top of their education and scope; this will necessitate that physician colleagues reexamine and relinquish some of the responsibilities and tasks traditionally “owned” by medicine. Nursing and medicine will need to work together to devise a vision for this new collaborative practice model to most efficiently and effectively address the needs of the population and improve the quality of care provided. The American Academy of Pediatrics’ concept of a medical home suggests that all individuals, particularly those with complex or chronic health conditions, should receive a comprehensive, coordinated approach to health care and social services (MDH, 2009). The proposed Health Care Home initiatives expand the definition of primary care provider to include physicians, APRNs, and physician assistants (MDH, 2009). The primary care provider will lead and coordinate the efforts of the interprofessional team to best meet the needs of the patient. Nurse practice acts, regulations, and reimbursement issues must be reviewed and revised to support the ability of APRNs to assume this role and

deliver comprehensive care. Continued research is needed to identify the full impact of workforce and regulatory issues on these collaborations as well as strategies to address these concerns. DNPs in both direct (certified nurse practitioner [CNP], clinical nursing specialist [CNS], certified registered nurse anesthetist [CRNA], certified nurse–midwife [CNM]) and indirect provider roles ([health policy makers, administrators, informatics specialists, public health experts]) must continue to effectively work with other members of the healthcare team to deliver comprehensive, patient-centered care. Interprofessional collaborations are an important facet of a reformed healthcare delivery system and a vital step toward improving health outcomes and reducing medical error.

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PART 2 Healthcare Delivery and Health Policy for Advanced Practice: Core Knowledge

F

or the advanced practice nurse, understanding the system in which one works is an essential foundation for successful practice. In acting simultaneously as an advocate for the consumer and as a provider and manager of care, nurses in advanced practice need basic knowledge of the following topics: The structure, operations, scope, and characteristics of the healthcare delivery system The means by which the healthcare delivery system is financed, including national healthcare expenditures and sources of payment The trends that will influence the future of the system The ways in which nurses can influence healthcare policy and, conversely, the ways in which policy influences practice The information provided in Part 2 can help the reader move beyond the perspective of the nursing profession to a broader understanding of the healthcare organization, relationships with other members of the interdisciplinary team, and the forces that affect current and future practices. The ultimate goal is to prepare the reader as an advanced practice nurse to provide high-quality, cost-effective care; to participate in the design and implementation of programs in a variety of systems; and to assume leadership for practice changes. New chapters were selected to prepare the advanced practice nurse with necessary change skills to influence policy makers and increase their understanding of the business side of health care. Guidance on specific health policy activities such as effective lobbying and developing written and oral testimony are included.

Typically, advanced practice nurses are not savvy when it comes to business and finance so a chapter on healthcare business essentials was added. The advanced practice nurse needs to understand budgeting, staffing ratios, and cost containment related to effective care delivery. In reviewing the information provided in this part, it is helpful to think of the issues as constituting a triad of cost, quality, and access. Any change to correct an issue in one component will have a significant and possibly negative effect on the other two. For instance, with the implementation of the Affordable Care Act, millions more citizens are insured and have access to health care, so costs may increase as a result of increased demands on the system, and these cost increases may in turn affect quality if healthcare organizations are not funded properly. The chapters in Part 2 were selected from several books. Chapter 7 is an introductory chapter in Delivering Health Care in America: A Systems Approach by Shi and Singh (Jones & Bartlett Learning, 2019). This chapter provides a foundation for understanding the healthcare delivery system. The authors paint a realistic—albeit gloomy—portrait of a complex, massive healthcare “system” in the United States. Because of the diversity of stakeholders in the U.S. healthcare system, including multiple providers, multiple payers, and the government, they suggest revolutionary changes in health care will be difficult, if not impossible, to achieve in this country. Chapter 8 was selected to give an overview of the major concepts of the regulation of health professionals, with emphasis on the oversight of advanced practice nurses who provide direct patient care. Understanding the process of licensure and credentialing and their effects on the practice of advanced practice nursing is fundamental to practicing as a competent practitioner. In this chapter, Loversidge reviews the historical roots of the regulation of advanced practice nursing at state and federal levels and provides the reader with the tools to navigate the regulatory process and become a confident spokesperson for issues critical to all advanced practice nurses. In Chapter 9 Mund offers specific insight on how advanced practice nurses can influence healthcare policy and advocate for the health care of their patients. The author points out that nurse practitioners are content experts and have the ability to advocate for the profession of nursing while shaping the healthcare agenda. Development of a policy brief, movement of a bill, and coalition building are discussed. Chapter 10, “Healthcare Business Essentials: A

Primer for Advanced Practice Nurses,” provides the reader with an understanding of operating budgets, revenue budgets, expense budgets, and capital budgets. In Chapter 11, Leger and Schultz introduce the reader to microeconomics. This is not an easy read, as much of the information and language is new to most advanced practice nurses. However, the information provided will ensure the reader in viewing health care from an economic perspective. Although the discussion uses hospitals as an example, the basic principles of competition, regulation, and the profit motive apply to any healthcare organization keeping in mind that advanced practice nurses are being called up to develop business cases to start new programs as well as to become entrepreneurs in their own right.

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CHAPTER 7 An Overview of U.S. Healthcare Delivery Leiyu Shi and Douglas A. Singh

CHAPTER OBJECTIVES 1. 2. 3. 4. 5.

Understand the basic nature of the U.S. healthcare system. Outline the key functional components of a healthcare delivery system. Obtain a basic overview of the Affordable Care Act. Discuss the primary characteristics of the U.S. healthcare system. Realize the importance of healthcare practitioners’ and managers’ understanding of the intricacies of the healthcare delivery system. 6. Acquire an overview of healthcare systems in selected countries. 7. Recognize global health challenges and reform efforts. 8. Describe the systems model as a framework for studying the healthcare system in the United States.

Introduction The United States has a unique system of healthcare delivery that is unlike any other healthcare system in the world. Almost all other developed countries have national health insurance programs run by the government and financed through general taxes. Nearly all citizens in such countries are entitled to receive healthcare services. Such is not yet the case in the United States, where Americans are not automatically covered by health insurance. Although U.S. health care is often called a system because it has various features, components, and services, it may be misleading to talk about the American healthcare delivery system because a true, cohesive system does not exist (Wolinsky, 1988). Indeed, a major feature of the U.S. healthcare system is its fragmented nature, as different people obtain health care through different means. The system has continued to undergo periodic changes, mainly in response to concerns regarding costs, access, and quality.

The U.S. healthcare delivery system is a behemoth that is almost impossible for any single entity

to manage and control.

Description Describing healthcare delivery in the United States can be a daunting task. To facilitate an understanding of the structural and conceptual basis for the delivery of healthcare services, this discussion is organized according to the systems framework presented at the end of this chapter. Also, for the sake of simplicity, the mechanisms of healthcare delivery in the United States are collectively referred to as a system throughout this chapter. The main objective of this chapter is to provide a broad understanding of how health care is delivered in the United States. Examples of how health care is delivered in other countries are also presented for the sake of comparison. The overview presented here introduces the reader to several concepts discussed more extensively in later chapters.

An Overview of the Scope and Size of the System TABLE 7-1 demonstrates the complexity of healthcare delivery in the United

States. Many organizations and individuals are involved in health care: educational and research institutions, medical suppliers, insurers, payers, and claims processors to healthcare providers, to name just a few. A multitude of providers are involved in the delivery of preventive, primary, subacute, acute, auxiliary, rehabilitative, and continuing care. A large number of managed care organizations (MCOs) and integrated networks now provide a continuum of care, covering many of the service components. TABLE 7-1 The Complexity of U.S. Healthcare Delivery

Description

The U.S. healthcare delivery system is massive, with total employment that exceeded 16.4 million people in 2010 in various health delivery settings. This number included more than 838,000 professionally active doctors of medicine (MDs), 70,480 osteopathic physicians (DOs), and 2.6 million active nurses (U.S. Census Bureau, 2012). The majority of healthcare and health services professionals (5.98 million) work in ambulatory health service settings, such as the offices of physicians, dentists, and other health practitioners; medical and diagnostic laboratories; and home healthcare service locations. Smaller proportions of these professionals are employed by hospitals (4.7 million) and nursing and residential care facilities (3.13 million). The vast array of healthcare institutions in the United States includes approximately 5,795 hospitals, 15,700 nursing homes, and 13,337 substance abuse treatment facilities (U.S. Census Bureau, 2012). In 2015, 1,375 federally qualified health center grantees, with 188,851 full-time employees, provided preventive and primary care services to approximately 24.3 million people living in medically underserved rural and urban areas (Health Resources and Services Administration [HRSA], 2015). Various types of healthcare professionals are trained in 180 medical and osteopathic schools (Association of American Medical Colleges, 2017), 66 dental schools (American Dental Association, 2017), 136 schools of pharmacy (American Association of Colleges of Pharmacy, 2017), and more than 1,500 nursing programs located throughout the country. Multitudes of government agencies are involved with the financing of health care, medical research, and regulatory oversight of the various aspects of the healthcare delivery system.

A Broad Description of the System U.S. healthcare delivery does not function as a rational and integrated network of components designed to work together coherently. To the contrary, it is a kaleidoscope of financing, insurance, delivery, and payment mechanisms that remain loosely coordinated. Each of these basic functional components represents an amalgam of public (government) and private sources. Government-run programs finance and insure health care for select groups of people who meet each program’s prescribed criteria for eligibility. To a lesser degree, government programs also deliver certain healthcare services directly to certain recipients, such as veterans, military personnel, American Indians/Alaska Natives, and some uninsured people. Nevertheless, the financing, insurance, payment, and delivery functions largely remain in private hands. The market-oriented economy in the United States attracts a variety of private entrepreneurs that pursue profits by facilitating the key functions of healthcare delivery. Employers purchase health insurance for their employees through private sources, and employees receive healthcare services delivered by the private sector. The government finances public insurance through Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP) for a significant portion of the country’s low-income, elderly, disabled, and pediatric populations. However, insurance arrangements for many publicly insured people are made through private entities, such as health maintenance organizations (HMOs), and healthcare services are rendered by private physicians and hospitals. This blend of public and private involvement in the delivery of health care has resulted in the following characteristics of the U.S. system: A multiplicity of financial arrangements for healthcare services Numerous insurance agencies or MCOs that employ various mechanisms for insuring against risk Multiple payers that make their own determinations regarding how much to pay for each type of service

A diverse array of settings where medical services are delivered Numerous consulting firms offering expertise in planning, cost containment, electronic systems, quality, and restructuring of resources There is little standardization in a system that is functionally fragmented and in which the various system components fit together only loosely. Because a central agency, such as the government, does not oversee the overall coordination of such a system, problems of duplication, overlap, inadequacy, inconsistency, and waste occur. Lack of system-wide planning, direction, and coordination leads to a complex and inefficient system. Moreover, the system as a whole does not lend itself to standard budgetary methods of cost control. Individual and corporate entities within a predominantly private entrepreneurial system seek to manipulate financial incentives to their own advantage, without regard to their impact on the system as a whole. Hence, cost containment remains an elusive goal. In short, the U.S. healthcare delivery system is like a behemoth that is almost impossible for any single entity to manage or control. The United States consumes more healthcare services as a proportion of its total economic output than any other country in the world. The U.S. economy is the largest in the world, and compared to other nations, consumption of healthcare services in the United States represents a greater proportion of the country’s total economic output. Although the system can be credited for delivering some of the best clinical care in the world, it falls short of delivering equitable services to every American. It certainly fails in terms of providing cost-efficient services. An acceptable healthcare delivery system should have two primary objectives: (1) enable all citizens to obtain needed healthcare services, and (2) ensure that services are cost effective and meet certain established standards of quality. Although the U.S. healthcare delivery system falls short of both these basic ideals, the United States leads the world in providing the latest and the best in medical technology, training, and research. It offers some of the most sophisticated institutions, products, and processes of healthcare delivery.

Basic Components of a Healthcare Delivery System FIGURE 7-1 illustrates that a healthcare delivery system incorporates four

functional components: financing, insurance, delivery, and payment; hence, it is termed a quad-function model. Healthcare delivery systems differ depending on the arrangement of these components. The four functions generally overlap, but the degree of overlap varies between private and government-run systems and between traditional health insurance and managed care–based systems. In a government-run system, the functions are more closely integrated and may be indistinguishable. Managed care arrangements also integrate the four functions to varying degrees.

FIGURE 7-1 Basic healthcare delivery functions.

Description

Financing Financing is necessary to obtain health insurance or to pay for healthcare services. For most privately insured Americans, health insurance is employment based; that is, the employers finance health care as a fringe benefit for their employees. A dependent spouse or children may also be covered by the working spouse’s or working parent’s employer. Most

employers purchase health insurance for their employees through an MCO or an insurance company selected by the employer. Small employers may or may not be in a position to afford health insurance coverage for their employees. In public programs, the government functions as the financier; the insurance function may be carved out to an HMO.

Insurance Insurance protects the insured against financial catastrophe by providing expensive healthcare services when needed. The insurance function determines the package of health services that the insured individual is entitled to receive. It specifies how and where healthcare services may be received. The MCO or insurance company also functions as a claims processor and manages the disbursement of funds to the healthcare providers.

Delivery The term delivery refers to the provision of healthcare services by various providers. The term provider refers to any entity that delivers healthcare services and either independently bills for those services or is supported through tax revenues. Common examples of providers include physicians, dentists, optometrists, and therapists in private practices, hospitals, and diagnostic and imaging clinics, and suppliers of medical equipment (e.g., wheelchairs, walkers, ostomy supplies, oxygen). With few exceptions, most providers render services to people who have health insurance, and even those covered under public insurance programs receive healthcare services from private providers.

Payment The payment function deals with reimbursement to providers for services delivered. The insurer determines how much is paid for a certain service. Funds for actual disbursement come from the premiums paid to the MCO or insurance company. At the time of service, the patient is usually required to pay an out-of-pocket amount, such as $25 or $30, to see a physician. The remainder is covered by the MCO or insurance company.

In government insurance plans, such as Medicare and Medicaid, tax revenues are used to pay providers.

Insurance and Healthcare Reform The U.S. government finances health benefits for certain special populations, including government employees, the elderly (people ages 65 years and older), people with disabilities, some people with very low incomes, and children from low-income families. The program for the elderly and certain disabled individuals, which is administered by the federal government, is called Medicare. The program for the indigent, which is jointly administered by the federal government and state governments, is named Medicaid. The program for children from lowincome families, another federal/state partnership, is called the Children’s Health Insurance Program (CHIP). However, the predominant employment-based financing system in the United States has left some employed individuals uninsured for two main reasons. First, some small businesses simply cannot get group insurance at affordable rates and, therefore, are not able to offer health insurance as a benefit to their employees. Second, in some work settings, participation in health insurance programs is voluntary, so employees are not required to join. Some employees choose not to sign up, mainly because they cannot afford the cost of health insurance premiums. Employers rarely pay 100% of the insurance premium; instead, most require their employees to pay a portion of the cost. This is called premium cost sharing. Self-employed people and other individuals who are not covered by employer-based plans have to obtain health insurance on their own. Individual rates are typically higher than group rates available to employers. In the United States, working people earning low wages have been the most likely to be uninsured because most cannot afford premium cost sharing and are not eligible for public benefits. In the U.S. context, healthcare reform refers to the expansion of health insurance to cover the uninsured—those without private or public health insurance coverage. The Patient Protection and Affordable Care Act of 2010, more commonly known as the Affordable Care Act (ACA), was the most sweeping healthcare reform in recent U.S. history. One of the main objectives of the ACA was to reduce the number of uninsured.

The ACA was rolled out gradually starting in 2010, when insurance companies were mandated to start covering children and young adults younger than age 26 under their parents’ health insurance plans. Most other insurance provisions went into effect on January 1, 2014, except for a mandate for employers to provide health insurance, which was postponed until 2015. The ACA required that all U.S. citizens and legal residents must be covered by either public or private insurance. The law also relaxed standards to qualify additional numbers of people for Medicaid, although many states chose not to implement the Medicaid expansion based on a 2012 ruling by the U.S. Supreme Court. Individuals without private or public insurance had to obtain health insurance from participating insurance companies through Web-based, government-run exchanges; if they failed to do so, they had to pay a tax. The exchanges—also referred to as health insurance marketplaces— would determine whether an applicant qualified for Medicaid or CHIP programs. If an applicant did not qualify for a public program, the exchange would enable the individual to purchase a governmentapproved health plan offered by private insurers through the exchange. Federal subsidies enabled low-income people to partially offset the cost of health insurance. A predictive model developed by Parente and Feldman (2013) estimated that, at best, full implementation of the ACA would reduce the number of uninsured by more than 20 million. Nevertheless, by its own design, the ACA failed to achieve universal coverage that would enable all citizens and legal residents to have health insurance. Possible future scenarios for healthcare reform are discussed later in this text. By March 2015, approximately 16.5 million uninsured Americans had gained health insurance coverage due to the Affordable Care Act (“Impact of Obamacare on Coverage,” 2016). By 2016, an estimated 20 million had gained coverage (Uberoi et al., 2016), and by 2017, 31 states and the District of Columbia had expanded Medicaid through the ACA’s provisions (Kaiser Family Foundation, 2017). By March 2016, states that had expanded Medicaid experienced an 8.1% decline in their uninsured rate (from 18.2% to 10.1%). States that had not expanded Medicaid experienced a comparably smaller decline of 7.3%—from 23.4% to 16.1% (“Impact of Obamacare on Coverage,” 2016). The uninsured rate declined among all race/ethnicity categories, with the greatest decreases

seen among African Americans and Hispanics, compared to whites (Uberoi et al., 2016). The uninsured rate declined from 22.4% to 10.6% among African Americans, from 41.8% to 30.5% among Hispanics, and from 14.3% to 7.0% among whites (Uberoi et al., 2016). In addition, females experienced a greater decline in their uninsured rate (49.7% decline) compared to males (37.6% decline). Specifically, the uninsured rate among females decreased from 18.9% to 9.5%, whereas the uninsured rate among males decreased from 21.8% to 13.6% (Uberoi et al., 2016). Despite these gains, however, the ACA left more than 27.3 million Americans uninsured in 2016 (Cohen et al., 2016). During his first week in office in January 2017, President Donald Trump signed an executive order to repeal and replace the ACA (commonly referred to as Obamacare) in an effort to minimize the ACA’s economic and regulatory burdens and to waive any requirement imposing a fiscal burden on states or families, individuals, healthcare providers, insurers, or other parties.

Role of Managed Care Under traditional insurance, the four basic health delivery functions have been fragmented; with few exceptions, the financiers, insurers, providers, and payers have been different entities. However, during the 1990s, healthcare delivery in the United States underwent a fundamental change involving a tighter integration of the basic functions through managed care. Previously, fragmentation of the four functions meant a lack of control over utilization and payments. The quantity of health care consumed refers to utilization of health services. Traditionally, determination of the utilization of health services and the price charged for each service had been left up to the insured individuals and the providers of health care. However, due to rising healthcare costs, current delivery mechanisms have instituted some controls over both utilization and price. Managed care is a system of healthcare delivery that (1) seeks to achieve efficiency by integrating the four functions of healthcare delivery discussed earlier; (2) employs mechanisms to control (manage) utilization of medical services; and (3) determines the price of services and, consequently, how much the providers are paid. The primary financier is still the employer or the government. Instead of purchasing health insurance through a traditional insurance company, the employer contracts with an MCO, such as an HMO or a preferred provider organization (PPO), to offer a selected health plan to its employees. In this case, the MCO functions like an insurance company and promises to provide healthcare services contracted under the health plan to the enrollees of the plan. The term enrollee (member) refers to the individual covered under the plan. The contractual arrangement between the MCO and the enrollee—including the collective array of covered health services that the enrollee is entitled to—is referred to as the health plan (or “plan,” for short). The health plan uses selected providers from whom the enrollees can choose to receive services. Compared with health services delivery under fee-for-service plans, managed care was successful in accomplishing cost control and greater integration of healthcare delivery. By ensuring access to needed health

services, emphasizing preventive care, and maintaining a broad provider network, managed care can implement effective cost-saving measures without compromising access and quality, thereby achieving a healthcare budget predictability unattainable by other kinds of healthcare delivery.

Major Characteristics of the U.S. Healthcare System In any country, certain external influences shape the basic character of the health services delivery system. These forces consist of a national political climate, economic development, technological progress, social and cultural values, physical environment, population characteristics (i.e., demographic and health trends), and global influences (FIGURE 7-2). The combined interaction of these environmental forces influences the course of healthcare delivery.

FIGURE 7-2 External forces affecting healthcare delivery.

Description

Ten basic characteristics differentiate the U.S. healthcare delivery system from most other countries: 1. No central agency governs the system. 2. Access to healthcare services is selectively based on insurance coverage. 3. Health care is delivered under imperfect market conditions. 4. Insurers from a third party act as intermediaries between the financing and delivery functions. 5. The existence of multiple payers makes the system cumbersome. 6. The balance of power among various players prevents any single entity from dominating the system. 7. Legal risks influence the practice behavior of physicians. 8. Development of new technology creates an automatic demand for its use. 9. New service settings have evolved along a continuum. 10. Quality is no longer accepted as an unachievable goal.

No Central Agency Unlike healthcare systems in most developed nations, the U.S. healthcare system is not administratively controlled by a department or agency. Most other developed nations have a national healthcare program in which citizens are entitled to receive a defined set of healthcare services. To control costs, these systems use global budgets that determine total healthcare expenditures on a national scale and allocate resources within budgetary limits. As a consequence, both availability of services and payments to providers are subject to such budgetary constraints. The governments of these nations also control the proliferation of healthcare services, especially costly medical technology. System-wide controls over the allocation of resources determine the extent to which government-sponsored healthcare services are available to citizens. For instance, the availability of specialized services is restricted. By contrast, the United States has a mainly private system of financing and delivery. Private financing, predominantly through employers, accounts for approximately 52% of total healthcare expenditures; the government finances the remaining 48% (Centers for

Medicare and Medicaid, 2015). Private delivery of health care means that the majority of hospitals and physician clinics are private businesses, which are independent of the government. No central agency monitors total expenditures through global budgets or controls the availability and utilization of services. Nevertheless, federal and state governments play important roles in healthcare delivery. They determine public-sector expenditures and reimbursement rates for services provided to Medicare, Medicaid, and CHIP beneficiaries. The federal government also formulates standards of participation through health policy and regulation, meaning providers must comply with the standards established by the government to be certified to provide services to Medicare, Medicaid, and CHIP beneficiaries. Certification standards are regarded as minimum standards of quality in most sectors of the healthcare industry.

Partial Access Access means the ability of an individual to obtain healthcare services when needed, which is not the same as having health insurance. Americans can access healthcare services if they (1) have health insurance through their employers; (2) are covered under a government healthcare program; (3) can afford to buy insurance with their own private funds; (4) are able to pay for services privately; or (5) can obtain charity or subsidized care. Health insurance is the primary means for ensuring access. Although the uninsured can access certain types of services, they often encounter barriers to obtaining needed health care. For example, although federally supported health centers provide physician services to anyone regardless of ability to pay, such centers and free clinics are located only in certain geographic areas and provide limited specialized services. However, under U.S. law, hospital emergency departments (EDs) are required to evaluate a patient’s condition and to render medically needed services for which the hospital does not receive any direct payments unless the patient is able to pay. Therefore, even the uninsured are able to obtain medical care for acute illness. Although one can say that the United States does have a form of universal catastrophic health insurance, it does not guarantee the uninsured access to continual basic and routine care, commonly referred to as primary care (Altman and Reinhardt, 1996).

Countries with national healthcare programs provide universal coverage. However, even in these countries, access to services may be restricted because no healthcare system has the capacity to deliver every type of service on demand. Hence, universal access—the ability of all citizens to obtain health care when needed—remains mostly a theoretical concept. As previously mentioned, having coverage does not necessarily equate to having access. The cost of insurance and care, as well as availability of services, have continued to present barriers to receiving healthcare services in a timely manner.

Imperfect Market Although the U.S. healthcare delivery system is largely in private hands, this system is only partially governed by free-market forces. The delivery and consumption of health care in the United States does not quite pass the basic test of a free market, so the system is best described as a quasimarket or an imperfect market. In a free market, patients (buyers) and providers (sellers) act independently, with patients able to choose services from any provider. Providers do not collude to fix prices, and prices are not fixed by an external agency. Rather, prices are governed by the free and unencumbered interaction of the forces of supply and demand (FIGURE 73). Demand—the quantity of health care purchased—is driven by the prices prevailing in the free market. Under free-market conditions, the quantity demanded will increase as the price is lowered for a given product or service. Conversely, the quantity demanded will decrease as the price increases.

FIGURE 7-3 Relationship among price, supply, and demand under free-market conditions.

Description Note: Under free-market conditions, there is an inverse relationship between the quantity of medical services demanded and the price of medical services. That is, quantity demanded goes up when the prices go down and vice versa. In contrast, there is a direct relationship between price and the quantity supplied by the providers of care. In other words, providers are willing to supply higher quantities at higher prices and vice versa. In a free market, the quantity of medical care that patients are willing to purchase, the quantity of medical care that providers are willing to supply, and the price reach a state of equilibrium. This equilibrium is achieved without the interference of any nonmarket forces. It is important to keep in mind that these conditions exist only under free-market conditions, which are not characteristic of the U.S. healthcare market. At first glance, it might appear that multiple patients and providers do

exist. Most patients, however, are now enrolled in either a private health plan or one or more government-sponsored programs. These plans act as intermediaries for the patients, and the enrollment of patients into health plans has the effect of shifting the power from the patients to the administrators of the plans. The result is that the health plans—not the patients—are the real buyers in the healthcare services market. Private health plans, in many instances, offer their enrollees a limited choice of providers rather than an open choice. Theoretically, prices are negotiated between the payers and the providers. In practice, prices are determined by payers, such as MCOs, Medicare, and Medicaid. Because prices are set by agencies external to the market, they are not governed by the unencumbered forces of supply and demand. For the healthcare market to be free, unrestrained competition must occur among providers based on price and quality. However, the consolidation of buying power in the hands of private health plans has been forcing providers to form alliances and integrated delivery systems on the supply side. In certain geographic sectors of the country, a single giant medical system has taken over as the sole provider of major healthcare services, restricting competition. As the overall healthcare system continues to move in this direction, it appears that only in large metropolitan areas will there be more than one large integrated system competing to get the business of the health plans. A free market requires that patients have information about the appropriateness of various services to their needs. Such information is difficult to obtain because technology-driven medical care has become highly sophisticated. Knowledge about new diagnostic methods, intervention techniques, and more effective drugs fall in the domain of the professional physician, not the patient. Moreover, because medical interventions are commonly required in a state of urgency, patients have neither the skills nor the time and resources to obtain accurate information when needed. Channeling all healthcare needs through a primary care provider can reduce this information gap when the primary care provider acts as the patient’s advocate or agent. In recent years, consumers have been seizing some measure of control over the flow of information: The Internet is becoming a prominent source of medical information for patients, and medical advertising is influencing consumer

expectations. In a free market, patients must directly bear the cost of services received. The purpose of insurance is to protect against the risk of unforeseen catastrophic events. Because the fundamental purpose of insurance is to reimburse major expenses when unlikely events occur, having insurance for basic and routine health care undermines the principle of insurance. When you buy home insurance to protect your property against the unlikely event of a fire, you do not anticipate the occurrence of a loss. The probability that you will suffer a loss by fire is very small. If a fire does occur and cause major damage, insurance will cover the loss, but insurance does not cover routine wear and tear on the house, such as chipped paint or a leaky faucet. However, unlike other types of insurance, health insurance generally covers basic and routine services that are predictable. Coverage for minor services, such as colds and coughs, earaches, and so forth, amounts to prepayment for such services. In this sense, health insurance has the effect of insulating patients from the full cost of health care. This situation may also create a moral hazard in that, once enrollees have purchased health insurance, they may use more healthcare services than if they were to pay for these services on an out-of-pocket basis. At least two additional factors limit the ability of patients to make decisions in the healthcare system. First, decisions about the utilization of health care are often determined by need rather than by price-based demand. Need has been defined as the amount of medical care that medical experts believe a person should have to remain or become healthy (Feldstein, 1993). Second, the delivery of health care can result in demand creation. This follows from self-assessed need, which, coupled with moral hazard, leads to greater utilization, creating an artificial demand because prices are not taken into consideration. Practitioners who have a financial interest in additional treatments also create artificial demand (Hemenway and Fallon, 1985). This is referred to as provider-induced demand, or supplier-induced demand. Functioning as patients’ agents, physicians exert enormous influence on the demand for healthcare services (Altman and Wallack, 1996). Demand creation occurs when physicians prescribe medical care beyond what is clinically necessary. This can include such practices as making more frequent follow-up appointments than necessary, prescribing excessive medical

tests, or performing unnecessary surgery (Santerre and Neun, 1996). In a free market, patients have information on the price and quality of each provider. The current system, however, has drawbacks that obstruct information-seeking efforts. Item-based pricing is one such hurdle. Surgery is a good example to illustrate item-based (also known as feefor-service) pricing. Patients can generally obtain the fees the surgeon would charge for a particular operation. But the final bill, after the surgery has been performed, is likely to include charges for supplies, use of the hospital’s facilities, and services performed by other providers, such as anesthesiologists, nurse anesthetists, and pathologists. These providers, sometimes referred to as phantom providers, function in an adjunct capacity and bill for their services separately. Item billing for such additional services, which sometimes cannot be anticipated, makes it extremely difficult to ascertain the total price before services have actually been received. Package pricing can help overcome these drawbacks, but it has made relatively little headway for pricing medical procedures. Package pricing refers to a bundled fee for a package of related services. In the surgery example, this would mean one allinclusive price for the surgeon’s fees, hospital facilities, supplies, diagnostics, pathology, anesthesia, and postsurgical follow-up.

Third-Party Insurers and Payers Insurance often functions as the intermediary among those who finance, deliver, and receive health care. The insurance intermediary does not have an incentive to be the patient’s advocate on either price or quality. At best, employees can air their dissatisfactions with the plan to their employer, who has the power to discontinue the current plan and choose another company. In reality, however, employers may be reluctant to change plans if the current plan offers lower premiums than a different plan.

Multiple Payers A national healthcare system is sometimes also referred to as a singlepayer system because there is one primary payer, the government. When delivering services, providers send the bill to a government agency that

subsequently sends payments to each provider. By contrast, the United States has a multiplicity of health plans. Multiple payers often represent a billing and collection nightmare for the providers of services. Multiple payers make the system more cumbersome in several ways: It is extremely difficult for providers to keep tabs on numerous health plans. It is challenging for providers to keep up with which services are covered under each plan and how much each plan will pay for those services. Providers must hire claims processors to bill for services and monitor receipt of payments. Billing practices are not standardized, and each payer establishes its own format. Payments can be denied for not precisely following the requirements set by each payer. Denied claims necessitate rebilling. When only partial payment is received, some health plans may allow the provider to balance bill the patient for the amount the health plan did not pay, the difference between provider charges and insurance payment. Other plans prohibit balance billing. Even when the balance billing option is available to the provider, it triggers a new cycle of billing and collection efforts. Providers must sometimes engage in lengthy collection efforts, including writing collection letters, turning delinquent accounts over to collection agencies, and finally writing off as bad debt amounts that cannot be collected. Government programs have complex regulations for determining whether payment is made for services actually delivered. Medicare, for example, requires that each provider maintain lengthy documentation on services provided. Medicaid is known for lengthy delays in paying providers. It is generally believed that the United States spends far more on administrative costs—costs associated with billing, collections, bad debts, and maintaining medical records—than do the national healthcare systems in other countries.

Power Balancing

The U.S. healthcare system involves multiple players, not just multiple payers. The key players in the system have traditionally been physicians, administrators of health service institutions, insurance companies, large employers, and the government. Big business, labor, insurance companies, physicians, and hospitals make up the powerful and politically active special-interest groups represented before lawmakers by high-priced lobbyists. Each set of players has its own economic interests to protect. Physicians, for instance, want to maintain their incomes and have minimum interference with the way they practice medicine; institutional administrators seek to maximize reimbursement from private and public insurers; insurance companies and MCOs are interested in maintaining their share of the health insurance market; large employers want to contain the costs they incur providing health insurance to their employees; the government tries to maintain or enhance existing benefits for those covered under public insurance programs and simultaneously contain the cost of providing these benefits. The problem is that the selfinterests of different players are often at odds. For example, providers seek to increase government reimbursement for services delivered to Medicare, Medicaid, and CHIP beneficiaries, but the government wants to contain cost increases. Employers dislike rising health insurance premiums. Health plans, under pressure from the employers, may limit fees for the providers, who then resent these cuts. The fragmented self-interests of the various players produce competing forces within the system. In an environment that is rife with motivations to protect conflicting self-interests, achieving comprehensive system-wide reform has been next to impossible, and cost containment has remained a major challenge. Consequently, the approach to healthcare reform in the United States has been characterized as incremental or piecemeal, and the focus of reform initiatives has been confined to health insurance coverage and payment cuts to providers rather than focusing on the better provision of health care.

Litigation Risks The United States is a litigious society. Motivated by the prospects of enormous jury awards, many Americans are quick to drag an alleged offender into a courtroom at the slightest perception of incurred harm.

Private healthcare providers, too, have become increasingly susceptible to litigation, and the risk of malpractice lawsuits is a real consideration in the practice of medicine. To protect themselves against the possibility of litigation, practitioners may engage in what is referred to as defensive medicine by prescribing additional diagnostic tests, scheduling return checkup visits, and maintaining copious documentation. Many of these additional efforts may be unnecessary, costly, and inefficient.

High Technology The United States has been the hotbed of research and innovation in new medical technology. Growth in science and technology often creates demand for new services, despite shrinking resources to finance sophisticated care. People generally equate high-tech care with highquality care. They want the latest and the best, especially when health insurance will pay for new treatments. Physicians and technicians want to try the latest gadgets. Hospitals compete on the basis of having the most modern equipment and facilities. Once capital investments in these new services are made, those costs must be recouped through utilization. Legal risks for providers and health plans may also play a role in discouraging denial of new technology. Thus, several factors promote the use of costly new technology once it is developed.

Continuum of Services Medical care services are classified into three broad categories: curative (i.e., drugs, treatments, and surgeries), restorative (e.g., physical, occupational, and speech therapies), and preventive (i.e., prenatal care, mammograms, and immunizations). Healthcare settings are no longer confined to the hospital and the physician’s office. Additional settings, such as home health, subacute care units, and outpatient surgery centers, have emerged in response to the changing configuration of economic incentives. TABLE 7-2 describes the continuum of healthcare services. The healthcare continuum in the United States remains lopsided, with a heavier emphasis on specialized services than on preventive services, primary care, and management of chronic conditions.

TABLE 7-2 The Continuum of Healthcare Services Types of Health Services

Delivery Settings

Preventive care

Public health programs Community programs Personal lifestyles Primary care settings

Primary care

Physician’s office or clinic Community health centers Self-care Alternative medicine

Specialized care

Specialist provider clinics

Chronic care

Primary care settings Specialist provider clinics Home health Long-term care facilities Self-care Alternative medicine

Long-term care

Long-term care facilities Home health

Subacute care

Special subacute units (hospitals, long-term care facilities) Home health Outpatient surgical centers

Acute care

Hospitals

Rehabilitative care

Rehabilitation departments (hospitals, long-term care facilities) Home health Outpatient rehabilitation centers

End-of-life care

Hospice services provided in a variety of settings

Description

Quest for Quality

Even though the definition and measurement of quality in health care are not as clear cut as they are in other industries, the delivery sector of health care has come under increased pressure to develop quality standards and demonstrate compliance with those standards. There are higher expectations for improved health outcomes at the individual and community levels. The concept of continual quality improvement has also received much emphasis in managing healthcare institutions.

Trends and Directions Since the 1980s, the U.S. healthcare delivery system has continued to undergo fundamental shifts in emphasis, as summarized in FIGURE 7-4.

FIGURE 7-4 Trends and directions in healthcare delivery.

Description These trends have been primarily driven by the desire to promote health while reducing costs. An example of a fundamental shift is the concept of health itself. Health is now increasingly seen as the presence of wellness rather than as solely the absence of illness. Such a change requires new methods for wellness promotion, although the treatment of illness remains the primary goal of the healthcare delivery system. The ACA had partially shifted the focus from disease treatment to disease prevention, better health outcomes for individuals and communities, and

lower healthcare costs. At present, the greatest challenge to the U.S. healthcare system is the quest to control costs while still meeting the increasing healthcare demands of an aging population, a population with more chronic diseases and comorbidities. This is challenging because patients are more informed about high-tech discoveries while economic conditions are also more uncertain. In response, players in the healthcare system have been moving toward providing more effective and efficient quality care. Recent trends have focused more on delivery of services by midlevel health professionals and health coaches as well as use of health information technology (HIT). However, the healthcare system continues to face challenges related to managing costs, focusing on care delivery, adopting new technologies, delivering new operating models, and meeting various federal and state regulations (Deloitte, 2019). Patients with multiple chronic conditions use the most health services, and each chronic condition increases costs by a factor of three (DeVore, 2014). Managing chronic diseases has been a major focus of efforts to control healthcare costs. Chronic care models, patient-centered care, and continuous care are being implemented as a means to improve healthcare delivery performance, quality, and patient health outcomes. In particular, patient-centered medical homes (PCMHs) and ambulatory intensive care units (A-ICUs) are being incorporated into accountable care organizations (ACOs). The main objective in establishing these programs is to better manage chronic conditions exclusively within a “clinically integrated, financially accountable primary care practice” (DeVore, 2014, para. 3). Ultimately, providers hope these measures can address behavioral health needs, lower hospital utilization rates, decrease inpatient bed days, shorten lengths of stay, limit admissions and readmissions, and minimize ED visits. Midlevel healthcare professionals and health coaches are important for managing chronic conditions and reducing costs. Health coaches, for example, complement medical professionals by getting to know patients through one-on-one contact and can keep the clinical staff apprised of financial struggles, issues with housing, family concerns, or other obstacles that may stand in the way of the patient following a prescribed care plan (DeVore, 2014). Health coaches do not need a medical degree, can be recruited from various professional backgrounds, and help

improve the effectiveness and efficiency of care. Similarly, HIT has helped improve access to information and, consequently, health. The market for telemedicine and remote monitoring applications was estimated to double from $11.6 billion in 2011 to $27.3 billion in 2016 (DeVore, 2014). This growth is in part driven by the increased demands for care owing to expansion of insurance coverage through the ACA; the health system may not have the capacity to treat each individual in person. For example, the Johns Hopkins Hospital at Home program delivers acute care services at the homes of patients with chronic illnesses who might otherwise need inpatient care. In this way, HIT also increases access to care, particularly for patients living in rural areas where distance to the closest hospital is a major barrier. Electronic health records (EHRs) have helped provide clinical measures and decision support tools, enabled providers to automate processes to reduce redundancy, and captured more clinical data (DeVore, 2014). Trends toward greater interoperability of health information systems, along with open source interfaces, will allow for greater transparency, increased availability of data, and more creative use of data.

Significance for Healthcare Practitioners An understanding of the intricacies within the health services system would be beneficial to all those who come in contact with the system. In their respective training programs, health professionals, such as physicians, nurses, technicians, therapists, dietitians, and pharmacists, may understand their own individual clinical roles but remain ignorant of the forces outside their profession that could significantly impact both current and future clinical practices. An understanding of the healthcare delivery system can attune health professionals to their relationship with the rest of the healthcare environment. It can help them understand changes and the impact of those changes on their own practice. Adaptation and relearning are strategies that can prepare health professionals to cope with an environment that will see ongoing change long into the future, particularly as the U.S. healthcare system is expected to further evolve under subsequent efforts to reform the system.

Significance for Healthcare Managers An understanding of the healthcare system has specific implications for both private and public health services managers, who must understand the macro environment in which they make critical planning and management decisions. Such decisions will ultimately affect the efficiency and quality of services delivered. The interactions between the system’s key components and the implications of these interactions must be well understood because the operations of healthcare institutions are strongly influenced, either directly or indirectly, by the financing of health services, reimbursement rates, insurance mechanisms, delivery modes, new statutes and legal opinions, and government regulations. For the foreseeable future, the environment of healthcare delivery will remain fluid and dynamic. The viability of delivery and the success of healthcare managers often depends on how the managers react to the system dynamics. Timeliness of action is often a critical factor that can make the difference between failure and success. Following are some more specific reasons why understanding the healthcare delivery system is indispensable for healthcare managers.

Positioning the Organization Managers need to understand their own organizational positions within the macro environment of the healthcare system. Senior managers, such as chief executive officers, must constantly gauge the nature and impact of the fundamental shifts illustrated in Figure 7-4. Managers need to consider which changes in the current configuration of financing, insurance, payment, and delivery might affect their organization’s longterm stability. Middle and first-line managers also need to understand their roles in the current configuration and how these roles might change in the future. How should resources be realigned to effectively respond to those changes? As an example, managers need to evaluate whether certain functions in their departments must be eliminated, modified, or added. Would the changes involve further training? Which processes are likely to

change, and how? Which steps do the managers need to take to maintain the integrity of their institution’s mission, the goodwill of the patients they serve, and the quality of care? Well-thought-out and appropriately planned changes are likely to cause less turbulence for both the providers and the recipients of care.

Handling Threats and Opportunities Changes in any of the functions of financing, insurance, payment, and delivery can present new threats or opportunities in the healthcare market. Healthcare managers will be more effective if they proactively deal with any threats to their institutions’ profitability and viability. Managers need to find ways to transform certain threats into new opportunities.

Evaluating Implications Managers are better able to evaluate the implications of health policy and new reform proposals when they understand the relevant issues and appreciate how such issues link to the delivery of health services in the establishments they manage. Healthcare reform has brought more individuals into the U.S. healthcare system, creating greater demand for health services. Planning and staffing to ensure that the right mix of healthcare workers are available to meet this anticipated surge in demand are critical.

Planning Senior managers are often responsible for strategic planning regarding which services should be added or discontinued, which resources should be committed to facility expansion, and what should be done with excess capacity. Any long-range planning must take into consideration the current makeup of health services delivery, the evolving trends, and the potential impact of these trends.

Capturing New Markets Healthcare managers will be in a better position to capture new health

services markets if they understand emerging trends in the financing, insurance, payment, and delivery functions. New opportunities must be explored before any newly evolving segments of the market become crowded with competition. An understanding of the dynamics within the system is essential to forging new marketing strategies that will let the institution stay ahead of the competition and, in some cases, find a service niche.

Complying With Regulations Delivery of healthcare services is heavily regulated. Healthcare managers must comply with government regulations, such as standards of participation in government programs, licensing rules, and security and privacy laws regarding patient information, and they must operate within the constraints of reimbursement rates. On a periodic basis, the Medicare and Medicaid programs have made drastic changes to their reimbursement methodologies that have triggered the need for operational changes in the way services are organized and delivered. Private agencies, such as the Joint Commission, also play an indirect regulatory role, mainly in the monitoring of quality of services. Healthcare managers have no choice but to play by the rules set by the various public and private agencies that regulate the healthcare marketplace. Hence, it is paramount that healthcare managers acquaint themselves with the rules and regulations governing their areas of operation.

Following the Organizational Mission Knowledge of the healthcare system and its development is essential for effective management of healthcare organizations. By keeping up to date on community needs, technological progress, consumer demand, and economic prospects, managers can be in a better position to fulfill their organizational missions to enhance access, improve service quality, and achieve efficiency in the delivery of services.

Healthcare Systems of Other Countries Except for the United States, the 25 wealthiest nations in the world all have some form of universal healthcare coverage (Rodin and de Ferranti, 2012). Canada and Western European nations have used three basic models for structuring their national healthcare systems: In a system based on national health insurance (NHI), such as that found in Canada, the government finances health care through general taxes, but the actual care is delivered by private providers. In the context of the quad-function model, NHI requires a tighter consolidation of the financing, insurance, and payment functions coordinated by the government. Delivery is characterized by detached private arrangements. In a national health system (NHS), such as that found in the United Kingdom, in addition to financing a tax-supported NHI program, the government manages the infrastructure for the delivery of medical care. Thus, the government operates most of the country’s medical institutions. Most healthcare providers, such as physicians, either are government employees or are tightly organized in a publicly managed infrastructure. In the context of the quad-function model, NHS requires a tighter consolidation of all four functions. In a socialized health insurance (SHI) system, such as that found in Germany, government-mandated contributions from employers and employees finance health care. Private providers deliver healthcare services. Private, nonprofit insurance companies, called sickness funds, are responsible for collecting the contributions and paying physicians and hospitals (Santerre and Neun, 1996). The insurance and payment functions are closely integrated in an SHI system, and the financing function is better coordinated with the insurance and payment functions than in the United States. Delivery is characterized by independent private arrangements, but the government exercises overall control of the system.

The terms national healthcare program and national health insurance are used generically and interchangeably to refer to any type of government-supported universal health insurance program. Following is a brief discussion of healthcare delivery in selected countries from various parts of the world to illustrate the application of the three models discussed and to provide a sample of the variety of healthcare systems in the world.

Australia In the past, Australia had switched from a universal national healthcare program to a privately financed system. In 1984, it returned to a national program—called Medicare—financed by income taxes and an incomebased Medicare levy. This system is built on the philosophy that everyone should contribute to the cost of health care according to his or her capacity to pay. In addition to carrying Medicare, approximately 49% of Australians carry private health insurance (Australian Government, Department of Health, 2016) to cover gaps in public coverage, such as dental services and care received in private hospitals (Willcox, 2001). Although private health insurance is voluntary, it is strongly encouraged by the Australian government through tax subsidies for purchasers and tax penalties for nonpurchasers (Healy, 2002). Public hospital spending is funded by the government, but private hospitals offer better choices. Costs incurred by patients receiving private medical services, whether in or out of the hospital, are reimbursed in whole or in part by Medicare. Private patients are free to choose and change their doctors. The medical profession in Australia is composed mainly of private practitioners who provide care predominantly on a fee-for-service basis (Hall, 1999; Podger, 1999). In 2011, the Council of Australian Governments (COAG) signed the National Health Reform Agreement, which established the architecture for national health insurance reform. In particular, the agreement provides for more sustainable funding arrangements for Australia’s health system. At the same time, the National Health Reform Act 2011 establishes a new Independent Hospital Pricing Authority and a National Health Performance Authority. The pricing authority determines and publishes the national price for services provided by public hospitals. The

Commonwealth Government determines its contribution to funding public hospitals on the basis of these prices. The performance authority is charged with monitoring and reporting on the performance of local hospital networks, public and private hospitals, primary healthcare organizations, and other bodies or organizations that provide healthcare services. The 2011 act also provides a new statutory framework for the Australian Commission on Safety and Quality in Health Care (Australian Government, 2011). Australia is focused on developing various health service delivery models to contain costs and provide high-quality and accessible care (Brownie et al., 2014). Notably, Australia has encouraged interprofessional practice as a means to enhance socioeconomic development and improve health outcomes (Brownie et al., 2014). The COAG defined new Australian Health Care Agreements (AHCAs), under which each state and territory funds a portion of the public hospital operation costs, commits to providing equitable access to free public hospital services based on clinical need, and agrees to match the rate of growth in the Australian government’s hospital funding (Australian Institute of Health and Welfare, 2017). In addition, Australia has developed a National Primary Health Care Strategy and established a Preventative Health Taskforce to lead its National Preventative Health Strategy (National Preventative Health Taskforce, 2009). The National Primary Health Care Strategy aims to better incentivize prevention, promote evidence-based management of chronic disease, support the role of general practitioners in healthcare teams, encourage a focus on interprofessional team-based care, and address the increased need for access to various health professional, including practice nurses and allied health professionals, such as physiotherapists and dieticians (National Preventative Health Taskforce, 2009). The National Preventative Health Taskforce aims to stop the obesity epidemic, reduce the prevalence of daily smoking to less than 9%, reduce the prevalence of binge consumption and other harmful alcohol consumption habits by 30%, and reduce the 17-year life expectancy gap between indigenous and nonindigenous people by the year 2020 (National Preventative Health Taskforce, 2009). Other health reforms seek to achieve continuity of care, provide high-quality education and training for existing and incoming healthcare workers, and embed a

culture of interprofessional practice (Brownie et al., 2014).

Canada Canada implemented its national health insurance system—referred to as Medicare—under the Medical Care Act of 1966. Medicare consists of 13 provincial and territorial health insurance plans, sharing basic standards of coverage, as defined by the Canada Health Act (Health Canada, 2013). The bulk of financing for Medicare comes from general provincial tax revenues; the federal government provides a fixed amount that is independent of actual expenditures. Public-sector health expenditures account for 70% of the total Canadian healthcare expenditures. The remaining 30% consists of private-sector expenditures, which include household out-of-pocket expenditures, commercial and nonprofit insurance expenditures, and nonconsumption expenditures (Canadian Institute for Health Information, 2012). Many employers also offer private insurance that gives their employees supplemental coverage. Provincial and territorial departments of health have the responsibility to administer medical insurance plans, determine reimbursement for providers, and deliver certain public health services. Provinces are required by law to provide reasonable access to all medically necessary services and to provide portability of benefits from province to province. Patients are free to select their providers (Akaho et al., 1998). According to Canada’s Fraser Institute, specialist physicians surveyed across 12 specialties and 10 Canadian provinces reported a total waiting time of 20.0 weeks between referral from a general practitioner and delivery of treatment in 2016—an increase from 18.3 weeks in 2015. Patients had to wait the longest to undergo neurosurgery (46.9 weeks) (Barua et al., 2016). Nearly all the Canadian provinces—Ontario is one of the exceptions— have resorted to regionalization of healthcare services, through the creation of administrative districts within each province. The objective of regionalization is to decentralize authority and responsibility in order to more efficiently address local needs and to promote citizen participation in healthcare decision making (Church and Barker, 1998). The majority of Canadian hospitals are operated as private nonprofit entities run by

community boards of trustees, voluntary organizations, or municipalities, and most physicians are in private practice (Health Canada, 2013). Most provinces use global budgets and allocate set reimbursement amounts for each hospital. Physicians are paid fee-for-service rates, which are negotiated between each provincial government and medical association (MacPhee, 1996; Naylor, 1999). In 2004, Canada created the 10-Year Plan to Strengthen Health Care, which focuses on problems with wait times, health human resources, pharmaceutical management, EHRs, health innovation, accountability and reporting, public health, and Aboriginal health. Overall, progress has been made in these areas, but the goals have not yet been fully achieved (Health Council of Canada, 2013). Although most Canadians are quite satisfied with their healthcare system, sustaining the current healthcare delivery and financing remains a challenge. Spending on health care has increased dramatically in recent decades, from approximately 7% of program spending at the provincial level in the 1970s to almost 41% in 2015. It is expected to surpass 50% in every province and territory within the next few years (Barua et al., 2016). With global pressure on health reforms, Canada is also transitioning to patient-centered care (Dickson, 2016) but has not implemented major country-wide health reform since 2005 (Health Systems and Policy Monitor [HSPM], 2012). In addition to leadership challenges, two reasons that Canada has been reluctant to reform its health system are (1) resistance from long-standing professional associations and (2) a lack of follow-through from provincial governments (Dickson, 2016). The 2014 version of the Canada Health Act expanded such services as nursing home intermediate care, adult residential care, home care services, and ambulatory care services (Canada Minister and Attorney General, 2016). Other initiatives include collaboration between provincial and territorial governments to purchase drugs in bulk and to cut costs in order to make drugs more affordable to patients and also a program to improve access to high-quality mental health services, particularly for veterans and first responders (Granovsky, 2016).

China

Since the economic reforms initiated in the late 1970s, health care in the People’s Republic of China has undergone significant changes. In urban China, health insurance has evolved from a predominantly public insurance (either government or public enterprise) system to a multipayer system. Government employees are covered under government insurance as a part of their benefits. Employees for public enterprises are largely covered through public enterprise insurance, but the actual benefits and payments vary according to the financial well-being of the enterprises. Employees of foreign businesses or joint ventures are typically well insured through private insurance arrangements. Almost all these plans contain costs through a variety of means, such as experience-based premiums, deductibles, copayments, and health benefit dollars (i.e., preallocated benefit dollars for health care that can be converted into income if not fully used). The unemployed, selfemployed, and employees working for small enterprises (public or private) are largely uninsured. They can purchase individual or family plans in the private market or pay for services out of pocket. In rural China, the New Cooperative Medical Scheme (NCMS), discussed later, has become widespread; it relies on funds pooled from national and local governments as well as private citizens. Although the insurance coverage rate is high (more than 90%) in China, the actual benefits are still very limited. Similarly to the United States, China has been facing the growing problems of a large uninsured population and healthcare cost inflation. Although healthcare funding was increased by 87% in 2006 and 2007, the country has yet to reform its healthcare system into an efficient and effective scheme. Employment-based insurance in China does not cover dependents, nor does it cover migrant workers, leading to high out-ofpocket cost sharing as part of total health spending. Rural areas in China are most vulnerable to poor access to health care because of a lack of true insurance plans and accompanying comprehensive coverage. Healthcare cost inflation is also growing 7% faster than the growth rate for China’s gross domestic product (GDP), which is 16% per year (Yip and Hsiao, 2008). In recent years, healthcare delivery in China has undergone significant changes. The former three-tier referral system (primary, secondary, tertiary) has been largely abolished. Patients can now go to

any hospital of their choice as long as they are insured or can pay out of pocket. As a result, large (tertiary) hospitals are typically overutilized, whereas smaller (primary and secondary) hospitals are underutilized. Use of large hospitals contributes to both escalation of medical costs and greater medical specialization. Major changes in health insurance and delivery have made access to medical care more difficult for the poor, uninsured, and underinsured. Consequently, wide and growing disparities in access, quality, and outcomes are becoming apparent between rural and urban areas and between the rich and the poor. After the severe acute respiratory syndrome (SARS) epidemic in 2003, the Chinese government created an electronic disease-reporting system at the district level. Each district in China now has a hospital dedicated to infectious diseases. However, there are still flaws in this system, particularly in monitoring infectious diseases in the remote localities that comprise some districts (Blumenthal and Hsiao, 2005). To fix some of its problems, the Chinese government has pushed through health reform initiatives in five major areas: health insurance, pharmaceuticals, primary care, public health, and public/community hospitals. For example, it created the New Cooperative Medical Scheme to provide rural areas with a government-run voluntary insurance program. This program is intended to prevent individuals living in these areas from becoming impoverished due to illness or catastrophic health expenses (Yip and Hsiao, 2008). In 2008, a similar program was established in urban areas, called the Urban Resident Basic Medical Insurance scheme. It targets uninsured children, elderly persons, and other nonworking urban residents and enrolls them into the program at the household level rather than at the individual level (Wagstaff et al., 2009). To improve access to primary care, China has reestablished community health centers (CHCs) that provide preventive and primary care services so that patients no longer need to seek expensive outpatient services at hospitals. The goal is to reduce hospital utilization and increase CHCs that can provide prevention, home care, and rehabilitative services (Yip and Hsiao, 2008; Yip and Mahal, 2008). The CHCs have not been very popular among the public because of their perceived lack of quality and because of their poor reputation from

perceived lack of quality. It remains uncertain whether China will restore its previously integrated healthcare delivery system, aimed at achieving universal access, or continue on its current course toward greater medical specialization and privatization. Another major component of Chinese health reform has been the establishment of an essential drug system that aims to enhance access to and reduce out-of-pocket spending for essential medicines. The reform policies specified a comprehensive system, including selection, procurement, pricing, prescription, and quality and safety standards (Barber et al., 2013). In terms of public hospital reform, quality, efficiency, and development of a hospital governance structure have been emphasized. Several pilot reforms have been launched in various cities in China, but no national implementation plan has been formulated (Yip et al., 2012). China’s National Health and Family Planning Commission (previously the Ministry of Health) and State Council have detailed several health reform objectives, such as constraining drug prices, enhancing the affordability of medical services at public hospitals, and improving staff performance (Hsu, 2015). Eliminating markups on drug sales in hospitals has led to financial losses in country-level pilot programs, although government subsidies to these programs have increased. In 2012, China lifted restrictions on foreign investments in private hospitals in an effort to increase the number of hospitals and improve access to care (Hsu, 2015). By 2015, the state council aimed to increase use of private health services by 20%. Health insurance reform is also being developed. The Chinese government plans to give tax breaks to private health insurance policyholders in an attempt to increase insurance coverage. Some of these tax breaks include allowing those privately insured to deduct 2,400 Renminbi per year from their assessable income for health insurance premiums (Hsu, 2015). In 2015, China announced a 5-year plan for the health system, which outlined key areas for development by 2020 (Zhu, 2015). Despite broad reforms, the Chinese healthcare system continues to be plagued by resource shortages and underdevelopment in rural areas. Thus, the latest reforms target three main areas: infrastructure development, reduction of costs expansion of insurance coverage, and investment in novel technologies. Importantly, these reforms will open up new

opportunities for foreign investments.

Germany Health insurance has been mandatory for all citizens and permanent residents in Germany since 2009 (Blumel and Busse, 2016). As mentioned earlier, the German healthcare system is based on the SHI model, and voluntary substitutive private health insurance is available. “About 86 percent of the population receive their primary coverage through SHI and 11 percent through substitutive PHI” and there are also special programs to cover the rest of the population (Blumel and Busse, 2016, para. 2). Sickness funds act as purchasing entities by negotiating contracts with hospitals. However, paying for the increasing costs of medical care has proved challenging in Germany because of an aging population, fewer people in the workforce, and stagnant wage growth during recessions. During the 1990s, Germany adopted legislation to promote competition among sickness funds (Brown and Amelung, 1999). To further control costs, its national system employs global budgets for the hospital sector and places annual limits on spending for physician services. Inpatient care is paid per admission based on diagnosis-related groups (DRGs)—a system that was made obligatory in 2004 (Blumel and Busse, 2016). Health reforms in Germany have focused on improving the efficiency and appropriateness of care. In 2011, the Pharmaceutical Market Reform Act introduced an assessment scheme for all new pharmaceuticals, under which only those drugs that offer additional benefits relative to existing alternatives can be reimbursed at a higher rate (World Health Organization [WHO], 2014). The Hospital Financing Reform Act of 2009 requires performance-based flat-rate grants for investments in hospitals rather than non-performance-based flat-rate grants on a case-by-case basis as of 2012 (WHO 2014). One of Germany’s biggest challenges is the division between SHI and private health insurance. The differences in risk pools, financing structures, access, and provisions in these alternative insurance plans contribute to inequalities in care (WHO, 2014). In addition, more work is needed to improve quality of medical services, patient satisfaction, and

accessibility of health services in rural communities (WHO, 2014). The most recent reforms in Germany have focused on improving services for SHI-covered patients and enhancing hospital quality. In June 2015, the Act to Strengthen SHI Health Care Provision gave municipalities the right to establish medical treatment centers, gave patients the right to see a specialist within 4 weeks, and promoted innovative forms of care in an effort to strengthen services for SHIcovered patients (HSPM, 2016). This act improves prevention services and health promotion through investments in schools, the workplace, and long-term care facilities. In addition, the 2016 Hospital Care Structure Reform Act introduced quality aspects in the regulation of hospital volume and payments (Blumel and Busse, 2016). Substantial funds will be invested to improve the hospital care structure in Germany.

United Kingdom The United Kingdom follows the national health system model. Its health delivery system is called the National Health Service (NHS). The NHS is founded on the principles of primary care and has a strong focus on community health services. The system owns its hospitals and employs its hospital-based specialists and other staff on a salaried basis. The primary care physicians, referred to as general practitioners (GPs), are mostly private practitioners. All NHS-insured patients are required to register with a local GP. In 2014, there were on average 7,171 patients per practice and 1,530 patients per GP (Thorlby and Arora, 2016). The NHS emphasizes free point of access and equal access to all (HSPM, 2015). In England, the Health and Social Care Act abolished the Primary Care Trust and Strategic Health Authority in 2012, replacing them with the Clinical Commissioning Group. In 2013, the Better Care Fund was enacted to improve integration of health and social care. In 2014, the Care Act was introduced to cap out-of-pocket expenditures (HSPM, 2015). Delivery of primary care occurs through primary care trusts (PCTs) in England, local health groups in Wales, health boards in Scotland, and primary care partnerships in Northern Ireland. PCTs have geographically assigned responsibility for community health services; each person living in a given geographic area is assigned to a particular PCT. A typical PCT

is responsible for approximately 50,000 to 250,000 patients (Dixon and Robinson, 2002). PCTs function independently of the local health authorities and are governed by a consumer-dominated board. A fully developed PCT has its own budget allocations, used for both primary care and hospital-based services. In this respect, PCTs function like MCOs in the United States. Approximately 83% of U.K. health expenditures in 2013 went to the public sector (Office of National Statistics, 2015). Private expenditures involve mainly drugs and other medical products as well as private hospital care. Despite having a national healthcare system, 10.9% of the British population maintains private health insurance (Arora et al., 2013). England, Scotland, Wales, and Northern Ireland are taking their own approaches to health care. England is moving toward decentralization, reinforcement of an internal market, and more localized decision making (HSPM, 2015). Scotland and Wales are dissolving the internal market and centralizing authority. Whereas Scotland is embracing a publicly funded universal health system, England is emphasizing private partnerships and internal competition. Costs are increasing in the United Kingdom owing to infrastructure improvements, technology innovations, an aging and growing population, more patients with chronic diseases, heightened focus on quality of care, informed and empowered consumers, and innovative treatments (Deloitte, 2019). In 2014, NHS England introduced the Five Year Forward View plan, which lays out strategies for addressing the most pressing challenges in the healthcare system (National Health Services England, 2015). This plan places a greater emphasis on prevention, integration of services, and patient-centered care. It sets out strategies and new care models whose goals include integrating primary and acute care systems, creating multispecialty community providers, and fostering collaborations in acute care. These models will redesign services and change the way health services are administered, financed, and regulated in the coming years.

Israel Until 1995, Israel had a system of universal coverage based on the German SHI model, financed through an employer tax and income-based contributions from individuals. When the National Health Insurance (NHI)

Law went into effect in 1995, it made insurance coverage mandatory for all Israeli citizens. Adults are required to pay a health tax. General tax revenues supplement the health tax revenues, which the government distributes to the various health plans based on a capitation formula. Each year, the government determines how much from the general tax revenue should be contributed toward the NHI. In 2013, public funds accounted for 60% of NHI revenues. The remaining share came from individuals’ copayments, supplemental health insurance, and sales of health products (Rosen, 2016). Health plans (or sickness funds) offer a predefined basic package of healthcare services and are prohibited from discriminating against those who have preexisting medical conditions. Recent reforms have added mental health and dental care for children to the benefits package (WHO, 2015). The capitation formula has built-in incentives for the funds to accept a larger number of elderly and chronically ill members. Rather than relying on a single-payer system, the healthcare reform supported the development of multiple health plans (today there are four competing, nonprofit sickness funds) to foster competition among funds, under the assumption that competition would lead to better quality of care and an increased responsiveness to patient needs. The plans also sell private health insurance to supplement the basic package. The system is believed to provide a high standard of care (Rosen et al., 2016). Israel has a highly efficient healthcare system due to the regulated competition among the health plans, the country’s strict regulatory controls on the supply of hospital beds, its accessible and high-quality primary care, and its reliance on EHRs (WHO, 2015). In 2014, the Ministry of Health created a national health information exchange for sharing clinical patient data across all general hospitals, health plans, and other providers in the country. Emerging challenges include an increasing reliance on private financing, which affects equity and efficiency; the need to expand public financing and to improve the efficiency of the public system; reduction of health inequalities; and goals related to measuring and improving quality of hospital care, reducing surgical waiting times, and enhancing dissemination of comparative data on performance (WHO, 2015).

Japan Since 1961, Japan has been providing universal coverage to its citizens through two main health insurance schemes: (1) an employer-based system, modeled after Germany’s SHI program, and (2) a national health insurance program. Generally, large employers (with more than 300 employees) have their own health programs. Nearly 2,000 private, nonprofit health insurance societies manage insurance for large firms. Smaller companies either band together to provide private health insurance or belong to a government-run plan. Day laborers, sailors, agricultural workers, the self-employed, and retirees are all covered under the national healthcare program. Individual employees pay roughly 8% of their salaries as premiums and receive coverage for approximately 90% of the cost of medical services, with some limitations. Dependents receive slightly less than 90% coverage. Employers and the national government subsidize the cost of private premiums. Coverage is comprehensive, including most dental care and approved prescription drugs, and patients are free to select their providers (Matsuda, 2016). Providers are paid on a national fee-for-service basis set by the government and have little control over reimbursement (Ikegami and Anderson, 2012). Several health policy issues have emerged in Japan in the past few years. First, since 2002, some business leaders and economists have urged the Japanese government to lift its ban on mixed public/private payments for medical services, arguing that private payments should be allowed for services not covered by medical insurance (i.e., services involving new technologies or drugs). The Japan Medical Association and the Ministry of Health, Labor, and Welfare have argued against these recommendations, stating such a policy would favor the wealthy and create disparities in access to care. Although the ban on mixed payments has not been lifted, Prime Minister Koizumi expanded the existing “exceptional approvals system” for new medical technologies in 2004 to allow private payments for selected technologies not covered by medical insurance (Nomura and Nakayama, 2005). Another policy development in Japan is hospitals’ increased use of a system of reimbursement for inpatient care services, called diagnosis‒ procedure combinations (DPCs). With the DPCs, hospitals receive daily

fees for each condition and treatment, proportionate to patients’ length of stay regardless of actual provision of tests and interventions. In theory, the DPC system will incentivize hospitals to become more efficient (Nomura and Nakayama, 2005). Japan’s economic stagnation in the last several years has led to an increased pressure to contain the country’s healthcare costs (Ikegami and Campbell, 2004). In 2005, Japan implemented reform initiatives in long-term care (LTC) delivery in an effort to contain the rapidly rising costs in this growing healthcare sector. The policy required residents in LTC facilities to pay for room and board. It also established new preventive benefits for seniors with low needs. Charging nursing home residents a fee for room and board was a departure from past policies, which had promoted institutionalization of elderly individuals (Tsutsui and Muramatsu, 2007). Despite their overall success, Japan’s health and long-term care systems face sustainability issues similar to those found in the United States, including rising costs and increasing demands for services. The Japanese government is considering and pursuing several options: preventive services, promotion of community-based services, and increases in taxes, premiums, and fees. In 2011, reform centered on the comprehensive community care model was implemented. This model ensures access to long-term care, medical or hospital care, preventive services, residential care facilities, and “life support” (or legal services) within a community where an elder lives. The focus on prevention and service consolidation is expected to result in healthy populations and, therefore, decreased use of more expensive services. More recently, health reforms in Japan have introduced the general practitioner (GP) and family physician (FP) system. In 2017, the Japan Primary Care Society began a training program to qualify doctors as GP/FP specialists (Takamura, 2015). By permitting the Japan Primary Care Society to run this program, the Japanese government aims not only to increase the number of systematically trained GPs/FPs but also to maintain good community care, improve health outcomes through prevention and primary care, and lower medical expenses. Challenges arising from the GP/FP reform include questions about where to place GPs and FPs (clinics or hospitals), how organ specialists currently providing primary care will be affected, and whether the GP/FP culture

will be accepted by Japanese patients and citizens at large.

Singapore Prior to 1984, Singapore had a British-style NHS program, in which medical services were provided mainly by the public sector and financed through general taxes. Since then, the nation has designed a system based on market competition and self-reliance. Singapore has achieved universal coverage through a policy that requires mandatory private contributions but little government financing. The program, known as Medisave, mandates every working person, including the self-employed, to deposit a portion of earnings into an individual Medisave account. Employers are required to match employee contributions. These savings can be withdrawn only for two purposes: (1) to pay for hospital services and some selected, expensive physician services or (2) to purchase a government-sponsored insurance plan, called MediShield, for catastrophic (expensive and major) illness. For basic and routine services, people are expected to pay out of pocket. Out-of-pocket expenditures can be quite high, as only 38% of health spending is publicly funded (Salkeld, 2014). Those who cannot afford to pay for healthcare services receive government assistance (Hsiao, 1995). In the first decade of the new millennium, the government introduced ElderShield, which defrays out-of-pocket medical expenses for elderly persons and severely disabled individuals who require long-term care (Singapore Ministry of Health, 2019). The fee-for-service system of payment is widely used throughout Singapore (McClellan and Kessler, 1999). In 2006, the Ministry of Health launched the Chronic Disease Management Program. By November 2011, this program covered 10 chronic diseases, including mental health illnesses. More than 700 GP clinics and GP groups are supported by the ministry to provide comprehensive chronic disease management to patients. Patients can use their own Medisave accounts or their family members’ accounts to pay for outpatient services under the program (Singapore Ministry of Health, 2012). Future challenges in Singapore include adjusting copayments to avoid discouraging patients from seeking necessary primary care and

preventive services that might lower their risk of developing chronic diseases. Overall, Singapore faces the challenge of ensuring positive health outcomes and containing costs given an aging population that is facing an increased prevalence of chronic disease (Tan et al., 2014).

Developing Countries Developing countries, which are home to almost 85% of the world’s population, are responsible for only 11% of the world’s total health spending—even though they account for 93% of the worldwide burden of disease. The six developing regions of the world are East Asia and the Pacific, Europe (mainly Eastern Europe) and Central Asia, Latin America and the Caribbean, the Middle East and North Africa, South Asia, and sub-Saharan Africa. Of these regions, the latter two have the least resources and the greatest health burden. On a per-capita basis, industrialized countries have six times as many hospital beds and three times as many physicians than do developing countries. People with private financial means can find reasonably good health care in many parts of the developing world. Unfortunately, the majority of the populations have to depend on limited government services that are often of questionable quality, when evaluated by Western standards. As a general observation, government financing for health services increases in countries with higher per-capita incomes (Schieber and Maeda, 1999). Developing countries are moving toward adopting universal health coverage to decrease the financial impoverishment due to health spending, improve health, and increase access to care (Lagomarsino et al., 2012). Trends in health reforms in developing countries include increasing enrollment in government-sponsored health insurance, expanded benefits packages, decreasing out-of-pocket expenditures, and increasing the government’s share of health spending. Countries that have successfully met the Millennium Development Goals—the world’s time-bound and quantified targets for addressing extreme poverty in its many dimensions (income poverty, hunger, disease, lack of adequate shelter, and exclusion) while promoting gender equality, education, and environmental sustainability—have used a comprehensive set of strategies to reduce maternal and child mortality, improve health financing, address workforce challenges, and improve quality of care

(Ahmed et al., 2016).

Global Health Challenges and Reform There is a huge gap in health care and health status between developing and developed countries. For example, in 2014, the global life expectancy at birth was 71.4 years of age, but life expectancy in the African region was only 60 years (WHO, 2016). In that same year, infant mortality rates varied between 2 deaths per 1,000 live births and 110 deaths per 1,000 live births. There were also wide variations in health care for pregnant women, availability of skilled health personnel for childbirth, and access to medicine. The poor quality and low efficiency of healthcare services in many countries—especially services provided by the public sector, which is often the main source of care for poor people—have become a serious issue for decision makers in these countries (Sachs, 2012). This issue, combined with the rising out-of-pocket costs and high numbers of uninsured, has forced many governments to launch healthcare reform efforts. Many low- and middle-income countries are moving toward universal health coverage (Lagomarsino et al., 2012). Even so, international health assistance continues to play a significant role in health care in many developing countries. Global aid for health care increased from $10 billion in 2000 to $27 billion in 2010 (Sachs, 2012) but then began to decrease in 2011 because of a global recession (Organization for Economic Cooperation and Development [OECD], 2012). Since 1999, the Bill and Melinda Gates Foundation (2017) has invested $7 billion in international health delivery programs. This foundation’s focus is on coordination of delivery efforts, strengthening of country health systems, and building of integrated delivery systems. Funded initiatives include community health worker programs, information and communications technology, and investment into data systems. From 2010 to 2015, the U.S. Agency for International Development (USAID) dedicated $50 billion to strengthening international health systems. This U.S. agency set forth a plan for continuing its progress, from 2015 to 2019, by strengthening six interrelated health system functions: (1) human resources for health; (2) health finance; (3)

health governance; (4) health information; (5) medical products, vaccines, and technologies; and (6) service delivery (USAID, 2015). The ultimate goal of that initiative is to strengthen these systems so that they will contribute to positive health outcomes and create an environment for universal health coverage.

The Systems Framework A system consists of a set of interrelated and interdependent, logically coordinated components designed to achieve common goals. Even though the various functional components of the health services delivery structure in the United States are, at best, only loosely coordinated, the main components can be identified using a systems model. The systems framework used here helps one understand that the structure of healthcare services in the United States is based on some foundations, provides a logical arrangement of the various components, and demonstrates a progression from inputs to outputs. The main elements of this arrangement are system inputs (resources), system structure, system processes, and system outputs (outcomes). In addition, system outlook (future directions) is a necessary feature of a dynamic system. This systems framework is used as the conceptual base for organizing later chapters in this text.

System Foundations The current healthcare system is not an accident. Historical, cultural, social, and economic factors explain its current structure. These factors also affect forces that shape new trends and developments as well as those that impede change. The chapter titled “Belief, Values, and Health” provides a discussion of the system foundations.

System Resources No mechanism for health services delivery can fulfill its primary objective without deploying the necessary human and nonhuman resources. Human resources consist of the various types and categories of workers directly engaged in the delivery of health services to patients. Such personnel—physicians, nurses, dentists, pharmacists, other doctoraltrained professionals, and numerous categories of allied health professionals—usually have direct contact with patients. Numerous ancillary workers—billing and collection agents, marketing and public

relations personnel, and building maintenance employees—often play important, but indirect, supportive roles in the delivery of health care. Healthcare managers are needed to manage various types of healthcare services. Resources are closely intertwined with access to health care. For instance, in certain rural areas of the United States, access is restricted due to a shortage of health professionals within certain categories. Development and diffusion of technology also determine the caliber of health care to which people may have access. Financing for health insurance and reimbursement to providers affect access indirectly.

System Processes System resources influence the development and change in the physical infrastructure—such as hospitals, clinics, and nursing homes—essential for the different processes of healthcare delivery. Most healthcare services are delivered in noninstitutional settings, mainly associated with processes referred to as outpatient care. Institutional health services provided in hospitals, nursing homes, and rehabilitation institutions, for example, are predominantly inpatient services. Managed care and integrated systems represent a fundamental change in the financing (including payment and insurance) and delivery of health care. Special institutional and community-based settings have been developed for long-term care. Delivery of services should be tailored to meet the special needs of certain vulnerable population groups (see the “Health Care for Special Populations” chapter).

System Outcomes System outcomes refer to the critical issues and concerns surrounding what the health services system has been able to accomplish, or not accomplish, in relation to its primary objective—that is, to provide, to an entire nation, cost-effective health services that meet certain established standards of quality. The previous three elements of the systems model play a critical role in fulfilling this objective. Access, cost, and quality are the main outcome criteria to evaluate the success of a healthcare delivery system. Issues and concerns regarding these criteria trigger

broad initiatives for reforming the system through health policy.

System Outlook A dynamic healthcare system must be forward looking. In essence, it must project into the future the accomplishment of desired system outcomes in view of anticipated social, economic, political, technological, informational, ecological, anthrocultural, and global forces of change.

Summary The United States has a unique system of healthcare delivery. Its basic features characterize it as a patchwork of subsystems. Health care is delivered through an amalgam of private and public financing, through private health insurance and public insurance programs; the latter programs are reserved for special groups. Contrary to popular opinion, healthcare delivery in the United States is not governed by free-market principles; at best, it is an imperfect market. Yet the system is not dominated or controlled by a single entity as would be the case in national healthcare systems. No country in the world has a perfect healthcare insurance system, and most nations with a national healthcare program also have a private sector that varies in size. Because of resource limitations, universal access remains a theoretical concept, even in countries that offer universal health insurance coverage. The developing countries of the world also face serious challenges due to the scarcity of resources and strong underlying needs for services in those nations. Healthcare managers must understand how the healthcare delivery system works and evolves. Such an understanding can help them maintain a strategic position within the macro environment of the healthcare system. The systems framework provides an organized approach to an understanding of the various components of the U.S. healthcare delivery system.

Test Your Understanding Terminology access administrative costs balance bill defensive medicine demand enrollee free market global budgets healthcare reform health plan managed care Medicaid Medicare moral hazard national health insurance (NHI) national health system (NHS) need package pricing phantom providers premium cost sharing primary care provider provider-induced demand quad-function model reimbursement single-payer system socialized health insurance (SHI) standards of participation system third party uninsured

universal access universal coverage utilization

Discussion Questions 1. Why does cost containment remain an elusive goal in U.S. health services delivery? 2. What are the two main objectives of a healthcare delivery system? 3. Name the four basic functional components of the U.S. healthcare delivery system. Which role does each play in the delivery of health care? 4. What is the primary reason for employers to purchase insurance plans to provide health benefits to their employees? 5. Why is it that, despite public and private health insurance programs, some U.S. citizens are without healthcare coverage? 6. What is managed care? 7. Why is the U.S. healthcare market referred to as imperfect? 8. Discuss the intermediary role of insurance in the delivery of health care. 9. Who are the major players in the U.S. health services system? What are the positive and negative effects of the often conflicting selfinterests of these players? 10. Which main roles does the government play in the U.S. health services system? 11. Why is it important for healthcare managers and policy makers to understand the intricacies of the healthcare delivery system? 12. What is the difference between national health insurance (NHI) and a national health system (NHS)? 13. What is socialized health insurance (SHI)? 14. Provide a general overview of the Affordable Care Act. What is its main goal?

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CHAPTER 8 Government Response: Regulation Jacqueline M. Loversidge

CHAPTER OBJECTIVES 1. Review the history of the role of advanced practice nursing in healthcare regulation. 2. Determine the role of the state board of nursing on the regulation of advanced practice nursing. 3. Understand the methods of professional credentialing for advanced practice nurses. 4. Explore the role of professional self-regulation for the advanced practice nurse and its influence on patient safety. 5. Realize how federal regulation influences payment mechanisms for advanced practice nurses. 6. Discuss strategies that the advanced practice nurses can employ to influence regulatory changes for effective patient care delivery.

Introduction Regulation of the U.S. healthcare delivery system and of healthcare providers exists to protect the interests of public safety, but regulatory structures are extraordinarily complex. The vastness of the industry, the manner of healthcare financing, and the proliferation of laws and regulations that govern practice and reimbursement contribute to that complexity. This chapter focuses on major concepts associated with the regulation of healthcare professionals. Understanding licensure and credentialing processes and their impact on nursing is essential. Understanding how regulations affect the healthcare system and individual providers empowers nurses and other providers to advocate on behalf of the profession and consumers. All healthcare professionals are licensed by state government agencies. Practice-specific boards or commissions (e.g., the Ohio Board of Nursing) or multiprofessional boards (e.g., Michigan’s Department of Licensing and Regulatory Affairs) are executive-branch regulatory agencies that govern each profession with the goal of protecting the public. State practice-specific board processes are similar from state to state but vary to some extent because their laws are determined by individual state legislatures, and their regulations are determined by the specific agency.

Regulation Versus Legislation The legislative and regulatory processes operate in parallel. Both are public processes and both are equally powerful; however, their processes differ in important ways. Legislation is shaped by elected lawmakers—for example, state legislators or members of the U.S. Congress. Laws are written in general terms to ensure applicability over time and to establish public policy. Regulations emerge from the law’s rulemaking authority and shape the details of implementation. The legislative process is the first step in this two-layer process. Lawmakers introduce bills and shepherd them through the complex legislative process. The process begins when one or more (usually not more than two) legislators from the same house sponsor introduction of a bill during a legislative or congressional session. Bills may address issues of interest to the sponsoring legislator or of concern to the sponsor’s constituents. Bills can be amended, substituted, or “die” at any number of points during the session. Checks and balances are built into the process; bills must be scrutinized by both houses and successfully navigate through committees, during which testimony is heard. If they are passed by both houses and signed by the president or governor, they are enacted (enrolled) and become law. Bills must pass during the session in which they are introduced; otherwise, they die, with the docket for that congressional session or state general assembly being cleared, and the bill must be reintroduced in a subsequent session. The terms legislation, act, law, and statute are synonyms. Legislation also refers to both a bill-in-progress and a law that has been enacted. When referring to laws regulating professions, the term practice act is used. Once signed into law, statute implementation is generally the responsibility of an administrative agency. Administrative agencies execute their responsibilities by enforcing both law and regulations. Regulations (rules) enable reasonable implementation of the law. Note that the terms regulation and rule are also used interchangeably. Whereas law is written in broad language, regulations are detailed and specify how the law will be put into practice. An administrative agency’s

authority to write and implement regulations is established in the laws that create the agency. Example: Nurse practice acts (NPAs) generally require the board of nursing (BON) to write rules with criteria that applicants must meet to be eligible to sit for licensure examinations and for issuing licenses. Rules amplifying that provision of law include specific eligibility criteria and application procedures, designate approved examinations (e.g., National Council Licensure Examinations for registered nurses [RNs] and licensed practical nurses [LPNs] or national certifying examinations for advanced practice registered nurses [APRNs]), and include renewal procedures and fees. The regulatory and legislative processes differ in other ways. Rulemaking is not dependent on legislative session schedules, so rules may be promulgated (written) at any time by an administrative agency. Also, regulations adhere to administrative procedures act (APA) requirements; some states require evaluation and revision of regulations on a predictable schedule to ensure that regulations reflect the current environment. Like lawmaking, regulation promulgation is a public process and is described in greater detail later in this chapter. The rulemaking process, like lawmaking, also includes structures to ensure checks and balances. For example, a nonbiased government body, such as Ohio’s legislative Joint Committee on Agency Rule Review (JCARR), may be charged with oversight; it reviews all administrative regulations to ensure that (1) the filing administrative agency does not exceed its statutory authority and (2) proposed regulations do not encroach on other laws or regulations. If an administrative agency finds that its regulations are inadequate to serve the needs of the public, and if the law does not support the additional rulemaking authority it needs, it may seek statutory modification to add a section in the law that allows additional rulemaking authority. To do so requires the agency to seek law change through the full legislative process. For nursing, this may include what is known as opening the nurse practice act. Both laws and regulations have the same force and effect of law. Therefore, even though regulations are written by a government agency

rather than by a legislative body, regulations carry great weight because their origin stems from the law that provided the agency with its rulemaking authority. From here forward, the term law is used instead of legislation, but regulation and rule are used interchangeably. There are uses for which the term rule is preferable (e.g., rulemaking authority).

Health Professions Regulation and Licensing Definitions and Purpose of Regulation Regulation, as defined in Black’s Law Dictionary, means “control over something by rule or restriction” (Garner, 2014, p. 1475). Health professions regulation is needed as a mechanism to protect the interests of public safety. There is extraordinary diversity and variability in health professions education programs—and, therefore, in licensure and other forms of credentialing. Laypersons cannot judge the competency of a health professional or determine whether that professional’s practice meets acceptable and prevailing standards. For these reasons, because of the potential risk for harm and because of the intimate nature of nursing and health care, states protect the public by establishing laws to regulate the profession (Russell, 2012). Health professions regulation seeks to safeguard the public by acting as a gatekeeper for entry into the health professions and by providing for ongoing maintenance of acceptable standards of practice for those professions. Practice acts, and the rules promulgated from those practice acts, constitute government regulatory oversight of professions. Practice acts vary by state, but most include the same basic elements (Russell, 2012): Creation of an agency/board that serves as the decision-making body Definitions, standards, and scopes of practice Scope of the board’s power and authority and its composition Standards for educational programs Types of titles, licensure, and certification Title protection Licensure requirements Grounds for disciplinary action, including due process (remedies) for the licensee charged with violation of the practice act or regulations Requirements for mandatory continuing education and/or competency

requirements for licensure and relicensure are also found in practice acts. The board’s rulemaking authority is specified in the practice act as one of its “powers and duties.” This rulemaking authority generally includes such categories as initial licensing requirements, standards of practice, delegation standards, requirements for prelicensure registered nurse and licensed practical nurse/licensed vocational nurse (LPN/LVN) educational programs, advanced practice registered nurse standards and requirements for practice and prescribing, disciplinary procedures, and standards for continuing education or competence. It cannot be presumed that silence of the law on an issue implies legislative intent for the BON to write a rule. When there is no prior statutory authority to address an issue, the legislative process must be initiated to allow the agency authority to promulgate new, specific regulations. Example: An APRN with prescribing authority petitions the BON to clarify whether prescriptive authority for Schedule II controlled substances is within the scope of practice for the APRN. The board’s staff refers the APRN to a provision in the statute that allows the APRN to “prescribe drugs and therapeutic devices” as long as the APRN practices in collaboration with a physician and in a way consistent with the nurse’s education and certification. The staff concludes that the phrase “prescribe drugs and therapeutic devices” may include Schedule II controlled substances if permitted in the APRN‒physician collaboration agreement. No specific language is found in the law that authorizes the prescribing of Schedule II controlled substances, but neither is it specifically prohibited. The medical board, which monitors BON opinions regarding potentially overlapping areas of practice, reads the BON’s opinion and requests a state attorney general’s opinion. The attorney general concludes that the BON may not extend the scope of practice of the APRN through either opinion or regulation. The expressed will of the legislature must be sought using the legislative process. Subsequently, the BON seeks a legislative sponsor to introduce a bill permitting APRNs to specifically prescribe

Schedule II controlled substances. Not all state boards of nursing are granted statutory authority to express formal opinions; some must rely on the specific language in the practice act and regulations, the official opinions of an attorney general’s office, or court decisions.

History of Health Professions Regulation Physicians were the first healthcare professionals to gain legislative recognition for their practice. Most states had physician licensing laws in place by the early 1900s. Nursing soon followed suit. North Carolina was the first state to establish a regulatory board for nurses in 1903, and by the 1930s, state licensing had been enacted in 40 states (Hartigan, 2011). Physician scopes of practice are broad; they are unlimited in many states. Historically, this has been problematic for nursing and other nonphysician healthcare providers seeking to define their unique scope, particularly in areas that may overlap with physicians’ services. The history of nursing regulation has been characterized by efforts to accommodate this medical preemption (Safriet, 1992). Early nursing regulation was permissive (voluntary). Systems were developed that allowed nurses to register with a governing board—hence the title “registered nurse.” In some states, nurses were registered by the medical board before separate boards of nursing were established. Registration is a minimally restrictive form of state regulation and does not usually require entrance qualification (e.g., examination). Between the 1930s and 1950s, states enacted mandatory licensure laws (NPAs) requiring practicing nurses to obtain licensure with the state regulatory agency. These early NPAs defined nursing as a dependent practice focused on physician order implementation. The American Nurses Association model definition, published in 1955, laid the groundwork for NPAs to define independent functions for nurses, although the model reaffirmed prohibitions against medical diagnosis and prescribing (Hartigan, 2011). Over time, BONs began establishing licensure criteria and administering licensure examinations. The early licensure examinations were BON-constructed paper-and-pencil examinations, performance

examinations, or a combination. During that time, BONs also independently established examination passing standards. Statutory authority to regulate schools of nursing and establish requirements for school structure, faculty, and curricula were added to NPAs. Because interstate mobility was becoming more common, states developed reciprocity agreements with other states. The National Council of State Boards of Nursing (NCSBN) Nurse Licensure Compact has since replaced reciprocity. Not all states participate in the compact, and this complex process should not be confused with the obsolete two-state reciprocal arrangements (Hartigan, 2011; NCSBN, 2019). By the 1940s, the need for a standardized licensure exam had become apparent. In 1944, the State Board Test Pool Examination (SBTPE) was established by the National League for Nursing (NLN). The SBTPE ensured standardization and relieved state BONs of the burdens associated with writing and grading the examination. Over the years, questions about potential for conflict of interest were raised. Although individual BONs set their own passing standards, authority for the creation and control of the examination had been absorbed by a professional association (the NLN). This relationship set up conflicts between governmental regulation and professional self-regulation, which should be separate and independent. Concurrently, BON leaders created a forum in which they could meet and discuss matters of common interest, although that forum was structured as a council of the American Nurses Association (ANA). This created additional conflict between BONs’ prescribed governmental duty to establish licensure standards and professional associations’ rights and responsibilities to remain independent of governmental influence. In 1978, the NCSBN was formed, with the assistance of a Kellogg Foundation grant, to address these issues. The NCSBN is autonomous and represents the states’ interests rather than those of professional nursing organizations (Hartigan, 2011).

History of Advanced Practice Registered Nurse Regulation In the 1960s, the birth of two federal entitlement programs, Medicare and Medicaid, increased the number of individuals with access to

government-subsidized health care. At the same time, a shortage of primary care physicians was predicted, particularly in rural areas. A window of opportunity opened, and the first formal nurse practitioner (NP) programs were begun, with the goal to increase access to primary care in the rural areas where physicians were unlikely to locate. In 1971, Idaho became the first state to legally recognize diagnosis and treatment as part of the scope of nurse practitioners. APRN (nurse practitioner) regulation in Idaho was accomplished through a joint agreement between the state boards of nursing and medicine. The Idaho model set a precedent for other states to include some form of joint nursing and medical board oversight for APRN regulation. The joint regulation model compensated for the broad definitions of medical practice but was a compromise because advanced practice nursing was still considered to constitute “delegated medical practice,” requiring some medical board oversight (Safriet, 1992). The struggle to define APRNs’ scope of practice and determine the necessity of medical board oversight continues in some states. Both the ANA and the NCSBN have proposed model rules and regulations for the governing of advanced practice nursing. The actual practice acts are inevitably a product of individual states’ political forces, so titles, definitions, criteria for entrance into practice, scopes of practice, reimbursement policies, and models of regulation are state specific. Since 1988, The Nurse Practitioner has published a map and summary of annual survey data from each state’s BON and nursing organizations relative to the legislative status of advanced practice nursing. Significant advances have been made in many states, particularly regarding independent APRN practice without direct physician supervision. In 2017, 15 states/jurisdictions reported that NPs are regulated solely by a BON and have both independent scope of practice and prescriptive authority without physician supervision, delegation, consultation, or collaboration. In 10 states, NPs are regulated by a BON, have full autonomous practice and prescriptive authority, but additionally must complete a postlicensure/certification supervision period or engage in a collaboration or mentorship. In the remaining states, NPs are regulated either solely by a BON or in combination with BON oversight (Phillips, 2017).

Methods of Professional Credentialing Various methods are used to credential health professionals. The method accepted in a particular state is determined by the state government and based on at least two variables: (1) the potential for public harm if safe and acceptable standards of practice are not met and (2) the profession’s degree of autonomy and accountability for decision making. Historically, government agencies have been encouraged to select the least restrictive form of regulation to achieve public protection (Pew Health Professions Commission, 1994). Today, four methods are used in the United State for credentialing and regulation of individual providers. These are described next, beginning with the most restrictive method and progressing to the least restrictive method.

Licensure A license is “a privilege granted by a state . . . the recipient of the privilege then being authorized to do some act . . . that would otherwise be impermissible” (Garner, 2014, p. 1059). Licensure is the most restrictive method of credentialing. Anyone who practices within the defined scope must obtain the legal authority to do so from the appropriate administrative state agency. Licensure serves as a barrier to those who are unqualified to perform within a specific scope of practice. Licensure also protects the monetary interests of those who are licensed to perform certain acts by limiting economic competition with unlicensed individuals. Licensure implies competency assessment at the point of entry into the profession. Applicants for licensure must pass an initial licensing examination, then comply with continuing education requirements or undergo competency assessment by the regulatory body that provides oversight for that profession. Because competency is unique to the individual professional and specialty, it is difficult to measure; most licensing agencies require mandatory continuing education in lieu of continued competency assessment for license renewal. Licensure offers the public the greatest level of protection by restricting use of a specific title and a scope of practice to professionals who meet these rigorous criteria and hold a current valid license. Unlicensed persons cannot

identify themselves by the title identified in law (e.g., medical assistants cannot hold themselves out as nurses), and they cannot lawfully perform any portion of the scope of practice, unless their own practice act allows them to provide such services because of overlap. Licensees are held accountable to practice according to provisions in law and rule and to adhere to legal, ethical, and professional standards. A licensee holds greater public responsibility than an unlicensed citizen. Therefore, disciplinary action may be taken against licensees who have violated law or rule. Notably, a revocable license means that the legal authority (e.g., a BON) may divest the licensee of the license if it is deemed that the license holder has violated law or regulations and that it is in the best interest of the public. Health professions are largely regulated by licensure because of the high risk of potential for harm to the public if unqualified or unsafe practitioners are permitted to practice.

Registration Registration is the “act of recording or enrolling” (Garner, 2014, p. 1474). Registration provides for a review of credentials to determine compliance with criteria for entry into a profession and permits the individual to use the title “registered.” Registration provides title protection but does not preclude individuals who are not registered from practicing within the scope of practice, so long as they do not use the title “registered” or misrepresent their status. Registration does not necessarily imply that prior competency assessment has been conducted. Some state laws may have provisions for removing incompetent or unethical providers from the registry or for “marking” the registry when a complaint is lodged against a provider. However, removing the person from the registry does not ensure public protection because the individual may practice without use of the title. An exemplar is the states’ Nurse Aide Registry, which tracks individuals who have met criteria to be certified for employment in long-term care settings; this registry was required by the Omnibus Budget Reconciliation Act of 1987.

Certification

A certificate is “an official document stating that a specified standard has been satisfied” (Garner, 2014, p. 275). In nursing, certification usually refers to the voluntary process requiring completion of a specialtyfocused education program, competency assessment, and practice hours. This type of certification in nursing is granted by proprietary professional nursing organizations and attests that the individual has achieved a level of competence in nursing practice beyond entry-level licensure. Certification awarded by proprietary organizations does not have the force and effect of law. However, the term certification may also be used by state government agencies as a regulated credential; states may offer a “certificate of authority” or an otherwise-titled certificate to practice within a prescribed scope of practice. In this case, certification is required by law for practice in the specific role. For example, an APRN may need to hold a certificate as a nurse practitioner from a proprietary organization to qualify for a certificate of authority from a state BON to practice as an NP in that state. Most states have enacted regulations requiring nationally recognized specialty nursing certification for an APRN to be eligible to practice in the advanced role. Astute consumers may ask whether a provider is certified as a means of assessing competency to practice. Employers also use certification as a means of determining eligibility for certain positions or as a requirement for internal promotion.

Recognition Recognition is “confirmation that an act done by another person was authorized . . . the formal admission that a person, entity, or thing has a particular status” (Garner, 2014, p. 1463). Official recognition is used by several boards of nursing as a method of regulating APRNs and implies that the board has validated and accepted the APRN’s credentials for the specialty area of practice. Criteria for recognition are defined in the practice act and may include requirements for certification.

Professional Self-Regulation Self-regulation occurs within a profession when its members establish

standards, values, ethical frameworks, and safe practice guidelines exceeding the minimum standards defined by law. This voluntary process plays a significant role in the regulation of the profession, equal to legal regulation in many ways. Professional standards of practice and codes of ethics exemplify professional self-regulation. National professional organizations set standards for specialty practice. By means of the certification process, these organizations determine who may use the specialty titles within their purview. Documentation of continuing education and practice competency or reexamination is usually required for periodic recertification. Standards are periodically reviewed and revised by committees of the membership to ensure they reflect current practice. Although professional organizations develop standards of practice, they have no legal authority to require compliance by certificate holders. Administrative licensing agencies retain that authority but look to prevailing professional standards of practice when making decisions about what constitutes safe and competent care. Legal regulation and professional self-regulation are two sides of the same coin, working together to fulfill the profession’s contract with society.

Regulation of Advanced Practice Registered Nurses The evolution of APRN practice across the United States has been inconsistent because the U.S. Constitution gives states the right to establish laws governing professions and occupations. As a result, titles, scopes of practice, and regulatory standards are unique to each state. To bring some uniformity to the education and regulation of advanced nursing practice, the NCSBN convened an Advanced Practice Task Force in 2000, at the behest of its BON membership, and invited the American Association of Colleges of Nursing (AACN) to join in a consensus-building process. Together they developed the Consensus Model for Regulation: Licensure, Accreditation, Certification, and Education (LACE). The LACE report proposed definitions of APRN practice, titling, and education requirements. It also described an APRN regulatory model, identified APRN roles/population foci, and offered strategies for implementation (APRN Joint Dialogue Group, 2008). This

model served as the basis of BON regulation of advanced practice nursing for some years. In 2015, however, the NCSBN convened an APRN Roundtable to consider revisions in education, certification, and other factors and issues currently facing APRN regulation (NCSBN, 2015). APRN regulation is also dependent on relationships between national nursing organizations and their affiliate certifying organizations (e.g., the ANA and the American Nurses Credentialing Center [ANCC]). Together these organizations play important roles in shaping APRN preparation and practice. The certifying organizations are nongovernmental bodies that develop practice standards and examinations to measure the competency of nurses in an area of clinical expertise. BONs require APRNs to hold a graduate degree in nursing and national certification in the specialty area relevant to their educational preparation. BONs also establish rules allowing acceptance of national APRN certification examination results according to predetermined criteria. The NCSBN guidelines (2002) continue to serve state BONs in determining those criteria. Historically, the courts have held that state boards may not abdicate their authority by passively accepting examinations from independent bodies without having conducted a thorough evaluation of the examination’s regulatory sufficiency and legal defensibility (NCSBN, 1993). The basis for regulatory sufficiency and legal defensibility of licensure or certification examinations includes two elements: (1) the ability to measure entry-level practice, based on a practice analysis that defines job-related knowledge, skills, and abilities and (2) the development of examinations using psychometrically sound test construction principles.

The State Regulatory Process The 10th Amendment of the U.S. Constitution specifies that all powers not specifically vested in the federal government are reserved for the states. One of these powers is the duty to protect its citizens (police powers). This power is translated in the form of states’ authority and interest in regulating the professions to protect the health, safety, and welfare of its citizens. Administrative agencies are given referent power, through their legislatively enacted practice acts, to promulgate (write) regulations and enforce both the laws and the regulations for which they are responsible. These administrative agencies have been called the fourth branch of government because of their significant power to execute and enforce the law.

Boards of Nursing Nurse practice acts vary by state, but all NPAs include the major provisions, or elements, discussed earlier in this chapter. Provisions included in NPAs focus on a central mission—protection of the public safety. There are 60 boards of nursing in the United States, including those in the 50 states, the District of Columbia, and the U.S. territories; each of these is known as a jurisdiction. Each BON is a member of the NCSBN. Some states have separate boards for licensing RNs and LPNs/LVNs. Several states regulate RNs and/or LPNs/LVNs through multiprofessional boards, which have jurisdiction over a variety of licensed professionals, such as physicians, nurses, and dentists. As members of the NCSBN, BONs represent the interests of public safety by providing oversight of the construction and administration of the National Council Licensure Examinations (NCLEX). BONs are allowed the privilege of using these examinations and meet to discuss and act on matters of common interest (NCSBN, 2008).

Composition of the Board of Nursing

Boards of nursing are generally composed of licensed nurses and consumer members. In most states, the governor appoints members. An exception is North Carolina, where board members are elected by nurses licensed to practice in the state. Some NPAs designate specific board member representation—for example, from advanced practice nursing or nursing education, and in the case of joint boards, representation from LPNs/LVNs in addition to RNs/APRNs. In other states, criteria for appointment comprise only licensure and state residency. Nurses interested in serving as board members may look to their professional associations to secure endorsements or to ask for support from their state district legislators. Knowing the composition of the board and its vacancy status allows professional organizations to influence the representation on the board.

Board Meetings Most state administrative procedures acts (APAs) require boards to post public notice of meetings and to make agendas available, usually 30 days prior to the meeting. State government agencies must comply with open meeting (“sunshine”) laws, which permit the public to observe and/or participate in board meetings. Board meetings may vary in their degree of formality. Public participation is usually permitted, but open dialogue between board members and the public is generally limited. Opportunities to address the board may be scheduled on the meeting agenda (e.g., during an “open forum” time) and may require advance notification of the individual’s name, topic, and the organization represented (if applicable). Boards may go into closed executive session for reasons specified in the state’s administrative procedures act (e.g., to obtain legal advice, conduct contract negotiations, and discuss disciplinary or personnel matters). Boards must comply with APA regulations regarding subject matter that may be discussed in an executive session and report out of executive session when the public session resumes. Board meeting participants include board members (appointed or elected), board staff (employees of the board), and legal counsel for the board. Legal counsel advises the board on matters of law and jurisdiction. Some boards may have “staff” counsel, but many state

boards receive advice only from an assigned representative of the state attorney general’s office, known as an assistant attorney general (AAG). All voting is a matter of public record, and board action occurs only in open public session. When board members vote, they must take into account implications for the public welfare and safety, the legal defensibility of the outcome of the vote, and the potential statewide impact of the decision. The board must act only within its legal jurisdiction. BONs may publish action summaries of board meetings in their newsletters, in addition to articles written by board members and staff that explain law and rule. BON newsletters typically include disciplinary actions taken against licensees during board meetings. The nature of the offense is included in some states’ newsletters. Some states mail newsletters to licensees, but many BONs now make newsletters available only electronically.

Monitoring the Competency of Nurses: Discipline and Mandatory Reporting Licensed nurses are accountable for knowing the laws and regulations governing nursing in the state of licensure and for adhering to legal, ethical, and professional standards of care. Some state regulations include standards of practice; other states may refer to professional or ethical standards established by professional associations. Employing agencies also define standards of practice through policies and procedures, although these are separate from, in addition to, and superseded by the state’s NPA and regulations. Most NPAs include provisions for mandatory reporting that require employers to report violations of the NPA or regulations to the BON. Licensed nurses also have a moral and ethical duty to report unsafe and incompetent practice to the BON. In addition, the public may file complaints against licensees with BONs. The NPA provides the BON with authority to investigate complaints against licensees and to potentially take action on the license, including the license or certificate to practice as an APRN. State APAs ensure that licensees subject to disciplinary action are provided due process. When a nurse is found, through the administrative processes, to have violated provisions of the NPA or

regulations, the BON can take action on the license; these actions may include a reprimand, fine, suspension, suspension of license with stay (i.e., probation), permanent revocation of license, or any other action permitted by the NPA. A nurse who holds a multistate license (i.e., a license that permits a nurse to practice in more than one state in accordance with a multistate compact agreement) is held accountable for knowing and abiding by the laws and regulations of the state of original licensure as well as the compact state in which the nurse practices. Multistate regulation is discussed in more detail later in this chapter. Nurses with multistate licenses should be aware that ignorance of the law in any state of licensure and/or practice does not excuse misconduct.

Changing the Rules Revising or Instituting New State Regulations State agencies exercise their authority and duty to promulgate regulations amplifying their laws by following the state’s administrative procedures act. The administrative procedures act of each state specifies the rulemaking process, including requirements for public notification and for providing an opportunity for public comment. State rulemaking processes differ. For example, some states designate government commissions or committees as the authorities for review and approval of regulations, whereas other states submit regulations to the general assembly or to committees of the legislature. Nevertheless, all state rulemaking processes share some common elements: Public notice that a new regulation or modification of an existing regulation has been proposed Opportunity to submit written comment or testimony Opportunity to present oral testimony at a rules hearing Agency filing of the rule in final form Publication of the final regulation in a state register or bulletin Public comment may be very influential in determining the final outcome. The administrative agency drafting the regulation has discretion in determining which amendments are made and may make amendments

based on public input prior to final filing. The time frame for implementation of new or revised regulations varies according to the state’s administrative procedures act. Generally, effective dates are within 30 to 90 days of publication of the final regulation. In some states, the agency is required to prepare a fiscal impact statement, providing an estimate of the costs that will be incurred as a result of the rule, both to the agency and to the public.

Board Rulemaking Processes BONs make regulatory decisions using methods similar to those used by other public officials in executive-branch agencies. When drafting new rules or revising existing rules, BONs examine matters of public safety and issues administering existing regulations, invite comment from stakeholders (in particular, nursing organization representatives), and may seek counsel from BON advisory committees or task forces. Leveraging participation opportunities early in the rule-drafting process is important, in addition to providing testimony during formal hearings. It is also imperative to appreciate that the process becomes complex when it is confounded by the perspectives, values, and ethics of a variety of stakeholders. Because rulemaking involves dealing with both political complexities and content issues, BONs may use policy design or process models to facilitate decision making. Using a process model that is both familiar in nursing and adaptable to the health policy arena—for example, evidencebased practice (EBP)—can facilitate a BON’s rulemaking because it provides an organized framework for problem solving. The South Dakota BON has successfully used an evidence-informed health policy (EIHP) model to analyze one of its policies (Damgaard & Young, 2017). The EIHP model is adapted from Melnyk and FineoutOverholt’s (2015) EBP model and is a paradigm and problem-solving approach to health policy decision making. Like EBP, EIHP combines the use of evidence with issue expertise and stakeholder values and ethics to inform and leverage policy discussion and negotiation. The hoped-for outcome is the best possible health policy agenda and improvements (Loversidge, 2016b). Using the term informed rather than based shifts the focus of evidence to its realistic uses in policy arenas, which include

informing and influencing stakeholders as well as mediating dialogue; it also acknowledges the complexity of multiple factors, relationships, and rapidly shifting priorities inherent in the political process (Loversidge, 2016a). Because EIHP is a full-cycle process model, it can facilitate decision making throughout the phases of regulation promulgation, rollout, implementation, and evaluation. The model includes three components and seven steps, summarized in TABLE 8-1. In particular, it makes use of the PICOT question. As used in health policy, the “P” part of this question —Population of interest—generally focuses on the consumer. The “I” (Intervention) refers to the policy change. “C” is the Comparison—the current policy or lack thereof. The “O” component describes the anticipated Outcome after policy implementation (Loversidge, 2016b). “T” is the Time needed to implement the policy. TABLE 8-1 Loversidge’s Evidence-Informed Health Policy Model: Components and Steps Components of EIHP

Steps of EIHP

■ External evidence: Includes best research evidence, evidence-informed relevant theories, and best evidence from opinion leaders, expert panels, and other relevant sources. ■ Issue expertise: Includes data from such sources as professional and healthcare associations/organizations and government agencies; also includes professions’ understanding/experience with the issue; may include other data resources. ■ Stakeholder values and ethics: Considers the values and ethics of healthcare providers, policy shapers, healthcare consumers, and others.

■ Step 0: Cultivate a spirit of inquiry in the policy culture or environment. ■ Step 1: Identify the policy problem; ask a policy question in the form of a PICOT question. ■ Step 2: Search for/collect relevant/best evidence. ■ Step 3: Perform critical appraisal of the evidence. ■ Step 4: Integrate best evidence with issue expertise and stakeholder values and ethics; the result will be the desired health policy decision/change. ■ Step 5: Contribute to the health policy development/implementation process. ■ Step 6: Frame the policy change for dissemination. ■ Step 7: Evaluate the effectiveness of the policy change and disseminate findings.

Data from Loversidge, J. M. (2016b). An evidence-informed health policy model: Adapting evidence-based practice for nursing education and regulation. Journal of Nursing Regulation,

7(2), 27–33.

Description

Monitoring State Regulations Administrative agencies promulgate hundreds of regulations each year. In this rapidly changing healthcare environment, conflicts related to definitions and scopes of practice, right to reimbursement, and requirements for supervision and collaboration may occur. Regulations that affect nursing practice may be implemented by a variety of agencies. Knowing which agencies regulate health care, healthcare delivery systems, and professional practice and monitoring legislation and regulations proposed by those agencies are important for safeguarding practice. Chief among the agencies that should be tracked are the health professions licensing boards, state agencies that govern licensing and certification of healthcare facilities, agencies that administer public health services (e.g., public health, mental health, and alcohol and drug agencies), and agencies that govern federal/state contribution program reimbursement (e.g., Medicare and Medicaid). In particular, APRNs should be aware of regulations that mandate benefits or reimbursement policies and lobby for their inclusion as potential recipients of these benefits or funds. Several states have instituted open-panel legislation, known as “any willing provider” and “freedom of choice” laws. These bills mandate that any provider who is authorized to offer the services covered in an insurance plan must be recognized and reimbursed by the plan. Conversely, insurance companies and business lobbyists oppose this type of legislation. As managed care contracts are negotiated, APRNs must ensure that their services are given fair and equitable consideration. Other important areas for nurses include worker’s compensation participation and liability insurance laws. In summary, agencies that may potentially promulgate regulations that could have implications for APRN and RN practice or reimbursement should be monitored. EXHIBIT 8-1 provides some key questions to consider when analyzing a regulation for its impact on nursing practice.

EXHIBIT 8-1 Questions to Ask When Analyzing Regulations 1. Which agency promulgated the regulation? 2. What is the source of the agency’s authority (the law that provides the agency’s rulemaking authority)? 3. What is the intent or rationale of the regulation, and is it clearly stated? 4. How does the regulation affect the practice of nursing? Does it constrain or limit practice? 5. Is the language in the regulation clear or ambiguous? Can the regulation be interpreted in different ways? Discuss the advantages of language that is clear versus ambiguous. 6. Are there definitions to clarify terms? 7. Are any important points omitted? 8. Is there sufficient lead time to comply with the regulation? 9. What is the fiscal impact of the regulation?

Serving on Boards and Commissions One way to actively participate in the regulatory process is to seek appointment to the state BON or to other health-related boards or commissions. Appointments to boards and commissions should be sought strategically. It is important to select an agency with a mission and purpose consistent with your own interests and expertise. Because most board appointments are gubernatorial or political appointments, it is important to obtain endorsements from legislators, influential community leaders, and professional associations. Individuals seeking appointment are more likely to acquire endorsements if they have an established history of service to the professional community. Letters of support should document the appointment candidate’s primary area of practice and contributions to professional and community service. Delineate involvement in local, state, and national organizations. A letter from the employer is recommended, as both an indication of the employer’s willingness to support time away from work to fulfill the responsibilities of the position during the term of office and as an endorsement of the candidate’s professional merit. A personal letter from the appointment candidate should include the rationale for volunteering to serve on the particular board or commission, evidence of a good match between the individual’s expertise and the board or commission purpose, and expression of clear interest in public service. A specific application form may be required (often found on the governor’s website), and a résumé or curriculum vitae should be attached.

Appointment decisions take into account the individual’s potential contributions to the work of the board or commission. This kind of public service requires a substantial time commitment, so it is wise to speak to other board members or to the executive director/agency administrator to determine the extent of that commitment.

The Federal Regulatory Process The federal government has become a central factor in health professions regulation. Several forces have influenced this trend; however, the advent of the Medicare and Medicaid programs was especially significant. Federal initiatives that have grown from these programs include cost containment (prospective payment), consumer protection (combating fraud and abuse) (Jost, 1997; Roberts & Clyde, 1993), and the initiatives and programs written into the Patient Protection and Affordable Care Act (ACA) and the Health Care and Education Reconciliation Act of 2010 (U.S. Department of Health and Human Services [DHHS], 2014). In July 2001, the Centers for Medicare and Medicaid Services (CMS) replaced the former Health Care Financing Administration (HCFA). As a result of its reformulation, this agency now provides increased emphasis on responsiveness to beneficiaries, providers, and quality improvement. Three business centers were established as part of the reform: Center for Beneficiary Choices, Center for Medicare Management, and Center for Medicaid and State Operations (CMS, 2014). In 2003, President George W. Bush signed the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) into law. The act created a prescription drug benefit for Medicare beneficiaries and established the Medicare Advantage program (O’Sullivan, Chaikind, Tilson, Boulanger, & Morgan, 2004), effectively providing seniors with prescription drug benefits and more choice in accessing health care. As the Medicare program has evolved, the practice of APRNs has likewise been influenced by changes in Medicare reimbursement policy. In 1998, when Medicare reimbursement reform was enacted, APRNs won the right to be directly reimbursed for provision of Medicare Part B services that, until that time, had been provided only by physicians. In addition, the reform lifted the geographic location restrictions that had limited patient access to APRNs. More recent revisions to the required qualifications, coverage criteria, billing, and payment for Medicare services provided by APRNs are specific, depending on whether the APRN is a certified registered nurse anesthetist (CRNA), nurse

practitioner (NP), certified nurse‒midwife (CNM), or clinical nurse specialist (CNS). Reimbursement for APRNs has generally improved; for example, NP services are now paid at 80% of the lesser of the actual charge or 85% of the fee schedule amount a physician is paid (U.S. DHHS & CMS 2016). However, APRNs continue to lobby for reimbursement at 100% of the amount paid to physicians. Relationships between the state and federal regulatory systems are highly dynamic. Responsibilities once assumed by the federal government have been shifted to the state level; administration and management of the Medicaid and welfare programs are examples. The perspective that states are better equipped to make decisions about how best to assist their citizens, coupled with a public sentiment that generally seeks to diminish federal bureaucracy and its accompanying tax burden, have been instrumental in moving the placement of authority to the states. However, although states have primary authority over regulation of the health professions, federal policies continue to have a significant effect on healthcare workforce regulation. For example, policies related to reimbursement and quality control over the Medicare and Medicaid programs are promulgated by the U.S. Department of Health and Human Services and administered through its financing agency, the CMS. The Veterans Health Administration, the Indian Health Service, and the uniformed armed services are also regulated by the federal government. Large numbers of health professionals, many of whom are nurses/APRNs, are employed by these federal agencies and departments. Federally employed health professionals must be licensed in at least one state/jurisdiction. These individuals are subject to the laws of the state in which they are licensed and the policies established by the federal system in which they are employed. However, the state of licensure need not correspond with the state in which the federal agency or department resides because practice that occurs on federal property is not subject to state oversight. This status reflects the fact that the Supremacy Clause of the U.S. Constitution, Article VI, Paragraph 2, establishes that federal laws generally take precedence over state laws (Legal Information Institute, 2017). State laws in conflict with federal laws cannot be enforced. The Commerce Clause of the U.S. Constitution limits the ability of states to erect barriers to interstate trade (Gobis, 1997). Courts have

determined that the provision of health care constitutes interstate trade under antitrust laws, which in turn sets the stage for the federal government to preempt state licensing laws regarding the practice of professions across state boundaries if future circumstances make this a desirable outcome for the nation. The impact of technology on the delivery of health care—for example, telehealth—allows providers to care for patients in remote environments and across the geopolitical boundaries defined by traditional state-by-state licensure. This raises the question as to whether the federal government would have an interest in interceding in the standardization of state licensing requirements to facilitate interstate commerce. If this occurred, the federal government would be in the position of usurping what is presently the state’s authority. Licensing boards have an interest in avoiding federal intervention and are beginning to identify ways to facilitate the practice of telehealth while simultaneously preserving the power and right of the state to protect its citizens by regulating health professions at the state level. One approach to nursing regulation that addresses this conundrum is multistate regulation, which is discussed later in this chapter.

Federal Rulemaking The federal regulatory process is established by the federal administrative procedures act. In this process, a Notice of Proposed Rulemaking (NPRM) is published in the Federal Register, a public, daily federal government publication containing current executive orders, presidential proclamations, rules and regulations, proposed rules, notices, and sunshine act meetings. The NPRM includes information about the substance of intended regulations and information about public participation in the regulatory process, including procedures for attending meetings or hearings and for providing comment. The agency writing the rules is mandated to consider all public comments, and amendments to draft regulations may be made based on public input if warranted. The agency publishes final regulations in the rules and regulations section of the Federal Register. Rules become effective 30 days after they are filed in final form by the agency and published in the Federal Register (FIGURE 8-1).

FIGURE 8-1 The federal rulemaking process. Reproduced from Carey, M. P. (2013, June 17). The federal rulemaking process: An overview. Congressional Research Service Report RL32240. Retrieved from http://www.fas.org/sgp/crs/misc/RL32240.pdf

Description

Emergency Regulations Provisions for promulgating emergency regulations are defined at both the state and the federal levels. Emergency regulations are enacted if an agency determines that the public welfare is in jeopardy and if the regulation will serve as an immediately enforceable remedy. Emergency regulations usually take effect upon their date of publication, are generally temporary, and are effective for a limited time period (usually 90 days), with an option to renew them. Emergency regulations must be followed with permanent regulations that are promulgated in accordance with the usual APA requirements.

Locating Information Each state government periodically publishes a document containing notices, proposed regulations, final regulations, and emergency regulations. The publication cycle for this document—usually called the State Register or State Bulletin—can be obtained by accessing the state legislative printing office/website or the state legislative information system office/website. Federal regulatory information is available online: the National Archives manages the Code of Federal Regulations (CFR) website and the U.S. Government Publishing Office oversees the eCFR website. Because state and federal agencies promulgate numerous regulations, it is in one’s best interest to belong to at least one national professional organization, most of which employ professional lobbyists who track legislation, monitor agencies’ rulemaking, and report to their membership. Some state organizations employ such lobbyists; many others do not have the financial resources to do so. Specialty organizations’ newsletters and journals and legislative subscription and monitoring services and bulletins can be relied upon to summarize proposed regulation content and track status progress.

Providing Public Comment Regulatory agencies provide a small window of opportunity for public comment. Most comment periods last 30 days from the date of publication of the proposed regulation. However, longer comment periods are sometimes permitted if the agency anticipates the issue will draw strong public interest or involves controversy. Public rule hearings are held by the agency proposing the regulation. Public agencies must comply with administrative procedures act regulations regarding public hearings. Federal agencies are generally required to hold hearings when a numeric threshold is reached (i.e., a certain number of individuals or agency/organization representatives make requests to offer testimony). Written comments received by the agency are made a part of the permanent record and must be considered by the agency’s board or commission members prior to publication of the final regulation. A final regulation can be challenged in the courts if the judge determines that the agency did not comply with the administrative procedures act or ignored public comments. The Federal Register provides agency contact information on its website, making it feasible for the public to provide comment on proposed regulations. Only written comments are included in the public record, although agencies may permit oral comments if time is short. Instructions for submitting electronic comments or written submissions by mail, hand delivery, or courier are generally included on the filing agency’s Federal Register webpage. Comments received after the comment period posted in the Federal Register is closed can be legitimately disregarded by the agency.

Strengths and Weaknesses of the Regulatory Process The regulatory process is somewhat more well ordered than the legislative process in that it is directed by state or federal administrative procedures acts. These procedures guarantee opportunities for comment and public input. The regulatory process also includes built-in delays and time constraints that slow the process of developing and implementing regulations. However, administrative agencies are able to exert a great

deal of control over the rule-drafting process. Agency staff have an interest in assuring that the final regulation has sufficient detail so that it can be reasonably enforced. It is possible that agency staff, although skilled regulators, may not be knowledgeable about a regulation’s impact from the practitioners’ point of view. If the agency did not invite stakeholders to assist with the original drafting of the regulation, then public input during the comment period is especially important. In addition to enforcement, administrative agencies may have legislative authority to interpret regulations. Sometimes regulations may be misinterpreted by agency staff or board members, resulting in the imposition of a new meaning that is not aligned with the original intent of the regulation. These interpretations may be published as opinions, interpretive statements, and/or declaratory rulings of the board. Opinions of the attorney general or court may also misinterpret the original legislative intent, but the judicial branch of government is more likely to apply sound legal standards to its fact-finding and conclusions of law. Regardless, official opinions carry the force and effect of law even if they are not promulgated as regulations, according to the administrative procedures act.

Regulation in a Transforming Healthcare Delivery System In the United States, the healthcare delivery system is undergoing a period of significant and rapid change. Evidence of system shifts began in 1995, when the Pew Health Professions Commission (1994) published a sweeping report that stimulated new thinking about existing regulatory systems. The report suggested that the system, based on a century-old model structured with separate health professions agencies regulating individual health professionals with potentially overlapping scopes of practice, was out of sync with the nation’s healthcare delivery systems and financing structures. The Pew Health Professions Commission suggested that major reform was needed and asked states to review regulatory processes with the following questions in mind (Dower & Finocchio, 1995, p. 1): Does regulation promote effective health outcomes and protect the

public from harm? Are regulatory bodies truly accountable to the public? Does regulation respect consumers’ rights to choose their own healthcare providers from a range of safe options? Does regulation encourage a flexible, rational, and cost-effective healthcare system? Does regulation allow effective working relationships among healthcare providers? Does regulation promote equity among providers of equal skill? Does regulation facilitate professional and geographic mobility of competent providers? The Pew Task Force on Health Care Workforce Regulation challenged state and federal governments to respond to the complex health professions education and regulation issues identified in the report. Report recommendations addressed the use of standardized and understandable language, standardization of entry-to-practice requirements, assurance of initial and continuing competence of healthcare practitioners, and redesign of professional boards, including creation of super-boards in which the majority of members are consumer representatives. The report also called for better methods of assessing the achievement of objectives and improved disciplinary processes (Pew Health Professions Commission, 1995). Some of these changes have already been implemented in regulatory agency structures, such as standardization of entry-to-practice requirements, but redesign of professional boards has been slow to change. Following the 1995 Pew report, the Institute of Medicine (IOM)—now known as the National Academy of Medicine—issued several reports related to safety in healthcare systems, known as the Quality Chasm Series. Many of these reports made recommendations with regard to regulation. For example, in its first report, To Err Is Human, the IOM called for licensing and certification bodies to pay greater attention to safety-related performance standards and expectations for health professionals (Kohn, Corrigan, & Donaldson, 2000). A consensus report, focused singularly on nursing, was jointly issued by the Robert Wood Johnson Foundation and the IOM in October 2010. This report, which bore the title The Future of Nursing: Leading Change,

Advancing Health, provided four key messages to guide changes and remove barriers that prevent nurses from being able to function effectively in a rapidly evolving healthcare system: Nurses should be enabled to practice to the full extent of their education and training. Nurses should be able to access higher levels of education and training in an improved education system that allows for academic progression. Nurses should be full partners in the interprofessional redesign of the U.S. healthcare system. Effective workforce planning and policy making need better data collection and information infrastructures. Eight recommendations for fundamental change are found in the report, along with related actions for Congress, state legislatures, the CMS, the Office of Personnel Management, the Federal Trade Commission, and the Antitrust Division of the Department of Justice. The recommendation most relevant to regulation is the first: to remove scopeof-practice barriers. Other recommendations with implications for regulation include the call to prepare and enable nurses to lead change to advance health—that is, nurses who serve on boards and commissions serve in such roles—and the suggestion to build an infrastructure for the collection and analysis of interprofessional healthcare workforce data (IOM, 2010). Regulatory boards often survey their licensees as a part of renewal, providing excellent sources of workforce data. Some progress toward accomplishment of the Future of Nursing report recommendations has been made, but, importantly, barriers to expansion of APRN scopes of practice remain (IOM, 2016). Another area ripe for regulatory reform relates to structures that encourage interprofessional collaboration. The Josiah Macy Jr. Foundation, an organization dedicated to improving the health of the public through the advancement of health professions education, has been instrumental in providing direction for regulatory reform. In 2013, this foundation held a consensus conference with health professions education leaders to discuss a vision for a joint future of healthcare practice and education. Recommendations for action in five areas were made; one of these was to “revise professional regulatory standards and

practices to permit and promote innovation in interprofessional education and collaborative practice” (Josiah Macy Jr. Foundation, 2013, p. 2). Together these reports and recommendations provide a substantive body of evidence that can be leveraged for health professions regulation reform, thereby ensuring that these professions can meet the needs of 21st-century healthcare consumers. APRNs have a window of opportunity to act on these recommendations but must be open to the notion that collaboration with other health professions is essential if new regulatory models are to emerge. Regulation determines who has access to the patient, who serves as a gatekeeper in a managed care environment, who is reimbursed, and who has autonomy to practice. APRNs must be visible participants in the political process that authorizes APRNs to practice to the full extent of their education in a collaborative environment as equal team members and that ensures consumer choice and protection.

Current Issues in Regulation and Licensure: Regulatory Responses Changes to the Affordable Care Act The ACA increased access for underinsured and uninsured U.S. residents, who are estimated to number more than 50 million. This law/program also had a significant impact on the estimated 6,400 shortage areas in the United States, including 66 million Americans who have limited access to primary care (ANA, 2011). The need for APRNs to work in a variety of settings, but particularly in primary care, has been enormous, but their usefulness has been dependent on lifting practice restrictions in their state of licensure. The ACA is now in the midst of partisan controversy, and the future of its key provisions is currently uncertain. Key policy issues related to the ACA include regulation of health insurance coverage and costs, potential changes to Medicaid and Medicare, potential changes in reimbursement for prescription drugs and prescribing practices, and handling of reproductive health services (Kaiser Family Foundation, 2016). Both state and federal regulatory agencies will play a part in enacting these changes; regulations governing the health insurance marketplace (CMS, 2019) and the Medicaid and Medicare programs (CMS, 2014) will need to reflect any changes made by the U.S. Congress. Programs that rely on state matching funds (e.g., Medicaid) will likely be forced to reevaluate their state’s contribution.

Reimbursement Significant breakthroughs have been made in reimbursement policy for APRNs, largely as a result of grassroots lobbying efforts and coalitions of APRN specialty nursing organizations. With the passage of federal legislation in 1997 allowing APRNs to bill Medicare directly for services, consumer access to care provided by APRNs has improved. Managed care markets value efficiency and provider effectiveness. Understanding

the concept of market value has motivated APRNs to become more skilled in costing out their services and in winning contracts in a competitive market.

Scope of Practice The Future of Nursing progress report (IOM, 2016) noted that only minimal change in expansion of nurses’ scopes of practice had been accomplished since 2010. APRNs continue to struggle with these issues, although progress has been made in some states as well as at the federal level. A 2014 report from the Federal Trade Commission (FTC) provided an unbiased analysis of the consequences of continuing to impose restrictions on APRNs’ scopes of practice. The report noted associations between mandatory physician supervision/collaborative practice agreement regulations and restriction of independent APRN practice. The FTC (2014) projected that these environmental factors would likely lead to decreased access to healthcare services, higher costs, and reduced quality of care, leading to minimization of nursing’s ability to innovate in the delivery of health care. The Department of Veterans Affairs (VA) recently finalized a regulation allowing full scope of practice for APRNs, with the exception of CRNAs (Dickson, 2016). Boundary disputes within and across the health professions create tension and are counterproductive to efforts to improve nursing’s contributions to care, as those efforts rely on equitable teamwork. It is imperative for APRNs to be cognizant of such reports as that published by the FTC and to keep abreast of inroads, such as those made in the VA. Compelling evidence (e.g., the FTC report) and progress in high-level government agencies (e.g., the VA) can serve as leverage when negotiating with lawmakers and other stakeholders at the state level to enact changes in scope of practice laws.

Increased Use of Unlicensed Assistive Personnel Unlicensed assistive personnel (UAPs) are individuals who are unregulated in many states, inexpensive, and employed in acute and primary care settings. In many settings, UAPs are used appropriately.

However, when employers misunderstand the UAP’s role or expand job descriptions in an effort to provide more care at less cost, there is a risk that UAPs may be asked to function beyond their capacity and in a way that approaches nursing practice. Potential dangers include unsafe patient care and liability for nurses who, because of their employment situations, feel forced to delegate more nursing tasks to UAPs than safe standards of delegation would dictate.

Electronic Access to Healthcare Services The impact of technology on the delivery of health care, including telehealth, was mentioned earlier in this chapter in the context of questions about whether the federal government has an interest in interceding in the standardization of state licensing requirements to facilitate interstate commerce. Such action would preempt the states’ authority to license health professionals. However, the states maintain their right to protect their citizens. Today, nurses who live in one multistate-regulation state and practice telehealth in another multistateregulation state have the benefit of multistate regulation (but must affirm licensure in the second state). Where no multistate compact exists between states, however, the nurse must generally seek licensure in the state in which the patient resides.

Interstate Mobility and Multistate Regulation Cumbersome licensure processes across geopolitical boundaries make seamless transition difficult or impossible, particularly for APRNs. The Nurse Licensure Compact (NLC) model, adopted by the NCSBN, is nursing’s mutual recognition model of multistate regulation and licensure for RNs. States adopting this model voluntarily enter into an interstate compact, which is a legal agreement between states to recognize the license of another state and to allow for practice between states. This allows the nurse to possess a “home state” license and to practice in a remote state without obtaining an additional license. The compact must be passed as law by the state legislature and implemented by the BON in each state (NCSBN, 1998). Several states moved quickly to enter the compact when it was

instituted, but many states remain independent. As of January 2018, 31 states were participating as compact states (NCSBN, 2018). Until 2015, there was no system for APRN participation in a nursing compact. Consequently, although the compact may apply to a nurse’s RN license, it does not extend to cover advanced practice, and APRNs must apply for licensure in each state of practice. In May 2015, the NCSBN approved the APRN Compact model, which would allow APRNs to hold one multistate license and extend privileges to practice in other APRN Compact states (NCSBN, 2017a). To participate in this system, state NPAs would need to be revised to include the Uniform APRN Requirements. Currently, no states have enacted APRN Compact legislation.

Conclusion The capacity to adapt is crucial in an era of rapid change. Today’s politically astute nurses have many opportunities to shape public policy, by working in coalition together and with other health professionals and consumers, and to advocate for state and federal health policies and regulations that will allow the public greater access to affordable, quality health care. The window of opportunity that opened with the enactment of the comprehensive ACA will look somewhat different as we move forward. It is essential for nurses and APRNs to develop skills to capitalize on the chaos present in the healthcare and political environments and to create opportunities to advance the profession as a whole. Familiarity with the regulatory process will give nurses and APRNs the tools needed to navigate this dynamic environment with confidence. Knowing how to monitor the status of critical issues involving scopes of practice, licensure, and reimbursement will allow APRNs to influence the outcomes of debates on those issues. Participation in specialty professional nurse organizations is especially advantageous. Participation builds a membership base, providing the foundation for strong coalition building and a power base from which to effect change in the political and regulatory arenas. Participation also gives members ready access to a network of colleagues, legislative affairs information, and professional and educational opportunities. Although supporting the profession through participation is central, it is equally important to remember that each professional nurse has the ability to make a difference.

Discussion Questions 1. Compare and contrast the legislative and regulatory processes. 2. Describe the major methods of credentialing. List the benefits and weaknesses of each method from the standpoint of public protection and protection of the professional scope of practice. 3. Discuss the role of state BONs in regulating professional practice. 4. Obtain a copy of a proposed or recently promulgated regulation. Using the questions in Exhibit 8-1, analyze the regulation for its impact on nursing practice. 5. Describe the federal government’s role in the regulation of health professions. To what extent do you believe this role will increase or decrease over time? Explain your rationale. 6. Analyze the pros and cons of multistate regulation (choose multistate regulation of RNs, APRNs, or a combination). Based on your analysis, develop and defend a position either for or against multistate regulation. 7. Prepare written testimony for a public hearing defending or opposing the need for a second license for APRNs. 8. Contrast the BON and the national or state nurses association vis-àvis mission, membership, authority, functions, and source of funding. 9. Identify a proposed regulation. Discuss the current phase of the process, identify methods for offering comments, and submit written comments to the administrative agency. 10. Evaluate the APRN section of the nurse practice act in your state using the NCSBN Model Act (NCSBN, 2012) or regulations using the NCSBN Model Rules (NCSBN, 2017b). 11. Identify the states that have implemented nurse-staffing ratios. List some of the obstacles one of the states has encountered in the implementation phase.

CASE STUDY 8-1: DELEGATION OF

MEDICATION ADMINISTRATION BY APRNs The authority to administer medications in one state is restricted and specific. The NPA allows RNs to delegate medication administration only to BON-certified medication aides in nursing homes and residential care facilities. Otherwise, unlicensed persons may only assist an individual with self-administration of certain medications, may give oral medication or apply topical medication in accordance with the laws and regulations of the Department of Disabilities, and may administer prescribed medication to a student if the RN is employed by a board of education or charter school if those medication administration procedures are in accordance with the laws regulating boards of education. However, with the exception of these special instances, RNs and APRNs are not permitted to delegate medication administration to non-nurses, including medical assistants. This restriction is problematic for APRNs, particularly NPs and CNSs who function in primary care settings. Patients in primary care settings frequently need immunizations, tuberculosis skin tests, and routine medications. Because the current law largely prohibits APRNs from delegating medication administration to unlicensed personnel, the flow of patient care must be interrupted. APRNs must perform all medication administration and associated tasks themselves, unless there is another RN who is available to administer the medication. This prohibition is a significant barrier to productivity and efficiency. APRNs and stakeholder nurse associations approached a legislator who has been a friend to nursing and who is interested in improving healthcare delivery in the state. This member of the state House of Representatives sponsored a bill to allow APRNs to delegate medication administration to a trained, unlicensed person, such as a medical assistant, so long as certain conditions are met. These conditions include (1) the APRN has assessed the patient prior to administration to determine appropriateness; (2) the APRN has determined that the unlicensed person has completed the requisite education and has the knowledge, skills, and ability to administer the drug safely; and (3) delegation is in accordance with rules that are established by the BON. Additional safeguards include (1) the drug must be within the formulary established by the BON for APRNs, is not a controlled substance, and is not to be administered intravenously; (2) the employer has given the APRN access to employment records documenting the unlicensed person’s education, knowledge, ability, and skills with regard to medication administration; and (3) the APRN must be physically present at the location where the drug is administered by the unlicensed person. Language in the bill clarifies that the APRN delegating authority would not affect or change the current law governing delegation authority in certain facilities, including nursing homes and residential care facilities. This legislation received four hearings in the House Health Committee and was reported out with two sponsor amendments. One amendment added ambulatory surgical facilities to the list of sites where an APRN cannot delegate medication administration, and the other moved the rule authority language to the general rule authority of the nurse practice act. Although this second amendment is technical, it is beneficial to APRNs in that it will authorize the BON to promulgate rules without the advice and counsel of its multidisciplinary Committee on Prescriptive Governance. One state nursing association and one APRN testified on behalf of nursing as proponents for the bill. The state medical association remained neutral throughout the process.

Discussion Points 1. Identify ways to increase the likelihood that the legislation will pass.

2. Determine a complete list of possible stakeholders. In addition to state nurses associations, which other associations or organizations might have an interest? 3. Discuss the position of neutrality on the part of the state medical association. Would you expect this? Why or why not? Could this organization’s position change? Why or why not? If so, what could you do in anticipation to ensure its continued neutrality or future support for the bill? 4. Although several state nurses’ associations have an interest in this bill, only one formally provided proponent testimony for the record. In addition, one adult NP, who represented herself as a single practitioner, provided testimony. What are the implications of limited proponent testimony? What does a small turnout, or silence, say to legislators? What might be done differently, or in addition, when the bill reaches the Senate?

CASE STUDY 8-2: EVIDENCE VERSUS STAKEHOLDER INTERESTS IN RULEMAKING Prelicensure nursing education in the United States is tightly regulated by BONs. Nursing education regulations include curriculum requirements and typically include provisions regarding what must be included in classroom instruction, in laboratory/simulation, and in clinical experience. Clinical generally refers to those faculty-supervised experiences that occur in authentic patient settings with persons who need nursing care. Some BONs specify a minimum number of hours of clinical experience; some do not. Prelicensure nursing education rules do not directly affect APRNs; however, their indirect effect can be substantial. APRNs may serve in administrative leadership roles or oversee the care of patients in healthcare organizations where graduates of programs will hold future employment. One BON was approached by rural-area nursing educator stakeholders who had encountered difficulties in securing clinical experiences for students in obstetrics, newborn care, and pediatrics. The BON asked its Education Advisory Committee to discuss the matter. The committee made a recommendation, based on a simulation study conducted by NCSBN, that as many as 100% of clinical experiences in those areas could be replaced by high-, mid-, or low-fidelity simulation in a skills laboratory setting. The BON heard testimony at its rules hearing from proponents, primarily representatives from the nursing education programs having difficulty finding the experiences for students. Testifying in opposition were individuals representing several nursing organizations, including the deans and directors of baccalaureate and higher-degree nursing education programs, an organization representing all chief nursing officers in the state, the state nurses association, and the state pediatric nurses association. Proponents verified the difficulty in obtaining clinical experiences for students and cited their rationale for substituting simulation for authentic clinical experiences. Opponents noted the findings of the NCSBN study that indicated a maximum of 50% of clinical experiences could be replaced with simulation and spoke to the qualitative differences between authentic clinical experiences and simulation. The individual representing chief nursing officers offered to work with nursing programs to facilitate procurement of clinical experiences. Following deliberation, the BON determined to file the rule as proposed, allowing substitution of up to 100% of clinical experience in the three specialties (obstetrics, neonatal,

pediatrics) with simulation.

Discussion Points 1. Which additional questions would you want answered about the methodology and detailed findings from the NCSBN simulation study? 2. Who were the stakeholders? Which specific arguments can you anticipate stakeholders on both the proponent and the opponent sides made for or against the rule change, respectively? 3. If you were a nursing leader or practicing APRN in one of the specialty areas, do you have any concerns about the proposed rule? Given your position, are there any current or future actions you might take to safeguard patients?

References

American Nurses Association. (2011). Advanced practice nursing: A new age in health care. American Nurses Association Backgrounder. Retrieved from https://www.nursingworld.org/~48dd7e/globalassets/docs/ana/aprnmediabackgrounder.pdf APRN Joint Dialogue Group. (2008). Consensus model for APRN regulation: Licensure, accreditation, certification & education. Retrieved from https://www.aacnnursing.org/Portals/42/AcademicNursing/pdf/APRNReport.pdf Carey, M. P. (2013, June 17). The federal rulemaking process: An overview. Congressional Research Service Report RL32240. Retrieved from http://www.fas.org/sgp/crs/misc/RL32240.pdf Centers for Medicare and Medicaid Services (CMS). (2014). History. Retrieved from https://www.cms.gov/About-CMS/Agency-information/History Centers for Medicare and Medicaid Services (CMS). (2019).The Center for Consumer Information & Insurance Oversight: Regulations and guidance. Retrieved from https://www.cms.gov/CCIIO/Resources/Regulations-andGuidance/index.html#%20Affordable%20Care%20Act Damgaard, G., & Young, L. (2017). Application of an evidence-informed health policy model for the decision to delegate insulin administration. Journal of Nursing Regulation, 7(4), 33–44. Dickson, V. (2016, December 13). VA finalizes rule that expands scope of nurse practice. Modern Healthcare. Retrieved from http://www.modernhealthcare.com/article/20161213/NEWS/161219974 Dower, C., & Finocchio, L. (1995). Health care workforce regulation: Making the necessary changes for a transforming health care system. State Health Workforce Reforms, 4, 1–2. Federal Trade Commission (FTC). (2014). Policy perspectives: Competition and the regulation of advanced practice nurses. Retrieved from https://www.ftc.gov/system/files/documents/reports/policy-perspectives-competition-regulationadvanced-practice-nurses/140307aprnpolicypaper.pdf Garner, B. A. (2014). Black’s law dictionary (10th ed.). St. Paul, MN: Thomas Reuters. Gobis, L. J. (1997). Licensing and liability: Crossing the borders with telemedicine. Caring, 16(7), 18–24. Hartigan, C. (2011). APRN regulation: The licensure‒certification interface. AACN Advanced Critical Care, 22(1), 50–65. Institute of Medicine (IOM). (2010). The future of nursing: Leading change, advancing health. Retrieved from https://www.nap.edu/download/12956 Institute of Medicine (IOM). (2016). Assessing progress on the Institute of Medicine report. The Future of Nursing. Retrieved from https://www.nap.edu/download/21838 Josiah Macy Jr. Foundation. (2013). Transforming patient care: Aligning interprofessional education with clinical practice redesign. Conference recommendations. Retrieved from https://macyfoundation.org/assets/reports/publications/jmf_transformingpatientcare_jan2013conference_fin_we Jost, T. S. (1997). Regulation of the health professions. Chicago, IL: Health Administration Press. Kaiser Family Foundation. (2016, November 9). Where president-elect Donald Trump stands on six health care issues. Retrieved from http://kff.org/health-reform/issue-brief/where-presidentelect-donald-trump-stands-on-six-health-care-issues/#opioid Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (Eds.). (2000). To err is human: Building a safer health care system. Washington, DC: National Academies Press. Legal Information Institute. (2017). Supremacy Clause.Retrieved from http://www.law.cornell.edu/wex/supremacy_clause

Loversidge, J. M. (2016a). A call for extending the utility of evidence-based practice: Adapting EBP for health policy impact. Worldviews on Evidence-Based Nursing, 3(6), 399–401. Loversidge, J. M. (2016b). An evidence-informed health policy model: Adapting evidence-based practice for nursing education and regulation. Journal of Nursing Regulation, 7(2), 27‒33. Melnyk, B. M., & Fineout-Overholt, E. (2015). Evidence-based practice in nursing and healthcare: A guide to best practice (3rd ed.). Philadelphia, PA: Lippincott Williams & Wilkins. National Council of State Boards of Nursing (NCSBN). (1993). Regulation of advanced nursing practice position paper. Retrieved from https://www.ncsbn.org/1993_Part6.pdf National Council of State Boards of Nursing (NCSBN). (1998, April). Multi state regulation task force communiqué. Chicago, IL: Author. National Council of State Boards of Nursing (NCSBN). (2002). Uniform advanced practice registered nurse licensure/authority to practice requirements. Retrieved from https://www.ncsbn.org/APRN_Uniform_requirements_revised_8_02.pdf National Council of State Boards of Nursing (NCSBN). (2008). Contact a board of nursing. Retrieved from https://www.ncsbn.org/contact-bon.htm National Council of State Boards of Nursing (NCSBN). (2012). NCSBN model act. Retrieved from https://www.ncsbn.org/14_Model_Act_0914.pdf National Council of State Boards of Nursing (NCSBN). (2015). The APRN Compact: A summary of the key provisions. Retrieved from https://www.ncsbn.org/Key_Provisions_of_New_APRN_Compact.pdf National Council of State Boards of Nursing (NCSBN). (2017a). APRN Compact. Retrieved from https://www.ncsbn.org/aprn-compact.htm National Council of State Boards of Nursing (NCSBN). (2017b). NCSBN model rules. Retrieved https://www.ncsbn.org/17_Model_Rules_0917.pdf National Council of State Boards of Nursing (NCSBN). (2018). Licensure compacts. Retrieved from https://ncsbn.org/listofmemberstatesanddates111618.pdf National Council of State Boards of Nursing (NCSBN). (2019). Nurse licensure compact. Retrieved from https://www.ncsbn.org/nurse-licensure-compact.htm O’Sullivan, J., Chaikind, H., Tilson, S., Boulanger, J., & Morgan, P. (2004). Overview of the Medicare Prescription Drug, Improvement and Modernization Act of 2003. Congressional Research Service. Order Code RL31966. Washington, DC: Library of Congress. Pew Health Professions Commission. (1994). State strategies for health care workforce reform. San Francisco, CA: UCSF Center for the Health Professions. Pew Health Professions Commission. (1995). Report of task force on health care workforce regulation (executive summary). San Francisco, CA: UCSF Center for the Health Professions. Phillips, S. J. (2017). 29th annual legislative update. Nurse Practitioner, 42(1), 18–46. Roberts, M. J., & Clyde, A. T. (1993). Your money or your life: The health care crisis explained. New York, NY: Doubleday. Russell, K. A. (2012). Nurse practice acts guide and govern nursing practice. Journal of Nursing Regulation, 3(3), 36–42. Safriet, B. J. (1992). Health care dollars and regulatory sense: The role of advanced practice nursing. Yale Journal of Regulation, 9(2), 419–488. U.S. Department of Health and Human Services (DHHS). (2014). The Affordable Care Act, section by section. Retrieved from http://www.hhs.gov/healthcare/rights/law U.S. Department of Health and Human Services (DHHS) & Centers for Medicare and Medicaid Services (CMS). (2016, October). Advanced practice registered nurses, anesthesiologist assistants, and physician assistants. Medical Learning Network. ICN901623. Retrieved from https://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNProducts/Downloads/Medicare-Information-for-APRNs-AAs-PAs-Booklet-ICN901623.pdf

* This chapter originally appeared in Health Policy and Politics: A Nurse’s Guide, Sixth Edition by Jeri A. Milstead and Nancy M. Short.

© Zen Rial/Moment/Getty Images.

CHAPTER 9 Healthcare Policy for Advocacy in Health Care Angela Mund There are three critical ingredients to democratic renewal and progressive change in America: good public policy, grassroots organizing and electoral politics. —Paul Wellstone

CHAPTER OBJECTIVES After completing this chapter, the reader will be able to 1. Describe the legislative process and the advanced practice nurse can influence the policy agenda. 2. Understand the components of a policy brief. 3. Review the role of professional organizations as a platform for policy change. 4. Identify the techniques that should be employed to effectively lobby for a cause. 5. Discuss state nurse practice acts and scope of practice laws that regulate the APRN licensure.

Introduction In 2001, the Institute of Medicine (IOM) challenged all healthcare professionals to improve the quality of patient care, with an emphasis on increasing its safety, effectiveness, efficiency, equitability, timeliness, and patient centeredness (IOM, 2001). With the release of the IOM report The Future of Nursing: Leading Change, Advancing Health (IOM, 2011), nurses are tasked with being active partners in this transformation of health care. However, advanced practice registered nurses (APRNs) continue to be encumbered by scope of practice restrictions and challenges to obtaining parity in reimbursement. These barriers can be removed through political advocacy. In addition, to create widespread change in the delivery of health care and in the structure of America’s health systems, policies supporting quality improvement must be researched, developed, funded, and implemented. The complexity of today’s healthcare environment and the increase in volume of scientific knowledge demand the involvement of nurses educated in the legislative process and prepared to influence policy on the local, state, and national levels. APRNs have the advantage of an appreciation of the patient care experience and the challenges of working within complex healthcare systems. According to Lyttle (2011), “Nurses in political office are also likely to do exactly what they’ve been doing in health care settings for years: adjust and adapt to ever-changing situations; listen carefully; gather facts; and discern, decide, and deal thoughtfully with unexpected outcomes and turns of events” (p. 19). However, those unique experiences must be combined with an education in the intricacies of policy and politics in order to create true and effective change. Policy activism translates into patient advocacy. In 1992, Ham described five basic elements critical to understanding the inherent complexity of policy. These elements are just as relevant today and include the following concepts: 1. Reviewing policies includes studying formal decisions and actions.

2. A policy may include a network of interacting decisions rather than a single decision. 3. Policies change over time. 4. Policies that were not acted on should also be included when reviewing policy making. 5. It is important to identify the policies that were created out of clear decision making and to use that information to develop an effective process of policy making (as cited in Hewison, 1999, p. 1378). During the creation of the American Association of Colleges of Nursing’s (AACN) Essentials of Doctoral Education for Advanced Nursing Practice, the AACN recognized and supported the integral relationship between policy and practice. Therefore, the AACN included the curricular requirement of instruction in “health care policy for advocacy in health care” in the Essentials (AACN, 2006). According to the AACN, doctorally educated nurses will have the tools to engage in and serve as leaders in the development and implementation of healthcare policy that affects financing, regulation, quality improvement, and equitable access to health care. Staebler et al. (2017) examined the barriers to teaching healthcare policy and found that the barriers varied based on level of nursing program. Lack of interest was stated as the primary perceived barrier to student engagement at the doctoral level. Although there were limitations in the study, several themes arose where it was noted there is still considerable work to be done, including lack of faculty interest in the topic, lack of leadership support, and differences in levels of competence at each program level (Staebler et al., 2017). These barriers will have to be overcome to reach the goals of the AACN. In 2000, Rains and Carroll asserted that there has never been a greater need for nurses to be involved in the political process in order to ensure the best use of shrinking resources, to provide affordable health care for all, and to advocate for changes in healthcare policy. Although nurses are increasingly being recognized as leaders in U.S. regulatory agencies, from Marilyn Tavenner, former administrator of the Centers for Medicare and Medicaid Services (CMS), to Mary Wakefield, former administrator of the Health Resources and Services Administration (HRSA), nursing continues to be underrepresented in the legislative

arena. Of the two nurses in the 115th Congress, one will not be returning to the next Congress. These numbers project a downward slide from three in the 113th Congress to a potential low of one in the upcoming year. Although the number of physicians elected to Congress has decreased over this time, physicians continue to have a significant presence and hold committee leadership positions. The ability to effectively engage in influencing policy can be created by obtaining an understanding of the foundations of nursing policy, the elements of the political process, and the relationship between leadership and policy making. APRNs can be at the forefront of changing the system of healthcare delivery in the United States by shaping local and legislative decision-making processes.

History of the Relationship Between Nursing and Policy Making The integration of nursing and policy is not a new concept. During the Crimean War, Florence Nightingale recognized the connection between policies made by Parliament and the British soldiers’ poor living conditions (Ennen, 2001). Nurses’ policy involvement has waxed and waned since the 19th century, when Nightingale exerted influence on the public policies of sanitation and infection control practices. There was a lack of political interest and influence in the early 20th century (Milstead, 2008, p. 2). After a few decades of silence, individual nurse leaders such as Lillian Wald and Lavina Dock spoke up and publically supported suffrage, women’s rights, nursing licensure, and the right to health care (Rubotzky, 2000). Nursing as a collective field, however, did not speak out on the issues. In 1985, Huston described several factors explaining nurses’ lack of political involvement, including the “socialization to view power and politics negatively and the invisibility of nurses in the media” (as cited in Rains & Carroll, 2000, p. 37). From the 1970s through the 1990s, nurses were gaining in the areas of nursing science and education, use of technological knowledge and clinical skills, and in the creation of a new paradigm of advanced practice nursing. APRNs were now confronted with understanding the political and practice implications of state and national legislation and with creating policies that supported the continued advancement of the profession.

During the 1970s, the Department of Health, Education, and Welfare created the Committee to Study Extended Roles for Nurses. This committee recommended further studies on cost–benefit analysis and attitudes toward the use of APRNs and recommended increased federal funding for nurse practitioners (NPs) (Hamric, Spross, & Hanson, 2000). The 1970s also brought battles over prescriptive authority, the right for APRNs to use the word diagnose, and the right to directly bill Medicare for nurse anesthesia services (Hamric et al., 2000). The 1980s brought the concepts of cost containment and diagnosis-related groups and the associated legislation that would have an impact on APRN practice. NPs and nurse anesthetists encouraged lawmakers and the Health Care Financing Administration, currently the CMS, to create policies and pass legislation concerning reimbursement procedures that would support the profession of advanced practice nursing. In 1989, nurse anesthetists became the first APRN group allowed to obtain direct reimbursement from Medicare for anesthesia services. The passage of this legislation is considered “one of the greatest lobbying achievements not only of the American Association of Nurse Anesthetists (AANA) but of the whole of nursing” (Bankart, 1993, p. 167). Throughout the 20th century, nursing organizations were created and led by nurses who acknowledged the need for involvement in the policy arena, the necessity of professional leadership, and the importance of strong grassroots efforts by their nurse members. The 1990s were a decade of growth in the numbers of APRNs and of both NP and nurse anesthetist programs. Comprehending the increased complexity of patients and of healthcare systems, APRN educational programs transitioned to requiring a master’s-level education for entry to practice. APRN organizations continued to develop a voice, while the American Nurses Association (ANA), realizing the need for access to legislators, moved its headquarters to Washington, DC (Hamric et al., 2000; Milstead, 2008). As we move into the 21st century, nurses and nursing organizations have demonstrated a continued and growing presence in Washington, DC, in the offices and chambers of Congress and in the meeting rooms of the regulatory agencies. Conflicts over physician supervision, prescriptive authority, scope of practice, equal access to healthcare providers, and the quality, safety, and cost-effectiveness of health care

are still being waged at the state and federal levels. These challenges will continue to support the need to educate all nurses in how to become influential in the policy arena. The incorporation of policy into the APRN role and the doctor of nursing practice (DNP) degree requirements is leading to a resurgence of interest in the responsibility of influencing healthcare reform, the promotion of global health, and the protection of the profession.

Influencing the Health Policy Agenda Public policy is created by governmental legislation and involves laws and regulations. It has been defined as “the purposeful, general plan of action developed to respond to a problem that includes authoritative guidelines” (Sudduth, 2008, p. 171). According to Mason, Leavitt, and Chaffee (2002), “Public policy often reflects the value, beliefs and attitudes of those designing the policy” (p. 8). Public policy can be further divided into social policy, which concerns communities, and then into health policy, which focuses on the health of the individual (Mason et al., 2002). The word politics has both positive and negative connotations. On one hand, it brings to mind images of corruption, misbehavior, and “politics as usual.” However, politics should also have positive undertones as the decision-making process whereby APRNs can influence the development of legislation and the allocation of resources. As APRNs are increasingly becoming empowered to engage in the process of transforming health care, they must be actively engaged in influencing the health policy agenda. A potential avenue to effect change in health policy is for APRNs to author a policy brief. Nurses have the public’s trust as well as the education and healthcare expertise to provide credible information to legislators and regulatory agencies. The purpose of a health policy brief is to provide background and to propose a solution to an issue facing a person or a group that does not have a background in health care. A policy brief can be defined as a brief report that addresses the interests and needs of policy makers though application of best evidence in an effort to produce a solution to a problem (DeMarco & Tufts, 2014). See BOX 9-1 for considerations on developing a policy brief.

BOX 9-1 Considerations for the Development of a Policy Brief Make it brief and understandable for a non–healthcare provider audience. Know your audience and what problem they are interested in solving. The brief should be no longer than four pages.

A typical format consists of four sections: an executive summary, background and significance, a statement of the author’s position, and a reputable reference list. Determine the most efficacious timing for submitting the brief. A sense of urgency is a powerful motivator in seeking solutions. Provide a convincing argument through a systematic review of the literature. Advocate for a desired solution based on the information. Provide data that refute objections to the solution proposed within the brief. Demonstrate credibility and expertise in the area of concern. DeMarco, R., & Tufts, K. A. (2014). The mechanics of writing a policy brief. Nursing Outlook, 62, 219–224.

DNP graduates are well positioned to influence the content and quality of healthcare legislation. Along with their extensive clinical background and a well-developed comprehension of the issues, APRNs must have a working knowledge of the language of legislation and regulation.

The Process of Legislation The legislative process is rarely the very linear, rational process described in textbooks. Instead, it is a process whereby competing interests attempt to influence policy making by creating bargains, trading votes, and using rhetoric to convince legislators that their policy agenda is the best. APRNs have the opportunity and responsibility to educate lawmakers as legislation moves through the legislative bodies and government agencies. FIGURE 9-1 notes the basic steps of moving a bill through the state or federal process. In the federal policy arena, proposed legislation is called a bill until it is passed by both houses of Congress and signed into law by the president. At the state level, a bill moves via a similar process and is passed by the state legislature and signed into law by the governor.

FIGURE 9-1 Movement of a bill.

Description Although APRNs can draft legislation, it is more common to partner with an interested and supportive legislator in either the state or federal House of Representatives or the Senate. These partnerships should be developed over time rather than forced during times of crisis or expediency. The drafting process may include only a small number of persons or may involve a significant number of interested parties. It will be beneficial at this stage to allow any stakeholder nursing groups to review the language of the proposed legislation. Why is this important? Not all language is viewed the same by all groups, and what may be good for one APRN group may be detrimental to another. The time to find this discrepancy is not during the hearing phase, when the ability to influence legislation may be limited by time constraints and lack of coalition support. The greater the political power of the sponsoring legislator, the greater the probability of successfully passing a piece of legislation. The likelihood of successful passing of legislation will also improve if supportive legislators introduce the bill to both chambers of Congress at the same time. Bipartisan support from both Republican and Democratic sponsors further increases the likelihood of successful movement of legislation through Congress. Following the drafting of the legislation, the senator or representative will introduce the proposed legislation to the

chamber; the legislation will then be referred to the proper committee, typically based on the recommendation of the sponsoring legislator. The bill is given a number corresponding to the chamber in which it was introduced (e.g., S.252). The details of each bill can be found at www.congress.gov. The selection of the “proper” committee is based primarily on the appropriateness of the committee but can also be a political decision based on whether members of the committee support or oppose the proposed legislation. In theory, members usually author bills that will be referred to the committees where they have jurisdiction. While the legislation is in committee, interested parties and stakeholders may be invited to submit written or oral testimony either supporting or refuting the legislation. The legislation then undergoes a process called markup in which the committee debates the legislation, discusses the flaws, and amends the legislation as necessary. During this process, APRNs should be prepared to serve as content experts while advocating for the profession of nursing and shaping the healthcare agenda. It is imperative at this point to know the “enemies” of your legislation and be able to generate a strategy for managing controversy. Well-prepared testimony includes a description of who is doing the testifying (e.g., a family NP in a rural practice), the background of the issue, and why the legislation is supportive or detrimental in resolving the issue. Effective testimony must also include what the APRN testifying would like the committee to do. Submitting oral testimony may be a stressful situation, but the key to presenting a logical, persuasive report is to prepare in advance. When preparing testimony, it is very important to be able to discuss the issue in great detail, know the influential legislators on the committee, and include the potential impact on patient care. Once the committee agrees on the content and language of the bill, it is then moved to the Senate or House floor and voted on by the members. The submitting committee must create a report to accompany the bill. The report includes such information as the intent of the legislation, the potential financial implications, dissenting opinions, and amendments to the initial bill. The bill may be referred back to committee, approved, or voted down. Meanwhile, companion legislation is introduced in the other chamber of Congress, typically with similar wording; however, rarely is the wording exactly the same. The passage of the original

legislation in one chamber encourages the forward movement of the companion legislation in the other chamber. Following the passage of both companion bills, one in the Senate and one in the House, the bill may be moved to a conference committee to work out any differences. The conference committee is composed of both senators and representatives. Both chambers must concur and approve their respective bills prior to the bill passing out of Congress and moving to the executive branch. If the bill does not come out of committee before the end of the legislative session, the bill is dead and must be reintroduced during the following session. An important role for APRNs during this phase is to contact their representatives or senators and to build coalitions with other professional associations. The importance of creating these relationships prior to the introduction of any legislation will become evident as the bill moves through Congress. Nurses must not wait until the proposed legislation is being voted on—this is too late! Instead, nurses must be involved during the very early stages. Although the emphasis of influencing legislation often lies within the Congress, at the federal level, the executive branch has the power to either veto the legislation or sign it. Again, a similar process occurs at the state level. Another important factor to consider is the power of the office of governor or president in supporting or blocking the legislative effort.

The Process of Regulation An equally important but maybe more complex segment of policy is regulation. Regulation is the implementation process of legislation and occurs at both the state and federal levels. After a bill is passed through Congress and signed into law by the president, it is sent to a regulatory agency within the government, which then interprets the law and creates the rules and regulations that shape the way the new law is executed. Congress rarely includes explicit directions for implementation within the legislation and in fact may be purposefully vague. Again, stakeholders are invited to comment on the proposed draft of the rules and regulations. It is important not to overlook this phase because a hard-fought battle to produce legislation favorable for nursing may become something completely different during the regulatory process. Conversely, if policy

cannot be changed in the legislative arena, APRNs may be able to persuade the regulatory agency to publish rules that are favorable to nursing. This may be a dangerous game to play because regulations must be consistent with the enabling statute. In the event that the regulation is inconsistent with the law, the law supersedes the regulation. Federal agencies of interest to APRNs include the Department of Health and Human Services, the CMS, the Department of Veterans Affairs, the Indian Health Service, and the Armed Forces. The CMS is the primary agency regulating reimbursement for APRN services, including supervision requirements for billing. Before a regulation is put into effect, two steps must occur. First, the proposed rule is published in the Federal Register, and information is included on how the public can participate in the process by providing comment and attending the meetings (Loversidge, 2008). The second step involves the agency considering all the information and deciding on a course of action. The final regulation is then published in the Federal Register and becomes effective after 30 days. The Federal Register is a daily journal of the government of the United States that contains the public notices of all the government agencies, executive orders, and presidential proclamations. All the information from the Federal Register is in the public domain and can be accessed by any APRN at www.federalregister.gov. Many professional organizations have paid staff to monitor the Federal Register for regulations that may have an impact on APRNs. Boards of nursing, medicine, and pharmacy are examples of state regulatory agencies that may create rules and regulations that affect nurses and the delivery of health care within states. These agencies have the power to control entry into the profession, monitor and discipline licensees, and ensure continued competency of licensees (Loversidge, 2008). State agencies obtain their rule-making authority through enabling laws. An enabling law is “one in which the state legislature delegates to an administrative agency the authority to adopt regulations to implement the law’s purposes” (Tobin, 2001, p. 113). In essence, enabling laws give regulatory agencies the power to create rules and regulations. APRNs should assist in maintaining a collegial relationship between their state professional organizations and the board of nursing. Most appointments to state boards are made by the governor and necessitate the support of legislators and professional organizations. APRNs must be represented

on boards of nursing to monitor the actions of the board and offer recommendations related to advanced nursing practice. Boards of medicine may attempt to regulate nursing practice through language concerning supervision and collaboration. Therefore, it is advisable for APRNs to be aware of the regulatory agenda of all state boards that may have an interest in limiting APRNs’ scope of practice and patient access. This involvement may include having an APRN presence at the board meetings of nursing and nonnursing state boards. When reviewing proposed regulations, it is important to understand the intent of the regulation and evaluate the language of the regulation for possible limits to APRN scope of practice and reimbursement. Other possible avenues to influence the regulatory process include seeking appointment to CMS panels, providing testimony at regulatory hearings, obtaining a position on advisory panels to the National Council of State Boards of Nursing (NCSBN), and agreeing to serve as an APRN expert during drafting of regulatory policy. The NCSBN is a coalition of state boards of nursing that provides an avenue for state boards to examine regulatory issues and “counsel together on matters of common interest and concern affecting public health safety and welfare,” including performing policy analysis, licensure, and research (NCSBN, n.d.). In 2008, the NCSBN partnered with the APRN Consensus Work Group and created the Consensus Model for APRN Regulation. The Consensus Model grew out of a concern that because each state determines the legal scope of practice and the criteria for entry to practice and competence through certification examinations, the ability of APRNs to move between states is limited, and access to health care for patients may decrease. The Consensus Model promotes a uniform regulatory process based on nationally accepted standards for certification, licensure, and practice. All APRN stakeholder professional associations were invited to comment on the proposed Consensus Model. It was essential throughout this process that all APRN groups had a place at the table and were able to discuss concerns with the regulatory language, create a coalition of a wide variety of nursing groups, and generate a model that all the nursing stakeholders could support. The APRN Model Act on Rules and Regulations was approved by the NCSBN in August 2008 and has slowly gained a foothold in state

legislative and regulatory processes. During 2014, states increasingly became in line with adoption of parts or the whole of the Consensus Model. States have passed laws and regulations that recognize all four clinical specialties as APRNs, that allow for NPs to order home health, and that have provider-neutral language. Additional work is being done to address issues of lack of claim payment, enhanced reimbursement of primary care services, and widened authorization for prescriptive authority (Phillips, 2015). As of January 2018, 31 states have full practice authority for NPs—an increase of over 100% since 2015. The IOM (2011) has supported the NCSBN Model for Nurse Practice Act and has recommended that Congress “limit federal funding for nursing education programs to only those programs in states that have adopted this model” (p. 278). Although the intent of the IOM is to remove scope of practice barriers through consistent education and regulation, these statements could have a profound and unexpected effect on APRN practice. Therefore, as language from the Consensus Model continues to appear in proposed state legislation, it is imperative that APRNs monitor the legislative language to ensure that the intent of the model is correctly displayed in the legislation at both the state and federal levels. Therefore, in policy making, it is important to consider all phases and potential areas for influence throughout the entire process. Although similarities exist between states, APRNs should also understand the peculiarities of their state of licensure and the differences between federal and state legislation and regulation. APRNs can influence policy by providing proactive solutions to the problems facing health care rather than lamenting the problems. The solutions should contain information on practicality, feasibility, financial implications, and the benefits for the profession of nursing and for overall health care. Armed with an understanding of the background of policy making, the APRN will be able to build coalitions, foster grassroots lobbying efforts, and cultivate effective lobbying skills.

Professional Organizations, Grassroots Lobbying, and Coalition Building The powerful combination of a united political voice through professional organizations and the grassroots efforts of APRNs has the power to

influence the healthcare agenda. Through membership dues and other revenue sources, professional organizations have the resources to create a network of federal government lobbyists, state government political affairs directors, and political action committees (PACs). Strength in numbers and coalition building are an important part of creating political influence. Membership in a professional organization is the responsibility of all APRNs. BOX 9-2 lists examples of APRN professional organizations. Professional organizations all have healthcare advocacy on their agenda, but their approach to influencing policy varies. The yearly legislative agenda for each professional organization is based on the current policy climate, the presence of pronursing members of Congress on important committees, and the current needs of the profession. Some organizations have offices based in Washington, DC, with paid office staff, professional lobbyists, and PACs. Others operate primarily on a grassroots-type scale, with members providing the majority of the legislative work. Regardless of the organizational makeup, all members should maintain a two-way channel of communication to facilitate the flow of policy information and generate a network of involved members for grassroots lobbying efforts.

BOX 9-2 APRN Professional Organizations American Academy of Nurse Practitioners (AANP) American Association of Colleges of Nursing (AACN) American Association of Nurse Anesthetists (AANA) American College of Nurse-Midwives (ACNM) American Nurses Association (ANA) National Association of Clinical Nurse Specialists (NACNS)

It is important to remember that political decisions are not made in the Senate or House chamber on the day of the vote but in offices throughout the legislative session. Decisions may be based on external pressures from other legislators, constituents, friends, and professional groups. A potentially powerful grassroots approach to influencing policy is to become involved in the election campaign of an official running for public office. Involvement may range from knocking on doors to discuss the campaigner’s stance on the issue of access to health care to hosting a

fundraising event. Visibility is critical. When elected, the legislator will remember the supporters who were involved in the early stages of his or her run for a position in the local, state, or federal government. An indication of effective involvement can be when a legislator introduces an APRN to another legislator with the words “the APRNs were with me from the beginning.” This early involvement translates into an open-door policy with the legislator for members of the organization. Lobbying is not a dirty word but an important part of the legislative process bound by ethical rules of conduct. Lobbyists are registered, educated professionals hired by both state and federal organizations to influence decisions made by legislators. One approach to influence legislation is to ensure that the legislators have all the pertinent information before making a decision on a certain piece of legislation. For example, in the recent healthcare bill, a legislator who has a reputation of being CRNA friendly proposed an amendment for reimbursement for pain management services. However, the wording covered only physician services. After a discussion with the AANA lobbyist, the amendment was changed. Because healthcare professional organizations are composed of members with full-time careers in the clinical arena, lobbyists are an integral part of influencing the healthcare agenda. Lobbyists are able to be continuously available during the legislative process. The lobbyists have cultivated relationships with legislative staff and understand the inner workings of Congress. Professional lobbying activities performed on behalf of an organization can include monitoring ongoing and proposed legislation, developing an agenda of legislative goals, advising on distribution of PAC funds, communicating with the membership, and educating members during grassroots lobbying efforts. Lobbyists often assist in creating a voice for the professional organization in developing oral and written testimony. Professional lobbyists do not create the message. APRNs have the message; the lobbyist just knows how to get the message to the right people and in the correct manner. Legislators are more likely to listen to the concerns of their constituents and to support the efforts of a group of constituents. APRNs must take on the professional responsibility of advocating for nursing and healthcare reform by contacting their representatives and senators in Congress. APRNs have the ability to tell the story of their patients who

cannot afford preventive health care, or the small-town hospital that is closing because of budget cuts, or the patient who does not have access to health care because of lack of providers. Personal stories told by a clinician in one of the most respected and trusted professions can be a powerful tool for influencing legislation. Also, storytelling can be the least intimidating entry into the world of grassroots lobbying. When APRN DNP students share their personal difficulties in obtaining funding for education and research, it creates a more lasting impression than when a nonstudent discusses the challenges of financing education. APRN students can also share the real risk of a decline in the number of providers because of the high cost of education, especially at a time when the healthcare system may see a large influx of patients as a result of healthcare reform measures and the aging population. Professional organizations play a significant role in preparing the membership and alleviating some of the fears of grassroots lobbying. For example, the AANA’s Federal Government Affairs Office creates “Action Alerts” to encourage members to contact their representatives or senators. A portion of the AANA website contains the information that members who are certified registered nurse anesthetists (CRNAs) can use to contact their legislators. At a yearly assembly held in Washington, DC, the staff at the AANA’s local office educates CRNAs on the legislative process as a whole, on the current issues facing health care and healthcare reform, and on the issues specific to CRNAs. A portion of the assembly is spent practicing for lobbying, including the do’s and don’ts of presenting the issues and very specific details on the agenda for lobbying visits to Capitol Hill. In addition, legislators and senior staff are invited to engage with the attendees in discussions of issues important to health care and the practice of nurse anesthesia. Attending these professional meetings can be a very empowering experience, creating an understanding of what one individual, as part of a larger organization, can do to advocate for the profession of nursing and for the health of the nation. BOX 9-3 lists examples of effective lobbying techniques.

BOX 9-3 Effective Lobbying Lobby in person or on paper.

Send letters to your member of Congress when necessary. Obtain face time with legislators early on and throughout their term(s). Make an appointment rather than just drop by (not just in Washington, DC, but at home too). Be professional in appearance and demeanor. Be punctual. Understand how the policy-making process works. Attend educational “boot camps.” Maintain two-way communication with your professional organization regarding the organization’s legislative agenda. Use your professional organization’s lobbyist. Cultivate relationships with key legislative staff. Take the time and opportunity to educate staff on nursing issues. Research your issues. Be knowledgeable, confident, and articulate. Know the number and status of the bill you are supporting or opposing (www.congress.gov). Research the legislator you will be lobbying. Build legislative profiles. Is there a healthcare provider in the legislator’s family? Is the legislator on a committee with jurisdiction over healthcare issues? Is he or she the chair of the committee or a ranking member? Drive the discussion. Tell your story. Provide credible, “at the bedside” information about the impact of policies on health care. Discuss the impact of proposed legislation on the individual in his or her district—on constituents, the healthcare consumer, and the overall health of the United States. Never bash or speak poorly of your adversaries’ position on the legislation. If applicable, ask the legislator to sign on to cosponsor a bill you are supporting. Stay in touch. Send a handwritten thank-you note as a follow-up. Include your business card and how to contact you for questions or assistance. Flaunt your credentials! Exemplify professionalism. Focus on advocacy, trust, knowledge, and competency. Focus on the unique role, skills, and pivotal position of APRNs in the healthcare system.

Another essential aspect of lobbying is appreciating the roles and responsibilities of congressional staff. Each member of Congress has a chief of staff, also called an administrative assistant (AA), who is responsible for overseeing the overall management of the office, including managing the media and public relations and serving as a political advisor. Legislative directors are responsible for the “day-to-day legislative activities and may have more policy expertise” (Wakefield, 2008, p. 70). Legislative assistants (LAs), often post-college interns or

fellows participating in a fellowship program, have the most contact with special interest groups such as nursing professional organizations. LAs can be very influential because they advise the member of Congress on health policy issues. They control what information is presented to the member of Congress and what groups get face time with the senator or representative. LAs are assigned to a specific issue, such as health or veterans’ affairs; this does not mean that the LA is an expert in that area, however When meeting with an LA for the first time, it is crucial to determine what he or she knows about advanced practice nursing and nursing’s stance on healthcare issues. It is important to spend time educating the LA, in a nondefensive, noncondescending manner, regarding APRN practice and the professional organization’s legislative agenda. Even if the exact goal of the lobbying visit was not met, the LA will have obtained a greater understanding of APRNs, including those with doctoral education, which may increase the probability that a doctoral prepared APRN may be sought out for advice on proposed legislation. An established relationship with the member of Congress’s health LA will serve as a communication conduit for information regarding upcoming legislation and committee hearings. Although the blend of money and politics may not always appear to be a good combination, a strong PAC will increase access to and gain the attention of members of Congress. A PAC is a “group that is formed by an industry or an issue oriented organization to raise and contribute money to the campaign of political candidates who likely can advance their issue” (Twedell & Webb, 2007, p. 279). PACs have been involved in the campaign process over the last 60 years. Two types of PAC exist: separate segregated funds (SSFs) and nonconnected committees. SSFs are established and administered by organizations, whereas nonconnected committees are not sponsored by any organization (Federal Election Commission, 2009). Nursing PACs collect funds from their membership, pool the money, research the candidates, and distribute the money to legislators who are more likely to support the agenda of the nursing organization. PACs may contribute primarily to Democratic or Republican candidates, but often the PAC may be nonpartisan, supporting the candidate with similar priorities or the candidate who is influential on healthcare issues. Certified registered nurse anesthetists (CRNAs), NPs, clinical nurse specialists (CNSs), and

certified nurse–midwives (CNMs) have APRN-specific PACs. The ANA’s PAC also contributes to candidates that support APRN issues. As Congress addresses campaign reform, PACs have come under increased scrutiny and have been required to increase transparency in regard to sources of funding, donation amounts to candidates, and relationships with Congress. The Federal Election Campaign Act of 1971 prohibited organizations from using their general funds and membership dues to fund campaign contributions, and the Bipartisan Campaign Reform Act of 2002 placed further limits on contributions (Twedell & Webb, 2007). However, in 2010, Citizens United, a conservative nonprofit organization, successfully used the First Amendment’s prohibition on the government placing limits on political spending by corporations or unions as a mechanism to allow for financing political expenditures through a corporation’s general treasury. This ruling by the United States Supreme Court allows for the creation of a “SuperPAC” with access to significant amounts of money to spend on media campaigns for or against a certain candidate. All PACs must continue to be transparent, as required from previous legislation related to campaign reform (Sullivan & Adams, 2010). Physician groups and pharmaceutical companies continue to have the top-spending PACs in health care, which often translates into greater political influence. During the 2016 election cycle, the top spending nursing PAC was the AANA, ranked 13th. The American Association of Orthopedic Surgeons led PAC contributions from specialty physician groups with receipts of $2.7 million with equal distribution to federal candidates (Center for Responsive Politics, 2018). According to the AANP (2018), there are 248,000 NPs in the United States and 45,500 CRNAs. If each NP and CRNA donated $50 to his or her PAC, the resultant $15 million could move APRN PACs toward the top of the list of influential healthcare PACs. Information regarding individual PACs, including where the money comes from, how it is spent, and the overall worth of each PAC, can be found at www.opensecrets.org. With nursing’s positive public image and a well-funded PAC, imagine the possibilities to influence legislation and advocate for improved quality and access to health care. Coalition building is an effective approach to obtaining legislative and regulatory approval for an organization’s policy agenda. Coalitions may

last for the short term or long term, with the objective of combining resources to achieve a common goal. Nursing organizations can form coalitions either with other healthcare organizations or between APRN groups. For example, a coalition of over 30 nursing organizations created the Nursing Community Consensus Document (2008) requesting improved funding for doctoral education and calling for the removal of the rule that limits traineeship grants for doctoral education. Although the emphasis is on increasing nursing faculty, the importance of removing the cap on doctoral grants for entry-level doctoral students should not go unnoticed. According to Rice (2002), the essential ingredients for strong coalitions include “leadership, membership, and serendipity” (p. 122). As in all organizations, it is important to have a leader who can organize the work of the coalition and motivate the group to stay on target (Rice, 2002). This could be an important venue for a DNP. Membership is essential to increase the productivity and the visibility of the organization. Coalitions may be formed by unforeseen opportunities. For example, proposed state legislation to remove the collaboration requirement for prescriptive authority may bring together the state nursing association and the state APRN organizations. The North Dakota Nurse Practitioner Association recognized the need to create a coalition of varied stakeholders before seeking a sponsor for a bill to change their nurse practice act (NPA). A dedicated group of NPs approached the North Dakota Board of Nursing for support and then obtained additional support from select North Dakota hospitals, county commissioner boards, the North Dakota Association of Nurses, individual physicians, and others (Madler, Kalanek, & Rising, 2014). Just as there are benefits for organizations in coming together, there are also potential pitfalls and challenges to effective functioning of the group. When forming a coalition, it is essential to have all the right people: members who will work hard and people with a stake in the common goal (Rice, 2002). One of the challenges of working in a group of differing organizations is the presence of varying perspectives. Although the group may have one common goal, each member organization may have contradictory perspectives on other goals. When this occurs, it is essential to have a leader, potentially one with a DNP degree, who will seek out diverse opinions, allow members to agree to disagree, and “work toward achieving decisions which members can live

with” (Rice, 2002, p. 128). Although opposing organizations may not agree on all topics, it is important to handle conflict effectively in order to maintain a working relationship if the need for collaboration does occur. Coalitions may be created for the purpose of countering a threat to the ability of member organizations to practice to the full scope of their professional licensure. The Coalition for Patients’ Rights (CPR) is composed of 35 organizations representing a variety of licensed healthcare professionals. The CPR, with strength in numbers and a diverse group of providers, aims to offset the efforts of the American Medical Association’s Scope of Practice Partnership (SOPP) initiative, which is designed to limit patients’ choice of healthcare providers and ultimately patient access to health care (CPR, 2017). Some coalitions may be formed without the express purpose of policy making. However, the data obtained by these nursing groups can be used to give a statistical significance to a proposed legislative agenda item. The Interagency Collaborative on Nursing Statistics (ICONS) “promotes the generation and utilization of data, information, and research about nurses, nursing education, and the nursing workforce” (ICONS, 2006). Coalitions of like-minded organizations may join forces to ensure a seat at the table while the details of the composition of healthcare reform legislation are debated. The Patients’ Access to Responsible Care Alliance (PARCA) is a coalition of nonphysician organizations that “aims to provide federal policymakers with access to information from all areas of the healthcare community . . . and is committed to quality cost-effective care and ensuring patients have options in the delivery of such care” (PARCA, n.d.). The inclusion of nondiscriminatory language for reimbursement for services provided by a nonphysician is critical for the future of APRNs and for equitable access to health care for all. This coalition was successful in getting nondiscrimination language included in the Patient Protection and Affordable Care Act (ACA) of 2010. The PARCA is composed of nursing APRN organizations, the American Academy of Audiology, the American Chiropractic Association, the American Optometric Association, the National Association of Social Workers, and others. As evidenced by the composition of the PARCA, an important aspect to consider when building effective coalitions is the significance of connecting diverse groups, including both depth and breadth of professions.

Healthcare Reform Because of increasing healthcare costs, “the insecurity resulting from basing healthcare insurance on employment,” and the significant number of uninsured, the American public grew increasingly dissatisfied with the state of health care in the United States throughout the 1990s (Schroeder, 1993, p. 945). In 1993, the Clinton administration attempted to reform health care in the United States. The proposed National Health Security Act (HSA) of 1993 included guaranteed comprehensive benefits, limitations on health insurance premiums, and increased emphasis on quality, and it mandated employers to provide insurance coverage through regulated health maintenance organizations (The Heritage Foundation, 1993). The proposed plan, spearheaded by then-first lady Hillary Clinton, had significant opposition from conservatives, small business owners, and the health insurance industry because of its cost and complexity, significant government oversight and control, and the potential to limit patient healthcare choices. In the end, legislation for healthcare reform was not passed. Because of the difficulty in creating a coalition for support and the appearance of political shenanigans, the American public’s interest in healthcare reform declined during the time that the HSA legislation was drafted. For the first time, nursing, the largest group of healthcare providers, had a significant presence during the debate over how to reform the U.S. healthcare system. This presence was due to the work of a small group of nurses who understood the importance of creating legislative relationships and of suggesting solutions to the problem and who demonstrated a “willingness to compromise in the present to secure the greater gain in the future” (Milstead, 2008, p. 20). In advance of the presidential and legislative impetus to restructure the healthcare system, the ANA created a task force in 1989 to begin work on an agenda to reform health care. Nursing’s Agenda for Healthcare Reform, published in 1992, focused on the contribution that reforming health systems would make in improving access to care while controlling costs and improving outcomes. The agenda called for a “federal standard of uniform basic benefits package for all U.S. citizens and residents financed through public-private partnerships using a variety of healthcare providers including provisions for community health and

quality measurement” (Trotter Betts, 1996, p. 4). Despite the failure of the HSA, the activism during this period allowed nurses to obtain increased visibility in the policy arena and develop skills in policy making. Nursing and the ANA came out better informed, with greater access to legislators, and better armed for the next legislative challenge (Rubotzky, 2000; Trotter Betts, 1996). Blendon and Benson, in a 2001 review regarding American opinions on health policy over the last 50 years, found that “Americans may have expressed dissatisfaction with private health insurance and managed care but most don’t trust the federal government to take over as a singlepayer provider or are satisfied enough with their current medical payment arrangements” (Blendon & Benson, 2001, as cited in Jamelske, JohsArtisensi, Taft, & German, 2009, p. 17). However, given the 2008 downturn in the economy, Americans and Congress are again concerned with enacting some variety of healthcare reform. With the rising cost of healthcare premiums and the increase in the number of Americans who are uninsured or underinsured, Americans have begun to realize that the potential to lose coverage in the future does exist. Policy lessons learned during the previous attempts at healthcare reform have set the stage for organized nursing to influence policy that will ensure improved health care for all Americans. An incremental healthcare reform policy would begin with small changes, allowing for the addressing of political dynamics at each stage. Influential policy makers exist on both sides of the plan for reform: creation of an immediate, all-encompassing change versus making small adjustments at regular intervals. In March 2010, President Barack Obama signed the ACA into law despite a lack of bipartisan support. The impetus for the passage of the ACA was the recognition that the United States spends more per capita on health care than any other country and is the one developed country that does not provide coverage to all its citizens (Hall & Lord, 2014). The ACA’s wide-ranging provisions address many of the issues that were facing health care in the prior decades including outmoded approaches to reimbursement, provider discrimination, lack of access to healthcare insurance at a reasonable cost, disparities in health care among all citizens, and rampant healthcare costs. Although many of the supporters of healthcare reform may have preferred a sweeping movement to publicly provided health care for all, many in Congress remembered the

failures of the Clinton administration and supported incremental, narrower calculated initiatives. The ACA was a middle-of-the-road approach that mandated individual health insurance but continued to preserve many aspects of the existing health insurance systems (Gable, 2011, p. 343). The ACA called for the expansion of Medicare coverage and provided for increased federal support for the Children’s Health Insurance Program (CHIP). An important achievement of the ACA is universal insurability, which precludes insurers from refusing to cover preexisting conditions (Hall & Lord, 2014). Of particular interest for APRNs is that it encourages the creation of new patient care models—accountable care organizations (ACOs)—and provider nondiscrimination language in reimbursement for service. Other diverse components include linking of Medicare payments to quality indicators through the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), increased access to preventive care, and increased federal financial support for careers in nursing. Even as the ACA was being fully implemented, the change in presidential administration in 2017 resulted in several areas of the ACA either being repealed or changed in significant ways. It remains to be seen whether the ACA will result in broad healthcare reform as it moves through the U.S. judiciary, regulatory agencies, and state government. According to Gable (2011), “the ultimate effects and significance of the ACA remain uncertain” (p. 340), and the same obstacles exist, including political opposition, concerns over constitutionality of mandates, and overall implementation of the legislation. Political influence developed by the ANA and nursing leaders in the 1980s and 1990s must be sustained throughout the upcoming legislative challenges during the anticipated long road to sustainable healthcare financing reform.

Long-Standing Policy Goals Before advocating for improvements in health care, it is crucial to understand the issues that have been at the forefront of nursing policy and politics for over four decades and that continue to warrant nursing’s legislative and regulatory involvement. According to Malone (2005), “it is important to understand the recent history of any policy issue to better understand the obstacles and resources in play” (p. 139).

Nursing Workforce Development As the demand for health care rises, the demographics of our population change, and the new ACA is being implemented, the nursing profession continues to be challenged with an overall nursing workforce shortage. Although the primary factor behind the nursing workforce shortage changes over time, “consistent factors include unfavorable working conditions, relatively low income potential, more satisfying alternative job opportunities, and lack of nursing faculty” (McHugh, Aiken, Cooper, & Miller, 2008, p. 6). Doctorally prepared APRNs and nursing faculty are drawn from the relatively small pool of baccalaureate-prepared nurses; therefore, deficiencies in the number of registered nurses (RNs) affect APRN vacancy rates and ultimately may limit patient access to care. Vacancy rates change over time relative to the changing economic times and healthcare market. Therefore, when advocating for legislative change concerning workforce development, it is necessary to have updated facts on past and current vacancy rates, the impact of past funding efforts on the shortage of nurses, and the impact of vacancy rates on healthcare delivery. For example, data from the U.S. Bureau of Labor Statistics (BLS) can be used to support the need for additional educational funding due to a projected need for a 31% increase in APRNs between 2016 and 2026 (BLS, 2018). The average rate of growth for all occupations is 7%. Additional information in the 2018 BLS Occupational Outlook Handbook reported that all four APRN specialties —CNS, CRNA, CNM, and NP—will be in “high demand particularly in medically underserved areas,” and “relative to physicians, these RNs

increasingly serve as lower-cost primary care providers.” The BLS handbook also acknowledges the role that changes in state NPAs will play regarding the need for more APRN practitioners as barriers to practice are removed and the public increasingly recognizes the role of APRNs. APRNs continue to play a vital role in providing care for uninsured and underserved populations. Liao, Quraishi, and Jordan (2015) found that when compared to physician anesthesiologists, CRNA practice correlated with lower income, Medicaid-eligible, uninsured, and unemployed populations. The data Liao et al. collected can be used to support removing restrictions on CRNA practice, thus allowing CRNAs “the opportunity to better serve the 47 million uninsured and vulnerable populations” (p. 269). According to McHugh et al. (2008), “The nursing shortage is not only of total numbers but also of the level of nursing education” (p. 7). Over the last decade, nursing organizations have continued to lobby for legislative support to increase funding for nursing education at both the baccalaureate and graduate levels. One legislative mechanism for funding is through the Nursing Workforce Development Programs (Title VIII of the Public Health Service Act). Title VIII programs have been the largest source of federal funding for nursing education over the last 45 years. In the 1960s, nursing leaders lobbied Congress to enact legislation that would alleviate the nation’s nursing shortage by funding nursing education. In 1964, President Lyndon Johnson signed the Nurse Training Act of 1964. In the years since its inception, Title VIII has expanded to include funding for advanced practice nursing education, for the education of disadvantaged and minority students, for nurse faculty loan programs, and for nurse education, practice, and retention grants (Nursing Community Consensus Document, 2008). Title VIII grants are an essential component for increasing the number of APRN graduates and for ensuring that medically underserved areas receive access to healthcare services. However, the level of funding is not guaranteed, and despite the increased costs of education and inflation, the relative level of funding has remained unchanged. It is through the continued action of involved nurses that Title VIII funding consistently remains in the national budget and on the legislative agenda. Along with a greater demand for nurses, the changing complexity of health care and healthcare systems requires that a greater number of

APRNs and nursing faculty be prepared at the graduate level. APRNs must continue to monitor and support legislative issues that alleviate the nursing shortage by expanding funding for nursing education, promoting a favorable work environment, and eliminating barriers to practice.

Reimbursement Although the complexity and changing nature of regulation make a detailed discussion of APRN reimbursement impractical for this venue, it is appropriate to discuss the fundamentals and historical background within the framework of advocating for APRN practice. It is imperative for the APRN provider to understand the challenges in achieving equality and to monitor for threats to APRN practice in the economic healthcare market within public policy. For over 3 decades, APRN groups have challenged our legislators to remove the financial barriers to practice (Sullivan-Marx, 2008). For example, until 1989, all direct reimbursement for anesthesia services was limited to anesthesiologists. CRNAs were reimbursed from the money paid to the institution through Part A of Medicare. The disparity in the ability to directly bill for services created an inequality between providers delivering the same care. The Omnibus Budget Reconciliation Act of 1987 required the federal Medicare program to create a separate payment plan for the anesthesia care delivered by a CRNA, which is now known as Medicare Part B. The change was budget neutral because responsibility for payment was moved from the Medicare Part A division to the Part B division (Broadston, 2001). The regulatory agency responsible for determining Medicare reimbursement was the Health Care Financing Administration (HCFA). When Medicare federal regulation changed, private insurance providers and state public health plans followed suit and opted to directly reimburse CRNAs for services provided (Broadston, 2001). It was essential during this time of legislative and regulatory change that CRNAs at all levels of the profession maintain close contact with Congress and the agencies responsible for transforming Medicare reimbursement. During the 1970s and 1980s, as the number of NPs grew and diagnosis-related groups (DRGs) were created, nursing leaders in the ANA recognized the need for parity between physician and NP

reimbursement. The ANA pressed for a mechanism to change Medicare rules through legislation (Sullivan-Marx, 2008). During this same time period, three policy reports were released supporting the role of NPs and the removal of barriers to reimbursement: the Graduate Medical Education National Advisory Council’s (GMENAC) report, the Office of Technology Assessment’s report to Congress, and the Physician Payment Review Commission’s report (Sullivan-Marx, 2008). The reports cited barriers, including the lack of NP Medicare reimbursement. The GMENAC report concluded that direct reimbursement by Medicare and Medicaid would be necessary to facilitate full use of NPs and CNSs (Sullivan-Marx, 2008, p. 122). Finally, with the passage of the 1990 Omnibus Budget Reconciliation Act, NPs and CNSs in rural health clinics and in nursing homes were allowed to directly bill Medicare at 85% of the physician rate. CNMs were allowed to bill at 65% of the physician rate (Sullivan-Marx, 2008). An additional 7 years of encouraging legislators to act was required to include all NPs in direct reimbursement from Medicare. The Balanced Budget Act of 1997 granted NPs and CNSs the ability to bill Medicare in all geographic areas and settings but still at only 85% of the prevailing physician rate (Abood & Franklin, 2000). These initial wins for parity in reimbursement demonstrated the importance of the political advocacy role for APRNs in influencing the structure of legislation and regulation that influence finance. The next step has been to remove the artificial barrier of supervision as a requirement for Medicare payment. In 2000, CRNAs lobbied extensively (and won) for a change at the federal level. Initial gains in removing the supervision requirement were lost with the change in presidential administration in 2001. However, the AANA and CRNAs fought to develop a compromise that would lead to the Medicare opt-out language that allowed states to decide whether to make physician supervision of CRNAs a requirement for reimbursement. As of May 2018, 17 states have opted out (www.aana.com). Although much of the fight for parity in reimbursement between APRNs and physicians has focused on Medicare/Medicaid, APRNs must stay vigilant to prevent limitations in reimbursement from other insurance providers. According to Abood and Franklin (2000), the ability to document and bill for APRN services creates transparency regarding which provider is actually performing the patient care. This documentation allows for

connecting patient outcomes to healthcare providers and gives APRNs an additional tool to demonstrate their value to both the institution and policy makers. As we move forward with healthcare reform, through the knowledge gained during doctoral education and practice, APRNs must be prepared to provide the skills necessary to analyze and engage in the discussion of cost-effectiveness, pay for performance, and reimbursement.

State Nurse Practice Acts and Scope of Practice The first board of nursing and the first NPA were created in 1903 in the state of North Carolina (Loversidge, 2008, p. 96). Initially, NPAs focused on protecting the use of the RN title rather than defining the delivery of nursing care (Tobin, 2001). Following the 1971 report of the Department of Health, Education, and Welfare’s Committee to Study Extended Roles for Nurses, state NPAs began to change to include regulations governing APRN practice (Tobin, 2001). The NPA is an example of an enabling law and contains the laws and regulations that credential and govern a profession (Loversidge, 2008). As noted in a previous section, boards of nursing and NPAs were created to protect the well-being of patients by ensuring consistent minimum standards of licensure and qualifications. Each state has a different NPA, which defines the scope of practice for all nurses within that state and delineates the officers, staff, and powers of the state regulatory board (e.g., the board of nursing). NPAs include language that defines the roles and responsibilities of APRNs, including “accepting referrals from, consulting with, cooperating with, or referring to all other types of health care providers” and “must practice within a health care system that provides for consultation and collaborative management and referral as indicated by the health status of the patient” (Minnesota Board of Nursing, 2008). The evolution of the NPA is evident in the language regarding the roles of nurses. The initial ANA model definition of nursing practice in 1946 included the provision that the scope of practice for nursing is “not deemed to include acts of diagnosis or prescription of therapeutic or corrective measures” (Tobin, 2001). The ANA amended the model definition to allow for nurses to perform specific tasks (diagnosis and treatment) “under emergency or special conditions as are recognized by the medical and nursing

professions” (Tobin, 2001). In 1996, the ANA revised the model practice definition to broaden the scope of practice of professional nursing, and a definition of APRN practice was explicitly included. The 2008 APRN Consensus Model grew out of the need for state NPAs to continue to evolve to meet the needs of the profession of nursing and the healthcare needs of the American public. During their successful attempt to grant full practice authority to APRNs in North Dakota, the NPs were able to convince the legislators that the current regulatory language was antiquated, did not meet the changing healthcare needs in the state, and “did not contribute to the advancement of North Dakotans’ health” (Madler et al., 2014, p. 115). State NPAs vary widely in defining the scope of practice of APRNs. Some states have very few restrictions, whereas others limit the ability of the APRN to prescribe medications, independently administer chronic pain injections, admit patients, and conduct a prehospital history and physical. NPAs also include rules on delegation of duties to non-RN providers, continuing education requirements, and the administration of certain medications, such as propofol, a potent amnestic. NPAs include the rules for prescriptive authority for APRNs. The authorization for APRNs to prescribe with or without a written collaborative agreement with a physician must be expressly written into the agreement. States differ in the authority for APRNs to prescribe controlled substances. CRNAs may be exempt from some of the prescriptive language requiring written collaboration in order to administer anesthetic agents and their adjuncts during the perioperative period. Historically, APRNs have had to be diligent in monitoring proposed changes to an NPA and to prevent other entities from attempting to supersede the power of the state board of nursing in defining APRN scope of practice. In 2005, the American Medical Association (AMA) created the SOPP and stated, in the report of the board of trustees, “[the AMA] agreed that it was necessary to concentrate the resources of organized medicine to oppose scope of practice expansions by allied health professionals that would threaten the health and safety of the public” (AMA, 2005). The SOPP objective is to fund studies refuting claims that APRNs were necessary to improve access to care in rural states and to create studies comparing the educational, training, and licensure requirements of physician and nonphysician providers. Just as

nursing organizations should have no role in defining the practice of medicine, physician groups are in no position to define APRN practice, licensure, certification, or education. According to the CPR, rather than creating division among healthcare professionals, the AMA and the allied health members of the CPR should be working together to find solutions to the current healthcare challenges. Although the SOPP did not gain either legislative or regulatory action, it should serve as a caution to APRNs about the value of maintaining engagement in the health policy arena. Any time a state nurse practice act is opened, whether the intent is to broaden scope of practice or not, the opportunity exists for language to be inserted regarding increasing the need for supervision by a physician or removing prescriptive authority. State nursing organizations may be reluctant to open their NPA for just those reasons. Before any decision to open up a state NPA, nursing organizations should have a welldeveloped supportive relationship with legislators who serve the committee that is reviewing any proposed changes. APRNs are responsible for remaining knowledgeable of the current status of the NPA in their state and for practicing within the limits of their scope of practice. DNP graduates will be expected not only to exhibit the skills of advanced clinical practice and systems thinking but also to be accountable for driving the discussion that sustains nursing workforce development, maintains parity in reimbursement, and removes barriers to the full scope of practice for APRNs.

Integration of Policy With Ethics, Research, and Education Ethics and Policy Making Just as a vital link exists between policy and practice, so too should the connection between policy and ethics be strong. The Code of Ethics for Nurses with Interpretive Statements (ANA, 2015) includes the following statement: “The profession of nursing, collectively through its professional organizations, must articulate nursing values, maintain the integrity of the profession, and integrate principles of social justice into nursing and health policy.” Policy decisions are ethical decisions on many different levels, from choices made by professional organizations, to prioritizing a legislative or regulatory agenda, to the allocation of scarce resources. A political ethical conflict “occurs when what one is told to do (either covertly or overtly) by those having more power in the organization or what one feels compelled to do by the organization is in conflict with one’s ethical belief structure” (Silva, 2002, p. 180). It becomes more of a challenge when the policy initially appears at odds with one’s values, but upon further examination, the eventual outcome of policy implementation does support the needs of the profession and public. For example, APRNs may have the ethical dilemma of supporting a legislator through PAC contributions who does not have the same values as organized nursing but sits in a position of power to influence legislation. Kent and Liaschenko (2004) examined the connection between nursing values and ANA PAC donations. They encouraged the ANA PAC to continue to evaluate the donation process for successful outcomes that are important to nursing while maintaining a connection with legislative leadership— Democratic or Republican (Kent & Liaschenko, 2004). As nursing continues to become more influential in the policy arena, it is important to develop partnerships on both sides of the legislative aisle. Regardless of the occasional differences in political viewpoints, it is necessary to ensure equal access when issues important to nursing arise.

Clinical APRNs are often the central decision makers in the allocation of resources, including laboratory and invasive testing, time spent in the delivery of patient care, medical equipment, and referrals for additional interventions (Aroskar, Moldow, & Good, 2004). This array of patient care concerns has the potential for both policy and ethical implications. Aroskar et al. (2004) used focus groups to examine the clinical nurse’s perspective on changes in healthcare policy that affect patient care. Changes in legislative policy influence institutional policy, which in turn influences patient care. The most frequently noted themes included the policy implications of cost containment, the effects of policy on quality of care and patient education, and the overall effect on nurses and nursing (Aroskar et al., 2004). Medicare regulations may dictate where patients may receive care and how much care will be reimbursed. Legislation may influence the appropriate allocation of healthcare resources as well as the decision makers who define “appropriate.” Regulation regarding APRN licensure may affect quality-of-life and end-of-life matters if patients do not have access to all providers who can provide pain management and palliative care. However, the researchers found that although all the focus groups stressed the importance of nursing having a voice in policy development, the recognized need for “assertiveness does not always translate to advocacy for patients or participation in policy development” (Aroskar et al., 2004, p. 274). APRNs educated and experienced in policy will have the ability to comprehend the ethical implications of policy development and implementation and be able to integrate both while achieving the ultimate goals of improving health and supporting the profession of nursing. According to Silva (2002), the solution to successful resolution of an ethical conflict between values and politics involves either integration or compromise. Integration includes the incorporation of all points of view into the policy, whereas compromise encourages all parties to forfeit something for the overall common good (Silva, 2002). Just as APRNs have a professional responsibility to be involved in policy, as noted by the ANA’s Code of Ethics, they also have an ethical responsibility to the public to be engaged in healthcare policy.

Research and Policy Making

The initial link between nursing policy, practice, and research may have begun in the 1960s as nurse researchers sought federal funding and an equal playing field with medicine for research dollars (Milstead, 2008). Research and policy are connected in two interrelated ways: there is nursing research and there is policy research. Nursing research is used to supply the data and background information for creating policy. Policy research is the “analysis of a social problem to provide policy makers with alternative recommendations for future initiatives aimed at alleviating problems” (Nagelkerk & Henry, 1991, p. 20). During the process of restructuring health care in the United States, both types of research will be essential for creating an evidence-based plan that includes an examination of the alternatives. Nurse researchers have begun to realize that when using research to create policy, the largest challenge may originate from the inherent potential for ambiguous data to produce different interpretations and then different policies. In these situations, the successful APRN leader must shape the policy agenda such that the issue becomes defined as a problem backed by research requiring legislative or regulatory action. Often nursing research is “published by nurse academicians in the nursing literature but policymakers do not access their work” (Short, 2008, p. 266). APRNs can be the experts who bring the data to the legislator and discuss the outcomes and how they can be applied to public policy. Short (2008) encouraged nurses to submit their research studies to journals outside nursing and to include the potential policy implications of nursing research. The media can be used to open a window of opportunity on an issue important to nursing. When the media started reporting on the childhood obesity epidemic, nurse researchers were the content experts who used supporting data to influence public policy. Because nurses have a favorable public impression, they are able to convey health-related information in a manner that is considered fact without a particular bias or slant. An institution or organization’s public relations staff can be used as a tool to stimulate public and legislator interest in nursing health policy research (Diers, 2002). Because research can be uninteresting or overwhelming to the lay public, the ability to translate research into powerful stories or anecdotes can serve as a catalyst for legislative activity. Although the value of evidence-based research outcomes is not

disputed, the ability of evidence to influence policy in the manner and to the degree expected by the researcher is still debated. Policy decisions are political decisions, and thus the rational, correct decision is not always made; instead, the decision may be a compromise between competing interests. The majority of citizens, who may have competing values at odds with the best policy evidence, must also support policy decisions. The quality of the research or the research design may be less important than an understanding of the current political agenda or the agenda of special interest groups. In that case, the research may even be called into question despite solid methodology, or politicians and healthcare providers may use researched outcomes selectively to back an alternative course of action. APRNs educated in healthcare policy will be able to anticipate political trends, discover areas lacking in data, and design studies to seek out the answers. The Future of Nursing Campaign for Action (CFA) engaged state and national nursing coalitions to support the recommendations of the IOM Future of Nursing report. To understand the progress of the implementation, the Robert Wood Johnson Foundation (RWJF) developed metrics, planned for statistical analysis, and developed a dashboard as an approach to graphically demonstrate progress on the recommendations (Spetz et al., 2014). Evidence-based practice data may be used to influence healthcare financing policy. Rather than focus on “this is the way we do it here,” the impetus should instead be to focus on whether “the evidence support[s] the need for a procedure with increased cost without a proven benefit.” According to P. R. Orszag (2009), former director of the Congressional Budget Office and of the Office of Management and Budget, when looking at the correlation between cost and quality, “the higher cost providers, the higher cost hospitals, the higher cost regions are not generating better health outcomes than the lower cost, more efficient providers” (p. 74). Outcome-based research may be assisted by the use of information technology. With the increased emphasis on the use of electronic health records (EHRs), APRNs must be involved in the development of data entry points to support further research of outcomes relative to nursing care, including cost versus quality. Program evaluation is an integral part of policy research. Doctorally prepared APRNs are experts in program evaluation. As experts, APRNs must continue to use feedback to ensure that “old problems are being addressed, new

problems are being identified and appropriate solutions are being considered” (Milstead, 2008, p. 21). The political agenda is often shaped by cost, quality, and access to care. Research designed with that in mind can be used to a professional organization’s benefit. In a May 2009 letter to the Senate Finance Committee answering a request for input into financing healthcare reform, Jackie Rowles, past president of the AANA and current president of the International Federation of Nurse Anesthetists, used data from a Government Accountability Office study (2007, p. 15) to communicate the financial incentive for including CRNAs in the blueprint for healthcare financing reform. Then-president Rowles stated, “CRNAs predominate where there are more Medicare patients than average. CRNAs also predominate where private payment is lower than average, which is also where the gap between Medicare and private payment is less. Where anesthesiologists predominate, private payments are higher than average and the gap between Medicare and private payment is greater” (Rowles, 2009). Recognizing that the current anesthesia staffing patterns may become unsustainable in an age of cost containment and healthcare reform, the AANA funded a study conducted by non-CRNA economists who analyzed a variety of staffing approaches. Hogan, Seifert, Moore, and Simonson (2010) were able to use economic modeling to prove that CRNAs working independently were more cost effective to hospitals. These data can prove powerful when discussing implementation of healthcare reform legislation. The IOM Future of Nursing report (2011) stressed the importance of better data collection on workforce planning and transforming the clinical practice environment. Outcomes research data continue to become more important as pressures to reduce cost and improve quality become a critical part of the conversation when APRNs meet with legislators and discuss removing barriers to practice. In recent years, professional nursing organizations and individuals have begun to take a more proactive role in gathering and publishing these important data. For example, Newhouse et al. (2011) conducted an extensive systematic review and found positive patient outcomes when APRNs were involved in the care of a variety of patients. Dulisse and Cromwell (2010) examined the impact of removal of the CRNA Medicare supervision rule on patient outcomes and found that there was no increased risk to

patients in states that had opted out. An important facet of the Dulisse and Cromwell research was its inclusion in a nonnursing journal, Health Affairs. Clinical systems research, inherent in the final scholarly or capstone project of the DNP degree, is a useful means to provide an evidencebased approach to making policy changes within local, state, or federal health systems. Health services research that focuses on scope of practice and outcomes, reimbursement models, and access to care for vulnerable populations should be a priority for doctorally prepared APRNs interested in healthcare policy. Challenges within health care can often be traced back to a systems problem. APRNs with the clinical background and the education in evidence-based practice and policy will be able to frame the questions to search for the solutions. Is there a need to create policies that providers must follow to ensure delivery of evidence-based diabetes care or guarantee on-time immunizations? Why are some medical centers more efficient than others, and should their processes be emulated? How do we ensure access to care with a sustainable health policy?

Education, Practice, and Policy Making According to Malone (2005), too often policy is not consistently emphasized as a part of nursing education even though policy can influence many aspects of patient care. When policy development has been included as part of nursing education, the primary focus has been on identifying and using an institution’s policy manual (Malone, 2005). Policy-making skills are an integral part of doctoral education. Just as nurses learn the clinical skills necessary to care for patients, they are also compelled to learn the skills necessary for influencing policy. When new graduates have a sense of competency obtained through education and practical experience, they are more likely to become involved in the process. In the past, there were limited opportunities for formal policy education within nursing. Most skills were learned on the job through mentoring or self-directed education. With the increased complexity of health care and an increased need for nurses to become politically involved, the education process should now include a focused, systematic, consistent approach.

One approach in educating APRNs in how to influence public policy is to apply the nursing process—assess, diagnose, plan, implement, and evaluate. For example, the nursing process can be applied to the challenges in delivering health care in the United States and the current outcome of the ACA of 2010. Begin with an assessment of the situation. A bipartisan report released by the U.S. Senate Finance Committee on May 18, 2009, noted that “46 million Americans lack health insurance coverage, employersponsored health care premiums have increased 117 percent between 1999–2008, and annual health care spending is expected to outpace annual growth in the overall economy by 2.1 percent in the next ten years. Also, in 2009, health spending will increase 5.5 percent while gross domestic product is expected to decrease 0.2 percent” (Senate Finance Committee, 2009). It is important to include both a financial and social perspective, for example, “The United States ranks last among industrialized nations in mortality from conditions preventable with timely and effective care” (Gable, 2011, p. 342). The next step in the process is to identify or diagnose the problem. Armed with data from government sources, including the Department of Health and Human Services, the Centers for Disease Control and Prevention, and the CMS, APRNs can recognize many of the problems in healthcare systems, including a healthcare delivery system that does not provide access to all Americans, the uncontrolled rise in healthcare cost, and the lack of preventive health care. The ability to analyze policy decisions will be a skill that informs this part of the process. Following a diagnosis of the problem, the biggest challenge becomes how to plan for resolution of the crisis while anticipating potential obstacles. According to Malone (2005), obstacles to policy intervention include “lack of media attention, ideological opposition from those in decision-making positions, lack of money, advocacy leadership struggles and efforts from those actively opposed” (p. 141). Many of these obstacles can be overcome with a policy curriculum that educates APRNs on the policy process, approaches to becoming influential when engaged with legislators or the media, and professional empowerment from other APRN leaders. The doctorally prepared APRN will be prepared, informed, and empowered to challenge any Congress or presidential administration to support a healthcare policy that meets the

six aims of the IOM: safe, effective, patient centered, timely, efficient, and equitable (IOM, 2001). The search for innovative solutions while using the resources at hand may prove to be more difficult than anticipated, as evidenced by the failure of the Clinton plan. How can the United States ensure equal access to high-quality care for all Americans while controlling cost? Is the U.S. nursing workforce substantial enough to handle the potential influx of patients into the healthcare system? APRNs may be asked to provide expert testimony, serve as content experts, and garner support from legislators during this stage of the process. While the legislation is being implemented, APRNs must continue their political activism with vigilance and a skeptical eye regarding any drafts, testimony, or regulations that do not support the intent of the reform legislation. The last step of the process—which should actually occur throughout the progression of legislation—is to evaluate whether the legislation works. Formative evaluation of the policy process should occur from the beginning. Did APRNs become involved, and how effective were they? What were the obstacles to policy legislation and implementation? Were the obstacles recognized early in the process? Does the legislation meet the six aims of the IOM? Does the legislation provide for equal access to providers and for patients? How will outcomes be measured, and will they be measured equitably for all providers? Will this plan be sustainable? Maynard (1999) described a four-dimensional intersecting model for teaching healthcare policy that includes information, commitment, initiative, and involvement. The first step is the responsibility that nurses have to remain informed and up to date about the health policy agenda. The second step is the commitment to act on an issue. Initiative, the third step, is the “power, ability, or instinct to begin or follow through with a plan or task” (p. 193). Although the model is not intended to be linear, the final step is involvement in the process of influencing policy. As the content of policy education is formalized within the curriculum of DNP programs, educators will need to be able to demonstrate the relevance of policy to practice. One approach to accomplish this is to instruct APRNs on how to determine the basis of proposed policy changes. An awareness of where legislation and regulation originate may be critical to understanding and influencing policy. Taft and Nanna (2008) stressed the importance of educating nurses on the sources of

healthcare policies that affect practice, including organizational, public, and professional sources. Examples of organizational sources are consumers of health care (patients), the media, and insurers. Patients who have experienced difficulties in the healthcare system are frequently an impetus for legislative change—for example, changes in insurance coverage for preventive exams. Public sources include the government at all levels and all branches, economic and demographic trends, and special interest groups (Taft & Nanna, 2008). Healthcare disciplines, including nursing, universities, and research-generating organizations, comprise the final type of source: professional sources. Professional APRN associations have played an integral role in proposing legislation that influences health care and have been involved in the regulatory role. Nursing educators at all levels of entry to nursing practice must serve as mentors by becoming role models for political activism, risk-taking, and health policy advocacy. Experienced nurses can successfully communicate the connection between professional commitment and political responsibility. Rather than merely encouraging nurses to be politically involved, nursing faculty should equip students with the knowledge and skills to feel confident in their ability to influence policy. According to Rains and Carroll (2000), “Health policy education at the graduate level has the potential to increase the political skills, involvement, and competence of nursing’s future leaders” (p. 37). It is crucial during doctoral education that APRN students become actively involved in the process by lobbying on Capitol Hill, by serving as student representatives on professional organization committees, and by successfully demonstrating the ability to articulate the legislative and regulatory process. Policy-educated APRN clinicians should serve as role models to the next generations of baccalaureate- and graduate-prepared nurses. APRNs will be able to create a teaching environment that synthesizes didactic knowledge with the practice and work environments (Short, 2008). Milstead proposed that hospitals consider developing a health policy/researcher position to combine advanced clinical skills with the research skills necessary to influence health policy decisions within the organization and on a larger scale (Peters, 2002). Although all APRNs must participate in healthcare policy at some level, it is unrealistic to assume that all APRNs should become policy experts in addition to their roles providing direct patient care. The

extensive commitment of time and energy necessary to effectively perform all the duties of both roles may not be achievable. Instead, the future of advanced practice nursing may include the specialty of health policy APRN. As nurses become more informed about and interested in policy, especially after doctoral education, they may choose to focus their career on influencing legislation and serving as a health policy expert. Nurses can gain practical experience by applying for policy fellowships in Washington, DC. Perhaps the most well known is the Robert Wood Johnson Foundation (RWJF) Health Policy Fellowship. Historically, nurses have not taken advantage of these opportunities. In the RWJF Fellowship’s 44 years, 277 fellowships have been awarded, but only 28 nurses have been fellows (Robert Wood Johnson Foundation Health Policy Fellowships Program, 2019). Health policy fellowships offer nurses an opportunity to brief legislators on healthcare issues, develop proposals, and staff conferences and hearings. Although the relationship between policy and practice has focused on clinical care, nurse executives with a doctoral education foundation can play a critical role in influencing the policies that have a direct impact on patient care. Peters (2002) compared influencing policy to teaching an elephant to dance: difficult to do, but it can be accomplished if approached methodically. Administrators must be “committed to political activism; stay informed through formal and informal channels; challenge the status quo; identify a base of support; and get the issues on the agenda” (pp. 5–7).

Phases of Policy Involvement All APRNs have the responsibility to their patients to become involved in the political process at some level. Various authors have described levels of political involvement and emphasized that the focus is on finding a level at which the individual can be engaged and that is compatible with where the individual may be in his or her career. Boswell, Cannon, and Miller (2005) identified “three primary levels of commitment: survival, success, and significance” (p. 6). As APRNs become more engaged in the process, they may move through the levels, or they may choose to stay at the level where they are comfortable. At the survival level, the individual takes part in the voting process or may serve on a community board. At the next level, success, the individual “chooses to become influential in the policy arena” by becoming involved on the state or national level (Boswell et al., 2005, p. 6). Significance is the final level of involvement, whereby the individual is intensely involved in all aspects of healthcare policy, assuming leadership positions in influencing legislation at the state and national level. Hewison (2008) described nursing involvement in policy as a continuum from policy literacy, to policy acumen, to policy competence, and, finally, to policy influence (p. 292). Rather than finding a level of engagement, Hewison (2008) applied the strategy to where individuals are in their careers, from novice to expert. Policy literacy may only involve reviewing the literature, defining the issues, and analyzing health policy research. This early stage provides a framework for the more experienced nurse to develop policy acumen. Policy acumen is “an awareness and understanding distilled from a policy analysis” that allows nurses to influence the manner in which health care is organized and delivered (Hewison, 2008, p. 293). APRNs who have come to understand the issues and can analyze policy that translates into action would be able to persuade policy leaders to make healthcare decisions that are favorable to nursing and to their patient population. They can make the transition from the introspective realm of acumen to the action of competence (Hewison, 2008). The final level of policy influence brings together all the elements of the previous levels. The APRN who has

achieved this level integrates the issues with health policy research, formulates the agenda, and influences policy on the national and international scale. Most authors agree that all nurses have the responsibility of becoming involved in the policy process (Boswell et al., 2005; Hewison, 2008; Peters, 2002). Although it may be an intimidating task for both the novice and the experienced APRN, there are opportunities for involvement at all levels and in all areas of interest to nursing, including legislation and regulation, research, ethics, and practice.

Conclusion According to Peters (2002), nurses should start to look at policy as not just the legislative process but as a comprehensive method of identifying healthcare issues and then bring those issues to the legislature and the American public. “Nurses will not be effective in politics or policy-making until they value their voices, develop policy agendas that embrace their core values, and learn the skills of policy making and influencing” (Mason et al., 2002, p. 12). Political expertise is essential for success. Nursing practice and health care must no longer be shaped by other dominant interest groups but instead by the inclusion of nurses using their education in policy combined with their unique understanding of the patient perspective. Nurses must take advantage of positive public opinion and their pivotal position in the healthcare system as the largest group of providers. Patient advocacy should include policy advocacy, with APRNs increasing their knowledge of the issues and increasing political involvement. APRNs can be a crucial part of reforming health care by offering guidance and support to elected leaders. In the United States, APRNs have never been in a better position to influence health care as a whole, but it will require a group of “policy initiators who are willing to work toward eliminating the inequality of healthcare resources” (Peters, 2002, p. 5). This statement has been borne out in the last few years; nurses are increasingly involved at the state and federal level as their expertise is recognized as a crucial part of ensuring that healthcare reform is implemented in a manner that is cost-effective, accessible, and based on the evidence. According to health policy expert Mary Wakefield (2008), “If nurses want to be sought out as health care resources and to have their views reflected in health policy, nurses have to get off the porch to run with the big dogs” (p. 86). It has been argued that clinically engaged APRNs already have a full daily agenda, so how can they take on the additional responsibility of influencing policy? A more vital question should be, how can we not? Political activism provides nurses with the means to promote overall health through passing supportive health policy legislation, using

evidence-based policy to transform institutional and national health systems, and employing policy language that prevents discrimination in reimbursement and patient access to providers. The doctorally prepared APRN is in the position to become this political advocate.

Discussion Questions 1. When developing a policy brief what components are essential for convincing an non health care provider audience a best solution for a given problem. 2. How would advance practice nurses get involved in the process of legislation? 3. Review the American Association of Nurse Practitioners website; what are three important health care concerns that are currently being discussed in congress? 4. What skills are needed to be an effective lobbyist?

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CHAPTER 10 Healthcare Business Essentials: A Primer for Advanced Nurses Mary Beth Kingston and Patti Rager Zuzelo

CHAPTER OBJECTIVES 1. 2. 3. 4.

Understand the business aspect of health care. Differentiate between private and government-managed care organizations. Describe the populations covered by Medicaid insurance versus Medicare insurance. Identify how bundled payment arrangements can improve the quality and efficiency of care. 5. Explain basic budgeting principles and the impact on health care.



N

ursing administration is a specialty that requires a combination of business savvy and regulatory expertise with an understanding of clinical practice demands. Advanced nurses have a systems perspective and an understanding of modes of influence that provide valuable insight to the finance and business aspects of nursing. Nurse executives require formal expertise in business and nursing administration, and nurses in all advanced roles require a grasp of healthcare business principles and a clear understanding of the healthcare system. This knowledge is necessary for rational, effective practice in multidisciplinary settings with outcomes emphases and tight fiscal constraints. Basic familiarity with health care and nursing “business” is critical for advanced nurses practicing in a variety of roles

who are expected to develop new programs and to improve clinical and operational processes. Basic business acumen is also useful for the advanced nurse who envisions future employment and advancement in nursing administration.

The Context of Nursing Practice: An Overview of the U.S. Healthcare System A variety of well-written resources are available on this subject. Shi and Singh (2015) provide an overview of the U.S. healthcare system that is concise and essential. Advanced nurses are advised to understand different types of managed care organizations (MCOs), including health maintenance organizations (HMOs), preferred provider organizations (PPOs), exclusive provider organizations (EPO), and point of service (POS) plans. It is also helpful to appreciate the significant changes that are occurring as the healthcare system moves from volume-based to value-based reimbursement models, including programs driven by the Patient Protection and Affordable Care Act (ACA) and healthcare reform. MCOs are part of a larger group referred to as third-party payors because they are connected to two other key parties of interest in health care, the patient and the provider (Shi & Singh, 2015). Other members of the third-party payor group include insurance companies, Blue Cross/Blue Shield, Medicare, and Medicaid. Each third-party payor pays differently, depending on its reimbursement method and contractual arrangement. Full payment fee-for-service is a rare arrangement when compared to other forms of reimbursement. Providers determine charges, bills are generated, and insurers pay. The higher the charges, the greater the net revenue. Diagnosis-related groups (DRGs) were an early strategy for curtailing the spiraling costs associated with fee-for-service arrangements. Fee-for-service refers to being paid for specific tests, procedures, or admissions, but the reimbursement does not typically cover the generated charges or, depending on the payor, even the cost of the service.

Third-Party Payors

The payor mix of an institution is a critically important variable in the assumptions underlying institutional budgets. Advanced nurses need to have a general sense of the payor mix of their practice or service line. They also must understand the payor mix of the employing institution or network, as this mix directly influences the amount and variability of revenue streams available for all types of services, including educational programs, equipment, and the affordability of staffing mix and nurse-topatient ratios. In terms of payor mix, private or commercial insurers tend to pay a higher percentage of charges than government programs (Medicare and Medicaid). Payor mix varies for many reasons, including the income level, age, and employment status of the population served in a hospital, clinic, or other healthcare setting. Reimbursement from payors can influence behavior, as seen in TABLE 10-1. TABLE 10-1 Impact of Payor Type Payor Type Private (Commercial) ■ Fee-for-service ■ Managed care

Percentage 39% 14%

Impact Private or commercial payors are the largest category of payor with a high percentage of fee-forservice. The incentive is to increase volume to increase revenue—more tests and procedures.

53% Subtotal Government ■ Medicare ■ Medicaid

30% 8%

Subtotal

38%

Miscellaneous ■ Self-pay ■ Other

5% 4%

Subtotal

9%

Total

100%

Typically, these programs pay a lower percentage of charges than private payors, with Medicaid reimbursement usually lower than Medicare. As the age of the population increases, Medicare percentage will rise. This example is a relatively low government payor mix, minimizing the impact of political decisions that affect reimbursement “Other” may include bad debt, charity care, and workers’ compensation and does not pose a significant financial risk in this example.



Description

Managed Care Organizations HMOs are the earliest forms of MCOs and continue as a popular arrangement. The goal of HMOs is to reduce costs while providing highquality care. Care is coordinated through the primary care provider, who serves as a gatekeeper to services and safeguards against unnecessary tests or treatments. Payor policies are often a barrier to advanced practice nurses (specifically nurse practitioners) serving in this gatekeeper role (Hain & Fleck, 2014). Although practices vary, private or commercial plans may not recognize advanced practice nurses as primary care providers, thereby limiting their scope of practice. Even in states with full practice authority, payors may opt to not pay the advanced practice nurse directly or reimburse at a lower rate (Yee, Boukous, Cross, & Samuel, 2013). HMOs offer services to maintain or improve health status, recognizing that it is more cost effective to avoid illness than to treat illness. Preventive services, such as smoking cessation, weight management, physical fitness, and routine wellness visits, are examples of services designed to reduce the risk of disease and to intervene early when illness occurs. HMOs usually pay providers a fee per person on a contracted basis. This fee is referred to as capitation. Enrollees are restricted to service providers, including hospitals, physicians, laboratories, and other diagnostic service facilities within the network. There are a variety of HMO models with differing physician arrangements; for example, staff models with HMO-salaried providers, group models with contracted physicians within a group practice rather than employed physicians, network models with a variety of contracted medical groups, and the independent practice association (IPA) model, in which the IPA shares risk and assumes responsibility for utilization and quality management (Shi & Singh, 2015). PPOs offer enrollees more choices and increased control over their utilization of specialists. Enrollees can opt for out-of-network service providers, albeit at a higher cost, through preestablished copayments (Shi & Singh, 2015). PPOs are typically more expensive in terms of plan premiums than HMOs (Campbell, 2016) and do not use capitation

arrangements. They typically work on a contractual arrangement with providers in a modified fee-for-service approach. PPOs are the dominant form of the employer health coverage market, and 58% of workers are covered with this type of plan with a mean family premium as high as $14,000 in 2010 (Kaiser Family Foundation, 2010). Exclusive provider organizations, or EPOs, are similar to PPOs, but enrollees cannot receive reimbursed care from a provider outside of the network (Briscoe, 2015). This arrangement prioritizes cost savings, although EPO plans provide flexibility in terms of choice. There is not a requirement to choose a primary care provider, nor is there a need to have a referral for specialist care. However, the network of providers and hospitals is limited, and if care is received outside of this network, it will not be covered unless it is an emergency. Knowing the panel of included providers and sites is, therefore, essential for enrollees. Limiting selection of providers and services is the key to reducing costs. Point of service plans (POS) combine features of both HMOs and PPOs. Enrollees are typically required to select a primary care provider who makes referrals to specialists within the network when needed. Plans may vary, and there are usually no or minimal costs or deductibles for care provided by the primary care provider. As in a PPO model, individuals can receive care from providers out of the network but will be subject to greater out-of-pocket costs and copayments.

Private Health Insurance Blue Cross/Blue Shield plans are nonprofit and cover hospital and physician services. In addition to Blue Cross/Blue Shield, other private health insurance plans may be purchased as an individual or family member or purchased as an employee participating in an employerprovided plan. Private health insurance is basically a program not provided for or administered by the government. Private health insurance plans are offered in a variety of forms, including MCOs, indemnity, or feefor-service.

Public Health Insurance The Centers for Medicare and Medicaid Services (CMS) are responsible

for Medicare and Medicaid programs. The CMS is organized within the U.S. Department of Health and Human Services (DHHS) and has a strategic plan that includes objectives related to regulatory, budgetary, and quality responsibilities for a variety of stakeholders (CMS, 2013). (See BOX 10-1). Advanced nurses need to have a basic understanding of the CMS and its programs, given that many hospitals and healthcare practices are significantly influenced by regulations and reimbursements controlled by the CMS.

BOX 10-1 The CMS Mission, Vision, and Strategic Goals Mission: As an effective steward of public funds, the CMS is committed to strengthening and modernizing the nation’s healthcare system to provide access to high-quality care and improved health at lower cost. Vision: A high-quality healthcare system that ensures better care, access to coverage, and improved health. Strategic Goals: Better care and lower costs Prevention and population health Expanded healthcare coverage Enterprise excellence Data from Centers for Medicare and Medicaid Services (2013).

Title 18 of the Social Security amendment of 1965 provided for Part A and Part B of Medicare, whereas Title 19 established the Medicaid program. Medicare provides publicly financed health insurance to elders, regardless of income. Some disabled people and individuals with endstage kidney disease are also covered (Shi & Singh, 2015). Prescription benefits have been added via Part D benefits, and most people pay a monthly premium for this coverage. Medicare Parts A and B cover different types of benefits. In general, Part A covers hospitalization and short-term nursing home stays following hospitalization. Part B covers physicians’ bills and other outpatient services. Elders pay part of the premium expense of Part B, whereas Social Security taxes pay for Part A (CMS, 2014). Traditional Medicare does not typically cover all expenses, including copayments and deductibles. Enrollees may choose to purchase a

supplemental insurance policy (Medigap—also known as Part C) that is sold by private insurance companies. Medicare will first pay the Medicare-approved portion of healthcare costs for services and then the Medigap contribution will be applied. Medicare does not provide coverage while traveling outside the United States, and Medigap policies will often include this provision. Another option for elders is to enroll in Medicare Advantage plans. Private insurance companies contract with Medicare to provide all Part A and Part B benefits. These plans include HMOs and PPOs and offer prescription drug coverage (Cubanski et al., 2015). Medicaid is a public health insurance program for individuals with low income. It is a combination of a federal and a state program, subject to federal standards, but administered by states. Individual states have flexibility to determine populations and services that are covered under the program. In 2017, Medicaid and the Children’s Health Insurance Plan (CHIP) covered over 74 million low-income Americans, including infants and children, parents, pregnant women, people with disabilities of all ages, and elders with very low incomes. Approximately three-quarters of nonelderly Medicaid recipients are from working families (Kaiser Family Foundation, 2017). The ACA increased the income eligibility for Medicaid, although not all states opted to participate in this expansion. Services covered by Medicaid vary by state, but several states have elected to cover optional services, including dental care and prescription drugs. Whereas Medicare and Medicaid are governmental programs, healthcare services are provided by private entities. Federal expenditures have dramatically increased since the inception of these programs. The United States spent $3.2 trillion on health care in 2015, an average of $9,990 per person. The health spending share of gross domestic product in 2015 was 17.8% (CMS, 2015). This per capita spending is more than twice the average of other developed countries, yet the outcomes, specifically life expectancy and infant mortality, are no better and in some instances worse than in those countries that spend less. Growth in healthcare spending is predicted to annually increase by 5.6% during the period of 2016 to 2025 (CMS, 2015). As healthcare costs climb, federal, state, and local governments exert more stringent controls over reimbursements. Simultaneously, healthcare consumers and practitioners demand increasingly sophisticated and expensive

technologies and services.

Healthcare Reform The high cost of health care in the United States has led to several legislative efforts to curb costs while maintaining and improving quality. One of the most significant is the ACA, which was signed into law in March 2010. There are many aspects and complexities to this law, but a few key provisions include: Expand access to insurance coverage Increase consumer insurance protections Emphasize prevention and wellness Improve health quality and system performance Promote health workforce development Curb rising health costs Although there has been debate about the success of the ACA, the number of uninsured Americans has decreased since its implementation. Healthcare costs have still continued to rise, although at a lesser rate than in prior years. Some insurers have opted out of the state exchanges, limiting choice and increasing copayments for service. There have been efforts to replace the ACA with other healthcare proposals that address rising costs as well as access to and quality of care. The ACA and related healthcare issues continue to be active and ongoing concerns within Congress.

Value-Based Care and Alternative Payment Models The traditional fee-for-service model incentivizes strategies that expand the number and volume of services to increase revenue. This payment model does not reward providers and organizations based on healthcare outcomes. As a result of increasing healthcare costs and quality and safety concerns, government payers, health plans, and employers are beginning to focus on value-based payment models, aligning payments and penalties based on quality, costs, and outcome measures. A variety of alternative (value-based) payment models exist. An

alternative payment model (APM) is an approach that offers incentive payments to organizations or networks to provide care that is high quality and cost effective. APMs can be utilized with a population, specific clinical condition, or a care episode. In a shared savings model, organizations are paid fee-for-service, but if spending is below a preset target, they share in the savings as a bonus. Shared risk models are similar to shared savings, but organizations also pay a penalty if spending exceeds the target. In a bundled payment arrangement, organizations are paid for an episode of care rather than separate payments for hospital, physician, and outpatient care related to a specific condition (EXEMPLAR 10-1). One area that the CMS has focused on is bundled payments for total joint replacement. These models promote achievement of quality outcomes as well as cost reduction.

EXEMPLAR 10-1 Improving Quality and Efficiency to Maximize Bundled Payment Arrangements Advanced nurses can play a significant role in identifying improvements in quality and efficiency in bundled payment arrangements. As part of a comprehensive joint management program, the nurse manager, clinical nurse specialist, and clinical nurse leader evaluated the postoperative care on an orthopedic unit. Their focus was on ambulation and pain management, as both play a significant role in recovery and costly inpatient length of stay. Compression devices are important but inefficient in terms of early ambulation. The advanced nurses identified a compression device that could be used while ambulating, increasing patient mobility and reducing time spent in removing and reapplying devices. After a review of best practices in pain management and collaboration with physician colleagues, the advanced nurses implemented a pain protocol that essentially avoided the use of parenteral narcotics, utilizing oral medications and a cooling device on the knee. Education was provided preoperatively to support these measures. As a result, the hospital length of stay was reduced and the incidence of readmission decreased.

Accountable Care Organizations (ACOs) An ACO is a network of physicians, nurses, other healthcare providers, hospitals, and other care delivery sites that work together to deliver highquality, coordinated care to their patients (CMS, 2017a). The ACA created Medicare Shared Savings Programs (MSSP), rewarding ACOs with financial savings for providing cost-effective care and positive patient outcomes. Preventive services, wellness programs, elimination of

unnecessary tests and procedures, and provision in the most appropriate, low-cost setting are cornerstones of the ACO approach. In the MSSP, the financing remains fee-for-service, but the incentive is paid only if the preset targets are achieved. The CMS has continued to build on the ACO strategy, developing programs that can receive additional incentive payments by assuming greater financial risk. Early results from the Medicare ACO MSSP programs are demonstrating mixed results (Baseman, Boccuti, Moon, Griffin, & Dutta, 2016). In 2014, the Medicare ACO programs generated savings totaling $411 million. However, after paying bonuses for the savings, the overall program resulted in a loss of $2.6 million to the Medicare trust fund. Performance on quality measures has been as good or better than the traditional Medicare program (Baseman et al., 2016).

Population Health Population health has been defined by Kindig and Stoddart (2003) as “the health outcomes of a group of individuals, including the distribution of such outcomes within the group” (p. 381). Alternative payment models may or may not be used in a population health model, but achieving desired quality and financial outcomes currently focuses on prevention, promotion of health behaviors, early intervention, and case management for those with significant healthcare issues. Data and predictive analytics are essential in determining individuals at risk for complications, hospital readmissions, and high-cost care. Intensive care management is often utilized to coordinate complex care. Social factors that may affect health, including access to food and transportation, are often considered, although these services are rarely reimbursed. The goal is to improve outcomes and reduce costs by promoting health.

Value-Based Purchasing The CMS has initiated a hospital value-based purchasing program (VBP) that rewards acute care hospitals for the quality of care delivered by providing incentive payments. The payments are based on (1) the quality of care provided to Medicare patients, (2) patient experience, and (3) adherence to clinical practices and processes. This program was

established as part of the ACA and rewards hospitals based on value and outcomes rather than on volume. Providing incentives or payment based on quality of care, cost effectiveness, and service is also utilized in ambulatory settings, home-care settings, and long-term care settings. The move from volume to value provides advanced nurses with a unique opportunity to demonstrate the impact of nursing on clinical outcomes and the organization’s bottom line. Specific measures are identified and typically include outcomes in the following categories (CMS, 2017b): Mortality and complications Healthcare-associated infections Patient safety Patient experience Process Efficiency and cost reduction Advanced nurses need to appreciate the changing and challenging context in which healthcare services are provided in the United States. A basic familiarity with various insurance models, differences between Medicare and Medicaid programs, the effect of payor mix on healthcare organizations’ budgets, and the move from volume to value will assist the advanced nurse in understanding the challenges confronting healthcare organizations and society. The interplay between cost and reimbursement and quality outcomes has significant influence on the bottom line of healthcare organizations. Understanding these concepts is important for well-informed nursing practice. There is concern that advanced nurses may have inaccurate or inadequate understanding of the CMS programs (Zuzelo et al., 2004) and that this knowledge deficit may affect care and disadvantage the public by artificially limiting the accessibility of advanced nurses to healthcare service recipients. Although advanced nurses are not consistently involved in budget and business processes at organizational or network levels, they are often involved in these activities at the unit or department level or by service line. Advanced nurses participate in capital budget development through product evaluations and recommendations. Clinical nurses often ask nurses in advanced roles to explain budget processes, and it is not uncommon for program administrators to solicit the input of advanced

nurses regarding basic operating and capital budget needs. Many nurses in various advanced roles have some budgetary responsibilities that range in scope and accountability. Understanding the pressures of healthcare organization financing is critical to the success of the organization at large and to the individual programs and departments within the system. Upcoming sections explain key concepts of nursing and capital budgets and provide strategies and tools for product evaluation, particularly given the importance of selecting products that satisfy the needs of the organization at an acceptable price point.

Budget Process Essentials The degree of advanced nurses’ involvement in the budget process varies depending on the organization and the advanced nurses’ roles and job responsibilities. Advanced nurses’ exclusion from the process can represent a missed opportunity for nursing administration. The experience and expertise of the advanced nurse, as well as the clinical or operational focus of the nurse’s role, has the potential to add value to many facets of the budget process, including resource planning for new clinical programs, identification of quality-of-care issues, and comparison of equipment and clinical supply items. The advanced nurse must have knowledge of general processes and principles of budgeting in order to have a positive impact on critical finance activities and decisions. The budget is an annual process of identifying anticipated revenues and expenditures for an organization. It provides a framework to allocate resources that support ongoing operations and programs. In addition, the budget serves as a monitoring and evaluation tool throughout the fiscal year (BOX 10-2). The fiscal year (FY) is defined by each organization. The FY can correlate with the calendar year (January through December), but it more often follows a July through June or October through September time frame.

BOX 10-2 Budget Functions 1. 2. 3. 4. 5. 6.

Identify anticipated revenues. Identify planned expenditures. Provide a framework for resource allocations. Monitor spending. Evaluate accuracy of allocation decisions. Evaluate fiscal responsibility.

Budgeting has often been described as an organization’s best guess regarding future performance and expenses. However, the budget is based on a careful review of factors that might influence revenue and

expenditures. The organization’s strategic plan provides the framework for beginning the review process. The external environment, prior year performance, new programs, additional physician practices, and marketing initiatives are carefully reviewed. Additional sources of information include projected salary and price increases, regulatory changes, and estimations of charity care and bad debt. The organization may start the budgeting process in several ways. In zero-based budgeting (ZBB), each budget request is justified every cycle regardless of prior history. Use of ZBB requires that managers justify why they should spend the organization’s resources in the manner proposed. Each planned activity or project must include an analysis of cost, benefit, alternatives, and measures of performance. One major drawback to ZBB is the amount of time required to review and justify, at times, routine operational costs in great detail on an annual basis. Historical or baseline budgeting begins with the organization’s historical data and builds on the readily available past performance of its operations. Historical budgeting works well in organizations with predictable operations. This method of budgeting saves time and is less likely to result in an omission of a key event, trend, or expense. Alternatively, it may also result in inclusion of items that no longer have relevance. In practice, many healthcare organizations use a combination of methods, relying on historical or baseline data combined with assessment of trends. A ZBB approach is frequently used when proposing new programs and initiatives (TABLE 10-2). TABLE 10-2 Budget Approaches: Zero-Based Budget Versus Historical Budget

Description

Types of Budgets There are several types of budgets: operating budgets, revenue budgets, expense budgets, and capital budgets.

Operating Budget The operating budget is the financial plan for the organization’s day-today activities. It details the immediate goals for revenues, volumes, and expenses. The operating budget is extremely detailed and is used for monitoring throughout the year. The revenue and expense budgets make up the operating budget.

Revenue Budget The revenue budget is the projected income for the fiscal year. The primary source of revenue in a healthcare organization is the delivery of healthcare services. Volume projections in each department drive the revenue budget. The definition of volume, or units of service, varies with the specific patient care area but includes visits to the emergency department and clinic settings, patient days in the inpatient areas, procedures in the surgical suite, and number of tests in the laboratory. Volume is a major factor in calculating anticipated revenue, but there are other primary considerations. Federal and state reimbursement

changes and contractual relationships with payors have a significant effect on revenue projection. Assumptions are also made regarding the acuity level of patients, specifically the case mix index (CMI) that affects Medicare reimbursement. The CMI is a marker of the severity of a patient’s illness and is tracked by Medicare. In the inpatient areas, the length of stay (LOS) and number of patient days affect revenue projections from admissions. LOS varies by specialty area and is influenced by historical data and the organization’s ability to move patients to the appropriate level of care at the right time. LOS is typically longer on an inpatient behavioral health or rehabilitation unit as compared to a general surgical patient care area. If an organization has the ability to move patients from an acute care area to a skilled or longterm nursing facility, then the LOS may be reduced. The number of patient days is another key revenue budget metric. The number of budgeted admissions multiplied by the LOS results in the total number of patient days (BOX 10-3). The number of patient days has a direct effect on patient revenue as well as expense. Many payors reimburse based on a case rate or diagnosis. In this instance, a prolonged LOS results in additional expense without corresponding revenue. If a payor pays a per diem rate, then an increased LOS might enhance revenue. Patient days are also an important metric in determining the nursing expense budget.

BOX 10-3 Number of Patient Days With Example Admissions × Length of stay = Patient days 20,000 annual admissions × 6.0 days LOS = 120,000 patient days

Expense Budget The expense budget includes salaries, supplies, fees, purchased services, repairs, maintenance, consulting, education, insurance, depreciation, and many miscellaneous items. Healthcare expenses, particularly in nursing, are largely made up of salary expenses.

Salary Expenses. Salary expense can be divided into productive and nonproductive time. Productive time is time actually worked, and nonproductive time includes sick, holiday, vacation, orientation, and education hours. Productive hours include direct time or time spent in caregiving activities. Indirect hours include unit secretarial, nurse manager, and educator time. Direct caregiver hours are usually classified as variable. These hours adjust to the patient care volume. Areas with minimum staffing requirements and those that have difficult-to-predict daily volume—for example, emergency departments or labor and delivery services—cannot routinely flex direct care staff. Fixed hours are those required to run the unit regardless of fluctuating volume and census and include such positions as the unit secretary, housekeeper, and nurse manager. Nonsalary Expenses. Supplies are second in importance to salary in the healthcare organization’s budget. Supply expenses can also be categorized as fixed versus variable. Patient care supplies and forms usually fluctuate or vary with patient days. Expenses that are fixed include phone services and electricity. Many organizations have joined group purchasing programs to take advantage of reduced supply prices when purchased in quantity. Supply costs can often be a large component of the budget, particularly in surgical areas.

The Bottom Line The bottom line, or net income, from operations is commonly measured as net patient revenues minus the total operating expenses (BOX 10-4). The organization’s operating margin is the percentage of profit realized from the operations of its day-to-day business. Profit can be defined simply as the difference between net expenses and net revenue.

BOX 10-4 The Bottom Line Net patient revenues – Total operating expenses = Bottom line

Capital Budget The capital budget is developed separately from the operational budget and pertains to the organization’s plan for investments in building or plant and major equipment. The capital budget is driven by the organization’s strategic plan and is composed of two components: (1) equipment purchases, building plans, and plant maintenance that occur within the annual budget cycle and (2) those that exceed one year in length. A defined dollar amount typically determines whether an item is defined as capital. The amount varies but usually is at least $500 and may be as high as $5,000 or greater. This has implications for the operating budget. For example, if the manager of a unit is purchasing equipment that falls under this threshold, the item will not be considered capital and will be reflected in the unit operating budget. The annual capital budget begins with identification of equipment needs or building/renovation projects for the upcoming year. Patient care equipment needs may be unit based, program specific, or cut across clinical specialty lines. The initial list in nursing is often generated at the department level and should be developed by the nurse manager or director, with significant input from advanced nurses and nursing staff. Examples of capital items are critical care monitoring equipment, dialysis machines, scales, hospital beds, and mattresses. Identification and communication of need are crucial steps, and the advanced nurse can play a major role in this area. Identifying and evaluating products as part of the capital budget process are important advanced nurse responsibilities, depending on the type of advanced nurse practice. Communication with other departments is particularly important when developing the capital budget. Determining which department is responsible for capital purchases may be confusing. For example, stretchers are purchased by the transport service for general use, yet the emergency department, operating room, and radiology areas purchase stretchers for their specific areas. Many capital requests from other departments affect nursing practice and patient care, particularly related to renovating existing patient care areas. Capital requests may require renovation, and this need must be noted early and identified as an associated cost (FIGURE 10-1). For example, if monitoring equipment is purchased and the current electrical

outlets are inadequate or in difficult-to-reach locations, renovation needs must be taken into account and communicated to the facilities and maintenance director (FIGURE 10-2).

FIGURE 10-1 Capital budget request.

Description Description

FIGURE 10-2 Space renovation form.

Description Once items for a specific area are identified, the manager generally identifies the following information: Describes the item or equipment Identifies the number of items needed and whether this is a replacement or addition Lists the date or quarter of the fiscal year the purchase will take place Prioritizes each item The manager typically works with the purchasing department to provide supporting documentation. The advanced nurse often plays a role in comparing different vendors’ products and networking with others to learn about new technology and efficacy.

Building the Inpatient Nursing Budget Nursing expenses are primarily based in the salary or personnel budget. The foundation of the salary budget is the full-time equivalent, or FTE (BOX 10-5). It is important to note that the FTE is not a person, merely a time equivalent. Nursing job requirements for being considered a full-time employee vary widely, particularly with 12-hour shifts and increasing flexibility in scheduling. A nurse who works three 12-hour shifts per week is considered full time in many organizations, but the budget will reflect the position as a .9 FTE (BOX 10-6).

BOX 10-5 Full-Time Equivalent (FTE) Calculation 40 hours per week × 52 weeks/year = 2,080 hours 1 FTE

BOX 10-6 Three 12-Hours Shifts Per Week Employee

36 hours per week × 52 weeks/year = 1,872 hours 1,872 hours/2,080 hours = .9 FTE

The number of FTEs required to provide care is determined in several ways. Nursing units begin with a standard and then match the standard to the projected volume. Inpatient units often utilize nursing hours per patient day (NHPPD) as the standard or metric; the number of hours of care divided by the number of patient days (TABLE 10-3). The required nursing hours are based on a variety of factors, including the type of unit, acuity of the patient population, and patient outcomes. TABLE 10-3 Sample Calculation of Required FTEs Based on a Standard NHPPD Projected patients days =

NHPPD standards = Patient days x NHPPD standard = 7,300 patient days x 10.0 NHPPD = 73,000 direct care hours/2,080 (1 FTE) =

7,300 patient days (equates to an average daily census (ADC) of 20 patients). 7,300 patient days divided 364 days/year = 20 patients/day 10.0 Total number of direct care hours required 73,000 direct care hours 35.09 required FTEs

Description In specialty areas that do not employ NHPPD, other standards are utilized. In the emergency department, nursing hours per patient visit is the metric. In the operating room, the number of staff required is case dependent but also determined by a standard FTE per room. Establishing the number of direct care FTEs is not the final step in building a nursing budget. Not all of an FTE’s 2,080 hours per year are productive or worked hours. Replacement time must be built in to provide coverage for nursing staff during expected non-productive hours including vacation, education, and unplanned absences for a year.

How Is Benefit Time Determined? Benefit time is calculated by subtracting the number of benefit hours from the total FTE time (BOX 10-7). In practice, there is individual variability with such factors as seniority playing a role in the amount of vacation time. Most organizations use an average to calculate time. It is important to recognize that on units with high percentages of senior staff, organizational averages may not be the best barometer for calculating benefit time.

BOX 10-7 Benefit Time Calculations Benefit Time Vacation time = 4 weeks’ vacation annually or 160 hours Sick time = average 6 days annually or 48 hours Holiday time = 6 days annually or 48 hours Personal time = 3 days annually or 24 hours Educational time = 4 days annually or 32 hours TOTAL = 312 hours 2,080 hours (1 FTE) – 312 hours of benefit time = 1,768 hours actually worked In this scenario, 312 hours, or 15% of total hours, will need to be replaced per FTE. FTEs x 15% = total number of direct care FTEs required

Staffing Patterns and Ratios A nursing budget can also be built by starting with a staffing pattern. Staffing patterns relate to NHPPD, but the budgeting process starts a bit differently depending on the metric. Recently, nurse–patient ratios have been a topic of debate and discussion. For example, California has a legislated 1:5 nurse (RN [registered nurse])–patient ratio on medical– surgical units, and the number of FTEs is based on this metric (BOX 10-8). When using a staffing pattern to build the budget, licensed practical nurses (LPNs) and assistive staff would be added to the matrix.

BOX 10-8 Using Staffing Ratios to Budget FTEs

Assumptions Unit census = 20 patients Nurse-to-patient ratio = 1:4 Number of required staff = 5 Three 8-hour shifts = 15 staff Replacement factor 15% (see Box 10-7): 15 staff x .15 replacement factor = 2.25 FTE Total number of required staff: 15 FTEs + 2.25 FTEs = 17.25 FTEs

Again, indirect salaries need to be added, including medical clerks, nurse manager, clinical nurse specialist, and any other support staff who are in the nursing budget. A replacement factor must be built in for the medical clerks but is not included for the nurse manager or clinical nurse specialist. Once FTEs are determined, the type of hours or who will be filling the FTEs is a key decision. The following areas must be considered: Skill mix (percentage may already be determined by standard or history) Special programs, such as weekend rates/shift differentials Use of supplemental staff

Skill Mix Skill mix refers to the proportion of licensed to nonlicensed caregivers in a patient care delivery model. Some organizations use an RN/LPN to nursing assistant/technician ratio and others use an RN to LPN/nursing assistant technician ratio. Ideally, the skill mix should be determined by carefully examining the patient population being served and by identifying skills and tasks required to provide care. In practice, many factors affect skill-mix determinations. Available RN supply affects skill mix. During times of RN shortage, skill-mix percentages often decrease because of inability to fill positions. Skill mix can also affect cost. Higher skill mix equals higher salary dollars. When developing the budget, the manager most often follows the historical trend for skill mix, unless a justification for change is submitted.

The advanced nurse can assist in identifying whether a change in skill mix is required based on the assessed needs of the patient population being served. Typically, the historical pattern for skill mix varies based on the patient population and the level of care. Critical care units tend to have a very high RN mix, and long-term care facilities have a lower RN mix. Nursing research has begun to focus on the impact of skill mix on patient outcomes. Frith, Anderson, Tseng, and Fong (2012) identified an inverse relationship with RN mix and medication errors. A decrease in medication errors was demonstrated as the proportion of RNs increased. However, findings did not generate specific staffing recommendations. Aiken et al. (2017) explored nursing skill mix in European hospital settings using a cross-section of data from patient discharges, hospital characteristics, and nurse and patient surveys. Data analysis revealed that a richer nurse skill mix was associated with lower odds of mortality, lower odds of low patient hospital ratings, and lower odds of poor quality reports, poor safety grades, and other poor outcomes, after adjusting for patient and hospital factors (Aiken et al., 2017). Findings support that for every 10 percentage point reduction in the proportion of professional nurses, there is an associated 11% increase in the odds of death. In this hospital sample, consider that there was an average of six caregivers for every 25 patients, four of whom were professional nurses. Substituting one nurse assistant for a professional nurse for every 25 patients would be associated with a 21% increase in the odds of dying (Aiken et al., 2017). Nurses in all types of advanced roles can track outcome data on individual units and identify associations between outcomes and staffing to determine whether changes are required.

Incentives and Differentials Organizations differ on how specific program incentives and differentials are captured. If shift differential or weekend program salary rates are not incorporated into the budget, then the unit will be over budget during the year, even though the hours of care remain constant. The manager is responsible for identifying the percentage of staff working hours requiring pay above the base salary rate. During times of

nursing shortages, such incentive programs as sign-on bonuses, additional differentials for night shift, and retention bonuses proliferate. Targeted incentives can be beneficial during unanticipated volume increases or nursing shortages but can be difficult to administer and maintain. Sign-on bonuses for new hires often create resentment among longterm staff. Sunsetting or ending very rich programs can feel like a pay reduction or takeaway to staff. The advanced nurse is instrumental in identifying workplace issues that promote retention and a satisfying work environment. Carefully reviewing past history and judicious use of supplemental staff are strategies that can reduce the need for incentives. If programs are in place or anticipated during the year, they must be included during the budgeting process.

Supplemental Staff Workload increases, staff vacancies due to resignations or leaves of absence, or increases in required staff numbers related to new programs lead to supplemental staffing strategies. Supplemental staff can include internal nursing pools, temporary staff provided by an external agency, increased hours for part-time staff, and overtime. With the exception of part-time staff increasing hours to full-time status, these options increase salary costs because of the higher associated hourly rate. Supplemental staff salaries are frequently the cause of a major variance in the nursing budget. It is crucial that the nurse manager realistically project supplemental staff needs and closely monitor these costs. Obviously, filling vacant positions reduces the need for supplemental staffing. Using per diem pool staff has become a major strategy for many organizations. Per diem staff usually have a minimum requirement of hours, no or reduced benefits, and a significantly higher hourly rate. In units with high vacancy rates, an interesting shift may occur. Nurses who have benefits through their spouses/partners or who do not need benefits coverage may choose to shift from full-time positions to per diem. They receive a higher hourly rate, often work up to full time, and have a reduced holiday and weekend commitment. In this case, the manager depends on the per diem staff for regular hours and does not have the

flexibility of the per diem pool to cover high-volume needs or replacement for leaves and sick calls. With a fairly consistent average daily census, a wise strategy is to hire full- and part-time staff into budgeted positions and to utilizing per diem staff for flexibility. An exception is in units with a widely fluctuating census, such as in neonatal intensive care units. In this type of unit, allotting a percentage of FTEs to per diem or pool staff is an important strategy for efficient resource management. When the census increases, per diem staff can increase their hours. If a decrease in census is sudden and prolonged, the number of full-time staff required to use nonproductive time may be minimized. Additional sources of premium pay are overtime and temporary staffing. Overtime can be incidental, short times to complete work, or additional shifts. Many organizations do not budget overtime, but inevitably a late sick call will result in the request for a staff member to stay, even if it is for a short time. Historical data are important in budgeting overtime; however, scheduling practices can often play a role. Prescheduling overtime or schedules that consistently create an overtime situation, such as scheduling staff for four 12-hour shifts within a week, are often reasons for an overage or increase in overtime pay. Temporary or agency help also provides a degree of flexibility, particularly during times of sustained volume. For example, if an organization has historical data that identify an increase in the average daily census of 20 patients during the month of January, utilizing temporary staff might be a viable strategy. Temporary supplemental staffing agencies can provide local individuals on a day-to-day basis, provide a “block” agreement for a longer time frame, or provide a consistent individual for a specific time period. Again, the hourly rate is significantly higher than the average staff nurse salary and can have a negative impact on the bottom line.

Predictive Analytics There are several software and staffing and scheduling tools that can assist in predicting staffing needs based on demand, typically built on historical data. Greater accuracy in matching supply to demand assists in identifying the core staffing needed at a given point in time. It may also

reduce the time that scheduled nurses are unexpectedly not needed for a particular shift, which can be a major source of dissatisfaction if occurring frequently.

The Demand for Close Observation Many organizations wrestle with the need for close observation, also known as one-to-one or sitter care. The advanced nurse can play a major role in establishing sitter criteria and working with staff to identify the appropriateness of one-to-one observation. This type of monitoring is clearly required for suicidal patients and in specific clinical situations. Sitters are frequently utilized to prevent falls, inadvertent tube removals, elopement, and wandering. With the focus on restraint-free environments, the use of sitters has increased. It is important to review past usage history and to assess the needs of the anticipated patient population during the budget process. Working with physicians and other members of the healthcare team to identify appropriate alternatives to one-to-one care is a key strategy. Video or remote monitoring has demonstrated promising results in reducing costs associated with the need for one-to-one observations while achieving desired safety outcomes (Burtson & Vento, 2015). A centralized monitoring system allows one or more trained individuals to observe several patients concurrently and then alerting the nurse if there appears to be an imminent risk of fall or elopement. Key to the success of this intervention is identification of appropriate patients and effective communication systems (EXEMPLAR 10-2).

EXEMPLAR 10-2 Remote Video Monitoring to Protect Patients From Harm A general medical unit in an academic teaching hospital often cares for patients with dementia who require close observation for wandering and fall prevention. At any given time, this unit often has five patients who require this level of supervision. The additional staffing requirements would be 5 nursing assistants or other designated sitters per shift or an additional 15 in a 24-hour time frame. This requirement places a significant burden on the unit staffing model, as nursing assistants may need to be reassigned from their responsibilities to augment sitter staffing needs. The hospital recently implemented a remote video program. The advanced nurse, a clinical

nurse specialist, evaluated all patients requiring sitters against criteria for participation in the remote video program option. Four patients met the criteria. The remote monitoring program supports one trained individual who monitors multiple patients. In this scenario, staffing needs were reduced to two sitters per shift. One sitter stayed on the unit with the patient who did not meet video monitoring criteria and one sitter remotely watched four patients. The 24-hour staffing requirements were reduced from 15 to 6 sitters, resulting in a less burdensome impact on unit staffing and decreased labor costs while maintaining required safety precautions.

Justification Considerations for Nursing Staffing It is important to note that although NHPPD and staffing patterns can be used to build the nursing budget, these figures are calculated averages. Staffing inpatient care areas on a daily basis must take into account the population of patients and the roles and responsibilities of the care providers. The American Nurses Association (ANA, 2012) recognizes that appropriate nurse staffing is integral to achieving safe, good-quality outcomes. It asserts that ascertaining appropriate staffing requires dynamic decision making that incorporates consideration of many variables. Cost effectiveness is an important consideration, and the reimbursement structure should not affect nurse staffing patterns or the level of delivered care. Select core components include, but are not limited to, the following: High-quality, cost-effective health care relies on appropriate nurse staffing. “All settings should have well-developed staffing guidelines with measurable nurse sensitive outcomes specific to that setting and healthcare consumer population that are used as evidence to guide daily staffing” (ANA, 2012, p. 6). Registered nurses are full partners collaboratively working with other interdisciplinary healthcare professionals. Registered nurses, including direct care nurses, must have a meaningful voice and active role in staffing decisions to make certain that they have the time necessary to meet patient needs and complete nursing duties. Staffing need determinations must be based on analysis of data, including patient characteristics, the care environment, and staff characteristics (skill set, mix, professional characteristics, and previous

staffing patterns that have demonstrated effectiveness on outcomes of importance). “Appropriate nurse staffing should be based on allocating the appropriate number of competent practitioners to a care situation; pursuing quality of care indices; meeting consumer-centered and organizational outcomes; meeting federal and state laws and regulations; and attending to a safe, quality work environment” (ANA, 2012, p. 6). These principles demonstrate the complexity of the various factors that must be considered when determining appropriate nursing staffing. Often the NHPPD is budgeted based on the prior year, and nursing leadership needs to make the case for an adjustment or increase. In recent years, there has been a concerted effort to benchmark nursing staffing data. Participation in national benchmarking initiatives, such as the National Database of Nursing Quality Indicators (NDNQI), has been increasing. The NDNQI compares an organization’s actual nursing care hours by specialty to the median of other participating hospitals on a quarterly basis. Nursing hours as reported by the NDNQI are the direct care provider hours and do not include indirect time. Nurse-sensitive quality indicators, such as the development of nosocomial pressure ulcers and fall rates, are also benchmarked in the NDNQI database. Data comparisons, including patient care outcomes and nurse-sensitive quality data, can provide a powerful tool when preparing budget justification for changes in nursing hours of care. Several investigators have studied the relationship between nurse staffing and patient outcomes. Aiken, Clarke, Sloane, Sochalski, and Silber (2002) noted that in hospitals with high patient-to-nurse ratios, surgical patients experience higher risk-adjusted 30-day mortality and failure-to-rescue rates than hospitals with lower ratios. In a more recent international study in nine countries, Aiken et al. (2014) found that an increase in nurses’ workload escalates the likelihood of inpatient hospital mortality. Similar findings were demonstrated in a study of surgical patients in Pennsylvania that suggested differences in nurse–patient ratios have an impact on postoperative mortality, with lower ratios resulting in fewer deaths (Shekelle, 2013). The body of nursing research

examining nurse staffing and outcomes is building, and the advanced nurse can play a role in continuing to examine this relationship.

Variance Reporting Budget monitoring during the year usually occurs on a monthly basis. Actual revenue and expense reports are compared to the budget figures. Identifying a variance is the first step, but analysis is essential to make needed adjustments. Factors that contribute to a positive or negative variance are numerous and multifactorial and cannot always be controlled. A report describing the reason for a discrepancy is consistently required for a variance of 5% or more. FTEs, actual dollars spent, and revenues vary with patient volume, but NHPPD and other standards remain constant. Supplemental staffing costing premium pay is a common area of negative variance in nursing. A unit could be well within the budgeted NHPPD or other standard but have a negative dollar variance because of higher hourly rates. Another metric that is used is the nursing costs per patient day. Cost per patient day encompasses the total salary and supply costs for a specific unit and divides it by the number of patient days. The higher salaries of supplemental staff or unusual supply usage are reflected in the total cost. A unit or department may end the month or even the year within budget but not have flexed appropriately to the units of services. It is also possible in a variable budget context to be over budget and to justify this variance as a result of volume increases. Cost per patient day is an important metric that often demonstrates failure or success in adjusting staff and associated expenses to volume fluctuations. Additional reasons for negative volume variances (over the budget) include unusually high sick calls, use of nonproductive time for vacation, unanticipated leaves of absence, high patient acuity, and supply costs for specific patient populations—for example, gowns and gloves. Righting course may be necessary but not at the expense of providing the agreedupon standard (NHPPD, hours per visit) of care.

Nursing Budget Considerations in a ValueBased Environment

Nursing’s impact has not always been quantifiable in the fee-for-service world. As nursing moves toward payment for outcomes and, in some instances, penalties for not achieving those outcomes, the profession has an opportunity to connect the impact of its practice to the bottom line of an organization. Advanced nurses can play a role in identifying staffing factors, such as turnover, inadequate resources, and high use of agency staff, that might impact the achievement of clinical outcomes. Another consideration is the importance of cross continuum care and communication. In an era of population health, nurses need to think beyond the care delivered in the inpatient setting. Utilizing nurses’ full capabilities in the inpatient, ambulatory, clinic, and home-care settings becomes essential when the focus is on maintaining the health of a specific group of patients. Budgetary impact might include the need for additional assistive personnel, additional time for communication to nurses in other settings, and a renewed focus on coordination of complex care.

Preparing for the Capital Budget: Product Evaluation Although advanced nurses may not be the architects of the hospital or nursing budgets, their clinical and operational expertise has the potential to inform many budget projections and decisions. Advanced nurses are especially needed as contributors to the capital budget process, particularly to lead or participate in product and equipment identification and evaluation. They influence the quality of the care environment and the efficiency of the work environment by assisting in the provision of cost-effective, high-quality devices and products that improve care processes and positively affect outcomes. Nurses in advanced roles are often involved in evaluating and selecting products and medical devices that are used in a variety of clinical settings. There is little in the literature to guide advanced nurses through this decision-making process. A review of published nursing literature reveals that perioperative nurses are at the forefront of product and device selection and management. Perioperative nurses and nurses in other specialized settings and departments are high-volume end users of hospital products. Given the emphasis on interprofessional

collaboration and team-based decision making, it makes sense that such multidisciplinary input should be used for medical device and product evaluation activities. There are more products than ever from which to choose. In 1992, Berkowitz, Diamond, and Montagnolo observed that in the early 1980s, there were more than 6,000 distinct types of medical devices and an estimated 750,000 brands, models, and sizes produced by approximately 12,000 manufacturers worldwide. The number and varieties have increased over the past 25 years, particularly when considered within the context of the technological and computerization explosion that has occurred in health care during this same period of time. Selecting the right product and the most appropriate technology or device requires effort. Fiscal resources are limited, so product and device decisions have to be good. Most hospitals’ capital equipment budgets are smaller than the amount of total requests, so competition for dollars is fierce between equally worthy projects. The goals of product evaluation include selecting products and devices that (1) meet specific performance criteria, (2) are safe for both patients and staff, (3) encourage positive patient outcomes, and (4) are cost effective for all stakeholders (Halvorson & Chinnes, 2007).

Opportunities to Explore Devices and Products: Trade Shows Trade shows and conferences are good venues for exploring new products. The American Association of Critical-Care Nurses’ (AACN) National Teaching Institute (NTI) & Critical Care Exposition has the largest trade show for critical care nurses, advanced practice nurses, and nurses who care for critically ill patients (AACN, 2018). The Association of periOperative Registered Nurses (AORN) Global Surgical Conference and Expo includes a large exhibit hall filled with new products, technologies, and services. Other specialty organizations also work to provide opportunities for conference attendees and product experts to meet, mingle, and network over patient care needs, customizable products, software platforms, and other latest and greatest devices. Advanced nurses should make certain to visit vendors and to keep current with new product opportunities. Vendors usually have business

contact cards, flyers, white papers, and samples that can be brought back to the work setting for group consideration. Although some products and devices may initially appear cost prohibitive, careful analysis may reveal that new equipment could reduce expenditures related to highticket patient care concerns, such as length of stay, complications, nurse injuries, and patient safety enhancements.

Product Evaluation and Medical Device Competencies and Considerations Malloch (2000) suggested that advanced nurses making purchasing decisions need three new competencies specific to product evaluation: end-user accountability, evidence-based product selection, and nursing commercial competence. End-user accountability relates to achieving specific results. Evidence-based product selection means that advanced nurses need to collect important end-user clinical information from staff members who preview the product or equipment. Nursing commercial competence is balancing clinical intent with economic impact. Malloch (2000) emphasized that advanced nurses need to consider the real value of different choices by analyzing alternatives and their consequences. Advanced nurses and staff may be inclined to think of price as the most important purchase consideration. Certainly, given constrained resources, product and device costs are important considerations. Contino (2001) identified two ways to consider costs when purchasing equipment. These include the payback period, defined as the number of years required to recover the original investment, or the internal rate of return, calculated to determine whether the generated revenue will cover the purchase cost. Advanced nurses should understand that there are other components affecting supply costs besides price, including but not limited to, (1) environmental impacts, such as disposability and recycling options; (2) technological congruity with other systems currently in use in the practice setting and expenses associated with connecting or revising; (3) options for communication with the electronic health record system; (4) satisfying regulation requirements, including the Health Insurance Portability and Accountability Act (HIPAA) and other privacy concerns; (5) infection control considerations; and (6) ease of repair, maintenance, and diagnostic surveillance options. Vendor reputation and supports should

also be considered (Plonien & Donovan, 2015). The AORN updated guidelines for evaluating and selecting products used in perioperative settings in 2010 (Stanton, 2017). A newly renamed and updated AORN publication, Guideline for Medical Device and Product Evaluation, is available in the Guidelines for Perioperative Practice (2019) to provide evidence-based guidance to perioperative team members as they design and implement a process for evaluating U.S. Food and Drug Administration approved medical devices and products used in the perioperative care setting (Stanton, 2017). Advanced nurses should consider similar, evidence-based guidelines for other practice areas, or building on the efforts of the AORN, as a reasonable way to ensure consistency, fairness, and quality in decision making.

Opportunities for Staff Engagement Nurses in advanced roles should consider establishing an interprofessional team for product selection and medical device evaluation processes. As an added bonus to the spirit of teamwork that may be generated by the collaboration, evaluation projects offer staff opportunities to learn the research process by devising small-scale studies that are practical and interesting. Pelter and Stephens (2008) designed an experimental study to compare first-attempt success rates, patient comfort, and insertion time between urinary catheterizations using a new device designed to facilitate urethral catheterization versus catheterization procedures without the new device. Consenting patients were randomly assigned to one of the groups. The nurses conducting the urethral catheterization procedure also received informed consent. Twotailed student t-tests and chi-square tests were used for statistical analysis. A small sample size limited the generalizability of the results; however, study findings did suggest that although the device had little influence on the dependent variables, findings indicated that nurses are challenged by urethral catheterization and some find that this is a difficult procedure to master. This study (Pelter & Stephens, 2008) provides a simple but elegant example of an opportunity to engage staff in research while evaluating devices in the clinical setting. The basic setup of this particular project

may be applied to a variety of product evaluation opportunities. For example, nurses could brainstorm outcomes or dependent variables of interest related to hygiene products, dressings, airway-securing devices, or any number of other devices, products, or systems and then use basic experimental or quasi-experimental designs to answer relevant questions. Research questions may relate to comparing different products as part of the purchase decision, determining whether a product is successfully addressing a particular clinical concern, or looking at already established products to ascertain whether implementation processes require improvement.

Opportunities Through Group Purchasing Arrangements Plonien and Donovan (2015) comment that many agencies participate in group purchasing organization (GPO) agreements that provide cost savings through negotiation of large purchase orders. Such GPO arrangements also promote standardization. However, there are times when physicians have preferences for similar products that come from vendors other than those in the GPO. Physician product preferences are often distinct from product or device cost, and these desires set the stage for conflict. Plonien and Donovan (2015) strongly advise including surgeons on intraprofessional purchasing committees. They also describe two methods to influence purchasing behaviors rather than using an autocratic approach. One method is the formulary model, where limits are placed on the variety of manufacturers and products. Another option is the payment-cap model that uses price caps for particular item categories (Plonien & Donovan, 2015, p. 428).

Value Analysis Products that do not add value to the practice environment should be avoided (Plonien & Donovan, 2015). To determine value, advanced nurses should incorporate evidence and performance improvement priorities. Efficient resource utilization is paramount, and making certain that a new item has additive benefits to the unit or department’s established arsenal of products and devices connects to performance

improvement (Plonien & Donovan, 2015).

Theft Concerns Over 25 years ago, Lyons (1992) reminded nurses that theft opportunities and preventions should be a consideration in product evaluation. Theft persists as a relevant concern that contributes to serious financial loss. Barlow (n.d.) comments that medical equipment may be sold online. Excluding embezzling and other crimes, small-item theft is also a worry because it makes a difference to the bottom line. When providers, staff, patients, and families steal chargeable, consumable supplies, there is an associated cost. High-frequency pilfering involves many items that might be best included in room rates or some sort of per diem supply cost applied per patient day (BOX 10-9).

BOX 10-9 Select Items Frequently Stolen From Hospitals Items Thermometers Fans Toilet paper Telephones Tissue Linens Gowns Incontinence products Baby towels Office supplies Baby formula Bandages Baby gowns and outfits Scrubs Towels Bath blankets Energy saver light bulbs Baby blankets Bed exit systems Dopplers Digital thermometers

It may be wise for advanced nurses to consider the possibility of item

attractiveness and thievery when considering products and devices. Some equipment requires chargeable housing that is not easily stolen. Other devices are simply not appealing to would-be thieves because of their limited practicality outside the healthcare setting. If a new product or device has a high theft appeal, advanced nurses may need to consider the additional expenses associated with storing the equipment or product and tracking its use.

Safety Concerns Nurses in advanced roles should consider searching for reports of adverse events (AE) involving medical devices as a step in product evaluation. The Food and Drug Administration (FDA) maintains a publicly available medical device reporting Manufacturer and User Facility Device Experience (MAUDE) database (FDA, 2017a). MAUDE data consist of reports submitted by mandatory reporters, manufacturers, importers, and device user facilities as well as reports from voluntary reporters, such as healthcare professionals, patients, and consumers (FDA, 2017a). The online database provides access to information on medical devices that may have malfunctioned or caused serious injury or death. MAUDE may be searched for reports that have been submitted over the previous 10 years. MAUDE is not intended to suggest cause and effect, and it does not represent all known safety data for a particular device (FDA, 2017a). Advanced nurses may not be aware of the rich data made available through the FDA’s Center for Devices and Radiological Health (CDRH). This center provides information about regulatory decisions and associated rationales, descriptions of regulatory processes, and data to support CDRH activities. MAUDE is a CDRH database. There is also a recalls as well as medical device databases and other searchable databases (FDA, 2017b). The available information has tremendous implications for advanced nurses practicing across all types of clinical and operational settings, regardless of specialty or population. One study using the MAUDE database analyzed reports of da Vinci robotic surgical system instrument failures to analyze possible root causes of failures and trends that might be useful to know (Friedman, Lendvay, & Hannaford, 2013). Instrument failures (N = 565) were

discerned via the reports, and although there were likely other failures that were not reported, the retrieved data illustrated the importance of devising standard failure reporting policies in practice settings so that failure rates and device concerns can be improved. Advanced nurses should consider the implications of this database for practice improvements and policy development and include such information during device inservice and education programs.

The What-If and More-Is-Better Syndromes of Materials Management It is important to remember that there is usually more than one way to perform a procedure or more than one product to accomplish a job. The best product, defined in any number of ways, is not always needed. An average product may work just as well and suit the needs of the organization quite satisfactorily. The problem is that advanced nurses may equate average with cheap. Lyons (1992) directs materials managers to assist advanced nurses in understanding that quality can be defined as meeting the requirement or the need. Average products may be the better choice. Lyons (1992) emphasizes that need must be separated from want. The what-if syndrome tends to encourage practitioners to think of every possible scenario, no matter how unlikely, and then to look for equipment or products that can address these unlikely situations (EXEMPLAR 10-3). This type of thinking drives up projected costs that may lead to rejection of the proposed capital budget expenditure.

EXEMPLAR 10-3 The What-If Syndrome of Product and Device Purchasing Several medical intensive care unit (MICU) nurses attended a regional critical care conference. During the conference’s trade show, the nurses came across a new automatic blood pressure cuff system. This system was very appealing for several reasons, but, in particular, it had a safety feature for cuff size and placement that the nurses believed would help to ensure the accuracy of MICU vital signs assessment. The conference attendees brought information back to their colleagues. The nurses were enthusiastic about the product, as there had been recent problems with assessment inaccuracies related to incorrect cuff fit and placement that had compromised patient

assessment data and potentially affected care. The nurses evaluated the project per the recommended checkpoints and concluded that the equipment should be submitted for review during the capital budget request period. As the nurses developed their proposal, they discussed the number of automatic cuffs that would be required on the unit. Some nurses believed that each room required this new system. Others were concerned that “extras” were required because equipment “always walks.” Each estimated figure cost more due to the increasing numbers of requested cuffs. The advanced nurse was consulted for assistance with the capital budget request. The advanced nurse began the consultation process by reviewing the nurses’ rationale for requesting this particular blood pressure monitoring system. Other brands of automatic cuffs were available and were considerably less expensive. The advanced nurse asked the staff to identify the “typical” types of patients who required such sophisticated technology. The advanced nurse encouraged the staff to think in terms of “must have” rather than “nice to have.” The nurses believed that patients with small upper arm circumferences and patients with above-average arm circumferences required these cuffs—in other words, patients who were outliers specific to arm circumference size. The advanced nurse worked with the staff to isolate the approximate number of MICU patients who met these criteria on an average shift. The nurses agreed that approximately two patients per shift were difficult to fit with the standard automatic blood pressure system, leading to accuracy concerns. After further guided discussion, the staff identified a simple strategy for confining the equipment on the unit to prevent loss. The nurses also developed guidelines for staff to consider when deciding whether to use manual, standard automatic, or specialized automatic blood pressure cuffs. The staff decided to requisition the budget for two of the new, specialized automatic blood pressure cuffs. They realized that their opportunity for expenditure approval was better with a tight proposal that clearly avoided the more-is-better syndrome. Although there was no guarantee that the equipment request would be approved, the nurses felt confident that if the request was denied, it would be denied because of funding limitations or competing priorities rather than because of an unrealistic needs assessment.

The more-is-better syndrome encourages the belief that if one is good, two must be better (Lyons, 1992). Nurses in advanced roles must assist staff in identifying exactly what is needed in terms of the number of products or the frequency of equipment use. Determining an accurate measure of “need” is important for calculating direct and indirect costs. Need does not have to pertain to number of units. It may also apply to the features of technological products (EXEMPLAR 10-4).

EXEMPLAR 10-4 The More-Is-Better of Product and Device Purchasing The surgical trauma unit’s nurses and physicians were interested in replacing the unit’s cardiac monitors. The biomedical engineering department agreed that it was time to replace the aging system. The staff contacted several reputable vendors and began to explore monitor

options. As the group was introduced to increasingly sophisticated equipment options, the nurses and physicians began to acquire the more-is-better syndrome. They were surprised by and impressed with the various technological advances and were amenable to the sales representatives’ premise that their patients deserved the best. The monitors were capable of powerful analyses, and the data collection and alarm options were impressive. After a few months of investigation, the group began to think about fiscal and clinical practice realities and asked a critical care advanced nurse to offer an unbiased opinion. The advanced nurse preliminarily collected historical data from the staff and physicians to explore the capabilities of the current monitoring system and to contrast these opportunities with the functions that were actually used on a regular basis. The interprofessional group was surprised to learn that the old monitoring system was not used to peak efficiency. Certain capabilities, including ST segment monitoring and historical trending data, were rarely used for nursing assessment or medical management, despite the perceived importance of the functions. The advanced nurse emphasized to the group that if monitoring capabilities were identified in policies and procedures as essential to quality of care and a required part of routine assessment, the nurses and physicians were potentially inviting risk or compromising care by failing to follow the established protocols that they had developed. The advanced nurse began the group process by meeting with the physicians and nurses to determine what monitoring functions were critical to patient care. The advanced nurse emphasized that unless equipment features are consistently used, they may become more of a care liability than a benefit. Staff was asked to prioritize equipment functions. Physicians were involved in discussions specific to detailing the information that they really would use for patient care management. Nurse educators were asked to review the equipment options from the perspective of teaching and learning. The advanced nurse compiled this information and developed a list of desired monitoring capabilities that would be valued and consistently utilized by nursing and medical staff. This list was reviewed by the prospective users and was validated for accuracy. Vendors were asked to respond to this list. Equipment was selected based on the match between price and capabilities. This experience revealed to practitioners that more is not always better. There is no value in paying for equipment capabilities that are not desirable or that are underutilized. Liabilities may increase if monitoring capabilities are available but not used by staff in the intended way. Educational needs should be considered as well. If orientation and inservice demands are too complex or rigorous, the likelihood of staff using the equipment correctly is reduced. The advanced nurse cautioned the group that neither more nor less is better. Rather, it is wisest to get exactly what is needed at an affordable price.

Nurses in advanced roles should be actively engaged in product and device identification, selection, and evaluation. Product and device possibilities should be considered methodically, with a clear idea to the intent and need underlying the review process (TABLE 10-4). Deliberate review processes may be enhanced by using a product evaluation tool that can be used to solicit feedback from nurses and other involved healthcare professionals (TABLE 10-5).

TABLE 10-4 Product and Device Evaluation Checkpoints Product/Device Consideration

Suggestions

1. Review and verify manufacturer claims for accuracy.

Advanced nurses should make certain that manufacturer claims are accurate. Products may not perform as promised during clinical use. Review the fine print of claims and make certain that these attestations are accurate when products are actually put to the test in clinical situations.

2. Compare available products or devices.

Advanced nurses should compare products during clinical use. Select a few competing products or devices and compare them.

3. Consider ease of use and maintenance.

Consider how easy the product or device is to use. This consideration includes ease of cleaning and storing.

4. Pay attention to ergonomics and product size and weight.

Advanced nurses should pay attention to the influence the product has on body mechanics. If a product requires repetitive movements, muscle straining, or periods of prolonged standing, solicit input from staff and other healthcare professionals as to the potential for injury, particularly given the aging nursing workforce.

5. Evaluate the complexity and readability of the manufacturer’s product instructions.

Review the written instructions for clarity, readability, and accuracy. Advanced nurses should explore whether troubleshooting information is available in print and/or Web forms. It may be reasonable to ascertain whether a 24-hour contact is accessible for troubleshooting, particularly if a product or device is new to the setting.

6. Consider safety features and prioritize features that are absolutely essential.

Advanced nurses should encourage staff to think about what could go wrong and ways in which the device might be misused. It is important to make certain that critical safety features cannot be turned off. Some devices may have delay switches that reset after a period of time to avoid the need to deliberately reset safety features once discontinued.

7. Estimate anticipated training costs.

Advanced nurses should calculate the training costs associated with assuring competent use of new devices and equipment. Some products are quite sophisticated and may require hours of training. Others may warrant competency assessments. Explore whether vendor-packaged training materials, including computer or Web-based instruction, are available.

8. Determine ease of repair.

Many devices and products are sophisticated by design and require experts for repairs or maintenance activities. If the institution cannot afford the cost of backup equipment or cannot justify the expense of developing in-house repair expertise, it may be difficult for staff to work without equipment when it malfunctions. Consider expenses associated with repair, replacement, and/or extended warranties.

9. Consider security needs.

Consider if this product or device requires protections from theft. Is this a product or device that is likely to be appealing to would-be thieves? Can the product be used outside of the healthcare facility? Is there a secondary market or home use for this item? If thievery is a concern, consider strategies for securing the product, restricting its access, or monitoring its use.

10. Evaluate the environmental impact.

Advanced nurses should investigate the costs associated with cleaning or disposing of the product. Environmental impacts are important not only in terms of the chemicals or processes necessary for cleaning but also the biodegradability and bulk of items when no longer useful. Are parts recyclable?

11. Consult device safety reports.

Review MAUDE databases for information about reported safety concerns that may be relevant to the devices that are under consideration.

Description Description TABLE 10-5 Product and Device Evaluation Tool Example

Description Description Description Description Healthcare resources are limited, and advanced nurses are obliged to participate in activities that promote the highest quality of care using the

dollars that are available. Understanding the budget process, engaging in conversations and data collection activities that inform the budget, teaching and coaching staff to develop a better sense of the fiscal realities of care, and contributing to capital budgets through product and device evaluations are responsibilities of nurses in advanced roles. Many teaching moments related to healthcare administration processes are experienced by advanced nurses as they work closely with nurses at the point of care. Having a good understanding of the business basics of nursing is an excellent way to contribute to the managerial functions of the institution, functions that are critical to the overall success of the organization.

Discussion Questions 1. How did the ACA affect the Medicaid program in terms of coverage and cost? 2. The CMS has focused on bundled payments as a model to improve quality outcomes and reduce cost. Give an example of how an advanced practice nurse would use this model to improve patient care. 3. Medicare is a social entitlement program; discuss the financing and cost-sharing features of Medicare Part A and Part B. Which main benefits are covered under Part A and Part B? Which services are not covered? 4. Differentiate between the Medicare Advantage program and the prescription drug program under Medicare Part D. What is the coverage? 5. What are the differences among operating budgets, revenue budgets, expense budgets, and capital budgets? 6. As an advanced practice nurse, in which aspect of budget management do you think you will have the most influence?

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Contino, D. (2001). Proposing the “capital” in capital budgets. Nursing Management, 32, 10, 13. Cubanski, J., Swoope, C., Boccuti, C., Jacobson, G., Casillas, G., Griffin, S., & Neuman, T. (2015). A primer on Medicare: Key facts about the Medicare program and the people it covers. Retrieved from http://files.kff.org/attachment/report-a-primer-on-medicare-key-facts-about-themedicare-program-and-the-people-it-covers Frith, K., Anderson, E., Tseng, F., & Fong, E. (2012). Nurse staffing is an important strategy to prevent medication errors in community hospitals. Nursing Economics, 30(5), 288–294. Food and Drug Administration. (2017a). MAUDE: Manufacturer and user facility device experience. Retrieved from https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/search.CFM Food and Drug Administration. (2017b). CDRH transparency. Retrieved from https://www.fda.gov/aboutfda/centersoffices/officeofmedicalproductsandtobacco/cdrh/cdrhtransparency/default Friedman, D. C., Lendvay, T. S., & Hannaford, B. (2013). Instrument failures for the da Vinci Surgical System: A Food and Drug Administration MAUDE Database study. Surgical Endoscopy, 27, 1503–1508. doi: 10.1007/s00464-012-2659-8 Hain, D., & Fleck, L. (2014). Barriers to nurse practitioner practice that impact healthcare redesign. OJIN: The Online Journal of Issues in Nursing, 19(2). doi:10.3912/OJIN.Vol19No02Man02 Halvorson, C., & Chinnes, L. (2007). Collaborative leadership in product evaluation. AORN Journal, 85(2), 334–352. Kaiser Family Foundation. (2010, September 2). Family health premiums rise 3 percent to $13,770 in 2010, but workers’ share jumps 14 percent as firms shift cost burden. Retrieved from https://www.kff.org/health-costs/press-release/family-health-premiums-rise-3-percent-to13770-in-2010-but-workers-share-jumps-14-percent-as-firms-shift-cost-burden Kaiser Family Foundation. (2017). Medicaid pocket primer. Retrieved from https://www.kff.org/medicaid/fact-sheet/medicaid-pocket-primer/ Kindig, D., & Stoddart, G. (2003). What is population health? American Journal of Public Health, 93(3), 380–383. Lyons, D. (1992). Making the purchase decision: Factors other than price. Hospital Material Management Quarterly, 13(4), 55–62. Malloch, K. (2000). Purchasing pointers. Wise buys. Nursing Management, 31(5), 30. Pelter, M., & Stephens, K. (2008). Evaluation of a device to facilitate female urethral catheterization. Medical-Surgical Nursing, 17, 19–25. Plonien, C., & Donovan, L. (2015). Continuing education. OR leadership: Product evaluation and cost containment. AORN Journal, 102, 426–432. http://dx.doi.org/10.1016/j.aorn.2015.07.007 Shekelle, P. G. (2013). Nurse–patient ratios as a patient safety strategy: A systematic review. Annals of Internal Medicine, 158, 404–409. Retrieved from http://annals.org/aim/fullarticle/1656445/nurse-patient-ratios-patient-safety-strategysystematic-review Shi, L., & Singh, D. (2015). Essentials of the U.S. health care system (4th ed.). Burlington, MA: Jones & Bartlett Learning. Stanton, C. (2017). Guideline first look. Guideline for medical device and product evaluation. Periop Briefing, 106(5), 7–9. http://dx.doi.org/10.1016/S0001-2092(17)30955-9 Yee, T., Boukus, E., Cross, D., & Samuel, D. (2013). Primary care workforce shortages: Nurse practitioner scope-of-practice laws and payment policies. National Institute for Health Care Reform (NIHCR) Research Brief No. 13. Retrieved from http://nihcr.org/analysis/improvingcare-delivery/prevention-improving-health/pcp-workforce-nps Zuzelo, P., Fallon, R., Lang, A., Lang, C., McGovern, K., & Mount, L. (2004). Clinical nurse specialists’ knowledge specific to Medicare structures and processes. Clinical Nurse Specialist, 18, 207–217.

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CHAPTER 11 Microeconomics in the Hospital Firm: Competition, Regulation, the Profit Motive, and Patient Care J. Michael Leger and Mary Anne Schultz

CHAPTER OBJECTIVES 1. Provide a broad view of the economics involved in the hospital environment that includes competition, regulation, and patient care. 2. Understand the impact of regulation in the U.S. healthcare system and the costs associated with it. 3. Demonstrate the impact of electronic medical records and how this affects the healthcare industry.



S

ince the introduction of a prospective payment system (PPS) for health care 25 years ago, hospital services have become increasingly driven by the market forces of price and quality. Rooted in a tradition of caring, hospitals were once seen as places where people could be healed and have their physical needs met—all through the professionalism and trust of healthcare providers. This was the hospital’s mission. Today, hospitals are businesses, big and small, where patient care is

but one service and patients are no longer the only constituent. Their caring (and, in some cases, curing) processes are now high tech, research based, and financially driven and serve several stakeholders, such as physicians, investors, patients, families, and employees, such as nurses, to name a few. Balancing the goals of the players and supporting the many purposes of a hospital require identification of the pressures shaping its operation. Chiefly, these are (1) competition, (2) regulation, (3) the profit motive, and (4) high-quality patient care. This chapter examines these key forces from the standpoint of theory and practices in both microeconomics and cost accounting focused on the hospital firm. Health care once derived its processes almost solely from its mission, but now a hospital’s margin comes first, because without a (profit) margin, the organization, like all businesses, ceases to exist, and hence, there is no mission. This chapter in no way provides a comprehensive survey of these interrelated forces but instead offers an explanatory primer, with examples, for a hospital’s economic and business behavior. An overview of the disciplines of both microeconomics and cost accounting is provided to acquaint the reader with what is probably an entirely new way of thinking (and talking) about the institution called a hospital. This way, the profession, through the nurse leaders, communicates with key nonprovider hospital decision makers, such as the chief executive officer or chief financial officer, with the same language and thus on a level playing field.

Microeconomics, Cost Accounting, and Nursing This section addresses the following question: “What is microeconomics (and, in turn, cost accounting) and what has it to do with nursing?” Economics, the study of how society allocates scarce resources, can be divided into two categories, macroeconomics and microeconomics, which are contrasted in TABLE 11-1. Macroeconomics (the prefix macro meaning large) is the study of the market system on a large scale. Microeconomics is the study of individual consumers in relationship to their markets. TABLE 11-1 Two Categories of Economics Macroeconomics Considers:

The aggregate performance of all markets, including the outcomes or performance of all companies or firms in all industries

Gives us:

Indices, or measures (indicators), of a nation’s economy, such as stock prices, interest rates, jobless claims, and housing statistics

Microeconomics Considers:

The choices made by smaller economic units, such as consumers or individual (hospital) firms

Gives us:

Such concepts as profit, profit maximization, price strategy, and nonprice competition to consider

Description Cost accounting is an element of financial management that generates information about the costs of an organization and its components. As such, it is a subset of accounting in general and encompasses the development and provision of a wide range of financial

management that is useful to managers in their organizational roles. Keep in mind that the goal in generating this information is to provide a basis for decision making. A quintessential question in our field is this: What should the nurse-to-patient ratio be, and on what basis is this decided? The field of cost accounting, borrowing from financial accounting (information generated by firms largely for external purposes—e.g., the Internal Revenue Service), while encompassing managerial accounting (information generated by firms for their own internal use), affords us tools to address the tough staffing questions, such as break-even analysis, profitability analysis, make-versus-buy decision making, marginal cost calculations, and cost-quality trade-off analysis. The relationship of the accounting disciplines is depicted in FIGURE 11-1. It is our considered opinion that these domains—economics and accounting —were once considered mutually exclusive from the field of nursing. Only as the number of nurses undertaking formal study of these quantitative disciplines, such as in master’s of business administration (MBA) or master’s of public health (MPH) programs, increased did our field place itself on equal footing with lay administrators at the top of the hospital hierarchy.

FIGURE 11-1 Relationship of the accounting disciplines.

Description

The nurse at the top of the administrative hierarchy, the nurse executive, may have trained with advanced preparation in all three disciplines discussed here: microeconomics, cost accounting, and nursing. The American Organization of Nurse Executives (AONE, 2005) published its view of the core competencies that the nurse executive should have. Among these are analyses of supply and demand data; analysis of financial statements; articulation of business models based on economics, strategic, and business planning; and the development of future business skill sets in leadership team members, all of which are listed under the Business Skills subsection of the AONE’s core competencies. This is brought to the attention of the reader to dramatize how important it is for current and future nurse leaders to maintain their own skill set in business and financial matters and to massage this process with key leaders in their organizations, such as nurse managers. The deployment of nurse resources at the unit level could quite possibly be the most important decision made in hospital care because it is through the provision of high-quality nursing care that high-quality patient outcomes are realized. Nursing administration, one form of advanced practice (Harris, Huber, Jones, Manojlovich, & Reineck, 2006), is an at-risk specialty, given the numerous reports of dropping enrollment in graduate nursing administration programs (Herrin, Jones, Krepper, Sherman, & Reineck, 2006), a perceived lack of attractiveness of nursing administration as a viable graduate program choice (Rudan, 2002), widespread nurse executive burnout (Rollins, 2008), and the dire situation of the aging nurse faculty workforce (Berlin & Sechrist, 2002). Without this vital specialty, nursing could lose its scientific basis for practice, nurse managers at the unit level might lose recently acquired gains in real autonomy and decision making, and, most of all, research done by nurses on the effectiveness of their measures will continue to be invisible in healthcare quality, health services research, health policy, and healthcare finance initiatives (Lang, 2003). This discussion is an appeal to the reader regarding the uniqueness of the nursing administration specialty as well as the special challenges afforded the profession if our critical mass of economic and systems thinkers continues to deteriorate.

Competition The theory of the firm (the theory of supply and demand) explains and predicts price, the quantity of products, and the likelihood of survival of firms in a competitive industry. Before the PPS was introduced into the healthcare market, hospital firms operated on a cost-plus basis, billing insurers for the total consumption of resources by an individual patient. After 1983, hospitals were switched to a diagnosis-related group (DRG) basis for reimbursement, receiving compensation for what a typical patient within a medical diagnosis and selected other medical conditions would consume. This departure from the cost-plus reimbursement scheme ended the era of price competition in health care, and hospitals began to compete on a nonprice, or quality, basis, which is when patient outcomes magnified in importance. For centuries, the relationship of the demand for a product or service to its supply has been thought to be largely the result of the intervening variable of price. In the fictional “market for widgets,” supply of a product consistently meets the demand for it, given a set of assumptions about the market for widgets. This theory (the theory of the firm) explains a lot about the way the world works, pending the strength of these assumptions: large numbers of buyers and sellers, perfect information about the product, absence of barriers to entry and exit as a business entity in the industry, and homogeneity of the product. Note that a full description of all four assumptions as they pertain to markets for health care is beyond the scope of this text, yet a focus on two of the assumptions—a large number of healthcare buyers and sellers and the existence of good information—is key. In health care, the four assumptions are less clearly visible than in the fictitious market for widgets for a variety of reasons. Among them are the fact that relatively little is known to the buyer of hospital care (the insurance company) about the quality of care purchased from the seller (in our case, the hospital), and the demand for hospital care is a derived demand. This is to say that it comes from health insurance companies as the intermediary between hospital care providers, such as hospitals, and the individual patient–consumer. When health care entered the

competitive arena, decision makers became highly sensitized to the customary business practices of restricting expenses and maximizing revenue while producing a service of measurable quality whenever possible. The change from a system loosely concerned with quality of care, through the professionalism and trust of providers, to a system that prices services strategically while competing on quality has resulted in a costconscious era unlike any ever seen before. It is widely recognized that as hospitals compete to provide services, they seek to strike a vital balance between cost reduction and quality of care to adapt successfully to external competitive threats to their survival. In an attempt to successfully adapt, organizations make an effort to (1) optimize profit through pricing strategies, (2) reduce expenses through decisions about personnel and equipment, and (3) achieve reimbursable patient outcomes by satisfying recipients of care through both high-tech and caring approaches. Better care provision (a result of wise resource allocation) may result in better patient outcomes (output), which results in better reimbursement and is alleged to be a benefit of an openly competitive, deregulated hospital market. Hospitals that can demonstrate higher quality of care, or even adequacy of care, will win higher reimbursement, or bids, for reimbursement plans, more patients, and better-qualified care providers. Over time, “good” hospitals will survive because they have established a pattern of good outcomes. The higher the hospital’s performance or improvement, the higher the value-based incentive payments. Additional evidence regarding this theory can be found through such organizations as HealthGrades (see www.healthgrades.com) and U.S. News and World Report’s ranking system (see http://health.usnews.com/sections/health/best-hospitals). Both report such measures as risk-adjusted mortality rates as well as complication rates, such as patient population-specific measures of comparative quality. In summary, the importance of these hospital ranking systems, or stamps of approval as the public might see them, is this: The information about the quality of the product or service of a hospital is accurate enough to create comparison ratings used by payers as well as by others interested in these data. Hence, the information qualifies as perfect information (not to be taken literally).

What microeconomic theory states regarding the eventual number of hospital firms within an industry under long-run equilibrium (hospitals that are rivals or that compete over the long term) is this: Those hospital firms with better products or services will survive, but those with inferior products and services will not. This is the result of the achievement of quality held by payers and consumers, which, in part, drives the industry’s (derived) demand. Unfortunately, relatively little is known about the tenets of competition in health care. More will come to light as variations in the quality of patient outcomes based on reimbursement in hospitals become available in the future. Thus, the usefulness of this theory for the explanation and prediction of future activities in health care remains challenged. This is not to say that “Supply and demand—it just doesn’t work in health care!” is an emotionally charged statement devoid of reason. It is, instead, appropriate to say that the predictive power of this theory in health care is limited to more than its explanatory power of interpreting the how and why of a hospital firm’s behavior. Stated another way, all hospitals seek to maximize patient outcomes/reimbursement and thus maximize performance ratings. In the world of competitive hospital management, hospitals must innovate with new programs, new patient populations, or quality initiatives to survive and better achieve the continuum of care in the value-based environment. New sources of information on hospital care continually become available in both print and electronic media, so decision makers must be savvy regarding patient outcome comparisons. Just as automobiles are rated for gas consumption and airlines for on-time arrivals, payers and consumers contract for hospital care based on price and quality through managed care negotiations.

Regulation and Managed Care The soaring cost of health care has been one of the most pressing domestic issues for decades. Politicians and pundits speak of how changes in laws could affect this crisis, sometimes provoking a discussion of socialized medicine and cross-country comparison of U.S. versus “other” healthcare expenditures and outcomes. With no clear answer to this type of healthcare ill emerging soon, most would agree that although our healthcare system is among the most market oriented (competitively driven) in the world, it remains the most heavily regulated sector of the U.S. economy (Conover, 2004). This author states that the costs of regulation are the benefits we would derive with alternative uses of those resources. After reviewing the literature on 47 different kinds of healthcare regulations, it was estimated that the net burden of health services regulation on society was $169.1 billion annually. For the novice in economic thinking, let’s examine what some of the costs of regulation are said to be. In lay terms, it is the sum total of all expenditures by federal or state regulators that oversee, inspect, supervise, monitor, or award privileges to healthcare providers, such as physicians, nurses, and hospitals. In just a quick survey of hospital and nursing regulation costs alone, consider the following: The Centers for Medicare and Medicaid Services (CMS) utilization reviews of appropriateness Occupational Safety and Health Administration (OSHA) inspection of workplace safety The National Labor Relations Board monitoring of nurse unions The National Council of State Boards of Nursing (NCSBN) licensing exam requirements Every state board of nursing, medicine, pharmacy, respiratory therapy, and physical therapy The American Association of Colleges of Nursing (AACN) and the National League for Nursing (NLN) accreditation of nursing schools National Practitioner Data Bank housing information on practitioners Limitations on medical resident or registered nurse (RN) working hours

Fraud and abuse protections Each one of these organizations or protections has staff, overhead, a place of business to run, and extensive reporting requirements to yet another governmental or quasi-governmental organization. The author makes a convincing case that if health care were deregulated, the cost savings from this could realize gains in health promotion and prevention. Although in our discussion of rivalry and what hospital firms must do to survive, indeed thrive, a convincing case is made about the benefits of the competitive, or market-driven, environment for hospital care, which is not diametrically opposed to regulatory efforts. This needs to be said because, in essence, a highly competitive market-driven industry is a bit like the polar opposite of one that is highly or completely regulated, as is the case in countries with a national single-payer health system. In short, the market for hospitals is not what is known as “purely competitive,” as is the market for widgets; far from it, in fact. It holds, instead, a complicated mixture of free-market principles, huge regulatory demands, a demand for sick-care services that is derived and not direct, and the most complicated reimbursement scheme known in modern times in any industry. Managed care was originally intended to reduce healthcare costs to society through the restriction of resource allocation and to improve the overall health of individuals. Now it is a generic term for healthcare payment systems that attempt to control costs and is considered an economic success and a social nightmare. Managed care has, in fact, reduced healthcare costs to society by tying clinical decisions to economic ones that previously were mutually exclusive. In these arrangements, a hospital or group of doctors agrees to provide services in exchange for third-party payment. Managed care networks make available to their members only those providers authorized by the plan. Often this designation is geographically derived, thereby restricting individuals’ choices to go to what they see as the “best” orthopedic or cancer care hospital or doctor if unavailable locally. It is worth mentioning that individuals still have free choice (lots of it)—if they are willing to get out their checkbook. In managed care, the provider (physician, nurse in advanced practice, or hospital) offers covered services at a discounted rate in exchange for a

steady revenue stream. If the novice reading this wonders why providers would “settle for less” by receiving a discounted rate, consider the alternative. Providers would have an uncertain revenue stream that challenges their abilities to cover the basic costs of doing business (reduces uncertainty), plus there are few, if any, alternative ways of conducting business, generally speaking. Stated another way, consider what is known as the first rule of finance: A dollar today is worth more than a dollar tomorrow, as a result of the time value or opportunity cost of money. That is, any entity that gains revenue in a timely manner not only can retire debt (an asset) but also invest; hence, the time value of money is realized. Remember that fee-for-service medicine has all but disappeared, taking with it the old model of the solo-practice physician, and patients who pay out of pocket are rare. Under a per diem rate agreement, the managed care plan pays the hospital a fixed rate for each day of care, when in fact nurses are in a particularly strategic position to observe that costs per diem to the institution can be (very) variable for one patient stay. Consider the surgical patient who consumes relatively few resources on the morning of admission for a procedure that afternoon. Once the patient enters the operating room, costs to the institution soar steeply and remain high as the patient travels to the postanesthesia recovery room; this can include even more costs if intensive care is involved. For a monthly fee, the hospital must provide the specified services to the third-party payer’s enrollees, such as this patient. Under this arrangement, the hospital is ensured money in a relatively timely fashion (based on the average consumption of patients within that DRG and other clinical factors) and the patient–consumer knows he or she will be covered for surgeries that are preapproved. The overall aim of managed care is to make the patient a better healthcare customer, evaluating whether the patient is getting what she or he is paying for (assuming the individual pays health insurance premiums, which most do). Also, the burden of prevention and wellness increases in importance for the patient, and, presumably, physicians and advanced practice nurses share in this responsibility by virtue of recent changes in medical and nursing education. In this system, the patient has less control over selection of the doctor or hospital and may be responsible for higher deductibles and copayments as well as for

penalties for services done outside the network. From a positive (or factual) point of view, the real cost savings to the healthcare system and society at large are through reduction and elimination of unnecessary services, tests, and procedures as well as time delays through the authorization process where untold numbers of individuals drop off, or attrition out of, the care-seeking process.

Profit Motive and Patient Care Amid the rhetoric and hysteria regarding hospitals and profit, not enough is said about why a hospital exists. A hospital exists to satisfy the needs of its various stakeholders. Among these are physicians, nurses, and other employees; patients and their families; consumers; researchers; schools of medicine and nursing; and the community at large, to name a few. Although many agree that today’s hospitals exist for the provision of sick care, this is not to say that there are no other compelling reasons for them to subsist. It is a business entity, and, as such, it responds to many demands from the players, or stakeholders. Among these demands are the volume and morbidity of patients, requests from physicians and nurses in advanced practice for necessary equipment and the efficient flow of patients, concerns from patients and families about inefficient or substandard care, and training opportunities for students of medicine and nursing. The profit motive drives all these. In an influential book in its time, The Profit Motive and Patient Care (Gray, 1991), the author made the previously unexplored claim that two unique accountability factors exist in health care that do not exist in other organizations: the vulnerability of the consumer (patient) being served and the absence of payers at the point of service. Gray goes on to describe the ways in which the profit motive has come to shape the behavior of all parties, including providers of health care, suppliers of their capital, physicians, employers who provide benefits for their employees, and administrators of health plan benefits. It is this shift in the paradigm of aligning profits with patient care that will shape how providers and purchasers of healthcare service respond to the two great accountability problems. Gray’s explanation of whom the important players (stakeholders) are and how they are motivated to perform has far-reaching implications for the overall philosophical and business approaches that healthcare providers, such as nurses, might take. His was among the first credible writings to shake the foundations of why a hospital exists as well as to articulate the important forces shaping the behavior of the stakeholders. In this section, it is necessary to debunk some myths still prevailing in

certain sections of our society, sometimes even among healthcare providers: Myth 1: We are a nonprofit entity; we don’t have profit. Myth 2: We are here to provide the highest possible quality of care. These are among the most important misconceptions forwarded by many stakeholders, among them nurses. Replacing what might be our wishes (myths) with factual statements helps us understand the pervasive economic forces shaping our work and provides resolve for nursing research aims and hypotheses.

Getting the Word Profit Back The first myth—that of no profit—has hung around for decades. First, it is important to clarify our terminology. Hospitals are now classified as either investor owned (IO), formerly known as “for-profit,” or not-for-profit (NFP), formerly known as “nonprofit.” All hospitals have profit, and each of them chases profit as fast and as furiously as the next, period. They may differ on many other factors, chiefly in how they approach profit optimization as well as descriptive characteristics, such as public versus private ownership, urban versus rural, small margin versus large margin, safety net versus nonsafety net, high mortality versus low mortality, and teaching versus nonteaching, to name some. Several these factors may, in fact, covary with profit status. For example, major teaching hospitals tend to be NFP hospitals, and nearly all IO hospitals are private, but it is thought that the variable of profit status, and possibly outcomes, is the prime mover of organizational behavior. Profit, loosely defined as the excess of revenues over expenses, is as necessary to hospitals, irrespective of profit status, as oxygen is to the living system. Almost no hospital could survive without it because it could not remain liquid or solvent. Without it, a hospital eventually goes out of business just like any other entity, leaving services unprovided and employees out of jobs. Profitability, as a construct, is measured by these variables: total margin ratio, operating profit margin, nonoperating gain ratio, and return on equity. As you continue reading the next section on the cost inputs for varying levels of quality, keep in mind that costs to the hospital (what is expensed on the hospital’s income statement) relative to

revenue (money given to the hospital in lieu of care provided) are nearly synonymous with profitability, at least in the short run. Finally, an accounting note about the differences in IO versus NFP hospitals. In lay terms, the key differences between these two sets of hospitals on the matter of profit goes like this: The dollar line item of profit is found on the income statement of general funds for NFPs versus the profit and loss statement for the corporation; profit is called “profit” in the IO world, versus a “positive fund balance” in the NFP one; and the IO distributes profit (after taxes) at year’s end to the shareholders, whereas the NFPs cycle profits back into facility maintenance or expansion after paying no taxes.

Quality of Care: At What Level? At What Cost? In this chapter’s discussion of competition, it was stated that a hospital is not in the business of providing the best care money can buy, but that a hospital is in the business of providing quality of care at a certain acceptable level where reimbursement is received. It is time to examine why. Measurement of the costs of providing care quality is a function of the cost of providing quality and the costs of failing to do so. Lowering quality also has costs to the organization. Besides reimbursement losses, this lowers the quality of care for patients. This can bring about more detrimental effects for patients to deal with, including death, and the organizational reimbursement and reputation suffer; and remember, reputation is an asset. So, as lowering quality occurs, this erodes the hospital’s competitive position and thus its longer-term viability. This costquality trade-off explains the behavior of the hospital firm in health care. In conclusion, what can be said about the profit motive and patient care? Profit, as an incentive, is here to stay. Profit is not a dirty word. Furthermore, cost-quality trade-offs drive operational (day-to-day) decisions in all organizations in a competitive industry. Also, cost shifts (costs to the hospital, or expenses) might be borne by the individual, or perhaps the employer, if the individual is discharged prematurely and is too sick to resume employment. Revenues would shift from one governmental organization (such as the CMS) to another if they could. And dramatically changing one variable, such as RN staffing, necessitates significant changes in another, such as expenses for other

personnel—a topic that will prove essential to our national debate about hospital staffing.

Quality Patient Care The discussion of profit motive demonstrated how a hospital comes to provide not the best care money can buy but instead an acceptable level of quality. The acceptable level of quality is driven by its cost. Next, to compete on a quality-of-care basis, the hospital must report measurable aspects of quality of care—patient outcomes (presumably at an acceptable level)—to various governmental (state health departments and federal agencies) and nongovernmental organizations, such as the Joint Commission. Through processes such as these, the information about the quality of care in one facility is said to be perfect information, a cornerstone of a competitive industry. The information can also be characterized as symmetric in that both the buyer (the insurer) and the seller (the providers) have access to it. Given the preponderance of information-reporting requirements, it is assumed that hospitals have numerous opportunities for improvement— assuming that these many reporting requirements translate to internal care-improvement processes. Next, through the movement now known as transparency (symmetric knowledge), hospitals can bid competitively to purchasers, boasting superior quality outcomes. A third quintessentially important thing this information preponderance gives us is the incentive for public programs (e.g., Medicare) and private insurers to reward and reimburse quality of care and efficiency. This incentive program has the overall goal of making hospitals miss reimbursement when they err with never events. It is essential to note that the quality and availability of the information to both buyers and sellers make hospital nonprice competition possible.

Information on Quality and the Risk-Adjustment Process A time-honored claim that hospitals and other providers have made regarding quality measures in general is that their patient populations contain more risk factors than others (e.g., “our patients are sicker”),

hence the appearance of “not looking good” to the state or inspection agency. Granted, patient populations from hospital to hospital (or even from doctor to doctor) likely always differ on factors other than the care provided, but, arguably, meaningful points of comparison have been devised by clinical and biostatistical experts within many agencies. One such agency is California’s Office of Statewide Health Planning and Development (OSHPD). California was among the first states to develop a database of risk-adjusted quality measures, and the California Hospital Outcome Project reported to the public for the first time in 1995 and has continuously updated and improved its risk-adjustment processes ever since (OSHD, 2019). Biostatisticians know that databases this large do, indeed, allow for meaningful points of comparison across hospitals. Generally speaking, risk-adjusted measures of quality of care are in fact useful tools for the comparison of hospitals on the quality of care provided, but imperfectly so. In the California hospital project, for example, the mortality measure was defined as the observed number of deaths from acute myocardial infarction divided by the number of qualifying persons admitted with this primary diagnosis multiplied by the statewide rate. By making the process known to all, agencies such as this assert that they have satisfactorily responded to providers’ claims about disparate findings based on (unmeasured) risk factors. In fact, on a yearly basis as the press releases come out about new editions of the data, the project offers the opportunity for hospital providers to respond in writing about why their facility “looked worse than expected” in the measures. This way, the project measures are refined yearly, in part on the basis of the responses of participating hospitals. Since inception of this project, the agency has made available other outcome measures, all risk adjusted, that are reflective of common and costly conditions. Earlier, this chapter expressed the thought that for our profession to be seated at the table of quality initiatives in the context of the hospital business entity, we need expert knowledge of the economic and quality measures being discussed. Furthermore, societal decision makers and gatekeepers, such as the OSHPD and the CMS, would benefit from nursing representation to make the hospital measures, now used for reimbursement, meaningful. Fortunately, through the years, as nursing acquired a critical mass of administratively prepared nurses, it has

become common for nurse executives from hospitals and/or representatives of our professional societies to be invited to such tables where the decisions are made. Because this was not always the case, it could be considered progress of the profession through acquisition of the same knowledge and the same financial language spoken by lay administrators that made this possible.

Healthcare Policy: The Staffing Ratios Debate The relationship between nurse staffing and patient safety is reasonably well established, especially when patient outcomes, such as medicalsurgical mortality rates (Aiken, Smith, & Lake, 1994), acute myocardial infarction mortality rates (Schultz, van Servellen, Litwin, McLaughlin, & Uman, 1997), community-acquired pneumonia mortality rates (Schultz, 2008), failure to rescue (Needleman, Buerhaus, Mattke, Stewart, & Zelevinsky, 2002), and shorter lengths of stay (Lang, Hodge, Olson, Romano, & Kravitz, 2004), to name a few, are considered. How patients fare has long been thought to be due to the result of the number of professional nurse staff available as well as their preparation, visibility, and experience. Additional organizational variables known to be important include: The leadership style of the nurse manager The overall quality of leadership in the institution Whether staffing and other operational decisions are decentralized Physician satisfaction with nursing care The nature of the information system used for patient care Research on hospital characteristics and their relationships to patient outcomes has broadened to include additional variables important in the complex relationships of people and technology relative to quality. Mandated minimum nurse-to-patient staffing ratios were legislated in California in 1999 and implemented on January 1, 2004. Also being considered is the importance of having patient classification system data to support the appropriate RN staff requirements. Some of the impetus for the movement toward mandating nurse staffing ratios through governmental and scientific imperatives comes from the challenging conclusions offered by the Institute of Medicine’s (2002) report To Err Is Human. This report shook both the scientific and the lay communities with its most memorable finding: Between 44,000 and 98,000 deaths occur each year as a result of medical errors. There is hardly a scientific

journal that focuses on these types of organizational studies that does not report the influence of nurse staffing, often in the form of RN hours per patient day or RN to all staff hours. The beginner in politics and policy might ask, “Isn’t this a no-brainer? More nurses equals better patient care, right?” Only a fool would disagree. But along the same lines, more police in a neighborhood and fewer pupils per teacher in schools would improve their respective situations, yet these commonsense ideas are difficult to carry out. The following subsections provide the novice nurse–politician with some food for thought on the potential implications, or consequences, of such legislation in the context of (1) the operation of a hospital within a community or (2) the market for hospitals as a whole. The implications can be summarized in four parts: hospital operations, including closure; feasibility and the nursing shortage; political opportunity costs; and costs to society. The implications—the economic consequences of legislation addressing what staffing should be (normative economics)—are couched in positive economics, or what is, factually.

Hospital Operations and Closure As mentioned previously, the healthcare workforce accounts for at least 50% of a hospital’s costs (Kazahaya, 2005). Most of this is nursing personnel costs. Starting with the assumption that some hospitals staff significantly better than the minimum staffing ratios suggest, whereas some staff significantly lower as a baseline, there is a variance around the regulated minimum ratio (also known as “the floor” ratio). Hospitals staffing well below this floor ratio will experience a rapid rise in operating expenses and lost reimbursement as well as a subsequent drop in operating profit margin. This endangers the hospital’s liquidity (ability to meet short-term obligations) and solvency (ability to meet maturing obligations as they become due). Hospitals staffing well above the floor ratio have an incentive to drop nurse staffing levels depending on the cutoff point of where reimbursement is negatively affected as well as the response to this by their rivals—in other words, it depends on whether neighboring hospitals can afford to remain in business after enactment of this law. Finally, hospitals staffing at about the mandated level may experience no significant change in their financial and, subsequently,

business activities, so their staffing may continue as is. Consider other hospital operations that are disrupted as a consequence of what many nurses thought was a great idea. As reported by Welton (2007): Elective procedures have been postponed, canceled, or moved to a nearby facility. Community hospitals have a more difficult time transferring patients to tertiary care facilities because beds cannot always be staffed. Emergency room (ER) wait times have increased. ERs have increasingly switched (or requested to switch) to diversion status. Night shifts are nearly impossible to staff. There is a huge shift to contract (agency or registry) nursing staff, causing a significant rise in expenses, often tens of millions of (unforeseen) dollars in a year. The regulations make the hospital increasingly vulnerable to lawsuits, especially on occasions when staffing is less than required. When the regulations allow for “licensed” nurses in the equation, RN unions block the effort to fill a void with licensed practical nurse (LPN) hours, thereby inflating union-to-union conflict. Evidence supporting the view that this mandate was too costly for hospitals to continue operating is seen in the number of hospitals that closed in the years during the implementation phase-in of the California law. Twenty hospitals closed (nine in 2003, eight in 2004, three in 2006; OSHPD, 2008), citing factors on the revenue side of the profitability equation (drop in inpatient revenue and utilization issues). The costs to hospitals of the mandate cannot be underestimated. It is important to note that many forces, both internal and external, cause a business to close and that many of these factors, when they occur simultaneously, push the firm close to the “edge,” or more specifically, to the margin. Usually, a hospital firm that closes had both failing business (patient care processes) and economic activities (on both revenue and expenditure sides) in the preceding years that ultimately caused its demise. To date, no one empirical effort has isolated the impact of such a law on a hospital’s propensity to close due to the complexity of the issues. Recall from the discussion of profit that when expenses rise in one

category, pressure is exerted in the hospital system (or any business) to (1) reduce expenses in another category, (2) make up the expensed activity with an increase in revenue, or (3) both. To formulate a guiding principle on hospital profit-maximizing behavior, Needleman (2008) suggests these questions to consider: How much would it cost to increase nurse staffing? Would these costs be offset by cost savings from better reimbursement, reduced length of stay (LOS), and fewer complications? Would the hospital realize these cost savings, or, because of how the hospital is paid, would these savings be captured by payers? Can the hospital attract additional profitable patients on the basis of its nurse staffing? Are there cost savings other than those achieved via better patient care that might also be realized if nurse staffing is increased? It should be clear that changing a regulation on the most significant personnel expenditure a hospital budget contains, RN hours, has farreaching consequences for both hospital business and economic activities. This subsection looks at the core organizational dynamics of a single hospital, which is a very limited aspect of the staffing ratios laws. Even looking at these activities in all hospitals in a state, or in the nation, offers only a partial view of the consequences of mandated ratios as described here. Read on to see how a hospital’s behavior cannot be viewed in such a microcosm because of its essential bond to the other subcategories, such as the sporadic nursing shortage.

Feasibility and the Sporadic Nursing Shortage In the past, hospitals, lawmakers, providers, consumers, and society as a whole were increasingly concerned about the international nursing shortage and its subsequent impact on the quality of care. After implementation of California’s safe-staffing law, RN hours per patient day on medical-surgical units rose significantly, perhaps by as much as 21% (Donaldson et al., 2005). Yet the nursing shortage, predicted to be a deficit of 400,000 RNs by 2020 (Buerhaus, Needleman, Mattke, & Stewart, 2002), continued to beg the question of where the nursing hours

came from. Over decades, it was a long-standing principle of hospital staffing to “borrow” nurse hours from unit to unit to (1) satisfy short-term patient care demands—for example, several new admissions arriving at the same time as intensive care unit transfers—and (2) satisfy regulatory and reporting requirements. Patient care demands may have been met, whereas regulatory and reporting requirements almost certainly were. Many obstacles hinder compliance with mandated staffing requirements. Consider these real-world examples from Welton (2007): Hospitals may start a shift in compliance but not end that shift in compliance. Hospitals may start and end a shift in compliance, but the middle of the shift is in question. Nurse recruitment efforts have been accelerated but often are not associated with the desired result of satisfactory staffing. California’s law requires nurses to be on standby to cover breaks for bedside nurses, which is a requirement that is practically impossible to meet. Penalties exist for noncompliance. Nurses increasingly report not taking their breaks, given the lack of coverage while they are to be gone. Hospitals could be held criminally liable for adverse outcomes in the context of staffing that is less than required by mandate, even in view of evidence of the intent to comply. These remarks point to regional shortages within one hospital, which carry yet another set of concerns for patient safety. Chiefly, these concerns are costs associated with noncompliance, nurse recruitment (especially as nurses from outside the country are involved), and legal defense. Also, there were no accompanying changes in the revenue side of the hospitals’ profit equation. The examples offered in this subsection highlight merely a few of the difficulties hospitals are having with the mandate. Additional issues include workplace safety, nurse injuries, nurse dissatisfaction, turnover, and the propensity to stay in current positions. This subsection emphasizes only some of the more immediate feasibility issues posed by such regulations. And this does not take into account how this will affect reimbursement.

Political Opportunity Costs for Nursing Highly publicized political wars have taken place, most notably in California and New York, over the staffing ratios debate. Both states had nurse unions that were successful in getting legislation sponsored that evolved into statewide acute care hospital staffing mandates, but at what political cost? California’s 12-year battle (Spetz, 2001; Doolan, 2005) spanned the reign of two governors, and New York’s campaign (Gerardi, 2006) was similarly protracted, both being punctuated by statewide town hall meetings, numerous “call to action” alerts to other professional societies, consumption of resources of nursing associations of all types, and bad press labeling nurses as unyielding and self-serving. In California, such ill will attracted national attention when Governor Arnold Schwarzenegger summarily dismissed both the nurses union’s leadership and membership and the nurses in general by calling nurses “a special interest group” that is just angry because “I kick their butt” (Marinucci, 2004). These campaigns occurred just as the state of the research was judged not to categorically support the thesis of better care provision through more RNs in each case. In fact, the research results are mixed (Burnes Bolton et al., 2007), reporting that although a clear and consistent rise in nurse staffing did exist post regulation in California, it was not accompanied by a commensurate rise in quality as measured by significantly fewer falls or pressure ulcers. In a study reported by Mark and Harless (2007), a superior distribution of outcomes (mortality and LOS) with a lower level of RN staffing was found. In sum, the evidence points to the prevailing conclusion that there is a strong, but not yet totally conclusive, case for an impact of nurse staffing on mortality (Needleman & Buerhaus, 2003) and other adverse outcomes. If you believe, as some do, that science drives policy and legislation— and that’s a leap—you have now identified a gap between just what we recommend on the matter of staffing mandates (the normative economic view) and a recommendation accompanied by a cogent economic rationale (the positive economic position) and plan. Stated another way, consider the words of Keepnews (2007, p. 236): Ongoing research on the impact of nurse staffing regulation can yield important information that can guide continued staffing policy

efforts. Understanding the impact of such efforts should include evaluating the outcomes of recent legislation in Oregon and Illinois as well as continued examination of staffing ratios in California. Successful efforts will need to transcend traditional boundaries between researchers, policy analysts, advocates, and organizations.

Costs to Society Social policy is the domain that aims to improve human welfare and to meet human needs for education, health, housing, and social security. Health is a part of public policy that has to do with social issues. There was a time when health was considered the absence of disease. Couple this limited definition of health with the Hippocratic admonition “to do no harm” to identify what the public expects from a hospital: to emerge from the experience with an improved state of health or, at a minimum, to avoid increased morbidity as a result of seeking hospital care. Although it is touted as a modern concept, we would do well to remember that the Hippocratic admonition regarding harm emerged centuries ago (Hippocrates, 2004). Previously, it was noted that, at a minimum, highquality care is identified as the absence of adversity or the absence of adverse events. The costs to society of this adversity are understudied or underreported in modern health services research. The costs to society include, but are not limited to, the alternative use of hospital resources in a community (e.g., feeding the poor, housing the homeless), consumption of a tax basis (in the case of NFP hospitals) for the same, the costs of ill health for individuals and employers (such as the opportunity cost of lost time and productivity at work), unreimbursed expenses related to caring for the underinsured or the uninsured, and the alternative use of people and technology resources in other employment. This subsection briefly lists some questions for further study in the context of the costs to society of mandated staffing ratios with respect to the latter two factors—the function and purpose of safety net hospitals and the opportunity realized in the operation of a hospital in a community context.

Safety Net Hospitals

Defined as hospitals disproportionately serving vulnerable, including financially vulnerable, populations, safety net hospitals also experienced a sustained significant rise in nurse hours after enactment of safe staffing ratios. It is inaccurate to assume that a higher nurse-to-patient ratio affects the financial structure of hospitals the same way across the board. Safety net hospitals, by definition, are at-risk institutions that have consistently been financially vulnerable organizations when viewed from the revenue side of the profit equation. With large numbers of underinsured or uninsured patients, they have no position from which to compete on price and may not have the resources to compete on the basis of quality. It would stand to reason that although they budget for bad debt expense, this line item varies considerably because it is volume dependent and sensitive to changes in the macroeconomic condition. In short, when the region of its location “has a bad year,” this institution has an even worse one. It is close to impossible for such a hospital to court more attractive (paying) patients not only because of geography but also because of poor internal economic conditions, including liquidity crises. Having just stated that the competitive position of these hospitals is weak to begin with (they are less able to compete on the basis of price or quality), it stands to reason that they run a high risk of closure, particularly in view of the fact that the patient-to-nurse mandate obliges them to spend more on nurse staffing. With this loss of flexibility to vary the nursing skill mix comes inefficient allocation of scarce resources and an inability to make trade-offs in other hospital services. The subsequent drop in operating profit margin (and perhaps in other measures of profitability) could easily cause negative consequences for patients, such as premature discharge, recidivism, and higher complication rates. With the Medicare pay for performance structure, it is easy to see the handwriting on the wall for such environments, with closure looming in the future. As providers, especially safety net hospital providers, struggle with these enmeshed issues of geographic limitations, a tangible floor in revenue, and dropping profit margins in light of rising bad debt expenses, it is no wonder that the hospital executive has an eye on cash flow relative to debt (cash flow-to-debt ratio) because it is the prime predictor of hospital closure. Once again, without a margin there is no mission, despite outcries that health care is a right. Is it? If yes, who pays for it?

A Hospital Firm Within a Community Context Recall that in the subsections on hospital operations and the nursing shortage, several questions were raised relevant to reducing or delaying services (diversion to neighboring ERs), the potential for a hospital to realize other cost savings as RN hours rise (better reimbursement, some economies of scale, perhaps, with nursing duties in common with nonlicensed personnel), and the costs to the hospital of recruiting and retaining nurses. We pose the following questions when considering the impact of such a government intervention on small-margin hospitals. Bear in mind that small-margin hospitals include those considered safety net hospitals or those classified as rural. Will there be a drop in the employees’ total compensation package, say, a reduction in health benefits or a rise in premium prices, in an effort to offset the rise in operating expenditures? As the line item for RN hours increases, what happens to the expenditures for nonprofessional nurses and ancillary nursing personnel? As these nonprofessional nurse budgets are trimmed, will it be necessary to start outsourcing programs in preparation for layoffs? As resources become more constrained, what is the subsequent impact on measurable levels of quality? On reimbursement? What is the effect of the change in levels of quality on managed care contract negotiations? In short, will the insurer continue to send covered lives to a facility thought or known to be substandard? As measurable levels of quality are affected, what is the impact of this on the hospital’s creditworthiness? As the hospital’s creditworthiness is adversely affected, how compromised is the hospital in borrowing, even in the short term, to meet economic obligations, such as employee wages and other compensatory line items? How will a hospital’s payment to its suppliers be affected? If the hospital does, in fact, close, what is the impact of this event on the unemployment rate in the surrounding community, especially if the hospital is the largest employer around? If the hospital closes, what are the costs to society of airlifting or otherwise transporting the most critical of cases to the appropriate

environment of care? As decision makers in small-margin hospitals wrestle with these tough questions, it remains whether the charge “Well, it’s a hospital that should have closed anyway” is defensible. This discussion does not provide an answer to such normative queries. Instead, the measures (or variables) necessary to construct an individual answer are offered from the logical positivist (factual) economic view. In concluding this discussion of one of the most challenging healthcare policy questions of modern times, mandated nurse staffing ratios, it is important to remember some guiding principles from positive economics—that is, costs shift and revenues shift, and this will always be the case. Costs and revenues shift both within and outside the hospital firm. As in the case of borrowing nurse hours from unit to unit to “look good” or to claim compliance with such mandates, what is the subsequent impact on patient care on the unit from which the borrowing occurred? As each hospital chases profit, how long will it continue to play the shell game of shifting ER patients from one safety net hospital to another or allowing premature discharge? This causes recidivism that results in no reimbursement if patients are readmitted within a month for the same problem. Finally, as far as costs to society are concerned, how is the health of a region or the nation affected by the loss of hospitals that fail seemingly from the economic or quality point of view?

The Business Case: Electronic Health Record Systems in Hospitals Although information systems, including the electronic health record (EHR), are considered essential to the quality and efficiency of our healthcare system as a whole, the high cost of these systems is prohibitive in successful widespread implementation, especially in hospitals. Vital to daily operations, these systems proclaim to bring many benefits, such as safety, accessibility, retrievability, and convenience. They are a major organizational investment, especially with respect to start-up costs (the initial one-time expenses), not to mention the ongoing costs of annual licensing fees, updates, and maintenance to dedicated servers. This section discusses some costs, some benefits, the relationship of these costs and benefits, and the elements of a successful business case for a hospital’s EHR system. As done previously, this section offers the reader some measures (variables) to consider when idealizing that healthcare systems, especially hospitals, ought to have a computerized recordkeeping and decision-support system. Clinical information systems that computerize the documentation of physicians, nurses, and other care providers, now nearly 20 years old, hold the promise of numerous benefits—for the healthcare system or hospital, for the patient, and for the health of the nation. Among them are patient safety, accessibility, legibility, process-adherence evidence, datamining capabilities (Manjoney, 2004), retrievability, convenience, and a reduction in indirect care time. The downside is that privacy issues, costs (including upgrades), data transfer inaccuracies, implementation problems, and so on, occur. Like the previous section on legislative mandates for professional nurse staffing, the desirability of successful EHR implementation, ongoing maintenance, and subsequent upgrades ensure that the integrity of the system is intact. This could be considered a no-brainer in that more time could be devoted to bedside care and thus generate better patient outcomes, such as fewer medication errors and increased patient satisfaction. However, this is more complex because of ongoing maintenance and subsequent upgrades (including staff time and

additional expense) that ensure the integrity of the system.

Costs for the Hospital The major costs in acquiring an EHR system include the costs of hardware, software, networking, maintenance, installation, and training as well as opportunity costs (Agrawal, 2002). Direct costs, such as training time, hardware, software, salary, and support fees, are expensed on the hospital’s income statement, and big-ticket items, such as the hardware and contracted software, are listed as assets on the balance sheet and depreciated over their useful life. This is a way of spreading out the tremendous cost outlay over time. This is also a way to pair these economic activities with the business or strategic plans the organization might have to determine an asset’s future benefits. For example, an EHR system is known to be associated with increasing patient satisfaction and reductions in risk-adjusted mortality or complication rates. It is possible that these improved patient outcomes could be leveraged in a hospital’s managed care contract negotiations with insurers. This matching of economic and business activities begins the process of identifying the benefits of the technology relative to its costs. Indirect costs, those expenses associated with ongoing operational costs, include software maintenance and support fees, salaries for support staff, fees related to space and utilities (Nahm, Vaydia, Ho, Scharf, & Seagull, 2007), and the expenses of safety/security measures. Note that all costs mentioned thus far are borne by the healthcareproviding institution—in this case, the hospital. The next section, however, discusses that the benefits are shared by more than just this one entity.

Benefits for the Hospital and the Patients Implementation of a system has both tangible and intangible benefits, further complicating a discussion of the dynamics of benefits and costs. Some tangible benefits are concrete measurable gains derived directly from the EHR system, further expanded in the next paragraph. The intangible, or hard-to-quantify, benefits are such things as patient and user satisfaction and safety, increased compliance with federal or state

regulations, decreased staff turnover, future leverage derived from the same, and hospital reputation. Other difficult-to-calculate benefits include reduced resource use (partially from reduced LOS), improved quality through convenient access to information at the point of care, enhanced data capture, enhanced business management, and improved legal compliance with subsequent reduction in claims. In an econometric model making the business case for electronic medical records (EMR) implementation, Kaiser Permanente justified the costs for an inpatient EMR system through such benefits as increased RN and medical records efficiency; decreased RN overtime; reduced lab expenses, chart review time, and physical therapy wait time, along with reduced inappropriate admissions, avoidable days, ER diverts, forms expenses, and medical records supplies; fewer adverse drug events; and redeployment of space (Garrido, Raymond, Jamieson, Liang, & Wiesenthal, 2004). On the revenue side, improved coding accuracy for Medicare risk was mentioned. Here is where we see a shared-benefit situation. In the case of adverse drug events, the hospital realizes as much as a 2.2-day reduced LOS for those events associated with injury. The patient is spared the inconvenience of the same amount of time, plus the reduced opportunity cost of further morbidity from hospital-acquired conditions and, presumably, a shortened recuperation time with subsequent earlier return to work or productivity. At this point, the patient, the family, and the employer begin to share the benefits that resulted from costs incurred by only the hospital in the business case model. Yet if this is in keeping with a hospital or healthcare organization’s mission, the business model is said to be a successful one. Many different ways of calculating the hospital’s return on investment (ROI), the benefits in relation to costs, exist. (See BOX 11-1.) Among these are net present value (NPV), payback analysis, and break-even analysis. In each of these, many other influences must be assessed simultaneously, making the ROI analysis, by definition, very complicated. Among these are inflation, deflation, changes in business and strategic goals, shifts in healthcare management methods, and changes in Medicare reimbursement rates. Well beyond the scope of this text, econometric models identifying the multiple simultaneous influences on a

successful analysis of this sort yield a partial solution for justifying the enormous outlay of costs for such information technology projects as EMR. Executive administration would do well to cost out both sides of the analysis in the short, intermediate, and long terms.

BOX 11-1 Definitions Cost-to-benefit analysis compares the cost of program goals that are being considered to the cost of implementing the proposed venture’s benefits. If the benefits are greater than the cost, you have a positive cost benefit. A cost-to-benefit example can be found in Trepanier, Early, Ulrich, and Cherry (2012). Return on investment (ROI) simply calculates the bottom line from your investments in the assets used for the investment—for example, positive ROI of 6% on the investment. Examples of ROI can be found in Pine and Tart (2007). Break-even analysis identifies the cost and number of units that must be sold at a minimum to recover the fixed costs.

Conventional wisdom leaves little doubt about the ability of information technology to improve clinical outcomes, but equally compelling evidence of the positive financial return of the same has yet to be established. Because the trend in reimbursement mechanisms continues to move toward outcomes achieved, technology may prove to be beneficial. However, equally compelling is pay for performance limiting reimbursements, the downturn in the U.S. economy, and security issues and other unexpected negative side effects of technology. Large purchases may continue not to be good business decisions. This means that there are currently inadequate incentives for hospitals to act on this important aspect of the hospital infrastructure, especially when many of the benefits are difficult to quantify and forecast, not to mention government intervention. This also means that as incentive programs to reward early adoption of technology or other innovations and quality of care are realized, they will act as a catalyst for the implementation of large-scale EMR projects in hospitals everywhere.

Summary In conclusion, healthcare information systems play a central role in both the quality of care and daily operations (Nahm et al., 2007). They are extraordinarily expensive, even when the potential benefits are considered. Recall some of the lessons learned in this chapter’s discussion of profit seeking: Costs shift and revenues shift, and this will always be the case. Costs and revenues shift both within and outside the hospital firm, as do costs and benefits, as shown. This is the factual view for any big-ticket item that a hospital might consider (such as substantially increasing professional nurse staffing or EHR implementation). This chapter does not provide an answer to normative queries on whether an EHR system should be implemented. Instead, the measures (or variables) necessary to construct an individual answer are offered from the logical positivist (factual) economic view. As each healthcare organization addresses the issue of widespread implementation of an EMR, it will be increasingly important for decision makers to evaluate the nuances of their own business cases. Given that many factors obscure the construction of a clear business case for EMR, hospitals are forced to consider the avoidance of an expense (e.g., future litigation costs, less reimbursement if pay for performance mandates are not met) as parallel with actual expense reduction (including less reimbursement, if that has already occurred), especially in the short term. Similarly, they are forced to identify benefits that are realized by the hospital as well as those gained by the individual patient, his or her employer, or society as a whole. The propensity of a hospital to invest this way will likely be enhanced by the changing CMS rules on nonreimbursement for selected hospital complications. Forcing a hospital to pay for its own mistakes, such as certain hospital-acquired infections, raises the question of what type of electronic system it will take to capture the processes associated with these adverse outcomes for purposes of both quality improvement and revenue sustainability. This chapter offers background information on the nature of competition and why it is important in the market for hospital care. In the discussion of profit motive and patient care, the reader was asked to join

in debunking some myths about why a hospital exists to fulfill its purpose —to satisfy the needs of various stakeholders, such as employees, the community at large, patients, and providers, such as physicians and nurses. The regulatory arena was addressed last in the context of the hospital system as a dynamic microcosm of activity affected, sometimes dramatically, by legislative and societal mandates, such as safe staffing laws. All this reflects the complexity of the system. Some of this monetary analysis is, in fact, a brand-new way of thinking for those who have not studied formally in the fields of economics, accounting, or finance. It is hoped that, through this examination of what it takes for a hospital firm to survive competitive circumstances, future cohorts of nurses can preserve the only sustained hospital foundation—the practice of professional nursing. As stated by Buerhaus et al. (2002), “Nursing matters greatly in the hospitals’ ability to provide quality of care and prevent avoidable adverse outcomes” (p. 130). The prevention of avoidable adversity is going to contribute most significantly to the survival of hospital firms through the coming years. Most of the statements on hospital conditions and the business activities therein are from the domain of positive economics (“what is” or “what exists”), leaving the reader to draw his or her conclusions in the normative economic (“what should be”) field of endeavor. Nursing’s history, of course, has been to embrace the mission of caring, often with less investment in the impact of ideals, such as safe staffing on the hospital’s margin. As quoted by Langley (1998), “No margin, no mission”, focused discussion on the consequences of nursing’s advocacy. This is to say that without a sustainable margin of profit, a hospital, like all businesses, fails to provide service, employ personnel, pay its suppliers, or fulfill its mission.

Discussion Questions 1. Support or refute the statement “Well, supply and demand . . . it just doesn’t work in health care!” 2. Discuss how margin and mission are related, or not related, in the hospital environment. 3. Frame some arguments for or against the policy of mandated minimum staffing ratios in the positive versus normative economic dichotomy. 4. Are hospitals competing on the basis of price, quality, or both? Explain. 5. Is hospital care overregulated? Cite some examples to support your argument. 6. What is healthcare regulation, and what are some of its costs? 7. Why is the provision of sick care (hospital) services said to be a derived demand? 8. Should there be minimum safe staffing ratios—from the standpoint of the patient? Why or why not? 9. Should there be minimum safe staffing ratios—from the standpoint of the hospital? Why or why not? 10. Should there be minimum safe staffing ratios—from the standpoint of the profession? Why or why not? 11. From an economic perspective, describe the cost of regulation in the healthcare environment. 12. What is your definition of profit?

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PART 3 Quality, Safety, and Information Systems for Advanced Practice Nurses

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ith specialized knowledge and practical application of that knowledge to influence patient outcomes, nurses in advanced practice have the fiduciary responsibility not only to provide and manage high-quality care but also to take leadership roles within the practice setting to promote a culture of quality and safety. As described in Part 2, quality is one of the major components of the healthcare triad, along with cost and access. In Part 3, we consider quality issues and the intersection of quality, patient safety, and information technology. There are many definitions of quality and many perspectives on what healthcare quality means. Consumers, providers, payers, and regulators may all have different viewpoints about what healthcare quality is and how it should be measured and reported. However, with the national, healthcare industry, and societal interest in the costs of health care and the outcomes of that care, the Institute of Medicine’s definition (IOM, 1990) of quality is a well-accepted one and the one used for this book. This agency defines healthcare quality as “The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” (p. 21). Further, in its report titled Crossing the Quality Chasm, the IOM (2001) described six quality aims for health care. Specifically, health care should be 1. Safe 2. Effective 3. Patient centered

4. Timely 5. Efficient 6. Equitable These characteristics of quality should be foremost in mind as readers study Part 3. Patient safety is one of the top—if not the top—current quality issues politically and professionally. Nevertheless, it is essential to think broadly about healthcare quality, going beyond just safety, and to keep foremost in one’s thinking all the aforementioned characteristics of quality. For instance, a patient may experience a safe healthcare episode, but if the providers do not consider the patient’s preferences and beliefs, it would not be defined as a high-quality encounter. With the recent emphasis on patient safety as a result of the IOM (1999) report To Err Is Human, a concerted, ongoing effort focused on assessing and improving patient safety has been a major driver in health care. In this report, the IOM documented the serious and pervasive nature of the United States’ overall patient safety problem, concluding that more than 98,000 deaths per year occurred due to medical error and stating that the U.S. healthcare system had a severe problem. In 2008, the Robert Wood Johnson Foundation (RWJF) and the IOM realized the need to assess and transform the nursing profession. The 2year initiative resulted in the 2010 IOM consensus report titled The Future of Nursing: Leading Change, Advancing Health. Through extensive dialogue, the committee developed four goals linked to policy, safety, and education: 1. Nurses should practice to the full extent of their education and training. 2. Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression. 3. Nurses should be full partners, with physicians and other healthcare professionals, in redesigning health care in the United States. 4. Effective workforce planning and policy making require better data collection and information infrastructure.

With the passage of the 2010 Affordable Care Act and the national recognition that nurses work on the frontlines of patient care, collaborative efforts will be made to ensure that the U.S. healthcare system provides seamless, affordable, high-quality care that is accessible to all and leads to improved health outcomes. In this part, we examine how the advanced practice nurse can meet this challenge. Chapter 12 sets the foundation for advanced practice nurses to explore new care models within interprofessional teams with the goal of providing safe care that yields improved health outcomes. It explores outcome measurement and quality improvement methodologies that can be applied not only to direct patient care in primary care or hospital settings but also to disease prevention and population initiatives in public health. These applications are characterized by continuous, ongoing learning and sharing among disciplines about ways to use quality improvement philosophies, processes, and tools. In this chapter, the authors discuss factors and processes that facilitate or impede the implementation of quality improvement as a dynamic programmatic innovation within a healthcare setting. The authors provide details of quality improvement methodologies such as Plan-Do-Study-Act (PDSA), Six Sigma, Lean, and Root case analysis. Despite a strong political, consumer, and industry response to the To Err Is Human (IOM, 1999) report and a national will to decrease medical errors, the results have been poor. A recent study suggests that between 210,000 and 440,000 medical errors occur annually, making medical errors the third highest cause of death (James, 2013). The next chapter acknowledges this concern and provides recommendations to mitigate adverse events and medical errors. In Chapter 13, the authors review the foundation of patient safety by exploring the historical events that have shaped patient safety as it is known today. By examining the issues health care faces and the history of patient safety in America, they argue that a more cohesive and united effort is needed to have a meaningful effect on both quality of care and patient safety. The authors suggest several approaches to accelerate the patient safety movement, including seamless patient care across the continuum, use of evidence-based practice improved processes for efficiency while increasing patient satisfaction, and the development of integrated information systems. Understanding what the patient values is

intrinsic to providing high-quality care. The last four chapters in Part 3 are dedicated to the use of information technology and electronic health records—factors that are transforming the U.S. healthcare environment into a more technologically sophisticated field and possibly creating a positive impact on quality and safety. Improving patient safety and the quality of health care are tied to technology in three ways: 1. Without databases at the local, state, and national levels we could not get the information to determine whether there is a problem and the scope of the problem. 2. Technology can assist the delivery of care in a myriad of ways such as with bar-coded medication administration, the electronic health record, and medical devices, to name few. 3. Without technology it would be difficult to measure outcomes and the effectiveness of practice changes. In Chapter 14, Kroth provides an overview of health information technology (HIT), including its history, present state, and future challenges. This chapter provides the reader a foundation to build on for the application of information technology to improving quality and safety. Chapter 15 discusses the implications of adoption of the electronic health record (EHR). This trend is being driven by legislation—specifically, the passage of the American Recovery and Reinvestment Act of 2009 (ARRA), including the HITECH Act, which offers incentives to health organizations and providers to become meaningful users of EHRs. The eight components of an EHR are reviewed: (1) health information and data, (2) results management, (3) order entry management, (4) decision support, (5) electronic communication and connectivity, (6) patient support, (7) administrative processes, and (8) reporting and population health management (IOM, 2003). In Chapter 16, Hebda provides the reader with an overview of the concept of big data and its significance for health care and advanced practice nursing. The use of big datasets in the healthcare arena provides information to benchmark performance against other organizations, improve patient outcomes, reform healthcare delivery, and lead to significant cost savings. The author provides a comprehensive overview of reputable big data sources relevant to health care. Advanced practice nurses providing direct patient care need to

have knowledge of big data within the context of evidence-informed practice. Being able to discern patterns in big datasets will afford the advanced practice nurse the benefit of providing informed care with the possibility of influencing health policies. Consideration of the needs and preferences of the healthcare consumer must be appreciated. Chapter 17 provides a broad overview of the use of informatics and its importance in healthcare delivery. The author provides case studies and critical thinking exercises for the reader to apply and integrate content.

References Institute of Medicine. (1990). Medicare: A strategy for quality assurance. Washington, DC: National Academies Press. Institute of Medicine. (1999). To err is human: Building a safer health system. Washington, DC: National Academies Press. Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academies Press. Institute of Medicine. (2003). Key capabilities of an electronic health record system. Washington, DC: National Academies Press. Institute of Medicine. (2010). The future of nursing: Leading change, advancing health. Washington, DC: National Academies Press. James, J. T. (2013). A new, evidence-based estimate of patient harm associated with hospital care. Journal of Patient Safety, 9(3), 122–128.

© Zen Rial/Moment/Getty Images.

CHAPTER 12 Influencing Outcomes: Improving the Quality of Care Delivery Patti Rager Zuzelo

CHAPTER OBJECTIVES 1. Differentiate between nursing-sensitive quality indicators and HEDIS measures of care. 2. Identify the major partners in healthcare outcomes measurement, management, and quality improvement. 3. Discuss strategies to engage interprofessional team members in the development of an outcomes improvement project 4. Understand approaches to quality improvement (QI), such as plan-do-study-act, Six Sigma, and root cause analysis.



T

he contributions of all types of advanced nurses, including advanced practice registered nurses (APRNs), are under scrutiny within and outside the profession as healthcare delivery models change and systems react to uncertainties related to the Patient Protection and Affordable Care Act (Affordable Care Act [ACA]) and recent legislative efforts to modify its central and defining components and requirements. Interprofessional education (IPE) and new care models are increasingly emphasized as opportunities to improve communication among team members and, ultimately, to provide better and safer care that yields improved health outcomes. Conflict persists between organized medicine and advanced nurse providers while grassroots efforts intensify to develop partnerships that challenge status quo power structures in efforts

to support just cultures, safe care, and teams that rely on collaborative problem solving. Some advanced roles are uniquely challenged including the clinical nurse specialist (CNS) and clinical nurse leader (CNL) roles. The CNL role, an advanced generalist role originally conceived as an opportunity for people with college degrees interested in changing careers and entering nursing with a master’s degree in nursing, presents challenges to CNSs as the delineation between CNL and CNS job responsibilities and skill sets appears murky, overlapping, and poorly articulated in realworld practice environments. In states without CNS title protection, nurse practitioners (NPs) and other RNs with or without graduate degrees in nursing view CNS opportunities as appropriate career options while administrators, confronted with shortages of CNS applicants and confused by the unique skills each APRN role offers, hire an assortment of nurses into CNS positions. It is noteworthy that there has been some progress in CNS title protection as Pennsylvania has passed House Bill 1254, amending the Professional Nursing Law and providing for the definition of CNS (Pennsylvania General Assembly, 2009). Four states either do not recognize the CNS as an advanced practice nurse or have no available data regarding CNS recognition; three states do not provide the CNS with advanced practice authority; and 14 states require CNSs to have a collaborative agreement for practice. Twenty-eight states provide CNSs with full scope of practice and 17 states permit CNSs to independently prescribe (National Council of States Boards of Nursing [NCSBN], 2017a, 2017b). Variability across states related to dependent or independent practice, advanced practice status, and pharmaceutical/durable goods prescription authorities create additional challenges for CNSs and resulting barriers to people who would benefit from CNS expertise. Nurse practitioners are also experiencing regulatory challenges largely in response to pushback from the medical establishment related to competition and independent practice opportunities. The American Medical Association (AMA) recently continued its vigorous resistance to allowing independent practice for physician’s assistants and advanced practice nurses; seeking to protect a physician-led team model (AMA, 2017; American Urological Association [AUA], 2017). The AMA House of Delegates debated and voted on a number of resolutions including those

specific to oppose nonphysician practitioners’ independent practice efforts (BOX 12-1). The American Association of Nurse Practitioners (AANP) responded in vigorous fashion and offered a presidential rebuttal that included, “Every major study over the last 50 years has found care provided by nurse practitioners to be safe, effective and similar in outcome to care provided by physicians. There is no study that suggests that care provided in states with more restrictive licensure is safer than states with independent licensure” (AANP, 2017).

BOX 12-1 AMA House of Delegates Interim Meeting, November 14, 2017 “Several resolutions relating to state & federal policies addressing physician and care team workforce issues were considered. Resolutions 214 and 229 were amended. The first policy was in support of the AMA convening an in-person meeting of relevant physician stakeholders to initiate creation of a consistent national strategy purposed to (1) effectively oppose the continual, nationwide efforts to grant independent practice to non-physician practitioners; (2) effectively educate the public, legislators, regulators and healthcare administrators; and (3) effectively oppose state and national level legislative efforts aimed at inappropriate scope of practice expansion of non-physician healthcare practitioners. Resolution 229 directs the AMA to work with state and national associations to oppose legislation to create a Doctor of Medical Science license. Resolution 230 directs the AMA to adopt policy to oppose legislation or regulation that allows physician assistant independent practice.” As cited from AUA. (2017). AMA House of Delegates Interim Meeting Update: November 14, 2017. Policy and advocacy brief. Retrieved from https://community.auanet.org/blogs/policybrief/2017/11/14/ama-house-of-delegates-interim-meeting-update-november-14-2017

Nurse anesthetists (NAs) are currently able to practice independently, without anesthesiologist supervision, in 17 states (Santiago, 2017). The American Society of Anesthesiologists (ASA) argues for physician anesthesiologists to continue to lead anesthesia care and asserts that a 2014 Cochrane Collaboration literature review was unable to find science that supports the premise that NA care is equivalent to anesthesiologydriven care (ASA, 2014). The organization calls for more study on this issue and reiterates its position that anesthesia care delivery must be physician led (ASA, 2014). These scenarios serve as powerful examples of concerns that directly affect advanced nurses and the public. Each stakeholder group, whether driven by nurses or physicians, offers outcomes data to support its

regulatory and policy recommendations. Outcomes data is critical to the position’s defense and its success or persuasiveness. Other variables do influence the discussion, including financial ramifications, provider availability, and legislative/regulatory motivating factors. APRNs and other advanced nurses need to maintain a vigilant focus on the importance of health outcomes and the ways that nurses influence these outcomes. Rigorous approaches to research, including valid and reliable data collection and analysis, must be ensured so that policy decisions are based on reputable and true scientific findings. The proposed requirement by the American Association of Colleges of Nursing (AACN, 2004) of a doctorate in nursing practice (DNP) as the minimum level of entry into advanced nursing practice initially triggered polarized reactions that influenced organizational discussions and contributed to many task force charges, white papers, and planning activities throughout all aspects of the profession. Although the AACN position on the DNP, particularly the degree as a minimum entry requirement, has not been fully embraced by professional organizations that serve and represent APRNs, the number of nurses interested in practice doctorates has increased in a fashion that is consistent with recommendations proffered by The Future of Nursing Report (Institute of Medicine [IOM], 2010). Some APRN organizations have offered time frames for practice doctorate requirements; the National Association of Clinical Nurse Specialists (2017) calls for a DNP for entry into CNS practice by 2030 and those interested in the National Certification Exam offered by National Board for Certification and Recertification of Nurse Anesthetists will require a DNP or doctor of nurse anesthesia practice (DNAP) degree by 2025 in order to sit for the initial nurse anesthetist credentialing examination. Other professional groups, including the AANP (2013), the American College of Nurse-Midwives (ACNM, 2012), and the American Organization of Nurse Executives (AONE, 2007) are supportive of the DNP degree and recognize its value but do not endorse it as a mandatory minimum educational requirement for those nurses or roles represented by the particular organization. There is confusion surrounding the mandatory nature of the DNP and many advanced nurses and APRNs anecdotally share concerns and mistaken information about the necessity of the degree. A quick webbased search reveals many nursing-focused blogs with postings

concerning questions about whether or the DNP is mandatory for movement into more advanced roles. The DNP is not required for practice by any state board of nursing. There certainly are benefits to doctoral preparation and some students may find it cost-effective to move directly from a bachelor of science in nursing (BSN) degree to a DNP degree; however, others may prefer to complete a master’s of science in nursing degree and delay, avoid, or progress slowly through a DNP plan of study. The degree discussion is important because it illustrates the importance of and preference for robust outcomes data. Some organizations suggest that there are no outcomes data supporting the premise that DNP preparation improves nurse-provided care outcomes. DNP students do develop scholarly projects that may be referred to as doctoral, scholarly, or capstone projects. There are likely opportunities for this vast array of work to be examined for outcomes data that could be compiled and used to provide support for the impact of the degree and its curriculum on health or practice outcomes; however, perhaps these projects represent required work rather than reflecting post-degree efforts. The challenge lies in determining whether or not DNP-prepared nurses influence outcomes in ways that differ from those with MSN preparation. To date, this sort of comparison is not available and, perhaps, might not be the best approach. The critical point is that outcomes management and outcomes measurement are frequently raised as important to this education and practice discussion, just as outcomes are critically important to conversations about healthcare quality, including effectiveness and costs. In addition to the unique role challenges confronting the wide variety of advanced nurses, there are also shared challenges related to state and national regulatory and legislative initiatives, for example, the Centers for Medicare and Medicaid Services’ (CMS) lengthened list of noncovered hospital-acquired conditions (HACs) (CMS, 2015) and the institutional ramifications of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey results. Advanced nurses work to address differing aspects of these and other challenges and while doing so, are challenged to consider, “What differences in care processes and outcomes are amenable to improvement through the individual and collective efforts of nurses, particularly nurses with

advanced skills and education?” Nurses with advanced preparation, including and not limited to APRNs, need to collect, analyze, and share outcomes data advancing the premise that nurses make unique contributions to positive patient outcomes and that these outcomes are measurable, meaningful, and important. This chapter introduces some important ideas about outcomes, discusses trends, describes resources and tools, identifies challenges, and offers suggestions.

What Is an Outcome? An outcome is the end result of particular healthcare practices and interventions. The paramount need for outcomes research was made obvious in the early 1980s when studies confirmed that surgical procedures and medical practices varied in frequency and type based upon geography rather than disease rates. In addition, there was no established way to compare the results of differing treatment approaches (Lorincz et.al, 2011.). These early discussions focused on patient outcomes related to prescribed medical therapies and interventions and stimulated outcomes discussions related to nursing practice as well as other types of clinical services. Kleinpell and Gawlinski (2005) define outcomes as a “measure of healthcare quality, and often, effectiveness is measured by the outcomes that are produced” (p. 43). Nursing-sensitive outcomes are influenced by nurses’ care practices. Nursing-sensitive patient outcomes (NSPOs) are best understood as “patient outcomes that are amenable to nursing intervention” (Given & Sherwood, 2005, p. 773). There is a need for increased research on the leadership outcomes of advanced practitioners given that the current state of evaluation research focuses on a limited range of patient, care and performance-related outcomes (Elliott, Begley, Kleinpell, & Higgins, 2014). Nurses in advanced roles of all sorts should consider opportunities to measure their influence on outcomes that are meaningful whether specific to patient care or not. Certainly indirect care responsibilities are integral to high-quality healthcare delivery systems and a keen eye on goals and measures is important, particularly given scarce resources. Nurses do not influence all patient outcomes, but many outcomes are responsive to nursing interventions. Outcomes that are influenced by nurses in collaboration with other healthcare providers are important, but these particular outcomes, although affected by nurses, do not reflect nursing’s unique contributions to healthcare structures and processes. Identifying the unique contributions of nurses, including those directly attributable to nurses’ influence, is key to the future of nursing practice. It is imperative that advanced nurses collect and analyze carefully

considered datasets that quantify the impact that nurses have on health outcomes. Nurses recognizing and marketing the differences they make in direct care patient outcomes and indirect care outcomes is critical to improving the healthcare system. Indirect care outcomes might be considered as outcomes that relate to policy efforts, administrative processes and policies, leadership responsibilities, educational endeavors, informatics, and the influence on care outcomes that are affected by changes in information management systems and other nonpatient care activities. If advanced nurses are able to discern which end results of patient care are directly affected by nursing interventions, then they will be able to determine better ways to intervene and thus contribute to improving thehealthcare system and patient outcomes. This linkage between nursing care and NSPOs provides justification for the current emphasis on evidence-based nursing (EBN). Although there is ambiguity in the definition of EBN and continued discussion as to what EBN should and should not be, the synergy is clear between outcomes and evidence. Evidence in all its forms, qualitative and quantitative, should inform nursing interventions (Zuzelo, 2006) and should assist in the measurement of nurses’ effect on outcomes as well as on improvements in the structures and processes of healthcare systems. NSPOs should be evaluated and future interventions should be revised or maintained depending upon the outcomes. Quality of care is determined by outcomes (FIGURE 12-1). Measuring advanced nurses’ influence on outcomes and quality of care is important to marketing advanced nursing practice, justifying the fixed costs associated with competitive compensation, and securing the full-time equivalents necessary for hiring nurses with advanced preparation and skills.

FIGURE 12-1 The feedback loop: Evidence-based practice, outcomes management, and quality.

Outcomes Measures: Key Players and Driving Forces Advanced nurses must become well informed about the National Database of Nursing Quality Indicators (NDNQI), a program developed by the American Nurses Association (ANA) and managed by the University of Kansas’s School of Nursing. The NDNQI was acquired by Press Ganey in 2014 (Press Ganey, 2015). The NDNQI is a national database that collects data at the nursing unit level. Indicators are regularly added and new projects are developed and implemented regularly. The database is dynamic and offers a variety of reports that enable institutions to compare their outcomes to those of other similar institutions across the country (Montalvo, 2007). Over 2,000 hospitals nationwide use the NDNQI program to track and improve nursingsensitive quality measures (Press Ganey, 2015). Press Ganey provides a searchable resource library that includes many resources, including reports, articles, webinars, case studies, videos, and other multimedia informational sources that are available immediately or via download after receipt of basic demographic information (Press Ganey, 2017). The best way to appreciate the importance of the NDNQI is to understand its history (Montalvo, 2007). The ANA launched the Safety and Quality Initiative in 1994 for the purpose of investigating and describing the empirical linkages between nursing care and patient outcomes. This project was early in the outcomes measurement movement and served to guide and support discussions about the connection between nurse staffing patterns and nurse preparation to patient care outcomes. Other organizations had called for outcomes measurement as early as the 1970s, including the Joint Commission, the Visiting Nurse Association (VNA) of Omaha, and the National League for Nursing (NLN). The ANA’s initiative was the first report card–style report specific to acute care hospital nursing (ANA, 1995). The outcome of the Safety and Quality Initiative was a report entitled The Nursing Care Report Card for Acute Care (ANA, 1995). This report card identified 21 measures of hospital performance with a conceptual or

quantifiable link to nursing services in acute care. The report card also established 10 nursing quality indicators that had a direct relationship to nursing services within acute care settings. Each indicator was operationally defined in careful terms to promote consistency in data collection and analysis. It is worthwhile to go back to this original ANA report and review the complexity and detail of the measures used to establish reliable and valid indicators. One of the most reliable predictors of outcomes indicators was the percentage of RNs of the total staff (Moore, Lynn, McMillen, & Evans, 1999). Staff mix, nurse education, and the number of available RNs continue to be important indicators with a direct effect on patient mortality in the hospital setting (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002; Aiken et al., 2011). Hours per patient day (HPPD) is another important metric used to compare staffing levels within and between healthcare organizations; however, there is mounting criticism concerning the adequacy of HPPD related to appropriate nurse staffing levels (Kirby, 2015). There is a need to consider staffing and skill mix within the context of achieved outcomes. Kirby asserts that it is important to quantify the savings associated with positive outcomes and to determine the staffing numbers and patterns that contribute to these outcomes. Advanced nurses need to consider this point as it directly relates to maximizing the utility of NDNQI data. Appreciating the import of the NDNQI requires understanding about the quality indicators and its potential contributions to outcomes research and comparative effectiveness research. Moore et al. (1999) cautioned that findings of the ANA report card, as well as summative evaluations compiled by other outcomes studies, should be considered within the framework of several contextual concerns. First, Moore et al. noted that there was no clear agreement about the indicators that should have been included in a report card. Second, the availability, reliability, and validity of these indicators had not always been demonstrated. Third, once indicators had been consensually selected, there was no consensus about how long it will take to have valid and reliable measures for the indicators. Fourth, many databases contained compromised data from which report cards are generated; and fifth, report card data may have been meaningful to one stakeholder group to the exclusion of others that are also important (Moore et al., 1999). Similar concerns were identified by Burston,

Chaboyer, and Gillespie (2013) following a review and synthesis of the published literature using an explicit methodology that included a rigorous search strategy. Despite these early and ongoing concerns, the ANA report card is acknowledged as an important and significant beginning to developing formalized, nursing-specific outcomes measurement. This foundational effort continues to inform quality determinations specific to nursing care delivery. The National Database of Nursing Quality Indicators evolved from the Nursing Care Report Card for Acute Care. In 1997, the ANA issued a request for development and maintenance of the national database. The University of Kansas’s School of Nursing housed this initiative (Owens & Koch, 2015). For the next 3 years, a series of ANA-funded pilot studies established the selected indicators and developed operational definitions and data collection methodologies for each indicator. In 1998, the NDNQI began accepting data from participating hospitals and providing feebased reports. The ANA identified 10 nursing-sensitive quality indicators for acute care; each had a recommended definition (BOX 12-2).

BOX 12-2 Nursing-Sensitive Quality Indicators for Acute Care Settings 1. Skill mix caring for patients; registered nurses, licensed practical/vocational nurses, and unlicensed staff 2. Total nursing care hours provided per patient day 3. Pressure ulcer prevalence 4. Patient falls 5. Patient falls with injury 6. Patient satisfaction with pain management 7. Patient satisfaction with educational information 8. Patient satisfaction with overall care 9. Patient satisfaction with nursing care 10. Nosocomial infection rate (central line catheter associated blood stream infection) 11. Registered nurse satisfaction Data from Owens and Koch (2015), with original indicators italicized Montalvo, 2007

The ANA’s organizational intent was to provide opportunities for hospitals to collect and report on indicators to make clear the difference that RNs make in the provision of safe, high-quality patient care. The NDNQI is dynamic and collaborative, working to further define quality

improvement indicators with the National Quality Forum (NQF), a membership-based not-for-profit, nonpartisan organization that strives to improve healthcare (NQF, 2017a), as well as collaborating with the Joint Commission (Owens & Koch, 2015). The NDNQI efforts have broadened to include various patient populations, hospital and unit types, institutional bed numbers, and structure indicators related to RN characteristics. Quality indicators (N = 19) continue to reflect structure, process, and outcomes of nursing care (Owens & Koch, 2015). The NDNQI is also integral to Magnet nursing data requirements (Press Ganey, n.d.) Many advanced nurses practice in acute care institutions that are interested in pursuing Magnet status through the American Nurses Credentialing Center (ANCC). To seek accreditation, healthcare agencies’ leadership may elect to participate in the NDNQI to assist with data collection and quality tracking necessary for the Magnet Recognition Program. Magnet certification achievement recognizes and celebrates exceptional nursing departments. The NDNQI reports provide one view of quality evaluation that is nursing specific and offer opportunities for benchmarking or comparisons. Additional information related to joining the NDNQI may be accessed via Press Ganey’s (2017) Nursing Excellence Solution. Measuring outcomes is important but should not be performed independent of outcomes management. Unless measurement is conducted and results are managed as components of quality improvement, problems arise related to data collection activities that are not valued as meaningful and meaning making. This potential problem is similar to the issues that arise when research studies are conducted but findings are not used to inform and improve practice. Advanced nurses should identify and measure outcomes that are important to their particular institution or type of clinical practice and then manage these outcomes to improve quality using available evidence. When nurses in advanced roles consider Magnet accreditation processes, the NDNQI and its historical roots in the ANA’s Nursing Care Report Card for Acute Care, and outcomes mandates from public and private foundations, organizations, and accreditors, linkages between quality improvement, evidence-based practice, and outcomes become evident and fairly simple to explain to nursing colleagues who may not have an understanding of the connecting relationships (FIGURE 12-2).

FIGURE 12-2 Nursing-sensitive quality loop.

Leaders and Partners in Outcomes Measurement and Management There are a number of organizations focusing efforts on improving healthcare outcomes and quality, in addition to the ANA’s landmark efforts and the subsequent efforts of Press Ganey partnered with the ANA. Some organizations have a multidisciplinary focus, whereas others predominantly serve a particular stakeholder group. Overall, there are many stakeholders with significant vested interest in the outcomes measurement and management movement (FIGURE 12-3).

FIGURE 12-3 Stakeholders in healthcare outcomes.

Corporations and smaller businesses have vital interest in outcomes measures as a data source to facilitate decision making about which plans and services provide employees with the best care (as measured by outcomes) in the most cost-effective manner (a fiscal outcome). For

example, the Leapfrog Group (n.d.) describes itself as a “nonprofit watchdog organization that serves as a voice for health care purchasers, using their collective influence to foster positive change in U.S. health care. Leapfrog is the nation’s premier advocate of hospital transparency —collecting, analyzing and disseminating hospital data to inform valuebased purchasing.” This organization has had important influence on data-driven outcomes management and measurement, particularly related to choosing hospitals for care based on comparison data. The Leapfrog Group is involved in other initiatives that may not appear to be outcomes-centric at first glance but are, in fact, very related to end results or the bottom line of safe care delivery. For example, providing access to the CANDOR Toolkit, developed by the Agency for Healthcare Research and Quality (2017) to assist hospital providers and leaders with honest responses to adverse events, including honest communication and effective resolution processes. Leapfrog’s efforts particularly focus on outcomes related to value and safety, including never events. Advanced nurses will find helpful its web-based resources and tools but should keep in mind that much of the focus is on risk, adverse events, and value-based purchasing. Although this is critically important summarized data, it does not provide information about potential savings and benefits associated with positive outcomes (Kirby, 2015), a more difficult metric to measure than frequencies of harmful events or costs. Healthcare consumers, including individual or organizational purchasers, benefit from the increasing access to outcomes-driven data necessary to make informed decisions as to where to seek general or specialty care services. The Joint Commission’s Quality Check and Quality Reports provide consumers with access to information about how well accredited and certified organizations perform and, when appropriate, how this performance stacks up against National Quality Improvement Goals (Joint Commission, 2016a). As an example, potential “customers” can ascertain the percentage of patients with a suspected cardiac event who receive aspirin therapy upon arrival to local emergency departments (ED) and make informed decisions as to which provides better care, based upon this criterion. The Quality Reports and Quality Check build upon the data submitted to the Joint Commission database, ORYX, from healthcare organizations.

Pioneers in Quality is a Joint Commission program that focuses on offering assistance to hospitals as they work toward adopting electronic clinical quality measures (Joint Commission, 2017a). Available supports include educational programs, electronic resources, advisory councils, speaker’s bureau opportunities, and other resources. It is also a recognition program that acknowledges three hospital contribution categories; expert, solution, and data (Joint Commission, 2017b). Another resource for helping consumers and employers choose between competing health maintenance organization (HMO) and preferred provider organization (PPO) plans is the Health Plan Employer Data and Information Set (HEDIS). HEDIS is a program of the National Committee for Quality Assurance (NCQA) that facilitates decision making based upon value and cost of service. HEDIS consists of standardized performance measures that are related to many significant public health issues. NCQA provides a State of Health Care Quality Report that offers consumers access to viewing HEDIS measures online and also provides archived reports. This annual report focuses on major quality issues by providing data-based performance trends for each measure (TABLE 12-1). More than 90% of health plans in America use HEDIS to measure performance outcomes related to care and service (NCQA, 2019) and these data may then be used by stakeholders to select the best health plan for their particular needs. Data are audited to protect validity (NCQA, 2019). HEDIS also includes Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey results to provide measures of members’ satisfaction with plans’ service provision, including claims processing, customer service, and responsiveness (NCQA, 2019). TABLE 12-1 Selected HEDIS Measures of Care HEDIS Measures of Care 1. Overuse and Appropriateness

a. b. c.

2. Screening, Prevention,

a.

Avoidance of antibiotic treatment in adults with acute bronchitis Use of imaging studies for low back pain Nonrecommended PSA (prostate-specific antigen) screening in older men Adult BMI (body mass index) screening

and Wellness

3. Chronic Condition Management

b. c. d.

Colorectal cancer screening Flu vaccinations Diabetes and cardiovascular disease screening and monitoring for people with schizophrenia and bipolar disorder

a.

Use of spirometry testing in the assessment and diagnosis of COPD (chronic obstructive pulmonary disease) Controlling high blood pressure Statin therapy for patients with cardiovascular disease and diabetes Antidepressant medication management Annual monitoring for patients on persistent medications

b. c. d. e.

4. Measures Targeted Toward Children and Adolescents

a. b. c.

5. Measures Targeted Toward Older Adults

a. b.

Lead screening in children Appropriate treatment for children with upper respiratory infection Metabolic monitoring for children and adolescents on antipsychotics

c.

Fall risk management Osteoporosis testing and management in older women Medication management in the elderly

6. Measures of Value and Utilization

a.

Emergency department utilization

7. Consumer and Patient Engagement and Experience

a. b. c. d. e. f.

About CAHPS Rating of health plan Rating of health care How well doctors communicate Rating of specialist Customer service

Data from from National Committee for Quality Assurance. (2017). State of Health Care Quality Report. Retrieved from http://www.ncqa.org/report-cards/health-plans/state-of-health-carequality/2017-table-of-contents

Description Web-accessible HEDIS measures of care are available via NCQA’s annually provided The State of Health Care Quality Report. Advanced nurses will be interested in HEDIS measures of care that pertain to their

particular area of direct practice or to those areas in which they have influence based on education or administrative responsibilities. Each measure is linked to its definition and an explanation as to why the measure is important and relevant, based on evidence. References are provided in a bottom-line format (NCQA, 2016). Summary data are organized by year and compared across commercial insurance plans (HMO and PPO), Medicaid (HMO), and Medicare (HMO and PPO). Other stakeholders in healthcare outcomes include practitioners and the public. Practitioners are affected by outcomes-driven data in a variety of ways. They need to compile and submit data, and these data collection processes require time and effort. Practitioners’ records are available for public review: specifically, malpractice cases and complaints through the National Practitioner Data Bank (NPDB) (n.d.-a), and indirectly, through publicly available outcomes data related to the practitioners’ employing institution or the National Provider Identifier (NPI) Database (NPIdb) from the NPI Registry (2017). The NPDB (n.d.-a), housed within the U.S. Department of Health and Human Services, is a federal repository of reports that are accessible only to registered entities (FIGURE 12-4). This database has been in existence since 1986 with the signing of the Health Care Quality Improvement Act (HCQIA) by President Reagan (NPDB, n.d.-b). From 1990 to 1998, the NPDB was queried more than 15 million times by state licensing boards, hospitals, and other healthcare entities. The NPDB had originally worked separately from the Healthcare Integrity and Protection Data Bank (HIPDB) that had been authorized in 1996 by the Health Insurance Portability and Accountability Act of 1996 as an effort to combat fraud and abuse in health insurance and delivery. Initially the HIPDB and NPDB operations were managed as separate entities, but by 2013, the two systems merged into one database (NPDB, n.d.-b). The general public does not have right of access to NPDB reports; however, many healthcare organizations, including state licensing and certification authorities, are required to report, query, or both to the NCPD. The available information is a form of outcomes data that is provided to protect the public and its healthcare system from practitioners who would, perhaps, otherwise move state to state without offering full disclosure of malpractice or other previously damaging performance (Figure 12-4).

FIGURE 12-4 What is the National Practitioner Data Bank? Reproduced from National Practitioner Data Bank. (n.d.-c). What is the NPDB?. Retrieved from https://www.npdb.hrsa.gov/resources/whatIsTheNPDB.jsp

Description Some established organizations and foundations are directly partnered with nursing whereas others do not have a formal relationship with nursing organizations but do provide a variety of supports, in the form of electronic resources, conferences, database information, benchmarking, public education initiatives, or printed materials. Advanced nurses need to become familiar with some of the critical contributors to the outcomes movement (TABLE 12-2), particularly because these organizations often offer a variety of materials that are useful to nurses responsible for evaluating clinically based patient care operations and for identifying opportunities to positively influence patient outcomes. Many times advanced nurses are directed to investigate and solve specific clinical issues. These directives may be driven by complaints, benchmarking analyses that reveal room for improvement, new programs, or other types of critical incidents. Other times, advanced nurses identify problems and opportunities that are apparent to them because of their expertise and experiences. TABLE 12-2 Select Partners in Healthcare Outcomes Measurement, Management, and Quality Improvement Partner

Website

Description

National Quality Forum

www.qualityforum.org/Home.aspx

Not-for-profit, nonpartisan, membership-based organization working to catalyze healthcare improvements (NQF, 2017a). Excellent resource for uniform, evidence-based measures necessary for healthcare quality measurement. NQF does not create

measures. It uses an endorsement process that involves diverse public- and privatesector stakeholders to support quality improvement. A Consensus Standards Approval Committee (CSAC) considers all measures recommended for NQF endorsement (NQF, 2017b). National Patient Safety Foundation (NPSF)

www.npsf.org www.ihi.org/Topics/PatientSafety/Pages/default.aspx

The NPSF partnered with the Institute for Healthcare Improvement (IHI) in May 2017 to form a new entity focused on patient safety and improved outcomes (IHI, 2017a).

Institute for Healthcare Improvement (IHI)

www.ihi.org/resources/Pages/default.aspx

Provides extensive resources for quality improvement. Website offers white papers, multimedia content, instructional materials, and popular tools that provide measurement guidance (IHI, 2017b).

PatientCentered Outcomes Research (PCOR) at the Agency for Healthcare Research and Quality (AHRQ)

www.ahrq.gov/pcor/index.html

The AHRQ invests in disseminating and supporting implementation of PCOR findings into practice using the PCOR Cycle that involves delivering health care, identifying evidence gaps, researching

answers, and disseminating evidence (AHRQ, 2016). The AHRQ contributes to this work by creating evidence syntheses from PCOR findings and designing tools and education that are understandable. The AHRQ distributes this evidence and supports those entities and professionals who use the evidence for practice improvement (AHRQ, 2016). American Society for Quality (ASQ)

https://asq.org

The ASQ works to support a global knowledge network to improve quality improvement. It offers 18 certifications and provides many quality-related learning tools and products. The ASQ has individual and organizational members (ASQ, 2017a).

Description

Take Advantage of Available Resources Advanced nurses should investigate available resources for quality improvement before planning interventions or before putting effort into homegrown resources. It is not uncommon for nurses to brainstorm and resolve practice issues without first reviewing tools, reports, and guidance documents that are established as valid, reliable, and

accessible. Many organizations have readily available, relevant, free materials that are very user friendly and well organized. Using established resources can also ensure that networking opportunities are more relevant For example, central line infection is a significant clinical concern across a variety of care settings but particularly in high-acuity nursing practice. Preventing central line-associated bloodstream infection (CLABI) was one of the six outcomes initiatives of the Institute for Healthcare Improvement (IHI) established as part of the early 100,000 Lives Campaign and continued as a priority in the 5 Million Lives Campaign (IHI, 2019). A search of the IHI’s website reveals a free, downloadable How-to Guide: Prevent Central Line-Associated Bloodstream Infection (IHI, 2012) that includes evidence-based care components of the IHI Central Line Bundle. A bundle is a group of evidence-based interventions that, when used concurrently, results in better outcomes than when followed individually. This guide provides clear instructions, defined outcomes, and supporting data for interventions that promote teamwork and reduce infection rates. An advanced nurse confronted with a need to prevent or reduce the prevalence of central line infections would be wise to begin by reviewing the IHI resources, available for public use, before attempting to develop a policy, procedure, or program based upon a literature review. As with most IHI resources, free registration is necessary to access materials.

Establishing an Outcomes Project of Interest Advanced nurses may have difficulty focusing on any one particular project that pertains to an outcome of interest. At times, nurses feel pulled in multiple directions and may be tackling multiple outcomes simultaneously thereby contributing to burnout. Nurses in many types of advanced roles, including practice roles and indirect care roles, often have some responsibility for engaging staff in meaningful work designed to enhance care quality or specific outcomes. Working on projects with staff and colleagues is an ideal way for advanced nurses to accomplish necessary quality improvements while also building colleagues’ expertise and supporting interprofessional team relationships. Identifying and selecting one outcome of interest may be the most difficult aspect of the

improvement project.

Search for Gaps Between the Actual Versus the Desired State of Practice There are a number of ways to identify a pertinent outcomes measure that may be amenable to nursing practice changes and that will positively affect the quality of care delivery. It is important to solicit input from the nursing staff members if their participation is needed for project success, including data collection and implementing practice changes. Advanced nurses should consider available outcomes measurement data, including benchmarking results from the NDNQI, the Joint Commission, HCAHPS, and other high-stakes reports, as potential opportunities for gap analyses and subsequent improvement efforts. There may be opportunities for outcomes improvement revealed through careful review of patient, physician, or staff complaints. Nurses often recognize systems problems that negatively affect outcomes, and these staff worries may provide insight into possible topics for project development. Incident reports offer opportunities for measuring and managing significant outcomes including but not limited to falls, medication errors, needle stick injuries, workplace violence, communication processes, transfusion errors, or compromised patient safety. Many times, staff have ideas for projects but need encouragement and support before they will attempt to address the issue in an organized, formal process (BOX 12-3).

BOX 12-3 Solicitation for Staff Input on Projects Wanted: Unit-Based Projects Have a great idea for a unit-based problem? Thinking about a better way of doing things? Recognize a problem just waiting to be solved or an outcome that you know requires improvement? Interested in participating in a unit-based workshop on literature searches? I am looking for RNs who are interested in developing and initiating unit-based projects related to clinical practice. Leadership and enthusiasm are “must-haves!” Technical skills and research expertise are not required.

Talk with your colleagues. Consider developing a simple project that might be of interest to other nurses or other interprofessional team members. Think about the possibility of presenting your work at a local, regional, or national conference as either a poster or podium presentation. I will help you throughout the process. Guarantee it! If you have an idea and are willing to assist in guiding a project, please contact me via email: jones @hospital.edu. I’d enjoy sitting down with you and chatting over a cup of coffee. The coffee is my treat!

Another strategy that may be useful when searching for outcomes improvement projects is a Waste Walk (Lean Enterprise Institute, 2012).

This approach involves a planned visit of team members who begin with a huddle to review the purpose of the activity and to ensure that all team members are consistent in their understanding and approach. The team members then make physical walking rounds on the units of interest and observe for occasions of wastefulness that, if removed, would benefit the institution. This may be a useful preliminary exercise for those interested in involving staff in projects that improve efficiencies by eliminating waste and that may serve as catalyst projects for encouraging staff on a trajectory of process improvement projects. These sorts of activities are concrete, practical, have real-world benefits, and may facilitate staff engagement in quality improvement initiatives.

Collaboratively Select a Project of Shared Interest Once gaps in a system of care provision have been identified, it is often productive to elicit staff input via group discussion. Staff meetings, informal chats, and electronic discussions are good methods for soliciting input and garnering ideas. It may be useful to collectively develop a list of outcomes that staff believe may be better managed. This list should be prioritized and reduced to a reasonable number of projects. The nurse leader should facilitate the prioritization process by using some type of sensible procedure including casting votes, assigning numeric values to projects and rank ordering based upon collective scores, Q-sort methodology, or Delphi technique to reduce the number of projects and to include only the most valued. The decision-making group may also find that the priorities are clearly evident after discussion. Advanced nurses may want to consider competitions or contests to elicit quality improvement ideas or evidence-based practice projects from staff (EXEMPLAR 12-1). Involving nurses in the identification of outcomes projects can accomplish several goals. Active involvement in project selection facilitates staff engagement, and this engagement improves participation. Outcomes projects provide opportunities to teach staff about outcomes management, measurement, and resources. For staff who have been practicing for more than 10 years and who have not been involved in formal academic programs, an outcomes project may be the first exposure to the outcomes movement. Advanced nurses should keep

in mind that outcomes projects do not have to be complex; rather, simple and elegant design is ideal for a first-time venture. Keeping things simple provides opportunities for relatively fast successes that can encourage staff enthusiasm and hardwire a feeling of confidence and empowerment.

EXEMPLAR 12-1 Competitions as Opportunities to Trigger EvidenceBased Outcomes Projects One example of a mechanism to elicit evidence-based outcomes projects from nursing professionals is the Unearthing the Evidence contest that was regularly sponsored by a large, urban healthcare network’s department of nursing (FIGURE 12-5). The contest had its origins in a research utilization competition that had been known as the Sacred Cow competition, designed to encourage nurses to submit fully developed research projects proposing simple but elegant research questions that had relevance to nursing practice within the organization. The organization’s nurse researcher was available to support applicants in crafting their applications, if requested. The selected project was funded with a small grants award. The winning nurse, often a novice first-time researcher, was required to present the study findings during a subsequent nursing grand rounds poster session.

FIGURE 12-5 Unearthing the Evidence competition announcement. Description

After a number of years of dwindling submissions, the Sacred Cow competition was stopped. The Unearthing the Evidence competition was created to encourage nurses to consider nursing and medical practices and offer suggestions for improvement based upon available evidence. The required format was narrative but also succinct with less of an academic structure. One winning submission addressed bladder catheterization practices and offered recommendations for change based upon a compelling need to reduce urinary tract infections. This project stimulated interest and was well received. Some recommendations were implemented by nursing in partnership with physicians. The following year’s winning project explored the frequency and type of saline lock use on a telemetry care unit in an effort to preliminarily explore the possibility of changing unit policy. This project served as the catalyst for a staff nurse to begin his journey as a beginning researcher and author (Szablewski, Zuzelo, Morales, & Thomas, 2009). This exemplar illustrates the positive effect that these sorts of competitions can have on nurses’ professional development, providing that the necessary supports are made available.

Another important opportunity inherent in staff-based projects is the likely possibility of interprofessional collaboration between nurses, physicians, and other professional counterparts. Interprofessional education (IPE) and practice are essential to team building and, ultimately, to improving the collaborative communication and practice patterns that are necessary for positive patient outcomes (Josiah Macy Jr. Foundation, 2015; Nester, 2016). Interprofessional projects help to break down communication barriers. As various types of professionals work together, they get to know each other as colleagues and learn to appreciate the differing perspectives and areas of expertise that team members contribute to practice improvements. There are many resources available to advanced nurses who are interested in joining the well-established IPE movement in health care (Interprofessional Education Collaborative [IPEC], 2017; National League for Nursing, 2018). The Josiah Macy Jr. Foundation (2015) is an excellent place to begin self-directed IPE learning and it is likely that opportunities and ideas will come to mind as advanced nurses explore project exemplars, writings, links, and opportunities related to IPE and its goal of meeting the IHI Triple Aim: (1) improving the patient experience of care, including quality and satisfaction; (2) improving populations’ health; and (3) reducing per capita healthcare costs (IHI, 2018).

Crafting the Outcomes Project As mentioned, advanced nurses may become involved in outcomes

management through interest in improving a clinical outcome or through assignation by the chief nurse executive or other administrator. For example, if urinary tract infection (UTIs) rates increase within the surgical service line, the advanced nurse may be asked to participate in a multidisciplinary ad hoc committee exploring strategies for reducing nosocomial UTI rates, or assigned responsibility to lead a nursing project exploring evidence-based practice changes that might improve this concerning UTI outcome measure. The current emphasis on outcomes management and measures fits nicely with the evidence-based practice (EBP) movement as the interventions that may be used to improve outcomes should be consistent with or based upon current EBP recommendations. The Centers for Medicare and Medicaid Services’ (CMS) policy to ensure safe, high-quality care by designating select hospital-acquired conditions as nonreimbursed expenses has also triggered the need for outcomes management and quality improvement efforts (CMS, 2015). In 2008, the CMS designated 10 HAC categories as compared to 14 categories in 2017, excluding International Classifications of DiseasesRevision 10 (ICD-10) subdiagnoses. The most recent list is 13 pages in length (CMS, 2017a) (TABLE 12-3). TABLE 12-3 Nonreimbursed Hospital-Acquired Condition Categories (Secondary Diagnoses Not Included) Organized by Year 2008 HAC Categories

2017 HAC Categories

1. Foreign object retained after surgery

1. Foreign object retained after surgery

2. Air embolism

2. Air embolism

3. Blood incompatibility

3. Blood incompatibility

4. Stage III and IV pressure ulcers

4. Stage III and IV pressure ulcers

5. Falls and trauma

5. Falls and trauma

6. Manifestations of poor glycemic control

6. Catheter-associated urinary tract infection

Catheter-associated urinary tract 7. infection

7. Vascular catheter-associated infection

8. Vascular catheter-associated infection

8. Surgical site infection—mediastinitis after coronary artery bypass graft procedures

9. Surgical site infection following coronary artery bypass graft, bariatric surgery, orthopedic procedures (spine, neck, shoulder, elbow)

9. Manifestations of poor glycemic control

10. Deep vein thrombosis (DVT)/pulmonary embolism (PE) following total knee replacement; hip replacement

10. Deep vein thrombosis/pulmonary embolism with total knee or hip replacement procedures



11. Surgical site infection—bariatric surgery procedures



12. Surgical site infection—certain orthopedic procures of spine, shoulder, and elbow procedures



13. Surgical site infection following cardiac implantable electronic device procedures



14. Iatrogenic pneumothorax with venous catheterization procedures

Data from CMS (2008, 2017a).

Description It is worth noting that there is much administrative consternation about publicly reported outcomes as well as adverse patient outcomes that reflect poor quality. HACs have serious financial ramifications and quality of care implications. The worrisome HACs, important indicators collected through the NDNQI, and measures from other established quality audits offer advanced nurses meaningful opportunities to show their stuff and demonstrate their impact on improving quality metrics. Nurses should design useful continuous quality improvement projects using established methodologies and datasets to change processes that affect patients at the point of care. Seize the opportunities offered by HACs and nurse-

sensitive indicators!

Selecting Indicators That Measure Improvement There are major limitations in the management and measurement of nursing outcomes (Jones, 2016). Lack of solid data that measures nursing processes and patient outcomes hinders nurses in their efforts to improve quality of care. Jones’s (2016) discussion of outcomes measures in nursing provides an excellent overview of historical and contemporary challenges in outcomes measurement. Nursing has a social contract with the public that requires the nursing profession to self-monitor so as to assure the public that it is providing quality performance (Jones, 2016). To this end, advanced nurses need to have a good understanding of quality measures and systems of management. Many advanced nurses are likely new to this work and may be hesitant about critiquing and selecting instruments for outcomes measurement. Seeking expert consultation is always a good idea and continuing to build personal expertise is certainly an option, particularly through doctoral studies. When advanced nurses design a project, including the data collection plan, they need to consider the validity, reliability, and feasibility associated with the instruments that will be used in outcomes measurement. It is often better to use a preexisting well-established instrument or a portion of an instrument rather than creating a new one. Creating a valid and reliable instrument requires careful processes that often involve quantitative methodologies, expert input, and pilot testing. Too often, surveys, Likert scales, and other tools and instruments are casually developed by nurses in an effort to quantify a measure of interest. These sorts of tools may or may not provide valid and reliable measures. As a result, persistent skepticism will likely result when the advanced nurse claims that a quality improvement initiative was successful as evidenced by analysis of data collected via an untested tool. If no instrument is available that examines the outcome or process of interest and constructing a tool is the only option, advanced nurses should make certain to establish content validity, interrater/observer reliability, test-retest, and internal consistency. Establishing the reliability of the tool and its usability are important activities. It may be necessary to

confer with a nurse scientist or other colleague that has established instrumentation expertise. Choosing to use a tool that does not have established validity and reliability undermines the believability and worth of the entire outcomes project. At the start of project planning, advanced nurses should establish a measurement plan. When working with colleagues or interprofessional teams, make certain to solicit input from those who have expertise in the measures of interest and familiarity with associated processes. In consultation with the project improvement team, achieve consensus on the following key items: (1) name of the measure of interest, (2) type of measure, (3) rationale for the selected measure, (4) operational definition to ensure consistency, (5) methodology including data collection and sampling plan, (6) data display, (7) evaluation of data availability, (8) baseline data opportunity and acquisition, (9) target or end goal, and (10) data sources (Health Quality Ontario [HQO], 2013). Consider several measures and varying types of types so as to capture a complete picture (HQO, 2013). Outcome measures address end results and they evaluate system performance. Process measures relate to the steps or inputs that lead to the systems outcomes. Detailing steps in the process of interest can be challenging and it is useful to engage the people who actually participate in the various process components to ensure accurate and comprehensive understanding of the inputs. It can be quite helpful to put effort into designing a flowchart that accurately depicts the process of interest. Make certain to include the hands-on experts in the construction of this detailed flow sheet, as those participating in the work process are the ones who best know what is actually done versus what might be described in policies or procedures. Balancing measures examine unintended effects of the newly applied changes. In other words, advanced nurses need to determine whether a change to one input creates unanticipated effects downstream. Once an appropriate measure and/or instrument has been selected, keep in mind that data collection activities do have associated expenses related to personnel, data storage, and printing, purchasing, or other types of costs. The budgetary impact of data collection and outcomes tracking should be considered before beginning the project. In addition, data collection requires proactive planning. Advanced nurses need to

determine who will collect the data and what processes will be followed. Ensuring a consistent, reliable process of data collection, particularly if there is more than one data collector, is essential. It is also important to decide how missing data will be managed during the project. Keep in mind that data are worthless if clinicians believe they are inaccurate in their measurement, collection, or analyses. To protect data integrity, HQO (2013) offers a few suggestions including the use of a flowchart to graphically depict the data collection process, verifying that data entry processes have integrity, considering data analysis prior to actual data collection, and reporting on the data in a regular and timely fashion. Data reporting may include quarterly reports for staff review, updates during staff meetings, signage, or electronic messages.

Systematically Examining and Managing Outcomes to Improve Quality Quality improvement is an important component of nursing practice. This indirect care responsibility is a critical skill that advanced nurses need to develop so that they are able to adeptly utilize a systems approach to QI that correctly ascertains the effects of practice changes on outcomes. There are often a variety of possible ways to influence outcomes, and discerning whether the selected interventions have yielded maximum positive effects given committed resources is an important question. Another important consideration when planning QI activities is accessibility of organized data. There is a great amount of collected data in healthcare institutions, but it is often in disarray. Data collection activities may be episodic, inconsistently reported, and superficially reviewed. Establishing organized systems of data collection, storage, and retrieval processes is important to QI initiatives. HQO (2013) notes that there are differences between research and QI measurements (TABLE 12-4). Many advanced nurses are familiar with the research process and have experience with traditional measurement concerns through graduate research studies or clinical research projects. A key difference between research and QI measurements is that measurement for improvement occurs frequently and is often performed rapidly in small batches so as to accelerate the implementation of desirable changes. TABLE 12-4 Contrasting Measurement for Improvement to Measurement for Research



Measurement for Research

Measurement for Learning and Process Improvement

Purpose

To discover new knowledge

To bring new knowledge into daily practice

Tests

One large “blind” test

Many sequential, observable tests

Biases

Control for as many biases as possible

Stabilize the biases from test to test

Data

Gather as much data as possible, “just in case”

Gather “just enough” data to learn and complete another cycle

Duration

Can take long periods of time to obtain results

“Small tests of significant changes” accelerates the rate of improvement

Copyright © Queen’s Printer for Ontario, 2013. Reproduced with permission. Health Quality Ontario. (2013). Quality improvement primers: Measurement for quality improvement. Page 4. Retrieved from http://www.hqontario.ca/Portals/0/documents/qi/qi-measurement-primer-en.pdf

Description Advanced nurses need to be able to compare the costs to benefits of practice changes, and this analysis requires a systematic, scientific approach. There are a number of approaches to QI that may be useful, including Plan-Do-Study-Act (PDSA), Six Sigma, rapid cycle improvement, positive deviance, failure mode and effects analysis (FMEA), root cause analysis (RCA), and flowcharting. The American Society for Quality (ASQ) provides overviews of these commonly used QI techniques. The ASQ offers individual and organizational memberships with opportunities for networking and support (ASQ, 2017a). A brief review of the above quality improvement methodologies may be useful to stimulate further exploration or activity.

PDCA or Plan-Do-Check-Act PDCA is the fundamental process of total quality management (TQM) developed by W. Edwards Deming in the 1950s. PDCA is also referred to as PDSA, the Deming Cycle, the Shewhart Cycle, or the Deming Wheel (ASQ, 2017b). Regardless of its title, the process consists of four steps: plan, do, study (check), and act (TABLE 12-5). These steps should be viewed as circular and continuous. PDSA quality improvement uses the scientific method to implement and test the effects of changes on the performance of the healthcare system based on outcomes of interest.

When used in TQM or continuous quality improvement (CQI) projects, PDCA is user friendly and may be useful when working with multidisciplinary groups or staff nurses unfamiliar with CQI processes. It is a cyclical and iterative process that requires an ongoing assessment of needs and effects (Peterson, Adlard, Hayakawa, McClean, & Feidner, 2015) (FIGURE 12-6).

FIGURE 12-6 PDCA cycle. Data from ASQ Quality Press. Copyright © 2005 American Society for Quality. Note: The cycle is continuous and circular.

TABLE 12-5 PDSA/PDCA Process Steps Plan

Diagnose an opportunity. Consider a change idea. Plan the change. Determine

metrics of success. Design data collection plan. Determine necessary sampling plan and numbers of subjects. Do

Test the change. Conduct a small-scale study. Track the results, measures, challenges, and unintended consequence.

Study or Check

Review the methods. Analyze results. Identify findings and compare to predictions. Summarize and reflect.

Act

Take action based on what was learned in the study step. Depending on findings, planned change should be adopted, adapted, or abandoned.

Data from ASQ (2017b); Health Quality Ontario (2013).

Description PDCA may be used to accomplish a number of goals. It was originally designed as a model for CQI and is successfully used for such activities in the private and public sector and in all types of ventures, including health care (Williams & Fallone, 2008). One example of the application of the PDCA process is provided by a collaborative effort of clinical nurse specialists to recognize, prevent, and treat pediatric pressure ulcers (Peterson et al., 2015). PDCA is also a useful tool in root cause analyses and when developing a new or improved design of a care delivery process. There are a number of Web-based, print, and program resources to help advanced nurses build expertise with the PDCA process and other QI methods (BOX 12-4; BOX 12-5).

BOX 12-4 Quality Tools and Templates Available From the ASQ Tool Name Box and Whisker Plot Check Sheet Control Chart Design of Experiments Template FMEA Template Fishbone (Cause and Effect) Diagram Flowchart Template Gantt Chart Histogram Pareto Chart Scatter Diagram

Stratification Diagram Data from American Society for Quality. (2018a). Learn about quality: Quality tools and templates. Retrieved from http://asq.org/learn-about-quality/tools-templates.html

BOX 12-5 Quality Tools and Templates Available From the IHI Toolkit Content Cause and Effect Diagram Driver Diagram FMEA flowchart Histogram Pareto Chart PDSA Worksheet Project Planning Form Run Chart & Control Chart Scatter Diagram Data from Institute for Healthcare Improvement. (2017e). Quality improvement essential toolkit. Retrieved from http://www.ihi.org/resources/Pages/Tools/Quality-ImprovementEssentials-Toolkit.aspx

FOCUS-PDCA Quality Improvement Model FOCUS is an acronym for find, organize, clarify, understand, and select (Zimnicki, 2015). FOCUS is frequently added as a forerunner to the PDCA cycle (FIGURE 12-7). FOCUS facilitates the discovery process and problem identification required for PDCA to begin. The advanced nurse begins by finding a process requiring improvement. As mentioned previously, this process may be discovered using a variety of methodologies, or it may be assigned to the advanced nurse as part of a department or institution initiative. Run charts can provide a useful depiction of the variability of the measure of interest (HQO, 2013). These charts can also be intriguing to staff and leadership and offer compelling support for why a particular measure is worthy of attention and effort.

FIGURE 12-7 FOCUS-PDCA.

Once a problem is found, the second step is to organize in order to improve the current state of the process. The nurse may elect to form an interprofessional committee or nursing committee or may determine that the best organizational structure is to use an existing standing committee. Brainstorming with colleagues may offer unique insights. It is imperative to establish a team that will be responsive, enthusiastic, and interested in knowledge building. Identifying appropriate team members is critical. The advanced nurse needs to make certain that key stakeholders are represented and that the individuals who know the way that the process truly works are included. This may also be a good

opportunity to establish ownership of the project not only in terms of budgetary responsibility but also specific to authorship and presentation rights, should the activity result in a scholarly outcome. The leader should determine whether secretarial, technical, or fiscal supports are in place. Clarification follows organization. This stage is concerned with accurately describing the process and identifying the details that may contribute to opportunities for improvement. Organizing activities may include searching the literature, examining available evidence, scrutinizing benchmarked data, flowcharting or diagramming current processes, or exploring the problem of interest using some type of descriptive data collection method, including focus groups, interviews, or surveys, among others. Organizing activities are important as they provide fodder for developing a clear understanding of the current processes and identifying the gaps and shortcomings. Chart audits and medical records reports may also provide useful information, depending upon the process requiring improvement. There are times when systems are needlessly complex and processes are onerous. Flowcharting or diagramming the process of interest in a step-by-step, detailed fashion is helpful. Understanding or uncovering the sources of variation or the problems in the process is the fourth step. The team may discover that some of the problems cannot be solved. For example, if a group is working on improving patient wait times in a small but busy emergency department (ED) and a key problem area is a lack of physical space, there may not be a realistic way to correct this problem until a new waiting room is constructed. However, there may be other opportunities in the ED arrival process or ED bed assignment that could be addressed and that might contribute to reducing waiting room time. The advanced nurse should think about variable measurement during this step. As previously noted, an important aspect of outcomes management and CQI is outcomes measurement. The team needs to consider the ways that variables and processes are measured and make certain that these measurements are useful and practical. Remember that data will need to be collected, compiled, and analyzed. It makes sense to establish a data collection plan early. If possible, take advantage of data collection processes that are already in play. Once a process has been selected, dissected, and understood, PDCA

activities begin. In general, PDCA should focus on particular aspects of the selected process. Complex processes should not be tackled all at once. Rather, the advanced nurse should start the process by selecting exactly what portion of the process will be examined. The selection criteria should include the feasibility of changing the selected process. At this point, the advanced nurse and team plan the improvement. The working group needs to decide whether the identified changes will be made in a pilot program or initiated on a large scale. This decision depends upon the recommended change and the process. For example, if the recommended change is dramatic and the consequences are not entirely understood, or if there is little in the literature or experientially that describes the potential impact of the change, a pilot study may be the wisest course. If the change is based upon research and is consistent with the recommendations of leading authorities, it may be acceptable to proceed on a larger scale. Remember that a data collection plan should be in place prior to implementing changes. The next step is to do or implement the recommendation. Part of the challenge of “doing” is to make certain that the recommended changes are being done correctly and consistently. The advanced nurse should be auditing processes, talking with people involved in the implementation, and maintaining careful data collection that follows the developed data collection plan. After implementing changes and collecting data, check for improvement, deterioration, or no change from the status quo. In the event of little or no positive change, the group needs to analyze how the intervention was implemented and whether the processes rather than the recommendations were deficient. Brainstorming and interviewing are effective strategies for collecting this information. Remember that there is a possibility that the change was not conducted as planned and that unaccounted intervening influences had a negative effect on the outcomes. Theory-driven evaluation strategies and considerations are necessary to avoid discarding appropriate changes to the system based upon faulty data (Chen, 2015). As previously noted, the final step is act, but the team needs to keep in mind that PDCA is a circular model when used for quality improvement. At this point, the advanced nurse and colleagues need to

decide whether to adjust, abandon, or adopt the change. If the data reveal that the change has positively affected the system, the group will need to devise strategies for establishing this change as fixed. Final activities should include updating policies and procedures and informing key personnel of the changes. The team may also want to give thought to potential ways to continuously improve the process. Certainly it is important to monitor measures to ensure that process fixes are maintained rather than returning to the original baseline. It can be difficult to protect the newly established or revised processes. Zimnicki (2015) offers an example of using FOCUS-PDCA to improve evidence-based preoperative stoma site markings. The FOCUS-PDCA model provided opportunities to identify barriers to consistent implementation of preoperative teaching and stoma site marking. The project was a successful endeavor but sustaining long-term change proved challenging. Zimnicki’s efforts illustrate the importance of regular evaluation of outcomes measures to ensure that process improvements persist. FOCUS-PDCA and PDCA are popular methods for quality improvement endeavors. Advanced nurses will find these methods useful and user friendly as they guide planned change that is predicated upon careful analysis. Changing systems and processes takes time and FOCUS-PDCA is a careful, deliberate strategy. Certainly there are aspects of patient care that can be swiftly and effectively changed without engaging in PDCA; however, it is a very useful tool for correcting and improving processes based upon clear understanding that has arisen from careful, informed analysis.

The Six Sigma Revolution: A Measure of Quality Striving for Perfection Six Sigma is a disciplined, data-driven approach and method for eliminating defects in any process (iSixSigma, 2017), including health care. It is an improvement process committed to excellence. Six Sigma originated in Motorola in the mid-1980s, and soon other industries, including General Electric, Allied Signal, Sony, and Polaroid, became users as well (Chowdhury, 2001; Ha et al., 2016). Six Sigma focuses on eliminating defects by reducing variability.

Sigma is the Greek letter used to describe variability as standard deviation (FIGURE 12-8). The “six” standard deviation refers to the sixth standard deviation or a 99.9996% success rate (Chowdhury, 2001), or not more than 3.4 defects per million opportunities (Ha et al., 2016; iSixSigma, 2017). As the name implies, Six Sigma relies heavily on quantitative data analysis.

FIGURE 12-8 Greek letter, Sigma.

Six Sigma methodology is appealing to the healthcare industry because of its emphasis on variation or error reduction. Hospitals and healthcare systems continue to display variability in outcomes that contribute to patient dissatisfaction and inefficiencies in processes and outputs (Woodward, 2005). Six Sigma methodologies have been used to improve operating room turnover time (Adams, Warner, Hubbard, & Goulding, 2004) and operating room efficiencies (Bender et al., 2015) and to improve quality and patient safety (Nimtz-Rusch & Thompson, 2008). Major and Huey (2016) used Lean and Six Sigma methodology with significant success to reduce the incidence of intravenous infiltrates in hospitalized children. The U.S. Naval Academy has used Six Sigma to improve a mass immunizations process at the academy (Ha et al., 2016), and it has been used in combination with simulation and Lean to improve the phlebotomy process (Huang & Klassen, 2016). A review of the literature reveals the increasing popularity of Six Sigma methods in the United States and internationally, with demonstrated utility across a wide variety of healthcare processes in numerous settings. Critics of Six Sigma may be concerned about the applicability of a quality improvement process with its roots in manufacturing can be reasonably applied to the healthcare industry. Six Sigma demands identification of specification limits that define acceptable performance.

Healthcare systems are not always inclined to evaluate performance within tight, prescriptive constraints despite the fact that continuous improvement requires accurate measurements. During the early stages of Six Sigma’s application to healthcare processes, Lazarus (2003) asserted that Six Sigma is adaptable to the development of best clinical practices and that the language of Six Sigma will benefit healthcare consumers. During the past 2 decades, Six Sigma has increased in popularity as an important tool to improving various healthcare outcomes and its utility will likely continue to increase as organizations put resources into establishing Six Sigma models for quality improvement. Improving an existing process using Six Sigma methodology follows a five-step analysis: (1) define the opportunity, (2) measure to establish baseline performance, (3) analyze data and critical elements, (4) improve the new process, and (5) control the new process (DMAIC) (iSixSigma, 2017). DMAIC (pronounced duh-may-ick) uses statistical analysis to find the most defective part of the process under scrutiny and applies rigorous control procedures to maintain improvement. A second key methodology in Six Sigma is DMADV, representing define, measure, analyze, design, and verify. DMADV is used to create new product or process designs (iSixSigma, 2017). DMAIC is the most popular Six Sigma methodology (ASQ, 2017c). There are various Six Sigma definitions but when used in terms of quality, Six Sigma represents a process that is well controlled with tolerance limits driving toward six standard deviations from the mean to the nearest specification limit (ASQ, 2017c; iSixSigma, 2017). Differing Six Sigma definitions share some commonalities, including the use of teams assigned to clearly defined projects that directly affect the organization’s bottom line; statistical thinking with some people, referred to as black belts, receiving extensive training in advanced statistics and project management; a prominent DMAIC approach; and a supportive management environment that values these efforts as an important business strategy (ASQ, 2017c). Six Sigma creates new positions within the organization. These positions have names taken from the martial arts (TABLE 12-6). In addition to belt designations, Six Sigma relies on champions that translate the company’s vision, mission, goals, and objectives to create a deployment plan and to identify individual projects. These champions smooth the way

for project work. Executives are needed to establish the Six Sigma program and keep it informed by the organization’s culture and vision (ASQ, 2017d). TABLE 12-6 Six Sigma Belts and Selected, Designated Responsibilities Belt Color

Selected, Designated Responsibilities

Master Black Belt

Trains and coaches black and green belts.

Black Belt

Project leader. Trains and coaches project teams.

Green Belt

Assists with data collection and analysis efforts. Leads green belt projects/teams.

Yellow Belt

Team participant.

White Belt

Aware of basic Six Sigma concepts. May work on local teams that support projects. May not be a Six Sigma project team member.

Description Change acceleration process identifies change barriers and works through them. Workout is a process that brings approximately 10 to 12 key people together for 4 to 8 hours to concentrate on reaching the best decision for improvement or change (Adams et al., 2004). The basic working premise of Six Sigma is Q × A = E (Chowdhury, 2001). This formula denotes that the effectiveness of the results (E) is equal to the quality of the solution (Q) times the acceptance of the idea (A). There is a substantial amount of training involved in Six Sigma, and it is not a trivial or insignificant commitment. As an example, Adams et al. (2004) describe the education commitment within their institution after having committed to using Six Sigma as 7 days for executive leadership training, 4 days for managers, 35 days for green belts, 7 days for change agents, and 21 days for team planning and training. When these days are distributed across a significant number of employees, the start-up costs are high. In general, a quick Internet search for information specific to Six

Sigma preparation, required resources, institutional supports, and other key words related to preparatory activities reveals the intensity of the Six Sigma initiation period. Six Sigma is an increasingly popular methodology for quality improvement. Healthcare institutions are looking for opportunities to reduce care process outcomes variances more than those provided in traditional quality improvement models. The published results of Six Sigma are impressive and suggest that advanced nurses should at least be aware of and comfortable with the basic underlying premises of this method, as it is likely that their exposure to Six Sigma methodologies may increase.

Lean Thinking Lean is a process improvement strategy designed to eliminate unnecessary steps and redundancies that are not critical to quality for the user. Lean is often integrated with Six Sigma because they share the same goal of providing the customer with the best quality, cost, delivery, and nimbleness (ASQ, 2017c). Within the healthcare enterprise, this user, or customer, may be the nurse, physician, patient, or other key stakeholder who is the direct beneficiary of the particular service. Lean is meant to eliminate waste, identified as waste in inventory, overproduction, waiting, transportation, defects, excess motion or walking, and processing. Underutilizing employee skills is also considered wastage (ASQ, 2018b). This waste reduction emphasis differs from Six Sigma’s emphasis on reducing variability but there is overlap and the two processes enhance each other when waste and variation coexist, a common finding when examining outcomes and the processes leading to such that require improvement. For example, Lean Six Sigma (LSS) may offer benefits to the purchasing departments of healthcare systems as they work to reduce waste while also lessening purchasing decision variations and errors. The tools and methodologies associated with LSS may have applicability to any number of healthcare processes (Barlow, 2008). Another difference between Lean and Six Sigma is Lean’s reliance on tools that are not as statistically driven. One such example is Lean’s use of kaizen, an emphasis on continuous improvement that relies on small,

incremental changes in work processes (ASQ, 2019).

Rapid Cycle Improvement Model The rapid cycle improvement model (RCIM) builds on organizations’ desires to accelerate the change process in order to make rapid improvements in outcomes. The model is also referred to as rapid cycle tests (RCTs) of change (Pape et al., 2005), rapid cycle change (RCC) methodology (Bisaillon, Kelloway, LeBlanc, Pageau, & Woloshyn, 2005), or rapid cycle improvements (Stover & Harpin, 2015). RCIM is based on the premise that traditional methods of quality improvement are too slow, fail to engage people, and inadequately utilize current evidence (Bisaillon et al., 2005). Even when advanced nurses use established quality improvement methods like PDCA, these projects may take too long with end dates open or too far in the future. Lloyd Provost discussed troublesome enddate challenges during his IHI Open School’s video presentation, “How Long Should a PDSA Cycle Last?” (IHI, 2017c). Provost asserts that end dates should be set for PDSA cycles, and these end dates should be shorter than what some teams might initially consider. PDSA/PDCA projects should be rapid tests of change, and keeping true to this rapid approach is necessary for project success (IHI, 2017c). RCIM builds on the position that if an organization wants to make rapid gains in quality, it must be able to answer three questions: (1) What does the organization want to accomplish? (2) How will change be recognized as an improvement, and how will it be measured? (3) What changes can be made that will result in an improvement? (Martin, 2003). Rapid change improvement (RCI) processes are often used in conjunction with DMAIC steps. The basic process is to follow the initial DMAIC steps and, after analyzing the problem or gap, to use RCIs to improve the system (Pape et al., 2005). RCIs may also be used in partnership with PDSA as a component of the “do” step. If results are positive, the improvements should be controlled and perpetuated. If results are not positive, or not positive enough, the action plan requires revision. Stover and Harpin (2015) conducted a quality improvement project to reduce emergency department wait times for patients needing psychiatric

admission. Following a review and appraisal of available evidence, an established team guided evidence-based process changes to improve patient flow and reduce wait time. These advanced nurses used rapid cycle improvement methodology guided by the PDSA method. Seven PDSA cycles were conducted and data were evaluated to reveal that ED wait times were reduced (Stover & Harpin, 2015). The entire project, including the seven PDCA cycles with RCIs, took place over a 12-month period. Information was not provided as to whether an end date was predetermined. It is also not clear if additional efficiencies could have reduced this yearlong time frame; however, one important takeaway is that the project did not languish or continue as an ad infinitum approach to improvement efforts. RCIM can be used in a variety of clinical venues. It has been used successfully as a process for improving medication use systems by addressing nurses’ distractions during medication administration (Pape et al., 2005). It has also been used to establish best practices in stroke care by incorporating small improvement changes, measuring results, and using the measured successes to facilitate further improvements in stroke care practices for both patients and care providers (Bisaillon et al., 2005). Terry, Disabata, and Krajicek (2015) used RCIM with PDCA to reduce the number of respiratory adverse events in pediatric patients undergoing surgery. Each cycle was described and a total of eight testing cycles were required. This project did improve identification of perioperative risk related to undiagnosed sleep-disordered breathing. The IHI (2017d) offers tips for testing changes that should be considered when using RCTs. The suggestions include staying ahead of the tests based upon the possible findings that were identified in the study phase of PDSA efforts. Other recommendations include working with people who want to work on the project, picking changes that are simple and reasonable, scaling down the breadth of the tests whenever possible, and preparing to eliminate a change if it is not improving the measure of interest (IHI, 2017d).

Positive Deviance Positive deviance (PD) describes uncommon, beneficial health behaviors that some people already practice. Positive deviant behavior is atypical

and confers benefits to people who practice it as compared to the rest of the community (Marsh, Schroeder, Dearden, Sternin, & Sternin, 2004) without any difference in available resources (Bertels & Sternin, 2003) and despite having characteristics that place them at high risk for unhealthy behaviors (Barbosa, Masho, Carlyle, & Mosavel, 2016). In the 1990s, the PD approach was first used to influence the nutritional status of children by Jerry and Monique Sternin in Vietnam during their efforts with Save the Children. The Sternins were the first to apply the PD approach and subsequent efforts have built on their initiatives. Since this time, PD has been used to effect changes via a variety of projects, including breastfeeding in rural Vietnam (Dearden et al., 2002), the eating strategies of low-income pregnant women (Fowles, Hendricks, & Walker, 2005), female genital cutting (UNICEF, 2008), persistent breastfeeding rather than formula feeding among low-income AfricanAmerican women (Barbosa et al., 2016), predictors of physical activity in adolescents (Spurr, Bally, & Trinder, 2016), and standardization of nursing operating procedures (Ausserhofer et al., 2016). PD addresses problems that require behavioral or social change. The approach is consistent with Six Sigma because it provides a design that Six Sigma projects can amplify and replicate (Bertels & Sternin, 2003). For Six Sigma to be successful in reducing outcomes variability, Six Sigma projects must be replicable across entire organizations. Replication is challenging and yet is crucial to benefiting fully from Six Sigma project efforts. The PD approach offers a way for Six Sigma organizations to spread successes. PD is composed of six steps: define, determine, discover, design, discern, and disseminate (Bertels & Sternin, 2003). The focus of PD is on behavior replication. Rather than targeting the acquisition of knowledge related to why people behave in the ways that they do, PD demonstrates that it is possible to find successful solutions before all the underlying causes are addressed. Marsh et al. (2004) identify six steps to the PD approach with the community as an active partner. The approach includes: 1. Developing case definitions 2. Locating four to six people who have managed to achieve an unanticipated good outcome despite their high level of risk

3. Interviewing and observing these deviants to uncover the atypical behaviors or enabling factors that might explain the positive outcome 4. Analyzing the findings to confirm that the behaviors really are atypical and are available to the people who would benefit by adopting the behaviors 5. Designing activities to change behaviors and to encourage the community to adopt the new behaviors 6. Monitoring performance and evaluate outcomes Marsh et al. (2004) suggest that there are three important processes that occur in response to the PD approach. The first is the positive reaction of community members when they learn that they are doing something right rather than hearing only negative feedback. The second process involves information seeking and gathering to identify the positive behaviors that may be spread and the factors that encourage this spread. The third process is the actual behavior change. Dearden et al. (2002) provide an early example of the PD process as it relates to exclusive breastfeeding in a rural Vietnam village. The goal of the project was to improve breastfeeding practices. Examination of Vietnamese breastfeeding practices revealed that women who return to work were confronted with barriers that hindered exclusive breastfeeding. Data were collected and women were grouped into (1) those who were not exclusively breastfeeding and had returned to work; (2) women who were exclusively breastfeeding and had returned to work; (3) women who were not exclusively breastfeeding and had not yet returned to work; and (4) women who were exclusively breastfeeding and had not yet returned to work. The women in the second group were identified as the positive deviants. These women were working and yet were able to maintain exclusive breastfeeding whereas other women in similar circumstances were not exclusively breastfeeding. The researchers explored the differences between these groups of women and determined the facilitators and barriers to exclusive breastfeeding. Based upon these findings, the researchers offered suggestions for programmatic changes that might increase the incidence of exclusive breastfeeding. The focus of the researchers’ activities was to identify the experiences of the positive

deviances in an effort to promote this deviant or abnormal behavior within the community of interest. Although this particular study was early in the trajectory of PD as an approach to improving health outcomes, it offers a clearly understood and uncluttered illustration of PD in action. Sternin (2002) defines positive deviance as “a departure, difference, or deviation from the norm resulting in a positive outcome” (p. 1). Sternin sees this deviance as proof that there are viable solutions to today’s complex problems that can be utilized before addressing all the factors underlying the problem. In other words, the PD approach offers hope. Sternin offers this assertion within the context of childhood malnutrition and points out that these children need immediate help if they are to survive and thrive. These children do not have time to wait for problem analysis; rather, they need immediate solutions. PD offers these solutions. Sternin states: A critical component of the definition of “positive deviants” is that PD individuals have exactly the same resource base as their nonpositive deviant neighbors. Hence, whatever they are doing, whatever resources they are using to achieve their successful outcomes, are by definition, accessible to their neighbors. By identifying the special beliefs and practices of the positive deviants and then making them accessible to the community, a demonstrably successful strategy is provided which can be acted upon today. (p. 2) Sternin (2002) comments that if a project’s objective is social or behavioral change and if there are some individuals exhibiting the behavior within the community, then PD is a useful tool. The advantage of PD is the sustainability that occurs because the resources required for change already exist within the community. In other words, external resources are not required. Positive deviants are successful with the resources that are available to them, illustrating that the fundamental structure of PD is the belief that there is “wisdom and untapped resources” within the community of interest (Sternin, 2002, p. 6). PD offers opportunities to improve outcomes and to sustain these changes within the healthcare system just as it offers opportunities within communities. Handwashing behaviors, best practice implementation,

infection control practices, and nursing documentation are examples of healthcare concerns that fundamentally rely on behavior and social changes. If there are units within a hospital or nurses employed on a particular unit whose practices are associated with uncommon but positive outcomes, these individuals may be identified as positive deviants. There are several examples illustrating the potential impact of PD on problem solving in health care. The Robert Wood Johnson Foundation awarded a Pioneer Grant 2006–2008 for a project targeting methicillinresistant Staphylococcus aureus (MRSA) infections in hospitals using the PD approach. As a consequence of this project, MRSA rates were lowered by 73% (Shaw, 2009). Cusano (2006) describes using the PD approach to improving medication use processes for patients at time of discharge and transfer. This medication reconciliation project included identification of positively deviant staff and practices related to those positively deviant patients who had no problems with their medical regimen after discharge. During the course of the study, the researchers identified that the uncommon but successful practices included following up discharge with a telephone call, using written instructions with specific information for complex regimens, providing instructions to caregivers, as well as other strategies. These practices were shared in small-group meetings with other professionals, and 6 months later the PD team found that patients were 66% more likely to use their medications without troubles (Cusano, 2006). Of course, one challenge following a successful endeavor is to figure out strategies for replicating the success across an entire organization. Difficulties duplicating successful results are the result of a lack in communication, transferability, processes and systems, and incentives (Bertels & Sternin, 2003). Six Sigma relies on the successful implementation and spread of changes that have been demonstrated as positive and useful via pilot studies or rapid change testing. If successes are not replicated, Six Sigma is ineffective as an improvement process. The PD approach may help to facilitate the spread of the improvements. Six Sigma pilots can be treated as positive deviants and then magnified. The potential connection between PD and Six Sigma may be useful to the advanced nurse employed by an organization who is using either or both of these approaches to QI. A basic understanding of the two

methodologies and their interconnectedness may be helpful as nurse leaders begin to learn and implement both processes. Bertels and Sternin (2003) caution that benchmarking and PD have similar objectives but that there are profound differences between the two concepts. They point out that the PD approach recognizes successful and accessible behaviors as critical whereas benchmarking targets efficiency and effectiveness. PD attends to the context of a process, and benchmarking applies the principles and attributes of an effective process as enacted by a different entity. Finally, benchmarking focuses on opportunities external to the organization that may be borrowed and applied; PD looks for successful ideas from within the organization. Bertels and Sternin (2003) appreciate the benefits of benchmarking as a helpful process when organizations are seeking to redesign or duplicate results but note that benchmarking is more applicable to situations that require unconventional ideas; for example, thinking that is outside the box. Positive deviance works best when an organization is looking for results that can be nurtured and replicated. In addition to using the PD approach to improving clinical outcomes, PD may also be useful to improve norms in the workplace, including those existing within healthcare organizations. The Center for Positive Organizations of the University of Michigan’s Ross School of Business works to promote the positive workplace and positive leadership. PD focuses on replicating positive behaviors, similar to the goal of those in workplace situations who aspire to encourage honorable and excellent organizational behaviors, also referred to as positive organizational scholarship (POS). The Center for Positive Organizations (2018) offers several examples of research studies that have utilized a positive deviance approach. Nurses in advanced roles may find the PD-position organizational scholarship connection useful as they attempt to positively influence problems in nursing work environments, including incivility or poor end-ofshift reports. PD may provide a method for exploring the positive deviants who nurture young, inexperienced staff members or who provide excellent, timely, and succinct end-of-shift reports. PD may be a wiser and more effective approach than telling staff what it is they are doing that is wrong and inappropriate. The PD approach offers an alternative

means of influencing behavioral and social outcomes within healthcare organizations and in clinical practice.

Failure Mode and Effects Analysis (FMEA) Failure mode and effects analysis is a proactive process focusing on predicting the negative outcomes of human, system, and machine failures (Senders, 2004). FMEA was created as an industrial tool and was developed by reliability engineers to evaluate complex processes in a systematic fashion, to identify the elements that may cause harm, and to prioritize remedial measures (Apkon, Leonard, Probst, DeLizio, & Vitale, 2004). It is a tool to guide systematic analysis of a process in which harm may occur (IHI, 2017e). FMEA is based on the idea that the amount of risk associated with a process, system, machine malfunction, or human behavior relates not only to the probability of a failure occurrence but also to the degree of severity of the failure and the ease with which failure might be noticed and addressed before causing harm. FMEA uses a variety of information sources to determine failure rates and then predicts the behavior of a system in the event of failure (Apkon et al., 2004). Teams use FMEA to examine processes for potential failures and to prevent these failures by proactively correcting the processes rather than waiting for adverse events to occur and then reacting. FMEA is a challenging exercise that the AHRQ (n.d.) evaluates as a difficult process that tends to take time. The process is useful for planning improvements to existing concerns or using preexisting processes, products, or services in new ways; forecasting errors; preventing mistakes; periodically evaluating existing concerns; or when examining failures (AHRQ, n.d.). Advanced nurses may be familiar with FMEA because of the Joint Commission’s requirement of hospitals to select one high-risk process and conduct a proactive risk assessment at least every 18 months (Joint Commission, 2016b). FMEA is important to outcomes because it offers a proactive strategy to potentially reduce harm. Adverse events should be consistently considered as opportunities to improve, although, ideally, healthcare care organizations protect patients from harm rather than contribute to or cause harm. The Joint Commission views quality and safety as indivisible

and identifies safety as a central aim of quality (Joint Commission, 2016b). Quality management systems are charged with ensuring reliable processes, decreasing variability and waste, achieving better outcomes, and using evidence to safeguard satisfactory service delivery (2016b). FMEA contributes to these responsibilities by facilitating risk assessment and identifying opportunities to improve outcomes. Advanced nurses should take advantage of the IHI resources available in its Quality Improvement Essentials Toolkit specific to FMEA (IHI, 2017e). The IHI provides instructions and resources, including an interactive FMEA tool on its website (2017e). For those interested in using a paper-based tool, the IHI provides a nine-column table to guide the FMEA process. Step-by-step instructions are clearly developed and scoring is described. A risk profile number (RPN) description is provided and tips are suggested for working toward RPN reduction based on proposed changes to the system (IHI, 2017e). An exemplar of an FMEA related to a medication dispensing process is included in the QI toolkit.

Root Cause Analysis (RCA) RCA is frequently used by health professionals, including advanced nurses, to figure out how and why adverse events have occurred. It is a retrospective analysis as compared to the FMEA prospective considerations. The IHI (2017f) has renamed the RCA process root cause analyses and actions (RCA2) to make clear that RCA is conducted to understand how medical errors, adverse events, and near misses have occurred with the ultimate goal of taking action to prevent future harm. Advanced nurses often have a vantage point in the practice setting that contributes to keen insights on system vulnerabilities. Working with nursing colleagues and other interprofessional team members to clearly delineate processes and structures that contributed to harm, advanced nurses have opportunities to improve quality for those dependent on the healthcare system and its representatives for safe, effective, evidencebased care. The RCA2 process was designed under the leadership of the National Patient Safety Foundation (NPSF) in 2015. The second version of this best practice document is available on the IHI website (IHI, 2017g). The tool is richly detailed and a terrific resource for advanced nurses,

regardless of RCA skill level. Content includes information about selecting events appropriate for RCA2 review, event classifications, RCA2 timing and team membership, interviewing strategies, and the event review process. Appendices offer terrific opportunities for guidance and skill acquisition. Practical information is highlighted via the use of textbox summaries. For example, one such narrative responds to the question: Why is “human error” not an acceptable root cause? The discussion emphasizes that human error may be involved in adverse events because it is inevitable; however, the point of the RCA is to understand system factors that allow such errors to occur and then identify solutions that will remove the error possibility or mitigate its effects (IHI, 2017g). FMEA and root cause analysis processes do improve healthcare outcomes and are useful for improving patient safety systems. Senders (2004) labels FMEA and RCA acronyms as “mantras of modern risk management” (p. 249). It is obvious that simply because a potential error is identified and associated with quantified risk, this does not guarantee a cause–effect relationship between one specific error and one specific injury. However, Senders points out that a benefit of using FMEA and RCA methodologies is their potential protective influence against lawsuits given that diligent use of these methodologies demonstrates a genuine organizational commitment to preventing avoidable patient injuries. Advanced nurses need familiarity with FMEA and RCA processes and, in some instances, a more advanced understanding in order to participate in these activities as a fully engaged member of a multidisciplinary committee. Staff may be more familiar with RCAs, particularly those practicing in acute care settings, because of the linkage between RCAs and sentinel event reporting requirements through the Joint Commission. The Joint Commission (2017c) defines a sentinel event as a patient safety event that reaches the patient and results in death, permanent harm, or severe temporary harm and intervention required to sustain life. Organizations are required to report sentinel events to the Joint Commission. The Joint Commission requires an analysis of the root causes of sentinel events and an action plan. However, this is a retrospective review that may improve outcomes for future patients but does not work to prevent the event from occurring in the first place. FMEA may assist by providing a prospective analysis of risk thereby enhancing improved

outcomes management and measurement. It is very likely that advanced nurses of all types will have opportunities to participate on teams conducting FMEA and RCA procedures as healthcare professionals continue to attend to improving quality and ensuring safe outcomes for patients.

Flowcharts and Diagrams: Visual Tools to Guide Outcomes Improvements The use of flowcharts and diagrams as pictorial representations of a process is a common practice in QI initiatives. To improve outcomes, advanced nurses must understand the processes leading to the outcome. Many people grasp material best when information is presented using a variety of modalities. Graphic representations of processes and group discussions that fill in gaps and ensure accuracy in the diagrammed steps are very important to multidisciplinary QI efforts. The IHI’s QI toolkit (2017e) provides helpful process tools, including flowcharts, cause–effect or fishbone diagrams (also known as Ishikawa diagrams), histograms, and Pareto diagrams, as well as instructional videos. The ASQ (2017e) offers a number of process analysis tools on its website, including a flowchart template that is in Excel. In general, providing that the process under scrutiny is not too complicated, flowcharts can be user friendly and efficient. They may also serve as a blueprint for group activities. There are common symbols used in flowcharts. Microsoft Word has a flowchart option in its AutoShapes feature. Each shape is tagged with an identifier making it easy for the novice flowchart creator to depict simple processes (FIGURE 12-9). There are also flowchart software programs available for purchase.

FIGURE 12-9 Select Microsoft™ Office Professional Plus 2013 shapes/flowchart.

Description Cause–effect diagrams or Ishikawa diagrams are useful to explore sources of variability within a process (FIGURE 12-10). This diagram appears as a fishbone skeleton. The name of the problem of interest is on the right side of the diagram at the end of the main “backbone” of the fish. The possible causes of the problem are pictorially represented as bones off the backbone.

FIGURE 12-10 Cause–effect or fishbone diagram. Microsoft. (2017). Cause and effect diagram: PowerPoint. Retrieved from https://templates.office.com/en-us/Search/results?query=Cause+and+effect+diagram

Description Ishikawa diagram templates are available through Microsoft’s website as a PowerPoint download. The ASQ (2018a) has a number of templates (return to Box 12-4) for use, most in Excel, and training is also available. The AHRQ provides a Practice Facilitation Handbook (Knox & Brach, 2013a) to support the training of new practice facilitators who will be working to promote meaningful primary care improvement practices. The handbook is comprised of 21 training modules, and each module contains a trainer’s guide. Advanced nurses may elect to complete some or all of these modules given their relevance to improving care processes and outcomes across a variety of healthcare settings. The appendices are quite useful and the Module 5 appendix provides a guide on workflow mapping formatted in PowerPoint (Knox & Brach, 2013b). Pareto diagrams depict the variables that contribute to a particular outcome or overall effect. Variables are arranged in the order of their contribution to the outcome of interest as a histogram or bar graph (IHI, 2017h). Identifying the influences responsible for the greatest effects

assists team members with making decisions as to which variables should be addressed in terms of costs and benefits. In other words, team members can use the chart to determine the factors that require the most attention. The contributions of the variables should be determined in a rigorous, objective fashion rather than through opinion gathering. Advanced nurses may find it useful to incorporate diagramming and flowcharting activities into group discussions, staff meetings, and multidisciplinary committee work. Visual aids are useful in establishing a common perspective and facilitate communication. There are times when problems become self-evident once details are diagrammed.

Standardizing the Language of Nursing As national progress is made in advancing electronic health records (EHRs), the need for nursing language standardization becomes more acute. Advanced nurses likely recognize that sharing data requires a common nursing language such as the nomenclature published by NANDA International, the Nursing Interventions Classification (NIC), and the Nursing Outcomes Classification (NOC). Collectively, NANDA, NIC, and NOC may be referred to as NNN, the standardized language of nursing. An EHR facilitates data aggregation that encourages knowledge development, including a better understanding of outcomes and quality (Lunney, 2006). To examine the quality of nursing care and its associated costs, outcomes and interventions must be connected in the clinical record to the relevant nursing diagnoses (Moorhead & Johnson, 2004). To date, NNN is not well captured in the EHR specific to nursing practice and patient outcomes. Flanagan and Weir-Hughes (2016) express concern that EHR development has excluded NNN and, as a result, nursing’s voice is lost. EHR progression consists of three stages (CMS, 2017b). The first stage sets the foundation by establishing requirements for the electronic recording of clinical data and provides patients with electronic access to their health information. This first stage has concluded. Stage two focuses on moving advancing clinical processes and making certain that the meaningful use of EHRs supports the target and priorities of the National Quality Strategy. Stage three began in 2017 and focuses on improving health outcomes (CMS, 2017b). Flanagan and Weir-Hughes (2016) point out that hospitals in Europe and the United Kingdom have adopted American EHR providers’ solutions and, as a result, the system is driven by medicine. Nursing’s voice will be extinguished if NNN is unaddressed in EHR systems and the rich data supporting nursing’s contributions to improved patient outcomes will be unobtainable. With this backdrop in mind, advanced nurses are cautioned to attend

to NNN and contribute to EHR visibility efforts. A necessary first step is for advanced nurses to develop their understanding of NNN. Using the standardized languages of NANDA, NIC, and NOC differs from using the familiar and customary nursing process. NNN compel data interpretation rather than data collection. NNN provides outcome data and nursing intervention using a standardized format rather than the narrative forms with which many nurses are familiar. Narrative documentation can be difficult to interpret owing to inconsistencies, inadequacies, and different style forms that make drawing comparisons difficult. NNN in an EHR supports consistency because the names used for patient outcomes and nursing interventions are available to all nurses (Lunney, 2006). Lunney (2006) suggests that both novice nurses and advanced beginners are capable of proficiently learning and using NNN. More experienced nurses, including advanced nurses, may need encouragement to document and think differently than the status quo. As the EHR is further integrated into the healthcare system, nurses will become more accountable for their diagnoses, outcomes, and interventions and the impact these processes will have on cost and quality. Educators will need to make certain that nursing curriculums include NNN so that nurses learn how to collect data, rule in or rule out diagnoses, and perform complex nursing interventions (Lunney, 2006). Staff development experts and those in administration will also need to be certain that nursing professionals are well versed in NNN. A good source of information is the website of the University of Iowa’s College of Nursing’s Center for Nursing Classification and Clinical Effectiveness. The center’s home page offers information about NIC and NOC and has resources for purchase, translations, and reports available for review. An extensive list of hyperlinks provides starting points for knowledge acquisition (University of Iowa, College of Nursing, 2017).

Conclusion Advanced nurses practicing in direct and indirect care roles have a critical responsibility for outcomes measurement and management. Patient safety, catapulted to the forefront of public attention with the published report To Err Is Human (Institute of Medicine, 1999), is a critical quality indicator in health care that has a broad and deep reach across all aspects of the national healthcare system. Rightly so. Advanced nurses must recognize the partnership between outcomes, quality improvement processes, and evidence-based practice. Outcomes measures provide indicators of quality that may be improved through the use of systematically applied evidence. In addition to using outcomes measures to demonstrate quality improvements within systems and processes, nurses are challenged to demonstrate their impact on patients/families, nurses, and organizations by using outcomes measures that are sensitive to their unique contributions. More attention must be paid to integrating the language of nursing into the EHR. Selecting measurable and meaningful outcomes is not an easy task. It can be challenging to discern the “best” outcomes measure out of the many potential outcomes that could exist related to a specific aspect of health care. Garnering input from interprofessional colleagues via working teams can be very helpful. Advanced nurses should use established resources that are available to them from the exceptional foundations, agencies, and organizations that have made outcomes improvement their reveille call. Tools from these experts provide valid and reliable measures of quality. Outcomes management and QI can be overwhelming to new advanced nurses or to those unfamiliar with this burgeoning area of inquiry; however, starting with unit projects or smallscale department activities can be a good way to develop a repertoire of QI process tools.

Discussion Questions 1. Identify a clinical problem or patient safety issue in your practice setting. Develop a business case for a quality improvement project in your setting. Why was this difficult to do? 2. Of the most common patient safety concerns discussed in this chapter, which was most pertinent to your practice setting? 3. As an advanced practice nurse you should investigate available resources for implementing quality improvement program; what resources are available to you at your institution? 4. Explore the website of the Institute for Healthcare Improvement; register to access the Quality Improvement Essentials Toolkit and download the PDSA worksheet and project planning form. Get started on your project.

References

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CHAPTER 13 Providing Patient Value While Achieving Quality, Safety, and Cost-Effectiveness J. Michael Leger, Sandy K. Diffenderfer, Janne Dunham-Taylor, Karen W. Snyder, and Dru Malcolm

CHAPTER OBJECTIVES 1. Articulate the goal of high-quality patient care. 2. Explain the four most important hospital strategies to be implemented to prepare for value-based payments. 3. Describe administrative practices that support performance improvement efforts. 4. Analyze the nurse leader’s role in patient safety. 5. Propose ways that nurse leaders can promote evidence-based practice. 6. Synthesize how nurse leaders can promote patient value while achieving good quality, safety, and cost-effectiveness.

Introduction The most important priority in all healthcare settings is to determine what the patient wants and values; to provide safe, loving, high-quality care; and to constantly improve care delivery and continuity across the continuum in a cost-effective way. This is true for staff and physicians at the point of care and for administrators in all decisions and actions. This is a demanding goal. Thankfully, at times it is achieved. When this goal is met, the patient and caregivers recognize that it was worth the effort. As healthcare payments are transformed from volume-based to value-based reimbursement over the next decade (American Hospital Association 2011 Committee on Performance Improvement [AHA], 2011), this goal must be met. Four significant challenges and related goals confronting contemporary health care are the focus of this chapter (BOX 13-1):

BOX 13-1 Four Significant Challenges in Health Care 1. 2. 3. 4.

To habitually determine what our patient/client/resident wants and values To provide the very best quality care, once we know what the patient wants and values To keep our patient/client/resident safe To accomplish the first three challenges in a cost-effective way

1. To habitually determine what our patient/client/resident wants and values. Healthcare workers often miss the goal related to this challenge. Many individuals in health care do not know how to discover what the patient wants and values. Often workers are focused only on the current care setting rather than on continuity across the continuum. Determining what the patient wants and values must be assessed by staff at the point of care. In addition, everyone in the organization, from board members and the chief executive officer (CEO) to the nurse aide and housekeeper, should make regular rounds to speak and interact with patients to determine whether their needs are being met. Often healthcare

workers are not good listeners; active listening must begin with those in administrative roles because executive leaders set the tone for the organization. Thus far, healthcare leaders have not clearly identified how to determine what the patient wants and values, and the current quantitative outcome measures do not capture whether this goal has been accomplished. Instead, healthcare measures focus on patient satisfaction scores, complications, financial ratios, and/or staffing or turnover metrics—none of which captures whether the patient got what was wanted or valued. The core principle of patient care quality is to determine what the patient wants and values and to make the patient the leader of his or her care. These are misunderstood principles. 2. To provide the very best quality care, once we know what the patient wants and values. Care that is provided must take into account what the patient wants and values while collectively using the nurses’ professional judgment, along with evidence-based care. What we believe is high-quality care may be at odds with what the patient wants and values. Nevertheless, healthcare providers must be cognizant of their patient advocacy and teaching responsibilities because the patient may not be aware of quality and safety standards. 3. To keep our patient/client/resident safe. To accomplish this, everyone in health care must constantly consider ways to improve safety. Healthcare organizations and systems are complex. As the complexity of healthcare delivery increased, bureaucracies were formed. The complexity has resulted in increased healthcare errors. Our goal is to simplify our organizational environment by carefully examining what we do to determine whether these activities reflect the organization’s mission and values. This means that everyone is a leader, especially the staff nurse and nurse aide, who make 90% of their work decisions at the point of patient care. These leaders continuously make small, incremental changes as they interact with each patient and determine the need for change. Thus, it is important that administrators recognize, value, and support leaders at the point of care and for administrators to be a part of the patient care team.

When problems are identified, the issues are recognized as critical opportunities to simplify the patient environment and to make it safer. Interdisciplinary shared governance and the accompanying complex communication are essential to hear the “voice of the customer” (National Institute of Standards and Technology, 2013, p. 13) and to keep patients safe. Failure to identify these problems and issues results in an increase in errors that results in poorer patient outcomes and reimbursement. 4. To accomplish the first three challenges in a cost-effective way. Cost-effectiveness is listed fourth because it should never be given a higher priority than the previous three goals. As stated in other discussions, “If we do what is right for the patients, financial well-being will follow.” The bottom line is never the first priority. To accomplish this goal, financial information needs to be transparent across the organization because staff at the point of care must understand the costs to complete delivery of care in the most cost-effective way. Everyone in the organization needs to make decisions based on the organization’s mission and values—what is best for patients—with the bottom line always being second. To present the information in this chapter in a more meaningful manner, it is being subdivided into three sections: Part 1: Problems We Must Address Part 2: What Does the Patient Want? Part 3: The Impact of Quality

PART 1: PROBLEMS WE MUST ADDRESS

We Have a Long Way to Go to Fix Our Healthcare System We are facing major healthcare problems in the United States. According to the World Health Organization (WHO, 2014), in 2011, the United States spent $6.9 trillion on health care, more than any other country, yet outcomes are comparable to third-world countries. In addition, the Commonwealth Fund (2013) reported that the 2011 National Scorecard on U.S. Health System Performance, which assessed health and health care in the United States based on quality, access, efficiency, and equity, assigned the United States a score of 52 out of a possible score of 100. This is far short of what is attainable, considering the U.S. per capita expenditure on health care. Care is often fragmented and depersonalized. Unintentional harm to patients is common. At times, the patient’s condition becomes worse rather than better—or the patient dies when he or she comes in contact with healthcare workers. Patients’ needs and values are often not considered in the plan of care. This is compounded by the sheer number of the U.S. population that is uninsured. It is a primary goal of the Patient Protection and Affordable Care Act (PPACA; U.S. Government Printing Office, 2010), otherwise known as the Affordable Care Act (ACA), to provide many of these individuals with health insurance; nevertheless, some individuals—for example, migrant workers—will remain uninsured. In 2017, under the new administration, President Donald Trump issued an executive order to repeal the ACA, which did not gain full congressional support; however, his administration is directing federal agencies to modify the PPACA of the Obama administration (Saltzman & Eibner, 2016). Under the Trump administration, states are able to impose work requirements on Medicaid recipients and to ease restrictions on short-term health plans. In addition, there is no longer a penalty to enroll for health insurance under the new tax plan. Moreover, current healthcare reforms include a directive to federal agencies to end rules forbidding employers from using health reimbursement arrangements (HRAs) to pay individual insurance premiums. This makes it easier for small businesses

to join and form association health plans (White House, 2019). The impact of current changes and plans for future ACA revisions remains to be seen. Preparing for the future state of health care requires leadership, planning, and change management. In the seminal work Hospitals and Care Systems of the Future (AHA, 2011), an outline of 10 must-do strategies was recommended that hospitals must implement in preparation for the future value-based market dynamic, termed the “second curve” (p. 3). An organizational culture of performance improvement (PI), accountability, and quality is critical to implementation of these strategies (AHA, 2011). The entrenched hierarchal, patriarchal culture that continues to thrive in the U.S. healthcare system will need to change in organizations that intend to remain viable. Nevertheless, organizational culture develops over time and is resistant to change. What is needed are transformational change agent leaders who understand the complex nature of the healthcare system. Complexity change agents refute the traditional assumptions of organization change that envision organizations as machines (Crowell, 2011). The complexity view of the leader/change agent recognizes that change starts with those closest to the work of the organization, efficiency does not come from control, and prediction is not possible (Crowell, 2011). Leaders who will be successful in navigating the turbulent coming years in health care recognize that improvements are emergent, not hierarchical. Successful leaders/change agents may arise at any level of the organization or even outside the organization; nevertheless, they recognize how and when to influence the system toward self-organization. Although incremental improvements are positive and need to continue, the entire healthcare system must change to meet the challenges of the upcoming healthcare reality. Of the 10 strategies set forth by the AHA (2011), four are identified as major priorities. The underpinnings for all four of these strategies are concomitant with quality and value: (1) seamless patient care across the continuum, (2) use of evidence-based practice to improve quality and safety, (3) improved efficiency, and (4) development of integrated information systems. The first priority addresses the need for seamless patient care across the continuum (AHA, 2011). Whereas all members of the healthcare team

are involved in implementation of this priority, it is recognized that nurses play a key role in patient continuity of care, including patient education and communication. As the focus of health care transitions to value across the continuum of care, the role of nurses, nurse practitioners, and case managers will come to the forefront. This priority is also linked to priority 2, second-curve metrics, “Utilizing evidenced-based [sic] practice to improve quality and patient safety” (p. 4) because the expectation is measurement and management of care transitions (AHA, 2011). The second priority set forth by the AHA (2011) proclaims the use of evidence-based practice to improve quality and safety. In addition to measurement and management of care transitions, second-curve metrics related to this priority include the following: Management of utilization variation Preventable admissions, readmission, nonemergent/nonurgent emergency department (ED) visits, and mortality Reliable patient care processes Active patient engagement in design and improvement (AHA, 2011, p. 4) Most contemporary nurse leaders have experienced the challenge of linear measurement models. Nevertheless, successful nurse leaders recognize the potential for integration of complexity principles into such measurement models and are positioned to lead change related to current measurement assumptions to create models that reflect the complex nature of healthcare delivery (Porter-O’Grady & Malloch, 2011). Because leaders are duty bound to ensure regulatory compliance— especially considering value-based purchasing mandates—measurement models must include industry standards and measures that reflect the mission, values, and context of the organization as well as what the patient wants and values. The third priority identified by the AHA (2011) is improved efficiency. It is well known that unnecessary operational inefficiency is a significant source of healthcare costs. Fortunately, healthcare workers have some control over this dynamic (de Koning, Verver, van den Heuvel, Bisgaard, & Does, 2006). This priority is a familiar one; nevertheless, robust PI work must continue using methods, such as Lean thinking and Six Sigma, to increase productivity and improve financial management.

These methods can be combined to provide a framework for systematic improvements in health care (de Koning et al., 2006). It is important here to point out that there is tension among professionals in regard to the best approach to improving quality, specifically whether an incremental approach or a systems approach is most effective. It is our opinion that both approaches are needed to survive in the ever-changing healthcare environment. The final priority for hospitals in preparation for the value-based market is the development of integrated information systems (AHA, 2011). Technological advances contribute significantly to the increasing cost of care. However, it is evident that data must be readily available for analysis and improvement to work. Regardless of what happens financially, health care will change.

Patient Safety Issues The priority for quality improvement work is always to provide a safe environment. The focus is to design quality and safety into our processes. The focus on safety is evident because publications about patient safety are published daily. For example, the Leapfrog Group (2018) published recommended “leaps” that organizations should take that promote quality. The recommendations include (1) implementing computerized physician order entry (CPOE), (2) having an electronic health record (EHR) (also called electronic medical record [EMR]), (3) implementing intensive care unit staffing with physicians experienced in critical care medicine, and (4) attaining a high Leapfrog Safe Practices score. The safe practices score measures the organization’s progress in meeting and implementing the safe practices endorsed by the National Quality Forum that are aimed at reducing the risk of harm in certain processes, systems, or environments of care (Leapfrog Group, 2018). It is estimated that if all hospitals implemented the first three leaps, “over 57,000 lives could be saved, more than 3 million medications errors could be avoided, and up to $12.0 billion could be saved” (para. 3) annually. Again, focusing on prevention of human pain and suffering is the priority. In a groundbreaking report, the Institute of Medicine (IOM, 1999) estimated that as many as 98,000 hospital deaths per year were the result of avoidable medical errors. The landmark study noted that hospital

medical errors were the eighth leading cause of death in the United States. These statistics did not take into account errors that may have occurred in the vast array of other healthcare settings. This report startled the healthcare community and consumers to action, yet the authors noted in a 2005 follow-up report that progress toward improved patient safety was slow (Leape & Berwick, 2005). In 2007, the IOM published findings from a workshop, Creating a Business Case for Quality Improvement Research, acknowledging a “reluctance to invest in quality improvement” (p. 1) throughout the country. Resources are limited and tend to be spent on “highly visible technology-driven programs” (IOM, 2007, p. 1). Although technology can improve systems, it is not the single answer to a safer healthcare system. The Eighth Annual HealthGrades Patient Safety in American Hospitals Study (Reed & May, 2011) reported that from 2007 through 2009, there were 708,642 identified patient safety events. This is daunting considering that only 13 potential patient safety indicators were evaluated in the study, and thus this number represents only a small portion of total patient safety events. Based on the total hospitalized Medicare patients, 1.6% experienced one or more patient safety events. Patient safety events cost Medicare nearly $7.3 billion and resulted in 79,670 potentially preventable deaths. One in 10 surgical patients died following serious but treatable complications. A total of 52,127 Medicare patients developed a nosocomial (hospitalacquired) bloodstream infection; of these patients, 8,114 died. Nosocomial-acquired bloodstream infections cost the federal government approximately $1.2 billion. If all hospitals performed at the level of top-ranked facilities, approximately 174,358 patient safety events and 20,688 deaths could have been avoided, saving the federal government $1.8 billion. These authors noted that preventable medical errors are so prevalent and expensive that selected indicators will be part of a hospital’s performance score for the value-based incentive plan. The Hospital Value-Based Purchasing Program, which was established by the PPACA of 2010 (U.S. Government Printing Office, 2010), represented the first

time that U.S. hospitals were paid for inpatient service based on quality rather than on quantity. Beginning in fiscal year 2013, Medicare made incentive payments to hospitals based on how well they performed on clinical measures as well as on measures based on patients’ experiences or based on improvement of the measures compared to their baseline (Centers for Medicare and Medicaid Services [CMS], 2011). Although the definitions of several of the indicators in the study were changed from the previous report, it is clear that patient safety events remain a problem in U.S. hospitals (Reed & May, 2011). The most important issue is human pain, suffering, and loss and death related to these preventable events. The healthcare system must be fixed. Being proactive in preventing patient safety events is important. However, when mistakes occur, administrators must react from the complexity, “no blame” perspective rather than from the patriarchal Industrial Age view. The traditional approach to patient safety violations was to identify what an individual practitioner did wrong. Serious errors resulted in occurrences being “reported to the board for disciplinary investigation because of an error or breach in the standards of safe practice” (Woods & Doan-Johnson, 2002, p. 45). Many facilities have adopted no-blame policies rather than focusing on blame and punishment. There are two issues here. First, assigning blame encourages individuals to hide or not report errors. Second, even when one individual made the error, upon critical examination, usually there are underlying process problems. Most often, there are multiple factors that caused the error. Administrators must consider the most important issue about errors —what can be done to prevent the error from occurring again? A more effective solution is to report the error and to undertake a root cause analysis to determine what process changes—or patterns or trends—occurred that provide clues for needed changes. Medical errors usually involve more than one individual and require a systems approach to find solutions. Usually, an organizational systems process went wrong or a better process needs to be implemented. Administrators must establish systems to prevent reoccurrence. A systems approach is best. Establishing a just or blame-free culture is critical if organizations are to focus on process and system improvements rather than on assigning blame. Without the occasion for open discussion, many opportunities for

improvement are hidden or go unreported because team members are fearful of losing their jobs or getting into trouble. To this end, the problem will reoccur. Creating a just culture begins with executive leaders and must be reinforced each time an incident occurs. Administrators must be informed. Once informed, it is important that administrators model expected behaviors, speak publicly about safety, set expectations, establish policy, and personally participate in significant event root cause analyses. Another important source for patient safety opportunities is the organization’s incident reports or variance reports. Healthcare risk managers have used these tools for years; nevertheless, the information provided in these reports needs to be used more effectively. Incident or variance reports are traditionally used to alert risk managers of potential litigation. The risk manager’s role has historically been to identify, manage, and reduce risk to support the delivery of safe health care while reducing organizational legal risks. Most risk management activities occur after an incident; thus, these functions are not the best way to achieve safe care. Nevertheless, administrators need to pay particular attention to these resources because these reports provide valuable information regarding organizational issues that need to be resolved to ensure patient safety. An emerging role in health care is the patient safety officer. This position promotes safety through education; examination of issues to determine better and safer organizational processes; discovering the root cause; creating system changes to prevent future incidents of the same kind; and involvement in implementing programs designed to foster safety. The patient safety officer works closely with risk management personnel to discover the root cause of patient safety events and to create system changes to facilitate a safer environment.

Medication Errors The IOM released a report in 2006 on prevention of medication errors. The research discovered a frightening statistic: “a hospital patient can expect on average to be subjected to more than one medication error each day” (p. 1). Errors occurred in every step of the medication process,

but more occurred during prescribing and administration. Experts estimate that error rates are actually higher than the numbers reported. One of the studies cited in the report documented an additional cost of $8,750 per hospital stay for each adverse drug event. The IOM (2004a) reported in an earlier study that “two hospitals over a 6-month period found that nurses were responsible for intercepting 86 percent of all medication errors made by physicians, pharmacists, and others involved in providing medications for patients before the error reached the patient” (p. 3). The IOM (2006) asserts that most of the errors and the additional costs were preventable. The risks of adverse drug events are higher for nursing home patients. Garcia (2006) predicted that nearly “two thirds of nursing facility residents will experience an adverse drug event over a 4-year period of time, with one in seven of these residents requiring hospitalization” (p. 306). Simonson and Feinberg (2005), in extensive work reviewing the medication issues in elderly adults, identified that one-half of adverse drug events in nursing home facilities are preventable. Caution is advised related to computerized provider order entry. Although EHRs, which include CPOE and clinical decision support (CDS), have improved some aspects of patient safety, Wetterneck et al. (2011) reported an increase in duplicate medication order errors following implementation of EHRs with CPOE and CDS. These researchers identified improved communication, teamwork, and CPOE usability and functionality as approaches to reducing such errors. This is important because EHRs are expensive and technology is often viewed as a failsafe way to prevent medication errors. Medication administration is a complicated process; most errors are system errors rather than user errors. Healthcare leaders need to monitor and analyze medication errors carefully because identified problems may warrant the time and expense of a PI team.

Healthcare-Associated (Nosocomial) Infections Healthcare-associated (nosocomial) infections continue to be an issue in organizations across the country. Healthcare-associated infections that occurred in U.S. hospitals were estimated at 1.7 million and were associated with approximately 99,000 deaths (Klevens et al., 2007). Scott

(2009) estimates the range of overall annual direct medical costs of hospital-associated infections as between $28.4 billion and $33.8 billion. Scott estimated the range for the cost benefits of prevention as $5.7 billion to $6.8 billion (low) to $25.0 billion to $31.5 billion (high). Reed and May (2011) reported that hospital-acquired bloodstream infections among hospitalized Medicare patients for the period of 2007 to 2009 were serious and costly: hospitalized Medicare patients acquired 52,127 bloodstream infections, 8,114 patients died, and the cost to the federal government was an estimated $1.22 billion. Again, the most important issue is human pain, suffering, and loss and death related to these preventable events. Methicillin-resistant Staphylococcus aureus, or MRSA, has reached endemic levels in hospitals and long-term care facilities, and rates continue to rise. The increasing numbers of patients with healthcare-associated infections provide evidence that healthcare workers are not following the most basic preventive measure: good hand hygiene. The healthcare system must be fixed. Nevertheless, complexity theory provides an underpinning for approaching this issue. Crowell (2011) describes complexity science as “nonlinear, dynamic, often uncertain, and very much relationship-based” (p. 3). The focus needs to be bottom-up rather than top-down management. Lindberg and Clancy (2010) propose that within organizations, some individuals or groups have different “deviant” practices that produce better “positive” (p. 152) outcomes. Positive deviance holds that staff members at the point of care are best equipped to solve the problem. The job is to discover positive deviant practices and then, through widespread engagement, spread these best practices throughout the organization and system. Positive deviance is a potentially dramatic breakthrough related to the culture of change for hospitals. An increasing number of hospitals are using this philosophy to solve the problem of MRSA (AHC Media, 2008).

Falls Falls among older adults (age 65 and older) continue to be a safety issue. Falls are the leading cause of death among older adults, with mortality rates from falls increasing over the past 10 years. In 2014, approximately 27,000 people 65 and older died from injuries from

unintentional falls (Bergen, Stevens, & Burns, 2016). In 2016, 3 million people 65 and older were treated in EDs for nonfatal injuries from falls and more than 800,000 of these patients were hospitalized (Centers for Disease Control and Prevention [CDC], 2017). In the report of their study, Stevens, Corso, Finkelstein, and Miller (2006) estimated that the direct costs of falls was $19.2 billion per year, and the CDC (2017) estimated that the direct medical costs of falls in 2015 alone was $50.0 billion. These figures include subsequent long-term care costs or loss of quality of life. The Institute for Healthcare Improvement (IHI, 2013) reported that patient falls are the most prevalent adverse events in hospitals. Of utmost concern is that “injuries from falls are often associated with morbidity and mortality” (para 1). Research suggests that an increasing risk of falls is associated with lower nurse staffing levels (Whitman, Kim, Davidson, Wolf, & Wang, 2002).

Missed Care Missed care is distressing to nurses, but most important, these omissions can result in patient morbidity and mortality. The omission of simple yet missed vital care tasks, such as turning, ambulating, feeding, mouth care, and toileting, can lead to patient complications—for example, decubitus ulcers and pneumonia. Although the patient is always the priority, pay-forperformance/value-based purchasing emphasizes the significant reimbursement ramifications of these two complications alone. It is important to acknowledge that nurses must be accountable for the patient care they provide. Nurses cannot abandon efforts to improve quality and safety; however, leaders can use complexity theory to adapt to the natural aspects of life within the healthcare system. Missed care may be related to poor professional nurses’ delegation skills or failure to properly supervise assigned care. When opportunities to improve are identified, real-time corrections must be made. Or, if the issue is more complex, follow-through is needed to determine next steps, improve and sustain the gains, and never give in to complacency where people say, “That’s just the way it is.” Regardless of the method used to improve quality, the complex nature of health care mandates a culture change in which all

healthcare workers make safety the priority focus every day and in all settings.

Interruptions Interruptions in the work environment are frequently occurring safety issues. When the work of nurses is interrupted, errors occur and efficiency is decreased (Biron, Lavoie-Tremblay, & Loiselle, 2009; Trbovich, Prakash, & Stewart, 2010). An example of process improvement that decreased the frequency of interruptions during medication administration involved the use of red aprons (Relihan, O’Brien, O’Hara, & Silke, 2010) worn by the medication nurse, signaling that the nurse was not to be disturbed (AHRQ, 2008; Relihan et al., 2010). This improvement example demonstrated Lean thinking related to unevenness of flow (Cookson, Read, Mukherjee, & Cooke, 2011). These are a few of the safety issues facing today’s healthcare system. Administrators must find ways to create a culture of safety that does not tolerate continuation of these problems. Ethical principles and standards of care mandate a focus on patient safety.

Workforce Management Issues We examine what happens when registered nurses (RN) or nursing budgets are cut. Studies have shown that the dissatisfaction rate of nurses is four times greater for hospital nurses than for all other U.S. workers (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002). Dissatisfaction is often related to high patient-to-nurse ratios. A poll of RNs by the American Nurses Association (ANA, 2008) revealed that close to half of the respondents are considering leaving their job because of inadequate staffing. Data from respondents were reported as follows: 73% of nurses asked do not believe the staffing on their unit or shift is sufficient. 59.8% of those asked said they knew of someone who left direct care nursing because of concerns about safe staffing. Of the 51.9% of respondents who are considering leaving their current position, 46% cite inadequate staffing as the reason. 51.7% of respondents said they thought the quality of nursing care on

their unit has declined in the last year. 48.2% would not feel confident having someone close to them receiving care in the facility where they work (para. 2). Research supports the gravity of inadequate staffing. Aiken et al. (2002) reported that nurse staffing ratios are linked to quality of care and patient outcomes. Adding one additional patient to the nurse assignment increases the likelihood of patient death by 7% within 30 days of hospital admission. On a positive note, the ANA (2012) cited that “each additional patient care RN employed (at 7.8 hours per patient day) will generate over $60,000 annually in reduced medical costs and improved national productivity” (para. 5). Evidence supports that improving the work environment for nurses can lead to improved job satisfaction and increased patient satisfaction and safety (Dunton, Gajewski, Klaus, & Pierson, 2007; Vanhey, Aiken, Sloane, Clarke, & Vargas, 2004). Likewise, Boev (2012) found preliminary support for the relationship between nurses’ and patients’ satisfaction in adult critical care. Researchers analyzed data from the National Database of Nursing Quality Indicators (NDNQI) regarding the nursing environment in relation to patient outcomes. These researchers concluded that multiple factors, including nurse staffing, percentage of RN staff, and RN years of experience, affect patient safety and nurse-sensitive outcomes. For example, the incidence of hospital-acquired pressure ulcers decreased with a more experienced staff, along with having a higher percentage of RNs caring for the patient (Dunton et al., 2007). The IOM (2004b) supported the following impact that leaner nurse staffing levels have on patient outcomes in their report Keeping Patients Safe: Transforming the Work Environment of Nurses. The report contends that not only have nurse staffing levels been associated with an increased length of stay, higher nosocomial infection rates, and increased pressure ulcer rates, but also there is evidence that indicates patient mortality increases when there is less nursing time provided to patients. In summary, nurses are “indispensable to our safety” (p. 3). Based on these data, the ANA (n.d.) called for support of the Registered Nurse Safe Staffing Act that would create reliable nurse staffing levels. The ANA (n.d.) proclaimed that managing the patient-toRN ratio improves job satisfaction and patient outcomes. Nurses’

dissatisfaction with inadequate staffing is often supported by the research and is linked to less than satisfactory patient outcomes. This is only the beginning of the problem. In Keeping Patients Safe: Transforming the Work Environment of Nurses, the IOM (2004b) noted the following (BOX 13-2):

BOX 13-2 The IOM Notes Negative Quality/Patient Safety Effects of Work Redesign Loss of trust in hospital administration Work redesign emphasized efficiency over patient safety Loss of a separate department of nursing Decline in nurse executives with the power and authority equal to the rest of the executive team Decrease in the number of nurse managers Remaining nurse managers have responsibility for more than one unit Data from Institute of Medicine. (2004b). Keeping patients safe: Transforming the work environment of nurses. Washington, DC: National Academies Press.

Loss of trust in hospital administration is widespread among nursing staff. . . . This loss of trust stems in part from a perception that initiatives in patient care and nursing work redesign have emphasized efficiency over patient safety. . . . Poor communication practices have also led to mistrust. Clinical nursing leadership has been reduced at multiple levels, and the voice of nurses in patient care has diminished. Hospital reengineering initiatives often have resulted in the loss of a separate department of nursing. . . . At the same time, nursing staff have perceived a decline in chief nurse executives with power and authority equal to that of other top hospital officials, as well as [a decline] in directors of nursing who are highly visible and accessible to staff. . . . These changes—along with losses of chief nursing officers without replacement; decreases in the numbers of nurse managers; and increased responsibilities for remaining nurse managers for more than one patient care unit, as well as for supervising personnel other than nursing staff . . . —have had the cumulative effect of reducing direct management support available to patient care staff. This situation

hampers nurses’ ability to fix problems in their work environments that threaten patient safety (p. 4). Evidence has shown that understaffing, negative cultures, burdening nurse managers with more than 50 full-time equivalents (FTEs), 12-hour shifts, the lack of interdisciplinary shared governance, allowing physician or other staff disruptive or abusive behaviors, and moral distress issues are linked to poor patient outcomes; decreased patient, nurse, and physician satisfaction; higher staff turnover; and decreased reimbursement.

Complexity Issues All the preceding problems are complexity issues; everything is interconnected. With a sentinel event as an example, the event causes disorder. A root cause analysis restores order but, it is hoped, with some small incremental change or changes in the way the work is done. Consider the following example of a sentinel event. During the time that the sentinel event occurred, staffing was inadequate, turnover was high because of a negative unit culture, and the nurse manager’s leadership skills were inadequate. All these issues created complexity and contributed to the error. There was no single cause, and “fixing” only one of the problems will not prevent the event from reoccurring. Such quick fixes increase complexity, which is counterproductive to PI work because more complexity creates more errors. This is the reason that all stakeholders are involved in the review and resolution of sentinel events because what is needed is to determine ways to fix the causes and to simplify processes. Sharing the lessons from root cause analyses with all staff demonstrates transparency. Secrets have a way of eventually becoming public knowledge.

Cultural Issues Another factor related to what patients want and value is culture. Increasingly, the U.S. population is becoming more racially and culturally diverse. The following is the U.S. population breakdown by race, according to the 2010 U.S. census (U.S. Census Bureau, 2011):

72% white (223.6 million) (includes 16% Hispanic, [50.5 million]) 13% black or African American (38.9 million) 5% Asian (14.7 million) 2.9% American Indian and Alaska Native (2.9 million) 0.2% Native Hawaiian or other Pacific Islander (0.5 million) 6% other races (19.1 million) The U.S. Hispanic population almost doubled in the last decade (43% growth), yet the U.S. Asian population grew faster than any other major race for the same time period (U.S. Census Bureau, 2011). It is common to see Spanish television stations or to buy a product with instructions written in several languages. Obviously, the U.S. population is ethnically diverse. This diversity constitutes a new perspective not only toward culturally diverse patients but also toward culturally diverse staff. We are often unaware of specific cultural beliefs, values, and traditions, and so we may inadvertently tread on those beliefs and practices as we deliver health care. Just as there is a need for improvement related to patient-centered care, quality, and safety, there is room for improvement related to culturally competent care. As healthcare professionals, it is important to recognize the wonderful differences that exist between cultures and to support the cultural beliefs and norms of others. It is important to educate all staff regarding cultural differences, to value these differences, and to encourage everyone to respect and give radical loving care to each person based on that person’s cultural beliefs. Healthcare workers are ethnocentric in giving care to clients when they do not provide care based on what patients want and value. It is imperative that we take the time to learn about patients’ cultural or ethnic differences. Care based on cultural differences affects nutrition, family functioning, lifestyle differences, spiritual or religious differences, biological variations, the way one relates to both health and disease, communication issues, differences in locus of control, differences in views about independence versus collectivism, and socioeconomic realities. Additional cultural differences exist among physicians, nurses, and nonclinical administrators. In medical school, physicians often learn that

they are autonomous and independent (although this is changing with group practices). This can lead to autocratic, domineering, and paternalistic behaviors because often teamwork and collaboration are not stressed or valued. Also, nurses may determine that they are in a lower position in the hierarchy of importance because administrators tend to provide more support to physicians (who have the power to admit; thus, they affect revenue). These differences can be overcome. It is important that each member of the healthcare team is valued and respected and that everyone upholds the same organizational values to provide quality care for patients. When administrators do not support organizational values and give too much autonomy to physicians, disruptive physician behaviors may continue, creating a less effective or even hostile work environment. Patient care, as well as reimbursements, can be compromised when this occurs.

Disparities Issues Significant healthcare access issues continue. The fifth National Healthcare Disparities Report (AHRQ, 2008) described disparities related to the quality of and access to health care. Although some progress has been made, the report highlights gaps that did not improve (BOX 13-3). A primary problem has been to decrease the identified gaps related to lack of insurance.

BOX 13-3 Disparities Among Races Blacks had a rate of new AIDS cases 10 times higher than whites. Asian adults aged 65 and over were 50% more likely than whites to lack immunization against pneumonia. Native Americans and Alaska Natives were twice as likely to lack prenatal care in the first trimester as whites. Hispanics had a rate of new AIDS cases over 3.5 times higher than that of non-Hispanic whites. Poor children were over 28% more likely than high-income children to experience poor communication with their healthcare providers. Reproduced from Agency for Healthcare Research and Quality. (2008). National healthcare disparities report: 2007. AHRQ Pub. No. 08-0041. Rockville, MD: U.S. Department of Health and Human Services.

Those without insurance often do not get needed medical care. Miller, Vigdor, and Manning (2004) claimed that lack of insurance creates hidden costs for society. These authors based this claim on data from the IOM report that estimated the cost in terms of foregone health, shorter lives, and demands on the healthcare infrastructure to be $65 billion to $130 billion a year. Using this hidden cost to provide insurance coverage would be more effective. Currently the healthcare “safety net” provides care for the uninsured or underinsured. The largest provider in this safety net is hospital EDs. Community clinics, public health departments, and hospital-based clinics, created to provide this care, cannot accommodate the demand. Hospital ED visits classified as nonurgent continue to increase. Key reasons for this include difficulty obtaining timely appointments with a primary care provider, the lack of affordable transportation, and the lack of insurance. Much of this is not reimbursed; thus, hospitals incur more and more of the expense of providing this care.

Regulatory Response: Restricting or Eliminating Reimbursement As healthcare expenses rise, federal and state governments are faced with deficits. At the same time, there is a growing elderly group who is eligible for Medicare. The CMS, which represents more than 50% of the health insurance in this country, responded by reimbursing for highquality care and withholding reimbursement when quality issues were identified (pay for performance or value-based purchasing).

Hospitals Acute care facilities must demonstrate compliance with the guidelines for care of certain conditions to receive the highest possible reimbursement. In this case, the CMS (the payer) specified certain patient care paths, founded on evidence-based practice, to obtain reimbursement. If the patient care path is not followed as specified, the healthcare organization does not receive reimbursement for the care. For example, if antibiotics are not given within 2 hours of a pneumonia diagnosis (the care path specification), the payer will not reimburse the hospital. This emphasizes

the importance of clinician timeliness in treating the patient, or everyone loses, including the patient. In 2008, additional indicators were put in place restricting or eliminating reimbursement for certain hospital-acquired conditions that were not present on admission (CMS, 2012d). These hospital-acquired conditions were expanded to 11 categories for fiscal year 2013 (CMS, 2012c). (See BOX 13-4.) These conditions have been termed never events.

BOX 13-4 2013 CMS Hospital-Acquired Conditions Foreign Object Retained After Surgery Air Embolism Blood Incompatibility Stage III and IV Pressure Ulcers Falls and Trauma Fractures Dislocations Intracranial Injuries Crushing Injuries Burn Other Injuries Manifestations of Poor Glycemic Control Diabetic Ketoacidosis Nonketotic Hyperosmolar Coma Hypoglycemic Coma Secondary Diabetes with Ketoacidosis Secondary Diabetes with Hyperosmolarity Catheter-Associated Urinary Tract Infection (UTI) Vascular Catheter-Associated Infection Surgical Site Infection, Mediastinitis, Following Coronary Artery Bypass Graft (CABG) Surgical Site Infection Following Bariatric Surgery for Obesity Laparoscopic Gastric Bypass Gastroenterostomy Laparoscopic Gastric Restrictive Surgery Surgical Site Infection Following Certain Orthopedic Procedures Spine Neck Shoulder Elbow Surgical Site Infection Following Cardiac Implantable Electronic Device (CIED) Deep Vein Thrombosis/Pulmonary Embolism Following Certain Orthopedic Procedures Total Knee Replacement Hip Replacement

Iatrogenic Pneumothorax with Venous Catheterization Reproduced from Centers for Medicare and Medicaid Services. (2012c). Hospital-acquired conditions (present on admission indicator). Retrieved from http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/HospitalAcquired_Conditions.html

The CMS (2013e) quality initiatives encompass the gamut of the healthcare system, from providers to hospital care, and include quality measures information that the CMS recommends that consumers use when faced with healthcare decisions. The CMS quality initiatives span several years, and thus only an overview is provided here. The Hospital Inpatient Quality Reporting Program was originally mandated by the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 (CMS, 2003). The MMA authorized the CMS to pay hospitals a higher annual update on their payment rates based on reporting of identified quality measures. The initial MMA rate was a 0.4% reduction for hospitals that did not successfully report. In 2005, the Deficit Reduction Act increased the reduction to 2.0 percentage points (CMS, 2013b). The Hospital Outpatient Quality Reporting Program was mandated by the Tax Relief and Health Care Act of 2006 (CMS, 2006). This program required hospitals to submit outpatient quality measures data. The data included process, structure, outcome, and efficiency measures. Outpatient care encompassed ED services, observation, outpatient surgical services, laboratory tests, and radiology (CMS, 2013a). An example of a quality initiative is the Hospital Value-Based Purchasing Program (CMS, 2013c), effective fiscal year 2013, which provides value-based incentive payments based on the hospital’s performance on quality measures (pay for performance) or based on the hospital’s improvement on quality measures from the baseline period. The higher the hospital’s performance or improvement, the higher the value-based incentive payment. If a hospital does not meet these guidelines, reimbursement will be decreased by a percentage for the following year. Thus, hospitals not only lose on a never event but also are penalized further for reimbursement the next year.

Home Health

There are three types of home health quality measures: (1) process, (2) outcomes, and (3) potentially avoidable events (CMS, 2012b). Details related to home health measures are extensive and can be found at www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/HomeHealthQualityInits/Home-Health-QualityMeasures.html.

Long-Term Care The CMS nursing home measures are also extensive. There are 5 shortstay quality measures and 13 long-stay nursing home quality measures (CMS, 2013c). Details related to nursing home quality measures are vast and can be found at www.cms.gov/Medicare/Quality-Initiatives-PatientAssessmentInstruments/NursingHomeQualityInits/NHQIQualityMeasures.html.

Postacute Care Finally, additional CMS quality initiatives are in place for postacute care (CMS, 2012e) and for end-stage renal disease (ESRD) (CMS, 2012a). The ESRD Quality Initiative, which became effective in 2012, was the first pay for performance (also known as value-based purchasing) quality initiative implemented as mandated by the Medicare Improvements for Patients and Providers Act (MIPPA) of 2008 (U.S. Government Printing Office, 2008). Its goal was to enhance the quality of care provided to ESRD patients as they battle this devastating disease (CMS, 2012a). Additional information regarding the CMS quality initiatives can be found at www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/QualityInitiativesGenInfo/index.html? redirect=/qualityinitiativesgeninfo/.

Quality Reporting System Mandate In an effort to align payment incentives across the healthcare system, the CMS (2013d) implemented payment incentives and adjustments to promote reporting of quality information by identified providers. The quality reporting system is mandated by federal legislation. Beginning in 2015, the program also applies to eligible providers who do not

satisfactorily report quality measures data (CMS, 2013d). Details related to the Physician Quality Reporting System can be found at www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/PQRS/index.html. Medicaid programs are funded at both state and federal levels; thus, these restrictions on reimbursement are being linked to Medicaid payments as well. Next, the AHA developed guiding principles for nonpayment for all insurance companies for certain serious adverse events (that are preventable, may indicate a hospital system error, or where there are published guidelines for prevention of these errors if the hospital deems the event was preventable) from the National Quality Forum’s list of 28 serious reportable events (Tennessee Hospitals & Health Systems, 2008). (See BOX 13-5.)

BOX 13-5 The American Hospital Association’s Guidelines for Reimbursement Restriction The American Hospital Association recommends that hospitals not seek payment from patients or their insurance companies for the following serious preventable adverse events if the hospital deems the event was preventable: Surgery on a wrong body part Surgery on the wrong patient Wrong surgical procedure Unintended retention of a foreign object Patient death or serious disability associated with an air embolism that occurs while being treated in a healthcare facility Patient death or serious disability associated with a medication error Patient death or serious disability associated with a hemolytic reaction due to administration of ABO/HLA incompatible blood or blood products Artificial insemination with the wrong donor sperm or wrong egg Infant discharged to the wrong person Death or serious disability (kernicterus) associated with failure to identify and treat hyperbilirubinemia in neonates Patient death or serious disability associated with a burn incurred from any source while being cared for in a healthcare facility Data from Tennessee Hospitals & Health Systems. (2008). THA develops nonpayment policy on serious adverse events. Nashville, TN: Tennessee Hospital Association.

Patient safety was of such concern to the public that the Joint Commission (JC) implemented National Patient Safety Goals in 2003

(JC, 2018). Accredited facilities must demonstrate compliance with the intent of these goals to maintain their accreditation status. Details regarding the National Patient Safety Goals (JC, 2018) can be found at www.jointcommission.org/standards_information/npsgs.aspx.

Our Reality Is Changing—Ready or Not As you read this chapter, begin to think of the many ways nurses can change how healthcare services are provided—ways that are much more effective and that involve the patient in care decisions. This leads us to something that we need to make top priority as we give care: finding out what the patient wants and values. There are opportunities all around us. Patients have access to more information about their care, yet they need our help in translating the meaning of various options available to them when they experience disease. At the same time, they are turning to healthier lifestyles so that they can live longer, healthier lives. Nurses have an advantage in this environment because, although we learn about disease and how it is treated, we also learn about prevention and health. In healthcare organizations, nurses are with patients far more than are physicians. Patients value our interpersonal skills because we are more likely to listen and to help. Thus, for us, moving into this new age is not as difficult as it is for physicians who are mainly focused on disease and which medications to prescribe to deal with disease. Nurses also have a lot to offer to bottom-line healthcare administrators who do not necessarily understand the care side of health care. We can help them in this shift because we are closer to the patient and can bring that perspective to the table. The important place for survival is at the point of care. As administrators, we need to encourage and empower staff at the point of care to make 90% of the decisions about that care. Staff need to become leaders, helping patients become leaders in their own care decisions. We administrators are here to facilitate staff to do this. We need to be sure that staffing is adequate, and more staff may be needed during peak times. We need to protect staff so that they can do their work. We need to support interdisciplinary shared governance at the bedside, with everyone in the organization doing regular rounds. Our intent is to help nurse leaders express what is needed, using

statistics, so that linear administrators are more likely to listen. This helps make it possible for patients to get what they value while they are with us. Linear administrators understand, and need, numbers. If we format what we believe is needed in a way that shows numbers and dollars, our suggestions are more likely to be supported within an organization. Along with this, we need to involve staff in budgets, sharing financial information. Transparency throughout the organization is the end goal.

PART 2: WHAT DOES THE PATIENT WANT?

Our First Priority: Discovering What the Patient Wants and Values Value from the patient’s perspective is the most important concern. Sometimes patients believe that the healthcare provider does not listen and does not care to listen to what the patient actually wants or needs. The old paternalistic medical model—we will just tell you what is best for you—is outdated, is resented, and no longer applies to most patients. Patients often feel depersonalized, experience long waits, and, worse yet, receive substandard care, especially if they are in a lower socioeconomic group or if they are a racial or ethnic minority. Porter-O’Grady and Malloch (2011) discuss the change in the patient– provider relationship: Patients now determine the parameters of the patient–provider relationship, setting the stage for a different kind of interaction than has historically occurred. Patients need to develop partnerships with providers to sort through the available choices and pick the best. They need providers to act as educators who are willing to assist them in making healthcare decisions. Patients need help from providers both in verifying the accuracy of the data they have independently garnered from a host of sources and in interpreting the data. Patients are interested in options, not an order to undergo a particular treatment. They want to be able to consider a range of options within the context of their own personal values and priorities and to choose the one option that best fits these. Providers now need to be concerned with what patients know and can do with regard to controlling their own health decisions in a “userdriven” world. More of the responsibility for health care will be placed on patients and their loved ones. Providers must now transfer skills to others and surrender ownership of care to others (p. 17). It is important for the nurse leader to constantly think, What does the

patient want and value? along with safety, safety, safety, quality, quality, quality, and cost-effectiveness, cost-effectiveness, cost-effectiveness. The nurse leader can facilitate what is valuable to patients. The expectation is that staff at the point of care do the same thing. This is a change for most of us, who are accustomed to providing care with no consideration of the patient’s perspective. Administrators are not alone in needing to change their perspective. All staff, board members, physicians, and the executive team must change their perspectives. Everyone has to talk with each patient and listen to what he or she has to say. The most important place is at the point of care, and administrators must support those who are at this point of care. Paying attention to what the patient values as the first priority, with safety and quality second, enables us to make better decisions, be more effective, and save money and risk to the patient. This perspective has a positive impact on the financial bottom line as well. Thus, everyone wins. Values depend on the circumstances and whose point of view is being considered. Patient perceptions, and what the patient wants, are more important than what we believe the patient should want when determining quality indicators. Once we have determined what evidence-based care might be necessary for a specific patient (after we have determined what the patient wants), there is still more to do. We need to then offer the patient choices in remedies and therapies that fall under that evidencebased care rubric while ensuring that the patient is fully informed. Currently healthcare team members fail in healthcare delivery because we often consider what we want instead of consulting the patient and finding out the patient’s wishes. Value has another implication. We all must understand the importance of including our patients as leaders in the decision-making process of their care, otherwise known as patient-centered care. The patient has to be involved in deciding which services will be provided. This pivotal point will change health care as we know it. The Consumer-Driven Health Care Institute (2013) promotes policy that empowers individuals to make decisions about their health care, advocating the following: Consumers will work with their physicians and healthcare providers to

create a better healthcare outcome for themselves and their families. Healthcare usage is more cost-efficient with empowered and knowledgeable consumers who use information tools. Price and quality transparency about healthcare professionals constitute a key method for effective consumer healthcare choices (para. 2). Transparency means that we share all pertinent information. Consider that if we did not share, the Internet nevertheless provides voluminous information, and the CMS provides information to the general public, including facility quality ratings. We cannot stop the tide—information is accessible to the public. Some of the information is helpful and excellent; some is erroneous and misleading. Nurses can assist patients to appropriately evaluate this information to make the best decisions. Another trap for nurses is to lament that improvements cannot be made because of inadequate resources. Active listening does require a lower patient-to-nurse ratio so that the nurse can take the time to determine what patients value and desire. In addition, traditionally there have been cyclical nursing shortages. But bemoaning shortages and financial constraints does not improve patient care. The excuse of inadequate resources needs to be discarded, and instead nurses must determine how to make a positive difference. However, that being said, it is important that administrators make sure that staffing is adequate for current patient needs. And all of us, including staff, need to be creative and make sure we are using the resources we have in the most advantageous way possible. This is important because, if nurses do not find a way to do things better, someone else will. Nurses need to be innovative and encourage all staff and physicians to be innovative. When contemplating current practice, nurses must evaluate what needs to be changed. For example, are limited visiting hours really necessary? Why are most procedures scheduled Monday through Friday? It is interesting that consumer groups advocate not having procedures scheduled on Friday because staff are often limited on weekends and are thus less equipped to deal with patient complications. If a patient has an acute episode on Friday evening, why does the patient have to wait until Monday for most services? We must question everything we do.

Not much has been discussed about quality and safety in this section because the issues that were reviewed are important if nurses are to deliver patient-centered quality services. It is important to emphasize listening to the patient, providing sufficient information for decision making, and supporting the patient in treatment decisions—all within a safe, cost-effective environment.

The Healing Relationship The IOM (2001) advocates, “Care is based on continuous healing relationships” (p. 3). At times in this chapter, we mention “loving” care. Love is necessary for healing. By love, we mean a caring relationship. Jean Watson (2004) examined the relationship between caring and curing in her book Postmodern Nursing and Beyond. She examines both the technical side of nursing and the holistic side, which is traditionally associated with caring. Over the years, a lot of emphasis has been put on the caring component of nursing practice. Chapman (2004) made the connection between loving and healing and stressed the importance of listening to the patient. This means that as we listen to each patient, we read between the lines using our intuition. The physical diagnosis may not be the most important issue for the patient. Instead, nurses must determine what the patient wants and values and focus the patient’s care on what is important to the patient. Chapman (2004) encourages us to see that what the patient needs goes beyond the physical needs to the emotions. Significant life changes are often thrust upon a patient. The patient may be in pain, and pain can be a lonely experience. The term radical loving care (Chapman, 2004) stresses the importance of making a significant connection with each patient. It is a trinity that is very beneficial to have present in a healthcare organization: the Golden Thread (the loving thread that connects us), the Sacred Encounter (each time we interact with a patient), and the Servant’s Heart (we serve others).

Patient and Family Advisory Councils One way to find out what patients want and value is to conduct focus groups with patients and families. Focus groups or patient advisory

councils can be very beneficial in determining what patients and families value and want related to health care. Many organizations find that focus groups augment other forms of feedback, such as results from patient satisfaction surveys. Consumers Advancing Patient Safety (2012) has a step-by-step guide with examples on how to partner with patient groups to enhance value and safety (AHRQ, 2012). Additional information regarding Consumers Advancing Patient Safety can be found at www.patientsafety.org. In addition, it is important to include the patient and family in interdisciplinary rounds and shift reports at the patient’s bedside. In some organizations, interdisciplinary rounds and shift reports are completed just outside the patient’s room. This is disrespectful to the patient, who is the leader of his or her plan of care, and these conversations may also pose confidentiality issues. Often the healthcare workers focus on their needs rather than on the needs and values of the patient. Of course, the patient’s acuity and state of rest may preclude report at the bedside.

Replace Patient Compliance With What the Patient Wants and Values Recall that the patient is the leader in his or her care. Value is based on what the patient wants and needs; thus, the phrase patient compliance should be eliminated from our healthcare vocabulary. The term originates from the patriarchal medical system. Patient compliance assumes that healthcare workers know better than the patient what the patient wants and values. This term has negative connotations, and thus many healthcare workers use the term adherence instead of compliance. The ethical principle of autonomy applies here. Special pause is needed related to this issue because the ANA Code of Ethics with Interpretive Statements (2001) upholds the patient’s right to selfdetermination, or autonomy. Patients have the moral and legal right to make knowledgeable, informed healthcare decisions, with the support of family and significant others, by: Receiving accurate, complete, and understandable information in a manner that facilitates informed judgment; Being provided available treatment options, including no treatment,

and the risks and benefits of those options; and Feeling supported by healthcare providers in the patient’s decision to accept, refuse, or terminate treatment, including the choice of no treatment (Provision 1.1.4). The patient has a right to choose, and what is termed noncompliant may be owing to what the patient wants and values, or it may result from a lack of knowledge. Thus, it is the healthcare worker’s responsibility to educate the patient related to current evidence-based care. Then the patient is equipped to make decisions based on what is valued and needed. To further understand “patient noncompliance,” consider the side effects that can occur with medications. When the physician or nurse practitioner prescribes a medication—for example, a steroid—and the patient decides that the harmful side effects outweigh the benefits and does not take the medication, perhaps being “noncompliant” is smart and safe. Health literacy has come to light as a problem that influences patient adherence to recommended treatment. The U.S. Department of Health and Human Services (n.d.) defined health literacy as the “degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions” (para. 1). This includes the individual’s basic reading levels. Poor health literacy is associated with poor health outcomes. The IOM (2004a) reported that 90 million people in the United States “have difficulty understanding and acting upon health information” (p. 1). An inability to understand medical language and printed instructions affects the individual’s ability to follow recommended treatments. Clear communication in plain language is imperative. It is important to determine that the patient understands the provided education. Another pervasive “noncompliance” issue is the cost of healthcare services. Again, using a medication example, consider a scenario in the local pharmacy. An elderly woman waits in line for her prescriptions, and the pharmacist tells her that her medications total $568. She says, “I am on a fixed income. I don’t have that much money.” The pharmacist says, “Well, your doctor insists on not using generic medications, so there is nothing I can do to bring the cost down.” They finally agree for her to pay

for a week’s worth of medications and to wait for her next Social Security check. If this woman uses her Social Security check to pay for medications, how will she pay for other necessities, such as rent and food? Her physician considers the generic medications less effective. However, did the physician take into account value as defined by the patient (what she needs)? Would it have been better for the pharmacist to call the physician to discuss the possibility of using generic drugs to save costs for the client? And even if generic drugs were used, can this woman afford to buy the medications and still have money for rent and food? Were all these drugs necessary? Why do the drugs cost so much? Larger societal issues add to the problem of patient “noncompliance.” Consider the difficulties that many patients encounter in seeing their physician when they experience problems. They are charged for an office visit. If they need to be transferred to a specialist, in a health maintenance organization system, they may or may not be able to get beyond the gatekeeper to obtain the care they need. The public deals with “compliance” issues by surfing the Internet and reading literature related to their health condition or illness—sometimes becoming better informed than healthcare providers—and by turning to alternative medicine. Perhaps the most important adherence issue is that nurses and other healthcare providers forget that patients have the right to make choices. It is important to discuss treatments, including medications, with patients. Nurses need to do a better job of patient (and family) education. Healthcare workers must encourage the patient (and family) to ask questions and to understand how to best deal with health problems. Nurses need to have time to do this activity to teach patients in ways that patients understand. When the patient compliance patriarchal system is gone, it will be replaced with what the patient wants and values.

PART 3: THE IMPACT OF QUALITY

The Quality Dimension Consider quality with the recollection that what the patient wants and values comes first. In addition to listening to the patient and involving the patient in decision making about treatments and care from the patient’s value perspective, quality (including safety) is paramount. When nurses are effective in the quality arena, our decisions and actions provide care that is needed in the safest, most effective way. What exactly is quality? This section describes a fundamentally different perspective in defining quality and what quality is really all about. Quality has many definitions and can mean different things to different people. Definitions of quality have been inadequate. In fact, most definitions do not consider the patient’s perspective but rather rely heavily on the perspective of the healthcare professional or that of the payer or regulator. Nurses have forgotten the most important person in the equation—our patient, our client, our resident. Most often healthcare professionals do not consult the patient to find out what the patient wants, needs, or values. Perhaps this is best captured in the definition of quality in the book Through the Patients’ Eyes (Gerteis, Edgman-Levitan, Daley, & Delbanco, 1993). The authors promote the concept that quality has two dimensions: technical excellence and the subjective experience. Technical excellence is defined as “the skill and competence of professionals and the ability of diagnostic or therapeutic equipment, procedures, and systems to accomplish what they are meant to accomplish.” The subjective experience is what the patient experiences most directly in their interactions with healthcare professionals. It is through these encounters that patients base “their perception of illness or well-being,” thereby forming their subjective experience upon which they closely identify as healthcare quality (p. xi). For this new century, the IOM (2001) recommends that healthcare workers commit to six aims for improvement that will change the perspective of care to one that focuses on what the patient wants and values. These aims are built around the core need for health care to be: 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 Patient centered: Providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions Timely: Reducing waits and sometimes harmful delays for both those who receive and those who give care Efficient: Avoiding waste, including waste 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 (pp. 2–3) Patient centered means listening to each patient. The patient might value something entirely different from the care that is provided. It is important to understand what the patient values. Often patients value different things at different times. For example, when a patient is in critical condition, the patient may want a highly skilled, prompt, technologically advanced, yet kind caregiver, whereas a nonacute patient may prefer a rapid turnaround with a kind, personable caregiver. Nevertheless, it is more than that. The answer to the value question depends on how the patient defines quality of life.

Performance Improvement It must be determined whether the total organization is achieving quality. Of course, all workers can improve. All organizations need PI work to examine quality and safety issues as well as to identify opportunities to improve processes and outcomes. It is a proactive process, meaning that everyone identifies problems and contributes to improvement efforts. Performance improvement has been implemented with varying success in many healthcare organizations and businesses. Performance improvement is referenced by several terms—for example, continuous improvement, continuous quality improvement, total quality measurement, and quality management, to name a few. Several methods are used to improve performance; however, many healthcare

organizations use some form of Plan-Do-Study-Act, or PDSA, to address quality improvement. The IHI (2012) outlined a model that includes questions the organization must answer, followed by the PDSA cycle to test the change to determine whether improvement was made (BOX 13-6). This is an efficient practice model that results in increased patient satisfaction and quality.

BOX 13-6 Model for Improvement The Model for Improvement, developed by Associates in Process Improvement, includes three fundamental questions and Plan-Do-Study-Act (PDSA) cycles to conduct small-scale tests of change. Questions to answer: What are we trying to accomplish? Set aims and time-specific measurable goals. How will we know that a change is an improvement? Establish measures, compare with a baseline measure for evaluating results. What changes can we make that will result in improvement? Brainstorm ideas and test them one at a time in a pilot setting. The idea is to fine-tune the process before fully implementing it across the organization. Prioritize which change should be tried first.

Plan the test of change. Activities, actions, task, or process step. Do implement the change. Study the change results. Is the result or outcome better? Was the defined goal met? Act to keep the change or go back to planning. Is fine-tuning needed, or is it necessary to start from scratch? Revisit the fundamental questions. Modified from the Institute for Healthcare Improvement (IHI). The Model for Improvement, as seen on IHI’s website (www.IHI.org), was developed by Associates in Process Improvement [Langley, Nolan, Nolan, Norman, Provost. The Improvement Guide. San Francisco: JosseyBass Publishers; 2009].

Six Sigma (Smith, 2003) is a popular approach to performance that was previously used in businesses other than health care. It provides a systematic approach to improve patient outcomes and acts as a PI tool that incorporates data analysis to identify and reduce variation, thereby reducing patient safety events (BOX 13-7). By reducing variability and promoting standardization, the potential for errors is greatly decreased,

resulting in increased patient safety and better outcomes. Standardization is an important concept.

BOX 13-7 Critical Elements of Six Sigma Genuine focus on the customer. Data- and fact-driven management: The numbers speak. Processes are where the action is; processes are the key vehicle to success. Proactive management: acting in advance of a problem rather than reacting. Boundaryless collaboration: break down barriers between departments, organize work teams across the organization. Drive for perfection but tolerate failure. Data from Smith, B. (2003). Lean and Six Sigma—a one-two punch. Quality Progress, 37–41.

Although it is helpful to have standardization in processes, this approach does not take into account individual patient differences and can increase complexity. When complexity increases, more errors occur. Some advocate making small, incremental changes at the bedside rather than standardization. Each patient’s expectations are different because patients want and value different things. Thus, nurses need to listen to patients about what they want and value. Although Lean and Six Sigma are separate entities, there is a current effort in health care to combine these two methods into a single approach to perform quality improvement (Glasgow, Scott-Caziewell, & Kaboli, 2010). Using both approaches provides processes focused on measuring and eliminating errors (Six Sigma) while ensuring efficient workflow and value-added time (Lean) (Glasgow et al., 2010). Combining these two approaches also balances the regulatory need to maintain process performance (Six Sigma) while supporting rapid continuous improvement (Lean) and thus also easing the tension between the need for incremental changes and system changes. An important part of the role of an administrator is to pay attention to, and promote, ways the healthcare team can reframe their work to better achieve each patient’s goals. This is complicated because it is a new concept for many individuals in health care. Paying attention to value, along with quality and safety, puts us in an interesting dilemma. Value, quality, and safety are somewhat elusive because they can never be

totally achieved. Yet nurses need to constantly improve patient care processes. It is important to dedicate time and effort to striving to achieve value, quality, and safety. When nurses believe that they have done their best, they have satisfying work experiences. When excellent, safe care is delivered, and the patient values the service, everyone on the healthcare team feels good about his or her work, and, most important, the patient benefits by experiencing the best possible care. Input and participation by staff are essential to the success of PI teams. Frontline staff are most familiar with the problems and opportunities and can be instrumental in identifying and implementing change or in orchestrating sabotage when they are not consulted. Involvement in PI programs is often mandated in annual employee evaluations and reflected in bonuses for incentive plans. Former patients are particularly valuable members of PI teams. Improvement efforts are meant to improve patient care, and input from these stakeholders may reveal what was important to them during their encounters with the healthcare system. It is also helpful if project members include patients’ families or significant others because these individuals experienced the difficulties inherent in a healthcare crisis or in encounters with the healthcare system. Input from all stakeholders related to the project is invaluable. They have the best ideas about what needs to be done, or changed, to achieve value. Performance improvement efforts must involve all stakeholders to critically evaluate current practice, processes, potential environmental hazards, and other unsafe situations before incidents occur. Again, the goal is to be proactive rather than reactive. The PI plan should be integrated with the organization’s operations and financial plan as well as with education and strategic plans to provide enhanced safety for patients. It is imperative that administrators focus on safety when considering budget requests. Nurses need to be assertive and consistently tout the importance of these expenditures. This means that all healthcare workers must look around with “new eyes” to see potential issues that, if recognized, could be prevented. Consider the following list: Drug packaging looks the same for different drugs or drug names are similar. Bar coding is critical.

Errors involve a breakdown in communication. High-risk communications include times of transition, such as shift change, patient transfer to another area, or transfer to another facility. Adopting a standard communication method is helpful. BOX 13-8 provides an example of an effective communication method that resulted in 96% to 100% retention of information.

BOX 13-8 SBAR Communication S situation (the current issue) B background (brief, related to the point) A assessment (what you found/think) R recommendation/request (what you want next) Data from Haig, K., Sutton, S., & Whittington, J. (2006). SBAR: A shared mental model for improving communication between clinicians. Journal on Quality and Patient Safety, 32(3), 167–175.

When staffing is inadequate, more safety issues occur. It may be better to employ more staff, close beds, merge units, or use other planned strategies so that everyone knows what to do when this occurs. It is important for every RN to routinely make rounds and to talk with the patients. These activities provide opportunities to discover what the patient wants and values. It is equally important for nursing assistants to make regular rounds and to ensure that patients are routinely turned and given important care. Poor teamwork and ineffective leadership bring on a multitude of safety issues. Sometimes an RN does not assume leadership of a team—for example, in the case of a new graduate RN. This brings to light the importance of mentors and preceptors. Woods and Doan-Johnson (2002) analyzed 21 disciplinary case files from nine boards of nursing to develop a taxonomy of nursing practice errors (BOX 13-9). In an effort to raise awareness, it is important to share this information with staff. These errors must be addressed through staff education and PI efforts.

BOX 13-9 Categories of Nursing Errors Lack of attentiveness Attentiveness refers to the nurse’s ability to find out and remember assessment data on each patient, “paying attention to the patient’s clinical condition and response to therapy, as well as potential hazards or errors in treatment” (p. 46). Lack of agency/fiduciary concern Lack of agency/fiduciary concern gets back to what the patient values. Here the nurse needs to be an advocate for the patient by questioning physician orders, calling physicians, and paying attention to patient/family requests. Inappropriate judgment The nurse’s judgment and clinical expertise are important if the nurse is to intervene on the patient’s behalf. Medication errors A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer. Such events may be related to professional practice, healthcare products, procedures, and systems, including prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use (p. 47). Many medication errors are never reported. Lack of intervention on the patient’s behalf Often symptoms that the nurse does not recognize or respond to in a timely manner result in a complication or death that could have possibly been prevented. Lack of prevention Teach all employees to identify any potential problems and to rectify them as soon as the problems are noticed. Infection control, immobility hazards, and a safe environment are areas of concern. Missed or mistaken physician or healthcare provider orders Use of a provider order entry and a computerized documentation system could more effectively prevent this occurrence. Documentation errors (p. 46) Additional documentation errors are problematic in two areas: Charting procedures or medications before they were completed. Such a documentation error can cause a patient to miss a dose of medication or a treatment and can confuse, misrepresent, or mask a patient’s true condition. Lack of charting of observations of the patient causes serious harm when a nurse fails to chart signs of patient deterioration, pain, or agitation or particular signs of complications related to the illness or therapies (p. 48). Data from Woods, A., & Doan-Johnson, S. (2002, October). Executive summary: Toward a taxonomy of nursing practice errors. Nursing Management, 45–48.

Lack of critical thinking can cause errors. Staff members need to be educated to go beyond “task orientation” to understand systems thinking before they select actions. Interdisciplinary miscommunication is a serious safety issue. Markey and Brown (2002) noted that a team of RNs, physical therapists, occupational therapists, patient care assistants, and physicians, when working together on teams, discovered that each discipline had a different vocabulary for the same activities (p. 1). These authors found that each department had its own activity and mobility vocabulary and because staff members’ duties for mobilizing patients were not defined, specific guidelines were most helpful in carrying out the activities specified by nurses, patient care assistants, physicians, physical therapists, or occupational therapists. These guidelines were also shared with patients and families, which accomplished better consistency when working with patients. For example, the patient care assistants understood specifically what to have the patient do as well as what the aide should do for the patient. These guidelines provided a set of scripted behaviors that achieved a more consistent approach.

Evidence-Based Practice When contemplating the quality of patient care, consider whether the most appropriate, up-to-date care is provided. Research has shown that both physicians and nurses plan care and treatment based on what they learned in school, even if that was 20 years ago. In addition, the nurse may not know what is best for a certain individual with a particular need. Nurses must have access to the latest research related to the problem, and/or treatment of the problem, and must use that information and professional judgment to determine the most appropriate approach. Evidence-based practice is a synthesis of research and clinical expertise that has been demonstrated to be successful related to particular conditions. This is a challenge because there is so much information available. Knowing where to find the best information, how to evaluate the information to determine what is the best or most appropriate research, and how to apply it to practice is complicated. The Internet and technology systems are powerful resources. For

example, a lot of research on patient outcomes is available. When a physician or nurse practitioner writes a medication order, he or she may not know which of several drugs might be most effective. Evidence-based decision-support systems can quickly determine the best available research for specific topics. These systems also provide evidence-based plans of care and therapy recommendations. Evidence-based practice is important, but only 15% of the nursing workforce consistently implements practice based on evidence (Shirey, 2006). One problem is that nurses and providers do not realize how easily information can be accessed, or they do not take the time to look up current research results. Many lack the skills to translate research knowledge into practice. Obtaining the information is only the first step. Administrators can encourage evidence-based practice by removing barriers to access, by providing technology (such as a computer or handheld device), and by establishing the expectation that practice must be based on current evidence. Sometimes evidence is available in the EMR system. In addition, administrators and leaders must use evidence to guide our leadership and management practices.

Clinical Pathways and Protocols When delivering care, evidence-based practice can be achieved by using clinical pathways, order sets, or clinical protocols, as long as the pathways or protocols are kept current. An effective clinical pathway is the result of interdisciplinary teamwork; the team includes the physician, nurse, social worker, dietitian, and patient and may include other members, such as a chaplain or nurse aide or significant family members. Approved protocols can automatically be implemented without an additional order. A caution related to clinical pathways is that all caregivers must continue to take into account patient idiosyncrasies or differences (and what the patient wants and values) that might change the pathway.

Changing Administrative Practices Variation in the success of PI programs is often related to administrative leaders who do not support the work. Thus, problem processes

proliferate that may negatively affect the success of the organization. Often PI endeavors are not perceived as important. Nurse leaders need to complete an organizational assessment and learn how to identify and make systems changes effectively. Note that the most effective changes are small, incremental, and at the point of care. Little by little, better quality is achieved. This is better than adding to the complexity with quick fixes, which create more issues to be dealt with later. As complexity increases, errors increase. Nurses need to know how to find information related to their administrative work to remain up to date in administrative practices and must encourage staff and physicians to use these resources. The IOM (2001) provides the best signpost, to date, for us to use as our ultimate goal. It advocates the redesign of our healthcare delivery systems based on 10 fundamental rules. Redesign has been so mismanaged in health care that the word has negative connotations. The difference here is that redesign, as described by the IOM, uses the administrative practices discussed in this text. It is not a bottom-line approach to downsizing. The 10 rules of redesign are as follows: 1. Care is based on continuous healing relationships. Patients should receive care whenever they need it and in many forms, not just in face-to-face visits. This implies that the healthcare system must be responsive at all times, and access to care should be provided over the Internet, by telephone, and by other means, in addition to in-person visits. 2. Care is customized according to patient needs and values. The system should be designed to meet the most common types of needs but should have the capability to respond to individual patient choices and preferences. 3. The patient is the source of control. Patients should be given the necessary information and opportunity to exercise the degree of control they choose over healthcare decisions that affect them. The system should be able to accommodate differences in patient preferences and encourage shared decision making. 4. Knowledge is shared and information flows freely. Patients should have unfettered access to their own medical information and to clinical knowledge. Clinicians and patients should

communicate effectively and share information. 5. Decision making is evidence based. Patients should receive care based on the best available scientific knowledge. Care should not vary illogically from clinician to clinician or from place to place. 6. Safety is a system property. Patients should be safe from injury caused by the care system. Reducing risk and ensuring safety require greater attention to systems that help prevent and mitigate errors. 7. Transparency is necessary. The system should make available to patients and their families information that enables them to make informed decisions when selecting a health plan, hospital, or clinical practice or when choosing among alternative treatments. This should include information describing the system’s performance on safety, evidence-based practice, and patient satisfaction. 8. Needs are anticipated. The system should anticipate patient needs rather than simply react to events. 9. Waste is continuously decreased. The system should not waste resources or patient time. 10. Cooperation among clinicians is a priority. Clinicians and institutions should actively collaborate and communicate to ensure an appropriate exchange of information and coordination of care (pp. 8–9).

Provider Accountability in the Cost–Quality Dilemma The linear healthcare administrator, heavily committed to the bottom line, may question, “Where is the money coming from for all this?” Reframing is in order. Finding the value of a healthcare service requires healthcare leaders and care providers to ask the following questions: What is the actual service provided? How do organizational processes support this service? What are the interactions between these processes? What impact does the service have on the patients and the

community? (Porter-O’Grady & Malloch, 2011, pp. 300–301) Striving for value will make a difference. The nurse leader is situated between senior leaders and staff and thus is in a pivotal position to influence change. The nurse leader is a teacher for staff and a role model for all healthcare workers. Focusing on what the patient values and wants is a wise choice, as opposed to focusing on those things that do not make a difference for patients. Often this is a new concept for patients and families as well. A proportion of patients will not accept the new role, some because of culture, and others because of health literacy, lack of knowledge, or a host of additional reasons (Longtin et al., 2010). This brings the nurse back to the foundational document, the ANA Code of Ethics with Interpretive Statements, which demands that nurses provide the patient with the needed knowledge. Patients have the moral and legal right “to be given accurate, complete, and understandable information in a manner that facilitates informed judgment” (ANA, 2001, p. 4). Habitually seeking what the patient wants and values is not optional; rather, it is our mandate. The issue is a serious one. A “bottom-line” administrator, simply on the basis of salary alone, may deem that RNs are more expensive to employ. To save money, the administrator may demand that the staffing mix be changed by decreasing the number of RNs and adding licensed practical nurses (LPNs) or nursing assistants. This demand is not supported by evidence. Melberg (1997) examined budgets and staffing at five hospitals, documenting that a hospital budget with a 96% RN staff mix is less expensive than another hospital budget with a 64% RN mix. In fact, the hospital with the highest costs had the lowest RN skill mix (64%). Melberg (1997) noted: A high RN mix does not correlate with higher nursing costs per patient day in acute or critical care. Diluting the RN mix does not always reduce staffing costs. Although hospital A has a 96 percent RN-skill mix, the highest in the system, total nursing salary per patient day falls exactly in the middle. The highest costs occurred at hospital C where, in fact, the 64 percent RN mix is the lowest in the system (p. 48). Likewise, a study by Lindrooth, Bazzoli, Needleman, and Hasnain-

Wynia (2006) corroborates that it is more cost effective to provide a higher RN ratio. Thus, cost may be higher with a higher ratio of non-RN staff. This is only the beginning of the cost issue because RNs save costs in other areas in addition to salaries. Consider patient outcomes and the cost of patient safety events. Recall earlier in this chapter that the IOM (2004a) documented that each patient safety event added an additional $8,750 to each hospital stay. Also recall research that notes that higher RN ratios are linked to better patient outcomes. When lower RN staffing leads to death or injury, it is a very high cost. Thus, determining the appropriate nursing skill mix requires analysis of the care environment, population served, patient acuity, patient turnover, the type and manner in which care is delivered, culture, budget, staff competencies, and evidence-based findings. There are no easy answers. What works best in one setting (for example, in a step-down unit) may not be best in another (for example, in a skilled unit). Thus, the nursing skill mix is determined by the current circumstances and changes to meet new situations as they occur. Administrators must critically analyze issues of adequate staffing and the RN staffing mix. Research supports the fact that increased RN staffing affects patient safety. This provides the impetus for administrators to focus on RN recruitment and retention efforts. Recall from earlier in this chapter that the ANA (2012) noted that “each additional patient care RN employed (at 7.8 hours per patient day) will generate over $60,000 annually in reduced medical costs and improved national productivity” (para. 5).

What Does It Mean to Be in the Information Age? Performance improvement in the Information Age means that nurses must use technology effectively. In the past, many computer systems were not integrated. The transition to a fully integrated computerized system moves the organization to a more viable state that enables improved access and use of information. Integration allows use of CDS at the point of care, which is crucial to implement evidence-based practice. This presents a major financial undertaking because computer systems are expensive. Costs extend beyond the walls of the organization, which

brings about additional challenges. Physicians and other providers need to be able to access the system from multiple locations, not just when they are in the facility. For true point-of-care access, computers must be mobile or at every point of care.

Online Clinical Documentation Systems The Leapfrog Group (2013) identified the importance of CPOE, which is especially pertinent in large healthcare systems. Online documentation provides integration of documentation from all disciplines. All disciplines chart together, and thus there is immediate access to relevant information as well as better continuity of care. In addition, preformatted charting presents an easy, time-saving format for the clinician to follow. Patient safety is enhanced through decision support. Built-in clinical alerts identify abnormal results, allergies, stop dates on medicines, incompatible medicines, and times to administer medications and to provide a variety of other safeguards that promote patient safety and quality. Online systems also provide immediate and virtual access to laboratory and radiology results in both the healthcare facility and the physician’s office. In addition, physicians can interact with the CPOE system from their office location. Prescriptions and discharge instructions can be generated. From a safety standpoint, the liability related to legibility problems is decreased. In these systems, documentation is thorough and better reflects patient status, resulting in enhanced safety and increased reimbursement as a result of accurate coding for billing. The systems can also link cost and quality data. An alert to clinicians using computers in the patient’s presence is that patients may erroneously think that providers are using the computer in a way unrelated to patient care. Thus, it is important for providers to explain computer work to clarify their actions for patients.

Bar Coding A closed-loop system composed of a scanner to bar-code the medication, the clinician administering the medication, and the patient’s armband has

proven very successful in reducing medication errors, when appropriately used, related to the five rights of medication administration: right patient, right route, right dose, right time, and right medication. Medicationdispensing systems are available in many facilities to assist with medication administration. Some facilities have implemented robotics to assist with medication identification in the pharmacy as well as with delivery from the pharmacy. These strategies also decrease the possibility of error. Although costs are significant, the savings realized from diverted errors, increased patient satisfaction, and promotion of quality more than make up for the expense.

Portable Electronic Devices Portable electronic devices are used to promote efficiency and to decrease transcription errors. Access is available from remote locations —for example, during the admission process to retrieve demographic and insurance information. In addition, clinicians can retrieve information about medications, diagnoses, and other health data immediately as needed.

Recognition of Value and Quality Several programs in healthcare focus on value and quality. Some have gained national awareness.

The Leapfrog Group Organizations have implemented voluntary programs that measure and report safety data and outcomes. An example is the Leapfrog Group, which supports pay for performance, whose primary focus is to improve and implement best practices. The Leapfrog Group is a consortium of major companies and other large private and public healthcare purchasers that focuses on measuring and publicly reporting hospital performance through the annual Leapfrog Hospital Survey. Although their evidence-based survey data are available for the public to access patient safety and quality scores for over 2,000 hospitals in the United States, Leapfrog members have agreed to base their purchase of health care on principles that encourage quality improvement among providers and consumer involvement (Leapfrog Group, 2018).

Magnet Recognition Program Earning the esteemed designation of a Magnet facility has become a renowned indicator of quality. This is an expensive process in terms of both money and resources for the facility. Magnet recognition is a voluntary process encompassing strenuous evaluation of nursing excellence and innovation in nursing practice (American Nurses Credentialing Center [ANCC], 2013). The Magnet Recognition Program has three goals: Promote quality in a setting that supports professional practice Identify excellence in the delivery of nursing services to patients/residents Disseminate best practice in nursing services (ANCC, 2013, para. 7)

The National Database of Nursing Quality Indicators The NDNQI was developed by the ANA (2013a) to collect and report nurse-sensitive outcomes data in an effort to show how nursing care promotes quality and patient safety. Participation is voluntary, and thus data may not provide an accurate picture of nursing care across the nation. Nevertheless, the NDNQI data provide nurse administrators with a tool to compare outcomes, staffing, and other nurse-sensitive measures. Some of the data include incidents of hospital-acquired pressure ulcers, fall rates, and restraint use in relation to nursing hours per patient day and skill mix.

Performance Measurement In an effort to contain costs, performance measurement became popular in the early 1990s when companies purchasing health plans needed to examine cost and quality data to determine which plan was best for the dollars spent. At first, these efforts were called report cards and only summary performance data were included. Later, report cards were used internally by healthcare organizations to improve services. (Details can be found at www.healthgrades.com.) The idea behind performance measurement is that patient outcomes could be used to determine the effectiveness of organizational performance. Although this measurement is an improvement on past practices, there are several problems with this measurement: (1) future performance cannot be determined from historical data; (2) no one asked the patient what the patient wanted or valued; (3) organizations are inundated with data, leaving little time to analyze or use the data effectively; and (4) sometimes the data were used punitively when outcomes were poor, which only impeded future improvements. As report card data became available, the JC (2013a) expanded performance measurement to include two sets of measures: core or standardized measures and noncore measures. In 2003, the JC joined forces with the CMS to align efforts and required organizations to report on certain measures, depending on the populations served (JC, 2013a). Measures are identified for hospitals, long-term care facilities, and home care. Current information and score card results are available to the public at www.qualitycheck.org (JC, 2018).

Benchmarking Many healthcare organizations benchmark quality measures. Often, when benchmarking, the organization sets a goal—for example, to be in the top 25th quartile. However, benchmarking can be fraught with problems. Rudy, Lucke, Whitman, and Davidson (2001) reported that although benchmarking is a common approach to establishing quality, the value of the benchmarks weigh heavily on the origination of the data: Is it

from the literature, from hospital-specific sources, or from an integrated hospital system? TABLE 13-1 provides a summary of some of the pros and cons with the three primary sources of benchmarking data. TABLE 13-1 Pros and Cons with Three Primary Sources of Benchmarking Data Types of Benchmarking

Pros

Cons

Literature

Broad range of access to benchmarking data and metrics

Relevant to populations or to clinical practice? What is the standard error of the benchmark?

Internal

Ease of access

Invalid assessment of performance when compared to other institutions

System

Avoids pitfalls of literature and internal sources

Requires coordinated database resources and sophisticated statistical analyses

Description There is an additional problem with benchmarking. Comparisons do not take into account what has value from the patient’s perspective. For example, when benchmarking the wait time for an ED visit, a wait time of 1 hour might compare favorably with other ED wait times. Nevertheless, consider this statement from the patient’s perspective: The patient does not enjoy experiencing an hour wait in the ED to be seen by the provider. From the patient value perspective, it is better to eliminate the wait time and to have the patient seen by the provider immediately. Some EDs already use 30 minutes as the benchmark; even a 30-minute wait is not as valuable to the patient as no wait time.

Patient Satisfaction Patient satisfaction is one early performance measure that focuses on what the patient values. Patient satisfaction instruments are a beginning

measurement of value, although they take place after the healthcare experience. Hospitals have used patient satisfaction measurements for some time because measuring patient satisfaction has been an important core outcome measure for Joint Commission accreditation. Examples of companies that provide patient satisfaction instruments and services to healthcare organizations include Gallup (2013) and Press Ganey Associates (2013). Generally, hospitals pay these companies to collect and tabulate the data. This is considered more effective because patients are more likely to be forthright with an outside vendor, as opposed to those providing their care. There are other advantages to using an outside vendor: The organization’s results are ranked among similar organizations, thus providing benchmarking opportunities. To adequately assess patient satisfaction, both the patient’s and the provider’s expectations must be clearly identified. In the past, patients were seen as customers in need of health care; now they are viewed as informed consumers looking for high-quality care. Health care has become a competitive business. Many facilities are using contract agencies to market their services and measure their success, and they have implemented service excellence initiatives to improve patient satisfaction. Some even have scripted behaviors and protocols to standardize dialogue in difficult situations. This is an example of standardization previously discussed. It is important to remember that nurses deal with people. What has value to one individual may not have value to another. For example, one individual may welcome talking about emotions with a healthcare provider, whereas another individual may find this invasive. One individual may respond to pain by being stoic, whereas another who experiences even mild pain may scream and yell. Staff evaluations may be directly linked to satisfaction results. Results from patient satisfaction surveys can be very useful and can be used to do the following: Improve and measure the quality of care Manage complaints Implement strategic planning and marketing decisions Evaluate and/or provide bonuses to departments or individual (physician and nonphysician) staff

Enhance public relations Meet accreditation standards Monitor for risk management Link survey results to clinical data Use survey results for contract payer negotiations Compare the results for benchmarking Link the results to financial data

Performance Measurement and Patient Value It is questionable as to whether these measures reflect what patients want and value. The CMS Quality Initiatives (CMS, 2013e) and the Joint Commission’s National Patient Safety Goals (JC, 2018) are patient centered, but, again, it is uncertain whether these measure the patient’s perception of value. Outside vendors measure patient satisfaction, but, again, do the operational definitions capture the patient’s perception of value? Empirical data have dominated the healthcare system. What is needed in addition to quantifiable data is capture of the complexity of healthcare work, including qualitative data—for example, “patient– provider relationships, effectiveness of the procedure, patient satisfaction, and health behaviors practiced is not considered in the reimbursement categories” (Porter-O’Grady & Malloch, 2011, p. 85). This links to the patient and family advisory focus groups discussed earlier in this chapter. The data received from these groups provide rich information for PI work. Administrators must maintain the focus on what patients want and value. If leaders lose sight of this goal, statistics are useless. The organization may be profitable and have stellar patient outcomes, but if patients are not getting what they need, want, and value, they have a choice as to whether or not to return to the facility. As organizations collect data from focus groups, or even as they organize the groups, they must consider the data in terms of populations served because voluminous qualitative data can become overwhelming. The emphasis must move from individuals to populations. As nurses examine patient populations, their focus should move beyond identified diseases or problems. For example, parents of young children have concerns that are

different from those of older adults who are experiencing chronic diseases and who are on fixed incomes. Focus group participants may need to be organized to better identify these populations.

Balanced Scorecard: Best Approach to Performance Measurement Balanced scorecards (BSC) are the best way to conduct improvement work (IHI, 2012). Metrics captured in the organization’s BSC are tied directly to the strategic plan. A primary utility of the BSC is the tie between strategic management and performance management. Measurement of key financial, quality, market, and operational indicators provides management with an understanding of performance in relation to established strategic goals and graphically displays a snapshot of the institution’s overall health (Health Care Advisory Board, 1999). Plotting the data for these measures using a run chart (and then a control chart when sufficient data points are collected) is a simple and effective way to determine whether changes are leading to improvement or whether the gains are sustained (IHI, 2012). Run charts and control charts are graphs of data over time and are important tools for assessing effectiveness of change (IHI, 2011). Benefits of run charts include the following: They help improvement teams formulate aims by depicting how well (or poorly) a process is performing. They help in determining when changes are truly improvements by displaying a pattern of data you can observe as you make changes. They give direction as you work on improvement and offer information about the value of particular changes (IHI, 2011, para. 2). It is vital that administrators and managers understand the type of data collected and the correct type of chart to be used. This information is beyond the scope of this chapter.

Utilization Review Another measurement related to the care provided is utilization review. Utilization management has a quality dimension in that the primary purpose is to ensure appropriate use of available services and resources.

Many organizations integrate utilization management into the case management role, creating a more complete system of quality management. Historically, healthcare organizations established a person or department to complete utilization review through the relay of clinical information to payers so that the payers could determine whether they would pay for additional care for patients. In the managed care climate, providers cannot provide the care and then submit the bill; rather, they must get preapproval for the care. The payers determine whether the care is allowable. Once the payers determine that the care meets their criteria, the patient is certified for payment.

Employee Issues When discussing value and quality, it is important to remember employees. When administrators value employees, employees value patients. Thus, this section describes value and quality related to employees.

OSHA Standards for Employee Safety The first issue is employee safety. There are many possible hazards in the healthcare industry. The Occupational Safety and Health Administration (OSHA) provides nationally mandated standards for the workplace (U.S. Department of Labor, n.d.). Detailed information is available at the U.S. Department of Labor OSHA website (www.osha.gov). Administrators and other leaders must be regularly oriented to OSHA standards. In addition, OSHA has recordkeeping requirements that mandate that organizational leaders keep records updated to document compliance with OSHA standards. In larger healthcare systems, both quality and infection control personnel are often concerned with workplace compliance with OSHA standards. In smaller systems, OSHA compliance often becomes an additional responsibility of staff who already have many other roles and responsibilities. Regardless, the nurse leader must be aware of the current standards, ensure that employees are oriented to these standards, and ensure that the patientcare environment is in compliance with the standards.

Promoting a Healthy Workplace Achieving a healthy workplace includes examining the environment. This can be quite complicated. For example, a sharps injury from a needle used by a patient is a major hazard. Of the nearly 14 injury cases per 100 long-term-care employees, a significant number are related to patient lifting or repositioning tasks. OSHA recommends “that manual lifting of residents be minimized in all cases and eliminated when feasible . . . possible solutions include using

mechanical lifts and ceiling-mounted lift systems. . . . For patients with the ability to assist, or who are able to bear weight completely, equipment, such as sit-to-stand devices, ambulation-assist devices, transfer boards, and lift cushions or chairs, can minimize assistance needed in transferring” [This includes height-adjustable beds with electric controls rather than cranks and showering and bathing assistive devices.] (Weber, 2008, p. 30). The general public, patients, employees, and administrators frequent healthcare facilities. The volume of people who have access to healthcare facilities presents many ways that employees and others could be put at risk (infectious diseases, violence, and so forth). Administrators are responsible for maintaining a safe environment for staff as well as for patients.

Disaster Planning and Preparedness Disaster planning and preparedness have assumed new significance. With the many weather-related events, facilities must be prepared to deal with these issues, even when the facility has been decimated. In addition, the issue of bioterrorism must be addressed for the safety of patients and employees. Procedures to address the identified emergency are dictated by the Federal Emergency Management Administration (FEMA, n.d.), but facility-related issues, such as lack of available nurses and methods to contain or quarantine, are facility specific and should be addressed in policy. Sadly, these issues must be considered at budget time to designate appropriate funds for protective apparel, vaccinations, preparation and training for staff, and public education.

Chaos Theory Another scientific field of thought is chaos theory. In this theory, the world all around us seems chaotic, but even when it seems that total chaos surrounds us, we must rise above it and look down to find the order and perfection. Sometimes when unexpected events happen or setbacks or difficult situations occur, it is comforting to know that these experiences accomplish good things for us. Nurses can learn from such situations and

become better persons and providers of care. In addition, these experiences can lead to something different or new that we would probably never have tried if the difficulties had not occurred. When considering planning for change, chaos theory tells us that we cannot possibly plan, or map out, all the details of the change because of chaotic occurrences. As these occurrences happen, they necessitate adjustments in the plan. This is why all staff need to be involved in understanding the plan and need to be empowered to accomplish it— because the final product, or components of the final product, will ultimately be different from what was planned. Really, there is no final product. Chaos continues to change what was implemented. No one can stop change; rather, it continually moves on into uncharted territory. Many administrative leaders do not understand the concept of constant change. Instead, they try to cling to the Industrial Age idea that everything is rational and can be planned in minute detail. It is as if they think they can just order others to follow through on their plan, and then they become frustrated when people do not follow through. This is not the new reality. Continuing to believe this opens us up to unnecessary frustration, and employees will be frustrated as well. Instead, all of us must be open to the reality around us, see the changes that are occurring, and help interpret the chaos for one another. Although everyone has their own views of reality, chaotic reality happens, and changes will occur and leave us behind, obsolete and unfulfilled. A good leader is one who can read the signposts suggesting that a change is imminent and can discern the direction of the change and the elements indicating its fabric. The good leader synthesizes rather than analyzes and views the change thematically and/or relationally, drawing out of it what kind of action or strategy should be applied—the response, that is, that best positions the organization to thrive in the coming circumstances. For a leader to act as a strategist today means not detailing the organization’s future actions but analyzing the relationship of the system to its external environment, determining the ability of the system to respond and adapt in a sustainable way, and translating that relationship and ability into language that has meaning for those who must do the work of the organization. Translating the signposts into understandable and inspiring language is more critical than almost any other strategic

task. It is vital that a change have implications for those who are doing the work. Another way of saying this is that it must have meaning to them within the framework of their work activities so that they can commit to it, which they must do if they and the organization are to adapt to the change successfully. The leader’s job is to describe the change in a way that allows the workers to understand its value and how it will affect their own efforts (Porter-O’Grady & Malloch, 2011, pp. 23–24). (See BOX 13-10.)

BOX 13-10 Interdependence In nature, everything is interdependent. There is an ebb and flow among all the elements of life. Leaders must see their role from this perspective. Most of the work of leadership will be managing the interactions and connections between people and processes. Leaders must remain aware of these truths: Action in one place has an effect in other places. Fluctuation of mutuality means authority moves among people. Interacting properties in systems make outcomes mobile and fluid. Relationship building is the primary work of leadership. Trusting feeling is as important as valuing thinking. Acknowledging in others what is unique in their contribution is vital. Supporting, stretching, challenging, pushing, and helping are part of being present to the process, to the players, and to the outcome. Reproduced from Porter-O’Grady, T., & Malloch, K. (2003). Quantum leadership: A textbook of new leadership. Sudbury, MA: Jones and Bartlett, p. 22.

Summary This chapter is concerned with how to best support patients being the leader in their care. To do this, we need to find out and provide only what patients value within a safe environment. In healthcare settings, we have not always stressed the importance of listening to our patients to find out what they want or need. Also, we must give our patient’s information so that they can make the best decisions on needed care. The old patriarchal system where we made decisions for patients, and many times did not tell our patients what would happen, is outdated. Along with this, we, as nurses, need to get out of the “task” box and become leaders to make sure that patients are receiving only what they really want. This new perspective is so important, and, as leaders, we need to support patient decisions. In addition, we also include information on both quality and patient safety. Nurses understand more about quality and patient safety than our patients do. This is another aspect of leadership that is needed at the point of care. However, we are still harming too many patients in our healthcare systems. Many patient safety issues are caused by a series of events or organizational processes that are broken. It is time to fix these problems and to leave blame behind. As we provide care that patients value in a safe environment, chances are we healthcare providers have a knowledge deficit: It is not possible to keep up with all the current treatments, drugs, and research results that could improve our practice and benefit our patients. Now that we are in the Information Age, this research evidence is not a big secret anymore. Yet despite the readily accessible research data, we tend to go on doing what we were taught in school, even though evidence-based practices have been identified that should change our practices. Thus, in the end, we must ask ourselves: What does each patient value? Is this what we are providing? And, as previously noted, this is the first priority, not the bottom line.

Discussion Questions 1. Describe strategies used by the nurse administrator that provide patients with what they want and value. 2. What administrative practices support PI efforts? 3. Provide examples of the 10 IOM (2001) rules for redesign applied to your healthcare setting. 4. State five ways that administrators promote patient safety. 5. Why is it important to provide evidence-based care? Discuss some of the challenges nurse administrators face in creating an environment in which bedside nurses use evidence-based care. 6. Discuss the use of run charts and control charts to improve quality. 7. Discuss how Lean thinking and Six Sigma can be used together to improve healthcare quality. 8. What are ways to promote employee safety? 9. Describe how complexity theory applies to your practice. 10. Explain reasons that chaos theory offers hope for the future of health care.

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CHAPTER 14 Health Information Technology Philip J. Kroth

CHAPTER OBJECTIVES 1. Review the major historical developments in the evolution of health information technology. 2. Discuss government initiatives to support the implementation of health information technologies. 3. State both the benefits and the challenges of using this new technology and the progress in implementation to date. 4. Consider the benefits and challenges of healthcare technology to the role of the advanced practice nurse.

Chapter Overview This chapter outlines major historical developments in the evolution of health information technology and discusses government initiatives to support its implementation. It highlights both the benefits and the challenges of using this technology and the progress of its implementation to date.

Historical Overview The concept of using modern health information technology (HIT) to improve the quality and reduce the costs of health care is not new. In fact, the U.S. federal government has a half-century history of many HIT initiatives. One of the earliest is traceable back to the Kennedy administration in the early 1960s. A report from the President’s Science Advisory Committee, Some New Technologies and Their Promise for the Life Sciences, was optimistic about the benefits HIT would bring to biomedical research and the healthcare system.1 Ironically, the report written more than a half century ago is still relevant to the HIT of today: The application of computer technology to the recording, storage, and analysis of data collected in the course of observing and treating large numbers of ill people promises to advance our understanding of the cause, course, and control of disease. The need for a general-purpose health information technology stems in large part from increasingly rapid changes in the pattern of illness in the United States and from equally significant changes in the way medicine is practiced. The acute infectious diseases from which the patient either recovered or died have largely given place to chronic disorders which run an extremely variable course dependent on many factors both in the environment and within the patient himself. . . . Within any sizable community there are numerous administrative organizations charged with providing health services. It is not uncommon for a single patient to be cared for by a large number of agencies in a single city, and workers in any one agency usually cannot find out about the activities of others; sometimes they even fail to learn that other agencies are active at all. . . . Modern data-processing techniques make it possible to assemble all the necessary information about all the patients in a given geographical or administrative area in one place with rapid access for all authorized health and welfare agencies. Such a system would produce an immediate and highly significant improvement in medical care with a simultaneous

reduction in direct dollar costs of manual record processing and an even greater economy in professional time now wasted in duplicating tests and procedures.1 The federal government took the most significant step in the history of HIT on April 27, 2004, when President George W. Bush created the Office of the National Coordinator for Health Information Technology (ONCHIT, or the ONC) by executive order.2 It was then legislatively mandated in the American Recovery and Reinvestment Act (ARRA) when signed by President Obama on February 17, 2009.3 Part of the ARRA is the Health Information Technology for Economic and Clinical Health (HITECH) Act that designated $36.5 billion to promote the development of a nationwide network of electronic health records (EHRs). EHRs are computerized patient records that are essentially replacing paper charts. Surprisingly, despite this sizable investment and more than a half century of government incentives and technological advancements, the best scientific evidence today indicates that the benefits of HIT on the quality and cost of health care are, at best, mixed.4 This chapter explores the history of how HIT has evolved and the imprint HIT has made on the current healthcare system and speculates on how HIT will likely influence the future healthcare system and health care in general.

Historical Challenges in Implementing Health Information Technology Using computers to improve health care in many ways parallels the development of the information technology industry. The late 1960s and early 1970s saw several pioneering efforts at a small number of universities to apply HIT to various aspects of the healthcare delivery process. Early systems were not the ubiquitous, web-based, interactive systems of today but were usually a hybrid of computer and paper integrated into a clinical work process. One early example from the 1970s at Indiana University is where a small army of data entry clerks manually entered data into a computer on key parts of patients’ medical records. The night before a patient’s clinic appointment, a one-page paper encounter form was printed for the next day’s appointment listing the patients’ name, record number, medical problem list (i.e., the known diagnoses and medical problems), medication list, medication allergies, and suggestions based on an analysis of the data in the computer system. “Suggestions” were calculated based on what patient information the computer had at the point in time the encounter form was printed the night before the patient’s visit (e.g., laboratory results, prescription data, diagnoses, vital signs). The software detected any of 290 agreed-upon patient-care protocols or conditions defined by the biomedical literature and best medical practice. When a physician saw the patient in the clinic, they would handwrite notes on the paper encounter form and manually annotate the computerprinted problem list, medication list, and other items. Later, a team of data entry clerks would review the annotated encounter forms and update the computer system to reflect the physician’s orders and updates to the patient’s condition. The encounter form would then be filed to the patient’s paper chart. The Indiana group conducted a study demonstrating a 29% improvement in adherence to agreed-upon treatment protocols in the group of physicians who received the computer “suggestions” for recommended treatments on the encounter forms versus those who did not.5 Similar systems were designed and built

during the same time period at a number of other U.S. universities, including the University of Pittsburgh,6 the University of Utah,7,8 Vanderbilt University,9,10 Duke University,11 and Harvard University/Massachusetts General Hospital.12 These pioneering systems were custom designed, built, and maintained by in-house teams of computer programmers and systems engineers. Because of the custom designs, their great expense, and the fact they did not comprehensively implement the entire patient record, they were not practical for widespread use. Despite these limitations, the pioneering work done with these early systems laid the foundation for modern EHR design. It was not until the 1990s that commercially produced EHR systems were mass marketed and sold to healthcare institutions in high volume. These commercially produced systems allowed hospitals to implement comprehensive EHRs without the prohibitive costs of designing and building custom systems. Instead, hospitals could buy an “off-the-shelf” system that although not completely customized to institutional workflows, could be configured to meet most of their perceived institutional needs. The off-the-shelf, commercially produced EHRs of today still require extensive configuration to accommodate a hospital’s unique and varying work processes. Also, commercial systems were not capable of easily exchanging patients’ health information between systems and institutions. In fact, the configuration differences between institutions are often so significant that even institutions with the same commercial EHR systems cannot electronically exchange patients’ records without customized software. As the installed base of commercial systems expanded, many researchers at universities that pioneered early, customized systems began to study issues with implementation of new HIT in the healthcare setting.13,14 Researchers learned there is a great deal more than just selecting the “right system” to ensure a successful HIT implementation. FIGURE 14-1 illustrates the three essential components required for successful HIT implementation.

FIGURE 14-1 The three essential components of a successful HIT implementation.

The first essential component is the technology. However, organizations often focus solely on this first component with the mistaken belief that merely selecting the “right” technology or the “right EHR” is the most important aspect of HIT implementation. The second component of successful implementation, work policies and procedures, makes implementing HIT systems in the clinical environment extremely challenging due to wide variations in work policies and procedures among different organizations and institutions. An organization’s policies and procedures describe and define the processes through which work is carried out. The process component is complex because it requires HIT system implementers to understand fully all

existing work processes. Many such processes are not written or formalized, having evolved over the years to accommodate the unique characteristics of a particular organization. Further, actual work processes may significantly differ from those officially documented or assumed to be in place while many critical work processes are not documented at all. When a HIT system is implemented, it is common for many of the undocumented processes to become apparent for the first time.15 Undocumented or unknown work processes have been the root cause for many HIT implementation failures.16 The third component is the most significant—the institutional and organizational culture—what people are willing to do.14 This is the most critical, least studied, and least understood of the HIT implementation components.17 Ash and Bates summarized the importance of organizational culture with regard to EHR adoption:13 The organizational culture must be ready to support adoption by the individuals within it. There has been a period when clinicians have not experienced a sense of collaboration and trust between them and hospital administration. Consequently, if clinicians believe the administration wants to force them to use Computerized Physician Order Entry (CPOE), for example, they may dig in their heels. They may be more resistant to arguments based on safety and patient care benefit if the level of trust is not there. On the other hand, if the impetus comes from the clinical staff, other clinicians may be more apt to adopt sooner, and readiness will be at a higher level. One gauge of readiness is the extent to which certain categories of people hold positions within the organization. In particular, administrators at the highest level must offer both moral and financial support and demonstrate that they really believe in the patient care benefits of the systems. There must be clinical leaders, including a chief medical information officer if at all possible, who understand the fine points of implementation strategies, and opinion leaders among the clinical staff members. In addition, there need to be sufficiently skilled implementation, training, and support coordinators who understand both clinical and technical issues.* *Reproduced from JS Ash and DW Bates, “Factors and forces affecting EHR system

adoption: report of a 2004 ACMIU discussion,” Journal of the American Medical Informatics Association, 12.1, pages 8-12, © 2005, with permission from Oxford University Press.

There is a significant publication bias in the biomedical literature against revealing HIT implementation failures. Because of the human tendency to avoid publicizing an individual’s mistakes, the body of literature is strongly skewed toward successful implementations and studies. This has made it more difficult to study and understand causes of HIT implementation failures. A significant advance for the HIT industry as a whole would be a shift in its culture toward not only reporting HIT failures but also viewing them as valuable learning opportunities to be highlighted rather than embarrassing events to be downplayed and forgotten. One major example of a HIT implementation failure occurred at the prestigious Cedars-Sinai Hospital in Los Angeles, California, in 2002. Three months after implementing a new $34 million HIT system, several hundred physicians refused to use it. Cedars-Sinai attempted to implement a new electronic medical record that changed the way physicians ordered patient treatments and tests in the hospital. Prior to implementing the new system, physicians wrote their orders on paper forms in the patients’ paper charts. After new patient orders were written, physicians gave the chart to nurses or ward clerks to read and implement the orders. The new system required physicians to type orders directly into a computer workstation, where the software provided the physician with immediate feedback if they attempted to enter an order that the computer either did not understand or interpreted as a mistake. An article in the Washington Post reported:18 A veteran physician at the prestigious Cedars-Sinai Medical Center here had been mixing up a certain drug dosage for decades. Every time he wrote the prescription for 10 times the proper amount, a nurse simply corrected it, recalled Paul Hackmeyer. The computers arrived—and when the doctor typed in his medication order, the machine barked at him and he barked back. . . . “What we discovered was that for 20 years he was writing the wrong dose.”

This failure illustrates the three principal HIT implementation components described previously: Technology: With physicians required to enter orders directly to the computer system, time required to enter orders became dependent on the computer’s ordering input format and system response time. Process: Many undocumented processes in the old system were not carried over to the new system. In this example, the nurse’s automatic correction of an obvious dosage error was a critical, undocumented process—a nursing check on the orders’ accuracy. Although the new system caught the error, the physician user in this case could no longer rely on the nurse’s checking and correcting his orders. Culture: The new system required physicians to interact with a computer, which took more time than writing orders on paper forms. The new system required physicians to change the way they practiced medicine in the hospital, and as is common, people dislike change. This was a significant change in physicians’ work culture in which nurses had routinely checked and corrected physician orders without communicating the corrections. Physicians also had to deal with a barrage of system alerts when they were imprecise or inaccurate in entering their orders. Although potentially enhancing patient safety, responding to the system alerts increased the time (and physician irritation) required for physicians to place orders. Another historical barrier to broad implementation of HIT is the gap between those who bear the costs of the technology and those who receive its benefits. The purchase and operation of an EHR system represent a major investment for large healthcare organizations and especially for small private physician groups. Not only must physician groups bear the costs of the hardware and software, but they also must support ongoing IT maintenance, staff training, and software upgrade costs. Because small practice groups often have no experience or expertise with IT issues, they also experience anxiety about making decisions necessary to convert from paper to electronic charting. Although economies of scale make the marginal costs of adopting EHR technology somewhat lower for large healthcare organizations, these organizations often do not realize the costs savings from their investment. A good example of this is a healthcare system participating in

a health information exchange (HIE). HIE systems share patient information across institutions and multiple EHR platforms. This allows patients and physicians access to a patient’s comprehensive health record from multiple institutions, regardless of where the patient was seen. HIEs often reduce the number of duplicate laboratory and imaging tests, saving the patient and the payer significant expense. However, the healthcare system may lose money by not receiving revenue for the duplicate tests not performed and for the expense they bear supporting the HIE. As with large healthcare systems, small practices that invest in EHR technology may not directly benefit from the technology. Patients may receive more age-appropriate screening19,20 and preventive care,21 along with reduced duplicate testing, because physicians have access to HIEs and patient records from outside the practice group or health system.22 However, from a practice’s financial perspective, these factors actually may produce a significant disincentive for adopting EHRs.

The Federal Government’s Response to Health Information Technology Implementation Challenges As mentioned previously, the U.S. government has sought ways to incentivize adoption of HIT for more than half a century. The largest incentive program to date has been the $36 billion in the HITECH Act that created the Medicare and Medicaid Electronic Health Record Incentive Program.23 The Centers for Medicare and Medicaid Services (CMS) used these funds to incentivize eligible professionals (individual physicians in solo or multiphysician practice groups) and eligible hospitals as they adopt, implement, upgrade, or demonstrate meaningful use of certified EHR technology to improve patient care. There were three progressive stages to the “meaningful use program” with deadlines; the highest financial incentives were awarded to eligible professionals or eligible hospitals for the earliest compliance with standards in each stage.24 This program was in part an effort to address a portion of the gap between those that bear the costs of HIT implementation (physicians and hospitals) and those who receive most of its benefits (patients, public health agencies, and payers). Eligible professionals could receive up to $44,000 through the Medicare EHR Incentive Program and up to $63,750 through the Medicaid EHR Incentive Program. Eligible professionals could participate in either the Medicare or the Medicaid EHR Incentive Program but not both. Eligible hospitals could participate in both the Medicare and Medicaid incentive programs.25 Each hospital incentive included a base payment of $2 million plus an additional amount determined by a formula based on the number of discharges per year.26–28 TABLE 14-1 compares the Medicare and Medicaid adoption incentive programs for eligible professionals and eligible hospital.23–25,29–35 TABLE 14-1 Comparison of Medicare and Medicaid Adoption Incentive

Programs for Eligible Professionals (Individual Physicians in Solo and Group Practices) and Eligible Hospitals (Including Critical Access Hospitals)

Medicare Program

Medicaid Program

Eligible Professionals

■ Administered by the CMS ■ $44,000 maximum per physician (over 5-year period) ■ 90% or more of practice must be outpatient based ■ Cannot participate in Medicaid program if enrolled in Medicare program ■ Must apply for stage 1 meaningful use by 2012 to obtain the maximum incentive ■ Medicare imposes payment penalty on those failing to demonstrate meaningful use beginning in 2015

■ Administered by state Medicaid agency ■ $63,750 maximum per physician (over 5 years) ■ Must have ≤ 30% Medicaid patient volume or ≤ 20% Medicaid patient volume and be a pediatrician or practice predominantly in a Federally Qualified Health Center or Rural Health Clinic and have ≤ 30% patient volume attributable to needy individuals ■ ≤ 90% of practice must be outpatient based ■ Cannot participate in Medicare program if enrolled in Medicaid program ■ Can begin to certify for meaningful use by 2016 and still receive full incentive ■ Nonparticipants exempt from Medicaid payment reductions

Hospitals (Including Critical Access Hospitals)

■ Administered by the CMS ■ Can begin receiving incentive FY 2011 to FY 2015, but payments will decrease for hospitals that start receiving payments in FY 2014 and later ■ Medicare and Medicaid program eligible

■ Administered by state Medicaid agency ■ Acute care hospitals (including critical access and cancer hospitals) with at least 10% Medicaid patient volume are eligible



■ Must apply for stage 1 meaningful use by FY 2013 to receive maximum incentive ■ Hospitals that do not successfully demonstrate meaningful use will be subject to Medicare payment penalties beginning in FY 2015 ■ Incentive payments are based

■ Children’s hospitals are eligible regardless of their Medicaid volume ■ Can apply for both Medicare and Medicaid programs ■ Incentive payments are based on several factors, beginning with a $2 million base payment

on several factors, beginning with a $2 million base payment Data from the Centers for Medicare and Medicaid Services and the Office of the National Coordinator for Health Information Technology.

Description Description In 2009, the ONC was designated “the principal federal entity charged with coordination of nationwide efforts to implement and use the most advanced health information technology and the electronic exchange of health information.”36 In short, the CMS provided the financial incentives for the meaningful use program and the ONC set the requirements. The ONC’s mission, noted in its 2016 budget justification to Congress, is to “improve health, health care, and reduce costs through the use of information and technology.”37 FIGURE 14-2 depicts the ONC’s current organizational structure. The ONC had a budget of $60 million in fiscal year 2015.38 The HITECH Act also created a HIT Policy Committee and the HIT Standards Committee under the auspices of the Federal Advisory Committee Act.39 Both committees have multiple work groups with representatives from payers, academia, and the healthcare industry. They address a variety of HIT-related issues including certification/adoption, governance, HIE, meaningful use, privacy and security, quality measures, implementation, and a HIT vocabulary standards committee.39

FIGURE 14-2 Office of the National Coordinator for Health Information Technology organizational structure. Modified from the Office of the National Coordinator for Health Information Technology: https://www.healthit.gov/newsroom/about-onc

Description The Health IT Policy Committee makes recommendations to the National Coordinator for Health IT on a policy framework for the development and adoption of a nationwide health information infrastructure, including standards for the exchange of patient medical information. The American Recovery and Reinvestment Act of 2009 provides that the Health IT Policy Committee shall at least make recommendations on the areas in which standards, implementation specifications, and certification criteria are needed in eight specific areas. The Health IT Standards Committee is charged with making recommendations to the National Coordinator for Health IT on standards, implementation specifications, and certification criteria for the electronic exchange and use of health information. The meaningful use requirements were developed by these

committees and the ONC. The evidence for the majority of meaningful use objectives was only at the expert opinion level. The science of HIT awaits rigorous research studies to validate the choices and designs of the meaningful use criteria. To receive the maximum incentive payment under the meaningful use program, eligible professionals who chose to participate in the Medicare program had to achieve stage 1 of meaningful use by 2012 or by 2014 for a reduced amount.32 Eligible professionals who chose to participate in the Medicaid program had to achieve stage 1 by 2016 to receive the maximum payment.40 Those eligible professionals who certified under the Medicare program in 2015 or later or under the Medicaid program after 2016 received no incentive payments. By the end of November 2014, only 25.2% of eligible professionals and 43.1% of eligible hospitals had met stage 2 requirements.41,42 Many physicians and hospitals complained about the difficulty and complexity of the reporting requirements as well as the lack of HIT tools readiness to support these requirements from HIT vendors. On October 6, 2015, the CMS published a fact sheet titled “EHR Incentive Programs in 2015 and Beyond” to communicate a simplification of the meaningful use requirements.43 The criteria for eligible professionals “modified stage 2” were simplified to 10 objectives, including one consolidated public health reporting objective. Previously, stage 2 required eligible professionals to meet 17 core objectives, plus 3 of 6 menu objectives, and to report electronically 9 out of 64 approved Clinical Quality Measures (CQM).44 (These are standardized measures for healthcare providers and institutions to report on various aspects of the quality of care they provide.) For eligible hospitals, modified stage 2 objectives were reduced to 9, including one consolidated public health reporting objective. Previously, stage 2 required eligible hospitals to report on 16 core objectives, plus 3 out of 6 menu objectives, and to electronically report 16 out of 29 CQMs.45 Under the same announcement, the CMS finalized the requirements for stage 3 for 2017 and subsequent years. These included eight objectives for eligible professionals and eligible hospitals more requirements for interoperability, and improved quality reporting alignment with CMS quality reporting programs.43 Detailed information on the meaningful use requirements for modified stage 2 is available for eligible professionals46 and eligible hospitals.47

Some examples of meaningful use requirements for modified stage 2 for eligible professionals include: Performing a security risk analysis one time per year Using clinical decision support to improve performance on high-priority health conditions. Using Computerized Physician Order Entry (CPOE) Using an e-prescribing system for at least 50% of prescriptions Providing a summary care record when transferring patients from facility to facility Providing patient education with HIT Performing medication reconciliation at appropriate times Providing the capability for patients to view their electronic health information securely online or by downloading or transmitting it directly to a third party Using secure electronic messaging (email) to communicate with patients Transmitting required public health information electronically to the appropriate agencies As noted previously, the ONC also has funded several programs to facilitate the adoption of EHRs. Examples include training programs to increase the number of professionals with information technology (IT) skills required in the healthcare domain. Other programs fund the development of HIE standards across multiple EHR vendor platforms. The ONC also funds annual surveys to track HIT adoption and more recently HIT “developer contests” that incentivize innovation in ONCtargeted areas with monetary prizes.

HIT Opportunities: Improving Healthcare Delivery Quality, Effectiveness, and Efficiency With mediocre evidence to date for HIT goals to improve healthcare quality and reduce costs, the question looms: What is the driving force behind the United States’ quest to implement HIT? The answer resides in understanding the limitations of the human brain and limited attention span. A healthy human’s performance begins to measurably decrease in about 40 minutes while monitoring a continuous process.48 These limitations explain regulations for work-time breaks for air traffic controllers and anesthesiologists, work-hour limitations for airplane pilots and commercial truck drivers, and more recently work-hour limitations for medical students and residents.49 These regulations recognize that human performance is limited by innate biology and physiology and that fatigue degrades performance; no amount of training or willpower can overcome these biological and physiological limitations. These acknowledgements apply to healthcare delivery where a physician in a busy outpatient clinic or inpatient ward is much like an air traffic controller monitoring a continuous process. Patients are tightly scheduled with additional patients often “doubled booked” at the last minute because of acute illness. Every patient must be seen and volumes of data accessed, processed, and synthesized to formulate a diagnosis and a plan of care. At the same time, the physician must document the encounter in detail, complete all required forms and insurance paperwork, respond to electronic pages and phone calls, speak with consultants, manage correspondence, and in many cases, also supervise midlevel providers, nurses, and office staff. Stead and Hammond have shown that the amount of data accessed and used by clinicians per medical decision is increasing exponentially despite the fact that physicians’ ability to cope with the higher information load remains constant.11 The driving concept behind EHRs’ potential to improve the quality and reduce the cost of health care is represented in FIGURE 14-3.50

FIGURE 14-3 Why EHRs have the potential to improve quality and reduce costs. Adapted from Friedman CP. What informatics is and isn’t. J Am Med Inform Assoc. 2013; 20(2):224-226. Computer: © iStockphoto/Thinkstock. Head: © Lightspring/Shutterstock, Inc.

The ultimate goal is to combine the intuitive strengths of humans with the limitless data retention and recall speed of computers to create a hybrid system that is intuitive with a tireless data-processing capability. The physician’s medical experience and communication and intuition abilities combine with the computer’s ability to never tire or forget information. In other words, the computer provides the physician with a computerized decision support system (CDSS). The computer does not supplant the physician’s role but enhances it by providing and managing the deluge of patient information to optimize the physician’s performance beyond the brain’s biological capability. However, for CDSS to work, “the [computerized] interventions must deliver the right information, to the right person, in the right format, through the right channel, at the right point in workflow.”51 If any of these five requirements are missing, the system will tend to fail. With EHRs, the right place and the right point in the workflow often are when the physician is entering patient orders at a computer workstation, a process termed CPOE. At this place and time, the physician’s mind is focused on the patient just seen or the patient they are currently thinking about. This also is the place and time at which it is easiest for the physician to take action, such as writing new orders that result in timely follow-through for a patient’s care. For example, when a physician has completed a patient interview and examination and is using an EHR to enter e-prescriptions that will be sent securely over the Internet to the patient’s pharmacy, the computer can present the physician with a pop-up “reminder” that the patient is allergic to the medication being prescribed. It can also indicate that the prescribed medication requires at least annual kidney function monitoring and that the last record of kidney function laboratory work is more than a year old. In this event, the system can present the physician with an

option to order the appropriate laboratory work or to ignore the warning with a keystroke or mouse click. Most decision support is designed with these “soft stops,” or interventions that allow the physician to heed or ignore the warning as they believe to be most appropriate. CDSS hard stops do not allow physician options to ignore a warning. An example of a hard stop could be the use of a very expensive, broad-spectrum antibiotic that by hospital policy can be ordered only by an infectious disease specialist. In this case, the CDSS would not allow the physician to order the medication but would inform them that an infectious disease consult is required to order the drug and would make ordering that consult a mouse click away. A nonmedical example of a hard stop is the automobile design preventing the shift of an automatic transmission out of park and into drive unless the brake pedal is depressed. This was implemented after reports of multiple accidental injuries and deaths attributed to unanticipated automobile movements. In this, like the medical example, the decision support system prevents the operator from making an error with high probability of significant adverse consequences. Because the computer never fatigues, the reminders compensate for physicians’ biological limitations and the human– computer hybrid system outperforms what either could accomplish on its own. There are hundreds of studies and randomized controlled trials published in the peer-reviewed, biomedical literature that have demonstrated how CDSS holds the potential to improve physician performance in myriad different healthcare venues. CDSS similarly designed to produce pop-up warnings and recommendations to physicians have been shown to improve ordering of age-appropriate screening tests,19,20 appropriate antibiotic prescribing for inpatients,52 appropriate advance directive discussions with patients,53 use of preventive care for hospitalized patients,19 appropriate weaning of patients from mechanical ventilators, appropriate reductions of inpatient resource utilization,54 reduction in prevalence of methicillin-resistant Staphylococcus aureus (MRSA) in a community,55 isolation rates of patients admitted to the hospital with drug-resistant infections,56 screening for sexually transmitted diseases in hospital emergency departments,57 accurate capture and recording of patient temperatures by nurses in the inpatient setting,58 and many other situations. Until recently,

most of these studies were performed at major university healthcare centers that had custom-designed EHR software systems maintained by local IT departments with relatively large IT support budgets (compared with the smaller budgets of community hospitals).17 In 2006, Chaudhry et al. published a systematic review of 257 CDSS studies published up to 2005 that concluded 25% of the studies were from four major academic institutions that all had custom-designed systems and “only 9 studies evaluated multifunctional, commercially developed systems.”17 Therefore, although there are hundreds of studies demonstrating the potential for CDSS to improve the quality of care and/or reduce its costs, the appropriate application of this research to typical healthcare settings in other than large academic institutions is largely unknown. The Agency for Healthcare Research and Quality commissioned the most systematic, rigorous, and comprehensive review of CDSS studies to date and published the results in 2012.59 The systematic review analyzed 311 studies in the peer-reviewed, biomedical literature and found moderately strong evidence confirming three previously reported factors associated with successful CDSS implementation: 1. Automatic provision of decision support as part of clinician workflow 2. Provision of decision support at time and location of decision making 3. Provision of a recommendation, not just an assessment The study also identified six additional factors that were correlated with the successful implementation of CDSS: 1. Integration with charting or order entry system to support workflow integration 2. No need for additional clinician data entry 3. Promotion of action rather than inaction 4. Justification of decision support via provision of research evidence 5. Local user involvement in the CDSS development process 6. Provision of decision support results to patients as well as providers The study found a high strength of evidence for CDSS to improve the ordering and completing of preventive care and ordering and prescribing

recommended treatments “across academic, VA, and community inpatient and ambulatory settings that had both locally and commercially developed CDSS systems.”59 There was a moderate strength of evidence that CDSS improves appropriate ordering of clinical studies, reduces patient morbidity and cost of care, and increases healthcare provider satisfaction. Studies demonstrated a low strength of evidence for CDSS impact on efficiency of the user, length of hospital stay, mortality, health-related quality of life, and “adverse events” or medical errors. The study also pointed out some significant voids in the current biomedical literature. None of the studies addressed the impact of CDSS on healthcare delivery organization changes, on the number of patients seen per unit of time, on user knowledge, on system cost-effectiveness, or on physician workload. In summary, the current cumulative evidence for the benefits of EHRs with CPOE and CDSS is mixed. Even in areas where there is a high strength of evidence, such as improvement in the ordering and completing of preventive care, the effective magnitude of the improvement is small, even though it is statistically significant.59

Health Information Exchanges Virtually none of the commercially available EHR systems available in today’s market or the custom-designed systems at large academic institutions can easily exchange patients’ health information with care providers outside of their institutions. Despite more than 50 years of efforts, patients’ health information remains “siloed” and “it is not uncommon for a single patient to be cared for by a large number of agencies in a single city, and workers in any one agency usually cannot find out about the activities of others; sometimes they even fail to learn that other agencies are active at all.”1 Barriers to interoperability of EHRs or the sharing of patient information across multiple institutions, providers, and EHR systems often become immediately apparent when a patient with a significant illness sees a number of different specialty physicians and attempts to coordinate the flow of information among them. Unlike other industries, such as air transportation, that has cooperated to create a standardized ticketing system, the healthcare system has been marginally successful in designing a common platform or standard to allow a patient’s records to be compatible with multiple vendor systems. In addition, health domain data are orders of magnitude larger and more complex than data for ticketing in the airline industry. In addition, the Health Insurance Portability and Accountability Act (HIPAA) regulations have had a chilling effect on healthcare institutions’ willingness to share data with other institutions because they are responsible for patient privacy and the security of patient data. Another reason patients’ health information is not easily transmitted between various institutions with different EHR systems is that some EHR vendors actively block information transfer. Allegations of information blocking reached a sufficient level that on April 10, 2015, the ONC delivered a Report to Congress on Health Information Blocking.60 According to the report, “The full extent of the information blocking problem is difficult to assess, primarily because health IT developers impose contractual restrictions that prohibit customers from reporting or even discussing costs, restrictions, and other relevant details. Still, from the evidence available, it is readily apparent that some providers and

developers are engaging in information blocking.”61 The ONC has taken several actions to address this problem, including proposing new certification requirements for EHR systems. These and other factors led to development of HIEs with their corresponding administering organizations, regional health information organizations (RHIOs). RHIOs attempt to create systems, agreements, processes, and technology to manage these factors in order to facilitate the appropriate exchange of healthcare information between institutions and across different vendor platforms. Although most states and regions of the United States have RHIOs, the actual state of implementation and real data exchange varies widely. For example, some states have active RHIOs that are in the planning stages of establishing relationships with all key stakeholders, creating administration agreements, creating governance structures, securing funding, attempting to develop business models for sustained funding of the organization, etc. Other RHIOs have functioning HIEs where medical data are being exchanged between institutions and across disparate software EHR platforms. The ONC has funded many RHIOS to develop and test their national standards for HIE with the ultimate goal of creating the “Nationwide Health Information Network” that would be a network of regional networks across the whole country. Despite the testing and demonstration projects to date, actively functioning HIEs exist only at regional levels. Each vendor’s building toward one common standard would significantly reduce the technical complexity of data exchange. Unfortunately, vendors’ products are still not being built toward one national standard to facilitate electronic HIE. Despite these limitations, there have been significant accomplishments in implementing the data and IT standards necessary to facilitate the exchange of health information among multiple EHR platforms. Today, most institutions participating in HIEs must build or configure “interface engines” that convert an institution’s data format to the form used by the HIE. This is a major challenge as no single standard provides sufficient specification of data formats and communication protocols. Rather, a number of standards address various domains of data management. In addition, the voluminous scope of modern health care and continuous advancements in knowledge and technology make managing data in the healthcare domain extremely dynamic and complex.

As an example of this complexity, the Logical Observations Indexes Names and Codes (LOINC) standard was developed in the 1990s to solve a problem with an older health information communication protocol that specified how clinical data should be identified for transmission between computer systems. LOINC uniquely defines codes for information, such as blood chemistry laboratory tests, and clinical observations, such as patient blood pressure, that can be recorded in many different formats. There are currently more than 70,000 LOINCdefined codes for uniquely reporting laboratory tests and clinical observations.62 For example, there are 419 different codes for reporting blood pressure. With its unique codes for laboratory tests and clinical observations, LOINC enables computer systems receiving the data to generate exact interpretations. This is called semantic interoperability. Semantic interoperability is essential for patient record transmission from one EHR system to another so that the meaning of the critical data contained within the records is not at risk of erroneous interpretation. Because new laboratory tests are constantly being developed and existing assays are being improved, LOINC creates and disseminates new codes so that semantic interoperability can be maintained. Old codes are not deleted from the system, ensuring that researchers using prior clinical databases can retrieve prior results comparable with new codes. LOINC is supported by the National Library of Medicine (NLM), one of the National Institutes of Health. The LOINC Committee publishes quarterly updates and holds twice-annual, national meetings to discuss proposed new clinical observations and laboratory tests for the assignment of new LOINC codes. For an HIE to transfer information accurately, each EHR system must map its own internal code for each datum to a standard code to ensure that information passed from one EHR to another in the exchange is interpreted exactly the same by the receiver as by the sender’s system. LOINC is one of the many HIT-related standards. The Systematic Nomenclature of Medicine (SNOMED) was originally developed by the College of American Pathologists (CAP) to specify tissue pathologic diagnoses. The same group also developed a standard for clinical observations called SNOMED Clinical Terms (SNOMED-CT). LOINC and SNOMED-CT domain standards somewhat overlap, but their design characteristics are valuable in different situations; for example,

exchanging laboratory results (where LOINC works better) versus coding patient problem lists within EHRs (where SNOMED-CT works better). Similar to LOINC, CAP also provides periodic updates to SNOMED-CT codes. To keep track of the many coding standards and the terms within, the NLM built and maintains the Unified Medical Language System (UMLS), which houses a massive “metathesaurus” and a variety of tools for mapping between and discovery of more than 200 biomedically related terminology standards.63 Because LOINC, SNOMED-CT, and the 200 or so other standards are periodically updated, the UMLS also is updated regularly to keep the interstandard terminology mapping current and accurate. Using HIEs, designated member groups of healthcare institutions exchange data in a standardized format using a combination of the previously described standards. This cooperation enables the access to a comprehensive clinical data set on individual patients across multiple institutions and multiple EHR vendor platforms. There are two kinds of HIE architectures: monolithic and federated. With the monolithic architecture design, all member institutions periodically send copies of their clinical data to one central repository where all the data reside together in one format. The advantage of this approach is that a patient’s comprehensive data can be maintained in one place and in one format. However, this approach has several disadvantages. First, the frequency with which members contribute and update copies of institutional data can vary, making the comprehensive HIE medical record potentially out of date. Second, aggregating data from multiple institutions creates administrative complexity with regard to HIPAA regulations. HIPAA requires each healthcare institution to maintain security of its patients’ data. If an institution’s data are “mixed” in the HIE database with data from other institutions, the responsibility of ensuring patient privacy and data security reverts to all HIE member institutions. HIPAA requirements make fulfilling healthcare organization obligations to ensure patient privacy more difficult and complex. Third, when data are aggregated by a third party or HIE, the ability of the source institution to assert control over data contributed to the collective HIE is limited. If, for example, an institution desires to stop participating in an HIE because of concern for patient privacy and data security, it may be technically difficult

and time consuming to selectively delete all data from one institution from the HIE database. The monolithic model of health information exchange is depicted in FIGURE 14-4.

FIGURE 14-4 The HIE monolithic model.

Description Institutions periodically send copies of their clinical data to one central repository. Individual transinstitutional patient records are maintained in the central database where they can be accessed by authorized users. The federated model of health information exchange is the most widely used, allowing contributing institutions to maintain control over data for which they are responsible under HIPAA. In this model, institutional data resides within each institution’s system. The HIE database is small, containing only a master patient index (MPI) housing the identifiers for each patient in the form of each institution’s unique patient record numbers, along with patient demographic data sufficient to facilitate accurate identification of individual patients with the same or similar names. This information is mapped to all the institutional-specific patient identifiers in the exchange. FIGURE 14-5 depicts the federated

model.

FIGURE 14-5 The HIE federated model.

Description Institutions maintain copies of their own data at their sites in the format used by the HIE. Individual transinstitutional patient records are assembled in real time by searching all institutions’ databases only when needed/requested by authorized users. Individual institutions can “opt out” of the HIE at any time by disabling access to their databases. With the federated model, a patient who has medical records at more than one institution in the HIE would have all medical record numbers from the various institutions that store their clinical data linked together in the common MPI, along with basic demographics such as address, date of birth, and Social Security number. This allows for fast and accurate identification of patients named “John Smith” because the MPI maintains sufficient identifying information to ensure selection of the correct patient among all institutions in the exchange. “John Smith” would be identified from others with the same name by parameters such as date of birth or Social Security number. No clinical data are stored in the MPI. Clinical data usually are maintained in the proprietary format of the particular EHR system used by each institution. Each institution also maintains a copy of the same data in the HIE standardized form. For example, all HIE members could agree to code all laboratory test results using the LOINC standard described earlier. Each

institution would create and maintain a database of all patients’ laboratory results coded with LOINC. When a user requests a comprehensive record from the HIE, the system would query all its institutional members in real time to send all the data available on a particular patient as identified using the MPI. In this way, when an HIE receives a records request on a particular patient, each institution sends data on the requested patient from the database where all clinical data are in the HIE format. This process ensures that the data are collected securely, assembled into a comprehensive record, and made available to authorized users in real time. This comprehensive record is only accessible on a patient-by-patient basis for immediate patient care purposes; it is not copied to any institution’s system. When the user logs out of the HIE, the comprehensive record assembled for that episode of patient care is deleted. The federated model has several advantages over the monolithic model. With the federated model, each institution maintains complete control over its data, simplifying compliance with HIPAA regulations. If, for example, a data breach occurs in the database of an HIE that uses the monolithic model, responsibility for the data breach is not always clear. Data breaches in a federated system usually are attributable to a particular institution and not the HIE (unless there is a data breach of the MPI). Another benefit of the federated system is that transinstitutional data can be up-to-the-minute accurate because each time a user requests access, the clinical data from all institutions are assembled in real time. Institutional HIT administrators typically favor the federated model because they have the option of withdrawing from the HIE at any time in order to maintain control of patient privacy and data security under HIPAA guidelines. Although communities with HIEs generally appreciate the benefits of interoperability, the current reality is that most of the operating HIEs are heavily subsidized with federal research grant funding to keep them afloat. The RHIOs that administer the HIEs and seek funding have not developed a business model that can be used in all communities in order to sustain their HIEs independent of federal funding. Some HIEs require each participating institution to pay an annual amount based on their institution’s size, the number of physicians, etc. Some have developed services for payers, charging them for access to the comprehensive

records available in the HIE. These services allow payers to increase their claims-processing efficiency. Other HIEs have developed services to generate comprehensive quality reports to sell to payers desiring to track physician and health plan outcomes or to help them meet the meaningful use requirements for CMS financial eligibility incentives. Some communities are resistant to allowing payer access to a data resource they believe should be solely dedicated to improving patient care and quality.64 An excellent example of this is the state of Vermont’s 2006 law that prevented data miners from selling physicians’ prescribing data to pharmaceutical companies who wanted the information to inform their marketing practices. In 2011, the law was struck down by the U.S. Supreme Court on a First Amendment basis.65 Physicians may feel uncomfortable participating in an exchange they know government, payers, or pharmaceutical companies may use for monitoring individual practice outcomes and patterns. Although the benefits of HIEs are documented and desirable, solving the cultural and business-model issues will be essential to obtaining the national goal of a network of regional exchanges that will span the entire country. Another challenge to developing interoperability is the fact that many institutions’ HIT resources are dedicated to keeping up with current quality reporting requirements, meaningful use adoption, and other mandated HIT issues. One recent example is the CMS-mandated conversion from using the International Classification of Disease Version 9 billing codes (ICD-9) to ICD-10. Originally designed to identify diagnoses for billing purposes only, ICD-9 codes have become valuable in performing automated chart reviews for quality control and research purposes. However, because of several deficiencies with ICD-9, the new ICD-10 standards have been mandated. A full discussion of the key differences between ICD-9 and ICD-10 is well beyond the scope of this book. A focus on just one issue illustrates the magnitude of the change— the impact on the complexity of physician documentation. There are approximately 13,000 ICD-9 codes and more than 65,000 ICD-10 codes. The greater number of ICD-10 codes is due to the higher specificity of ICD-10. For example, ICD-9 codes did not include laterality (i.e., right and left side of body). ICD-9 has a grand total of two possible codes for a thumb fracture:

815.01

Closed Fracture of base of Thumb (First) Metacarpal

815.11

Open Fracture of Base of Thumb (First) Metacarpal

Description Some of the codes for the same injury in ICD-10 include: S62.511B

Displaced fracture of proximal phalanx of right thumb, initial encounter for open fracture

S62.511D

Displaced fracture of proximal phalanx of right thumb, subsequent encounter for fracture with routine healing

S62.511G

Displaced fracture of proximal phalanx of right thumb, subsequent encounter for fracture with delayed healing

S62.511K

Displaced fracture of proximal phalanx of right thumb, subsequent encounter for fracture with nonunion

S62.511P

Displaced fracture of proximal phalanx of right thumb, subsequent encounter for fracture with malunion

S62.511S

Displaced fracture of proximal phalanx of right thumb, sequela

Description In addition to the six ICD-10 codes listed here, there are 99 additional choices to account for various combinations of displaced/nondisplaced, open/closed, proximal/distal location, right/left, union/nonunion/malunion of fracture, routine/delayed healing, initial/subsequent encounter, and so on. For decades, physicians have been writing their narratives in patient records supporting the billing process for the simpler ICD-9 code set. With ICD-10, the narrative in this example requires sufficient documentation to support the selection of the exact ICD-10 billing code; in other words, the narrative must include mention of displaced/nondisplaced, open/closed, proximal/distal phalanx location, right/left, etc. Failure to do so could result in not being reimbursed or

even being fined if a CMS chart audit was performed. This requirement for added specificity has been the most significant change to the way in which physicians document diagnoses in decades.

The Veterans Administration Health Information System No discussion of HIT, EHRs, and HIEs would be complete without noting the HIT system used by the Veterans Administration (VA). The VA is a model representing a single-payer healthcare system in the United States. Unlike other components of the healthcare delivery system, the VA HIT system supports only one payer, one pharmaceutical formulary, one provider group, and one supplier of laboratory testing. All VA physicians are employees of the same organization, so new policies and practices can be communicated, implemented, and monitored much more easily and efficiently than in the U.S. multipayer, multiformulary, siloed systems. Also, the VA has one universal EHR system with CPOE and CDSS. The VA EHR is able to code all data in one format that allows veterans who move from state to state to have their entire VA medical record seamlessly follow them. All these factors have allowed the VA to offer high-quality care at a relatively reasonable cost. Until the United States creates a single-payer system and uses the same EHR universally, the larger system will suffer from the enormous complexity and costs of developing and maintaining multiple data standards to support the exchange of health information among institutions and across vendor platforms.

Electronic Health Record Adoption Progress in the United States The National Center for Health Statistics (NCHS) has tracked the use of EHRs in the outpatient setting since 2006. The NCHS specifically defines two levels of adoption as “any” and “basic.” This distinction is important because many other surveys report EHR adoption rates but do not define in any detail what “EHR adoption” actually means. This survey uses an exacting definition of “any” and “basic” EHR adoption that produces results that are much more valid than surveys where “adoption” is not well defined. FIGURE 14-666 illustrates the adoption trends for the outpatient setting. According to Hsiao and Hing (2014), the National Center for Health Statistics (NCHS) National Ambulatory Medical Care EHR Survey showed that about 78% of office-based physicians used any EHR system. Since 2006 (the first year for which data are available), the percentage of physicians who reported having an EHR system that met the criteria for a basic system increased 336%—from 11% in 2006 to 48% in 2013. Adoption of a basic EHR system varied greatly by state. Adoption ranged from 21% in New Jersey to 83% in North Dakota.

FIGURE 14-6 EHR adoption among U.S. office-based physicians, 2001–2013.

Reproduced from CDC/NCHS, National Ambulatory Medical Care Survey, Electronic Health Records Survey NCHS Data Brief No. 143 http://www.cdc.gov/nchs/data/databriefs/db143.htm

Description The ONC has been tracking hospitals’ adoption of EHRs since 2008 using standard definitions of “Certified” and “Basic” EHR systems. FIGURE 14-7 illustrates the hospital EHR adoption rates.67 This brief, titled Adoption of Electronic Health Record Systems among U.S. Non-Federal Acute Care Hospitals: 2008-2014, examined trends in EHR adoption in U.S. nonfederal acute care hospitals between 2008 and 2014, stating:

FIGURE 14-7 Percentage of nonfederal acute care hospitals with adoption of at least a basic EHR with notes system and possession of a certified EHR: 2008–2014. Reproduced from ONC/American Hospital Association (AHA), AHA Annual Survey Information Technology Supplement.

Description In 2008, hospital adoption of at least a Basic EHR system was above 20% in only 2 states (Connecticut and New Mexico). Three years later, hospital adoption of at least a Basic EHR system was above 20% in 32 states and above 40% in 7 states. In 2014, hospital adoption of at least a Basic EHR system was above 60% in all but 2 states (Hawaii and West Virginia), and above 80% in 17 states.68 Note that EHR adoption rates are typically published every 2 to 3

years by the NCHS and the ONC. At the time of this printing, the most recent surveys published by the NCHS and the ONC were through 2013 and 2014, respectively. As part of the Medicare and Medicaid EHR Incentive Programs, or meaningful use programs, eligible providers had to use their EHRs to meet several program objectives, including e-prescribing. In addition, the Medicare Improvements for Patients and Providers Act, or the “eRx incentive” program, begun in 2008, offered financial incentives for providers to facilitate the use of e-prescribing.68 FIGURE 14-8 is a graph from an ONC data brief illustrating the e-prescribing rates in relation to the meaningful use and eRx incentive programs. From the data brief:69

FIGURE 14-8 Percentage of physicians e-prescribing using an EHR from December 2006 and April 2014. Reproduced from ONC analysis of physician prescriber data from Surescripts. Denominator from SK&A 2011 Office Based Providers Database. https://www.healthit.gov/sites/default/files/oncdatabriefe-prescribingincreases2014.pdf

Description The growth in e-prescribing has not been limited to physicians. In the same period, the percent of community pharmacies enabled to accept e-prescriptions grew from 76% to 96%. Nearly all community pharmacies are enabled to accept e-prescriptions in Delaware (99%) and Maine (99%). The growth of physicians and pharmacies e-prescribing has corresponded with a thirteen-fold increase in the growth of new and renewal prescriptions sent electronically. In 2008, only 4% of new and renewal prescriptions were sent electronically. In 2013, 57% of new and renewal prescriptions were sent electronically. Minnesota (89%), Wisconsin (83%), and Massachusetts (77%) had the highest rate of new and renewals sent electronically.

Future Challenges Although there is mounting evidence supporting the value of EHRs with CPOE and CDSS in several well-defined areas such as improving preventive care delivery, extensive meta-analyses report combined average results. There have been several inconclusive and negative studies, and some have actually shown patient harm associated with the installation of CPOE. In one of the most extensively reported, the mortality rate in a neonatal intensive care unit more than doubled after a CPOE system was installed at the University of Pittsburgh.69 Much has been written about the reasons for this negative result, and despite the finger pointing, there is virtually universal agreement that HIT can be very disruptive to work processes and work cultures resulting in significant harm to patients.70 Some have called for more HIT standards and regulations to prevent these negative consequences in the same way as the U.S. Food and Drug Administration regulates medical devices.71,72 Because of the administrative and technical difficulties of achieving the Nationwide Health Information Network, proprietary entities have offered alternate approaches to develop personal health records (PHRs) through which patients create their own records in a standardized format. In these approaches, patients may physically carry records or make them available to caregivers via the Internet. Microsoft, Google, and many other corporate entities have built such systems but with little marketing success. Google Health announced its shutdown on June 24, 2011, after only 3 years of operation. Google joins other lesser-known firms that have decided to close down PHR services.73 Design of existing PHRs requires patients to have a high level of health literacy and computer savvy. A major reason analysts believed Google Health failed was the newness of the concept and the facts that PHRs are difficult to use and many people find the data entry work necessary to complete their record too laborious.74 One survey of patients found that only 7% had tried using a PHR and only about 3% continued to use them in 2011.74 Other barriers to patient adoption include lack of personal health management tools, the difficulty in achieving semantic interoperability such that personal health management tools could be useful, problems vetting the identity of PHR

users, patient privacy concerns, and perhaps, most important, the lack of a business model to support the long-term operation of PHRs.73 In addition to physicians and patients affected by development and implementation of HIT, there are many other healthcare professionals and venues affected by significant complexities and characteristics that make HIT implementation challenging. Many of the same issues previously discussed in this chapter apply to these venues, such as standardized data formats to facilitate data portability, work culture barriers, system costs, training issues, and other matters. For example, some emergency medical services (EMS) providers have begun to use a variety of portable EHRs to collect data at the scenes of patient incidents with systems designed to transmit data to receiving hospitals. The same issues that complicate the ease of universal HIE between healthcare institutions apply to the data exchange between EMS and hospital systems and will not be resolved easily. To achieve the HIT goals of improving healthcare quality and reducing costs, extensive and rigorous work remains in the research and implementation arenas. After 50 years of efforts, most notably in the past 5 years, government, industry, and academia are only now recognizing the critically important and interdependent roles that standardization, administrative processes, and work cultures play in the achievement of HIT-desired outcomes.

Discussion Questions 1. Describe the ways that electronic health records can eliminate redundant efforts. 2. What are the ethical considerations for a shared EHR with other healthcare institutions? 3. Does your institution define objectives that have to be met for meaningful use of the EHR to gain financial incentives? If so, what is being tracked specific to your unit?

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http://www.cms.gov/Regulations-andGuidance/Legislation/EHRIncentivePrograms/index.html?redirect=/ehrincentiveprograms. Accessed March 8, 2016. 36. Office of the National Coordinator for Health Information Technology. About ONC. 2014. https://www.healthit.gov/newsroom/about-onc. Accessed January 25, 2016. 37. Office of the National Coordinator for Health Information Technology. Justification of estimates for appropriations committee fiscal year 2016. https://www.healthit.gov/sites/default/files/ONCFY2016-budget-justification.pdf. Accessed March 8, 2016. 38. Office of the National Coordinator for Health Information Technology. Justification of estimate for appropriations committee fiscal year 2015. https://www.healthit.gov/sites/default/files/onc_fy2015justificationforappropriations.pdf. Accessed March 8, 2016. 39. Office of the National Coordinator for Health Information Technology. Health Information Technology Advisory Committee (HITAC). https://www.healthit.gov/facas. Accessed March 8, 2016. 40. Centers for Medicare and Medicaid Services. Medicaid electronic health record incentive payments for eligible professionals. https://www.cms.gov/regulations-andguidance/legislation/ehrincentiveprograms/downloads/mln_medicaidehrprogram_tipsheet_ep.pdf Accessed March 8, 2016. 41. Healthcare Information and Management Systems Society. CMS and ONC provide MU data update to health IT policy committee. http://www.himss.org/News/NewsDetail.aspx? ItemNumber=37995. Accessed March 9, 2016. 42. Office of the National Coordinator for Health Information Technology. Health IT policy committee meeting data analytics update. January 13, 2015. http://www.healthit.gov/facas/sites/faca/files/HITPC_Data_Analytics_update_2015-0113_v3.pptx. Accessed March 9, 2016. 43. Centers for Medicare and Medicaid Services. CMS fact sheet: EHR incentive programs in 2015 and beyond. https://www.cms.gov/newsroom/fact-sheets/cms-fact-sheet-ehr-incentiveprograms-2015-and-beyond. Accessed February 20, 2019. 44. United States Department of Health and Human Services Office of the National Coordinator for Health Information Technology. Eligible professional’s guide to stage 2 of the EHR incentive programs. https://www.cms.gov/regulations-andguidance/legislation/ehrincentiveprograms/downloads/stage2_guide_eps_9_23_13.pdf. Accessed February 20, 2019. 45. United States Department of Health and Human Services Office of the National Coordinator for Health Information Technology. Stage 2 overview tipsheet. https://www.cms.gov/Regulationsand-Guidance/Legislation/EHRIncentivePrograms/Downloads/Stage2Overview_Tipsheet.pdf. Accessed February 3, 2016. 46. Centers for Medicare and Medicaid Services. Eligible professional EHR incentive program objectives and measures for 2015 table of contents. https://www.cms.gov/Regulations-andGuidance/Legislation/EHRIncentivePrograms/Downloads/2015EP_TableofContents.pdf. Accessed March 8, 2016. 47. Centers for Medicare and Medicaid Services. Eligible hospital and critical access hospital EHR incentive program objectives and measures for 2015 table of contents. https://www.cms.gov/Regulations-andGuidance/Legislation/EHRIncentivePrograms/Downloads/2015EHCAH_TableofContents.pdf. Accessed March 8, 2016. 48. Dukette D, Cornish D. The Essential 20: Twenty Components of an Excellent Health Care Team. Pittsburgh, PA: RoseDog Books; 2009:72-74. 49. Parthasarathy S. Sleep and the medical profession. Curr Opin Pulm Med. 2005;11:507-512.

50. Friedman CP. What informatics is and isn’t. J Am Med Inform Assoc. 2013;20:224-226. 51. Sirajuddin AM, Osheroff JA, Sittig DF, et al. Implementation pearls from a new guidebook on improving medication use and outcomes with clinical decision support. Effective CDS is essential for addressing healthcare performance improvement imperatives. J Healthc Inf Manag. 2009;23:38-45. 52. Evans RS, Pestotnik SL, Classen DC, et al. A computer-assisted management program for antibiotics and other antiinfective agents. N Engl J Med. 1998;338:232-238. 53. Tierney WM, Dexter PR, Gramelspacher GP, et al. The effect of discussions about advance directives on patients’ satisfaction with primary care. J Gen Intern Med. 2001;16:32-40. 54. Tierney WM, Miller ME, Overhage JM, et al. Physician inpatient order writing on microcomputer workstations. Effects on resource utilization. JAMA. 1993;269:379-383. 55. Kho AN, Dexter P, Lemmon L, et al. Connecting the dots: creation of an electronic regional infection control network. Stud Health Technol Inform. 2007;129:213-217. 56. Kho A, Dexter P, Warvel J, et al. Computerized reminders to improve isolation rates of patients with drug-resistant infections: design and preliminary results. AMIA Annu Symp Proc. 2005:390-394. 57. Rosenman M, Wang J, Dexter P, et al. Computerized reminders for syphilis screening in an urban emergency department. AMIA Annu Symp Proc. 2003:987. 58. Kroth PJ, Dexter PR, Overhage JM, et al. A computerized decision support system improves the accuracy of temperature capture from nursing personnel at the bedside. AMIA Annu Symp Proc. 2006:444-448. 59. Agency for Healthcare Research and Quality. Evidence report/technology assessment number 203: Enabling health care decisionmaking through clinical decision support and knowledge management. http://www.ncbi.nlm.nih.gov/books/NBK97318/pdf/Bookshelf_NBK97318.pdf. Accessed March 9, 2016. 60. Office of the National Coordinator for Health Information Technology. Report to congress on health information blocking. https://www.healthit.gov/sites/default/files/reports/info_blocking_040915.pdf. Accessed March 9, 2016. 61. Reproduced from DeSalvo KB, Daniel JG. Blocking of health information undermines health system interoperability and delivery reform. http://www.healthit.gov/buzz-blog/from-the-oncdesk/health-information-blocking-undermines-interoperability-delivery-reform. Accessed March 9, 2016. 62. Lin MC, Vreeman DJ, McDonald CJ, et al. Auditing consistency and usefulness of LOINC use among three large institutions–using version spaces for grouping LOINC codes. J Biomed Inform. 2012;45:658-666. 63. National Library of Medicine. UMLS quick start guide. http://www.nlm.nih.gov/research/umls/quickstart.html. Accessed March 9, 2016. 64. Sorrell WH. Supreme Court strikes down Vermont prescription privacy law. 2011. https://www.supremecourt.gov/opinions/10pdf/10-779.pdf. Accessed March 9, 2016. 65. The Supreme Court of the United States. Sorrell, Attorney General of Vermont, et al. vs. IMS Health inc. et al. 2011. http://www.supremecourt.gov/opinions/10pdf/10-779.pdf. Accessed March 9, 2016. 66. Hsiao CJ, Hing E. Use and characteristics of electronic health record systems among officebased physician practices: United States, 2001–2013, NCHS Data Brief No. 143. 2015. http://www.cdc.gov/nchs/data/databriefs/db143.htm. Accessed March 9, 2016. 67. Charles D, Gabriel M, Searcy T. Adoption of electronic health record systems among U.S. nonfederal acute care hospitals: 2008-2014. ONC Data Brief No. 23. Office of the National Coordinator for Health Information Technology: Washington DC. https://www.healthit.gov/sites/default/files/data-brief/2014HospitalAdoptionDataBrief.pdf.

Accessed May 17, 2019. 68. Gabriel MH, Swain M. E-prescribing trends in the United States. ONC Data Brief No. 18. 2014. https://www.healthit.gov/sites/default/files/oncdatabriefe-prescribingincreases2014.pdf. Accessed March 9, 2016. 69. Han YY, Carcillo JA, Venkataraman ST, et al. Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system. Pediatrics. 2005;116:1506-1512. 70. Sittig DF, Ash JS, Zhang J, et al. Lessons from “unexpected increased mortality after implementation of a commercially sold computerized physician order entry system.” Pediatrics. 2006;118:797-801. 71. Miller RA, Gardner RM. Summary recommendations for responsible monitoring and regulation of clinical software systems. American Medical Informatics Association, the Computer-Based Patient Record Institute, the Medical Library Association, the Association of Academic Health Science Libraries, the American Health Information Management Association, and the American Nurses Association. Ann Intern Med. 1997;127:842-845. 72. Miller RA, Gardner RM. Recommendations for responsible monitoring and regulation of clinical software systems. American Medical Informatics Association, Computer-Based Patient Record Institute, Medical Library Association, Association of Academic Health Science Libraries, American Health Information Management Association, American Nurses Association. J Am Med Inform Assoc. 1997;4:442-457. 73. Rishel W, Booz RH. Google Health shutdown underscores uncertain future of PHRS. 2011. http://www.gartner.com/resources/214600/214682/google_health_shutdown_under_214682.pdf Accessed March 9, 2016. 74. Lohr S. Google is closing its health records service. New York Times. June 24, 2011.

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CHAPTER 15 The Electronic Health Record and Clinical Informatics Emily B. Barey, Kathleen Mastrian, and Dee McGonigle

CHAPTER OBJECTIVES 1. 2. 3. 4.

Describe the common components of an electronic health record. Assess the benefits of implementing an electronic health record. Explore the ownership of an electronic health record. Evaluate the flexibility of the electronic health record in meeting the needs of clinicians and patients.

Introduction The significance of electronic health records (EHRs) to nursing cannot be underestimated. Although EHRs on the surface suggest a simple automation of clinical documentation, in fact their implications are broad, ranging from the ways in which care is delivered to the types of interactions nurses have with patients in conjunction with the use of technology, to the research surrounding EHRs that will inform nursing practice for tomorrow. Although EHR standards are evolving and barriers to adoption remain, the collective work has a positive momentum that will benefit clinicians and patients alike. A basic knowledge of EHRs and nursing informatics is now considered by many to be an entry-level nursing competency. Various nursing work groups have delineated nursing informatics competencies from entry level to nursing informatics specialists, and other groups have identified competencies specific to the EHR. The American Health Information Management Association (AHIMA) collaborated with the Health Professions Network and the Employment and Training Administration to create a graphic depiction of competencies necessary for EHR interaction. The electronic health records competency model is divided into six levels: personal effectiveness competencies, academic competencies, workplace competencies, industry-wide technical competencies, industry-sector technical competencies, and a management competencies level shared with occupation-specific requirements. The EHR competency model can be viewed at www.careeronestop.org/CompetencyModel/competencymodels/electronic-health-records.aspx. Hovering over each block in the model provides a definition of each of the competencies covered by the model. For example, the industry-sector technical competencies section includes health information literacy and skills, health informatics skills using the EHR, privacy and confidentiality of health information, and health information data technical security. This drive to adopt EHRs was underscored with the passage of the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009. It is essential that EHR competency be developed if nurses are to participate fully in the

changing world of healthcare information technology. This chapter has four goals. First, it describes the common components of an EHR. Second, it reviews the benefits of implementing an EHR. Third, it provides an overview of successful ownership of an EHR, including nursing’s role in promoting the safe adoption of EHRs in day-to-day practice. Fourth, it discusses the flexibility of an EHR in meeting the needs of both clinicians and patients and emphasizes the need for fully interoperable EHRs and clinical information systems (CISs).

Setting the Stage The U.S. healthcare system faces the enormous challenge of improving the quality of care while simultaneously controlling costs. EHRs were proposed as one solution to achieve this goal (Institute of Medicine [IOM], 2001). In January 2004, President George W. Bush raised the profile of EHRs in his State of the Union address by outlining a plan to ensure that most Americans have an EHR by 2014. He stated that “by computerizing health records we can avoid dangerous medical mistakes, reduce costs, and improve care” (Bush, 2004). This proclamation generated an increased demand for understanding EHRs and promoting their adoption, but relatively few healthcare organizations were motivated at that time to pursue adoption of EHRs. The Healthcare Information and Management Systems Society (HIMSS) has been tracking EHR adoption since 2005 through its Stage 7 award, and in 2013 reported that most U.S. healthcare organizations (77%) were in Stage 3, reflecting implementation of only the basic EHR components of laboratory, radiology, and pharmacy ancillaries; a clinical data repository, including a controlled medical vocabulary; and simple nursing documentation and clinical decision support (HIMSS, 2013). Higher stages of the electronic medical record adoption model include more sophisticated use of clinical decision support systems (CDSSs) and medication administration tools, with HIMSS Stage 7—the highest level—consisting of EHRs that have data sharing and warehousing capabilities and that are completely interfaced with emergency and outpatient facilities (HIMSS Analytics, 2013). Real progress is being made on the adoption of more robust EHRs. HIMSS Analytics (2015) reports that 1,313 hospitals in the United States have achieved Stage 6, with full physician documentation, a robust CDSS, and electronic access to medical images. Healthcare IT News (2015) reported that, to date, over 200 hospitals have achieved Stage 7 and are totally paperless and that more organizations reach this goal every day. In President Barack Obama’s first term in office, Congress passed the American Recovery and Reinvestment Act (ARRA) of 2009. This legislation included the HITECH Act, which specifically sought to

incentivize health organizations and providers to become meaningful users of EHRs. These incentives came in the form of increased reimbursement rates from the Centers for Medicare and Medicaid Services (CMS); ultimately, the HITECH Act resulted in payment of a penalty by any healthcare organization that had not adopted an EHR by January 2015. The final rule was published by the U.S. Department of Health and Human Services (USDHHS) in July 2010 for the first phase of implementation. Stage 1 meaningful use criteria focused on data capture and sharing (USDHHS, 2010). Stage 2 criteria, implemented in 2014, advanced several clinical processes and promoted health information exchange (HIE) and more patient control over personal data. Stage 3, which had a target implementation date of 2016, focuses on improved outcomes for individuals and populations and introduction of patient selfmanagement tools (HealthIT.gov, 2013).

Components of Electronic Health Records Overview Before enactment of the ARRA, several variants of EHRs existed, each with its own terminology and each developed with a different audience in mind. The sources of these records included, for example, the federal government (Certification Commission for Healthcare Information Technology, 2007), the IOM (2003), the HIMSS (2007), and the National Institutes of Health (2006; Robert Wood Johnson Foundation [RWJF], 2006). Under ARRA, there is now an explicit requirement for providers and hospitals to use a certified EHR that meets a set of standard functional definitions to be eligible for the increased reimbursement incentive. Initially, USDHHS granted two organizations the authority to accredit EHRs: the Drummond Group and the Certification Commission for Healthcare Information Technology. In 2015, there were five recognized bodies for testing and certifying EHRs (HealthIT.gov, 2015a). These bodies are authorized to test and certify EHR vendors against the standards and test procedures developed by the National Institute of Standards and Technology (NIST) and endorsed by the Office of the National Coordinator for Health Information Technology for EHRs. The initial NIST test procedure included 45 certification criteria, ranging from the basic ability to record patient demographics, document vital signs, and maintain an up-to-date problem list, to more complex functions, such as electronic exchange of clinical information and patient summary records (Jansen & Grance, 2011; NIST, 2015). BOX 15-1 lists the 45 certification criteria outlined by NIST in 2010. These criteria have been updated several times since 2010, with the 2015 version developed after going out for public comment (HealthIT.gov, 2015b). Each iteration of certification criteria and testing procedures seeks to make the EHR more robust, interoperable, and functional to meet the needs of patients and users.

BOX 15-1 EHR Certification Criteria Criteria #

Certification Criteria

§170.302 (a)

Drug–drug, drug–allergy interaction checks

§170.302 (b)

Drug formulary checks

§170.302 (c)

Maintain up-to-date problem list

§170.302 (d)

Maintain active medication list

§170.302 (e)

Maintain active medication allergy list

§170.302 (f)(1)

Vital signs

§170.302 (f)(2)

Calculate body mass index

§170.302 (f)(3)

Plot and display growth charts

§170.302 (g)

Smoking status

§170.302 (h)

Incorporate laboratory test results

§170.302 (i)

Generate patient lists

§170.302 (j)

Medication reconciliation

§170.302 (k)

Submission to immunization registries

§170.302 (l)

Public health surveillance

§170.302 (m)

Patient-specific education resources

§170.302 (n)

Automated measure calculation

§170.302 (o)

Access control

§170.302 (p)

Emergency access

§170.302 (q)

Automatic log-off

§170.302 (r)

Audit log

§170.302 (s)

Integrity

§170.302 (t)

Authentication

§170.302 (u)

General encryption

§170.302 (v)

Encryption when exchanging electronic health information

§170.302 (w)

Accounting of disclosures (optional)

§170.304 (a)

Computerized provider order entry

§170.304 (b)

Electronic prescribing

§170.304 (c)

Record demographics

§170.304 (d)

Patient reminders

§170.304 (e)

Clinical decision support

§170.304 (f)

Electronic copy of health information

§170.304 (g)

Timely access

§170.304 (h)

Clinical summaries

§170.304 (i)

Exchange clinical information and patient summary record

§170.304 (j)

Calculate and submit clinical quality measures

§170.306 (a)

Computerized provider order entry

§170.306 (b)

Record demographics

§170.306 (c)

Clinical decision support

§170.306 (d)(1)

Electronic copy of health information

§170.306 (d)(2)

Electronic copy of health information Note: For discharge summary

§170.306 (e)

Electronic copy of discharge instructions

§170.306 (f)

Exchange clinical information and patient summary record

§170.306 (g)

Reportable lab results

§170.306 (h)

Advance directives

§170.306 (i)

Calculate and submit clinical quality measures

Reproduced from National Institute of Standards and Technology (NIST). (2010). Meaningful use test method: Approved test procedures version 1.0. Retrieved from http://healthcare.nist.gov/use_testing/finalized_requirements.html

Despite the points articulated in the ARRA, the IOM definition of an EHR also remains a valid reference point. This definition is useful because it has distilled all the possible features of an EHR into eight essential components with an emphasis on functions that promote patient safety—a universal denominator that everyone in health care can accept. The eight components are (1) health information and data, (2) results management, (3) order entry management, (4) decision support, (5) electronic communication and connectivity, (6) patient support, (7) administrative processes, and (8) reporting and population health management (IOM, 2003). These initial core components, as well as more recent modifications described by the Health Resources and Services Administration (HRSA, n.d.) and the components of a comprehensive EHR identified by HealthIT.gov (Charles, Gabriel, & Searcy, 2015), are described in more detail here. With the exception of

EHR infrastructure functions, such as security and privacy management, controlled medical vocabularies, and interoperability standards, the 45 initial NIST standards easily map into the IOM categories (Jansen & Grance, 2011).

Health Information and Data Health information and data comprise the patient data required to make sound clinical decisions, including demographics, medical and nursing diagnoses, medication lists, allergies, and test results (IOM, 2003). This component of the EHR also includes care management data regarding details of patient visits and interactions with patients, medication reconciliation, consents, and directives (HRSA, n.d.). A comprehensive EHR will also contain nursing assessments and problem lists (Charles et al., 2015).

Results Management Results management is the ability to manage results of all types electronically, including laboratory and radiology procedure reports, both current and historical (IOM, 2003).

Order Entry Management Order entry management is the ability of a clinician to enter medication and other care orders, including laboratory, microbiology, pathology, radiology, nursing, and supply orders; ancillary services; and consultations, directly into a computer (IOM, 2003). A comprehensive EHR will also contain nursing orders (Charles et al., 2015).

Decision Support Decision support entails the use of computer reminders and alerts to improve the diagnosis and care of a patient, including screening for correct drug selection and dosing, screening for medication interactions with other medications, preventive health reminders in such areas as vaccinations, health risk screening and detection, and clinical guidelines for patient disease treatment (IOM, 2003).

Electronic Communication and Connectivity Electronic communication and connectivity include the online communication among healthcare team members, their care partners, and patients, including email, Web messaging, and an integrated health record within and across settings, institutions, and telemedicine (IOM, 2003). This component has been expanded to include interfaces and interoperability required to exchange health information with other providers, laboratories, pharmacies (e-prescribing), patients, and government disease registries (HRSA, n.d., para. 2)

Patient Support Patient support encompasses patient education and self-monitoring tools, including interactive computer-based patient education, home telemonitoring, and telehealth systems (IOM, 2003).

Administrative Processes Administrative processes are activities carried out by the electronic scheduling, billing, and claims management systems, including electronic scheduling for inpatient and outpatient visits and procedures, electronic insurance eligibility validation, claim authorization and prior approval, identification of possible research study participants, and drug recall support (IOM, 2003).

Reporting and Population Health Management Reporting and population health management are the data collection tools to support public and private reporting requirements, including data represented in a standardized terminology and machine-readable format (IOM, 2003). NIST has not provided an exhaustive list of all possible features and functions of an EHR. Consequently, different vendor EHR systems combine different components in their offerings, and often a single set of EHR components may not meet the needs of all clinicians and patient populations. For example, a pediatric setting may demand functions for immunization management, growth tracking, and more robust order entry

features to include weight-based dosing (Spooner & Council on Clinical Information Technology, 2007). These types of features may not be provided by all EHR systems, and it is important to consider EHR certification to be a minimum standard. See FIGURE 15-1 for a graphic depiction of EHR functions and communication capabilities.

FIGURE 15-1 EHR functions and communication capabilities. Reproduced from American Hospital Association. (2010). The road to meaningful use: What it takes to implement EHR systems in hospitals. Retrieved from http://www.aha.org/research/reports/tw/10apr-tw-HITmeanuse.pdf

Description Another group that focuses on EHR standards and functionality is Health Level Seven International (HL7). Founded in 1987, “Health Level Seven International (HL7) is a not-for-profit, ANSI-accredited standards developing organization dedicated to providing a comprehensive framework and related standards for the exchange, integration, sharing, and retrieval of electronic health information that supports clinical practice and the management, delivery and evaluation of health services” (Health Level Seven International, 2019, para. 1). This group concentrates on developing the behind-the-scenes programming standards (Level Seven is the application level of the open systems interconnection model) for interfaces to ensure interoperability and connectivity among systems.

Advantages of Electronic Health Records Measuring the benefits of EHRs can be challenging. Possible methods to estimate EHR benefits include using vendor-supplied data that have been retrieved from their customers’ systems, synthesizing and applying studies of overall EHR value, creating logical engineering models of EHR value, summarizing focused studies of elements of EHR value, and conducting and applying information from site visits (HealthIT.gov, 2012; Thompson, Osheroff, Classen, & Sittig, 2007). Early on, the four most common benefits cited for EHRs were (1) increased delivery of guidelines-based care, (2) enhanced capacity to perform surveillance and monitoring for disease conditions, (3) reduction in medication errors, and (4) decreased use of care (Chaudhry et al., 2006; HealthIT.gov, 2012). These findings were echoed by two similar literature reviews. The first review (Dorr et al., 2007) focused on the use of informatics systems for managing patients with chronic illness. It found that the processes of care most positively affected were guidelines adherence, visit frequency (i.e., a decrease in emergency department visits), provider documentation, patient treatment adherence, and screening and testing. The second review (Shekelle, Morton, & Keeler, 2006) was a cost– benefit analysis of health information technology completed by the Agency for Healthcare Research and Quality (AHRQ) that studied the value of an EHR in the ambulatory care and pediatric settings, including its overall economic value. The AHRQ study highlighted the common findings already described but also noted that most of the data available for review came from six leading healthcare organizations in the United States, underscoring the challenge of generalizing these results to the broader healthcare industry. As noted previously by the HIMSS Stage 7 Awards, the challenge to generalize results persists in the hospital arena, with fewer than 1% of U.S. hospitals or eight leading organizations providing most of the experience with comprehensive EHRs (HIMSS, 2010a). Finally, the literature reviews cited here indicated that there are a

limited number of hypothesis-testing studies of EHRs and even fewer that have reported cost data. The descriptive studies do have value, however, and should not be hastily dismissed. Although not as rigorous in their design, they do describe the advantages of EHRs well and often include useful implementation recommendations learned from practical experience. As identified in these types of reviews, EHR advantages include simple benefits, such as no longer having to interpret poor handwriting and handwritten orders, reduced turnaround time for laboratory results in an emergency department, and decreased time to administration of the first dose of antibiotics in an inpatient nursing unit (HealthIT.gov, 2012; Husk & Waxman, 2004; Smith et al., 2004). In the ambulatory care setting, improved management of cardiac-related risk factors in patients with diabetes and effective patient notification of medication recalls have been demonstrated to be benefits of the EHR (Jain et al., 2005; Reed & Bernard, 2005). Two other unique advantages that have great potential are the ability to use the EHR and decision support functions to identify patients who qualify for research studies or who qualify for prescription drug benefits offered by pharmaceutical companies at safety net clinics and hospitals (Embi et al., 2005; Poprock, 2005). The HIMSS Davies Award may be the best resource for combined quantitative and qualitative results of successful EHR implementation. The Davies Award recognizes healthcare organizations that have achieved both excellence in implementation and value from health information technology (HIMSS, 2010a). One winner demonstrated a significant avoidance of medication errors because of bar-code scanning alerts, a $3 million decrease in medical records expenses as a result of going paperless, and a 5% reduction of duplicate laboratory orders by using computerized provider order entry alerting (HIMSS, 2010b). Another winner noted a 13% decrease in adverse drug reactions through the use of computerized physician order entry; it also achieved a decrease in methicillin-resistant Staphylococcus aureus (MRSA) nosocomial infections from 9.8 per 10,000 discharges to 6.4 per 10,000 discharges in less than a year using an EHR flagging function, which made clinicians immediately aware that contact precautions were required for MRSA-positive patients (HIMSS, 2009). At both organizations, there was qualitative and quantitative evidence of high

rates of end-user adoption and satisfaction with use of the EHR. A 2011 study of the effects of EHR adoption on nurse perceptions of quality of care, communication, and patient safety documented that nurses report better care outcomes and fewer concerns with care coordination and patient safety in hospitals with a basic EHR (Kutney-Lee & Kelly, 2011). In this study, nurses perceived that in hospitals with a functioning EHR, there was better communication among staff, especially during patient transfers, and fewer medication errors. Bayliss et al. (2015) demonstrated that an integrated care system utilizing an EHR resulted in fewer hospital readmissions and emergency room visits for over 12,000 seniors with multiple health challenges. Without an EHR system, any of these benefits would be very difficult and costly to accomplish. Thus, despite limited standards and published studies, there is enough evidence to embrace widespread implementation of the EHR (Halamka, 2006; HealthIT.gov, 2012) and certainly enough evidence to warrant further study of the use and benefits of EHRs. BOX 15-2 describes some of the specific CIS functions of an EHR.

BOX 15-2 The EHR as a Clinical Information System Denise Tyler A CIS is a technology-based system applied at the point of care and designed to support care by providing instant access to information for clinicians. Early CISs implemented prior to the advent of EHRs were limited in scope and provided such information as interpretation of laboratory results or a medication formulary and drug interaction information. With the implementation of EHRs, the goal of many organizations is to expand the scope of the early CISs to become comprehensive systems that provide clinical decision support, an electronic patient record, and in some instances professional development and training tools. Benefits of such a comprehensive system include easy access to patient data at the point of care; structured and legible information that can be searched easily and lends itself to data mining and analysis; and improved patient safety, especially the prevention of adverse drug reactions and the identification of health risk factors, such as falls. Tracking Clinical Outcomes The ability to measure outcomes can be enhanced or impeded by the way an information system is designed and used. Although many practitioners can paint a very good picture of the patient by using a narrative (free text), employing this mode of expression in a clinical system without the use of a coded entry makes it difficult to analyze the care given or the patient’s response. Free-text reporting also leads to inconsistencies of reporting from clinician to clinician and patient information that is fragmented or disorganized. This can limit the

usefulness of patient data to other clinicians and interfere with the ability to create reports from the data for quality assurance and measurement purposes. Moreover, not all clinicians are equally skilled at the free-text form of communication, yielding inconsistent quality of documentation. Integrating standardized nursing terminologies into computerized nursing documentation systems enhances the ability to use the data for reporting and further research. According to the IOM (2012), “Payers, healthcare delivery organizations and medical product companies should contribute data to research and analytic consortia to support expanded use of care data to generate new insights” (para. 2). McLaughlin and Halilovic (2006) described the use of clinical analytics to promote medical care outcomes research. The use of a CIS in conjunction with standardized codes for patient clinical issues helps to support the rigorous analysis of clinical data. Outcomes data produced as part of these analyses may include length of stay, mortality, readmissions, and complications. Future goals include the ability to compare data and outcomes across various institutions as a means of developing clinical guidelines or best practices guidelines. With the implementation of a comprehensive CIS, similar analyses of nursing outcomes could also be performed and shared. Likewise, such a system could aid nurse administrators in cross-unit comparisons and staffing decisions, especially when coupled with acuity systems data. In addition, clinical analytics can support required data reporting functions, especially those required by accreditation bodies. Supporting Evidence-Based Practice Evidence-based practice (EBP) can be thought of as the integration of clinical expertise and best practices based on systematic research to enhance decision making and improve patient care. References supporting EBP, such as clinical guidelines, are available for review at the click of a mouse or the press of a few keystrokes. The CIS’s prompting capabilities can also reinforce the practice of looking for evidence to support nursing interventions rather than relying on how things have been done historically. This approach enhances processing and understanding of the information and allows the nurse to apply the information to other areas, increasing the knowledge obtained about why certain conditions or responses result in prompts for additional questions or actions. To incorporate EBP into the practice of clinical nursing, the information needs to be embedded in the computerized documentation system so that it is part of the workflow. The most typical way of embedding this timely information is through clinical practice guidelines. The resulting interventions and clinical outcomes need to be measurable and reportable for further research. The supporting documentation for the EBP needs to be easily retrievable and meaningful. Links, reminders, and prompts can all be used as vehicles for transmission of this information. The format needs to allow for rapid scanning, with the ability to expand the amount of information when more detail is required or desired. Balancing consistency in formatting with creativity can be difficult but is worth the effort to stimulate an atmosphere for learning. EBP is supported by translational research, an exciting movement that has enormous potential for the sharing and use of EBP. The use of translational research to support EBP may help to close the gap between what is known (research) and what is done (practice). The CIS as a Staff Development Tool Joy Hilty, a registered nurse from Kaweah Delta, came up with a creative way to provide staff development or education without taking staff away from the bedside to a classroom setting. She created pop-up boxes on the opening charting screens for all staff who chart on the computer. These pop-ups vary in color and content and include a short piece of clinical information, along with a question. Staff can earn vacations from these pop-ups for as long as 14 days by emailing the correct answer to the question. This medium has provided

information, stimulation, and a definite benefit: the vacation from the pop-up boxes. The popup box education format has also encouraged staff to share their answers, thereby creating interaction, knowledge dissemination, and reinforcement of the education provided. Embedding EBP into nursing documentation can also increase the compliance with Joint Commission core measures, such as providing information on influenza and pneumococcal vaccinations to at-risk patients. In the author’s experience at Kaweah Delta, educating staff via classes, flyers, and storyboards was not successful in improving compliance with the documentation of immunization status or offering education on these vaccinations to at-risk patients. Embedding the prompts, information, and related questions in the nursing documentation with a link to the protocol and educational material, however, improved the compliance to 96% for pneumococcal vaccinations and to 95% for influenza vaccinations (Hettinger, 2007). As more information is stored electronically, nurse informaticists must translate the technology so that the input and retrieval of information are developed in a manner that is easy for clinicians to learn and use. A highly usable product should decrease errors and improve information entry and retrieval. Nurse informaticists must be able to work with staff and expert users to design systems that meet the needs of the staff who will actually use the systems. The work is not done after the system is installed; the system must continue to be developed and improved because as staff use the system, they will be able to suggest changes to improve it. This ongoing revision should result in a system that is mature and meets the needs of the users. In an ideal world, all clinical documentation will be shared through a national database, in a standard language, to enable evaluation of nursing care, increase the body of evidence, and improve patient outcomes. With minimal effort, the information will be translated into new research that can be analyzed and linked to new evidence that will be intuitively applied to the CIS. Alerts will be meaningful and will be patient and provider specific. The steps required of the clinician to find current, reliable information will be almost transparent, and the information will be presented in a personalized manner based on user preferences stored in the CIS.

A more recent description of the benefits of an EHR by HealthIT.gov (2018) emphasizes that EHRs hold the promise of transforming healthcare; specifically, EHRs will lead to: Better health care by improving all aspects of patient care, including safety, effectiveness, patient-centeredness, communication, education, timeliness, efficiency, and equity Better health by encouraging healthier lifestyles in the entire population, including increased physical activity, better nutrition, avoidance of behavioral risks, and wider use of preventive care Improved efficiencies and lower healthcare costs by promoting preventive medicine and improved coordination of healthcare services as well as by reducing waste and redundant tests Better clinical decision making by integrating patient information from multiple sources (para. 4)

Standardized Terminology and the EHR As we inch closer to interoperable EHRs that provide for seamless health information exchange among providers and healthcare institutions, the need for standardizing terminologies becomes ever clearer. Consider also the trend toward value-based care reimbursements, in which healthcare data are mined “to demonstrate nursing’s contributions to improving the cost, quality, and efficiency of care, key elements of the value equation” (Adams, Ponte, & Somerville, 2016, p. 127). EHR data must be formatted in a machine-readable manner in order to support interoperable exchange of information and data mining. An important distinction that needs to be made here is the difference between interface terminologies (NANDA, NIC, or NOC) and reference terminologies (SMOMED-CT, LOINC). While interface terminologies play an important role in promoting direct entry of categorical data by health care providers, both terminology developers and the standards community historically have focused on other types of terminologies, including reference and administrative (rather than on interface) terminologies. Such terminologies are generally designed to provide exact and complete representations of a given domain’s knowledge, including its entities and ideas and their interrelationships. For example, reference terminologies can support the storage, retrieval, and classification of clinical data; their contents correspond to the internal system representation storage formats to which interface terminologies are typically mapped. (Rosenbloom, Miller, Johnson, Elkin, & Brown, 2006, p. 278) The various interface terminologies and their subsets are coded in the EHR and typically presented to the user in drop-down menus. Users may also be able to use a search function in the EHR to identify the most appropriate term that represents the patient’s condition(s). Bronnert,

Masarie, Naeymi-Rad, Rose, and Aldin (2012) described the value of an interface terminology for clinician workflow: Clinicians interact with interface terminology when documenting diagnoses and procedures in the patient’s electronic record. The physician performs searches using the search functionality in designated locations in the EHR, which returns terms to the provider to select the appropriate problem or procedure. The physician [nurse] selects the appropriate term to capture the clinical intent. The term(s) populate predetermined fields in the electronic record. The selected term contains mappings to one or more industry standard terminologies, such as ICD or SNOMED CT. The “behind-the-scenes” mappings allow the physician to focus on patient care while at the same time capturing the necessary administrative and reference codes. (para. 17) The National Library of Medicine has been designated as the central coordinating body for clinical terminologies by the USDHHS. (See BOX 153 for a list and description of administrative and reference terminologies used in an EHR.) Recall the ongoing work of nursing groups looking to standardize nursing terminologies to capture and codify the work of nursing. (See Chapter 6 for a list of approved nursing terminologies.) In 2015, the American Nurses Association reaffirmed its support for the use of standardized terminologies:

BOX 15-3 Standard EHR Administrative and Reference Terminologies Administrative (Billing) Terminologies ICD-10 (International Classification of Diseases, Version 10): Medical diagnosis code set CPT (Current Procedural Terminology): Used to code procedures for billing Clinical Terminologies SNOMED-CT (Systematized Nomenclature of Medicine—Clinical Terms): Comprehensive clinical terminology (mapping to this terminology is ongoing, including nursing-orders mapping) LOINC (Logical Observation Identifier Names and Codes): Universal codes for laboratory and clinical observations RxNorm: Terminology system for drug names, providing links to drug vocabularies and interaction software

Unified Medical Language System (UMLS) and the Metathesaurus: Support terminology integration efforts and online searches (not a terminology system) See the U.S. National Library of Medicine website for more comprehensive information: http://www.nlm.nih.gov/hit_interoperability.html

The purpose of this position statement is to reaffirm the American Nurses Association’s (ANA) support for the use of recognized terminologies supporting nursing practice as valuable representations of nursing practice and to promote the integration of those terminologies into information technology solutions. Standardized terminologies have become a significant vehicle for facilitating interoperability between different concepts, nomenclatures, and information systems. (para. 1) Because no single model of standardized terminology for health care or nursing can represent all the contributions to the health of a patient, work is ongoing to map terminologies to one another. For example, Kim, Hardiker, and Coenen (2014) studied the degree of similarity between the International Classification for Nursing Practice (ICNP) and the Systematized Nomenclature of Medicine–Clinical Terms (SNOMED–CT); although they identified some areas of overlap, they cautioned that there is still more work to be done to truly represent nursing concepts in the EHR. Adams et al. (2016) issued a call to action to chief nursing officers (CNOs): “CNOs must begin partnering with and influencing EHR developers and vendors to ensure the EHRs implemented in their organizations capture nursing content using a standardized taxonomy that is evidence based and mapped to SNOMED-CT and LOINC” (p. 127). Ongoing efforts to map nursing problem lists to SNOMED-CT are evident in the work of Matney and colleagues (2012) and on the National Library of Medicine website (www.nlm.nih.gov/hit_interoperability.html). It is probably safe to say that the number of different types of EHRs and the variability of EHRs are likely to contract and converge as the demand for robust systems supporting interoperability expands. Nurse informatics specialists and CNOs participating in the selection and implementation of EHRs must ask a critical question: To what extent are nursing care contributions visible, retrievable, and accurately represented in this EHR?

Ownership of Electronic Health Records The implementation of an EHR has the potential to affect every member of a healthcare organization. The process of becoming a successful owner of an EHR has multiple steps and requires integrating the EHR into the organization’s day-to-day operations and long-term vision as well as into the clinician’s day-to-day practice. All members of the healthcare organization—from the executive level to the clinician at the point of care —must feel a sense of ownership to make the implementation successful for themselves, their colleagues, and their patients. Successful ownership of an EHR may be defined in part by the level of clinician adoption of the tool, and this section reviews key steps and strategies for the selection, implementation and evaluation, and optimization of an EHR in pursuit of that goal. Historically, many systems were developed locally by the information technology department of a healthcare organization. It was not unusual for software developers to be employed by the organization to create needed systems and interfaces between them. As commercial offerings were introduced and matured, it became less and less common to see homegrown or locally developed systems. As this history suggests, the first step of ownership is typically a vendor selection process for a commercially available EHR. During this step, it is important to survey the organization’s level of interest, identify possible barriers to participation, document desired functions of an EHR, and assess the willingness to fund the implementation (Holbrook, Keshavjee, Troyan, Pray, & Ford, 2003). Although clinicians, as the primary end users, should drive the project, the assessment should also include the needs and readiness of the executive leadership, information technology, and project management teams. It is essential that leadership understands that this type of project is as much about redesigning clinical work as it is about technically automating it and that they agree to assume accountability for its success (Goddard, 2000). In addition, this preacquisition phase should concentrate on understanding

the current state of the health information technology industry to identify appropriate questions and the next steps in the selection process (American Organization of Nurse Executives, 2009). These first steps begin to identify any organizational risks related to successful implementation and pave the way for initiating a change management process to educate the organization about the future state of delivering health care with an EHR system. The second step of the selection process is to select a system based on the organization’s current and predicted needs. It is common during this phase to see a demonstration of several vendors’ EHR products. Based on the completed needs assessment, the organization should establish key evaluation criteria to compare the different vendors and products. These criteria should include both subjective and objective items that cover such topics as common clinical workflows, decision support, reporting, usability, technical build, and maintenance of the system. Providing the vendor with these guidelines will ensure that the process meets the organization’s needs; however, it is also essential to let the vendor demonstrate a proposed future state from its own perspective. This activity is critical to ensuring that the vendor’s vision and the organization’s vision are well aligned (Konschak & Shiple, n.d.). It also helps spark dialogue about the possible future state of clinical work at the organization and the change required in obtaining it. Such demonstrations not only enable the organization to compare and contrast the features and functions of different systems but also are a good way to engage the organization’s members in being a part of this strategic decision. Implementation planning should occur concurrently with the selection process, particularly the assessment of the scope of the work, initial sequencing of the EHR components to be implemented, and resources required. However, this step begins in earnest once a vendor and a product have been selected. In addition to further refining the implementation plan, this is the time to identify key metrics by which to measure the EHR’s success. An organization may realize numerous benefits from implementing an EHR. It should choose metrics that match its overall strategy and goals in the coming years and may include expected improvements in financial, quality, and clinical outcomes. Commonly used metrics focus on reductions in the number of duplicate

laboratory tests through duplicate orders alerting, reductions in the number of adverse drug events through the use of bar code medication administration, meaningful use objectives and measures, and the EHR advantages mentioned earlier in this chapter. To ensure that the desired benefits are realized, it is important to avoid choosing so many that they become meaningless or unobtainable, to carefully and practically define those that are chosen, to measure before and after the implementation, and to assign accountability to a member of the organization to ensure the work is completed. End-user adoption of the EHR is also essential to realizing its benefits. Clinicians must be engaged to use the EHR successfully in their practice and daily workflows so that data may be captured to drive the decision support that underlies so many of the advantages and metrics described. To promote adoption, a change management plan must be developed in conjunction with the EHR implementation plan. The most effective change management plans offer end users several exposures to the system and relevant workflows in advance of its use and continue through the go-live and post-live time periods. Successful pre-live strategies include involving end users as subject-matter experts to validate the EHR workflow design and content build, hosting end-user usability testing sessions, shadowing end users in their current daily work in parallel with the new system, and conducting formal training activities. The goal of these pre-live activities is not only to ensure that the EHR implementation will meet end user needs but also to assess the impact of the new EHR on current workflow and process. The larger the impact, the more change management is required above and beyond system training. For example, simulation laboratory experiences may be offered to more thoroughly rehearse a significant workflow change, executive leadership may need to convey their support and expectations of clinicians about a new way of working, and generally more anticipatory guidance is required to communicate to those affected by the changes. Training may be delivered in a variety of media. Often a combination of approaches works best, including classroom time, electronic learning, independent exercises, and peer-to-peer, at-the-elbow support. Training must be workflow based and reflect real clinical processes. It must also be planned and budgeted for through the post-live period to ensure that competency with the system is assessed at the go-live point and that any

necessary retraining or reinforcements are made in the 30 to 60 days post-live. This not only promotes reliability and safe use of the system as it was designed but also can have a positive impact on end users’ morale: Users will feel that they are being supported beyond the initial go-live period and have an opportunity to move from basic skills to advanced proficiency with the system. Finally, the implementation plan should account for the long-term optimization of the EHR. This step is commonly overlooked and often results in benefits falling short of expectations because the resources are not available to realize them permanently. It also often means the difference between end users of EHRs merely surviving the change versus becoming savvy about how to adopt the EHR as another powerful clinical tool, much as clinicians have embraced such technologies as the stethoscope (HealthIT.gov, 2012). Optimization activities of the EHR should be considered a routine part of the organization’s operations, should be resourced accordingly, and should emphasize the continued involvement of clinician users to identify ways that the EHR can enable the organization to achieve its overall mission. Many organizations start an implementation of EHRs with the goal of transforming their care delivery and operations. An endeavor that differs from simply automating a previously manual or fragmented process, transformation often includes steps to improve the process so as to realize better patient care outcomes or added efficiency. Although some transformation is experienced with the initial use of the system, most of this work is done postimplementation and relies on widespread clinician adoption of the EHR. As such, it makes optimization a critical component to successful ownership of an EHR.

Flexibility and Expandability Health care is as unique as the patients themselves. It is delivered in a variety of settings, for a variety of reasons, over the course of a patient’s lifetime. In addition, patients rarely receive all their care from one healthcare organization; indeed, choice is a cornerstone of the American healthcare system. An EHR must be flexible and expandable to meet the needs of patients and caregivers in all these settings, despite the challenges. At a very basic level, there is as yet no EHR system available that can provide all functions for all specialties to such a degree that all clinicians would successfully adopt it. Consider oncology as an example. Most systems do not yet provide the advanced ordering features required for the complex treatment planning undertaken in this field. An oncologist could use a general system, but he or she would not find as many benefits without additional features for chemotherapy ordering, lifetime cumulative dose tracking, or the ability to adjust a treatment day schedule and recalculate a schedule for the remaining days of the plan. Some EHRs do a good job of supporting the work of nursing staff and physicians but are not as supportive of the work of clinicians such as dieticians, physical and occupational therapists, and other healthcare personnel. These systems will continue to evolve and support interprofessional collaboration as more healthcare professionals are exposed to the power of these systems to support their work and become better able to articulate their specific needs. Further, most healthcare organizations do not yet have the capacity to implement and maintain systems in all care areas. As one physician stated, “Implementing an EMR is a complex and difficult multidisciplinary effort that will stretch an organization’s skills and capacity for change” (Chin, 2004, p. 47). These two conditions are improving every day at both vendor and healthcare organizations alike. Improvements in both areas were recently fueled by ARRA incentives (see BOX 15-4).

BOX 15-4 Cloudy EHRs A paradigm shift from healthcare facility–owned, machine-based computing to offsite, vendorowned cloud computing, Web browser–based log-in accessible data, software, and hardware could link systems together and reduce costs. Hospitals with shrinking budgets and extreme information technology (IT) needs are exploring the successes in this area achieved in other industries, such as Amazon’s S3. As providers strive to implement potent EHRs, they are looking for cloud-based models that offer the necessary functionality without having to assume the burden associated with all the hardware, software, application, and storage issues. However, in the face of the HITECH Act and its associated penalties, how can we overcome the challenges to realize the benefits of this approach? Cloud computing has both advantages and disadvantages, and while they explore this new paradigm, healthcare providers must relinquish control as they continue to strive to maintain security. The vendors responsible for developing and maintaining this new environment are also facing challenges originating from both legislatures and healthcare providers. As the vendors and healthcare providers work together to improve the implementation and adoption of the cloud-based EHR, the sky is the limit!

ARRA has also set the expectation that despite the large number of settings in which a patient may receive care, a minimum set of data from those records must flow or “interoperate” among each setting and the unique EHR systems used in those settings. Today, interoperability exists through what is called a Continuity of Care Document (CCD). This dataset includes patient demographics, medication, allergy, and problem lists, among other things, and the formatting and exchange of the CCD is required to be supported by EHR vendors and healthcare organizations seeking ARRA meaningful use incentives. The document formatted according to HL7 standards is both machine readable and human readable. Despite this positive step forward, financial and patient privacy hurdles remain to be overcome to achieve an expansive EHR. Most health care is delivered by small community practices and hospitals, many of which do not have the financial or technical resources to implement robust, interoperable EHRs. USDHHS recently loosened regulations so that physicians may now be able to receive healthcare information technology software, hardware, and implementation services from hospitals to alleviate the financial burden placed on individual providers and to foster more widespread adoption of the EHR. Finally, patient privacy is a pivotal issue in determining how far and how easy it will be to share data across healthcare organizations. In

addition to the Health Insurance Portability and Accountability Act privacy rules, many states have regulations in place related to patient confidentiality. An experience of the state of Minnesota foreshadows what all states may encounter. In 2007, Governor Tim Pawlenty announced the creation of the Minnesota Health Information Exchange (State of Minnesota, Office of the Governor, 2007). Although the intentions of the exchange were to promote patient safety and increase healthcare efficiency across the state, it raised significant concerns about security and privacy. New questions arose about the definition of when and how patient consent is required to exchange data electronically, and older paper-based processes needed to be updated to support real-time electronic exchange (Minnesota Legislator, 2007). For health exchanges such as these to reach their full potential, members of the public must be able to trust that their privacy will be protected, or else the healthcare industry risks that patients may not share a full medical history, or worse yet, may not seek care, effectively making the exchanges useless.

Accountable Care Organizations and the EHR EHRs with data-sharing capabilities are central to the support of accountable care organizations (ACOs), a payment incentive program established by the CMS (2015). As discussed elsewhere, this program of shared medical and financial responsibility is designed to provide highquality, coordinated care while limiting costs. Some of the core information technology requirements for an ACO are EHRs, HIEs, care management systems, and analytics and reporting systems (Mastagni, Welter, & Holmes, 2015). A robust EHR can support many of these functions: EHR solutions that are interoperable across organizations can significantly reduce the cost and complication of IT infrastructure by creating full EHR visibility between providers. This shared visibility reduces or eliminates the need to participate in HIEs or invest in solutions to integrate data across different EHR platforms. Many EHRs also can serve as a program’s care management system, eliminating the need for a separate system to document care management efforts and help care teams engage with patients. (Mastagni et al., 2015, para. 5) See FIGURE 15-2.

FIGURE 15-2 How EHRs support accountable care. Data from ECG Consultants. (2015). The use of technology in healthcare reform: IT considerations for accountable care. Retrieved from http://www.ecgmc.com/thoughtleadership/articles/the-use-of-technology-in-healthcare-reform-it-considerations-for-accountablecare

Description

The Future Despite the challenges, the future of EHRs is an exciting one for patients and clinicians alike. Benefits may be realized by implementing standalone EHRs as described here, but the most significant transformation will come as interoperability is realized between systems. As the former national information technology coordinator in the USDHHS, David Brailer, predicted about the potential of interoperability: For the first time, clinicians everywhere can have a longitudinal medical record with full information about each patient. Consumers will have better information about their health status since personal health records and similar access strategies can be feasible in an interoperable world. Consumers can move more easily between and among clinicians without fear of their information being lost. Payers can benefit from the economic efficiencies, fewer errors, and reduced duplication that arises from interoperability. Healthcare information exchange and interoperability (HIEI) also underlies meaningful public health reporting, bioterrorism surveillance, quality monitoring, and advances in clinical trials. In short, there is little that most people want from health care for which HIEI isn’t a prerequisite. (Brailer, 2005, p. W 5-20) The future also holds tremendous potential for EHR features and functions that will include not only more sophisticated decision support and clinical reporting capacity but also improved support for all healthcare professionals, improved biomedical device integration, ease of use and intuitiveness, and access through more hardware platforms. Implementation of robust and interoperable EHRs is becoming more commonplace. More organizations adopting EHRs will facilitate broader dissemination of implementation best practices, with the hope of further shortening the time required to take advantage of advanced EHR features. In the future, we can expect to see more EHRs housed in the cloud,

usable patient portals as we move toward more patient-centered health care, better mobile applications for the EHR, the expansion of telemedicine applications for rural patients and those with chronic illnesses, and precision medicine advances supported by data analytics (Reisenwitz, 2016).

Summary It is an important time for health care and technology. EHRs have come to the forefront and will remain central to shaping the future of health care. In an ideal world, all nurses, from entry-level personnel to executives, will have a basic competency in nursing informatics that will enable them to participate fully in shaping the future use of technology in the practice at a national level and wherever care is delivered. Such initiatives as Technology Informatics Guiding Education Reform (TIGER, 2006) and the important nursing terminology work are imperative for better integration and, ultimately, more visibility of nursing contributions to health care.

Discussion Questions 1. What are the implications for advanced practice nursing as the EHR becomes the standard for caring for patients? 2. What are the ethical considerations related to interoperability and a shared EHR? 3. You are asked about a diagnosis with which you are unfamiliar. Where would you start looking for information? How would you determine the validity of the information? 4. Think about the documentation and knowledge management functions of your specialty. If you had the opportunity to create a wish list, what would you include in an EHR to support your work?

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CHAPTER 16 The Impact of EHRs, Big Data, and Evidence-Informed Practice Toni Hebda

CHAPTER OBJECTIVES 1. Provide an overview of electronic resources and their relationship to health care. 2. Define and discuss big data, its significance for health care and nursing, and its uses and issues. 3. Review the relationship between evidence-informed practice and big data. 4. Outline initiatives that support big data. 5. Examine the relationship among big data, policy, and health care. 6. Discuss implications for registered nurses (RNs), advanced practice registered nurses (APRNs), and other healthcare professionals.

Introduction As a society, we are situated at a virtual junction. Technological advances now allow us to collect, store, and manipulate huge pools of data, which can reveal previously unknown patterns to inform us, guide our decisions, and improve outcomes (Boulton, 2014). Businesses leverage technology daily to collect information on shopper preferences with each use of a preferred shopper’s card, completion of a survey, or product registration; the information is then used to improve services, target specific populations, and improve efficiencies. The healthcare delivery system in the United States has begun to embrace the same types of tools used by business and industry in an attempt to achieve some of the same types of benefits (Spencer, 2016). Electronic health records (EHRs) from one organization, or from many organizations, with data in those records collected through meaningful use, represent one source of data. Collectively, the enormity of the available datasets dwarfs the results from a single study or even a meta-analysis. This capability to collect large datasets (i.e., big data), and to manipulate and analyze those data to discover new knowledge, is exciting and consistent with our transformation from an information society to a knowledge society (Mehmood, Rehman, & Haider Rizvi, 2014; Ricaurte, 2016). A knowledge society exists when there is the ability to create new meanings from data, allowing for improvement of the human condition. The theoretical underpinnings for a knowledge society are attributed to the writings of Peter Drucker, a sage known for his work in management theory and knowledge work, including his classic 1985 work, Innovation and Entrepreneurship: Practice and Principles (Karpov, 2016; TurriagoHoyos, Thoene, & Arjoon, 2016). The transition to a knowledge society holds great potential to improve health care but also requires the development of new skills and responsibilities to realize those advances. Education in research methods is integral to socialization of all young people for life in a knowledge society (Karpov, 2016). As Brennan and Bakken (2015) noted, in the healthcare realm, nurses must play a pivotal role in developing and using the tools and methods associated with big data and the subsequent

knowledge generated so as to influence health policies that consider healthcare consumer needs and provide for the best use of resources. This role is consistent with the American Nurses Association’s Social Policy Statement. Nurse involvement is imperative to ensure that discoveries are useful for nursing.

Electronic Resources: Their Relationship to Health Care Healthcare professionals and consumers alike have ready access to a wide variety of electronic resources that serve to expedite access to information and services. TABLE 16-1 provides an overview of the types of available resources, and TABLE 16-2 lists some of the many services that are available online. A critical consideration for both healthcare professionals and consumers is whether sources provide truly reliable and valid information. Government, academic, and professional organization websites are considered to be good sources, although they are not entirely free of bias. Scrutinizing a website for the sponsoring organization’s mission statement, funding sources, and background information on who sits on the board of directors can sometimes reveal political bias. Information with no clear authorship, date of publication or review, or evidence of subject-matter expertise for posted content should be avoided. TABLE 16-1 Types of Electronic Resources With Some Exemplars Type

Exemplar

Websites

Professional organizations American Nurses Association American Association of Nurse Practitioners American Medical Association American Association of Medical Colleges American Association of Colleges of Nursing

Social media

Social networking: Facebook, Google+, LinkedIn Photo sharing: Pinterest, Snapchat, Flickr, Instagram Video sharing: YouTube, Vimeo, Yahoo video, Shutterfly video Microblogging: Twitter, tumblr Blogging: WordPress, Blogger Crowdsourcing: Ushahidi, CrowdFunding Live streaming: Facebook Live, Blab, Periscope, YouTube Live

Search engines (in order of volume of users)

Google Bing Yahoo Baidu Ask AOL Search Wolfram Alpha (for computational searches) DuckDuckGo (does not retain your search histories) DogPile (uses other search engines to compile results) Others

Electronic databases

Literature PubMed/Medline CINAHL Ovid Specialty databases ClinicalTrials.gov TOXNET National Cancer Database U.S. National Library of Medicine: electronic databases and directories by alphabetical listing

Information systems

Electronic health records (vendors): Epic, Cerner, Allscripts, NextGen, Athena Health Clinical support systems Administrative systems

Description TABLE 16-2 Types of Services Available Electronically Information

Professional Political/policy Opinions Consumer health advice Comparing providers, facilities

Networking/ communication

Job searches Webinars/conferencing Document sharing Real-time patient communication (Twitter, texting) Language translation

Education

Online degrees Continuing education

Libraries Personalized learning assessments Provision of services

Manage appointments and schedules Professional license application, renewal, and verification Patient registration and history Reminders to patients Communicate with healthcare providers

Marketing

Branding Advertising Price comparisons

Maintain or view records

Access patient portal: ask questions, renew medications

Description The process of making text, audio, and images available electronically for ease of access, processing, storage, and transmittal via computer technology is known as digitization. Nearly all the world’s stored data have been converted to a digital format (McNeely & Hahm, 2014). In addition to increased availability and access, digitization affords new opportunities to examine collected data and is fundamental to the big data phenomena.

Big Data The term big data originally referred to very large datasets (Spencer, 2016). It includes data of different types, levels of complexity, formats (structured and unstructured), and processed and unprocessed items from several sources that can be analyzed to reveal patterns, trends, and associations (Jukić, Sharma, Nestorov, & Jukić, 2015; Manerikar, 2016). The healthcare industry defines big data by its size, the ability to make sense of the data, its complexity, and the degree to which the data flow into the organization (Spencer, 2016). Big data is beyond human capability to comprehend or manage without the aid of computers (Brennan & Bakken, 2015). In many cases, it endeavors to encompass entire, complex processes (Gharabaghi & Anderson-Nathe, 2014). Healthcare professionals and health services researchers manipulate and analyze big data to provide policy makers and thought leaders with vital information.

Background Data, information, and knowledge are valuable assets. Examination of big data internally enables an organization to identify effective processes, eliminate wasteful processes, improve products, improve customer experience, and establish a competitive advantage (Spencer, 2016). In the healthcare arena, big data provides a tool to benchmark performance against other organizations, improve patient outcomes, reform healthcare delivery, and lead to significant cost savings. In this way, big data complements traditional sources of data, such as the data obtained from the trending of vital signs for a single patient or the findings of a study; the latter data are sometimes referred to as small data because they can be analyzed by a single person (Brennan & Bakken, 2015; Sacristán & Dilla, 2015). The ability to use big data as a tool requires an understanding of what it is, what its background and sources are, which surrounding issues are relevant, and how it can be applied to healthcare delivery and policy. Nurse informaticists, health services researchers, and data scientists

have special expertise in these areas and can facilitate the collection, analysis, and application of knowledge gleaned from big data. A nurse informaticist is a specialist who integrates nursing and other sciences to “identify, define, manage, and communicate data, information, knowledge, and wisdom” (American Nurses Association [ANA], 2015, pp. 2‒3) to support nurses and healthcare professionals, consumers, and other stakeholders in their decision making.

Significance for Healthcare Delivery and Policy As Americans struggle to reform the U.S. healthcare delivery system and improve patient outcomes, scarce resources and increased demands for accountability call for informed decision making, which in turn requires data; increasingly, these data equate to big data (Gharabaghi & Anderson-Nathe, 2014; McNeely & Hahm, 2014). Big data has the potential to create approximately $300 billion annually in value in the healthcare realm (Roski, 2014). Much of that value would likely come from lower costs associated with the more effective outcomes obtained with personalized medicine. Additional value would come from data generated by individual healthcare consumers to tailor diagnostic and treatment decisions, educational messages to foster desired health practices, and improved population health analysis. Big data also supports tools for improved fraud detection and prevention.

Big Data Sources By definition, big data is derived from multiple data sources. The list of sources discussed in this chapter is not comprehensive but does serve to acquaint the reader with a few reputable big data sources relevant to health care. Exemplars of both traditional and emerging data sources are discussed, followed by a discussion of issues related to big data. Traditional datasets are collected with an express purpose or objectives in mind. This purpose provides direction for which data are collected, its format, and methods to safeguard integrity and security. The structure in traditional datasets is at odds with the definition for big data, but the potential of these sources to contribute to new knowledge is rich. Electronic health records and databases are two examples of traditional

sources of big data. Electronic health records represent one of the best sources of big data in health care today. Individual organizations commonly use data found in EHRs to track metrics such as patient outcomes, length of stay, number of sentinel incidents, and costs to support research. EHRs may offer users the opportunity to customize views of patient data for individuals or groups, access clinical decision support using evidencebased practice guidelines and literature, provide treatment reminders, use lockout features and alarms, and integrate the EHR with monitoring devices and other clinical systems. Integration with monitoring devices and point-of-care devices, such as glucometers or urine output, provides additional data streams for EHRs while eliminating the need to manually enter measurements such as vital signs, thereby simultaneously streamlining workflow and improving data quality. Data may also be transmitted in a real-time manner from EHRs directly into databases, also saving time and money. This approach has been demonstrated successfully on a limited basis to collect data on patients who have undergone thoracic surgery and bariatric procedures (Salati et al., 2014; Wood et al., 2012). Currently, the realization of large-scale data collection on a real-time basis for research purposes requires resolution of issues that include, but are not limited to, interoperability across different vendor platforms (Coorevits et al., 2013). Today’s EHRs are composed of a mix of different data types that include text and images. A database is a collection of information organized and used to provide ease of access, management, and updates to its contents. EHRs fit this basic definition because of their reliance upon database technology to house information, but EHRs’ emphasis on their content rather than overall functionality leads most individuals to consider databases to be a separate entity from EHRs. A staggering amount of health-related information now exists in different databases across various settings. One example that is familiar to U.S. healthcare providers and consumers is the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. HCAHPS collects data on hospitalized patients’ perspectives on their care experience (Centers for Medicare and Medicaid Services [CMS], n.d.). It has created a national standard that enables comparison across all participating hospitals. HCAHPS scores provide financial incentives in the form of

increased or decreased Medicare reimbursement for hospitals to improve the quality of care provided; results are available to the public. Notably, hospital reimbursement from the Centers for Medicare and Medicaid Services is determined by HCAHPS ranking (Keith, Doucette, Zimbro, & Woolwine, 2015). Other databases collect information about specific diseases, encounter information, and clinical data. Disease registries enable tracking of clinical care and outcomes for specific patient populations, such as those affected by cancer, heart disease, trauma, infectious diseases, diabetes, or asthma. Input is accepted from multiple sources. The underlying intention in creating such a registry is to minimize fragmentation of care, identify at-risk populations, and improve care through evidence-based practices (Davis, 2016). Chronic disease registries also support evaluation of providers to ensure that they use current evidence; however, this evaluation may not include data that reflect patient choice and provider judgment. The Healthcare Cost and Utilization Project (HCUP) maintains encounter-level information on inpatient hospital stays, emergency department visits, and ambulatory surgery in U.S. hospitals. The HCUP databases are created by the U.S. Department of Health and Human Services’ Agency for Healthcare Research and Quality (AHRQ) through a federal‒state‒industry partnership. An excellent resource of databases and repositories is Health Services Research Information Central, which can be accessed through the HCUP website (www.hcupus.ahrq.gov/databases.jsp). The National Patient-Centered Clinical Research Network (PCORnet) supports a repository of clinical data gathered in a variety of healthcare settings, including hospitals, physician offices, and community clinics, for the purpose of conducting comparative effectiveness research. PCORnet collects and stores data in standardized, interoperable formats to facilitate secure sharing designed to ensure confidentiality of the data (Patient-Centered Outcomes Research Institute, 2017). Interoperable refers to the exchange of data and information while retaining their meaning. Although global digitization makes it easier to create, post, and transmit information for healthcare professionals and the public, there is no mechanism in place to uniformly ensure the accuracy of information

available on the Internet. Healthcare professionals recognize the potential to study data gleaned from a variety of electronic resources, including Internet searches, social media, crowdsourcing, mobile applications (apps), and body sensors; these data may serve as a valuable source of research and knowledge and learning through big data exploration. The Internet facilitates the creation, collection, sharing, and use of information, but it can also be used to collect research information and big data. In excess of 2 billion people are connected to the Internet, with projections estimating there will be 50 billion connected devices by 2020 (Khan et al., 2014). Internet searches to find health information to aid healthcare decision making are one common use of this resource by healthcare consumers. Researchers continue to work to determine how consumers choose these websites, how many searches are performed, and which websites are visited (Song, Song, An, Hayman, & Woo, 2014; Zhang, Sun, & Kim, 2017). Social media data have been mined to detect early signs of disease outbreaks, recruit subjects, provide interventions, and monitor population health and behavior (Kuehn, 2015; Sinnenberg et al., 2017). One specific social networking site that has been explored is Twitter, where users interact via messages limited to 280 characters. EXHIBIT 16-1 describes features of Twitter that make it an effective source of data for disease detection and management.

EXHIBIT 16-1 Advantages of Twitter for Disease Detection and Management Real-time nature Used across the globe High volume of messages Ability to search messages for content, frequency of discussion, or response by topic Analysis of content as a means to predict demand for services or patient outcomes

In excess of 6,000 mobile apps now exist to track activity, food intake, and calories (Peek, 2015). Real-time data streams from fitness tracking apps and sensors, particularly when combined with Twitter data, might be mined to provide early warnings of emergency situations, adverse drug

reactions or drug misuse, and the development of chronic disease issues. These kinds of apps may allow public health officials, healthcare delivery systems, and individual nurses to better prepare for these events, assuming that someone is analyzing data for trends and that agency policy supports this approach (Kuehn, 2015). Crowdsourcing is a process in which a task or problem is posed and solutions solicited, resulting in the formation of an unofficial group of individuals who are geographically dispersed and who offer their help. The PatientsLikeMe platform is a healthcare-related example, which allows patients and their families to share medical data and experiences to help others learn. This platform compiles data to answer frequently asked questions (Chiauzzi & Lowe, 2016). It can also provide insights for healthcare professionals into the patient experience. As with other forms of social media, there is no assurance of the accuracy of all posted information. Along with its potential benefits, this form of publicly available medical data presents concerns related to privacy and the possibility of discrimination, erroneous research findings, and even litigation (Hoffman, 2015).

Issues Issues associated with big data include, but are not limited to, data quality, different data types and formats that complicate the ability to exchange data, data governance, barriers to sharing data, understanding results, available tools and human resources, uneven production of learning, and possible misinterpretation or misuse. High-quality data are accurate, complete, consistent, clear, precise, and useful (Otto, 2015). Poor data quality can occur when, for example, fields are left blank, a wrong choice is entered, or a typing or spelling error is made. Organizations can improve poor quality data through machine methods (computer applications or software) that scrub or clean data, but correct entry from the beginning is always the best option (Vaziri, Mohsenzadeh, & Habibi, 2016). Poor-quality data has a negative impact on decision making, raises information management costs, and compromises big data findings (Clarke, 2016). At present, there is a lack of standardization in methods to share big data, along with a mix of raw and processed types and of structured and

unstructured data (Copping & Li, 2016; Spencer, 2016). Structured data are typically organized into a repository or database for effective processing. Unstructured data may exhibit internal organization but do not reside in databases. Examples of unstructured data include documents, emails, and multimedia resources. The lack of data standardization can lead to lost opportunities for learning when it affects the type and amount of data analyzed (Auffray et al., 2016). Data governance refers to the policies, standards, processes, and controls applied to the organization’s data to ensure that it is available when, where, and to whom it is needed; is usable; and is appropriately secured (Dutta, 2016). At present, the growth in new information is outpacing the ability to develop policies and technology, thereby exposing organizations to legal, financial, and organizational risks (Marbury, 2014). Data governance needs to reflect knowledgeable and appropriate use of data both within and beyond the walls of any one organization (Roski, 2014). Big data benefits cannot be realized unless the vast amounts of diverse data are amassed and analyzed. This outcome will require sharing of data. Barriers to sharing include concerns by healthcare delivery systems that divulging information to competitors may negatively impact market share (Bordone, 2013; Roski, 2014) and an inconsistent slate of state and federal privacy laws (Habte, 2015). There are also concerns about the ethics of the process of collecting and storing data that may be about or from vulnerable populations in the event that those data may prove useful at a future date (Gharabaghi & Anderson-Nathe, 2014). Conventional strategies do not support big data analysis. A knowledge strategy and infrastructure, expertise, and tools are required to discover new learning and knowledge in big data (Dulin, Lovin, & Wright, 2016; Kabir & Carayannis, 2013). The late arrival of healthcare organizations to the big data phenomenon and the shortage of skilled personnel capable of dealing with this resource have placed this industry at a disadvantage for turning data first into knowledge and then into actionable results (Copping & Li, 2016; Spencer, 2016; Steinwachs, 2015). Adding to the chaos is the fact that many critics believe that the adoption of EHRs may not yield the consistent results desired by health policy makers.

The Relationship Between Evidence-Informed Practice and Big Data The terms evidence-informed practice (EIP) and evidence-based practice (EBP) are sometimes used interchangeably but actually refer to different concepts (Melnyk & Newhouse, 2014). EBP is an approach that takes the best evidence, evidence-based theories, clinician expertise, and patient preferences and values to make decisions about patient care using a five-step process. EIP requires practitioners to be familiar with the levels of research evidence and clinical insights and to use them creatively without introducing nonscientific bias or the need to go through the fivestep process of EBP (Nevo & Slonim-Nevo, 2011). EIP extends beyond evidence to incorporate other factors that influence the nurse’s care decisions—namely, context and patient values (Florczak, 2017). The demand for the best evidence leads healthcare professionals to consider options that include combining data from separate studies for a greater impact of research findings as well as analyzing big data. Combining data from separate studies requires common data elements (Cohen, Thompson, Yates, Zimmerman, & Pullen, 2015). Increasingly, big data is seen as a form of evidence either on its own or as a supplement to clinical trials and is being used to inform policy and practice decisions (de Lusignan, Crawford, & Munro, 2015; Kennedy, 2016). A learning health system captures and delivers the best available evidence to guide and support decision making (Steinwachs, 2015).

Laying the Groundwork for Big Data Effective big data use requires a combination of policy, legislation, and a knowledge strategy, infrastructure, and skills. Health policies need clear objectives if they are to be effective (Heitmueller et al., 2014). The following questions, among others, should be considered when formulating policies for big data use: Which aspects of big data are relevant for health care? What is the intent of the policy/data use? Which barriers exist to achieving the objectives of the policy? What are the incentives to share information?

Examination of these questions will determine whether data are classified as personal, proprietary, or government held, leading to strategies for how to link or share the appropriate types of data. Intent speaks to the ways that the data may be used. In health care, improvement of patient outcomes and reform of payments to providers constitute examples of intent. Barriers include concerns over how data will be used, privacy, loss of competitive advantage, technology issues, and user fatigue with technology, among others. Incentives revolve around building a case for data sharing as well as providing financial incentives for this practice. The paradox is that although health policy helps to establish a framework for big data, big data also serves to inform policy. Legislation establishes requirements and incentives so that policies can be carried out. Some important exemplars of U.S. legislation and initiatives that helped to provide a framework for use of big data in the healthcare realm appear in TABLE 16-3. As big data use increases, legislation and professional practices will need to keep pace to ensure that data are always used appropriately and mistakes are avoided (Williamson, 2014). TABLE 16-3 Important Legislation and Initiatives for Big Data in Health Care Public Laws, Executive Orders, and Initiatives

Year Enacted

Major Content Related to Data

Health Insurance Portability and Accountability Act

1996

Affects healthcare data availability. Assures a bridge for health insurance coverage for persons who have a change in employment. Requires national electronic standards for claim submission. Provisions protect the privacy of personal health information.

Medicare Improvements for Patients and Providers Act

2008

Provides financial incentives for electronic prescribing (e-prescribing), which creates digital data for analysis.

American Recovery and Reinvestment Act

2009

Economic stimulus package. Allocated funds to create jobs, boost

economic growth, and increase accountability and transparency in government spending. Funded comparative effectiveness research. Created a nationwide health information network. Provided financial incentives for hospitals and physicians who adopted and began using EHRs. Strengthened Health Insurance Portability and Accountability Act privacy and security requirements. Included Title VIII Health Information Technology for Economic and Clinical Health Act. Health Information Technology for Economic and Clinical Health Act

2009

Offers financial incentives to providers participating in Medicare and Medicaid for adoption of certified EHRs; ushered in widespread adoption of EHRs in the United States. Goals included improvements in care and reduced disparities. Increased digital data for big data purposes.

Patient Protection and Affordable Care Act

2010

With its amendment, the Health Care and Education Reconciliation Act is known as Obamacare. Provides incentives for reporting provider performance; established public reporting of quality and cost metrics. Increases hospital data collection and analysis. Increases the ability to share data across settings.

Genetic Information Nondiscrimination Act

2008

Protects individuals from discrimination by insurers and employers based on the results of genetic information and test results, encouraging data collection and use.

Medicare Access and CHIP Reauthorization Act of 2015

2015

Reforms Medicare payments to physicians, other providers, and suppliers to reflect a value-based payment model, effective 2019. Monitors program effectiveness and reports on Medicare-eligible provider performance.

Executive order 13642: Making Open and Machine Readable the New Default for Government Information

2013

Federal government requirement to make information easy to find, access, and use. Adds to the amount of digital data available for exploration and to support decision making.

Precision Medicine Initiative

2015

Research initiative that considers individual differences in genetic makeup, environments, and lifestyles. Seeks to improve treatments for cancer, expand research, create new public– private partnerships, and infrastructure needed to expand cancer genomics.

Description Description

Implications for RNs, APRNs, and Other Healthcare Professionals More than at any previous point in history, RNs, APRNs, and other healthcare professionals now have the power of knowledge gleaned from large pools of information within reach primarily through EHRs and various databases and increasingly via additional data streams from mobile technology, wearable sensors, social media, and tracking apps. The ability to harness and use this knowledge requires awareness of the potential of big data as a new form of evidence, a plan for how it may be used, skills to understand the significance of findings, and the ability to apply the evidence and learning in practice settings. Working to obtain this level of awareness and learning will necessitate the combination of personal and professional strategies, professional accountability, and advocacy. Nurses have experience in the traditional uses of EHRs, claims data, and public health data, and this experience provides good foundational skills to use big data. RNs, APRNs, and other healthcare professionals need to consider which data and information they would like to be able to retrieve from EHRs as evidence to better support their work and patient outcomes. As an example, it would be logical for patients rated as being at a high risk of falling to require more staff attention, but the current fall risk assessments may not provide the real-time aggregate information on increased acuity levels that is needed for safe staffing on a unit-by-unit basis or throughout the organization. This type of information would support safe staffing levels, enhance patient safety, and demonstrate the need for increased staffing (and costs) when greater numbers of at-risk patients are receiving care. APRNs concerned about the possibility of position cuts could request data that would demonstrate a link between level of staff preparation and patient outcomes. There are an infinite number of ways to apply big data from EHRs, public databases, and other data streams so as to further contribute to learning, patient safety, patient satisfaction, and lower costs.

Understanding Big Data Nurses in practice settings need to have a grasp of big data within the context of evidence-informed practice (Brennan & Bakken, 2015). Although the concept of evidence gleaned from big data is not difficult to understand, the ability to discern patterns in big data requires expertise provided through data science. There is a shortage of data scientists in all fields at present, with this shortage being especially pronounced in health care. There is also a lag in the inclusion of data science into course content in formal academic programs. As with other emerging areas of competencies, all healthcare professionals must make an effort to keep abreast of ongoing developments in this area. Brennan and Bakken (2015) listed the training, roles, and activities for nurses at different levels of practice relative to data science. Data science is “the systematic study of digital data” (National Consortium for Data Science, 2017, para. 2). This emerging discipline incorporates techniques and theories from many areas, including predictive analytics, a facet of data mining that uses extracted data to forecast trends. Brennan and Bakken (2015) espoused the hope that data science will support the complex inquiries needed by nurses to understand health within day-to-day life to deliver contextually relevant interventions. Data science differs from traditional nursing inquiry, which is guided by theory that determines the data selected for analysis. Data science can also benefit from nurses’ expertise in the following areas: Data types and sets (e.g., the Nursing Minimum Data Set) Defining and providing context for datasets Use of theories to organize variables Creation of interventions that can help healthcare consumers interpret the results of big data analysis A patient-centered approach Another emerging specialty, known as discovery informatics, focuses on scientific models and theories to create computer-based discovery of new learning in big data—something that in the past has been dependent upon human cognition—with the goal of accelerating discovery and learning (Honavar, 2014). As nurses at all levels are exposed to data science content, both

baccalaureate-level and advanced practice nurses will become able to evaluate and use findings generated through data science methods; in addition, the doctoral-prepared nurse could lead research supported by data science methods (Brennan & Bakken, 2015). Nurses, however, must do even more. As knowledge workers, nurses must be involved in knowledge management (Soares, Jacobs, Bolis, Brunoro, & Sznelwar, 2012). Starting at the point of data entry, all nurses have an obligation to ensure data quality. Input of accurate data and clear, unambiguous entries provide a solid foundation for usable data later. A concrete example in which information quality is critical is family history documentation that, when well done, can predict health risks and contribute to a personalized treatment approach (Hickey, Katapodi, Coleman, Reuter-Rice, & Starkweather, 2017). Nurses can provide feedback on electronic systems design and adoption of data standards to ensure that important information is collected, available in a usable format, and available for reuse later. Nurses should craft and implement data policies and integrate findings from big data at the point of care. The doctoral-prepared nurse should use data science methods to research nursing phenomena (Brennan & Bakken, 2015). Advanced practice registered nurses have an obligation to shape health policy to support big data and to use big data findings to influence policy and resource allocation (Kostas-Polston, Thanavaro, Arvidson, & Taub, 2015). The ANA’s Social Policy Statement provides a moral compass on the use of big data and data science.

CASE STUDY 16-1: RESEARCH EVIDENCE VERSUS BIG DATA Your hospital’s evidence-based practice council has looked at levels of traditional research and ways to incorporate evidence into care, with an emphasis on building evidence into clinical pathways used to guide care and documentation. As the APRN leading the council, you believe that the members now demonstrate a good grasp of different levels of research findings and are making excellent progress with their work to integrate evidence into practice. Your chief nursing officer, however, states that this is not enough: He expects to see the integration of findings from big data at the point of care. Council members have expressed great anxiety relative to the push to use big data findings, protesting that they have limited

knowledge about big data, let alone how to make the best use of its related findings.

Discussion Questions 1. As the APRN leading the council, do you agree with this decision by the chief nursing officer? Defend your position. 2. Write a one-page explanation for the council outlining the differences between data and big data. 3. Compare the use of research outcomes for a specific patient problem and the use of big data in addressing population-based health problems. 4. Which resources (e.g., people, technology) would your hospital need to use big data appropriately? 5. Describe how population-based data (e.g., pre/postintervention data) can be used to create community-level health policy. 6. Which implications does the integration of big data findings at your facility and elsewhere have for healthcare policy development at the local, state, and national levels?

CASE STUDY 16-2: IMPLICATIONS OF USING VARIOUS DATA SOURCES The technology committee at your medical center has been asked to look at current applications within the facility that generate data streams to determine which applications should feed into patient records. Some devices, such as glucometers and other point-of-care testing devices, automatically feed results into the patient’s electronic health record. Other devices that track fitness, for example, are heavily used outside of the medical center but have not been linked with health records. As the APRN representative on the committee, you have been asked to provide your expert opinion on the integration of these additional data streams.

Discussion Questions 1. Which types of body sensors, tracking devices, and applications would provide valuable information to nurses and other healthcare professionals when providing care to a patient? Discuss the pros and cons of the value of each item vis-à-vis EHRs. 2. What relationships do you see between these types of data streams and the ability to inform and shape healthcare policy in your medical center? 3. Describe the relationship between the policy at your organization and the inclusion of additional data streams into EHRs. How do individual hospitals stream their EHR data into big datasets? How does national healthcare policy support, or not support, the inclusion of additional data streams into EHRs? Into big data findings? 4. Discuss how nurse-sensitive data can be used to create health policy at the state or national level. 5. Describe ethical and security issues involved in including patients’ personal information in EHRs. 6. Create a framework or model that illustrates how the integration of multiple data streams

collected from point-of-service devices can be used to inform healthcare policy.

CASE STUDY 16-3: MAGNET STATUS AND BIG DATA Your 600-bed medical center is a Magnet facility and was one of the first healthcare delivery systems in the nation to attain Magnet recognition. Maintaining Magnet recognition is a goal for the organization that requires planning and resources. You recently joined a committee that is responsible for overseeing the process to apply for Magnet recognition.

Discussion Questions 1. How can aggregate data collected from this facility be used to demonstrate the value of nursing (e.g., a correlation between nurse credentials and patient outcomes)? 2. Analyze how data obtained from all Magnet facilities in the United States can be used to influence national healthcare policy relative to the following issues: a. The value of nursing care b. Allocation of resources for specific populations c. Funding for further education for nurses

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* This chapter originally appeared in Health Policy and Politics: A Nurse’s Guide, Sixth Edition by Jeri A. Milstead and Nancy M. Short.

© Zen Rial/Moment/Getty Images.

CHAPTER 17 Utilize Informatics Anita Finkelman

CHAPTER OBJECTIVES 1. Discuss the Institute of Medicine core competency: utilize informatics. 2. Describe health informatics and its relationship to advanced practice nursing. 3. Explain the purpose of documentation and key issues related to informatics and documentation. 4. Explain the importance of meaningful use. 5. Critique the need for standardized terminologies in healthcare delivery. 6. Describe telehealth and its relationship to healthcare delivery and advanced clinical practice. 7. Compare and contrast high-touch care with high-tech care.

Introduction This chapter concludes the section that focuses on quality, safety, and information systems for advanced practice nurses with a discussion of the Institute of Medicine core competency: utilize informatics. Informatics technology (IT) is an important topic in all areas of life today; with the explosion of technology, there are many opportunities for communication and sharing of knowledge. The impact of health informatics technology (HIT) on nursing care is explored here. Other issues that need to be addressed are documentation; confidentiality and privacy of information; and technology and informatics methods used in practice, education, and research. This chapter also includes content about biomedical equipment or medical devices, an expanding area in healthcare technology that affects nurses and nursing care. Some of this equipment also uses IT. Nurses today cannot avoid technology, whether it is used in communication, care provision, or monitoring the quality of care. The chapter concludes with a discussion about the potential conflict between high-touch care versus high-tech care and the need for nursing leadership in health informatics—important issues for nurses to consider. FIGURE 17-1 identifies key elements in this competency.

FIGURE 17-1 Utilize informatics: Key elements.

Description

The Core Competency: Utilize Informatics The fifth healthcare profession core competency is “communicate, manage knowledge, mitigate error, and support decision making using information technology” (Institute of Medicine [IOM], 2003, p. 4). Informatics entails more than just understanding what is HIT and its clinical implications. It also includes how that technology is used to prevent errors and improve care, particularly in the measurement of care. From the initial use of computers to share information, to management of financial records, to the current use of informatics with more emphasis on patient care, there has been a major move toward HIT application in health care. Some examples are greater use of informatics to find evidence to implement evidence-based practice (EBP); use of informatics in research; greater consumer access to information via the Internet; and more specific clinical applications, such as reminder and decision systems, telehealth, online prescribing, and use of email for provider– provider communication and patient–provider communication. The Quality Chasm report on healthcare professions core competencies concludes that every healthcare professional should meet the following informatics competencies (IOM, 2003, p. 63): Employ word processing, presentation, and data analysis software. Search, retrieve, manage, and make decisions using electronic data from internal information databases and external online databases and the Internet. Communicate using email, instant messaging, email lists, and file transfers. Understand security protections such as access control, data security, and data encryption, and directly address ethical and legal issues related to the use of IT [HIT] in practice. Enhance education and access to reliable health information for patients. A position statement from the Healthcare Information and

Management Systems Society (HIMSS, 2011) addresses The Future of Nursing (IOM, 2010) report from the perspective of informatics. The following HIMSS recommendations were made and align with The Future report on the key points of nursing leadership, education, and practice (HIMSS, 2011): Partner with nurse executives to lead technology changes that advance health and the delivery of health care. Support the development of informatics departments. Foster the evolution of the chief nursing informatics (NI) officer role. Transform nursing education to include informatics competencies and demonstrable behaviors at all levels of academic preparation. Promote the continuing education of all levels of nursing, particularly in the areas of electronic health records (EHRs) and HIT. Ensure that data, information, knowledge, and wisdom form the basis of 21st-century nursing practice by incorporating informatics competencies into practice standards in all healthcare settings. Facilitate the collection and analysis of interprofessional healthcare workforce data by ensuring data collection from existing IT systems. The statement also indicates that nurses play a critical role in HIT and there are expanded roles for nurses—there is strong support for nursing leadership in HIT. “Nurses are key leaders in developing the infrastructure for effective and efficient health information technology that transforms the delivery of care. Nurse informaticists play a crucial role in advocating both for patients and fellow nurses who are often the key stakeholders and recipients of these evolving solutions. Nursing informatics professionals are the liaisons to successful interactions with technology in healthcare” (HIMSS, 2011, p. 4).

STOP AND CONSIDER #1 Every nurse applies the informatics competency.

The Federal Health Informatics Reports The federal government increased its involvement in HIT, particularly through the U.S. Department of Health and Human Services (USDHHS), Office of the National Coordinator for Health Information Technology (ONC). This office published Health Information Technology: Patient Safety Action & Surveillance Plan, which identifies advantages for greater use of the electronic medical record (EMR), a key HIT example found in healthcare organizations (HCOs) (USDHHS ONC, 2013, pp. 5–6): Increase clinicians’ awareness of potential medication errors and adverse interactions. Improvement of the availability and timeliness of information to support treatment decisions, care coordination, and care planning. Make it easier for clinicians to report safety issues and hazards. Give patients the opportunity to more efficiently provide input on data accuracy than what paper records would allow. These continue to be advantages in linking EMRs to quality improvement. The increased use of electronic records was initially driven and still is driven by important federal legislation, the Health Information Technology for Economic and Clinical Health Act of 2009, known as HITECH. All this set the stage for greater federal involvement in HIT. In 2015, the USDHHS published a report, Connecting Health and Care for the Nation: A Shared Nationwide Interoperability Roadmap, Draft Version 1.0. The purpose of this extensive report is to describe a roadmap supporting interoperability or “the ability of a system to exchange electronic health information with and use electronic health information from other systems without special effort on the part of the user” (USDHHS ONC, 2015a, p. 18). This is a critical element in making HIT more accessible and sharing information across systems and providers. A second report describes the federal health IT strategic plan for 2015 through 2020. FIGURE 17-2 describes the framework for this strategic plan, including the vision, mission, and four goals. The key issue

is access to information when needed by people. FIGURE 17-3 highlights the vision that guides the strategic plan, focusing on high-quality care, lower costs, a healthier population, and engaged individuals—thus providing patient-centered care. This is a good example of how HIT is not just about computers and software. There needs to be a relationship between the technology and care delivery—needs and outcomes. Important principles should be followed when HIT plans are developed (USDHHS ONC, 2015b, pp. 20–21).

FIGURE 17-2 Federal health IT strategic plan: Vision, mission, and goals. U.S. Department of Health and Human Services (HHS), Office of National Coordinator for Health Information Technology (ONC). (2015). Federal health IT strategic plan: 2015–2020, p. 6. Retrieved from https://www.healthit.gov/sites/default/files/9-5-federalhealthitstratplanfinal_0.pdf

Description

FIGURE 17-3 The vision to guide the federal health IT strategic plan, 2015–2020. U.S. Department of Health and Human Services (HHS). The Office of National Coordinator for Health Information Technology (ONC). (2015). Federal Health IT Strategic Plan. 2015-2020, p. 13 Retrieved from https://www.healthit.gov/sites/default/files/9-5-federalhealthitstratplanfinal_0.pdf

Description Build upon the existing health IT infrastructure. Recognize that one size does not fit all. Empower individuals, giving them more access to information. Leverage the market—greater need now for seamless flow of electronic clinical health information. Simplify. Maintain modularity and provide flexibility to the system, as change will

be ongoing. Consider the current environment and support multiple levels of advancement. Focus on value. Protect privacy and security in all aspects of interoperability. Include scalability and universal access. These two reports—the strategic plan and follow-up initiatives— demonstrate the importance of HIT and the need for better standards and consistency as well as the important role of the federal government through the work done by USDHHS and its agencies. Undoubtedly, there has been major expansion in the use of HIT. The USDHHS through the ONC must now report annually to Congress on the status of HIT. The 2016 report indicated that prior to 2009, most HCOs— including hospitals, physician practices, clinics, and so on—used paper documentation. Sharing was done using fax machines. Indicating major improvement, the ONC notes that 7 years later, 78% of physician practices and 96% of hospitals use a certified electronic medical/health record (EMR/EHR; USDHHS ONC, 2016a, 2016b). Now there is more emphasis placed on creating a better seamless and secure system that considers interoperability.

STOP AND CONSIDER #2 The federal government is very involved in ensuring effective health information technology.

Informatics Informatics is complex, and the fact that it is changing daily makes it even more difficult to keep current with this field. Healthcare delivery has been strongly influenced by the changes in informatics, but what is informatics? Technology is revolutionizing the way that healthcare is delivered with a steady infusion of new solutions into clinical environments. At the same time, outside of healthcare, both clinicians and consumers are learning to incorporate technological solutions into their daily lives with tools like high-speed data networks, smart phones, handheld devices, and various forms of patient engagement in social media exchanges. Bringing these types of technologies into the healthcare marketplace will transform the time and place for how care is provided. Having individuals who understand the unique complexities of healthcare practices along with how to best develop technological tools that positively affect safe patient care is essential. Nurses integrating informatics solutions into clinical encounters are critical for the transition to an automated healthcare environment that promotes the continuum of care across time and place, in addition to wellness and health maintenance activities. (HIMSS, 2011, p. 3) Some nurses may hold health informatics positions, as discussed later in this chapter, but all nurses use HIT in their positions—it is not an area that concerns only a specific nursing specialty. HIT is now a critical element throughout the healthcare delivery system. It is a foundational tool to change the healthcare industry; however, it is not an instant fix. Rather, it is one tool in the arsenal of health reform. Health IT impacts quality by providing users the unique ability and opportunity to truly capture and derive the benefits from data. This allows users to translate seemingly independent pieces of data into meaningful conclusions that, if

applied and implemented correctly, can improve the health of individuals and populations; lower costs; and help tailor healthcare to individual patient needs. The implementation of Health IT is intended to support the National Quality Strategy and help achieve the three broad aims of better care, quality care, and lower cost. (Kennedy, Murphy, & Roberts, 2013)

Description and Definitions Informatics has opened doors to many innovative methods of communication with patients and among providers, individuals, and HCOs of all types, some of them discussed in this chapter. HIT often saves time but can also lead to information overload. With these changes comes greater risk of inappropriate access to information through hacking and other means. Informatics is also used to evaluate HCO and individual healthcare provider performance. The use of HIT has a major impact on quality improvement (Finkelman, 2018). Today, it is much easier to collect, store, and analyze large amounts of data that, in the past, were collected by hand. Insurers rely heavily on informatics as they provide insurance coverage, manage data, and analyze performance, which has a direct impact on whether care is covered for reimbursement. Informatics allows governments at all levels—local, state, national, and international—to collect and use data for policy decision making and evaluation. Informatics has its own language and is a highly specialized area. Nurses do not have to be informatics experts, but they do need to understand the basics. Some common IT terms that most people know are Internet and email. Other terms that nurses should know are highlighted here (American Nurses Association [ANA], 2008; Glassman & Rosenfeld, 2015): Clinical data repository: This is a physical or logical compendium of patient data pertaining to health; an information warehouse used to store data longitudinally, in multiple forms (text, voice, images, and so on). Clinical decision support systems: These systems are computer applications designed to facilitate human decision making. Decision support systems are typically rule based, using a knowledge base with

a set of rules to analyze data and information to reach recommendations. Clinical information system: This is an information system that supports the acquisition, storage, manipulation, and distribution of clinical information throughout an HCO, with a focus on electronic communication, using HIT applied at the point of clinical care. Typical clinical information system components include EMRs/EHRs, clinical data repositories, decision support programs (such as application of clinical guidelines and checking drug interaction), handheld devices for collecting data and viewing reference material, imaging modalities, and communication tools, such as electronic messaging systems. Coding system: This is a set of agreed-upon symbols (frequently numeric or alphanumeric) associated with a concept representation or terms to allow exchange of meaning. Examples are the SYNTEGRITY Perioperative Nursing Data Set (PNDS) and the Clinical Care Classification System. Computer literacy: Specific knowledge and skills are required to use basic computer applications and computer technology. Data: These are discrete entities described objectively without interpretation. Dashboard: A method to provide a quick view of data using key elements of concern. Data analysis software: Computer software used to analyze data; used in health care to meet regulatory requirements, performance assessment and quality improvement, accreditation, and research. Data bank: A method used to store a large amount of information; may include several databases. Database: A collection of interrelated data organized according to a scheme to serve one or more applications with data stored so that several programs can use the data without concern for data structures or organization. An example is the National Database of Nursing Quality Indicators, discussed in other content in this text. Data mining: This is a method used to locate and identify unknown patterns and relationships within data. Email list: A list of email addresses can be used to send an email to many addresses simultaneously. Encryption: A method used to change information into a code, usually

for security reasons, so as to limit access to that information. Information: This represents data that have been interpreted, organized, or structured. Information literacy: This is the ability to recognize when information is needed and then to locate, evaluate, and effectively use that information. Minimum dataset: This describes the minimum categories of data with uniform definitions and categories; concerns a specific aspect or dimension of the healthcare system that meets the basic needs of multiple data users. Nomenclature: This is a system of designations (terms) that is elaborated on according to preestablished rules. Examples include Systematized Nomenclature of Medicine—Clinical Terms International and International Classification for Nursing Practice. Scorecard: This is a metric method used by management to assess and track performance, typically related to the HCO’s agenda (or unit, service, department); it can focus on clinical, financial, and other indicators. Another term that may be used is report card. Security protections (access control, data security, and data encryption): Methods used to ensure that information is not read or taken by unauthorized persons. The role of HIT in e-measurement and quality care has become increasingly more important in recent years (Dykes & Collins, 2013). Emeasurement is the secondary use of electronic data to populate standardized performance measures (National Quality Forum [NQF], 2017). The NQF is engaged in ensuring that effective e-measures are available so that data can be used for clinical documentation and reused to measure patient outcomes that are clear and consistent. This endeavor, which is very complex, remains far from complete at this time. A current problem in our everyday lives and in our professional lives is information (cognitive) overload, which is an “interpretation that people make in response to breakdowns, interruptions, interruptions of ongoing projects, or imbalances between demand and capacity” (Weick, 2009, p. 76). We are so overwhelmed with information that we may experience it as a barrier in using the information and, in some cases, it may interfere with our decision making and work that must be done. Interruptions,

attention issues, and not having enough time can also influence information overload, making it a greater problem. The bottom line is this problem can lead to other problems (Sitterding, 2015). We are attached to our devices personally and now more and more in our work in health care. Managing the use of devices and information is a critical requirement for success. Information and accessibility to information have a positive impact on the quality of care; however, we are learning that this can also have a negative impact, which may prevent us from reaching outcomes—we have too much information or we cannot manage the information effectively.

Nursing Standards: Scope and Standards of Nursing Informatics NI is a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, knowledge, and wisdom in nursing practice. NI supports consumers, patients, nurses, and other providers in their decision making in all roles and settings. This support is accomplished through the use of information structures, information processes, and HIT. The goal of NI is to “improve the health of populations, communities, families, and individuals by optimizing information management and communication” (ANA, 2008, p. 1). Undergraduate and graduate nursing programs may include HIT in the curriculum, sometimes as a course on informatics, but not all programs include this content. This omission from nursing education programs is a problem because of the greater emphasis on informatics as a healthcare professions core competency. Some schools of nursing offer master’s degrees in NI. Data alone are not useful—understanding the data and then using this knowledge is what is important. This view is important to include in discussions with students. The steps in moving from data to wisdom can be described as data naming, collecting, and organizing, following this pattern: (1) information—organizing and interpreting; (2) knowledge— interpreting, integrating, and understanding; and (3) wisdom— understanding, applying, and applying with compassion. FIGURE 17-4 illustrates this process. Nelson and Joos (1989) define wisdom as “the

appropriate use of knowledge to manage and solve human problems. It is knowing when and how to apply knowledge to deal with complex problems or specific human needs” (p. 6). Knowledge and wisdom are related: “While knowledge focuses on what is known, wisdom focuses on the appropriate application of that knowledge. For example, a knowledge base may include several options for managing an anxious family, while wisdom would help decide which option is most appropriate for a specific family” (ANA, 2008, p. 5). Data are important to the delivery of nursing care, but without effective analysis, it is not useful to us. In hospitals, data can be used to evaluate outcomes, identify problems for a specific group of patients, and assist in making plans for change to improve care. In the community, aggregated data are often collected to better understand the health issues in a population or community and to formulate a plan of action.

FIGURE 17-4 From data to wisdom.

Certification in Informatics Nursing Nurses who practice in the area of informatics can be certified if they

meet the eligibility criteria and satisfactorily complete the certification examination. The following list identifies the application eligibility criteria required for the informatics certification exam sponsored by the American Nurses Credentialing Center (ANCC). The nurse must (ANCC, 2016): Hold a current, active registered nurse license in a state or territory of the United States or the professional, legally recognized equivalent in another country. Have practiced the equivalent of 2 years full time as a registered nurse. Hold a bachelor’s or higher degree in nursing or a baccalaureate degree in a relevant field. Have completed 30 hours of continuing education in informatics within the last 3 years Meet one of the following practice hour requirements: a. The nurse must have practiced a minimum of 2,000 hours in informatics nursing within the last 3 years. b. The nurse must have practiced a minimum of 1,000 hours in informatics nursing in the last 3 years and must have completed a minimum of 12 semester hours of academic credit in informatics courses that are a part of a graduate-level informatics nursing program. c. The nurse must have completed a graduate program in NI containing a minimum of 200 hours of faculty-supervised practicum in informatics. © American Nurses Credentialing Center (ANCC) 2016. Reprinted with permission.

These are not simple eligibility criteria; they take time to meet. They also provide a good overview of the need for expertise in this area. The informatics nurse is involved in activities that focus on the methods and technologies of information handling in nursing, such as the development, support, and evaluation of applications, tools, processes, and structures that help nurses to manage data in direct care of patients as well as in nursing education and research. Informatics nurses can be involved in a variety of information systems, including theory formulation, design, development, marketing, selection, testing, implementation, training, maintenance, and evaluation. They may hold positions in HCOs,

such as in clinical practice, management, or education; serve as an HIT consultant; and hold positions that support research. It is clear that a nurse who wants to function in this specialty area must have excellent computer skills, understand practice needs for information, and know how best to apply HIT to nursing practice. The nurse must also be able to work collaboratively in interprofessional teams and demonstrate leadership. By advocating for the needs of the practicing nurse, the informatics nurse represents all nurses in practice—clinical, education, and research—as applies to the specific situation.

Informatics: Impact on Care Effective use of informatics can lead to safe, high-quality care. Application of informatics, however, does not guarantee perfection. It is commonly thought that work processes will be better if using IT; however, potential glitches need to be considered so that problems will be prevented. Examples include the following: clear expectations for staff HIT use and outcomes, ease of use, staff time for HIT training, quality of HIT training, staff time required to use HIT, monitoring of errors and methods used to address problems, accessibility to HIT such as access to a computer or device that supports the task, acceptance of HIT by staff, methods used to introduce HIT changes and communication of these changes, HIT tech support, and so on. Introducing and maintaining HIT requires careful planning with input from staff that will use HIT. Nurses need to assume an active role in the development of HIT for patient care and not wait to be asked to participate. When an HCO is choosing an EMR system, nurses need to be involved to ensure that the system meets nursing care documentation requirements and that relevant data can be collected to assist nurses in providing and improving care. Nurses may serve in key HIT roles to guide development and implementation. Nurses may also serve as resources in identifying needs and testing systems to ensure that the systems are nurse–user friendly. Many nurses who provide feedback about systems do not have special HIT training; they review the system to determine if it is user friendly for nurses who have limited informatics knowledge and help to determine if the system meets documentation needs and standards. All nurses need to be skilled in managing and communicating information, but most

nurses are primarily concerned with the content of that information and getting it when they need it. In today’s dynamic healthcare environment, coordination of care is very important. One of the barriers to seamless coordination is the lack of interoperable computerized records with hospitals and also office-based physicians (Bodenheimer, 2008). Interoperability is receiving more attention on the national level, as discussed earlier in this chapter. A problem that is not yet fully solved is the need to share information from one system to another, which is a limitation that needs to be resolved for better coordination of care. For example, it should be possible to share current information among healthcare providers in private practice, clinics, and hospitals when it is needed. All this requires greater use of standardized definitions related to data and measurement to ensure objectivity and reliability of data, allow for comparisons, consistently track data over time, and increase opportunity to provide/observe empirical evidence of outcomes (Glassman & Rosenfeld, 2015). Innovative methods to improve coordination that focus on informatics have been developed. One method is to use electronic referral (ereferral.) This approach allows a healthcare provider to send an email to another provider, such as a specialist, with information about the patient and ask for consultation. In many situations, such communication eliminates the need to see the patient. The specialist reviews information such as lab reports, surgical reports, and so on, and the specialist can share opinion and treatment recommendations with the other healthcare provider. It is critical that reimbursement be provided for this type of service, or it will not be used. Health Insurance Portability and Accountability Act of 1996 (HIPAA) requirements must also be considered, with all parties working together to ensure patient privacy. Timely information flow from the hospital to posthospital care should improve patient coordination. Not having this is a major drawback; even though the technology to improve it is available, it is not freely used.

Implications for Nursing Education and Nursing Research Informatics is important not only for practice but also for nursing education and nursing research. Today, there is greater use of IT in

nursing education than was the case in the past. The increased use of online courses throughout the nursing curriculum, at both the undergraduate and graduate levels, has revolutionized nursing education. This has led to the need for faculty to consider use of more interactive learning methods. Moreover, as students use more technology in their personal lives, they expect correspondingly greater use of IT in education. Such tools as tablets and smartphones and Internet tools and apps such as Facebook, Instagram, and Twitter provide instant information and can be very interactive. These methods can also be used to increase student–faculty communication and have the potential to provide different means of student–faculty supervision in the clinical area. This is particularly true in such areas as public/community health when students visit multiple sites and faculty move from site to site to spend time with students. Informatics also affects simulation experiences for students, allowing faculty to create complex learning scenarios that use the computer and computerized equipment and, in many cases, provide opportunity for students to use an EMR system in a simulated environment. Nursing research uses informatics in data collection and analysis; it saves time and improves the quality of data collection and analysis. Researchers have greater access to tools that can make their work easier and organize and save data for later use. It is then easier to analyze the data to determine research results. Nurse researchers and their staff do some of this work, and specialists such as statisticians may assist in using technology.

STOP AND CONSIDER #3 Health informatics is now integrated in practice, management, education, and research.

Documentation Over time, clinical documentation has increased in terms of its relevance to nurses and to other healthcare professionals, thus increasing its impact on patient care and patient outcomes. Today it is expected that documentation should be accurate and accessible to those who need and should have access given confidentiality and privacy law requirements, as has been the case for a long time. Many different staff document in the medical record. Documentation must describe nursing practice, which should be evidence based. Both nurse managers and nurses involved in direct care are accountable for ensuring that documentation meets the expected standards. Nurse educators in academic and HCO settings are also involved in ensuring effective documentation. Documentation meets many needs, such as clear communication for the team and others who need the information to provide care and meet legal and ethical, accreditation, documentation, and reimbursement and budget requirements. We now place greater emphasis on documentation as a source for quality improvement and research data. The format and content of nursing documentation have also changed. It is a professional responsibility to document planning, actual care provided, and outcomes. Care coordination and continuity are supported by documentation. With many different staff caring for patients around the clock and use of interprofessional teams, it is critical that a clear communication mechanism exists, and the key mechanism is documentation. Verbal communication is important, but a written document must be available. Staff can refer to such documentation when other care providers are not available. Through documentation, outcomes and evaluation of patient care are made clear. The medical record is a legal document, and as such, rules must be followed when creating and amending it. Once documentation has been created, changes to it must be accompanied by a note indicating who made the change(s) and when (date and time), following HCO policy and procedure. Only certain staff may document; they must note the date and time on the documentation and include their name and credentials. If

there are questions about care or a legal action, such as a malpractice suit, the medical record is the most important source of evidence. Consequently, medical records must be saved. A nurse can say that he or she provided certain care, but if it is not documented, then it is as if that care did not occur. The following provides a list of the advantages of using EMRs (USDHHS & HealthIT.gov, 2015): Quick access to patient information from multiple locations to assist in providing coordinated, efficient care Decision support, clinical alerts, reminders, and medical information Performance-improving tools, real-time quality reporting Legible, complete documentation that facilitates accurate coding and billing Interfaces with labs and other sources of information Safer, more reliable prescribing Reduction in errors when multiple caregivers are involved in the care —care coordination Improvement of care transitions (handoffs) between settings Up-to-date information for emergency care—care coordination The summary of the following guidelines should also be considered in documentation (Iyer & Camp, 1999): Do not include opinion but only objective information in documentation. The nurse does not make subjective comments (for example, comments about the patient being uncooperative, lazy, or impolite). Nurses document only what they have done and objective data. A nurse does not document another staff member’s actions. Supervision of care, however, can be documented. Write neatly and legibly. Many HCOs now use computerized documentation, although not all HCOs have moved to an EMR system. If a computerized system is used, typos (typographical errors) may be a problem. Other issues may arise in electronic systems that use a checklist for a particular section of the EMR but do not allow for narrative notes. Nurses and others may be frustrated when they cannot add a narrative note. Use of the copy and paste feature in an EMR/EHR increases the risk

of errors, particularly perpetuating an error (Yadav et al., 2016). Use correct spelling, grammar, and medical terminology. Use authorized abbreviations. Using unapproved abbreviations increases the risk of errors. Use graphic records to record specified patient data, such as vital signs and medication administration. Record the patient’s name on every page (for hard-copy medical records); this should be part of the EMR. Follow HCO policies and procedures about verbal and telephone orders. Transcribe orders carefully; double-check and ask questions if an order is not clear. In computerized systems, orders do not need to be transcribed; however, this does not mean that there is no risk of an error. All orders need careful review, and if they are not clear, they may require follow-up. Document omitted care. Document medications and outcomes. Document patient noncompliance/nonadherence and the reason(s) for it. Document allergies, and use this information to prevent errors and complications. Document sites of injections and other procedures. Record all required information about intravenous therapy and blood administration. Report abnormal laboratory results. Document as soon as possible after care is delivered. If documentation is done later, note this in the record. The nurse should not leave blank areas to come back to for later documentation. When quoting, use quotation marks and note the person who made the statement. When documentation is corrected because of a mistake, follow the HCO policies regarding corrections as per a hard-copy record or electronic record. Medical records are never rewritten or destroyed by staff. Document patient status change. When contacting the physician, document the time, date, name of physician, reason for the call, content, physician response, and steps

taken after the call. This note should not include subjective analysis of the response such as the physician’s attitude. The Joint Commission does not provide details as to what must be in a medical record (the term used by the Joint Commission for this document is record of care/treatment and services), but it does provide some guidelines that are required for accreditation as follows, with additional comments (Clark, 2011; Joint Commission, 2011, 2016): The minimum content that should be included is the patient’s name, address, date of birth, name of any legally authorized representative, assessment, diagnosis, clinician notes and actions, signatures and countersignatures as required, dates, details of procedures performed, laboratory reports, medications administered, and treatment plans. Other data may be included. The record should be clear and understandable. The record provides a system of communication and in doing so is a source of data for quality improvement monitoring. Storage of documents must be secure and reasonable. For example, security requirements need to identify who has access to records and prevent casual viewing by nonstaff. All Medicare storage rules must be followed. Today, with increased risk of problems with computer systems or hacking, HCOs need policies and procedures to assist staff when there may be problems with the EMR and access. HIPAA requirements must be followed—ensuring patient privacy and confidentiality. HCOs should have policies and procedures that support HIPAA, and staff must adhere to them. Use acceptable abbreviations identified by the HCO. These guidelines apply to hospital medical records. The content is somewhat different for medical records in other types of settings, such as ambulatory care, long-term care, and home care, although some information and guidelines are the same. It is important for all HCOs to have clear documentation policies and procedures and ensure that staff are aware of them and follow them. When changes occur, staff must be informed so that the new requirements will be met.

STOP AND CONSIDER #4 Documentation is a critical communication method for the care team.

Meaningful Use Meaningful use focuses on use of certified EHR technology for the following purposes (USDHHS & HealthIT.gov, 2019): Improve quality, safety, efficiency, and reduce health disparities. Engage patients and family. Improve care coordination as well as population and public health. Maintain privacy and security of patient health information. The American Recovery and Reinvestment Act of 2009 specifies the following three components of meaningful use (USDHHS & CMS, 2016): Use of certified EHR in a meaningful manner (for example, eprescribing) Use of certified EHR technology for electronic exchange of health information to improve quality of health care Use of certified EHR technology to submit clinical quality measures and other such measures selected by the Secretary of HHS Meaningful use identifies specific objectives that eligible professionals and hospitals must achieve to qualify for Centers for Medicare and Medicaid Services (CMS) reimbursement. Given that most hospitals receive CMS reimbursement, most hospitals have a strong incentive to follow these requirements. Nurses are also required to consider meaningful use, particularly if they are in leadership positions where decisions about HIT are made. Ultimately, it is hoped that meaningful use compliance will result in the following benefits: Better clinical outcomes Improved population health outcomes Increased transparency and efficiency Empowered individuals More robust research data on health systems All of the meaningful use purposes are in line with the Quality Chasm reports on quality and are associated with continuous quality

improvement.

STOP AND CONSIDER #5 Meaningful use relates to nursing practice.

Standardized Terminology Health care has expanded in multiple directions and includes the services of many different healthcare providers. Ensuring effective communication among these myriad providers is not always easy. Certainly, there are issues regarding willingness to communicate, lack of time to communicate, and so on, but a critical problem is the lack of a common professional language/terminology. For those entering healthcare profession, such as nursing students, this is probably a surprising comment. Each healthcare professional area has its own terminology. There are some common medical terms, but each profession has specific terminology that is often not known or understood by other healthcare professionals. “Creating a common language is no small task. Developing and adhering to distinct profession-specific terms may be a manifestation of professionals’ desire to preserve identity, status or control” (IOM, 2003, p. 123). This problem affects all the core competencies and the ability to develop educational experiences that meet the competencies across healthcare professions, such as nursing, medicine, pharmacy, and allied health. The issue of shared terminology is even more important in HIT because informatics is dependent on language, requiring a shared terminology. We now recognize its effect on practice and interprofessional teams. A standardized terminology is a collection of terms with definitions for use in information systems databases. This enables comparisons to be made because the same term is used to denote the same condition, and it is necessary for effective documentation in EMRs/EHRs. It is recognized that we need a common language across health professions supporting the five core healthcare professions competencies. Accomplishing this requires that healthcare professionals

are willing to actively work together to achieve this goal. The USDHHS has been tasked with meeting this goal, though it is a difficult goal to reach—getting different healthcare professionals to accept a universal terminology. This will require compromises and has yet to be fully accomplished. The ANA (2006) notes, “The data element sets and terminologies are foundational to standardization of nursing documentation and verbal communication that will lead to a reduction in errors and an increase in the quality and continuity of care. It is through standardization of nurse documentation and communication of a patient’s care that the many nurses caring for a patient develop a shared understanding of that care.” These statements are an example of why developing and accepting a universal language is difficult but necessary, but they also illustrate how it is easy to approach this from silos—focused on individual healthcare professions. Such statements are nursing focused, but all healthcare professions need to address this issue using interprofessional collaboration. Determining how best to move from a specific profession approach to a collaborative approach to solve this problem is the challenge. The National Library of Medicine (NLM), serving as the coordinating body for clinical terminology standards within HHS, offers products and services for HCOs and healthcare professionals that support interoperability and the unambiguous exchange of health data (National Institutes of Health [NIH] & U.S. National Library of Medicine, 2016a). The NLM website provides a current overview of activities focused on standardized terminologies.

STOP AND CONSIDER #6 Standardized terminologies are needed, but it will be difficult to reach consensus among healthcare professionals.

Systems and Terminologies Informatics is not as simple as email and the Internet. Informatics in general and HIT include many database systems, terms, and other factors that make this a complex area. The following provides examples illustrating the complexity of HIT: Systematic Collection of Nursing Care Data or Data Element Sets • Nursing Minimum Data Set: This dataset describes patient problems across healthcare settings, different populations, geographic areas, and time. It provides clinical data to assist in identifying nursing diagnoses, nursing interventions, and nursingsensitive patient outcomes. In addition, the Nursing Minimum Data Set is useful in assessing resources used in the provision of nursing care. The goal is to link data between HCOs and providers. Data can also be used for research and healthcare policy. • Nursing Management Minimum Data Set: This dataset focuses on nursing administrative data elements in all types of settings. Interface Terminologies • Clinical Care Classification: The clinical classifications software for the International Classification of Diseases, 10th revision, Clinical Modification (ICD-10-CM), is a diagnosis and procedure categorization scheme that can be used in many types of projects to analyze data on diagnoses and procedures. The software is based on ICD-10-CM, a uniform and standardized coding system. ICD-10-CM includes more than 13,600 diagnosis codes and 3,700 procedure codes (USDHHS, Centers for Disease Control and Prevention, & National Institute for Occupational Safety and Health, 2016). • Nursing Intervention Classification and Nursing Outcome Classification: The North American Nursing Diagnosis Association (NANDA) focuses on nursing diagnoses, Nursing Intervention Classification (NIC) on nursing interventions, and Nursing

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Outcome Classification (NOC) on nursing outcomes (NANDA International, 2017; University of Iowa, Center for Nursing Classification and Effectiveness, 2017). Omaha System: The Omaha System is a comprehensive, standardized taxonomy designed to improve practice, documentation, and information management. It includes three components: the problem classification scheme, the intervention scheme, and the problem rating scale for outcomes. When the three components are used together, the Omaha System offers a way to link clinical data to demographic, financial, administrative, and staffing data (Omaha System, 2018). The Omaha System is used in home health care, community health, and public health services. PNDS: The PNDS is a standardized nursing vocabulary that addresses the perioperative patient experience from preadmission until discharge, including nursing diagnoses, interventions, and outcomes. This set was developed by a specialty organization, the Association of periOperative Registered Nurses (2017) and recognized by the ANA as a dataset useful for perioperative nursing practice. This standardized system is now called SYNTEGRITY PNDS. It is an IT tool that can be personalized by HCOs to meet individual organization needs. The framework supports electronic documentation, patient quality and EBP, a common language/terminology, and a method to collect and compare data. It connects nursing diagnoses, care implementation, and assessment to measure outcomes.

Examples of Multiprofessional Terminologies • Logical Observation Identifiers Names and Codes: This clinical terminology classification is used for laboratory test orders and results. It is a system designated for use in U.S. federal government systems for the electronic exchange of clinical health information (NIH & NLM, 2008). This system can be used to collect data about assessments and outcomes for nursing and other healthcare services. • Current Procedural Terminology: This code is used for reimbursement (American Medical Association, 2016).

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Systematized Nomenclature of Medicine—Clinical Terms: This comprehensive clinical terminology is one of several standards approved for use in U.S. federal government systems for the electronic exchange of clinical health information (NIH & NLM, 2016b). The system is applicable to nursing and other healthcare services and focuses on diagnoses, interventions, and outcomes.

With the increased use of technology for documentation, nursing has been more concerned about two issues (Schwiran & Thede, 2011): How to differentiate nursing’s contributions to patient care from those of medicine How to incorporate descriptions of nursing care into the health record in a manner that is commensurate with its importance to patients’ welfare This requires systems that can meet these needs; therefore, nurses need to engage in HIT so that nursing can be better represented in decisions about EMRs. In a study conducted by Schwiran and Thede (2011), the researchers examined nurses’ knowledge of and experience with standardized nursing technologies. The results indicate that most nurses do not have much knowledge of or experience with standardized nursing technologies, such as the NIC, NOC, and NANDA. They may have used these technologies in their nursing education but not in practice after graduation. Given the increasing use of informatics in healthcare settings, such a lack of knowledge and experience may hamper nurses’ ability to participate actively in HIT development and evaluation and better ensure that nursing practice is supported.

STOP AND CONSIDER #7 Nursing is more involved in approaches to develop and improve health information technology.

Informatics: Types and Methods For informatics to be effective, three concerns must be addressed. First, the HCO must have effective and easily accessible HIT support services. Staff must be able to pick up the telephone and get this support. Failure of the information system has major implications for patient care and increases staff stress, so backup systems are critical. The second critical concern is staff training. This requires resources: financial resources, trainers, and time. Time is needed for staff to attend training, and there must be recognition that it takes time for staff to learn how to use a system—and during this time, there is an impact on care and work processes. Incorporation of informatics with any of the methods described next (and others that are not included here) requires a major change in care delivery. Change is stressful for staff, and it needs to be planned, representing the third concern. Trying to implement too many changes at one time may increase staff stress, affect the success of using more informatics in the future, decrease staff motivation to participate, and increase the risk of errors that might affect patient outcomes. Change is discussed in several chapters in this text. It is not difficult to find nurses who will complain about a hospital’s attempt to increase the use of informatics, particularly if it has been badly planned. Often, in these complaints, staff members note that the system selected was not effective and that they had no part in the decision and implementation process. Equipment and software are very costly, and decisions regarding them are critical—getting an ineffective system or bad fit for what is needed only increases costs and management and staff stress. Time must be taken to evaluate equipment and software to make sure they meet the needs and demands of the organization and the users, such as nurses. Examples of current activities in this area are automated dispensing of medications and bar coding; computerized monitoring of adverse events; the use of EMRs/EHRs, provider orderentry systems, clinical decision support systems, use of devices such as tablets and smartphones, computer-based and reminder systems; access to patient records at the point of care; prescribing via the Internet; using nurse call systems, voice mail, and the telephone for advice and other

services; use of Internet or virtual appointments; and online support groups for patients and families. These methods are discussed in this section. It is important to note that there is now a serious risk with the use of electronic methods for documentation and communication today. Hacking has become more common with IT in general, and there have been incidents of hacking health records. Why would this be done? One reason is health records often include personal identification information that might be used for illegal purposes, such as to obtain addresses, telephone numbers, email addresses, credit card information, and Social Security numbers (McCann, 2014; Pagliery, 2014; Peterson, 2015). Another experience that some HCOs have had is hacking data or control of data and then the hacker(s) demand a ransom for the HCO to regain access to the system (Conn, 2014). This can happen to small or large HCOs. All this emphasizes that the data we have are important— valuable—not only to us and to our patients but also to others who may not have the same goals. We must be careful and use appropriate passwords and procedures to protect data. We see an increasing use of emails as a method to communicate with patients—sharing important personal information. Is this wise? Patients are often asked and encouraged to provide their email—but it is their choice to make, and in all cases, it should be their decision. We need to take care with what we put in emails or what we ask patients to send in an email—for example, Social Security numbers should never be sent in an email. When we keep data for health care, we have ethical and legal responsibilities to ensure the information is accurate and safe.

Automated Dispensing of Medications and Bar Coding Pharmacies in all types of HCOs are using or moving toward expanding use of automatic medication dispensing systems with bar coding. These systems select the medication based on the order and prepare it in single doses for the patient. The bar code is on the packaged dose. This code can then be compared with the bar code on the patient’s identification band using a handheld device. This type of system can decrease errors, and it supports all five rights of medication administration, as discussed in

other content in this text. Bar coding can also be used to collect data about prescribed and administered drugs. Data then may be used for monitoring quality improvement and for research. Bar coding systems are expensive to install and maintain, but they can make a difference in decreasing errors and can reduce time required for all medication administration steps.

Computerized Monitoring of Adverse Events Computerized systems that monitor adverse events assist in identifying and monitoring adverse events. Developing and using a database of these events facilitates analysis of data and the development of interventions to decrease adverse events. A major problem with data collection, such as for adverse events, is not using structured collection— overdoing collection and ending up with data that are not needed or not in a format that could be used. Careful planning is required to identify information or data needed and how it will be accessed and used to prevent this from occurring.

Electronic Medical/Health Records EMRs/EHRs are slowly replacing the written medical record for an individual patient while the patient receives care within a specific healthcare system. A second type of electronic documentation system is the personal health record (PHR). The PHR is less common than the EMR, but the goal is for it to become standard in the future. The PHR is a computer-based health record for which data are collected over the long term—for a lifetime. With the patient’s permission, the healthcare provider can access this record easily to obtain information. To reach this point, there must be agreement on a minimum dataset—uniform definitions of data (that is, standardized language/terminology) that would enable all healthcare providers to understand and use the information. There is still much to be done to make this a reality in every HCO, including clinics and medical offices, but the technology is already available. The EMR/EHR is a record of the patient’s history and assessment, orders, laboratory results, description of medical tests and procedures,

and documentation of care provided and outcomes. Current requirements for electronic records referred to as the Common Clinical Data Set guides EMR content. The following are the minimum requirements identified by the HHS (USDHHS ONC, 2015a): Patient name Sex Date of birth Race Ethnicity Preferred language Smoking status Problems Medications Medication allergies Vital signs Care plan field(s), including goals and instructions Procedures Care team members Immunizations Unique device identifier(s) for the patient’s implantable device(s) Notes/narrative Care plans are included. It should be easy to input, search, and review information, and it should be possible to print reports. Electronic data can be stored over the long term, which is harder to do with written records. Written records require significant storage space, and they may not be easy to find once archived. In addition, written records can be less readable over time. The hard-copy record is not always easy to access when it is needed in a hospital unit. If one person is using the record, others cannot use it. With the EMR, this is not a problem as long as staff can access the computerized record system. EMR systems do require security and backup systems to ensure that data are not lost in the event of a power outage, natural disaster, or other event that may make access difficult. Electronic documentation has many advantages such as timeliness of care. Staff can document as care is provided or soon after, providing a system for all members of the team to view the care process when

needed. Documentation may take place at the unit workstation, at a hallway computer station, at the bedside in the hospital, or in an examining room in a clinic. Bedside systems are better because they are easy to access when the nurse or other healthcare professional needs information and point-of-care documentation is enhanced. This all improves documentation and communication. Other advantages are legibility; greater access to records for multiple users; increase in efficiency and effectiveness in the work environment; less opportunity to change records inappropriately; inclusion of safety elements, such as alerts for allergies or incompatible drug orders, and reminders to do certain tasks or add certain information to the record; ability to print records when need; and more accurate and accessible data for reimbursement, budget, and quality improvement. It is important to recognize that when HCOs change to electronic documentation or make changes in a current electronic system, this is a time of great disruption in clinical practice and workflow processes, typically with negative staff responses to the change process and/or the change itself (Ford, Silvera, Kazley, Diana, & Huerta, 2016). A study conducted by Barnett, Mehrotra, Jena, and Newhouse (2016) also refers to the disruption in work processes during transition to electronic records, particularly noting the negative impact on patient outcomes. In this study of 17 hospitals transitioning to electronic methods, the hospitals demonstrated more problems with adverse patient outcomes than hospitals that were not transitioning to electronic records. All of this affects the culture of safety. HCOs and their providers must have time to adjust to the change and to recognize the benefits and, during change, be alert to prevent errors.

Clinical Provider Order-Entry System A clinical provider order-entry system (CPOES) may be included in an EMR, although it may also be a stand-alone system. The healthcare provider inputs orders into this system rather than using a hard-copy record. This is an expensive system to implement. One clear advantage of the CPOES is legibility; written orders are often very difficult to read because handwriting varies, and this may cause errors. It also takes time to transcribe written physician/provider orders into a form in which the

orders can be used. During this process, the risk of transcription errors increases. Typing orders into a computer can also lead to typos, but this is less of a problem than errors with handwritten orders. A systematic review of 34 studies on CPOES used identified key areas of the EMR and its CPOES that may be associated with CPOES errors: computer screen display, drop-down menus and auto-population, wording, default settings, nonintuitive or inflexible ordering, repeat prescriptions and automated processes, users’ work processes, and clinical decision support systems (Brown et al., 2017). The studies reviewed identified examples of how an EMR and its CPOES might have weaknesses in these areas—such as incomplete medication lists that led to prescription error, misinterpretation of text, and lack of flexibility in the CPOES so the staff member uses a workaround—increasing the risk of an error. Dropdown menus need to include safeguards to prevent selection errors. Another study examined alerts of automated identification of antibiotic overdoses and adverse drug events via a CPOES (Kirkendall et al., 2016). This study highlights alert fatigue. If providers get a number of alerts, there is increased chance they will override the alert because of too many alerts—viewing them as irritants to getting work done. Alert systems need to be carefully reviewed and revised to reduce alerts that are not critical. Clinical decision support systems can be included with the CPOES. Brown and colleagues’ (2017) systematic review concludes that development of better clinical decision support systems may reduce errors and improve workflow. Combining the CPOES with the decision support system enhances the provider order-entry system and can lead to improved care and a decrease in errors as noted in the Brown study. CPOES is not only a clinical tool to assist in providing effective care, but it also offers a source of information about quality improvement—data that may be used by the QI program. Analysis of medication order voiding provides critical information for why providers who write the orders void them or why the system voids them (Kannampallil et. al., 2017). Kannampallil and colleagues examined 6 years of CPOES data, looking at void and not void orders and reasons for the voiding. In the sample, 0.49% of all the orders were voided, with most voiding due to medication ordering errors. The use of a voiding provides the HCO with an easy method for self-reporting of near-miss medication ordering

errors, and the data should be used to assess the current status within the HCO and to develop strategies to reduce the need for voiding orders.

Clinical Decision Support Systems Clinical decision support systems have led to major changes in healthcare delivery. These systems provide immediate information that can influence clinical decisions. Some of the systems actually intervene when an error is about to be made. For example, when an order for a medication is put in a patient’s EMR, the computerized system might indicate the patient is allergic to that medication by immediately sending an alert, stopping the order. The nurse can also get alerts for a variety of potential problems such as the patient at risk for falls or decubiti. In the past, nurses depended on textbooks or journals that the unit or hospital library might have available to find information, and such searches were often not done effectively. Easy electronic access to current information eliminates many problems related to obtaining information when needed. This, too, can improve the quality of care. EBP relies heavily on access to EBP literature, which is most easily accessible via the Internet and databases. As is true for all electronic methods, healthcare professional critical thinking, as well as clinical reasoning and judgment, must still be applied. Errors can still be made with technology. When HIT is used, staff may go on “automatic pilot,” assuming the electronic system will catch all potential errors, which is not always the case. More research is needed to fully understand the impact of clinical decision support systems on patient outcomes. Romano and Stafford’s (2011) study indicated that there was no consistent association between such systems and the quality of care in an investigation that included 3 billion patient visits. Only one of 20 indicators—diet counseling for highrisk adults—demonstrated significantly better performance when clinical decision support systems were utilized. In contrast, earlier studies had shown that use of the clinical decision support systems improved outcomes. A critique of the 2011 study questions whether the results were influenced by the following factors: (1) clinical decision support system rules may have been different in the systems studied; (2) the study focused on medication management, whereas earlier studies were

broader; and (3) the study looked at the outcome of a single visit rather than the cumulative effect. More research is needed to understand the use of this method and better determine the effectiveness of using clinical decision support systems, which is a complex research area.

Tablets and Smartphones Tablet computers are very popular with the general public and also in the workplace. Most mobile telephones now have Internet capability, such as access to the Internet and storage of information. These phones give users quick access to information, Internet, email, and text messaging, and of course, telephone service. Such handheld devices can hold a significant amount of information, serve as a calendar, keep contact information, monitor tasks, and so on, and are an effective method for transmission of information. Nurses who use tablets and/or smartphones carry information with them and can look up side effects of a medication or any other type of medical information necessary as they provide care. In some cases, the nurse can access EMRs to get to patient information through the tablet. Some textbooks can now be uploaded into tablets, such as pharmacology and clinical laboratory resources. This is useful information for the nurse to have available—it is accessible in seconds at the point of care. Nurses working outside a structured setting, such as in public/community health or in home care, may also find this type of system useful for support information and documentation needs (patient information, visit data, and so on); however, they must be very careful to maintain HIPAA regulations. Tablets are used in public/community health to collect data such as health assessments; data are stored locally on the tablet and then uploaded to a secure cloud server (that is, a server that is encrypted to protect personal health information) when the user is back in network/wireless range. Any time such technology is used, the data must be protected to keep information secure and confidential. It is not only the concern about security of information but also the devices, which can be lost and should be used with security codes. HCOs should have clear policies and procedures for actions staff should take if a device is lost or a person(s) who should not have access to the information gains access to the device. If the healthcare provider is using these devices for oral

communication in any location, he or she must be careful to ensure privacy.

Computer-Based Reminder Systems Computer-based reminder systems are used to communicate with patients via email or text messages to remind them of appointments and screenings and to discuss other health issues. In the future, these methods will most likely take the place of telephone calls to remind patients of appointments. Any reminder system must also maintain HIPAA regulations. For example, the healthcare provider must ensure that only authorized parties have access to the computer and email data. More narrowly defined, only the patient should have access to the information unless the patient wants the information shared. An example of concern about privacy is using a patient’s work email or work mobile phone. Employers have the right to view employee emails and phones, and thus private health information may be shared if the employer does view employee information and devices.

Access to Patient Records at the Point of Care Many hospitals are moving toward providing access to patient records either in the patient’s room or in the hallway via computers. In the future, more nurses will carry small laptops or tablets that allow access to the EMR when needed for work requirements. This reduces time spent returning to the workstation to get information and allows for more timely documentation—it can be completed as soon as care is provided. This reduces errors and improves quality because all care providers know when care has been provided in a timely manner. Point-of-care access decreases the chance that details may be forgotten, documented incorrectly, or not documented at all. In addition, it saves nurses time and eliminates the need to delay documentation. For example, if they do not have this type of immediate access, nurses may document at certain times during the shift such as midmorning or near the end of a shift, requiring them to find a block of time to complete documentation without interruptions. This is an approach that can lead to errors, incomplete data in the record if the nurse forgets information, and situations in which other

providers need current patient information that has not yet been documented.

Internet Prescriptions There has been rapid growth in consumer access to prescribed medications via the Internet. The medications are then mailed to the patient. The consumer must be careful and check the legitimacy of the source to prevent errors.

Nurse Call Systems Nurse call systems are a form of informatics that is very important in communication within a healthcare system. They allow for improved and efficient communication and are a great improvement on the old method of yelling out for a staff member or a unit speaker system calling for staff. Many types of nurse call systems exist, such as pagers, light signals, buzzers, methods that allow patients to talk directly to nurses through an easily accessible direct audio system, smartphones, miniature label microphones, and locator badges. The goal is to get a message to the right person as soon as possible while maintaining privacy and confidentiality. Doing so can improve care, improve patient satisfaction, reduce errors, and make staff more efficient, thus preventing the unnecessary work of trying to obtain and share information.

Voice Mail and Texting Computer-based messaging systems are found in all healthcare settings today so that staff and others can leave and receive voice and text messages; for example, staff and patients can use these systems, often reducing the need for callbacks. Complicated systems may annoy consumers, however, and there is an impersonal quality to this form of communication, though it is part of everyday life today. One has to be very careful about leaving voice mails and even text messages. Clearly, others may listen to or view messages, and this may lead to a HIPAA violation.

Telephone for Advice and Other Services Mostly, insurers use patient advice systems, although some HCOs and providers provide these services as well. In such systems, staff determine the caller’s problem or questions and provide advice. Typically, insurers develop standard protocols or clinical pathways that the nurses use to respond to common questions, but nurses must still use professional judgment when providing advice. This type of service should not become “cookbook” care in which there is no consideration of assessment and individual patient needs. Assessment is the key to successful telephone nursing because it enables providers to identify the caller’s problems and interventions required that may or may not be found in the guidelines. Some physician offices have telephone advice services that are manned by a physician in the practice or by a nurse. Pediatric practices are the most common type of practice using this system. Patient advice systems via telephone require clear documentation policies and guidelines that include content related to who called, when, and for what reason; the required assessment data; problem(s); and recommended interventions—as well as any follow-up taken, such as a return call by the service to check on the patient. Telephone advice systems are typically used to answer questions, remind patients of appointments or follow-up needs, and check in on how a patient is doing. Many hospitals now use the telephone to begin the admission process for patients with scheduled admissions, procedures, and testing. Patients are called before the scheduled date, asked questions related to required information, and told what to expect and any required preparation. Pretesting may also be scheduled prior to hospital admission. This saves the hospital time, is more cost effective, and may be more convenient for the patient. This method can also identify problems that may affect patient care so that they can be addressed early on.

Internet or Virtual Appointments The Internet may be used as a means for increasing accessibility to physicians, advanced practice registered nurses, or other healthcare professionals or for making appointments. The Internet is used today to

obtain advice from health professionals. Portable family histories can be maintained in this fashion and passed on to a new primary care provider. Patients and families who have limited resources—financial, transportation, or insurance—can more easily receive medical advice in this format if they have Internet access. It also keeps some patients from missing work or taking a child or other family member to an appointment. Some virtual methods allow the patient and the healthcare provider to see each other, which may provide more effective communication between the patient and provider. Many of these sites link to cellular devices to send an alert of high importance to whoever is on call for virtual hours. These types of services have increased, providing quick connection with health professionals to get answers to questions, provide patient monitoring data, and/or make decisions about next steps such as an appointment or to go in for emergency services. Mental health services may also be provided in this format.

Online Support Groups for Patients and Families Online support groups can focus on any problem or disease. Patients and their families may use chat rooms, email, and websites for information sharing. Consumers gain information, education about their health and health needs, and support from others with similar problems. A healthcare provider may or may not be involved. Privacy issues must be discussed with participants, along with the risk of lack of privacy. Blogging has also become very popular and can be done by anyone with some basic technology information. This can make information from consumers more available to other consumers; however, as is true with any information available on the Internet, the accuracy of that information is important. Blogging can lend support and let consumers know they are not alone with their problems. Many of these methods use the Internet. It can be an excellent source for all types of information, including health and medical information. When the Internet is used as a source of health information, it is important to evaluate the websites because they are not all of the same quality. A nurse needs to consider the following factors when evaluating a website: The source or sponsor of the website: The government, academic

institutions, healthcare professional organizations, and HCOs sponsor the most reliable websites. Current status of the information: When was it posted or revised? Accessibility of the information on the site: Can one find what one needs? References provided for content when appropriate: Sources should be cited, and data should be current. As is true with all methods such as the ones discussed in this section, patient confidentiality must be maintained. Notably, the risk of confidentiality problems increases with use of technology. There are many ways that privacy can be violated, such as viewing data, overhearing conversations, and obtaining actual documents. It is the responsibility of healthcare providers, HCOs, insurers, and consumers (patients, families) to consider privacy a critical issue whenever technology is used and to ensure as much as possible that information is safe—available only to those who need the information and for whom the patient wants the information shared.

STOP AND CONSIDER #8 During a single shift, a nurse will interact with and use multiple types and methods of informatics.

The Future of Health Informatics and Medical Technology The future will continue to bring about expansion in the use of technology, informatics, and medical devices. This expansion is already in process. Cutting-edge technology is sometimes hard to believe, and some of these changes are discussed here.

Nanotechnology Nanotechnology—microscopic technology on the order of one billionth of a meter—will likely affect the diagnosis and treatment of many diseases and conditions (Gordon, Lutz, Boninger, & Cooper, 2007). Some of the pending technologies are highlighted here: Sensing patients’ internal drug levels with miniature medical diagnostic tools that circulate in the bloodstreams Chemotherapy delivered directly to a tumor site, reducing systemic side effects New monitoring devices for the home: a talking pill bottle that lets patients push a button to hear prescription information, bathroom counters that announce whether it is safe to mix two medications, a shower with built-in scales to calculate body mass index, measuring devices in the bathroom to track urine frequency and output and upload these data to a system or care manager, noninvasive blood glucose monitors to eliminate sticks, and sensors to compute blood sugar levels using a multi-wavelength reflective dispersion photometer

Wearable Computing A computer can be worn, much as eyeglasses or clothing is worn, and interactions with the user are based on the context of the situation (ANA, 2008). Wearable fitness tools are now popular. With heads-up displays, embedded sensors in fabrics, unobtrusive input devices, personal wireless local area networks, and a host of other context sensing and

communication tools, wearable computers can act as intelligent assistants or data collection and analysis devices. Many of these devices are available now using smart fabrics. Such wearable computer and remote monitoring systems may depend on the user’s activity so that the technology becomes transparent. Sensors and devices can gather data during the patient’s daily routine, providing healthcare providers or researchers with periodic or continuous data on the person’s health while he or she is at work, at school, exercising, or sleeping, rather than the current snapshot captured during a typical hospital or clinic visit. A few applications for wearable computing devices include sudden infant death syndrome monitoring for infants, ambulatory cardiac and respiratory monitoring, monitoring of ventilation during exercise, monitoring the activity level of poststroke patients, monitoring patterns of breathing in asthma, assessment of stress in individuals, arrhythmia detection and control of selected cardiac conditions, and daily activity monitors (Ootex Specialty Narrow Fabrics, 2017).

Telehealth and Remote Telemetry Monitoring Remote telemetry monitoring technology informs staff when a patient’s condition has changed. The patient is placed on a monitor, and signals are sent to staff through a page system, which today may not even be within an HCO but, rather, an external alert to a healthcare provider. Staff may be informed, for example, of the patient’s identity, heart rate, and readout of rhythm without being right next to the patient; status of labor contractions; and other monitoring needs. Telehealth, or telemedicine, is the use of telecommunications equipment and communication networks for transferring healthcare information between participants at different locations, applying telecommunication and computer technologies to the broad spectrum of public health and medicine. This technology offers opportunities to provide care when face-to-face interaction is impossible (such as in home care, school-based care, and rural areas) and can be used in a variety of settings and situations as long as the equipment is available. Two-way interactive video is the most effective telehealth method. Telenursing refers to the use of telecommunications technology used to provide nursing care. This may be done with audio and/or visual—it is a virtual

method of care. Issues that arise with telehealth include the cost of equipment and its use; training for staff and for patients if they need to actively use the equipment; limited or no insurance coverage for telehealth services; the need for clear policies, procedures, and protocols; privacy and confidentiality of information; and regulatory issues (for example, a nurse who is located and licensed in one state providing telenursing for a patient in another state where the nurse is not licensed). A systematic review of 58 studies on telehealth concluded that “the most consistent benefit has been reported when telehealth is used for communication and counseling or remote monitoring in chronic conditions such as cardiovascular and respiratory disease, with improvements in outcomes such as mortality, quality of life, and reductions in hospital admissions as well as for psychotherapy as part of behavioral health” (USDHHS & Agency for Healthcare Quality and Research, 2016, pp. vi–vii). The report discusses the need for research about expanding implementation of telehealth and elimination of barriers to use areas such as consultation in maternal and child health, use for triage in urgent care, and new delivery models. Future applications will arise, and nurses need to consider how this might be used more in nursing practice. Telehealth also has implications for international health care because it provides a method for connecting expertise to patients who may need care that is not accessible in their home country—for example, during disasters.

Robotics Robots have been used for many years to deliver supplies to patient care areas, and its use has expanded. Robotics enables remote surgeries and virtual reality surgical procedures. Hand-assist devices help patients regain strength after a stroke (Science Daily, 2016). Robots may provide a remote presence to allow physicians to virtually examine patients by manipulating remote cameras (Thomas, 2015). They are also used for microscopic, minimally invasive surgical procedures. For example, the da Vinci surgical system helps surgeons perform such procedures as mitral valve repairs, hysterectomies, and prostate surgeries (Intuitive Surgical, 2017). This type of surgery has increased, decreasing some of the past

surgical risks, decreasing the need for long hospital stays, and supporting more rapid overall recovery. In the future, robots may also be used in direct patient care—for instance, to help lift obese patients.

Genetics and Genomics The use of genomics has expanded as knowledge about genetics has become more accessible. Healthy People 2020 added a goal related to this expanding area: “improve health and prevent harm through valid and useful genomic tools in clinical and public health practices” (Healthy People 2020, 2016, para. 1). Genetic data, especially once data are integrated into EMR/EHR/PHR, are expected to advance customized patient care and medications targeted to individual responses to medications—precision medicine is recognized as a critical aspect of future health care. This is leading to more precise customization of treatment and medication based on the patient’s unique DNA profile and how the patient responded to medications and other interventions in the past. This will dramatically change how patients are managed for specific diseases and conditions and will extend into the prevention of some diseases. The inherent complexity of customized patient care will demand computerized clinical decision support that reflects individual needs and health history. Predictive disease models based on patients’ DNA profiles are emerging as clinicians better understand DNA mapping. These advances have implications for a new model of care and for informatics and nursing care. Nurses’ participation in the development of genomic HIT solutions is important. Nurses are beginning to collaborate more with bioengineers and informatics experts to develop new products, participate in research using these products, and help to develop implementation and evaluation plans to use with these products. More than ever, patients will need to be partners in this development as part of patient-centered care.

Medical Devices Development of medical devices has improved medical care. Some of these devices assist with diagnosis and others with treatment, rehabilitation, and ongoing health maintenance. Nurses use medical

equipment every day, some of which is associated with informatics. The HCO is responsible for ensuring that the equipment functions effectively and responding when questions are asked about its use or repair is required. Nurses also have responsibilities for reporting problems to appropriate persons in the organization. As use of medical devices has expanded, so have adverse events associated with devices. One concern is the lack of clarity regarding reporting of medical device concerns in incident reporting, resulting in underreporting of these incidents (Polisena, Gagliardi, Urbach, Clifford, & Fiander, 2015). The U.S. Food and Drug Administration (FDA) Med-Watch adverse event reporting program focuses on reporting medical device concerns, noting examples of medical devices that should be reported when adverse events occur. The following is a list of examples (Simone, Brumbaugh, & Ricketts, 2014; USDHHS & FDA, 2017): electric beds (such as electric shock or patient entrapment), patient lifts resulting in falls, peritoneal dialysis machines (for example, increased intraperitoneal pressure), foley catheters (for example, infections, breakage), and so on. The FDA provides updated information on medical device problems on its website.

STOP AND CONSIDER #9 The nursing profession needs to be up to date with changes in technology because many will affect nursing practice.

HIPAA: Ensuring Confidentiality The HIPAA has had a major impact on healthcare delivery systems and healthcare communication. Privacy and confidentiality have long been problematic issues in health care. Because HIPAA focuses on the issue of information and confidentiality, it applies to HIT. The law also requires data security and electronic transaction standards. With the growth of information sharing, it became increasingly evident that existing means of transactions and systems were not ensuring privacy and confidentiality— key elements that had long been part of the healthcare delivery system. Privacy is the right of a person to have personal information kept private. As discussed in this text, this relates to professional ethics and also has legal implications. Privacy restrictions even apply to all family members, unless the adult patient specifically communicates that it is acceptable for family members to be given information. This cannot be assumed. HIPAA requires that only necessary information be shared among providers, including insurers. Patients may also access their medical records. Health information cannot be openly shared by healthcare providers— for example, discussing patient information in public places, calling a patient’s work or home and leaving a message that reveals information about health or health services, and so on, must not be done. Carrying documents outside an HCO with patient identifier information is prohibited; this constraint has implications for students who may take notes or have written assignments that include this information. How information is carried, such as in tablets, laptops, or smartphones, is also of concern. For example, taking pictures on smartphones in clinical settings is a privacy violation. Many institutions have implemented strict policies about taking patient photos, even if they are deidentified. As a nurse, you should make sure you know your employer’s policies on smartphone and email use in a clinical setting and follow them. Development of new technology has been moving so fast that critical prior issues have not always been addressed effectively. The 1996 law, however, requires that staff know the key elements of HIPAA and apply them. As a result, HCOs and healthcare profession schools, such as

nursing programs, are required to provide information and training about HIPAA. Patients are informed about HIPAA when they enter the health system; they are given written information and asked to sign documents to indicate that they have been informed. Ensuring that the requirements are met must be incorporated into HIT. It is easy for patients and staff to report HIPAA violations to HHS via its website. Violations are examined, and the provider may have to pay a fee for not following HIPAA regulations.

STOP AND CONSIDER #10 There is high risk of problems with privacy and confidentiality when using HIT.

High-Touch Care Versus High-Tech Care High-touch care is why most people become nurses, but nursing is much more than this today. This chapter describes the growing influence of technology on all segments of health care. This influence will not decrease but rather increase in the future. Nurses need to understand and know how to use technology that is applied to their practice areas. They need to be involved in the development of this technology when possible, and they must be involved in the implementation of the technology. But there are concerns. When we “talk” through machines, do we lose information and the personal relationship? How can this be prevented so that we are not disconnected from our patients? How can we ensure that the information we are getting is correct and complete? Are people able to communicate fully through some of these other means? It is clear that over time, the public has become increasingly comfortable with informatics, which they are using more and more in their everyday lives, but when it comes to their health care, they may want more personal communication. As nursing increasingly adopts informatics, nurses need to keep in mind the potential for isolation and the continuing need for effective patient communication throughout the care process. Nurses, also, must not forget the need for touch and faceto-face communication. When a nurse uses a computer or some type of handheld device while asking the patient questions and does not look at the patient, this does not engage the patient in the process. The future will include many more new uses of technology; change is ongoing. For example, the e-intensive care unit (eICU) is used to monitor patients from afar to improve patient outcomes (Rouse, 2017). In this example, a system is attached to four hospitals in Iowa and their ICUs. This system allows intensivists at a remote monitoring center to view patients’ vital statistics, electrocardiograms, ventilators, and X-ray and lab results. The eICU includes two-way conference video capability so that patients and staff can interact when required. This type of system has advantages—for example, experts can be located in one place and then

consult with multiple locations and staff that may not have the required experts. This is particularly useful in providing expert medical care for residents in rural and remote areas. There is no reason that this type of system is limited to physician consultation because nurses use it too. For example, a nurse clinical specialist might view patient data and consult on patient care with nurses in an ICU in an external location from where the nurse specialist is located. There is potential for increased access to information and expertise. The other side of this innovation coin is the effect on the touch side of care when the provider is not actually in the room with the patient. It is not clear how this might affect care because these types of systems are very new.

STOP AND CONSIDER #11 A computer can stand in the way of relating to patients.

Nursing Leadership in Health Informatics We are currently at a critical junction for nurses and the informatics competency, with all nurses called upon to assume more leadership in the expansion of informatics in health care. This call to action corresponds to the recommendations in The Future of Nursing (IOM, 2010) report. Ongoing implementation of the Affordable Care Act of 2010 led to further changes in healthcare delivery and more dependence on informatics, and nurse informaticists should be part of the structure that develops and implements greater use of informatics (HIMSS, 2011). The report titled Health IT and Patient Safety: Building Safer Systems for Better Care (IOM, 2012) makes a strong statement that HIT is not something separated from care delivery or the providers of care. “We are at a unique time in health care. Technology—which has the potential to improve quality and safety of care as well as reduce costs—is rapidly evolving, changing the way we deliver health care. At the same time, health care reform is reshaping the health care landscape” (IOM, 2012, p. ix). This report highlights patient and family concerns about safety and shared responsibility. These same themes have also been emphasized throughout this text.

STOP AND CONSIDER #12 With the expansion of health informatics in all sectors of health care, nurses need to be leaders by participating in this expansion and providing feedback.

Discussion Questions 1. Explain how the core competency “utilize informatics” relates to the other four core competencies. 2. What is informatics? Why is it important in health care and nursing? 3. Describe the certification requirements for the role of the informatics nurse. 4. Describe four examples of healthcare informatics and implications for advanced practice nurses. 5. Why is documentation important? 6. Explain how the EMR and PHR can increase the quality of care and decrease errors. Provide examples. 7. Discuss issues related to confidentiality and informatics.

Critical Thinking Activities 1. Divide into teams. Identify an HCO (hospital or other type) in your local community and try to find out how it uses informatics and applies meaningful use. You can focus on the entire organization or select a department or a unit. Are there any future plans to increase the use of informatics? Teams should then compare and contrast their information. 2. In a team, develop six questions to ask a nurse who works in a hospital that uses an EMR. Each student on the team then interviews one registered nurse. After the interviews, combine your data and analyze the results. 3. Speak to a registered nurse who works in staff development/education in an HCO. Discuss the training that staff members receive for using informatics (for example, type of content, cost and time commitment, challenges). Share this information with classmates. 4. If you have used an EMR in clinical practice, what was it like for you? Did you get sufficient orientation? If not, what was missing? If you have not yet done this, interview a senior student and ask about the experience. 5. Which biomedical equipment have you used or seen used? How does the use of this equipment affect care?

ELECTRONIC REFLECTION JOURNAL

What is your opinion of the potential conflict between high-touch care and high-tech care? Describe some examples where you thought technology interfered with patient care, either for you or for something you observed. What could have been done to prevent this?

© Galyna Andrushko/Shutterstock

CASE STUDY 17-1 A 6-year-old has come to the attention of the child welfare department as a possible victim of sexual abuse. The child’s school nurse reported the situation as required by law. The child lives in a very rural part of a western state. Rather than have the child travel a distance to experts, she was taken to the nearest clinic with sexual assault nurse examiners and a knowledgeable pediatrician skilled in sexual abuse examinations. At the time of the examination, pictures were taken of the child’s body, including the genital area. These pictures were crucial if charges were to be filed. To ensure that an accurate diagnosis was made, local experts sought a second opinion because the results of the physical examination were not believed to be completely definitive. The experts for the second opinion were linked via the Internet and Internet videoconferencing equipment so that the two teams could talk and view deidentified (because the information was going across unsecure Internet channels) photos. Within 15 minutes, it was determined that the hymen was intact and no penetration had occurred. Other markers indicated that there was evidence of child abuse, but none that supported a claim of sexual assault. This case used an EMR, digitized photos, school records, and Internet consultation to arrive at a diagnosis that had both medical and legal implications.

Discussion Questions 1. Discuss the impact of the use of these methods in the case on the nurse–patient relationship and on patient confidentiality, including HIPAA requirements. 2. How else might this technology be used? 3. What is your opinion of the human, caring part of the care process in relation to this case description?

CASE STUDY 17-2 The hospital where you work is assessing its EMR system, which has been in use for 1 year. You volunteered to be on the task force that is leading the review. The team meets to discuss critical issues that need to be addressed. Some of the issues are staff acceptance of the new system, errors, and information that is not easy to access in the EMR. The representative from the hospital finance team asks, “What about meaningful use?”

Discussion Questions 1. What is meaningful use? 2. Why is the team member’s question important? 3. How might meaningful use affect what the task force does?

Working Backward to Develop a Case Write a brief paragraph that describes a case related to the following questions. 1. What should we tell them about our documentation concerns? 2. Why are we discussing quality improvement when we are talking about documentation? 3. The timeline—why do we need to consider it?

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http://searchhealthit.techtarget.com/definition/Electronic-Intensive-Care-Unit-eICU Schwiran, P., & Thede, L. (2011). Informatics: The standardized nursing terminologies: A national survey of nurses’ experiences and attitudes. Online Journal of Issues in Nursing, 16(2). Retrieved from http://ojin.nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/HealthIT/Standardized-Nursing-Terminologies.html Science Daily. (2016). Robotic brace aids stroke recovery. Retrieved from https://www.sciencedaily.com/releases/2007/03/070321105223.htm Simone, L., Brumbaugh, J., & Ricketts, C. (2014). Medical devices, the FDA, and the home healthcare clinician. Home Healthcare Nurse, 32(7), 402–408. Sitterding, M. (2015). An overview of information overload. In M. Sitterding & M. Broome (Eds.), Information overload: Framework, tips, and tools to manage in complex healthcare environments (pp. 1–9). Silver Spring, MD: American Nurses Association. Thomas, L. (2015, November 15). What is telemedicine? Retrieved from http://www.newsmedical.net/health/What-is-Telemedicine.aspx University of Iowa, Center for Nursing Classification and Effectiveness. (2017). Center for Nursing Classification and Effectiveness. Retrieved from https://nursing.uiowa.edu/center-for-nursingclassification-and-clinical-effectiveness U.S. Department of Health and Human Services & Agency for Healthcare Quality and Research. (2016). Telehealth: Mapping the evidence for patient outcomes from systematic reviews. Technical Brief No. 26. AHRQ Publication No. 16-EHCO34-EF. Rockville, MD: AHRQ. U.S. Department of Health and Human Services Centers for Disease Control and Prevention, & National Institute for Occupational Safety and Health. (2016). International classification of diseases (ICD-10). Retrieved from https://wwwn.cdc.gov/eworld/Appendix/ICDCodes U.S. Department of Health and Human Services & Centers for Medicare and Medicaid Services. (2016). Electronic health record: What is meaningful use, and how does it apply to the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs? Retrieved from https://www.cms.gov/Regulations-andGuidance/Legislation/EHRIncentivePrograms/Downloads/FAQs_2016.pdf U.S. Department of Health and Human Services & Food and Drug Administration. (2017). Medical device reporting. Retrieved from https://www.fda.gov/medicaldevices/safety/reportaproblem/default.htm U.S. Department of Health and Human Services & HealthIT.gov. (2015). What are electronic health records (EHRs)? Retrieved from https://www.healthit.gov/topic/health-it-and-healthinformation-exchange-basics/what-are-electronic-health-records-ehrs U.S. Health and Human Services & HealthIT.gov. (2019). Meaningful use definition and objectives. Retrieved from http://www.healthit.gov/providers-professionals/meaningful-usedefinition-objectives U.S. Department of Health and Human Services, Office of the National Coordinator for Health Information Technology. (2013). Health information technology. Patient safety action & surveillance plan. Retrieved from https://healthit.gov/sites/default/files/safetyplanhhspubliccomment.pdf U.S. Department of Health and Human Services, Office of the National Coordinator for Health Information Technology. (2015a). Connecting health and care for the nation: A shared nationwide interoperability roadmap, draft version 1.0. Retrieved from https://www.healthit.gov/policy-researchers-implementers/interoperability U.S. Department of Health and Human Services, Office of the National Coordinator for Health Information Technology. (2015b). Federal health IT strategic plan: 2015-2020. Retrieved from https://www.healthit.gov/sites/default/files/9-5-federalhealthitstratplanfinal_0.pdf U.S. Department of Health and Human Services, Office of the National Coordinator for Health

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PART 4 Theoretical Foundations, Research, and Evidence-Based Practice

T

he chapters included in Part 4 are not intended to be a summary of major nursing theories or research methods but rather provide a foundation for understanding, critiquing, evaluating, and using theory, research, and best evidence for advanced practice. Theory can provide a framework that encompasses what nurses know, do, and think, and it can guide the advanced practice nurse to know what to ask, what to observe, what to focus on, and what to think about (Chinn & Kramer, 2011). The terminology and definitions surrounding theory can be confusing for the novice advanced practice nurse to fully understand. Further, scholars of nursing theory do not always agree on the definitions, leading to a lack of clarity in this field of study. As way of introduction to Part 4, the generally agreed-upon definitions of terms that provide the foundation for the chapters in this part are presented here. What is theory? As with many concepts, a variety of definitions for this term have been proposed, which typically share a common set of characteristics. For our purposes, theories are organized systems that describe, explain, predict, or prescribe phenomenon. They are composed of concepts (constructs or variables) and propositions (hypotheses) that specify the relationships among the concepts. Further theories are substantiated by and derived from established evidence and can be repeatedly confirmed by observation and testing. Four types of theories are derived from the preceding definition: 1. Descriptive theories describe concepts of a discipline. 2. Explanatory theories explain how the concepts relate to one another.

3. Predictive theories predict the relationships between the concepts of a phenomenon and predict under which conditions it will occur. 4. Prescriptive theories prescribe interventions and the consequences of interventions. Additionally, four levels of theory can be placed on a continuum ranging from very abstract and broad (metatheory) to very specific and narrow (practice theories): 1. Metatheory is the most abstract and cannot be easily tested. There are no theories labeled as such in nursing. The most commonly cited examples of metatheory are the big bang and evolution. 2. Grand theories define broad perspectives for nursing practice and are less abstract than metatheory is. As such they can be tested. Some of the more well-known nursing theories classified as grand theory are those proposed by Nightingale, Parse, Leininger, Benner, and Henderson. There are many more, however, and a search of the Internet can lead to a long list of nursing grand theories. 3. Middle-range (midrange) theories are moderately abstract and have a limited number of concepts. They can be tested directly. Midrange theories can predict and prescribe nursing interventions and patient outcomes. Many new midrange nursing theories have been proposed over the last 2 decades. They are often used for both nursing research and practice. Some examples include theories of uncertainty, comfort, pain, social support, and quality of life. A search of the Internet can reveal many nursing middlerange theories useful to the advanced practice nurse. 4. Practice theory traces the outline for practice. Objectives are set and actions are set to meet the objectives. Another important fundamental understanding of nursing theory is needed before reading the chapters in Part 4. In 1984, Fawcett presented a seminal paper on the metaparadigms of nursing. It is now widely accepted, but not universally, that the metaparadigms for nursing theory are fourfold: Nursing

Health Person Environment Theory, practice, research, and evidence based practice (EBP) are intimately intertwined. Theory informs practice, just as practice informs theory. Research is used to test the theory but at the same time can be used to develop and refine theory. As nursing goes forward as a discipline, and as consumers and policy makers demand effective, costconscious, evidence-based information, we must understand theory and research and use theories to guide practice, while simultaneously analyzing and critiquing our practice to generate new theories that can be tested by research. In Chapter 18, the first chapter in Part 4, Rodgers discusses the historical development of nursing as a science and professional discipline and provides an overview of the major principles of epistemology that have influenced the development of theory and nursing science. She also considers emerging trends in nursing knowledge development as it relates to the future of nursing. In Chapter 19, Sultz and Young provide a historical overview of nursing research and highlight the role the Agency for Health Care Policy and Research (AHCPR) has played in the development of clinical practice guidelines. Future trends related to nursing research, including population research, evidence-based practice, and outcomes research, are reviewed. Current opportunities and goals of the National Institute of Nursing Research (NINR) are outlined, with a focus on health promotion, chronic disease management, and reproductive health. It is essential for advanced practice nurses to have a solid foundation in the utilization of EBP guidelines to incorporate research findings into clinical decision making. In Chapter 20, Milner discusses the historical roots of evidence-based practice and explores evidence-based practice models and clinical appraisal tools applicable to advanced practice nursing. The author gives a broad overview of the five elements necessary in the EBP process: (1) formulating an appropriate question, (2) performing an efficient literature search, (3) critically appraising the best available evidence, (4) applying the best evidence to clinical practice, and (5) assessing outcomes of

care. A template for implementation of an evidence-based practice project is provided for application to real-life clinical scenarios. In Chapter 21, Tymkow eloquently compares and contrasts clinical scholarship and EBP and the role of the doctor of nursing practice (DNP) to this end. The American Association of Colleges of Nursing (AACN) DNP Essentials document further defines the skills, tools, and methods necessary to implement and support clinical scholarship and EBP as the following: (1) translating research in practice, (2) quality improvement and patient-centered care, (3) evaluation of practice, (4) research methods and technology, (5) participation in collaborative research, and (6) disseminating findings from evidence based practice. In the final chapter of Part 4, Johnston Taylor provides the advanced practice nurse scholar with the essentials of writing for publication. In order to distinguish our profession the advanced practice nurse must disseminate evidence, share initiatives and innovations, and provide new clinical information to keep healthcare professionals up to date. Communicating the findings of research studies, evidence-based practice, and quality improvement projects will help establish the science base of the profession. On a final note theAACN recommends separate coursework in research, and an informal survey of DNP and master of science in nursing curricula demonstrates that most often research or evidencebased practice courses are done in separate courses in advanced nurse practice programs. Thus it is not the intention of this book to explicate the research process and methods in detail but rather to put the need for health research and nursing research into a broader context so the reader can appreciate how research improves practice and informs decision making.

References Chinn, P. L., & Kramer, M. K. (2011). Integrated theory and knowledge development in nursing (8th ed.). St. Louis, MO: Mosby/Elsevier. Fawcett, J. (1984) The metaparadigm of nursing: present status and future refinements. Image Journal of Nursing Scholarship 16(3):84-9.

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CHAPTER 18 The Evolution of Nursing Science Beth L. Rodgers

CHAPTER OBJECTIVES 1. Discuss the historical development of nursing as a science and professional discipline. 2. Describe the major principles of epistemology that have influenced the development of theory and nursing science. 3. Identify emerging trends in nursing knowledge development.

Introduction In discussions of nursing, images that commonly come to mind are those of the nurse performing certain acts, such as listening to blood pressure sounds, changing a dressing for a wound, assisting someone with ambulation, giving medication, or starting an intravenous line. Undoubtedly, people who have been registered nurses for some time recall their early days in school and the tremendous anticipation of performing the first immunization or urinary catheterization, or the excitement the first time an intravenous catheter was inserted smoothly and successfully. Nurses who have been engaged in the broad professional role of the registered nurse recognize that there is a great deal more to nursing than the performance of those skills. Nonetheless, when talking about nursing, discussion often turns to a focus on what nurses do—the skills, tasks, and functions that are associated with the actions and behaviors of nurses. Much less common is an emphasis on what nurses know—the knowledge base that underlies the performance of those acts—as well as the many more things that nurses do beyond obvious physical functions. No doubt it is much easier to describe the mechanics of listening to breath sounds than it is to describe the detailed thinking that goes into formulating a holistic portrayal of an individual patient for whom those breath sounds are only a small part of his or her scenario. Nurses engage in a variety of actions that are far subtler than those involving the common skills that are directly observable. For example, they form important relationships with patients to help them achieve their health and wellness goals; they counsel, educate, guide, facilitate, assess, plan, relate, evaluate, and engage with people as individuals or in groups or communities on a variety of levels consistent with a holistic approach to health concerns and health promotion. Nurses also engage in activities such as arranging for referrals, managing various stages of care, and facilitating access to necessary resources. This list is in no way exhaustive, but it provides some indication of the tremendous number of cognitive activities associated with nursing. These actions also are done not as simple tasks but as the result of complex decision making based

on the intricate details determined through comprehensive assessment of each situation. Because these activities lack implements or other tangible equipment, the cognitive work of the nurse may be recognized less readily by the public. This lack of recognition is compounded by the fact that nurses are not typically thought of in terms of their knowledge base, unlike other professions where there is more awareness of education and knowledge. Nurses have perpetuated that lack of awareness by being less quick to describe their knowledge, possibly because of the difficulty associated with articulating the specific thought processes that are essential for effective and appropriate care. Many nurses seem to give themselves less credit than is warranted for the cognitive capabilities and knowledge that go into nursing. When asked why they reacted to a situation in a particular way or what prompted them to intervene, it is not uncommon to hear the nurse say, “I just knew,” referring to a gut feeling or intuition as the basis for significant action. These responses on the part of nurses fail to give credit to the vast amount of knowledge that nurses carry with them every day. It is not the tasks and skills that nurses perform that make them such an indispensable part of health care but rather what they “know.” The knowledge of nurses not only lies at the root of competent and effective care but also provides the foundation that makes nurses essential contributors to broader decision making and planning. When nurses argue that they should be involved in committees, on boards, or in other influential positions, and when they discuss why certain concerns or problems clearly could benefit from nursing involvement, it is the knowledge of nurses that makes these arguments so meaningful. Although nurses often find themselves in a position of needing, or at least wanting, to articulate what is unique about their particular level of preparation, discussion of the knowledge base of nursing can be a challenging undertaking. It is much easier to describe what nurses do than what they know.

The Impact of the Doctor of Nursing Practice Degree As nurses have achieved higher levels of education (particularly doctoral degrees), the need to understand the knowledge base of the discipline has become even more imperative. Nurses with doctoral-level education are likely to be perceived as leaders both in the discipline and in the broader community, and they should be prepared and willing to assume roles as leaders in a number of contexts. They often are confronted with both the opportunity and the need to explain what constitutes nursing at that level. No doubt this need will persist and most likely will expand greatly as more nurses with doctor of nursing practice (DNP) degrees work within a variety of settings. The DNP is an advanced degree, which surely will grab the interest of the public, whose familiarity with nursing is most likely limited to personal experience with hospital or clinic nurses (i.e., nurses who have completed shorter programs leading to the ability to obtain a license as a registered nurse). In addition, it is a relatively new degree that carries with it credentials and titles that are not known to the broader public and that are perhaps also not well understood within nursing. At the same time, nurses with the DNP degree are in an important position to serve as leaders in the continuing articulation of the discipline as well as contributors on multiple levels to the development of the knowledge base for nursing. All these factors create a tremendous need for nurses at all levels of preparation to articulate with clarity the nature of nursing knowledge and what nurses are capable of contributing to health in all realms— individual, family, local, community, and global. DNP-prepared nurses have particular responsibility to assume leadership roles to represent the discipline and profession of nursing well and to identify and discuss the particular expertise and advanced knowledge of the DNP-prepared nurse. In addition, nurses with the DNP degree often are in important positions to collaborate with researchers and to identify both needs for research and innovations that add to the knowledge base of nursing as it continues to develop as a discipline. Similarly, they have a key role in

implementing new knowledge for the improvement of healthcare access and delivery. All these responsibilities point to the importance of the DNPprepared nurse’s understanding the nature of nursing and the knowledge base of the discipline.

Science and Knowledge Without an understanding of the overall discipline, including the knowledge that underlies the thoughts and actions of the nurse, both practice and research can become isolated, individualistic, situational endeavors. Science is the general term used to refer to the knowledge base of a discipline that has been developed rigorously and systematically. The idea of “science” has an interesting history, however, and science was not always the dominant term used to refer to credible knowledge. As evidenced by the writings of Aristotle, for example, and in the work of many others continuing into the 19th century, the terms science and knowledge were used almost interchangeably for much of recorded history. It is only in modern times that science has been recognized as a rather specialized form of knowledge, replete with specific methodologies and means to evaluate credibility. In exploring the underpinnings of nursing work, especially those elements that provide nurses with valuable and trustworthy information as a foundation for practice, it is helpful to look at not just science but also the broader realm of nursing knowledge. The discipline of nursing includes components other than just the knowledge base. Disciplines also involve a human component in that judgments are made about what is acceptable science and what are current priorities. This component necessarily involves the expression of the values embodied in the discipline in regard to what is needed for knowledge development. The human component, what Toulmin (1972) referred to as the “profession,” works with and develops the knowledge base of the discipline and develops mechanisms for the sharing of ideas through debate and dialogue, both oral and in the form of publications. Organizations within the discipline provide leadership, whether through societies that have bestowed honors upon esteemed nurses, research organizations that promote the conduct of research and dissemination of results, or specialty organizations that shape practice. Those organizations also have important roles in the ongoing development of nursing as a discipline. Discussion of the science of nursing, or the knowledge base, cannot be carried out without recognition of the context

that exists for that knowledge in the discipline. In addition, this nursing context exists within a larger societal context that includes expectations for nurses as well as standards for what is considered to be knowledge or science, and especially “good” science. It is easy to identify examples of how knowledge has changed, sometimes rapidly, and just as often in radical ways. Recent discoveries related to genetics are stimulating revolutionary developments in treatment as well as renewed efforts at prevention as that genetic knowledge evolves. Dietary guidelines are evolving as awareness develops that blood lipid profiles are not inextricably linked to dietary intake of fats, with new information being in substantial opposition to prevailing ideology about nutrition and illness. Awareness of the effect of environmental conditions and artificial substances on health and the development of health problems has raised questions in areas that were not given much consideration in the prior germ theory–oriented approach to medicine, questions ranging from food production to vaccination guidelines. In such a context of ever-changing science, often accompanied by competing values and priorities, significant challenges are presented for nurses who not only provide “best practice” in their realm of work, but who also must defend those practices in the face of changing knowledge. It is clear that context has considerable influence on the discipline of nursing and the development of the corresponding knowledge base. Because of that influence, it is reasonable to look at the evolution of nursing knowledge using a chronological approach; in fact, many aspects of context are associated with historical events and timing. One limitation associated with such a chronology is that it gives the impression that change is linear. That would be quite a naïve view, however. Science is inextricably tied to human behavior and attitudes; given that science is a human enterprise, and multiple stakeholders and influences exist, the development and change of knowledge over time is far from linear. In contrast, the movement of knowledge often involves multiple and simultaneously existing and competing areas of focus influenced by diverse philosophical systems and sets of values. Nonetheless, early ideas do provide the impetus for later ideas; societal needs and expectations at one period of time eventually lead to other sets of ideas. As such, there is continuity in the progression of

ideas, and that continuity provides a useful framework for studying the history of ideas about nursing science. It is important to keep in mind that changes in ideas and emphasis must be considered as an evolutionary process and not necessarily a progression. Progression implies movement toward some specified point or goal, such that it is possible to say that nursing knowledge or science is getting closer to whatever that goal might be. Because of the fluidity of the context of nursing, as well as the context of the greater society, that endpoint or goal must be amenable to change as well. Although the evaluation of progress in regard to knowledge is a difficult task, nurses can say with certainty and, perhaps, with pride that there have been incredible improvements in educational preparation, in leadership and organization within the discipline, and in the ability to address the changing needs of the people who are the beneficiaries of nursing care. This element of continuity also needs to be examined from the standpoint of ideas about nursing. Nursing, in various forms, has existed, depending on how it is defined, since the beginning of time. Nursing also exists in a global context despite the variation that might exist from one setting to the next, even within general geographic regions. It is tempting sometimes to avoid defining nursing, or making clear statements about what nursing “is” because of this variation. However, there are some things that enable all these disparate situations to be thought of as nursing. Despite all the differences, there are some things that hold nursing together as a distinct type of knowledge and work; some essence persists across time and contexts and makes it proper to call these things nursing. Leaders and scholars in nursing have the obligation to be able to discuss nursing with others who may have different perceptions of nursing and be able to articulate to others the nature of nursing and the incredible contributions to human health that can be made by those who are registered nurses.

Nursing as a Discipline Despite the tremendous contributions of nurses to meeting the healthcare needs of individuals, groups, and populations, and despite the pervasiveness of nursing throughout much of history, it can be difficult to delineate clearly what constitutes nursing as a discipline. Problems articulating the nature of the knowledge base of nursing can give the impression that there is not a specific, unique substance of knowledge or science that underlies the practice of nurses. Such claims might seem absurd to any nurse who has been carrying out acts of nursing for an entire career. Although it should be self-evident that nurses cannot act without some base of knowledge—otherwise, their actions would be totally without reason—significant challenges have arisen as they have tried to articulate precisely what constitutes that knowledge base. This desire to define the knowledge base of nursing has been enhanced by some authors who have argued that it is essential for nursing’s continued viability to distinguish its knowledge base from that of other disciplines (Feldman, 1981; Smith & McCarthy, 2010; Visintainer, 1986). Although such concerns are not voiced in nursing as frequently today as they were a few decades ago, lingering questions persist about precisely what constitutes nursing and what reflects or represents some other field of knowledge or inquiry. To respond to these concerns, unique languages have been created in the form of nursing diagnoses and other taxonomies, and research has been conducted rather extensively on intuition and clinical decision making in nursing. Nurses have focused on aesthetics, empathy, and “caring” as a way to capture what some consider to be the unique essence of nursing knowledge. These and more themes evident in the evolution of nursing science reflect the ongoing quest by nurse scholars to answer questions about the nature of nursing and, especially, the knowledge base or science that constitutes the discipline.

The Education of Nurses As noted previously, concern has been expressed in nursing literature, especially during the period of the late 1960s through the late 1980s, about the apparent lack of a unique knowledge base for the discipline. At other times, critics noted a failure to articulate what makes up that unique knowledge. No doubt the history of the development of nursing supports concerns about the existence of a distinct, unique knowledge base in the discipline. Education for nurses has been referred to historically as training, a term that was particularly relevant during the apprentice-type model of early nursing preparation. Despite Florence Nightingale’s revolutionizing the preparation of nurses for her day, even well into the 20th century a substantial portion of the preparation of nurses occurred through on-the-job apprenticeships. Nurses educated as recently as the 1970s (and sometimes even more recently) may still refer to their preparation as training rather than as education. Although these semantics might seem like a minor point, terminology can be quite powerful in its ability to convey unintended messages as well as those desired by the speaker or writer. The term education carries a different connotation than the term training; the latter is focused on the ability to perform certain actions, not on the knowledge and understanding that precede reasoned action. In addition to this distinction, the emphasis in early nursing training was placed on selecting the best candidates to be nurses on the basis of personal characteristics that were presumed to be appropriate; the focus was not on the intellectual capacity or aptitude for gaining the knowledge needed to be an effective nurse. A review of conditions for nurse preparation in the early days of the discipline clearly reveals that fortitude and persistence were valued as characteristics essential to successful completion of these preparatory programs. At the same time, rules for nurses mandated subservient behaviors rather than critical thinking. At the time that nurses began to receive formal education through actual involvement in classroom work and didactic presentations, much of the content of nursing programs was taught by physicians. Programs were associated with hospitals rather than colleges and universities, and

the learning of the skills associated with nursing continued to occur primarily by actually doing the work of the nurse. Nursing was not associated closely with academic settings until 1909, when Richard Olding Beard successfully integrated the nursing program into the formal academic structure of the University of Minnesota. This program led to a 3-year diploma and was subsumed under the medical school, yet it was the first instance of nursing education as an official part of a university structure. Yale School of Nursing, which opened in 1924, was the first autonomous school of nursing with its own dean and budget (Kalisch & Kalisch, 1995). Education at the graduate level developed slowly within the context of academic settings. Master’s degrees were available in the early 1930s, yet by 1962 data revealed only 2,472 students pursued the master’s degree in nursing; for the period 1961–1962, only 1,098 graduates were enrolled in master’s degree programs (U.S. Public Health Service, 1963). Opportunities for doctoral-level education were severely limited in nursing, and nurses who wanted such preparation typically pursued their degrees in the discipline of education rather than nursing per se. The first programs that enabled nurses to pursue doctoral degrees were established in schools of education at Teacher’s College, Columbia University, and at New York University, both developed in the 1920s and 1930s. As nursing evolved as a discipline, recognition of the need for nurses with doctoral-level preparation as researchers grew, yet there was almost no opportunity to obtain such education within the discipline of nursing. In 1962, the U.S. Public Health Service began the Nurse Scientist Program to support advanced education to prepare nurses as researchers. Because of the absence of doctoral programs in the discipline of nursing, nurses who pursued their education as a part of this program had no choice but to receive their education in other fields. As a result, they typically were socialized into those other disciplines, bringing the perspective of physiologists, sociologists, and educators to bear on their ideas about nursing. Nurses with doctoral preparation in nursing and increased nursing research activity are fairly recent developments. The first doctoral nursing program was established at the University of Pittsburgh in 1954 and was limited to maternal–child health, with a doctor of nursing science (DNS)

program being established at Boston University 6 years later in 1960 (Kalisch & Kalisch, 1995). Because many universities did not support doctoral-level preparation in nursing, doctoral programs often had to offer a distinct degree, typically the DNS or DNSc. Journals devoted to nursing research did not emerge until the 1950s, with an additional surge of activity in this area occurring in the 1970s. It is only within the last 30 years or so that a preponderance of people teaching in programs that lead to a doctoral degree in nursing also have had their own doctorallevel preparation in nursing. Awareness of this historical development in nursing helps to explain the nature of research that has been done and, similarly, the development of the discipline over the last several decades. It is only within the last 2 or 3 decades that the individuals conducting research within the field of nursing were likely to have been educated with degrees in nursing and socialized primarily as researchers and scholars in nursing. As a result, there has been an increase in research conducted by nurse investigators with a viewpoint that has been derived from and has reflected a nursing perspective toward the problems addressed by the research. This brief glimpse into a significant aspect of the history of nursing education makes it easy to see why concerns about borrowed knowledge have had a prominent role in the evolution of nursing as a discipline. This lack of clarity in regard to a unique knowledge base for nursing was compounded by prevailing ideas about the nature of disciplines. Prominent nurse scholars in the 1960s through the late 1970s brought to nursing ideas from education about the nature and structure of disciplines.

Delineating the Discipline Underlying all this historical activity was a variety of theoretical thinking about knowledge in nursing, including nursing as a discipline, the role of theory in nursing, mechanisms for theory development, and, in more recent years, a broad interest in nursing science and its development. In the early stages, attention was focused on the delineation and development of nursing as a discipline, motivated to some extent by the need to demonstrate the unique aspects of nursing. Early efforts were focused particularly on knowledge development consistent with prevailing ideas about the way disciplines were structured. This focus on structure likely was a result of, at least in part, close connections between nursing and the discipline of education, and the structure of disciplines was an area of considerable theoretical interest and emphasis in education, particularly in the 1960s. The premise in the literature that promoted this focus in nursing was that the determination of the nature of nursing as a discipline, including its structure and boundaries, would provide direction for continuing development. Donaldson and Crowley (1978) pointed out the need for work on the discipline of nursing, indicating that such investigation would determine “the essence of nursing research and of the common elements and threads that give coherence to an identifiable body of knowledge” (p. 113). Invoking ideas about borrowed versus unique knowledge, Donaldson and Crowley (1978) argued that much of the basis for nursing was “tacit rather than explicit” (p. 113), and they emphasized the need to ensure that nursing research was actually research in the discipline of nursing and not merely research that was conducted by nurses. Donaldson and Crowley described a discipline as “characterized by a unique perspective, a distinct way of viewing all phenomena, which ultimately defines the limits and nature of its inquiry” (p. 113). Developing nursing knowledge consistent with this idea of disciplinary structure would make it possible to demonstrate what knowledge was unique to nursing in contrast to knowledge that might be considered borrowed. Donaldson and Crowley’s work was seen as providing some important direction for continuing knowledge to develop what ultimately could be seen as a distinct

discipline of nursing. As part of their work, Donaldson and Crowley (1978) used an approach to disciplines based on the writings of Schwab (1962) to provide guidance for development of the discipline. Schwab and others who worked in the area of disciplinary structure (Shermis, 1962) argued that disciplines comprised two components: a substantive structure and a syntax. The content of the discipline constitutes the substantive structure; it includes concepts, theories, and other knowledge, principles, and ideas that make up the knowledge base of the discipline of nursing. Research to develop the discipline, therefore, should focus on content according to this idea of the disciplinary structure. The syntax includes the methods used in inquiry as well as means to evaluate the value, credibility, or usefulness of inquiry done in the discipline. A general perspective, or worldview, provides the context for the substantive structure and the syntax to be brought together as characteristic of the particular discipline. Overall, these authors argued for the importance of delineating a distinct discipline of nursing, ensuring that the substance of the discipline served as a guide for practice and establishing clear connections between research, the development of the discipline, and nursing practice. It is worth noting that the approach to disciplinary structure that was advocated in nursing was that of the natural sciences. Although this strategy may seem appropriate, it is important to consider how nursing might have developed differently if an idea relative to social sciences or humanities had been employed. This placement of nursing within the ranks of natural sciences became evident again when the philosophy of science known as logical positivism began to influence nursing knowledge development beginning in the 1970s, such that greater use of references in the area of natural, rather than social, sciences (although such works existed within the philosophy of science) continues to be found throughout the nursing literature.

The Idea of a “Professional” Discipline The focus on disciplines occupied the nursing knowledge literature for some time, providing a framework for discussion of the uniqueness of nursing. This discussion encompassed topics such as the differences between basic and applied sciences, with nursing being held out as distinct from the basic sciences through its focus on application (Donaldson & Crowley, 1978; Johnson, 1959). The notion of applied science as a key aspect of nursing was captured sometimes through the references to nursing as a professional discipline. Professional or practice disciplines were thought to have specific characteristics that set them apart from those without a clear practice component. Thus professional disciplines, such as nursing, were viewed as different from the academic disciplines. A unique characteristic of the professional discipline is the delivery of service of some sort by those engaging in practice. It is easy to argue that all disciplines have individuals who carry out the work of the discipline, who teach its substance, and who contribute to its ongoing development. Anyone who applies the knowledge of a discipline is engaging in practice related to that knowledge. The mere existence of people who engage in practice is not sufficient to differentiate a field from other disciplines whose members lack such a component. Nurses have used the argument that nursing is a “practice discipline” or a “professional discipline” to delineate nursing from other disciplines and to rationalize certain constraints or other challenges that set nursing apart from more traditional disciplines. However, describing nursing as a practice discipline is misleading because all disciplines have individuals who apply the knowledge. Without such application, there would be no opportunity for testing, studying, enhancing, refining, or sharing the knowledge of the particular discipline. What is important in regard to nursing, however, is that there are social constraints, licensing requirements, and means of public oversight that create a special context for nursing. These aspects are critical to the development of nursing and

do require important considerations about the process of knowledge development. These characteristics also translate into specific needs for the nursing knowledge base (Dickoff, James, & Wiedenbach, 1968a, 1968b). Merely referring to nursing as a practice discipline may not draw sufficient attention to these aspects that affect its development. Despite these social and legal constraints, however, it may not be beneficial to the development of nursing to emphasize these differences. It is not selfevident that nursing as a discipline is sufficiently distinct from other disciplines in its organization and development, and a focus on similarities may bring greater progress to understanding and valuing nursing than a continuing emphasis on differences. Indeed, failure to recognize the academic basis for nursing practice and the need for ongoing knowledge development may have contributed to the slow acceptance of nursing and valuing of nursing knowledge within university and healthcare settings. The idea of a discipline having a unique substance, as advanced by scholars in nursing during the 1970s and 1980s, contributed to concerns mentioned previously about whether knowledge can be borrowed. This idea of borrowing knowledge from one discipline to the next does not hold up to further scrutiny. First, for something to be borrowed, it must belong to someone, yet it is not reasonable to think of knowledge as the possession of any one person or group of people. Researchers in the field of psychology may have created much of what is known about stress or behavior change, for example, yet it is clear that there are important connections to physiology, medicine, nursing, and sociology, in addition to other disciplines. Similarly, the members of other disciplines use, expand, critique, revise, and refine what is known on an ongoing basis, often with minimal regard for the origin of the knowledge. There is some legitimate reason to be concerned about the perspectives that are represented in existing knowledge. To that end, nursing’s holistic viewpoint and focus on relationships and contexts could be overlooked if nurses are not involved in the generation of that knowledge. Looked at another way, knowledge developed within other disciplines could fail to address the problems that nurses confront and that are important to their work with their populations of interest. Borrowing and the viability of the discipline of nursing are not the concerns here; rather, there is a legitimate concern that knowledge be

generated that addresses the epistemic (knowledge-oriented) needs of nurses. The idea of borrowed versus unique knowledge may not have much utility or support at this time, yet the need to pay attention to the knowledge base of nursing still has considerable merit. Nurses need to have an understanding of their discipline, particularly nurses who are in positions to help shape that knowledge. Nurses with DNP-level preparation will be in roles that enable them to have a significant influence over which knowledge development activities are pursued, and they should be engaged as members of research teams to ensure that the knowledge generated addresses areas of need. Because of the advanced practice focus of DNP education, DNP-prepared nurses are especially likely to have meaningful interaction with the public—the recipients of care—and, therefore, are in important positions to influence public perceptions of nursing. Understanding the current status of the discipline, and particularly the evolution of nursing to the present day, helps to create an understanding of the discipline that can be shared with others, can guide continuing research, and can shape the individual nurse’s own perception of the role of nursing and the area of practice. The earlier brief mention of nursing history points to the continuing emergence of nursing as a discipline with a body of what can be called nursing knowledge. Although there are occasional references to nursing as being in an early stage of development, particularly in reference to other disciplines, such a characterization does not do justice to the long history that exists, especially in connection with religious orders or the military, of people providing essential health services to those in need. Human beings have always needed individuals to whom they could turn for support with health and illness situations, whether that support has taken the form of the recommended cures of the day or more long-term care. To the extent that certain humans were identified as being particularly adept at providing such care, nursing has existed. As early as the time of the Crusades (the 11th century CE), efforts were made to provide a means for placing the work of tending to ill individuals in the hands of those skilled at providing needed care. These early efforts served as a harbinger of nursing that would develop in a more formal sense in later centuries, making it clear that nursing care in some form has been available to people for an exceptionally long time. Although the

nursing of centuries ago bears little resemblance to the nursing of modern times, it does support the idea that the practice of nursing is not new or embryonic—a characterization occasionally used to describe nursing’s state of development. Contemporary nursing involves formal education with complex substantive content reflecting a variety of disciplines, yet integrated into an approach to health and illness situations that represents the special influence of nursing. Arriving at this point in nursing education and practice reflects centuries of ongoing development.

The Emergence of Nursing Science As emphasis increased on nursing as a discipline, there emerged a concomitant drive to develop what can be referred to as nursing science. This emphasis became the specific focus of theory development for nursing and was the primary consideration in the development of the discipline from the 1960s through the 1980s. This section and subsequent sections of this chapter describe the major traditions in epistemology that have influenced the development of theory and nursing science (see BOX 18-1).

BOX 18-1 Epistemologies in Nursing Science Development Logical positivism Historicism Postmodernism Phenomenological philosophy Hermeneutics Feminist epistemology Pragmatism and neopragmatism

A review of nursing knowledge development over the latter half of the 20th century shows the steady and profound influence of logical positivism. Logical positivism produced a lasting impact on nursing knowledge development, with one particularly strong example of its influence being extensive theory development activities demonstrated from the late 1960s into the 1990s. Nurses who received their doctorallevel education in fields other than nursing were influenced by the dominance of this ideology at the time, a factor that helped to ensure its translation to a nursing context. Logical positivism, in fact, was pervasive throughout all the sciences and has had a lasting impact on broad societal ideas about science and what constitutes appropriate or acceptable scientific activity. Logical positivism no longer occupies the forefront of philosophical thought about science; in fact, Webster, Jacox, and Baldwin (1981) declared it dead in the early 1980s. It is questionable,

however, whether any philosophical movement ever dies completely, and there can be no doubt that the influence of logical positivism persists and has had a major role in shaping current ideas about science. Logical positivism placed great emphasis on the demarcation of science from other forms of knowledge. Science was characterized as developing in a cumulative and linear fashion, with successive studies building on prior research. This process was oriented toward continuously refining and building theory in the quest for parsimonious statements that accurately corresponded with reality. Science, in essence, was seen as a theory-building activity, with the ideal theoretical statements being those that were capable of expression using the rules of logic and mathematics. Theory formed the core of scientific activity, and investigations represented an attempt to further develop, refine, or verify existing theory. With this emphasis on theory, it is easy to see how a discipline that lacked specific theoretical statements and clearly delineated bodies of theory might have been hindered in its efforts to gain recognition as a scientific discipline. If science was a theory-building activity, then nurse scholars suggested that there must be a theoretical foundation for nursing knowledge and practice for the discipline to be considered a science.

The Theory Movement in Nursing Nurse scholars and leaders devoted considerable effort to identifying the core or essence of nursing, to constructing theoretical formulations that would reflect this core, and to promoting further inquiry as well as theorybased nursing practice. Federal funding was provided during the 1960s to support a series of conferences on theory development. The first conference was held at Case Western Reserve University in 1968; the second was held at the University of Colorado in 1969. Papers and discussion at these conferences clearly revealed the focus on the science of nursing and the influence of the philosophy of logical positivism on such activities during this time. The theoretical activity that took place under this influence amply illustrates the impact of logical positivism and this philosophical movement in the evolution of nursing as a discipline. Early nursing theory development activities, reflected in the work of Orlando (1961), Rogers (1970), Roy (1970, 1971), and others, served as important milestones in the effort to develop a theoretical basis for nursing. Developing status as a science required not only the identification or development of theory for nursing but also the use of existing theory as a basis for research. Logical positivism, after all, required that scientific activity focus on development and further articulation of theory. Descriptive research—that is, inquiry intended to discover or document events or conditions—did not meet the criteria for science that were espoused by philosophers and the dominant thinking of the period. As a result of this emphasis, the literature of nursing during this time includes a number of articles and ongoing discussion about the necessary connection between theory, research, and practice, with Fawcett’s “double helix” metaphor being a particularly poignant example of this focus (Fawcett, 1978, 1985). Writings related to the role of theory in science reflected the tenets of logical positivism; theory development was viewed as a very formal activity with a focus on axioms and propositions in the construction of theory. Reynolds’s (1971) A Primer in Theory Construction is referenced frequently in the nursing literature of this era and shows the emphasis on the development of formal theory, the

importance of concepts being defined in operational terms to show their means of empirical testing, and a focus on quantitative testing of hypotheses derived from the theories. Research with an emphasis on describing situations or phenomena was possibly of some value but only to the extent that it provided baseline data for further theory development (Fawcett, 1978, p. 60). Science that was developed according to the tenets of logical positivism represented what is sometimes referred to as hard science, yet nurse scholars and leaders in the area of knowledge development encountered considerable difficulty with this philosophy in that a significant amount of nursing was not amenable to this conception of science. Despite the great strides that were made during this time in developing the scientific and theoretical foundations of nursing, some aspects of nursing just could not fit these specific criteria. Nursing had maintained a long history of being regarded as holistic, humanistic, and relational, with an emphasis on psychological and social aspects of health and wellness as much as physiological and biological aspects. Concepts such as dignity, empathy, presence, and caring could not be forced into the mold of logical positivism without tremendous difficulty and, as nurses readily recognized, without considerable disservice to those crucial aspects of the human condition. The lack of fit between nursing and prevailing ideas about science left nurses with some difficult choices. One option was for nurses to strive to meet the criteria of science as defined by the logical positivist philosophers. This endeavor would, however, require forcing some elements of nursing knowledge to meet the requirements of the prevailing ideology. Needless to say, this option was akin to the square peg and round hole metaphor, and it is debatable whether some of the highly valued aspects of nursing could ever be recast in this fashion without significantly changing their nature. As a second option, nurses could argue that some components of nursing fit the idea of science, maintaining the logical positivist idea of science, while acknowledging that other aspects did not fit this ideology. Those other aspects are referred to as art: The dogma of nursing as “an art and a science” (Rodgers, 1991) persists throughout the history of modern nursing thought. As a third option, nurses could accept that the knowledge base of the

discipline, in its totality, did not meet the requirements of logical positivism. Carper’s (1975, 1978) widely cited work identifying patterns of knowing in nursing addressed some of these concerns, identifying the empirical knowing that is consistent with traditional ideas of science as only one of four types of knowing inherent in nursing. Personal knowing, aesthetic knowing, and ethics were the terms used to label other forms of knowing that she argued were essential in nursing. This schema went beyond the mere separation of knowledge into science and everything else (e.g., art) and emphasized the existence of numerous ways of knowing, all of which are essential to the work of nursing.

The Importance of Evaluating Philosophical Ideology The fact that nurses largely failed to raise questions about the legitimacy of logical positivism as a useful and acceptable definition of science regardless of discipline is notable. The challenge for nurses should not have been viewed as only the determination of how to adopt and follow a particular line of activity or thought. In the case of logical positivism, nurses could have argued—as some did—that this philosophical approach just was not an acceptable or legitimate approach for nursing. In fact, there are significant problems with this philosophy regardless of discipline, even for those that seem to be a more reasonable fit with this idea of traditional science. Although logical positivism was not an appropriate view for the development of the discipline of nursing, looking only at whether this philosophy “fit” nursing (rather than evaluating its merits overall) has two strong detrimental effects. First, it sets nursing apart as different, and not necessarily in a good way, but in a way that indicates nursing cannot, or will not, conform to prevailing standards for science. Second, and particularly significant in the case of logical positivism, it fails to address the crucial question of the legitimacy of the philosophy. Without that challenge, a philosophical tradition can continue to be held as an ideal, and progress in disciplines can be evaluated relative to its major tenets regardless of whether a particular discipline accepts that view. Those who rejected logical positivism as a suitable guide for the development of nursing without assessing the philosophy’s inherent value created a situation where nursing could easily be viewed as “different,” or as a lesser science than others that appeared to follow prevailing standards. The situation that resulted from this rejection (perpetuated in the argument that nursing is an art and a science) is similar to criticisms that continue to be levied against qualitative research—that it is “soft” and fails to meet the criteria of real science. Trends and paradigm shifts are always occurring, and the critical questions asked by nurses cannot be limited to whether to follow along

as viewpoints shift. The most important questions that need to be asked by nurses in regard to the knowledge base involve two things. First, is the latest ideology sound, not just for nursing but for any discipline? Second, does it enable progress in nursing? In other words, is it an ideology that will help nurse scholars and researchers to make sound moves toward achieving the goals of the discipline? Applying such questions to logical positivism reveals quite quickly that the answer is no in regard to both aspects. Indeed, the shortcomings of logical positivism led to its demise as the dominant ideology of science by the mid-1900s. The ideal put forth by the philosophers of this genre, however, continues to influence expectations and desires in the creation of science in nursing and elsewhere, ideals that persisted long after logical positivism lost its favored status. Science continues to be seen by society at large, as well as in many of the academic disciplines, as a special or unique form of knowledge with greater credibility than other forms of knowledge. Expectations for widespread generalizability of results, for statistical significance as the measure of meaningful results, for theory development as a focus of scientific activity, and for objectivity and a value-free orientation to inquiry continue to shape both the conduct of research and the needs of the public and others who will apply the results of scientific endeavors. Webster and colleagues (1981) clearly pointed out the effects of “undue adherence to the positions and ideas of the received view” and noted how that perspective “stilted the development of nursing theories” (p. 34). Truth, as a criterion for evaluating theory, particularly in the form of correspondence with facts, presented other problems in the logical positivist viewpoint. The correspondence theory requires that phenomena be objectified—that is, measured in some way that is precise, repeatable, rigorous, and, as is evident in any research methods text, a valid measure of the phenomenon being studied. As a result, the phenomenon is believed to be captured successfully through the collection of empirical data. Although this goal of precision and high validity certainly is an admirable one, it ignores elements of phenomena that can be the source of important information but are not reducible to means of measurement. With this approach, grief, for example, could be understood only as “grief as measured by a score on the grief instrument” because that is the only

means for assigning numbers to grief to quantify and validate its existence. An individual’s description of grief, including its emotional impact, its effect on daily life, and feelings that are often expressed by people using metaphors rather than checklists or Likert scales, could not be included under the heading of scientific. It is easy to see how social or psychological phenomena are particularly troublesome to study from the perspective of logical positivism because these phenomena have strong personal—or what might be called subjective—components. Physiological phenomena, however, are not immune to these difficulties either. Consider, for example, hypertension, measured as the pressure of the blood against vessel walls, or diabetes control, measured with glucose or HgbA1c levels. Although these methods clearly are meaningful measures of these physical phenomena, they do not provide a broad or holistic perspective on how these conditions affect individuals with these diagnoses or what it is like to live with and try to maintain control of these physiological challenges. There are many challenges with the logical positivist philosophy of science. For purposes here, the significant point is to note the barriers to progress in the discipline of nursing that were confronted as a result of the rise in popularity of logical positivism and a staunch adherence to empirical ways of knowing, particularly within the context of a discipline that derives a significant amount of its identity from a holistic approach to human beings. These challenges also led to difficulties with the adoption of logical positivism in other disciplines. Despite these barriers, however, logical positivism had a profound and lasting role on shaping views of science through the 20th century and beyond. Specifically, the philosophy created expectations for science in both academic settings and society at large that continue to influence the evaluation of knowledge for its applicability and meaningfulness. Before moving on to address the changes that have arisen since the logical positivist approach became prominent, it is appropriate to reiterate some important points. Methods and philosophy are linked inextricably: The choice of method that a nurse or any scientist takes in regard to knowledge development has strong philosophical underpinnings that need to be recognized as an inherent part of the science or knowledge development enterprise. These foundations are not always obvious, yet the philosophical position taken by a researcher can be determined by

assessing the approach to inquiry that is taken. It also is possible to use similar strategies for inquiry despite different philosophical positions. When a researcher measures some phenomenon, the researcher is indicating that it is possible and appropriate to measure the phenomenon of interest. Yet one researcher using a quantitative instrument to measure a phenomenon may believe that those measurements reflect true and meaningful data, whereas another may believe that the results are meaningful, but only a piece of a complex human situation, and that the answer to the research question is just one of many possible answers. Logical positivism, for example, undoubtedly leads to a quantitative approach to science, but, conversely, not all quantitative science is necessarily based on logical positivism. From a philosophical or disciplinary standpoint, it is important to look at assumptions about the nature of reality, truth, the goals and purpose of science, and the criteria that are used for differentiating good science as reflective of the philosophical viewpoint of the researcher or scientist. Those underpinnings are reflected in the methods used, but the methods essentially are tools, and they can be used with perspectives that have some perhaps subtle—but important—variations. Failure to distinguish method from philosophical underpinnings can lead to wholesale rejection (or, conversely, blind adoption) of alternatives to knowledge development without appropriate thought being given to the choices that are being made. The responses of nurses to various trends as evidenced in the literature of nursing do not always capture this subtle yet important difference. Without that understanding, however, there is a tendency to abandon useful aspects of some approaches to knowledge development or to develop a bandwagon mentality when new trends emerge and either become popular or later are found to be insufficient to meet the needs of the discipline. As noted earlier, the logical positivist approach to knowledge had significant limitations as a focus for the development of knowledge, especially within the narrower realm of scientific knowledge. As a philosophy of science, it not only presented challenges within the philosophy itself with regard to views of the nature of reality, truth, and the proper goal of science, but it was also created as a prescriptive view —in other words, a directive dictating how science should be done. In essence, logical positivism was not comprehensive in terms of how

science actually was conducted. Prescriptive approaches can be of great value, of course; this point is clearly seen in health care where prescriptions for all sorts of things are intended to set people on a healthier and more productive path, just as a prescriptive view of science could have the same intention. This prescriptive focus likely added to the strength of its influence because it was put forth as a directive for how science should be carried out.

The Search for a Nursing Paradigm An obvious problem raised by this prescriptive focus was the fact that it ignored much of how science actually was carried out. An insider view of science would provide great insight into how science worked, not just on the level of particular methods but also in regard to the broader enterprise of science—an enterprise consisting not only of theories and ideas but also of scientists (the people who do the work of science) and the context in which their work takes place. Thomas Kuhn (1970, 1974) provided just such insight into not only the workings of science but the people who did that work. Because logical positivism was found to be lacking for nursing, Kuhn’s views quickly gained the attention of nurses looking for a useful understanding of science. One of the major shifts presented in Kuhn’s writing was the change in the philosophy of science from a focus on product to a focus on process —in other words, the way in which science was done. Kuhn’s view of science was organized around the idea that a central paradigm provided a focal point for activity in a discipline. The paradigm served as a disciplinary matrix and included the values and aims inherent in the major substantive content of the discipline. The work of scientists, according to Kuhn, was to articulate this paradigm. Progress, truth, and theory, among other aspects of science, were determined by viewing these developments from the perspective of the paradigm. This was a radically different approach to science than the view of the logical positivist because it allowed judgments about science to be made relative to a viewpoint—in this case, the disciplinary matrix or paradigm—rather than in reference to an objective reality. Although there were some limitations to this new perspective, nurses writing during this period gave a great deal of attention to Kuhn’s views and argued for the relevance of this philosophical position for knowledge development in nursing. Kuhn’s discussion of scientific revolutions and the term paradigm, derived from his work, became common features in discussions of nursing as a discipline and, especially, as a science. Writers in nursing during this period ultimately concluded that nursing had a metaparadigm, a broader worldview and conceptualization or important

elements of the discipline, yet evidence of a paradigm as required by Kuhn was presented as lacking (Hardy, 1983; Kim, 1989). Kim (1989) identified a number of distinct paradigms that were used in nursing but acknowledged the lack of a single overriding paradigm that would characterize nursing as a discipline in accordance with Kuhn’s position. Interestingly, although logical positivism experienced a relatively long life in nursing, Kuhn’s view was quite short lived in comparison. Nurse leaders and theorists during this time had become more familiar with philosophy and philosophical principles through their advanced education. As a result, there may have been a greater level of sophistication employed in evaluating ideology such as that presented by Kuhn. Limitations of Kuhn’s view were quite obvious in nursing and perhaps contributed to acceptance of this tradition being less widespread as well as shorter in duration in nursing. Although the term paradigm still has a prominent place in discussions about science, Kuhn’s view overall was supplanted rather quickly by the views of other historicists and the rise of postmodernism, which followed shortly after the popularity of his work faded. It is important to acknowledge the work of other historicist philosophers and the connection of such ideas to the development of nursing science. Larry Laudan was another noted philosopher of the late 1970s and a historicist whose work received some attention from nurse scholars. Laudan’s (1977) philosophy was particularly noteworthy because he provided a view of science that addressed both conceptual and empirical problems in the conduct of science and the determination of progress. In general, Laudan focused on science as a problem-solving activity and assigned some weight to both conceptual and empirical work. Relatively few nurse authors (articles such as Fry, 1995, and Tinkle & Beaton, 1983, are good examples) described positions in support of Laudan’s viewpoint and the practicality of his approach for nursing, and his work, like that of Kuhn, received far less attention than did the positions advocated by the logical positivists. Two significant aspects of the time could have contributed to this lack of attention. First, there was a continuing dominance of logical positivism and its influence on views of science, even as historicist viewpoints were being articulated; this entrenched view would not be supplanted easily. Second, the philosophy of postmodernism emerged, developing particularly in the social sciences

and then gradually spilling over into a number of other fields. Postmodernism served as a direct counterpoint to the rigidity of logical positivism, its emphasis on foundationalism, and its adherence to a belief in objective reality. This perspective represented quite a radical departure from both positivism and historicism, although it overlooked what might be considered the more moderate or intermediate position presented by historicist philosophers.

Conceptual Problems and Concept Development The potential contributions of historicism to nursing knowledge development are evident when reviewing the emphasis placed on concepts during the 1970s and 1980s. Although concepts and conceptual problems received attention during this time, the focus was not totally consistent with a historicist or postmodern perspective; in fact, discussion of concepts during this time had a strong positivist orientation. Concepts were valued primarily as elements of theory or, to use a popular phrase in nursing, as the “building blocks of theory,” and not in a broader philosophical sense as ways to reflect, describe, and navigate through existence. Nonetheless, at least some attention was being paid to concepts, an occurrence that stands out in the history of the development of nursing science and points to the significance of concepts within the knowledge base. Catherine Norris (1982) gave conceptual activity an important emphasis with the publication of a detailed book on concept clarification in nursing. Walker and Avant (1983, 1988) drew on the work of John Wilson (1969) to bring a method of concept analysis to nursing. This method remains popular in nursing and has been used in the analysis or clarification of a wide range of concepts. The text by Walker and Avant (1983, 1988) that addressed a method of concept analysis actually was focused on strategies for theory development in nursing, consistent with that common focus during the time of its initial publication. Content included analysis, synthesis, and derivation in the three categories of concepts, statements, and theories, all discussed as strategies for theory development. Perhaps as a remnant of logical positivism, or perhaps merely as recognition of the role of theory in science, work continued to be focused on theory development through much of the 1990s. More recent work emphasizing concepts in nursing has been focused on developing useful concepts and resolving conceptual problems without being limited to theory development as the only relevant context for such work. Numerous philosophers addressed the role of concepts in

cognition and, to a lesser extent, in science, yet their work has not received much of a reception in nursing. Rodgers (1989) constructed a view of concepts that emphasized concept development, not merely analysis, with analysis being a component of a broader process to generate meaningful and useful concepts. This work was informed by philosophers such as Laudan (1977), Toulmin (1972), Price (1953), and others and was oriented toward providing a solid foundation for conceptual work as part of the development of science and the discipline. Since that time, increased attention has been paid to concept development rather than merely to analysis or to analysis as a strategy oriented more broadly to the development of useful and effective concepts (Rodgers, 2000a, 2000b; Rodgers & Knafl, 2000). Despite this development, a great deal of conceptual work in nursing continues to follow the techniques described by Walker and Avant, being empirical in orientation and poorly linked to resolution of conceptual problems. Although sound philosophy and techniques for improving the conceptual base of nursing are readily available, this aspect of knowledge development is not well utilized in nursing. This is an unfortunate situation because a number of the significant problems regarding nursing knowledge are conceptual in nature rather than empirical. Even for problems that are clinical in nature, clear and sound concepts are needed to ensure that empirical problems are articulated with clarity and relevant variables are understood, defined, and measured appropriately. There is a need for additional work in concept development because many of the problems that are paramount in nursing are conceptual in nature and because methodological advances in concept development are not well integrated into nursing inquiry. In addition, concepts are important in delineating the identity and scope of the discipline. Consistent with the earlier effort to identify the essence of nursing, fundamental concepts were stipulated as constituting the core of nursing knowledge. Kim (1987), Flaskerud and Halloran (1980), and others identified nursing, person, health, and environment as the key concepts in nursing, with Flaskerud and Halloran referring to the centrality of these concepts as an important area of agreement in nursing. Other writings around this time were consistent with this focus, specifying that these concepts could provide a foundation for theory development in the discipline (Hardy, 1978; Johnson, 1968; Newman, 1972). As noted

previously, although work conducted during the 1980s and 1990s reveals attention to the role of concepts in developing the knowledge base, a significant part of this effort, particularly in the early phases, was consistent with the positivist focus on theory development. More recently (Rodgers, 1989, 2000b), concepts have begun to take on a role as significant parts of knowledge outside of theory development. There is a continuing need for attention to concept development that goes beyond the basic level of analysis to modes of inquiry that result in better ways to conceptualize important phenomena in nursing (Rodgers, 2000a, 2000b). The analysis of concepts should not be seen as an endpoint to inquiry; instead, the results of any analysis should be tied to a continuing process of developing knowledge that addresses significant problems in the discipline.

The Postmodern Turn The historicist tradition (historicism) presented a stark contrast to the major tenets of logical positivism. Historicism provided an emphasis on problem solving as evidenced by the work of Laudan (1977), conceptual repertoires as discussed by Toulmin (1972), the notion of science as an enterprise with work conducted by people with their own values and perspectives, and a focus on science as a process rather than the product—all of which prompted questions about appropriate ways of doing and evaluating science. The historicist tradition offered substantial advantages over the rigid requirements placed on science by logical positivism. The potential contributions of historicist philosophy, however, received relatively scant attention in nursing. A review of the literature for nursing knowledge development and nursing science in the 1980s and 1990s reveals few works that address the work of historicist philosophers. This lack of attention likely is related to the development of yet another philosophical tradition, postmodernism, which garnered substantial attention in nursing shortly after the peak of historicism. Postmodernism involves an emphasis on hermeneutics, narrative traditions and discourse, and philosophies of critical social theory and feminism. The emergence of this array of ideologies overshadowed discussions of historicism and quickly became a major focus of interest in nursing. Postmodernism, to many nurse authors at the time, seemed to closely approximate many of the values and purposes of nursing knowledge. This philosophical tradition was based on ideas of relativism, or viewpoints that truths existed on an individual level. This orientation was consistent with a long-standing emphasis in nursing on the whole person and the uniqueness of each individual. Nursing had developed around a focus on individualized care, and postmodernism was wholly consistent with that idea, not only allowing for but requiring recognition of uniqueness related to gender, culture, social status, and other characteristics inherent in the individual. Postmodernism also captured the idea that power differentials present in society are reflected in the healthcare system and interactions with care providers. In contrast to the idea that one single, central, fundamental overarching reality exists, with

the purpose of science being to discover that reality, postmodernism was founded on uniqueness, diversity, power structures, and multiple realities as a result of human and social variation. This notion that there is not one single, central truth or story that is applicable to everyone is a defining feature of postmodernism and is referred to as the rejection of metanarrative, overarching narratives that are broadly generalizable. Feminism, in particular, received a tremendous amount of attention, and it was not uncommon for authors to stipulate that feminism was a natural fit for nursing given that the majority of nurses were female. Feminism provided a clear example of postmodernism and was seen by many nurse leaders as exemplary of the postmodern emphasis on the uniqueness of each individual; the importance of individual realities with their gender, class, social, economic, and other influences; recognition of cultural relativism; and awareness of the role of power differentials in health care as in the rest of society. As a result, postmodernism garnered considerable attention as a good fit as a philosophical system for nursing knowledge development. Postmodernism represented a radical departure from earlier philosophies dealing with science and knowledge. As a result of its emergence, new modes of inquiry and new methodologies began to receive attention in nursing. The emphasis on individual beliefs, cultural and social contexts, multiple realities, power differentials, and so on, required the development of methods that were able to capture these aspects of existence through research. With such significant philosophical differences, it was clear that traditional scientific principles could not be applied to the study of human beings given their individual and social contexts. At the very least, a pluralistic approach to inquiry would be necessary, balancing the supposedly objective and quantifiable facets with the more personal and individual aspects of human beings. A more extreme form of ideology at the time held that reduction and quantification could be rejected in their entirety and replaced with more holistic traditions of inquiry. Techniques for deconstruction could be applied to language, as well as images, and reveal power differentials and biases implicit in communication. Similarly, narrative or text, including the idea that action constitutes a text as described by Ricoeur (1981, 1984), provided a means to identify precepts, values, hidden meanings, and other contextual elements of experience. During this time there was

an increasing emphasis on language and communication, with the development of narrative modes of inquiry that focused on individual story rather than attempts to uncover any form of truth. Qualitative research began to emerge as a viable option for inquiry in nursing and in other disciplines. Philosophical methods, such as phenomenology and hermeneutics, had existed for a long time, with hermeneutics having a particularly long history dating back to the early study of biblical texts. Despite this extensive history, however, these philosophical methods had not been compatible with traditional ideas of science. Acceptance of qualitative research grew slowly and continues to meet resistance in some disciplines and by some researchers even in nursing. Nonetheless, the rise of postmodern philosophy opened the door for, and subsequently fueled rapid growth in, qualitative methodologies to develop knowledge for the discipline. In fact, the popularity of qualitative research grew so quickly that it appeared at times to be a sort of bandwagon, drawing significant attention and support simply because it offered such a stark contrast to the method supported by the quantitative methods of logical positivism. The quality of studies was variable, and there was evidence of some confusion regarding the various specific methods, resulting in awkward piecemeal combinations of different, and sometimes incompatible, methodological traditions. This blending of perspectives and methods was referred to as “method slurring” by Baker, Wuest, and Stern (1992). Over time, an increasing number of publications dealt with aspects of quality in qualitative research, and the initial excitement about qualitative methods gradually evolved to leave a variety of distinct, clear, and highly rigorous approaches for the conduct and the evaluation of such forms of inquiry. Postmodernism led to the emergence of a particular form of qualitative inquiry referred to as interpretive approaches. These approaches focus on experiences as people live them with all their individual interpretations and reactions; consistent with this view is the idea that actions represent values and an emphasis on the primacy of dialogue and language as means to share realities. As a result, actions, dialogue, and language provide a mechanism for the investigator to gain a greater understanding of those unique realities. Hermeneutical, phenomenological, narrative, and other interpretive approaches have been used to explore a variety of experiences of interest to nurses,

including suffering (Steeves, Kahn, & Benoliel, 1990), race and attrition in nursing programs (Jordan, 1996), the care provider–patient relationship (Sundin, Jansson, & Norberg, 2002), and nurses in various roles, such as nurse consultant (Walters, 1996). The philosophy of postmodernism reflects another unique turn in ideas about the development of knowledge by raising significant questions about the presumption of objectivity in the conduct of science. In postmodernism, the separation of what is known from who is doing the knowing no longer exists; moreover, social elements not only have an effect on knowledge, but they also are viewed as an appropriate focus for inquiry. As noted previously, feminism and feminist epistemology gained considerable attention in relation to the growth of postmodernism. Postmodern philosophy makes it clear that social elements, such as class and gender, are important in regard to knowledge development; in feminism, the specific emphasis is on gender. Feminism exists in numerous forms, ranging from a moderate view that gender is important when looking at ways of interacting with the world to a more extreme version that holds gender to be the most important factor in interactions. In the extreme view, political action to counteract the dominant patriarchy is crucial to social progress (Harding, 1986, 1991). Some of the roots of feminism can be traced to historical events in which women were denied what are now considered to be basic social and civil rights. Adding to this historical origin is a considerable body of research that was biased against women. Kohlberg’s (1981) research on moral development, for example, was groundbreaking, but the stages of moral development that were identified, when used in research with female subjects, led to the conclusion that females functioned at a considerably lower level of moral development than their male counterparts. Subsequent research using a different frame of reference, such as the work conducted by Carol Gilligan (1982), revealed the gender bias inherent in Kohlberg’s work. The differences between male and female subjects in regard to development was argued by Gilligan to be not a matter of more or less of something, or one group being more developed than the other, but rather an altogether different way of approaching ethical problem solving. Gilligan’s work was foundational in supporting the idea that females have a different frame of reference and a different

way of working through ethical problems than do males. Such differences do not equate to higher or lower levels of moral development. Additional work in this area was carried out by Belenky, Clinchy, Goldberger, and Tarule (1986), who interviewed a group of 135 women; their study revealed that women interact with the world and have ways of knowing that appear to be substantially different from how men interact with and know the world. The recognition of gender differences evident in research, along with the postmodern emphasis on individual realities rather than grand narratives, made it easy to see how feminism could be viewed as a philosophy with a good fit for nursing. In addition, a number of noted scholars in nursing recognized the consistency between a feminist view and the professional status of nurses. History is replete with references to nurses as the handmaidens of the physician, and it is likely that most nurses have heard stories of nurses giving up their chairs or handing over patient charts to the physician whenever he was present (and, of course, in early years, physicians were he rather than she, as the discipline of medicine demonstrated a similar bias against women). From a political standpoint, then, feminism was seen as offering some potential benefit to a predominantly female profession such as nursing. Feminist ideology, however, often results in assigning a gender orientation to knowledge, labeling some approaches as distinctly feminine. This can create awkwardness in regard to thinking of knowledge claims as having a particular gender and presenting some views as superior to others based on a gender orientation. Rather than offering a means to overcome problems with bias that are presumed to be present in science, this approach sometimes seems only to offer yet a different form of bias in knowledge development. Some authors have justified this development, arguing that the masculine, patriarchal orientation is so strong that it is necessary to promote an equally strong feminist orientation as a counterpoint to the male hegemony. Others see feminism as opening the door to more diversity in a broad scope of perspectives that can be considered. Chinn (1989) described nursing as emphasizing wholeness, with any singular perspective—masculine or feminine—being insufficient to accomplish this idea of wholeness in health. According to Chinn, nurses see the world through the lens of integration and wholeness. We cannot conceive of knowing sufficiently in

any way nor can we rely on any one way of knowing that disregards another dimension of experience. We know we experience reality in a whole way. It seems essential that myriad viewpoints be considered in the development of a view that meets the expectations of being holistic and values the uniqueness of individuals. As societies and cultures evolve, the viewpoints to be considered and included in knowledge development have evolved as well, a situation evident in the development of viewpoints based on voices of many unique groups including immigrants and gay, lesbian, and transgendered persons. The relationship between nursing and feminism as a political movement has been a difficult one in many regards. Historically, men had positions of prominence in nursing because of the association of nursing with the military and with religious orders. In addition, women who in earlier times had worked to advance the professional status of nursing did not always see this work as connected to promoting the status of women in general. The American Nurses Association, for example, was not a supporter of women’s right to vote in the early years of the organization. At the same time, as opportunities for women have expanded throughout recent history, there has been a tendency for women in traditionally female occupations to feel disenfranchised for choosing those occupations rather than new ones that have become available to them. The tensions surrounding nurses in relation to feminism as a political movement in nursing, therefore, emanated from both the feminist action side and the nursing professional side. Despite political tensions and debates regarding the merits of gender as a specific focus in knowledge development, feminism has had a significant role in the development of nursing knowledge. Leaders in this movement in nursing brought energy to workplace issues that affect both nursing practice and the nursing workforce. Awareness of bias in scientific research—particularly the historical exclusion of women from a large body of medical research—raised questions about the applicability and generalizability of scientific findings to the care of patients. Recognition of the role of gender and science and what Lather (1991) referred to as the failure of traditional science increased awareness of numerous factors in the development of nursing knowledge and the ways in which knowledge is applied in practice.

The postmodern movement, including feminism, led to considerable research in nursing dealing with cultural and unique individual factors and helped to illuminate on a much broader scale the spectrum of human health and illness as lived by real people in their natural social and cultural settings. Through developments consistent with this ideology, meaningful work has been used not only to understand but also to empower people in their interactions related to health and health care. Philosophies of the postmodern, critical social theory, and feminist traditions continue to evolve and stimulate new ideas for research methodology and criteria for evaluating the quality and range of application for research results. Work remains, however, to explore ideas of postmodernism and the methodologies consistent with these ideas in a context of contemporary science. Prevailing notions of quality and what constitutes science still tend to be consistent with a positivist or logical positivist philosophy. To date, considerable effort has been devoted to articulating standards for evaluating the quality of inquiry in postmodern traditions (Guba & Lincoln, 1989; Hall & Stevens, 1991; Rolfe, 2006), and the rules associated with such work represent a vast departure from traditional notions of science. Reconciling these disparate viewpoints is important so that the merit of each viewpoint is appreciated and the potential usefulness understood. This is an area in which continuing work can develop a cohesive body of nursing knowledge and have that knowledge valued across an array of situations and contexts.

Pragmatism and Neopragmatism The philosophical tradition known as pragmatism has received little attention in nursing but may warrant consideration for its potential to inform the development of nursing as a discipline (Mason, 2008). Pragmatism emerged in the United States in the late 19th century with philosophers John Dewey (Boydston, 2008), William James (2000), and Charles Sanders Peirce (1878) as leaders of this movement. Other philosophers carried on this work in the 1970s and later, including Hilary Putnam (1991) and Richard Rorty (1979, 1982), a particularly prominent and prolific writer in this tradition. Pragmatism had a strong influence on views of truth; thus it has significance for views of science, even though the specific approach to truth varied among the early pragmatists. More important for the early pragmatists is the idea that understanding the nature of truth is not necessarily a desirable endpoint. Instead, it becomes meaningful when it has significant consequences in the quest for knowledge. Most writers would refer to this tenet of pragmatism in terms of the importance of “practical consequences” of truth. It is risky to do so, however, because pragmatic and practical are often considered to be interchangeable in everyday speech. To continue that trend would provide a very superficial view of pragmatism and its more recent iterations, such as neopragmatism, which has a particular focus on language. Because of differences of ideologies that fall under the heading of pragmatism, it is not possible to provide a list of basic tenets as is possible with many of the other philosophical traditions discussed in this chapter. There is, however, sufficient commonality to identify pragmatism as a distinct tradition—embodied by an idea that is typically referred to as the pragmatic maxim (or what should be referred to as variations of the pragmatic maxim, as it exists in a number of versions). The pragmatic maxim, very broadly, relies on language and conceptualization and the consequences of certain beliefs. One of Peirce’s (1878) most well-known works was an article titled “How to Make Our Ideas Clear.” In some respects, this work involved a rejection of the skepticism of Descartes and an attempt to render science as a more meaningful and useful

process, freeing it from the mental gymnastics that were so prominent in Descartes’s writings. In a clear operationalization of this shunning of Cartesian ideology, Rorty (1979, 1982) openly rejected the idea that the mind is a mirror of nature, thus rejecting the notion of correspondence theories of truth and the idea that acts of cognition must necessarily relate to a verifiable external reality. This may seem like a simple, or perhaps even obvious turn of events, yet this shift in thinking had a significant outcome; it opened philosophy, and also science, to the possibility of developing belief systems rather than requiring strict correspondence with facts, and it allowed a renewed focus on things that are clear and that make sense in a general way. A related outcome would be the development of theory that does something, particularly that stands up to the test of time and continues to answer important questions. This shift in thinking might look like it was in synch with other established philosophical traditions adopted in nursing inquiry. The emphasis on language, consequences, practical results, establishment of belief systems, pluralism, and rejections of single views of truth is somewhat consistent with historicism and postmodernism in their different forms. Yet in the literature of nursing, postmodern thought and newer variations of empiricism have remained most prominent, though no tradition is without significant criticism (Garrett, 2016; Rodgers, 2005). In philosophy, pragmatism experienced renewed interest with the writings of Rorty and Putnam, though it has remained rather diffuse with numerous different forms. This lack of a single cohesive ideology may be responsible, at least in part, for this tradition not receiving the attention of nurses and researchers that the other developments have. Nonetheless, this tradition’s similarities with some other established views may make it worth remembering as nurses explore the many different viewpoints that exist to inform nursing inquiry and knowledge development.

Emerging Trends in Nursing Science The prior examination of developments and trends in the evolution of nursing science provides a glimpse into the progress made in the discipline and attempts to provide a solid foundation for nursing knowledge. Numerous approaches to knowledge relevant to nursing practice have been entertained within the discipline; some were taken as prescriptions for nursing thought, whereas others offered what was considered a closer fit with nursing as it existed. Although the variety of philosophical approaches and methodologies may be appealing simply because of the diversity of perspectives offered, the plethora of philosophies also places some demands on the nurse in an advanced practice role. One option for dealing with the myriad approaches that might be appealing to adopt is a pluralistic view, or something similar to an anything goes attitude. Each era in nursing history has contributed to the development of the discipline of nursing through expansion and articulation of the knowledge base and, concomitantly, a stronger identity for nursing. In addition, each viewpoint has some merits, just as each has limitations. So why not selectively apply pieces of these traditions, if not the whole tradition, when addressing a problem relevant to nursing? Noted Austrian philosopher Feyerabend (1975) specifically supported an approach allowing for maximum creativity and innovation in the process of knowledge development. Numerous authors in nursing have taken such a position as well by suggesting that there should be a variety of methods and perspectives from which nurses can choose whatever is appropriate to guide their research or practice (Baker, Norton, Young, & Ward, 1998; Coward, 1990; Schultz, 1987). Such an approach, referred to as pluralism, requires thoughtfulness rather than merely accepting the wide variety of options as equally meaningful. One complex issue that needs to be considered is the notion of philosophical congruence, coherence, and fit with the values and ontological perspective of the discipline. Philosophical congruence and coherence concern whether different perspectives in nursing are compatible with a philosophical basis. If nursing holds that the human

being is holistic and cannot be viewed specifically in terms of parts, the viewpoints that are considered as a philosophical foundation for knowledge development need to be consistent on that point. Given this example, positions based on the philosophy of logical positivism are likely to be incompatible with nursing values and principles. This example also points out the importance of ontological fit with nursing. In this case, the ontological view supports the position that human beings need to be considered on a holistic basis. The human being cannot be both holistic and reducible at the same time, and advocating this position would be inconsistent with nursing’s expressed metaphysical position on the nature of the human being. Positions about truth, generalizability, the nature of reality, the nature of facts, the role of the investigator, and the role of ethics and values are fundamental considerations and intrinsic parts of the discipline. There is certainly a need for differing perspectives in the process of knowledge development, but whatever approaches are taken need to be consistent with the espoused values and worldview held by the discipline at large. Arguing for coherence and congruence does not preclude the use of a variety of methodologies for developing the knowledge base for nursing. The discipline will benefit most, however, if the use of a variety of means of knowledge development relevant to nursing is based on a consistent philosophical viewpoint that supports such diversity. The purpose of nursing knowledge is to support the work of nurses and provide information critical to both the delivery of effective care and the continuing development of the discipline. These real and practical aims provide an organizing viewpoint for continuing knowledge relevance. For example, Rodgers (2005, 2007) advocated a problem-solving approach based on the philosophies of Laudan (1977) and Toulmin (1972) as a way to justify multiple approaches to knowledge development and nursing while still maintaining some consistency and identity for the discipline. These philosophers, reflecting different historicist ideas, allow for a problem-driven focus to knowledge development such that both conceptual and empirical problems are important and there are mechanisms or at least judgments involved in determining what problems are of greatest concern at any specific time in the development of the knowledge base. From a philosophical standpoint, a focus on problem solving pertains

specifically to epistemic problems in the discipline—in other words, problems of knowledge development. An epistemic problem is different from a clinical problem. A clinical problem is a problem of care delivery or system structure, such as how to document nursing care effectively in a new electronic health record. A nurse might think also of ethical problems such as those that arise from conflicts of values in end-of-life care. Epistemic problems are at the root of practice or clinical problems, and part of the important role of the DNP-prepared nurse is to help make that translation from clinical to epistemic problems. A nurse might be concerned about decreasing the incidence of catheter-associated urinary tract infections and might think about addressing the problem as one of proper equipment or education for the individual with recurrent infection. The DNP-prepared nurse, approaching this as an epistemic problem, can identify the knowledge that is lacking in terms of the body of evidence that underlies the clinical situation and be part of the development of research to uncover the reason for the infections. In clinical problems, there is a challenge relating to what care to provide; epistemic problems arise from a lack of knowledge needed to ensure that practices are built on a sound knowledge base and whatever work that is done to solve the problem also helps to expand knowledge. It requires thinking about what is known and not known and also a vision of the nurse as not just using information but actually contributing to new knowledge. The advanced practice nurse with a practice-focused doctoral degree is the ideal person to facilitate this process. The advanced practice nurse has clinical expertise and practical experience that enables the nurse to detect problems that need to be addressed. The DNP-prepared nurse also has sufficient knowledge of processes of inquiry and an understanding of the discipline of nursing, both of which help to ensure that attempts to expand the knowledge base are properly conducted and are relevant to the discipline. The DNP-prepared nurse can identify problems, determine what knowledge is needed, and work with others with research expertise to address the lack of science and expand the knowledge base needed for effective care delivery. Other developments in the history of nursing helped to bring some focus and direction to knowledge development in the discipline. During the 1980s and 1990s, a series of conferences was held in the northeastern United States, alternately sponsored by schools of nursing

at the University of Rhode Island and Boston College. These conferences served as a vital forum for discussion of ideas about science and knowledge development relevant to the discipline of nursing. After this period of sharing and development, it became apparent to the conference organizers that the next appropriate step would be the development of a consensus statement reflecting crucial areas of agreement about nursing as a discipline. The purpose of the Nursing Knowledge Consensus Conference in Boston in 1998 was for the 40 participants “to discuss and synthesize various perspectives on knowledge development related to (1) the nature of the human person, (2) the nature of nursing, (3) the role of nursing theory, and (4) the links of each of these understandings to nursing practice” (Consensus Statement on Emerging Nursing Knowledge, 1998, as cited in Roy, 2007, p. 26). The document that resulted from this effort, the Consensus Statement on Emerging Nursing Knowledge, served as an important event in the history of contemporary nursing and reflected the values and knowledge that were thought by participants to be essential to the discipline, as well as the practice, of nursing. The consensus statement was an attempt to move beyond repeated discussion of the nature of nursing and the knowledge base and provide a foundation for continuing focused development of the discipline. What this manifesto provided was a statement of agreed-upon values and perspectives that could provide some cohesiveness among nurses, a reminder of the lens through which nurses see the world and the recipients of their care. A variety of philosophical traditions, modes of inquiry, and research methods may be used to solve epistemic problems in nursing. Keeping in mind the key assumptions and values embedded in the discipline allows plurality in approaches to knowledge development while still supporting a sense of unity in the discipline and the knowledge that underlies the work of nurses. The consensus statement was disseminated through a website, and there was an opportunity for sharing and continuing dialogue.

The Future of Nursing Knowledge Development Reference to the future of nursing knowledge development does not imply that anyone truly can make accurate predictions. It is reasonable, however, to anticipate some changes and developments based on current trends and existing priorities both in nursing and in the society in which nursing exists in the United States. The future of nursing knowledge development certainly will require nurses with strong analytical skills to clearly identify problem areas where research is needed. Nurses also are needed who can work with trends within society, as well as within the discipline, and demonstrate the leadership and interpersonal skills to address the needs on all levels. The development of a cohesive discipline with clear identity also depends on nurses who can construct approaches to nursing knowledge development and practice that are cohesive, consistent, and grounded in a clear understanding of nursing as a discipline. Along those lines, patterns that reveal potential significance for nursing involvement can be identified. Changes in philosophy, as well as in social context, call for new methods to address pressing issues in nursing. Recognition of the role of culture and social context requires increasing development, application, and evaluation of methods effective at capturing those aspects of existence. These changes also require nurses who understand the philosophy and knowledge development enterprises well enough to articulate the value of differing approaches to inquiry. Advanced practice nurses will provide a critical link in this process through their skill and understanding of both the knowledge development and scientific enterprises, as well as the realm of application in practice. Nursing science work without that critical link to practice is likely to fail in meeting the needs of nurses who apply that science on a daily basis. Nurses at levels prior to advanced practice need leadership and guidance from advanced practice nurses to offer a few problems suitable for inquiry as well as to help evaluate and apply new information for evidence-based practice.

Promoting continuing progress in nursing in regard to knowledge development also requires nurses who recognize that the future is something to be constructed as well as anticipated. Perhaps what the future of nursing knowledge development needs most is nurses who have a vision of what nursing can be and who have a commitment and desire to help create that idealized future. Advanced practice nurses will continue to be an essential part of the process of developing the discipline of nursing. One area in need of increased attention in nursing is that of theory development. Theory often is poorly understood in nursing, with a common misperception being that theory is limited to the work of the grand theorists such as Orem, Johnson, and others. Exposure to theory in nursing programs unfortunately has perpetuated a gross misunderstanding about the role of theory in the knowledge base and in support of the practice of nursing. Ideas of theory need to be expanded beyond these broad narratives about nursing and also beyond the axiomatic and propositional constructions supported by the logical positivists. Theory is merely organized knowledge—knowledge that is connected and structured in such a way as to be slightly abstract, rather than case dependent, and potentially relevant to a variety of situations. Theories exist that can be immensely beneficial to nurses dealing with a wide array of topics commonly encountered in practice. Nurses also need to recognize that knowledge changes. Just as the history of philosophical views about knowledge has changed over time, knowledge itself can and must change. Nurses need to develop skills that enable thoughtful critique of knowledge, characteristics of flexibility, a spirit of creativity, and a willingness to evaluate and embrace changes in knowledge. Along with this approach, particularly critical for nurses in leadership positions such as those with DNP degrees, nurses need to recognize the vital connection between the knowledge base and the discipline of nursing and to look beyond immediate practice implications to promote changes in the discipline and perception of nursing among the public, other health professionals, and the nursing community itself. All activities, whether administrative, clinical, or research oriented, should be undertaken with an understanding of the essential connections among the discipline; the knowledge base, including the organization of

knowledge into theories; and the practice of nursing.

Summary In this chapter, the nonlinear evolution of nursing science was explored in regard to philosophical traditions in epistemology and philosophy of science, specifically logical positivism, historicism, postmodernism, phenomenological philosophy, hermeneutics, and feminist epistemology. Events in the development of nursing as a discipline were examined in light of philosophical change. Emerging trends were presented along with suggestions for continuing development appropriate to the role of the DNP nurse.

Discussion Questions 1. Discuss significant historical trends that have shaped the development of nursing knowledge. 2. Describe trends in philosophy that have influenced the development of nursing science. 3. Describe the role of the DNP-prepared nurse in the development of nursing science.

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© Zen Rial/Moment/Getty Images.

CHAPTER 19 Research: How Health Care Advances Harry A. Sultz and Kristina M. Young

CHAPTER OBJECTIVES 1. Define and recognize the focus of different types of research and how each type contributes to the advancement of knowledge about health and the healthcare system. 2. Describe the functions and goals of the Agency for Healthcare Research and Quality and how to access information pertinent to advanced nursing practice. 3. Recognize the interface of health research and policy and of research and quality improvement. 4. Discuss future challenges for healthcare research and the impact they will have on advanced practice nursing.



T

his chapter explains the focus of different types of research and how each type contributes to the overall advances in health and medicine. Health services research, a newer field that addresses the study of the healthcare system itself rather than specific problems of disease or disability, is described. The offices and goals of a major funding source for health services research, the federal Agency for Healthcare Research and Quality, are listed. Finally, research into the quality of medical care, the problems being addressed, and the research challenges of the future are discussed. The last half of the 1900s and the early 2000s have seen remarkable growth of scientifically rigorous research in medicine, dentistry, nursing,

and other health professions. The change from dependence on the clinical impressions of individual physicians, tradition, and other healthcare practitioners to reliance on more accurate scientific findings from carefully controlled studies is one of the most important advances in medicine. Readers of peer-reviewed professional journals can now monitor the progress of basic science and clinical and technologic discoveries, more confident that the published findings were based on research studies designed and conducted to yield statistically significant results. In contrast, volumes of reports of medical developments that appear in the popular media and on the Internet are often premature and, depending on the source, may be cause for skepticism. The imprudent publication of inadequately proved or unproved therapies, the sensationalizing of minor scientific advances, and the promotion of fraudulent devices and treatments create unrealistic patient expectations that often result in disappointment, mistreatment, and costly deceptions. Although the Internet can be a valuable tool for patients to learn about healthcare issues, it also often provides bad information, which can lead to confusion, anxiety, and false hopes about fraudulent cures. Despite the advanced state of the Internet and modern communications technologies, from both professional and public perspectives, the continuing emergence of new technologies and clinical advances creates ongoing challenges of evaluation, interpretation, and potential applications.

Focus of Different Types of Research FIGURE 19-1 illustrates the focus of different types of healthcare research.

There are clear distinctions among researchers in terms of methods and the nature of their subsequent findings. Although the kinds of information derived from each type of research may be different, each knowledge gain is an essential step in the never-ending quest to create a more efficient and effective healthcare system.1

FIGURE 19-1 Variations in research focus. Republished with permission Health Administration Press. From Aday, Lu Ann, et al.: Evaluating the Healthcare System: Effectiveness, Efficiency and Equity, 3rd edition,© 2004; permission conveyor through Copyright Clearance Center, Inc.

Description

Types of Research Research studies conducted by those in professional disciplines fall into several categories.

Basic Science Research Basic science research is the work of biochemists, physiologists, biologists,

pharmacologists, and others concerned with sciences that are fundamental to understanding the growth, development, structure, and function of the human body. Much of basic science research is at the cellular level and takes place in highly sophisticated laboratories. Other basic research may involve animal or human studies. Whatever its nature, basic science research is an essential antecedent of advances in clinical medicine.

Clinical Research Clinical research focuses primarily on the various steps in the process of

medical care: the early detection, diagnosis, and treatment of disease or injury; the maintenance of optimal physical, mental, and social functioning; the limitation and rehabilitation of disability; and the palliative care of those who are irreversibly ill. Individuals in all the clinical specialties of medicine, nursing, allied health, and related health professions conduct clinical research, often in collaboration with those in the basic sciences. Much of clinical research is experimental, involving carefully controlled clinical trials of diagnostic or therapeutic procedures, new drugs, or technological developments. Clinical trials test a new treatment or drug against a prevailing standard of care. If no standard drug exists or if it is too easily identified, a control group receives a placebo or mock drug to minimize subject bias. To reduce bias further, random selection is used to decide which volunteer patients are in the experimental and control groups. In a welldesigned study, none of the personnel associated with the study (e.g., patient, physicians, outcomes assessors) know who is receiving the test

drug or treatment until the study is completed and the identifying code revealed. Research studies have several safeguards to protect the safety and rights of human and animal subjects. Studies funded by governmental agencies or foundations are subject to scrutiny by peer-review committees or “study sections” that judge the scientific merit of the research design and the potential value of the findings. Next, a hospitalor academically based institutional review board (IRB) ensures the safeguarding of human subjects and appraises the use of research animals. Human subjects must provide an informed consent agreement to participate in research to ensure that they appreciate both the risks and the potential benefits of their participation. Studies with a very low potential for human harm often require only verbal consent, whereas studies that collect blood or tissue from a subject usually require a more formal written consent agreement. The agreement spells out in plain language the risks, benefits, and possible side effects of participating. Some studies may be potentially harmful just based on the mental anguish the subjects may experience by being contacted by investigators or when the subject of the research may be embarrassing or stigmatizing. Subjects must weigh any potential risks against any potential benefits. Often there are risks but no direct benefits to the subjects other than the knowledge that they are helping to advance science. The processes for the protection of human subjects in medical research is far too complex a topic to be described in complete detail in this text. There is a multitude of existing references the reader can consult to learn more.2

Epidemiological Research Epidemiology, or population research, is concerned with the distribution and determinants of health, diseases, and injuries in human populations. Much of that research is observational. An observational study is the collection of observed information about natural phenomena, the characteristics and behaviors of people, aspects of their location or environment, and their exposure to certain circumstances or events. Observational studies may be descriptive or analytical. Descriptive

studies use patient records, interview surveys, various databases of

existing medical data, and other information sources to identify those factors and conditions that determine the distribution of health and disease among specific populations. They provide the details or characteristics of diseases or biologic phenomena and the prevalence or magnitude of their occurrences. Descriptive studies are relatively fast and inexpensive and often raise questions or suggest hypotheses to be tested. They often are followed by analytic studies, which test hypotheses and try to explain biologic phenomena by seeking statistical associations between factors that may contribute to a subsequent occurrence and the initial occurrence itself. Some analytic studies attempt, under naturally occurring circumstances, to observe the differences between two or more populations with different characteristics or behaviors. For example, data about smokers and nonsmokers may be collected to determine the relative risk of a related outcome, such as lung cancer, or a cohort study may follow a population over time, as in the case of a Framingham, Massachusetts, study.3 For years, epidemiologists have been studying a cooperating Framingham population to determine associations between such variables as diet, weight, exercise, other behaviors, and characteristics related to heart disease and other outcomes. These observational studies are valuable in explaining patterns of disease or disease processes and providing information about the association of specific activities or agents with health or disease effects.

Experimental Epidemiology Observational studies are usually followed by experimental studies. In experimental studies, the investigator actively intervenes by manipulating one variable (often called the independent variable) to see what happens with the other (often called the dependent variable or the one that changes when the independent variable is changed). Although they are the best test of cause and effect, such studies are technically difficult to carry out and often raise ethical issues. For example, it would not be ethical to conduct a clinical trial where one group was going to be exposed to a potential toxin to determine if the toxin caused cancer. Control populations are used to ensure that other nonexperimental

and usually unknown variables are not affecting the outcome. Like clinical trials, such studies may raise ethical issues when experiments involve the use of a clinical procedure that may expose the subjects to significant or unknown risk. Ethical questions also are raised when experimental studies require the withholding of some potentially beneficial drug or procedure from individuals in the control group to prove decisively the effectiveness of the drug or procedure. For example, it would not be ethical to test a new antihypertension medication using a control group of patients with hypertension that would not receive any treatment because the risks of untreated hypertension are known to be harmful. In such a case, the control group may receive their usual care with their current antihypertension medication and the intervention group would receive a new drug hypothesized to better treat hypertension.

Other Applications of Epidemiologic Methods Because the population perspective of epidemiology usually requires the study and analysis of data obtained from or about large-scale population samples, the discipline has developed principles and methods that can be applied to the study of a wide range of problems in several fields. Thus, the concepts and quantitative methods of epidemiology have been used not only to add to the understanding of the etiology of health and disease but also to plan, administer, and evaluate health services. The concepts and methods also are used to forecast the health needs of population groups, to assess the adequacy of the supply of health personnel, and to determine the outcomes of specific treatment modalities in a variety of clinical settings. Advances in statistical theory and the epidemiology of medical care make it possible to analyze and interpret performance data obtained from the large Medicare and other insurance databases. Many of the research findings of seemingly inexplicable geographic variations in the amount and cost of hospital treatments and in the use of a variety of healthcare services have resulted from the analysis of Medicare claims data and other large health insurance databases.

Health Services Research

Until the 1980s, most medical research was basic science research or research into the biological processes of the human body at the cellular and molecular levels. In the 1980s, the concept of health services research was born. Investigators focused on using established scientific methods in basic medical research to study the healthcare system itself. The goal was to find new and more effective means of diagnosis and treatment and, in effect, to improve the quality and length of life. For the 2 decades after World War II, supply-side subsidy programs dominated federal healthcare policy. Like other subsidy programs, Medicare and Medicaid were politically crafted solutions rather than research-based strategies. Nevertheless, these major healthcare subsidy programs were the driving forces behind the rise of health services research. The continuous collection of cost and utilization data from these programs revealed serious deficiencies in the capability of the healthcare system to efficiently and effectively deliver the knowledge and skills already at hand. In addition, evidence was growing that the large variations in the kinds and amounts of care delivered for the same health conditions represented unacceptable volumes of inappropriate or questionable care and too much indecision or confusion among clinicians about the best courses of treatment. Health services research was born of the need to improve the efficiency and effectiveness of the healthcare system and to determine which of the healthcare treatment options for each health condition produces the best outcomes.

Agency for Healthcare Research and Quality Beginning with John Wennberg’s documentation of large differences in the use of medical and surgical procedures among physicians in small geographic areas in the late 1980s, several similar studies brought the value of increasingly more costly health care into serious question. Wennberg noted that the rate of surgeries correlated with the number of surgeons in a geographic area and that the number of available hospital beds rather than differences among patients correlated with the rate of a population’s hospitalization. He found that per-capita expenditures for hospitalization in Boston, Massachusetts, were consistently double those in nearby New Haven, Connecticut.2,4,5 Widely varying physician practice patterns provided little direction as to the most appropriate use of even the most common clinical procedures. In addition, adequate outcome measures for specific intervention modalities generally were lacking. The problem did not escape the attention of the 101st Congress. The development of new knowledge through research has long been held as an appropriate and essential role of the federal government, as evidenced by the establishment and proactive role of the National Institutes of Health (NIH). When it became clear that indecision about the most appropriate and effective ways to diagnose and treat specific medical, dental, and other conditions was contributing to unacceptably large variations in the cost, quality, and outcomes of health care, federal legislation was passed to support the development of clinical guidelines. The Agency for Health Care Policy and Research (AHCPR) was established in 1989 as the successor to the National Center for Health Services Research and Health Care Technology. It became one of eight agencies of the Public Health Service within the U.S. Department of Health and Human Services. AHCPR was responsible for updating and promoting the development and review of clinically relevant guidelines to assist healthcare practitioners in the prevention, diagnosis, treatment, and management of

clinical conditions. The authorizing legislation directed that AHCPR or public and not-for-profit private organizations convene panels of qualified experts. These panels were charged to review the literature that contained the findings of numerous studies of clinical conditions and, after considering the scientific evidence, to recommend clinical guidelines to assist practitioner and patient decisions about appropriate care for specific clinical conditions.6 The agency’s priority activities included funding two types of research projects: patient outcome research teams and literature synthesis projects or meta-analyses. Both the patient outcome research teams and the smaller literature synthesis projects identified and analyzed patient outcomes associated with alternative practice patterns and recommended changes where appropriate. During its decade-long existence, the AHCPR supported studies that resulted in a prodigious array of publications focused on patient care and clinical decision making, technology assessment, the quality and costs of care, and treatment outcomes. Although no longer directly involved in producing clinical practice guidelines, the agency currently assists private sector groups by supplying them with the scientific evidence they need to develop their own guidelines. Significant changes occurred in the mandate of AHCPR since its 1989 inception. The agency narrowly escaped the loss of funding and faced possible elimination in 1996 after incurring the wrath of national organizations of surgeons. In keeping with its original mission, AHCPR had issued clinical guidelines. One such guideline discouraged surgery as a treatment for back pain on the grounds that it provided no better outcomes than more conservative treatments. Organizations of angry surgeons led a lobbying effort that convinced key members of Congress that the agency was exceeding its authority by establishing clinical practice standards without considering the expertise and opinions of the medical specialists involved.7 The dispute was resolved when the AHCPR agreed to function as a “science partner” with public and private organizations by assisting in developing knowledge that could be used to improve clinical practice. The agency agreed to produce clinical guidelines that would focus on funding research on medical interventions and analyzing the data that would underlie the development of clinical guidelines.

The Health Care Research and Quality Act of 1999 renamed the AHCPR to the Agency for Healthcare Research and Quality (AHRQ). The mission of the AHRQ is to (1) improve the outcomes and quality of healthcare services, (2) reduce its costs, (3) address patient safety, and (4) expand effective services through the establishment of a broad base of scientific research that promotes improvements in clinical and health systems practices, including prevention of disease.8 Although clinical practice guidelines subsequently would be generated by medical specialty and other healthcare organizations, the AHRQ’s role would be to evaluate recommendations made in the clinical practice guidelines to ensure they were based on a systematic review of the literature (evidence based) and were revised for currency on a regular basis. More than 2,000 active, evidence-based clinical practice guidelines that have met the AHRQ evaluation criteria have been collected in a database, organized by searchable topics, and made available online at the AHRQ’s National Guideline Clearinghouse (www.guideline.gov). The AHRQ also maintains a searchable database of nearly 5,000 archived guidelines that have been updated or withdrawn. A top priority of the AHRQ is transmitting its sponsored research results and new health information to consumers. In addition to several consumer-oriented publications, the agency provides information to the public via the Internet. Its website, www.ahrq.gov, offers a robust array of healthcare information. The AHRQ is now a major collaborating organization of the Patient-Centered Outcomes and Research Institute (PCORI) established by the Affordable Care Act (ACA), described later in this chapter.

Health Services Research and Health Policy Health services research combines the perspectives and methods of epidemiology, sociology, economics, and clinical medicine by applying the basic concepts of epidemiology, biostatistics, process, and outcome measures that reflect the behavioral and economic variables associated with questions of therapeutic effectiveness and cost–benefit. The ability of health services research to address issues of therapeutic effectiveness and cost–benefit during the nation’s quest for fiscal exigency has contributed to the field’s substantial growth and current value. The contributions of health services research to health policy are impressive. Major examples include the Wennberg studies of small area variation in medical utilization, the prospective payment system based on diagnosis-related groups,9,10 research on inappropriate medical procedures,11 resource-based relative value scale research,12–14 and the background research that supported the concepts of health maintenance organizations and managed care. The RAND Health Insurance Experiment,15,16 one of the largest and longest-running health services research projects ever undertaken, began in 1971 and contributed vast amounts of information on the effects of cost-sharing on the provision and outcomes of health services. Participating families were assigned to one of four different fee-forservice plans or to a prepaid group practice. Individuals in the various plans differed significantly in their rate of healthcare use, with little measurable effect on health outcomes. The Health Insurance Experiment was followed by two large research studies: the Health Services Utilization Study and the Medical Outcomes Study. The findings of both gave impetus to the federal support of outcomes research.17 Determining the outcomes and effectiveness of different healthcare interventions aids clinical decision making, reduces costs, and benefits patients.

Quality Improvement Until the 1990s, health care’s impressive accomplishments had made it difficult for healthcare researchers, policy makers, and organizational leaders to publicly acknowledge that poor-quality health care is a major problem within the dynamic and productive biomedical enterprise in the United States. In 1990, after 2 years of study, hearings, and site visits, the Institute of Medicine issued a report that cited widespread overuse of expensive invasive technology, underuse of inexpensive “caring” services, and implementation of error-prone procedures that harmed patients and wasted money.18,19 Although these conclusions from this prestigious body were devastating to healthcare reformers, they were hardly news to health service researchers. For decades, practitioners assumed that quality, like beauty, was in the eye of the beholder and therefore was immeasurable, except in cases of obvious violation of generally accepted standards. The medical and other healthcare professions had promoted the image of health care as a blend of almost impenetrable, science-based disciplines, leaving the providers of care as the only ones capable of understanding the processes taking place. Thus, only physicians could judge the work of other physicians. Such peer review-based assessment has always been difficult for reviewers and limited in effectiveness. Peer review recognizes that only part of medical care is based on factual knowledge. A substantial component of medical decision making is based on clinical judgment. Clinical judgment requires combining consideration of the potential risks and benefits of each physician’s implicit list of alternatives in making diagnostic and treatment decisions with his or her medical intuition regarding the likelihood of success based on the condition of each patient. Under these complex and often inexplicable circumstances, physicians are repelled by the notion of either judging or being judged by their colleagues. For these reasons, until recently, quality assurance, whether in hospitals or by regulatory agencies, was focused on identifying only exceptionally poor care. This practice, popularly known as the bad apple theory, was based on the presumption that the best way to ensure quality

was to identify the poor performers, or bad apples, and remove or rehabilitate them. Thus, during the 1970s and 1980s, quality-assurance interventions followed only the detection of undesirable occurrences. For example, flagrant violations of professional standards had to be documented before professional review organizations required physicians to begin quality improvement plans. Physicians were guaranteed due process to dispute the evidence. Focusing on isolated violations required a great deal of review time to uncover a single case that called for remedial action. In addition, it was an unpleasant duty for reviewers to assign blame to a colleague who might soon be on a committee reviewing their records. Most important, such quality inspections represented a method that implicitly defined quality as the absence of mishap. Clinician dislike of quality-assurance activities during the 1970s and 1980s was well founded, as these processes were professionally offensive and had little constructive impact. Specifying and striving for excellent care are very recent qualityassurance phenomena in the healthcare arena. Hospitals and other healthcare organizations that had long focused on peer-review committees, incident reports, and other negative quality-monitoring activities experienced difficulty in transforming to teamwork and higher levels of transparency in quality monitoring and reporting activities. Health services researchers had known for decades that healthcare quality was measurable and that excellent, as well as poor, care could be identified and quantified. As early as 1966, Avedis Donabedian20 characterized the concept of health care as divided into the components of structure, process, and outcomes and the research paradigm of their assumed linkages, all of which have guided quality-of-care investigators to this day. Donabedian suggested that the number, kinds, and skills of the providers, as well as the adequacy of their physical resources and the manner in which they perform appropriate procedures should, in the aggregate, influence the quality of subsequent outcomes. Although today the construct may seem like a statement of the obvious, at the time, attention to structural criteria was the major, if not the only, quality assurance activity in favor. It was generally assumed that properly trained professionals, given adequate resources in properly equipped facilities,

performed at acceptable standards of quality. For example, for many years, the then Joint Commission on Accreditation of Hospitals made judgments about the quality of hospitals on the basis of structural standards, such as physical facilities and equipment, ratios of professional staff to patients, and the qualifications of various personnel. Later, it added process components to its structural standards and, most recently, has shifted its evaluation process to focus on care outcomes. Early landmark quality-of-care studies used implicit and explicit normative or judgmental standards. Implicit quality standards rely on the internalized judgments of the expert individuals involved in the quality assessment. Explicit quality standards are those developed and agreed on in advance of the assessment. Explicit standards minimize the variation and bias that invariably result when judgments are internalized. More recent studies judge the appropriateness of hospital admissions and various procedures and, in general, associate specific structural characteristics of the healthcare system with practice or process variations. Another method for assessing the quality of healthcare practices is based on empirical quality standards. Derived from distributions, averages, ranges, and other measures of data variability, information collected from several similar health service providers is compared to identify practices that deviate from the norm. A current popular use of empirical standards is in the patient severity-adjusted hospital performance data collected by health departments and community-based employer and insurer groups to measure and compare both process activities and outcomes. These performance “report cards” are becoming increasingly valuable to the purchasers of care who rely on an objective method to guide their choices among managed care organizations, healthcare systems, and group practices. The empirical measures of quality include such variables as: Timeliness of ambulation Compliance with basic nursing care standards Average length of stay Number of home care referrals Number of rehabilitation referrals Timeliness of consultation completion Timeliness of orders and results

Patient waiting times by department or area Infection rates Decubitus rates Medication errors Patient complaints Readmissions within 30 days Neonatal and maternal mortalities Perioperative mortalities Both normative and empirical standards are used in studying the quality of health care in the United States. For example, empirical analyses are performed to test or modify normative recommendations. Empirical or actual experience data are collected to confirm performance and outcome improvements after the imposition of clinical guidelines derived from studies using normative standards.

Medical Errors In 1999, the Institute of Medicine again issued a report on the quality of medical care.21 Focused on medical errors, the report described mistakes occurring during the course of hospital care as one of the nation’s leading causes of death and disability. Citing two major studies estimating that medical errors killed 44,000 to 98,000 people in U.S. hospitals each year, the Institute of Medicine report was a stunning indictment of the systems of hospital care at that time. The report contained a series of recommendations for improving patient safety in the admittedly high-risk environments of modern hospitals. Among the recommendations was a proposal for establishing a center for patient safety within the AHRQ. The proposed center would establish national safety goals, track progress in improving safety, and invest in research to learn more about preventing mistakes.21 Congress responded by designating part of the increase in budget for the AHRQ for that purpose. In 2005, the Patient Safety and Quality Improvement Act was enacted by Congress to establish patient safety organizations (PSOs) to improve the quality and safety of healthcare delivery by encouraging healthcare providers and institutions to identify, analyze, and implement prevention strategies to reduce or eliminate the risks and hazards associated with the delivery of care to patients and to voluntarily report and share patient safety data without fear of legal discovery. PSOs are overseen by the AHRQ, which also maintains online access to the latest annotated links to patient safety literature and safety news at the Patient Safety Network (PSNet).22 Despite the government reaction to the 1999 Institute of Medicine (IOM) report and the intervening 17 years, an analysis published in 2016 indicates that medical errors are likely the third most common cause of death in the United States.23

Evidence-Based Medicine According to Sackett et al., “Evidence-based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. Individual clinical expertise refers to the proficiency and judgment that individual clinicians acquire through clinical experience and clinical practice.”24 A more recent and concise definition from Chilvers et al. is evidence-based medicine (EBM), which “involves combining the best research evidence with the patient’s values to make decisions about medical care.”25 Although these statements may appear to be a description of the way physicians and other healthcare providers have practiced since the inception of scientific medicine, it reflects a concern that the opposite is true. The wide range of variability in clinical practice, the complexity of diagnostic testing and medical decision making, and the difficulty that physicians have in keeping up with the overwhelming volumes of scientific literature suggest that a significant percentage of clinical management decisions are not supported by reliable evidence of effectiveness. Although everyone generally assumes that physicians are reasonably confident that the treatments they give are beneficial, the reality is that medical practice is fraught with uncertainty. In addition, the ethical basis for clinical decision making allows physicians to exercise their preferences for certain medical theories or practices that may or may not have been evaluated to link treatment to benefits.26 Proponents of EBM propose that if all health services are intended to improve the health status and quality of life of the recipients, then the acid test is whether services, programs, and policies improve health beyond what could be achieved by different means or by doing nothing at all. Although evidence is the key to accountability, patient preference is also integrated into the practice of EBM, which more recently has become known as evidence-based practice (EBP). The overarching tenet of EBP is that the decisions made by healthcare providers,

administrators, policy makers, patients, and the public all should be based on the highest level of evidence currently available and appropriate application to individual patients.27 What constitutes “the best evidence” refers to the highest form of evidence available for the particular medical issue or question in the hierarchy of evidence. The following is an abridged summary of the hierarchy of evidence: 1. Systematic review: A meta-analysis of several high-quality randomized controlled clinical trials. An analysis of multiple analyses has more value, as its conclusions are based on the larger, combined populations studied in all the individual clinical trials. This usually is considered the highest level of evidence but is also the most expensive and difficult to carry out. 2. Randomized controlled clinical trial: A study where patients are randomly assigned to two or more experimental groups where each group is identical to the others with the exception of the treatment they are assigned. Often one of the “treatments” is a placebo or no treatment. Selection of patients is carefully controlled to reduce the potential for any confounder or bias between the experimental groups. Often the study patients, their physicians, and the outcomes assessors are “blinded” to what treatment each patient was randomized to, again to minimize potential bias of the results. After systematic reviews, this is generally considered the highest form of evidence. 3. Observational study: An analysis of real-world data. Studies can be either prospective, where one or more groups of patients is followed for a period of time, or retrospective, where existing data representing past clinical events are analyzed. 4. Case series: A published summary of a small number of individual cases in the biomedical literature. These usually occur for extremely rare conditions or for new illnesses or syndromes and often when the diagnosis is unknown. Rigorous analyses usually are not performed. The goal is to attempt identification of the similarities between the cases presented and to posit a unifying cause or effective treatment. Case series are generally developed by experts and undergo peer review before they are

published. 5. Expert opinion: Usually expresses the opinion of a medical specialist in an area of interest to a particular patient. This is the lowest or least rigorous form of evidence but also the most commonly practiced. It can occur formally, with a referral to a specialist by a patient’s primary care physician, or informally, when one physician discusses a case or medical issue with a colleague in person, over the phone, or via email. The goal of EBM is to inform the practice of medicine by providing the practitioner with the ability to determine the highest level of evidence for their clinical questions and then use their clinical judgment, along with the patients’ preferences and values, for its application. This is may be referred to the process of using evidence-based practice to solve clinical problems. Many, if not most, medical decisions are made using the lower levels of evidence (i.e., only expert opinion, case series, or observational evidence). This is not at all a bad thing if the evidence used is indeed the highest level of evidence that exists at the time of the medical decision. There are many reasons why randomized controlled clinical trials cannot be conducted. They are expensive in terms of time and effort, and they often can raise ethical questions. For example, who would volunteer for a randomized trial of radiation exposure by receiving either harmful doses of radiation or placebo? It would be highly unethical to conduct such a study, so the best science can do is to perform observational studies on “natural experiments” where people were accidentally exposed to harmful radiation, such as in the Chernobyl disaster or the Japanese populations of Hiroshima or Nagasaki after the United States dropped nuclear bombs to end World War II. Similar examples are populations exposed to toxic chemicals in their water, land, or air. In such cases, observational studies compare the groups exposed to the toxic agents with similar populations from other similar areas that were not exposed. Although it is difficult to adjust the findings for all possible confounders between the two groups, the evidence produced by such analyses likely will be the highest level researchers will be able to obtain for toxic exposures. Another reason observational studies are performed is because the data are readily available and the analyses are often relatively

inexpensive. With the ever-increasing amount of data as artifact to our daily lives, many observational studies that were only dreamed of a few years ago can now be performed simply due to the depth and breadth of available data. This has produced the unfortunate terms big data and big data analytics. These terms refer generally to the potential knowledge that can be gained from the analyses of extremely large datasets. However, this concept is nothing new, and the size of the data stores available does not compensate for the well-established limitations of observational studies. Also, the methods of analysis for big data (i.e., statistics and modeling) are not new. One of the major problems with observational studies is the existence of unknown confounders between groups or cohorts. A confounder is a variable that explains the difference in outcome between groups that is not known or compensated for in the observational analysis; in effect, association between variables does not prove causation. For example, the rate of drownings correlates with the rate of ice-cream consumption. However, it is apparent that eating ice cream does not really put individuals at risk of drowning. The confounding variable in this case is the season, as the rate of ice-cream consumption and the rate of drowning both increase during warm weather when more people swim. Even though the rates of drowning and ice-cream consumption correlate, obviously, one does not cause the other. Unaware of the seasonal variable, it might indeed be concluded that eating ice cream inexplicably is related to the risk of drowning. This example represents the power of randomization in a controlled clinical trial. The randomization, if truly random, automatically adjusts for all possible confounding variables, known or unknown, between the groups under study. With observational studies, all the confounders must be known and adjusted for in the analysis to ensure accurate results. This is often extremely difficult to do because there are myriad potential confounders in the real world. A famous example that illustrates the limitations of observational studies and the value of randomized controlled clinical trials is the research on postmenopausal estrogen supplementation. For a time, the highest level of evidence on the benefits of the use of estrogen supplementation in postmenopausal women used only several observational studies.28–31 These observational studies grouped women of similar age, race, and demographics into two groups—those taking

estrogen supplementation and those not taking it. The two groups were followed and the rates of heart attack, stroke, bone loss, and other outcomes were documented. Because these studies showed a small but significant benefit for women who took estrogen supplementation in terms of reduced rates of heart attack, stroke, bone loss, and high cholesterol, the studies had enormous influence on the prescribing of supplemental estrogen to postmenopausal women. Eventually, a large, well-designed randomized controlled trial was conducted and, surprisingly, demonstrated that taking estrogen supplementation not only did not reduce the rates of heart attack or stroke but also actually slightly increased them and increased the rates of invasive breast cancer and pulmonary embolus.32 What was wrong with all the prior observational studies? It was the fact that women who took supplemental estrogen proactively also were more likely to be generally more health conscious. Further analysis showed that the women in the observational studies who took estrogen also were more likely to see their doctors for preventive checkups, eat more healthfully, and follow preventive instructions from their physicians, such as taking estrogen. It was not that the estrogen reduced the rates of heart attack and stroke in the observational studies, it was that the women who would take estrogen were just healthier than the women who did not take estrogen. The unknown confounder in all the observational studies was the participants’ overall health practices. Published results of the randomized controlled clinical trial led to the discontinuation of supplemental estrogen prescriptions almost overnight. But, as stated earlier, for many questions in medicine, observational studies will likely be the only ones ever carried out and are therefore the best available evidence. This is why evidence-based practice includes the use of clinical judgment and patient preference and values, as all the available evidence is far from perfect and in some cases just incorrect. Despite its common-sense approach, EBM has had many detractors. When EBM started gaining traction in the 1990s, many dismissed it as “cookbook medicine.”33 Others focused on the limitation of outcomes research. “Outcomes research using claims data is an excellent way of finding out what doctors are doing, but it’s a terrible way to find out what doctors should be doing,” stated Thomas C. Chalmers, MD, of Harvard School of Public Health.34 The situation has changed rapidly, however. Articles on evidence-

based medicine appear frequently in the medical literature.35 Cost-control pressures that encourage efforts to ensure that therapies have documented patient benefit, growing interest in the quality of patient care, and increasing sophistication on the part of patients concerning the care they receive have stimulated acceptance of the concepts of EBM.35

Outcomes Research and the PatientCentered Outcomes Research Institute Given the enormous investment in U.S. health care and the inequitable distribution of its services, do the end effects on the health and well-being of patients and populations justify the costs? Insurance companies, state and federal governments, employers, and consumers all look to outcomes research for information to help them make better decisions about what kinds of health care should be reimbursed, for whom, and when. Because outcomes research evaluates results of healthcare processes in the real world of physicians’ offices, hospitals, clinics, and homes, it contrasts with traditional randomized controlled studies that test the effects of treatments in controlled environments. In addition, the research in usual service settings, or effectiveness research, differs from controlled clinical trials, or efficacy research, in the nature of the outcomes measured. Traditionally, studies measured health status, or outcomes, with physiologic measurements—laboratory tests, complication rates, recovery, or survival. To capture health status more adequately, outcomes research also should measure a patient’s functional status and well-being. Satisfaction with care also must complement traditional measures. Functional status includes three components that assess patients’ abilities to function in their own environment: 1. Physical functioning 2. Role functioning—the extent to which health interferes with usual daily activities, such as work or school 3. Social functioning—whether health affects normal social activities, such as visiting friends or participating in group activities Personal well-being measures describe patients’ sense of physical and mental well-being—their mental health or general mood, their

personal view of their general health, and their general sense about the quality of their lives. Patient satisfaction measures the patients’ views about the services received, including access, convenience, communication, financial coverage, and technical quality. Outcomes research also uses meta-analyses, a technique to summarize comparable findings from multiple studies. More important, however, outcomes research goes beyond determining what works in ideal circumstances to assessing which treatments for specific clinical problems work best in different circumstances. Appropriateness studies are conducted to determine the circumstances in which a procedure should and should not be performed. Even though a procedure is proved to be effective, it is not appropriate for every patient in all circumstances. The frequency of inappropriate clinical interventions is one of the major quality-of-care problems in the system, and research is underway to develop the tools to identify patient preferences when treatment options are available. Although most discussions about appropriateness stress potential cost savings that could be achieved by reducing unnecessary care and overuse of services, outcomes research may be just as likely to uncover underuse of appropriate services. It is important to recognize that the ultimate value of outcomes research can be measured only by its ability to incorporate the results of its efforts into the healthcare process. To be effective, the findings of outcomes research must first reach and then change the behaviors of providers, patients, healthcare institutions, and payers. The endpoint of outcomes research, the clinical practice guidelines intended to assist practitioners and patients in choosing appropriate health care for specific conditions, must be disseminated in acceptable and motivational ways. With the healthcare industry in a state of rapid change, the need to make appropriate investments in outcomes research became increasingly apparent with the inescapable conclusion that the United States cannot continue to spend more than 17% of its gross domestic product each year on health care without learning more about what that investment is buying.36,37 The American Recovery and Reinvestment Act (ARRA) of 2009 included $1.1 billion over a period of 2 years to expand comparative effectiveness research by the AHRQ and the NIH. The ARRA established a Federal Coordinating Council to recommend research priorities and to

create a strategic framework for research activities. The IOM recommended 100 priority research areas for funding by the ARRA. Recommendations from the Federal Coordinating Council and the IOM were released in June 2009, and the ARRA required the secretary of the U.S. Department of Health and Human Services to consider these recommendations in directing research funds.38,39 The goal of comparative effectiveness research is to enhance healthcare treatment decisions by providing information to consumers, providers, and payers to improve health outcomes by developing and disseminating evidence “on the effectiveness, benefits, and harms of different treatment options. The evidence is generated from research studies that compare drugs, medical devices, tests, surgeries, or ways to deliver health care.”39 Historically, clinical research examined the effectiveness of one method, product, or service at a time. Comparative effectiveness research compares two or more different methods for preventing, diagnosing, and treating health conditions using such methods as practical clinical trials, analyses of insurance claim records, computer modeling, and systematic reviews of literature. Disseminating research findings in a form that is quickly usable by clinicians, patients, policy makers, health plans, and other payers about the effectiveness of treatments relative to other options is key to comparative research effectiveness goals. In addition, “identifying the most effective and efficient interventions has the potential to reduce unnecessary treatments, which may help lower costs.”39,40

The Patient-Centered Outcomes Research Institute Empowering the Federal Coordinating Council, the ACA created the Patient-Centered Outcomes Research Institute, a not-for-profit, independent agency dedicated to conducting comparative effectiveness research. The PCORI is governed by a board of directors appointed by the U.S. Government Accountability Office and is funded through the Patient-Centered Outcomes Research Trust Fund. The ACA allocated $210 million to PCORI activities for the fiscal years 2010 to 2012 and a total of $970 million for the years 2013 to 2019. Support is derived from the general U.S. Treasury fund, and fees are assessed to Medicare, private health insurance, and self-insured plans.41 The PCORI maintains a strong patient and stakeholder orientation, with patient satisfaction recognized as an essential component of quality of care. Although the subjective ratings of health care rendered by patients may be based on markedly different criteria from those considered important by healthcare providers, they capture aspects of care and personal preferences that contribute significantly to perceived quality. The PCORI recognizes that it has become increasingly important in the competitive market climate of health care that the providers’ characteristics, organization, and system attributes that are important to patients be identified and monitored. In addition to healthcare providers’ technical and interpersonal skills, such patient concerns as waiting times for appointments, emergency responses, helpfulness and communication of staff, and facilities’ appearances contribute to patient evaluations of health services delivery programs and subsequent satisfaction with the quality of care received. As of May 2016, the PCORI has funded a total of 774 research projects with $4.4 billion. The top five areas funded included cancer, mental/behavioral health, cardiovascular health, respiratory diseases, and trauma/injury.42 They also funded the national Patient-Centered Clinical Research Network (PCORNET), thus far composed of 13 clinical data research networks and 20 patient-powered research networks to increase the efficiency of various comparative effectiveness research

projects. In the few years that PCORI has been in existence, there are already dozens of papers published on the emerging research findings.43

Patient Satisfaction Surveys Prior to the PCORI’s establishment in 2006, several instruments were devised to measure patient satisfaction with health care. Most insurance plans, hospitals, and other health service facilities and agencies adopted one or more to regularly assess patient satisfaction. In 2016, the “first national, standardized, publicly reported survey of patients’ perspectives of hospital care” was created by the Department of Health and Human Services. It is known as the Hospital Consumer Assessment of Healthcare Providers and Systems Survey (HCAHPS).44 “The HCAHPS survey is administered to a random sample of adult patients across medical conditions between 48 hours and six weeks after discharge; the survey is not restricted to Medicare beneficiaries. Hospitals may either use an approved survey vendor or collect their own HCAHPS data (if approved by CMS to do so). HCAHPS can be implemented in four different survey modes: mail, telephone, mail with telephone follow-up, or interactive voice recognition (IVR).”45 Results are publicly reported on the Hospital Compare website. In addition, beginning in 2008, hospital reporting is required in order to receive full inpatient prospective payment systems reimbursement updates.46 Other surveys, such as the Patient Satisfaction Questionnaire developed at Southern Illinois University School of Medicine, are short, self-administered survey forms. Others, such as the popular patient satisfaction instruments of the Picker Institute of Boston, Massachusetts, may be used as self-administered questionnaires mailed to patients after a healthcare experience or completed by interviewers during telephone surveys.47 Whether by mail, direct contact, or telephone interview, questioning patients after a recent healthcare experience is an effective way both to identify outstanding service personnel and to uncover fundamental problems in the quality of care as perceived by patients. These activities help promote humane and effective care and are sound marketing techniques for providers.48 Since the 1950s, the federal government has invested heavily in biomedical research. The ensuing public–private partnership in health

has produced some of the finest medical research in the world. The growth of medical knowledge is unparalleled, and the United States can take well-deserved pride in its research accomplishments. However, many, if not most, of the sophisticated new technologies have addressed the need to ameliorate the problems of patients who already have a condition or disease. Both the priorities and the profits intrinsic to the U.S. healthcare system have focused on remedial rather than preventive strategies. Only in the cases of frightening epidemics, such as that of polio in the mid-1900s and AIDS in the 1990s, have the requisite moral imperatives prevailed in order to adequately fund research efforts that address public health problems. Much of the funding for medical research has failed to fulfill the generally held belief that the products of taxpayer-supported research should benefit not only the practice of medicine but also the community at large. If its intended goals are achieved, the PCORI will change the research focus to be highly inclusive of all stakeholders with a major voice from healthcare consumers by involving them in research topic priority determination and identifying the best mechanisms for meaningfully translating findings into clinical settings.49

Research Ethics and Conflicts of Interest The increasing volume of research funding emanating from pharmaceutical and medical device companies is of serious concern. Pharmaceutical companies that pay researchers to design and interpret drug trials have been accused of misrepresenting the results or suppressing unfavorable findings. The conflicts that arise in the testing of new drugs and medical devices and publishing the results deepen as increasing numbers of studies are shifted from academic institutions to commercial research firms.50 For example, in 2009, the attorney general of New Jersey issued subpoenas to five prominent medical device makers for failing to disclose financial conflicts of interest among the physicians researching their products. Physicians who were testing and recommending the use of certain medical devices were found to have been compensated with stock in the companies making those devices.51 To compound the problem, since the 1990s, much of the U.S. Food and Drug Administration’s (FDA) budget is funded by the user fees the pharmaceutical industry pays the FDA to evaluate and approve new drugs.52 The funding of the clinical trials required for new drugs as part of the FDA’s approval process also are funded by the pharmaceutical companies themselves. The FDA is supposed to oversee the design and outcomes of the trials. However, political and pharmaceutical pressures have caused the FDA to stray from its science-based public health mandate. For example, in 2005, the FDA was sharply criticized for its alleged failure to adequately monitor the risks of widely advertised and commonly used drugs for the treatment of arthritis.53 The FDA’s handling of clinical trial data collected is a major problem. Although the information collected is necessary for FDA approval of a product, once the product is approved, the FDA does not provide the public with a full report of the drug’s safety and efficacy. The withheld information falls into the definition of “trade secrets,” and the FDA has taken the position that research data are entitled to protection as proprietary information. This explains the

number of recent examples of FDA-approved drugs that were later discovered to have major safety risks.54 Clearly, the FDA must reconsider its position that clinical trial data fall into the classification of trade secrets. The most egregious violation of professional ethics is found in the growing body of evidence that physicians at some of the most prestigious U.S. medical schools have been attaching their names and reputations to scientific publications ghostwritten by employees of pharmaceutical companies. The publications are intended, of course, to boost the sales of pharmaceutical products.55 The NIH, which funds much of the nation’s medical research, suggests that the universities involved, rather than the government, should address the problem of ghost authorship. Because university administrators find it difficult to censure the prestigious medical faculty at their institutions, the problem remains minimally addressed with no noted measurable decline in frequency in professional biomedical literature. However, in 2010, Section 6002 of the ACA, also known as the Sunshine Act, now “requires medical product manufacturers to disclose to the Centers for Medicare and Medicaid Services (CMS) any payments or other transfers of value made to physicians or teaching hospitals. It also requires certain manufacturers and group purchasing organizations (GPOs) to disclose any physician ownership or investment interests held in those companies.”56 The pharmaceutical industry also has had a long history of influence in medical education throughout the United States and Canada by providing medical students with funding for food at medical student conferences as well as free medical equipment, books, office supplies, and the like. In large part due to medical student-led investigations and activism, many medical schools are creating policies to significantly limit or curtail this influence by preventing pharmaceutical companies from making such donations.57

Future Challenges The change in emphasis from basic science research toward health services research and population health will likely continue as the federal government moves its Medicare payment model from volume-based to value-based purchasing. This new model under the Medicare Access and CHIP Reauthorization Act (MACRA) will require more health services research on not only how to improve the health of populations but also what changes to the existing healthcare infrastructure will be required to drive the new system. Research will be needed on what organizational structures and policies for new accountable care organizations work best as physicians, hospitals, and other healthcare providers will be working together in new ways and with new goals. Research also will be needed on what changes to the existing health information technology infrastructure are necessary to better support population health, centralized electronic reporting to various government agencies, and information sharing among multiple healthcare institutions, which will be essential for new accountable care organizations to function efficiently. The advent of ubiquitous advanced genetic testing will require research on how to analyze, summarize, and present unprecedentedly large volumes of genetic sequencing data into meaningful information in a form busy clinicians can use efficiently. Medical education will require updating new skills needed by clinicians in areas of population health, systems-based care, health information technology, and basic outcomes research. Research on what new curricula are needed in the era of MACRA will be essential. Continued pressure to improve the quality and drive down the cost of medical care will fuel more comparative effectiveness research to ensure that the best and most cost-effective treatments are utilized. In summary, research that advances science and develops new technologies will be an integral part of healthcare reform for the foreseeable future. This will be true regardless of the method or kind of reform that takes place in the United States.

Discussion Questions 1. What is clinical research, and how is this different from epidemiological research? 2. When reviewing research studies, which is considered the highest level of evidence: systematic reviews, randomized controlled trials, or outcomes research? 3. Explain what is meant by conflicts of interest in research.

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CHAPTER 20 Evidence-Based Practice Kerry Milner

CHAPTER OBJECTIVES 1. 2. 3. 4. 5. 6.

Discuss the historical roots of evidence-based practice. Define key assumptions of evidence-based practice in nursing. Explore evidence-based practice models applicable to advanced practice nursing. Develop a searchable question to answer a clinical problem using the PICOT format. Use common bibliographic databases to search for best current evidence. Identify critical appraisal tools for different sources of evidence.

The History of Evidence-Based Practice The concept of evidence-based practice (EBP) originated in medicine and was first introduced to U.S. healthcare providers in the published literature in a 1992 Journal of the American Medical Association article (Ragan & Quincy, 2012). In this article, evidence-based medicine (EBM) was described as deemphasizing tradition, unsystematic clinical experience, and pathology as sufficient grounds for practice decisions, and it was suggested that critical examination of evidence from practicebased studies should underlie clinical decision making (Evidence-Based Medicine Working Group, 1992). The EBM movement called for physicians to learn the skills of efficient literature searching and the use of formal rules to critically evaluate evidence from the clinical literature. In the early published definitions of EBM, the areas of foci included identifying, critically appraising, and summarizing best current evidence. However, it became clear that evidence alone was not sufficient to make clinical decisions, so in 2000, the Evidence-Based Medicine Working Group presented the second fundamental principle of EBM. This principle specified that clinical decisions, recommendations, and practice guidelines not only must focus on the best available evidence but also must include the values and preferences of the informed patient. Values and preferences refer not only to the patients’ perspectives, beliefs, expectations, and goals for life and health but also to the practices individuals use to consider the available options and the relative benefits, harms, costs, and inconveniences of those options (Guyatt et al., 2000). A similar definition by Canadian medical doctor David Sackett, who is credited with pioneering EBM, emerged around the same time. His definition follows: The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. By individual clinical expertise we mean the proficiency and judgment that individual clinicians

acquire through clinical experience and clinical practice. Increased expertise is reflected in many ways, but especially in more effective and efficient diagnosis and in the more thoughtful identification and compassionate use of individual patients’ predicaments, rights, and preferences in making clinical decisions about their care. (Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996, p. 71) While EBM was being written about in U.S. scientific literature, Archie Cochrane, a British epidemiologist and physician, had been vocal about the lack of systematic reviews upon which to base medical practice, so he published a systematic review on care during pregnancy and childbirth. It was so well received that he was granted government funding for the Cochrane Center in 1992 (Cochrane, 2019). The central mission of the Cochrane Collaboration is to promote healthcare decision making throughout the world that is informed by high-quality, timely research evidence. Today the Cochrane Collaboration is an international network of nearly 30,000 people from over 100 countries helping healthcare providers, policy makers, patients, their advocates, and caregivers make well-informed decisions about health care by preparing, updating, and promoting the accessibility of systematic reviews. While the United States, Canada, and England were implementing EBM, in Australia, in response to the growing trend of evidence-based health care, the Joanna Briggs Institute was created at the Royal Adelaide Hospital in 1996 to facilitate evidence-based health care globally (Jordan, Donnelly, & Piper, 2006). The institute’s original focus was on nursing, and later it changed to incorporating medicine and allied health practitioners. The institute’s definition of evidence-based health care is consistent with early definitions of EBM, stating that clinical decisions should be based on best available scientific evidence while recognizing patient preferences, the context of health care, and the judgment of the clinician (Jordan, Munn, Aromataris, & Lockwood, 2015).

Nursing and EBP Concern about overlooking the patient’s values and preferences in the early definition of EBM by the Evidence-Based Medicine Working Group (1992) prompted nursing to adopt a definition similar to those written by Sackett et al. (1996) and the Joanna Briggs Institute. In 2000, Ingersoll articulated the following definition of EBP for nursing: Evidence-based nursing practice is the conscientious, explicit, and judicious use of theory-derived, research-based information in making decisions about care delivery to individuals or groups of patients and in consideration of individual needs and preferences. (Ingersoll, 2000, p. 154) Unique to this EBP definition was the inclusion of the use of theory as well as evidence when making clinical practice decisions. Leaders in nursing believed that theory and clinical research should be the basis for evidence-based nursing instead of ritual, isolated, and unsystematic clinical experiences, ungrounded opinion, and tradition (Fain, 2014; Ingersoll, 2000). The goal of EBP is to promote effective nursing practice, efficient care, and improved outcomes for patients and to provide the best available evidence for clinical, administrative, and educational decision making (Newhouse, Dearholt, Poe, Pugh, & White, 2007). Key assumptions of EBP in nursing practice include: 1. Nursing is both a science and an applied profession. 2. Knowledge is important to professional practice, and there are limits to knowledge that must be identified. 3. Not all evidence is created equal, and there is a need to use the best available evidence. 4. Evidence-based practice contributes to improved outcomes. Two nurse practitioners (NP), who are educators and researchers in nursing (Melnyk & Fineout-Overholt, 2014), define EBP using Sackett’s definition as a platform and identify seven steps in the EBP process. The EBP process, per this definition, starts with an organizational culture that

supports EBP and encourages nurses at all levels to wonder whether we are doing the best thing. Nurses turn a clinical question into a searchable format using an established method (e.g., PICO) and use this focused question to search for the most relevant evidence. Step 3 involves critically appraising the evidence found in step 2, summarizing the strength and quality of the best relevant evidence, and formulating recommendations. The evidence is integrated with a nurses’ clinical expertise and patients’ values and goals when making a decision or practice change. The next step is to evaluate the outcomes of the EBP decision or practice change. The last step is to disseminate the outcomes of the decision or change locally (e.g., grand rounds) or through traditional methods (e.g., poster or podium presentation, publishable manuscript). Evidence-based practice for nursing is not EBM because it is imperative that many sources of evidence are critically appraised when making practice decisions. Although randomized controlled trials or systematic reviews may provide the most rigorous scientific evidence for EBM, that evidence may not be applicable to nursing and patient care, which requires a holistic approach and a broad range of methodologies as the basis for care (Houser & Oman, 2010). No one research design is better than another when evaluating evidence on effective nursing practices, and appropriate clinical decision making can be achieved only by using several sources of evidence (DiCenso, Cullum, & Ciliska, 1998; Rycroft-Malone et al., 2004). Nonresearch evidence is useful for answering some types of clinical questions. For example, practice-based evidence includes “evidence concerning the contexts, experiences, and practices of healthcare providers working in real-world practice settings” (Leeman & Sandelowski, 2012, p. 171), and the use of qualitative methodologies plays an essential role in creating more practice-based evidence in the evidence base for nursing practice used for problem solving and clinical decision making. Missing from the earlier definitions of EBM and EBP is clinical decision making related to available resources. The reality is that there is a limited amount of healthcare dollars. Therefore, when making evidence-based clinical decisions, nurses and other healthcare professionals must also weigh the cost of benefit, cost of harm, and cost

to the system when providing evidence-based care (Hopp & Rittenmeyer, 2012). NPs are actively championing the advancement of EBP in health care and academia. The Center for Transdisciplinary Evidence-based Practice (CTEP) is a world-renowned center, based at The Ohio State University, that serves as a leader and resource to health professionals, healthcare systems, and academic institutions for implementing best practices through an EBP approach to decision making and sustaining a culture of EBP for the ultimate purpose of improving the quality of health care and outcomes for all (CTEP, 2018). The founders are nurse practitioners whose mission is to: Improve EBP knowledge, skills, and attitudes in clinicians from all disciplines Facilitate EBP across the care continuum and healthcare systems Assist with creating sustainable EBP culture in healthcare systems Synthesize and disseminate evidence to advance evidence-based care Influence health policy by advocating for EBP Assist clinicians and healthcare organizations with expediting the process of translation of evidence into practice Disseminate findings of EBP implementation and research Conduct ongoing research on many aspects of EBP It is clear from the inception of EBM and evidence-based nursing that all healthcare disciplines should be making decisions based on the best available evidence, clinical expertise, patient values and preferences, and available resources. Moreover, leaders in nursing are calling for EBP to be the foundation for everything healthcare providers do (CTEP, 2018).

Why Should NPs Use EBP? If you were diagnosed with breast cancer and were faced with the decision of whether to have a lumpectomy versus mastectomy and chemotherapy versus radiation, would you want your NP to give you the best and latest information on treatment options and the risks and benefits associated with each treatment from systematic reviews or randomized controlled trials (RCT), including patients with the same

diagnosis and similar personal characteristics? Would you want to know about how others with your type of cancer coped with the treatment based on evidence from well-designed descriptive or qualitative studies? There are many reasons why NPs should base their practice on the EBP process. First and foremost is that care that is not evidence based is likely unethical and incompetent (Vincent, Hastings-Tolsma, Gephart, & Alfonzo, 2015). Thus, as the basis of patient care, NPs should integrate research evidence with clinical evidence and patient values while considering available resources in order to provide the best care. NPs should use the EBP paradigm to promote optimal patient outcomes, stimulate innovation in clinical practice, and promote the value of the nursing profession in the healthcare system (Melnyk, 2014). In today’s complex and dynamic patient-care environment, nursing practice informed by the best evidence is vital to realizing healthcare improvements and cost savings (Dearholt & Dang, 2012). The role of the NP has expanded over the years to include a wider scope of practice in many states, thus prompting the need for all NPs to acquire EBP skills and to use best current evidence for clinical decision making (Facchiano & Snyder, 2012a). NPs need to practice using the EBP process because studies have shown that patient care outcomes are substantially improved when health care is based on well-designed studies rather than relying on tradition and clinical expertise alone (Houser & Oman, 2010; Melnyk, 2016a). Existing practices based on tradition or clinical expertise may be harming patients. It is unethical to continue using untested interventions. NPs need to use and understand the EBP process so that they can take a lead role in facilitating the evaluation of evidence to develop EBP guidelines, form EBP teams, identify practices and systems that need study, and collaborate with nurse scientists to initiate research (Melnyk, 2016b).

Evidence-Based Competencies for Advanced Practice Nurses The doctor of nursing practice (DNP) is a practice-focused doctorate that prepares advanced practice nurses for clinical, faculty, and leadership roles; to improve practice and patient outcomes; and to strengthen practice and health care delivery (American Association of Colleges of Nursing, 2004). The American Association of Colleges of Nursing and the DNP essentials are clear that DNP-prepared nurses are the leaders and experts in EBP (Melnyk, 2016b). The following EBP competencies have been developed for NPs working in health systems and should be a part of NP performance evaluations (Melnyk, Gallagher-Ford, Long, & Fineout-Overholt, 2014). 1. Questions clinical practice in order to improve healthcare outcomes. 2. Uses internal evidence (e.g., data from clinical setting) to describe clinical problems. 3. Develops clinical questions in a searchable format (e.g., PICO = Patient population; Intervention; Comparison intervention; Outcome). 4. Conducts systematic, exhaustive searches for external evidence (e.g., evidence from research studies) to answer clinical questions in PICO format. 5. Critically appraises all different evidence types (e.g., clinical practice guidelines, systematic reviews, research studies, evidence reviews, manufacture guidelines). 6. Synthesizes a body of evidence to determine its strength and worth to clinical practice. 7. Collects data from practice (e.g., patient, system, or quality/performance improvement data) to inform clinical decision making. 8. Plans and implements evidence-based practice changes using internal and external evidence, clinical expertise, and patient

preferences to improve healthcare processes and outcomes. 9. Evaluates evidence-based decisions and practice changes for individuals, populations, and systems to determine best practices. 10. Develops evidence-based policies and procedures. 11. Participates in research studies with other healthcare professionals. 12. Is an EBP mentor. 13. Disseminates evidence-based best practices that improve healthcare outcomes. 14. Implements strategies to sustain an EBP culture. 15. Shares best evidence with individuals, colleagues, and policy makers.1 Incorporating these competencies into the standards of practice for NPs working in health systems should facilitate higher quality, efficient care, and improved healthcare outcomes (Melnyk et al., 2014).

How to Translate EBP Into Practice Many EBP models exist that help to guide healthcare systems and their clinicians with implementing EBP policies, protocols, and guidelines. It is important for organizations or healthcare systems to have EBP models that assist clinicians with translating research evidence into the practice setting. A central goal of these EBP models is to speed up the transfer of new knowledge into practice because this has taken years in the past. Use of a model provides an organized approach to EBP implementation and can maximize the use of nursing time and resources (Gawlinski & Rutledge, 2008). There are several EBP models that help with translating research into practice. Common aspects of these models include the EBP process that identifies problems and practice questions and reviews the latest evidence, existing clinical practices and practice guidelines, and other data specific to quality indicators in that setting. No one model of EBP exists that meets the needs of all nursing environments. For the purposes of this chapter, some of the more popular models are described in TABLE 20-1. TABLE 20-1 Evidence-Based Practice Models Model

Description

Processes

ACE Star (Stevens, 2004)

EBP framework for systematically putting EBP processes into operation

1. Knowledge discovery 2. Evidence summary 3. Translation into practice recommendations 4. Integration into practice 5. Evaluation

Advancing Research and Clinical Practice through Close Collaboration Model (ARCC model) (Melnyk & Fineout-Overholt, 2014)

Provides healthcare systems with a guide for implementation and sustainability of EBP to achieve quality outcomes

1. Assessment of organizational culture and readiness for EBP 2. Identification of strengths and major barriers 3. Development and use of EBP mentors 4. EBP implementation

Johns Hopkins Nursing Evidence-Based Practice Model (Dearholt & Dang, 2012)

Assists nurses at the bedside in translating evidence to clinical, administrative, and educational practice

1. Practice question 2. Evidence 3. Translation

Iowa Model of EvidenceBased Practice to Promote Quality Care (Titler et al., 2001)

A guide for nurses and clinicians in making decisions about day-to-day practices that affect patient outcomes

1. Identify type of organizational trigger: problem or knowledge focused 2. Form a team 3. Gather and critically appraise evidence 4. Assess if sufficient evidence 5. Pilot practice change or conduct research 6. Evaluate pilot practice change 7. Institute practice change

Promoting Action on Research Implementation in Health Services Framework (PARIHS framework) (Kitson, Harvey, & McCormack, 1998)

Provides healthcare systems with a framework for how research findings can be successfully implemented into practice with equal recognition of level of evidence, the context into which the evidence is being implemented, and the method of facilitating the change

1. Critical appraisal of evidence 2. Gain understanding of practice area where change will happen 3. Create a strategic plan for practice change 4. Successful implementation is a function of evidence, context, and facilitation

Model for EBP Change (Rosswurm & Larabee, 1999)

Model for translating EBP into the healthcare organization

1. Assess the need for change in practice 2. Locate the best evidence 3. Critically analyze the evidence 4. Design practice change 5. Implement and evaluate change in practice 6. Integrate and maintain change in practice

Transdisciplinary Model of EBP (Newhouse & Spring, 2010)

Interdisciplinary EBP model to accelerate the translation of EBP across disciplines

1. Primary researcher 2. Systematic reviewer 3. Practitioner

Trinity Evidence-Based Practice Model (Vratney & Shriver, 2007)

A conceptual model for EBP that addresses how to overcome barriers to implementation; a guide for growing EBP in your organization while weeding out barriers

1. 2. 3. 4. 5. 6. 7.

Breaking ground Planting seeds Sprouting up Showering of education Heating things up Branching out Bearing fruit

Description Description The ACE Star model, ARCC, PARIHS, model for EBP change, and Trinity EBP model are all models or frameworks for systematically putting the EBP process into operation within a healthcare system. The Johns Hopkins Nursing EBP model and the Iowa Model of Evidence-Based Practice to Promote Quality Care are geared toward clinical decision making at the bedside. The goal of the transdisciplinary model of EBP is to accelerate the translation of the EBP process across disciplines within an organization. In summary, there are many models and frameworks that nurse leaders can choose to help guide and integrate EBP into their healthcare systems.

Searching for Evidence Before you can find the best current evidence for clinical decision making, you must identify a clinical problem and translate it into a searchable, answerable question. The PICOT method is a widely accepted format for creating clinical questions. Melnyk and FineoutOverholt (2014) have developed question templates for asking PICOT questions in nursing based on the type of clinical problem (e.g., intervention/therapy, prevention, diagnosis). (See FIGURE 20-1.) Examples of intervention and prognosis/prediction PICOT questions are displayed in FIGURE 20-2.

FIGURE 20-1 PICOT definitions and questions. Reproduced from Melnyk, B., & Fineout-Overholt, E. (2010). Evidence-based practice in nursing & healthcare. New York, NY: Lippincott Williams & Wilkins, p. 26. Reprinted by permission of Lippincott Williams & Wilkins.

Description

FIGURE 20-2 Examples of intervention and prognosis/prediction PICOT questions.

Description Searching databases for the best current evidence after developing a PICOT question is the next step in the EBP process. Melnyk and FineoutOverholt (2014) identified eight steps for an efficient search: 1. Begin with a PICOT question, and the P, I, C, O, T should be used as the key words (e.g., P = veteran with diabetes, I = shared medical appointment, C = routine office visit, O = clinical outcomes, T = 1 year) that will be used for the search. 2. Establish inclusion and exclusion criteria before searching (e.g., studies published in the last 5 years). 3. Use controlled vocabulary headings when available (e.g., MeSH). 4. Expand the search using the explode option. 5. Use tools to limit the search so that the topic of interest is the main point of the article. 6. Combine searches generated from PICOT key words. 7. Limit the final search results with meaningful limits, such as year,

type of study, age, gender, and language. 8. Organize studies in a meaningful way using evidence summary tools (e.g., Johns Hopkins Nursing Evidence Based Practice [JHNEBP] Individual Evidence Summary Tool). Bibliographic databases commonly used for searches by NPs include the Cochrane Library, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medical Literature Online (MEDLINE), PubMed, National Guideline Clearinghouse, and Embase. Several of these databases require a subscription fee. TABLE 20-2 includes a variety of sources for finding evidence to aid clinical decision making, a description of the evidence for each source, the website addresses, and whether a fee is needed to access. In the following paragraphs, some of the more popular databases are described in more detail. TABLE 20-2 Sources of Evidence

Description Description Description The Cochrane Library is a collection of seven databases that may be used to find the best current evidence in health care. The most popular database is the Cochrane Database of Systematic Reviews. This database contains systematic reviews of primary research in human health care and health policy. This database is maintained by the Cochrane Working Group, and their reviews are held to the highest scientific standards. Abstracts of reviews are available free of charge from the Cochrane website; however, full reviews are available by subscription. The Cochrane Database of Systematic Reviews is found online at https://www.cochranelibrary.com. The CINAHL database produced by EBSCO Information Systems has greater than 2.6 million records and provides indexing to more than 3,000

journals from nursing and allied health fields. In addition to journals, this database has publications from the National League for Nursing, American Nurses Association, references to healthcare books, nursing dissertations, legal cases, clinical innovations, critical paths, drug records, evidence-based care sheets, research instruments, and clinical trials. To access this database, you need a subscription. The MEDLINE database is provided by the National Library of Medicine and is widely known as the premier source for bibliographic and abstract coverage of biomedical literature. It has indices that reference more than 5,000 journals and includes at least 300 journals specific to nursing. PubMed is the National Library of Medicine’s Web interface, through which MEDLINE can be accessed for free. PubMed has free tutorials on how to conduct searches. Abstracts are free as well as some full-text articles; otherwise, a fee is charged to retrieve full-text articles. A guide of MEDLINE and PubMed resources can be found at www.nlm.nih.gov/bsd/pmresources.html. The Joanna Briggs Institute is an international collaboration involving nursing, medical, and allied health researchers, clinicians, academics, and quality managers across 40 countries in every continent. The Joanna Briggs Institute connects healthcare professionals with the best available international evidence at the point of care. They offer systematic reviews, best practice information sheets, and critical appraisal tools. Some information is free, but most information is accessed by paying a fee. The National Guideline Clearinghouse is a search engine for finding clinical practice guidelines. This database is available free of charge from the AHRQ and is a mechanism for obtaining objective, detailed information on clinical practice guidelines from all over the world. Guidelines can be searched using medical subject headings (MeSH) or by disease/condition, treatment/intervention, or health services administration. You can also sign up for email alerts based on a topic of interest. Embase is a subscription-based international biomedical and pharmaceutical database that includes over 24 million indexed records and 7,600 peer-reviewed journals. All MEDLINE records produced by the National Library of Medicine are included, as are over 5 million records not covered on MEDLINE. Embase has in-depth indexing of the drugrelated and clinical literature, with a particular focus on comprehensive

indexing of adverse drug reactions, systematic reviews, and development and use of medical devices. Busy NPs with limited resources or limited time should start their search in PubMed because it is a free database that can be accessed via the Internet from any mobile device (Facchiano & Snyder, 2012b). Natural language or key words can be used for the search by typing in words from your PICOT question (e.g., diabetes). Searches may also be done using controlled vocabulary called medical subject headings (MeSH). In PubMed, when you type in key words or natural language, you will automatically get MeSH and you can click on these words and continue the search with these words. You can use built-in filters within PubMed to further refine the search. One example is the clinical queries filter that extracts evidence based on the best study design to answer that PICOT question. Boolean operators include and, or, and not. They can link key words and further define the search, such as diabetes care and veterans. Searches can be further defined using the limit feature. This feature includes many categories, such as age, gender, English language, year of publication, and humans or animals. It is important to become familiar with how to do searches efficiently. PubMed offers free tutorials on how to search their database and can be accessed via the home page. NPs should investigate gaining access to a health science librarian to aid with searches for evidence. Librarian-provided services have been shown to be effective in saving time for health professionals and providing relevant information for decision making (Perrier et al., 2014). Moreover, studies demonstrated decreased patient length of stay when clinicians requested literature searches related to a patient’s case.

What Counts as Evidence? NPs use a variety of sources of evidence to make clinical decisions regarding diagnoses, treatments, and interventions on a daily basis. Evidence can come from external sources, such as published research studies, or internal sources, such as quality improvement (QI) data or clinical data. What is important to remember is that not all evidence is equally rigorous or applicable to your practice setting or the patient populations that you manage. Evidence from a textbook, colleague, or single journal article is not the same as evidence from a systematic review of randomized controlled trials that answers a particular research question. Moreover, the evidence must match the type of clinical question in PICOT format being asked. For example, a synthesis of cohort or case control studies is the highest level of evidence for answering prediction/prognostics questions. Lastly, NPs must be adept at assessing the level, quality, and strength of evidence in order to make a judgment about whether to translate that evidence into practice. Evidence hierarchies exist to help healthcare providers assess the level of evidence that is based on type of research design (quantitative or qualitative), summaries of research (e.g., systematic review of quantitative, qualitative, or both), and types of nonresearch evidence (e.g., clinical practice guideline). In most evidence hierarchies, the strongest evidence is from rigorous scientific research or systematic reviews with or without meta-analysis of single randomized control trials and the weakest evidence is manufacture recommendations. Evidence hierarchies that contain other evidence types in addition to research studies are most useful to the practicing nurse because many nursing care problems cannot be investigated using such research designs as RCT (Jones, 2010). In this section, select evidence hierarchies from different organizations in nursing and medicine are described. The American Association of Critical-Care Nurses created their own evidence-leveling system for all their publications, as outlined in TABLE 203 (Armola et al., 2009). The AACN’s system is unique in that it includes meta-analysis of multiple controlled trials or metasynthesis of qualitative

studies in the highest level of evidence and manufacturer’s recommendations in the lowest level of evidence. All AACN resources include the evidence-leveling system so that practitioners have a reliable guide to assist in determining the strength of evidence. TABLE 20-3 AACN Evidence-Leveling System Level

Evidence Type

A

Meta-analysis of multiple controlled studies or metasynthesis of qualitative studies with results that consistently support specific action, intervention, or treatment.

B

Well-designed controlled studies, both randomized and nonrandomized, with results that consistently support a specific action, intervention, or treatment

C

Qualitative studies, descriptive or correlational studies, integrative reviews, systematic reviews, or randomized controlled trials with inconsistent results

D

Peer-reviewed professional organizational standards, with clinical studies to support recommendations

E

Theory-based evidence from expert opinion or multiple case reports

M

Manufacturers’ recommendations only

Reproduced from Armola, R. R., Bourgault, A. M., Halm, M. A., Board, R. M., Bucher, L., Harrington, L., . . . Medina, J. (2009). AACN levels of evidence: What’s new? Critical Care Nurse 2009, 29(4), 70–73. © AACN. Reprinted by permission.

Description The Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence is a hierarchy of evidence described in TABLE 20-4. The OCEBM hierarchy of evidence was designed to help busy clinicians, researchers, or patients find the best evidence for a particular type of clinical question (e.g., intervention/diagnosis, prognosis/prediction or etiology, meaning). A clinician who needs to find the best evidence for a treatment clinical query should look for systematic reviews of randomized trials first because they usually provide the most reliable answers. If no evidence is found, the search should continue with individual randomized trials, and

so on down the OCEBM Levels of Evidence table. TABLE 20-4 OCEBM Levels of Evidence Type of Question

Level of Evidence

Diagnostic or diagnostic test

1. 2. 3. 4. 5. 6. 7.

Systematic review/meta-analysis of RCTs RCTs Nonrandomized controlled trials Cohort study or case-control studies Metasynthesis of qualitative or descriptive studies Qualitative or descriptive single studies Expert opinion

Prognosis/prediction or etiology

1. 2. 3. 4. 5.

Synthesis of cohort study or case-control studies Single cohort study or case-control studies Metasynthesis of qualitative or descriptive studies Single qualitative or descriptive studies Expert opinion

Meaning

1. 2. 3. 4.

Metasynthesis of qualitative or descriptive studies Single qualitative studies Synthesis of descriptive studies Expert opinion

Reproduced from OCEBM Levels of Evidence Working Group*. (2011). The Oxford Levels of Evidence 2. Oxford Centre for Evidence-Based Medicine. Retrieved from http://www.cebm.net/index.aspx?o=5653. Reprinted by permission. * OCEBM Levels of Evidence Working Group = Jeremy Howick, Iain Chalmers (James Lind Library), Paul Glasziou, Trish Greenhalgh, Carl Heneghan, Alessandro Liberati, Ivan Moschetti, Bob Phillips, Hazel Thornton, Olive Goddard and Mary Hodgkinson

Description An important concept raised early in this section that the OCEBM Levels of Evidence table highlights is that different types of evidence are appropriate for answering different clinical questions. For example, an NP working in obstetrics may ask the health sciences librarian to do a literature search to answer the question: How do pregnant women (P) with gestational diabetes (I) perceive reporting their blood sugar results (O) to their healthcare providers during pregnancy and 6 weeks postpartum (T)? Because this is a meaning PICOT question, the highest

level of evidence appropriate for answering this question would be metasynthesis of qualitative or descriptive studies. Conversely, an NP working in labor and delivery has seen a 3-month spike in postpartum hemorrhage after a practice change from an oxytocin infusion dosage of 80 mg/500 mL to 10 mg/500 mL. The NP should use the PICOT intervention question template to develop a searchable clinical question; systematic reviews with meta-analysis of RCTs would be the appropriate highest level of evidence to answer the question. Multiple evidence hierarchies can be overwhelming, so I created a single general level of evidence hierarchy based on evidence type for the busy NP to refer to when rating level of evidence (TABLE 20-5). The type of PICOT question each evidence type answers is included. TABLE 20-5 General Levels of Evidence Hierarchy Based on Evidence Type

Evidence Type

Type of PICOT Question Answered

Level

Systematic review with or without metaanalysis of single randomized controlled trials

Intervention, Diagnostic

1

Single randomized controlled trial

Intervention, Diagnostic

2

Systematic review with or without metaanalysis of mixed experimental study designs (RCT or quasi-experimental)

Intervention, Diagnostic

3

Nonrandomized controlled trial or systematic review of mixed experimental and nonexperimental study designs

Intervention, Diagnostic, Prognosis/Prediction, Etiology

4

Observational studies (cohort, casecontrol)

Intervention, Diagnostic, Prognosis/Prediction, Etiology

5

Metasynthesis or single qualitative or descriptive studies

Prognosis/Prediction, Etiology, Meaning

6

Peer-reviewed professional and organizational standards with clinical

Intervention, Diagnostic, Prognosis/Prediction, Etiology

7

studies to support recommendations Expert opinion or literature review or peer-reviewed professional and organizational standards without clinical studies to support recommendations

Meaning

8

Manufacturer recommendations

Meaning

9

Description In practice, there is often a lack of clarity among the terms, level of evidence, quality of evidence, and strength of evidence (Jones, 2010). In this section, level of evidence was described and examples of different hierarchies of evidence that can help the NP to rate level of evidence were provided. Rating the level of evidence is the first in a three-step process for assessing evidence for translation into practice, as outlined by Jones (2010). The additional steps of assessing quality of evidence and strength of evidence are described in the next section.

Critical Appraisal of Evidence Critical appraisal of evidence is an important step in the EBP process that comes after the search for best current evidence. Publication of research studies and other types of evidence do not guarantee quality, value, or applicability to clinical practice. Thus, NPs must have strong research and statistical literacy to critically appraise all types of evidence sources and to determine their worth to practice. There are many types of critical appraisal tools that NPs can use to assess the quality of research and nonresearch evidence (TABLE 20-6). These tools are designed to help the user systematically examine and critique evidence to determine its validity, clinical significance, and applicability to practice. Critical appraisal tools include specific questions based on a particular methodology or research design; therefore, it is important to pick the correct tool based on the type of evidence you are critically appraising. TABLE 20-6 Critical Appraisal Tools for Different Sources of Evidence

Description Description Johns Hopkins Nursing (Dearholt & Dang, 2012), Melnyk and FineoutOverholt (2014), Centre for Evidence-Based Medicine, and United Kingdom Critical Appraisal Skills Programme (CASP) have created critical appraisal tools for specific research designs and nonresearch evidence. Craig Hospital in Colorado created a pocket-sized general critical appraisal tool for their nurses to carry and use as a quick guide when reading research (FIGURE 20-3).

FIGURE 20-3 Craig Hospital critical appraisal tool. Journal Club Critique Book Mark. Research/EBP/Quality Committee, Craig Hospital, Englewood, CO. Used with permission.

Description

Strength of the evidence is determined by synthesizing the information on the level of evidence (hierarchy of evidence) and quality of evidence (critical appraisal tool) (Jones, 2010). This process begins by organizing the important pieces of information from the completed critical appraisal tools for each evidence source in a meaningful way, and this can be done by using a summary of evidence table. Using Word or Excel software, you may create your own table or use TABLE 20-7. If your evidence is solely from experimental studies, you may want to use TABLE 20-8, which is an example of an evidence summary table for RCT/nonRCT created by Facchiano and Snyder (2013). The underlying concept is to choose a table format that will help you organize evidence from multiple studies or sources in the most efficient manner that answers your PICOT question. The summary table should provide a succinct, stand-alone account of the important study/article details that is understandable to anyone viewing the table. The summary of evidence table forms the basis for creating an evidence synthesis table and the recommendations described in the next section. TABLE 20-7 Summary of Evidence Table

Description Modified from JHNEBP Tools

TABLE 20-8 Evidence Summary Table for Randomized or Nonrandomized Trials

Description

Evidence Synthesis and Recommendations Evidence synthesis is the next step after organizing the evidence in a meaningful way. This can be done using the evidence synthesis table (TABLE 20-9). This table is organized by number of evidence sources for each level of evidence as well as overall summary of evidence source results and overall rating of quality of evidence sources. Strength of evidence is determined from the evidence synthesis table. TABLE 20-9 Evidence Synthesis

Description Strength of a body of evidence has been defined in terms of quality, quantity, and consistency for intervention studies (Manchikanti, Abdi, & Lucas, 2005). Quality is the extent to which relevant studies for a given topic minimized bias. Quantity includes the number of studies that have evaluated the given topic, intervention effect size, and overall sample size across all studies. Consistency reflects the extent to which similar findings are reported from work on a given topic using similar and different study designs. The JHNEBP model includes a broadly defined quality of evidence rating scale for research and nonresearch evidence sources (Dearholt & Dang, 2012) that has characteristics of the domains (quality, quantity, and consistency) for rating overall strength of a body of evidence by

Manchikanti et al. (2005). For research evidence, a rating of high is defined as “consistent, generalizable results; sufficient sample size for study design; adequate control; definitive conclusions; consistent recommendations based on comprehensive literature review that includes thorough reference to scientific evidence” (p. 108). A rating of good is defined as “reasonably consistent results; sufficient sample size for the study design; some control; fairly definitive conclusions; reasonably consistent recommendations based on fairly comprehensive literature review that include some reference to scientific evidence” (p. 108). A rating of low or major flaw is considered “little evidence with inconsistent results; insufficient sample size for the study design; conclusions cannot be drawn” (p. 108). The JHNEBP model has a Quality Rating System for Organizational Experience that can be used to rate the quality of evidence sources from QI, financial evaluation, or program evaluation (Dearholt & Dang, 2012). A high quality rating has “clear aims and objectives; consistent results across multiple settings; formal quality improvement or financial evaluation methods used; definitive conclusions; consistent recommendations with thorough reference to scientific evidence” (p. 244). Good quality is defined as “clear aims and objectives; formal quality improvement or financial evaluation methods used; consistent results in single setting; reasonably consistent recommendations with some reference to scientific evidence” (p. 244). Evidence rated as low quality or major flaws is “unclear or missing aims and objectives; poor defined quality improvement/financial analysis method; recommendations cannot be made” (p. 244). Judgments about a body of evidence are used to support recommendations. For example, the strength of evidence (level of evidence + quality of rating of evidence) may be very strong with consistent, high-quality evidence to support a practice change. Conversely, there may be very little strong, consistent, quality evidence, so original research is needed. It is also possible to find good evidence, but conflicting results and a practice change is not recommended until more consistent research evidence becomes available. A pilot of the practice change may be in order if there is good evidence with consistent results from lower level evidence sources and quality ratings. In the next two sections, critical appraisal skills for single intervention

study and clinical practice guidelines are described.

Critical Appraisal of a Single Intervention Study It is probable as an NP that you will hear about results from a single RCT and ask, “Should I incorporate these findings into my practice?” To answer this question, you should follow the EBP process from the critical appraisal step. Step 1 is to assess the level of evidence, and based on the evidence hierarchy in Table 20-5, a single RCT is level 2 evidence. Next, read the study abstract to assess if the study is relevant to your practice and the patients in your practice. If the clinical problem is one you encounter frequently, then you should read the whole article to determine if the treatment is feasible given the resources in your practice (Vincent et al., 2015). Step 2 involves an assessment of the quality of evidence, and you could use any of the tools for RCTs listed in Table 20-6 under Critical Appraisal Tools by Research Method. The next step is to determine the clinical significance. This can be done by looking at the number needed to treat (NNT) and the absolute relative risk, otherwise known as the effect size. The absolute risk reduction (ARR) compares the event rate in the treatment group to the event rate in the control group. If a study found that 80% of patients in the treatment group improved and 20% of patients in the control group improved, the ARR would be 80% – 20% = 60%. The NNT is calculated by dividing 100 by the ARR: 100/60 = 1.6; so for every two patients exposed to the treatment, one will benefit. After validating the findings from the study, the last step is to determine if patients in your practice mirror the patients described in the study. If this were a real-life example and your patients’ values and preferences were open to the treatment, costs were low, and the treatment could be easily adopted into your setting, then you would adopt this new treatment.

Critical Appraisal of Clinical Practice Guidelines NPs should be able to rapidly appraise the strength of clinical practice guidelines and the quality of evidence used to create the guidelines. Guidelines should be critically appraised in terms of validity, usefulness, when last updated, and clinical context, including environment and

patient values and preferences. Rapid critical appraisal checklists for clinical practice guidelines have been developed by the AGREE Collaboration and by Melnyk and Fineout-Overholt (2014). At the bottom of Table 20-6, there is a listing of the tools for appraising clinical guidelines and where they can be accessed. The AGREE II tool is a free, valid, and reliable 23-item tool that is organized into the domains of scope and purpose, stakeholder involvement, rigor of development, clarity of presentation, applicability, and editorial independence. Each of the 23 items focuses on an area of the clinical practice guideline quality. The AGREE II tool also includes two overall guideline assessment items where the appraiser rates the overall quality of the practice guideline and makes a determination of whether to use the practice guideline (BOX 20-1).

BOX 20-1 AGREE II Instrument Scope and Purpose The overall objective(s) of the guideline is (are) specifically described. The health question(s) covered by the guideline is (are) specifically described. The population (patients, public, etc.) to whom the guideline is meant to apply is specifically described. Stakeholder Involvement The guideline development group includes individuals from all relevant professional groups. The views and preferences of the target population (patients, public, etc.) have been sought. The target users of the guideline are clearly defined. Rigor of Development Systematic methods were used to search for evidence. The criteria for selecting the evidence are clearly described. The strengths and limitations of the body of evidence are clearly described. The methods for formulating the recommendations are clearly described. The health benefits, side effects, and risks have been considered in formulating the recommendations. There is an explicit link between the recommendations and the supporting evidence. The guideline has been externally reviewed by experts prior to its publication. A procedure for updating the guideline is provided. Clarity of Presentation The recommendations are specific and unambiguous. The different options for management of the condition or health issue are clearly presented. Key recommendations are easily identifiable.

Applicability The guideline describes facilitators and barriers to its application. The guideline provides advice and/or tools on how the recommendations can be put into practice. The potential resource implications of applying the recommendations have been considered. The guideline presents monitoring and/or auditing criteria. Editorial Independence The views of the funding body have not influenced the content of the guideline. Competing interests of guideline development group members have been recorded and addressed. Overall Guideline Assessment Rate overall quality of guideline. I would recommend this guideline for use. “AGREE III : advancing guideline development, reporting and evaluation in health care” by Melissa C. Brouwers, et al. Canadian Medical Association Journal, volume 182, issue 18, 2010, p. 841. Copyright © 2010 by Canadian Medical Association. This work is protected by copyright and the making of this copy was with the permission of Access Copyright. Any alteration of its content or further copying in any form whatsoever is strictly prohibited unless otherwise permitted by law.

A new feature is My AGREE PLUS, which allows users to complete individual AGREE II Appraisals, contribute to and coordinate group AGREE II appraisals, save appraisals to a personal library, and share appraisals with colleagues. The AGREE II website, www.agreetrust.org/agree-ii, has excellent tutorials on how to use the tool and the software. Grading recommendation systems have been created to assist the clinician with evaluating the strength of recommendations and the quality of underlying evidence that the clinical guideline is based upon. The strength of a recommendation reflects the extent to which the clinician can be confident that the clinical guideline has the desired effect rather than the undesired effect (Guyatt et al., 2008). A systematic approach in the grading of recommendations is important to cut down on bias and to aid in the interpretation of clinical guidelines developed by experts. Two examples of grading systems are the U.S. Preventive Services Task Force (USPSTF) and the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach that is used by clinical decision-making systems like UpToDate and Cochrane Collaboration. The USPSTF grading system is displayed in TABLE 20-10. In this

system, Grade A is the strongest recommendation, and clinicians should offer this service to their patients. Grade D is the weakest recommendation, and clinicians should not provide this service to their patients. There is an additional recommendation of Grade I, which means clinicians should proceed with caution, and patients who want the service need to be aware of the uncertainty of the benefits and harms. Clinicians can visit the website and access free clinical guidelines for many clinical categories (e.g., cancer, heart and vascular diseases, mental health conditions). The guidelines are created by rigorously evaluating clinical research and assessing the merits of preventive measures, including screening tests, counseling, immunizations, and preventive medications. The USPSTF provides a grade for each clinical guideline. TABLE 20-10 USPSTF Task Force Recommendation Grades and Suggestions

Grade

Grade Definitions

Suggestions for Practice

A

The USPSTF recommends the service. There is high certainty that the net benefit is substantial.

Offer or provide this service.

B

The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.

Offer or provide this service.

C

The USPSTF recommends selectively offering or providing this service to individual patients based on professional judgment and patient preferences. There is at least moderate certainty that the net benefit is small.

Offer or provide this service only if other considerations support offering or providing the service in an individual patient.

D

The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits

Discourage the use of this service.

I Statement

The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the

Read the clinical considerations section of USPSTF Recommendation Statement. If the service is

balance of benefits and harms cannot be determined.

offered, patients should understand the uncertainty about the balance of benefits and harms.

Reproduced from USPSTF. (2017). Grade definitions. Retrieved from https://www.uspreventiveservicestaskforce.org/Page/Name/grade-definitions

Description The GRADE, which began in 2000, is a method of linking evidencequality evaluations to clinical recommendations (Guyatt et al., 2008). In the GRADE approach, recommendations are classified as strong or weak, according to the balance between desirable effects (health benefits, less burden, cost savings) versus undesirable effects (harms, more burdens, costs). A strong recommendation means that the most informed patients would choose the recommended management, and clinicians can recommend the intervention to patients. Weak recommendations mean the intervention has too many undesirable consequences (Guyatt et al., 2008). The GRADE approach also includes quality of evidence and patient preferences. UpToDate, a clinical decision system, uses the GRADE approach (TABLE 20-11). In this system, a grade of 1A means a strong recommendation to use this intervention and the guideline has high-quality evidence backing it. Conversely, a grade of 2C means a weak recommendation with low-quality evidence, and other options should be explored. Both the GRADE Working Group and UpToDate have GRADE resources and tutorials that are free and can be accessed at www.gradeworkinggroup.org and www.uptodate.com/home/grading-tutorial, respectively. TABLE 20-11 UpToDate Grading System for Clinical Practice Recommendations



Description Description Reproduced with permission from UpToDate and GRADE. (2013). Grading guide. In UpToDate, D. S. Basow (Ed). UpToDate, Waltham, MA, 02013 (Accessed March 16, 2019). Copyright © 2019 UpToDate, Inc. For more information, visit www.uptodate.com.

Outcomes of the EBP Process The EBP process should be the core foundation from which all NPs practice. NPs should routinely question practice, describe practice problems using internal evidence (e.g., QI data), formulate clinical questions to answer practice problems in PICOT format, systematically search for external evidence, critically appraise evidence, synthesize evidence, and make recommendations. Outcomes of the EBP process can take the form of research, EBP, QI, and program evaluation. Therefore, a comparison of these outcomes with an example of each is displayed in TABLE 20-12. TABLE 20-12 Comparison of Research, EBP, QI, and Program Evaluation Characteristics

Description Description

Shared Decision Making: An Important but Often Missed Part of EBP Despite the varied definitions of shared decision making (SDM) in the literature (Makoul & Clayman, 2006), Charles, Gafni, and Whelan (1997) first described this collaborative process between patient and provider where information is exchanged and deliberated and treatment decisions are made. Healthcare reform, including the passage of the Affordable Care Act and subsequent regulations, has spurred healthcare delivery systems to engage patients and families in SDM (Friedberg, Van Busum, Wexler, Bowen, & Schneider, 2013). Existing evidence suggests that SDM benefits patients of all ages and educational levels (Wexler et al., 2015). Both patient-centered care and evidence-based practices are foundational to the SDM process between providers and patients. Although SDM is the preferred model for engaging patients in the process of decisions about care when more than one reasonable option is available, no option has a clear advantage, or the options have benefits and harms that the patient may value differently (Stacey et al., 2014; Stiggelbout, Pieterse, & De Haes, 2015); use of this model in practice by clinicians is lacking (Couët et al., 2015; Légaré et al., 2008). The SHARE Approach is a model for SDM developed by the AHRQ (2016). It is a five-step process that includes exploration and comparison of the benefits, harms, and risks of care options using meaningful provider–patient dialogue. Step 1 is seeking the patient’s participation. Step 2 is helping the patient explore and compare treatment options. Step 3 is assessing the patient’s values and preferences. Step 4 involves reaching a decision with your patient. Step 5 is to evaluate the patient’s decision. In situations where the patient cannot make decisions, the family may participate in each step. Decision aids (DA) are effective tools to facilitate the SDM discourse between the patient and the provider (Stacey & Légaré, 2015). These

tools can be used to prepare the patient to make informed, value-based decisions with their provider. High-quality evidence exists that DA improve patients’ knowledge of options and facilitate informed, clear decisions based on preferences (Stacey & Légaré, 2015). Moderate quality evidence suggests that patients participate more in decision making when using DA. Despite the availability of hundreds of free DA through the AHRQ and the Ottawa Hospital Research Institute (OHRI), translation of these tools into practice is slow. NPs must be the leaders in implementing SDM and DA in the practice setting as part of the EBP process.

Barriers to EBP If EBP is as much about removing harmful or ineffective practices as it is about implementing robust evidence into practice (Vincent et al., 2015) and it is unethical to practice using evidence-less care (Jones, 2010), why do barriers to EBP continue to exist? Houser and Oman (2010) identified three categories associated with barriers to using evidence in clinical practice that continue to be relevant today (Warren et al., 2016). The first category includes limitations in EBP systems caused by an overwhelming amount of evidence and sometimes contradictory findings in the research. The second category is human factors that create barriers. These factors include lack of knowledge about EBP and the skills needed to conduct EBP, nurses’ negative attitudes toward research and evidence-based care, nurses’ perception that research is only for medicine and is a cookbook approach, and patient expectations. The last category identifies the lack of organizational systems or infrastructure to support clinicians using EBP. Causes for barriers in this category include lack of authority for clinicians to make changes in practice, peer emphasis on practicing the way they always have practiced, lack of time during the workday, lack of administrative support or incentives, and conflicting priorities between unit work and research. The barriers described here may seem overwhelming; however, all healthcare-related disciplines are becoming evidence based, and professional organizations, accrediting bodies, insurers, and third-party payers are requiring nurses to use evidence to support clinical practices and decision making. Therefore, organizations need to address these barriers and to put systems in place to support EBP (Warren et al., 2016). Moreover, NPs with DNP degrees must be EBP leaders who mentor others and promote the EBP process as the foundation upon which practice is built.

Summary Evidence-based nursing practice is the conscientious, explicit, and judicious use of theory-derived, research-based information in making decisions about care delivery to individuals or groups of patients and considers individual needs and preferences. It is vital to a practice-based profession like nursing to use the best current evidence from many sources when making clinical decisions. EBP competencies have been described for the NP and should be part of performance evaluation criteria. There are several steps in the EBP process, beginning with fostering a spirit of inquiry, asking the right clinical question in a PICOT format, finding the best current evidence, critically appraising the evidence, and integrating the synthesis of evidence with patient values and preferences. Best current research evidence can be found in many Web-based electronic databases, such as the Cochrane Database of Systematic Reviews. There are databases for clinical practice guidelines, such as the National Guideline Clearinghouse. There are quantitative, qualitative, and nonresearch tools specific to study design or evidence type to assist clinicians with rapid systematic appraisal of evidence. Strength of the evidence is determined by synthesizing the information on the level of evidence (hierarchy of evidence) and quality of evidence (critical appraisal tool). An evidence summary table provides a succinct, stand-alone account of the important study/article details and the critical appraisal results. An evidence synthesis table incorporates data from the evidence summary table to make recommendations that are based on the strength of the evidence. Existing EBP models can be used to implement and sustain a culture of EBP. These models may aid with translation of evidence into practice. Outcomes of EBP can take the form of NPs collaborating on original research, QI studies, or program evaluation. Shared decision making and the AHRQ SHARE Approach can be used by NPs to facilitate the incorporation of patient values, preferences, and goals when making care decisions. Existing decision aids for many health conditions or treatments are available for free. NPs should be

leaders in adopting this practice. Health systems continue to face the same barriers to implementing and sustaining EBP. NPs need to take an active role in breaking down these barriers, being EBP mentors, and promoting the EBP process as the foundation from which all practice is built.

Discussion Questions 1. Explain the steps of the EBP process. 2. Write a clinical question in PICOT format for each template type for common practice problems encountered by NPs. Swap answers with a peer and provide feedback. 3. Sign up for clinical practice alerts from the TRIP database in your specialty area. 4. Think about a patient problem you have had in the clinical setting and answer the following: a. What formal structures were in place to help you address the problem? b. How did you use evidence to investigate the problem? c. Did you have time to search for evidence? If no, what were the barriers? d. What databases did you access for evidence and why? e. Did you use a health sciences librarian to help with your search? Explain why or why not. 5. Go to www.guideline.gov and search for chronic pain management clinical practice guidelines. Compare and contrast two guidelines. 6. Find a clinical practice guideline from the National Guideline Clearinghouse. Use the AGREE II Plus software to critically appraise the guideline with two or more peers. 7. Find a recent randomized controlled trial on a topic of interest. Critically appraise the study using a tool from this chapter. Using an evidence hierarchy from this chapter, identify the level of evidence. Enter the relevant data into an evidence summary table. Rate the quality of evidence using the JHNEBP quality rating. Summarize clinical significance using NNT and effective size. 8. Using the databases described in this chapter, find two or more of the following evidence types: research study, QI study, EBP project, or program evaluation. Describe the search process used. After reading the articles, compare and contrast the different methodologies. Did the authors provide support for the selected methodology? Give

examples to support your answer. 9. Identify areas where SDM can be used in your practice. Go to https://decisionaid.ohri.ca and browse the decision aids by topic. Select a decision aid and write a plan for how it can be incorporated into your practice setting.

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1 Modified from Melnyk, B. M., Gallagher-Ford, L., Long, L. E., & Fineout-Overholt, E. (2014). The establishment of evidence-based practice competencies for practicing registered nurses and advanced practice nurses in real-world clinical settings: Proficiencies to improve healthcare quality, reliability, patient outcomes, and costs. Worldviews on Evidence-Based Nursing, 11(1), 5-15. Retrieved from https://sigmapubs.onlinelibrary.wiley.com/doi/full/10.1111/wvn

© Zen Rial/Moment/Getty Images.

CHAPTER 21 Clinical Scholarship and Evidence-Based Practice Catherine Tymkow True scholarship consists in knowing not what things exist, but what they mean; it is not memory but judgment. —James Russell Lowell

CHAPTER OBJECTIVES 1. Discuss differences between the practice doctorate in nursing and the research doctorate. 2. Describe the evolution of the doctor of nursing practice curriculum and its potential impact on the future of nursing. 3. Identify different educational pathways to the doctor of nursing practice degree. 4. Analyze factors in our current healthcare delivery system that are driving the need for nurses prepared as a expert clinicians.



A

ny discussion of scholarship and evidence-based practice (EBP) and the doctor of nursing practice (DNP) degree must first begin with some essential questions. These include questions as basic as the following: What is scholarship? Are EBP and clinical scholarship the same thing? How does clinical scholarship differ from the traditional definition of scholarship? Why do we need nursing scholars in practice settings? What is the role of the DNP-prepared nurse in clinical scholarship? What are the knowledge resources, tools, and methods

necessary to implement and support clinical scholarship and EBP? These questions are important ones to consider as healthcare organizations and schools of nursing redefine and expand nurses’ roles. If nursing is to maintain a full partnership with medicine in the delivery of health care, the education of nurse leaders and nurses in advanced practice roles must be at a comparable level with other doctorally prepared healthcare practitioners such as MDs, PharmDs, and PsyDs. The merging of nursing leadership skills, evidence-based decision making, and expert clinical care will ensure that nursing has a strong and credible presence in an ever-changing and complex healthcare system. In a presentation by former president Faye Raines to the American Association of Colleges of Nursing (AACN), the leader noted that “the DNP degree more accurately reflects current clinical competencies and includes preparation for the changing healthcare system” (Raines, 2010, p. 5). The DNP degree is a terminal practice degree and is now considered by many healthcare organizations as the preferred degree for nursing leaders involved in the delivery and organization of clinical care and healthcare systems. The result has been a proliferation of DNP programs throughout the United States. Since the first edition of this book, the number of DNP programs and DNP graduates has increased exponentially. In a recent survey, the AACN reported that there are now 303 DNP programs in 50 states, with 124 more in the planning stages. Of those in planning, 58 are post-baccalaureate programs and 66 are postmaster’s programs. In 2016 there were 25,289 students enrolled in DNP programs and 4,855 graduates—a 29% increase since the last edition of this book (AACN, 2017). The DNP’s academic preparation—with a strong curricular base in advanced practice principles, experiential learning, intra- and interprofessional collaboration, and application of the best clinical research evidence—as illustrated by this growth in numbers, is positioned to fulfill nursing’s goals for leadership in practice and clinical education. In addition, clinical scholarship, including critical inquiry, analysis, synthesis, creativity, and translational research, must be a distinguishing feature of the DNP’s role and expertise. The purpose of this chapter is to define and explore the meaning of clinical scholarship; to distinguish EBP from other forms of scholarly

activity; to describe the unique role of the DNP in scholarship; and to provide an overview of the language, methodological tools, strategies, and thought processes that are necessary to ensure that nursing’s scholarship is useful, significant, and of the highest quality. Entire books are dedicated to research processes, methodologies, and EBP. This is not the intent of this chapter; rather, it is to explore concepts, provide resources, and whet the reader’s appetite for more in-depth information on the topic.

What Is Clinical Scholarship? In Sigma Theta Tau International’s Clinical Scholarship Resource Paper (1999), Melanie Dreher, chair of the task force, wrote that “clinical scholarship is about inquiry and implies a willingness to scrutinize our practice” (Dreher, 1999, p. 26). In addition, “clinical scholarship is not clinical proficiency . . . unless we are questioning the reason for its use in the first place . . . and neither is it clinical research, although it is informed by and inspires research” (p. 26). Finally, she noted that “clinical scholarship is an intellectual process. . . . It includes challenging traditional nursing interventions, testing our ideas, predicting outcomes, and explaining both patterns and exceptions. In addition to observation, analysis, and synthesis, clinical scholarship includes [translation], application and dissemination, all of which result in a new understanding of nursing phenomena and the development of new knowledge” (p. 26). The AACN’s Position Statement on Defining Scholarship for the Discipline of Nursing (1999) defined scholarship as “those activities that systematically advance the teaching, research, and practice of nursing through rigorous inquiry that: 1) is significant to the profession, 2) is creative, 3) can be documented, 4) can be replicated or elaborated, and 5) can be peer-reviewed through various methods” (p. 1). According to the National Organization of Nurse Practitioner Faculties (NONPF), scholarly projects can be varied but should meet the needs of a group, community, or population versus an individual. Examples include, but are not limited to, translating research in practice, quality improvement, implementing and evaluating EBP guidelines, and collaborating on legislative change using evidence (NONPF, 2007). These definitions and examples are congruent with the evolving definition of scholarship in academia since Boyer’s (1990, 1997) groundbreaking work, Scholarship Reconsidered: Priorities of the Professoriate. Ernest L. Boyer was an American educator, chancellor, and president of the Carnegie Foundation for the Advancement of Teaching (Carnegie Foundation for the Advancement of Teaching, 1996). Since the publication of Scholarship Reconsidered (1990), a new and expanded role for scholarship has emerged in academia that makes the

previously mentioned definitions of scholarship more compatible with the goals and processes of practice disciplines. The traditional definition of scholarship in academia did not account for the nuances and rigors of clinical practice knowledge and its application for problem solving and interactive, human engagement (AACN, 2006). Boyer’s model (1990, 1997), however, is well suited to scholarship in nursing practice. In Boyer’s view, scholarship is not linear; rather, there is a constant, reciprocal, iterative relationship between each of its four aspects. It embraces the concepts of discovery (building new knowledge through research and careful inquiry to refine existing knowledge), integration (interpreting knowledge through dissemination in various forms), application (using knowledge for problem solving, service, and growth), and teaching (developing and testing instructional materials to advance learning, including the formation and sustaining of an engaging environment for learning between teacher and student) (Boyer, 1990, 1997; Stull & Lanz, 2005). The AACN’s Essentials of Doctoral Education for Advanced Nursing Practice (2006) embodies much of Boyer’s criteria in the specification of the eight core essentials and specialty-focused competencies as the basic underpinnings to be integrated into the DNP curriculum (AACN, 2006). Essential III of the core elements is Clinical Scholarship and Analytic Methods for Evidence-Based Practice (AACN, 2006). In this document, the authors stated that “scholarship and research are the hallmarks of doctoral education” (p. 11), and, further, that “research doctorates are designed to prepare graduates with the research skills necessary to discover new knowledge in the discipline. However, DNPs engaged in advanced nursing practice provide leadership for EBP. This requires competence in knowledge development activities such as the translation of research in practice, the evaluation of practice, activities aimed at improving the reliability of health care practice and outcomes, and participation in collaborative research” (DePalma & McGuire, 2005). Therefore, DNP programs focus on the translation of new science, its application, and its evaluation. In addition, DNP graduates generate evidence to guide practice. As DNP programs have proliferated, the curriculum has evolved to include more focus on research translation and EBP. An internet review of the curricula from several national DNP programs indicates that most

curricula include courses that provide graduates with the skills needed to participate in whatever level of research is appropriate to their setting and scholarship goals. Such courses include, for example, theory or scientific foundations for knowledge development, research and/or applied methods, statistics, and translating evidence into practice.

Evidence-Based Practice and Clinical Scholarship: Are They the Same? Scholarship is an evolutionary process that raises the level of the profession through participation in the generation of new knowledge and through scientific and social exchange. “The difference between evidence-based nursing practice and scholarship or applied nursing research is that evidence-based practice is practice driven” (French, 1999, p. 77). Whereas scholarship was often viewed by many practicing professionals as an add-on, optional activity, EBP has become a necessity in our current information-based, technological age. Computers have given everyone access to both good and bad information. The defining feature of EBP is the linking of current research findings with patients’ conditions, values, and circumstances. In addition, it involves “the conscientious, explicit, and judicious use of current best evidence for making decisions about the care of individuals” (Sackett, Richardson, Rosenberg, & Haynes, 1997, p. 2). Nursing’s unique addition to this process must offer a more holistic approach that adds artful practice and ethical standards to the empirics of evidence (Fawcett, Watson, Neuman, Hinton Walker, & Fitzpatrick, 2001). The work of clinical scholars has increased during the past 2 decades. A review of published nursing articles from 1999 to 2017 in the Cumulative Index to Nursing and Allied Health Literature (CINAHL) database resulted in 200 published articles with clinical scholarship as the focus. When evidence-based practice was added to the search terms, an additional 27 articles were found. When evidence-based practice alone was used as the search term, the search returned 67,484 articles—six times the number from the previous publication of this chapter! While not all the articles were authored by nurses, the uptake in evidence-based practice as a subject for scholarly writing across disciplines is significant. Since the prior versions of this chapter, there has been progress in closing the gap between nursing science discovery and application or implementation of evidence in practice. Broome, Riner, and Allam (2013)

specifically noted the increase of clinical investigations and practice/provider-based studies published by DNP-prepared authors from the years 2005–2012. A total of 300 articles in 59 journals were found. Of the 300 articles found, 175 met the study criteria. However, the authors recommended “greater integration of translational science models into DNP curricula to achieve the goal of publishing scholarly products that use evidence to improve practice or patient outcomes” (p. 429). The principles of EBP were an outgrowth of the work of Dr. Archie Cochrane, a British epidemiologist who criticized the medical profession for not using evidence from randomized clinical trials as a basis for clinical care. He believed that the evidence from these trials should be systematically reviewed and constantly updated to afford patients the best quality care (Cochrane Collaboration, 2004). EBP includes an emphasis on the efficacy of treatments or interventions based on the results of experimental comparison between untreated control groups, treatments, or both. The core principles include (1) formulating the clinical question; (2) identifying the most relevant articles, research, and other best evidence; (3) critically evaluating the evidence; (4) integrating and applying the evidence; and (5) reevaluating the application of evidence and making necessary changes. TABLE 21-1 presents the hierarchy of evidence for practice. TABLE 21-1 Hierarchy for Evaluating Evidence for Practice Level 1 (strongest)

Systematic reviews/meta-analysis of all randomized controlled trials (RCTs); clinical practice guidelines based on RCT data

Level 2

Evidence from one or more RCTs

Level 3

Evidence from a controlled trial; no randomization

Level 4

Case control or cohort studies

Level 5

Systematic reviews of descriptive/qualitative studies

Level 6

Single descriptive or qualitative study

Level 7 (weakest)

Opinions of authorities/experts

Note: All levels assume a well-designed study. This article was published in The Practice of Nursing Research: Appraisal, Synthesis, and Generation of Evidence, 7th ed., Grove, S. K., Burns, N. & Gray, J. R., p. 30, Copyright Elsevier 2013.

Description The definition of evidence-based practice has been adapted to include provisions for the provider’s experience and the patient’s values. It is through the incorporation of intuition, observation, theory, research, intelligent analysis, and judgment based on the data that nurses provide care that is truly individualized, reflective, and evidence based. With an increased knowledge of the theory and the tools necessary to critique and translate research into practice, the DNP-educated nurse is in a prime position to affect the delivery of care and to aggregate and translate evidence that can be disseminated to improve overall care and outcomes in myriad clinical areas. The translation and dissemination of clinical knowledge constitute the core of clinical scholarship.

What Is the Role of the Doctor of Nursing Practice in Clinical Scholarship? In advanced practice, scholarship should be integrated with practice as a purposeful, systematic, and conscious endeavor. The emphasis is on inquiry, outcomes, and evidence to support practice (Sigma Theta Tau International Clinical Scholarship Task Force, 1999). Because of their education, advanced practice nurses (APNs), particularly DNPs, are expected to have mastery of essential information so that the teaching of staff, patients, and communities becomes a key function of the role. The dynamic nature of health care requires that DNPs be up to date on new information and that they be able to discern nuances in research findings so as to translate those findings in understandable ways that improve care and practice. This requires constant critique, integration, and synthesis of new information from various sources into formats that can be disseminated to patients, colleagues, and others. What distinguishes the role of the DNP from that of other advanced practice degree holders? The answer is not a simple one; the difference is, in fact, a combination of knowledge, expert skill, and the integration of best research to advance the practice and the profession. This skill comes from additional formal education, experience, and the translation, application, and evaluation of research in practice. Although most practicing nurses are exposed to “research” and “evidence” in practice, the DNP must not only embrace the process but also implement the findings in ways that ultimately change or improve practice and outcomes. Scholarship is the dissemination of those findings in publications, presentations, and offerings that can be used by others. As envisioned in The Essentials of Doctoral Education for Advanced Nursing Practice (AACN, 2006), the DNP program prepares graduates to do the following: 1. Use analytical methods to critically appraise existing literature and other evidence relevant to practice.

2. Design and implement processes to evaluate outcomes of practice, practice patterns, and systems of care within a practice setting, healthcare organization, or community against national benchmarks to determine variances in practice outcomes and population trends. 3. Design, direct, and evaluate quality improvement methodologies to promote safe, timely, effective, efficient, equitable, and patientcentered care. 4. Apply relevant findings to develop practice guidelines and improve practice and the practice environment. 5. Use information technology and research methods appropriately: • Collect appropriate and accurate data to generate evidence for nursing practice. • Inform and guide the design of databases that generate meaningful evidence for nursing practice. • Analyze data from clinical practice. • Design evidence-based interventions. • Predict and analyze outcomes. • Examine patterns of behavior and outcomes. • Identify gaps in evidence for practice. 6. Function as a practice specialist/consultant in collaborative, knowledge-generating research. 7. Disseminate findings from evidence-based practice to improve healthcare outcomes (p. 12). These objectives encompass the essential skills, tools, and methods necessary to implement and support clinical scholarship and EBP. They can be distilled into six categories: (1) translating research in practice, (2) quality improvement and patient-centered care, (3) evaluation of practice, (4) information technology, databases, and evidence for practice, (5) participation in collaborative research, and (6) disseminating findings from EBP. Each of these areas is discussed in the following sections.

Translating Research in Practice The use of evidence to support clinical practice is not a new phenomenon. Medical professionals have relied on data from science, empirical observation, case reviews, and other means for centuries (Monico, Moore, & Calise, 2005). However, as electronic access to sources of data has increased, the amount of evidence now available as a basis for clinical practice has become overwhelming. In addition, the use of translational science has increased and includes several processes, including knowledge translation, quality improvement, adoption of innovation, implementation science (applied research) for quality, and safety improvement (May, 2013; Newhouse, Bobay, Dykes, Stevens, & Titler, 2013). The key to making best practice decisions is using the best quality evidence—evidence that is scientifically based and that has been replicated with success in repeated research and application. Unfortunately, although knowledge and availability of EBP have increased in the last decade, EBP remains underutilized as a tool to improve patient outcomes (Newhouse et al., 2013). Implementation science provides the tools—methods, interventions, and variables—that facilitate decision making toward practice change (May, 2013; Newhouse et al., 2013). Stevens (2011) specified three primary knowledge sources for EBP: valid research evidence, clinical expertise, and patient choice. Currently, evidence generated from large-scale randomized controlled trials is considered the gold standard for application in interventions (Fawcett & Garrity, 2009). Depending on the clinical situation and the patient’s personal preference, other sources of evidence may be appropriate. These sources may include meta-analyses of all relevant randomized controlled trials; EBP guidelines from systematic reviews of randomized controlled trials, case control, or cohort studies; expert opinion; and nursing theory (Fawcett & Garrity, 2009; O’Mathuna, DiCenso, FineoutOverholt, & Johnston, 2011). To understand research evidence that may be used in practice, the following sections on qualitative and quantitative research offer a brief

description of the processes and questions to be considered in the evaluation of such research. Exhaustive coverage of every research method is beyond the scope of this chapter. However, the definitions, discussion, and examples are meant to illustrate how different types of research might be applied or used in practice and how their rigor and adequacy as evidence for practice should be evaluated.

Understanding, Distinguishing, and Evaluating Types of Research Evidence Qualitative Research Evidence Qualitative research is based on four levels of understanding: 1. What is the nature of reality? (Ontology) 2. What constitutes knowledge? (Epistemology) 3. How can we understand reality? (Methodology) 4. How can we collect the evidence? (Methods) (Maggs-Rapport, 2001; Porter, 1996) Types of Qualitative Research Studies. Qualitative research is important in that it allows the nurse to consider the context of a situation while connecting with patients and noting individual differences. In addition, it permits nursing’s unique perspective to be valued and considered critically when making clinical decisions. In her discussion of qualitative research and evidence-based nursing (EBN), Zuzelo (2007) proposed that “nursing needs to ensure that qualitative research is as much a part of the considered evidence as quantitative evidence is” (p. 484). There is evidence that such methods are being utilized by DNPs in their scholarly work. In a recent study, Howard and Williams (2017) designed a successful request for proposal (RFP) and used a traditional qualitative approach to gain evidence for a pilot study of an academic practice partnership model between a healthcare entity and the college of nursing’s RN-DNP program in Kentucky. The outcome was an initial healthcare system transformation and model of care, and the development of plans for longitudinal cost–benefit analysis of the partnership. There are several kinds of qualitative research studies, including

critical social theory, ethnographic studies, grounded theory research, historical research, phenomenological studies, and philosophical inquiry. Each of these methods is discussed briefly to provide an overview of the scope and potential uses of qualitative evidence and to provide a basis for evaluating the use of qualitative studies as a basis for changes in practice. Critical Social Theory. Critical social theory uses multiple research methods as a basis for promoting change in areas where power imbalances exist (Burns & Grove, 2009). According to Horkheimer (1895–1973), Marcuse (1898–1979), Adorno (1903–1969), and Habermas (1929–), critical social theory is based on the belief that individuals should seek freedom from domination (Maggs-Rapport, 2001). Habermas, in particular, believed that people must understand the nature of “constraining circumstances” before they can be liberated from them (Maggs-Rapport, 2001). Another critical social theorist, Giddens (Maggs-Rapport, 2001), believed that we can understand why people act in certain ways only if we can appreciate the meanings of their actions. The DNP might use data from critical social theory to identify meaning or patterns of concern where certain societal cultural norms exist in the form of barriers that affect particularly vulnerable populations such as the elderly, the incarcerated, abused women, and the chronically ill. Analysis would necessarily include an examination of the underlying conditions, a critique of the social phenomena, and the discovery and revelation of the social and political injustices embedded in the experience of the population in question that could lead toward removal of barriers (MaggsRapport, 2001). Ethnographic Research. Ethnographic research is used to describe the nature or characteristics of a culture to gain insight into the lifeways or behaviors of a group. Distinguishing features are immerged in the participant’s way of life (Polit & Hungler, 1997), and the information gathered speaks for itself rather than being interpreted or explored for additional meanings (Maggs-Rapport, 2001). Field notes based on researcher observations over time describe daily interactions with subjects. In one ethnographic study, Kovarsky (2008) compared clients’ and families’ personal experiences of outcomes and interventions with written professional discourse, technical reports, and other conceptualizations of

evidence in practice. Of note was “the dismissal of subjective, phenomenally oriented information that functioned to marginalize and silence voices . . . of clients when constituting proof of effectiveness” (Kovarsky, 2008, p. 47). Further, “the current version of EBP needs to be reformulated to include subjective voices from the life-worlds of clients as a form of evidence” (p. 47). As one example of an ethnographic approach, Kovarsky proposed the personal experience narrative as a measure of qualitative outcomes and intervention analysis (p. 48). Citing a study by Simmons-Mackie and Damico (2001), Kovarsky described an ethnographic interview with a patient experiencing post-stroke aphasia. When asked to comment on life before her stroke, K. [the patient] said, “Before teacher . . . now I don’t know . . . what,” and “Uh . . . uh . . . always, always . . . uh . . . busy, busy, busy, . . . teachin . . . teachin . . . always, I love it. . . . It’s me. . . . But now . . . here (points to mouth) talk, not uh . . . teaching.” When asked about a typical day, she shrugged and said, “Nothing . . . here (points to television),” and later added, “Eat . . . and (points to newspaper) and shows (points to television).” (Simmons-Mackie & Damico, 2001, as cited in Kovarsky, 2008, p. 51) These statements illustrate an altered level of life activity that cannot be appreciated in objective technical descriptions of outcomes of disease processes and their sequelae. The ethnographic narrative is a method of subjective evidence gathering that can enhance the specificity and richness of other research methodologies, including evidence gained from logical positivist approaches such as randomized controlled trials. DNPs in public health or community health could use this method in conjunction with other, more traditional forms of evidence to gain a better real-world understanding of the populations they serve. Grounded Theory Research. Grounded theory research is focused on the influence of interactional processes (identification, description, and explanation) among individuals, families, or groups within a social context (Strauss & Corbin, 1994). It is an observational method used to study problems in social settings that are “grounded” in the data obtained from those observations (Glaser & Strauss, 1967; Grove, Burns, & Gray,

2013). Grounded theory is an applicable framework for study of myriad contexts, situations, and settings because it bridges the gap between empirical observation and the generation of theory by providing a structured method of sampling procedures and coding observations for explaining social phenomena or generating new theory (Annells, 1996; Barnes, 1996; Glaser & Strauss, 1967; Hammersley, 1989). For example, a study of the implementation of EBN in Iran (AdibHajbaghery, 2007) sought to distinguish factors influencing the implementation of EBP in Eastern countries (versus Western countries), particularly Iran. A brief description of this study using the grounded theory approach is presented here. Data collection consisted of purposive sampling of 21 nurses (9 staff and 6 head nurses in differing clinical settings) with experience in nursing greater than 5 years. An interview questionnaire consisted of open-ended questions, such as “What is the basis of care you give your patients?” (p. 568), “In your opinion, what is the basis of evidence-based nursing?” (p. 568), and “Can you describe some instances in which you used scientific evidence in nursing?” (p. 568). “Issues were clarified, and interviews were audiotaped, transcribed verbatim and analyzed consecutively” (AdibHajbaghery, 2007, p. 568). A total of 36 hours of observations and interviews were carried out concurrently and involved observations of those interviewed and others working on the units. According to the procedure identified by Strauss and Corbin (1998), each interview was analyzed before the subsequent interview took place, and the results were coded in three ways: open coding (breaking down, examining, comparing, conceptualizing, and categorizing), axial coding (putting data back together in new ways by linking codes to contexts, consequences, and patterns of interactions), and selective coding (identifying core categories and systematically relating and validating relationships) (Adib-Hajbaghery, 2007). To confirm the credibility of the data, participants were given a full transcript of their responses and a list of codes and themes to determine whether the codes and themes matched their responses. To establish validity, two peer researchers also checked codes and themes using the same procedure as the researcher. The results were that two main categories emerged from the research: (1) the meaning of EBN and (2) factors in implementation of EBN, including the themes of

possessing professional knowledge and experience, having opportunity and time, becoming accustomed, self-confidence, the process of nursing education, and the work environment and its expectations (AdibHajbaghery, 2007). The process and results of grounded theory research and analysis provide rich data for application in practice when paired with evidence from other sources. This is especially true when there is little clinical trial evidence to support the effective dimension of care or practice. Historical Research. Historical research is a description or analysis of events that have shaped a discipline. Although historical research may not be used directly in practice, it provides the foundation for examination of the discipline and for providing future directions (Fitzpatrick & Munhall, 2001; Grove et al., 2013). Often history is handed down in written documents. The Library of Congress’s (n.d.) American Memory Collection has original writings, newspaper clippings, photos, and other documents that provide a realistic account of the influence and actions of famous women in history, including nursing leaders. Pictures and other documents showcase the original work of early nurse leaders such as Lavinia Dock (1858–1956), Margaret Sanger (1879–1966), Clara Barton (1821–1912), and Mary Breckinridge (1881–1965), which provides a basis for advanced nursing practice and can be used by DNPs in education to provide a historical perspective for practice. Another source of historical research is oral history. Using both written documents and oral history, Libster and McNeil (2009) traced the history and meaning of a religious tradition of care of the sick and poor by the Sisters of Charity. Wall, Edwards, and Porter (2007) used oral history and a method of textual analysis to determine how retired nurses made sense of their educational experiences. Tropello (2000) used oral history technique in her dissertation, “Origins of the Nurse Practitioner Movement: An Oral History.” The purpose was to gain a better understanding of current advanced nursing practice roles through an exploration of the original movement. Eight participants in the original movement were the primary sources, and the information obtained and transcribed from taped interviews was enhanced by supportive papers, correspondence, and other documents, including secondary sources. One conclusion of the study was that the politics of the 1960s, which emphasized greater freedoms for women and a focus on social

programs, helped alleviate healthcare manpower shortages (Tropello, 2000). This movement has paved the way for additional professionalization in nursing, including the evolution of the DNP curriculum. Started as a research project, it became part of the core curriculum under the continuing education division of the School of Nursing at the University of Colorado. The program used a nursing– physician team approach to aid families with limited access to primary providers (Tropello, 2000). For DNPs to prescribe their future, they must have a clear understanding of and appreciation for their history so that they can build on and shape EBP in ways that preserve the essence of nursing. The National League for Nursing and Sigma Theta Tau International have excellent historical resources. Several of the audiotapes, videotapes, and other historical resources produced by these and other nurse theorists whose original work and theory development continue to provide frameworks for advancing nursing practice were referenced by Allen (1996) in a special report, Celebrating Nursing History: What to Keep. Phenomenological Research. The aim of a phenomenological (hermeneutic) study is to understand a phenomenon through the recognition of the meaning of an experience or occurrence. Phenomenology focuses on discerning the truth of a phenomenon rather than arguing a point or developing abstract theory (Hallett, 1995). Researchers explore an experience as it is lived by the participants in the study. The phenomenon of interest may include any number of experiences, such as death, divorce, pain, or cancer. The researcher collects data and interprets the experiences as they are lived (Grove et al., 2013). In one phenomenological approach, Maggs-Rapport (2001) used van Manen’s (1990) social scientific approach to look at women’s immediate response to the phenomenon of egg sharing (donation of one woman’s eggs to another woman) after consultation with a clinician, and their lived experiences of egg sharing in return for free fertility treatment. The indepth open-ended interviews of this technique established a conversational relationship about the meaning of the experience and produced a narrative that “enriches the understanding of the phenomena” (Maggs-Rapport, 2001, p. 374). Before each description can be transformed into phenomenological language, meaning units must be

made of each description (Giorgi, 2000). However, only a small number of descriptions are necessary for the nature of the phenomenon to become apparent (Giorgi, 2000; van Manen, 1990). In a recent study Tillman, Creel, and Pryor (2016) used hermeneutic (interpretative) phenomenology to explore and document the lived experience of nursing students providing care to members of the LGBT community during a pride health fair. Using the method identified by van Manen (1990), interviews with 30 female students who self-identified for inclusion in the study were audiotaped and the transcripts were reviewed for accuracy and authenticity of representation by the two primary researchers who had experience with the LGBT community. Each interview was read individually, followed by reflection across all interviews and concept mapping to organize data and draw conclusions. The main themes that emerged from the student experiences were gender role confusion, acceptance/tolerance, and pride in the school for supporting the experience and providing the opportunity to increase awareness of the community and their health issues (Tillman et al., 2016, pp. 176–181). Phenomenological techniques with a strong nursing orientation include those of Crotty (1996) and Munhall (1994, 2007). Other studies that utilized the phenomenological approach in advanced practice include those about the meaning of U.S. childbirth for Mexican immigrant women (Imberg, 2008); how family practice physicians, nurse practitioners (NPs), and physician assistants (PAs) incorporate spiritual care into practice (Tanyi, McKenzie, & Chapek, 2009); the leadership and management role of the DNP in the care of older persons in the United States (Stoekel, 2010); hospital nurses’ lived experience of power (Fackler, Chambers, & Bourbonniere, 2015); the use of phenomenology in mental health nursing research (Picton, Moxham, & Patterson, 2017); and virtual mentoring program within an online doctoral nursing education program (Welch, 2017). Phenomenological studies contribute to the evidence base by enhancing our understanding of the true meaning of patients’/participants’ experiences and the broader dimensions of a problem, thus aiding in a more holistic perspective in practice. Philosophical Inquiry. Philosophical inquiry is used to explore the nature of knowledge, values, meaning, and ethical factors related to a question of interest. Although philosophical inquiry is related to theory, it is not the same as theory, which is more specific and concrete (Pesut &

Johnson, 2007). Citing Edwards (2001), Pesut and Johnson described three “strands” that compose philosophical inquiry: (1) philosophical presupposition, which involves identifying and analyzing presuppositions in nursing (an example might be a concept analysis of nursing practice or advanced practice); (2) philosophical problems, such as what constitutes knowing in a particular situation, or ethical analyses, such as the ethics of caring in situations in which nurses’ and patients’ values conflict; and (3) scholarship, in which nurse theorists’ works are examined from a philosophical perspective. In this case, as noted by Burns and Grove (2009), the researcher would “conduct an extensive search of the literature, examine conceptual meaning, pose questions and propose answers including the implications for those answers” (p. 26). In a practical application of philosophical inquiry, Dorn (2004) described a model, caring-healing inquiry for holistic nursing practice, to guide nursing research and quality improvement in a tertiary hospital. The model, which integrated the values of the hospital, provided the basis for nurses (mostly APNs) to describe their contributions to care through research and practice improvement in a partnership between a hospital and university nursing program. Facilitated by a nurse– researcher faculty member, the group served as an advisory group for program planning, development, and clinical innovation. In a more recent example, Alimohammadi, Taleghani, Mohammadi, and Akbarian (2014) used philosophic inquiry to explore the meaning of “human being” in the eastern Islamic tradition. Included were implications for practice and patient care. Knowledge about the process of philosophical inquiry and a focus on value analysis, as demonstrated in these examples, provides DNPs with a basis for facilitating ethical decision making in practice. Evaluating Qualitative Research Evidence. What are the evaluative questions? Regardless of the type of research design, the general criteria for evaluation of qualitative studies are as follows: 1. Question, purpose, and context: Is the research question clear, the primary purpose and the focus of the study stated, and the context described? 2. Design: Was the design appropriate; were the units of analysis and sampling strategy described and the sampling criteria clear?

3. Data collection: What types of data were collected? Were data collection processes systematic and adequately described? How were logistical issues addressed? 4. Data analysis: Was data analysis systematic and rigorous? What controls were in place? What analytical approach or approaches were used? How were validity and confidence in the findings established? 5. Results: Were results surprising, interesting, or suspect? Were conclusions supported by data and explanation (theory)? Were the authors’ positions clearly stated? 6. Ethical issues: How were ethical issues and confidentiality addressed? 7. Implications: What is the worth/relevance to knowledge and practice? (Gifford, Davies, Edwards, Griffin, & Lybanon, 2007; Grove et al., 2013; Patton, 1990; Russell & Gregory, 2003) Qualitative research questions and methods provide an avenue for truly knowing patients and practicing both the art and science of nursing. These are the hallmarks of nursing that nurses at every level must retain and that DNPs must foster as role models to ensure that best practice does not exclude the best of nursing’s perspective.

Quantitative Research Evidence Steps in the Quantitative Research Process. Two important aspects of any quantitative research project are that the project builds on prior results or evidence and provides a basis for future research and discovery (Grove et al., 2013). FIGURE 21-1 shows the steps in the quantitative research process.

FIGURE 21-1 Quantitative research process. Modified from Grove, S. K., Burns, N., & Gray, J. R. (2013). The practice of nursing research: Appraisal, synthesis, and generation of evidence (7th ed., p. 39). St. Louis, MO: Elsevier Saunders.

Description The research problem is often derived because there is a gap in knowledge that needs to be addressed or described. Research problems or questions often arise from direct observations made in practice. The purpose of the study is to address the problem. To better understand the problem, an extensive literature review must be done to develop an understanding of the nature and scope of the problem and to determine what research has already been done. A framework, map, or theoretical base made up of concepts is developed to provide structure and help the researcher make sense of the findings. The research objectives, questions, or hypotheses set the study limits in terms of who will be studied, what question(s) will be addressed, and what relationships among variables exist. The remaining steps are to define the variables in conceptual terms (theoretical meaning) and operational terms (how the variables will be measured or manipulated); explain assumptions (those things we take for granted to be true, whether proved or not); and then select the research design, including the population to be included, the methods of measurement, the plan for data collection, and data analysis. Implementing the plan follows, including piloting the study, collecting and analyzing the data, and evaluating and interpreting the research findings, including identifying study limitations (any issue within the study that serves to limit its generalizability beyond the population or sample studied) and applicability for practice. The final step is to communicate the research findings. A brief description of the research process steps and methodological considerations follows. The reader is directed to a research book for a complete description of each of the steps in this process. Categories and Selection of a Design. Quantitative research may be categorized as experimental, quasi-experimental, or nonexperimental (descriptive or correlational). Quantitative research may be either basic

research (as in laboratory studies) or applied (as in clinical research). In an experimental or quasi-experimental study, the researcher actively manipulates the independent variable (treatment or intervention) to see the effect on the dependent variable. In an experimental study, the variables and the setting are highly controlled. In a nonexperimental design, the researcher may simply want to describe or explain a phenomenon or predict a relationship (Grove et al., 2013). Quantitative designs may also be retrospective (the proposed cause and effect have already occurred), prospective (the cause, but not the effect, has occurred), cross-sectional (examines groups in various stages of development), or longitudinal (the same subjects are studied over time). None of the categories are mutually exclusive (Schmidt & Brown, 2015). Population and Sample. The population is everyone or everything that meets the criteria for inclusion. The criteria for inclusion may be narrow or broad depending on the size and scope of the study and the specific research question to be addressed. The sample is a subset of the population and the process for how the subset will be selected. This may be random (all have a better than zero chance of selection), nonrandom (convenience), cross-sectional (groups studied over time), or stratified (divided to ensure representation from groups when some variables are known). Often the population and the sample are determined by the method and how accessible the population is to the researcher (Grove et al., 2013). Measurement Instruments. Measurement instruments are tools used by the researcher to answer the operational questions posed in research studies. These tools may be questionnaires, tests, indicators of health status, and a variety of other measurement techniques. Data Collection and Analysis Plan. Most data collected in quantitative research studies are coded numerically so they can be systematically analyzed and interpreted through statistics. A plan for data collection and analysis is an important part of the research process and is crucial to meaningful interpretation of results. Pilot Study. A pilot study, a smaller version of a proposed study, is an

important part of the research implementation plan. It allows the researcher to refine methodology, instruments, and data collection procedures before the full study is launched (Grove et al., 2013). This cursory overview of the research process provides the basis for evaluating evidence from research. The following sections describe considerations for evaluating research evidence for use in practice. Interpreting and Evaluating Quantitative Evidence. Interpretation involves “1) examining the results from data analysis, 2) exploring the significance of findings, 3) identifying study limitations, 4) forming conclusions, 5) generalizing the findings, 6) considering the implications for nursing, and 7) suggesting further studies” (Grove et al., 2013, p. 48). Once the researcher has synthesized, interpreted, and evaluated the quantitative evidence, implications for further study, practice, or both should be discussed. When a quantitative study is appraised for use in practice, three questions are generally considered: Is the study valid? Is the study reliable? Is the study applicable in the identified case? Is the Study Valid? Specifically, were the methods used scientifically sound? Are the independent (manipulated variable) and dependent variables (observed result) clearly identified? Is the study free from bias or confounding variables? Bias is a standard point of view or personal prejudice, especially when there is a tendency “to affect unduly or unfairly, or to impose a steady negative potential upon [a result or process]” (Bias, 2003, p. 135). It is an influence or action that distorts or “slant[s findings] away from the true or expected” (Grove et al., 2013, p. 197). In research, bias (sometimes called systematic variation) may occur when participants’ characteristics specifically differ from those of the population (Grove et al., 2013). This is always possible because volunteers are used for samples. It is less likely to occur, however, if the sampling strategy is well planned and followed and there is random assignment to groups. Bias may also occur if the instruments or measurement tools are faulty or if the data or statistics are inaccurate. Selection Bias. When a researcher decides to prospectively compare two types of strategies for educating nursing students, such as online instruction and traditional classroom instruction, selection bias may occur

if the students are allowed to select which group they enter. Students who select online teaching may be very different from those who choose the traditional classroom experience. Random assignment to the groups minimizes the risk of selection bias. Gender Bias. Another form of bias is gender bias. Gender bias occurs in research when one gender is used more than the other to study research interventions, thus impacting generalizability of results. In nursing, gender bias is prevalent, with most studies “over-sampling” women (Polit & Beck, 2008). In an update of their 2005–2006 study, the authors sampled 300 studies over the 2010–2011 period in four research journals. One-third of the study authors and 74% of study participants were female. Less bias was seen in studies authored by males (Polit & Beck, 2013, pp. 78–79). Timmerman (1999) outlined a procedure for ensuring that research decisions avoid gender bias. The procedure includes critically analyzing the literature, testing gender-specific differences, and identifying researchers’ personal biases. The following example of binge-eating behaviors between men and women illustrates the point. Timmerman (1999), citing Hawkins and Clement (1984) and Spitzer et al. (1992), stated, “We know that men tend to binge less frequently, consume less during binges and are less distressed by their binge eating behavior than women” (p. 642). And, “In this case, the literature provides justification for either separately studying binge eating behavior in men and women, or, if the sample has both men and women, analyzing the data separately for men and women” (Timmerman, 1999, p. 642). TABLE 21-2 lists some gender-based studies. Additional genderbased studies can be found online through the Office on Women’s Health of the U.S. Department of Health and Human Services. TABLE 21-2 Gender-Based Studies Auhor

Title

Edward, Hii, Giandinoto, Hennessy, and Thompson (2016)

Personal Descriptions of Life Before and After Bariatric Surgery From Overweight or Obese Men

Galbany-Estragués and Comas-d’Argemir (2017)

Care, Autonomy, and Gender in Nursing Practice: A Historical Study of Nurses’ Experiences

Kellet and Fitton (2017)

Supporting Transvisibility and Gender Diversity in Nursing Practice and Education: Embracing Cultural Safety

Lauffenburger, Robinson, Oramasionwu, and Fang (2014)

Racial/Ethnic and Gender Gaps in the Use of and Adherence to Evidence-Based Preventive Therapies Among Elderly Medicare Part D Beneficiaries After Acute Myocardial Infarction

Pederson, Greaves, and Poole (2015)

Gender-Transformative Health Promotion for Women: A Framework for Action

Skop, Lorentz, Jassi, Vesprini, and Einstein (2018)

“Guys Don’t Have Breasts”: The Lived Experience of Men Who Have BRCA Gene Mutations and Are at Risk for Male Breast Cancer

van Anders et al. (2017)

Biological Sex, Gender, and Public Policy

Wander et al. (2014)

The Impact of Patients’ Gender, Race, and Age on Health Professionals’ Pain Management Decisions: An Online Survey Using Virtual Human Technology

Yuh-Min, Yueh-Ping, and Min-Ling (2015)

Gender Differences in the Predictors of Physical Activity Among Assisted Living Residents

Description Confounding Variables. Confounding occurs when a third variable, either known or unknown, produces the relationship with the outcome instead of the research intervention itself. Or, stated differently, confounding may occur when comparing two groups that may be different in additional ways from the treatment being studied (Leedy & Ormrod, 2010). Randomizing participants to either the intervention or study group helps to eliminate the possibility of confusion because there is an equal chance that extraneous variables will appear equally in both groups, thus minimizing the confounding effect. One type of confounder is the effect of history. The history effect occurs when an event outside the researcher’s control occurs at the same time as, or during, the period of the intervention. For example, in a study of patients with hypertension, a researcher may be interested in the impact of a low-salt diet on hypertension levels. The plan is to take a baseline blood pressure and then start patients on the low-salt diet. However, if, during the study period, some of these same patients also

began a rigorous exercise routine and others did not, a confounding effect would be present. In this case, the intervening exercise program would make it difficult to attribute the outcome solely to the effect of the intervention. Adding a control group whose members adhered to a lowsalt diet and exercise routine or using statistical tests to control for this confounding variable would minimize the threat to validity in this study. In another example of confounding, a researcher was interested in comparing lung cancer and smoking incidence in various regions of the country. In this study, a region was seen to have a significantly higher rate of lung cancer death among smokers (15 times higher) than other regions of the country. The confounding factor was that these smokers had also worked in asbestos coal mines for many years. When the researchers controlled for the variable of working with asbestos by removing the confounder, the rate of cancer due to smoking was nearly the same as that in other regions of the country. FIGURE 21-2 shows the relationship among the independent variable (smoking) and confounding variable (working in an asbestos coal mine) in relationship to the dependent variable (lung cancer) (International Development Research Center, 2009).

FIGURE 21-2 Interrelationships among smoking, working in an asbestos coal mine, and risk for lung cancer in a cohort/case control study Used with permission of IDRC Canada, www.idrc.ca.

Description Is the Study Reliable? The reliability of a study is based on questions such as the following: Does the instrument or test measure what it is

supposed to measure? Does it do this consistently? Do the items on the instrument consistently measure the same characteristic? How much consistency is there between raters? (Fain, 2009; Grove et al., 2013). Reliability is measured using a reliability coefficient (r) and ranges from 00.0 (lowest) to 1.00 (highest). Therefore, the closer a reliability score is to 1.00, the higher the reliability. In most cases, a coefficient of 0.80 or higher is considered acceptable if the instrument has already been tested and has been used frequently. If an instrument is new, a reliability coefficient of 0.70 may be acceptable depending on the purpose of the study (Griffin-Sobel, 2003). Reliability also focuses on stability (test– retest reliability—whether an instrument yields the same results for the same two people on two different occasions), homogeneity (internal consistency—the extent to which all the items within a single instrument yield similar results), and equivalence (interrater reliability—the extent to which two or more individuals evaluating the same product or performance give identical judgments) (Fain, 2009; Leedy & Ormrod, 2010). A simple example of reliability is seen in the selection of timing devices used in sports events. Timing devices must work consistently every time so that competitors are ensured an equal chance of winning. An example of interrater reliability is that of a classroom situation in which two evaluators are trained to use the same tool with a Likert scale to measure student performance on oral presentations. Are the Results of the Study Applicable in the Identified Case? Once the science of a study has been appraised and the reliability of results assessed, the next important questions are: Do the results apply to the case of interest? Are the populations in the study and in the proposed population for application similar? If the populations studied are not similar, the significance of results in the study has little value for real-life implementation in a given clinical situation. Is the effect size sufficient so that application of the study intervention makes a significant difference? The effect size is calculated by determining the mean difference between two groups (intervention and control) and dividing by the standard deviation. It is not the same as the statistical significance but rather is the size of the difference between two groups. The effect size is often used in meta-analysis for combining and

comparing estimates from different studies to determine the effectiveness of an intervention. “An effect size is exactly equivalent to the Z-score of a normal standard deviation. For example, an effect size of 0.8 means that the score of the average person in the experimental group is 0.8 standard deviations above the average person in the control group, and hence exceeds the scores of 79% of the control group” (Coe, 2002, p. 2). Thus,

Generally, in evaluating any quantitative study, additional questions include the following: Why was the study done? How was the sample size decided? How were the data analyzed? Were there any surprises or unexpected events that occurred during the study? How do the results of this study compare with others? (Melnyk & Fineout-Overholt, 2015). The standard of care for practice is increasingly based on scientific evidence. Finding the most current research based on well-conducted clinical trials is an important first step. But how do we evaluate that evidence in practice? Several statistical measures help in the evaluation of study results. TABLE 21-3 briefly describes some commonly used statistical tests. An excellent brief guide to epidemiological concepts, common biostatistics terms, and study designs, authored by Israni (2007), is also available from MedPage Today online. TABLE 21-3 Clinical Statistical Measures Clinical Statistic Odds ratio (OR)

Description The odds of risk for a person in the experimental group having an adverse outcome compared with a person in the control group. An odds ratio of 1 means the event is equally likely in both groups. An odds ratio greater than 1 means the event is more likely in the intervention group than the control group. An odds ratio less than 1 means the event is less likely in the intervention group than the control group. Used most in case control and

retrospective studies. Relative risk ratio (RR)

The risk of an outcome in the intervention/treatment group (Y) compared with the control group (X). RR = Y/X. A relative risk of 1 means there is no difference between the two groups. A relative risk of less than 1 means a smaller potential for the effect to occur in the intervention group than in the control group. Used most in randomized controlled trials and cohort studies.

Relative risk reduction (RRR)

The percentage of reduction in the treatment group (Y) compared with the control group (X). RRR = 1 – Y/X? 100%.

Absolute risk reduction (ARR)

The difference in risk between the control group (X) and the intervention group (Y). ARR = X – Y.

Number needed to treat (NNT)

The number of patients that must be treated over a given period of time to prevent one adverse outcome. NNT = 1/(X – Y).

Modified from Long, C. O. (2015). Weighing in on the evidence. In N. A. Schmidt & J. M. Brown (Eds.), Evidence-based practice for nurses: Appraisal and application of research (3rd ed., pp. 417–432). Burlington, MA: Jones & Bartlett Learning.

Description What happens if the evidence conflicts with patients’ values and preferences? What if our own experience conflicts with the evidence? The key is that the evidence must be relevant to the problem and tested through application. In addition, some scholars (Fawcett et al., 2001; Kitson, Harvey, & McCormack, 1998; Rycroft-Malone et al., 2004) insist that evidence as defined by medicine is too narrowly focused and does not recognize the complexities of nursing practice. Others recommend that the definition include the influence of context in the application of evidence (Scott-Findley & Pollack, 2004). This would include findings from qualitative research. Regardless of the definition, however, once evidence is implemented, the results must be evaluated. Did the evidence support better decision making? Was the patient’s care improved? In what ways were care or outcomes improved? If they were not improved, why not? (Melnyk & Fineout-Overholt, 2011).

Determining and Implementing the Best Evidence for Practice According to the Agency for Healthcare Research and Quality (West et al., 2002) three benchmark domains must be considered when evaluating evidence: quality, quantity, and consistency. Quality refers to the absence of biases due to errors in selection, measurement, and confounding biases (internal validity). Quantity refers to the number of relevant, related studies; total sample size across studies; size of the treatment effect; and relative risk or odds ratio strength (causality). Consistency refers to the similarity of findings across multiple studies (or statistical power) regardless of differences in study design. These considerations make it essential that all types of evidence be considered when delivering individual care and implementing systems of care. Based on these domains of evidence, a critical appraisal of types of studies can be facilitated and evaluated to determine the best approach for practice (Melnyk & Fineout-Overholt, 2011; West et al., 2002). A distinguishing feature of EBN is that nurses treat and work with patients rather than “work on them” (McSherry, 2002). In addition, nursing’s approach is more holistic, so that “effectiveness of treatment” is but one indicator; costeffectiveness and patient acceptability also matter (McSherry, 2002). Recent studies show a shift in the paradigm of EBP that supports nursing’s approach. While the AHRQ domains identified here remain relevant, other researchers have noted the shift toward more populationbased research, risk and disease assessment, prevention, health promotion, and the need for inclusion of all “stakeholders value assumptions” (Fernandez et al., 2015).

Quality Improvement and PatientCentered Care The steps in the quality management, monitoring, and evaluation processes are based on the work of William Edwards Deming, an American author, professor, statistician, and consultant best known for his work in improving manufacturing production efficiency during World War II. Deming believed that quality is based on continuous improvement of processes and that when work is focused on quality, costs decrease over time (Deming, 1986). In patient care, a process that facilitates continuous improvement is central to an environment that produces changes in practice, is patient centered and focused on care, and is both evidence based and of high quality. The process must be based on a commitment by all those involved to change practice, and this commitment must be made in advance so that the research findings are applied early in the process (French, 1999). As changes are made, they must be continuously evaluated for their impact on care and care systems. The EBP process is consistent with total quality improvement, and often the same resources can be used for both processes. DNPs, in whatever role they assume, must be constantly attuned to and knowledgeable about changes in practice to ensure that current best practice is maintained. Considering the context of empirical evidence and patients’ preferences and using processes and frameworks that aid translation evaluation help to ensure quality.

Conceptual Frameworks for Evidence and Practice Change Models serve as good frameworks for design. Several models that were originally designed for research utilization were the historical precursors to EBP. Four well-known models for research utilization and EBP are the conduct utilization of research in nursing (CURN) model (Horsely, Crane, & Bingle, 1978), the Kitson model (Kitson et al., 1998), the

Stetler/Marram model (Stetler, 1994; Stetler & Marram, 1976; Stetler et al., 1998), and the Iowa model of research utilization (Titler et al., 1994). As EBP has evolved, some of these models have been adapted and/or revised with emphasis on EBP use in organizational settings. Other models have also been developed. Some later models include the advancing research and clinical practice through close collaboration (ARCC) model (Melnyk & Fineout-Overholt, 2002), the Rosswurm and Larrabee model (1999), the revised Iowa model of evidence-based practice to promote quality care (Titler, 2001, 2002), the Johns Hopkins model (Newhouse, Dearholt, Poe, Pugh, & White, 2008), the PARIHS framework (Rycroft-Malone et al., 2002, 2004, 2013), and the AGREE model (2001). Each of these models has been successful in disseminating research and/or facilitating the implementation of change toward EBP. The ARRC model is useful for implementing EBP in community and hospital settings. As noted by Schaffer, Sandau, and Diedrick (2013), it is primarily used for implementation of EBP and helps to assess an organization’s culture and readiness for change. In their text and accompanying CD-ROM, Melnyk and Fineout-Overholt (2011) provide tools to assess feasibility of implementation and evaluate outcomes. The revised Iowa model (Titler et al., 2001, 2002) has been used extensively in designing organizational practice change. As shown in FIGURE 21-3, the model shows a number of algorithmic steps and decision points that include determining whether a problem is an organization priority, searching for evidence and deciding adequacy of the evidence, piloting a change if evidence affirms adequacy, deciding on a practice change based on the outcome of the pilot, and ongoing evaluation and dissemination of the results (Schaffer et al., 2013).

FIGURE 21-3 The Iowa model revised: Evidenced-based practice to promote excellence in health care. Reproduced from Iowa Model Collaboration. (2017). Iowa Model of evidence-based practice: Revisions and validation. Worldviews on Evidence-Based Nursing, 14(3), 175-182. doi: 10.1111/wvn.12223

Description Additional conceptual frameworks that help in the promotion and translation of evidence into practice are the PARIHS (promoting action on research implementation in health services) model (Rycroft-Malone et al., 2002) and the AGREE (appraisal of guidelines for research and evaluation) model (AGREE Collaboration, 2001). The PARIHS model, which is based on the work of Kitson et al. (1998, 2008), suggests that the integration of evidence is based on three factors: the nature of the evidence, the context of the desired change, and the mechanism of facilitating change. This evidence, and its translation for practice, includes practice guidelines and other forms of evidence specific to patient outcomes. The use of randomized controlled trials was central to implementation of this model. The model was revised by Rycroft-Malone et al. (2002, 2004) to include research information, clinical experience, and patient choice. Further work by Doran and Sidani (2007) identified gaps in the PARIHS model that led to an intervention framework that specifically addressed indicators for evaluating nursing services, systems, performance measures, and feedback to design and evaluate practice change. The intervention framework incorporates the work of Batalden and Stoltz (1993) and Batalden, Nelson, and Roberts (1994), which identified four categories of information in making care improvements. This information included “clinical (e.g., signs and symptoms), functional (e.g., activities of daily living), satisfaction (e.g., perceived benefit of care) and cost (i.e., both direct and indirect cost to the health care system and the patient)” (Doran & Sidani, 2007, p. 5). FIGURE 21-4 depicts Doran and Sidani’s outcomes-focused knowledge translation intervention framework.

FIGURE 21-4 Outcomes-focused knowledge translation intervention framework. Reproduced from Doran, D. M., & Sidani, S. (2007). Outcomes-focused knowledge translation: A framework for knowledge translation and patient outcome improvement. Worldviews on EvidenceBased Nursing, 4(1), 3-13.

Description The PARIHS model has continued to be used and referenced extensively and was revised again in 2013; it continues to be refined to include more deliberative processes for implementation of the framework in practice including greater emphasis on the role of individuals and the evaluation of outcomes (Rycroft-Malone et al., 2013). The purpose of the AGREE instrument, as defined by the collaborators, “is to provide a framework for assessing the quality of clinical practice guidelines” (AGREE Collaboration, 2001, p. 2). As further described, quality means that potential biases are addressed and that the recommendations are valid and feasible for practice. In addition, as described in AGREE, “this process involves [considering] the benefits, harms, and costs of the recommendations, as well as the practical issues

attached to them. Therefore, the assessment includes the judgments about the methods used for developing the guidelines, the content of the final recommendations, and the factors linked to their uptake” (AGREE Collaboration, 2001, p. 2). The AGREE instrument consists of 23 items organized in six domains: scope and purpose (items 1–3), stakeholder involvement (items 4–7), rigor of development (items 8–14), clarity of presentation (items 15–17), applicability (items 18–21), and editorial independence (items 22–23). The complete instrument and user guide are available for download from the internet. In another application of the AGREE instrument, Zadvinskis and Grudell (2010) used the guideline to appraise the National Kidney Foundation Kidney Disease Outcomes Quality Initiative Clinical Practice, Guideline for Chronic Kidney Disease. Since its original publication in 2003, AGREE was revised as AGREE II. The four-point Likert-type scale has been replaced with a seven-point scale. The domains and item numbers remain essentially the same in the two versions except that in the AGREE II version, the term patient has been replaced by target population to account for a broader focus, including nonclinical guideline evaluation (e.g., public health policy). The updated AGREE II scale and the process of guideline evaluation can be conducted online. A user’s manual and online tutorial is available from the AGREE Trust website, www.agreetrust.org. Practice exercises allow users to rate a sample guideline and compare their scores with that of the experts (Levin & Ferrara, 2011). Since its revision, the use of AGREE has expanded internationally and continues to afford improvements in the “quality of patient care and system performance through the differentiation and reporting of clinical practice guidelines [CPGs]” (Makarski & Brouwers, 2014, p. 103). The Johns Hopkins nursing evidence-based practice model (JHNEBP), another evidence-based model, was developed as a collaborative effort between Johns Hopkins Hospital and the Johns Hopkins School of Nursing (Johns Hopkins Center for Health Services and Outcomes Research, 2012). The model is explained in six sections. Section I introduces the concept, the evolution of EBP, and the role of critical thinking in EBP. Section II describes the components of the model, which uses the PET process—practice question, evidence, and translation. Section III further explores the PET process in developing

EBP projects. Section IV describes the environment necessary for the success of EBP. Section V provides examples of EBP projects. Section VI contains tools used for EBP at Johns Hopkins. The model was revised in 2017 and, according to the authors, “existing tools were modified and three new tools were added which address: analysis of stakeholders, implementing and tracking the action plan, and active dissemination of EBP findings” (Dang & Dearholt, 2017). It is beyond the scope of this chapter to detail specifics of each model discussed here. However, although there are nuances and structural differences, all the models support some form of practice change through the systematic review of research, data from practice, and other evidence. Clinical practice guidelines can be created, monitored, and modified from these data to create a culture of evidence-based practice and research utilization that becomes an essential part of practice, organizational change, and continuous evaluation to improve systems and quality of care. An overview and comparison of the uses and features of the some of the EBP models discussed here as well as other models can be found in a discussion paper by Schaffer et al. (2013) in the Journal of Advanced Nursing.

Designing and Implementing Processes to Evaluate Outcomes of Practice and Systems of Care As nursing moves practice decisions from those based on tradition to those based on empirical evidence, the APN, particularly the DNP, is in the best position to effect and assess change within the clinical setting. Why? EBP and quality management are both practice-driven processes (French, 1999). Each is informed by experience and outcomes that can be directly seen and measured. In most cases, the observations that arise during daily practice provide the basis for questions, which can be empirically tested, and their results implemented and evaluated. The findings of previous research studies can be replicated in a variety of settings with resources that are already in place. The curriculum of DNP programs includes specialty-focused competencies delineated by specialty nursing organizations, and the core

essentials include courses and application experiences in research methods, statistical analysis, and translation of knowledge for practice (AACN, 2006). Listed in TABLE 21-4 are some recent examples of clinical studies concerning advanced practice nursing interventions and outcomes designed by DNPs. TABLE 21-4 Selected DNP Scholarly Publications: Evidence-Based Research Interventions and Outcomes

Description The Essentials of Doctoral Education for Advanced Nursing Practice (AACN, 2006) states that “DNP graduates must understand principles of practice management, including conceptual and practice strategies for balancing productivity and quality care” (p. 4). In addition, “they must be able to assess the impact of clinical policies and procedures on meeting the health needs of the patient populations with whom they practice” (p.

4). In addition, “they must be proficient in quality improvement strategies and in creating and sustaining changes at the organizational and policy levels” (p. 4). Education in the skills necessary for EBP through the translation of knowledge from research allows DNPs to “reclaim ownership of their practice” (Reavy & Tavernier, 2008).

Quality Improvement Initiatives to Promote Safe, Timely, Effective, Efficient, Equitable, and Patient-Centered Care The design of quality improvement initiatives must be empirically based and dependent on sources of knowledge that include research evidence; clinical experience; reasoning; authority; quality improvement data; and the patient’s situation, values, and experience (Brown, 2005). These are the tools that can help the DNP decide whether the clinical guidelines and scientific evidence are consistent with the context, values, and desires of the patient (Glanville, Schirm, & Wineman, 2000). For the past century, most outcome measurement has focused on the outcomes of medical care, particularly negative outcomes. However, during the past several years, there has been a greater focus on positive indicators of nursing care delivery (Melnyk & Fineout-Overholt, 2011). The development of nurse-sensitive patient outcomes (NSPOs) was an outgrowth of public demand for greater accountability by healthcare providers. Some more recent examples of nurse-sensitive indicators of quality include ambulatory care and ambulatory surgical environments (Mastol, Matlock, & Start, 2016; Brown & Aronow, 2016), pressure injuries (Schindler, 2018), failure to rescue (Mushte, Rush, & Andersen, 2018); older and still relevant indicators include quality of life (Ingersoll, McIntosh, & Williams, 2000), support systems available to assist with caregiver burden (Craft-Rosenburg, Krajicek, & Shin, 2002), trust in care provider (Ingersoll et al., 2000), and nurse staffing ratios (Hodge, Asch, Olson, Kravitz, & Sauve, 2002). TABLE 21-5 presents additional examples of evidence-based outcome indicators. TABLE 21-5 Selected Evidence-Based Outcome Indicators for

Advanced Practice Nursing Outcomes

Examples and Indicators

Patient satisfaction

Ambulatory care: Survey

Risk

Morbidity and mortality: Summary Patient falls: Reports Medication errors: Medication administration records (MARs); comprehensiveness of exams

Knowledge

Blood pressure medication: Blood pressure control

Conditionspecific

Postoperative pain: Pain management scale Diabetes management: Blood glucose levels

Infection control

Surgical procedures: Hand washing; nosocomial infection rates

Compliance

Fluid restriction: Daily weights Prenatal and postpartum visits

Description The success of EBP depends on asking the right questions at the right time, critically analyzing results of other studies for fit in a given situation, observing for differences in responses, and evaluating outcomes. In this regard, quality improvement evaluation is important in advanced practice to ascertain the impact of interventions and their effect on cost-effective care. DNP and APN interventions are appropriately evaluated based on physiological, psychosocial, functional, behavioral, and knowledge-focused effectiveness (Glanville et al., 2000). The evaluation process involves the selection of appropriate measurement instruments. Glanville et al. (2000) made the point that instruments that measure effectiveness in care processes are not the same as those that measure outcomes. For example, a tool that measures risk for patient infections is not the same tool as one that tracks infection rates in a group of postsurgical patients. Similarly, in process management, the focus is on which components produce or contribute to practice variations that may ultimately affect, but are not the same as, outcomes (Ingersoll, 2005).

Some basic provisions for an effective outcomes model are to keep the outcomes as short as possible; to use outcomes, not activities or processes; and to use singular, not compound, outcomes (Duignan, 2006). Components of an effective outcomes management model include the following: 1) identification of the problem, 2) scanning the existing evidence and standards of care, 3) identification of benchmark targets, 4) determination and selection of outcomes measuring and monitoring tools, 5) development of specific guidelines to drive care delivery processes, 6) assessment of existing processes, 7) measurement and monitoring of processes and outcomes of care, 8) reporting findings to key stakeholders and decision makers, and 9) refining care delivery processes and data collection techniques based on findings. (Ingersoll, 2005, pp. 314–315) A significant time commitment is required for designing systems for promoting safe, timely, patient-centered care. However, the benefits are efficiency and effectiveness. Since the Institute of Medicine (IOM) studies, patient safety has been a primary focus of quality improvement initiatives. Safety issues are of concern in every care setting—primary, secondary, and tertiary. A review of the literature from 2008 to 2018 in the CINAHL databases produced over 6,000 nursing studies that involved quality improvement projects with safety as a focus. Of these, 918 studies included the word evidence as a descriptor, and 27 included advanced practice nursing as a descriptor. Study topics included pharmacotherapy, environment, technology, acute care, pediatrics, critical care, intravenous infusions, long-term care and home health, rural health, diabetes, health education, chronic obstructive pulmonary disease, Alzheimer’s, mental health treatment in children, head injury and neuroscience issues, electronic medical records, pregnancy, diabetes, and behavioral health. Of particular interest since the previous version of this chapter were the number of studies that dealt with the issues of safety, culture, and environment, including ergonomics (599 studies); surgical safety (610 studies); interdepartmental communication and “hand-off” (e.g., via electronic medical records; from hospital to primary care; after anesthesia; in ambulatory care) (322 studies). However,

despite the number of new DNP graduates and the fact that publishing by DNPs has increased as noted previously by Broome et al. (2013), few studies included “DNP” in the title or focus of the article. Since CINAHL is the widely used database for all nurses, it serves as a source for role modeling for nurses at all levels. Direct care providers, particularly DNPs, can continue to take a lead role in improving care delivery systems that benefit patients, families, and providers of care by disseminating their accomplishments in professional literature.

Using Practice Guidelines to Improve Practice and the Practice Environment As Goolsby, Meyers, Johnson, Klardie, and McNaughton (2004) have noted, “clinical practice guidelines are protocol-driven, step-wise recommendations for diagnosing and treating specific conditions, or patient populations” (p. 178). Clinical decision making is grounded in the use of clinical research, expert opinion, and clinical practice guidelines. Further, clinical practice guidelines “minimize differences in practice patterns and the risk of misdiagnosis or treatment failures” (Goolsby, Meyers, et al., 2004, p. 178). In one recent example, Mortenson, Singhal, Hengel, and Purtzki (2016) described the development and evaluation of CPGs to promote evidence-based treatment of pediatric concussions in primary care. The AGREE II framework was used for this published DNP scholarly project. The “CPG was found to meet the standard for general recommended use in pediatric primary care” (p. 1). Unfortunately, although the use of practice guidelines is increasing, they are not always used for a variety of reasons. Time, communication, involvement, resources, patient expectations, and perceived priority are all facilitators of or barriers to the implementation of EBP guidelines (Abrahamson, Fox, & Doebbeling, 2012; Gagan & Hewitt-Taylor, 2004; Graham, Graham, & Davies, 2013; Lopez-Bushnell, 2002; McCaughan, Thompson, Cullum, Sheldon, & Thompson, 2002; Rutledge & Bookbinder, 2002). Jun, Kovner, and Stimpfel (2016) found additional facilitators and barriers for the use of CPGs. Their integrative review included 52 articles using the Critical Skills Appraisal Program (CASP) with final inclusion of

16 articles from multiple countries that met all inclusion criteria from a total of 15,823 screened from multiple databases (Medline, CINAHL, Embase, PubMed, and ProQuest) between 2005 and 2015. Additional facilitators and barriers for the use of CPGs included usability, leadership, organizational culture, and multidisciplinary communication. The authors noted that “nurses must have an active role in the development, implementation and updating of clinical practice guidelines to ensure high quality care” (Jun et al., 2016). Nevertheless, the use of practice guidelines and published articles on their use has been substantial. For the 10-year period from 2008 to 2018, using the search term practice guidelines, there were 5,252 articles in CINAHL. In PubMed, when nurses was added to the practice guidelines search term, there were 5,614 articles out of a total of 71,768 when only practice guidelines was used as the term. DNPs as leaders in clinical practice are in an excellent position to collaborate on the development and implementation of guidelines.

Evaluation of Practice He who every morning plans the transaction of the day and follows out that plan, carries a thread that will guide him through the maze of the most busy life. But where no plan is laid, where the disposal of time is surrendered merely to the chance of incidence, chaos will soon reign. —Victor Hugo

Planning for evaluation is as important as the change itself and must be a systematic process. Evaluation is an ongoing process that must start early in a project and be continual. Evaluating practice and changes in practice is essential to the successful implementation of any quality improvement or EBP initiative. Classification schemes allow for an organized approach to evaluating outcomes. Outcomes may be classified according to population served (e.g., pediatric, adult, geriatric), time (long term, medium term, or short term), or type (care related, patient related, or performance related) (Rich, 2015).

Using Benchmarks to Evaluate Clinical Outcomes and Trends One method of evaluating practice is to evaluate practice patterns against national benchmarks to determine variances in clinical outcomes and population trends. Benchmarking is the process of comparing performance with an external standard to motivate improvement (AHRQ, 2013). Organizations that regularly collect data on outcomes in health care are state boards of health and the Centers for Medicare and Medicaid Services (CMS). The Joint Commission and the Magnet Recognition Program (American Nurses Credentialing Center, 2018) also have performance measurement standards that are based on quality indicators. In addition to these organizations, many hospitals and healthcare facilities have memberships in organizations that benchmark indicators of quality in specialty services. Benchmarking is especially important since the passage of the Patient Protection and Affordable Care Act (2010). One interesting example was a study that compared NP and PA practices and productivity in outpatient oncology clinics at

national comprehensive cancer network institutions. NPs were seen to be marginally more productive in seeing follow-up patients, whereas PAs conducted slightly more procedures. Both providers were a useful addition to oncology practices in these centers (Hinkel et al., 2010). Nursing services are an important aspect of outcome evaluation and reporting at any healthcare institution because nurses make up such a large part of the healthcare workforce. Effectiveness of nursing care is determined by nurse-sensitive indicators. Nursing administrators are responsible for maintaining evaluation systems and reporting nursesensitive outcomes. As leaders in clinical care and outcome evaluation, DNPs must be in the forefront of designing outcome evaluation plans for advanced practice. DNPs in advanced practice roles are also included in medical outcome working groups within their scope of practice. The American Medical Association Physician Consortium for Performance Improvement (AMA-PCPI) has performance measures available for several topics or conditions. According to Gallagher (2009) the general approach to measurement includes six steps: “1) identifying the opportunities for improvement, 2) involving representation from medical specialties and other care disciplines, 3) linking measures to an evidence base, 4) supporting clinical judgment and patient preferences, 5) testing measures, and 6) promoting a single set of measures for widespread use and multiple purpose” (p. 185). TABLE 21-6 contains a brief listing of websites for healthcare outcomes and data. TABLE 21-6 Websites for Healthcare Outcome Information Organization

Website

Academy Health

www.academyhealth.org

Agency for Healthcare Research and Quality

www.ahrq.gov

Centers for Medicare and Medicaid Services

www.cms.gov

Institute for Healthcare Improvement

www.ihi.org

The Professional Society for Health Economics and Outcomes Research

www.ispor.org

Johns Hopkins Center for Health Services and Outcomes Research

www.jhsph.edu/research/centers-andinstitutes/health-services-outcomes-research

The Joint Commission

www.jointcommission.org

National Cancer Institute

www.cancer.gov

National Committee for Quality Assurance

www.ncqa.org

National Quality Forum

www.qualityforum.org/Home.aspx

University of Iowa College of Nursing

www.nursing.uiowa.edu/excellence/evidencebased-practice-guidelines

University of Arizona Center for Health Outcomes and PharmacoEconomic Research (HOPE)

www.pharmacy.arizona.edu/centers/healthoutcomes-and-pharmacoeconomic-center

Description

Database Design to Generate Meaningful Evidence for Nursing Practice A systematic process for patient care and practice data is essential to guide practice. This requires the development of standardized databases to guide outcomes research for practice. Clinical databases from computerized medical records and disease registries are the result of documentation of care or research protocols. Outcome data are also available from birth logs, death records, discharge summaries, and clinical pathways. Most important is that evidence is generated from measurable outcomes, and the data generated must relate to the care processes or interventions (Ulrich, Arthur, & Marfell, 2013). Other useful resources for aggregated evidence-based outcomes are the Healthy People 2020 evidence-based resources at the Centers for Disease Control and Prevention (CDC), the National Information Center on Health Services Research and Health Care Technology (NICHSR/HSRIC), the AHRQ Quality Indicators, the CMS, the American

Medical Association (AMA), and the Substance Abuse and Mental Health Services Administration (SAMHSA). The Cochrane Collaboration Review is another source that provides reprints online of the newest intervention reviews. The Review lists authors and their affiliations; an abstract, including background, objectives, search strategies, selection criteria, data collection, and analysis; authors’ conclusions; and a plain-language summary. The library contains sections for clinicians, researchers, patients, and policy makers. Podcasts are also available. These and other evidence-based resources are effective tools to aid in the efficient delivery of evidence-based care. TABLE 21-7 provides a brief description of other available databases. The use of these resources is valuable when combined with the best empirical knowledge and judgment. The true measure of their effectiveness is in the evaluation of the outcomes of management and care decisions, and delivery processes. TABLE 21-7 Evidence Databases Source

Content

American College of Physicians (ACP) Journal Club

Articles reporting original studies and systematic reviews.

ACP JournalWise

Personalized journal alerting service sends messages to a smartphone or email inbox according to subscriber interest and specialties.

AHRQ

Guidelines and technology assessments on selected topics from 12 evidence-based practice centers.

AHRQ (SHARE)

A five-step process for shared decision making that includes exploring and comparing the benefits, harms, and risks of each option through meaningful dialogue about what matters most to the patient.

AIDSLINE

Indexes the published literature on HIV and AIDS. The index includes journal articles; monographs; meeting abstracts; and papers, newsletters, and government reports (Fain, 2009).

CDC Sexually

Includes web-browsable sources with cross links.

Transmitted Disease Treatment Guidelines Cochrane Database of Systematic Reviews

“Reviews individual clinical trials and summarizes systematic reviews from over 100 medical journals” (Fain, 2009, p. 277).

DynaMed

Point-of-care resource to support clinical decision making.

EPPI Centre

Evidence for Policy and Practice Information and Coordinating Centre, Institute of Education, University of London.

Essential Evidence Plus (formerly InfoPOEMs)

Includes reviews and commentary of recently published articles by the Journal of Family Practice.

Evidence-Based Practice at the University of Iowa

Includes an evidence-based practice toolkit, information about recent evidence-based practice projects, and an evidence-based practice model and resources.

HSTAT

Health Services Technology Assessment Text, full-text guidelines.

Johns Hopkins Evidence-Based Practice Center

Includes systematic reviews of evidence.

MEDLINE

A compilation of information from Index Medicus, Index to Dental Literature, and the International Nursing Index. It includes published research in allied health, biological sciences, information sciences, physical sciences, and the humanities.

MedPage Today

Includes daily research updates, news by specialty, policy news, continuing medical education (CME), and surveys. Includes an excellent tool, MedPage Tools Guide to Biostatistics, that can be used as a reference guide when reading research articles.

National Cancer Institute

Includes cancer literature from research, journal articles, government reports, technical reports, meeting abstracts, and papers and monographs.

Prescriber’s Letter

Includes evidence-based information on new drug developments, with links to articles and continuing education offerings.

PubMed

Provides source for queries and evidence-based filters for Medline.

School of Health and Related Research

Comprehensive up-to-date evidence on the web.

(ScHarr) The Joanna Briggs Institute

International institute that provides resources for evidence-based practice for healthcare professionals in nursing, medicine, midwifery, and allied health.

The National Quality Forum (NQF): Improving Care Through Nursing

Provides information on quality and nurse-sensitive outcomes from the American Nurses Association database of nursing quality measures/indicators.

Modified from Fain, J. A. (2009). Understanding evidence-based practice. In Reading, understanding and applying nursing research (3rd ed., pp. 276–278). Philadelphia, PA: F. A. Davis.

Description Description Description As nursing takes on larger, more autonomous roles in the delivery of health care through advanced practice, the need for accountability will continue to increase. DNPs, with their knowledge of clinical practice, research, and informatics, can best represent advanced practice nursing by participating in and guiding the development of databases that are relevant to the care that DNPs and APNs provide. Becoming involved in professional organizations that have quality initiatives is an excellent way for DNPs to become knowledgeable in research that contributes to quality care and the profession. The Doctor of Nursing Practice, Inc., an organization whose purpose is to promote global networking, curricular and program enhancement, and research collaboration, offers conferences, practice updates, and scholarship of interest to DNPs. In addition, the ANA and specialty organizations such as the Oncology Nursing Society, the National Quality Forum, the AHRQ, and the CMS provide avenues for collaboration and dissemination of information on quality and nurse-sensitive outcomes (Grove et al., 2013).

Information Technology, Databases, and Evidence for Practice Digital technologies, including computers, handheld devices, and internet software applications, have changed the face of clinical care, making them a necessary tool for research and EBP. They provide efficiency in the inputting of statistical data and the retrieval of the most current information on relevant clinical trial outcomes, supportive research, and accepted practice protocols. It is essential to pay attention to the kinds of data that are retrieved and how they are used to make clinical decisions and evaluate practice.

Collecting Appropriate and Accurate Data Data and observations from practice can be augmented and strengthened through evidence from clinical trials. Several electronic databases provide access to clinical trial data and other peer-reviewed research and outcome data. However, clinical trial data and data from other aggregate sources do not always address the outcomes that can be uniquely attributed to APN/DNP practice. For APNs/DNPs to assess and demonstrate their effectiveness, data are needed that reflect what they do. Although the primary goal of outcome data and analysis is to improve care, DNPs in direct practice may be asked to justify their roles in terms of factors such as cost, time, patient outcomes, and revenue generation, among other indicators (Burns, 2009). Most institutions rely on aggregated data to determine nursing outcomes. Unfortunately, most aggregated data do not show the APN’s/DPN’s specific contribution to the outcomes (Burns, 2009). For this reason, it is important to develop role-sensitive indicators and collect data that are specific to those indicators in a systematic way. Indicators such as satisfaction with APN/DNP care related to a program or procedure that the APN/DNP initiates, controls, or coordinates are better than trying to extrapolate the APN’s/DPN’s role in a multidisciplinary effort. Time savings or clinical outcomes related to a change in practice

coordinated by the APN/DNP may also be role sensitive. Instruments for measuring outcomes are also a necessary component in the assessment process. A systematic search of the databases mentioned in Table 21-7, such as the AHRQ, PubMed, and the National Cancer Institute, may be helpful as a starting place for appropriate measurement tools, especially if they can be adapted to include outcomes sensitive to the role of the DNP in an area of practice or leadership.

Analyzing Data From Clinical Practice Data from practice are rich and can be analyzed in a number of ways, depending on the nature of the research question. Computer-based statistical tools such as absolute risk (AR) and absolute risk reduction (ARR) calculations, relative risk (RR) and relative risk reduction (RRR) calculations, number needed to treat (NNT), survival curves, hazard ratios, and sensitivity and specificity are helpful measures for assessing risk of disease in studies of different cohort groups and in aiding clinical decision making. In an excellent article in the Journal of the American Academy of Nurse Practitioners, Goolsby, Klardie, Johnson, McNaughton, and Meyers (2004) analyzed the implementation of clinical practice guidelines and their outcomes in a hypothetical patient situation. The analysis includes a review of commonly used statistical concepts, including some of those just mentioned, with examples of their application in interpreting and reporting research. O’Mathuna et al. (2011) also provided a detailed section on statistical measures and their meaning in a chapter entitled “Critically Appraising Quantitative Evidence for Clinical Decision-Making.”

Designing Evidence-Based Interventions When data from practice have been generated and analyzed, areas of gap and/or problems can be discerned. Selecting and defining the problem is one of the most critical steps in the design of any evidencebased intervention. The problem statement provides the direction for the study design and is usually stated at the beginning. Essential to good design is adequate background information that includes a rationale for

pursuing an intervention, evidence from research that has already been done on the topic, and the goals to be achieved (Fain, 2013). Depending on the problem to be addressed, evidence-based interventions may be generated from quantitative research, qualitative research, outcome studies, patient concerns and choices, or clinical judgment. The first step in the design of any practice intervention is to define the clinical practice issue needing change. Once that is accomplished, critical questions include the following: What patients will be affected? What treatment or intervention or practice change is involved? What old practice would need to be discontinued? What outcomes are expected? (Collins et al., 2008). The next step is to review the evidence, basing the analysis on the hierarchy of evidence (see Table 21-1) and a search of all relevant databases (e.g., Cochrane, CINAHL, PubMed). Once the evidence has been verified, assessing applicability to the population and environment is crucial. Questions to be considered may include the following: Will implementing this practice increase patient safety? Are there ethical or legal considerations? Will other departments or providers be affected? How will the change affect practitioner time? How will patients react to the change? The next step is to develop a plan for the change. Who are the key stakeholders? How will they be apprised and included? Who has final sign-off authority? Is a pilot study indicated before full-scale implementation? Finally, determine the methods of education and communication. How much time, money, and personnel resources will be needed? When implementing the plan, the following questions should be considered: Who is responsible for coordinating the effort? What contingency plans are in place if a change must be made? Who is managing issues that may arise? Will evaluation of implementation be ongoing? How will feedback be generated? Who will conduct the evaluation? What is the method of analysis? What are the measurement tools? How will results of the evaluation be presented? (Collins et al., 2008). Carey, Buchan, and Sanson-Fisher (2009) outlined some specific strategies to promote guideline implementation. TABLE 21-8 summarizes their recommendations. Although the examples reference general practitioner (GP) practice and earlier research outcomes, the strategies and constructs are applicable to DNP/APN practice. In her study of

patients with atrial fibrillation (n = 712), a DNP noted the increased use of CPGs by advanced practice nurses. “Patients were randomized to a systematic approach using guidelines software. [This] nurse led clinic had significantly reduced composite outcomes, death, cardiovascular events, and hospitalizations compared to patients randomized to standard cardiology care” (Deaton, 2012, p. 263). TABLE 21-8 Strategies to Promote Guideline Implementation: Theoretical Constructs and Examples of Application

Strategy

Relevant Constructs

Key Illustrative Examples





Phase 1

Concrete and specific recommendations

Knowledge, executability, decidability

Concrete and specific recommendations were more likely to be adopted by general practitioners (GPs) than vague, nonspecific recommendations. Observational study (Grol et al., 1998).

Identify priorities Set targets for implementation

Goal setting, action planning

Of 228 primary care patients with cardiovascular disease risk factors who made an action plan to identify behavioral change goals, 53% also reported making behavioral change related to their action plan. Descriptive study (Handley et al., 2006).

Present a rationale

Beliefs, attitudes, perceived relative advantage

Recommendations compatible with current values were more likely to be adopted by GPs than those perceived as controversial or incompatible with values. Observational study (Grol et al., 1998).

Highlight clinical norms

Normative beliefs, attitudes, modeling/verbal persuasion

An intervention to improve myocardial infarction care that involved using local medical opinion leaders to influence peers through small-group discussions, informal consultation, and revisions of clinical protocols was compared with performance feedback alone. Hospitals in both groups improved from baseline to follow-up on indicators of quality; however, the

improvement was greatest for those allocated to the peer intervention. Randomized controlled trial (Soumerai et al., 1998). Orient to the need of the end user

Complexity

Among the guideline characteristics most commonly endorsed to promote use by GPs was “clarity, simplicity and availability of a short format.” Descriptive study of 391 GPs (Watkins, Harvey, Langley, Gray, & Faulkner, 1999).

Skills training

Skills, knowledge, selfefficacy

Continuing medical education (CME) improves knowledge, skills, attitudes, and patient outcomes. CME that is interactive, uses multimedia, uses live media, and involves multiple exposures is more effective than other types. Systematic review (Marinopoulos et al., 2007).

Social influences

Normative beliefs, attitudes, modeling, verbal persuasion

The use of local opinion leaders in hospital settings can be effective in promoting evidence-based practice. Systematic review of 12 studies (Doumitt, Gattelliari, Grimshaw, & O’Brien, 2007).

Environmental influences

Cues to action, environmental triggers

Guideline adherence improved due to the implementation of a computerized clinical decision aid that gave clinicians real-time recommendations for venous thromboembolism prophylaxis. Time series study (Durieux, Nizard, Ravaud, Mounier, & Lepage, 2000).

Patient mediated

Knowledge, skills, and attitudes of patients

Patient request for a new drug and patient acceptability were cited as contributing to decisions to prescribe a new drug in approximately 20% of cases. Descriptive study (Prosser, Almond, & Walley, 2003).

Feedback

Positive/negative reinforcement, goal setting, skill development

Audit and feedback are effective strategies for improving care, particularly when baseline adherence to the recommended practice is low. Systematic review of 118 studies (Jamtvedt, Young, Kristofferson, O’Brien, & Oxman, 2006).

Incentives

Positive/negative

Five of six studies examining physician-level

Pilot testing with iterative refinement of implementation strategies

reinforcement

incentives and seven of nine studies examining provider-group-level incentives demonstrated partial or positive effects on quality indicators. Systematic review (Peterson, Woodward, Urech, Daw, & Sookanan, 2006).

Perceived advantages, beliefs, trialability

Breakthrough collaborative model intervention that involved a series of iterative plan-do-study-act cycles was found to be effective in improving care for chronic heart failure. Quasi-experimental, controlled study (Asch et al., 2005).

Carey, M., Buchan, H., & Sanson-Fisher, R. (2009). The cycle of change: Implementing the best-evidence clinical practice. International Journal for Quality in Health Care, 21(1), 37–43. Reproduced with permission.

Description Description Description Further research in implementation science is proposed to update implementation strategies for greater consensus and uptake of clinical practice guidelines and strategic change toward EBP at institutional levels (Gagliardi & Alhabib, 2015; Liang, Safi, & Gagliardi, 2017; Stetler, Ritchie, Rycroft-Malone, & Charns, 2014). DNPs as practice experts and leaders need to play a part in these processes.

Predicting and Analyzing Outcomes Often in clinical practice, the occurrence of one event in time may be the basis for predicting a future event. In such instances, a predictive relationship is established. In this case, the practitioner or researcher is looking for a correlation between the two events that may predict the outcome of a future intervention or occurrence that could be designed to affect or influence the independent variable. Although correlational prediction is not the same as cause and effect, it is stronger than a purely descriptive study (Melnyk & Cole, 2011). This type of study would be appropriate if, for example, the DNP was interested in how a person’s initial attitude toward insulin-affected compliance with the regimen 3, 6, or 12 months after the therapy began. Correlation statistics would be used to measure the relationship

between the two variables. The results of the correlation could later be used to design interventions, such as educational strategies or follow-up programs, that would help those with negative attitudes toward therapy learn, adapt, and achieve more positive outcomes. Correlational statistics are also used to measure the strength of relationship between two variables. A direct correlation is seen in correlation coefficients between the values of 0 (no correlation) and 1 (large positive correlation) and means that when there is a large change in the value of one predictor, there is a large change in the value of the other predictor; likewise, a small change in one predictor is accompanied by a small change in the other predictor. A relationship that has a correlation coefficient of 0.5 is stronger than 0 but less than 1.0. Conversely, in a negative correlation— between 0 (no correlation) and –1 (large negative correlation)—large changes in the value of one predictor would be accompanied by small changes in the other, or small changes in one would be accompanied by large changes in the other. Therefore, a negative correlation coefficient of –0.6 shows a stronger negative relationship between two variables than a coefficient of 0 but not as strong as a coefficient of –1.0 (Lanthier, 2002). An example of this kind of analysis is shown in a correlation study on salary and income levels. TABLE 21-9 shows salary levels and corresponding years of education. FIGURE 21-5 shows an example of a correlation scatter plot, with years of education on the y-axis and income on the x-axis. Each point on the plot shows one person’s answers to the questions regarding years of education and income. In a positive correlation such as this, the line is always in the upward direction. In another example, TABLE 21-10 and FIGURE 21-6 show a negative relationship between grade point average (GPA) and number of hours spent watching television. The scatter plot (Figure 21-6) shows the direction of the line when the correlation is negative. In these cases, the researcher is measuring conditions that already exist and looking for relationships— either positive or negative.

FIGURE 21-5 Regression scatter plot, salary, and education in years. Reproduced form Lanthier, E. (2002). Correlation. Retrieved from www.nvcc.edu/home/elanthier/methods/correlation.htm. Copyright 2002 by Elizabeth Lanthier, PhD.

Description

FIGURE 21-6 Regression scatter plot, hours of television use, and grade point average. Lanthier, E. (2002). Correlation samples. Retrieved from https://blogs.nvcc.edu/elanthier/psy213/correlation-information. Copyright 2002 by Elizabeth Lanthier, PhD. Reproduced with permission.

Description TABLE 21-9 Salary and Years of Education Participant

Income

Years of Education

#1

125,000

19

#2

100,000

20

#3

40,000

16

#4

35,000

16

#5

41,000

18

#6

29,000

12

#7

35,000

14

#8

24,000

12

#9

50,000

16

#10

60,000

17

Lanthier, E. (2002). Correlation. Retrieved from https://blogs.nvcc.edu/elanthier/psy213/correlation-information. Copyright 2002 by Elizabeth Lanthier, PhD. Reproduced with permission.

Description TABLE 21-10 Grade Point Average and TV Use Participant

GPA

TV Use (hrs/wk)

#1

3.1

14

#2

2.4

10

#3

2.0

20

#4

3.8

7

#5

2.2

25

#6

3.4

9

#7

2.9

15

#8

3.2

13

#9

3.7

4

#10

3.5

21

Lanthier, E. (2002). Correlation samples. Retrieved from https://blogs.nvcc.edu/elanthier/psy213/correlation-information. Copyright 2002 by Elizabeth Lanthier, PhD. Reproduced with permission.

Description

Examining Patterns of Behavior and Outcomes Although much of the research and evidence for practice is focused on cause and effect, patterns of behavior, dispositions, and attitudes are also outcomes that require examination. Behavioral theories can be classified as intrapersonal (individual), interpersonal (relational), and community based. The stages of change model (Prochaska & DiClemente, 1986), the health belief model (Rosenstock, 1966), and the theory of reasoned action (Fishbein & Ajzen, 1980) are useful models to use in framing behavioral outcome studies. Aggregated data derived from large datasets can be useful in examining patterns of behavior and outcomes. Organizations such as the AHRQ, the CDC, the National Institute for Child Health and Development, and the National Institutes of Health (NIH) have large national datasets from various sources, such as quality-of-life surveys, hospital discharge data, and infection control data. The datasets can be accessed or purchased to allow researchers to develop clinical, behavioral, or interventional outcome questions that can be statistically analyzed. The advantage of this kind of analysis is that the datasets are large enough to provide an adequate sample and effect size from which to generalize intervention effects. The AHRQ also maintains a database of comparative effectiveness reviews that synthesizes information from the most current studies on numerous diseases through the Evidence-Based Practice Centers (AHRQ, 2015). In addition to aggregated evidence, clinical trial data, and comparative effectiveness reviews, some innovative healthcare systems are bringing “‘practice-based evidence’ to the bedside or work setting in aggregate form so that providers have the most up-to-date information available on outcomes before evidence-based interventions are begun” (Lambert &

Burlingame, 2009, p. 1). As an example, this kind of decision support was trialed in the Mental Health Services Centers for the state of Utah. The state partnered with an outcomes measurement vendor (OQ, LLC) to provide aggregated evidence from clinical trials and laboratory research that resulted in a 5-minute self-report outcome measurement for patients in any setting—outpatient, inpatient, or residential. Adult patients used a handheld personal digital assistant, computer kiosk, or paper survey to report information to clinicians based on the domains of symptomatic distress, interpersonal relations, and functional ability. According to the designers, the advantage of this kind of tracking is that the system provides immediate evidence-based support for direct patient care. Furthermore, it provides a method for storing data for future review, evaluation, and benchmarking (Lambert & Burlingame, 2009). Recent studies by researchers such as Bischoff and Hinjosa (2015); Johansson, Petersson, and Nilsson (2011); Mickan, Atherton, Roberts, Heneghan, and Tilson (2014); and Mickan, Tilson, Atherton, Roberts, and Heneghan (2013) have shown that use and expansion of these kinds of digital assistant systems improved information seeking, confidence, adherence to guidelines, and decision making. In addition, telemedicine (phone and televideo) was found to be an effective mechanism for coordinating care especially by caregivers of those with complex needs (Looman et al., 2015).

Identifying Gaps in Evidence for Practice In a systematic analysis of reviews published by the Joanna Briggs Institute between 1998 and 2002, high-quality evidence to support nursing interventions was not evident (Averis & Pearson, 2003). Further, the report identified considerable gaps in the evidence base available for nurses in relation to 22 discrete areas of practice that were examined in the analysis. Since the impetus to improve patient safety generated by the IOM reports To Err Is Human (Kohn, Corrigan, & Donaldson, 2000), Crossing the Quality Chasm (IOM, 2001), and Health Professions Education: A Bridge to Quality (IOM, 2003), significant gains have been made in the availability of support for EBP through educational restructuring and systems support. A literature search of recent articles in CINAHL (2013–2018) produced over 1,700 nursing articles identifying

synthesis articles, systematic reviews, and meta-analyses of nursing interventions, including those based on randomized controlled trials. When meta-analysis and advanced practice or DNP nursing interventions were added to the search terms, only 15 additional articles were found between PubMed and CINAHL. However, Broome et al.’s (2013) more rigorous analysis and specific focus on DNPs as authors found 300 articles in 59 journals with at least one DNP author. Nevertheless, gaps in the translation of evidence remain. Research by nurses and family physicians suggests that a translational model to fill the gaps is necessary (Armson et al., 2007; Gumei, Tiedje, & Oweis, 2007). One such model, developed in Canada, uses a small, self-formed group-discussion format within local communities. The impetus for this model was the need to stay competent in view of the vast amount of medical information currently available. In these groups, a facilitator guides physicians’ discussion using sample patient cases and prepared modules on selected clinical topics. The group discussions have been ongoing for 15 years and have attracted international interest (Armson et al., 2007; Kelly, Cunningham, McCalister, Cassidy, & MacVicar, 2007). Nurses engage in similar forums in hospital grand rounds within their professional specialty organizations and at regional and national conferences. However, collaborative engagement and priority setting needs to be broader and more systematic to reduce the practice-translational-dissemination gap (Brown & Crabtree, 2013; Cooke, Ariss, Smith, & Read, 2015). DNPs are in an excellent position to initiate this kind of practice-based dialogue in community-based practice settings. The AMA, the AACN, the NONPF, and other professional nursing organizations in each specialty all have agendas for advancing research and evidence for practice in their respective areas. As examples, the American Academy of Nurse Practitioners, Nurse Practitioner Associates for Continuing Education, and the Practicing Clinicians Exchange provide excellent forums for translating current research into practice and for networking with peers about research and clinical outcome information. The Joint Commission, the National Database of Nursing Quality Indicators, and individual hospital report cards may be used as sources of research or outcome analysis to identify gaps in care delivery or in patient or staff education institutions or practice groups. Examples

include adverse events, smoking cessation, rates of adherence to best practice, blood glucose control, patient satisfaction rates, time spent with patients, tests ordered, and number of consultations (care related); knowledge, functional status, and access to care (patient related); and collaboration, technical quality, exam comprehensiveness, and adherence to guidelines (performance related) (Kleinpell, 2009, 2013). Within these and other categories, the gaps may be identified through the development of a specific plan based on target areas of APN practice. Planning questions should include the following: What exactly can be measured? How can it be measured? What will be done with the information? When should it be done? (Kleinpell, 2007, 2013). FIGURE 21-7 shows a sample timeline for outcome assessment.

FIGURE 21-7 Timeline for outcome assessment for APN practice. Modified from Kleinpell, R. M. (2007). APNs: Invisible champion? Nursing Management, 38(5), 18–22.

Description As advanced practice nursing continues to evolve with DNP-prepared nurses taking leadership positions as direct care providers, senior-level nurse executives, and doctorally prepared nurse educators, quality improvement and patient safety will remain a priority (O’Grady, 2008). Identifying, testing, and disseminating information about nurse-sensitive quality indicators is essential to close the gap in quality care delivery.

Participation in Collaborative Research It is a credit to the profession of nursing and its leaders that there are several EBP centers in the United States: the ANA National Center for Nursing Quality, Sigma Theta Tau International, the National Institute of Nursing Research at the NIH, and centers at many of the major university schools of nursing. However, as O’Grady (2008) noted, turf battles have limited collaboration. On the macro level, “APN organizations along with governmental and private research enterprise must come together to develop a research plan that identifies the most critical research questions” (O’Grady, 2008, p. 12). On the micro and macro levels, APNs individually and as a group must “demonstrate specific clinical performance and patient outcomes” (p. 12). This means “clearly distinguishing APNs in the context of interdisciplinary practice” (p. 12). Individual studies can demonstrate gaps in care in smaller samples, but the time has come for a more comprehensive and collaborative agenda for research that focuses on such issues as roles, function, outcomes, access improvements for vulnerable populations, interdisciplinary collaboration impacts, cost-effectiveness, safety, and other indicators. To identify gaps in care that are of concern to APNs/DNPs, nurses must have representatives from their ranks on research decision-making bodies. The AHRQ is positioned to take the lead in outcomes research, whereas the NIH focuses on biomedical aspects of disease management (O’Grady, 2008). To have their voices heard and their studies funded and disseminated, DNPs must use the power of their professional organizations and garner positions on national and international research and EBP collaboratives. Participating in collaborative research is an excellent way for APNs/DNPs to resolve clinical dilemmas and highlight their expertise through well-constructed questions that interest scientists and engage professional peers within and outside nursing. The dynamic nature of scientific evidence and the speed with which it is now possible to generate new knowledge using technology demand that all care

providers combine their expertise to interpret, plan, and evaluate the outcomes of interventions based on these new discoveries. Collaboration “implies collective action toward a common goal in a spirit of trust and harmony” (D’Amour, Ferrada-Videla, San Martin-Rodriguez, & Beaulieu, 2005, p. 116). Examples of interprofessional education programs to better integrate teaching, research, and professional activities among the healthcare and related disciplines are increasing. Some best practice models are those of the University of Washington School of Medicine (Seattle), Rosalind Franklin University of Medicine (North Chicago, Illinois), and the University of Florida (Gainesville) (Bridges, Davidson, Odegard, Maki, & Tomkowiak, 2011). The models incorporate didactic, community-based, and simulation experiences with interprofessional team-building and service learning in a variety of ways. Specialization in nursing, medicine, and other healthcare disciplines demands collaboration between peers and patients to resolve complex clinical dilemmas if patients are to be treated holistically instead of as a collection of organ systems. In fact, as Nolan (2005) noted, patients must be included as “shapers of knowledge and action” (p. 503). Nursing now has a body of knowledge, separate and unique from that of medicine, that provides the basis for unique contributions to science and to the care of individuals. At the same time, “nursing scholarship remains contextual and contingently situated” (Fairman, 2008, p. 10). Nurses have shown in practice that they are creative and capable of managing changing circumstances and dynamic cultural milieus, thus ensuring that APNs with both research and clinical skills are in a prime position to function as practice consultants in collaborative knowledgegenerating research (AACN, 2006). This role is illustrated in the following example. A DNP was a voluntary member of an advisory board of a suburban primary healthcare network that provided care to uninsured patients. The members of the board were very interested in ascertaining information about the effectiveness of the organization and its efforts to provide costeffective, timely primary care. The following were questions of interest: Are emergency department visits decreased by offering this service? If they are, how much cost is saved? The DNP collaborated with the organization’s administrator and developed an initial research question and a preliminary plan for presentation to a grant-funding agency. The

DNP researched the literature and took the preliminary plan to her institution’s research group; with the help of a colleague from the college’s health administration program, the DNP designed a study that was submitted to a grant-funding agency specializing in grants to medical centers and community health agencies. The agency did not fund the grant that year. However, the following year, the original proposal was reframed as a cohort study, “Emergency Room Usage Among Uninsured Patients With Access to a Primary Care Provider” (Tymkow, Shen, & MacMullen, 2006), and resubmitted as a subproject of a much larger NIH grant that was funded. A primary aim of the larger National Center on Minority Health and Health Disparities grant was to build capacity for research in healthcare disparities through mentoring by senior-level researchers (Samson, 2006). The DNP who was a mentee became the primary investigator and worked with two coinvestigators on this project. In another example of collaborative research, Oman, Duran, and Fink (2008) described a collaborative EBP project to institute evidence-based policy and procedure development at the University of Colorado Hospital using the hospital’s evidence-based multidisciplinary practice model. The model established the evidence base through valid and current research and through other forms of evidence or benchmark data, including costeffectiveness analysis; pathophysiology; retrospective or concurrent chart review; quality improvement and risk data; international, national, and local standards; infection control data; patient preferences; and clinical expertise. The more sources that are added to the research core, the stronger the evidence. However, all sources are contributory to the evidence. The Evidence-Based Practice Council used the levels of evidence of Stetler (1994) to guide the process of gathering evidence. As described by Oman et al. (2008), because there was nothing addressing policy and procedure in the literature, the members identified steps and created an algorithm to describe the process. Once developed, the algorithm was piloted on the units using six nurse champions, mentored by a researcher. The champions and researcher reviewed an orthostatic vital sign policy that was scheduled for update. After obtaining 12 researchbased articles, 8 clinical articles, 1 national guideline, and anecdotal recommendations, the group was divided into subgroups, and each person was assigned 2 reports to review using a standardized critique

form. Each nurse was responsible for reading the articles, completing the critique form (with levels of evidence), and presenting the findings at a journal club. The policy being reviewed was checked for references and levels of evidence by the research scientist. A comparison of agreement between the policy author and reviewers was then determined, and the percentage of agreement between reviewer and author tabulated. Only clinically based policies were reviewed. This process is a good example of how collaboration between practice and education could be merged in any number of areas. Whether collaboration involves clinical research or quality improvement, DNPs in clinical and leadership roles are key stakeholders in the process. As identified in the IOM report Crossing the Quality Chasm (IOM, 2001), communication and collaboration are requisites to the achievement of quality systems and patient outcomes. These skills are also a necessary part of a culture of collaboration that begins in educational programs and continues in the professional work setting. Collaborative efforts may include small unit-based or practice-based efforts or large system-wide initiatives. These efforts have been driven by consumer demand for excellence, accountability, and transparency in quality care, patient safety, and patient satisfaction (Freshman, Rubino, & Chassiakos, 2010). In any collaborative initiative, three levels of expertise are required: system leadership, including the authority to implement change; clinical technical expertise (guidance and know-how); and dayto-day leadership (details of the system) (Baker, Reising, Johnson, Stewart, & Baker, 1997).

Disseminating Findings From Evidence-Based Practice A primary reason for disseminating research is to use the findings to improve practice and health outcomes. Communicating the results of research and EBP trials is the culminating step of the research and research utilization processes. It is one of the most important steps in research and the application of research in practice because it is the communication of research findings that provides the basis for meaningful critique, development of new questions, and testing of research evidence in practice (Lyder & Fain, 2009). The methods used to communicate evidence from practice trials are similar to those used for communicating research findings: journal publications, podium or poster presentations, internet webinar sessions, media communications, journal clubs, and community presentations. However, the forums for dissemination may be broader because the audience of interest may be more diverse, including those with practice, research, and community development interests. In addition, the choice of method for communicating information depends on several important factors. For example, a journal publication may be personally advantageous to the author, but the time from submission to actual publication and dissemination may delay utilization of important evidence-based treatments in practice. Oral reports at national conferences may facilitate timelier dissemination. Webinars may be the fastest way to disseminate information but may not reach all the desired audiences. Journal clubs are useful forums for discussions of research findings in academic settings. Reports of community-based studies to advisory boards or media venues may also become the basis for further research and political support that help nonprofit and other community organizations. Nevertheless, because theory, research, and practice must be constantly intertwined, the circular and reciprocal relationship among these elements must be apparent regardless of where the research is presented (McEwen & Wills, 2014).

Preparing a Journal Publication Preparing a journal article for publication is time consuming and at times tedious, but the rewards of feeling that you have contributed and seeing your work in print are worth the effort. Once the topic for an article has been established, the next step is selecting the journal. Peer-reviewed journals have the most rigorous review criteria. Therefore, publication in one of these journals is more credible. The actual content will be determined by the editorial guidelines of the journal, which may be found in the “Information for Authors” section of the journal. In most cases, the guidelines may also be obtained from the journal’s website. Generally, the submission requirements cover technical details such as page length, margins, font style and size, reference format, use of graphics and figures, and method of submission. It is very important to follow the submission requirements because many journals will not review articles that are not submitted in the correct format. Once submitted, articles in peer-reviewed journals are blind (anonymously) reviewed by several reviewers. It is not uncommon for the review process to last several weeks or months; articles may be rejected, accepted with revisions, or accepted. It is common to have articles returned for revision. The key to success is to be persistent, correct those things that can be corrected, explain those that cannot, and return the submission in the agreed-on time frame.

Preparing a Research Presentation Regardless of where or how evidence is reported, the essential element is that it combines the knowledge and values of the study patients or population with practitioner expertise and the best in available and current research evidence. Reporting evidence also requires knowledge of the audience and their needs. Specifically, the presenter must ask the following questions: What is the specific content to be addressed? How will the audience use the information? What is the knowledge level of those who are to receive the information? What is the time allowed for the presentation? What audiovisual resources are available for the presentation? Once these questions have been answered, specific learning objectives should be developed to guide and organize the presentation.

An outline for presentation of research study findings is shown in TABLE 21-11. Important points of each aspect of the study can be displayed in a PowerPoint presentation to help keep the presentation within the designated time frame and allow the audience to stay focused on the important elements. Some useful websites for building PowerPoint presentations are listed in TABLE 21-12. TABLE 21-11 Outline for Research Presentation I. II. III. IV. V.

VI.

VII. VIII. IX.

Introduction Purpose of the study Theoretical framework Hypothesis Design A. What kind of study B. Intervention C. Sample 1. Population 2. Inclusion/exclusion criteria D. Instruments Analysis A. Method B. Types of statistical tests used Findings Discussion Implications A. Research B. Clinical practice

Description TABLE 21-12 Resources and Websites for Developing Multimedia and PowerPoint Presentations PosterPresentations.com (Scientific Template)

www.posterpresentations.com

Indiana University-Purdue University, Indianapolis, Center for Teaching and Learning

http://ctl.iupui.edu/Resources/Documenting-YourTeaching/Resources-for-Poster-Presentations

Posters4Research.com

https://posters4research.com/free-templates/a01-36x48ppt.php

University of North Carolina, Academic Poster Presentations

http://gradschool.unc.edu/academics/resources/postertips.html

Vanderbilt University Poster Presentations

https://ww2.mc.vanderbilt.edu/evidencebasedpractice/50289

Description

Preparing a Poster Presentation Disseminating information from scholarship—original research, practice innovations, clinical projects—through poster presentations has become an accepted medium for the exchange of ideas in a more personal and less formal environment than the podium presentation. It is both efficient and effective. Presenters and participants have the freedom to engage in a dialogue that allows for education, clarification, and networking. Posters also allow for the formatting of data in creative ways. As Berg (2005) noted, “imagery can be substituted for words and this is a powerful way to convey information” (p. 245). Like any presentation, posters require preparation. The following steps are essential.

Plan Ahead A good poster presentation takes considerable time. The planning stage is a most important step. In this stage, ample thought should be given to the message you are trying to convey. What is the purpose? The format for a research presentation will be different from that of a practice innovation. Is the conference only for nurses, only for APNs, or for a multidisciplinary audience? How much background information or detail do you need to include? Is the audience generally familiar with the topic? If they are, do not include familiar details, but if they are not, do not make the information so specific that those who are not familiar with the topic will be put off. Avoid using abbreviations that only a select audience will understand. These and other considerations specific to the venue should be addressed during the planning stage (Berg, 2005; Hardicre, Devitt, & Coad, 2007).

Decide on Layout and Format A good poster presentation is focused on a single message, uses graphics to tell the story, and is orderly with an obvious sequence (Hess,

Tosney, & Liegel, 2013). Most people read top to bottom, left to right. This is the usual sequence for poster layout. Generally, the layout for a research poster presentation is as follows: title, abstract, introduction, methods, results, discussion, and acknowledgments. If the presentation is a practice innovation, the layout will be different. The innovation is usually in the center, with explanatory text at the periphery or below the diagram or explanation of the protocol or change (Hardicre et al., 2007). References are also included, as in the research poster. The poster should be easy to read from 4 to 6 feet (Halligan, 2005; Hess et al., 2013). Section heads should be at least 40 point and supporting text 32 point (Halligan, 2005, p. 49). Titles should be short, with letters 2 to 3 inches high (Berg, 2005).

Determine the Content If the purpose of the poster is to display a research project, it will not be the same as one designed to describe a clinical innovation. The content of the research poster should follow the format established by the conference guidelines. If the study is funded by an outside or government agency, some grant-funded studies require specific wording of the acknowledgment; this should be determined during the poster planning. If an abstract is required, it should include the main purpose of the study, be clearly worded, and be succinct. A key component is to keep it simple because posters “show,” they do not “tell” (Miracle, 2008). Clinical project content will vary according to the specific topic and scope. The title for either a research study or clinical innovation should be creative, but, most important, it should accurately reflect the content of the project and “highlight the project’s take-home message” (Christenberry & Latham, 2013). The title banner should also include authors and affiliations in order of authorship and/or contribution to the effort. In many instances, the organization’s logo will be included as well (Hardicre et al., 2007).

Prepare a Brief Presentation “The poster is a story board of information” (Hardicre et al., 2007; Jackson & Sheldon, 1998, p. 398). However, it also gives the presenters

an opportunity to present themselves. As with any kind of communication, you want to convey confidence and knowledge. Preparing a short presentation script or handouts for participants allows you to organize your thoughts and prepare for possible questions. The handouts are always welcomed by participants, who are inundated with information during a conference. Be sure to include your name and contact number or attach a business card so that participants may contact you with questions. This is a very effective networking tool (Miracle, 2008).

Media Communications Communicating with large audiences is often facilitated through professional media communications. This kind of communication is essential when there is a major event or change, such as a policy to be initiated. It is usually best to engage the resources of a professional organization to make the preliminary contact and to aid in constructing the message.

Journal Club Presentations Another way to facilitate the communication of evidence-based research is through journal club presentations. Journal clubs are not new, especially in academic and many professional settings. However, they can be used to facilitate EBP development and as a forum for clinical guideline development (Kirchoff & Beck, 1995; McQueen, Miller, Nivison, & Husband, 2006). In a small survey study of the use of journal clubs to determine changes in practice, McQueen et al. found that journal clubs were effective in “1) focusing staff on clinical evidence in discussions, 2) increasing confidence as they became more aware of evidence, and 3) bridging the evidence-practice gap” (p. 315). Additionally, with the aid of the internet, evidence-based articles or studies can be posted in advance and facilitated online, thus increasing the possibility of wider participation. This technique may be especially helpful in garnering increased participation and may be an avenue for further research to assess its effectiveness because participation has been a limitation of journal clubs. Nevertheless, it is an effective

teaching/learning/continuing education strategy (Lachance, 2014). BOX 211 presents an outline of a journal club.

BOX 21-1 Online Journal Club Outline of the Journal Club 1. 2. 3. 4. 5. 6. 7. 8.

9.

A specific clinical question is chosen. All evidence-based literature related to the question is derived from online databases. A reference list of all literature for review is generated. High-level evidence, randomized controlled trials, and systematic reviews are critiqued and given more weight than quasi-experimental case studies and opinions. Participants critically appraise the relevant literature before attending the journal club. Journal club discussions center on the critical appraisal of evidence found for clinical interventions. Implications for practice and further research are discussed, with key findings recorded in minutes. A resource folder that includes a reference list of resource critiques, guidelines for practice, treatment resources, standardized assessments, disease management strategies, and gaps in evidence is created. A system for ongoing evaluation of outcomes and changes in practice is developed and communicated.

Modified from McQueen, J., Miller, C., Nivison, C., & Husband, V. (2006). An investigation into the use of a journal club for evidence-based practice. International Journal of Therapy and Rehabilitation, 13(7), 313.

Whether live or internet based, journal clubs provide a mechanism for promoting professional debate, increasing confidence, and, most important, improving practice and quality care (Hernandez, 2017; McQueen et al., 2006; Sheratt, 2005). With their educational background and advanced skills, DNPs are in an excellent position to implement this kind of strategy in a collaborative, interdisciplinary format.

Summary Scholarship and EBP are not the same, but each has elements that support the other. Scholarship involves research and application, as does EBP. Whereas scholarship may be a joint or singular effort, EBP requires teamwork and collaboration. The outcome of scholarship is a scholarly product, a new way of thinking, or a change in awareness about a subject or phenomenon—an end in itself. EBP is based on the scholarship of research and evidence gathering and synthesis. It is a means for improving care for patients or effecting a change in a system that results in better care for patients, providers, and communities. It is a transformation of knowledge to new levels of understanding and integration. Changing to a model of EBP does not just happen; it requires the integration of several skills, such as the use of good research and the synthesis of best information and other “evidences,” including patient choice and professional expertise. Dissemination of information gleaned from synthesis and translation in practice is essential for successful change. Using the knowledge of research methods to discover and interpret the best evidence for practice gives the DNP the tools to transform care.

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CHAPTER 22 Writing for Professional Publication Elizabeth Johnston Taylor

CHAPTER OBJECTIVES 1. Understand the process of writing for publication. 2. Discuss the features of a journal that would be appropriate for publication of your clinical scholarly research. 3. Identify online resources to support the development of your publication. 4. Review the steps for article submission, editorial review, and revision process per the journal’s guidelines.



T

he clinical nurse scholar with a doctor of nursing practice (DNP) degree must be able to write effectively. Writing not only allows the clinical scholar to disseminate evidence and information for improving practice but also provides a means for refining one’s thinking. That is, the process of writing requires writers to concretize their abstract ideas (e.g., into words or figures) and to organize their thoughts (e.g., into seriated lists or paragraphs). When they read their drafts objectively, the gaps in logic, the unaddressed questions, and the incongruities between what they think and what is on the page become clearer. Indeed, the process of writing is an essential activity and skill for all scholars. Whereas writing allows the clinical scholar to hone thinking, writing for publication allows the DNP scholar to share this thinking. This thinking

may be packaged as a formal report about a quality improvement or change project, a synthesis of evidence about a clinical concern, a description of a clinical innovation, a case study, a personal story, an opinion piece, an editorial, a blog, a news story, or another type of publication. Yet nurses, even at the doctoral level, often complain that the ability to write was “taken out of them” during their years of charting in health records. Therefore, this chapter describes the process required for writing a publishable manuscript. In so doing, many of the problems that DNP students face when writing are identified, along with solutions for these problems.

The Process of Writing for Publication The process of writing for publication will be divided into the following stages: prewriting, topic selection, journal selection, authorship negotiation, writing, submission, responding to reviews, and rewriting. These stages often overlap and may not occur exactly in this order. Although this discussion is relevant to writing for publication in a journal, much of it can be transferred to writing for another venue.

Prewriting Before putting pen to paper or fingertips to keyboard, several things must be considered. Fowler (2010) suggested that authors should first consider their motivations for writing for publication. You must have a reason to write for publication. You do not need to have already authored something or have established a reputation. You just need some novel information or new knowledge, an inspirational story, or an innovative idea. Whereas the publish-or-perish mandate may motivate academicians, career advancement (along with its increased status and salary) may motivate clinicians. You may also simply sense a spiritual calling or a personal striving to share via the press; publishing a piece may be on someone’s bucket list. Regardless, it is best if an author is internally prompted by an altruistic motive, given the arduousness of the work. Before you begin to write, consider your barriers to writing. A common barrier is writer’s block (Morton, 2013). Writer’s block may reflect a deep fear that one is not good enough as a writer, or not smart enough to have important knowledge, or not worthy enough to have a perspective worth sharing. These fears could have been planted earlier in life by a teacher who denigrated a writing assignment or by other experiences that have created a feeling of unimportance or mediocrity. Naming these fears and inadequacies will weaken their negative effects. Another barrier to writing, which may be an extension of a deeper fear, is the inability to find time to write (Morton, 2013). Whereas some experienced authors set aside a specific time each day or week to write,

others clear their desks and calendars and binge-write. Similarly, a writer may use delay tactics, such as doing housework or answering email that is not urgent, to postpone writing. Delay tactics should not be confused, however, with prewriting that is beneficial. That is, gardening, knitting, walking, or other activities that allow mental pondering of the content or structure for a manuscript are not wasting time. Antidotes to avoiding writing are offered in BOX 22-1.

BOX 22-1 Strategies for Addressing Barriers to Writing Name your fears and explore their origin; examine whether they are fallacious. Adhere to a writing time frame that works for you (e.g., regular short blocks of time, binges). Engage in activities that foster mental prewriting, but avoid delay tactics. Keep a folder (electronic or hard copy) with resources, random ideas, clippings, anecdotes, quotes, or anything that you would like to remember when you do start to write. Identify a delimited topic, appropriate audience, and your unique slant. It is best if your slant reflects your expertise and passion. Work with an experienced coauthor(s). Find a writing mentor. Write an outline or a mind map, or in some way identify and organize the elements of the manuscript; write only doable chunks or sections at a sitting. Write the parts you feel like writing first; you do not have to start at the beginning of the manuscript.

Topic Selection Determining the focus of the manuscript, of course, is a fundamental prewriting activity. Heinrich (2013) recommended that authors identify the unique idea, readers, venue, and slant of their manuscript at the beginning of the writing process. Heinrich differentiated between supersized, midsized, and article-sized topics for journal articles. For example, an article about illness-related psychosocial concerns would be too general and impossible to describe adequately in a journal article. Psychosocial concerns of the chronically ill, or even of persons with cancer, could also be too unwieldy a topic. An article addressing how chemotherapy infusion nurses can address the psychosocial concerns of persons, however, would allow for some depth and breadth. Whether the DNP scholar is planning to report a capstone project or write about a

clinical innovation, the topic must be article-sized. For many DNP scholars, their first manuscript is often a report about their DNP capstone project. If the project is too large to report completely in one article, however, it may need to be “chunked” (Heinrich, 2011). Although one needs to avoid “salami slicing” (i.e., writing multiple articles with thin slices of information from the same study in each [Zeitman, 2013]), a focus is needed. For example, a project could generate both a clinical article that provides the content of an educational intervention about how to insert a difficult male catheter and an article describing the system challenges of a quality improvement (QI) project that implemented and evaluated this intervention. Regardless of the topic, choose a focus with a high “glitter” (attention-getting) factor (Heinrich, 2011). Once you have settled on a topic for a professional journal article, a bit of research is in order. A brief literature search on a pertinent database (e.g., PubMed, CINAHL) ought to explore how recently and how extensively the topic has been covered in the literature. Questions the author should keep in mind during this literature search include: What facets of the topic have not been well addressed? What slant would fill a gap in the literature on this topic? What journals publish articles about this topic? How old are the most recent articles on this topic? Some journals may like to have a monopoly on the topic and will be receptive to a new slant on it. Others may not want to publish on a topic that is similar to what they have already recently published.

Journal Selection As just implied, selecting the journal (or other venue) in which you want to publish needs to happen somewhat concurrently with topic selection. It is vital to select the venue for your manuscript prior to writing so that you can compose with the right reader, journal format, and style in mind (Cals & Kotz, 2014). In 2017, over 660 scholarly English-language nursing journals were listed in Ulrich’s Periodical Directory (check your library’s databases for Ulrich’s). These journals included clinical and research, specialty and generalist, and international and national journals; journals that are the official organ of a professional society; and those published by for-profit corporations. Some journals address a theme in special

issues. Many journals accept various types of manuscripts, such as practice columns, case studies, letters, research briefs, teaching tips, and so forth. When selecting the journal and type of article within a journal, keep in mind whether it allows you to reach the readers you want and whether its scope matches your purpose. Additional considerations when selecting a journal must be considered, including the following, which can often be determined from reading the journal’s website and author guidelines: What is the reputation of this journal? How widely distributed is the journal? (Although not all journals make this fact available, it can sometimes be found on a journal’s website in the marketing information.) What is the journal impact factor (JIF)? (Journal Citation Reports showed that 226 nursing journals in 2015 were rated, with JIFs ranging between 0.22 and 3.56. JIF is calculated by dividing the number of citations accrued during a specified time by the number of articles published.) Is the journal peer reviewed? That is, are manuscripts determined to be meritorious or not by experts with knowledge about the topic or methods? How rapidly does the journal take a submission through the review process to publication? (The journals with good turnaround times often indicate this on their websites.) When reviewing the author guidelines (found on the journal website), do the manuscript requirements appear doable, given your personal constraints? Look at several potential venues for the manuscript you are envisioning and identify at least two or three before homing in a first pick. Select not only the preferred journal but also the type of submission acceptable to that journal. When selecting a journal, it is vital to consider whether it is open access or not. Open-access journals follow a business model that respects the need for scholars to disseminate their information easily and for any person to be able to access this information (Chinn, 2014). Indeed, several large research funders (e.g., the National Institutes of Health) mandate that researchers publish their funded studies in venues

allowing public access. Thus, a multitude of publishers now offer open access in some way. Public access typically involves the author paying an article processing fee to the publisher, who then makes the article free during a specified time. Free access is a model whereby a journal makes a few articles free to nonsubscription readers as an enticement. A third category of open-access models is “pay to publish,” or predatory publishing (Chinn, 2014). Predatory publishers have multiplied exponentially during the past decade and use strategies for financial gain that harm authors and science. Oermann and colleagues (2016) determined that at least 140 predatory nursing journals existed. These online publishers charge a processing fee, usually $100 (but it can range from $75 to $1,500) and potentially other initially hidden fees once the author is lured (INANE Collaborative, 2014; Oermann et al., 2016). For example, a fee may be charged to keep the article archived. The journal publisher often has a template that allows for a multitude of journals, yet typically the scope of a predatory journal encompasses several tangentially related disciplines. Editorial boards of predatory journals are known to sometimes include bogus members as well as members without pertinent expertise. Articles published in predatory journals are characteristically scientifically weak and poorly written. The title of a predatory journal often mimics that of a legitimate journal. How does a novice author avoid the snare of a predatory journal? Several strategies are offered: Check the Nurse Author & Editor website page for the Directory of Journals, which provides a list of journals that have passed a vetting process (https://nursingeditors.com/journals-directory). If the journal is peer reviewed, make sure that it is a member of the Committee on Publication Ethics (COPE), which is an organization of editors and publishers dedicated to ensuring ethics in publication. For more information, visit https://publicationethics.org. Confirm that the indexers used by the journal can be accessed by nurses and other healthcare professionals (e.g., PubMed). Note that Google Scholar does not vet what it makes available. Read the journal or publisher’s website to look for clues of predation. For example, who is the editor, and who is on the editorial board?

Where is the publisher located? How accessible are old issues? Ask an experienced nurse author. After due diligence, the novice author can wisely select a nonpredatory journal. Once the journal or potential journals are selected, the author can email the editor(s) about whether the envisioned manuscript is desired. Whereas some journal editors urge prospective authors to query them, others do not expect queries; indeed, some may never respond to queries. Follow the advice offered in the journal’s author guidelines whether to query and, if querying is recommended, to whom to direct that query. If you do write a query, know that it is best to keep it short. In a few sentences, introduce yourself and propose what the manuscript would provide. Ask if it is a match for the journal and what input the editor might have for you. Remember that your thinking and writing, even in this brief email, will provide an indication to the editor about your abilities. It may influence how much the editor may choose to engage with you.

Authorship Negotiation Because there may be much at stake behind becoming a published author, the process of writing a manuscript with multiple authors can sour friendships and damage collegial trust if it is not negotiated adequately. Thus, negotiating authorship should also occur during the prewriting phase (Albert & Wager, 2003). Some writing teams create a contract (see Gaffey, 2015, for an example). The respective roles that each author will contribute are identified in this contract, as are the deadlines and what the consequences of failing to make the contribution will be. Although this negotiation can feel uncomfortable, it allows important relationships to survive. Not only should who will be an author be agreed upon but also the lineup of the authors. Generally, the most important author position is that of first author; the first author usually takes the lead in the writing process and will also have played a significant role, if this is a research or project report, in that research or project. The last author position is often the second most important, although this may vary somewhat by discipline and type of article. It is typically reserved for the senior researcher or mentor. The lineup of authors between first and last ought to reflect the

amount each contributed to the piece. It is important to remember what constitutes authorship. The International Committee of Medical Journal Editors (ICMJE, 2017) proposed the following attributes. An author must have (1) made a “substantial contribution” to the work described in the article, (2) assisted in drafting the manuscript, (3) reviewed the final draft prior to submission, and (4) taken responsibility for the work. Most journals now reiterate these attributes in their author guidelines and ask that all listed authors meet these criteria. Meeting these criteria eliminates the problems of ghost and gift authorship (Albert & Wager, 2003). Ghost authors are those who are not listed in the lineup, perhaps because they do not want to be associated with the content of the manuscript. Gift authors are those who are listed in the lineup but failed to contribute significantly. Either of these ethical issues of ghost or gift authorship can challenge DNP students. It is possible that a DNP faculty member may insist that his or her name be listed in the lineup when he or she does not meet the ICMJE criteria for authorship. A faculty member could be embarrassed by a student’s work and ask not to be identified as an author. Either situation can be avoided if authorship is negotiated prior to the start of writing. Also, remember that those who supported the work in the manuscript yet do not meet the criteria for authorship can still be gratefully recognized in an acknowledgment (ICMJE, 2017).

Writing the Manuscript Once the prewriting is complete, the active writing can begin. Numerous books and articles describe how to write for publication and how to write about a capstone project or research (e.g., Oermann & Hays, 2015; Roush, 2015). Given the vastness of the topic, this chapter provides a brief overview of salient elements to consider when writing. These elements include overall organization, sentence and paragraph structure, style and language, grammar and punctuation, citing sources, and proofreading and obtaining feedback.

Organization When brainstorming about the scope and content of your manuscript, you

may find yourself beginning to organize these thoughts. Whether mind mapping or creating a traditional outline, content needs to be organized. Although this organization should be flexible, it needs to provide some overall structure. The detail of the outline should be to whatever degree is helpful to you. The overall structure for a data-based manuscript is formulaic; however, there are some differences between how a QI or change project is reported compared to a report of research. When writing about research findings, the content is organized as follows: Introduction and Background (these sections may be separate or merged, but they should include an explanation of the significance of the research, review pertinent literature, and state research aims and questions) Methods (a section that should include subsections about the design, sample, data collection [i.e., procedures, instruments], analysis, and ethical considerations—usually in this order) Results or Findings (which includes a description of the sample as well as the outcomes of the analysis) Discussion (which usually begins with a summary of primary findings and the main takeaway points, followed by an unpacking and interpretation of the findings, with comparisons made to other existing evidence) Conclusion (a “therefore” statement rather than a summary) Some reports about QI or change projects may try to follow this traditional approach, but it is best to follow a more suitable structure (Adams, Farrington, & Cullen, 2012). Journals that publish QI or change projects are increasingly recommending a structure for these reports in their author guidelines. Ideally, this structure, as well as content, should follow Standards for Quality Improvement Reporting Excellence (SQUIRE) guidelines (Ogrinc et al., 2015). Although there is some variation in how these reports can be organized, the following sequential organization is common: Introduction and description of Local Problem, culminating with a purpose statement (e.g., population, intervention, comparison, outcome, time [PICOT] question addressed)

Background (i.e., literature review) The Project (with descriptions of the context and process for developing, implementing, and evaluating the intervention or change) Implications for Practice (or Discussion, with a summary and interpretation of the findings, recommendations and lessons learned, and recognition of the project limitations) Conclusion Sometimes the Introduction and Background precede the Local Problem. When describing the project (under the heading The Project), it is important to address all the pertinent elements, just as a research report Methods section would (e.g., participants and setting, intervention procedures, measures and analytics used in evaluation, and ethical considerations). Following an outline prevents placing information about how an intervention was implemented into the evaluation section or putting the data that determined a local problem existed with the findings from the project evaluation. An outline allows authors to know where content belongs.

Section, Paragraph, and Sentence Structure Just as the manuscript needs organization, so do its components. Each major section of the paper should present information in an organized manner that flows logically from the general to the specific (Goldman & Schmalz, 2013). For example, when describing the local problem in a QI report, present the story in chronological order. When discussing the pertinent literature in the Background section, organize it by themes or concepts (e.g., by information about incidence, prevalence, and importance of X; by what are the health outcomes of X; by evidence about patient experience of X; by how nurses have been educated to address X). Use subheadings to define these subsections, if that will help readers. Remember that there must be at least two subheadings per section. Paragraphs also need structure. Each paragraph should begin with one or two topic or introductory sentences that tell the reader what the paragraph is about (Goldman & Schmalz, 2013). For example, the topic sentence of this paragraph lets you know that this paragraph is about structuring a paragraph. The paragraph will then provide details on this

topic. The topic can be expanded by providing further information or ideas or by giving illustrations. The paragraph can end with a concluding sentence that summarizes or suggests a “so what” for the paragraph. Ideally, the start or end of a paragraph provides some signposting, or cues, about how the content relates to the previous or next paragraph. For example, the first sentence of this paragraph included the word also to show how this paragraph relates to the previous one. This structure will help paragraphs to flow smoothly; it also helps a reader to find and understand information quickly. There are many other considerations when writing a paragraph. Some that may be helpful for DNP-prepared writers include the following: Standard convention suggests that a paragraph should be about six to eight sentences; at minimum, there should be three sentences. Do not begin or end a paragraph with a quotation. Do not use quotes to explain something you cannot. When including a quote, use your own voice to introduce, explain, or apply the quote. Do not start or finish a paragraph with parenthetical material. Often parenthetical content can be substituted for the object it is explaining, eradicating the need for the parentheses. When reviewing literature, synthesize the evidence. If there is a research study, policy analysis, or other especially significant source, then summarize it. A literature review should not be a litany of summarized studies, each described in one paragraph. Writing the literature synthesis is easier after creating a table that summarizes and organizes key elements of each article (Foster, 2013). When presenting findings from research, provide some contextual information so that the reader can weigh this evidence (for example, “Themes identified in two qualitative studies with small samples recognized . . .” or “. . . was observed in a retrospective chart review of 1,234 hospice patients who had died at home.”). Remembering these points will help you write an understandable and effective paragraph. The structure of a sentence is also fundamental to how readily the reader will be able to understand what is written. Of course, if the grammar or punctuation is incorrect, the writing may be uninterpretable or misinterpreted. The joke found on T-shirts illustrates this well: “I like

cooking my family and my pets.” This sentence is then followed by “Commas save lives.” Indeed! Here are other recommendations about how to structure sentences: Consider where you want to place emphasis in a sentence and structure it accordingly. For example, “In 2017, Taylor advocated for . . .” instead of, “Taylor (2017) advocated . . .” places the emphasis on when rather than on what Taylor advocated. In the sentence “Whereas Smith argued for X, Lee posited Y,” Lee’s position is given favor because the name Smith appears in the subordinate clause of the sentence. The shorter the sentence, the easier it is to understand it. If a sentence is more than 15 to 20 words, it is too long (Plain English Campaign, 2019). Split the sentence into two separate sentences, or look for ways to make it more concise. Vary the structure of sentences in each paragraph. Use varied and descriptive language. An exception to this rule is to use the same term for studied concepts to maintain conceptual clarity. If possible, don’t use the same word twice in a sentence. Be concise (TABLE 22-1). Let every word matter. Avoid fluff and redundancy. Typically, sentences that are not concise are also unclear in their intent. TABLE 22-1 Strategies for Writing Concisely Strategy

Wordy Examples

Concise Examples

Edit common phrases that are wordy.

in order to for the purpose of in the event that which is who are

to to if [likely can be omitted] [likely can be omitted]

Eliminate redundant pairs; keep the one word that best reflects your intent.

first and foremost whole entire hopes and dreams

first entire dreams

Cut repetitive words from phrases.

period of time personal opinion free gift short in length

time opinion gift short

short in length

short

Reduce prepositional phrases.

of particular interest in an effort to decrease

of interest to decrease (or decreasing)

Remove unneeded qualifiers or modifiers.

actually, really, basically, probably, very, definitely, somewhat, kind of, extremely, practically

To write an excellent manuscript, you have to relearn how to write.

Eliminate nominalization (i.e., transform a noun into a verb).

The DNP students jointly gave a presentation at the conference.

The DNP students presented jointly at the conference.

Eliminate grand phrases that add no meaning to a sentence.

as a matter of fact, by virtue of the fact, for the most part, in a very real sense, in the process of, it seems that In the process of learning how to write, the DNP students— for the most part—did extremely superbly.

While learning to write, most of the DNP students did superbly.

Data from Guide to Grammar and Writing. (n.d.). Writing concise sentences. Retrieved from http://grammar.ccc.commnet.edu/grammar/concise.htm; Nichol, M. (2014). 8 steps to more concise writing. Retrieved from http://www.dailywritingtips.com/8-steps-to-more-concisewriting; The Writing Center, University of North Carolina at Chapel Hill. (2019). Writing concisely. Retrieved from http://writingcenter.unc.edu/handouts/conciseness-handout

Description Description Use active voice. That is, use the sentence structure of subject, then verb, then object (for example, The nurse provided comfort) instead of object, then verb and subject (for example, Comfort was provided by the nurse) (Plain English Campaign, 2019). Sentences that are concise, clear, varied in structure and wording, and so forth, increase the chances that the reader will understand what the author intends to convey. More information about paragraph and sentence structure is available from the many online resources listed in BOX 22-2.

BOX 22-2 Online Writing Resources http://www.writing.utoronto.ca This University of Toronto site offers many excellent downloadable files with information about aspects of writing (e.g., how to avoid use of unnecessary words, writing a literature review, etc.). http://www.equator-network.org This site for Enhancing the Quality and Transparency of Healthcare Research (EQUATOR) provides links to standards and checklists to guide the reporting of various types of research (e.g., randomized controlled trials (RCTs), observational research). A link to Standards for Quality Improvement Reporting Excellence (SQUIRE), which includes the guidelines for reporting QI projects, is found on this home page. http://www.squire-statement.org/index.cfm?fuseaction=page.viewPage&pageID=471 This site provides links to numerous other online writing resources. http://www.cws.illinois.edu/workshop/writers This link sponsored by the University of Illinois has a “Writers Workshop” with information about grammar. http://www.icmje.org/urm_main.html The webpage for the International Committee of Medical Journal Editors has links to its many recommendations about how to report scientific information. It also proposes widely accepted criteria for authorship. https://owl.english.purdue.edu/owl This is the home page for the Online Writing Lab at Purdue University; it is an excellent resource where you can get quick instruction on American Psychological Association (APA) formatting, writing a thesis statement, using logic in writing, and so forth. http://naepub.com This website offers the free, quarterly online magazine Nurse Author & Editor. It also lists nonpredatory nursing journals. http://www.plainenglish.co.uk/free-guides.html This page, found on the Plain English Campaign site (a campaign to improve understandability and simplicity in writing), provides free guides to such resources as a glossary for simpler ways to write something, grammar tips, and how to punctuate. http://writingcenter.unc.edu/handouts/conciseness-handout This website from the Writing Center at the University of North Carolina at Chapel Hill offers dozens of free handouts on aspects of writing an academic paper, style and sentence-level issues, using citations, and other topics. Short YouTube videos on many of these topics are also available at this website. https://writingcenter.unc.edu/tips-and-tools Tips and Tools is a website with hundreds of short articles about a myriad of writing topics; the site has published one article every day since 2007. These articles, authored by professional writers, are archived and are available for free.

Style and Language The style of a manuscript must conform to that used by the journal. Thus, a DNP project report or other paper written for a course assignment

cannot be submitted as is for publication (Morton, 2013). If the journal’s target audience is clinicians without a graduate degree, the style will be more colloquial. Bulleted lists, tables, figures, illustrative vignettes, and artwork are desirable. In contrast, a research journal adheres strictly to the organization described previously, uses scientific language, and is free of figures of speech and colloquialisms. Check the journal’s author guidelines. Also read the journal to get a sense of the style its editors prefer. The best language for any writing is simple language; use words that are commonly understood and usually short (Plain English Campaign, 2019). For example, instead of writing “affording the opportunity,” write “let.” Instead of “completion,” write “end.” Why use gobbledygook that loses the reader? Novice authors often assume that if they write with “sophisticated” language, they will impress the reader, but while trying to write with sophistication, novice authors sometimes use inappropriate or imprecise words. For example, instead of writing “researchers observed/noted/found/reported . . .,” a novice author might write that the “researchers conferred/illustrated/perceived . . .” when that is not precisely what the researchers did. A thesaurus can be useful, but it must be used with discernment. Nurse scholars often manifest acute fulminating jargonitis (Goldensohn, 1982) when they create noun chains and clusters. As Goldensohn cleverly described: At first, nouns may appear in seemingly innocuous pairs (health behaviors, communication facilitation, intimacy skills). Soon afterward, clusters appear (health maintenance techniques, support system network). Use of adjectives becomes sporadic; prepositional phrases are rarities. Finally, indiscriminant chains of nouns take over whole sentences: “Communication facilitation skills development intervention,” writes the jargonitis sufferer. (p. 541) This jargonitis occurs when the writer creates an abstract noun from a verb (Plain English Campaign, 2019). For example, instead of providing comfort-care measures, a nurse can comfort. Using (instead of utilizing) plain English can make scholarly writing faster to write and read.

Additional information about writing with appropriate style and language can be found at the online resources listed in Box 22-2.

Grammar and Punctuation The Publication Manual of the American Psychological Association (APA) (2010) provides the standards that nurse scholars generally follow for grammar, punctuation, and other aspects of writing. Several online resources are also available (see Box 22-2). Some assistance can also be obtained from the word-processing software used to draft the manuscript. In Microsoft Word, red, blue, and green squiggly lines underline possible errors in spelling and grammar. Right-clicking on the underlined word or phrase will show what the problem is and how to correct it. Of course, human judgment is required to determine if indeed there is an error and how to fix it. Rather than review the myriad of rules and recommendations for grammar and punctuation found elsewhere, a few common mistakes doctoral students often make are identified and illustrated in TABLE 22-2. TABLE 22-2 Common Punctuation and Grammar Errors Illustration: Incorrect

Illustration: Correct

Failing to hyphenate a compound adjective that could be misread when it precedes the term it modifies

Evidence based practice Middle class community

Evidence-based practice Middle-class community

Using a colon instead of a semicolon to separate clauses in a sentence ■ Use a colon if it follows what could stand as a complete sentence. (Capitalize the first word that follows the colon). Use a colon if it follows a phrase that introduces a series. ■ Use a semicolon to separate two independent clauses

This sentence is complete, another sentence would complement it. The following punctuation marks are used. Commas, periods, quotation marks, colons, and semicolons. This sentence could end with a period, however, it is short and connects well with this thought.

This sentence is complete: Another sentence complements it. The following punctuation marks are used: commas, periods, quotation marks, colons, and semicolons. This sentence could end with a period; however, it is short and connects well with this thought.

Error

that are not linked by a conjunction (e.g., however, if, and, or, but). Using the wrong punctuation in a series (i.e., items in a list). If the list is introduced by a clause (punctuated by a colon), then use commas. If, however, any phrase in the series has punctuation within it, then use semicolons.

This series of items is punctuated incorrectly: colons, which are symbolized by two vertically oriented dots, commas, and periods symbolized with one dot.

This series of items is punctuated correctly: colons, which are symbolized by two vertically oriented dots; commas; and periods, symbolized with one dot.

Anthropomorphizing, or attributing human characteristics to inanimate objects or abstractions

The study found that . . . The QI project showed . . .

The researchers found that . . . The project leaders showed . . .

Overuse of pronouns, leaving uncertainty about to whom or to what the pronoun refers

It was helpful to read its origins. (What is the antecedent for the possessive pronoun its?)

Lee found it helpful to read about the origins of nursing.

Disagreement of the subject and verb; both should be either singular or plural

The data is missing. (Datum is singular.)

The data are missing. The word data is plural. (Word is singular, so verb is singular.)

Misplaced or dangling modifiers, or failing to link the describing word or phrase with the word it modifies

Being uncertain about how to write, journal guidelines were followed.

Sammy was uncertain about how to write, so he followed the journal guidelines.

Lack of parallel construction, or writing a list where each item is written using a different grammatical structure; instead, make each item parallel (e.g., all starting with an active verb phrase or with an adjective plus noun)

The DNP students include men and women, compassionate clinicians, and those who are eagerly anticipating a doctorate.

The DNP students include men and women, clinicians and academicians, and experienced and inexperienced writers.

Data from APA (2010), Purdue Online Writing Lab (2019), and Truluck and Veale (2015).

Description Description

Citing Sources Any time an author offers an idea or information that is not generated from personal knowledge or experience, credit must be given to the source (APA, 2010; Fowler, 2015). It is not only courteous but also shows academic integrity. It also reveals how knowledgeable the author is. The following observations may help you to cite sources appropriately: Generally, when citing sources to support an idea or information, one to three sources are adequate. If the idea or information is obscure or debatable, it is best to provide more rather than less documentation. If the idea or information is supported by a meta-analysis of evidence or comparable study, then there is no need to cite the studies included in the meta-analysis or any others unless they provide a contrast. Cite literature that is not outdated. Often the directive is given that literature cited should not be more than 3 to 5 years old. The age of the literature, however, should reflect the speed with which new knowledge is being generated in the area and the purpose for which it is being cited. If a manuscript is reviewing literature about a rarely researched or discussed topic, then the literature that is most pertinent to the manuscript may be old. It may also be that the strongest evidence is older than more recent evidence. In such cases, explain to the readers why you are citing the sources that you use. If you cite multiple sources, choose the sources that will be the strongest or most fitting. For example, if you want to cite a source that says DNPs can affect patient outcomes, cite a high-grade research study that provides empirical evidence for this statement rather than a secondary source like a textbook. If quoting directly from another source (even three to five words in a row), place the quoted material within quotation marks and follow correct formatting for identifying the source of the quotation. Following these suggestions will allow you to give credit where credit is due and to build credibility with your readers. When a manuscript is submitted to a journal for review, it will likely be analyzed by software to determine if any of the copy was plagiarized (Zeitman, 2013). Authors not only must avoid copying (or even paraphrasing) another’s work without citing the source but also must

avoid copying any of their own previously published writing without using quotations and proper citation (APA, 2010). Doing so constitutes selfplagiarism, a legal problem for the publisher who owns the copyright and the publisher who must not infringe.

Proofreading and Obtaining Feedback The best manuscripts are authored by writers who allow time for refinements in thinking and writing prior to a submission deadline. Of course, proofreading multiple times will minimize sloppy errors. An excellent way to proofread, however, is to read a manuscript aloud. This will allow the author to recognize confusing writing, lengthy sentences, poor grammar, and so forth. It is also beneficial to obtain feedback from colleagues or others who can read your manuscript critically. Incorporate their feedback as you, the expert, believe is best.

Submission Once the manuscript is finally drafted, it must be formatted exactly as specified in the journal’s author guidelines. The citation style must match that requested by the journal; not all nursing journals request APA format. The title, abstract, key words, author information, and so forth, must comply with the guidelines. Failure to follow these details could cause an immediate rejection. The guidelines may direct you to provide a cover letter that acknowledges such specifics as contributions of respective authors, ethics board approval, or information about any additional manuscripts or publications from the same dataset. A manuscript can be submitted to only one journal at a time. Thus, a statement from the article author(s) acknowledging this may also be requested. Most submission processes now involve entering information electronically into a platform accessed from the journal website. Registering, entering author information, and uploading the manuscript files can take about an hour. Typically, authors are asked to create separate files for the title page and other portions of the manuscript. The manuscript should allow for blind review. Therefore, any references to the writer himself or herself or previous publications that could tell a reviewer

who the author is should be masked so that they do not show.

Responding to Reviews and Rewriting Some clinical journals may not use peer reviewers to evaluate manuscripts; instead, the editor(s) make the acceptance decision. Most journals do, however, send submitted manuscripts out for peer review to volunteer reviewers who should have some expertise on the topic or methods discussed in the manuscript. Depending on the journal, these volunteer reviewers may be members of the journal’s editorial board or recruited via email after being identified in a literature search on the manuscript topic. Some journals ask authors to submit names and contact information of potential reviewers. Although journal editors are eager to support a rapid review process, it is often at least 4 to 6 weeks before reviews are completed. If the review process goes longer than 3 months, it is not rude for an author to query the editor politely about when the review(s) will be finished. The status of your manuscript can be monitored on the platform where the manuscript was submitted. Usually one to three reviewers will provide a critique. Typically, they will be asked to evaluate the manuscript as acceptable, acceptable with minor revisions, acceptable with major revisions, or rejected. The editor will make the final decision, however, after compiling the reviewer’s or reviewers’ comments. The reviewer feedback and editorial decision will be sent to the author identified as the corresponding author. Most manuscripts require some revision. Even a request for major revisions does not mean the manuscript will be rejected. Reviewer critiques are an excellent way to get sound feedback and improve the manuscript. The author’s response to the feedback, however, may determine whether the manuscript is ultimately accepted for publication. Thus, the author(s) should revise and craft a response carefully. An effective way to respond to any requests for revision is to construct a table that lists all the reviewer and editor recommendations in the first column and then your corresponding responses to each recommendation in the second column. Write the responses with gratitude and civility. For example, if a reviewer asked for additional statistical analysis, a response could be: “Thank you for this recommendation because it provides further

depth to the report. Please find the additional analysis highlighted and described on p. 15.” If you do not agree with the recommendation, politely state why. Of course, make the requested changes in the manuscript as you deem appropriate.

Next Steps The process of writing for publication does not end with a submission or resubmission with revisions. If a manuscript is rejected after revisions are submitted, it can be submitted elsewhere. Reviewer feedback about the merit of the manuscript should hint at where to submit the manuscript next. For example, the reviewers may tell you that your educational intervention content was excellent, but the strength of the QI project that implemented and evaluated it was weak. Thus, you might rewrite the manuscript so that it focuses on the educational information for staff nurses. Tailor the rewrite to fit the style and scope of the newly selected journal for staff nurses. If your manuscript was accepted, you must complete some additional tasks before the article is published. If the journal is not an open-access journal, you will be signing a copyright transfer agreement that will give the publisher ownership of the article. You will also be asked to review the typesetting and to verify that it was done perfectly. Often the copy editor will have a few author queries for you at that time. When you receive the prepublication copy electronically, be sure to note the legal terms for how and where you can share the article because you will no longer own it. Once the article is published, market it. As appropriate, share it with colleagues you know who would benefit from it. Let the world know about it via social media (e.g., on your Facebook page, LinkedIn, ResearchGate, or your email signature). Refer to it in presentations you make and distribute it as a handout. Write a summary of the article or use its abstract and submit it to your employer’s or professional organization’s newsletter. After all, you wrote it because you had a novel idea or new evidence to share. So share it—with a helping of humility, of course.

Summary This chapter provided an overview of the process of writing for publication. Although drafting a manuscript is an arduous task, it is rewarding. Because writing is a process, it affords the opportunity to grapple with and fine-tune thinking. Indeed, writing begets deep, careful, nuanced thinking. Thus, if you want to develop as a scholar, write. 1. Writing for publication may be divided into the following stages: prewriting, topic selection, journal selection, authorship negotiation, writing, submission, responding to reviews, and rewriting. 2. During the prewriting phase, it is helpful to address barriers to writing. 3. Topic selection for DNP scholars may include publishing an aspect of their DNP project (e.g., description of the intervention for clinicians or report of a QI project). 4. When selecting a journal, one must review the author guidelines for potential journals, and research what journals would want the planned manuscript. Also, determine if the selected journal is bona fide; avoid publishing in predatory journals. 5. Authorship negotiation should be based on the recommendations of the ICMJE. 6. Writing the manuscript should include organization of content into concise and coherent sentences and paragraphs. The manuscript may follow a specific outline if it is a research report or quality improvement or change project. 7. Many online resources can support novice authors; these resources discuss paragraph and sentence structure, writing concisely, style and language, grammar and punctuation, and how to cite sources. 8. Proofreading is an important phase of writing for publication and may include reading the manuscript aloud. 9. Responses to reviewer comments can be organized in a table that clearly outlines each reviewers’ comments with the accompanying

author(s) response. 10. After the article is published, market your work by sending it to colleagues and advertising it on social media.

Discussion Questions 1. What personal barriers impede you writing for publication? How might you overcome these barriers? 2. How comfortable are you asking for feedback? What creates inner discomfort? How do you respond to constructive criticism? 3. How committed are you to writing for publication after you earn a DNP degree? What clinical practice tips or innovative ideas would you like to share with nurses in this way? 4. Your DNP program faculty may expect you to submit a report on your DNP project after graduation. Although you likely have not completed the project yet, in what ways might you “chunk it” or write about a focused aspect of the project?

Suggested Group Activities In dyads, share your fears about writing for publication. What is their basis? Also, what barriers and procrastination methods do you have for writing? Discuss the best ways to address these fears and barriers. Creating a table with a column for fears and barriers and a second column for concomitant solutions will help you to concretize your thinking. Write one paragraph or one section of a manuscript. In a small group, exchange these writing samples and provide peer reviews. This activity can occur online or in person. You may use Track Changes in Microsoft Word, write a summative review, verbally present your feedback, or use a combination of these approaches. Use the points in Tables 22-1 and 22-2 to guide the review.

References Adams, S., Farrington, M., & Cullen, L. (2012). Evidence into practice: Publishing an evidencebased practice project. Journal of PeriAnesthesia Nursing, 27, 193–202. Albert, T., & Wager, E. (2003). How to handle authorship disputes: A guide for new researchers. Retrieved from https://publicationethics.org/files/2003pdf12_0.pdf American Psychological Association. (2010). Publication manual of the American Psychological Association (6th ed.). Washington, DC: Author. Cals, J. W. L., & Kotz, D. (2014). Effective writing and publishing scientific papers, part X: Choice of journal. Journal of Clinical Epidemiology, 67, 3. Chinn, P. (2014). Open access: What it is and what it is not. Retrieved from https://ansjournalblog.com/2014/11/26/open-access-what-it-is-and-what-it-is-not Foster, R. L. (2013). Extracting and synthesizing information from a literature review. Journal for Specialists in Pediatric Nursing, 18(2), 85–88. Fowler, J. (2010). Writing for professional publication. Part 1: Motivation. British Journal of Nursing, 19(16), 1062. Fowler, J. (2015). Writing for professional publication: From staff nurse to nurse consultant: Part 4: Unsupported statements. British Journal of Nursing, 24(20), 1032. Gaffey, A. (2015). Determining and negotiating authorship. American Psychological Association. Retrieved from http://www.apa.org/science/about/psa/2015/06/determining-authorship.aspx Goldensohn, E. (1982). Acute, fulminating jargonitis. Nursing Outlook, 30, 541. Goldman, K. D., & Schmalz, K. J. (2013). Writing well: A writing style checklist to promote publication among practitioners. Health Promotion Practice, 14(1), 5–6. Guide to Grammar and Writing. (n.d.). Writing concise sentences. Retrieved from http://grammar.ccc.commnet.edu/grammar/concise.htm Heinrich, K. T. (2011). Chunk it: How to turn large written projects into articles. Nurse Author & Editor, 21(3), 1. Heinrich, K. T. (2013). How to whiz past your blank page fears? Structure before you write. Nurse Author & Editor, 23(1), 6. INANE Collaborative. (2014). Predatory publishing: What editors need to know. Nurse Author & Editor, 24(3), 2. International Committee of Medical Journal Editors. (2017). Defining the role of authors and contributors. Retrieved from http://www.icmje.org/recommendations/browse/roles-andresponsibilities/defining-the-role-of-authors-and-contributors.html Morton, P. G. (2013). Publishing in professional journals, part II: Writing the manuscript. AACN Advances in Critical Care, 24, 370–374. Nichol, M. (2014). 8 steps to more concise writing. Retrieved from http://www.dailywritingtips.com/8-steps-to-more-concise-writing Oermann, M. H., Conklin, J. L., Nicoll, L. H., Chinn, P. L., Ashton, K. S., . . . Budinger, S. C. (2016). Study of predatory open access nursing journals. Journal of Nursing Scholarship, 48, 624–632. Oermann, M. H., & Hays, J. C. (2015). Writing for publication in nursing (3rd ed.). New York, NY: Springer. Ogrinc, G., Davies, L., Goodman, D., Batalden, P., Davidoff, F., & Stevens, D. (2015). SQUIRE 2.0 (Standards for Quality Improvement Reporting Excellence): Revised publication guidelines from a detailed consensus process. American Journal of Medical Quality, 30, 543–549. Plain English Campaign. (2019). Plain English tools. Retrieved from http://www.plainenglish.co.uk Purdue Online Writing Lab. (2019). General writing resources. Retrieved from

https://owl.english.purdue.edu/owl/section/1 Roush, K. (2015). A nurses’ step-by-step guide to writing your dissertation or capstone. Indianapolis, IN: Sigma Theta Tau International. Truluck, C. A., & Veale, B. L. (2015). Writing for publication: Enhancing your scientific writing skills. Radiologic Technology, 86(4), 462–466. The Writing Center, University of North Carolina at Chapel Hill. (2019). Writing concisely. Retrieved from http://writingcenter.unc.edu/handouts/conciseness-handout Zeitman, A. L. (2013). Falsification, fabrication, and plagiarism: The unholy trinity of scientific writing. International Journal of Radiation Oncology, Biology, Physics, 82, 225–227.

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PART 5 The Role of Race, Culture, Ethics, and Advocacy in Advanced Nursing Practice

T

he fifth section of this text covers other core concepts as recommended by the American Association of Colleges of Nursing for advanced practice nursing knowledge—namely, diversity and ethics. Diversity in this context incorporates two complementary issues: diversity of the population cared for by nurses and diversity of the nursing workforce itself. As the U.S. population moves toward a more diverse and pluralistic society, the nursing profession is challenged to develop greater cultural competence. In Chapter 23 the authors discuss issues pertaining to beliefs, values, justice, and equity in health care in the United States and globally. Concepts such as social determinants of health, levels of prevention and American anthro-cultural values are presented. Given the multicultural, multiethnic, and multilingual society now found in the United States, Cole and Gunther (Chapter 24) provide working definitions for transcultural nursing, cultural competence, and diversity as it relates to patient care. The chapter provides a review of theoretical models that have shaped the thinking of the nursing profession as related to cultural diversity and cultural competence. In Chapter 25, Shi and Singh provide a comprehensive overview of the major characteristics of select U.S. population groups whose members face challenges and barriers in accessing healthcare services. These groups include racial/ethnic minorities, children and women, persons living in rural areas, persons who are homeless, those who are mentally ill, and individuals with HIV/AIDS. The health needs of these population groups are summarized, and the services available to them

are described. The gaps that currently exist between these population groups and the rest of the population indicate that the nation must make significant efforts to address the unique healthcare disparities of U.S. subpopulations. Chapter 26 comprises a discussion by Milliken, Amari-Vaught, and Grace on the individual and environmental factors that interfere with ethical nursing actions. Issues regarding informed consent, proxy decision making, and advanced directives are analyzed. The authors also addresses contemporary issues regarding the role of social media as it pertains to privacy and confidentiality in healthcare settings. In the final chapter of this section, Gaylord and Grace provide an overview of ethical leadership and its importance to advance nursing practice. Although advanced practice roles are relatively new in terms of the development of the broader nursing profession, evidence supports the increasing need for nurses who are well educated, skillful, knowledgeable, and motivated to meet the healthcare needs of their populations.

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CHAPTER 23 Beliefs, Values, and Health Leiyu Shi and Douglas A. Singh

CHAPTER OBJECTIVES 1. Understand the concepts of health and disease, risk factors, and the role of health promotion and disease prevention. 2. Summarize the disease prevention requisites under the Affordable Care Act. 3. Understand public health and appreciate its expanding role in health protection both in the United States and globally. 4. Explore the determinants of health and measures related to health. 5. Understand the American anthro-cultural values and their implications for healthcare delivery. 6. Evaluate justice and equity in health care according to contrasting theories. 7. Explore the integration of individual and population health.

Introduction From an economic perspective, curative medicine appears to produce decreasing returns in health improvement while increasing healthcare expenditures (Saward and Sorensen, 1980). There has also been a growing recognition of the benefits afforded to society by the promotion of health and the prevention of disease, disability, and premature death. Even so, progress in this direction has been slow because of the prevailing social values and beliefs, which continue to focus on curing diseases rather than on promoting health. The common definitions of health, as well as measures for evaluating health status, reflect similar inclinations. This chapter proposes a balanced approach to health, although fully achieving such an ideal is not without difficult challenges. The 10-year Healthy People initiatives, undertaken by the U.S. Department of Health and Human Services (USDHHS) since 1980, illustrate steps taken in this direction, even though these initiatives have been typically strong in rhetoric but weak in actionable strategies and sustainable funding.

“This is the market justice system. Social justice is over there.”

Description Anthro-cultural factors reflected in the beliefs and values ingrained in American culture have been influential in laying the foundations of a U.S. healthcare system that has remained predominantly private as opposed to a tax-financed national healthcare program. Failures of past proposals to create a nationalized healthcare system are discussed in the context of

cultural beliefs and values. This chapter further explores the issue of equity in the distribution of health services, using contrasting theories of market justice and social justice. U.S. healthcare delivery incorporates both principles, which are complementary in some ways and create conflicts in other areas.

Significance for Managers and Policy Makers The material covered in this chapter has several implications for health services managers and policy makers alike: The health status of a population has tremendous bearing on the utilization of health services, assuming the services are readily available. Planning of health services must be governed by demographic and health trends and initiatives toward reducing disease and disability. The basic meanings of health, determinants of health, and health risk appraisal should be used to design appropriate educational, preventive, and therapeutic initiatives. There is a growing emphasis on evaluating the effectiveness of healthcare organizations based on the contributions they make to community and population health. The concepts discussed in this chapter can guide administrators in implementing programs that have the greatest value to their communities. Quantified measures of health status and utilization can be used by managers and policy makers to evaluate the adequacy and effectiveness of existing programs, plan new strategies, measure progress, and discontinue ineffective services.

Basic Concepts of Health In the United States, the concepts of health and health care have largely been governed by the medical model, more specifically referred to as the biomedical model. The medical model defines health as the absence of illness or disease. This definition implies that optimal health exists when a person is free of symptoms and does not require medical treatment. However, it is not a definition of health in the true sense. This prevailing view of health emphasizes clinical diagnoses and medical interventions to treat disease or symptoms of disease but fails to account for prevention of disease and health promotion. Therefore, when the term healthcare delivery is used, in reality it refers to medical care delivery. Medical sociologists have gone a step further in defining health as the state of optimal capacity of an individual to perform his or her expected social roles and tasks, such as work, school, and household chores (Parsons, 1972). A person who is unable (as opposed to unwilling) to perform his or her social roles in society is considered sick. However, this concept also seems inadequate because many people continue to engage in their social obligations despite suffering from pain, cough, colds, and other types of temporary disabilities, including mental distress. Their efforts are counterbalanced by individuals who shirk their social responsibilities, even when they may be in good health. In other words, optimal health is not necessarily reflected in a person’s engagement in social roles and responsibilities. An emphasis on both the physical and the mental dimensions of health is found in the definition of health proposed by the Society for Academic Emergency Medicine. According to this organization, health is “a state of physical and mental well-being that facilitates the achievement of individual and societal goals” (Ethics Committee, Society for Academic Emergency Medicine, 1992, p. 1381). This view of health recognizes the importance of achieving harmony between the physiological and emotional dimensions. The definition of health developed by the World Health Organization (WHO) is most often cited as the ideal for healthcare delivery systems; it recognizes that optimal health is more than the absence of disease or

infirmity. The WHO (1948) defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” As a biopsychosocial model, the WHO’s definition specifically identifies social well-being as a third dimension of health. For example, having a social support network is positively associated with resilience to life stresses, self-esteem, and social relations. Conversely, many studies show that social isolation is associated with a higher risk of poor health and mortality (Pantell et al., 2013). The WHO has also defined a healthcare system as all the activities whose primary purpose is to promote, restore, or maintain health (McKee, 2001). As this chapter points out, health care should include much more than medical care. Thus, health care can be defined as a variety of services believed to improve a person’s health and well-being. In recent decades, increased interest has been directed toward holistic health, which emphasizes the well-being of every aspect of what makes a person whole and complete. Thus, holistic medicine seeks to treat the individual as a whole person (Ward, 1995). For example, within this approach, diagnosis and treatment would take into account the mental, emotional, spiritual, nutritional, environmental, and other factors surrounding the origin of disease (Cohen, 2003). In addition to the physical, mental, and social aspects necessary for optimal health, the spiritual dimension is incorporated as a fourth element in holistic health (FIGURE 23-1). A growing volume of medical literature, both in the United States and abroad, points to the healing effects of a person’s religion and spirituality on morbidity and mortality. The importance of spirituality as an aspect of health care is also reflected in several policy documents produced by the WHO (2003) and other bodies.

FIGURE 23-1 The four dimensions of holistic health.

Based on their extensive review of the literature, Chida et al. (2009) concluded that religious practice/spirituality is associated with reductions in deaths from all causes as well as deaths from cardiovascular diseases. Patients with heart disease who attend regular religious services have been found to have a significant survival advantage (Oman et al., 2002). Religious and spiritual beliefs and practices have been shown to have a positive impact on a person’s physical, mental, and social well-being. In addition, many studies have identified a positive relationship between religious practice and protective health behaviors (Chida et al., 2009). Several religious communities promote healthy lifestyles in terms of (lack of) tobacco use, (lack of) alcohol consumption, and diet. An examination of the literature found a reduced risk for cancer in these communities (Hoff et al., 2008). Spiritual well-being has also been recognized as an important internal resource for helping people cope with illness. For instance, in a study conducted at the University of Michigan, 93% of the women undergoing cancer treatment indicated that their religious lives helped them sustain their hope (Roberts et al., 1997). Studies have also found that a large percentage of patients want their physicians to consider their spiritual needs, and almost half express a desire for the

physicians to pray with them if they can (Post et al., 2000). The spiritual dimension is frequently tied to one’s religious beliefs, values, morals, and practices. Broadly, this dimension is described as meaning, purpose, and fulfilment in life; hope and will to live; faith; and a person’s relationship with God (Marwick, 1995; Ross, 1995; Swanson, 1995). A clinically tested scale to measure spiritual well-being included such categories as belief in a power greater than oneself, purpose in life, faith, trust in providence, prayer, meditation, group worship, ability to forgive, and gratitude for life (Hatch et al., 1998). In addition, several formal assessments have been developed to help physicians address the spiritual needs of their patients. One such tool is the HOPE Questions, which enable physicians to speak about spirituality with their patients so as to obtain important information about patients’ views of health care and faith (Anandarajah and Hight, 2001). Respect for patient values and beliefs is increasingly recognized as an important aspect of culturally appropriate care by the medical community. An growing number of medical schools and continuing education courses now offer formal courses in spirituality in medicine (Fortin and Barnett, 2004). Furthermore, the Joint Commission (2003) recommends that healthcare institutions accommodate and assess patients’ spiritual beliefs and practices as a routine part of care. The Committee on Religion and Psychiatry of the American Psychiatric Association has issued a position statement to emphasize the importance of maintaining respect for a patient’s religious/spiritual beliefs. In fact, in 2013, “religious or spiritual problem” was included as a diagnostic category for the first time in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). The holistic approach to health also alludes to the need to incorporate alternative therapies into the predominant medical model.

Quality of Life The term quality of life is used to capture the essence of overall satisfaction with life during and following a person’s encounter with the healthcare delivery system. This term is employed in two ways. First, it is an indicator of how satisfied a person is with his or her experiences while receiving health care. Specific life domains—such as comfort factors, respect, privacy, security, degree of independence, decision-making autonomy, and attention to personal preferences—are significant to most people. These factors, in turn, are now regarded as rights that patients can demand during any type of healthcare encounter. Second, quality of life can refer to a person’s overall satisfaction with life and with selfperceptions of health, particularly after some medical intervention. The implication is that desirable processes during medical treatment and successful outcomes should subsequently have a positive effect on an individual’s ability to function, carry out social roles and obligations, and have a sense of fulfilment and self-worth.

Risk Factors and Disease The occurrence of disease involves more than just a single factor. For example, the mere presence of the tubercle bacillus does not automatically mean the infected person will develop tuberculosis. Other factors, such as poverty, overcrowding, and malnutrition, may be essential for development of the disease (Friedman, 1980). Hence, tracing risk factors—attributes that increase the likelihood of developing a particular disease or negative health condition in the future—requires a broad approach. One useful explanation of disease occurrence (for communicable diseases, in particular) is provided by the tripartite model, sometimes referred to as the epidemiology triangle (FIGURE 23-2). In this model, the host is the organism—generally, a human—that becomes sick. Factors associated with the host include genetic makeup, level of immunity, fitness, and personal habits and behaviors. For the host to become sick, an agent must be present, although presence of an agent does not ensure that disease will occur. In the previous example, tubercle bacillus is the agent for tuberculosis. Other examples of agents include chemicals, radiation, tobacco smoke, dietary indiscretions, and nutritional deficiencies. The third entity, environment, is external to the host and includes the physical, social, cultural, and economic aspects of the environment. Examples include sanitation, air pollution, anthro-cultural beliefs, social equity, social norms, and economic status. The environmental factors play a moderating role that can either enhance or reduce susceptibility to disease. Because the three entities of host, agent, and environment often interact to produce disease, disease prevention efforts should focus on a broad approach to mitigate or eliminate risk factors associated with all three entities.

FIGURE 23-2 The epidemiology triangle.

Behavioral Risk Factors Certain individual behaviors and personal lifestyle choices represent important risk factors for illness and disease. For example, smoking has been identified as the leading cause of preventable disease and death in the United States because it significantly increases the risk of heart disease, stroke, lung cancer, and chronic lung disease (USDHHS, 2004). Substance abuse, inadequate physical exercise, a high-fat diet, irresponsible use of motor vehicles, and unsafe sex are additional examples of behavioral risk factors. TABLE 23-1 presents the percentages of the U.S. population with selected behavioral risks. TABLE 23-1 Percentage of U.S. Population With Behavioral Risks

Behavioral Risks Alcohol (12 years and older)

Percentage of Population

Year

52.7

2014

Marijuana (12 years and older)

8.4

2014

Cocaine use (12th graders)

1.0

2014

Cocaine use (10th graders)

0.6

2014

Cocaine use (8th graders)

0.5

2014

Cigarette smoking (18 years and older)

16.8

2014

Hypertension (20 years and older)

30.4

2011–2014

Overweight and obese (20 years and older)

69.5

2011–2014

Serum cholesterol (20 years and older)

12.1

2011–2014

Data from National Center for Health Statistics (NCHS). 2016. Health, United States, 2015. Hyattsville, MD: Department of Health and Human Services. pp. 2, 192, 194, 202, 216.

Description

Acute, Subacute, and Chronic Conditions Disease can be classified as acute, subacute, or chronic. An acute condition is relatively severe, episodic (of short duration), and often treatable and subject to recovery. Treatments are generally provided in a hospital. Examples of acute conditions include a sudden interruption of kidney function and a myocardial infarction (heart attack). A subacute condition is a less severe phase of an acute illness. It can be a postacute condition, requiring continuity of treatment after discharge from a hospital. Examples include ventilator and head trauma care. A chronic condition is one that persists over time and is not severe but that is generally irreversible. A chronic condition may be kept under control through appropriate medical treatment, but if left untreated, it may lead to severe and life-threatening health problems. Examples of chronic conditions are hypertension, asthma, arthritis, heart disease, and diabetes. Contributors to chronic disease include ethnic, cultural, and

behavioral factors and the social and physical environment, as discussed later in this chapter. In the United States, chronic diseases have become the leading cause of death and disability. Almost 50% of Americans have at least one chronic illness (Robert Wood Johnson Foundation [RWJF], 2010), and 8.7 out of every 10 deaths are attributable to chronic disease, with heart disease and cancer accounting for nearly 50% of all deaths (WHO, 2011). Cardiovascular diseases are responsible for one-fourth of all deaths annually. Although heart disease is largely preventable, the burden associated with this disease continues to grow. Approximately half of Americans have at least one of the major clinical risk factors: high low-density lipoprotein (LDL) cholesterol, high blood pressure, or smoking (Centers for Disease Control and Prevention [CDC], 2011). Other major risk factors include physical inactivity, diabetes, and obesity (Kannel and Abbott, 1984). Cancer is the second leading cause of death in the United States, with more than 1.5 million people being diagnosed with cancer annually (Xu et al., 2016). The most commonly diagnosed types of cancer are breast cancer, prostate cancer, lung cancer, and colon cancer (CDC, 2016a). Although the specific risk factors vary by type of cancer, general risk factors include family history, age, exposure to cancerous substances, diet, obesity, and tobacco use. As of 2018, more than 30 million Americans were living with diabetes and another 84 million were living with prediabetes, a health condition that increases the risk of type 2 diabetes (CDC, 2018). The major risk factor for diabetes is obesity. Chronic diseases have a major impact on the economy, in terms of both medical costs and lost productivity. Approximately 71% of all healthcare spending is attributable to people with at least one chronic condition (Gerteis et al., 2014). For example, the estimated cost of diagnosed diabetes in 2012 was $245 billion, which includes $69 billion in reduced productivity. The high costs of prescription medications, hospital inpatient care, and diabetes supplies contribute to the $176 billion in medical costs associated with this disease (American Diabetes Association, 2013). The economic burden of heart disease and stroke is also high, with these conditions costing the U.S. economy approximately $207 billion each year for healthcare services, medications, and lost

productivity (Mozaffarian et al., 2016). In total, cardiovascular disease is responsible for an estimated $317 billion annually in direct and indirect costs. The direct medical costs for cancer are approximately $88 billion per year in the United States, and the economic burden of this disease is expected to increase significantly in the future due to the growth and aging of the population, improvements in survival, and increased costs of care (Yabroff et al., 2011). Three main reasons underlie the rise of chronic conditions in the U.S. population: New diagnostic methods, medical procedures, and pharmaceuticals have significantly improved the treatment of acute illnesses, survival rates, and longevity, but these achievements have had the consequence of creating a larger population living with chronic conditions. The prevalence of chronic disease is expected to continue to rise with an aging population and longer life expectancy. Screening and diagnosis have expanded in scope, frequency, and accuracy (RWJF, 2010). Lifestyle choices, such as consumption of high-salt and high-fat diets and sedentary lifestyles, are risk factors that contribute to the development of chronic conditions. Some risk factors that contribute to the most common chronic diseases can be modified through prevention. For example, smoking, obesity, physical inactivity, and poor nutrition are risk factors for most chronic diseases. Proven prevention methods include lifestyle change programs, although such programs are notoriously difficult to sustain. Increasing prevention efforts and awareness of the need to reduce cholesterol levels and hypertension so as to prevent heart disease and stroke remain a challenge (Franco et al., 2011). In the United States, obesity and diabetes rates have increased over the last several decades, at least in part due to changes in food consumption and technological advances, which have reduced energy expenditure in labor-intensive occupations (Caballero, 2007; Finkelstein et al., 2005; Franco et al., 2009). State and local health departments face such challenges as budget restrictions in enacting health-promotion programs. Moreover, many state and local programs directed at people with chronic diseases have been reduced or eliminated (Johnson et al., 2011). Chronic disease programs are not

standardized or comprehensive in most healthcare settings (Bauer et al., 2014; Maylahn et al., 2013). The CDC supports strengthened collaboration between public health agencies and private healthcare providers to prevent chronic diseases and improve population health. One comprehensive initiative geared toward meeting this aim was launched by the USDHHS with funding of $650 million allocated to the American Recovery and Reinvestment Act of 2009. The goal of this initiative, called Communities Putting Prevention to Work (CPPW), is to “reduce risk factors, prevent/delay chronic disease, promote wellness in children and adults, and provide positive, sustainable health change in communities” (USDHHS, 2010a, p. 1). By June 2013, CPPW had met 73% of its objectives (CDC, 2013a). CPPW was successful in increasing access to environments with healthy food and beverage options in communities nationwide. It also created bike lanes in cities, supported the development of walking trails, and provided guidelines for daily physical activity in schools to increase access to physical activity. The program decreased exposure to secondhand smoke through expansion of smoke-free areas and expanded smoking cessation services. In addition, CPPW increased local capacity to improve public health interventions, developed products to support public health departments, and guided the development of programs to better support long-term community health. It is estimated that if these health improvements are sustained in CPPW communities beyond the intervention period, there will be 14,000 fewer deaths and $2.4 billion in healthcare costs will be averted through 2020 (Khavjou et al., 2014).

Health Promotion and Disease Prevention A program of health promotion and disease prevention is built on three main principles: Risk factors associated with host, agent, environment, and their health consequences are evaluated through a process called health risk appraisal. Only when the risk factors and their health consequences are known can interventions be developed to help individuals adopt healthier lifestyles. Interventions for counteracting the key risk factors include two main approaches: (1) behavior modification geared toward the goal of adopting healthier lifestyles and (2) therapeutic interventions. Adequate public health and social services, as discussed later in this chapter, include all health-related services designed to minimize risk factors and their negative effects so as to prevent disease, control disease outbreaks, and contain the spread of infectious agents. Various avenues can be used in motivating individuals to alter behaviors that may contribute to disease, disability, or death. Behavior can be modified through educational programs and incentives directed at specific high-risk populations. For example, in the case of cigarette smoking, health promotion efforts aim to build people’s knowledge, attitudes, and skills to avoid or quit smoking. These efforts also seek to reduce the number of advertisements and environmental enticements that promote nicotine addiction. Likewise, financial incentives and disincentives, such as higher cigarette taxes, have been used to discourage purchase of cigarettes. Therapeutic interventions fall into three areas of preventive effort: primary prevention, secondary prevention, and tertiary prevention. Primary prevention refers to activities undertaken to reduce the probability that a disease will develop in the future (Kane, 1988). The objective of primary prevention is to restrain the development of a disease or negative health condition before it occurs. For example,

therapeutic interventions can include community health efforts to assist patients in smoking cessation and exercise programs to prevent such conditions as lung cancer and heart disease. Safety training and practices at the workplace can reduce serious work-related injuries. Prenatal care is known to lower infant mortality rates. Immunization has had a greater impact on prevention against childhood diseases and mortality reduction than has any other public health intervention besides providing clean water (Plotkin and Plotkin, 2012). Hand washing, refrigeration of foods, garbage collection, sewage treatment, and protection of the water supply are other examples of primary prevention (Timmreck, 1994). There have been numerous incidents where training on food safety and proper cooking could have prevented outbreaks of potentially deadly episodes, such as those caused by Escherichia coli. Secondary prevention refers to early detection and treatment of disease. Health screenings and periodic health examinations are just two examples. Screening for hypertension, cancers, and diabetes, for example, has been instrumental in prescribing early treatment for these conditions. The main objective of secondary prevention is to block the progression of a disease or an injury—that is, to keep it from developing into an impairment or disability (Timmreck, 1994). Tertiary prevention refers to interventions that could prevent complications from chronic conditions and prevent further illness, injury, or disability. For example, regular turning of bed-bound patients prevents pressure sores, rehabilitation therapies can prevent permanent disability, and infection control practices in hospitals and nursing homes are designed to prevent iatrogenic illnesses (i.e., illnesses or injuries caused by the process of health care). As shown in TABLE 23-2, prevention, early detection, and treatment efforts helped reduce cancer mortality quite significantly between 1991 and 2013. This decrease was the first sustained decline since recordkeeping was instituted in the 1930s. TABLE 23-2 Annual Percentage Decline in U.S. Cancer Mortality, 1991–2013

Description Data from National Center for Health Statistics (NCHS). 2016. Health, United States, 2015. Hyattsville, MD: Department of Health and Human Services. pp. 2, 192, 194, 202, 216.

Disease Prevention Under the Affordable Care Act Prevention and wellness received significant emphasis under the Affordable Care Act (ACA). At least partially as a result of the ACA, an estimated 137 million Americans, including 28.5 million children, received no-cost coverage for preventive services (Office of the Assistant Secretary for Planning and Evaluation, 2015). Other ACA initiatives included the Prevention and Public Health Fund (PPHF) for national preventive efforts and programs geared toward improving health outcomes and enhancing the quality of health care (American Public Health Association, 2013). The Office of the Surgeon General developed a National Prevention Strategy to encourage partnerships among federal, state, tribal, local, and territorial governments; business, industry, and other private-sector entities; philanthropic organizations; community and faith-based organizations; and everyday Americans to improve health through prevention (National Prevention Council, 2011). As one example of a federally driven effort directed toward reducing chronic disease, the CDC established a National Diabetes Prevention Program (NDPP). In 2012, six organizations received $6.75 million to develop partnerships, with the aim of reaching people with prediabetes (CDC, 2013b, 2013c). Through the NDPP, organizations nationwide offer diabetes prevention lifestyle programs in healthcare clinics, pharmacies, wellness centers, worksites, and other community centers. These organizations also work to increase awareness of lifestyle changes. Organizations encourage health professionals to refer patients with prediabetes to a lifestyle change program. The program has also increased awareness across employers, some of which now provide coverage for lifestyle change programs as health benefits for their employees. The NDPP is working to ensure quality and standardized reporting and to monitor and evaluate program effectiveness (CDC, 2016b). In 2011, $10 million in federal funding was made available to establish

and evaluate comprehensive workplace wellness programs (USDHHS, 2011b). Beginning in 2014, $200 million in wellness grants was made available to small businesses to encourage the establishment of wellness programs and employee health-promotion incentives (Anderko et al., 2012). In 2015, 46.8 million employees worked in firms that offered wellness programs. Although workplace wellness programs are diverse and vary in the services and activities offered, they are all required to promote health and/or prevent disease to qualify for federal funding support. Of the companies that provided health benefits in 2015, 50% offered wellness programs for tobacco cessation, weight control, nutrition, and other lifestyle or behavioral coaching (Mattke et al., 2013). Health-promotion activities, such as on-site vaccination services, biometric screenings, fitness benefits, and health food options at the workplace, are also common. The majority of workplaces that offer wellness programs offer a combination of screening and intervention services. These programs have been shown to generate savings in medical costs of approximately $3 for every $1 spent on the program and to reduce absenteeism (Baicker et al., 2010).

Public Health Public health remains poorly understood by its prime beneficiaries, the public. For some people, public health evokes images of a massive social enterprise or welfare system. To others, the term means healthcare services for everyone. Still another image of public health is of a body of knowledge and techniques that can be applied to health-related problems (Turnock, 1997). However, none of these ideas adequately reflects what public health is. The Institute of Medicine (1988) has proposed that the mission of public health should be understood as fulfilling “society’s interest in assuring conditions in which people can be health” (p. 12). Public health deals with broad societal concerns about ensuring conditions that promote optimal health for the society as a whole. It involves the application of scientific knowledge to counteract any threats that may jeopardize the health and safety of the general population. Because of its extensive scope, the vast majority of public health efforts are carried out by government agencies, such as the CDC in the United States. Three main distinctions can be seen between the practices of medicine and public health: Medicine focuses on the individual patient—diagnosing symptoms, treating and preventing disease, relieving pain and suffering, and maintaining or restoring normal function. Public health, in contrast, focuses on populations (Shi and Johnson, 2014). The emphases in modern medicine are the biological causes of disease and the development of treatments and therapies. In contrast, public health focuses on (1) identifying environmental, social, and behavioral risk factors as well as emerging or potential risks that may threaten people’s health and safety; and (2) implementing populationwide interventions to minimize these risk factors (Peters et al., 2001). Medicine focuses on the treatment of disease and recovery of health, whereas public health deals with various efforts to prevent disease and counteract threats that may negatively affect people’s health.

Public health activities range from providing education on nutrition to passing laws that enhance automobile safety. For example, public health includes dissemination, both to the public and to health professionals, of timely information about important health issues, particularly when communicable diseases pose potential threats to large segments of a population. Compared to medicine, public health involves a broader range of professionals. The medical sector encompasses physicians, nurses, dentists, therapists, social workers, psychologists, nutritionists, health educators, pharmacists, laboratory technicians, health services administrators, and so forth. In addition to these professionals, the public health forum includes such professionals as sanitarians, epidemiologists, statisticians, industrial hygienists, environmental health specialists, food and drug inspectors, toxicologists, and economists (Lasker, 1997).

Health Protection and Environmental Health Health protection is one of the main public health functions. In the 1850s, John Snow successfully traced cholera outbreaks in London to contamination of the Broad Street water pump (Rosen, 1993). Since then, environmental health has specifically dealt with preventing the spread of disease through water, air, and food (Schneider, 2000). Environmental health science, along with other public health measures, was instrumental in reducing the risk of infectious diseases during the 1900s. For example, in 1900, pneumonia, tuberculosis, and diarrhea, along with enteritis, were the top three killers in the United States (CDC, 1999); that is no longer the case today (TABLE 23-3). With the rapid industrialization that occurred during the 20th century, environmental health faced new challenges due to serious health hazards from chemicals, industrial waste, infectious waste, radiation, asbestos, and other toxic substances. In the 21st century, the possession of chemical, biological, and nuclear agents by terrorists and rogue nations has emerged as a new environmental threat. TABLE 23-3 Leading Causes of Death, 2014 Percentage of All

Cause of Death

Deaths

Deaths

All causes

2,626,418

100.0

Diseases of the heart

614,348

23.4

Malignant neoplasms

591,699

22.5

Chronic lower respiratory diseases

147,101

5.6

Unintentional injuries

136,053

5.2

Cerebrovascular diseases

133,103

5.1

Alzheimer’s disease

93,541

3.6

Diabetes mellitus

76,488

2.9

Influenza and pneumonia

55,227

2.1

Nephritis, nephrotic syndrome, and nephrosis

48,146

1.8

Suicide

42,773

1.6

Data from National Center for Health Statistics (NCHS). 2016. Health, United States, 2015. Hyattsville, MD: Department of Health and Human Services. p. 107.

Description

Health Protection During Global Pandemics Over time, public health has become a complex global undertaking. Its main goal of protecting the health and safety of populations from a variety of old and new threats cannot be achieved without global cooperation. Influenza is the most common infectious disease on a global scale, affecting nearly 3 to 5 million people annually and resulting in 250,000 to 500,000 deaths (Thompson et al., 2009). It spreads around the world in a yearly outbreak. The global threat of avian influenza has also elicited a public health response. The CDC launched a website dedicated to educating the public about avian influenza, the means by which it is spread, and past

and current outbreaks. This website contains specific information for health professionals, travelers, the poultry industry, state departments of health, and people with possible exposures to avian influenza (CDC, 2007). Although several strains of influenza exist, the subtypes currently circulating among humans are H1N1 and H3N2 (WHO, 2016a). After a novel H1N1 influenza virus emerged from Mexico in April 2009, U.S. health officials anticipated and prepared for an influenza pandemic, and these efforts stretched the response capabilities of the public health system. The virus affected every U.S. state, and Americans were left unprotected because of the unavailability of antiviral medications. Since then, a global effort has been undertaken to establish collaborative networks to exchange information and to contain global pandemics (WHO, 2013). Coronaviruses are believed to cause a large percentage of all common colds in adults (Committee on Infectious Diseases et al., 2015). However, two strains of coronavirus have particularly serious health effects. Severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS) coronavirus outbreaks occurred in 2003 and 2012, respectively. In 2003, SARS—a contagious disease that is accompanied by fever and symptoms of pneumonia or other respiratory illness—spread from China to Canada. Worldwide, more than 8,000 people were affected by this infection (CDC, 2012). MERS still occurs in parts of the Middle East. Since 2012, 27 countries have reported cases of MERS, for a total of 1,888 cases and 670 deaths from this disease (WHO, 2016b). The WHO’s (2016c) 2016 World Malaria Report provides estimates of the global prevalence and mortality due to malaria. In 2015, there were an estimated 212 million malaria cases and 429,000 malaria deaths worldwide. The majority of cases were in Africa (90%), followed by southeast Asia (7%). The global incidence of malaria decreased by 21% between 2010 and 2015, and the number of deaths decreased by 29% in the same time period. The Global Tuberculosis (TB) Report, also published by the WHO (2016d), provides current estimates of the worldwide TB epidemic. In 2015, there were an estimated 10.4 million incidents of TB cases worldwide. Sixty percent of cases were concentrated in six countries:

India, Indonesia, China, Nigeria, Pakistan, and South Africa. Multidrugresistant TB cases are especially problematic, with 480,000 new cases in 2015 and an additional 100,000 new cases of rifampicin-resistant TB. An estimated 1.4 million deaths due to TB occurred in 2015. Nevertheless, the number of TB deaths fell 22% between 2000 and 2015, and TB treatment averted 49 million deaths globally. Even so, TB remains among the top 10 causes of death worldwide. Prevent HIV, Test and Treat All: Progress Report 2016, a WHO (2016e) report, provides estimates of the global human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) epidemic. As of 2015, 36.7 million people were living with HIV/AIDS worldwide; in that same year, 1.1 million people died of AIDSrelated illnesses. This mortality was the lowest number of deaths from HIV/AIDS in 2 decades. The burden of the pandemic is greatest in subSaharan Africa, where an estimated 25.5 million people are living with the disease (70% of all people living with HIV worldwide) as of 2017. In 2015, 800,000 people in this region died from HIV/AIDS. Approximately 66% of all new HIV infections occur in this region as well. As of June 2016, 18.2 million people living with HIV globally were receiving life-prolonging antiretroviral therapy (ART), compared to 7.5 million people in 2010 and fewer than 1 million people in 2000. In addition, access to ART to prevent transmission of HIV from mother to baby is increasing, with new HIV infections among newborns declining by 50% since 2010. Although some types of hepatitis are more problematic (i.e., hepatitis B and C) than others, all variants of this infection are viral in nature and present in the global population. An estimated 400 million people are affected by at least one type of viral hepatitis, and 6 to 10 million are newly infected annually. In total, approximately 1.4 million people die from hepatitis each year globally (GBD 2013 Mortality and Causes of Death Collaborators, 2015; Jacobsen and Wiersma, 2010). Hepatitis B accounts for approximately 686,000 deaths and an estimated 240 million chronic infections each year. In sub-Saharan Africa and East Asia, 5% to 10% of the population is chronically infected with hepatitis B; in the Middle East and India, an estimated 2% to 5% of the population is chronically infected. Approximately 130 to 150 million people have chronic hepatitis C, and 700,000 die annually from related liver diseases. Africa, Central Asia, and East Asia are the regions most affected by the

hepatitis C pandemic. The most current outbreak of the Ebola virus, which started in December 2013 and ended in April 2016, led to more than 28,000 cases and 11,000 deaths in Africa (WHO, 2016f). The countries most severely affected by the recent major Ebola outbreak—Guinea, Sierra Leone, and Liberia—are all in West Africa. Now that the outbreak has ended, the current focus is on preparedness and prevention of future epidemics (WHO Ebola Response Team et al., 2016). In December 2016, scientists reported highly promising results for an experimental Ebola vaccine (Henao-Restrepo et al., 2017). The first vaccine to prevent infections from this virus, it is estimated to be 70% to 100% effective.

Health Protection and Preparedness in the United States Since the horrific events of what is commonly referred to as 9/11 (the terrorism attacks on September 11, 2001), the United States has begun a new chapter in health protection. These efforts to protect the health and safety of Americans began in June 2002 when President George W. Bush signed into law the Public Health Security and Bioterrorism Preparedness Response Act of 2002. Subsequently, the Homeland Security Act of 2002 created the Department of Homeland Security (DHS) and called for a major restructuring of the nation’s resources, with the primary mission of helping prevent, protect against, and respond to any acts of terrorism in the United States. It also provided better tools to contain attacks on food and water supplies, protect the nation’s vital infrastructures (i.e., nuclear facilities), and track biological materials anywhere in the United States. The term bioterrorism encompasses the use of chemical, biological, and nuclear agents to cause harm to relatively large civilian populations. Today, health protection and preparedness comprise a massive operation to deal with any natural or human-made threats. Dealing with such threats requires large-scale preparations, which include appropriate tools and training for workers in medical care, public health, emergency care, and civil defense agencies at the federal, state, and local levels. It requires national initiatives to develop countermeasures, such as new vaccines, a robust public health infrastructure, and coordination among numerous agencies. It also requires development of an infrastructure that can handle large numbers of casualties and isolation facilities for contagious patients. Hospitals, public health agencies, and civil defense must be linked together through information systems. Containment of infectious agents, such as smallpox, necessitates quick detection, treatment, isolation, and organized efforts to protect the unaffected population. Rapid cleanup, evacuation of the affected population, and transfer of victims to medical care facilities require detailed plans and logistics.

The United States has confronted several major natural disasters in the 21st century, such as Hurricane Katrina in 2005, Hurricane Sandy in 2012, and tornadoes in Oklahoma in 2013 as well as human-made mass casualties, such as the Boston Marathon bombing on April 15, 2013. Health protection and preparedness have become ongoing efforts through revitalized initiatives, such as the Pandemic and All-Hazards Preparedness Act (PAHPA) of 2006, which also authorized a new Assistant Secretary for Preparedness and Response (ASPR) within the USDHHS and called for the establishment of a quadrennial National Health Security Strategy (NHSS). The CDC has developed the National Biosurveillance Strategy for Human Health, which covers six priority areas: electronic health information exchange, electronic laboratory information exchange, unstructured data, integrated biosurveillance information, global disease detection and collaboration, and biosurveillance workforce. Based on the National Health Security Strategy developed by the USDHHS in 2009, Healthy People 2020 focused on four areas for reinforcement under an overarching goal to “improve the Nation’s ability to prevent, prepare for, respond to, and recover from a major health incident.” This national security strategy aims at the release of official information about a public health emergency, time for designated personnel to respond to an emergency, Laboratory Response Network (LRN) laboratories, and time to develop after-action reports and improvement plans in states (USDHHS, 2010b). A progress report shows that most states and localities have strong biological laboratory capabilities and capacities, with nearly 90% of laboratories in the LRN reachable around the clock (CDC, 2010b). In 2011, the Health Alert Network (HAN) was established; this nationwide program is designed to facilitate communication, information, and distance learning related to health threats, including bioterrorism (USDHHS, 2011a). When fully established, the network will link together local health departments and other components of bioterrorism preparedness and response, such as laboratories and state health departments. One of the key concepts of preparedness is surge capacity, defined as “the ability of a health care facility or system to expand its operations to safely treat an abnormally large influx of patients” (Bonnett and Peery, 2007, p. 298). The initial response is conducted at a local healthcare

facility, such as a hospital. Strategies for expanding the surge capacity of a hospital include early discharge of stable patients, cancellation of elective procedures and admissions, conversion of private rooms to double rooms, reopening of closed areas, revision of staff work hours to a 12-hour disaster shift, callback of off-duty personnel, and establishment of temporary external shelters for patient holding (Hick et al., 2004). If the local level response becomes overloaded or incapacitated, a second tier of disaster response can be activated: community-level surge capacity. Cooperative regional planning necessitates sharing of staff and supplies across a network of regional healthcare facilities (Hick et al., 2004). An important aspect of disaster planning at the community level entails the transportation logistics for the region. The number of ambulances in the area and the means of accessing such resources during an event is crucial to delivering proper care to critical patients (Kearns et al., 2013). The final tier of disaster response involves federal aid under the National Disaster Medical System (NDMS), which dates back to the 1980s and was designed to accommodate large numbers of military casualties. Disaster Medical Assistance Teams (DMATs) are a vital component of the NDMS that directly respond to the needs of an overwhelmed community. DMATs deploy with trained personnel (in both medical and ancillary services), equipped with tents, water filtration, generators, and medical supplies (Stopford, 2005). Developments in technology have made major contributions to advances in disaster preparedness. For example, the United States is using new information and communication technologies to streamline emergency responses among various organizations. Social media is increasingly being used as a tool by governments, communities, and organizations for a range of purposes in disaster preparedness (i.e., detecting an event; connecting individuals following a disaster; and preparing and receiving disaster preparedness information, warnings, and signals) (Houston et al., 2015). Despite the progress that has been made, disaster preparedness efforts in the United States remain fragmented and underfunded. For example, review, rotation, replacement, and upgrading of equipment and supplies in the system on a regular basis remain challenging (Cohen and Mulvaney, 2005). Given the differences in institutional and local

structures, it is difficult to develop clear and objective standards and methods while still respecting local authorities (Nelson et al., 2007). Other challenges include retention of high-quality staff in emergency departments and having insufficient funding and resources to provide education and training opportunities (Walsh et al., 2015).

Determinants of Health Health determinants are major factors that affect the health and wellbeing of individuals and populations. An understanding of health determinants is necessary to plan and implement any positive interventions that improve health and longevity.

Blum’s Model of Health Determinants In 1974, Blum (1981) proposed an “Environment of Health” model, later called the “Force Field and Well-Being Paradigms of Health.” Blum proposed that four major inputs contribute to health and well-being (“force fields”): environment, lifestyle, heredity, and medical care. All these factors must be considered simultaneously when addressing the health status of an individual or a population. In other words, there is no single pathway to better health because health determinants interact in complex ways. Consequently, improvement in health requires a multipronged approach. The four wedges in Blum’s model represent the four major force fields. The size of each wedge signifies its relative importance. Thus, the most important force field is environment, followed by lifestyle and heredity. Medical care has the least impact on health and well-being. Blum’s model also explains that the four main forces operate within a much larger context and are affected by broad national and international factors, such as a nation’s population characteristics, natural resources, ecological balance, human satisfactions, and cultural systems. One of these factors is the type of healthcare delivery system. In the United States, the majority of healthcare expenditures is devoted to the treatment of medical conditions rather than to the prevention of factors that produce those medical conditions in the first place.

Environment Environmental factors encompass the physical, socioeconomic, sociopolitical, and sociocultural dimensions. Among physical

environmental factors are air pollution, food and water contaminants, radiation, toxic chemicals, wastes, disease vectors, safety hazards, and habitat alterations. The positive relationship between socioeconomic status (SES) and health may be explained by the general likelihood that people who have better education also have higher incomes. The greater the economic gap between the rich and the poor is in a given geographic area, the worse the health status of the overall population in that area is likely to be. It has been suggested that wide income gaps produce less social cohesion, greater psychosocial stress, and, consequently, poorer health (Wilkinson, 1997). For example, social cohesion—characterized by a hospitable social environment in which people trust each other and participate in communal activities—is linked to lower overall mortality and better self-rated health (Kawachi et al., 1997, 1999). Even countries with national health insurance programs, such as the United Kingdom, Australia, Denmark, and Sweden, experience persistent and widening disparities in health according to socioeconomic status (Pincus et al., 1998). The joint relationship of income inequality and availability of primary care has also been found to be significantly associated with individuals’ self-rated health status (Shi et al., 2002).

Lifestyle Lifestyle factors, also known as behavioral risk factors, were discussed earlier in this chapter. This section provides some illustrations of how lifestyle factors are related to health. Studies have shown that diet plays a major role in most of today’s significant health problems. Heart disease, diabetes, stroke, and cancer are some of the diseases with direct links to dietary choices. Throughout the world, incidence and mortality rates for many forms of cancer are rising, although research has clearly indicated that a significant portion of cancer is preventable. Researchers estimate that 30% to 50% of all cancers and as many as 30% to 35% of cancer deaths are linked to diet (World Cancer Research Fund and American Institute for Cancer Research, 2007). Research also shows that a diet rich in fruits, vegetables, and low-fat dairy foods, as well as a diet low in saturated and total fat, can substantially lower blood pressure (see, for example, the DASH Eating Plan recommended by USDHHS [2006]).

Increasing exercise and physical activity is a potentially useful, effective, and acceptable method for reducing the risk of colon cancer (Macfarlane and Lowenfels, 1994) and many other health problems. Smoking and alcohol consumption are also important lifestyle factors that affect health. In addition to increasing the risk of lung cancer, smoking increases the risk of coronary heart disease and stroke by 2 to 4 times (USDHHS, 2014). Half of all cancer deaths and nearly half of all cancer diagnoses could potentially be prevented through a healthy lifestyle that includes not smoking, drinking in moderation, maintaining a healthy weight, and exercising regularly (Song and Giovannucci, 2016).

Heredity Genetic factors may predispose individuals to certain diseases. Although cancer is not entirely genetic, cancer can occur when the body’s healthy genes lose their ability to suppress malignant growth or when other genetic processes stop working properly (Davis and Webster, 2002). Although people can do little about the genetic makeup they have inherited, their lifestyle and behavior can have a significant impact on their progeny. Finally, advances in gene therapy hold the promise of treating a variety of inherited or acquired diseases.

Medical Care Although the factors of lifestyle, environment, and heredity are more important in the determination of health, medical care is, nevertheless, a key factor affecting health. Although, according to Blum, medical care is the least important factor in determining health and well-being, the United States focuses more on medical research and development of new medical technologies than it does on the other three factors. It can be noted that significant declines in mortality rates were achieved well before the modernization of Western medicine and the escalation in medical care expenditures. The availability of primary care may be one way in which income inequality influences population-level health outcomes. Research by Shi and colleagues (Shi and Starfield, 2001; Shi et al., 1999) suggests that access to primary care significantly correlates with reduced mortality,

increased life expectancy, and improved birth outcomes. Access to primary care includes access to and use of preventive services, which can prevent illness or detect disease at an earlier, often more treatable stage. In the United States, individuals living in states with a higher primary care physician-to-population ratio are more likely to report good health than those living in states with a lower ratio (Shi et al., 2002).

Contemporary Models of Health Determinants More recent models have built upon and extended Blum’s framework of health determinants. For example, the model proposed by Dahlgren and Whitehead (2006) identifies age, sex, and genetic makeup as fixed factors but states that other factors can be modified to positively influence population health. Although individual lifestyle factors can benefit or damage health, broader social, economic, cultural, and environmental conditions often have greater influence on both individual and population health. Ansari and colleagues (2003) have proposed a public health model of the social determinants of health in which the determinants are categorized into four major groups: social determinants, healthcare system attributes, disease-inducing behaviors, and health outcomes. The WHO (2008) Commission on Social Determinants of Health concluded that “the social conditions in which people are born, live, and work are the single most important determinant of one’s health status” (Satcher, 2010, p. 6). The WHO model provides a conceptual framework for understanding the socioeconomic and political contexts, structural determinants, intermediary determinants (including material circumstances, social‒environmental circumstances, behavioral and biological factors, social cohesion, and the healthcare system), and the impact on health equity and well-being measured as health outcomes (FIGURE 23-3).

FIGURE 23-3 The WHO Commission on Social Determinants of Health conceptual framework. Reproduced from Centers for Disease Control and Prevention (CDC). 2010a. Establishing a holistic framework to reduce inequities in HIV, viral hepatitis, STDs, and tuberculosis in the United States. Available at: https://www.cdc.gov/socialdeterminants/docs/SDH-White-Paper-2010.pdf. Accessed April 2017. Modified from Solar O., and A. Irwin. 2010. A conceptual framework for action on the social determinants of health. Social Determinants of Health Discussion Paper 2 (Policy and Practice). Geneva, Switzerland: WHO.

Description U.S. government agencies, such as the CDC and the USDHHS, have recognized the need to address health inequities. The CDC’s National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention adopted the WHO framework on social determinants of health as a guide for its activities.

Measures Related to Health Certain quantitative measures are commonly applied to health, health status, and the utilization of health care. The conceptual approaches for defining health and its distribution help form a vision for the future, and objective measures play a critical role in evaluating the success of programs and directing future planning activities. Practical approaches for measuring health are, however, quite limited, and mental health is more difficult to quantify and measure than physical health. An objective evaluation of social and spiritual health is even more obscure. The concept of population, as it applies to population health, has been borrowed from the disciplines of statistics and epidemiology. The term population is not restricted to describing the total population. Although commonly used in this way, the term population may also apply to a defined subpopulation—for example, age groups, marital categories, income levels, occupation categories, racial/ethnic groups, people having a common disease, people in a certain risk category, or people in a certain community or geographic region of a country. The main advantage of studying subpopulations is that it helps trace the existence of health problems to a defined group. Doing so avoids the likelihood that serious problems in a minority group will be hidden within the favorable statistics of the majority. By pinpointing health problems in certain welldefined groups, targeted interventions and new policy initiatives can be deployed in the most effective manner.

Measures of Physical Health Physical health status is often interpreted through morbidity (disease and disability) and mortality (death) rates. In addition, self-perceived health status is a commonly used indicator of health and well-being because it is highly correlated with many objective measures of health status. With this measure, respondents are asked to rate their health as excellent, very good, good, fair, or poor. Self-perceived health status is also a good predictor of patient-initiated physician visits, including general medical and mental health visits.

Longevity Life expectancy—a prediction of how long a person will live—is widely used as a basic measure of health status. The two common measures are life expectancy at birth (TABLE 23-4)—or how long a newborn can expect to live—and life expectancy at age 65—expected remaining years of life for someone at age 65. These measures are actuarially determined and published by government agencies, such as the National Center for Health Statistics (NCHS). The U.S. Census Bureau (2016) has projected that life expectancy in the United States will increase from 78.8 years in 2014 to 84.1 years in 2050. TABLE 23-4 U.S. Life Expectancy at Birth—2002, 2007, and 2014

Description Data from National Center for Health Statistics (NCHS). 2016. Health, United States, 2015.

Hyattsville, MD: Department of Health and Human Services. p. 95.

Morbidity The measurement of morbidity or disease, such as cancer or heart disease, is expressed as a ratio or proportion of those who have the problem and the population at risk. The population at risk includes all the people in the same community or population group who could acquire a disease or condition (Smith, 1979). Incidence and prevalence are two widely used indicators for the number of cases of people who end up acquiring a negative health condition. Both incidence and prevalence rates can apply to disease, disability, or death. Incidence counts the number of new cases occurring in the population at risk within a certain period of time, such as a month or a year (Smith, 1979; FORMULA 23-1). It describes the extent to which people in a given population acquire a given disease during a specified time period. Incidence is particularly useful in estimating the significance or magnitude of conditions of relatively short duration. Declining levels of incidence indicate successful health promotion and disease prevention efforts because they prevent new cases (Ibrahim, 1985). High levels of incidence may suggest an impending epidemic, a large number of people who get a specific disease from a common source.

FORMULA 23-1 Incidence = Number of new cases during a specified period/Population at risk

Prevalence determines the total number of cases at a specific point in time, in a defined population (FORMULA 23-2). Prevalence is useful in quantifying the magnitude of illnesses of a relatively long duration. Decreased prevalence indicates success of treatment programs by shortening the duration of illness (Ibrahim, 1985).

FORMULA 23-2 Prevalence = Total number of cases at a specific point in time/Specified population

The calculation of rates often requires dividing a small number by a large number representing a defined population. The result is a fraction. To make the fractions meaningful and interpretable, they are multiplied by 100 (to get a percentage), by 1,000 (to get a rate per 1,000 people), by 10,000 (to get a rate per 10,000 people), or by a higher multiple of 10.

Disability Disease and injury can lead to temporary or permanent, as well as partial or total, disability. Although the idea of morbidity includes disabilities, as well as disease, specific measures of disability have been developed. Some commonly used measures are the number of days of bed confinement, days missed from work or school, and days of restricted activity. All measures are in reference to a specific time period, such as a year. One of the most widely used measures of physical disability among the elderly, in particular, is the activities of daily living (ADLs) scale. The ADLs identify personal care functions with which a disabled person may need assistance. Depending on the extent of disability, personal care needs can be met through adaptive devices; care rendered by another individual, such as a family member; or care in a nursing facility. Consequently, the ADL scale is appropriate for evaluating disability in both community-dwelling and institutionalized adults. The classic ADL scale, developed by Katz and Akpom (1979), includes six basic activities: eating, bathing, dressing, using the toilet, maintaining continence, and transferring from bed to chair. To evaluate disability in communitydwelling adults, a modified Katz scale, which consists of seven items, is used (Ostir et al., 1999). Five of these items—feeding, bathing, dressing, using the toilet, and transferring from bed to chair—have been retained from the original Katz scale. The additional two items are grooming and walking a distance of 8 feet. Thus, the modified scale includes items measuring self-care and mobility. Another commonly used measure of physical function is the

instrumental activities of daily living (IADLs) scale. This scale measures activities that are necessary for living independently in the community, such as using the telephone, driving a car or traveling alone on a bus or by taxi, shopping, preparing meals, doing light housework, taking medicines, handling money, doing heavy housework, walking up and down stairs, and walking a half-mile without help. IADLs typically require higher cognitive functioning than ADLs and, as such, are not purely physical tests of functional disability. The IADL scale measures the level of functioning in activities that are important for self-sufficiency, such as the ability to live independently.

Mortality Death rates are computed in different forms as indicators of population health. Crude rates refer to the total population; they are not specific to any age group or disease category (FORMULA 23-3).

FORMULA 23-3 Crude death rate = Total deaths (usually in 1 year)/Total population

Specific rates are useful because death rates vary greatly by race, sex, age, and type of disease or condition. Specific rates allow healthcare professionals to target programs at the appropriate population subgroups (Dever, 1984). Examples of specific rates are the age-specific mortality rate (FORMULA 23-4) and the cause-specific mortality rate (FORMULA 23-5). The age-specific mortality rate provides a measure of the risk (or probability) of dying when a person is in a certain age group. The causespecific mortality rate provides a measure of the risk (or probability) of dying from a specific cause.

FORMULA 23-4

Age-specific mortality rate = Number of deaths within a certain age group/Total number of persons in that age group

FORMULA 23-5 Cause-specific mortality rate = Number of deaths from a specific disease/Total population

The infant mortality rate (actually a ratio; FORMULA 23-6) is an indicator that reflects the health status of the mother and the child throughout pregnancy and the birth process. It also reflects the level of prenatal and postnatal care (Timmreck, 1994).

FORMULA 23-6 Infant mortality rate = Number of deaths from birth to 1 year of age (in 1 year)/Number of live births during the same year

Demographic Change In addition to measures of disease and mortality, changes in the composition of a population over time are important in planning health services. Population change involves three components: births, deaths, and migration (Dever, 1984). For example, the migration of elderly individuals to the southern and southwestern states requires planning of adequate retirement and long-term care services in those states. Longevity is also an important factor that determines demographic change. For example, lower death rates, lower birth rates, and greater longevity, taken collectively, indicate an aging population. This section presents measures of births and migration.

Births

Natality and fertility are two measures associated with births. Natality, or the birth rate, is useful in assessing the influence of births on demographic change and is measured by the crude birth rate (FORMULA 23-7).

FORMULA 23-7 Crude birth rate = Number of live births (usually in 1 year)/Total population

Fertility refers to the capacity of a population to reproduce (FORMULA 23-8). Fertility is a more precise measure than natality because fertility relates actual births to the sector of the population capable of giving birth.

FORMULA 23-8 Fertility rate = Number of live births (usually in 1 year)/Number of females aged 15–44

Migration Migration refers to the geographic movement of populations between defined geographic units and involves a permanent change of residence. The net migration rate (FORMULA 23-9) defines the change in the population as a result of immigration (in-migration) and emigration (out-migration) (Dever, 1984). This rate is calculated for a specified period, such as 1 year, 2 years, 5 years, and so on.

FORMULA 23-9 Net migration rate = (Number of immigrants – Number of emigrants)/Total population (during a specific period of time)

Measures of Mental Health Measurement of mental health is less objective than measurement of mortality and morbidity because mental health often encompasses feelings that cannot be observed. In contrast, physical functioning, as reflected in behaviors and performances, can be more readily observed. Hence, measurement of mental health more appropriately refers to assessment rather than measurement. Mental health can be assessed by the presence of certain symptoms, including both psychophysiologic and psychological symptoms. Examples of psychophysiologic symptoms are low energy, headache, and upset stomach. Examples of psychological symptoms are nervousness, depression, and anxiety. Self-assessment of one’s psychological state may also be used for mental health assessment. Self-assessment can be obtained through self-reports of frequency and intensity of psychological distress, anxiety, depression, and psychological well-being.

Measures of Social Health Measures of social health extend beyond the individual to encompass the extent of social contacts across various facets of life, such as family life, work life, and community life. Breslow (1972) attempted to measure social health along four dimensions: (1) employability based on educational achievement, occupational status, and job experience; (2) marital satisfaction; (3) sociability, determined by the number of close friends and relatives; and (4) community involvement, encompassing attendance at religious services, political activity, and organizational membership. Social health status is sometimes evaluated in terms of social contacts and social resources. Social contacts are the number of social contacts or social activities a person engages in within a specified period. Examples are visits with friends and relatives as well as attendance at social events, such as conferences, picnics, or other outings. Social resources refer to social contacts that can be relied on for support, such as relatives, friends, neighbors, and members of a religious congregation. Social contacts can be observed, and they are the more objective of the two categories; however, one criticism of social contact measures is their focus on events and activities, with little consideration of how the events

are personally experienced. Unlike social contacts, social resources cannot be directly observed and are best measured by asking the individuals direct questions. Evaluative questions include whether these individuals can rely on their social contacts to provide tangible support and needed companionship and whether they feel cared for, loved, and wanted.

Measures of Spiritual Health Depending on the person’s individual, social, and cultural context, spiritual well-being can have a large variety of connotations. Such variations make it extremely difficult to propose standardized approaches for measuring the spiritual dimension. Attempts to measure this dimension are illustrated in the General Social Survey, which includes people’s self-perceptions about happiness, religious experiences, and their degree of involvement in activities, such as prayer and attending religious services. A wide range of tools for spiritual assessment are now available. Generic methods of spiritual assessment are not associated with any particular religion or practice, so they do not require a detailed understanding of any particular religious tradition (Draper, 2012). An example of a generic scale is the tool developed by Vella-Brodrick and Allen (1995), which evaluates such items as reaching out for spiritual intervention; engaging in meditation, yoga, or prayer; duration of meditation or prayer for inner peace; frequency of meditation or prayer; reading about one’s religious beliefs; and discussions or readings about ethical and moral issues. Quantitative measurement scales are also available to assess such dimensions as general spirituality, spiritual wellbeing, spiritual needs, and spiritual coping (Monod et al., 2011), but their use has been confined mainly to clinical research.

Measures of Health Services Utilization Utilization refers to the consumption of healthcare services and the extent to which healthcare services are used. Measures of utilization can be used to determine which individuals in a population group do or do not receive certain types of medical services. With this type of measure, a

healthcare provider, such as a hospital, can find out the extent to which its services are used. Managers can use these measures to decide whether certain services should be added or eliminated, and health planners can determine whether programs have been effective in reaching their targeted populations. For example, managers can use these measures to ascertain how many hospital beds are required to meet the acute care needs of a given population (Pasley et al., 1995). Therefore, measures of utilization play a critical role in the planning of healthcare delivery capacity. Measures of utilization are too numerous to be covered here, but some common measures are provided (FORMULAS 23-10 to 23-16).

Crude Measures of Utilization

FORMULA 23-10 Access to primary care services = Number of persons in a given population who visited a primary care provider in a given year/Size of the population (This measure is generally expressed as a percentage; that is, the fraction is multiplied by 100.)

FORMULA 23-11 Utilization of primary care services = Number of primary care visits by people in a given population in a given year/Size of the population

Specific Measures of Utilization

FORMULA 23-12

Utilization of targeted services = Number of people in a specific targeted population using special services (or visits)/Size of the targeted population group (The fraction obtained is multiplied by 100, 1,000, or a higher multiple of 10 to facilitate interpretation of the result. This measure is generally expressed as number of visits per person per year.)

FORMULA 23-13 Utilization of specific inpatient services = Number of inpatient days/Size of the population (The fraction obtained is multiplied by 100, 1,000, or a higher multiple of 10 to facilitate interpretation of the result.)

Measures of Institution-Specific Utilization

FORMULA 23-14 Average daily census = Total number of inpatient days in a given time period/Number of days in the same time period

FORMULA 23-15 Occupancy rate = Total number of inpatient days in a given time period/Total number of available beds during the same time period or Average daily census/Total number of beds in the facility (This measure is expressed as a percentage; that is, the fraction is multiplied by 100.)

FORMULA 23-16 Average length of stay = Total number of inpatient days during a given time period/Total number of patients served during the same time period

Measures of Global Health Global monitoring of changes in the health of various populations requires the use of tried-and-true global health indicators. Global health indicators can be divided into those that directly measure health phenomena (e.g., diseases, deaths, use of services) and indirect measures (e.g., social development, education and poverty indicators); these are also referred to as proximal and distal indicators, respectively. As one example, when using population statistics to describe levels of educational attainment and access to safe water and sanitation, it is possible to accurately categorize a country as having a population with high, medium, or low burden of disease (Larson and Mercer, 2004). The WHO (2015) compiles more than 100 indicators of a broad range of key public health issues. Commonly used indicators of life expectancy and mortality include life expectancy at age 60, healthy life expectancy at birth, infant and under-5 mortality rates, and the adult mortality rate. Cause-specific mortality rates are collected for selected communicable and noncommunicable diseases. Health services indicators reflect the extent to which people receive important health interventions. These services include unmet needs for family planning, prenatal care coverage, births attended by skilled health personnel, vaccination coverage, and other prevention and treatment coverage for common diseases among children. It is also important to report indicators of risk factors that are associated with increased mortality and morbidity. In order to assess the risk of transmission of diarrheal disease, it is important to know the percentage of the population that do not have safe water supplies and sanitation. Use of solid fuels in households is a proxy indicator for household pollution. Indicators of the prevalence of diabetes, hypertension, and obesity all signal the risk of cardiovascular disease and several types of cancer. Indirect indicators of global health include health system indicators

related to the workforce, infrastructure, medical technologies and devices, and government expenditures on health. Demographic and socioeconomic factors that are major determinants of health include primary school enrollment, population living in poverty, population size, crude birth and death rates, total fertility rates, and per-capita gross national income.

Anthro-Cultural Beliefs and Values A value system orients the members of a society toward defining what is desirable for that society. It has been observed that even a society as complex and highly diverse as that found in the United States can be said to have a relatively well-integrated system of institutionalized common values at the societal level (Parsons, 1972). Although such a view still prevails, American society now includes distinct subcultures whose membership has increased significantly due to a steady influx of immigrants from different parts of the world. The current system of health services delivery has roots in the traditional beliefs and values espoused by the American people. This belief and value system governs the training and general orientation of healthcare providers, the type of health delivery settings, the financing and allocation of resources, and access to health care in the United States. Among the main beliefs and values prevalent in the American culture are those outlined here. 1. The United States has a strong belief in the advancement of science and the application of scientific methods to medicine. This belief was instrumental in the creation of the medical model that primarily governs U.S. healthcare delivery. As a result, the United States has long led the world in medical breakthroughs. These developments have had numerous implications for health services delivery: a. They increase the demand for the latest treatments and raise patients’ expectations for finding cures. b. Because medical professionals focus on clinical interventions, they do not provide adequate emphasis on the holistic aspects of health and use of alternative therapies. c. Healthcare professionals have been trained to focus on physical symptoms rather than on the underlying causes of disease. d. Integrating diagnosis and treatment with disease prevention

has lagged behind other concerns. e. Most research efforts have focused on the development of medical technology. Fewer resources have been committed to the preservation and enhancement of health and well-being. f. Medical specialists, using the latest technologies, are held in higher esteem and earn higher incomes than do general practitioners. g. The desirability of healthcare delivery institutions, such as hospitals, is often evaluated based on their acquisition of advanced technology. h. Whereas biomedicine has taken central stage in the biomedical model, mental health diagnosis and treatment have been relegated to a lesser status. i. The biomedical model has neglected the social and spiritual elements of health. 2. The United States has been a champion of capitalism. Due to the public’s strong belief in capitalism, health care has largely been viewed as an economic good (or service), not as a public resource. 3. A culture of capitalism promotes entrepreneurial spirit and selfdetermination. Hence, individual capabilities to obtain health services have largely determined the production and consumption of health care (i.e., which services will be produced, where and in which quantities, and who will have access to those services). Some key implications are as follows: a. Because medical professionals focus on clinical interventions, they do not provide adequate emphasis on the holistic aspects of health and use of alternative therapies. b. Healthcare professionals have been trained to focus on physical symptoms rather than on the underlying causes of disease. c. Integrating diagnosis and treatment with disease prevention has lagged behind other concerns. d. Most research efforts have focused on the development of medical technology. Fewer resources have been committed to the preservation and enhancement of health and well-being. e. Medical specialists, using the latest technologies, are held in

higher esteem and earn higher incomes than do general practitioners. f. The desirability of healthcare delivery institutions, such as hospitals, is often evaluated based on their acquisition of advanced technology. g. Whereas biomedicine has taken central stage in the biomedical model, mental health diagnosis and treatment have been relegated to a lesser status. h. The biomedical model has neglected the social and spiritual elements of health. 4. The United States has been a champion of capitalism. Due to the public’s strong belief in capitalism, health care has largely been viewed as an economic good (or service), not as a public resource. 5. A culture of capitalism promotes entrepreneurial spirit and selfdetermination. Hence, individual capabilities to obtain health services have largely determined the production and consumption of health care (i.e., which services will be produced, where and in which quantities, and who will have access to those services). Some key implications are as follows: a. Upper-tier access to healthcare services is available mainly through private health insurance. Those with public insurance fall in a second tier. The uninsured make up a third tier. b. A clear distinction exists between the types of services for poor and affluent communities and between the types of services available in rural and inner-city locations. c. The culture of individualism emphasizes individual health rather than population health. Consequently, medical practice has been directed at keeping the individual healthy rather than the entire community. d. A concern for the most underprivileged classes in society—the poor, elderly, disabled, and children—led to the creation of the public programs Medicaid, Medicare, and the Children’s Health Insurance Program (CHIP). 6. U.S. healthcare delivery is guided by principles of free enterprise and a general distrust of big government. Hence, healthcare delivery is largely in private hands, and a separation exists

between public health functions and the private practice of medicine.

Equitable Distribution of Health Care Scarcity of economic resources is a central economic concept. From this perspective, health care can be viewed as an economic good. Two fundamental questions arise with regard to how scarce healthcare resources ought to be used: How much health care should be produced? How should health care be distributed? The first question concerns the appropriate combination of health services that should be produced in relation to all other goods and services in the overall economy. If more health care is produced, a society may concomitantly devote fewer resources to producing some other goods, such as food, clothing, and transportation. The second question affects individuals at a more personal level—namely, it deals with who can receive which type of medical service and how access to services will be restricted. The production, distribution, and subsequent consumption of health care must be perceived as equitable by a society. No society has found a perfectly equitable method to distribute limited economic resources. In fact, any method of resource distribution inevitably leaves some inequalities in its wake. Therefore, societies try to allocate resources according to some guiding principles that are deemed acceptable by the particular society. Such principles are ingrained in a society’s value and belief system. It is recognized, for example, that not everyone can receive everything medical science has to offer. A just and fair allocation of health care poses conceptual and practical difficulties. Hence, a theory of justice is necessary to resolve the problem of healthcare allocation (Jonsen, 1986). Even though various ethical principles can be used to guide decisions pertaining to just and fair allocation of health care in individual circumstances, the concern about providing equitable access to health services on a population level is addressed by two contrasting theories referred to as market justice and social justice.

Market Justice The principle of market justice leaves the fair distribution of health care up to the market forces in a free economy. Medical care and its benefits are distributed based on people’s willingness and ability to pay (Santerre and Neun, 2010). In other words, people are entitled to purchase a share of the available goods and services that they value; they purchase these valued goods and services by means of wealth acquired through their own efforts. This is how most goods and services are distributed in a free market. The free market implies that giving people something they have not earned would be morally and economically wrong. In Chapter 7, “An Overview of U.S. Healthcare Delivery,” we discussed several characteristics that describe a free market. Free market characteristics are a precondition to the distribution of healthcare services according to market justice principles. As previously mentioned, health care in the United States is not delivered in a free market; it is delivered in a quasi-market. Hence, market justice principles are only partially applicable to the U.S. healthcare delivery system. Distribution of health care according to market justice is based on the following key assumptions: Health care is like any other economic good or service, the distribution and consumption of which are determined by the free market forces of supply and demand. Individuals are responsible for their own achievements. With the rewards of their achievements, people are free to obtain various economic goods and services, including health care. When individuals pursue their own best interests, the interests of society as a whole are best served (Ferguson and Maurice, 1970). People make rational choices in their decisions to purchase healthcare products and services. Grossman (1972) proposed that health is also an investment commodity—in other words, people consider the purchase of health services an investment. For example, the investment has a monetary payoff when it reduces the number of sick days, making extra time available for productive activities, such as earning a living. Alternatively, it can have a utility payoff—a payoff in terms of satisfaction—when it makes life more enjoyable and fulfilling. People, in consultation with their physicians, know what is best for

them. This assumption implies that people place a certain degree of trust in their physicians and that the physician–patient relationship is ongoing. The marketplace works best with minimum interference from the government. In other words, the market, rather than the government, can allocate healthcare resources in the most efficient and equitable manner. Under market justice, the production of health care is determined by how much consumers are willing and able to purchase health care at the prevailing market prices. Thus, prices and ability to pay ration the quantity and type of healthcare services that people consume. The uninsured and individuals who lack sufficient income to pay for private healthcare services face barriers to obtaining health care. Such limitations to obtaining health care are referred to as demand-side rationing, or “rationing by ability to pay” (Feldstein, 1994). To some extent, the uninsured may be able to overcome some barriers through charitable services. The key characteristics of the market justice system and their implications are summarized in TABLE 23-5. Market justice emphasizes individual—rather than collective—responsibility for health. It proposes private—rather than government—solutions to social problems of health. TABLE 23-5 Comparison of Market Justice and Social Justice Market Justice

Social Justice

Characteristics ■ Views health care as an economic good

■ Views health care as a social resource

■ Assumes free-market conditions for health services delivery

■ Requires active government involvement in health services delivery

■ Assumes that markets are more efficient in allocating health resources equitably

■ Assumes that the government is more efficient in allocating health resources equitably

■ Production and distribution of health care

■ Medical resource allocation determined

determined by market-based demand

by central planning

■ Medical care distribution based on people’s ability to pay

■ Ability to pay is inconsequential for receiving medical care

■ Access to medical care viewed as an economic reward of personal effort and achievement

■ Equal access to medical services viewed as a basic right

Implications ■ Individual responsibility for health

■ Collective responsibility for health

■ Benefits based on individual purchasing power

■ Everyone is entitled to a basic package of benefits

■ Limited obligation to the collective good

■ Strong obligation to the collective good

■ Emphasis on individual well-being

■ Community well-being supersedes that of the individual

■ Private solutions to social problems

■ Public solutions to social problems

■ Rationing based on ability to pay

■ Planned rationing of health care

Description Description

Social Justice The idea of social justice is at odds with the principles of capitalism and market justice. The term social justice was invented in the 19th century by the critics of capitalism to describe the “good society” (Kristol, 1978). According to the principle of social justice the equitable distribution of health care is a societal responsibility, which is best achieved by letting the government take over the production and distribution of health care. Social justice regards health care as a social good rather than as an economic good that should be collectively financed and available to all citizens regardless of the individual recipient’s ability to pay. The main characteristics and implications of social justice are summarized in Table 23-5. Canadians and Europeans long ago reached a broad consensus that

health care is a social good (Reinhardt, 1994). Public health also has a social justice orientation (Turnock, 1997). Under the social justice system, inability to obtain medical services because of a lack of financial resources is considered inequitable. Accordingly, a just distribution of health care must be based on need, not simply on the individual’s ability to purchase such care in the marketplace (demand). Need for health care is determined either by the patient or by a health professional. The principle of social justice is also based on certain assumptions: Health care is different from most other goods and services. Healthseeking behavior is governed primarily by need rather than by ability to pay. Responsibility for health is shared. Individuals are not held completely responsible for their condition because factors outside their control may have brought on the condition. Society is held responsible because individuals cannot control certain environmental factors, such as economic inequalities, unemployment, or unsanitary conditions. Society has an obligation to the collective good. The well-being of the community is superior to that of the individual. An unhealthy individual is a burden on society. A person carrying a deadly infection, for example, is a threat to society. Society, therefore, is obligated to cure the problem by providing health care to the individual. By doing so, the whole society will benefit. The government, not the market, can better decide through central planning how much health care to produce and how to distribute it to all citizens. Just as true market justice does not exist in health care, so true social justice also does not exist. In the real world, no society can afford to provide unlimited amounts of health care to all its citizens (Feldstein, 1994). The government may offer insurance coverage to all but must also find ways to limit the availability of certain healthcare services. For example, under the social justice principle, the government decides how technology will be dispersed and who will be allowed access to certain types of costly high-tech services, even though basic services may be available to all. The government engages in supply-side rationing, which is also referred to as planned rationing, or nonprice rationing. In social justice systems, the government uses “health planning” to limit the supply

of healthcare services, although the limited resources are often more equally dispersed throughout the country than is generally the case under a market justice system. The necessity of rationing health care explains why citizens of a country can be given universal coverage but not universal access. Even when a covered individual has a medical need, depending on the nature of health services required, he or she may have to wait until services become available.

Justice in the U.S. Health Delivery System In a quasi-perfect or imperfect market, such as the market for healthcare delivery in the United States, elements of both the market and the social justice principles exist. In some areas, the principles of market and social justice complement each other. In other areas, the two present conflicts. The two contrasting principles complement each other in the employer-based health insurance available to most middle-class working Americans (market justice) and the publicly financed Medicare, Medicaid, and CHIP coverage for certain disadvantaged groups (social justice). Insured populations access healthcare services delivered mainly by private practitioners and private institutions (market justice). Taxsupported county and city hospitals, public health clinics, and community health centers can be accessed by the uninsured in areas where such services are available (social justice). Market and social justice principles create conflicts when healthcare resources are not uniformly distributed throughout the United States and when there is a general shortage of primary care physicians. Consequently, in spite of having public insurance, many Medicaidcovered patients have difficulty obtaining timely access, particularly in rural and inner-city areas. This conflict is partly created by artificially low reimbursement from public programs; in comparison, reimbursement from private payers is more generous.

Limitations of Market Justice The principles of market justice work well for allocating economic goods when their unequal distribution does not affect the larger society. For example, based on individual success, people live in different sizes and

styles of homes, drive different types of automobiles, and spend their money on a variety of things. In other cases, the allocation of resources has wider repercussions for society. In these areas, market justice has severe limitations: Market justice principles fail to rectify critical human concerns. Pervasive social problems, such as crime, illiteracy, and homelessness, can significantly weaken the cohesion of a society. Indeed, the United States has recognized such issues and instituted programs based on the social justice principle to combat such problems. These programs have added police protection, publicly supported education, and subsidized housing for many poor and elderly populations. Health care is an important social issue because it not only affects human productivity and achievement but also provides basic human dignity. Market justice does not always protect a society. Individual health issues can have negative consequences for society because ill health is not always confined to the individual. The AIDS epidemic is an example of how a society can be put at serious risk by illness originally affecting just a few subpopulations. The initial spread of the SARS epidemic in Beijing, China, was largely due to patients with SARS symptoms being turned away by hospitals because they were not able to pay in advance for the cost of the treatment. Similar to clean air and water, health care is a social concern that, in the long run, protects against the burden of preventable disease and disability—a burden that is ultimately borne by society at large. Market justice does not work well in healthcare delivery. On the one hand, a growing national economy and prosperity in the past did not materially reduce the number of uninsured Americans. On the other hand, the number of uninsured increases during economic downturns. For example, during the 2007 to 2009 recession, 5 million Americans lost employment-based health insurance (Holahan, 2011).

Integration of Individual and Population Health It has been recognized that the typical emphasis on the treatment of acute illness in hospitals, biomedical research, and high technology has not significantly improved the population’s health. Instead, the medical model should be integrated with a disease-prevention, health-promotion, primary care–based model to produce significant gains in health. Society will always need the benefits of modern science and technology for the treatment of disease, but health promotion and primary care can prevent and delay the onset of many diseases, disability, and premature death. An integrated approach will improve the overall health of the population, enhance people’s quality of life, and conserve healthcare resources. The real challenge for the healthcare delivery system is incorporating the medical and wellness models within the holistic context of health. For instance, the Ottawa Charter for Health Promotion mentions caring, holism, and ecology as essential issues in developing strategies for health promotion (De Leeuw, 1989). “Holism” and “ecology” refer to the complex relationships that exist among (1) the individual; (2) the healthcare delivery system; and (3) the physical, social, cultural, and economic environmental factors. In addition, as noted by an increasing body of research, the spiritual dimension must be incorporated into the integrated model. Another equally important challenge for the healthcare delivery system is focusing on both individual and population health outcomes. The nature of health is complex, and the interrelationships among the physical, mental, social, and spiritual dimensions are not well understood. Translating this multidimensional framework of health into specific actions that are efficiently configured to achieve better individual and community health is one of the greatest challenges that today’s healthcare systems face. For an integrated approach to become reality, the best American ingenuity must be applied in addressing health-spending reductions and coordination of services among public health agencies, hospitals, and

other healthcare providers. Community hospitals, in particular, are increasingly held accountable for the health status of the communities in which they are located. To fulfill this mission, hospitals must first conduct a health assessment of their communities. Such assessments provide broad perspectives of the local population’s health and point to specific needs that healthcare providers can address. These assessments can help pinpoint interventions that should be given priority to improve the population’s health status or address critical issues pertaining to certain subgroups within the population.

Healthy People Initiatives Since 1980, the United States has undertaken 10-year plans outlining certain key national health objectives to be accomplished during each of the 10-year periods. The objectives are developed by a consortium of national and state organizations under the leadership of the U.S. Surgeon General. The first of these programs, with objectives for 1990, provided national goals for reducing premature deaths among all age groups and for reducing the average number of days of illness among persons older than age 65. A final review of this program concluded that positive changes in premature deaths had been achieved for all age categories except adolescents but that illness among the elderly had not been reduced. However, the review set the stage to develop and modify the goals and objectives for the subsequent 10-year program (Chrvala and Bulger, 1999). Healthy People 2000: National Health Promotion and Disease Prevention Objectives identified three main goals to be reached by the year 2000: (1) increase the span of healthy life for Americans; (2) reduce health disparities and wasteful care; and (3) promote individual responsibility and accountability for one’s health as well as improved access to basic services. In a broad sense, these services include medical care, preventive services, health promotion, and social policy to improve education, lifestyle, employment, and housing (FIGURE 23-4). According to the final review, the major accomplishments of Healthy People 2000 included surpassing the targets for reducing deaths from coronary heart disease and cancer; meeting the targets for mammography exams, violent deaths, tobacco-related deaths, and

incidence rates of AIDS and syphilis; nearly meeting the targets for infant mortality and number of children with elevated levels of lead in their blood; and making some progress toward reducing health disparities among special populations.

FIGURE 23-4 Integrated model for holistic health.

Description The Ottawa Charter has proposed achieving health objectives through social public policy and community action. An integrated approach also necessitates creation of a new model for training healthcare professionals that forms partnerships with the community (Henry, 1993). The following paragraphs describe examples of community partnerships reflected in community health assessments and Healthy People initiatives. Community health assessment is a method used to conduct broad assessments of populations at a local or state level. To integrate individual and community health, the assessment is best conducted through collaboration with community members and local authorities (USDHHS, 1992). Healthy People 2010: Healthy People in Healthy Communities continued the earlier tradition as an instrument to improve the health of the American people in the first decade of the 21st century. It focused on two broad goals: (1) to increase quality and years of healthy life and (2) to eliminate health disparities. It went a step beyond the previous initiatives by emphasizing the role of community partners (businesses, local governments, and civic, professional, and religious organizations) as effective agents for improving health in their local communities (USDHHS, 1998). The final report revealed that 23% of the targets were met or exceeded and that the nation had made progress toward 48% of the targets. Specifically, life expectancy at birth, expected years in good or better health, and expected years free of activity limitations all improved, although expected years free of selected chronic diseases decreased. Although many of the targets have been met or are in progress, the goal of reducing health disparities has not been achieved. Health disparities identified in approximately 80% of the objectives have not changed, and they even increased in another 13% of the objectives (NCHS, 2012a). Hence, challenges remain in the reduction of chronic conditions and health disparities among population groups.

Healthy People 2020 Launched in 2010, Healthy People 2020 (USDHHS, 2010b) has a fivefold

mission: (1) identify nationwide health improvement priorities; (2) increase public awareness and understanding of the determinants of health, disease, and disability and the opportunities for progress; (3) provide measurable objectives and goals that can be used at the national, state, and local levels; (4) engage multiple sectors to take actions that are driven by the best available evidence and knowledge; and (5) identify critical research and data collection needs. This initiative also has four overarching goals: Attain high-quality and longer lives free of preventable disease, disability, injury, and premature death. Achieve health equity, eliminate disparities, and improve the health of all groups. Create social and physical environments that promote good health for all. Promote quality of life, healthy development, and healthy behaviors across all life stages. These overarching goals are in line with the tradition of earlier Healthy People initiatives but place particular emphasis on the determinants of health. FIGURE 23-5 illustrates the action model to achieve the Healthy People 2020 overarching goals. This model illustrates that interventions (i.e., policies, programs, information) influence the determinants of health at four levels and lead to improvements in outcomes: (1) individual; (2) social, family, and community; (3) living and working conditions; and (4) broad social, economic, cultural, health, and environmental conditions. Results are to be demonstrated through assessment, monitoring, and evaluation, and the dissemination of findings will provide feedback for future interventions.

FIGURE 23-5 Action model to achieve the U.S. Healthy People 2020 overarching goals. Courtesy of Department of Health and Human Services (DHHS). 2008. The Secretary’s Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2020. 2008. Phase I report: Recommendations for the framework and format of Healthy People 2020. Section IV. Advisory Committee findings and recommendations. Available at: http://www.healthypeople.gov/2010/hp2020/advisory/phasei/sec4.htm. Accessed April 2017.

Description Healthy People 2020 differs from previous Healthy People initiatives in that it includes multiple new topic areas to its objectives list, such as adolescent health, genomics, global health, health communication and health information technology, and social determinants of health. Healthy People 2020 has 42 topic areas, with 13 new areas (TABLE 23-6). TABLE 23-6 Healthy People 2020 Topic Areas 1. Access to health services 2. Adolescent health1 3. Arthritis, osteoporosis, and chronic back conditions 4. Blood disorders and blood safety1 5. Cancer 6. Chronic kidney disease 7. Dementias, including Alzheimer’s

22. 23. 24. 25.

HIV Immunization and infectious diseases Injury and violence prevention Lesbian, gay, bisexual, and transgender health1 26. Maternal, infant, and child health 27. Medical product safety 28. Mental health and mental disorders

8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21.

disease1 Diabetes Disability and health Early and middle childhood1 Educational and community-based programs Environmental health Family planning Food safety Genomics1 Global health1 Health communication and health information technology Healthcare-associated infections1 Health-related quality of life and wellbeing1 Hearing and other sensory or communication disorders Heart disease and stroke

29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42.

Nutrition and weight status Occupational safety and health Older adults1 Oral health Physical activity Preparedness1 Public health infrastructure Respiratory diseases Sexually transmitted diseases Sleep health1 Social determinants of health1 Substance abuse Tobacco use Vision

1 New topic area.

Description

Measurement of Healthy People 2020 Healthy People 2020 establishes four foundational health measures to monitor progress toward achieving its goals. The foundational health measures include general health status, health-related quality of life and well-being, determinants of health, and disparities. Measures of general health status include life expectancy, healthy life expectancy, years of potential life lost, physically and mentally unhealthy days, self-assessed health status, limitations of activity, and chronic disease prevalence. Measures of health-related quality of life and well-being include physical, mental, and social health-related quality of life, well-being/satisfaction, and participation in common activities. Healthy People 2020 discusses social determinants of health as a range of personal, social, economic, and environmental factors that influence health status. Determinants of health include such things as biology, genetics, individual behavior, access to health services, and the environment in which people are born,

live, learn, play, work, and age. Measures of disparities and inequity include differences in health status based on race/ethnicity, gender, physical and mental ability, and geography (USDHHS, 2019a). Global health is also an important topic area in Healthy People 2020. The measurement of global health focuses on two aspects: (1) measuring the reduction of global diseases in the United States, including malaria and tuberculosis (TB); and (2) measuring global capacity in support of the International Health Regulations to detect and contain emerging health threats (USDHHS, 2019b). The indicators include the number of global disease detection (GDD) regional centers worldwide, the number of public health professionals trained by GDD programs worldwide, and the number of diagnostic tests established or improved by GDD programs (USDHHS, 2019b).

Achievement of Healthy People 2020 Ongoing review has focused on how well the healthcare system is working toward achieving its delineated goals (HealthyPeople.gov, 2014). The findings of these ongoing studies are compared to the baseline data from the beginning of the 10-year period to determine whether adequate progress has occurred. In total, Healthy People 2020 contains 42 topic areas with more than 1,200 objectives. A subset of 26 of the objectives, known as the leading health indicators (LHI), is used to track the progress of the initiative and to communicate high-priority health issues. Of the 26 LHIs, 4 indicators have met or exceeded their Healthy People 2020 targets, 10 show improvement, 8 show little or undetectable change, and 3 are getting worse. One indicator has only baseline data available. To date, indicators for access to health services show little change in this area. Although the proportion of people with medical insurance increased under the ACA, the target of 100% has not been reached. Similarly, access to a usual-care provider has increased but has not met Healthy People 2020’s target. Many of the LHIs for clinical preventive services show improvement. The percentage of adults receiving colorectal cancer screenings, adults with hypertension whose blood pressure is controlled, and children receiving recommended vaccines have all increased significantly, moving

toward the Healthy People 2020 target (Egan et al., 2014). In contrast, the rate of adults with diabetes who also have poor glycemic control has not shown any significant improvement. Some environmental quality indicators have not only met their Healthy People 2020 goals but also exceeded them. The Air Quality Index, which assesses changes in air quality by number and severity of unhealthy days, met its goal. Likewise, the goal for reducing the percentage of children exposed to secondhand smoke has been achieved. So far, the LHIs for injury and violence show positive progress. Injury deaths have decreased by 43% and the homicide rate has declined by 13%, both of which meet the Healthy People 2020 targets. Maternal and child health LHIs are significantly improving, with infant deaths and total preterm live births almost achieving their Healthy People 2020 targets. Conversely, the LHIs for mental health appear to be significantly worse than those measures at baseline. The suicide rate has increased by 7%, and the percentage of adolescents with major depressive episodes has increased by almost 10%. The LHIs for nutrition, physical activity, and obesity mostly show little or no detectable change. Rates of obesity among adults, children, and adolescents have all increased between 4% and 5%, although these changes are not statistically significant. Intake of vegetables remains stagnant. In a promising development, the percentage of adults meeting the federal physical activity guidelines has increased by 13%, exceeding the Healthy People 2020 target. In the area of oral health, the LHI is moving away from the target, showing a 6% decrease in the percentage of children, adolescents, and adults who had a dental visit in the past year. In contrast, the LHIs for reproductive and sexual health and social determinants show some progress toward the Healthy People 2020 goals. Substance abuse indicators are mixed. Although the number of adolescents using alcohol or illicit drugs has decreased, the prevalence of binge drinking among adults shows no change. The prevalence of adolescent cigarette smoking has slightly decreased, with the overall cigarette smoking rate showing an even larger decrease of approximately 12%.

Summary The delivery of health care is primarily driven by the medical model, which emphasizes illness rather than wellness. Holistic concepts of health, along with the integration of medical care with preventive and health promotional efforts, need to be adopted to significantly improve the health of Americans. Such an approach would require individuals to take responsibility for their own health-oriented behaviors as well as the establishment of community partnerships to improve both personal and community health. Understanding the determinants of health, providing health education, utilizing community health assessment, and promoting national initiatives, such as Healthy People, are essential to accomplish these goals. Healthy People 2020, launched in 2010, continues its goals of improving health and eliminating health disparities in the United States. Public health has drawn increased attention in recent times because of the growing recognition of its role in health protection, environmental health, and preparedness for natural disasters and bioterrorism. Moreover, public health has now become global in its scope. Programs to address the various facets of health and its determinants, and ongoing initiatives in the areas of prevention, health promotion, health protection, and equality, are complex undertakings and require substantial financial resources. Objective measures play a critical role both in evaluating the success of various programs and in directing future planning activities. The broad concern of achieving equitable access to health services can be addressed by considering the contrasting theories of market justice and social justice. Countries offering universal coverage have adopted the principles of social justice, under which the government finances healthcare services and decides on the distribution of those services. However, because no country can afford to provide unlimited amounts of health care to all citizens, supply-side rationing becomes inevitable in such a system. Many of the characteristics of the U.S. healthcare system trace back to the beliefs and values underlying the American culture. Under market justice, not all citizens have health insurance coverage, a phenomenon called demand-side rationing.

Discussion Questions 1. How can the advanced practice nurse use the health risk appraisal in health promotion and disease prevention in your practice? 2. Discuss the definitions of health, health promotion, and disease prevention presented in this chapter in terms of their implications for your practice. 3. Since the tragic events of 9/11, which “preparedness”-related measures have been taken in your practice setting to cope with potential natural and human-made disasters? Assess their effectiveness. 4. The Blum model points to four key determinants of health. Discuss their implications for your practice. 5. Discuss the main cultural beliefs and values in American society that have influenced you, your practice, and your organization. 6. Discuss how the concepts of market justice and social justice are evident in your practice. In what way do the two principles complement each other, and in what way are they in conflict? 7. Give examples of how health care is rationed in the market justice and social justice systems. 8. How can the objectives set forth in Healthy People guide your practice changes?

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CHAPTER 24 Cultural Sensitivity and Global Health Michelle A. Cole and Christina B. Gunther

CHAPTER OBJECTIVES 1. 2. 3. 4.

Provide working definitions for cultural competence, cultural sensitivity, and diversity. Recognize that diversity is a global phenomenon. Explore theoretical models of cultural competence and its application to patient care. Utilize cultural competence tools to reflect on your own mores related to caring for diverse populations.

Introduction One of the most noted fundamental teachings in many of the world’s religions is commonly referred to as the Golden Rule. The Golden Rule, “Do unto others as you would have them do unto you,” is likely the most familiar moral value in Western culture (Stanglin, 2005). The rule has a strong connection to many religions, including Christianity, Buddhism, Judaism, and Islam. Despite the origin, the tenet of the Golden Rule guides us to treat others as we would like to be treated. Its foundation is the reciprocity of kindness and human giving. The Golden Rule must be used with caution; our best intentions to treat others with compassion, respect, and care while following the fundamental underpinnings of the Golden Rule may have unintended outcomes (Corazzini et al., 2006). The general principles that often drive the day-to-day decisions and actions of nurse practitioners (NPs) need reconsideration for the diverse and unique populations in their care. There is an assumption that people who resemble us or who speak our language are the same and should be treated as we would like to be treated. As the providers of direct care to individuals and populations, NPs must consider how those they provide care for want to be treated. This consideration differs from the Golden Rule, in which we treat others in a manner that is acceptable to our standards and beliefs without consideration of the individual’s preferences. Stepping away from viewing circumstances from our own perspective to the patient’s perspective is a critical step in the care of others in a diverse world. Putting aside an imperialistic attitude of thinking one knows what is best for others, and taking the time to know what is significant to individuals and communities, is an important step in developing a successful patient–NP relationship (Ott & Olson, 2011). As the United States is becoming more diverse, healthcare providers are caring for individuals and groups who have varied perspectives; many are distinct from the mainstream healthcare system. Many healthcare providers, including NPs, do not identify themselves with any one particular culture; however, they often do view their patients and families as having cultural traits (Matteliano & Street, 2012). The notion

that our own cultural and societal norms can be applied to the general population can create obstacles and barriers in caring for patients. These beliefs are a result of personal, professional, and educational socialization. Ethnocentrism impedes the delivery of culturally competent nursing care (Dayer-Berenson, 2014). Not understanding others, or having limited information about another group, can lead primary care providers to make false assumptions that could potentially be harmful, hurtful, and destructive. Believing that the culture one is most familiar with is the cultural standard does not afford providers the opportunity to comprehend and appreciate the needs of others. Critical to understanding the perspective of others is the willingness of NPs to acknowledge their own beliefs and to recognize that other individuals’ values are cogent despite being different from their own (DayerBerenson, 2014). Considering the viewpoint of others is the first step to comprehending the ideals from the eyes of others and the avoidance of unfounded assumptions and biases.

Global Diversity The world is becoming increasingly more diverse. Globalization brings diversity and affects societies as cultures, values, and traditions transcend into new territory. The U.S. population is becoming increasingly more ethnically and socioculturally varied. In the United States between 2000 and 2010, a large increase in the Hispanic population accounted for more than half the growth in the total U.S. population while growth of the Asian population grew more rapidly than any other main race group (U.S. Census Bureau, 2011). These data highlight the changes in population and increasing diversity of the United States. Considering the United States as a melting pot, or the blending together of various cultures to form one, is not considering the unique qualities of the various cultures of the population. Instead, looking at U.S. society as a tossed salad, where the diversity of the culture is valued for what it contributes to the whole, embraces a more culturally aware viewpoint. As advanced practice nurses, NPs are challenged to respond to this tossed salad culture by providing care for the health and wellness needs of the population. In 2009, a study commissioned by the Joint Center for Political and Economic Studies indicated the estimated combined cost of health disparities and subsequent deaths due to inadequate and/or inequitable care at $1.24 trillion (LaVeist, Gaskin, & Richard, 2009). Clearly, this is unacceptable, and healthcare providers and organizations need to work on reducing health disparities. Leininger’s theory on diversity and universality implies that for a caregiver’s work to be meaningful and relevant, transcultural knowledge and competencies are imperative to guiding decisions and actions for effective and successful outcomes (Tomey & Alligood, 2002). Leininger’s theory is suitable for application to the care of diverse populations. Her theory states that the provision of care needs to be harmonious with an individual’s or group’s cultural beliefs, practices, and ideals (Sitzman & Eichelberger, 2004). With the impact of globalization, primary care providers must possess sensitivity, compassion, and competence to care for individuals and communities from diverse cultural backgrounds. To effect positive health promotion activities and influence positive

healthcare outcomes of individuals and communities, healthcare providers must understand and appreciate the importance of culturally competent care (Sitzman & Eichelberger, 2004). NPs are charged with integrating cultural care into practice through a comprehensive clinical approach, role modeling, policy development, performance, evaluation, and use of the advanced nursing process (McFarland & Eipperle, 2008). The advanced practice NP has an obligation to develop the skills necessary to be a culturally competent practitioner.

Cultural Competency and Clinical Education Cultural competency is an essential component to be infused into professional practice. Professional nursing organizations recognize the need for nurses, at all levels, to respond to the diversity in the population. The American Association of Colleges of Nursing (AACN, 2008), in the Essentials of Baccalaureate Education for Professional Nursing Practice, states, “The professional nurse practices in a multicultural environment and must possess the skills to provide culturally appropriate care” (p. 6). The Essentials of Master’s Education of Advanced Practice Nurses includes cultural competence as an essential component of the advanced practice nurse’s educational preparedness (AACN, 2011). Cultural sensitivity and awareness are concepts guiding the practice of the doctorate of nursing practice prepared nurse (AACN, 2006). Cultural competency is an essential component of the educational preparedness of nurses; and the inclusion of cultural sensitivity and awareness into the curriculum will promote cultural competency within the profession of nursing. Medical and nursing academics are infusing cultural competence preparation into their educational curricula. Over 90% of medical schools’ curricula in the United States include cultural competence training (Boutin-Foster, Foster, & Konopasek, 2008). The AACN essentials outline the required curriculum requirements and student learning outcomes, which include cultural competency. Nursing and medical faculty are charged to develop teaching strategies to achieve the set standards over the curriculum, recognizing that cultural competence is a developmental process. In an effort to design the graduate nursing curriculum to meet these expectations, faculty have collaborated with community leaders to develop recommendations for the development of competencies for graduate nursing curricula (Axtell, Avery, & Westra, 2010). Five student themes emerged: (1) self-awareness, (2) basic knowledge of culture and identity, (3) attitudes that promote intercultural communication, (4) crosscultural clinical skills, and (5) advocacy skills. The inclusion of the

community to assist in the development of the graduate nurse was viewed as a positive strategy in the development and projected outcomes of the identified objectives (Axtell et al., 2010). Caring for individuals necessitates understanding the influence of culture on their healthcare situation. Approach the individual without preconceived assumptions to avoid treating persons with common backgrounds the same. Each individual should have input into their healthcare choices, incorporating their cultural preferences. Assume every encounter is a cross-cultural encounter. This refers to the fact that even when a care provider and care recipient may appear to have a common background, they most likely do not view health care situations in the same way, so it is important to ask questions, discuss relevant issues, and avoid making assumptions in all clinical encounters. Axtell, S., Avery, M., & Westra, B., Journal of Transcultural Nursing 21(2), p. 187, copyright © 2010 by SAGE Publications. Reprinted by permission of SAGE Publications. Permission conveyed through Copyright Clearance Center, Inc. The NP must be aware of the secondary elements of diversity in these situations that are not typically considered to be a cultural encounter. Loden and Rosener (1991) first developed the dimensions of diversity model to incorporate such elements of diversity as religion, sexual orientation, education, gender, age, and socioeconomic class, among others. Asking questions that incorporate the broader elements of diversity will make the patient encounter and healthcare outcomes more successful.

Cultural Awareness We don’t see the world the way it is. We see the world the way we are. —Anais Nin

Cultural awareness is being knowledgeable about one’s own thoughts, feelings, and sensations as well as the ability to reflect on how these can affect one’s interactions with others (Giger et al., 2007). One’s perceptions of “what is” are connected to our interpretation of the world, our experiences, values, and beliefs. To deliver care that is culturally sensitive, the NP needs to have an appreciation of the culturally relevant facts about a client and the provision of care. Giger and Davidhizar’s transcultural assessment model includes six cultural phenomena that influence healthcare delivery (Giger, 2017).

Communication Language or communication patterns are a significant part of how information is transferred in the healthcare setting. Communication, however, extends beyond linguistics and includes the process of communication. “Nurses need to have not only a working knowledge of communication with clients of the same culture, but also a thorough awareness of racial, cultural, and social factors that may affect communication with persons from other cultures” (Giger, 2017, p. 20).

Space Personal space is the area that surrounds an individual and his or her level of comfort, which may vary from one individual to another. Space should consider sensory aspects, including olfactory, sensory, auditory, and visual, all of which can have cultural implications. After discussing the pathology report, the NP reached out and embraced the young female patient. The NP, feeling her embrace was not welcomed, later reflected on the gesture. The gesture, intended to be a measure of comfort, was not positively received by the client. The

client, from a culture where touch is limited, felt that the NP was intrusive, especially when distressing news was recently discussed.

Social Organization Social organizations are structured groups that have a pattern of behaviors and set norms, beliefs, and values that influence the persons within the group. Examples include family, religious groups, communities, and organizations. Race and ethnicity may also be considered a social organization.

Time The concept of time can have different implications based on a person’s cultural view. Culture can affect one’s relationship to time—past, future, or present orientation. Future orientation considers the future in presentday terms; past orientation has a connection to the past. New changes are based on what was considered in the past. Present orientation is focused on the current time. Understanding a client’s orientation to time can be helpful in determining possible reasons for motivation, compliance, and participation. The toddler came into the office with several layers of clothing. The day was warm and comfortable. The mother stated, “My baby has a cold.” Believing that the source of the cold was from the cool evening air that the infant was exposed to was a literal belief that the mother held from her past; the “chill was caught.”

Environmental Control The relationship between a person, the environment, and health and wellness determines the person’s environmental control. Considerations of environmental control include the locus of control. The client verbalized that the illness was in God’s hands and they did not have any control. Alternative therapies are more frequently considered in Western medicine. In 2007, approximately 38% of adults and approximately 12% of children were using some form of complementary and alternative medicine (CAM) (Barnes, Bloom, & Nahin, 2008). The scent of lavender was present in the hospital room. The patient

applied the essential oil to her temples to relieve the tension headache she was experiencing.

Biological Variations Biological variations exist among different racial groups and should be considered when caring for individuals and groups. A person’s shape, size, and skin color are variable and have genetic and ethnic connections. Genetics (the study of heredity) and genomics (the study of genes and their functions) are part of the NP’s practice. Some genetic conditions are more likely to occur in a particular group; however, one cannot assume that a biological variation exists based on an individual’s culture or ethnicity. For example, in the United States, sickle cell anemia is most prevalent in the African American population. A young African American mother brought her toddler in for a physical exam. She reported her daughter was pale, and she expressed concern that her daughter might have sickle cell disease, like her brother. She was told as a young child that their family had “bad cells,” and the idea of her daughter having the disease was frightening. Upon further examination of the child, it was determined that she had iron deficiency anemia, a condition common in toddlers who consume excessive amounts of cow’s milk, and not sickle cell disease caused by a genetic mutation.

Hofstede’s Cultural Dimensions Theory Geert Hofstede developed a framework for cross-cultural communication that describes the effects of a society’s culture on the values of its members. Understanding the culture’s values can provide a clearer understanding of how to relate to the culture. Although Hofstede’s work focused on the influence of culture on the values in the workplace, the information obtained can be applied to other settings. Applying Hofstede’s model on national culture to the healthcare industry equips the provider with insight into culture and fosters opportunities to recognize the uniqueness of another culture through a comparison perspective. (Hofstede’s model on national culture can be found at https://geerthofstede.com/culture-geert-hofstede-gert-jan-hofstede/6d-

model-of-national-culture.)

Cultural Humility Culture has many different components that shape who we are and how we interact with the world. It is dynamic and multifaceted. Each of us has our own personal culture evolving from not only our own ethnic background but also our gender, age, socioeconomic status, life experiences, and so on (California Health Advocates, 2007; Office of Minority Health [OMH], 2011b; Tervalon & Murray-Garcia, 1998). Reading and learning about other cultures is a worthwhile endeavor; however, it is unlikely that one can become competent in every culture. Being aware of this limitation, the concept of “cultural humility” is perhaps a better term to assist the NP in improving meaningful relationships with patients, coworkers, and others. In the Handbook of Humility: Theory, Research, and Applications (2017), Mosher, Hook, Farrell, Watkins, and Davis describe cultural humility as placing a priority on “developing mutual respect and partnership with others” (p. 91). This requires self-awareness and reflection as a lifelong process to develop a respectful relationship with patients. It also requires the provider to be flexible and humble in order to be open to the cultural dimensions of each patient encounter. Values associated with cultural humility include openness, appreciation, and acceptance, in addition to flexibility (Luluquisen, Schaff, & Galvez, n.d.). Further, it is important for the NP to focus on both interpersonal and intrapersonal components of cultural humility—realizing one’s own limitations in understanding cultural backgrounds and being open to the “other” (Mosher et al., 2017). One needs to be acutely aware of the potential power imbalances that can occur in the healthcare expert– patient interaction. By continually working to be open, flexible, appreciative, and accepting of their patients, in addition to striving to avoid any imbalance of power, NPs can create meaningful partnerships with patients and communities to develop treatment plans as well as individual and community goals to improve health. Practicing lifelong selfawareness and reflection will assist the NP to be a culturally sensitive healthcare provider. In an effort to educate healthcare providers (NPs, physicians, and

physician assistants [PAs]) about delivering culturally sensitive care, A Physician’s Guide to Culturally Competent Care was developed by the U.S. Department of Health and Human Services, Office of Minority Health (OMH, n.d.-b). It contains nine Cultural Competency Curriculum Modules (CCCMs), including Standards for Culturally and Linguistically Appropriate Services in Health Care (CLAS standards), which are available for free at https://cccm.thinkculturalhealth.hhs.gov. CME credits can be earned. The objectives for this educational program are for NPs, PAs, and physicians to: Define issues related to cultural competency in medical practice. Identify strategies to promote self-awareness about attitudes, beliefs, biases, and behaviors that may influence clinical care. Devise strategies to enhance skills toward the provision of care in a culturally competent clinical practice. Demonstrate the advantages of the adoption of the CLAS standards in clinical practice. In many of the modules are patient cases and scenarios that require the healthcare provider to reflect upon what is being presented by the case as well as how the reader feels about the situation. The fictional practice setting includes a profile of the community and the patients who are seen at the setting. The vast majority of the populations are white, nonHispanic, who have at least a high school education; however, there are many migrant farmworkers who use the practice as well as Native Americans. The providers and support staff come from a variety of ethnic backgrounds and take different approaches to their practice. The practice setting is in need of much improvement to work more efficiently and to provide culturally competent care to their patients. Through the learning modules, the healthcare provider is encouraged to consider what the patient’s perspective is and to be more sensitive to one’s own attitudes, including biases and the behaviors they may have displayed that affect patient care. BOX 24-1 represents eight essential elements to consider in developing a culturally competent healthcare provider.

BOX 24-1 Eight Elements of Cultural Competence for Primary

Healthcare Providers 1. Examine your values, behaviors, beliefs, and assumptions. 2. Recognize racism and the institutions or behaviors that breed racism. 3. Engage in activities that help you to reframe your thinking, allowing you to hear and understand other worldviews and perspectives. 4. Familiarize yourself with core cultural elements of the communities you serve. 5. Engage clients and patients to share how their reality is similar to, or different from, what you have learned about their core cultural elements. 6. Learn, and engage your clients to share, how they define, name, and understand disease and treatment. 7. Develop a relationship of trust with clients and coworkers by interacting with openness, understanding, and a willingness to hear different perceptions. 8. Create a welcoming environment that reflects the diverse communities you serve. Reproduced from Nova Scotia Department of Health. (2005). A cultural competence guide for primary health care professionals in Nova Scotia. Halifax, Nova Scotia: Author.

Cultural Competence and the Clinician Nurse practitioners are poised to lead initiatives to implement the strategies to meet the challenge of fulfilling national standards of cultural competence in health care. Because there are hundreds of ethnic groups in our society with diverse needs, there is no one specific intervention for each health issue. To improve the health and well-being of individuals and communities, there are some general principles that can be practiced when delivering care to clients with a different culture than our own (Bomar, 2004). Reflecting on one’s own culture, seeking knowledge about local cultures, understanding political issues of culturally diverse groups, and using culturally sensitive and linguistically appropriate resources are among the few strategies (Bomar, 2004). Schools of nursing and organizations recognize the need to promote cultural awareness and sensitivity and provide opportunities for enhancing the practice of nursing (AACN, 2009). The American Association of Colleges of Nursing (2009) calls for the need for cultural competence education in graduate nursing to address the diverse needs of patients and to minimize disparities in health. Once healthcare providers identify their own need for cultural growth, they can engage themselves in a variety of actions to increase their cultural competence on an individual level. This engagement calls for self-reflection and acknowledgement that their own beliefs, values, and attitudes may affect the care they provide to others. The NP can take a “cultural approach,” being cognizant of “cultural variations” that will be advantageous to the patient as a management plan is developed for the individual. Each encounter should be approached as unique. Clustering values, beliefs, and behaviors from a cultural group and applying them to all persons of that culture does not consider the multiple variables that may influence an individual’s cultural uniqueness. The following example demonstrates misinterpretation of communication style. Elsu, a 76-year-old Native American male, arrived to the clinic for reevaluation of hypertension. The nurse assessing the patient felt that

Elsu was “not truthful.” The nurse expressed this concern to the practitioner in charge of his care. Upon entering the room, the practitioner noticed that Elsu avoided eye contact and participated minimally in conversation. The nurse who initially encountered the patient viewed his behaviors as untrusting. Elsu, being a Native American, is quiet and reserved when meeting new people. Eye contact, for the Native American, is considered a sign of disrespect and hence is avoided. The nurse assumed that Elsu’s communication style had a different and undesirable meaning. Patterns of culturally incompetent care from providers affect patient care outcomes and may widen the healthcare disparities gap (Doorenbos, Schim, Benkert, & Borse, 2005). Health disparities are linked to social, economic, and environmental disadvantages causing a difference in one’s well-being (Office of Disease Prevention and Health Promotion, 2010). Healthy People 2020 identifies populations who experience barriers to health care at higher rates than the general population; these groups include Hispanics, African Americans, those with low levels of education, and the poor. In a position paper titled Racial and Ethnic Disparities in Health Care, the American College of Physicians (2010) discusses the disparities and poor health care that exist among racial and ethnic groups and makes several recommendations to reduce the disparities that affect health and wellness. Culturally competent care providers can influence the health of the population by reducing the barriers that negatively affect health. Cultural sensitivity and awareness are important steps to understanding the complex issue of racial and ethnic health disparities.

Culture Awareness and Cultural Sensitivity According to the American Nurses Association (ANA, 2012), diversity awareness can be defined as the acknowledgement and appreciation of the existence of differences in attitudes, beliefs, thoughts, and priorities in the health-seeking behaviors of different patient populations. Cultural awareness is having the knowledge or information about what is unique or the same among various cultures. In contrast, cultural sensitivity is the individual’s attitude about themselves or others and their desire to learn about the cultural aspects of others (Schim, Doorenbos, Benkert, & Miller,

2007). In an effort to meet the needs of communities and populations, we must be open to learning about the unique characteristics they possess. Being aware and sensitive will allow us the ability to see beyond what is the accepted norm within our society. Cultural sensitivity is when we are able to appreciate the situation from another’s perspective and value the viewpoint of others, despite it being different from our own.

What Determines Cultural Competence? Many theoretical and methodological models exist that attempt to determine cultural competence. Schim, Doorenbos, Miller, and Benkert (2003) describe a theoretical model of cultural competence with three components: the circumstance in which the clinician incorporates the cultural diversity experience, the clinician’s awareness of his or her reactions to people who are different, and examination of attitudes and cultural bias toward other sociocultural groups. Based on this description and the cultural competence model developed by Schim and Miller (as cited in Schim et al., 2003), the Cultural Competence Assessment (CCA) was developed. The CCA tool is a method of measuring cultural competence behaviors (CCB) and cultural awareness and sensitivity (CAS). In contrast, the Purnell model for cultural competence (Purnell, 2002) uses a methodological approach to determine cultural competence. The basic assumptions of the model derive from multidisciplinary theories, including organizational, administrative, communication, and family development as well as anthropology, sociology, psychology, and several others. The model has evolved to include 12 domains in a framework that assists the NP in developing cultural competence abilities. TABLES 24-1 and 24-2 feature other theoretical and methodological models. None of the models are without limitation. Constraints vary from lack of measurement of healthcare outcomes to the abstract nature, making the models difficult to put into practice. One model that lies outside of the healthcare realm describes a more concrete approach to cultural competence. TABLE 24-1 Theoretical Models of Cultural Competence

Description Description Description Reproduced from Shen, Z. (2015). Cultural competence models and cultural competence assessment instruments in nursing: A literature review. Journal of Transcultural Nursing, 26(3), 308-321. Retrieved from https://www.semanticscholar.org/paper/Cultural-competence-modelsand-cultural-competence-Shen/b5090fa857c61ed62c2eab1831c532be02f8ee8a

TABLE 24-2 Methodological Models of Cultural Competence

Description Description Reproduced from Shen, Z. (2015). Cultural competence models and cultural competence

assessment instruments in nursing: A literature review. Journal of Transcultural Nursing, 26(3), 308-321. Retrieved from https://www.semanticscholar.org/paper/Cultural-competence-modelsand-cultural-competence-Shen/b5090fa857c61ed62c2eab1831c532be02f8ee8a

International education scholar Darla Deardorff developed the pyramid model of intercultural competence (2006, 2009), which includes requisite attitudes necessary to develop cultural competence. These attitudes include respect, openness, and curiosity and discovery. Respect includes valuing other cultures and cultural diversity; openness is a measure of withholding judgment of other cultures and diversity; curiosity and discovery allow for tolerating ambiguity and uncertainty. See FIGURE 24-1.

FIGURE 24-1 Pyramid model of intercultural competence. Reproduced with permission of SAGE Publications, Inc. from Deardorff, D. (2006). Identification and assessment of intercultural competence as a student outcome of internationalization. Journal of Studies in International Education, 10(3), 241-266. Permission conveyed through Copyright Clearance Center, Inc. Retrieved from https://repository.lib.ncsu.edu/bitstream/handle/1840.16/5733/etd.pdf?sequence=1&is.

Description Measuring our cultural competency aids in our understanding and responsiveness to the components of care crucial for meeting the needs

of the diverse populations that NPs serve. Using a tool such as the CCA will enable educators, mentors, and primary care providers the opportunity to evaluate their progress or journey of cultural competency. A personal self-assessment tool for the primary healthcare provider can offer insight into the cultural competence of the care provider (BOX 242). This quantitative tool requires the clinician to reflect on various areas of the cultural provision of care. Although there are no right or wrong answers, responding that “I rarely or never do” may suggest limitations in the ability to “demonstrate beliefs, attitudes, values, and practices that promote cultural competence within healthcare delivery programs” (Nova Scotia Department of Health, 2005, p. 19).

BOX 24-2 Promoting Cultural Competence in Primary Health Care I. Physical Environment, Materials, and Resources A. I ensure the printed and posted information in my work environment reflects the diversity and literacy of individuals or families to whom I provide service. II. Communication Styles A. When interacting with individuals and families who do not have spoken English proficiency, I always keep in mind that: 1. Spoken English proficiency does not reflect literate English proficiency or language of origin proficiency or literacy. 2. Limited ability to speak the language of the dominant culture has no bearing on ability to communicate effectively in one’s mother tongue. 3. Limitations in English proficiency do not reflect mental ability. B. I use bilingual and/or bicultural staff trained in medical interpretation when required or requested. C. For individuals and families who speak languages other than English, I attempt to learn and use key words in their language so I am better able to communicate with them during assessment, treatment, or other interventions. D. I understand the cultural context for naming disease and try to be respectful of this in my interactions. (In some cultures, there is stigma associated with terminal disease, sexually transmitted disease, and/or communicable diseases. In some cultures, this stigma is avoided by naming the disease by its attributes, rather than its medical name (e.g., AIDS is sometimes named “the sleeping sickness”). E. I can provide alternatives to written communication if required or preferred. III. Social Interaction A. I understand and accept that family is defined in a variety of different ways by different cultures (e.g., extended family members, kin, godparents). B. Even though my professional or moral point of view may differ, I accept individuals and families as the ultimate decision makers for services and supports affecting their lives. C. I understand that age, sex, and life-cycle factors need to be considered in interactions with individuals and families. For instance, a high value may be placed on the decisions

of elders, the role of eldest male or female in families, or roles and expectations of children within the family. D. I accept and respect that male–female gender roles may vary among different cultures and ethnic groups (e.g., which family member makes major decisions for the family). IV. Health, Illness, and End-of-Life Issues A. I understand that the perceptions of health, wellness, and preventive health services have different meanings to different cultural or ethnic groups. B. I intervene in an appropriate manner when I observe other staff or clients within my program or agency engaging in behaviors that are not culturally competent. C. I screen resources for cultural, ethnic, or racial stereotypes and/or inclusion before sharing them with individuals and families served by my program or agency. D. I am aware of the socioeconomic and environmental risk factors that contribute to the major health problems of culturally, ethnically, and racially diverse populations served by my program or agency. E. I avail myself to professional development and training to enhance my knowledge and skills in the provision of services and supports to culturally, ethnically, racially, and linguistically diverse groups. F. I advocate for the review of my program or agency’s mission statement, goals, policies, and procedures to ensure that they incorporate principles and practices that promote cultural and linguistic competence. Reproduced from Nova Scotia Department of Health. (2005). A cultural competence guide for primary health care professionals in Nova Scotia. Halifax, Nova Scotia: Author.

Cultural Immersion Experiences Cultural competency, infused into the skill set of all NPs, is a starting point for the reduction of disparities that exist within our healthcare system. Increasing cultural competence among providers will facilitate the goal of decreasing the healthcare disparities gap (Doorenbos et al., 2005). Cultural immersion experiences have been cited as a method to increase cultural awareness and sensitivity (Green, Comer, Elliott, & Neubrander, 2011; Johns & Thompson, 2010; Jones, Ivanov, Wallace, & VonCannon, 2010; Larson, Ott, & Miles, 2010). When individuals interact with various culturally diverse groups, their own beliefs regarding a cultural group will be affected and thus prevent stereotyping (CampinhaBacote, 2003). A substantial portion of the literature on cultural immersion experiences affecting cultural awareness and sensitivity relates to students within the educational setting. Inclusion of service-learning activities that increase the cultural sensitivity and awareness of students is a means to addressing the needs of our society. Students are likely to gain global attitudes and perspectives when schools of nursing include global experiences in their curriculum (Riner, 2011). This preparation will develop a sensitivity to and appreciation of cultures in an effort to provide high-quality care across various settings. The following is a reflection of a graduate student who participated in a clinical immersion experience in Central America: One of the things that really affected me while we were in Guatemala was seeing the number of children who were unable to go to school because they had to work to help support their families. Growing up in the United States, our culture prides itself on education for all children. However, going to Guatemala and speaking with children who actually cannot go to school because they have to work really struck a chord with me. It is so easy for Americans to live in their little bubble because many have no idea what it is like to not have that option. In other words, we can complain about school because there is little risk that school won’t be there for us. We see it as our inherent “right.” Then there are

the kids in Guatemala who are longing to go to school who are denied because their family needs them to help put food on the table. Kids who are 6, 7, and 8 years old, who, in America, would be doing homework, are instead out on the street selling bracelets at 10 pm at night in order to help their families. Talk about perspective! It really helps me to appreciate all the educational opportunities I have been and still am being given. (Regina, graduate student) Cultural awareness and sensitivity improvements can be directed toward practicing providers within the healthcare setting. Communication and cultural awareness education can infuse a healthcare provider’s communication skills with empathy, a nonjudgmental approach to patients, enhanced awareness of self, and awareness of his or her own nonverbal communication (Thomas & Cohn, 2006). To care for the population in a culturally competent manner, NPs should see themselves on a journey to grow and cultivate distinctive experiences that will lead toward achieving cultural competence (Campinha-Bacote, 2003). This journey provides the opportunity to learn and appreciate the uniqueness of culture. In the following excerpt, a nurse educator speaks about her journey to develop cultural competency: As an educator I prided myself on having knowledge to share with others. Reflecting on years of direct patient care, caring for individuals and groups of various cultural and ethnic backgrounds, I was humbled by what I still did not know. It is when I examined my cultural competence that I began to realize that I will not “achieve” cultural competence but will be on a journey forever to reach competency. Each interaction I have with others will increase my understanding, my sensitivity, and my awareness. I will approach others with openness and nonjudgment as I persist in my efforts along the journey. (Carolina, nurse faculty)

Demystifying the Cultural Competence Puzzle Cultural awareness training may be helpful in increasing cultural awareness, yet it is not an easy fix to improving outcomes for disparate populations. In a randomized controlled study, Sequist and colleagues (2010) noted that primary care clinicians had increased awareness of racial disparities after an intensive 12-month program consisting of cultural competency training and race-stratified performance feedback. This training did not improve important aspects of disease control for black diabetic patients in the program, suggesting a need for further interventions (Sequist et al., 2010). Awareness of cultural aspects of a particular group can be insightful, aiding in increased understanding, but it is not until the provider recognizes the influence of culture on a person’s existence that it is significant. A partnership between an NP and a client could assist in developing a greater understanding and appreciation of the culturally specific needs of the client in the context of his or her population. As expressed by the graduate student in the following excerpt, having one piece of the cultural competence puzzle is not enough: We talked about various cultures in the cultural nursing course, but it had little meaning to me. I am an NP student who has not encountered much diversity in my life. As a future NP, I know I need cultural skills to be effective in my role. But is having the knowledge I learned in class enough? In a 2010 qualitative study, Erwin et al. (2010) examined the barriers and opportunities of Latino women to obtain health screenings and interventions. The researchers found that country of origin and their current geographic location affected their experiences with healthcare systems and access to services. Several cultural themes emerged, including the influence of machismo and putting the family before themselves. The effects of these culturally based influences can present

as barriers to women obtaining healthcare services (Erwin et al., 2010). Cultural influences, such as the (American/U.S.) approach where women are encouraged to care for themselves and seek health promotion services, may be regarded as a method of empowerment in one culture yet be perceived as a barrier in other cultures. For the Latino woman who depends on the input of her husband to receive care, it is in the best interests of the woman to involve her husband in the decision-making process regarding care decisions. By considering the Latino family’s views as the preferred approach to health care, the healthcare team may have greater success in meeting the family’s healthcare needs. The following case study is representative in that it involves a Guatemalan male in the implementation of care for his infant child: Ana, a mother who walked 90 minutes to the clinic in a developing country, brought her 3-month-old baby, Alessandra, to the clinic our team sponsored. The mother reported that she was told to bring her baby home to die; the doctors in her country could not help her. When Alessandra arrived at the clinic, she was just over 3 pounds, nearly 2 pounds less than her birth weight. The team, after assessing the baby, determined that she was drinking cow’s milk and had severe gastrointestinal and cutaneous symptoms. The team developed a feeding plan using soy-based formula. When the team discussed the plan with the mother, it was apparent that the father of the baby needed to consent to the outlined plan. Ana was not able to make the decision for her baby. A community leader, who served as the liaison between team and family, facilitated the communication of the plan to the father, who consented. It was through the use of the community leader and a nonjudgmental approach, incorporating cultural considerations into the plan, that a successful plan was created for Alessandra. (Ellen, public health nurse) In an article describing the fasting practices of women during pregnancy and breastfeeding, the differences between some practicing Muslim women and U.S. standards were discussed (Kridli, 2011). In a culture where pregnant women are encouraged to “eat for two,”

caregivers may find that the practice of fasting during pregnancy or breastfeeding is strange or wrong. It is important for the NP to take the time to understand the significance of fasting in the spiritual life of the Muslim woman. It is when healthcare providers can accept and appreciate the cultural uniqueness of an individual that they can then adapt the provision of care to meet the needs of the patient. The following case scenario is an example of how the nurse practitioner helped the patient with strong religious beliefs navigate his care in a complex health system: As a nurse practitioner, I often need to reassess my own ability to reframe the ability to accept my patients’ beliefs regarding healthcare treatments as well as their spirituality. It is sometimes difficult when we feel strongly that current practices are the only viable option for patients to choose, particularly when their choice is almost always one that will significantly alter the ability to survive. Religious beliefs can stir up much passionate argument for insisting patients do things “our” way. I will touch upon this in my short story. George was a middle-aged gentleman who came in yearly for his physical examination. He was doing very well in keeping his cholesterol in check with diet and a low-dose statin and was up to date with immunizations. Until one recent visit, there were no other significant healthcare-related issues. At that visit, George described feeling so fatigued that he could hardly get through his workday as a manager for a large home goods store. He said he was bruising easily and was very concerned, as was I. I knew that George was a Jehovah’s Witness, and we had in his file his official document regarding no blood transfusions. I have some members of my family who are also Jehovah’s Witnesses, so I was well aware of all the details and scriptural support for this belief. Unfortunately, his blood work returned showing a severe pancytopenia. I convinced him to go for the consultation with the hematologist we worked closely with, assuring him that I would be his advocate for him to be the main director of his own healthcare treatment plan once he was fully assessed and treatment options were discussed. Being an advocate, I also had to speak with the

hematologist before George went there so that he could understand what issues could cause tension within their patient– physician relationship during this time of turmoil. Unfortunately, it did appear that George had aplastic anemia. We are working to find the cause, and he has opted to use complementary and alternative therapies instead of blood transfusions. The hematologist made George sign a document that released him from liability regarding George’s decisions; however, he is still working with us for the time being. George is well aware of the possibility of dying without getting transfused, and he strongly holds to his belief system. As his primary care provider, I try to be supportive, as well as honest, when discussing his current status and his options. I have found that I am often being an advocate for George among the staff and other providers, using opportunities to correct inaccurate understanding regarding Jehovah’s Witnesses. Incorporating a cultural assessment or the collection of relevant cultural data relating to a patient’s diagnosis or health concern is vital in the care of diverse populations (Campinha-Bacote, 2003). It is important to consider the biological, physical, and physiological cultural variations that may influence the physician’s ability to conduct an appropriate and correct physical evaluation (Purnell, 1998, as cited in Campinha-Bacote, 2003). Significant cultural data should be gathered, adapted prior to and during the evaluation, and used in the planning and implementation of care. Goldbach, Thompson, and Holleran Steiker (2011) discuss the importance of cultural consideration in the care of Latinos with substance abuse. The Latino culture values family orientation, familismo, and respect, respeto, in their lives. The inclusion of culturally specific aspects of care, along with acculturation, were identified as considerations when treating adolescents with substance abuse (Goldbach et al., 2011). Current strategies or approaches that do not include culturally specific strategies may be ineffective in meeting the unique needs of a specified population. To care for the adolescents, the practitioner must care for the family, use respect, and understand the psychosocial adjustment to the society in which the adolescent lives. To understand health, it must be examined from the viewpoint of the

individual or family. Health must not be gauged by others; the information must come directly from the person or community and be related to their specific circumstances (Kagan, 2008). To be effective practitioners caring for individuals, communities, and populations of need, it is important to use awareness and sensitivity, authentic listening, trust, partnerships, and commitment. It is when we strive for cultural competence that we are able to improve the lives of others.

Language and Communication The Institute of Medicine (IOM, 2003) report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, illustrates the importance of cross-cultural communication. Effective culturally sensitive communication will result in patient satisfaction, leading to adherence, and thus favorable patient outcomes, as seen in FIGURE 24-2. Faulty communication and a lack of consideration of the sociocultural factors will lead to poor patient outcomes and racial and ethnic disparities in care (IOM, 2003). To be an effective communicator, the NP must possess curiosity, empathy, respect, and humility (IOM, 2003) during interactions with individuals and communities. It is when providers ask questions and listen to the response that assumptions can be avoided.

FIGURE 24-2 Communication model.

Description The Office of Minority Health (OMH) was established in 1986 in response to the increased awareness regarding poor health outcomes in racial and ethnic minority populations in the United States (OMH, 2011a). CLAS standards were developed by the OMH for healthcare systems to use in order to provide the best care possible for the diverse patient populations seeking care in the United States. These standards were recently enhanced, and the goals are to (1) advance health equity, (2) improve quality, and (3) help eliminate healthcare disparities. Providing

services that are adapted to an individual’s cultural and language preference can aid in positive patient outcomes. The 14 CLAS standards guide the NP and other healthcare providers to the recommended language and communication processes in healthcare settings that will enhance patient care outcomes (OMH, n.d.-a). For example, the NP should know the qualifications of the interpreter, interpreters must be trained in their role, and the clinician should speak directly to the patient and not the interpreter. The Think Cultural Health initiative contains educational resources to aid in the development of healthcare providers and organizations (see www.thinkculturalhealth.hhs.gov/index.asp).

Listening An essential element of communication must not be overlooked: listening. Listening is an important yet underused skill. Patients express a desire to be listened to by their healthcare providers more than anything else (Berman & Chutka, 2016). Listening is an essential part of the appreciation and awareness of the viewpoints and feelings of others and is inherently connected to quality of life (Kagan, 2008). It is especially beneficial to employ therapeutic listening when working with individuals or groups from other cultures. One study illustrated the benefit of listening and gaining insight into the lives of immigrant women (Belknap & Vandevusse, 2010). Using active listening, the researchers were able to identify emerging themes related to the lived experience of the women. Interventions and support related to the themes can be developed based on the knowledge obtained from listening sessions. The NP must become familiar with culturally competent organizations in the community to assist families. Partnering with the community and listening to their needs can assist the NP with the assessment, development, and implementation of interventions for the specified community. The listener, by providing a safe environment, allows the individual or group to feel secure to voice their expression. It is essential for the listener to be nonjudgmental and accepting and to negate all preconceived ideas, prejudices, and negative attitudes (Shipley, 2010). It is through active listening that the provider is receptive to discovering the needs and desires of others. NPs are often seen as the care providers who hear the patient; NPs often have the

ability to truly listen to the patient’s voice, and this has significant implications in the cultural considerations of care. The ETHNIC mnemonic represented in BOX 24-3 has been identified as a tool to assist the primary care provider in obtaining a history that encourages the inclusion of the patient’s cultural perspective.

BOX 24-3 The ETHNIC Mnemonic E: Explanation What do you think may be the reason you have these symptoms? What do friends, family, or others say about these symptoms? Do you know anyone else who has had or who has this kind of problem? Have you heard about/read/seen it on TV/radio/newspaper? (If patient is unable to offer an explanation, ask patient what is most concerning about the problem.) T: Treatment What kinds of medicines, home remedies, or other treatments have you tried for this illness? Is there anything you eat, drink, or do (or avoid) on a regular basis to stay healthy? Tell me about it. What kind of treatment are you seeking from me? H: Healers Have you sought any advice from alternative/traditional or folk healers, friends, or other people (nondoctors) for help with your problems? Tell me about it. N: Negotiate Negotiate options that will be mutually acceptable to you and your patient and that do not contradict, but rather incorporate, your patient’s beliefs. I: Intervention Determine an intervention with your patient. This may include incorporation of alternative treatments, spirituality, and healers, as well as other cultural practices (e.g., foods eaten or avoided both in general and when sick). C: Collaboration Collaborate with the patient, family members, other healthcare team members, healers, and community resources. Adapted, displayed, and reproduced with permission from Patient Care: The Practical Journal for Primary Care Physicians. Special Issue: Caring for Diverse Populations: Breaking Down Barriers, 34(9), 189. Patient Care is a copyrighted publication of Advanstar Communications Inc. All rights reserved.

Trust There is mistrust of the healthcare system by minority patients. Their

mistrust is connected to treatment refusal for a variety of reasons, including discontentment with the patient–provider relationship (Baldwin, 2003). As part of the most trusted profession (ANA, 2016), NPs are in a position to establish trusting and meaningful relationships with individuals, groups, and communities. Many of the skills necessary to build cultural awareness and sensitivity are instrumental in establishing trust: empathy, respect, listening, and a nonjudgmental approach. Taking the time to build rapport will aid in the development of trust and build relationships between the provider and the patient community. The following offers examples of a trusting relationship between an NP and a high-risk patient: Jana is an African American mother of a 2-year-old, recently paralyzed child. The child suffered the injuries during a motor vehicle accident in which her maternal grandmother was under the influence of an illegal substance. Jana herself is a recovering drug addict and prostitute who is starting to make great strides in her life. She is working and independently living in a small apartment with her daughter. As the NP overseeing her care in the hospital setting, I have the tremendous responsibility of working with the mother with the mutual goal of discharging the daughter home. The initial discharge was complex. There were many considerations: ventilator, G-tube feedings, wheelchair, and nursing, to highlight several. As I discussed the plan with the discharge coordinator, we were encountering obstacle after obstacle to meeting our goal. Was the home accessible? Was it safe? Did the mother have adequate support? We updated the mother frequently with the progress (or lack of progress). One morning the mother was angry and started to voice her concerns in a loud and disruptive manner; she said she “had it” with “all of you.” After calming her and listening to her concerns, it was apparent that she did not trust that we were truly trying to discharge her daughter to home. She felt the obstacles were hiding what she felt we considered the “true” issue: that she was unfit, due to her past history, to provide care to her daughter. Despite displaying the skills and behaviors that could support her daughter’s needs, Jana felt that the staff saw her as an unfit

parent. I was shocked. I thought we had a professional relationship that fostered trust, but what I did not understand was how Jana’s life events affected her ability to trust us and voice her concerns. I learned, after caring for Jana and her daughter, that experiences can affect a person’s perception and reaction. As an NP, I need to ensure that patients and their families are able to trust me as their care provider. I need to find ways to better understand them and their experiences. Trust and privacy were major themes that emerged in a 2012 study examining the provision of health-related services to bisexual men (Dodge et al., 2012). Perception of others, confidentiality, and trusting relationships influenced their likelihood of seeking healthcare services. Fearing that their privacy and trust will be violated, many marginal groups may distance themselves from the healthcare services they require. This separation leads to continued disparities in the provision of care and negatively affects their health and well-being. In a recent study, researchers found that global and race-based medical mistrust were high among black women who have sex with black women (Brenick, Romano, Kegler, & Eaton, 2017). Individuals with mistrust have less engagement in health care, which is of concern for the health and well-being of this identified population. Stigma from race or sexual orientation, although low in the study, should be considered to reduce disparities and promote engagement in health care. Trust can influence health. Another study examining the relationship of trust between patients with type 2 diabetes and their physicians demonstrated that trust was related to patient outcomes. The authors concluded that “trust in physicians could contribute to improvements in patient outcomes over time” (Lee & Lin, 2011, p. 411). When caring for populations, trust is essential to building a caring relationship, and having trust in a relationship is an important aspect of care that can improve health outcomes. If a provider is culturally competent, it will have a positive impact on the treatment adherence of the patient and the quality of care (Davey, Waite, Nuñez, Niño, & Kissil, 2014). Nurse practitioners are viewed as being skillful in developing trusting relationships with patients. The trust is developed by learning about the patient’s family, culture, and socioeconomic needs; developing and using

cultural tools; and incorporating nursing tenets from professional training.

Community Partnerships When providing care to marginalized or culturally based populations, establishing a relationship with the community is essential. Partnership, defined as two or more individuals or groups working together for a shared goal, is a key element to community engagement. Meade, Menard, Thervil, and Rivera (2009) discuss the importance of community partnerships in the development and adaptation of sustainable breast education and outreach programs for Haitian women. The partnership worked on the unique needs of the community and included cultural, educational, and literacy considerations. The development of a partnership affords the ability to determine factors that affect health and to develop approaches to maximize health and wellness. Partnerships with community leaders and community gatekeepers are essential features to the success of outreach initiatives (Meade et al., 2009). An example of a lack of partnerships within the healthcare setting was presented in a 2009 study examining the use of CAM in the treatment of autism spectrum disorder (ASD) in the United States and China. An interesting finding from this study revealed that only 22.4% of respondents informed their doctors about CAM use to treat ASD. The study suggests that the participants did not inform their physician of the CAM use because they felt that the Western physician would not allow CAM or believe its effectiveness (Wong, 2009). Lack of trusting partnerships can lead to continued healthcare disparities. In a study exploring the influence of NPs on the delivery of culturally competent care, NPs stated that collaborating with other members of the healthcare team, as well as patients, was effective in the delivery of culturally competent care. Working with patients to meet their identified needs was a priority for the NP as well as for the patient. Addressing other impending concerns was completed by negotiation and partnering. In a 2011 study of Native American men and HIV, barriers to HIV/AIDS care were presented. Many of the barriers were related and contributed to the disparity in the provision of care to Native American men. The participants in this study identified that using indigenous outreach workers would be an effective approach to the prevention and

intervention efforts (Burks, Robbins, & Durtschi, 2011). They also expressed the importance of inclusion of traditional healing practices into the provision of HIV/AIDS services. Establishing partnerships with community leaders and outreach workers could improve the health of the community by addressing their needs with a culturally focused approach. In addition, Saha and colleagues (2013) found that minority HIV patients who had a provider who scored toward the middle or high ranges of cultural competence were more likely to be on antiretrovirals than patients who had a provider who scored low in cultural competence. Again, this study shows that the cultural competence of the healthcare provider is connected to healthcare quality and patient outcomes.

Pulling It All Together Caring for patients and addressing and adapting care to meet the cultural needs of patients takes a holistic approach. When care is provided in a culturally sensitive manner, it extends beyond the medical concerns presented. The inclusion of social, spiritual, lifestyle, societal, and familial aspects of the individual is imperative to determining and responding to the patient’s needs. Having a holistic approach is to look at the patient’s complete life, not solely focusing on illness. The LIAASE, a general cultural competence tool, is a helpful structure to guide the provider in offering care that is sensitive to the individual’s culture and preferences (BOX 24-4).

BOX 24-4 The LIAASE: A General Cultural Competence Tool Learn Read literature from other cultures. Identify your own biases and stereotypes.

Avoid Polarization Solicit other options or points of view. Ask what perspective a person from a different background would have.

Inquire Ask questions to clarify and understand information. Dig deeper to find reasons for behaviors or attitudes. Frame inquiries as searches for answers, showing a willingness to learn. Do not judge or interpret actions or speech; verify that what you understand is correct.

Avoid Arguing and Defending Curb the impulse to defend your point of view or opinion. Agree to disagree on differences in values. Show Empathy Listen not just to the words, but to the feelings behind the words. Acknowledge and validate powerful emotions when

Speak clearly; avoid slang, colloquial expressions, and large, complex words.

expressed.

State Your Needs and Expectations It is important to set a respectful tone for the interaction. Let people know what you want and what you consider unacceptable behavior. In this way assumptions, conflict, and/or resentment can be avoided.

Reproduced from Nova Scotia Department of Health and Wellness. (2005). A cultural competence guide for primary health care professionals in Nova Scotia. Retrieved from http://www.healthteamnovascotia.ca/cultural_competence/Cultural_Competence_guide_for_Primary_Health_C Used by permission of Nova Scotia Department of Health and Wellness.

In the following case scenario, the NP uses components of the LIAASE tool as she develops a culturally competent plan of care for the patient.

Using the LIAASE Tool to Provide Culturally Sensitive Care While working in a busy OB/GYN clinic as a new family nurse practitioner (FNP), I was quickly moving my novice skill level to advanced due in part to the resident physicians’ avoidance of the clinic. It was also a wonderful place to provide culturally sensitive care. We had a large number of patients from Haiti and Guatemala in addition to almost every other country. One day I went into an examination room and found a pleasant young couple waiting for a new OB examination. The woman was covered in a very colorful sari and was smiling, but she was quiet and deferential to her equally pleasant husband. He very nicely told me that because I was the only female provider in the clinic that day that they had requested I do her initial intake and examination. I loved doing the new OB visits, so that was not the challenge—the challenge was in trying to do a pelvic exam and get a PAP smear and ultrasound with all that clothing. Saris can be worn in different colors to represent different meanings; for instance, yellow can

typically be worn for the first 7 days postpartum, and paisley can be worn as a symbol of fertility. The couple was pleased that I managed to get all the necessary portions of the examination done while maintaining the woman’s privacy. We developed a mutually understanding and respectful partnership during a time of joy for this newly pregnant couple in what could have been disastrous if the provider who attended to them was not culturally sensitive.

Evaluation When working with individuals or groups, there is a need to evaluate the outcomes of the interventions, including the evaluation of those we partner with. Outcome evaluations should be culturally sensitive; they should use wording and terms that the community or individual would understand within the context of their culture. It is important to receive feedback from the community or individual on whom the intervention focused. Do they perceive the intervention as useful or beneficial? After using focus groups to determine the best interventions to use in a community-based intervention program for Mexican American women, Ingram et al. (2012) used a participatory evaluation process to adapt to the needs of the women in the community. The authors, using the women’s responses, were able to understand the behavioral and knowledge changes as a result of the program’s interventions. Their responses revealed why they adapted their behaviors and the barriers they encountered when following the intervention recommendations (Ingram et al., 2012). Their input was valuable in gaining their perspective on the significance of the interventions as well as on their perceived barriers, thus contributing an important aspect of program evaluation. When examining the outcomes of a program or intervention, cultural influences must be considered when applying meaning to the results (Issel, 2009). Evaluation is the ability to reflect on our care as NPs in an effort to gain greater clarity on the provision of culturally competent care. It is a time to ask if the care was what the patient needed or desired. In our role, this feedback ensures that we are evaluating not only the care provided but also ourselves as care providers. In summary, nurse practitioners must respond to the unique and distinct needs of the diverse and ever-changing society. Attention to cultural variations as well as to societal factors influencing health must be considered to care for an increasingly diverse population. Cultural awareness and sensitivity are critical to the achievement of culturally competent care.

Discussion Questions 1. Identify your own cultural beliefs and values. 2. Discuss the variety of cultures in your professional practice. 3. Reflect on your cultural journey. What do you consider as obstacles to achieving cultural competence? What strategies can be employed to overcome the barriers? 4. Describe a situation or circumstance when cultural factors influenced the care of an individual or family. Were culturally sensitive interventions/approaches implemented? If yes, please describe. If interventions/approaches were not based on the individual’s or family’s cultural preferences, how could the encounter have been adapted to meet the unique cultural needs? 5. What method or strategy could be implemented to evaluate the integration of cultural strategies during a patient encounter?

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© Zen Rial/Moment/Getty Images.

CHAPTER 25 Health Services for Special Populations Leiyu Shi and Douglas A. Singh

CHAPTER OBJECTIVES 1. Identify population groups facing greater challenges and barriers in accessing healthcare services. 2. Understand the racial and ethnic disparities in health status. 3. Explore the health concerns of America’s children and the health services available to them. 4. Discuss the challenges faced in rural health and learn about measures taken to improve access to care. 5. Analyze the characteristics and health concerns of homeless populations and migrant workers. 6. Develop an understanding of the U.S. mental health system. 7. Comprehend the AIDS epidemic in the United States, the population groups affected by it, and the services available to HIV/AIDS patients.

Introduction Certain population groups in the United States face greater challenges than the general population in accessing timely and needed healthcare services (Shortell et al., 1996). As a consequence, members of these groups are at greater risk of poor physical, psychological, and/or social health (Aday, 1993). Various terms are used to describe these populations, such as underserved populations, medically underserved, medically disadvantaged, underpriviledged, and American underclasses. The causes of their vulnerability are largely attributable to unequal social, economic, health, and geographic conditions. These population groups consist of racial and ethnic minorities, uninsured children, women, persons living in rural areas, homeless individuals and families, mentally ill individuals, chronically ill and disabled individuals, and persons with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS). These population groups are more vulnerable than the general population and experience greater barriers in access to care, financing of care, and racial or cultural acceptance.

They all have something in common.

After presenting a conceptual framework to study vulnerable populations, this chapter defines these special population groups, describes their health needs, and summarizes the major challenges they face. The potential impact of the Affordable Care Act (ACA) on vulnerable populations is also discussed.

Framework to Study Vulnerable Populations The vulnerability framework (EXHIBIT 25-1) is an integrated approach to studying vulnerability (Shi and Stevens, 2010). From a health perspective, vulnerability refers to the likelihood of experiencing poor health or illness. Poor health can be manifested physically, psychologically, and socially. Because poor health along one dimension is likely to be compounded by poor health along others, the health needs are greater for those persons with problems along multiple dimensions compared to those persons with problems along a single dimension.

EXHIBIT 25-1 The Vulnerability Framework According to the framework, vulnerability is determined by a convergence of (1) predisposing, (2) enabling, and (3) need characteristics at both individual and ecological (contextual) levels (EXHIBIT 25-2). Not only do these predisposing, enabling, and need characteristics converge and determine individuals’ access to health care, but they also ultimately influence individuals’ risk of contracting illness or, for those already sick, recovering from illness. Individuals with multiple risks (i.e., a combination of two or more vulnerability traits) typically experience worse access to care, care of lesser quality, and inferior health status than do those with fewer vulnerability traits.

Description

EXHIBIT 25-2 Predisposing, Enabling, and Need Characteristics of Vulnerability Predisposing characteristics: Racial/ethnic characteristics Gender and age (women and children) Geographic location (rural health) Enabling characteristics: Insurance status (uninsured) Homelessness Need characteristics: Mental health Chronic illness/disability HIV/AIDS

Understanding vulnerability as a combination or convergence of disparate factors is preferred over studying individual factors separately

because vulnerability, when defined as a convergence of risks, best captures reality. This approach not only reflects the co-occurrence of risk factors but also underscores the belief that it is difficult to address disparities related to one risk factor without addressing others. This vulnerability model has a number of distinctive characteristics. First, it is a comprehensive model, including both individual and ecological attributes of risk. Second, it is a general model, focusing on the attributes of vulnerability for the total population rather than vulnerable traits of subpopulations. Although we recognize individual differences in exposure to risks, we also think that some common, crosscutting traits affect all vulnerable populations. Third, a major distinction of our model is its emphasis on the convergence of vulnerability. In other words, the effects of experiencing multiple vulnerable traits may lead to cumulative vulnerability that is additive or even multiplicative.

Racial/Ethnic Minorities The 2010 U.S. census questionnaire listed 15 racial categories, as well as places to write in specific races not listed on the form (U.S. Census Bureau, 2009b). These racial categories were White, Black, American Indian or Alaska Native, Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, Other Asian, Native Hawaiian, Guamanian or Chamorro, Samoan, Other Pacific Islander, or some other race. Respondents could choose more than one race. The U.S. Census Bureau (2015) estimated that, in 2015, more than 38% of the U.S. population was made up of minorities: black or African Americans (13.3%), Hispanics or Latinos (17.6%), Asians (5.6%), Native Hawaiian and Other Pacific Islanders (0.2%), and American Indian and Alaska Natives (1.2%). In addition, 2.6% of all Americans self-identified as being two or more races (U.S. Census Bureau, 2010a). Significant differences exist across the various racial/ethnic groups on health-related lifestyles and health status. For example, in 2014, the percentage of live births in which the neonate weighed less than 2,500 grams (low birth weight) was greatest among blacks, followed by Asians or Pacific Islanders, American Indians or Native Americans, Hispanics, and whites (FIGURE 25-1). Asians and Pacific Islanders were most likely to begin prenatal care during their first trimester, followed by whites, Hispanics, blacks, and American Indians or Alaska Natives (TABLE 25-1). Mothers of whites and individuals of Asian and Pacific Islander origin were least likely to smoke cigarettes during pregnancy, followed by Hispanics, blacks, and American Indians or Alaska Natives; mothers in the last group had a smoking rate more than double that of any other group (18%) (FIGURE 25-2). The white adult population is more likely to consume alcohol than other races (FIGURE 25-3). Among women 40 years of age and older, utilization of mammography is the highest among whites and lowest among Hispanics (FIGURE 25-4).

FIGURE 25-1 Percentage of U.S. live births weighing less than 2,500 grams by mother’s detailed race.

Description

FIGURE 25-2 Percentage of U.S. mothers who smoked cigarettes during pregnancy according to mother’s race. Data from Centers for Disease Control and Prevention (CDC). 2016d. Smoking prevalence and cessation before and during pregnancy: Data from the birth certificate, 2014. National Vital Statistics Reports 65, no. 1. Available at: https://www.cdc.gov/nchs/data/nvsr/nvsr65/nvsr65_01.pdf. Accessed July 2017.

Description

FIGURE 25-3 Alcohol consumption by persons 18 years of age and older. Data from National Center for Health Statistics (NCHS). 2014a. National Health Interview Survey. Available at: https://www.cdc.gov/nchs/nhis. Accessed March 2017.

Description

FIGURE 25-4 Use of mammography by women 40 years of age and older, 2013. Data from National Center for Health Statistics (NCHS). 2016b. Health, United States, 2015. Hyattsville, MD: U.S. Department of Health and Human Services. p. 246.

Description TABLE 25-1 Characteristics of U.S. Mothers by Race/Ethnicity

Description 1 Data from 2008.

Note: Numbers are percentages. Data from National Center for Health Statistics (NCHS). 2010. Health, United States, 2009. Hyattsville, MD: U.S. Department of Health and Human Services. pp. 159, 163; National Center

for Health Statistics (NCHS). 2013. Health, United States, 2012. Hyattsville, MD: U.S. Department of Health and Human Services. p. 144; National Center for Health Statistics (NCHS). 2016b. Health, United States, 2015. Hyattsville, MD: U.S. Department of Health and Human Services. p. 74.

Black Americans Black Americans are more likely to be economically disadvantaged than whites. They also fall behind in health status, despite progress made during the past few decades. Blacks have shorter life expectancies than whites (FIGURE 25-5); higher age-adjusted death rates for a majority of leading causes of death (TABLE 25-2); higher age-adjusted maternal mortality rates (FIGURE 25-6); and higher infant, neonatal, and postneonatal mortality rates (TABLE 25-3). On self-reported measures of health status, blacks are more likely to report fair or poor health status compared to whites (FIGURE 25-7). In terms of behavioral risks, black males are slightly more likely to smoke cigarettes than white males (21.7% versus 18.8%), but white females are more likely to smoke than black females (16% versus 13.4%) (FIGURE 25-8), although smoking among black females has increased in recent years. Conversely, blacks have lower levels of serum cholesterol than whites (TABLE 25-4). Rates of heart disease and stroke deaths are highest among non-Hispanic blacks, and rates of hypertension are highest among this racial group as well. Non-Hispanic black women are more likely to lose more expected years of life due to breast cancer than non-Hispanic whites (Hung et al., 2016). The prevalence of diabetes is highest among Hispanics and non-Hispanic blacks compared to non-Hispanic whites (National Center for Health Statistics [NCHS], 2016b).

FIGURE 25-5 U.S. life expectancy at birth, 1970–2014. Data from National Center for Health Statistics (NCHS). 2016b. Health, United States, 2015. Hyattsville, MD: U.S. Department of Health and Human Services. p. 93.

Description

FIGURE 25-6 Age-adjusted maternal mortality rates. Data from National Center for Health Statistics (NCHS). 2011. Health, United States, 2010. Hyattsville, MD: U.S. Department of Health and Human Services. p. 231; Centers for Disease Control and Prevention (CDC). 2016e. Pregnancy Mortality Surveillance System. Available at: https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html. Accessed July 2017.

Description

FIGURE 25-7 Respondent-assessed health status. Data from National Center for Health Statistics (NCHS). 1996. Health, United States, 1995. Hyattsville, MD: U.S. Department of Health and Human Services. p. 172; National Center for Health Statistics (NCHS). 2013. Health, United States, 2012. Hyattsville, MD: U.S. Department of Health and Human Services. p. 168; National Center for Health Statistics (NCHS). Health, United States, 2015. Hyattsville, MD: U.S. Department of Health and Human Services. p. 182.

Description

FIGURE 25-8 Current cigarette smoking by persons 18 years of age and older, age adjusted, 2014. Data from National Center for Health Statistics (NCHS). 2016b. Health, United States, 2015. Hyattsville, MD: U.S. Department of Health and Human Services. p. 186.

Description TABLE 25-2 Age-Adjusted Death Rates for Selected Causes of Death, 1970–2014

Description Description Data from National Center for Health Statistics (NCHS). 2016b. Health, United States, 2015.

Hyattsville, MD: U.S. Department of Health and Human Services. pp. 99–101.

TABLE 25-3 Infant, Neonatal, and Postneonatal Mortality Rates by Mother’s Race (per 1,000 Live Births)

Description Data from National Center for Health Statistics (NCHS). 2013. Health, United States, 2012. Hyattsville, MD: U.S. Department of Health and Human Services. p. 66; National Center for Health Statistics (NCHS). 2016b. Health, United States, 2015. Hyattsville, MD: U.S. Department of Health and Human Services. p. 86.

TABLE 25-4 Selected Health Risks Among Persons 20 Years and Older, 2011–2014

Description 1 20–74 years, age adjusted.

Data from National Center for Health Statistics (NCHS). 2016b. Health, United States, 2015. Hyattsville, MD: U.S. Department of Health and Human Services. pp. 202, 204, 216.

Hispanic Americans The Hispanic segment of the U.S. population is growing at a significantly faster rate than other population segments. Between 2000 and 2010, the Hispanic segment increased by 43%, compared to a 10% increase for the total U.S. population (U.S. Census Bureau, 2011a, 2011b). In 2014, the U.S. Hispanic population numbered nearly 55 million; it is projected to reach 119 million by 2060. Hispanic Americans are also one of the youngest groups in the United States. In 2014, the median age for Hispanic Americans was 28.4 years, compared to 43.1 years for non-Hispanic whites. In 2013, 9.7% of Hispanics were younger than age 5, compared to 5.1% of non-Hispanic whites (U.S. Census Bureau, 2013). In 2012, 25.6% of Hispanic persons lived below the federal poverty level (FPL), compared to 9.7% of nonHispanic white persons (U.S. Census Bureau, 2013). Many Hispanic Americans experience significant barriers in accessing medical care. This represents a greater problem for those from Central America (39% foreign born) than those from South America (25.6%

foreign born) and Mexico (32.6% foreign born). Place of birth also contributes to some Hispanic people’s inability to speak English, which is another factor associated with reduced access to medical services (Solis et al., 1990). Because of their relatively low education levels, Hispanic Americans have higher unemployment rates than non-Hispanic whites (5.6% versus 4.0% in 2016; U.S. Bureau of Labor Statistics, 2016) and are more likely to be employed in semiskilled, nonprofessional occupations (U.S. Census Bureau, 2011a). Consequently, Hispanic Americans are more likely to be uninsured or underinsured than non-Hispanic whites. In 2014, 25.5% of Hispanic persons were uninsured, compared to 13.3% of non-Hispanic whites and 13.7% of non-Hispanic blacks or African Americans (NCHS, 2016b). Among Hispanics, 27.2% of Mexican Americans were uninsured, followed by 19.4% of Cubans, 13.0% of Puerto Ricans, and 26.2% of other Hispanics (NCHS, 2016b). In 2006, homicide was the ninth leading cause of death for Hispanic males. This cause of death has the highest ranking in this group, along with blacks (NCHS, 2016b). Hispanic Americans are less likely to take advantage of preventive care than non-Hispanic whites and members of certain other races. Hispanic women 40 years of age or older were least likely to use mammography (61.4% versus 66.8% for non-Hispanic whites and 67.1% for non-Hispanic blacks; see Figure 25-4). In 2014, fewer Hispanic mothers began their prenatal care during the first trimester than the U.S. average (83.3% of Hispanic mothers versus 84.8% as the U.S. average; see Table 25-1). Among Hispanics 2 years of age and older in 2014, 59.7% had at least one dental visit during a year, compared to 67.7% for non-Hispanic whites (NCHS, 2016b). People of Hispanic origin also experience greater behavioral risks than whites and members of certain other racial/ethnic groups. For example, among individuals 18 years and older in 2014, a higher proportion of Hispanics drank five or more alcoholic drinks per day than people of other ethnic origins (24.4% for Hispanics versus 17.6% for blacks and 14.5% for Asians; see Figure 25-3). In contrast, fewer Hispanics smoked compared to people from other ethnic groups. In 2014, 15.7% of Hispanic males 18 years and older identified themselves as “current smokers,” compared to 20.0% of non-Hispanic white males and

21.8% of non-Hispanic black males (NCHS, 2016b). Among female adults, 7.3% of Hispanics smoked in 2014, compared to 16.4% of nonHispanic whites and 14.2% of non-Hispanic blacks (NCHS, 2016b).

Asian Americans Minority health epidemiology has typically focused on blacks, Hispanics, and American Indians or Alaska Natives because Asian Americans represent a relatively small proportion of the U.S. population. In 2015, Asians accounted for only 5.6% of the U.S. population, with this subpopulation including 19 million individuals (U.S. Census Bureau, 2012a). To include the diversity of Asian Americans, the NCHS has expanded the race codes into nine categories for Asian Americans: White, Black, Native American, Chinese, Japanese, Hawaiian, Filipino, Other Asian/Pacific Islanders, and other races. Nevertheless, even the category of “Other Asian/Pacific Islander” is extremely heterogeneous, encompassing 21 subgroups with different health profiles. Asian Americans constitute one of the fastest-growing population segments in the United States. The growth rate for this population was 43% between 2000 and 2010, compared to 10% for the U.S. population as a whole (U.S. Census Bureau, 2012a). The U.S. Census Bureau (2010b) projected that the Asian American population would reach 16.5 million by 2015. In education, income, and health, Asian Americans and Pacific Islanders (AA/PIs) are very diverse. In 2013, 86.2% of AA/PIs 25 years of age or older had at least graduated from high school, compared with 87.6% of non-Hispanic whites; in addition, the percentage of AA/PIs with a bachelor’s degree or higher was 51.3%, compared to 30.3% for nonHispanic whites (U.S. Census Bureau, 2012a). Educational attainment varies greatly among the subgroups, however. For example, between 2007 and 2009, 94% of adults of Japanese descent had graduated from high school, whereas that rate was 72% for adults of Vietnamese descent and only 61% for Hmong adults (U.S. Census Bureau, 2010a). In 2013, the median income for Asian males (aged 15 years and older) was $72,472, compared to $40,963 for non-Hispanic white males (U.S. Census Bureau, 2010a). In addition, a smaller percentage of Asians (12.7%) lived below the FPL, compared to blacks (27.4%), and

Hispanics (23.5%) (U.S. Census Bureau, 2011c). One study found that Chinese, Asian Indian, Filipino, and other AA/PI children were more likely to be without contact with a health professional, compared to non-Hispanic white children. Citizenship/nativity status, maternal education attainment, and poverty status were all significant independent risk factors for healthcare access and utilization (Yu et al., 2004). In addition, cultural practices and attitudes may prevent AA/PI women from receiving adequate preventive care, such as Pap smears and breast cancer screening. Overall, the AA/PI population reported lower Pap smear test utilization; in 2013, 65.3% of AA/PI women aged 18 and older had a Pap smear test, compared with 68.7% of non-Hispanic whites, 75.3% of non-Hispanic blacks, and 70.5% of Hispanics (NCHS, 2016b). Failure to recognize the heterogeneity of this minority population sometimes contributes to the myth that the entire AA/PI population is both healthy and economically successful. In fact, the heterogeneity of the AA/PI population is reflected in the various indicators of health status. For instance, people of Vietnamese descent are more likely to assess their own health status as fair or poor, compared to people of Korean, Chinese, Filipino, Asian Indian, and Japanese descent (NCHS, 2014a). The incidence of overweight and obesity varies greatly, with Filipino adults being 70% more likely to be obese than the rest of the AA/PI population. In terms of the total U.S. population, overall smoking rates are the lowest among AA/PIs. Nevertheless, 22% of Koreans are current smokers—a rate higher than that for black (17%) and Hispanic adults (10%). Compared with whites, Asian Indians are more than twice as likely to have diabetes (Centers for Disease Control and Prevention [CDC], 2015a).

American Indians and Alaska Natives More than three-fourths of the American Indian and Alaska Native (AIAN) population resides in rural and urban areas outside of reservations or offreservation trust lands (U.S. Census Bureau, 2011d). According to the Census Bureau (2011d), the AIAN population is growing at a rate of 26.7% per year. Concomitantly, demand for expanded healthcare services within this population has been increasing for several decades

and is becoming more acute. The incidence and prevalence of certain diseases and conditions—such as diabetes, hypertension, infant mortality and morbidity, chemical dependency, and AIDS- and HIV-related morbidity—in the AIAN population are all high enough to be matters of prime concern. Compared to the general U.S. population, Native Americans also have much higher death rates from alcoholism, tuberculosis, diabetes, injuries, suicide, and homicide (Indian Health Service [IHS], 2010a). It is also no secret that Native Americans continue to occupy the bottom of the socioeconomic strata in the United States. AIANs are approximately twice as likely to be poor and unemployed as other Americans (U.S. Census Bureau, 2011d). Nevertheless, the health status of American Indians appears to be improving. For example, the mortality rate among Native American expectant mothers dropped from 28.5 deaths per 100,000 live births in 1972–1974 to 8.3 deaths per 100,000 live births in 2007–2009 (IHS, 2014); infant mortality declined from 8.3 deaths per 1,000 births in 2000 to 7.6 deaths per 1,000 births in 2013 (NCHS, 2016b). Even with these gains, Native Americans continue to experience significant health disparities compared to the general U.S. population. The life expectancy of Native Americans is 4.6 years less than that for the U.S. population as a whole (IHS, 2010a). Native Americans die at higher rates than other Americans from alcohol abuse (519% higher), tuberculosis (500% higher), diabetes (195% higher), unintentional injuries (149% higher), homicide (92% higher), and suicide (72% higher) (IHS, 2010a). The provision of health services to American Indians by the federal government was first negotiated in 1832, as partial compensation for land cessions. Subsequent laws have expanded the scope of services and allowed American Indians greater autonomy in planning, developing, and administering their own healthcare programs. These laws explicitly permit the practice of traditional as well as Western medicine.

Indian Health Care Improvement Act The Indian Health Care Improvement Act of 1976 (IHCIA), which was amended in 1980, outlined a 7-year effort to help bring American Indian health to a level of parity with the general population. Although this goal

of health parity remains unmet, the IHCIA has at least been successful in minimizing prejudice, building trust, and putting responsibility back into the hands of American Indians. The Affordable Care Act included the permanent reauthorization of the IHCIA.

Indian Health Service The goal of the federal program administered by the Indian Health Service (IHS) is to ensure that comprehensive and culturally acceptable health services are available to AIANs (IHS, 2013). The IHS (2010b) serves the members and descendants of more than 560 federally recognized AIAN tribes. The healthcare needs of a rapidly expanding American Indian population have grown faster than medical care resources, however, and most American Indian communities continue to be medically underserved. IHS is divided into 12 area offices, each responsible for program operations in a particular geographic area. Each area office is composed of branches dealing with various administrative and health-related services. Delivery of health services is the responsibility of 161 tribally managed service units operating at the local level (IHS, 2010b). The IHS mandate has been made particularly difficult because the locations of Indian reservation communities are among the least geographically accessible in the United States (Burks, 1992). Besides rendering primary and preventive care, special initiatives focus on areas such as injury control, alcoholism, diabetes, mental health, maternal and child health, Indian youth and children, elder care, and HIV/AIDS (IHS, 1999a). Additional areas of focus include domestic violence and child abuse, oral health, and sanitation (IHS, 1999b). Even with the limitations in the IHS’s scope of service, many American Indians do not avail themselves of the system’s services. More than half of lowincome uninsured Indians do not have access to IHS. Among the lowincome population, Indians with IHS access fared better than uninsured Indians (Zuckerman et al., 2004).

The Uninsured The Health Services Financing chapter discussed the number of uninsured people in the United States and the reasons why so many Americans have been without health insurance. Although the rate of uninsurance among adults has increased, lack of health insurance coverage among children declined from 8.9% in 2008 to 4.5% in 2015 (NCHS, 2016a), mainly because of the success of the Children’s Health Insurance Program (CHIP). Ethnic minorities are more likely than whites to lack health insurance. The U.S. Census Bureau (2014) estimated that, in 2014, 19.9% of Hispanic residents were uninsured, compared with 11.8% of blacks, 9.3% of Asian Americans, and 7.6% of whites. Most of the uninsured population comprises young workers (O’Neill and O’Neill, 2009). Lack of coverage is also more prevalent in the southern and western regions of the United States and among individuals who lack a college degree. Generally, uninsured persons are in poorer health than the general population (NCHS, 2016a). Studies have also shown that the uninsured use fewer health services than the insured (CDC, 2010a). In 2015, 54% of uninsured people reported having no regular source of health care (Kaiser Family Foundation, 2016d). Decreased utilization of lower-cost preventive services—a characteristic of the uninsured population—can ultimately result in an increased need for more expensive emergency health care. Even when the uninsured can access health care, they often have serious problems paying their medical bills. In 2015, 20% of uninsured people postponed obtaining needed prescription drugs because of cost concerns, compared to 12% of those with public insurance and 6% of privately insured people (Kaiser Family Foundation, 2016d). The plight of the uninsured affects those who have insurance as well. Medical expenditures for uncompensated care to the uninsured were estimated to total $85 billion in 2013 (Kaiser Family Foundation, 2014a). Much of this cost was absorbed by Medicaid, federal grants to nonprofit hospitals, and charitable organizations. The ACA did make sizable progress in reducing the number of

uninsured in the United States. It is not clear how the new reform proposal in the form of the American Health Care Act (AHCA) will address the ongoing problem of uninsurance.

Children There were approximately 74 million children younger than 18 years living in the United States in 2015, representing 23% of the total population. Approximately 15.5 million children (21%) lived in households with incomes below the U.S. Census Bureau’s poverty threshold. The racial and ethnic diversity of U.S. children continues to increase; notably, Hispanic children represented more than 25% of all U.S. children in 2015, up from 8.8% in 1980. Nearly 20% of U.S. children younger than 18 years have a special healthcare need, defined as having a chronic medical, behavioral, or developmental condition lasting 12 months or longer and experiencing a service-related or functional consequence (Federal Interagency Forum on Child and Family Statistics, 2016). Excess body weight in children is associated with excess morbidity during childhood and excess body weight in adulthood. From 1988–1994 to 2011–2014, the percentage of children age 6–17 years with obesity increased by 8 percentage points, from 11% to 19%. During the same period, the percentage of children with obesity increased by 7 percentage points for white, non-Hispanic children; by 9 percentage points for black, non-Hispanic children; and by 10 percentage points for Mexican American children (NCHS, 2014b). Children living in rural areas were more likely to be overweight or obese than their urban counterparts. In addition, children with lower household incomes were significantly more likely to be overweight or obese than those living in households with higher incomes. The rate of overweight and obesity among children in households with incomes below 100% of the FPL was approximately twice that of children with household incomes of 400% or more of the FPL (Health Resources and Services Administration [HRSA], 2017). Health insurance is a major determinant of access to and utilization of health care. From 2000 to 2014, the percentage of children with public coverage increased and the percentage with no health insurance and with private health insurance declined (Federal Interagency Forum on Child and Family Statistics, 2016). The proportion of children younger than 18 years without health insurance was 4.5% in 2015 (CDC, 2016b), but the coverage rates varied across races and ethnicities. Hispanic

children were more likely to be uninsured (10%) than white, non-Hispanic and black, non-Hispanic children (4% each). White, non-Hispanic children were more likely to have private insurance (68%) compared to Hispanic children (31%) and black, non-Hispanic children (34%). In urban and large rural areas, children living in households with the lowest incomes were less likely to have health insurance than their peers living in households with the highest income categories. For instance, 95.3% of children in large rural areas with household incomes below 100% of the FPL had current health insurance, compared to 98.2% of those with household incomes of 400% or more of the FPL. Among children living in households with incomes below 100% of the FPL, children in small and large rural areas were significantly more likely to have health insurance than those in urban areas—94.7% and 95.3% versus 91.2%, respectively (HRSA, 2017a). Unintentional injuries are the leading cause of death for children and adolescents. In 2014, 35% of deaths among adolescents age 15–19 and 30% of deaths among children age 1–14 were due to unintentional injuries. For both age groups, motor vehicle‒related (MVR) injury was the leading cause of unintentional injury death (NCHS, 2016b). Asthma is one of the most common childhood chronic diseases. The prevalence of asthma among U.S. children doubled from 1980 to 1995 but then increased more slowly during the 2000s. More than 10 million U.S. children younger than age 18 (14%) have ever been diagnosed with asthma; 6.8 million children still have asthma (9%) (Federal Interagency Forum on Child and Family Statistics, 2016). In 2014, 13% of black, nonHispanic children were reported to currently have asthma, compared with 8% of white, non-Hispanic children; 8% of Hispanic children; and 6% of Asian, non-Hispanic children. Depression has a significant impact on adolescent development and well-being. In 2014, approximately 11% of youths ages 12–17 had a major depressive episode (MDE) during the past year—a higher prevalence than was reported in 2004 (9%). Among children ages 2‒17 years who had an ongoing emotional, developmental, or behavioral problem, 61.0% had received mental health care or counseling in the previous year (Federal Interagency Forum on Child and Family Statistics, 2016; HRSA, 2017a). Vaccination rates for children for selected diseases differ by race,

poverty status, and area of residence (TABLE 25-5). White children have greater vaccination rates for diphtheria/tetanus/pertussis (DTP), polio, measles, Haemophilus influenzae serotype b (Hib), and combined series compared to blacks. Children who come from families with incomes below the FPL, or who live in inner-city areas, have lower vaccination rates than other children. TABLE 25-5 Vaccinations of Children 19–35 Months of Age for Selected Diseases According to Race, Poverty Status, and Residence in a Metropolitan Statistical Area (MSA), 2014 (%)

Description 1 Diphtheria/tetanus/pertussis, four doses or more. 2 Three doses or more. 3 Respondents were asked about measles-containing or measles/mumps/rubella (MMR)

vaccines. 4 Haemophilus influenzae type b, three doses or more. 5 The combined series consists of four doses of DTP vaccine, three doses of polio vaccine, and

one dose of measles-containing vaccine (4 : 3 : 1 : 3 : 3 : 1). Data from National Center for Health Statistics (NCHS). 2016b. Health, United States, 2015. Hyattsville, MD: U.S. Department of Health and Human Services. p. 238.

Children’s health has certain unique aspects in terms of delivery of health care. Among these factors are children’s developmental vulnerability, dependency, and differential patterns of morbidity and mortality. Developmental vulnerability refers to the rapid and cumulative physical and emotional changes that characterize childhood and the potential impact that illness, injury, or disruptive family and social circumstances can have on a child’s life-course trajectory. Dependency refers to children’s special circumstances that require adults—parents, school officials, caregivers, and sometimes neighbors—to recognize and respond to their health needs, seek healthcare services on their behalf, authorize treatment, and comply with recommended treatment regimens. These dependency relationships can be complex, change over time, and affect utilization of health services by children.

Children and the U.S. Healthcare System The various programs that serve children have distinct eligibility, administrative, and funding criteria that can present barriers to access. The patchwork of disconnected programs also makes it difficult to obtain health care in an integrated and coordinated fashion. These programs can be categorized into three broad sectors: the personal medical and preventive services sector, the population-based community health services sector, and the health-related support services sector. Personal medical and preventive health services include primary and specialty medical services, which are delivered in private and public medical offices, health centers, and hospitals. Personal medical services are principally funded by private health insurance, Medicaid, and out-ofpocket payments. Population-based community health services include community-wide health promotion and disease prevention services. Examples are immunization delivery and monitoring programs, lead screening and abatement programs, and child abuse and neglect prevention. Other health services include special child abuse treatment programs and rehabilitative services for children with complex congenital conditions or other chronic and debilitating diseases. Community-based programs also provide assurance and coordination functions, such as case management and referral programs, for children with chronic diseases

and early interventions and monitoring for infants at risk for developmental disabilities. Funding for this sector comes from federal programs, such as Medicaid’s Early Periodic Screening, Diagnosis, and Treatment (EPSDT) program; Title V (Maternal and Child Health) of the Social Security Act; and other categorical programs. Health-related support services include nutrition education, early intervention, rehabilitation, and family support programs, among other services. An example of a rehabilitation service is education and psychotherapy for children with HIV. Family support services include parent education and skill building in families with infants at risk for developmental delay because of physiological or social conditions, such as low birth weight or very low income. Funding for these services comes from diverse agencies, such as the U.S. Department of Agriculture, which funds the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), and the U.S. Department of Education, which funds the Individuals with Disabilities Education Act (IDEA).

Women In 2015, the U.S. population was estimated to include more than 320 million individuals, with females accounting for 50.8% of the total population (U.S. Census Bureau, 2016). Women are playing an increasingly important role in the delivery of health care. Not only do women remain the leading providers of care in the nursing profession, but they are also well represented in various other health professions, including allopathic and osteopathic medicine, dentistry, podiatry, and optometry (FIGURE 25-9).

FIGURE 25-9 Percentage of female students of total enrollment in schools for selected health occupations, 2013–2014. Data from Association of American Medical Colleges (AAMC). 2017. The state of women in academic medicine: The pipeline and pathways to leadership, 2013-2014. Available at: https://www.aamc.org/members/gwims/statistics/#bench.

Description Women in the United States can expect to live about 4.8 years longer than men (NCHS, 2013), but they suffer greater morbidity and poorer health outcomes. Morbidity is greater among women than among men, even after childbearing-related conditions are factored out. For instance, nearly 38% of women report having chronic conditions that require ongoing medical treatment, compared to 30% of men (Salganicoff et al., 2005). Women also have a higher prevalence of certain health problems

than men over the course of their lifetimes (Sechzer et al., 1996). Heart disease and stroke account for a higher percentage of deaths among women than among men at all stages of life. Approximately 42% of women who have heart attacks die within a year, compared to 24% of men who have heart attacks (Misra, 2001). Research has also demonstrated that women are more likely to experience functional limitations due to health than men (35% and 26%, respectively; NCHS, 2013). Among respondents to the 2014 National Health Interview Survey, 60.2% of women reported being in excellent or very good health, 26.8% reported being in good health, and 13% reported being in fair or poor health (NCHS, 2016a). Self-reported health status was similar among men and women but varied greatly with age and educational attainment (NCHS, 2016a). Overall, though, women reported more physically and mentally unhealthy days than men. Women reported an average of 4.2 days of poor physical health, compared to 3.5 days per month for men in 2014. Similarly, women reported an average of 4.2 mentally unhealthy days, whereas men reported an average of 3.1 such days per month (CDC, 2014a). The CDC defines binge drinking as consuming four or more drinks on a single occasion for women and five or more drinks on a single occasion for men. In 2015, men were more likely than women to report both binge drinking (29.9% versus 17.4%, respectively) in 1 day at least once in the past year. However, among women, incidence of heavy drinking increased from 11.2% in 2004 to 17.4% in 2015 (NCHS, 2016a). An estimated 13.6% of women 18 years and older currently smoke cigarettes, with this rate having declined in recent years (NCHS, 2016a). Overweight and obesity are associated with an increased risk of numerous diseases and conditions. In 2011–2014, 38.8% of U.S. women 20 years and older were obese, which was higher than the corresponding rate for men (34.5%). In addition, obesity has increased significantly over the past decade for non-Hispanic black and Mexican American women, contributing to widening health disparities. The rates of obesity among females in 2011–2014 were 36.2% in non-Hispanic white women, 56.9% in non-Hispanic black women, and 45.0% in Hispanic women (NCHS, 2016b). In 2014, 1,298,177 women ages 18 and older died in the United

States. Of these deaths, nearly half were attributable to heart disease and cancer—responsible for 22.3% and 21.6% of deaths, respectively. Compared to men, women also had a greater relative burden of mortality from chronic lower respiratory disease (6%), which was the third leading cause of death for women but the fourth leading cause for men. After stroke, Alzheimer’s disease was the fifth leading cause of death for women; by comparison, it ranked eighth as a cause of death for men (CDC, 2015b). Between 2000 and 2014, three causes of death increased in relative burden among women: chronic lower respiratory diseases (from 5.1% to 6.0% of deaths), Alzheimer’s disease (from 2.9% to 5% of deaths), and unintentional injury (from 2.6% to 3.9% of deaths) (CDC, 2015b). In terms of health insurance coverage, most of the 98 million women ages 19 to 64 residing in the United States had some form of coverage in 2015 (Kaiser Family Foundation, 2016c). However, gaps in private-sector and publicly funded programs left 11% of women uninsured. In addition, women were less likely than men to be insured through their own jobs (35% versus 44%, respectively) and more likely to be covered as a dependent (24% versus 16%, respectively) (Kaiser Family Foundation, 2016c). There was considerable state-level variation in uninsured rates across the United States, with these rates ranging from 21% of women in Texas to 4% of women in Washington, D.C. (Kaiser Family Foundation, 2016c). Low-income women, women of color, and immigrant women were also at greater risk of being uninsured (Kaiser Family Foundation, 2016c).

Office on Women’s Health The Public Health Service’s Office on Women’s Health (OWH) is dedicated to the achievement of a series of specific goals that span the spectrum of disease and disability. These goals range across the life cycle and address cultural and ethnic differences among women. OWH promotes, coordinates, and implements a comprehensive women’s health agenda on research, service delivery, and education across various government agencies. OWH was responsible for implementing the National Action Plan on Breast Cancer (NAPBC), a major public–private partnership dedicated to

improving the diagnosis, treatment, and prevention of breast cancer through research, service delivery, and education. OWH also worked to implement measures to prevent physical and sexual abuse against women, as delineated in the Violence Against Women Act of 1994. This agency is currently active in projects promoting breastfeeding, women’s health education and research, girl and adolescent health, and heart health. Within the Substance Abuse and Mental Health Services Administration (SAMHSA), the Advisory Committee for Women’s Services has targeted six areas for special attention: physical and sexual abuse of women; women as caregivers; women with mental and addictive disorders; women with HIV/AIDS, sexually transmitted diseases, and/or tuberculosis; older women; and women detained in the criminal justice system. The Women’s Health Initiative, supported by the National Institutes of Health (NIH), was the largest clinical trial conducted in U.S. history, involving more than 161,000 women (NIH, 2002). It focused on diseases that are the major causes of death and disability among women—heart disease, cancer, and osteoporosis. In 2002, the Women’s Health Initiative published a groundbreaking study, finding detrimental effects of postmenopausal hormone therapy on women’s development of invasive breast cancer, coronary heart disease, stroke, and pulmonary embolism (NIH, 2002).

Women and the U.S. Health Care System Women face a distinct disadvantage in obtaining employer-based health insurance coverage because they are more likely than men to work part time, receive lower wages, and have interruptions in their work histories. Hence, married women are more likely to be covered as dependents under their husbands’ plans and are at a higher risk of being uninsured. Women also place greater reliance on Medicaid for their healthcare coverage. In 2014, 11.9% of women were uninsured compared to 14.7% of men, and 21.4% of women were covered by Medicaid compared to 17.8% of men (NCHS, 2016b). Women are more likely than men to use contraceptives (FIGURE 25-10), but contraceptives have been among the most poorly covered

reproductive healthcare services in the United States. As of September 2013, 28 states required private health insurance plans to cover prescription contraceptives if they covered other prescription drugs (Guttmacher Institute, 2013).

FIGURE 25-10 Contraceptive use in the past month among women 15–44 years old, 2011–2013. Note: Numbers may not add to 100 because of rounding. Data from National Center for Health Statistics (NCHS). 2016b. Health, United States, 2015. Hyattsville, MD: U.S. Department of Health and Human Services. pp. 81–82.

Description The ACA required private insurance to cover, with no cost sharing, a wide variety of preventive services and additional services for women, including Food and Drug Administration (FDA)‒approved prescription contraceptives, domestic violence screening, breastfeeding supports, and human papillomavirus (HPV) testing. Although such services are not required under Medicaid, several states have started to cover all preventive services important for women with or without cost sharing (Kaiser Family Foundation, 2013). It remains to be seen how these services may be affected by the ACA replacement.

Rural Health For rural citizens, access to health care may be affected by poverty, long distances to service providers, rural topography, weather conditions, lack of transportation, and being uninsured. Consequently, residents of rural areas are less likely to utilize health services, and they have poorer health outcomes than their counterparts in more urban areas. A greater percentage of persons residing in a rural area report being in fair or poor health compared to those in urban areas (National Rural Health Association, 2016). In addition, rural residents are more likely to report health problems, such as headaches and back and neck pain, than urban residents—17.2% versus 14.7%, respectively (CDC, 2012a, 2012b). People in rural areas are more likely than urban residents to forgo or delay care due to cost—15.6% versus 13.3%, respectively (Ziller et al., 2015). Across all races and ethnicities, rural residents have lower levels of insurance coverage. Among Hispanic rural residents, 45.3% do not have health insurance, compared to 40.9% of urban Hispanics. Among whites, 21.3% of rural residents were uninsured, compared to 13.1% of urban residents (U.S. Census Bureau, 2014; Ziller, 2014). The uninsured often do not have a usual source of care (Larson & Fleishman, 2003). Geographic maldistribution that creates a shortage of healthcare professionals in rural settings results in barriers in access to care. As of January 2017, there were approximately 6,600 designated primary care health professional shortage areas (HPSAs), 5,500 dental HPSAs, and 4,600 mental health HPSAs in the United States (HRSA, 2017b). Nearly 21% of the U.S. population resides in rural areas where primary care health professionals are in short supply (HRSA, 2018). More than 57 million Americans live in a nonmetropolitan federally designated health professional shortage area (HRSA, 2018b). The scarcity of healthcare providers encompasses a broad spectrum of professionals, including pediatricians, obstetricians, internists, dentists, nurses, and allied health professionals (Patton and Puskin, 1990). Rural hospitals are often under financial strain, which results in these facilities generally being smaller hospitals that provide fewer services than urban hospitals. Various steps have been taken to improve access in rural America,

including the promotion of the National Health Service Corps (NHSC), the designation of HPSAs and medically underserved areas (MUAs), the development of community and migrant health centers (C/MHCs), and the enactment of the Rural Health Clinics Act. In 2015, there were 4,099 certified rural health clinics throughout the United States (Kaiser Family Foundation, 2015). In addition, the Federal Office of Rural Health Policy, within the Health Resources and Services Administration of the U.S. Department of Health and Human Services (USDHHS), was established in 1987 to promote better health care in rural America (HRSA, 2015). Several measures and enhanced funding have been initiated to improve rural emergency medical services, to bolster the rural health workforce, and to develop behavioral health capacity in rural areas (National Conference of State Legislatures, 2013).

National Health Service Corps The NHSC was created in 1970, under the Emergency Health Personnel Act, with the intention being to recruit and retain physicians to provide needed services in areas with physician shortages. A 1972 amendment created a scholarship program targeting HPSAs. The scholarship and loan repayment program applies to doctors, dentists, nurse practitioners, midwives, and mental health professionals who serve a minimum of 2 years in underserved areas. Since 1972, more than 50,000 health professionals have been placed in medically underserved communities in hospitals and clinics (HRSA, 2013). Currently, nearly 10,400 health professionals are providing services under the NHSC (HRSA, 2017b).

Health Professional Shortage Areas The Health Professions Educational Assistance Act of 1976 provided the designation criteria for health manpower shortage areas, later renamed health professional shortage areas (HRSA, 2007). The act provided that three different types of HPSAs could be designated: geographic areas, population groups, and medical facilities. A geographic area must meet the following three criteria for designation as a primary care HPSA: 1. The geographic area involved must be rational for the delivery of

health services. 2. One of the following conditions must prevail in the area: • The area has a population to full-time equivalent primary care physician (PCP) ratio of at least 3,500:1. • The area has a population to full-time equivalent PCP ratio of less than 3,500:1 but greater than 3,000:1 and has unusually high needs for primary care services or insufficient capacity of existing primary care providers. 3. Primary care professionals in contiguous areas are overutilized, excessively distant, or inaccessible to the population of the area under consideration (HRSA, 2007). A population group can be designated as an HPSA for primary care if it can be demonstrated that access barriers prevent members of the group from using local providers. Medium- and maximum-security federal and state correctional institutions and public or nonprofit private residential facilities can be designated as facility-based HPSAs. HPSAs are classified on a scale of 1 to 4, with scores of 1 and 2 signifying areas of greatest need.

Medically Underserved Areas The primary purpose of the MUA designation, which was established in the HMO Act of 1973, was to target the community health center and rural health clinic programs. The 1973 statute required that several factors be considered in designating MUAs, such as available health resources in relation to area size and population, health indices, and care and demographic factors affecting the need for care. To meet this mandate, the Index of Medical Underservice was developed, comprising four variables: Percentage of population below poverty income levels Percentage of population 65 years of age and older Infant mortality rates Number of primary care practitioners per 1,000 population The index yields a single numerical value on a scale from 0 to 100; any area with a value less than 62 (the median of all counties) is designated

as an MUA.

Migrant Workers Migrant workers are farm workers who travel long distances from their primary residence or lack a primary residence entirely, either due to seasonal crop changes or work availability. Although their exact number is difficult to assess because of citizenship issues and the transient nature of this population, it is widely accepted that there are at least 3 million migrant workers in the United States (Larson and Plascencia, 1993; National Center for Farmworker Health, 2012, 2018; Rust, 1990). The migrant population is largely composed of racial and ethnic minorities. As of 2009, 72% of migrant workers in the United States were born in Mexico or Central America (U.S. Department of Labor, 2011). In 2009, the average annual income of a family in which at least one member is a migrant worker was between $17,500 and $19,999. Furthermore, only 43% of workers were currently receiving any public assistance (U.S. Department of Labor, 2011). As of 2013–2014, approximately 84% of migrant workers were uninsured (U.S. Department of Labor, 2016). Furthermore, approximately 30% of female migrant workers who become pregnant do not have their first prenatal visit until their second trimester, and approximately 14% do not have their first visit until their third trimester (Bircher, 2009). In addition to the occupational health risks to which this population is exposed, their lack of access to and utilization of health services translates into poor health outcomes. The rate of obesity among migrant workers has risen to 81% of males and 76% of females (Villarejo et al., 2000). These rates are not found among migrant workers during their first year in the United States, so dietary changes in later years likely account for these high rates of obesity. In addition to higher rates of chronic conditions, migrant populations are at greater risk for developing infectious diseases. Notably, in part due to their living conditions, migrant workers are at greater risk of contracting tuberculosis (TB). In total, 388 agricultural worker patients were diagnosed with TB at migrant health centers in 2011, equating to a prevalence rate of 48.8 cases per 100,000 population. In comparison, nonagricultural worker patients at all health centers in 2011 had a prevalence rate of 33.1 TB cases per 100,000

population (National Center for Farmworker Health, 2015). The rate of HIV/AIDS is also considerably higher in the migrant worker population than in the general population, with observed rates between 5% and 26% (National Center for Farmworker Health, 2011). To address the growing health needs of this population, services have been provided to migrant workers and their families through state programs and through HRSA’s Migrant Health Program.

Community and Migrant Health Centers Community and migrant health centers (CMHCs) provide services to lowincome populations on a sliding-fee scale, thereby addressing both geographic and financial barriers to access. Whereas community health centers must be located in areas designated as MUAs, migrant centers must be located in “high-impact” areas, defined as areas that serve at least 4,000 migrant and/or seasonal farm workers for at least 2 months per year. For more than 4 decades, CMHCs have provided primary care and preventive health services to populations in designated MUAs. Because of a shortage of physicians, CMHCs heavily rely on nonphysician providers (NPPs) to deliver care. In 2015, CMHCs served approximately 898,950 migrants and seasonal farm workers (HRSA, 2015).

Rural Health Clinics Act The Rural Health Clinics Act was developed in 1977 to respond to the concern that isolated rural communities could not generate sufficient revenue to support the services of a physician. In many cases, the only sources of primary care or emergency services in these areas were NPPs, who were ineligible at that time for Medicare or Medicaid reimbursement. The Rural Health Clinics Act permitted physician assistants (PAs), nurse practitioners (NPs), and certified nurse–midwives (CNMs) associated with rural clinics to practice without the direct supervision of a physician; enabled rural health clinics (but not NPPs directly) to be reimbursed by Medicare and Medicaid for their services; and tied the level of Medicaid payment to the level established by Medicare.

To be designated as a rural health clinic, a public- or private-sector physician practice, clinic, or hospital must meet several criteria, including location in an MUA, geographic HPSA, or a population-based HPSA. More than 4,000 rural health clinics currently provide primary care services to more than 8 million people in 50 states (HRSA, 2017b).

The Homeless Although their exact number is unknown, an estimated 3.5 million people (1.35 million of whom are children) are likely to experience homelessness in a given year (National Law Center on Homelessness and Poverty, 2015). Across the United States, approximately 1 in 200 people became homeless in 2011 (U.S. Department of Housing and Urban Development [USHUD], 2012). Although most homeless persons live in major urban areas, a surprising 27.7% live in suburban and rural areas (USHUD, 2012). The adult homeless population is composed of 63% men and 37% women (USHUD, 2012). An estimated 22.8% of all homeless people are children younger than the age of 18, 35.8% are families with children, and 14% are veterans (USHUD, 2012). Homeless women, in particular, face major difficulties: economic and housing needs and special gender-related issues that include pregnancy, childcare responsibilities, family violence, fragmented family support, job discrimination, and wage discrepancies. The economic standing of women is often more unstable than that of men, and women are more likely to live in poverty than men. In 2015, 17 million women were living in poverty in the United States, of whom 46% were in extreme poverty (National Women’s Law Center, 2015). The low wages and extreme poverty faced by women increase their risk for becoming homeless. In addition, domestic violence is a factor that contributes to family homelessness, with 18% of families citing this issue as the main cause of their status (U.S. Conference of Mayors, 2011). Among all homeless women, one in four state that their homelessness was a direct result of violence committed against them (Jasinski et al., 2005). Homeless women, regardless of parenting status, should be linked with social services, family support, self-help, and housing resources. Mentally ill women caring for children need additional consideration, with an emphasis on parenting skills and special services for children. Thus, homelessness is a multifaceted problem related to personal, social, and economic factors. The economic picture for homeless persons is dismal and suggests

that homeless persons are severely lacking in the financial and educational resources necessary to access health care. A majority (60%) of mothers living in poverty who have ever been homeless did not complete high school (Institute for Children, Poverty, and Homelessness, 2011). In addition, approximately 38% of the homeless population is unsheltered, living in the streets or outside (National Alliance to End Homelessness, 2012). Receipt of public benefits among the homeless is low. For example, a survey revealed that among more than 9,000 clients served by Maryland’s Health Care for the Homeless, 75% were uninsured (Health Care for the Homeless, 2012). The number of homeless individuals who receive public benefits remains low because of federal restrictions that prohibit giving federal help to persons without a physical street address. The shortage of adequate low-income housing is the major precipitating factor for homelessness. Unemployment, personal or family life crises, rent increases that are out of proportion to inflation, and reduction in public benefits can also directly result in the loss of a home. Illness, by comparison, tends to result in the loss of a home in a more indirect way. Another indirect cause of homelessness is deinstitutionalization of individuals from public mental hospitals, substance abuse programs, and overcrowded prisons and jails. Community-based residential alternatives for mentally ill individuals vary from independent apartments to group homes staffed by paid caregivers. Independent living may involve either separate apartments or single-room occupancy units in large hotels, whereas group homes are staffed during at least a portion of the day and traditionally provide some on-site mental health services (Schutt and Goldfinger, 1996). The homeless—both adults and children—have a high prevalence of untreated acute and chronic medical, mental health, and substance abuse problems. The reasons for this increased prevalence are debatable. Some argue that people may become homeless because of a physical or mental illness. Others argue that homelessness itself may lead to the development of physical and mental disability because homelessness is associated with specific risk factors, such as excessive use of alcohol, illegal drugs, and cigarettes; sleeping in an upright position, which results in venous stasis and its consequences; extensive walking in poorly fitting shoes; and grossly inadequate nutrition. Although

the reasons for the generally poorer health of the homeless may not be agreed upon, the outcomes are easily seen. Homeless adults typically have eight to nine medical conditions or illnesses (Breakey et al., 1989). Homeless children have a risk of mortality nearly double that of housed children (Kerker et al., 2011). Homeless persons are also at a greater risk of assault and victimization regardless of whether they live in a shelter or outdoors. Many are exposed to extreme heat, cold, and other weather conditions. They are also exposed to illness because of overcrowding in shelters and overexposure to weather. Between 2015 and 2016, the number of people experiencing homelessness in the United States declined by 3%; these decreases occurred mostly because of people staying in sheltered locations, whereas homelessness increased among people staying in unsheltered locations (USHUD, 2016). Chronic homelessness among individuals declined by 7% between 2015 and 2016 (USHUD, 2016).

Barriers to Health Care The homeless face barriers to obtaining ambulatory services but incur high rates of hospitalization. A high use of inpatient services in this manner amounts to the substitution of inpatient care for outpatient services. Both individual factors (competing needs, substance dependence, and mental illness) and system factors (availability, cost, convenience, and appropriateness of care) account for the barriers to adequate ambulatory services. Other barriers to accessing health care include lack of accessible transportation to medical care providers and competing needs for basic food, shelter, and income, which often take precedence over obtaining health services or following through with a prescribed treatment plan. Homeless individuals who experience psychological distress and disabling mental illness may be in the greatest need of health services, yet may be the least able to obtain them. This inability to obtain health care may be attributable to such individual traits of mental illness as paranoia, disorientation, unconventional health beliefs, lack of social support, lack of organizational skills to gain access to needed services, and fear of authority figures and institutions resulting from previous

institutionalization. The social conditions of street life also affect compliance with medical care, as unsheltered persons often lack proper sanitation and a stable place to store medications. In addition, they lack resources to obtain proper food for the medically indicated diets necessary for conditions such as diabetes or hypertension. Federal efforts to provide medical services to the homeless population are delivered primarily through the Health Care for the Homeless (HCH) program. Community health centers supported by the 1985 Robert Wood Johnson Foundation/Pew Memorial Trust HCH program (subsequently covered by the 1987 McKinney Homeless Assistance Act) have addressed many of the access and quality-of-care issues faced by the homeless. In 2015, U.S. community health centers served approximately 1.2 million homeless patients (HRSA, 2015). A walk-in appointment system reduces access barriers at these medical facilities. Medical care, routine laboratory tests, substance abuse counseling, and some medications are provided free of charge to eliminate financial barriers. The Mental Health Services for the Homeless Block Grant program sets aside funds for states to implement services for homeless persons with mental illness. These services include outreach services; community mental health services; rehabilitation; referrals to inpatient treatment, primary care, and substance abuse services; case management services; and supportive services in residential settings. Services for homeless veterans are provided through the Department of Veterans Affairs (VA). The Homeless Chronically Mentally Ill Veterans Program provides outreach, case management services, and psychiatric residential treatment for homeless mentally ill veterans in communitybased facilities in 45 U.S. cities. Homelessness among veterans declined by 47% between 2009 and 2016 (USHUD, 2016). The Domiciliary Care for Homeless Veterans Program addresses the health needs of veterans who have psychiatric illnesses or alcohol or drug abuse problems; it offers over 2,000 beds at 43 sites across the United States (U.S. Department of Veterans Affairs, 2012). This program had nearly 8,000 episodes of care in 2010 (U.S. Department of Veterans Affairs, 2012). The Salvation Army also provides a variety of social, rehabilitation, and support services for homeless persons. Its centers include adult rehabilitation and food programs and permanent and transitional housing.

Mental Health Mental disorders are common psychiatric illnesses affecting adults and present a serious public health problem in the United States. Mental disorders are among the leading cause of disability for the U.S. population (CDC, 2014b). Mental illness is a risk factor for death from suicide, cardiovascular disease, and cancer. Suicide is currently the tenth leading cause of death in the United States and the fourth leading cause of death among persons aged 22–44 (CDC, 2015b). Non-Hispanic white men 85 years or older have one of the highest rates of suicide— approximately 50 suicide deaths per 100,000 population (Population Reference Bureau, 2006). AIAN males are at higher risk for suicides as well; their mortality rate from this cause is approximately 16 suicide deaths per 100,000 population (CDC, 2015b). Mental health disorders can be either psychological or biological in nature. Many mental health diseases—including mental retardation (MR), developmental disabilities (DD), and schizophrenia—are now known to be biological in origin. Other behaviors, including those related to personality disorders and neurotic behaviors, are still subject to interpretation and professional judgment. National studies have concluded that the most common mental disorders are phobias; substance abuse, including alcohol and drug dependence; and affective disorders, including depression. Schizophrenia is considerably less common, affecting an estimated 0.6% of the U.S. population (Reeves et al., 2011). Nearly one in five adults experiences a mental disorder every year (National Institute of Mental Health [NIMH], 2015). In 2015, 43.4 million adults (18 years or older) had a mental illness, including 9.8 million adults with severe mental illness (SMI) (NIMH, 2015). Among adults with any diagnosable mental disorder, 62.1% did not seek mental health treatment (SAMHSA, 2012a, 2012b). Prevalence of SMI was higher among Medicaid recipients, women, and individuals in the 18–25 age group (SAMHSA, 2012a, 2012b). The mental health of children has drawn increasing attention in recent years. More than one in five children has a mental disorder—a higher

rate than that for adults; approximately 4 million children or adolescents have SMIs (NIMH, 2015). Only half of those children diagnosed with mental health disorders receive mental health services (U.S. Public Health Service, 2000). If left untreated, mental health problems in children can lead to more severe and/or co-occurring mental illness (Kessler et al., 1997). Most mental health services are provided in the general medical sector—a concept first described by Regier and colleagues (1988) as the de facto mental health service system—rather than through formal mental health specialist services. The de facto system combines specialty mental health services with general counseling services, such as those provided in primary care settings, nursing homes, and community health centers by ministers, counselors, self-help groups, families, and friends. Specifically, mental health services are provided through public and private resources in both inpatient and outpatient facilities. These facilities include state and county mental hospitals, private psychiatric hospitals, nonfederal general hospital psychiatric services, VA psychiatric services, residential treatment centers, and freestanding psychiatric outpatient clinics (TABLE 25-6). TABLE 25-6 Mental Health Organizations, 2010

Service and Organization

Number of Mental Health Organizations

All organizations

10,374

Psychiatric hospitals

648

General hospitals

1,170

Outpatient clinics

6,305

Residential treatment centers for emotionally disturbed children

781

All other

1,470

Data from Substance Abuse and Mental Health Services Administration (SAMHSA). 2014a.

National Mental Health Services Survey (N-MHSS): 2010. Data on mental health facilities. BHSIS Series S-69, HHS Publication No. (SMA) 14–4837. Rockville, MD: Author.

Description Total expenditures for mental disorders have increased dramatically in the last few decades, from $31 billion in 1986 to $172 billion in 2009 (SAMHSA, 2014b). Nevertheless, only 37.9% of all individuals with mental illness received mental health services, and only 48.5% of individuals covered under Medicaid/CHIP received care in 2010 (SAMHSA, 2012a, 2012b). The U.S. mental health system essentially consists of two subsystems: one primarily for individuals with insurance coverage or private funds and the other for those persons without private coverage.

Barriers to Mental Health Care Two main barriers to access for mental health care are commonly experienced across the United States: prohibitive costs of services and shortage of available mental health professionals. In 2013, among young adults who delayed or did not seek needed mental health care, 50.1% stated that their failure to seek care was due to the prohibitive cost of treatment (SAMHSA, 2015). In addition to being unable to cover the high costs of care, many individuals currently reside in a mental health professional shortage area. A mental health HPSA is defined as an area in which the population to mental health professional ratio is 30,000 people to 1 mental health professional and 30,000 people to 1 psychiatrist (Kaiser Family Foundation, 2017). As of 2017, there were more than 4,600 mental health HPSAs across the United States (Kaiser Family Foundation, 2017). This shortage translates to the available services being able to meet only 56% of the need for mental health services, leaving a large number of patients without needed care (Kaiser Family Foundation, 2017).

The Uninsured and Mental Health Patients without insurance coverage or personal financial resources are

treated in state and county mental health hospitals and in community mental health clinics. Care is also provided in short-term, acute care hospitals and emergency departments. Local governments are the providers of last resort, with the ultimate responsibility to provide somatic and mental health services for all citizens regardless of ability to pay.

The Insured and Mental Health For patients who have insurance coverage or personal ability to pay, availability of both inpatient and ambulatory mental health care has expanded tremendously in recent decades. Inpatient mental health services for patients with insurance are usually provided through private psychiatric hospitals. These hospitals may operate on either a nonprofit or a for-profit basis. Notably, there has been substantial growth in national chains of for-profit mental health hospitals. Patients with insurance coverage are also more likely to receive care through the offices of private psychiatrists, clinical psychologists, and licensed social workers. In addition, mental health services are provided by the VA and by the military health care system; however, access to these services is limited based on eligibility.

Managed Care and Mental Health Managed care has expanded its services to include delivery of mental health care. Many state and local governments have also contracted with managed care organizations (MCOs) to manage their full healthcare benefits packages, which include mental health and substance abuse services for their Medicaid enrollees. Many health maintenance organizations (HMOs) contract with specialized companies that provide managed behavioral health care, an arrangement called a carve-out; such carve-outs are implemented mainly because HMOs typically lack the in-house capacity to provide treatment. Using case managers and reviewers, most of whom are psychiatric nurses, social workers, and psychologists, these specialized companies oversee and authorize the use of mental health and substance abuse services. The case reviewers, using clinical protocols to guide them, assign patients to the least expensive appropriate treatment,

emphasizing outpatient alternatives over inpatient care. Working with computerized databases, a reviewer studies a patient’s particular problem and then authorizes an appointment with an appropriate provider in the company’s selective network. On average, psychiatrists constitute approximately 4.5% of any given provider network, psychologists 18%, counselors 17%, and psychiatric social workers 65% (NIMH, 2015).

Mental Health Professionals A variety of professionals provide mental health services (TABLE 25-7), including, but not limited, to psychiatrists, psychologists, social workers, nurses, counselors, and therapists. TABLE 25-7 Mental Health Providers by Discipline, Selected Years Staff Discipline

Number

Year

Psychiatrists

33,727

2011

Child and adolescent psychiatrists

6,398

2009

Psychologists

95,545

2011

Clinical social workers

193,038

2008

Psychiatric nurses

13,701

2011

Substance abuse counselors

48,080

2011

Counselors

144,567

2011

Marriage and family therapists

62,316

2011

Data from Substance Abuse and Mental Health Services Administration (SAMHSA). 2013. Behavioral health, United States, 2012. Available at: http://archive.samhsa.gov/data/2012BehavioralHealthUS/2012-BHUS.pdf.

Description

Psychiatrists are physicians who specialize in the diagnosis and treatment of mental disorders. They receive postgraduate specialty training in mental health after completing medical school. Psychiatric residencies cover medical—as well as behavioral—diagnosis and treatments. A relatively small proportion of the total mental health workforce consists of psychiatrists, but they exercise disproportionate influence in the system by virtue of their authority to prescribe drugs and admit patients to hospitals. Psychologists usually hold a doctoral degree, although some have master’s degrees. These professionals are trained in interpreting and changing the behavior of people. Psychologists cannot prescribe drugs, but they provide a wide range of services to patients with neurotic and behavioral problems. Psychologists use such techniques as psychotherapy and counseling, which psychiatrists typically do not engage in. Psychoanalysis is a subspecialty in mental health that involves the use of intensive treatment by both psychiatrists and psychologists. Social workers receive training in various aspects of mental health services, particularly counseling. These professionals are trained at the master’s degree level. They also compete with psychologists for patients. Nurses are involved in mental health care through the subspecialty of psychiatric nursing. Specialty training for nurses had its origins in the latter part of the 1800s. Nurses provide a wide range of mental health services. Advanced practice nurses who received education and certification as a psychiatric-mental health nurse practitioner (PMHNP) assess, diagnose, and treat individuals and families with psychiatric disorders using their full scope of therapeutic skills, including the prescription of medication and administration of psychotherapy. Many other healthcare professionals, including marriage and family counselors, recreational therapists, and vocational counselors, contribute to the array of available services. Numerous people work in related areas, such as adult day care (ADC) and alcohol/drug abuse counseling, and as psychiatric aides in institutional settings.

The Chronically Ill Chronic diseases are now the leading cause of death in the United States —heart disease, cancer, and diabetes account for more than 50% of all U.S. deaths each year. Overall, 7 out of 10 deaths each year are from chronic diseases (CDC, 2019a). Heart disease is the number one cause of death in the United States, with a mortality rate of 167 deaths per 100,000 persons (NCHS, 2016b). The prevalence of heart disease from 2013 to 2014 was 10.7%, which is equal to 36.1 million Americans having some form of this disease (NCHS, 2016b). In 2010, more than 1 in 4 adults (80 million Americans) had more than one chronic illness (Ward and Schiller, 2013). Chronic disease results in adverse consequences such as limitations on daily life activities. Among normal-weight adults with one or more chronic illnesses, the number of sick or unhealthy days they experience each month leads to loss of productivity that costs more than $15 billion per year (Witters and Agrawal, 2011). For overweight or obese adults with one or more chronic illnesses, this loss is more than double—an estimated $32 billion annually. Overall, the total loss of productivity due to overweight, obesity, or other chronic illnesses is estimated at more than $153 billion each year. The loss in human potential and workdays notwithstanding, chronic disease is expensive. Chronic disease places a huge economic demand on the United States. Treatment of people with chronic diseases accounts for 86% of total U.S. healthcare costs, which amounted to $2.9 trillion in 2013 (CDC, 2015c). In 2008, expenditures related to obesity were an estimated $147 billion (Finkelstein et al., 2009). The total estimated cost of diagnosed diabetes in 2012 was $245 billion, including $176 billion in direct medical costs and $69 billion in decreased productivity (CDC, 2019). For the years 2009‒2012, the economic cost due to smoking was estimated to exceed $289 billion per year (CDC, 2019a). In addition, costs related to heart disease totaled more than $475 billion in 2009 (Lloyd-Jones et al., 2009). Much of the burden of chronic diseases results from four modifiable risk behaviors: physical activity, nutrition, smoking, and alcohol use

(CDC, 2010b). In 2017, more than half (54%) of adults 18 years or older did not meet the CDC’s recommendations for aerobic exercise or physical activity. In addition, 27% did not meet the recommendations for muscle-strengthening physical activity (CDC, 2017). There has also been a decline in participation in physical education classes among high school students, from 42% in 1991 to 31% in 2011. In addition, the U.S. population as a whole suffers from poor nutrition. In 2011, more than onethird (36%) of adolescents and 38% of adults said they ate fruits less than once a day, and 38% of adolescents and 23% of adults said they ate vegetables less than once a day (CDC, 2016c). More detailed coverage on chronic diseases can be found in the Beliefs, Values, and Health chapter.

Disability As of 2015, approximately 53 million people in the United States had a disability (CDC, 2015d). The prevalence of disability increases with age, with 70.5% of adults age 80 or older having a disability (U.S. Census Bureau, 2012b). The chronic conditions most responsible for disabilities are arthritis, heart disease, back problems, asthma, and diabetes (Kraus et al., 1996). Disabled individuals tend to be covered by public insurance (30% by Medicare and 10% by Medicaid), whereas those who have no disabilities are more likely to have private health insurance (U.S. Census Bureau, 2011e). In addition, Medicaid is the primary payer (40%) for longterm services and supports for disabled individuals, including nursing facility stays and home- and community-based services (Kaiser Family Foundation, 2014a). Disability can be categorized as mental, physical, or social; tests of disability tend to be more sensitive to some categories than others. Physical disability usually relates to a person’s mobility and other basic activities performed in daily life, mental disability involves both the cognitive and emotional states, and social disability is considered the most severe disability because management of social roles requires both physical and mental well-being (Ostir et al., 1999). The two commonly used measures of disability are activities of daily living (ADLs) and instrumental activities of daily living (IADLs). They are covered in the Beliefs, Values, and Health chapter. Another tool for

assessing disability is the Survey of Income and Program Participation (SIPP), which measures disability by asking participants about functional limitations (difficulty in performing activities such as seeing, hearing, walking, and having one’s speech understood). The ADL and IADL scales are more widely used than the SIPP. Despite the availability of community-based and institutional long-term care services for people with functional limitations, many people do not get the help they need with the basic tasks of personal care. It is estimated that approximately one in five individuals with an ADL limitation do not receive needed assistance (Newcomer et al., 2005). Furthermore, racial minorities are more likely to experience unmet personal assistance needs (Newcomer et al., 2005).

HIV/AIDS FIGURE 25-11 illustrates trends in AIDS reporting. The number of AIDS

cases reported increased between 1987 and 1993, decreased between 1994 and 1999, increased between 2000 and 2004, and has decreased since 2005 (U.S. Census Bureau, 2010c).

FIGURE 25-11 AIDS cases reported in the United States, 1987–2014. Data from Centers for Disease U.S. Census Bureau. 2001. Statistical abstract of the United States, 2001. Washington, DC: Government Printing Office. p. 119; U.S. Census Bureau. 2007. Statistical abstract of the United States, 2007. Washington, DC: Government Printing Office. p. 120; U.S. Census Bureau. 2008. Statistical abstract of the United States, 2008. Washington, DC: Government Printing Office. p. 121; U.S. Census Bureau. 2009a. Statistical abstract of the United States, 2009. Washington, DC: Government Printing Office. p. 120; U.S. Census Bureau. 2010e. Statistical abstract of the United States, 2010. Washington DC: Government Printing Office. p. 122; U.S. Census Bureau. 2012a. Statistical abstract of the United States, 2012. Washington DC: Government Printing Office. p. 125; Centers for Disease Control and Prevention (CDC). 2016a. HIV in the United States: At a glance. Available at: https://www.cdc.gov/hiv/statistics/overview/ataglance.html. Accessed March 2017.

Description In the United States, deaths from AIDS declined 19% between 2005 and 2014 (CDC, 2016a). Declines in reported AIDS cases are attributed

to new treatments; decreasing death rates may reflect the fact that benefits from new treatments are being fully realized. Consequently, the number of people living with AIDS has continued to increase. In 2010, 487,692 people were living with AIDS; by comparison, that figure was 341,332 in 2001 (CDC, 2011). Among blacks, Hispanics, and minority women, AIDS/HIV is still a major public health concern. In 2014, males and blacks continued to have significantly higher rates of HIV/AIDS than females and whites (TABLE 25-8). Notably, only among black males is HIV a leading cause of death (CDC, 2012c). In 2011, rates of AIDS cases were 51.3 cases per 100,000 people in the black population, 16.2 cases per 100,000 people in the Hispanic population, and 4.9 cases per 100,000 people in the white population (CDC, 2012d). Blacks accounted for a rate of annual diagnoses that was 8 times greater than the rate for whites in 2009 (CDC, 2013b). Racial differences in HIV/AIDS infection probably reflect social, economic, behavioral, and other factors associated with HIV transmission risks. TABLE 25-8 AIDS Cases Reported in the United States, 2010–2014 Cumulative and 2014

Description Data from National Center for Health Statistics (NCHS). 2016b. Health, United States, 2015. Hyattsville, MD: U.S. Department of Health and Human Services. p. 154.

HIV Infection in Rural Communities In 2015, 39,513 people were diagnosed with HIV infection in the United States, and 18,303 people were diagnosed with AIDS. Since the HIV/AIDS epidemic began in the early 1980s, a total of 1,216,917 people have been diagnosed with AIDS in the United States (CDC, 2016a). Rural persons with HIV and AIDS are more likely to be young, nonwhite, and female and to have acquired their infection through heterosexual contact. Additionally, a growing number of these HIV-

infected persons live in the rural South, a region historically characterized by a disproportionate number of poor and minority persons, strong religious beliefs and sanctions, and decreased access to comprehensive health services (CDC, 1995). Trends in new cases of HIV and AIDS in rural areas indicate that poor and nonwhite residents are disproportionately affected by these diseases (Aday, 1993; Lam and Liu, 1994).

HIV in Children In the absence of specific therapy to interrupt transmission of HIV, an HIV-infected woman has a 20% chance of having a child born with HIV (Cooper et al., 2000). Building on previous success with zidovudine monotherapy in the 1990s, clinical studies established the efficacy of antiretroviral therapy in reducing the mother-to-child transmission rate when administered prenatally (Cooper et al., 2000). Use of antiretroviral therapy has resulted in a decrease of the rate of mother-to-child transmission to only 2% (Cooper et al., 2000). Guidelines on the use of antiretroviral drugs in pregnant HIV/AIDS-infected women have now been established (NIH, 2012; World Health Organization, 2004). The importance of preventing perinatal transmission is underscored by the fact that 68% of all AIDS cases among U.S. children are caused by mother-to-child transmission in pregnancy, labor, delivery, or breastfeeding (CDC, 2016a). Children who are born with AIDS suffer from failure to thrive, which leaves them unable to grow and develop as healthy children. Without intervention, failure to thrive may lead to developmental delays that can have negative lifetime consequences for the child and his or her family.

HIV in Women Women account for a rapidly growing proportion of the population with HIV/AIDS. In 2015, women represented 51% of HIV/AIDS cases worldwide (UN Women, 2015). For black U.S. women age 15 to 44 and Hispanic women age 25 to 44, HIV/AIDS was among the top 10 causes of death in 2010 (CDC, 2019b). For women in general, heterosexual sexual practices, followed by injection drug use (IDU), are the greatest

causes of HIV exposure (CDC, 2019b). Aside from the inherent risks of IDU, drug use contributes to a higher risk of contracting HIV if heterosexual sex with an IDU user occurs or when sex is traded for drugs or money (CDC, 2013a). Black and Hispanic minority women are at particular risk for these modes of exposure. Despite accounting for less than one-fourth of the total U.S. female population, black and Hispanic women represent more than three-fourths (76%) of all AIDS cases in women (CDC, 2017a).

HIV/AIDS-Related Issues Need for Research HIV-related research is currently focusing on the development of a vaccine to prevent HIV-negative people from acquiring HIV. Researchers are also seeking to develop a therapeutic vaccine to prevent HIV-positive people from developing symptoms of AIDS. People with HIV/AIDS cover a broad spectrum of social classes, races, ethnicities, sexual orientations, and genders. Therefore, behavioral intervention research should focus particularly on the subpopulations most vulnerable to HIV infection and are in urgent need of preventive interventions. These groups include gay youth and young adults, especially those who are black and Hispanic; disenfranchised and impoverished women; heterosexual men, especially those who are black and Hispanic; inner-city youth; and out-of-treatment substance abusers and their sexual partners. Research should focus on not only the individual but also the impact of broader interventions (e.g., among drug users or those involved in sexual networks or community-wide groups) that change behavioral norms and consequently, affecting individual behavior (Merson, 1996).

Public Health Concerns Trends related to AIDS underscore the synergy between poverty and intravenous drug use. Further, control of the HIV epidemic among the poor is hampered by this population’s preoccupation with other problems related to survival, such as homelessness, crime, and lack of access to adequate health care.

Additionally, a relationship exists between the current tuberculosis epidemic and HIV. Indeed, tuberculosis, which is classified as an opportunistic infection (OI) in the HIV/AIDS setting, is the leading cause of death among HIV-infected people on a worldwide basis. Tuberculosis in HIV-infected persons is also a particular public health concern because HIV-infected persons are at greater risk of developing multidrug-resistant tuberculosis. Multidrug-resistant tuberculosis is understandably difficult to treat and can be fatal (CDC, 2017b). Reducing the spread of AIDS requires understanding and acceptance of a variety of sexual issues, ranging from the concept that even heterosexual men may engage in anonymous homosexual intercourse to the difficulty that adolescents may have controlling their sexual urges. Prejudice against gays and lesbians is manifested as homophobia, fear, and/or hatred of these individuals. Homophobia explains the initially slow policy-related response to the HIV epidemic. Unfortunately, testing for HIV may not limit the virus’s spread because many people who learn their HIV status do not change the behaviors that contribute to its spread. HIV infection has no cure, and current treatments do not affect the transmissibility of HIV. In some cases, criminal law has been used to contain the spread of HIV and to protect public health. For example, some U.S. laws require that persons convicted of sex offenses be tested for HIV. Most of these laws, however, are disproportionately enforced against prostitutes. These laws suggest that persons who test positive for HIV may receive longer prison sentences; however, it is questionable whether this type of punishment actually reduces the spread of HIV. Health promotion efforts, including those used to reduce the transmission of HIV, are often hamstrung by psychosocial and other factors. For example, humans generally have difficulty changing their behaviors. Further, much human behavior is associated with functional needs (e.g., unsafe sex might fulfill a need for intimacy). Social learning theory explains that behavior change first requires knowledge, followed by a change of attitude or perspective.

Discrimination HIV-positive people may experience discrimination in access to health

care. The policies of various government agencies intended to help have also had a discriminatory impact on people with HIV/AIDS. For example, the Social Security Administration has not historically considered many of the HIV-related symptoms of women and IV drug users in adjudicating disability claims. Although the Department of Defense provides adequate medical care to individuals who acquire HIV in the military, recruits who test positive for HIV cannot join the military.

Provider Training Increased knowledge about HIV and personal contact with people who have HIV have improved the attitudes of healthcare providers toward individuals with HIV and contributed to their willingness to care for people with HIV. Training of healthcare professionals should encompass not only medical and treatment-related information but also a range of competencies related to interpersonal skills. In the area of psychosocial skills, the following characteristics are essential in an effectively trained provider: good communication skills (ability to establish rapport, ask questions, and listen), positive attitudes (respect, empowerment, trust), and an approach that incorporates principles of holistic care. In the area of cultural competence, essential elements include understanding of and respect for the person’s specific culture; understanding that racial and ethnic minorities have important and multiple subdivisions or functional units; acknowledging the issues of gender and sexual orientation within the context of cultural competence; and respecting the customs, including modes of communication, of the person’s culture. In the area of substance abuse, the following elements are essential for primary care providers: understanding the complex medical picture presented by a person who suffers from both HIV and addiction; understanding the complicated psychosocial, ethical, and legal issues related to care of addicted persons; and being aware of personal attitudes about addiction that may impair providers’ ability to give care objectively and nonjudgmentally (e.g., in the administration of pain medication; Gross and Larkin, 1996).

Cost of HIV/AIDS

Medical care for patients with HIV/AIDS is extremely expensive. Pharmaceutical companies claim that the high prices they charge for AIDS drugs reflect their extensive investment in research and development of drugs. Medicaid currently covers more than 240,000 people with HIV (Kaiser Family Foundation, 2016a). In fiscal year (FY) 2016, combined federal and state Medicaid spending on persons with HIV totaled $9.4 billion, making it the largest source of public financing for HIV/AIDS care in the United States. Of this amount, the federal share was $5.9 billion in FY 2012, or 30% of federal HIV care spending (Kaiser Family Foundation, 2016a). Lack of insurance and underinsurance represent formidable financial barriers to HIV/AIDS care. The U.S. government also invests substantial amounts of money in research and development through research supported at the NIH and the CDC. Government programs spend money in several areas for HIV (FIGURE 25-12). Of these expenditures, 73% is devoted to antiretroviral medications, 13% to inpatient care, 9% to outpatient care, and 5% to other HIV-related medications and laboratory costs. For patients who initiate highly active antiretroviral therapy (HAART) when their CD4 cell count is 200/L, projected life expectancy is 22.5 years, discounted lifetime cost is $354,100, and undiscounted cost is $567,000 (Schackman et al., 2006). Indirect costs attributable to HIV/AIDS include lost productivity, largely because of worker morbidity and mortality. However, other factors affect cost projections associated with the HIV/AIDS epidemic, including the level of employment of HIV-positive people; regional differences in the cost of care, which is often associated with the lack of subacute care in many parts of the country; and the rate at which HIV spreads.

FIGURE 25-12 Federal spending for HIV/AIDS by category,1 FY 2016. 1 Categories may include funding across multiple agencies/programs. 2 The “global” category includes international HIV research at NIH.

Reproduced from Kaiser Family Foundation. 2016b. U.S. federal funding for HIV/AIDS: Trends over time. Available at: http://kff.org/global-health-policy/fact-sheet/u-s-federal-funding-for-hivaidstrends-over-time/. Accessed March 2017.

Description

Containment of escalating medical costs, including the coordination of medical care, is the objective of two HIV-specific efforts: the Medicaid waiver program and the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act. Through the Medicaid waiver program, states may design packages of services to specific populations, such as the elderly, the disabled, and persons who test HIV positive. At this time, it is unknown whether the program is cost effective. The passage of the Ryan White CARE Act in 1990 provided federal funds to develop treatment and care options for persons with HIV/AIDS (Summer, 1991). Title II of this legislation is administered by states and has been used to establish HIV clinics and related services in areas lacking the resources needed to offer this specialty care. Some public health systems have used Ryan White CARE Act money to provide HIV/AIDS services in rural communities in which poor or medically underserved persons lack access to adequate care. Federal spending attributable to the Ryan White CARE Act totaled an estimated $2.4 billion in 2016 (Kaiser Family Foundation, 2016b).

AIDS and the U.S. Healthcare System The course of AIDS is characterized by a gradual decline in the patient’s physical, cognitive, and emotional function and well-being. Such a comprehensive decline requires a continuum of care, including emergency care, primary care, housing and supervised living, mental health and social support, nonmedical services, and hospice care. This continuum can encompass elements such as outreach and case finding, preventive services, outpatient and inpatient care, and coordination of private and public insurance benefits. As HIV disease progresses, many persons become disabled and rely on public entitlement or private disability programs for income and healthcare benefits. These programs include Social Security Disability Income and Supplemental Security Income, administered by the Social Security Administration. Medicare and Medicaid become primary payers for health care because of the onset of disability and depletion of personal funds. Approximately 70,000 previously uninsured people with HIV/AIDS were expected to gain coverage under the ACA. Most of them would have gained insurance through Medicaid expansion (Kaiser Family

Foundation, 2014b).

Summary This chapter examines the major characteristics of certain U.S. population groups that face challenges and barriers in accessing healthcare services—namely, racial/ethnic minorities, children and women, persons living in rural areas, the homeless, migrants, mentally ill individuals, and persons with HIV/AIDS. The health needs of these population groups vary, as do the services available to them. The gaps that currently exist between these population groups and the rest of the population indicate that the United States must make significant efforts to address the unique health concerns of U.S. subpopulations.

Discussion Questions 1. How can the framework of vulnerability be used to study vulnerable populations in the United States? 2. What are the racial/ethnic minority categories in the United States? 3. What health challenges do white Americans face, compared with those faced by minorities? 4. What is the Indian Health Service? 5. Which health services are currently available for children? 6. What are the health concerns of women? 7. What are the challenges faced in rural health? 8. Which measures have been taken to improve access to care in rural areas of the United States? 9. What are the characteristics and health concerns of the homeless population? 10. How are mental health services provided in the United States? 11. How does AIDS affect different population groups in the United States? 12. What is the impact of the ACA on vulnerable populations?

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CHAPTER 26 Advanced Practice Nursing: The Nurse–Patient Relationship and General Ethical Concerns Aimee Milliken, Eileen Amari-Vaught, and Pamela J. Grace

Acknowledgment The authors wish to acknowledge the following graduate students at UMKC School of Nursing and Health Studies for their contributions to the social media case studies: Charles Mark Weatherby, Kristina Collins, Tria Doner, Joann Esponge, Nikki Harvey, Kalie Leinenbach, Julia Crouch, and Kristina Mitchell. Our privileges can be no greater than our obligations. The protection of our rights can endure no longer than the performance of our responsibilities. —John F. Kennedy, “The Educated Citizen,” Vanderbilt University 90th Convocation Address, May 18, 1963

CHAPTER OBJECTIVES 1. Identify which individual and environmental factors interfere with ethical nursing actions. 2. Describe ethical issues that can occur when obtaining one of the three types of informed consent. 3. Discuss proxy decision making and advance directives. 4. Understand the role of social media as it pertains to privacy and confidentiality in healthcare settings.

Introduction In this chapter we explore common issues faced by advanced practice nurses regardless of country of practice or specialty concentration. As reported in 2006, an estimated 24 countries have nurses practicing in advanced roles (Nieminen, Mannevaara, & Fagerström, 2011), and the number has likely increased since then. For this reason and where possible, the expertise of colleagues from countries outside the United States has been solicited to help understand and account for both similarities and differences in ethical issues faced by persons who are in a variety of roles and designations. For North America, and especially the United States, changes have been proposed (including the doctor of nursing practice curriculum) for the preferred education and credentialing of advanced practice nurses. To avoid confusion in this chapter, we use the acronyms APN (advanced practice nurse) or APRN (advanced practice registered nurse) to denote advanced practice nurses. Where the reader is likely to become confused, we spell out what we mean by a given acronym. It is important to consider the commonalities as well as differences in ethical issues faced by APNs across countries and settings. Contemporarily, there is wide interest in describing the scope and boundaries of such roles as well as in deriving a coherent and internationally acceptable definition of advanced nursing practice (INP/APN Network, 2016). Concerns have been raised that the APN role is becoming more aligned with medicine than nursing and is used in some countries to “fill a gap” created by physician shortages (Rolfe, 2014), leading to a loss of focus on nursing values in patient care. Hanson and Hamric (2003) have synthesized a definition of advanced practice nursing from several important source documents and their own experiences of the development of advanced practice: “Advanced nursing practice is the application of an expanded range of practical, theoretical, and research-based therapeutics to phenomena experienced by patients within a specialized clinical area of the larger discipline of nursing” (p. 205). The International Council of Nurses (ICN) Nurse Practitioner/Advanced Practice Nursing Network (INP/APN Network)

proposes that, “A Nurse Practitioner/Advanced Practice Nurse [is] a registered nurse who has acquired the expert knowledge base, complex decision-making skills and clinical competencies for expanded practice, the characteristics of which are shaped by the context and/or country in which s/he is credentialed to practice. A master’s degree is recommended for entry level” (INP/APN Network, 2016). Advanced nursing roles have existed for several decades in many countries: for example, midwifery and health visitors in the United Kingdom and other countries and nurse anesthetists in the United States. However, the first officially designated advanced practice role in the United States was that of nurse practitioner (NP) in the mid-1960s (Schober & Affara, 2006). Ketefian, Redman, Hanucharurnkul, Masterson, and Neves (2001) identified several critical factors that have been conducive to the development of these roles internationally. These are “environment; the health needs of society; the health workforce supply and demand; governmental policy and support; intra- and interprofessional collaboration; the development of nursing education; and documentation of effectiveness of the advanced role” (p. 152). The APN role is nevertheless a nursing role that is distinguishable from other nursing roles only by the breadth and depth of responsibility to patients implied by the term advanced practice. This means, for example, that APNs often oversee a patient’s total care in a given practice setting (e.g., primary care, anesthesia, midwifery, gerontology, etc.), and in alternate settings they also have expanded responsibilities. For example, in acute care they may be responsible for handling emergencies and ordering and carrying out invasive interventions. For this reason and in this sense, their moral responsibilities can sometimes seem more complex and onerous “than those of nurses who share [patient] oversight with other health-care professionals” (Grace, 2004b, pp. 321–322). Effective exploration of ethical issues faced in advanced practice, then, should reflect the implications of these broad role obligations. That is, although the ethical substance of situations may not differ from that faced by nurses in nonexpanded roles, advanced practice nursing ethics take into account the more extensive duties incurred in these roles. The following inquiry focuses on a variety of ethical problems and concerns that are common across many advanced practice settings. Such concerns are also discussed in general nursing ethics textbooks

and will not be unfamiliar to the seasoned clinician. Here, however, the implications of these issues are discussed specifically in terms of the APN’s augmented responsibilities. In this chapter we have expanded the analysis of ethical issues associated with the escalating use of social media and electronic health records and provided several cases at the end of the chapter for independent or group analysis. Illustrative examples are drawn from a variety of advanced practice sources and from our experiences as nurses and advanced practice nurses, as well as from cases shared by nurses in master’s-level ethics courses taught by two of the authors. Because it is not feasible to cover all issues that an APN is likely to encounter, it is suggested that any troubling issues that the student or graduate APN faces that are not directly addressed in this text be brought up for in-class exploration with faculty and peers or explored with colleagues using the insights and strategies provided here, or in other resources. Other helpful resources include clinical ethicists, philosophers who have ethics expertise, ethics websites, and networking groups. The next section is a comprehensive discussion of the demands of the nurse–patient relationship. Characteristics discovered to be essential for consistently good patient care and decision making are explored, with suggestions for their development. These qualities, which are sometimes called virtues, include the intentional use of intellect (thinking) to manage knowledge and affect (emotions and motivation) in decision making about good actions and persevering to carry out and evaluate those actions. Certain philosophers, such as Aristotle and more contemporarily Alasdair MacIntyre (2007), have argued that virtues can be developed through habitual practice. A person who develops a virtuous personality through habitual practice is predisposed to consistently engage in “good” actions. It is debatable whether all persons can become virtuous in this way or even that people who might be considered “good” persons always act in “good” ways (Doris & Moral Psychology Research Group, 2010; Kahnemann, 2011). Nevertheless, we should strive to develop qualities that are known to facilitate professional–patient relationships while remaining aware that circumstances “in the moment” are sometimes insurmountable and must be addressed at a different level. Examples of important qualities are discussed in more depth later in the chapter; they include such characteristics as empathy, veracity, transparency of

purpose, cultural sensitivity, motivation to act, courage to act, and perseverance in carrying an act through. A further important issue for all clinical and research settings is that of adequately informing patients (or their surrogate decision makers) about their options for care, treatments, and procedures. Thus, the parameters and demands of informed consent are explicated in this chapter, with the exception of informed consent regarding protection of human research subjects. Problems associated with the adequacy of informed consent to the provision of care and therapeutics include the issue of patients who lack decision-making capacity for a variety of reasons, persons who are difficult to engage with, and people who are making decisions that seem to be at odds with their own values. A further topic of investigation is that of privacy and confidentiality related to patients’ health information. In this highly technological age, it is becoming increasingly difficult to adequately protect patient information from entities that do not necessarily have a patient’s best interests in mind in seeking it. Additionally, inadvertent breaches of confidentiality can occur via the use of social media and in the use of electronic health records (EHR). Unethical use of social media can also lead to loss of trust in the involved profession (examples are provided later). The protection of information is multifaceted. One important aspect is transparency. The person at risk should be told for what purposes the data are required and to what uses they will be put, and (insofar as these are known) the risks and benefits of sharing the data. This is in addition to being careful about who can have access to a person’s data. Additionally, APNs often have concerns about how to maintain their personal integrity or self-respect when asked to participate in actions that contravene their deeply held values. Sometimes this is related to patient or peer requests to engage in something that is at odds with a nurse’s values, or it may be related to conflicts within the healthcare system, such as managed care or institutional pressures to limit care. Some of the sources of these concerns, along with strategies to address them, are presented. Finally, because some practice problems end up as complex and extremely difficult to sort out, the issue of preventive ethics is woven throughout this section. Many so-called dilemmas can actually be prevented or diffused by good communication or an early understanding of the likelihood that unaddressed problems might cause critical

difficulties for the patient in question and/or the patient’s significant others.

Virtue Ethics: The Characteristics of Good APNs Many people are attracted to the nursing profession because they see it as a practice that contributes to the good of individuals as well as the greater societal good. This is true not just at the undergraduate level but also for those who choose nursing as a second career and take an accelerated route to advanced nursing practice. Thus, the personal values of nurses are often congruent with the values of the nursing profession—for example, nascent nurses are drawn to the idea of contributing to the well-being of others—although it is also true that a nursing career may be viewed by some as one that offers a level of economic security. The desire to contribute to the welfare of others is often considered a virtue (as opposed to the desire to hurt someone, which would be considered a vice). As Feldman (1978) writes, in acknowledging that something is good, we are noting its qualities “relative to some class of comparison... some feature of that thing in virtue of which [we] hold it to be good. This feature is its virtue, or good-making characteristic” (p. 234). This section explores the issue of virtue ethics as it relates to good APNs, where good is taken to be synonymous with ethical. Virtue ethics in healthcare practice is essentially the idea that a person can cultivate certain characteristics (virtues) that will predispose him or her to good actions related to the profession’s predetermined goals. These goals are outlined in codes of ethics and in nursing’s historical documents and reflect the reason nursing exists as a profession. Contemporary proponents of virtue ethics almost all trace their influences back to Aristotle, although ideas about virtue can also be discovered in ancient texts on Eastern philosophy. Aristotle’s idea is that a good or virtuous person is someone who possesses practical wisdom or prudence. The Greek term for this is phronesis. Practical wisdom permits a man (in ancient times, women were considered subordinate to men) to understand both what is a good way to live and that living a good life necessarily means developing mutually beneficial relationships with

others. To act well, a man must learn to habitually moderate emotional impulses by using reasoning. This is what is required to achieve the desired purpose of living a good life. Eventually, a person will habituate himself to always engaging in good action: he will become a good or virtuous person. The desirable or virtuous purpose of all human beings, according to Aristotle, is to live in accordance with their human nature. The essential characteristic of human nature—that which distinguishes human nature from the nature of all other beings—is rationality. The ability of human beings to use logical reasoning gives human beings purpose, and that purpose is the pursuit of a satisfying life. The Greek term for this is eudaimonia, often also referred to as happiness, although it loses something in the translation and does not mean happiness in any superficial sense of the term (Hutchinson, 1995). Practical reason acts as a constraint on emotional and instinctual drives that can result in harmful actions on the one hand and on the other hand in a lack of needed action or inadequate action. Reason mediates a balance between extremes of action. For example, according to Aristotle, courage is a virtue. Unrestrained courage can cause unnecessarily risky behavior, which is therefore irrational. Alternatively, timidity about doing something important is problematic and also requires reason to moderate action. Practicing the development of virtue eventually leads to the formation of a virtuous character. Additionally, a satisfying life, which is necessarily lived within society and in relationships with others, facilitates harmony in these relationships. It is noteworthy that, for Aristotle, being virtuous has a self-focus, but nonetheless a harmonious society is also requisite for a satisfying life. Thus, the actions of a virtuous man have the serendipitous result of contributing to the good of others. How does this explanation of virtue pertain to the current project of understanding what characteristics are necessary for good practice? The answer is that contemporary moral philosophers, such as Elizabeth Anscombe (1958/1981), Bernard Williams (1985), and Alasdair MacIntyre (2007), have been interested in resurrecting the idea of virtue as a way to understand people’s relationships to each other and to inform provider– patient relationships. This move represents, in part at least, a way around the problem that deontological and consequentialist ethical theories do not account for the contextual and relationship-dependent nature of human life in situations where moral decision making is needed. Neither

do these theories always capture contingencies of healthcare providers’ multifaceted and relationally oriented roles. Moreover, contemporary research in psychology and the cognitive sciences has uncovered occult aspects influencing human action that may not easily be within conscious control (Eagleman, 2011). MacIntyre’s work, though not resulting in a theory that can be applied directly to action, does provide some unifying ideas about virtues (Sellman, 2000, p. 27). The constituents of virtue, or those characteristics that make a person virtuous in MacIntyre’s view, are context dependent. Thus, virtues may be “seen as supporting and maintaining particular ends” (Sellman, 2000, p. 27). Because virtues are seen as those characteristics necessary to support a particular end, goal, or practice, some common objections to the idea that a virtue ethic is helpful in healthcare practice are overcome (Armstrong, 2006; Begley, 2005; Sellman, 2000). Criticisms of virtue ethics include the observation that what is virtuous in one situation or in a given culture may not be considered virtuous in another. Therefore, there is no stable footing for the idea of a virtuous person, nor is there a list of virtues a person must possess to be virtuous. An additional and potentially serious criticism is that there is no external criterion (within virtue theory) for judging whether the actions of a virtuous person are actually good. There is no “gold standard” for good actions. Moreover, the actions of someone who is thought to be virtuous will not necessarily always be good; that is, they may not always be aimed at achieving a good for a variety of reasons, or they may fail to achieve a good. Many factors can interfere with a good person’s ability to do good actions, as listed in TABLE 26-1. TABLE 26-1 Factors That Interfere With Ethical Nursing Action Locus

Factors

Agent related

Level of moral development Capacity to recognize ethical content; Chambliss (1996) discusses the phenomenon of “routinization of disaster” Openness to reflection Personal or emotional issues Energy levels

Creativity Locus of control (powerfulness/powerlessness) Inability to connect with patient Fear of disapproval (peer or other) Disapproval of patient’s choice Time of day—complexity of preceding workload or decisions Level of knowledge related to the issue Subconscious cognitive processes—effects of unexamined “universal” cognitive biases—overreliance on intuitions (Doris & Moral Psychology Research Group, 2010; Kahnemann, 2011) Environmental

Pressures from peers—supervisors Competing demands (peers/patients/relatives/institution) Social sanction Economic and institutional conditions Time or resource constraints Conflicts of interest Job insecurity Catastrophic conditions

Description However, if certain virtues are viewed as pertaining to a particular professional practice and necessary for meeting the goals of that practice, then it is possible to evaluate a given action based on how well it addresses those goals. Because nursing is a practice profession with relatively well-articulated goals, it is possible to agree that persons who possess certain characteristics are more likely than those who do not to routinely engage in good practice and to be willing to address practice structures that interfere with good actions. A further consequence is that, as a profession, nursing must continue to investigate what the characteristics of a good nurse are and then nurture these traits during the education and mentoring of nurses. A big question for the profession itself is whether all prospective nurses are capable of developing the characteristics of good nurses. If not, what is the profession’s responsibility (assumed by its educators) to weed out those who are incapable of being or becoming good nurses?

Virtues of Nursing Nursing practice and the fulfillment of nursing goals, then, can be understood as requiring the development of certain facilitative

characteristics. Indeed, by exploring what is needed to provide good nursing care to patients—as outlined in the literature and in codes of ethics—relatively quickly, it becomes possible to compose a list of virtues that it would be desirable for nurses to cultivate. Additionally, nursing curricula should include strategies for nurturing these characteristics (Haggerty & Grace, 2008). Begley (2005) has composed such a list; it includes compassion, integrity, honesty, patience, tolerance, courage, imagination, perception, perseverance, self-reflection, and many more. For her dissertation, Optimizing Stewardship: A Grounded Theory of Nurses as Moral Leaders in the Intensive Care Unit, Breakey (2006) studied characteristics of nurses who reportedly engaged successfully in end-of-life (EOL) decisions. Salient characteristics for this important nursing role included understanding the professional obligations of the role, the ability to empathize with others, and willingness to understand an issue in detail and to support others in their decision making using expertise and knowledge. The possession and exercise of any virtue within a nursing care setting will also rely on other interrelated virtues, the clinician’s knowledge, and skills pertinent to the practice domain. Compassion for a cancer patient’s suffering, for instance, without knowledge of how to mitigate it and/or the motivation to alleviate it, is an empty virtue. However, theoretical knowledge of pain management without experience in patient assessment, planning, delivery, and evaluation, or without understanding the meaning that suffering holds for the patient, is also problematic. Two unpublished studies by one of the chapter authors, focused on understanding nurses’ views of what the characteristics of a “good” nurse are, support these ideas. One study analyzed essays (N = 42) from a graduate nursing ethics class, and the other interviewed nurses from a variety of settings who had been identified by others as “good nurses” (N = 11). The major characteristics of “good” nurses are dependent on having a certain level of knowledge and expertise relevant to the setting. Roughly, these characteristics include perceptiveness, engagement, understanding of the nursing role as having obligations, good communication, the ability to collaborate, the ability to support others, and moral courage (the courage to act for the patient and/or family in the face of obstacles). Additionally, initial data analyses from the Clinical Ethics Residency for Nurses (CERN) project (Grace, Robinson, Jurchak,

Zollfrank, & Lee, 2014; Robinson et al., 2014), along with ethics class discussions, support the assumption that being a “good” nurse requires nurses to understand and act on their obligations to patients, patients’ families, and those they supervise. These studies are examples of descriptive ethics. Descriptive ethics portrays what people think are good actions and good characteristics. It is differentiated from normative ethics, which mandates certain types of behaviors. A code of ethics provides the normative aspects of action (that is, what nurses should do and how they should do it), whereas descriptive ethics paints a picture of what is actually happening in practice or what nurses perceive as their obligation and appropriate action and what sorts of things get in the way of providing, or ensuring the provision of, “good” patient care. The two types of ethics, taken together, provide a bigger picture of what changes in education, environment, or policy may be necessary for good patient care. For APNs, who may supervise, mentor, or collaborate with others, virtues such as leadership, cooperation, and discernment of the different needs of those with whom they interact are important to cultivate in order to meet professional duties. Chapter 27 discusses leadership characteristics in depth. The next section examines the idea that certain virtues are needed for interacting with patients who are faced with making decisions about their care. Patients give their consent to care implicitly, verbally, or in written form, depending on the invasiveness or risk of the proposed action. APNs are in the privileged position of assisting with, or empowering the patient to make, healthcare decisions that by their nature have some sort of effect on that patient’s life. With this privilege comes added responsibility.

Informed Consent The principle of autonomy, underlies the idea of informed consent. Because human beings have the capacity to reason, decide, and act and because they might be presumed to know better than anyone else what their interests are, all things being equal, they have the right to make decisions concerning their health care. They should (barring any incapacitating factors) be free from the interference of others, at least as far as personal decision making is concerned. This translates into the moral right of patients to accept or refuse healthcare treatments regardless of risk, given the possession of decision-making capacity and an adequate understanding of the risks of refusal and the potential benefits of treatment. As a reminder, moral and ethical are considered equivalent concepts in the context of healthcare practice. This moral right was legally validated in the United States with passage of the Patient Self-Determination Act (PSDA), ratified in 1991 (as part of the Omnibus Budget Reconciliation Act [OBRA] of 1990), which is discussed in more detail shortly. In the United Kingdom, the right to make autonomous care decisions is protected by the Mental Capacity Act 2005 (legislation.gov.uk, 2019) and in several other countries the right is also legally protected. Regardless of whether or not there are legal protections for the healthcare professional in helping patients understand their human rights related to health care, understanding the generally accepted and fundamental right of persons to make their own decisions provides a strong foundation for advocating that patients’ real needs be evaluated and met, including the need for information tailored to their level of understanding and preferences.

Types of Consent People give three types of consent in permitting healthcare professionals to evaluate and act on their health needs. The first is implicit consent, the second is verbal consent, and the third is written consent. When a patient is unable to consent, as discussed later, then ideally an informed proxy makes a decision on the patient’s behalf and with the patient’s best

interests (where these are knowable) in mind. Informed consent, then, is the process of interaction between a healthcare provider and person in which necessary information is exchanged and an appropriate level of understanding is gained to enable that person to make a decision about acceptable care, treatment, interventions, or courses of action in light of his or her preexisting values, beliefs, and lifestyle. One critical message implicit in this idea is that consent is not a static concept. Evaluation of current circumstances, patient understanding, and continued willingness to participate or proceed requires that consent be, for the most part, an ongoing process. Advance care planning (ACP) for acceptable interventions in the event of incapacity is beyond the scope of this chapter.

Implicit Consent In presenting to a healthcare delivery setting in search of assistance with health needs, a person is implicitly consenting, at minimum, to be evaluated for those needs. If the setting is an inpatient or institutional setting such as a hospital, the person might sign a form giving consent for certain routine evaluations. However, this form is general and does not detail all aspects of the evaluation, which may include tests and manual assessments such as a physical examination. Moreover, typically the admitting personnel charged with obtaining signatures have no or little medical or nursing knowledge. Thus, implicit consent is not usually very informed, and patients may well not understand what rights they have. In primary care sites, those who present for care do not necessarily understand the customary routines of the practice site—nor are they required to accept them, although frequently both ancillary staff and clinic nurses do not act as if they understand this. For these reasons, nurses need to be ready to ascertain what the patient has understood, and what it would be helpful for him or her to know. If a patient objects to some aspects of routine care, nurses are responsible for discovering what underlies the objection, how important it is to gather the data in question, and whether acceptable alternatives may be offered. For example, a faculty colleague of the third author who is also a women’s health nurse practitioner (WHNP) reported that she was doing a breast exam on a

patient as part of the patient’s yearly checkup. She asked the woman if she did monthly breast exams on herself. The woman replied, “No, I don’t like to touch my breasts, and for that matter I don’t like anyone else to touch them either—not even my husband.” At that point, the WHNP realized both that she had not asked permission and had not sought to understand what, if any, meaning this particular act of assessment held for the woman. She apologized and the patient said she understood that it was part of the exam and had to be done. But in retrospect the WHNP wished she had thought to ask permission before beginning. She felt that this might have allowed the patient to discuss the issue with her, but the opportunity had been lost. Touching someone without that person’s permission is also a legal consideration and may subject a nurse to legal charges such as battery or assault. The preceding scenario, which happened early in the WHNP’s professional life, made her more sensitive to the idea that patients can have good reasons for refusing even routine care and that they have a right to refuse it. However, nurses also have a responsibility to ensure that patients understand the implications of refusing evaluations, tests, or treatments and try to lessen any risks from this refusal by reformulating an acceptable plan of care. To illustrate this point, we give an example drawn from practice. A slightly overweight woman in her early twenties came to a primary care setting for treatment of a sore throat. It was her first visit. The office assistant, a nurse’s aide, told her she had to be weighed as part of the “new patient” routine. The young woman refused. The aide tried to persuade her but to no avail. The nurse practitioner heard arguing in the hall, went to investigate, and saw a very upset young woman. She brought the patient right away into an empty room, acknowledged how upset the patient was, and asked her what happened. She said, “I really hate being weighed—I don’t see why it is necessary—they used to do that at the other clinic.” It was explained to her that measuring a person’s weight is in many cases a very useful assessment and was routine, but that in view of her reaction the providers would rethink the policy. In the course of the interaction, and because she could see that her concern was taken seriously, the patient confided that she used to be weighed weekly by her mother when she was a teenager and was physically punished for gaining weight. This opened an opportunity to help her further, and she eventually got

counseling for unresolved issues with her mother. After this, we changed our office policy and educated the medical assistants and aides about a patient’s right to accept or refuse some of the routines that were not important for the given patient’s care. If the routine was important—for example, weighing a patient with chronic heart failure—then rationale should be given. Alternatives, such as selfweighing and reporting significant changes, can be negotiated. Also, there are, of course, some cases in which weighing a patient becomes crucial. For example, some drug dosages are calculated based on weight. In surgical operating areas, intensive care units, and pediatric settings, accurate weights may be crucial to avoid the harms (nonmaleficence) of over- or underdosing patients with essential therapeutics. In such cases nurses remain responsible for anticipating and minimizing any possible harms, including psychological distress.

Verbal Consent Although for many patients a host of routines covered by implicit consent cause neither distress nor affect their care in any perceptible way, in the cases described earlier, informed consent to care was important both for the patients’ immediate well-being and for determining whether follow-up care was necessary or desired. Gaining informed verbal consent permitted the nurse to understand what else might be required to provide good care. Sound clinical judgment facilitates identification of the patient’s particular needs, which in both of the preceding examples proved to be more extensive than initially understood. Obtaining verbal consent to care—including evaluation, tests, therapeutics, and decisions about the best ways of managing chronic conditions—is synonymous with good APN practice in direct patient care and is dependent on establishing a nurse–patient relationship that is concerned with understanding the patient’s vulnerability and needs and then addressing them.

Written Consent The third type of informed consent is a written consent. Written consent “is intended to protect patients from... ethical or legal breaches and make

formal their right to all relevant information, tailored specially to them” (Grace & McLaughlin, 2005, p. 79). Experienced nurses practicing in institutional settings are mostly familiar with informed consent as it relates to invasive medical procedures and perhaps to patients who are participating in research studies (see Chapter 6). In their definition of the term, Beauchamp and Childress (2009) acknowledge that “informed consent occurs if and only if a person or subject, with substantial understanding and in the absence of substantial control by others, intentionally authorizes a professional to do something” (p. 78). Although Beauchamp and Childress are explicitly discussing the necessary criteria for written and verbal informed consent rather than implicit consent, these criteria are also relevant for implicit consent. In the case of proposed invasive procedures or surgery, the person responsible for carrying out or supervising the intervention is the one responsible for obtaining written consent. This is usually a physician, although increasingly it may be an APN. APNs who are qualified to carry out procedures or perform anesthesia are responsible for obtaining written consent. Staff nurses have responsibilities for ensuring that their patients are in a position to adequately understand what they are agreeing to. This has implications for the clinical nurse specialist (CNS) or nurse manager who serves as a floor resource, mentor, and educator and who sets the tone for the staff nurses on his or her unit.

Informed Consent: Ethical Problems Informed consent, however, is a complex and tricky concept. For each person, the information needed for the person’s consent to be “substantially informed” is different. For procedures or interventions that involve more than minimal risk (risk that is encountered in daily life), informing the patient should be viewed as a process because, for the most part, those faced with invasive procedures are already upset and anxious. Information processing under conditions of anxiety and stress is difficult, and studies have shown that people neither process nor retain information well under such conditions (Broadstock & Michie, 2000; Charles, Gafni, & Whelan, 1999; Kegley, 2002; Starcke, Wiesen, Trotzke, & Brand, 2016). The informing process involves understanding certain things about the patient. Nurses need to understand the patient’s beliefs,

including culturally based beliefs, values, and goals; the patient’s ability to process information; and psychological, physiological, or environmental factors that might interfere with or facilitate processing of information. Patient-related psychological factors that can interfere with information processing are such things as psychological denial of a physical illness or diagnosis, loss of hope, unreasonable expectations of an intervention, a desire to please a provider or significant others, lack of energy to think through possible options and how they relate to goals, and cognitive problems. Physical factors include pain, sedation, fever, and poor cerebral perfusion, among others. Provider-related problems include inadequate knowledge about a procedure and its potential side effects (for example, a lack of understanding of the full range of implications related to genetic testing; an inability to connect with a particular person, which can interfere with the project of tailoring information to that person’s specific needs and abilities; lack of understanding of the origins or meaning of any cultural factors; lack of knowledge about existing options or objections to providing the full range of options (for example, provider beliefs about the moral status of emergency contraception); and self-knowledge related to prejudice or bias. Additionally, certain situations are fraught with communication difficulties. Examples of such situations include language barriers, hearing impairments, and patients who are perceived as “difficult.” This discussion focuses on three important complicating factors related to appropriately informing patients: (1) the provider’s appeal to conscience in not providing patients with the full range of options legally available, (2) cultural considerations in informing patients, and (3) the issue of difficult patients. Early identification of potential communication problems and attempts to anticipate and address these problems has been termed preventive ethics. One important professional problem is that of withholding information or not offering the available range of options for a patient’s situation because it is against the provider’s conscience. The next section addresses this issue.

Conscience and Personal Integrity The issue of healthcare professionals’ refusal to provide patients with

certain information and/or services has recently received publicity in the popular press in the United States. There are also reports from Europe of movements to protect healthcare providers who refuse care or limit information to patients based on conscience (Catholics for Choice, 2012). In 2010, the Parliamentary Assembly of the Council of Europe (PACE) debated the issue of the right of healthcare providers to conscientious objection (resolution #1763), urging states to provide patients timely access to legally permissible options (PACE, 2010). In opposition, the Swedish parliament has urged that their delegates work to change this resolution, reportedly because they overwhelmingly find it problematic that providers can withhold legally available options (Protection of Conscience Project, 2012). The ethical implications of refusing to disclose legally available options or to offer a full range of services have elicited renewed scrutiny on the part of moral philosophers, ethicists, and scholars in the various healthcare professions (Lamb, 2016; Wicclair, 2011). Appeals to conscientious refusal to provide certain options are usually based on one of the following arguments: (1) although legally available, the healthcare provider finds the option morally objectionable based on religious grounds or on the basis of other personal beliefs; (2) the provider believes that certain options are congruent with his or her beliefs, and others are not, and there is no obligation to reveal this bias to the patient; or (3) the provider believes that some available options are inferior or have too many side effects, and thus the provider is saving the patient from confusion. As an example of the first argument, Jacobson (2005) highlights the case of registered nurse Andrea Nead, who did not want to “administer emergency contraception” (p. 27) as part of her role responsibilities. She claimed that she did not get a position she sought in a university health clinic because of her religious beliefs. Other examples (of the second and third arguments) from advanced practice settings include a colleague who referred patients in need of mental health services only to a Christian mental health facility, and another colleague who neglected to offer a variety of therapeutic options available for labor pains by encouraging patients to “have an epidural—it is a woman’s best friend.” In palliative care settings, refusal to provide adequate pain relief may result from providers’ beliefs that they are contributing to a person’s death.

The preservation of personal integrity is very important. It enables nurses to provide for a patient’s good, sometimes against sturdy barriers and sometimes against the “generally accepted view” of what is permissible. Integrity means maintaining a sense of self as a whole. It is tied into ideas of personal identity (Benjamin, 1990). Loss of a sense of self and personal integrity has been associated with the experience of moral uncertainty and moral distress, especially when a nurse is unable to ensure that a patient receives the care that clinical judgment reveals is needed. These experiences can lessen an APN’s confidence and resolve related to decision making. Provision 5 of the American Nurses Association’s (ANA, 2015a) Code of Ethics for Nurses with Interpretive Statements upholds nurses’ needs to care for the self, asserting, “The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth.” Additionally, many U.S. state laws (45 states) have conscience clauses that allow providers to refuse treatment or recuse themselves from participating in care based on philosophical or religious objection. Charo (2005) notes that conscience clauses in U.S. state law result from “the abortion wars” in the United States (p. 2471). That is, conscience clauses are “laws that balance a physician’s conscientious objection to perform an abortion with the profession’s obligation to afford all patients non-discriminatory access to services” (Charo, 2005, p. 2471). These laws are often broad enough to protect other professionals from the legal consequences of conscientious objection to certain procedures or treatments. However, legal protection is not a good reason for a person to impose his or her beliefs and values on someone else. In fact, refusing to provide care because of personal beliefs requires that the nurse carefully consider the situation and understand the implications of this refusal. This is especially important when the nurse is in a strong (powerful) position relative to the person who is seeking legally available information or treatment. A nurse’s ethical responsibilities for good care may often include following the considered wishes of patients for something with which the nurse does not agree because it is not what the nurse herself would want, because the nurse does not think it is in the patient’s best interests, or because the nurse thinks it is misguided. However, it is

important to keep in mind that a healthcare decision should not be based on a provider’s preferences; ideally, decisions should be based on the lifestyle, culture, beliefs, and values of the person whom they will most affect. Thus, nurses must understand whether they have the facts straight, to what extent they are likely to be affected by going against what they believe, and how enduring the insult to their sense of identity is likely to be. Moral distress is the feeling of disequilibrium experienced by nurses when they either cannot give the care needed or are asked to participate in care that they feel is wrong or harmful. The experience of moral distress and its residue (Webster & Baylis, 2000) can have long-lasting effects on nurses’ practice. Some nurses leave the profession, whereas others may end up distancing themselves from certain patients because of repeated or serious experiences of emotional or ethical conflict. The question, then, is, “How do nurses preserve integrity while fulfilling their professional duties related to informed consent?” First, it is crucial to remember the almost inevitable inequality of any provider–patient relationship. Patients are vulnerable because of a lack of knowledge, skills, resources, or capacities in regard to meeting their health needs. They present to a provider trusting that their concerns will be taken seriously, the healthcare provider will be honest and transparent, and the healthcare provider will not either deliberately or unthinkingly hide available options or potential resources. In a sense, healthcare providers can be said to “hold the keys” to a wide variety of not-easily-available knowledge and have the necessary skills of interpretation for making distinctions clear. Such privileges should not be abused. The recently revised ANA position statement, Risk and Responsibility in Providing Nursing Care (ANA, 2015b) provides important guidance. “When moral objection is made, the nurse is obligated to provide for the patient’s safety and ensure that alternate sources of nursing care are available.” Both the revised and earlier statement (ANA, 2006), arguing that “the nurse who decides not to take part on the grounds of conscientious objection must communicate this decision in appropriate ways [and] whenever possible, such refusal should be made known in advance and in time for alternate arrangements to be made for patient care,” provide detailed criteria for determining what level of personal risk is acceptable and what further responsibilities fall to the nurse involved. Magelssen

(2012) provided a set of criteria for determining the permissibility of conscientious objection for healthcare providers. He emphasizes that conscientious objection is permissible when the clinician’s “moral integrity is [likely to be] disrupted . . . [by] a serious violation . . . of a deeply held conviction” (p. 19). He focuses on the “plausibility” of the objection. A moral or religious objection should be able to withstand logical critique. Additionally, certain criteria should be met related to the likely effects of care refusals on the patient and the patient’s rights to care. Finally, selfrecusal from providing care is acceptable only when “the burdens to colleagues and healthcare institutions are acceptable and small” (p. 19). Several integrity-preserving options are open to APNs in difficult situations. First, self-reflection should reveal the source and strength of the objection and whether the APN has a thorough grasp of the state of the science involved. For example, many objections to emergency contraception are based on inaccurate information related to how it works. The APN’s objection may stand even after researching the facts involved; nevertheless, fact gathering is a professional responsibility. Sometimes the nurse is faced with choosing what he or she considers the “lesser of two evils” related to actions of conscientious objection. For example, the recently highlighted problem of fetal microcephaly caused by the Zika virus may cause dilemmas for nurses and others with strong religious objections to abortion and/or contraception in providing advice to those exposed (Zhang, 2016). Second, the APN should answer the following questions: “If I needed information about a healthcare issue with which I was unfamiliar, what would I want from the specialist? How would I feel if I discovered the provider had selectively withheld options or information from me?” If after answering these questions the APN remains strongly opposed to participation in a legally available procedure or to providing certain types of information, the reason for not discussing options or not providing the requested care must be communicated to the patient. The patient should be enlightened about the fact that resources are available and/or referred to another provider who is willing to discuss the range of options or undertake the procedure. The APN should clearly communicate that there are other options but that the APN’s own beliefs do not permit him or her to discuss them. Further, if the APN personally does not object to providing certain

types of information or interventions but is restrained by the institution or practice (e.g., in a setting that is managed by a religiously based organization) from discussion of options or undertaking the procedure, this should be acknowledged and appropriate resources provided.

Culturally Based Communication Issues Other issues that serve as obstacles to obtaining substantially informed consent are related to culture differences and lack of fluency in the patient’s language or the patient’s lack of fluency in the language of the context. Although in Western cultures the idea of autonomy is valued, in many other cultures decision-making responsibility belongs to the head of the household or is a family affair. Trying to understand the beliefs and values of someone from another culture can be a perplexing and frustrating task. It can be difficult to separate issues of coercion and undue influence from the cultural norm. Additionally, the cultural norm in some cultures can be oppressive for a particular group, such as women, or (less commonly) may be age related. What are the APN’s responsibilities in such circumstances? There are no ready answers to such questions. It is an obligation of practice to learn more about a culture, if members of that culture are seen frequently in the APN’s practice environment. In some cultures where there is evidence to show that certain practices are harmful (for example, female circumcision), the nurse can join with concerned others to understand more about the practice, the underlying assumptions of the practice, and what others have done either to change it or to provide appropriate care for its subjects. Most important, maintaining a nonjudgmental but interested affect is probably the most helpful both in ascertaining a person’s needs and in providing assistance. For language difficulties, certain considerations are important. Does the APN have a good interpreter? Are there ways to validate understanding and ensure that the interpreter has translated the intent of the APN’s evaluation or information sharing? The following are some helpful hints synthesized from a variety of sources, including our own professional experiences. In line with viewing informed consent as a process, time and patience are needed. More than one appointment or session may be required. It is

helpful to speak in short units and have all parties take turns speaking— the nurse, the interpreter, and the patient. For exchanges involving complex information, the nurse should request the interpreter to report what the patient understood the information to mean for himself or herself in addition to conveying the patient’s responses. This permits identification of areas of concern and facilitates patient understanding. The nurse should look at the patient while speaking and be aware of the patient’s body language and appearances of confusion or discomfort. The nurse must also validate with the patient if the nurse’s perception is accurate and respond accordingly. Speaking directly to the patient is important, as in, “This will mean that you . . .” The interpreter will interpret everything, so the nurse should be careful not to say to the interpreter something that he or she does not want shared with the patient. Explanations should be supplemented with visual materials when possible. Practices may want to invest in video presentations in the patient’s language as an adjunct, but this does not substitute for a fuller process of information gathering and giving. The focus should be on meeting the patient’s needs and not on any inconvenience or discomfort that the nurse feels. It is best not to use family members for interpretation service (except for mundane matters such as what kind of food they like), especially not children. It can be a temptation to rely on a person’s children because they may be more fluent in English (or the language of the provider) than their elders are, but interpreting is a heavy responsibility to place on them and inappropriately shifts family roles. A case study outlined in the Hastings Center Report (2004) describes the case of a 15-year-old daughter of a Chinese male immigrant. Her father was admitted with a cardiac problem. Circumstances were such that a Cantonese interpreter could not be found easily. The physician wondered if she should allow the daughter to interpret the situation for her father, including, among other things, the seriousness of his condition.

Difficult Patients All nurses have encountered patients whom they perceive as difficult in some way. Wolf and Robinson-Smith (2007) define difficult patients “as those whom nurses perceive consume greater periods of time than their

condition suggests; they impede the work of the nursing staff with demands, complaints, and lack of co-operation” (p. 74). Sometimes it is not the patient so much as the patient’s family that is perceived as difficult. Patients may seem or be difficult for a variety of reasons. Nurses may experience a dislike for them for unknown reasons. Perhaps the patient reminds the nurse of someone with whom the nurse argues, or the patient questions the nurse’s knowledge or expertise. Perhaps the patient is violent, abusive, or argumentative. Patients may be difficult because of the complexity of their issues or the perceived hopelessness of their situations. Additionally, certain patients may be stigmatized by their lifestyle, obesity, or disease. Reports of patient violence toward nurses are also on the rise worldwide (Robert Wood Johnson Foundation, 2015). There are, thus implications for nursing leaders related to protection and support of those with whom they work or for whom they are responsible. Whatever the reason for the perception of a patient as difficult, APNs are still responsible for trying to meet these patients’ needs. Wolf and Robinson-Smith’s (2007) study investigates strategies that are used by CNSs in “difficult clinician–patient situations” (p. 74). Two frequently used strategies were demonstrating “respect for the patient” and “focusing on the issue at hand” (pp. 79–80). This includes avoiding labeling the patient and CNSs setting an example for others. A fairly recent example from the locale of two of the authors is that of Dzhokhar Tsarnaev, the younger of the two brothers responsible for the bombings at the 2013 Boston Marathon. Tsarnaev survived his capture with serious injuries. He was cared for by nurses at a major Boston hospital where many of the bombing victims had been treated. Nurses were asked to volunteer to provide care. “All of the nurses asked by supervisors to care for Tsarnaev agreed, the hospital said. The Globe interviewed seven of them, and all said that the ethical bedrock of their profession requires them to treat patients regardless of their personal history” (Kowalczyk, 2013). Maintaining a nonjudgmental attitude permits the sharing of information needed for the patient’s decision making related to care preferences. Supportive environments are also critical for nurses to be able to adhere to their professional obligation to treat each individual with dignity. For example, as recounted by some of the nurses to a colleague (one of the chapter authors), some subsequently found themselves the object of

disdain from those around them, and some also struggled with what it meant to have “cared for a terrorist” and experienced guilt for their moments of compassion for him. Both of the strategies for dealing with such cases avoid bias and are aimed at trying to understand who the patient is and what underlies the patient’s actions and affect in order to meet the patient’s needs. In keeping to nursing’s ethical ideals, we also avoid having to decide who is and who is not worthy of our attention. In other words, we honor the humanity of each person. In addition to the problems just discussed related to assessment of the patient’s particular needs, the provider may also be subtly influenced to emphasize some aspects of information over others, as discussed next.

Other Influences on the Informing Process Conflicts of Interest Ensuring that patients’ decision making is adequately informed for their needs also requires nurses to reflect on which other factors may be subtly influential, such that they are not readily or easily recognized. The ethos of the practice environment, economic or time constraints, the influence of drug company practices, and pressures from colleagues all have the potential to cause a subtle skewing of the information given to patients. Conflicts of interest (COIs) are pervasive in healthcare practice, regardless of profession. A COI exists any time there is pressure or temptation to act in such a way that a given patient’s interests are not held as primary. COIs in professional nursing practice can be of several types: economic, such as when the financial pressures on a clinic or healthcare institution shift the primary focus off patient “good”; interpersonal, such as when a battle between providers for control of a situation causes loss of focus on mutual goals; and environmental, such as when others do not notice that there is a problem and put pressure on nurses to go along with the status quo. In addition, COIs may arise when appropriate resources or referring physicians are not available; in psychiatric and counseling practices, sexual or boundary-related issues can arise. Studies show, for example, that drug companies have been quite successful in influencing prescribing practices in the United States (Angell, 2004; Kassirer, 2005; Steinman, Harper, Chren, Landefeld, &

Bero, 2007). An example from our experiences is that of the drug company representative who provides dinner for the local APN association. The representative brings samples to the office and urges us to try them with patients (Kassirer, 2005). Several studies have confirmed the suspicion that drug company gifts influence prescribing patterns (Coyle, 2002; Steinman et al., 2007; Wazana, 2000). Kassirer’s book urges physicians to divorce themselves altogether from accepting drug company gifts. NP prescribing practices are perhaps not as amenable to study as physicians’ are but probably would mirror those of physicians. As discussed earlier, ensuring that patients are well informed is a difficult task that must not be taken for granted. Ongoing self-reflection and reflection on nursing practice are crucial, as is remaining aware that conflicts of interest are ever present and may result in subconscious biases that do not serve the patient well. Understanding the important elements of the process, as well as likely problem areas, necessitates vigilance. The other side of the problem has to do with the obstacles that exist for patients in apprehending and processing the information they need for decision making. The next section explores a concern related to informed consent: that of determining decision-making capacity. APNs in different roles and across specialties may be faced with the responsibility of determining whether a patient is reasonably capable of making an informed decision.

Decision-Making Capacity How does an APN know when a patient is not able to make an informed decision? In some cases, the answer to the question is relatively easy. It is obvious, for example, that a comatose patient, a neonate, or a patient with advanced dementia cannot process information or communicate his or her wishes directly to a provider. For such patients, an alternate decision maker is necessary. This person acts as a proxy either to convey what the person’s wishes would probably have been, given knowledge of the person’s beliefs, values, and life goals, or to ensure the patient’s probable best interests where no knowledge is possible (neonates) or available. The issue of decision-making capacity is especially pervasive in mental health settings and is addressed in detail in another chapter. In other cases, determinations of decision-making capacity may be more difficult. Buchanan and Brock (1989) note that decision making in healthcare settings is almost always for the purposes of accomplishing a task and occurs along a continuum. In the United States, the issue of decision-making capacity was explored in depth by the President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, a group assembled by President Carter in 1978. This commission was formed in response to the increasing complexity of problems caused by biological and technological advances. Examples of such problems include how and when to determine death when it is possible to indefinitely prolong life artificially. What is the range of possible effects caused by the application of genetic innovations in health care? What can APNs do about health disparities? And, important for the purposes of this discussion, how do nurses ensure that patients are capable of making their own medical decisions and are not subject to undue interference by interested others who may or may not hold the patient’s best interests as primary? The commission’s report (President’s Commission for the Study of Ethical Behavior in Medicine and Biomedical and Behavioral Research, 1982) concluded that minimal capacities for decision making are “1. Possession of a set of values and goals, 2. the ability to communicate and to understand information, and 3.

the ability to reason and deliberate about one’s choices” (p. 57). These criteria are made more stringent when the risks are high and the patient seems to be making a choice that is not in concert with his or her own values and goals. Beauchamp and Childress (2009) note that in cases where the risk of action or inaction is relatively high (the possibility of serious harm exists), it is also important to assess for the voluntariness of the decision. That is, nurses should evaluate whether some internal or external influence is pressuring the person to make a particular decision (see the section “Informed Consent: Ethical Problems” earlier in this chapter). The following case is provided as an example of considerations related to decision-making capacity.

CASE STUDY: JENNY Jenny is a 33-year-old woman brought into the emergency room from a homeless shelter by shelter staff. She is evaluated by Pauline Hill, an emergency department NP, who, after evaluating Jenny, determines that Jenny’s provisional diagnosis is pneumonia accompanied by dehydration. Jenny is also confused and keeps saying, “How did I get here?” The shelter staff person tells Pauline that Jenny completed detoxification for alcohol and unspecified drug abuse just 2 weeks ago, was staying sober, and had just gotten a job. Currently, she is febrile with a temperature of 103.5°F and RR 36. Pauline determines that intravenous fluids and antibiotics are necessary because Jenny is in danger of sepsis. Jenny refuses treatment; she says, “I am trying to stay clean. I want to get my kids back.” Pauline talks to Jenny about her worries, tells her of the proposed plan, and reassures her that she is not receiving anything that will set her rehabilitation back. At first Jenny seems to understand and acquiesces, but when it is time to insert the cannula, Jenny starts crying and yelling, “No, I don’t want it! I can’t have it!” When questioned further, it becomes obvious that Jenny has not retained the information that Pauline discussed with her, nor does she see the connection between treatment and achieving her goals. Pauline realizes that Jenny is not capable of making this decision because she keeps misunderstanding what is proposed. There is a lot more that could be said about this case, including responsibilities to try to improve Jenny’s ability to process information (oxygen, or a respiratory treatment) or to consider alternative courses of action that might achieve the purpose of resolving Jenny’s immediate physical needs without further distressing her. However, the purpose of Jenny’s case is to illustrate a problem with decision-making capacity for the task at hand. The risks of not treating are high and do not serve Jenny’s goals of becoming physically capable of having her children returned to her and being able to care for them. Therefore, the nurse does need to treat the pneumonia and dehydration because not doing so could result in harm to Jenny, perhaps even death. Thus, the point is that, paradoxically, in treating Jenny against her will, which could be seen as not honoring her autonomy, the nurse is actually facilitating autonomous future decision making. A person cannot exercise autonomy when she is not alive to do so.

Proxy Decision Making Proxy decision making is the act of deciding what healthcare actions are permissible for someone who temporarily or permanently has lost decision-making capacity, never had decision-making capacity (profound cognitive deficits), or is not yet considered to have sufficient maturity to make healthcare decisions (children). When children are involved, the proxy decision maker is usually a parent or guardian who makes decisions on the child’s behalf. If developmentally appropriate, children may assent or dissent to a course of treatment. However, a child’s dissent may be overruled by a parent or guardian when the risk of not treating is high.

Types of Proxy Decision Making In clinical ethics literature and practice, a hierarchy of three levels of proxy decision making is used to determine appropriate treatment for those who are or have become incapacitated. The first level is based on the principle of autonomy and aims to reproduce as nearly as possible what an incapacitated person’s wishes would have been. The person may have previously formulated a written directive (also known as a living will or advance directive [AD]), or may have appointed a person who could accurately represent those wishes. When these formal arrangements do not exist, the healthcare team may be able to discern what a patient’s wishes would likely be by gathering information about the patient from family members and friends. The second level is often called the best interests standard. Beauchamp and Childress (2009) note that sometimes “the patient’s relevant preferences cannot be known” (p. 138). In such cases a surrogate decision is made based on quality of life (QOL). Thus, actions are favored if they are likely to provide the highest net benefits in terms of QOL. The best interest standard may permit overriding a surrogate decision maker’s directions for treatment when the proposed treatment does not seem capable of benefiting the patient or may cause more harm than benefit. The third level is that of the reasonable person standard. It is used when neither level one nor two is applicable. For example, it is not possible to discern from neonates or

profoundly cognitively disabled persons what they would want for themselves. In such cases a decision is made based upon what a “reasonable” person would want. This third level is problematic because it is hard to determine who is “reasonable” given the host of contextual factors involved in any decision-making process (Beauchamp & Childress, 2009; Grace, 2004b).

Legal Aspects In the United States, what is accepted as legal surrogate decision making differs from state to state. This necessitates that APNs familiarize themselves with the laws of the state (or country) in which they practice. This section outlines some general issues associated with APNs’ role in assisting their patients to be prepared for a variety of possibilities related to decision making. Proxy decision making in health care may be needed for everyday healthcare decisions, for decisions related to an acute illness, and for EOL issues. Although many APNs do not work in a hospital setting, understanding a little about legislation related to EOL decision making, such as the PSDA (OBRA, 1990) in the United States, provides clarity about the reasons for such legislation and likely related issues. The PSDA applies to institutions that receive federal funding (almost all U.S. hospitals and long-term care facilities) and was meant to improve patient decision making especially concerning (though not limited to) EOL decisions. It was meant to improve providers’ as well as patients’ knowledge about patients’ rights to accept or refuse therapeutics and interventions and providers’ obligations to provide appropriate information. It was also hoped that providers would assist patients to think about what they would want in the event that they lost decisionmaking capacity.

Advance Directives It is, of course, generally better for patients to have considered in advance what sort of care they would like and who might best serve as a good proxy decision maker on their behalf. Although such decisions may be made when patients are already critically ill, this is not optimal

(Hiltunen, Medich, Chase, Peterson, & Forrow, 1999; Marshall, 1995; Wolf et al., 2001). Adequate time, a low-pressure environment, and the assistance of a trusted health provider are probably the best conditions under which to process information. Thus, good APN practice means taking the opportunity to raise questions and provide necessary information related to the idea of proxy decision making if a patient appears receptive. Additionally, research (Parks et al., 2011) questioning prospective proxies and those for whom they were to make decisions found that “spousal proxies were more accurate in their substituted judgment than adult children, and proxies who perceive higher degree of family conflict [within their family] tended to be less accurate than those with lower family conflict” (p. 179). From our experiences in both critical care and primary care settings and from the research cited, it is very difficult to discuss such issues when a person is gravely ill, already receiving highly technical care, and in a noisy and hectic environment. Proxy decision making can be an arduous task at the best of times, but is made even more difficult with the potential loss of a loved one looming and when the decision maker may already be overwhelmed with circumstances and lack of needed clinical knowledge (Dionne-Odom, Willis, Bakitas, Crandall, & Grace, 2015). Preventive ethics strategies include providers making routine a practice of discussing patient preferences at primary care or regular provider visits; helping patients to select an appropriate surrogate (that is, one who can separate personal desires and wishes from the preferences of the person in question); and encouraging patients to provide written instructions for their proxy. A reminder is needed that a proxy only makes healthcare decisions for another person in the event of that person’s loss of decision-making capacity. When a proxy is obviously not making decisions that are in the patient’s best interests, the proxy can legally be relieved of proxy duties. Discussion about ADs need not be limited to the older population. McAliley, Hudson-Barr, Gunning, and Rowbottom (2000) studied adolescent attitudes toward living wills, or as they are alternatively known, ADs. Of the 107 participants in the study, the majority felt that it was “somewhat important” or “very important” for someone of their age to have a living will (p. 471). A study of young adults living with chronic illness also supported the idea that conversations about ACP are

desirable (Wiener et al., 2008). The advent of ADs or living wills is relatively new. According to Clarke (1998), the term living will was invented in 1967 by Louis Kutner, a human rights lawyer and cofounder of Amnesty International, “in a law journal proposal” (p. 92). Kutner, having gone through a disturbing EOL scenario with a close friend, wanted to ensure the right of patients to determine how their last days should unfold in the event of a catastrophe.

The Patient Self-Determination Act: International Implications The PSDA in the United States (OBRA, 1990) was conceptualized as a result of several landmark right-to-die cases. It relies on state laws related to EOL care and “was designed to encourage communication about end-of-life issues” (Grace, 2004b, p. 310). It requires institutions that receive Medicare and Medicaid funds (U.S. government funds), which includes essentially all healthcare institutions in the United States, to inform patients in writing of their rights to accept or refuse care. It was meant to increase healthcare provider knowledge and thus affect current EOL problems arising in tertiary care institutions. The PSDA has not been as effective as hoped, and there are many documented reasons for this. A large study undertaken to understand prognoses and preferences for outcomes and risks of treatment conducted over several years, which initially involved observation but later added interventions aimed at improving the communication of patients’ wishes, failed to show that patients’ preferences were respected. Marshall (1995) and others have argued that this is because institutional hierarchies and power structures have not significantly changed as a result of the PSDA. Others have noted a variety of concerns about ADs that might make some people reluctant to draft them and some healthcare providers reluctant to comply with them. The concerns include the idea that people do not like to imagine themselves experiencing serious illness or death. Accurately predicting what might be needed given a wide array of possibilities is difficult. Patients are afraid they might change their minds, but not in time to change their ADs, or that not accepting certain interventions might lead to their abandonment by caregivers (Teno,

Gruneir, Schwartz, Nanda, & Wetle, 2007; Wolf et al., 2001). In addition, there are cultural and minority fears about the untrustworthiness of predominantly white middle-class healthcare professionals (Baker, 2002); see the next section for further discussion. Regulations related to the use of ADs, whether in the written form or in the form of an appointed proxy, vary from country to country. Regardless of the existence of regulations enforcing or supporting patients’ previously articulated wishes, it is a healthcare professional’s responsibility to help patients and those close to them think through what care and interventions they might wish for in the event of a loss of decision-making capacity. This permits advocacy and honors autonomy. Durbin, Fish, Backman, and Smith (2010) reviewed available research on the influence of educational interventions in improving AD completion. They found (perhaps not unsurprisingly) that a two-pronged approach— providing written and oral information—had the best effects on completion, but the results were not strongly compelling. More interventional research is needed. Despite concerns about ADs, many professionals and ethicists who are involved in EOL care think that with time and custom more people will become involved in the process of advance planning for the event of lost decision-making capacity. The most effective plan is probably a two-part initiative: the appointment of a trustworthy representative who may or may not be a relative, and written instructions to assist the proxy. Understanding both the benefits and the criticisms of formal ADs allows APNs to assist patients in thinking about their specific advance planning wishes. In advanced practice, nurses are key to interpreting a variety of EOL scenarios in terms that are tailored to a particular patient’s needs and level of understanding.

Advance Care Planning: Minority and Cultural Issues Although ACP is generally thought to be a good thing, facilitative of an individual’s choices, there are historical and cultural reasons for certain groups to view ACP with uncertainty and fear. Indeed, such fears (coupled with the ones noted earlier) may be in part responsible for the slow progress made in preparing and educating the public about the

potential benefits of ACP. Johnstone and Kanitsaki (2009) draw attention to the problem in the United States and Australia in particular; it is likely that in other multicultural societies certain groups feel disenfranchised by society as well. “Emerging international research suggests that in multicultural countries, such as Australia and the United States, there are significant disparities in end-of-life care planning and decision making by people of minority ethnic backgrounds compared with members of mainstream English-speaking background populations” (p. 405). Moreover, public policies in these countries are not always sensitive to this problem. Johnstone and Kanitsaki note that the few studies that have looked at differences between cultural majority and cultural or linguistic minority groups within a society related to ACP reveal several tendencies on the part of minority cultures: a smaller number complete ADs; family involvement in discussions about decision making is preferred; ADs are viewed as an intrusive and legalistic mechanism that has no place in health care; and aggressive treatment is preferred, especially when patients have experienced prior mistreatment or bias (Bito et al., 2007, p. 260). In ethical terms, these patients’ prior experiences, distrust of the system, and fears about undertreatment can paradoxically lead to greater harms (a nonmaleficence problem) from overtreatment or treatment that is futile for the intended purpose and causes unnecessary suffering. Strategies for APNs include engaging patients in dialogue about their cultural values, their prior experiences, and their fears. Planning for the future includes understanding what patients’ goals are given a variety of scenarios and helping them to envision desirable courses of action.

Veracity and Transparency Veracity is an ethical principle underlying the idea of trust and fiduciary relationships. “Veracity or truthfulness in giving patients information about their health-care needs facilitates autonomous choice and enhances patient decision making” (Grace, 2004b, p. 315). However, the concept of veracity is more difficult to apply than it appears on the surface. It is fair to say that in ordinary life people are rarely completely truthful with friends, family, and strangers. People hold information back, either because they feel it could come back to haunt them or because to be completely truthful may well hurt another person. Nevertheless, “truthfulness has long been regarded as fundamental to the existence of trust” (Fry & Grace, 2007, p. 287), and, as noted earlier, trust is fundamental to the nurse–patient relationship. Patients are vulnerable because of their healthcare needs and must rely on nurses to help them. If APNs are not able to gain a certain level of trust with patients, then their data-gathering activities are likely to be frustrated. This, in turn, lessens the likelihood that nurses will be able to give holistic care, which in turn means that nursing goals are not met. However, being too honest or giving patients more information than necessary for their decision-making purposes can also frustrate the project of attending to their needs. Clinical judgment is required to make determinations about acceptable levels of information for a given patient; that is, what will permit the patient’s participation in decision making. For example, to the family nurse practitioner (FNP) caring for Ms. Jones, a 60-year-old in a rural family practice clinic, it has become obvious that her patient needs to add an antihypertensive drug to her care plan. Although for several years Ms. Jones has, with the FNP’s help, managed to control her blood pressure by increasing her exercise regimen, reducing stress, and being careful with her diet, her blood pressure is starting to show a pattern of persistent elevation above recommended levels. She does not want to start taking blood pressure pills, but the FNP has done a good job of educating her about long-term effects of poorly controlled hypertension, so she is willing to start taking them now. What drug the FNP tries initially and how much information she gives Ms.

Jones depends on what the FNP knows about Ms. Jones. Discussion of the side effects Ms. Jones is most likely to experience and how these match her lifestyle and preferences will facilitate a first choice. Explanation of likely side effects will also be tailored to this patient’s needs. However, transparency about the extensiveness of what is known related to the drug and the amount of information the FNP gives are also important. These are all clinical judgments based on knowledge of the patient and, like many clinical judgments, they have some element of uncertainty. With Ms. Jones, it might be beneficial to discuss major side effects, whether these effects are acceptable to her, and what she should report to the FNP. Additionally, the FNP should acknowledge that there are possible side effects that Ms. Jones may not experience and that the best way to deal with this is to remain accessible for questions Ms. Jones may have if she experiences unexpected changes. In palliative care or EOL care settings, problems of veracity can occur when relatives pressure nurses and others to withhold the truth about a condition from patients. Veracity has some implications in the care of patients from cultures where the patient is traditionally protected from knowledge of the criticality of the condition. “Decision making about whether to honor [the demands] of veracity in such cases must take into consideration what is known about the culture, the particular patient, the strength of his or her personal and cultural beliefs, and whether there is evidence about what sort of things the patient would like to know” (Grace, 2004b, p. 316). If a patient is asking questions about his or her condition, then nurses need to respond accordingly. Nurses need to draw on what is known or has been discovered (evidence) related to a person’s needs to come to terms with his or her condition and nearness to death. However, nurses also may need to assist the family with their needs to fulfill cultural responsibilities. Resources may be found within the cultural community. In pediatric settings, the issue of veracity is also complicated. Questions arise about how to communicate information in age- or developmentally appropriate ways. How do APNs interact with parents or guardians who seem overly protective or are working in ways that seem at odds with what is known about the child? This question is explored in depth in later chapters.

Privacy and Confidentiality The healthcare principles of privacy and confidentiality are also derivations of the ethical principle of autonomy. The terms privacy and confidentiality are often lumped together as if they mean the same thing. Privacy, however, is “the broader concept and includes the right to be free from the interference of others” (Grace, 2004a, p. 33) and freedom to grant or withhold access to information about oneself. Justification for the right to privacy, as noted by Beauchamp and Childress (2009), “flow[s] from fundamental rights to life, liberty, and property” (p. 295). Confidentiality is related more specifically to the protection of a person’s information, particularly the person’s healthcare information. Beauchamp and Childress (2009) note that in healthcare settings, the right to privacy is most often a control right of sorts: it is the right to control both access to and distribution of information. For Beauchamp and Childress (2009), a helpful distinction can be made between privacy and confidentiality in terms of the status of violations thereof. Confidentiality is violated when one person discloses information about another person, whereas when privacy is violated, one person gains access to another person’s personal data. Rights to privacy and confidentiality in healthcare settings are contemporary recognitions. The reason for recognition of these rights is that a person’s healthcare information can be used in negative ways that cause harm. In nonhealthcare situations, the status of confidentiality is considered so important that it is protected by privilege and is “shielded from exposure by the legal system” (Grace, 2005, p. 114). For example, the clergy– supplicant privilege prevents courts from forcing clergy to reveal confidential information entrusted to them by congregants.

Limitations on the Right to Privacy For healthcare providers, honoring privacy, which includes the maintenance of patient confidentiality, is important but does not supersede all other considerations. There may be occasions when an APN should break confidentiality to prevent serious harm to another

person. The difficulty, however, lies in making the assessment of dangerousness: how imminent it is and how severe the likely consequences are. There are also legal limitations in different states and countries on the right to privacy based on likelihood of “harm to self” caused by certain proposed actions (discussed in more detail in later specialty chapters). Also, providers may be mandated to report certain suspicions of abuse, such as child or elder abuse. The well-known Tarasoff case set a precedent in the United States related to limitations in provider–patient privilege. In October 1969, Prosenjit Poddar killed Tatiana Tarasoff. Poddar had been seeing a psychiatrist and told the therapist he was going to kill a woman, who was easily identifiable as Tatiana. At the time of Poddar’s statement to his therapist, Tatiana was out of the country in Brazil. The therapist sought to have Poddar committed but was unsuccessful because Poddar appeared rational. No one warned Tatiana or her family of the threat, and on her return, Poddar killed her. The courts, in this case, aligning against the idea that psychiatrist–patient privilege is absolute, concluded that “once a therapist does in fact determine, or under applicable professional standards reasonably should have determined, that a person poses a serious danger of violence to others, he bears a duty to exercise reasonable care to protect the foreseeable victim of that danger” (Tarasoff v. Regents of University of California, 1976). Beauchamp and Childress (2009) note three main areas where limits on privacy might require a “balancing of privacy interests against other interests” (p. 297). These areas are “(1) screening and testing for HIV infection, (2) ensuring effective treatments for patients with active tuberculosis (TB), and (3) human genetics” (p. 297). Contemporary issues of dangerousness to others include the deliberate dissemination to, or careless exposure of, others by someone with a transmissible disease, such as HIV or TB.

The Meaning of Privacy in Health Care The concept of privacy is important to the earlier discussion of informed consent, although this was not explicitly stated. Essentially, the privacy principle means two things: (1) patients should have a say in who is allowed access to their bodies or, for the purposes of evaluation and

treatment, other information; and (2) unless the patient gives explicit permission, there is a proscription against healthcare personnel sharing information gained, except for the purposes of helping that patient. In contemporary society, privacy and confidentiality concerns are exacerbated by the pervasive nature of electronic media, as discussed in more detail shortly. The ease with which information, including photographs, can be transmitted via cell phones and other devices, and the ubiquitous use of social media such as Facebook, Twitter, and so on, can lead to the careless exposure of patient information. For example, a mother in the neonatal infant care unit takes a photo of her baby and posts it on Facebook; inadvertently, she has included the baby in the next incubator and the visiting parents. The protection of a patient’s privacy has a variety of implications, both in institutional settings and in primary care. It requires nurses to think carefully about their actions related to patients, including what they tell referral sources, how they transfer information, and what the implications of testing are related to privacy and protection. It is a reminder not to take privileged access to sensitive patient information for granted. Respecting a patient’s right to privacy means that when a student APN interacts with a patient as part of gaining clinical expertise, the student status should be revealed. In patient rounds, persons in the rounding group should be clearly identified. Patients can waive this right but should be made aware of it. The principle of privacy has numerous other implications as well; for the most part, though, concern for the delivery of good patient care will ensure that a patient’s privacy is respected. For example, the privacy principle means that providers protect those who are not capable of protecting themselves from the intrusion of others, perhaps because they are not aware of the possibility that sharing personal information can affect such opportunities as job prospects and the ability to have health insurance. Providers in the United States should be aware of the socalled Privacy Rule and its impact on their practice. This rule is explored in more detail in the following section. It is impossible in this text to discuss the regulations surrounding privacy concerns in all countries that have such regulations; however, the implications of the Privacy Rule and ethical considerations concerning privacy and confidentiality are pertinent regardless of country of practice.

HIPAA and the Privacy Rule in the United States: History According to Beauchamp and Childress (2009), “Privacy received little attention in the law or legal theory until the late 19th century” (p. 294), and then it was concerned with protecting family life, child-rearing practices, and other areas of personal choice. Confidentiality as a subcategory of privacy refers to patients’ rights to have their healthcare information safeguarded. The irony of confidentiality is that in order to receive care, highly personal information has to be revealed to those who will be providing that care. Those providing direct care may sometimes need to share patient information with others whose expertise is important in meeting patient needs. Thus, illness itself makes a person vulnerable, and in trying to address illness a person also becomes vulnerable to those who have access to that personal information. Prior to 1996, rights to privacy and confidentiality were protected by state or country laws, professional ethical codes, and ethical deliberation. The advent of large electronic databases for storing medical records, however, jeopardized providers’ ability to protect their patients’ records. Most who have been involved in health care in the United States, whether patients or providers, have become familiar with the Health Insurance Portability and Accountability Act (HIPAA); however, much confusion about this act remains (F. Anderson, 2007). HIPAA was enacted in 1996. Before HIPAA, if a person lost his or her job, he or she often also lost health insurance coverage, because health insurance in the United States for the most part is attached to a particular place of employment. HIPAA ensured that a person could continue coverage until regaining employment, at which point new coverage would begin with the work-associated health insurance company at the new employer. HIPAA was also supposed to expand coverage. Another section of HIPAA, the “Privacy Rule,” was meant to standardize the use of health information across the country while providing privacy protection. Suggestions had been made for the development of a huge database that could track almost everyone’s health care in the United States from birth to death. Thus, HIPAA was supposed to accomplish two somewhat contradictory tasks: (1) allow for the flow of information that would enable research and access to patient care records for the purposes of improving care and

public health and (2) act as a brake on covered entities’ free use of medical information enabled by such a database. A covered entity is a person, practice, clinic, pharmacy, or institution covered by HIPAA. Essentially, a covered entity is anyone providing patient care services or undertaking research on human subjects. Subsequently, a privacy rule was attached to HIPAA (U.S. Department of Health and Human Services, Office for Civil Rights, 2016). The Privacy Rule specifically covers all individually identifiable information, including written, oral, or computerized information. This went into effect in 2003. An important point to note is that if state rules about privacy are more stringent than HIPAA, then the more stringent standard applies. That is, state regulations trump HIPAA if they are more rigorous than HIPAA standards. The problem with the Privacy Rule, as noted earlier, and the problem with maintaining privacy and confidentiality based purely on ethical considerations (i.e., without such a rule), is that it is impossible to delineate all imaginable scenarios related to privacy infringements, so clinical judgment, including ethical reflection, is still needed for its interpretation in specific situations. “A rule of thumb for health care professionals related to sharing information with others is to disclose only as much information as is necessary to permit optimal care and only information that is pertinent to the situation” (Grace, 2005, p. 115). Additionally, prudence and mindfulness are required when other people’s healthcare records are in the APN’s hands. F. Anderson (2007) provides tips for ensuring that patient information is not overheard or overseen. Importantly, care must be taken not to leave information lying around and not to discuss patients in public places; the nurse must consider whether an outsider could identify the person being discussed if he or she overheard the conversation. In rural settings, maintaining confidentiality can be especially difficult. Providers are often members of the small communities in which they practice. It is not unusual for an APN to be asked about the status of a family member or friend’s health in a grocery store or other local gathering place. Additionally, in rural settings, office staff may have access to the records of family members or friends. Part of the APN’s responsibilities in such settings is educating the staff about the implications of accessing information that they have neither a need nor a right to access.

In an American Journal of Nursing article, F. Anderson (2007), the privacy officer for her institution, provided and answered some questions that may be helpful in understanding the intent of the Privacy Rule; some of these suggestions also have utility outside of the Privacy Rule. Anderson posed some common questions to highlight confusions and to illustrate commonsense answers. Is it permissible to call or write to a community provider when referring a patient? Yes, if the disclosure is for treatment purposes. Am I allowed to e-mail a diagnostic report to another provider for treatment or consultation purposes? Yes, but encryption is strongly encouraged. May I videotape or photograph patients for teaching purposes? Yes, but consent should be obtained or patients should be “de-identified” (F. Anderson, 2007, p. 67). Additional insights into APNs’ experiences related to privacy and confidentiality are provided by Deshefy-Longhi, Dixon, Olsen, and Grey (2004). They conducted a series of studies aimed at describing the views of APNs and their patients related to the protection of healthcare data. Of nine issues identified in focus group explorations, six were identified by both patients and nurses. One of these mutual concerns was the issue of “breaches in privacy occurring through carelessness” (p. 387). Examples given included phone conversations that could be overheard, conversations about patient information that took place in public spaces, and patient information lying around or viewable on computer screens. Additionally, both groups worried that excessive regulation prevented needed information from being communicated to appropriate resources. Even the need to leave a telephone message for a patient at home posed concerns; nurses wondered how much, if any, information to leave. Additional concerns of the APN group were abuses of privacy related to the use of computers and problems attending to the privacy concerns of adolescents.

Social Media and Electronic Medical Records Social Media A contemporary challenge to privacy and confidentiality is the widespread use of social media by patients, providers, and healthcare organizations. The mechanisms of communication via social media weaken the control individuals have over their personal information. Privacy is the freedom to grant or withhold access to information about oneself; confidentiality involves protecting the redisclosure of private information divulged between two people in an established confidential relationship, such as the patient–provider relationship (Beauchamp & Childress, 2009). APNs and other healthcare providers may enhance their ability to protect patient privacy and confidentiality by keeping abreast of the benefits as well as potential misuses of social media. Several nursing organizations have established social media guidelines for nursing and healthcare professionals (National Council of State Boards of Nursing [NCSBN], 2011; National Student Nurses’ Association, n.d.). The 2015 revision of the American Nurses Association Code of Ethics with Interpretive Statements affirms: “The nurse has a duty to maintain confidentiality of all patient information, both personal and clinical, in the work setting and off duty in all venues, including social media or any other means of communication. Because of the rapidly evolving communication technology and the porous nature of social media, nurses must maintain vigilance regarding postings, images, recordings, or commentary that intentionally or unintentionally breaches their obligation to maintain and protect patients’ rights to privacy and confidentiality” (ANA, 2015a, p. 9). Institutional policies and professional, legal, and ethical guidelines provide basic frameworks to guide ethical behavior related to social media use. Since the early part of the 21st century, the Internet evolved from an information transmission forum in the form of static web pages to more dynamic and interactive information exchange, categorized under the

broad heading of “social media.” This transformation changed how individuals and organizations communicate and relate with one another. The nursing profession benefits from the use of social media through the enhancement of social and professional connections, exchange of knowledge among colleagues, and dissemination and discussion of health-related education, research, and best practices (Randolph, 2012), as well as for marketing pursuits (Malette, Cipollone, Sanchez, Smolinksi, & Carpenter, 2014). Many nurses find social media an effective vehicle for “venting” frustrations or talking through workplace issues (Westrick, 2016). Indeed, there are ethics forums and other resources available via social media. The use of social media in health care has increased so rapidly that healthcare providers are often unsure whether their use of social media will have no impact, a beneficial impact, or a harmful impact on their patients, themselves, or their organizations. Although social media may provide new opportunities for effective patient education and disease management, there is a potential risk of overstepping patient–provider boundaries, violating patient privacy and confidentiality, jeopardizing a nurse’s employment opportunities, contributing to cyberbullying, or undermining the community’s trust in healthcare organizations (Randolph, 2012; Westrick, 2016). State boards of nursing have disciplined nurses for misuse of social media, with the most serious consequences being termination of employment (Westrick, 2016).

Definition of Social Media Social media refers to Internet or cell phone-based applications and tools for communicating information instantly to a large audience (Fillipo & Fencl, 2016; Melnik, 2013). Examples of social media include Facebook, Twitter, LinkedIn, Pinterest, Instagram, MySpace, Google+, Tumblr, Snapchat, and YouTube. Forums such as blogs and online chat rooms are also popular platforms in which participants build relationships with others who have similar interests (ANA, 2011a; Fillipo & Fencl, 2016; Henderson & Dahnke, 2015; NCSBN, 2011). People who use social media engage in the activity of social networking: the use of different forms of social media to create a public or semipublic profile within a bounded system. By providing access to one’s own profile and viewing

other’s social media profiles, people create virtual communities that may actually affect their outward or public behavior, self-esteem, and sense of belonging to a group (Wisniewski, Xu, Lipford, & Bello-Ogunu, 2015). Social networking involves maintaining a list of contacts with whom one shares a virtual social connection. Viewers may have access to each contact’s lists of social media connections (ANA, 2011a; NCSBN, 2011; Wisniewski et al., 2015) and thus learn about an individual’s personal and professional associations. Prior to the advent of social media, the extent of an individual’s social contacts may not have been as apparent or well defined. Keeping information private and confidential among one’s social contacts has become challenging. Within the framework of social media, a healthcare provider may, for example, inadvertently post something on a “friend’s” Facebook page, unaware that the friend is connected with one of the healthcare provider’s patients, and in the process blur the provider–patient boundaries.

Use of Social Media in Health Care A Facebook report notes that as of December 31, 2015, there were nearly 1.59 billion monthly active users worldwide. Nearly 60% of Americans over the age of 18 and 73% of Americans between the ages of 12 and 17 use Facebook. Another social media provider, Twitter, reported that 255 million tweets were sent daily in 2014. Patients, healthcare providers, and healthcare organizations all use social media tools for a variety of purposes to meet a variety of ends (Henderson & Dahnke, 2015).

Patient Uses for Social Media Patients use social media for easy access to healthcare information. Social media has created virtual communities in which individuals can access affordable and convenient health information. Low- and middleincome HIV-positive patients participating in a Peruvian study reported that they had greater knowledge about HIV and health-related behaviors, felt better about themselves, and developed increased trust in research after joining a private Facebook page for the purpose of HIV education. Most participants found this setting acceptable and preferable to the

vulnerable feeling of meeting in person, but some participants were concerned that their preexisting online network would discover they are members of an HIV education class (Chiu, Menacho, Fisher, & Young, 2016). Patients also benefit from finding support communities, such as www.patientslikeme.com (Melnik, 2013). In their research on social media, Wisniewski and colleagues (2015) concluded that there is a certain privacy paradox: Facebook users have a fairly high level of privacy concerns, but the benefits of emotional attachment through Facebook keep individuals involved.

Provider Uses of Social Media Advanced practice nurses and other healthcare providers benefit, both professionally and personally, from social media use. APNs may network with others in their profession; exchange knowledge about new healthcare developments and research; disseminate and discuss healthrelated information, research, and best practices; and provide health education for the public (ANA, 2011b). Social media channels increase professional visibility. With social media’s instantaneous communication, providers can reach out in emergencies to specialists worldwide for assistance to diagnose rare cases. In 2009, healthcare providers gave advice to chronically ill tsunami survivors through Twitter, facilitating the connection of patients to emergency resources. Those healthcare providers were able to reach a large audience of citizens in need (Melnik, 2013). Many providers use social media for professional reasons and maintain their own personal social media accounts as well in order to preserve the appropriate professional boundaries. Most healthcare organizations have policies outlining appropriate use of social media in the workplace. For example, policies exist that address use of employee computers for personal use during work hours, websites that may or may not be accessed from employer computers, and limitations about what may or may not be posted to company websites (NCSBN, 2011). Employer policies typically do not address the APN’s use of social media outside of the workplace (NCSBN, 2011), however. Nursing students at all levels of study should learn the social networking policies in both their clinical sites and educational institutions before utilizing any social media during their clinical training (Westrick, 2016).

Nurses often use blogs and other social networking sites as a source for handling challenging and emotionally charged issues, with the intent of receiving support from fellow colleagues. Although the use of social networking to connect with other nurses may provide much-needed support quickly and from a wide audience, even the most careful attempts to keep patient information confidential may fail.

Clinic and Organization Use Clinics and healthcare organizations have the potential to disseminate health information economically via social media (Melnik, 2013). Richter (2014) writes that when used effectively, social media can benefit hospitals through recruiting employees, increasing revenue, and increasing patient satisfaction. Educating consumers, acknowledging staff, and sharing news about awards are common uses of social media by hospitals. Seven out of 10 U.S. hospitals use social media. Large, urban, nonprofit hospitals and hospitals affiliated with universities or health systems are more likely to employ social media; Facebook is the most commonly used method. These hospitals generally do not engage their consumers in reciprocal communication when using social media, however. There is some fear that by engaging consumers, they run the risk of privacy breaches and damaging their reputations with a potentially public display of negative comments and feedback. However, some hospital systems have invested in personnel to manage these concerns, and they do engage the public while keeping private information contained (Richter, 2014).

Ethical Issues Associated with Social Media Confidentiality and Privacy Implications.Inadvertent breaches of privacy and confidentiality by healthcare providers on social media have damaged the reputation of organizations and undermined trust in the nursing profession. Such breaches risk strict punishments by the state board of nursing, thus jeopardizing individual nursing careers (ANA, 2011a; Melnik, 2013). In the United States, based on HIPAA (1996) and the Health Information Technology for Economic and Clinical Health (HITECH) Act (2009), state boards of nursing have applied and will apply

strict sanctions to nurses who engage in unauthorized access, use, or dissemination of protected health information. There are also sanctions for knowing about breaches and failing to report them. Individuals who know about breaches have no more than 60 days to report the breach. For example, in United States v. Zhou, a research assistant in a rheumatology clinic looked at the health records of a celebrity and was sanctioned by the state board of nursing. “[Institutions] have generally taken a hard line against violations of patients’ privacy rights on social media, choosing to terminate the offenders immediately” (Melnik, 2013, p. 8). In a prominent case at the Johnson County Community College Nursing School in Kansas, three nursing students were immediately dismissed from their programs upon the administration’s discovery that they had posted a picture of an unidentified patient’s placenta on social media (Westrick, 2016). A long legal process ensued. Ultimately, violation of patient privacy and confidentiality erodes the trusting relationship that is at the foundation of the nurse–patient relationship, discouraging patients from disclosing important information to the healthcare provider. The quality of patient care and trust in the nursing profession are thus placed at risk. The use of social media creates unique situations of patient vulnerability. Advanced practice nurses who work in the operating room (OR) might face issues relating to social media and patient harm. Use of social media in the OR could potentially distract the team members during a procedure and increase the risk of infection from handheld devices (Fillipo & Fencl, 2016). Patients under anesthesia who have not given prior specific instructions about what is or is not permitted in terms of pictures or the like cannot consent to inclusion in social media. Recently, a surgeon photographed a celebrity undergoing a routine laryngeal procedure during an outpatient endoscopy without the patient’s consent. After a series of errors, the patient died and the cell phone photograph was discovered during the investigation (Fillipo & Fencl, 2016). The family is suing the surgeon. Blurring of Professional Boundaries. The boundaries between patients and providers are blurred by the use of social media. Patients may initiate a “friend” request to their provider through Facebook or may post a photo of their loved one and his or her nurse or the APN. There is an inherent

risk in blurring the boundaries of the professional relationship (Henderson & Dahnke, 2015) when posting such photos. An APN’s professional and private identities are “not entirely separate, not entirely merged, but are integrated” (ANA, 2001, pp. 18–19). Students in an ethics class for advanced practice nurses (2015) at the second author’s institution reported receiving Facebook friend requests from parents of pediatric patients or families of NICU patients as a result of bonds developed from their children’s long hospitalizations. Parents wanted to continue the relationship after discharge. Other parents felt that “friending” their nurse on Facebook would help them work through the grieving process and feel supported after their child passed away. Because the families were not the patients and the social media relationship would start after patient discharge, honoring the friend request seemed ethical and an act of kindness at first glance. However, after considering the far-reaching effects of such relationships—for example, the family depending on the nurse for healthcare advice, or even placing an undue burden on the nurse who receives multiple such requests—the ethical nature of these types of social network friendships requires further exploration. Nurses faced with these issues should consult their organization’s policy and evaluate the harms versus benefits of blurring the professional boundary in this manner. Risk for Harm to Patients and Providers. Nurses sometimes unintentionally post patient information on social media based on several myths about social media, including that: 1. Communications are private and accessible only by the person who wrote the information. 2. Photos and information may be deleted and rendered inaccessible when in fact they may be retrieved after deletion. Sometimes a photo is circulated so fast that it is already widely shared even when it is deleted soon after posting. 3. Omitting the name and other identifiable information will protect patient privacy and confidentiality. 4. Privacy settings are adequate to protect communications. 5. If you tell the receiver the information is confidential, the information will stay with that person. 6. If an individual thinks it is appropriate to post information, it is

probably allowable. In reality, there may be far-reaching implications, not previously realized (Westrick, 2016). All of the preceding are myths about social media and should not be used as reasons to justify posting or sending any patient information electronically. Nurses have posted information about patients on blogs, social network sites, and other forums in which the patient was unintentionally identified. In some of these instances, the nurses mistakenly believed that leaving out the person’s name or other identifying information would ensure protection of patient privacy. Actually, there are 18 identifiers that must be removed to protect the patient’s privacy. Geographic subdivisions smaller than a state, such as a city, and date of service provided could be enough to compromise patient privacy. As noted by Henderson and Dahnke (2015), “A nurse who posts about caring for an 85-year-old female in her own city could cause the patient to be identified by content in the post” (p. 63). Even if the identity of the patient is never discovered, the nurse puts the patient at risk, especially because information saved to social media can be retrieved later, even if the user deletes the information (Henderson & Dahnke, 2015; NCSBN, 2011). A benefit of social media is its ability to be used as a tool for journaling, blogging, and having a sounding board in difficult or challenging situations. However, by using social media in this way, nurses risk harming the integrity of the profession, their institution, the healthcare team, and, in turn, the individual patient (Henderson & Dahnke, 2015; NCSBN, 2011). In 2015, KOAT News reported the case of a nurse at the University of New Mexico Sandoval Regional Medical Center who tweeted that she was bored in the ICU and wished the plug could be pulled on a patient to give her something to do (Fernandez, 2015). Corrective actions were taken by the employer because, although there was no breach of privacy, the statement put the profession in a negative light. It created an ethical issue related to breach of trust. Tagging Facebook pictures and posts is another avenue by which Facebook users may unintentionally breach their friends’ privacy. Tagging a person on Facebook creates a link between the pictures uploaded by one individual and to the tagged friend’s timeline. The picture of the tagged friend will be available to all of their Facebook friends. Tagged

posts do not always require the user’s permission, so the picture may be shared against the tagged person’s wishes. Tagging has been found to lead to higher levels of self-esteem, bonding, and acceptance but does take the control over a patient’s information away from the patient (Wisniewski et al., 2015). A risk of tagging is that nurses may inadvertently and unknowingly be seen by their patients, employers, and colleagues. Likewise, a nurse may view a patient’s picture on Facebook, even if the patient is not on the nurses’ friend list. For example, the nurse may be Facebook friends with a neighbor. She may not realize her neighbor is also Facebook friends with the nurse’s patient. Through tagging, the patient may see photos of the nurse and vice versa. Some photos may be of a more personal nature than the nurse intends to share with patients. Both the APN and the patient lose control over the provider–patient boundary in these situations. Guidelines and Recommendations. Although the guidelines provided here are mostly U.S. specific, they may be helpful to policy makers and nurse leaders in other countries who are supporting nurses in practicing ethically. The National Council of State Boards of Nursing (2011) recommends that nurses recognize their ethical and legal obligations to patients to protect confidentiality and maintain privacy. Nurses at all levels of practice should never transmit any patient-related images by electronic media. Nurses should avoid identifying patients by name or posting anything that might lead to identification of a patient. Nurses should not post any disparaging remarks about a patient, even when certain that the patient will not be identified. Nurses should enforce professional boundaries with patients and their families and be very careful about having contact with former patients on social media. All nurses should report breaches of confidentiality and privacy. It will be helpful for nurses to understand the rationale for limiting this sort of contact so they can explain their reluctance to families in a way that facilitates family trust. Nurses should know and abide by employer policies regarding the use of employer-owned computers, cameras, and other electronic devices. Also, to avoid being accused of cyberbullying, nurses should not make unkind, threatening, offensive, or harassing remarks about colleagues. Nurse educators have a responsibility to understand the ethical pros and cons of social media and pass this

knowledge on to their students. Lastly, nurses should not post content or speak on behalf of an employer unless authorized to do so. Employers have advisers who, ideally, understand the risks and benefits of social media related to their services. The American Nurses Association’s Principles for Social Networking (ANA, 2011b) include many of the preceding recommendations; in addition, the ANA reinforces the notion that patients, colleagues, institutions, and employers may all view one’s postings due to the public nature of social media. Even strict privacy settings do not provide complete control over information dissemination. Professional associations also recommend keeping personal and professional online information separate. The National Student Nurses’ Association draws on the recommendations of the ANA and NCSBN and in addition, recommends to student nurses that they be cognizant of the impact of any post made, understanding that faculty, employers, family, and classmates may gain access to their posts and form an opinion about their potential as future professionals. Student nurses should stay informed about privacy settings, as these often change. Also, student nurses should be aware that their professionalism could be affected by how their friends choose to post about them on their sites. Westrick (2016) lists several nursing schools that have developed examples of social media policies for nursing programs, and she encourages all nursing programs to do the same. Although guidelines provide a framework within which to evaluate cases involving social media as they arise, some cases do not fit neatly into the frameworks and require additional critical analysis. Considering the benefits and risks of using social media, and the existing guidelines for ethical use, and drawing on the principles of autonomy, beneficence, nonmaleficence, and justice, as well as the rules of privacy and confidentiality, analyze and discuss the cases that are provided at the end of this chapter. The following section takes up the issue of the electronic health record and associated ethical issues.

Electronic Health Records Background and Definition The electronic health record (EHR), sometimes called the electronic

medical record, is broadly defined as a “computer application that electronically stores individually identifiable health data” (Layman, 2008, p. 167). In both inpatient and outpatient healthcare settings, the EHR is used to maintain detailed patient records, document clinical interventions, and ensure the transportability of both the record and recordkeeping (Bernat, 2013). Although EHRs have been commercially available since the 1970s (Cimino, 2013), the United States has been comparably slower than other countries in uptake (Anderson & Balas, 2006; Layman, 2008). Nevertheless, in 2010, the Patient Protection and Affordable Care Act (PPACA) included guidelines for the institution and use of EHRs, in an effort to “reduce paperwork and administrative burdens, cut costs, reduce medical errors and most importantly, improve the quality of care” (U.S. Department of Health and Human Services, 2015). The guidelines mandated that by 2014, all healthcare providers (public and private) “adopt and demonstrate ‘meaningful use’” of EHRs in order to maintain their current levels of Medicare and Medicaid funding (University Alliance, 2013). Thus, American healthcare systems are moving toward universal adoption of the EHR.

Uses and General Benefits of the EHR The EHR is used in primary, secondary, and tertiary care settings (Häyrinen, Saranto, & Nykänen, 2008) by nurses, physicians, and other healthcare providers such as respiratory, physical, and occupational therapists. Its primary purpose is to document patient progress; however, it also serves several other functions, including documentation for legal, regulatory, and quality considerations (De Ruiter, Liaschenko, & Angus, 2015). The EHR is not standardized across the United States, so the actual appearance and function of the record and types of programs used are diverse. The improved transportability, access, and purported accuracy of the EHR (Bernat, 2013) are major benefits. Because documentation is computerized, the EHR is more legible than handwritten records (Cimino, 2013), thereby reducing the risk of errors from misinterpretation of poor handwriting. The electronic nature of the EHR reduces or eliminates the need for a paper record; this ideally ensures easier portability and access to records via computer systems across health networks (Bernat, 2013;

Cimino, 2013; Layman, 2008), all at a decreased cost (Layman, 2008). Many EHR systems also have built-in safeguards, such as warnings about potential drug interactions and reminders about health maintenance tasks such as appointments, and some have the potential to continuously monitor patient data in order identify dangerous trends and alert providers (Cimino, 2013). Although there are obvious benefits for providers and healthcare organizations, there are benefits for patients as well.

Use by Patients The EHR has revolutionized the way patients are able to both access their own medical records and communicate with their providers though capabilities such as e-mail and messaging systems (Layman, 2008). For example, some healthcare systems enable patients to have access to their records through the Internet. This allows patients to see provider’s notes and test results online (Layman, 2008), which may expedite the process of finding out test results and may also improve accuracy of the medical record by empowering patients to correct errors they notice (Pyper, Amery, Watson, & Crook, 2004). The online and computer-based nature of the EHR can help with health promotion by facilitating the ease with which patients can make appointments and by sending automated reminders about routine preventive care (Layman, 2008).

Use by Providers The EHR incorporates a variety of functions used by providers, including daily charting, documentation of physical assessments and examinations, medication order entry, medication administration records, medical and nursing notes and care plans, documentation of past medical histories, and admission and discharge summaries (Häyrinen et al., 2008). In addition to these documentation functions, some providers perceive the EHR as reducing errors, increasing productivity, and reducing costs (Anderson & Balas, 2006). Many hospitals and outpatient settings now have computers in patient rooms and exam areas, so providers are able to chart in real time, in the presence of the patient.

Use by Healthcare Organizations The portability of the EHR facilities the transferability of the medical record across institutions; rather than faxing patient information, many organizations now have EHR systems that communicate with each other (although this capability is far from universally available). This function ensures that the most recent and accurate patient information is available, particularly in emergent situations such as an inpatient admission in a new medical center. There are multiple safety benefits to the EHR. In addition to access to up-to-date information, the EHR can reduce medical errors (J. Anderson, 2007). Furthermore, organizations in which the EHR is used in conjunction with other associated safety systems such as medication bar coding, have demonstrated cost savings (J. Anderson, 2007). The EHR has additional uses at an organizational level. For example, healthcare organizations can use the data generated by the EHR to develop health databases (Layman, 2008) for purposes such as data mining and research (Bernat, 2013). As mentioned, institutions can also incorporate important billing and quality elements into the EHR in order to better track various priorities to ensure reimbursement (De Ruiter et al., 2015).

Electronic Health Records: Potential Ethical Issues Despite its benefits, the EHR is not without its challenges. The very purposes that the EHR serves make it vulnerable to multiple ethical issues of which APRNs, along with other providers, should be aware. In particular, EHRs raise issues of confidentiality and privacy. Privacy and Confidentiality. The EHR, by definition, stores individually identifiable health data protected under HIPAA and subject to the Privacy Rule. As described previously in this chapter, violations in confidentiality involve disclosure of information without the person’s consent, and violations of privacy involve a person gaining access to another person’s personal health data. Breaches in both privacy and confidentiality are possible with the EHR, and privacy concerns have historically been major

barriers to the adoption of the EHR (J. Anderson, 2007). The EHR is vulnerable to potential breaches in security given its portable, network-based nature. When breaches do occur, they are usually accidental and involve lost or stolen laptops and external data storage (Layman, 2008). Accidental disclosure of patient information can also occur through practices such as leaving computer screens open in a public area, such as a nurses’ station. However, breaches in confidentiality can also occur through willful inappropriate sharing of health records (sharing patient information without consent), or through hacking of computer networks. For example, in 2011, a U.S. hospital had 2,000 X-rays stolen by Chinese hackers (Akpan, 2016). Some reports estimate that the United States had nearly four data breaches per week in 2016 (Akpan, 2016). It is also possible for privacy to be breached when clinicians uninvolved in a patient’s care access the EHR, such as when a celebrity’s records are accessed without his or her knowledge or consent. Although this is a possibility with the paper record, it is much more challenging to control with the EHR (Bernat, 2013). Patient privacy can also be violated when data collected in the EHR are used for research and data mining without explicit consent. This practice also constitutes a violation of autonomy (Layman, 2008) and fidelity; patients trust their providers and the healthcare system to properly protect their health information. Other Ethical Issues. Along with confidentiality and privacy concerns, there are additional ethical considerations related to the EHR. Many EHR systems incorporate time-saving elements, such as templates for notes and assessments in which providers can point and click, copy and paste, or select prepopulated data. These built-in functions can inadvertently lead to problems such as ambiguity over authorship, misleading notes and records, and impairments in communication due to inaccurate notes, all contributing to a risk of patient harm (Bernat, 2013). Disease-based template selection, for example, can lead to inadvertent misdiagnosis (Bernat, 2013). Templates can also blur important patient information, both by depersonalizing descriptions of the physical assessment and by forcing the inclusion of extraneous information; these factors contribute to a phenomenon called “note bloat” (Cimino, 2013) in which charting and documentation become longer and take clinicians more time to complete,

but are less directly relevant to the particular patient’s status. The EHR can become burdensome from a time perspective when products or systems malfunction (J. Anderson, 2007) and when the amount of documentation required is excessive (De Ruiter et al., 2015). This is particularly problematic when organizations use the EHR to document data for billing purposes and other legal and institutional priorities (such as regulatory/accreditation and quality improvement/safety considerations) (De Ruiter, 2015). The timeconsuming nature of these uses forces clinicians to take time away from patient care in order to chart or to focus on the computer during interactions rather than the patient (Bernat, 2013; De Ruiter, 2015). De Ruiter and colleagues (2015) argue that this represents a shift in priorities with the EHR, which has led to a “de-emphasis on the patient’s narrative as a source of input into the health record, accompanied by a shift towards representing the patient as a set of data points or metrics” (p. 4). Other considerations surround patient access to the EHR. Although patients may appreciate the ability to access lab and test results earlier, for example, it may be problematic if sensitive test results are disclosed without the APRN or provider being present to help interpret their meaning or to offer counseling and support. There is also ongoing dialogue about the benefits and risks of enabling patients of mental health providers to access notes. Although many institutions with “open note” policies have excluded this population from being able to access records, others have argued that such exclusions are unnecessary (Kahn, Bell, Walker, & Delbanco, 2014). Finally, even the role of business must be considered. For example, one clinic in Maine lost complete access to its EHRs due to a billing dispute with the software vendor (Rowland, 2014). This rendered the clinic unable to look up even simple pieces of information, such as patient allergies. Thus, considerations of ownership, location, and intended use of the data must play a role in evaluating the safety of the EHR. Guidelines. In the United States, HIPAA serves as the regulatory guideline for protection of individually identifiable health information (U.S. Department of Health and Human Services [USDHHS], 2016). In addition, the HITECH Act was enacted in 2009 in part to address privacy and security concerns associated with the EHR by increasing penalties

associated with breaches (USDHS, 2016). Other countries, such as Germany, have released guidelines concerning the use of patient information for purposes such as secondary research (Layman, 2008). Professional organizations have also developed recommendations for APRNs regarding the EHR. The American Nurses Association (2009) has released a position statement in support of the use of EHRs. In it, they emphasize a focus on patient safety and high-quality care, and highlight that the “principles of privacy, confidentiality, and security cannot be compromised” (ANA, 2009). They also call for a standards-based EHR (ANA, 2009) that, although present in other countries, such as the United Kingdom, is not a characteristic of the EHRs used in the United States where there are many vendors competing for a share of the market (J. Anderson, 2007). Additionally, Provision 3 of the ANA’s Code of Ethics affirms the nurse’s responsibility to maintain patient privacy and confidentiality, particularly through ensuring data security when working with an EHR (ANA, 2015a). The International Council of Nurses (2012) also calls for the use of “recording and information management systems that ensure confidentiality” (p. 6). Collectively, these regulatory standards and recommendations from professional nursing organizations provide a starting point for APRNs to seek guidance regarding the use of the EHR.

Analysis of Problems and Potential Problems Associated With EHRs Although the breadth of potential ethical issues facing EHR users is broad, a principled approach to action can aid in ensuring that patient confidentiality is protected in line with professional obligations and guidelines. Although EHR users include healthcare professionals, organizations, and patients, patients are at the greatest risk of adverse outcomes from EHR security failures, as the EHR primarily functions to collect and store personal health data. As described earlier, a breach in confidentiality occurs when a patient’s protected health information is disclosed without the patient’s consent. This type of action violates the fiduciary relationship between provider and patient and is a violation of the patient’s autonomy. Breaches in patient confidentiality present a risk to patients on multiple

levels. Patients can face retribution from employers or insurance companies if private health data are released without their consent. Depending on the scope of the disclosure, patients may also be at risk for social stigma and related psychological sequelae. Consequently, disclosure of a patient’s private health data can result in actual harm. A breach in confidentiality also negatively affects the individual patient’s and general public’s perceptions of the provider or healthcare organization at fault. In this way, the consequences not only have an impact on the person affected by the disclosure but also negatively affect the fidelity of the patient–provider or patient–organization relationship. Nursing has long been considered one of the most trusted and ethical professions; mistakes such as these can put this reputation at risk. Hence, consequences of a breach in confidentiality can be far-reaching at a system level. APNs must keep in mind the vulnerability of those whose data are being recorded in the EHR and must act diligently to protect this information. Guidelines, such as those previously described, have established that this is an obligation of the profession. Several recommendations can aid in protecting patients, APNs, and organizations from inadvertent disclosure of patient information.

Recommendations Several governmental resources provide information and recommendations about the EHR to providers, patients, and organizations, along with specific actionable steps to accomplish them in order to be in compliance with the HIPAA Privacy Rule and the Security Rule. The U.S. government’s Health IT website, for example, recommends that providers implement safeguards to protect patients’ health information, set reasonable limits on uses and share the minimum necessary information, and have procedures in place to limit who can access a patient’s health information (HealthIT.gov, 2018). Some additional measures include password protection of the EHR system, encryption of stored information, and maintenance of an audit trail to monitor who accesses information (Rodriguez, 2011). If providers choose to access medical records from home, they must ensure that their home computers offer the same level of security as the computers in their place

of work (Texas Medical Association, 2015). The Health Resources and Services Administration (HRSA) recommends additional safeguards for organizations utilizing EHRs (HRSA, 2018). These include workstation use and design security measures, such as computer screens that lock after a period of inactivity, routine audits, and separation of sensitive information from easily accessible information in order to prevent inadvertent access. HRSA also recommends restricting the movement of hardware (such as phones or computers) that contain health information. APRNs can help to ensure that patient confidentiality is protected through the diligent use of these protective measures.

Summary of Benefits and Harms Associated With EHRs The EHR has many benefits, including enhanced safety and time-saving functions. Nevertheless, APRNs must be aware of the ethical issues involved in use of the EHR and the potential risks that come with imprudent use of the system. An awareness of these issues, and familiarity with professional and organizational guidelines and recommendations, can help ensure that patient privacy and confidentiality are protected and maintained.

Summary This chapter discussed ethical issues that are common to advanced practice across settings and countries. Although the context of practice for the authors is the United States, many ethical issues faced in our context apply more broadly across countries and settings, although the laws that apply may differ. Regardless of the content of laws governing the conduct of health professionals in different countries, interpretation of those laws often requires ethical analysis. Moreover, rigid enactment of a given law without ethical analyses may harm a particular patient. Thus, APNs may have difficult decisions to make regardless of the legal implications. An argument for the APN to engage in ongoing professional and personal development in the interests of good patient care was made. The possession of certain nursing virtues is necessary both for facilitating patient decision making and protecting patient information. These virtues are not all or nothing—there are barriers to practicing well. Mindfulness allows the APN to maintain focus, and ongoing knowledge acquisition along with institutional or clinic supports facilitates moral agency. We reinforced the idea that professional nursing practice at the advanced level is nursing practice rather than medical practice and is based on nursing goals and perspectives. All healthcare practice that involves individual human beings is ethical in nature because of professional goals. The broad importance of honoring the ethical principle of autonomy was the assumption underlying discussion of the topics in this chapter. Patients have the right to make personal decisions both about what care will or will not be accepted and who may have access to personal information and for what purposes. The APN has responsibilities to help patients safeguard these rights. Unfortunately, as hard as APNs work to secure information, insurance companies and other groups that are privy to the private health information of individuals and families are not always so scrupulous. An expanded discussion of the contemporary ethical implications of social media and electronic medical records was added to assist APNs in their decision making.

CASES AND DISCUSSION QUESTIONS Cases 1. Karen, APRN, eats lunch with two APN friends at a local restaurant on her days off. She lives in a large city and works in urgent care 3 days per week. During lunch, she receives a Snapchat from her friend, Russell, who works with her at the urgent care center. Russell likes to Snapchat Karen on her days off just to say, “Hello.” The Snapchat lasts 10 seconds and then disappears. Karen’s lunch dates look over her shoulder to catch a glimpse of Russell, because they have not seen him for a while. The Snapchat image shows Russell smiling but also shows a vague profile of a male patient surrounded by two security guards in the background. Karen does not recognize the patient, but Russell did say there were some “unexpected guests” in urgent care today. Karen and her friends discuss whether the patient might be the injured politician they heard about 1 hour ago on the news, who had to cancel his political rally due to an unexpected health concern. The politician’s story is all over the news. Are there any ethical issues in this case concerning the use of social media? If so, what are they? Does the Snapchat breach privacy or confidentiality in this case? Does Karen have a moral responsibility to report Russell’s Snapchat to her superiors? Does the fact that Snapchat photos disappear in 10 seconds affect the ethical analysis of this case? How would you handle the case if you were Karen? Explain your reasoning. 2. Glenn is a family nurse practitioner at a community health center. He has three children in the local schools. His teenage daughter tells him that one of her friends sent a couple of nude photos around to her classmates during school hours. She thinks everyone has deleted them, but she is not sure. She did catch a glimpse of one of the photos. Research the laws in your state or country. Does Glenn have any legal obligation as a mandatory reporter to become involved in this situation? What are Glenn’s ethical responsibilities? What would you do if you were Glenn? 3. Gretta is an APN in a family practice clinic in a small community. She suspects that one of her patients, Chloe, who is also her 14-year-old daughter’s Facebook friend, has been using drugs and alcohol, but Chloe won’t admit this in clinic. Gretta is worried about her. It would be easy to access Chloe’s social media information through her daughter’s Facebook page. Gretta and her daughter have an agreement that Gretta may look at her daughter’s social media sites once per month, as many parents do to monitor usage. Is there anything ethically wrong with quickly glancing at Chloe’s Facebook page in the process, given that Gretta would not otherwise have access to Chloe’s pages? Why or why not? Justify your answer. 4. You are an APN managing a busy primary care clinic. Susan, who is one of the RNs in the clinic, reports that she saw Jennifer, the pediatric nurse practitioner, in a Facebook photo last night. Jennifer was smiling and standing in front of the reception desk at the clinic. Craig, one of Jennifer’s adolescent patients, was checking in, and he and his mom smiled and waved at the cell phone camera too. No names were tagged to the photograph. When Susan asked Jennifer about the post, Jennifer said, “Craig’s mom said it was fine for me to post this picture. She told me to tag her so she could have a copy too, but I forgot to tag her.” Is this a breach of patient confidentiality? Are there any other ethical concerns? Why or why not? If so, who is responsible? As the manager of the clinic, how would you address this issue? If you were the clinic manager, what would you include in the social media policy at your clinic?

5. You are an APN working as a hospitalist (supervising care for a group of hospitalized patients) at an urban healthcare institution. Fred is a 37-year-old male in the ICU. He arrived 5 days ago after a receiving a gunshot wound to his head. He is on a ventilator and has been unresponsive since he arrived. His family would like to post a picture of the patient on Facebook to ask their social networking community for prayers. The nurses felt uncomfortable with this request and asked you, as you made your rounds, if you could stop the family from posting the photos. Are there any ethical issues involved in this situation? What are the harms and/or benefits to the patient, staff, or organization if photos are posted? What is the most ethically appropriate course of action and why? What would you do if you were the hospitalist? 6. Jane is a clinical nurse specialist for an intensive care unit. One of the nurses, Karen, is providing care for a retired physician who used to work at the hospital. His two sons are also physicians in the hospital. Karen tells Jane that the sons, who stopped by to visit their father, were speaking in detail about his lab work and radiology results. Karen discovers that they have this information because they looked him up in the EHR system, to which they have access to because they are employees of the hospital. Karen is uncomfortable and asks Jane for help in thinking through the problem. Jane discovers that her physician colleagues in the ICU do not see a problem with it. How should Jane help Karen and the unit in dealing with such issues? Is it ethically problematic for the patient’s sons to have access to their father’s records? Why or why not? What sorts of actions should be taken? 7. Steve is an APN on an inpatient progressive care unit (PCU; a level of care between intensive and regular floor or ward). One of the patients has been on his unit for several weeks and he and the rest of the team have developed a close bond with her. The patient’s health status has improved, and she is transferred out of the PCU to a medical floor. Steve is no longer part of her care team. He finds himself wondering about her status, and looks her up in the EHR to check on the progress notes written about her. Is Steve justified in this action? Are there other ways to alleviate his concern? How does this align with HIPAA’s or other countries’ privacy policies? 8. Lucy is an APN in a primary care office, where her best friend is also a patient (though her friend sees another provider). Her friend has recently had lab work done, and calls Lucy to ask her to look the results up in the EHR system. Should Lucy look up the results? What are the potential ethical implications of Lucy accessing the record and divulging the information to her friend?

Discussion Questions 1. A case study outlined in the Hastings Center Report (2004) describes the case of a Chinese immigrant man who was admitted with a cardiac problem. Circumstances were such that the physician could not get a Cantonese translator in the middle of the night, and he wanted the patient’s 15-year-old daughter to translate for her father; among other things, she would be discussing the seriousness of the man’s condition. What are the implications of asking an adolescent to interpret for a family member? What information would an APN need to decide the appropriateness of this course of action? What risks are involved? How would you resolve this issue for the current situation? In the future? 2. Have you cared for a patient whom you would describe as difficult? Explore the situation you encountered with classmates or colleagues. Identify assumptions that you made

about the patient. What is the basis for these assumptions? Did you think the patient was responsible for the characteristic that made him or her difficult? In what ways was he or she responsible? How would you have liked the person to have acted? Have you ever been considered difficult or felt that you were misunderstood? What would you have liked those around you to consider? 3. Joe, a 17-year-old patient, is scheduled for a sports physical at your clinic. After examining him, you decide to draw a complete blood count because he complains of feeling a bit “more than usually tired” after 30 minutes of shooting hoops. Joe asks you to tell his dad what you are doing because “he gets antsy when he has to wait.” You bring Joe’s dad into your office to talk to him, and he asks you to draw extra blood for drug testing and not to tell Joe what you are doing. The father says, “I just know he is taking something.” What is the main issue in this case? What are the APN’s responsibilities? Discuss with classmates or peers how this situation should be addressed. 4. What is the relevance of discussing advance directives for care, in the event of incapacitation, with your population of patients? (Neonatal intensive care unit nurses may have to imagine caring for another population.) Do you have an AD? Why or why not? What innovative approaches to educating patients about ADs might be used? What obstacles would you anticipate (e.g., personal, environmental, time constraint cultural)? 5. You are the chief nursing officer in a healthcare institution/system and have received some patient and staff complaints as well as praise for a game called Pokémon Go. Research the game and anticipate what some of the patient and staff feedback might be. Propose a policy statement about the use of this game in healthcare facilities. Include ethical issues that may arise from participation in this game.

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CHAPTER 27 Ethical Leadership by Advanced Practice Nurses Nan Gaylord and Pamela J. Grace

Acknowledgment The authors would like to acknowledge Stacy A. Emerson, EdD, MSN, FNP-BC, CNE, for her contribution of a case study. May I stress the need for courageous, intelligent, and dedicated leadership. . . . Leaders of sound integrity. Leaders not in love with publicity, but in love with justice. Leaders not in love with money, but in love with humanity. Leaders who can subject their particular egos to the greatness of the cause. —Dr. Martin Luther King, Jr., “Challenge of a New Age” (speech on the Prayer Pilgrimage for Freedom in Washington, DC, May 17, 1956)

CHAPTER OBJECTIVES 1. Discuss the concept “ethical leadership” and its importance to advanced nursing practice. 2. Understand the characteristics of effective leadership. 3. Describe the levels of leadership as they pertain to your role as an advanced practice nurse. 4. Identify facilitators of and barriers to ethical leadership in advanced nursing practice.

Introduction Nurses have responsibilities for individual and societal health. These responsibilities are to further the profession’s goals of promoting, protecting, and restoring health. Nursing has a central unifying focus on these goals that is evident in the discipline’s collective and historical literature (Willis, Grace, & Roy, 2008). This focus is primarily on humanization in the context of a person’s health needs throughout his or her lifespan. Nurses over the decades and across nations have been concerned with advancing the health of their societies in the face of tremendous obstacles. These obstacles include the lack of respect accorded to women, racism, dehumanization of the poor, expediencies of war, and ignorance of (or disregard for) the roots of ill health in societal conditions. Pioneering nurses recognized the deeply entrenched nature of many healthcare problems in the organization of society and the special interests of those in power and were concerned enough to marshal political support for change using formal and informal knowledge, skills, and political savvy. Many of these nurses exhibited a courage that put them at risk. The fact that almost all of these leaders were women at a time when women’s views were not taken seriously makes their successes even more remarkable. How did they do it? What motivated them? Most important, what can be learned from their leadership, as well as from new understandings and philosophies of leadership, in order to empower modern-day advanced practice nurses (APNs) in their desire to enable good practice? Nursing is no longer essentially a female profession; males are becoming nurses in increasing numbers, including at the APN level (U.S. Census Bureau, 2011), contributing to the diversity of the profession. Nevertheless, furthering nursing’s purposes in contemporary healthcare environments requires constant efforts and solid leadership skills. APNs should not necessarily subject themselves to the sorts of serious risks that some of their predecessors did; however, among other things, the APN role is a leadership role. APNs can envision and address needed changes in the immediate context of care or in broader environments including the healthcare delivery system, and calculating

acceptable levels of risk is an inevitable part of their decision-making process. This chapter provides some definitions of leadership that are pertinent for meeting the professional responsibilities of APNs regardless of their role (direct or indirect patient care). It discusses characteristics needed for facilitating nursing goals, including skills of collaboration, communication, mediation, and, where necessary, referral. Several types of leadership are explored and related to the essentials of advanced practice, as delineated specifically in the United States (American Association of Colleges of Nursing [AACN], 2011; Zaccagnini & White, 2011), and explicitly as well as implicitly in other countries where the APN role has been developed (Pulcini, Jelic, Gul, & Loke, 2010). Although advanced practice roles are relatively new in terms of the development of the broader nursing profession, evidence supports the increasing need for nurses who are well educated, skillful, knowledgeable, and motivated to meet the healthcare needs of their populations (Aiken, Clarke, Cheung, Sloane, & Silber, 2003; Benner, Sutphen, Leonard, & Day, 2009; Dyess, Sherman, Pratt, & Chiang-Hanisko, 2016; Edmonson, 2010; Institute of Medicine [IOM], 2010; International Council of Nurses [ICN], 2010). Finally, because it is critical that APNs advocate for justice in health care and in healthcare access, and that they influence policies that negatively affect their populations, some past and current projects of pioneer APNs are highlighted and useful leadership strategies are discussed.

Leadership Defined Leadership has been defined as moving a group of persons toward a common goal. Leaders establish a direction and influence others to follow that direction; they motivate people toward a shared goal (Curtis, de Vries, & Sheerin, 2011; Sullivan & Garland, 2010; Weihrich & Koontz, 2005). This ideal of movement toward common goals is, in a sense, what distinguishes leadership from management. A review of studies on the psychology of leadership defines leadership as “a process of social influence in which one person is able to enlist the aid and support of others in the accomplishment of a task or objective” and characteristics of effective leadership as requiring that “the person in the leadership role

establish trust and credibility to enlist the support of followers; build relationships with those followers that motivate them to contribute their energy and resources to the collective effort; and manage, direct, and apply those collective resources to accomplish the group’s mission or task” (Chemers, 2001, p. 8580). Many types of leadership have been described in the literature. Two major types derived from studies are transactional and transformational leadership, and there are elements of overlap between the two. Different leadership styles may be successful depending on whether there is a specific task that has to be completed or an ongoing process of change. For example, elements of transactional leadership may be needed to achieve a task within a process of transformational leadership for change.

Transactional Leadership Transactional leadership is perhaps most reflective of many contemporary institutional management practices. It can be conceptualized as a bartering system where one person has more power in the process than others. There are three discernible styles of transactional leadership as discussed by Howell and Avolio (1993). In one scenario, the leader rewards participants for a job well done— contingent leaders. In a second, the leader sets the terms and rules and takes to task those who do not perform well—active leadership. In a third, the leader does not set the rules but expects certain outcomes, passively watches what is going on, then takes remedial actions when things go wrong. Criticisms of transactional leadership include the idea that it is task oriented rather than visionary (Howell & Avolio, 1993; Murphy, 2005).

Transformational Leadership Transformational leadership is aimed at change. The leader has a vision or mission to achieve certain goals. To reach those goals, the assistance of others is needed. Initially these others are followers in the sense that they are persuaded that the leader’s goals are both worthwhile and of interest. “Such leaders energize and motivate their followers to achieve

their goals, share their visions, and embrace empowerment” (Grimm, 2010, p. 76). Several characteristics have been noted as important for effective transformational leadership: (1) transformational leaders have charisma—others are fascinated by them and inclined toward their ideas; (2) they are self-motivated in relation to their goals (internal locus of control) and inspire others accordingly; (3) they are intellectually curious and willing to challenge assumptions or be challenged; and (4) their attention is individualized and focused on the needs of followers, for whom they act as mentors and coaches (Chemers, 2001; Grimm, 2010; Judge & Piccolo, 2004; Murphy, 2005).

Characteristics of Effective Leadership Certain leadership traits are found in many good leaders. Kirkpatrick and Locke (1991) identified six core characteristics that the majority of effective leaders possess: 1. Drive—Leaders are ambitious and take initiative. 2. Motivation—Leaders want to lead and are willing to take charge. 3. Honesty and integrity—Leaders are truthful and do what they say they will do. 4. Self-confidence—Leaders are assertive and decisive and enjoy taking risks. They admit mistakes and foster trust and commitment to a vision. Leaders are emotionally stable rather than recklessly adventurous. 5. Cognitive ability—Leaders are intelligent, perceptive, and conceptually skilled but are not necessarily geniuses. They show analytical ability, good judgment, and the capacity to think strategically. 6. Business knowledge—Leaders tend to have technical expertise in their businesses. In addition to these characteristics, the nature of the APN role inevitably also requires well-honed communication and mediation skills. Communication skills are needed for the comprehensive and appropriate exchange of information, and mediation skills are needed to offset conflicts caused by individual personality and perspectival differences within a group, especially a multidisciplinary group. Interdisciplinary collaborative efforts require that all members of a working group have their perspectives and ideas heard. This means drawing out the voices of the reticent and restraining the input of the overly insistent in a respectful and dignity-preserving way. This facilitates collaborative efforts that are egalitarian (Grace, Willis, & Jurchak, 2007). Other commentators (Grimm, 2010; Lachman, 2007) on leadership for nursing purposes have added the characteristic of moral courage. Moral courage is a necessary

characteristic of nurse leaders who “hold true to their beliefs and convictions” (Grimm, 2010, p. 75) even when it is risky to do so. However, the risks taken are calculated and rational. Moreover, leaders have “ethical fitness,” meaning that they reflect on the values and beliefs that underlie their own thoughts and actions with the intent of understanding prejudices and biases and accounting for them.

The Goals of Nursing: Advanced Practice Leadership Throughout this text, the responsibilities of APNs are described as firmly grounded in the idea that first and foremost an APN is a member of the nursing profession and bound by the code of ethics of the profession. Codes of ethics are developed by the profession as public articulations of the services provided and the expected conduct of nurses in the course of their nursing work. Although the nursing bodies of many countries have developed their own country-specific codes of ethics, the nursing organizations of these countries also had input in and affirm the ICN’s code of ethics (ICN, 2012). The internationally specified goals of nursing are to promote health, prevent illness, restore health, and alleviate suffering (ICN, 2012). Meeting these goals for individuals and groups may require anticipatory proactivity (analyzing the status quo or proposed policy changes for their likely effects), ethical perception or discernment (that things are not right and why), and moral agency (actions toward change). Every nursing action taken should be aimed at furthering one of these nursing goals for an individual, a particular society, or sometimes on an international level (as in nurses involved with global issues). When working conditions, the environment, or other influences block the ability to further these goals, nurses have further obligations (Grace, 2001). At the APN level, these responsibilities include ethical leadership for change. Ethical leadership by the APN means that he or she uses knowledge, skills, and influence to lead a group of persons (perhaps other nurses or perhaps an interdisciplinary group) toward a shared goal of improving an aspect of health care or healthcare delivery. Many experienced and thoughtful nurses without advanced preparation have proven themselves to be effective leaders—changing practice and environments, and influencing health policy—but APNs are especially well prepared to serve as leaders. The ICN’s nurse practitioner/advanced practice nursing network has recognized some unifying aspects of the role internationally:

Integrates research, education, practice, and management High degree of professional autonomy and independent practice Case management/own case load Advanced health assessment skills, decision-making skills, and diagnostic reasoning skills Recognized advanced clinical competencies Provision of consultant services to other health providers Plans, implements, and evaluates programs Recognized first point of contact for clients (ICN, 2009) Though not listed explicitly, these role expectations clearly depend on leadership abilities. Advanced education is widely recognized as critical for the APN role.

The Doctor of Nursing Practice In the United States, there has been a recent drive to educate APNs at a higher level. Initially the goal was that all master’s degree programs would convert to the doctor of nursing practice (DNP) degree by 2015. The DNP degree is distinguished from a research doctorate in that it is aimed at preparing practitioners to provide institutional leadership and to serve as educators rather than as researchers, although they may still be involved in research. The DNP was formally approved by the AACN in 2004, as of last account: 264 DNP programs are currently enrolling students at schools of nursing nationwide, and an additional 60 DNP programs are in the planning stages. DNP programs are now available in 48 states plus the District of Columbia. States with the most programs (more than five) include Florida, Illinois, Massachusetts, Minnesota, New York, Ohio, Pennsylvania, and Texas. From 2013 to 2014, the number of students enrolled in DNP programs increased from 14,688 to 18,352. During that same period, the number of DNP graduates increased from 2,443 to 3,065 (AACN, 2016). The focus of the practice doctorate is to improve outcomes “for individuals or populations, including the direct care of individual patients,

management of care for individuals and populations, administration of nursing and healthcare organizations, and the development and implementation of health policy” (AACN, 2004, p. 1). The DNP degree is controversial, having both critics and supporters. The “pro” positions assert that added education helps nurses fill certain gaps or shortcomings in healthcare provision. Magyary, Whitney, and Brown (2006) assert that the existence of a DNP degree is very important in that it will equip nursing leaders and managers with the wherewithal to critically question practice status quo and underlying assumptions in order to influence future practices. To this end, the degree includes additional courses in leadership, management, financing, health informatics, and policy (AACN, 2006; Rodriguez, 2016). A major focus is on improving health outcomes and engaging in practice improvement projects. Additionally, DNPs are able to fill clinical faculty positions (Bellini, McCauley, & Cusson, 2012). In the United States, there is a serious shortage of qualified faculty (AACN, 2017). Moreover, it is thought that this advanced education will remove barriers to autonomous practice for nurses with advanced knowledge and skills. One other argument is that nursing master’s degrees are already very course heavy, beyond that of almost any other academic master’s degree, because of curricular and clinical practice requirements; thus, it is not a very big step to add a few more courses that would put the DNP in line with other professional practice doctorates such as pharmacy and physical therapy. The “con” arguments are from various sources both within and outside of the discipline. The medical community has been fairly vocal in its opposition in the media and in academic journals. There are worries that the DNP role will increase confusion for patients, as nurses’ roles and physicians’ roles are more closely interactive than those of other professions (Miller, 2008). Additionally, nurse scholars worry that these APNs will lose their focus on nursing goals. Concerns about interprofessional conflicts include the deleterious effects on patient care and collaborative relationships, which are essential for projects that require both nursing and medical knowledge for their success (Miller, 2008). Although it is important for U.S. APNs to understand the issues related to the DNP so that they can discuss them in interdisciplinary

forums, the most important point for any nurse who is working in an APN role is to stay mindful of the fact that it is a nursing rather than a medical role and, as such, to be guided by nursing’s perspectives and goals regarding human health. Moreover, the leadership responsibilities that accompany these roles mean that APNs may need to help and collaborate with others in order to envision good practice and work toward good outcomes (Rodriguez, 2016). In the inevitably interdisciplinary settings where advanced nursing is practiced, staying focused on nursing goals and perspectives may be the most difficult task. There will be many distracting influences. Another difficult task is articulating to others what it is that nurses bring to patient care and policy discussions that is different from, and complementary to, the contributions of allied health professionals and physicians (Grace et al., 2007).

The Institute of Medicine’s Report In the United States, an exploration of the status of nursing commissioned by the IOM, an independent, nonprofit, multidisciplinary organization, resulted in the report The Future of Nursing: Leading Change, Advancing Health (IOM, 2011). The report emphasizes the importance of the profession to the nation’s health. The preface asserts that “we believe nurses have key roles to play as team members and leaders for a reformed and better-integrated, patient-centered health care system” (IOM, 2011, p. xii). A summary of the report (IOM, 2010) outlines four key messages; two of them are especially focused on advanced practice. Key Message #1 contends that nurses should be able to practice to the full extent of their education and training. More than a quarter of a million nurses are now educated at an advanced level. Thus, legal restrictions placed on nursing practice by individual states should be questioned. Leaders in nursing are called upon to advocate and lobby for state boards of nursing and legislatures to remove practice restrictions imposed by other health professionals. Key Message #3 argues that nurses should be considered full partners with physicians and other health professionals in redesigning health care in the United States. Full partnership implies equality of voice and influence. That is, nursing’s perspective on the health of persons should receive parity of expression

and consideration in multidisciplinary assemblages. As discussed earlier, the DNP is one movement aimed at enhancing nursing practice and making visible the particular perspective and expertise of nurses.

Enhancing APN Leadership There are ongoing questions about who is or can be a leader. Some people are obvious leaders; some might even say they are “born leaders.” But the question remains whether leadership is possible for all APNs. The answer has to be yes. Leadership is possible for all, but the level of leadership may differ depending on setting and goals. Earlier a reminder was given as to the nature and extent of APNs’ responsibilities for individual and societal health. This is what makes all leadership ethical. APNs must have some capacity for taking the lead in furthering these goals. Otherwise they cannot be said to have ethical responsibilities. In order to be held ethically responsible, choices in action must exist. Many, many books have described leadership models and leader characteristics or traits. Seminars to develop leaders are offered within institutions, outside institutions, sometimes even by employers or contracted by employers for their employees. Nurses should avail themselves of opportunities to develop and refine their own leadership skills and behaviors. Arguments about whether leadership skills can be learned or whether natural personal traits are required for leadership continue; however, leadership behaviors that are regularly practiced can become well-honed skills, just like other skills developed for nursing practice. Case examples of leadership behaviors and the education and skills underlying them are given shortly.

APN Leadership Expectations This next part of the discussion assumes that leadership by APNs is both an expectation and an ethical activity. For nursing, all leadership activities have ethical content. They are directed toward the ultimate goals of protecting and promoting health and relieving suffering using nursing’s perspectives, whether at the individual level or at unit, clinic, or healthpolicy levels. The Canadian Nurse Practitioner Core Competency Framework (Canadian Nurses Association [CNA], 2010, p. 10) is directed at the nurse practitioner (NP) role but exemplifies (with the exception of the NP-specific criteria) leadership expectations for APNs in general.

They include effective “management of clinical care and [serving as] a resource person, educator and role model.” The NP mentors other nurses, peers, and interdisciplinary team members. He or she should be able to explain the nuances and benefits of advanced practice roles to others, including allied “health-care providers, social and public service sectors, the public, legislators and policy-makers.” As an essential aspect of the role, the NP “advocates for and participates in creating an organizational environment that supports safe client care, collaborative practice and professional growth” and “provides leadership in the development and implementation of standards, practice guidelines, quality assurance, and education and research initiatives.” At the public and health policy level, the NP is responsible for activities that inform and influence decision making. To insist to the new APN graduate that leadership is an expected responsibility within the role may be unrealistic initially. The new graduate in a direct patient care role is orienting to a new clinical environment, with many processes and expectations to master. One antecedent of good leadership is an understanding of the environment. However, once an APN has been in the role for a period of time, clinical or policy concerns become evident. It is at this time that leadership skills are needed to implement the needed changes. One of the assumptions reinforcing this reality is stated in the Canadian Nurse Practitioner Core Competency Framework (CNA, 2010, p. 7, #10): “Newly graduated nurse practitioners gain proficiency in the breadth and depth of their practice over time, with support from employers, mentors and health-care team members.” Sherman (2013), however, encourages younger nurses to seek leadership opportunities and describes a competency model used for nursing leadership development. The Nurse Manager Leadership Partnership’s (NMLP) learning domain framework was developed by the American Organization of Nurse Executives, the Association of periOperative Registered Nurses, and the American Association of Critical-Care Nurses. The model’s key domains include the science and art of leadership and the development of the “leader within.” Shirey’s (2007) discussion accords with Sherman’s argument. She likens leadership development to that found in Benner’s work on the development of nurses from novice to expert that occurs over time. However, Shirey’s leadership development model maintains that the

successful attainment of leadership competencies is more important than years of experience. Leadership abilities are developed on the same continuum from novice to expert, and leaders are frequently in roles where they have no particular leadership competencies. To progress to competence, these leaders need access to leadership learning opportunities or to identify mentors who can guide them. The American Nurses Association (2013) is building a cadre of nurse leaders through its Leadership Institute, which offers a series of five webinars (interactive conferences). This institute covers five key areas: strategic thinking, results-oriented leadership, leading people, personal leadership, and unleashing innovation and creativity. Implied qualities or skills underlying the key areas are those of making connections with others, communicating well (skills of listening and articulation), mediating conflicts, and motivating others.

Models of Leadership Useful for Nursing Empowerment In the past, the nursing profession and its members have sometimes been, or have seen themselves as being, disempowered for a variety of reasons, including that nursing is a predominantly female profession (Manojlovich, 2007; Matheson & Bobay, 2007). Thus, use of an empowerment model of leadership makes sense when educating nurses to be leaders. The theoretical basis for the empowerment model is found in Paulo Freire’s critical pedagogy of the oppressed. Freire’s contention is that the oppressed must be made aware of their position and the reasons they are oppressed in order to be able to transcend the oppression. The oppressed must be willing to rethink their way of life and to examine their own role in oppression if true liberation is to occur. This insight allows the oppressed to regain a sense of dignity and become empowered to act (Freire, 1970). Freire was interested in liberating oppressed members of a society to enhance their situation. The nursing profession has two related tasks in regard to empowerment: (1) it must facilitate the empowerment of its members (2) so that they can provide needed and promised (via codes of ethics) services. A nursing study (MacPhee, Skelton-Green, Bouthillette, & Suryaprakash, 2011) from Canada describes a nursing leadership intervention with a theoretical

empowerment framework. This framework was chosen because, according to the authors’ research, structural and psychological empowerment resulted in safer work environments. This model was effective in developing nurse leaders by demonstrating how to remove organizational (structural) barriers and instill confidence (psychological) that the nurses had control and influence over their work environments. Empowered nurses can empower others. The outcome of the study was that nurse leaders reported “increased self-confidence with respect to carrying out their roles and responsibilities, positive changes in their leadership styles, and increased recognition of staff for positive stylistic changes” (p. 159).

Emancipatory Emancipatory leadership is another model of leadership utilized in nursing. Emancipatory leadership involves integrated knowing being brought to bear on an environment to transform that environment. This model of leadership draws on Carper’s ways of knowing and extends them to include sociopolitical knowledge as described by White (1995). In Barbara Carper’s (1978) extensive review of the nursing literature, she identified four interrelated patterns of knowing that nurses use to achieve nursing purposes: empirics (the science of nursing knowledge of facts and evidence), esthetics (the art of nursing), ethics (what are good actions), and personal (self-knowledge). Chinn and Kramer (2008) argued that integrated knowledge permits nurses (as well as others) to free themselves from situations that limit ethical actions (FIGURE 27-1).

FIGURE 27-1 Nursing Leadership Knowing (N.L.K.) Model. Reproduced from Jackson, J., Clements, P., Averill, J., & Zimbro, K. (2009). Patterns of knowing: A theory for nursing leadership. Nursing Economics, 27(3), 149–159.

Description Jackson, Clements, Averill, and Zimbro (2009) proposed that each of the areas of knowing could also be considered knowledge required for nursing leadership. Empirical knowing facilitates appropriate and comprehensive data collection, analysis, and evaluation. Esthetic knowing can be considered the art of leadership and includes empathic understanding of others and what might motivate them. Personal knowing is essential for ethical leadership. It is the ability to know oneself and be authentic; it is the cultivation of reflectiveness to listen and evaluate one’s presence as a leader. Ethical knowing supports the core values of nursing and the conduct that supports those values. The leader is responsible for the moral environment in which nursing is practiced. This includes respect for patients and colleagues. Arries (2009) found that student nurses judged their interactions with other nurses as unjust in terms of fairness and quality of the interpersonal treatment in comparison to another person or standard. Ethical leadership requires intervention when unethical behaviors occur in the workplace. Leadership is needed for the promotion of justice, fairness, and respect for persons

in the workplace and other environments in which nursing is influential. Nursing leaders, however, are also frequently required to intervene beyond their immediate area of concern or comfort. Their contributions may be needed to make an impact on an institutional or political system where laws and healthcare justifications are made. Effective nurse leaders are knowledgeable about rules, regulations, and policies governing nursing practice, and they collaborate with others to modify them as needed. This is sociopolitical knowing. There are times when the leader does not know the answer or the direction in which to move, and acknowledgment of knowledge limits is a characteristic of a good leader. These integrated ways of knowing are possessed by effective nursing leaders and used to transform the workplace. Transformation of problem practice environments and healthcare policies requires emancipatory leadership.

Levels of Leadership Gallagher and Tschudin (2010)—the current and former editors of the international Nursing Ethics journal, respectively—delineate levels of nursing’s ethical leadership into the following: The micro level—where nurses provide leadership as role models in their work with individuals and teams; The meso level—where nurses contribute to organizational discussions and policy development; and The macro level—where nurses engage politically, lobbying politicians and ensuring that their voice is heard in national and international forums (Gallagher & Tschudin, 2010, p. 225). How leadership plays out at each of these levels is exemplified by reallife cases shortly. Importantly, Gallagher and Tschudin argue that “the meaning of ethical leadership begins with self (personal) knowledge especially of one’s emotional and practical boundaries” (p. 225). They also highlight the reality that nurses who understand their professional responsibilities and when necessary assume a leadership role may sometimes opt to “follow” and support another whom they wisely recognize as better able to achieve a mutually shared purpose. Thus, leaders are sometimes followers. “Life is a constant stream of responses

in conversations and to events, and how we respond to people with whom we talk, or to items of personal or media-generated news, depends largely on values that have been acquired through upbringing, culture, training, or deliberate choice. These are not static aspirations, however, and to remain ethically alive, change is necessary in order to make the fitting response in a given situation” (p. 225).

Facilitators of and Barriers to Ethical Leadership in Nursing Practice Barriers to ethical leadership are environments that do not support nursing’s goals for the good of the patient. In those environments, there are frequently no leaders who are role models for addressing the issues or barriers to good care. Nurses in these environments do not feel as though they have the ability to control their own practice or workplace. When leaders arise from these environments, it is from their own intrinsic motivation that they act and make a difference. However, nurses and even APNs may feel inadequately prepared educationally to take on a leadership role (Curtis et al., 2011). Facilitators of ethical leadership in nursing practice are the same as those that support ethical nursing practice or environments that have the patient’s, group’s, or perhaps society’s good as the motivator of every action. These include supportive unit or clinic structures, strong collegial and collaborative relationships, adequate preparation, and strong mentors. Other facilitators mentioned previously include leadership development academies or educational opportunities for nurse leadership. Contemporarily, there are many examples of all levels of nursing leadership, although the public visibility of such leaders may not always be as high as deserved. Nevertheless, the difference made in peoples’ lives is real and often profound.

Cognitive Processes Underlying Nursing Leadership Ethical leadership for nurses in advanced practice roles means taking action to meet nursing goals for patients, patient groups, and society and engaging and motivating necessary others in the interest of a successful

outcome. The leadership process in turn can be described in terms of Rest’s cognitive processes. Rest (1982) derived a model of the cognitive processes needed for ethical action—as described or exhibited by the individuals studied—from research literature. Rest is clear that this process is not a guarantee of ethically correct action but rather is a description of what happens in the brain of a person who is motivated to do the right thing. The processes are as follows: first, a problem that has ethical aspects is perceived and interpreted; second, pertinent knowledge and analytic skills are mobilized to determine what possible appropriate courses of action exist; third, actions are planned and initiated; and finally, the person perseveres even in the face of adversity to achieve desired goals.

Historical and Contemporary Nursing Leaders Each nursing leader listed in this section exhibited the qualities that are needed for ethical leadership. However, their environments were such that these early leaders sometimes had to be more autocratic than egalitarian in their leadership actions. All perceived a problem that interfered with human well-being—an ethical problem—and determined that the problem had to be addressed. They used knowledge, skills, and decision-making processes to determine what possible courses of action were appropriate. They carefully planned their actions, enlisting the assistance of powerful and/or influential others as needed. Finally, they persevered until nursing goals were actualized.

Leadership at the Macro or Health-Policy Level Florence Nightingale saw that soldiers from the Crimean War were dying of typhus and cholera in far greater numbers than soldiers who were dying of wounds. She understood that these were needless deaths and also what was needed to lessen the death toll. But she met resistance from the military doctors and leaders. She used data, influence, and persuasion in order to be allowed to change the situation. She and her nurses traveled to the front lines, where they activated sanitation measures that were successful in reducing the death rate by two-thirds (Lee, Clark, & Thompson, 2013). Mary Breckenridge was born to a wealthy Kentucky family. She was aware of the terrible deprivations suffered by the poor people in the Appalachian states, especially the high infant mortality rate. Having suffered many losses herself and having been exposed to the work of the British nurse–midwives in France during World War I, she was determined to get the education she needed to change the situation. Using a model of care she had witnessed during her nursing education in Scotland, and funding it out of her own money-raising efforts, she set up a decentralized system of clinics staffed by nurse–midwives from the

United Kingdom who went out to the homes of patients to give primary health and midwifery care. Eventually, as the U.K. nurses left for home, Breckenridge set up a school in Kentucky to educate the first U.S. nurse– midwives (American Society of Registered Nurses, 2007). Other examples of nurse leaders in the United States can be found at the American Academy of Nursing website, Raise the Voice: Edge Runners. All of these APN nurses “are the practical innovators who have led the way in bringing new thinking and new methods to a wide range of healthcare challenges. Edge Runners have developed care models and interventions that demonstrate significant, sustained clinical and financial outcomes. Many of the stories underscore the courage and fighting spirit of nurse leaders who have persevered despite institutional inertia or resistance” (American Academy of Nursing, 2015). Additionally, scattered throughout the IOM’s report, The Future of Nursing: Leading Change, Advancing Health, are more examples of leadership, almost exclusively demonstrated by APNs (IOM, 2011).

Leadership at the Meso Level: Contributions to Organization Discussion and Policy Two APNs with whom the second author of the chapter (Grace) has collaborated on ethics-related projects—Ellen Robinson, clinical nurse specialist in ethics at Massachusetts General (MGH) and Martha Jurchak, executive director of the Ethics Service at Brigham and Women’s Hospital (BWH) in Boston, Massachusetts—are exemplars of transformational leadership at the institutional level. In the necessarily interdisciplinary settings of their institutions, they provide ethics leadership that is aimed at including consideration of all relevant perspectives. In addition, both have been instrumental in mentoring other staff and APNs to institute interdisciplinary ethics rounds and ethics on their units in the interests of good care. Finally, Robinson, Jurchak, Grace, and MGH Chaplain Angelika Zollfrank, with funding from a U.S. Government Health Resources and Services grant, were able to develop and put into practice a model of ethics education that enhances the confidence of point-of-care nurses and APNs in their ethical decision making and advocacy. This endeavor is called the Clinical Ethics Residency for Nurses (CERN) (Grace, Robinson, Jurchak, Zollfrank, &

Lee, 2014; Robinson et al., 2014). On a visit to Switzerland in 2013, Grace met several APNs who had also exhibited leadership at the meso level. Hansruedi Stoll is a master’sprepared oncology nurse and educator at the Universitätsspital Basel. His interest in informed consent issues led him to develop an outpatient program to help people interpret what they want from their lives. He notes that “this question also lies at the core of an advance directive . . . when asking a patient about his/her values, the plans and the question what makes my life worth living. Ultimately this all leads to the question what is my life worth to me. This cannot be answered by a certain mg of an anticancer drug.” Stoll also models this philosophy and approach with colleagues and students. Monica Fliedner is a master’s-prepared oncology/palliative care nurse at the University Hospital in Bern, Switzerland. Along with colleagues, she recognized the need for a dedicated palliative care unit in her hospital and was instrumental in proposing and collaboratively developing an inpatient palliative care unit in her institution where members of different disciplines work together to plan and provide the best care possible for patients.

Leadership at the Micro Level: APNs as Role Models in Their Work With Individuals and Teams Ursi Barandun Schäfer is a clinical nurse specialist for the surgical intensive care unit at the Universitätsspital Basel. One of her many leadership activities involves using a model of ethical decision making developed by an interdisciplinary team, of which she was a member. This model guides unit nurses in their early identification of emerging ethical problems, analysis of the issues, and ways of collaboratively addressing the problem. In this sense, it serves as a preventive ethics strategy. believe that APN educators have an obligation to mentor their students in leadership roles. Case analyses, group discussions, and role-playing can all help to develop APN leadership characteristics. Such activities can be considered leadership at the micro level.

Special Conditions Requiring Leadership: Dual Loyalties There is recognition that military healthcare providers, regardless of country and like their nonmilitary colleagues, continue to be confronted with situations that cause moral distress. It is also recognized that situations of moral distress can be compounded by the problem that military healthcare providers suffer from the problem of dual loyalties (Williams, 2009). Nurse leaders/military officers are called upon to demonstrate loyalty to both the military and their patients. There are good reasons, in times of war or conflict, why there are expectations of obedience based on rank within the armed forces. In general this is thought to contribute to efficiency and effectiveness. However, the same expectations can cause problems for those who are also expected to heed their profession’s code of ethics. An example of how the problem of dual loyalty can present a dilemma for the nurse follows. Implications for nurse leadership are discussed in terms of preventive ethics and the need to address policies and provide educational support for healthcare personnel in the military related to such problems.

Case A military pilot was transported to the hospital for immediate surgical stabilization after crashing his fighter jet into the ocean. According to immediate reports, the pilot “lost the bubble,” which is military flying slang referring to losing one’s equilibrium or control of the aircraft and ejecting from the aircraft without following proper procedure. The result of not following the proper procedure resulted in a death and debilitating injuries to several others. Surgery and subsequent hospitalization took place in a military hospital. The military physician caring for the pilot had written medical orders that he was not to be disturbed, questioned, or interrogated. Physician orders stated that vital signs were to be obtained and normal nursing duties were to be carried out, but no other communication or

visitors were allowed. Within 24 hours of the pilot being admitted to the orthopedic hospital wing, an entourage of high-ranking military officers showed up at the nurses’ station very early on a Sunday morning. Several enlisted medical personnel and one entry level-ranking officer staffed this hospital wing. Upon reaching the nurses’ station, the general from the pilot’s home base demanded to see him. Although the lowranking military nurse explained to the general that he had physician’s orders that the patient was not to be disturbed, the general became increasingly impatient and at times belligerent. Military chain of command is rank determined: regardless of the branch of service, the higherranking officer prevails with orders that are to be followed. During this encounter, the nurse was threatened with loss of rank, punishment under the Uniform Code of Military Justice, and potential court martial for refusing the commands of not only a higher-ranking officer, but of a commanding general. The nurse was concerned for his patient’s optimal recovery. The pilot was still heavily sedated for pain and had expressed sadness and anxiety about what had happened. Moreover, his assessment was supported by the physician’s order. Fortunately, in this situation, the hospital command (leadership) had anticipated such a visit and provided the staff with avenues of action. However, the dilemma is evident: nurses serving in the military walk a fine line, balancing between ensuring that the military mission is met while continuing to provide appropriate health care for patients regardless of whether they are military personnel or detainees. Leaders, military and otherwise, have obligations to anticipate tensions related to dual loyalty and put protocols into place that provide guidance for, and prevent retaliation against, the healthcare providers who are striving to provide ethical patient care. Several recommendations have been made to safeguard the ethical practices of military healthcare personnel. In March 2015, the Defense Health Board’s Medical Ethics Subcommittee, which advises the Secretary of Defense on health policy, compiled a 78-page report titled Ethical Guidelines and Practice for U.S. Military Medical Professionals. These recommendations suggested the following: Create an office within the Department of Defense dedicated to ethics, leadership, policy, and oversight

Establish specific education and training programs in the area of ethics Form policies recognizing that the military health professionals’ first ethical obligation is to the patient Develop mechanisms that allow health professionals to be excused from participating in medical procedures that violate their professional code of ethics Should these recommendations be taken seriously, they will provide a platform and anchor upon which nurse leaders can draw to reinforce nurse moral agency even under extremely difficult circumstances, of which the dual-loyalty problem may be seen as an extreme example.

Summary The nursing profession should encourage all nurses, particularly APNs, to be leaders. The content of APN education varies internationally, but the same critical skills are needed for leadership in health policy and public health, in addition to the clinical skills for direct care, in order to meet nursing’s goals. Where any of these foci are not included in curricula, nurse educators need to lead the way in advocating for their inclusion. APN graduates are encouraged to seek additional opportunities for leadership development commensurate with their practice setting and associated leadership needs. As all leadership in nursing must be aimed at improving individual and societal health, an ethical nurse leader is one who takes this charge seriously, identifies deficits in the environment, and works for change that serves the needs of the population, whether it is an individual patient, group, society, or global concern. Nurses have unique perspectives on health care and the care needed for health. They should continue to involve themselves in contemporary healthcare debates and equip themselves to provide leadership for change.

Discussion Questions 1. Who are the nurse leaders in your country or state at the macro level? What are their characteristics? How did they achieve change? 2. Who are the effective leaders in your area of practice at the meso and micro levels? What are their characteristics? How did they achieve change? 3. What are the areas of knowledge needed contemporarily to provide leadership in the clinic environment or at the bedside? 4. Upon reflection, what do you feel you need to become a more confident, empowered leader? What skills/education is needed? How will you access those opportunities? 5. Thinking about your current context, what is one concern that has to be addressed? Suggest several appropriate plans of action that may be instituted. Describe your motivation for the action and how you will persevere through adversity.

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PART 6 Leadership and Role Transition for the Advanced Practice Nurse The last four chapters of this book take a different perspective on the role of the advanced practice nurse, looking at both professional and personal development of the reader for assuming a new role and leadership in the profession. In Chapter 28, Zuzelo approaches professional development as activities related to acquisition of clinical expertise and dissemination of scholarly activities; however, she purports that self-appraisal and personal development are equally important. She calls for advanced nurses to attend to the self and to model the health-promoting behaviors that nurses advocate as important for clients, colleagues, and family members. The author provides the reader with access to personal inventory tools, self-care plans, and mindfulness exercises. Essential electronic expertise and etiquette is discussed from perspectives of involvement in professional organizations, networking, and marketing self for employment opportunities. In Chapter 29 Taylor Sullivan and Barker identify the importance of having a mentor and suggest how to select a mentor and how the relationship may develop over time. The checklist for selecting a mentor presented in this chapter is a helpful tool for the reader. Conventional wisdom for all leaders states that to be successful, the individual needs to lead a balanced life. To achieve this goal, both time and stress management are central. However, the authors suggest that a slightly different perspective be considered: energy management with time and stress management being strategies. Taylor Sullivan and Barker in Chapter 30 suggest relevant strategies related to other aspects of self-care and offer tools to assist readers in assessing their own skills and developing strategies to capitalize on their strengths and note opportunities for improvement. In the final chapter of this textbook, Beauvais discusses role transitions for advanced practice registered

nurses and the importance of lifelong learning. She outlines the pathway from novice to expert and reviews important strategies for career development, including interviewing skills, portfolio and curriculum vitae development, and involvement in professional organizations. The author’s expertise in executive administration lends itself well to her discussion of organizational fit, continued professional development, and credentialing and obtaining hospital privileges.

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CHAPTER 28 Strategic Career Planning: Professional and Personal Development Patti Rager Zuzelo

CHAPTER OBJECTIVES 1. Practice self-reflection as a component of successful career advancement. 2. Develop a self-care plan encompassing both physical and psychological needs. 3. Explore a variety of strategies to market yourself as you advance your career.



N

urses have access to a wide variety of career paths, and a master’s or a doctoral degree provide entrée to any number of advanced roles. Some roles are considered advanced practice, including clinical nurse specialists (CNS), nurse practitioners (NPs), nurse anesthetists (NAs), and nurse–midwives (NMs). These advanced practice roles require national certifications and state-specific credentialing. The educational programs that provide the degrees needed for advanced practice credentialing examinations are periodically evaluated by recognized accrediting bodies that have verified the quality of the program and its adherence to established curricular requirements. In addition to these advanced practice registered nurse (APRN) roles, nurses have options to prepare for advanced roles that do not fall under the practice designation. These roles directly or indirectly influence health

care in some sort of clear or tangential way; but a nurse with a graduate degree from an educational program exclusive of the four APRN roles is likely not directly engaging with patients as would nurses in advanced practice. Nonetheless, although these nurses are not titled as APRNs, their contributions to informatics, administration, education, quality assurance/improvement, risk management, and other key healthcare system components are important and valuable. Given the many diverse role opportunities available to nurses, it is not uncommon for nurses to lack full understanding of the work performed by those who practice in unrelated advanced roles, including APRN roles. One such example is the lack of familiarity that many nurses express regarding knowledge of the role and responsibilities of the CNS. The specialization of the CNS and the CNS spheres of influence are sometimes difficult to articulate in comparison to a clinical nurse leader (CNL) who may have many years of clinical practice within a particular specialty plus a graduate degree as a “nurse generalist.” Some nurses are confused by the responsibilities of a certified registered nurse anesthetist (CRNA). Nurse informatics specialists are often called on to explain their unique specialization. The nurse practitioner title is highly recognizable and is usually appreciated as an APRN role; however, many members of the healthcare team continue to be misinformed as to the role’s uniqueness as compared to physician assistants or physicians. The takeaway message is that role diversity in nursing is one of the profession’s strengths while simultaneously contributing to role confusion and, at times, role antagonisms within and outside of nursing practice. Advanced nurses, those in APRN roles and those practicing in other roles that require advanced education, specialization, and expertise, share common job tasks and professional performance expectations. Getting to know each other and working together to meet common goals are important outcomes that require acknowledgement and attention. A good starting point is to consider how nurses can strategically bloom in their respective roles while supporting other advanced nurse colleagues, working with nonnursing healthcare team members, and improving healthcare processes and health outcomes. This chapter focuses on both professional and personal development. Professional development is considered from two vantage points: advanced expertise and professional or scholarly development. Personal development is

approached as a requisite component of professional practice, in other words, a call for advanced nurses, APRNs and others, to attend to the self and to role model the health-promoting behaviors that nurses advocate as important for clients, colleagues, and family members.

Reflection and Self-Appraisal: Know Yourself Prior to beginning the activities of this chapter, it is important to reflect on individual accomplishments, learning needs, challenges, expectations, talents, and experiences. Honest appraisal requires self-knowledge. For example, if an advanced nurse is beginning a search for a new expanded opportunity, it is important to proactively consider aspects of potential opportunities that are most appealing and least appealing in order to distinguish opportunities that may be a good fit from those that are likely a poor match. If routinized work patterns are not appealing and contributing to diverse projects, taking risks, and addressing systems issues that require rapid change sounds intriguing, an advanced role with a focus on shortterm projects, data-driven systems changes, or Six Sigma organizations may be an ideal match. On the other hand, if careful attention to detail, consistency, and an interest in patient education, staff development, and continuous quality improvement activities are of interest, a position as a unit or program-based advanced nurse with shared responsibilities for outcomes management or staff education may be very suitable. For the nurse who feels accomplishment when “watching things grow” and appreciates opportunities to tend to the needs of developing nurses when facilitating professional growth, a position that includes teaching, evidence-based practice coaching, or shared governance activities might be ideal. Advanced nurses who prefer working with professionally diverse colleagues and shepherding new initiatives via interprofessional teams may be well served by looking for opportunities that focus on improving systems efficiencies by using nursing science and analytical sciences. Knowing what is personally appealing versus unappealing about work environments, job tasks, and role responsibilities is an important preliminary step for effective career building.

Contemplate Self-Care Practices

Reflecting on the personal self is a valuable activity and may be useful to do in partnership with professional reflection activities. Professional nurses frequently advise patients, families, and colleagues to take time out for self-care. Nurses recognize that there is value in leisure, exercise, and physical fitness and that these behaviors are critical for long-term physical and mental health. Yet many nurses have poor diets with resulting excess body weight or obesity (Miller, Alpert, & Cross, 2008). Many nurses use tobacco products, do not exercise, and internalize stress. The Healthy Nurse, Healthy Nation movement is a nationwide effort in which nurses participate to improve their personal health and that of their families and their patients (American Nurses Association [ANA], 2018). This initiative provides an opportunity to register at no cost and complete a health behaviors survey that assesses health strengths, risks, and possibilities for improvement. Respondents are encouraged to commit to individualized improvement goals and, if desired, communicate with others for support and networking via an active discussion board that is organized around topics of interest.

Tobacco Cessation One particularly concerning health behavior that warrants serious reflection is tobacco use. Conversations about cigarette smoking can be difficult to initiate with colleagues because striking a balance between actively and energetically promoting nicotine cessation versus berating and chastising smokers is challenging (Zuzelo, 2017). Self-appraisal is associated with its own set of challenges because nurses who smoke often experience guilt, self-blame, and remorse. They may conceal the extent of their smoking habits. Although a majority of healthcare professionals has not smoked, a significant number are smokers (Sarna, Bialous, Nandy, Antonio, & Yang, 2014). The good news is that the number of registered nurse (RN) smokers has dramatically decreased since 2003 with one-third fewer nurses smoking by 2011 (Sarna et al., 2014). A review of literature did not reveal RN smoking rates organized by differing types of roles, but it is likely that the RN smoker group includes nurses practicing in advanced capacities. The experiences of nurses who smoke are influenced by their status as healthcare professionals. One research study used focus groups to

describe issues related to nurses’ attitudes toward smoking and quitting while also examining nurses’ preferences for smoking cessation strategies (Bialous, Sama, Wewers, Froelicher, & Danao, 2004). Thematic analysis revealed that nurses’ experiences with smoking addiction and cessation were consistent with those experienced by the general public, including feelings of shame and guilt. These emotional experiences were particularly applicable to nurses because family and friends believed that nurses were in a position to make better choices (Bialous et al., 2004). Advanced nurses need to consider smoking cessation as a critical intervention for self-health and also as a necessary contribution to workplace health, particularly professional role modeling. Utilizing cessation opportunities and supports, pharmacologic and nonpharmacologic, may enable the advanced nurse to successfully quit tobacco usage and to promote the cessation efforts of others. Tobacco Free Nurses (2017) is an initiative that works to build capacity among nurses to equip them to assist patients with tobacco dependence and to become more involved in tobacco control efforts. Tobacco Free Nurses (https://tobaccofreenurses.org) provides links to smoking cessation programs that advanced nurses may use or recommend to staff colleagues. Cessation programs may also be available in workplace settings and, if so, they are often accessible through employee assistance or employee health programs.

Stress Management Nurses, including those in advanced roles, are challenged by work stress, shift schedules, and other circumstances that thwart healthy wellbeing. Many nurses are overweight due to job stress, snacking, inadequate exercise, and a work environment that encourages junk food, end-of-shift desserts, pizza, and pastries (Jackson, Smith, Adams, Frank, & Mateo, 1999). Nurses often do not engage in regular physical activity and live with irregular eating patterns (Nahm, Warren, Zhu, An, & Brown, 2012). Obese people are generally stigmatized in society (Zuzelo & Seminara, 2006) and these negative attitudes may be particularly pronounced in the healthcare setting.

Diet and Physical Activity Challenges Nutritional deficiencies, caloric excess, and the need for self-care may be awkward conversation topics for nurses to have with their providers or colleagues but they are concerns that require contemplation and action. Approximately 20 years ago, Jackson et al. (1999) called for nurses to engage in and promote healthy lifestyles and to confront the mixed message that patients receive when interacting with obese healthcare professionals. These concerns persist and are likely just as significant when it is the advanced nurse who is overweight with poor physical stamina, given that nurses in leadership roles are perceived as role models and often expected to serve as examples for staff and care recipients. Nurses tend to inconsistently address body mass index measurement with patients and avoid dietary counseling. They worry about hurting patients’ feelings. As a result, many nurses avoid difficult conversations with patients about the need to diet, exercise, and lose weight (Zuzelo & Seminara, 2006). It is likely that conversation topics around nutritional challenges are equally difficult for nurses to have with colleagues. Physical activity is a key determinant of health condition. Midlife women are particularly at risk for inactivity and although the percentage of men in nursing has increased by 12.5% between the years 2000 to 2010, the nursing workforce is predominantly female at 91% (ANA, 2014). Compiled nurse demographics reveal that most nurses are in their fifth decade and female. Over 53% of working nurses are over 50 years of age (ANA, 2014). Midlife women tend to experience physiological and psychological transitions that decrease the amount of personal time available for physical activity (Dearden & Sheahan, 2002). Lack of physical activity contributes to weight gain, heart disease, and colon cancer, whereas exercise benefits physical health and mood while reducing distressing signs and symptoms of menopause (Dearden & Sheahan, 2002). Postmenopausal women are at risk for obesity as well as osteoporosis and reduced joint flexibility. These factors contribute to musculoskeletal compromise as do many of the features inherent in nurse work, including prolonged walking and standing. Technologies such as standing computer stations or computerized medication administration

carts increase musculoskeletal risks by reducing opportunities to sit, contributing to problems with feet and lower legs (Zuzelo, Gettis, Hansell, & Thomas, 2008). Advanced nurses need to carefully consider these concerns and develop strategies to reduce employee health risks and enhance well-being, particularly because the healthcare system needs aging nurses to stay in the workforce and contribute as productive and highly skilled professionals. Advanced nurses must evaluate their personal health profiles and encourage staff and colleagues to do the same (TABLE 28-1). They should think about exercise, smoking cessation, sleep patterns, stress management, habits of health promotion, and weight. Advanced roles are incredibly challenging. Whether responding to project deadlines, orchestrating work assignments across disciplines, addressing health outcomes, responding to staffing challenges, or dealing with financial ramifications associated with reimbursement penalties, nurses in advanced roles certainly work within complicated and stressful practice environments. TABLE 28-1 Queries to Guide a Personal Health Improvement Plan Psychological/Social Queries

Physical Health Queries

Do I have quiet, reflective time for rejuvenating? Is there an opportunity for me to lead efforts to improve the practice environment so that a healthy milieu is created and maintained? How might I increase my opportunity for calm and solace? Is there an opportunity for incorporating meditation in my daily work routine? How do I increase my mindfulness? Alcohol intake inventory. Does my intake suggest a pattern of misuse? Depression screening Relationship health check. What is the status of my relationships? How do I want them to change, and what do I need to do to achieve these goals? Am I safe from interpersonal violence?

Physical screenings. What is my current status? ■ Blood pressure ■ Blood glucose ■ Colonoscopy ■ Mammography ■ Lipid panel ■ Dental examination and cleaning ■ Vision examination ■ Sex-specific screenings: gynecologic or prostate ■ Hepatitis C virus testing ■ Bone health evaluation, including osteoporosis assessment if needed ■ Peripheral vascular health Sexual health, if sexually active ■ Gonorrhea and chlamydia screening ■ Human immunodeficiency virus status ■ Am I a candidate for preexposure

prophylaxis, or PrEP? Body mass index ■ What is my height/weight/body mass? ■ How has my weight and body composition changed? Is this pattern cause for concern? Nutritional intake ■ Meal patterns ■ Diet composition Tobacco-related behaviors Sleep patterns Exercise and physical activity routines

Description

Prioritize Self-Care Needs Although these challenges are onerous in their own right, compounding the unhealthy effects is nurses’ tendency to place role demands ahead of self-care activities. It is easy to justify a lack of exercise when the physical work of nursing is so demanding; however, a long day at work is not equal to a 20-minute brisk walk or aerobic exercise with weights. Jackson et al. (1999) suggest that nurses must begin “walking the walk of a healthy life style” (p. 1), and this directive certainly includes advanced nurses.

Keep Up With Personal Primary Care Needs One excellent tool to assist advanced nurses in their quest for good health is the Electronic Preventive Services Selector (ePSS) (https://epss.ahrq.gov/PDA/index.jsp) developed by the Agency for Healthcare Research and Quality (AHRQ) (n.d.) and available to download at no charge. Designed to assist primary care practitioners to offer evidence-based recommendations to patients, the ePSS tool offers U.S. Preventive Services Task Force (USPSTF) recommendations and provides them in rank order based on appraised evidence. Interventions range from recommended to selectively recommended to not recommended and culminate in uncertain (AHRQ, n.d.). Specific USPSTF recommendations are provided with rationales, assessments,

clinical considerations, burden of disease descriptions, and links to tools, including those for screening purposes. The ePSS provides an excellent guide for coordinating patient care but also for self-care planning. Many nurses work outside of primary care and keeping up with changes in primary care can be challenging for nurses who already struggle to maintain specialty expertise. The ePSS can be accessed via the Web or downloaded onto a variety of electronic devices. It also has an application (app) available for smartphones. The low rates of influenza vaccination among healthcare providers (HCP) when compared to the 90% Healthy People 2020 target (Centers for Disease Control and Prevention [CDC], 2014) provides an excellent example of the need for advanced nurses to act on primary care and CDC health recommendations not only to protect patients but also to protect themselves and their loved ones. Advanced nurses should serve as role models to colleagues and to the public. The CDC analyzed data that were retrieved from an Internet panel survey conducted on healthcare providers. Findings revealed that early 2014–2015 season flu immunization rates among HCPs were 64.3%. Vaccination coverage in descending rank order by occupation reveals that pharmacists had the highest coverage followed by nurse practitioners and physician assistants, physicians, nurses, and other clinical professionals (CDC, 2014). Advanced nurses have a role to play in improving these rates, not only by personally contributing to successful immunization campaigns via self-immunization but also by (1) exploring policies mandating immunizations, (2) developing systems to track rates while identifying and responding to barriers, and (3) educating employees about the evidence that underlies the push to immunize for flu. Survey findings exposed learning needs of healthcare professionals by revealing that the most common justification for nonimmunization status was an inaccurate belief that flu vaccines do not work (CDC, 2014). The CDC recommends that flu vaccination should be conveniently accessible to healthcare workers at no cost. Although many healthcare systems do provide free and convenient vaccination, there is room for improvement, and, in particular, more attention is required to long-term care employee immunization rates. This is only one example of where advanced nurses may contribute to improving the healthiness of work environments.

It may be difficult for advanced nurses to prioritize personal health needs. Many organizational cultures are more inclined to implicitly reward the sacrificing, busy, tired advanced nurse rather than the nurse who insists on time for exercise, healthy lunches, bathroom breaks, personal time, and adequate hydration. However, it is empowering and necessary to promote self-health. Leading staff toward positive health practices may improve the quality of health-promotion activities in which nurses engage with patients. Most nurses recognize the importance of teaching patients about health promotion and disease prevention. They may be neglectful of promoting these behaviors among colleagues and within their advanced practice peer group. Self-care is a worthwhile endeavor, but it must be a deliberately planned activity, or it will be unaddressed. Advanced nurses should take the lead and promote smoking cessation, regular exercise, normal weight maintenance, snacking avoidance, routine healthy breakfast intake, regular sleep patterns with 7 to 8 hours nightly, and moderate alcohol intake. They can demonstrate this commitment to health as they strategically plan their professional and personal lives. They must proactively address both of these areas, never one at the consistent expense of the other. Professional success is enhanced by a state of personal well-being, and certainly longevity is improved when positive health practices become a routine way of life. Advanced nurses influence through example. Those involved and engaged in professional activities tend to have more opportunities to share with interested staff. They have an increased ability to mentor because their repertoire of activities and experiences is greater than that of nurses who are less engaged. This premise applies to self-care practices as well. Advanced nurses cannot be haphazard in their approach to professional practice and must be equally disciplined in their approach to self-care. Leaders who manage their time and activities to benefit their health also benefit their families, colleagues, patients, and the organization (EXEMPLAR 28-1).

EXEMPLAR 28-1 The Too Much to Do Snare: Risking It All by Avoiding Self-Care

Judy Moore, DNP, RN, NEA-BC, is an administrator responsible for directing a cardiopulmonary program at a busy university teaching hospital. Her partner, Tanya Johnson, MSN, RN, ANP-BC, is also very busy providing advanced care services in a primary care practice. Both Judy and Tanya are passionate about nursing practice and they work hard to satisfy the many professional demands of their respective roles. Their workdays begin early, typically arising by 5:30 a.m., and end late with a home arrival time that is usually around 6:30 p.m. They have a teenage daughter living at home and an older son in college. Their financial status is secure, although they both worry about paying for their son’s college expenses while saving for their daughter’s upcoming tuition post high school graduation. Judy’s mother lives with them and she is helpful but does require some assistance managing her diabetes type 2. Judy does not provide direct care but is quite engaged with her team and values the close relationship that she has with managers and staff. Tanya practices in a stressful work environment that is understaffed and underresourced. Although she enjoys her job and is dedicated to the population that she serves, Tanya is conflicted about the toll that work is having on her personal health status and worries that she and Judy are failing to realistically address their personal health needs. Both women are 50 years old and experiencing menopause. Both are committed to service and teaching, and they are actively involved in running health fairs and blood pressure screening events at their place of worship. They recently participated in a community blood glucose screening event. Neither is current in their age-appropriate screenings and immunizations. Judy has not had time for a mammogram for 2 years, and Tanya needs a vision screening given her family history of glaucoma and increased intraocular pressure findings revealed during her last appointment, approximately 2 years ago. Neither woman has had cervical cancer screening for the past 4 years. During a particularly busy workday, Judy dropped in on the employee health fair with the sole intention of receiving the required influenza immunization. The fair booth had a variety of informational pamphlets and recommended Web resources. A Healthy Nurse, Healthy Nation (HNHN) (www.healthynursehealthynation.org) flier caught her eye and she began to chat with a clinical nurse specialist who had familiarity with the program and had expertise in women’s health. Judy shared with the CNS that both she and her partner were approximately 20 to 30 pounds overweight. They often purchased prepared meals and enjoyed ice cream and “treats” with a glass of wine or two in the evening before bed. Insomnia was a commonly experienced symptom for both of them and Judy had also noticed that she was waking in the morning with a cough, sore throat, and unpleasant taste in her mouth. She suspected that she had gastroesophageal reflux disease but was self-treating it with over-the-counter, intermittently administered medications. The CNS enthusiastically encouraged Judy to consider exploring the HNHN website at home. Judy was intrigued enough to agree to do so, with a tentative plan to speak with the CNS at some point over the following week. Later that evening, Judy and Tanya completed the HNHN survey and each responded to the queries related to nutrition, quality of life, physical activity, rest, and safety. Both were distressed to find that their survey results demonstrated high to moderate risk in every category. Tanya then suggested that they quickly take a look at the Agency for Health Care Research and Quality’s Electronic Preventive Services Selector and conduct a candid evaluation of their current state of screenings and compile these results in combination with the HNHN survey results. Their daughter became involved in the conversation as well and pointed out that both parents were overweight, highly stressed, and poor sleepers. She followed this observation with questions about their family history. Judy and Tanya began to earnestly consider their genograms and were compelled to recognize that Judy’s familial risk for cardiovascular disease and diabetes was well established and Tanya had a clear pattern of cardiovascular disease, glaucoma, and breast cancer. Later that evening, Judy and Tanya developed a prioritized list of the U.S. Preventive

Services Task Force recommendations that were relevant to their circumstances. They created a checklist that included mammography, colonoscopy, cervical cancer screening, and eye examinations. Tanya noted that her practice was emphasizing the importance of hepatitis screening, particularly hepatitis C. In addition, both noted that they had not been tested for human immunodeficiency virus (HIV). They shared their disappointment in their lack of attention to their personal health, particularly given the influence that these behaviors may have on their children’s prioritization of health screenings and health promotion activities. They reflected on evidence supporting that nurses are less healthy than the average American (ANA, 2018) and are more likely to be overweight and highly stressed. The nurses also agreed that feelings of sleeplessness and sleepiness were more typical than feeling rested and that they often lamented these concerns during conversations at the dinner table that extolled their fatigue, stress, and workload anxiety. The couple developed a plan that included their daughter so as to demonstrate the importance of self-care and to model behaviors that they recognized as essential to healthy aging and quality of life. This plan included biweekly engagement on the HNHN website to explore suggestions, strategies, and peer support in partnership with other nurses. Other selfcare management goals included: Appointments for each scheduled with their primary care nurse practitioner to arrange for: complete physical examinations lipid panels cervical cancer screening blood glucose screening/glycosylated hemoglobin hepatitis screening total body skin checks blood pressure screening referrals for mammography and colorectal cancer screening Age-appropriate immunizations (www.cdc.gov/vaccines/schedules/hcp/imz/adult.html) tetanus/diphtheria/pertussis influenza pneumococcal conjugate immunization (see Centers for Disease Control and Prevention recommendations) pneumococcal saccharide immunization hepatitis A hepatitis B Shingrix (herpes zoster protection) (www.cdc.gov/vaccines/vpd/shingles/public/shingrix/index.html) Health promotion plan Routine exercise program, including flexibility, strengthening, and stamina activities Weekly shopping plan to include healthy foods and routine meal preparation Reduced alcohol consumption Reduced simple carbohydrates, including avoidance of white sugar and flour in meal planning Establish and stick to a sleep program that includes restful downtime 1 hour before bed; herbal tea, and no electronic devices with a scheduled time frame that allowed for 7.5 hours nightly Schedule eye examination Judy and Tanya were pleased with their plan. They recognized the challenges but also

appreciated the risks associated with a continued pattern of too much to do and not enough time to do it. They reflected on the piece written by Kreider (2012) and attached a small sign to their refrigerator that said “Avoid the busy trap!” The excited nurses brought their story to their colleagues at work and encouraged their nursing friends and coworkers to consider joining the HNHN Grand Challenge. They discussed the HNHN program with the nursing administration team and established an ad hoc committee to explore a partnership relationship with the program in hopes that the promotional materials and other resources might encourage participation (www.healthynursehealthynation.org/globalassets/all-images-view-with-media/partners/hnhngc-toolkit-final.pdf). Judy and Tanya printed their primary care and health promotion plan checklist and shared it as well. A few colleagues contributed additional items to the checklist. Many of the nurses shared their own personal health pitfalls, and they collectively decided to support one another and to celebrate those who came to work sharing stories about feeling rested and happy in their lives. They vowed to bring in healthy snacks to share rather than chips, pretzels, and soda. Caffeine consumption was discussed without resolution, but there was firm resolve to cut back on caffeinated beverages during the second half of each shift. The nurses working with Tanya resolved to devote 15 minutes of each weekly staff nurse meeting to sharing health-promoting tips and exploring ideas for enhancing the healthfulness of the work environment. Advanced nurses are encouraged to build on this health promotion plan and consider the checklist created by Judy and Tanya. While doing so, advanced nurses should reflect on the following questions: How might an advanced nurse begin the process of learning to prioritize self-care, if this is an area of care requiring improvement? What barriers to self-care are often experienced by advanced nurses? How are some nurses able to manage these challenges? What may be learned from these positive deviants? (Refer to Chapter 9 for information about positive deviants.) What sorts of workplace changes could be designed to maximize the healthcare setting’s positive impact on nurses’ and other employees’ health status? Is there a need for interprofessional opportunities for self-care support? What does the published literature reveal about workplace opportunities to improve employee health, including weight-management, exercise, and stress reduction programs or self-care education?

Relationships Matter: Nurture Connections In addition to attending to physical self-care needs, nurses usually recognize that relationships are important and need to be attentively tended in order to be healthy and resilient. Relationships require effort and engagement. However, nurses in all sorts of roles, including advanced nurses, may neglect to set aside deliberate time for nurturing relationships that are important to them. Despite advising others to attend to these needs, many times nurses are neglectful of their own personal priorities.

For example, it is not uncommon for advanced nurses to become involved in local, regional, and, in some cases, national organizations. These activities are rewarding but time consuming. The needs can be great, and nurses are accustomed to taking obligations very seriously. As a result, these committed nurses may experience personal burnout as they juggle family, clinical work, scholarship, and organizational activities. It is imperative for nurses to carefully determine the time that is available for professional work within the context of the priorities of particular periods in life while consciously deciding to recognize and celebrate the events of life. “Living each moment” or “Live life to the fullest” are phrases that may be rather overdone, but they are important to keep in mind when working to effectively meet the demands of advanced nursing roles.

Reflective Practice: Developing the Professional Self Reflective practice is advocated in the United Kingdom (U.K.) as a learning process that encourages self-evaluation with subsequent professional development planning. U.K. practitioners are expected to meet a continuing professional development (CPD) standard, and reflection is a strategy that facilitates meeting this standard for revalidation (Royal College of Nursing [RCN], 2018). Registered nurses and midwives are required to develop a minimum of five written reflections related to selected activities. A template is provided to guide these written reflections and nurses are expected to reflect in and on action, defined as reflecting on an activity while in the midst of carrying it out or considering the practice event post hoc and creating knowledge from this consideration (RCN, 2018). Tools are offered as resources to improve reflection, including a template to guide the written reflection, a list of tips to prepare reflections, a video that explores how to reflect as a component of revalidation, and RCN advice on reflection and reflective discussion (RCN, 2018). Several reflective models are provided to assist those nurses interested in a structured approach to reflections. Selected models highlighted by RCN (2018) include the reflective cycle by Gibbs; Johns’s model of structured reflection that connects reflective cues to Carper’s (1978) patterns of knowing; specifically, aesthetics, personal, ethics, and empirics; and Driscoll’s cycle (2007). Each model is linked to supplementary resource materials. The revalidation resources provide solid descriptive information and are rich with practical information, exemplars, and strategies (www.rcn.org.uk/professionaldevelopment/revalidation/reflection-and-reflective-discussion). Much of the work describing reflective practice as a strategy for facilitating continued lifelong learning and promoting professional competence has been published in U.K. journals. In the United States, the term reflective practice is increasingly visible in the nursing literature, particularly in education-focused publications.

Reflective activities are popular in baccalaureate and graduate nursing programs because the activities are valued as self-discerning. Students learn to question their practice and analyze situations to consider alternative behaviors and develop plans for future action. Journal-keeping is one particular learning strategy that encourages self-reflection and promotes critical analysis. This useful tool is now available as a feature on many popular distance or Web-based teaching platforms. Reflection is a useful strategy for advanced nurses. It facilitates critical self-query and encourages movement toward the personal ideal of one’s best nursing self. It is important to differentiate between thinking about daily work versus reflecting on an experience, which requires intentionality and skill (Driscoll & Teh, 2001). Johns (2013) notes that reflective practice traverses from doing reflection to being reflective. Reflective practice demands the ability to analyze situations and make judgments specific to the effectiveness of situational interventions and the quality of outcomes. Johns (2017) offers a typology of reflective practices that can be quite helpful in appreciating the transition of moving from reflecting as an activity to reflection as a state of being (TABLE 28-2). Johns’s work on reflective practice challenges nurses to think differently about experiences that may typically be viewed as routine and yet, upon thoughtful reflection, are likely to be revealed as incredibly powerful. One particularly interesting quote that offers interesting fodder for reflection is shared by Johns (2013): TABLE 28-2 A Typology of Reflective Practices

Description There are no easy answers to the life problems that face patients and nurses who strive to care. When we think we know the solutions to complex situations, we endeavor to apply such knowledge, yet when we seek to impose control of events through applying such knowledge, we somehow miss the point. Practice is a mystery, drama unfolding. We may have had similar experiences but not this one. We draw parallels but it is not the same. (pp. 4–5) Typically, nurses are inclined to keep care practices the same, as there is comfort in routine. Long-established rituals provide security. Reflection encourages nurses to reveal and consider behaviors, feelings, and ideas that would not ordinarily be examined. For this reason, reflection facilitates professional development. It is also a timeconsuming activity that cannot be forced. Driscoll and Teh (2001) note that the benefits of reflective practice include helping practitioners make sense of challenging and complicated practice, reminding practitioners that there is no end to learning, enhancing traditional forms of knowledge required for nursing practice, and supporting nurses by offering formal opportunities to converse with peers about practice. There are also downsides to reflective practice; finding the time, being less satisfied with the status quo, being labeled as a troublemaker, and having more questions than answers are a few of

the challenges associated with the deliberate examination of practice (Driscoll & Teh, 2001). Advanced nurses may want to consider the various reflective practice models and look for opportunities to connect with a view that is particularly appealing or, conversely, a model that challenges an individually held worldview. In general, the models encourage nurses to consider a situation in clinical practice. This situation may be positive or negative but should be important in some sense. After describing the event in writing, practitioners are encouraged to dissect the experience. Practitioners reflect on the emotions, thoughts, and beliefs underlying the experience. They consider the motivation underlying their action choices and think about the consequences of their behaviors. The reflective practitioner is urged to consider alternatives and to challenge assumptions. The final step in the process typically relates to identifying the learning that has occurred and applying this new knowledge in future situations. Reflective activity is viewed as an opportunity to deliberately think about practice events; evaluate choices, reactions, and behaviors; consider alternatives; develop plans for improvement or identify learning needs; and to follow this action plan in new or similar situations. Johns (2004) warned that stage models of reflection may support the belief that reflection occurs in a sequential fashion moving from step to step. He cautioned that although this approach may be helpful for practitioners new to reflection, in general, reflective practice does not follow a rote stage model. However, rather than offering critique of alternative models of reflective practice, Johns (2013) suggests that nurses should reflect on the models and develop insights into what might work best in practice. Reflective practice is described as holistic practice because it is focused on understanding the significance and meaning of the whole experience (Johns, 2004). Johns recognized layers of reflection that progress from a reflection on experience to mindful practice, which are in juxtaposition with moving from “doing reflection” to “reflection as a way of being” (p. 2). Reflection is defined as being mindful of self, either within or after experience, as if [there is] a window through which the practitioner can view and focus self within the context of a particular

experience, in order to confront, understand and move toward resolving contradiction between one’s vision and actual practice. (Johns, 2004, p. 3) Reflective practice may provide a means for connecting the art and science of nursing within a caring context. Reflective practice is an active process and supports the development of practical wisdom (Johns, 2004). Mindfulness is a type of meditative practice that may be viewed as a technique or strategy or intervention or a way of life, depending upon cultural influences and philosophical beliefs (Myers, 2017). Acute awareness of the present can help nurses experience relaxation, tranquility, and self-attentiveness. Myers (2017) asserts that cultivating mindfulness in deliberate fashion can promote self-care and assist nurses in promoting well-being, particularly given the stressful practice environments in which nurses provide care. Advanced nurses have challenging roles with stressors that are multifactorial and contribute to burnout and chronic stress responses. Developing mindfulness as a component of reflective practice takes time and a commitment to regular and frequent practice. There are many free resources that offer opportunities for nurses in advanced roles to support and encourage subordinates, colleagues, patients, and families to also learn to take advantage of the benefits afforded by mindfulness meditation (TABLE 28-3). Wise advanced nurses need to keep in mind Myers’s (2017) admonition that if leaders expect their employees to care for patients in environments that are safe, supportive, respectful, and transparent, they “must care for their employees by supporting mindfulness practices that promote wellbeing, joy, and meaning in the workplace” (p. 265). Of course, advanced nurses who accept this challenge will need to be knowledgeable about reflective practice and mindfulness so that they can model these desired behaviors and practices for staff. TABLE 28-3 Opportunities for Nurturing Mindfulness Type of Resource

Web Address/Contact Information

Descriptions/Notes

Professional Associations/Organizations American Mindfulness Research Association

https://goamra.org

Scientific database of references available for download. Links to mindfulness centers and programs.

Mindfulness Association

http://www.mindfulnessassociation.net

Offers courses and resources with an emphasis on longterm, systematic training.

Center for Mindfulness in Medicine, Health Care, and Society

https://umassmed.edu/cfm/training

The Oasis Institute is housed in the center and provides professional education and training. The center’s website provides a rich repository of evidence-based recommendations, class options (online and video resources as well as other learning supports and opportunities.

Mindfulness Everyday

http://www.mindfulnesseveryday.org

Charitable organization that provides programs on mindfulness and mindfulnessbased stress reduction for people of all ages.

Mindful

https://www.mindful.org/freemindfulness-apps-worthy-of-yourattention/

A mission-driven nonprofit that publishes a bimonthly magazine, Mindful, and offers workshops, conferences, and networking opportunities to support mindfulness.

Applications for Electronic Devices (refer to Web address or app stores for details) Insight Timer (Newman, 2017)

https://insighttimer.com

Aura (Newman, 2017)

https://www.aurahealth.io

Omvana

http://www.omvana.com

(Newman, 2017) Stop, Breathe, & Think (Newman, 2017)

https://www.stopbreathethink.com

Calm (Newman, 2017)

https://www.calm.com

The Mindfulness App (Fischer, 2018)

App store

Headspace (Abate, 2017)

App store

MINDBODY (Abate, 2017)

App store

Buddhify (Abate, 2017)

App store

Insight Timer (Abate, 2017)

App store

Smiling Mind (Abate, 2017)

App store

Meditation Timer Pro (Abate, 2017)

App store

Description Description Nurses should consider that the tension that exists between vision and current reality provides learning opportunities (Johns, 2004). This tension may be uncomfortable, but it offers the opportunity to face and solve the problems creating the anxiety state. Johns (2004) suggests that reflection is a learning process that may develop tacit knowledge. One vehicle for reflection is journaling, whereas others include poetry writing, sharing stories, or creating a portfolio.

Professional Portfolios: Opportunities to Gather Personal and Professional Insights The act of creating a professional portfolio provides an opportunity to reflect on experiences and establish insights that may inform future decisions specific to practice, education, and professional activities. Portfolio creation compels advanced nurses, as well as other nurses, to carefully consider a variety of potential items for inclusion and, in doing so, to contemplate the relative worth of each activity and the contribution of the parts related to the “whole” of the individual’s practice. Advanced nurses also should evaluate the various portfolio components and identify strengths, challenges, and gaps in knowledge, expertise, or experience. The professional portfolio provides a context to examine subsets of practice with a focus on self-improvement and self-development. Just as with reflective practice, portfolio development requires self-awareness. The professional portfolio has become an increasingly popular modality for reflecting on professional development, self-evaluation, creativity, and critical thinking. Portfolios are also useful to track expertise acquisition and to demonstrate competency. McColgan (2008) conducted a literature review to explore current thinking on portfolio building and registered nurses. The literature review revealed four themes: (1) portfolio use as an assessment method for validating competence; (2) portfolio use as a work-based reflective evaluation tool; (3) the relationship between portfolio building and lifelong learning; and (4) portfolio building as a strategy to motivate and develop nurses. McColgan (2008) noted that although there is much theoretical discussion concerning the benefits and influences of the portfolio as a vehicle for promoting professional development, there is a lack of empirical evidence supporting these claims. The reflective activities associated with portfolio development intuitively seem connected to selfdiscovery, self-evaluation, and professional and personal growth; however, evidence-based practice does not prioritize intuition as an

effective way of knowing (Duffy, 2007).

Differentiating Portfolios and Profiles It is important to understand the basic premise of a professional portfolio and to appreciate the differences between a portfolio and a profile. The terms portfolio and profile are often used interchangeably but they are not the same product. A professional portfolio provides a record of professional development. It is a collection of evidence of products and processes documenting professional development and learning experiences (McMullan et al., 2003). A profile is derived from the personal portfolio and the materials selected for inclusion should vary according to the audience and the purpose. For example, a CNS applying for advanced practice role recertification might select a portable document format (pdf) of a published research study, continuing education certificates, and a transcript of a recent pharmacology course from the portfolio to include in a profile that is being submitted with a recertification application. Portfolios in some form are often encouraged or required in undergraduate or graduate education programs (Alexander, Craft, Baldwin, Beers, & McDaniel, 2002; Joyce, 2005). They also offer opportunities for advanced practice registered nurses seeking credentialing when certification examinations in unique clinical specialty areas are unavailable. Some agencies use professional portfolios as tools that document the professional development necessary for advanced practice and, in some cases, validate excellent performance (Chamblee, Dale, Drews, & Hardin, 2015). The United Kingdom requires a professional portfolio to demonstrate continued competency and current professional knowledge. CPD is required and is included in the portfolio (Bowers & Jinks, 2004). The portfolio is registered with the U.K. Central Council and addresses the need for some type of assurance that professional development has continued after basic training is complete. Professional nurses practicing in Ontario must also meet standards of mandatory portfolio management as part of the college’s quality assurance program (College of Nurses of Ontario, 2019). The National Council of State Boards of Nursing (NCSBN) considered a proposal for nurses to initiate and maintain a

professional profile referred to as the Continued Competency Accountability Profile (CCAP) (Meister, Heath, Andrews, & Tingen, 2002). At this point in time, the CCAP is on hold, but NCSBN continues to work on developing methods for ensuring nurse competency to protect the public. One analysis paper published by NCSBN (2005) explored continued competence in nursing and the important issues and challenges associated with regulating competence and assuring the public that competence is, in fact, present. NCSBN identified the barriers to establishing a national system for competence regulation and described the various state-level efforts to address competence. This background information is important for a few reasons. Competency is a hot issue that is likely to increase in its intensity as a focal point of professional practice regulation. Unsafe nursing practice poses public risk and, as a result, assurance of professional competence is a perpetual concern that requires consideration and regulation supported by states’ consensus. Variability across states regarding licensure and practice regulations is concerning and confusing to the public. Some states do not require continuing education, and some have varying title protections with differing licensure requirements and educational mandates. The Pew Health Professions Commission (1998) and the Institute of Medicine (2011) raised similar concerns related to the state of self-regulation and the need to protect the public. NCSBN defines competence as “the application of knowledge and the interpersonal, decision-making, and psychomotor skills expected for the nurse’s practice role, within the context of public health, welfare, and safety” (2005, p. 1). Advanced nurses must give serious thought to strategies for demonstrating competence, particularly given the breadth and depth of the scope of advanced practice and the varying competencies and standards applicable to each advanced nursing role, whether an APRN role or a role associated with advanced certifications that build on recognized standards of practice. Portfolios may facilitate this process by encouraging reflection, strategizing, and documentation.

Contextualizing the Professional Portfolio Keep in mind that a portfolio provides a record of growth and change.

Think of a portfolio as an evidentiary collection of products and processes (McMullan et al., 2003). A portfolio showcases accomplishments and serves to display the unique experiences of an individual nurse’s professional efforts and expertise (Chamblee et al., 2015). The idea of a professional portfolio originated with professionals who were expected to display their work in a portfolio, for example, artists, models, and architects. Portfolios offer advanced nurses a chance to reflect on achievements, develop goals, and forge new insights. In some cases, a portfolio may be required for professional advancement. A portfolio is also useful for developing clinical career pathways (Joyce, 2005) and is frequently encouraged within academic centers as a vehicle for selfassessment and professional development. Portfolio contents vary, but most include a résumé or curriculum vitae, selected examples of individual or group projects, letters of recommendation or commendation, awards, transcripts, continuing education certifications, community service activities, publications, and presentation abstracts or handouts. Typical portfolio components may also include evidence that supports an individual’s experience with the appraisal of colleagues, including mentoring, educating, and precepting. Evidence-based practice activities are also often included (Chamblee et al., 2015). In general, a professional portfolio is an excellent way to organize personal best work products for personal perusal while also serving as a vehicle for showcasing work efforts to future employers or to peer review panels. Portfolios can assist in self-evaluation or reflective practice strategies, and they provide a physical structure for organizing materials that support the premise of competency.

Organizing the Portfolio The physical nature of the portfolio may exist as an electronic folder, expandable file folder, three-ring binder, or any type of form that is portable, professional, and visually appealing. An electronic portfolio is likely the best choice given that an electronic portfolio may be easily printed into hard copies. It is also readily backed up, secure, and conveniently shared with others via email, share services, or other modalities. Creating the portfolio in an electronic form suggests that the advanced nurse is comfortable with technology and has an appreciation

for the benefits of keeping current with required skill sets. Another less obvious benefit of an electronic versus hard-copy portfolio is that credentialing applications are more efficiently submitted using copy and paste functions across electronic mediums. The American Nurses Credentialing Center (www.nursecredentialing.org) offers an individualized member’s database that can be regularly updated and used to inform applications for certification examinations or certification renewals. This database serves as an electronic portfolio, including information about continuing education, academic credits, presentations, publications or research, preceptorship experiences, and professional service. Advanced nurses should carefully consider the contents of the portfolio. If too much documentation is included without sufficient organization, it can become unwieldy and overwhelming, regardless of whether the portfolio structure is print or electronic. In general, view the portfolio as a valuable tool for formative assessment rather than summative assessment. Formative assessment is used to monitor professional progress and to guide development; summative assessment is used to measure proficiency or to appraise performance. Portfolio perusal provides evidence of professional growth over time rather than providing a summary of advanced nurses’ expertise or talents.

The Printed Portfolio Jasper (1995) suggested that the portfolio resembles a scrapbook and noted that Benner’s (1984) model of skill acquisition is compatible with the portfolio strategy. Meister et al. (2002) recommended that portfolios include a table of contents, provide section dividers, and use high-quality paper. Bright white paper greater than 90 brilliance with weight greater than 20 pounds will provide a professional look and feel to a hard-copy portfolio. Even if the portfolio is housed in electronic form, keep the recommendations for hard-copy portfolios in mind when printing select content areas. The intended audience is an important consideration. Do not assume that sophisticated technologies are always best. There are times when the intended audience may not have easy access to cloud access, software platforms, or speedy Web access. In these events, a high-technology portfolio may elicit frustration from the intended viewer

and an attractive, readily available hard-copy portfolio may be the best option. Binders are available for purchase in a wide range of sizes from 1/2 inch to 6 inches. In general, purchasing a heavy-duty binder is well worth the money. The rings of economy-style binders tend to slip open or have gaps when closed, leading to portfolio disarray. Professional portfolios should be contained in a single binder. If there is a lot of documentation, purchase the heavy-duty, 6-inch binders. Anticipate paying $30 to $40 for this binder style. When creating the portfolio in paper form, avoid handwritten work. Tables of contents and dividers can be easily created with a word processor. Professional work requires a standard font style. The sixth edition of the Publication Manual of the American Psychological Association (2009) offers suggestions for professional writing and identifies Times New Roman or Courier, 10- or 12-point font, as appropriate styles. Use black ink and avoid “word art,” dramatic shading, or friendly borders. Although such artistry may be appealing in a creative arts project, they are inappropriate for professional work. Plastic page covers or sheet protectors provide convenient, attractive protection for the portfolio contents. Several styles of sheet protectors are available. A heavyweight, diamond clarity type of protector will allow clear visualization of the covered documents without lifting print. Purchase the acid-free variety for archival quality. Remember that the portfolio is meant to provide formative evaluation data and will be useful for decades.

The Electronic Portfolio Electronic portfolios have many advantages over traditional hard-copy portfolios. They are easily revised, stored, shared, and protected. Selected documents and activities can be quickly shared, and spellcheck, grammar check, and formatting tools are readily available and handy. As electronic devices become more accessible and technology skills become more requisite, electronic portfolios become more attractive. The convenience and relatively inexpensive costs associated with compact discs (CDs), digital video discs (DVDs), and flash drives should encourage advanced nurses to consider developing an electronic

portfolio rather than a paper copy. Electronically produced portfolios validate nurses’ technology skills and suggest that the advanced nurse is technologically savvy. Certainly such an impression is important given the high-tech nature of many healthcare settings. Do consider that many notebooks, tablets, and other electronic devices are no longer built with CD or DVD drives. Although how an advanced nurse decides to store electronic data for easy access is a personal choice, it may be best to consider a cloud service or large file transfer system as an option for delivering portfolios to intended recipients. Doing so will avoid possibly vexing access issues. Flash drives, also known as thumb drives or USB drives, are easily attached to key rings, attaché cases, or handbags and are conveniently shared. A thumb drive may hold up to one terabyte of data and are the size of a stick of chewing gum. Keep in mind that the greater the memory capacity, the more expense the flash drive. A one terabyte drive may cost approximately $700. Lower capacity drives may be purchased at a more reasonable cost; however, it is important to select a flash drive that has the capacity to store the entire portfolio. The portfolio may demand significant memory if it includes videos, hyperlinks, presentations, and other multimedia files. Many electronic devices have USB ports, making the flash drive a convenient and likely practical choice for physically transporting the electronic portfolio. Electronic portfolios allow video, audio, and interactive components to be included in the formative dataset. The multimedia presentation maximizes individualism and gives the reviewer a real look at the interactive and presentation skills of the advanced nurse. For example, a hard-copy presentation built in PowerPoint software offers less information than the actual slideshow with embedded files and hyperlinks. It is also possible to include a video stream of an actual slideshow presentation that includes the advanced nurse interacting with the audience. The possibilities are practically endless and it is this sort of creative effort that builds on reflection. Keep in mind that few people will want to view numerous full-length presentations or program events. Rather, it is best to also reflect on the sections of a presentation that provide the richest opportunity to best represent the total work product.

The Web-Based Portfolio There are an increasing number of Web-based commercial options for maintaining a professional portfolio. In general, the consumer begins by establishing an account for a set fee. Once the account is created, the advanced nurse uploads pertinent documents and enters data into the portfolio system. Data may be retrieved in the form of comprehensive or mini-portfolios, depending upon the situation. Initial data entry may be time consuming; however, once the account is established, portfolio maintenance is simple and very convenient. Web-based portfolio systems are also available for entire departments and institutions. Such a system can be very useful for Magnet certification and recertification processes. The American Heart Association, Sigma Theta Tau International, the Academy of Medical Surgical Nurses, and multiple healthcare systems and agencies use electronic portfolio services offered through HealthStream (2017). This is one example of a talent management system that combines credentialing, education, and other administrative features using a comprehensive Web-based system. These types of systems are increasingly popular to provide standardized and timely documentation of education and credentialing as well as to centralize data collection and analysis with attention to improving various outcomes. Although this is one example of a fee-based product, the benefits of a systemwide electronic portfolio are somewhat similar to the benefits of establishing and maintaining an individual professional electronic portfolio.

Potential Risks of Portfolio Assessment Portfolios require reflective practice, a process of self-scrutiny. Ideally, this scrutiny includes peer review. It is very likely that in the process of self-evaluation or peer review, errors or weakness in practice may be identified. When a portfolio is used as a public document to renew professional licensure or regulation, as in Canada or the United Kingdom, it is possible that if an area of practice has been identified as “weak” within a portfolio and a nurse makes a mistake in this particular area of practice, potential defense from lawsuits may be problematic. At this point in time, the concern is unresolved but recognized.

Publicizing Professional Experiences and Expertise: The Curriculum Vitae and Résumé Advanced nurses must develop and maintain a written log that showcases their education, work history, contributions to the profession, awards and honors, and other key components that demonstrate a richly engaged professional life. This record may be in the form of a curriculum vitae or résumé. Many advanced nurses have both types of records available for relatively quick review. They differ from each other, but both require constant maintenance and each has a unique role to play as advanced nurses progress in their professional development.

Competing With a Curriculum Vitae A curriculum vitae (CV) is a comprehensive list of professional accomplishments. The term is derived from the Latin curriculum (course of action) and vitae, meaning life (Weinstein, 2002). The advanced nurse should view the CV as the door opener to opportunity. It should accurately reflect the accomplishments and interests of the advanced nurse while providing the viewer with a solid sense of the nurse’s professional identity. The CV is a marketing tool as well as a record. The acknowledged 4 Ps of marketing include product, promotion, price, and position. Weinstein (2002) suggests that the fifth P is portfolio. It may be that a sixth P is worth acknowledging and avoiding; specifically, padding of the vitae. Cleary, Walter, and Jackson (2013) describe padding as “misrepresenting one’s achievements or contributions to a particular field, with the aim of inflating one’s record or role(s) for the purpose of securing an unfair advantage over others in competitive endeavours (sic)” (p. 2363). CV padding is usually more subtle than overt record falsification but is still a dishonest approach to self-representation (BOX 28-1). Advanced nurses should make certain that they regularly update their CVs and also carefully scrutinize the document to ensure veracity.

BOX 28-1 Padding the Curriculum Vitae Overstating work responsibilities, including supervisory and budgetary accountabilities. Suggesting a greater contribution to a project, manuscript, or research protocol than is accurate. Listing published abstracts from podium presentations or poster presentations as though they are published manuscripts. Claiming credit for student work products without fully acknowledging the actual percentage of contributed effort. Listing committee memberships without having participated or engaged in the committee’s work efforts. Documenting works “in progress” or “under review” when the work has stalled or has been reviewed on several occasions without likely publication. Failing to specify when professional activities have been invited or subjected to blind review. Avoiding to note when positions are rotating appointments (e.g., taking turns) versus competitively elected roles. Citing awards and recognitions without describing the selection process as noncompetitive, juried, peer reviewed, or student/staff initiated. Documenting fellowships without sharing significant details, including competitive versus noncompetitive admission processes. Taking credit for work setting projects that were group endeavors and overstating outcome improvements.

The CV differs from a résumé (TABLE 28-4). There are general, customary guidelines for CV structure. Use a standard font and consistent font size. Although bold may be used, avoid designer fonts, colors, and elaborate spacing. Customary font styles include Times New Roman, Arial, and Courier in a 12-point size. Do not use a font size less than 10. Using spell-check is critical. TABLE 28-4 Résumé and Curriculum Vitae in Contrast Résumé

Curriculum Vitae

Overview

Extensive description

One page in length—never more than two

Several pages in length; may be dozens of pages, depending on career length and productivity

Job application

Multiple uses, including professional office, job application, awards, grants, presentations

Employment origins

Academic origins

Description CVs should be printed as one-sided documents usually on goodquality paper. In general, the CNS will not err by selecting bright white paper of 92 or greater brilliance in 24-pound weight. Other paper forms are acceptable, including 100% cotton fiber; however, it is best to avoid pastel or tinted paper unless the color is off-white. Create a header and include the last name with page number. Although it is acceptable to staple the pages together, there is still a possibility that pages will detach. A header or footer will make it easier to identify missing pages. Also, the advanced nurse may find it necessary to electronically send the CV, and a paginated header or footer will assist the recipient in keeping the CV organized.

Structuring the Curriculum Vitae Format the pages with the CV’s headings flush with the left margins. Consider 1-inch margins or less. In general, begin with name, home address, and home telephone number and/or mobile phone number. Include the preferred electronic mail (email) contact information. Make certain that each provided phone number is connected to a voice message that is professional and is readily identifiable as the message center for the applicant. Consider that the provided email address should be designed with return address information, including any quotations or expressions that have been added to the address that is appropriate and helpful. Although some older publications recommend including a Social Security number (Hinck, 1997), given the possible distribution of the CV and the threat of identity theft, this is not a wise decision. Professional license numbers and certification credentialing should be included. Do not use pronouns. Use an active voice with appropriate tense and phrases rather than full sentences. For example, avoid, “I developed a research-based protocol for bladder ultrasound in lieu of bladder catheterization with annual savings of $165,000.” Instead use, “Designed and implemented bladder ultrasound program with $165,000 annualized

savings.” CV formatting varies and is primarily based on personal preference as well as the underlying purpose of the CV. For example, if the advanced nurse is submitting a CV to self-nominate for a key leadership position of a professional organization, the applicant may want to consider reformatting the CV to highlight the skills and experiences that are requisite for this type of opportunity. It is easy to revise and update wordprocessed CVs, but make certain to save revised files by the revision date for easy access. There are many ways to structure a CV. Most list recent experiences first and move in a reverse chronological order. For example, in the education section, the highest degree earned is identified followed by the next highest degree. Do not include postsecondary school education prior to college. Include nondegree coursework under continuing education or as a separate category. Professional certifications should be noted on the CV. Certification as an APRN or as an advanced nurse with specialty expertise is increasingly important for practice, albeit inconsistently regulated at state levels or unevenly required across healthcare systems. The advanced nurse should note all types of certifications, including advanced cardiac life support (ACLS), cardiopulmonary resuscitation (CPR), chemotherapy, neonatal advanced life support (NALS), and any other relevant type of certified expertise. It may be useful to include the date of the most recent child abuse clearance and a criminal background check and offer to make these reports available on request. These clearances save time and are increasingly expected, particularly when nurses are working with vulnerable patient or client populations. All types of publications should be listed. Consider separating publication types: research versus nonresearch, and refereed, nonrefereed, invited, and newsletters. Organize newsletters by professional organization, public organization, institution, department, or unit-based categories. Make certain to include published abstracts, but clearly identify the name of the conference proceedings and whether the abstract was accepted following peer review, blinded or nonblinded. Be clear about whether published abstracts pertain to competitively selected podium presentations at local, regional, state, national, or international venues versus poster presentations or group symposiums.

For the advanced nurse who has not yet published or has done so but scantily, consider this as a possible area for development. There are beginning opportunities to publish, including book reviews, newsletters, and letters to the editors. These first steps demonstrate an interest in writing and set the CV apart from those without publications in any form. In the meantime, if there is no publication credit, simply leave this topic off the CV. Do not include the heading and note “not applicable” or “none.” Grant applications, successful or unfunded but competitively scored, are important indicators of professional efforts. The type of grant should be notated, for example, federal, state, or local agency; competitive nature of the grant; funding request/award; contribution to the grant application endeavor if multiple people worked on the submission; and any other details that assist the reader in appreciating the significance of the grant. If there are multiple unfunded and poorly scored grant applications, it may be best not to include them on the CV. Although they do demonstrate effort, there is a possibility that they also represent a lack of organization, writing ability, or appreciation for the priorities of the funding agency. Of course, the grants environment is very competitive and this context requires some consideration as well. Again, reflection is needed to make good decisions about what to include or exclude from the CV. Professional organizations should be included on the CV. Note any leadership positions within an organization. The advanced nurse should critique the depth and breadth of the active membership organizations and contemplate joining a collection of organizations that represent a national nursing interest, clinical area of practice, local or regional organization, scholarly activity or research focus, as well as an organization that reflects a commitment to relationships, such as an alumni organization. Dues can become burdensome, so it is wise to select carefully. On the other hand, advanced nursing practice demands professionalism. It is difficult to demonstrate professional commitment without any type of nursing organization membership, particularly if there is a nursing organization that is solely designed to address the needs of nurses within the organization’s specialty or to respond to policy or politics as the representative voice of nursing. Honor society memberships should be included on the CV. Sigma

Theta Tau International is the international honor society for nursing, and admission is competitive. Other honor societies should also be listed, including those that are outside nursing, for example, Phi Beta Kappa or Phi Kappa Phi. Honor society memberships outside nursing are not uncommon, given the increasing number of nurses who enter the profession as second-degree students. Social sororities or fraternities may also be included if the nurse is actively involved. Community activities, including leadership roles, should be documented on the CV. This area of the CV demonstrates citizenship and can be important in a competitive job search. Do not include trivial activities that contribute very little to the overall picture. For example, routinely donating money to a particular charity or tithing to the church are inappropriate to include on a CV. Serving on the church board of directors or volunteering with the Girl Scouts of America are important to include because they require individual sacrifice and benefit a larger societal good in an organized fashion with recognized duties. Do not include salary information or salary expectations on the CV. If the CV is in response to a potential job opportunity and salary information is requested or required by the employer, this information should be addressed in the cover letter. If the advanced nurse has taught in a formal academic setting or participated in precepting or formal mentorships during clinical practica experiences, include a brief description of course responsibilities. For the experienced advanced nurse who has been involved in healthcare education, offer specific, factual information about program development and outcomes. If the nurse is a novice in the advanced field or new to the advanced role, consider including select educational activities that were part of the graduate educational program. Remember that appropriate CV style is terse rather than detailed and narrative, so keep descriptions of graduate activities to a tightly woven minimum.

Designing the Résumé The advanced nurse should keep in mind that résumés are quite different than CVs. A résumé is usually recommended as no more than two pages in length, although some suggest that the résumé can be too constrained when subjected to the two-page rule and should, instead, be crafted

within whatever page length is needed to provide the required information. Advanced nurses should give the length serious consideration, and if they make the decision to go with a résumé that is longer than the generally accepted two-page limit, it is imperative that the résumé be succinct, actively voiced, tightly organized, and free of embellishments and unnecessary description. The résumé is meant to provide the necessary information without unduly burdening the reader by excessive length. Generally, the résumé represents a tightly constructed outline of educational background and work experiences, with some sharing of professional activities. If more detailed information is needed, a CV may be helpful. Most academic positions require a CV, whereas business settings request résumés. The employer-focused résumé differs from the traditionally formatted résumé in that it focuses on what the employer needs and wants from the potential hire. Résumés that are crafted with employers’ needs in mind are designed to speak to the skills and competencies that are required of the successful applicant (Welton, 2013). Résumés can be devised in three formats, including chronological (organized by time in a sequential pattern of most recent to later events), functional, or a combination of the two (Welton, 2013). The chronologically organized résumé is the most common style and is likely the format that is less risky to submit given its familiarity to employers. The résumé should begin with a header that identifies the name of the candidate, credentials, and preferred contact information. This section of the résumé is the only content that may be slightly larger in font size and in bold text. Otherwise, the résumé should be consistently formatted with a font size of 10–12. The credentials are important. They should be correctly listed; in other words, the credentials should reflect the actual license or earned certification. For example, if an advanced nurse is certified as an Adult Health Clinical Nurse Specialist through the American Nurses Credentialing Center examination, the correct credential is ACNS-BC to represent the appropriate board certification. The credential should not be shortened or revised to CNS. This requirement holds true for all types of advanced nurses, including those in APRN roles or those with advanced certifications, for example, Nurse Executive Advanced-Board Certified (NEA-BC). The customary order of credentials is as follows: highest academic

degree earned, highest academic degree earned in nursing, professional licensure, certifications, honorary awards, and fellowships. The distinction between highest academic degree earned versus highest academic degree earned in nursing is often a moot point, as many nurses in advanced roles have earned master’s or doctoral degrees in nursing. However, there are many nurses who do earn their highest degrees in disciplines other than nursing. In this case, if the license or certification that the nurse carries requires a particular degree, it may be reasonable to avoid including the highest nursing degree in the credentials list, particularly if the list becomes cumbersome (TABLE 28-5). TABLE 28-5 Examples of Résumé Credentials Incorrect Credentials

Corrected Credentials

Explanation

Micah Ivers, M.S.N, B.S.N, NP, CCRN

Micah Ivers, MSN, RN, CRNP, ANPBC, CCRN

Avoid periods. Use commas between credentials. Use the correct acronym of the earned certification credential. If CRNP is the license issued by the state and held by the candidate, it should be included.

Maria Rodriguez, DNP, MHA, BSN, RN, CRNA, FAAN

Maria Rodriguez, DNP, MHA, RN, CRNA, FAAN

The DNP degree requires the MSN or BSN, so there is no need to include the BSN. The MHA (master’s of health administration) is a nonnursing degree and may be included.

Frank Bruce, PhD, MSN, FNP-BC, CRNP

Frank Bruce, PhD, RN, CRNP, FNP-BC

Because an MSN is required for the FNP-BC certification, even if the PhD degree is in a nonnursing area (e.g., organizational behavior), it is common practice to avoid listing the MSN degree so as to avoid an overwhelming list of letters. If the state provides a required nurse practitioner credential designated as “Certified Registered Nurse Practitioner”, the license should be included.

Description Welton (2013) suggests that it is best to avoid including doctoral degree candidacy status in the credential list. Although it is tempting for those who have nearly completed their doctorate to include PhD-C, PhD-

Candidate, or DNP-Candidate, it is a highly controversial and, frankly, can trigger a negative reaction from employers, particularly those in academic positions. Candidacy status is traditionally used only by those in research degree programs who have successfully passed candidacy examinations and have transitioned into the dissertation phase. A second important point is that many people do not complete doctoral degrees, even those who have mastered the competency examinations. As a result, the candidacy credential is often viewed as a premature acknowledgement of degree completion and the use of an implied degree that has not yet been earned. It has been long-standing tradition to follow the résumé header with a statement describing the applicant’s desired objective. These statements tend to lack impact because they address what the applicant hopes to obtain from the potential employer rather than responding to the needs of the person reviewing the résumé. The employer-focused résumé should offer a statement that describes the expertise and talents that the applicant has to offer to the employer, informed by the needs of the advertised position. Welton (2013) suggests that another opening approach is to provide a bulleted list or summary statement that describes the qualifications of the applicant based on the employment advertisement. This strategy potentially requires a résumé update with each submission, but it may provide the sort of personalized, targeted approach that speaks to the employer who is looking for a specific skill set. The education section typically follows the introductory information. Do not include high school data, including extracurricular activities. Do include all coursework, nursing and nonnursing, whether from a vocational/technical program, two-year degree experience and college education, and undergraduate and graduate studies. In-progress educational endeavors should be included as well with an expected date of completion. Do not include anticipated degree programs if the plan of study has not yet been started. Welton (2013) recommends including the cumulative grade point average (GPA) if it is 3.0 or higher; however, keep in mind that most graduate programs require a maintained GPA of 3.0 or higher, so a GPA that hovers close to 3.0 is actually not particularly impressive; rather, it is at or near the lowest required average. Generally, it may be wise to only include GPAs if they are exceptional overall.

Otherwise, degree completion or continued enrollment in a program already support that the applicant has earned a satisfactory GPA. For those advanced nurses who are new to their roles and have little work experience in their area of academic specialization, it is appropriate to include graduate student clinical/practice experiences, including graded projects and internship details. Once employment is found, the résumé is best served by deleting the graduate student experiences and focusing on employment projects and work experiences. Make certain to select important and quantifiable outcomes for each project that is listed on the résumé. Outcomes may be fiscal, quality based, or productivity focused or may relate to any number of focused areas of interest. Be specific but also remember to avoid padding the CV. Take ownership where appropriate and share credit as it should be shared. Publications, presentations, research projects, and evidence-based practice endeavors should be included on the résumé. Depending on the richness of these experiences, it may be necessary to organize them using standard taxonomy. For example, research projects may be funded or nonfunded, interdisciplinary or unit/department based. Publications are often organized by invited versus blind, peer-reviewed statuses. Alternatively, if there are very few, it is reasonable to organize by chronological date and provide information that describes the individual percentage of effort, type of published media, and selection process. Once the résumé is constructed, including pagination, make certain to solicit critique from colleagues and, if available, from those with relevant expertise. Editing suggestions should be actively solicited from those with experience. It is useful to add the last name to a footer with the page number so that if the résumé pages and cover letter become separated, the potential employer can correctly reconnect the pages in the correct order.

Disseminating the CV or Résumé Make certain to craft cover letters that accompany each distributed résumé. If responding to a job solicitation via traditional mail, the cover letter is included with the résumé. Keep the letter brief and in pristine form. Typographical errors or grammar mistakes offer a quick excuse for application removal from the candidate pile, so careful proofing is

essential. Make certain that the cover letter speaks to the job requirements described in the advertisement. The CV is often submitted in response to a query for background information or as an initial step in a job search, particularly in academic environments. The CV is sent electronically or in hard-copy form, depending on the instructions of the request. In both instances, a cover letter is necessary. The cover letter to an electronically attached CV may be submitted as an email message. If the CV is mailed in paper copy, the cover letter should be consistent with the CV in style and form. The paper or electronic cover letter should include an acknowledgment of why the CV has been forwarded. If there is specific information related to a job opening position number, name of an award, or request, this should be included in the letter. The cover letter should be brief but cordial. Acknowledge the availability of references on request and thank the reviewer for their interest in the CV. The nurse should offer to be available for questions or if additional information is required. One difference between an electronic cover letter and a paper cover letter is the addressee. Emails require an address, but this address is often unrecognizable as an individual’s name. Given the succinct, abbreviated nature of email, a salutation of some form may not even be necessary, thereby releasing the advanced nurse from finding out the formal name and title of the intended recipient. If a salutation is preferred, a simple “Dear Employment Specialist” or “Dear Recruiter” may be appropriate. Paper cover letters require a recipient name and address. The nurse needs to make certain that the addressee’s name is spelled correctly and that the job title and credentials are also correct. If there is uncertainty as to any of this information, effort should be made to contact the organization and verify the addressee’s information. If contact information is not available and a position title rather than an individual name is provided, the advanced nurse should begin the letter with an appropriate salutation. For example, if a CV is required by an organization for award consideration, the applicant may wish to begin the cover letter with “Dear Awards Committee Representative.” If the cover letter and CV or résumé are sent electronically and it is important to ensure that they have been received, use the email system

message options functions (or use the Help function to search for “read receipt”) to request a delivery receipt and a read receipt. The delivery receipt will acknowledge that the electronic message was received by the Internet Protocol address. The read receipt will ask the recipient to acknowledge that the CV was received. These options allow the sender to verify that the materials were received in a timely fashion. If a CV or résumé is being mailed, particularly if they are related to an important professional opportunity, consider using certified mail. When certified mail is used, mail travels as first class, and delivery is confirmed. Certified mail is a smart choice for the advanced nurse who may need to substantiate that the CV was mailed and received. These confirmation and verification suggestions are applicable to any situation in which the nurse is committed to replying to a request for written materials or submitting completed work. If the advanced nurse is looking for a position and is considering using a Web-based job search engine, keep in mind that electronic résumés will be found only via keywords that have been selected by a potential employer. Some applicant tracking systems search approximately the first 80 words of a document, so be certain to include critical phrases and terms early in the résumé. Avoid graphics, shading, italics, and underlining in electronic résumés; however, this suggestion is reasonable for résumés of any type. Many resources are available for creating résumés. Advanced nurses interested in constructing a résumé should cautiously use these resources and request guidance from experts. Although many resources are Web based and user friendly, they can be difficult to revise and reformat. Software templates may also be difficult to reformat. Keep résumés and CVs clean and avoid creative fonts, colors, and styles, including bullet types. Developing the document without using a template may lead to a document that has greater utility and more efficient revising options. Some advanced nurses may choose to disseminate their open access publications by posting their CVs on the Web and using hyperlinks to connect to their work products (Kousha & Thelwall, 2014).

Providing References: Points to Consider The advanced nurse should give careful thought to references. In

general, employers are interested in hearing from individuals who can substantiate the character and abilities of the applicant. Most institutions have a standardized reference form, although reference letters may be acceptable. It is increasingly common for employing agencies to have policies in place about whether or not supervisors are permitted to provide references for current or previous employees and, if so, permissible information parameters. Some workplaces will not permit references, whereas others may require that human resources department personnel generate any and all references. These rules are designed to protect the referring agency from liability, but they can create challenges for the applicant and for the potential future employer. Nurses who are new to their advanced roles may be uncertain as to whom to ask for a reference. Select an individual who can offer evaluative insight and who has a clear idea of the skill set required of the advanced role position in question. At times, graduate students will request references from professors who worked with the student during beginning graduate courses and who have little to share regarding advanced practice skills or professional attributes. This individual may not be the best referring choice and this poor choice may provide a reference letter that does not speak to the relevant talents of the applicant. Instead, the advanced nurse applicant should consider requesting references from a previous preceptor, faculty member with responsibility for evaluating end-of-program work, recent employer, or professional organization leader. It is useful to request reference letters before they are needed and include them in the professional portfolio. If references are gathered before the job search process, ask referring individuals if an employer, committee person, or admissions professional has permission to contact them at a later date for validation of the reference. Having written reference letters at the start of a process can save valuable time. One helpful strategy that the applicant may wish to consider is to offer to the potential referring professional a copy of the résumé to assist with developing reference letter content. Another useful option is for the applicant to craft a one-page categorized bullet list of key activities and accomplishments that are relevant to the position of interest so that the referring professional can handily view dates, activities, and brief descriptions to more readily craft a meaningful reference. Make certain to offer this supplemental tool and provide it only if the person agrees that it

would be helpful. Providing a résumé is always acceptable and it may be provided with the reference letter template or form, if one is provided. If not, the résumé can be shared at the time of the request for the reference.

Contributing to the Meaningful Work of Professional Associations There are so many professional organizations that it would be nearly impossible for an advanced nurse in any role or specialty to identify an area of clinical or leadership interest that is not represented by an organization. Generally, a Web-based search will identify appropriate professional nursing organizations. It is also useful to visit the ANA’s website (www.nursingworld.org) or another large nursing organization’s website and look for organizational links. The links will connect directly to other established, reputable organizations. Part of the challenge of declining memberships may be that with the proliferation of organizations, nurses feel confusion and pressure specific to selecting the few organizations that are most compatible with their interests and priorities. Another reason for avoiding membership may be that family responsibilities compete for the scarce resources of a nurse’s time and money. Given the busy nature of nursing work and the often simultaneous demands of family and other personal commitments, advanced nurses need to carefully craft a personalized strategy for involvement in professional organizations (BOX 28-2). In other words, it may be wise to carefully consider personally important aspects of professional association membership and, having prioritized these concerns, identify the most logical organizations for membership.

BOX 28-2 Audit to Assist in Selecting a Best Fit Professional Association Membership The advanced nurse should consider each of these criteria: 1. Mission statement 2. Goals and objectives 3. Web-based resources 4. Membership fees

5. Ease of dues payment: a. Direct withdrawal from bank account (monthly/annually) b. Direct debit from credit card (monthly/annually) c. Annual dues by check 6. Continuing education opportunities 7. Journal resources: online versus hard copy? 8. Database access, including evidence-based practice resources 9. Professional activities, including conferences and workshops: a. Regional/local activities b. National activities c. International activities d. Relationships to other professional organizations 10. Volunteering options and ease of getting involved 11. Mentoring prospects 12. Leadership and networking possibilities 13. LISTSERV opportunities

Professional associations offer members opportunities to develop new skills, network, and participate in relevant continuing education programs (Escoffery, Kenzig, & Hyden, 2015). Organizations can be a terrific vehicle for recruiting new employees or finding a new professional position. Opportunities to develop relationships with people who otherwise would have been inaccessible or unknown are also highly valued aspects of association membership. Fully engaging in a professional organization is a win/win situation for both the member and the organization. The member contributes to the life of the association and assists in supports its goals while the organization uses its clout and resources to advocate for its members (Escoffery et al., 2015). Membership and leadership in associations demonstrates the advanced nurse’s commitment to the profession and illustrates the nurse’s understanding of collective power and responsibility.

Stepping Up and Stepping In: Getting Organizationally Involved Advanced nurses may be interested in becoming involved within an organization but may be a bit hesitant. This uncertainty is normal and understandable, but it is important to not allow reticence to impede participation. Organizations are eager to have interested, committed, and enthusiastic new members.

Professional organizations face many challenges. Many nursing organizations are experiencing stagnant or declining membership (White & Olson, 2004). Nursing societies are struggling with declining memberships, an aging nursing workforce, increasing expenses, and competition among professional organizations for both members and leaders. This trend is concerning for a number of reasons. Professional organizations provide opportunities for enhancing clinical expertise; keeping apprised of regional, national, and international issues; and developing professional networks. Most groups offer continuing education programs. Some are very involved in political action and have done good work in advancing nursing and societal healthcare agenda items. When an advanced nurse joins a new nursing organization, the nurse should anticipate that active involvement can be easiest to initiate at the local level, if not geographically, then organizationally. Local or regional groups are good places to volunteer as a committee member or to begin participation by attending meetings, offering time to assist at registration tables, or contributing on an as-needed basis. For those that cannot commit to a contribution of time and presence, encouraging others to join or donating monies have a positive impact on the association’s fiscal health and energy. Many national organizations have committees that are filled by appointments rather than elections. It is not uncommon for organizations to publish requests for participation. Members may be asked to submit a CV and a brief letter indicating interest in the committee work. As an example, the Oncology Nursing Society (2019) website devotes a section of the member center page (www.ons.org/make-difference/volunteer) to opportunities for involvement in project teams, advisory panels, mentoring programs, or recruitment events. There are also opportunities noted in local chapters or special-interest groups. The ONS offers application forms in pdf form on the website and is very user friendly. The American Association of Critical-Care Nurses also offers lots of information on its Web page with a Volunteer Opportunities page that describes current needs and provides profile forms for application (AACN, n.d.). These opportunities are wonderful networking vehicles for advanced nurses with an interest in acute and critical care. Other associations also solicit volunteers for any number of activities but some

are not as overt in their search. One such example is the American Nursing Informatics Association (www.ania.org). A volunteer tab or section is unavailable on its website; however, a search using key word volunteer in the search tool reveals opportunities for involvement. In addition to using the search tools available on organizations’ websites, consider contacting the local chapter or national office and ask for information about calls for volunteers.

Connecting Professionally in an Electronic World Listserv Opportunities There is an increasing number of email lists, discussion boards, open forums, and chat opportunities for advanced nurses. One particularly useful tool for connecting with health professionals that share a common professional interest or practice area is the listserv. It is interesting to note that LISTSERV is a trademark for a product distributed by L-Soft International. For this reason, LISTSERV is capitalized. The term listserv is used in a variety of forms, but those groups using the LISTSERV product refer to it in the aforementioned style. Upon joining any type of email list, it is a good idea to print instructions for future reference or save a screenshot for convenient access to the participation “rules” of the list, including temporarily halting emails, disconnecting from the list, or rejoining. Instructions for joining always include the instructions for withdrawing from the list. Generally, there is a moderator or owner of the list. Usually there is a contact person associated with the list to whom questions and concerns may be addressed. LISTSERVs specific to organizations do not typically require membership but do require an email address. Many lists are interprofessional and offer opportunities for engaging with a broad network of professionals. Lists vary in their audience of interest. Some lists address the needs of a particular group of nurses or healthcare professionals. For example, the CNS listserv is designed to encourage connections and support shared expertise between CNSs. There are opportunities for nurse practitioners, specifically, to join a listserv, and there are options for the broader group of APRNs to contribute to lists

that address a broader range of subjects that relate to advanced practice. Other groups address particular subject areas; for example, the Agency for Healthcare Research and Quality recently initiated a TeamSTEPPS LISTSERV for professionals interested in exchanging ideas and needs specific to this particular program (Washington Patient Safety Coalition, 2016). Some groups use the LISTSERV product, for example, AHRQ. Others refer to their groups as a “listserv” and use a provider such as Yahoo to organize the group. Regardless of the provider or product, joining a list is easy. The LISTSERV product offers options for organizing and delivering the electronic mail. This feature can be useful when trying to minimize the number of daily emails or when working with vacation or part-time schedules. Many LISTSERVs offer the option of a daily summary rather than receiving individual emails. This is an important feature when receiving email via portable electronic devices such as cell phones or personal data assistants, as the frequent email responses can be quite burdensome. There are often guidelines for contributing to list discussions (BOX 283). Advanced nurses must be diligent about remembering the purpose of the list. In other words, each contributed message should relate to the overarching subject of the list. The connection may be weak but must be readily apparent. The advanced nurse must remember that the list is absolutely not for marketing or profiteering use of any sort.

BOX 28-3 LISTSERV Rules of Engagement Generic rules for polite LISTSERV participation: 1. Absolutely no commercial advertisements of any sort. 2. Remember that LISTSERV participation is open to the world. There are going to be communication challenges related to diversity and language/communication differences. Try to be open minded. Avoid taking immediate offense, and give the benefit of doubt. 3. Avoid sending messages to the entire subscriber group that are relevant to only a select one or two. Send “thank yous” and other pleasantries to the relevant person only. 4. Do not post materials that are under copyright protection. 5. Do not attach files or hyperlinks to LISTSERV comments. 6. No inappropriate or generally offensive language or slang. 7. Do not post personal information to a LISTSERV. Private contact should be handled through email.

List participants should carefully evaluate the content and wording of postings before clicking the send button. Many lists have significant numbers of members. Once the message has been sent, it cannot be retrieved. If each member follows the rules, the communications and connections can be useful and the networking opportunities invaluable. Advanced nurses often share policies, procedures, instruments, tools, product evaluations, experiences, and sage advice via the LISTSERV.

Discussion Boards and Forums Electronic discussion boards and forums are handy and informative. They offer access to a variety of colleagues, sometimes around the world, and can provide important networking when looking for ideas, data, expertise, speakers, and other contacts. Many professional organizations have discussion boards available for members. Registration is free with membership, and participants usually have a self-configured password provided after the registration process is complete. Numerous electronic forums are also available for nurses that require registration without fees. One forum, www.allnurses.com, is reportedly the largest peer-to-peer nursing site across the globe, with over one million members and over 1,700 posts each day from nurses around the world (allnurses, 2018). Discussion topics vary and are organized by subject. A variety of advertisements are posted on the website offering products, including education and employment opportunities, targeted to nurses. As mentioned previously, courtesy is required, and discussion board rules are clearly posted for review.

Essential Electronic Expertise Technology skills are essential for employment in an advanced role. There is simply no way to effectively practice in today’s healthcare environment without a basic understanding of commonly used software products. Technological competence in electronic mail, Excel, PowerPoint, Word, and Internet search strategies are particularly important. Familiarity with database software such as Microsoft Access may also be useful.

Technological competence is increasingly viewed as a routine expectation of advanced nurses. Abstracts for professional organization conferences as either poster or paper presentations increasingly mandate electronic submissions. Many organizations require the use of PowerPoint software as the presentation format and expect that presentations will be electronically forwarded to the conference committee to load the presentation for the conference and to develop conference CDs or for online viewing, synchronous or asynchronous. It is increasingly rare for organizations to use hard-copy forms, and the ease of PowerPoint software makes other presentation media comparatively cumbersome and prohibitively expensive. As an example, 35-mm slides and overhead transparencies are not acceptable presentation formats at most national nursing conferences. There are a variety of ways to develop software expertise. In-house educational programs are ideal. These programs are free to employees and are geared to the software and hardware used within the place of employment. The challenge lies in arranging the necessary time to attend. Community colleges and university settings offer credit and noncredit courses, as do postsecondary technology schools. Online tutorials are available, and there are vendors that sell videotapes designed as user-friendly tools for learners who learn best through visual processes. Microsoft (www.microsoft.com) offers information related to tutorials and software program classes. YouTube (www.youtube.com) is an excellent resource for instruction on technology. A simple search of “how do I use Excel?” retrieved over five million results. Hardware familiarity is also valuable. Mobile tools like phones and tablets use android or iOS (i Operating System or Internet Operating System). Android is an open source software that permits users to download the base software at no charge and build on it. As a result, there are many different types of android devices and accessories. In comparison, iOS is an operating system for mobile devices that was created by Apple, Inc. and is used in Apple products including IPhones and IPads. Products that use either Android or iOS operating systems are popular and incredibly powerful. Advanced nurses must work to develop expertise with mobile devices. Drug databases, clinical references, personal scheduling, wireless access, email options, and electronic medical record systems are increasingly designed for mobile

devices. Most systems, whether android or iOS, are easy to use and intuitive. Many of the mobile programs and devices are accessible to desktops as well as handheld devices, making it easy to have uninterrupted data access.

Certification: A Value-Added Enhancement Nurses may notice that the terms advanced practice nurse (APN) and advanced practice registered nurse (APRN) are used interchangeably. APRN is the designated term used by the APRN Consensus Work Group and the NCSBN APRN Advisory Committee, otherwise referred to as the APRN Joint Dialogue Group (APRN JDG) report (2008). This group was charged with developing a regulatory model for APRN practice to ensure patient safety and allow for patient access to APRN services. The model has significant implications for advanced practice. The model has been endorsed by many professional organizations and by NCSBN. State boards of nursing have not yet adopted this model into nurse practice acts; however, this model includes elements pertaining to licensure, accreditation, certification, and education (LACE) (APRN JDG, 2008). Advanced nurses of all types should carefully review the JDG report and consider how they need to position themselves specific to professional development, education, and certification within the context of their anticipated career trajectory. Conversely, advanced nurses with responsibility for personnel management and program planning or program operationalization need to understand the APRN Consensus Model so as to make decisions that are consistent with policy recommendations. The JDG report defines an APRN as a nurse who has met educational criteria for one of the four APRN roles within at least one of the six population foci. Specialization provides depth, but the model specifies that the APRN cannot be licensed solely within a specialty area. For CNSs in particular, this proposal is quite a change and requires careful deliberation as they plan for their professional futures or nurse executives craft strategic workforce plans. For example, CNSs may identify themselves as specialized in “critical care” or “oncology” without regard for population. The APRN Consensus Model requires CNSs to be educated in at least one of the six population foci: family/individual across the life span, adult-gerontology, pediatrics, neonatal, women’s

health/gender-related, or psych/mental health (APRN JDG, 2008). The selected population of study would become the licensed population based on certification. Specialization would not be a component of licensure.

APRN Certification Opportunities The American Nurses Credentialing Center (2017) is a subsidiary of the American Nurses Association and is responsible for promoting worldwide excellence in nursing and health care through credentialing programs. It offers advanced role and APRN certification examinations. It also provides individual portfolio creation and maintenance to facilitate future certification renewals. Certification examinations are not inexpensive, but keep in mind that certification examination development is expensive. Examinations are not constructed for practice areas that are unpopular or underutilized because examination integrity necessitates a high number of users to support test bank development and test validity.

Discussion Questions 1. What internal and external factors contribute to stress in your workplace? Discuss strategies to alleviate the issues. 2. Review your self-improvement plan and develop three attainable short-term goals that are realistic for you to achieve. 3. Use the Internet to search for personal inventory tools, self-care plans, and mindfulness exercises. 4. Understand the importance of professional portfolios as they pertain to career development. 5. Discuss the differences between the curriculum vitae and the professional résumé and identify which will be most useful for you to develop as you apply for a position as an advanced practice nurse.

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CHAPTER 29 Developing Leadership Skills for the Advanced Practice Nurse Through Mentorship Dori Taylor Sullivan and Anne M. Barker

CHAPTER OBJECTIVES 1. Discuss the benefits of having a mentor for transitioning to and growing in the role of an advanced practice nurse. 2. Assess issues to consider when selecting and working with a mentor. 3. Explore the stages of the mentor–mentee relationship. 4. Distinguish between mentoring, precepting, networking, and coaching. 5. Embrace one’s responsibilities to mentor less experienced nurse colleagues.

Introduction A mentor is an experienced, influential person who guides and nurtures a less experienced person (the mentee). The mentor is someone who inspires, instructs, nurtures, and encourages the mentee to reach professional and personal goals. Further, the mentor has a respected reputation in the organization and profession and can access the resources and connections to help advance the career of the mentee. Seminal research regarding mentorship shows that individuals who have a mentor, as compared to those not having a mentor, have increased job satisfaction, higher salaries, enhanced self-esteem and confidence, greater opportunities for promotion and advancement, enhanced role socialization, and a definitive career plan (Grindell, 2003). These benefits continue today and have been expanded to include, among others, confidence of practitioners, employee retention, improved interpersonal relationships, and positive coping skills, with continued expression of support for mentorship programs, noting that appropriate mentorship, clinical supervision, and supported development alongside formal education programs are essential for advanced practice nurses before and after their official licensure (Gerhart, 2012; Moran & Naim, 2017; O’Grady, 2018).

Mentorship: The Barker–Sullivan Model FIGURE 29-1 illustrates the Barker–Sullivan model of mentorship (Barker,

Sullivan, & Emery, 2006), which was devised through a review of the literature and through personal experiences of having a mentor and being a mentor. The relationship between the mentor and mentee can best be described as a partnership. In this partnership there is a congruence between the expertise and organizational connections of the mentor and the learning needs of the mentee. As a result of the relationship and interactions between the two, the mentee is energized for self-reflection, learning, and action, leading to professional role development and growth.

FIGURE 29-1 The Barker-Sullivan model of mentor partnerships.

Description At the heart of this relationship, there is open communication, passion in exchange of knowledge, mutual respect and trust, and roles modeling (Eller, Lev, & Feurer, 2014). Because the mentee will likely be disclosing sensitive information, exposing weaknesses, and discussing development of skills and competence in job-related areas, the mentee needs to be open and honest and, in return, can expect confidential, nonjudgmental, and sensitive feedback from the mentor. Because mentorship is a relationship that exists over a long period of time, the relationship goes through several stages (Grossman, 2013).

Stage 1: Initiation: Selecting a Mentor and Determining Expectations At the heart of the mentor–mentee relationship is an attraction of both people whose personality and values fit. Mentor–mentee relationships happen because both the mentor and the mentee wish to work together and they share mutual respect and admiration. (Mentorship and preceptor relations are compared and contrasted later in this chapter.) There are several guidelines to assist the advanced practice nurse to identify an appropriate individual to serve as a mentor. First, one may find that there are several people to consider as mentors. Each of these individuals might bring something different to one’s professional growth and development; therefore, one should not rule out having more than one mentor. However, more than likely, most people will have only one mentor at any one point in time. Second, the mentor should not be a direct supervisor or a potential supervisor. There are several reasons for this. Most important, because the supervisor serves as an evaluator, the mentee may be reluctant to share weaknesses for fear that these will be included in an official evaluation or in decisions regarding advancement. This means that an honest conversation about developmental needs will not happen. On the other hand, to be an effective advanced practice nurse, the nurse does need to establish an effective and appropriate relationship with one’s

supervisor. And, there are some who advocate the mentoring role as part of supervisory responsibilities. Should this be the case, the advanced practice nurse can synthesize this information and with a chosen mentor. A third consideration is whether to ask someone within or outside the organization to serve as a mentor. The pros of having an internal mentor are that the person knows the organization, can help make connections, can observe behaviors and outcomes, and may get feedback about the mentee’s performance from others. A mentor external to an organization, however, can offer new insights and different ways of doing things and can help make connections outside the organization. Over time, it is not uncommon to have both an internal and external mentor. A final consideration is whether to use a peer mentor or someone in an advanced position other than the supervisor position. The advantages of having a mentor from among peers are that the person is experiencing the issues and needs of the role in a similar way. That person’s network of connections may be more appropriate. A mentor at a higher level in the organization, however, can provide a broader view of the organization and a different level of connections with others. TABLE 29-1 is a checklist for nurses to use in selecting a mentor. The first six questions focus on the person’s skills and role expertise. If the answer to any of these questions is no, then the advanced practice nurse might want to consider whether this person would be the best mentor. However, that person might have several important skills the mentee wishes to learn, and the assessment might make clear what the potential mentor can and cannot offer. The last five questions relate to the person’s ability to be an effective mentor. A negative response suggests the need to clarify expectations in the relationship or to seek someone else to be a mentor. After using the checklist to select a mentor, the next step is to establish ground rules. Borges and Smith (2004) provide a set of strategies to set up expectations for the relationship in the very early stage. First, they suggest setting up the details of when, where, and how long meetings will take place and which other forms of communication, such as email, should be used. Second, the mentee should write down long-term career goals and visions and use this information as a starting point for discussion and planning. The last strategy is to develop specific professional learning goals and personal goals. In this process, the mentee should also consider life goals such as salary, health, family,

spiritual needs, and so forth. Advanced practice nurses must lead balanced and happy lives to be effective. A mentor can help the advanced practice nurse pay attention to personal goals while at the same time balancing them with professional goals. TABLE 29-1 Mentor Selection Checklist

Description Description

Stage 2: Cultivation In stage 2, the mentee works on goals by engaging in specific learning activities to develop competencies as an advanced practice nurse with the guidance and support of the mentor. During this period the mentee works on both personal and professional goals. The mentor serves as teacher, adviser, facilitator, coach, and sounding board (Anderson et al., 2002; Grossman, 2013). During this time the mentor connects the mentee to appropriate people both inside and outside the organization and helps the mentee develop the skills, knowledge, and attitudes to be effective in their role and move forward in their career.

Stage 3: Separation and Growing Independence As time progresses, the mentee grows in confidence, gains the necessary knowledge and skills to be an effective advanced practice nurse, and demonstrates the attainment of the role competencies. At this point the mentee begins to seek independence, and the mentor role changes to consultant, with the mentee requesting advice and consultation.

Stage 4: Redefinition of the Relationship In the last stage, the mentee is ready to move on from the relationship and no longer needs the mentor’s advice and support. However, often an enduring relationship and colleagueship evolve and may continue many years (Grossman, 2013).

Other Support Systems Mentorship is a support system that requires much time and commitment from one person for another person’s professional growth. Often people commit to being a mentor because someone had been a meaningful mentor for them and they are paying it forward. Others commit to being a mentor because of their commitment to the profession. However, other professional relationships exist that provide important adjunct but not replacement development opportunities to having a mentor.

Orientation Transitioning to an advanced practice nurse role from that of a registered nurse can be a challenging career change. A formal orientation program introduces the new practitioner to the organization to socialize them into the system, establish general performance expectations and skill sets, and assess and enhance required skills, among other topics. Barnes (2015) studied the factors that influence nurse practitioner role transition in a descriptive, cross-sectional survey of practicing nurse practitioners attending a national conference. A multiple regression analysis was used to explore the relationship of two variables related to successful role transition: prior registered nurse experience and participation in a formal orientation. Prior experience was not significantly related to nurse practitioner role transition, whereas completion of a formal orientation program was significantly associated with a positive transition. Together, the two variables explained only 9% of the variance, and the authors included the amount of mentorship, among other factors, as a possible influencer of successful transition. In addition to orientation and mentorship, Gerhart (2012) differentiated two other support structures for advanced practice nurse transitions: preceptorship and collaboration.

Preceptorship Some organizations have formal, structured programs, which may

mistakenly be called mentorship programs, whose purpose is to assist employees, primarily new hires, in developing into a new role. These programs are better called preceptorships, and they typically follow a formal orientation program. A preceptor is assigned by the organization, and the relationship lasts a defined period of time, usually a shorter time than a mentorship. The purpose is to meet established objectives for knowledge and skill acquisition and socialization. The benefits of formal preceptorship programs are that they provide structured and well-defined expectations for both parties as well as deploy organizational resources, particularly time, for the ongoing development of the relationship (Gerhart, 2012). If the organization offers such a program, the advanced nurse practitioner should take full advantage of this resource, but this does not preclude having a mentor as well.

Collaboration Collaboration for an advanced practice nurse often refers to a regulatory requirement for collaborative agreement with a physician. Although not all states require collaborative agreements, many advanced practice nurses develop a relationship with one or more physicians and other experts to request input on difficult or unusual cases.

Networking Networking is connecting with many influential individuals within and outside the organization to share ideas, to keep current, and to give and get advice. Networking is mutually beneficial to both parties. In contrast to mentoring and precepting, networking is less sustained and less structured and there are fewer interactions with others. Having a network of people is as important for professional success as it is to have a mentor. Networking is a major activity at professional meetings and conferences, providing the opportunity to expand individual perspectives on important topics, including career growth and opportunities (Goolsby & Knestrick, 2017). For internal networking to be effective, advanced practice nurses must reflect on networking needs and set up processes to ensure that they interact with people who can contribute to their professional growth

and development. First of all, one should think about people in the organization who can provide good insights about the organization, whose personality and values are similar to one’s own, whose communication style is compatible, and who might be willing to share. In turn, the advanced practice nurse should think about people in the organization with whom to share experiences and ideas. One can think about this broadly and include other disciplines and peers. Next, the advanced practice nurse needs to make contact with these people by asking them to have coffee or lunch or to stay after a meeting for a few minutes just to talk or to give advice about a specific issue. As nurses establish a relationship with others, phone calls and email can assist them in maintaining contact even when busy. The key here is to be attentive about developing and sustaining networks rather than just letting relationships emerge. Besides having a network within the organization, a network of contacts external to the organization is important for professional growth. Most often this occurs through professional organizations and meetings. The same thought process for establishing an internal network can be used for establishing a network of people outside the organization. Contact with others can be made and can be easily maintained over time using the current technology available.

Coaching In the past few years, coaching has become another popular approach to assist one’s professional development. While sharing some actions, there is a difference between mentoring and coaching (MacLennan, 2017). Some organizations provide a formal coaching and mentoring function, but many do not. Mentors are virtually always unpaid and an expert colleague with whom one shares career interest. In contrast, coaching is often a paid relationship between a person needing a sounding board and expert tailored advice from a person with organizational expertise. Because coaches may not have direct observation of one’s performance, their advice is limited to what they are told by their client versus what they directly observe. A good coach has insight and knowledge that transcends any one organization or individual; rather, the coach understands organizational behavior. Additionally, many coaches used a

variety of assessment techniques to assist their clients to enhance knowledge of self and design plans for growth and change. The relationship, similar to mentoring, is based on trust and confidentiality.

Paying It Forward A core value of the nursing profession is to help others to develop for the good of patients, communities, and society. The previous sections of this chapter discussed a variety of connections with others to assist the advanced practice nurse to grow professionally. At times the focus of making such connections may seem self-serving. However, on the other side of the coin, it is equally important for the advanced practice nurse to be a mentor, preceptor, and networker to help novice advanced practice nurses.

Discussion Questions 1. Identify several individuals you know who may be a good mentor for you. Use Table 29-1 to assess these individuals. Which one would you choose as a mentor and why? 2. Discuss your experiences of being a mentor and/or mentee. What were the advantages of the relationship for you?

References Anderson, M., Kroll, B., Luoma, J., Nelson, J., Sheman, K., & Surdo, J. (2002). Mentoring relationships. Minnesota Nursing Accent, 74(4). Barker, A., Sullivan, D. T., & Emery, M. (2006). Leadership competencies for clinical managers: The renaissance of transformational leadership. Sudbury, MA: Jones and Bartlett. Barnes, H. (2015). Exploring the factors that influence nurse practitioner role transition. Journal of Nurse Practitioners, 11(2), 178–183. Borges, J. R., & Smith, B. C. (2004, June). Strategies for mentoring a diverse nursing workforce. Nurse Leader, 45–48. Eller, L. S., Lev, E. L., & Feurer, A. (2014). Key components of an effective mentoring relationship: A qualitative study. Nurse Education Today, 34(5), 815–820. Gerhart, L. A. (2012). Mentorship: A new strategy to invest in the capital of novice nurse practitioners. Nurse Leader, 10(3), 51–53. Goolsby, M. J., & Knestrick, J. M. (2017). Effective professional networking. Journal of the American Association of Nurse Practitioners, 29(8), 441–445. Grindell, C. G. (2003). Mentor managers. Nephrology Nursing Journal, 30(5), 517–522. Grossman, S. (2013). Mentoring in nursing: A dynamic and collaborative process (2nd ed.). New York, NY: Springer. MacLennan, N. (2017). Techniques for coaching and mentoring. New York, NY: Routledge. Moran, G. M., & Nairn, S. (2017). How does role transition affect the experience of trainee advanced clinical practitioners: Qualitative evidence synthesis. Journal of Advanced Nursing, 74(8), 251–262. O’Grady, N. (2018). The role of mentorship in trainee advanced clinical practitioner development. Journal of Advanced Nursing, 75(4), 707–708.

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CHAPTER 30 Managing Personal Resources: Time and Stress Management Dori Taylor Sullivan and Anne M. Barker

CHAPTER OBJECTIVES 1. Consider how to maximize personal resources by managing energy, appreciating the need to balance efficiency and effectiveness. 2. Assess and reflect on time and stress management strategies to be a successful advanced practice nurse and mitigate potential for burnout. 3. Incorporate strategies into daily patterns to promote resiliency and work-life harmony, including the use of reflective practice.

Introduction Schippers and Hogenes (2011) propose a contemporary view of managing personal resources as energy management, with time and stress management being strategies. For the purpose of this chapter, energy is defined as one’s capacity for sustained activity, be it mental or physical, characterized by enthusiasm and focused effort. Considering conservation of resources (COR) theory (Hobfoll, 2001), it is especially important for those in high-demand positions to manage energy well to achieve desired performance and occupational well-being (Parker et al., 2017). This chapter presents several tools to assess and reflect on time and stress management, concluding with a discussion of reflective practice. By completing the self-assessment activities in this chapter, reflecting on the findings using the self-reflection model, and adopting new ways to manage time and stress, the reader can become more productive, have more energy, prevent burnout, and be more satisfied.

Time Management Covey (1989) suggests in his classic, bestselling book that one of the seven habits of effective people is to “put first things first.” He further proposes that the current understanding about time management as it has evolved over the past decades is now focused on managing oneself versus managing time. Managing time in today’s healthcare organizations is more difficult than it was a decade ago because of the complexity of the industry and the need to respond to the external environment to decrease costs while at the same time providing highquality care. Advanced practice nurses in clinical practice roles may have special challenges in this area because much of their time is scheduled according to practice schedules, with specific amounts of time per encounter. Still, time management principles will be important to maximizing use of this time and for the related professional responsibilities, such as documentation, communication and collaboration, organizational requirements, and professional development, etc. Balancing efficiency and effectiveness is perhaps the biggest challenge in managing time. Being efficient means completing tasks on time and with good-quality output. Being effective means working with others to sustain the goals of the organization. Because this involves building trust, developing high-performance teams, and making changes that will last, being effective while at the same time being efficient is a challenge. Although there is no one solution to this challenge, by being reflective and self-aware, understanding the conflict, and applying some of the strategies discussed here, the goal to balance efficiency and effectiveness can be achieved. Compounding the issue may be that time management is not the organization’s priority (Schippers & Hogenes, 2011). In today’s technological environment, there is frequently an organizational norm that people are immediately available through email, text, and social media, leading to distractions and interruptions that are the major causes of wasting time. As the advanced practice nurse develops increased expertise and assumes more responsibilities in the healthcare

organization, it becomes increasingly more difficult to balance work life and personal life. Although it is difficult, it is essential for health, personal, and professional satisfaction and a sense of well-being to achieve this balance. The good news is that people can find additional time to be both more effective and efficient in their lives by assessing how they manage time and by adopting specific strategies to capture wasted time. The newfound time can then be deployed to work on strategic initiatives to meet personal and organizational goals. Research supports that longterm success is determined by the amount of time an individual spends on the most important goals on a weekly basis (Schippers & Hogenes, 2011).

Benefits of Managing Time Managing one’s time has many benefits (Barker, 2013): Conserving personal energy. By assessing personal energy levels while keeping a time log, one can learn to expend energy when it is most effective. Having clarity of mind. Managing time well leads to having a clear, calm mind when confronted with multiple demands. In the confusion and disorder of daily activities and crises, the advanced practice nurse still must pay attention to long-term strategic goals for both oneself and the organization. If one is struggling to accomplish daily tasks and to keep on top of work demands, one will not have the peace of mind to reflect, engage with others, and act proactively. Nonverbal messaging about significance. How a person spends time sends a message to others about what is important and what is not important. It is in essence “walking the talk” by spending time on important, strategic activities. Contributing to feelings of well-being and happiness. When individuals effectively manage time, they feel more in control of life, less stressed, and less likely to experience burnout. In fact, personal success can be measured by how a person spends time on activities that bring meaning, satisfaction, and joy to life.

Consequences of Poor Time Management

The consequences of not managing time well include the following (Barker, 2013): Reflecting poorly on one’s performance. Missed deadlines and poorquality work do not reflect a nurse’s best work, thus possibly leading to being overlooked for advancement and receiving poor performance evaluations. Negatively affecting others. Others in the workplace can be negatively affected if someone does not complete work and projects on time. People often rely on others’ input and work to complete their work. It is simply unfair to others not to be timely in submission of one’s own work. Burnout. People who are burned out are emotionally and often physically exhausted. Burnout can occur when one feels overwhelmed by demands and a constant pressure of not completing work on time or completing it poorly. Burnout is an extreme form of stress leading to lack of motivation, low personal satisfaction, and adoption of bad habits.

Time Management: Self-Assessment This section presents two approaches for assessing time management skills. The first is a self-assessment survey of best practices in time management. Many of these practices are further explained later in this chapter. The second assessment, and the most effective, is to keep a time log. We suggest completing the survey and log prior to reading the rest of this chapter; but before you analyze the log, read the rest of the chapter to help with a meaningful self-assessment. The following conditions are symptoms of suboptimal selfmanagement and should alert the reader to complete the two selfassessments and to reflect on behaviors now and periodically over time. Regularly exceeding the number of required hours spent on the job Regularly taking work home and working in the evenings and on weekends Feeling resentful about the amount of time that one must devote to the job Having no clarity of mind and an inability to focus

The good news is that people can gain control over their time. When individuals assess how time is spent and adopt the suggested techniques, they should be able to capture wasted time for more meaningful, strategic, and important activities. The first self-assessment activity is to complete a brief self-report survey (TABLE 30-1). These practices are described in more detail later, and the results of the survey can guide where readers can pay particular attention. TABLE 30-1 Assessment Tool for Time Management

Description

The second self-assessment is to keep a time log for at least 1 week. This should be done for a routine week. This is a more detailed and timeconsuming assessment but is well worth the effort. It is best to keep a time management log for both organizational time and personal time because the goal is to have a balance between both aspects of life. TABLE 30-2 is a time log format that can be used for completing this activity. Column 1 identifies the beginning and ending times for an activity. There should be an entry for every activity switch. In column 2, the individual completing the log states what the activity is and who else is involved in this activity. In column 3, the purpose of the activity is recorded. Next, one’s energy level is noted in column 4 using the following scheme: L for low, M for medium, and H for high. In column 5, the individual notes interruptions while completing the activity. Indicate who interrupted, the time the interruption took, and whether the interruption was important or urgent. TABLE 30-2 Time Management Log

Description The last column is to be used to analyze the log. This can be done at the end of each day. First, look at each column and ask the following: Column 1: Time Was I able to maintain the planned schedule (e.g., appointments,

meetings, project work, or other)? Did I spend too much or not enough time on the activity? Was I able to complete the task? Column 2: Activity/People Constantly feeling rushed and out of control Not having time for personal reflection and growth Not achieving long-term personal and professional goals Was this activity directly related to my role in the organization and/or to ensuring positive patient outcomes? Could the task have been done in a better way or delegated? Column 3: Purpose Was the activity a mundane task or not meaningful? Was the activity related to long-term or short-term goals? Column 4: Energy Level Was the task performed at the right time in relation to my energy level? Column 5: Interruptions How many times were you interrupted during the day? By whom? For how long? Column 6: Effectiveness of the Time Spent What percentage of time is spent in activities that are important or urgent? Are the people interacting on a daily basis appropriate to reaching individual and organizational goals?

What are the main interruptions? Assess the percentage of time interruptions fall into each of the categories: very important, important, not important. Can the number of interruptions be reduced? How? (Note: This analysis may have the biggest impact on better use of time.) What are the biggest time wasters? Are there any activities that can be reduced or eliminated? What can be delegated to others? Overall, how effective and efficient was the activity? At the end of the week, the advanced nurse practitioner performs an analysis of the entire week looking for themes and areas of improvement where less time could be wasted, activities could be more effective and efficient, and items could be delegated to others. In addition to the preceding questions, the advanced practice nurse can ask these questions: What percentage of time is spent in work, family and home, social, spiritual, and physical activities? Is there a balance? Were there any tasks that had been put off and then became urgent/a crisis to complete?

Strategies for Managing Time Time management is not easy, and everyone will experience setbacks and days when they will not feel they have managed their time well. Keeping a time log can be completed annually or more often if a time management tune-up is needed. It will help identify areas of improvement and suggest what else can be done in the future. It takes constant care and attention to be a good manager of time. But there are strategies that can be adopted and when practiced regularly can improve one’s time management skills. Based on the self-assessment survey and the findings from the time management log, the reader should focus on the strategies discussed in this section that are most applicable to provide leverage in managing time.

Goal Setting and Planning Most time management experts agree that goal setting and planning are the premier time management strategies. In this section, ways to plan for goal achievement are suggested. First, individuals should write down short-term and long-term goals. The goals should be readily available electronically on the device most often carried by the advanced nurse practitioner or in a written format on a calendar or planner. Practitioners should do two complementary things with these documented goals. First, they should look at the goals daily to keep them fresh. By doing so, practitioners will be more sensitive to opportunities that will help them reach their goals. Second, at the beginning of each day, individuals should have a list of activities to accomplish that day to move toward their written goals. It is not easy to set realistic daily goals; at first it is common to plan more than one can accomplish, but as time progresses most people get better at this task. Most important, people should not get frustrated if they do not accomplish every task every day. In fact, one time management principle suggests that a task will consume the time that has been allotted for it. Therefore, planning an aggressive schedule is a good strategy as long as the person does not get frustrated about not accomplishing everything he or she set out to do. Barker (2013) suggests several guidelines to follow when setting goals: Goals should include all aspects of life, including work, family, social, financial, spiritual, physical, and psychological areas. Goals should be measurable and achievable yet challenging. In determining realistic goals, organizational constraints, resources, and personal strengths and skills should be considered. Time frames for goal completion should be realistic but should not allow for procrastination. Timelines can be reassessed, new deadlines set, old goals dropped when they are no longer appropriate, and new goals added as needed. Individuals should reward themselves upon completion of goals. People should pursue goals with enthusiasm, even when they are not feeling enthusiastic.

Strategy: Scheduling Time to Achieve Goals Today most individuals use a smartphone and/or an e-calendar to schedule meetings. These devices can also be used to block out time to accomplish tasks, keep written goals, and have an ongoing to-do list. Blocking out time to complete both short- and long-term work on important activities is one of the top time management strategies and leads to peace of mind. When one knows that there is time set aside to complete the activity, one can decrease worrying about the activity until the scheduled time. Blocking out time also provides a picture of what is needed when and supports saying no when a time is set aside for a certain activity and someone wants to intrude on this time.

Prioritizing Tasks: Urgent Versus Important A useful way of prioritizing daily, weekly, and monthly goals and tasks is to consider whether activities are important or not important and whether they are urgent or not urgent. This schema can also be used for assessing interruptions in the time management log. Urgency has to do with an immediate need to take some action. On the other hand, important activities are generally those that contribute to short- and longterm goal attainment. FIGURE 30-1 provides a template to assess the importance and urgency of tasks. On the vertical axis is a rating of urgency from high to low; on the horizontal axis is a rating of importance from low to high. The grid can be used in two ways: in the short term to make a decision about how to use one’s time and for the long term to view how much time one is spending in each quadrant. For the short term, a task can be assessed to determine its urgency and importance and to decide whether to engage in the activity. In the longer term, the advanced practice nurse can use the grid to reflect on how much time is spent in each quadrant.

FIGURE 30-1 Assessing tasks for importance and urgency.

Description Covey (1989) suggests that highly effective people who can selfmanage spend most of their time in Quadrant II paying attention to developing, implementing, and evaluating strategic plans, vision, and values. Because these matters are often important (the most important work of the organization) but not urgent, there may be a tendency to procrastinate and spend time and energy on the urgent. A cautionary note is that spending too much time in Quadrant I, high urgency and high importance, is crisis management mode and may be a symptom that Quadrant II work was put off, with important, nonurgent work suddenly becoming urgent. This can lead to increased stress and burnout.

Controlling Interruptions Controlling interruptions is not only one of the most lucrative ways to gain time but also one of the hardest. Sykes (2011) reports that an average of

2 hours per day is spent addressing unplanned tasks, which results in an employee’s inability to focus and taking more time to complete tasks and making more errors than employees who are not distracted. Therefore, controlling interruptions has great potential for capturing time to work on important activities. The advanced practice nurse should go back over the time log and identify patterns in the interruptions, the time spent dealing with them, and whether there are people who interrupt more than others do. After this analysis, the nurse can then implement strategies to decrease interruptions. For example, if one person interrupts more than others, it might be necessary to routinely schedule time with this person and ask that individual to have a list of items to discuss rather than ask for time on the fly. Also consider improvements in work processes if not optimal, especially if specific issues regularly interrupt workflow.

Allowing Oneself Private Time An oft-spoken value for which people take great pride is having an opendoor policy. However, there is a difference between having an open-door policy (meaning being accessible and listening) and having the door open all the time. In order to control interruptions one can schedule and set aside time every week to literally close the door to work on the important activities. Two ways to accomplish this are to have a regularly scheduled time to close the door and request no interruptions and to review one’s calendar at the beginning of each week and find 2 to 4 hours within the week to block off periods for quiet time and individual work.

Avoid Multitasking The term multitasking is derived from the ability of computers to process more than one task at a time and in parallel. It is now used to describe the human activity of doing two or more things simultaneously, moving back and forth from one task to another or moving quickly from task to task. For instance, a person can read and write emails while attending a meeting, take a phone call while composing a written document, and so forth. Multitasking is a form of interruption that can be managed to find more time. After considering research about multitasking, the American

Psychological Association (2006) stated that “multitasking may seem efficient on the surface but may actually take more time in the end and involve more error. Even brief mental blocks created by shifting between tasks can cost as much as 40 percent of someone’s productive time.” Further, multitasking in the presence of others sends a message that one is not mentally or emotionally present with those with whom one is faceto-face and is not fully listening to or engaged with them.

Delegation Delegation is an important skill that enables one to accomplish one’s work and goals. As readers will appreciate in this section, delegation is a fine art with many things to consider and approaches to take. Depending on the role and reporting structure in the organization, some advanced practice nurses may not have others to whom they can formally delegate. However, there may be others in the organization who do not have a formal reporting structure but who can assist nonetheless, such as graduate teaching assistants, program assistants/secretaries, and patient care technicians. Having the right person doing the right tasks leads to higher efficiency. Before a person can successfully delegate to others, however, that person needs to reflect on his or her attitude and values about delegating. Too often one hears “I’d rather do it myself” or “It is faster to do it myself than to tell someone else how to do it.” These statements imply that there are others in the organization to whom one can delegate, yet those individuals are not ready or able to give up control. And, indeed, it might in the short term be faster to complete a task alone, but, in the long term, once someone has successfully accomplished a delegated task it becomes easier and easier for the delegator and the delegatee. Delegation has many advantages: Delegation is a trust-building activity. Delegation builds the confidence and self-esteem of others. Delegation unburdens one from routine, mundane tasks to provide the time for important activities and relationship building. Delegation helps others to grow, learn, and become leaders as they see more of the big picture.

Delegation is an important tool in succession planning. Delegation can match the right person with the right expertise to the right job. The process of delegation involves looking at the task(s) the advanced practice nurse plans to delegate and the skills of the delegatee. Some tasks should not be delegated. This includes important organizational functions and meetings where one’s presence is needed and noted. Human resources matters, such as rewarding people, disciplining people, and managing conflict, also cannot be delegated. Eliminating these tasks from the delegation possibilities leaves the nurse with a substantial number of routine tasks that can be delegated. The next step is to consider the individuals to whom one might delegate. The advanced practice nurse should judge the expertise, strengths and weaknesses, knowledge, interests, skills, and attitudes of the potential delegatee. These should match the job to be done. When delegating, one also needs to be sensitive to the workload of the person to whom one is delegating. Giving the person the ability to negotiate what the scope of the task will be and when it will be done is essential for success. There is a fine line between individuals’ perception that they are being trusted to complete an important task and the perception they are being “dumped on.” To accentuate the positive and minimize the negative, involvement of the person who is being asked to do the task, open communication, negotiation, and lots of praise are required. Further, the process used to delegate is important. First, the person who is being assigned a task needs to understand its importance and urgency, why it is being delegated, and what the requirements and guidelines are. The delegatee needs appropriate information and resources, such as time, space, and money, to complete the task. The person should be aware of dates for task completion and periodic evaluation if the task extends over a long time period. As difficult as this may be to accept, the results of the assignment are more important than the means by which the person completes it, as long as he or she completes the task consistent with organizational policies and works with others in a positive manner. Throughout the process of task completion, the person who assigned

the task must be available to give advice, support, and guidance. Once the task is completed the delegatee should be provided feedback and recognition and an appropriate reward.

Procrastination and Perfectionism Procrastination—delaying what needs to be done until the last minute—is often referred to as “putting off until tomorrow what I should have done today.” Procrastination can take several forms, including knowingly doing something other than what needs to be done; starting to work on a project but then stopping work on it, only to have to complete it at the last minute; or doing less difficult tasks rather than the required one (Seaward, 2004). Being aware of a tendency toward procrastination is important in understanding time management skills and strategies. Scheduling, maintaining to-do lists, and adhering to the list can help break this habit. A different but parallel problem is being a perfectionist. Perfectionists generally get caught up in the details and never see the whole picture; thus, they waste time (Seaward, 2004). Further, believing that one can be perfect is detrimental to one’s self-esteem. No one is or can be perfect. To moderate this is to consider “what is good enough?” while at the same time holding high standards and expectations of oneself and others.

Managing Communications Email The problem with emails is that they convert issues that are not important or urgent to having an aura of being urgent and important. Many people in organizations are connected to their email full time. For example, someone may send an email noting he or she will be late for a meeting that is starting in a half hour and expect it to be read. Reading and responding to email can consume a large portion of time. Here are several hints for making the task more meaningful and less time consuming: Read emails one to two times per day, depending on one’s schedule and the volume received. Prescheduling time for this rather than trying

to fit the emails in between other tasks means one can focus better. Turn off email when doing other tasks on the computer to avoid constant interruptions. Keep the inbox uncluttered by reading and responding to messages and then moving those emails to an appropriate folder if they need to be retained. Otherwise, immediately delete emails that do not need to be saved. For emails that need a short response, respond and delete. This is an example of an old adage “handle each piece of paper once.” Read emails that are marked as urgent first. However, what the sender thinks is urgent is not necessarily what is truly urgent, and the urgent/important grid can be used to assess the response. Use the From button at the top of the inbox to sort email by sender versus by date. This then lumps all emails in one chain of correspondence and makes the communication easier to follow. Further, for emails from senders that do not require reading, you can delete all the messages at once. If one cannot respond to an email quickly and one does not have time to answer it, schedule time for composing a response later.

Phone Calls Managing phone calls is another important time management technique. Phone conversations can be much more pertinent and personal than emails. However, common advice is to keep phone conversations to less than 5 minutes. One of the downsides of phone calls is that of playing phone tag, which can be a time waster. When leaving a voicemail, specify a good time for the person to reach you, which can increase the possibility of being available when the person returns the call. If the advanced practice nurse has a support person who answers the phone, instructions for how to handle phone calls are needed. Whoever is taking calls should be able to screen calls and refer the caller to the appropriate person. The support person can find out when a convenient time is to return the call or can schedule a phone appointment. The advanced practice nurse can also instruct the support person on how to communicate availability. For example, saying, “She is not on the unit” is a different message from saying, “She is at x meeting, and I expect her

back in an hour.”

Stress Management Advanced practice nurses are already familiar with the physiology of stress and stress-related diseases. The focus of this section is on the causes of occupational stress. The premise of the discussion is that stress cannot be avoided or eliminated, but how one reacts to stressors can be altered. No doubt most advanced practice nurses already use many different techniques to reduce their own stress. In the section, the author reviews some well-known, conventional techniques. These techniques provide both cognitive and biochemical strategies to manage stress. Occupational stress, and specifically burnout among healthcare professionals, is of growing concern in the United States, leading to a formal report issued by the National Academy of Medicine (Dyrbye et al., 2017). In this report, burnout is nearly twice as prevalent among physicians as U.S. workers in other fields. Similarly, studies of nurses showed significant rates of burnout and depression, along with emotional exhaustion (Khamisa, Oldenburg, Peltzer, & Ilic, 2015; McHugh et al., 2011). Thus, health professionals must be aware of this threat and be proactive in establishing healthy practices for self-care that promote satisfaction with work and achievement of work/family harmony. Later in this chapter, some specific recommendations are made related to reflective practice as a strategy for achieving this balance. TABLE 30-3 can be used to assess job-related stress based on the reasons identified by the National Safety Council (Seaward, 1994). After completing the assessment, the advanced practice nurse can look at each item rated at 3 or more to reflect on their occupational stress. TABLE 30-3 Assessment Tool for Occupational Stress

Description

Stress Management Techniques This section provides a review of techniques to manage stress both cognitively and biochemically. The cognitive approach to selfmanagement of stress has been the primary focus over the past several decades, but there is new evidence of the effectiveness of techniques to change biochemistry. The goal is to manage one’s energy through selfassessment and self-reflection.

Cognitive Approach The cognitive stress management techniques fall into four categories: (1) altering one’s thinking, (2) avoiding stress, (3) adapting to the stress, and (4) accepting stress (Miller, 2013).

Altering Techniques Many stressors cannot be eliminated, but techniques can be used to alter how one deals with stress more effectively: Problem solving: This allows a better understanding of the stressor and thinking about it differently. By doing this, one may be able to better accept what one cannot control and let it go. Communication: The purpose is to make sure that people know in a respectful way how one is feeling about a situation. This prevents building up resentment and feeling one’s voice has not been heard. Having the right information: Given how information sometimes get distorted in an organization, having the right information may elucidate the issue and decrease stress. Time management, priority setting, and planning: These activities provide clarity of mind.

Avoidance Techniques A second set of strategies to deal with stress suggests ways to avoid

stress rather than altering one’s reactions to it: Use an assertive communication style. Respectfully state one’s point of view and stand up for what one believes in. After this is done, one should once more let go, content in the realization that one’s opinion had been expressed. Say no and walk away. This is very difficult to do. The most direct way is to simply say no to a request. However, other approaches may be to (1) reflect on other priorities currently needing time, (2) suggest someone else who might be more appropriate for the task, and (3) delay the request for a better time, particularly if this activity is important and exciting for you. Avoid people, situations, and hot-button topics that increase stress.

Adapting Techniques Adapting techniques call for the person to adapt to the change.

Acceptance Techniques Acceptance techniques enable one to recognize there are many stressors outside one’s control and that one must accept this and change how one reacts to the stress. Let go and recognize what one cannot control. Look for how the issue is helping you to grow, develop, and perhaps gain new competencies. Share your feeling with others who are neutral and objective. Write down one’s viewpoint and concerns as means for venting.

Stress Management Techniques to Adjust the Biochemical Response to Stress Although it is beyond the purpose of this text to summarize the pathophysiology of stress, neuroendocrine hormones play a crucial role in the human response to stress and in its management. In a review of the evidence to reduce stress and promote health, Varvogli and Darviri (2011) suggest the following techniques for managing stress. A person

can learn these techniques by working with trainers, through additional reading including Web resources, from audiotapes, and on one’s own: Progressive muscle relaxation is the alternate tensing and relaxing of major muscle groups. Reframe the picture. Look at the issue from another’s point of view, try to gain a better understanding, and look at the positive aspects. Consider how important the issue is in the long run. Will it really matter in a month from now? Think back on similar stressors and recognize how much meaning they had in the long term. Adjust expectations. Similar to a negative impact on one’s time management, perfectionism can be a cause of stress. Adjust expectations without compromising values and visions and accept “good enough.” Autogenic training is a self-relaxation technique. Relaxation response uses the repetition of a word and concentration. Biofeedback monitors reactions using instrumentation. Guided imagery uses a person’s images to reduce stress and improve health. Diaphragmatic breathing is deep breathing characterized by expansion of the abdomen rather than the chest. Transcendental meditation, or TM, is a form of silent mantra meditation designed to achieve a silent and peaceful level of your own awareness. Widely practiced around the world, it has been shown to have benefits for stress and anxiety, brain function, and cardiovascular health.

Reflective Practice and Resiliency Resilience is often described as the ability to bounce back. Managing stress and time (e.g., energy) better are two important initial steps for performing well in advanced practice roles and reducing occupational stress. Novice practitioners are at high risk for burnout due to significant ambiguity and the need for positive mentoring. To achieve and maintain high levels of performance, adoption of reflective practice principles is highly recommended for novice and experienced advanced practice nurses in all roles, as this will contribute to maintaining resilience (Skovholt & Trotter-Mathison, 2016). Reflective practice may be simply described as the ability to review one’s actions for the purpose of continuous learning and self-improvement. A commitment to reflective practice is encouraged, and numerous excellent resources have been published, including books by Horton-Deutsch and Sherwood (2017) and Thompson and Thompson (2018).

Discussion Questions 1. Based on the assessments in this chapter, what time and stress management strategies were you already using? How effective have they been? What new ones will you adopt and why? Do you have other techniques you use that have been useful for you? 2. If you completed a time management log, what were your findings and what strategies will you adopt to improve your time management skills? 3. Review the information regarding stress management. Realistically, how much stress are you experiencing? Which strategies will you try to help you cope with stress? 4. Consider how to incorporate reflective practice into your routine. What plan would work best for you?

References American Psychological Association. (2006). Multitasking: Switching costs. Retrieved from https://www.apa.org/research/action/multitask Barker, A. M. (2013). Managing personal resources: Time and stress management. In S. M. DeNisco & A. M. Barker (Eds.), Advanced practice nursing: Evolving roles for the transformation of the practice (2nd ed., pp. 595–606). Burlington, MA: Jones & Bartlett. Covey, S. R. (1989). The 7 habits of highly effective people: Powerful lessons in personal change. New York, NY: Simon & Schuster. Dyrbye, L. N., Shanafelt, T. G., Sinsky, C. A., Cipriano, P. F., Bhatt, J., Ommaya, A., . . . Meyers, D. (2017). Burnout among health care professionals: A call to explore and address this underrecognized threat to safe, high-quality care. Washington, DC: National Academy of Medicine. Hobfoll, S. E. (2001). The influence of culture, community, and the nested-self in the stress process: Advancing conversation of resources theory. Applied Psychology International Review, 50, 337–421. Horton-Deutsch, S., & Sherwood, G. (2017). Reflective practice: Transforming education and improving outcomes (2nd ed.). Indianapolis, IN: Sigma Theta Tau International. Khamisa, N., Oldenburg, B., Peltzer, K., & Ilic, D. (2015). Work-related stress, burnout, job satisfaction, and general health of nurses. International Journal of Environmental Research & Public Health, 12, 652-666. McHugh, M. D., Kutney-Lee, A., Cimiotti, J. P., Sloane, D. M., & Aiken, L. H. (2011). Nurses’ widespread job dissatisfaction, burnout, and frustration with health benefits signal problems for patient care. Health Affairs, 30(2), 202–210. doi:10.1377/hlthaff.2010.0100 Miller, H. S. (2013). The Serious Pursuit of Happiness: Everything You Need to Know to Flourish and Thrive. Goyang-si, Republic of Korea: Wisdom House Media LLC. Parker, S. L., Zacher, H., de Bloom, J., Verton, T. M., & Lentink, C. R. (2017). Daily use of energy management strategies and occupational well-being. The moderating role of job demands. Frontiers in Psychology, 8. doi:10.3389/fpsyg.2017.01477 Schippers, M. C., & Hogenes, R. (2011). Energy management of people in organizations: A review and research agenda. Journal of Business Psychology, 26, 193–203. Seaward, B. L. (1994). National Safety Council’s stress management. Sudbury, MA: Jones and Bartlett. Seaward, B. L. (2004). Managing stress: Principles and strategies for health and well-being (4th ed.). Sudbury, MA: Jones and Bartlett. Skovholt, T. M., & Trotter-Mathison, M. (2016). The resilient practitioner: Burnout and compassion fatigue prevention and self-care strategies for the helping professions (3rd ed.). New York, NY: Routledge. Sykes, E. R. (2011). Interruptions in the workplace: A case study to reduce their effects. International Journal of Information Management, 31, 385–394. Thompson, S., & Thompson, N. (2018). The critically reflective practitioner. London, England: Macmillan International Higher Education. Varvogli, L., & Darviri, C. (2011). Stress management techniques: Evidence-based procedures that reduce stress and promote health. Health Sciences Journal, 5(2), 74–89.

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CHAPTER 31 Entering the Job Market and Promoting Your Future Success Audrey Beauvais

CHAPTER OBJECTIVES 1. Discuss strategies to facilitate role transition for advanced practice nurses. 2. Conduct a personal, marketplace, and organizational analysis when transitioning to the job market. 3. Identify components of a professional portfolio. 4. Develop a curriculum vitae. 5. Review interviewing skills and techniques. 6. Recognize opportunities to foster professional development and lifelong learning.

Introduction The Institute of Medicine (IOM, 2010) has made recommendations about the role of nursing for the future. Several of these recommendations apply to this chapter and the role transition for advanced practice nurses. These include Allow advanced practice registered nurses to practice to the full extent of their education and training. Expand opportunities for nurses to lead and diffuse collaborative improvement efforts. Ensure that nurses engage in lifelong learning. Prepare and enable nurses to lead change to advance health. If advanced practice nurses are to meet the recommendations set forth by the IOM, they will need to secure a work setting that enables them to work to the full extent of their education and to collaborate with the other disciplines, that encourages lifelong learning, and that supports the role of the nurse to lead and influence change. This chapter is intended to help advanced practice nurses who are entering the job market by addressing how to find employment opportunities, how to complete several different assessments to prepare them for the job market, how to develop a professional portfolio, and how to apply for a job. Once employed, it is essential that advanced practice nurses put structures and strategies in place to promote their growth and development. To this end, the chapter identifies ways to foster professional development.

Transitioning Roles The role transition from registered nurse to advanced practice can be a challenging journey (Cleary, Matheson, & Happell, 2009; Spoelstra & Robbins, 2010). Having realistic expectations about new roles and responsibilities can help alleviate the angst associated with this evolution. Experiencing a positive transition between roles will help facilitate the advanced practice nurse’s ability to achieve independence, selfsufficiency, and influence over his or her professional practice. In addition, it will help foster a sense of worth and identity within the profession of nursing (Cleary et al., 2009). The role transition from registered nurse to advanced practice nurse begins during educational preparation and goes right through the first few years of practice. Some scholars have proposed that this transition happens in a three-phase composite model of social, cultural, and professional components that involves identity loss, transitional role evolution, and incorporation into clinical practice (Barton, 2007). The following subsections briefly describe the three phases.

Identity Loss Phase Identity loss happens early in the educational program (Barton, 2007). Students become cognizant that they are both novice advanced practice nurses and experienced, practicing, professional nurses (Barton, 2007; Spoelstra & Robbins, 2010). For students to progress in their transition, it is necessary for them to reexamine and separate from their prior career status. However, advanced practice nursing students often attend school part time. Hence, it is difficult for them to completely disengage from their previous professional role because they are functioning in that role as part of their ongoing nursing employment. This duality can enhance the feeling of identity loss. The perception of identity loss is advanced through these learning transitions, which enable the students to acquire new knowledge and skills that affect their clinical practice within their current nursing role (Barton, 2007; Lindblad, Hallman, Gillsjo, Lindblad, & Foerstrom, 2010; Spoelstra & Robbins, 2010). Interestingly, during this

phase students tend to have intensified consciousness of the anxieties among their colleagues, which can help foster cohesion and a unique group identity (Barton, 2007).

Transitional Role Evolution Phase The uncertainty of professional identity can grow as students cope with the increasing duality of roles. During the transitional role evolution phase, students experience a sense of role limbo and at times feel invisible and/or inept. Fortunately, during this stage, graduate students have developed a strong sense of community and group identity. This mutual support is critical, as they often experience opposition and aggression from professionals in the healthcare field. The camaraderie and support from peers allows them to become competent in their new skill sets. The transition phase and sense of community often emerge at the midpoint of the academic preparation. After this time, the sense of unity gradually decreases as the students anticipate graduation from the program. This trend helps foster resocialization into the new professional role as students grow individually and develop their new identities. The end of the transition phase is denoted by the students’ independence and self-reliance as well as decreased group cohesion (Barton, 2007).

Incorporation Phase During the incorporation phase, which begins during the latter part of the educational program, students begin to resolve their issues regarding their new role in their practice (Barton, 2007). By the time their studies are completed, advanced practice nurses have increased confidence and security in their new role (Lindblad et al., 2010). Throughout this phase, students start to look at practical problems and begin to select role models. Specifically for nurse practitioners, these role models may be from both the medicine and nursing disciplines, allowing students to take various traits and develop them into the new role construct. During this stage, their relationships with their medical peers change (Barton, 2007). For example, nurse practitioners may begin to describe a reciprocal trust and confidence between themselves and the general medical

practitioners who serve as their role models and supervisors. The medical staff become aware of the skills the nurse practitioner has acquired and note those areas in which the individual requires additional guidance (Lindblad et al., 2010). This changing clinical relationship tends to support mutual admiration and increasing collegiality. Students’ licensure exam is perceived as the final initiation and source of legitimacy of their new clinical role (Barton, 2007). Although they are still novices who are developing their professional identity in clinical practice, after passing their licensing examination they are qualified nurse practitioners.

Strategies for a Successful Transition In order to successfully transition, you will need to establish your credibility within the organization (Bath, Lucas, & Ward, 2017). In order to gain the support of others, you will need to demonstrate that you are a competent, knowledgeable advanced practice nurses who exhibits critical thinking, self-awareness, and effective interpersonal and leadership skills. To promote successful role transition, advanced practice nurses should utilize a framework that emphasizes evidence-based practice, research, collaboration, and consultation as a way to inform nursing practice. Additionally, those in advanced nurse practice roles who provide direct care (e.g., nurse practitioners, clinical nurse leaders, midwives, clinical nurse specialists, and nurse anesthetists) must provide patient care that is grounded in evidence and theory while viewing the patient holistically and as deserving of comprehensive treatment. Finally, they need to demonstrate comprehension and exemplification of professional responsibilities. To be successful, advanced practice nurses will need to demonstrate leadership skills grounded in ethical values. Not only will they need to be knowledgeable in their area of clinical practice but also they will have to communicate effectively with others, identify goals, determine effective strategies to accomplish those goals, model professional behavior, and collaborate with others to improve patient and financial outcomes (Spoelstra & Robbins, 2010). Ideally, students’ academic programs will implement strategies to help foster the development of the previously mentioned characteristics. However, once students have graduated, it is essential for advanced practice nurses to function within a supportive learning milieu that continues to encourage the synthesis of knowledge and critical thinking (Forbes, While, Mathes, & Griffiths, 2006; Heitz, Steiner, & Burman, 2004). Advanced practice nurses in direct care roles have a unique set of issues for their transition because of their interaction with physicians and families. They may need to overcome some barriers—such as a lack of knowledge about advanced practice nurses’ scope of practice, lack of knowledge about advanced practice nurses’ role, negative physician

attitudes, lack of respect, poor communication, and patient and family reluctance to accept advanced practice nurse care—if they want to facilitate a positive transition. Fortunately, several useful strategies to overcome these barriers are easily implemented. For example, advanced practice nurses can provide formal and informal education and orientation to physicians and medical students on their scope of practice and roles. In addition, they can develop and utilize integrated collaboration models when establishing a new advanced practice nurse’s position within a particular organization or practice. Furthermore, advanced practice nurses can attend interdisciplinary rounds to demonstrate to the patients and families their involvement with the medical management of care. Moreover, they can advocate for medical students to be exposed to graduate nursing students early in their education as well as advocate for uniformity in advanced practice nurse education and certification. An essential part of overcoming these barriers and, therefore, of ensuring a successful transition is to demonstrate and showcase the positive outcomes that advanced practice nurses can foster, such as decreased length of hospital stay, improved medical management resulting in decreased numbers of unnecessary office visits, more comprehensive patient education, improved health maintenance, and greater patient satisfaction (Clarin, 2007). Transition to the advanced practice nurse role often comes with stress during the first year. This stress may arise from a few different sources. For example, workload can cause anxiety for a new advanced practice nurse (Brown & Olshansky, 1997) as organizations may expect that you meet the same quotas for caring for clients as seasoned healthcare providers (Owens, 2018). As a new advanced practice nurse, you may lack experience and feel pressure to function at an independent and competent level while trying to keep up with client schedules and maintaining documentation (Brown & Olshansky, 1997). Concern that you may miss important data regarding a client’s health can cause stress (Brown & Olshansky, 1998). Another stressor can be role ambiguity if the role has not been clearly delineated, communicated, and accepted by members of the organization. Don’t let the above stressors scare you as there are supports and strategies that can be implemented to relieve your anxieties. A smooth transition can be fostered by selecting preceptors and mentors who can

help ensure sufficient socialization and encourage feelings of self-worth. Some organizations offer mentorship program where an experienced advanced practice nurse will help you develop your competence and independence as well as support your socialization into the organization (Owens, 2018). Mentors can provide additional teaching of skills needed for the job, if necessary. Moreover, they can help expose advanced practice nurses to additional aspects of their role and boost their confidence in their capability to assume the role. Novice advanced practice nurses are more apt to assimilate other facets of their role when they observe their preceptors/mentors in action (Hayes, 1998). Formal and informal mentorship are discussed in greater detail later in this chapter. In addition, some organizations are offering residency and fellowship programs for new advanced practice nurses to help your transition into practice (Owens, 2018). Finally, reflective journaling can be used as a strategy for promoting a successful transition. Reflective journaling can help novices transition successfully into an expert role by keeping a written record in which they contemplate their professional experiences and learn from the process (Hamric & Taylor, 1989; Latham & Fahey, 2006). The method used can be as simple as daily written reflections on the following four questions: 1. What happened today? 2. What did I think about that? 3. How do I feel about it? 4. What did I learn? The act of analyzing thoughts, ideas, and feelings helps to develop metacognitive skills by assisting nurses to self-evaluate and discern what they know versus what they have yet to learn. Such reflection, which addresses their cognitive, psychomotor, and emotional growth, will help identify potential educational strategies to help them advance their professional development. The practice of analyzing one’s thoughts and feelings is especially useful for learning how to handle complicated situations that exceed a straightforward right or wrong response. A reflective journal can assist advanced practice nurses in recognizing their capabilities, professional worth, and future educational needs critical to the development of their new role. Reflective journals can also be a positive way to map one’s growth and development (Latham & Fahey,

2006).

Entering the Job Market To complete the transition from students to experts working in the healthcare field, graduating advanced practice nursing students will need to secure their first position. This section discusses some practical aspects to entering the job market, such as how to find open positions. In addition, it reviews the personal, marketplace, organization, and organization fit assessments that can be used to prepare for the job market. Furthermore, it presents practical ideas for developing a portfolio that can be shared with potential employers to highlight one’s knowledge and skills. Specifics about applying for a job such as applications and interviews are reviewed.

The Job Market The statistics for employment of nurses and advanced practice nurses for the next decade are dramatic. In general, the Bureau of Labor Statistics (U.S. Department of Labor, Bureau of Labor Statistics, 2018b) reports that there will be a 15% growth in the demand for registered nurses from 2016 to 2026. Even more astounding is that the employment of nurse anesthetists, nurse midwives, and nurse practitioners is expected to grow 31% from 2016 to 2026 (U.S. Department of Labor, Bureau of Labor Statistics, 2018a). Similarly, the demand for nursing faculty will continue to grow to prepare these nurses for practice and to meet the market demand. According to a report by the American Association of Colleges of Nursing (AACN) in October 2016, there was a national nurse faculty vacancy rate of 7.9% with a total of 1,567 faculty vacancies in higher educational settings (AACN, 2017). However, most of these vacancies require a doctorate. These statistics bode well for students pursuing education in all the advanced practice roles in nursing. Additionally, the IOM report previously discussed further suggests that there are many driving forces that will increase the need for advanced educated nurses.

Finding Employment Opportunities A first step with regard to entering the job market is to locate job openings. There are several sources to find openings via print and online resources, professional memberships, and networking. These strategies are discussed next.

Print and Online Resources Job openings can be found via multiple media. The traditional way to find jobs has been through printed classified advertisements. Today, however, few practices or organizations post job openings only in printed advertisements, if they publish them in printed form at all. Instead, most job postings appear on the Internet. There are job boards, such as advanced practicejobs.com, nursepractitionerjobs.com, and higheredjobs.com, to name a few, that may be of use. However, nurses must bear in mind that national job boards attract large numbers of job seekers. As a result, the national job boards may not produce the results that one would like. Experts warn that it is difficult for individuals to differentiate themselves online; as such, it is more useful to follow leads through contacts and thorough research (Vilorio, 2011). Many organizations post job openings on their own websites; searching individual websites can be a cumbersome approach but worth the effort if one is familiar with the local market.

Professional Memberships An initial step in a job search should be to get involved in the appropriate professional organizations at the local, state, and national levels. Actively participating on committees within professional organizations helps job seekers to be visible and known to people who might be making selection decisions.

Networking

Referrals are one of the key ways of finding employment opportunities, even for positions that are not being publicized (Hosking, 2010). In fact, research results indicate that approximately 70% of job postings are never advertised publicly (Owens & Young, 2008). In addition, referrals help raise advanced practice nurses’ chances of having their curriculum vitae placed directly in front of employers who are hiring (Hosking, 2010). Practices and organizations are apt to hire individuals with whom they are familiar and who are recommended by someone they trust (Vilorio, 2011). For this reason, it is suggested that advanced practice nurses develop a network of professionals in the healthcare field (Hosking, 2010; Vilorio, 2011). A network involves cultivating relationships that are mutually beneficial. Remember—it is not about who the advanced practice nurse knows but who knows the advanced practice nurse that will make a difference (Owens & Young, 2008). When meeting individuals, it is imperative that the advanced practice nurse elicit feelings of liking, trust, and knowing to establish a good rapport and relationship. When advanced practice nurses initially interact with individuals, they should ask these persons about themselves and their careers rather than immediately inquiring how they can get a job (Owens & Young, 2008). In addition to the professional healthcare network, advanced practice nurses can utilize other contacts, such as professors, alumni networks, former classmates, colleagues, family, friends, and employers both past and present (Mize, 2011a; Vilorio, 2011). Advanced practice nurses should start developing their professional network while they are students. This can be done by becoming active in professional organizations, participating in professional conferences, attending continuing education programs, and partaking in volunteer work (Vilorio, 2011). One of the benefits of networking is that it allows the chance to create contacts with potential employers as well as to determine the work environment and employee morale in that organization or practice (Critchley, 2003; Vilorio, 2011). A word of caution—professional contacts will become leery if an advanced practice nurse talks about a specific job opportunity before having established a good rapport and trusted relationship. This kind of relationship can take some time to develop and foster. It is important to show genuine interest in each contact and learn about the individual and his or her job. For example, it is appropriate to

ask what contacts’ responsibilities are, what the most rewarding and challenging aspects of the role are, and what the work environment is like (Vilorio, 2011). Advanced practice nurses should take care to organize their networks. One suggestion is to keep a file that lists all the contacts and identifies a little something of note about each person. Then, when nurses review an article of interest or need a contact in a certain specialty, the network is at their fingertips. If the network list is short, then a simple tickler file based on a notebook, note cards, or business cards may be helpful (Owens & Young, 2008). Advanced practice nurses should make a conscious effort to stay in contact with the people in their network. Although underutilized, thankyou notes can help set individuals apart. Techniques such as sending a note with a clipping from the paper or a journal relating to the individual’s area of interest and sending a link to an appropriate website are strategies to stay in contact (Owens & Young, 2008). Other strategies, such as arranging follow-up meetings over coffee, can also be helpful when trying to establish a mutually beneficial relationship.

Assessments to Prepare for the Job Market For advanced practice nurses to promote their success in today’s competitive job markets, they need to be prepared (Selph, 1998). Part of that preparation should involve in-depth personal, marketplace, organizational, and organizational fit analyses.

Personal Assessment Prior to engaging in pursuit of work, advanced practice nurses should complete a comprehensive, honest, affirmative personal assessment (Shapiro & Rosenberg, 2002). This assessment should identify their strengths and weaknesses as well as their goals and objectives (Hosking, 2010; Shapiro & Rosenberg, 2002; Vilorio, 2011). Organizations and practices are seeking the most qualified advanced practice nurses to fill their open positions (Mize, 2011a). If advanced practice nurses want to stand out as the most qualified candidates to potential employers, then they will need to begin with an objective and constructive assessment of their strengths and weaknesses (Selph, 1998). Nurses should highlight the unique qualities that they offer and indicate how they complement the position for which they are applying (Mize, 2011a; Shapiro & Rosenberg, 2002). For example, advanced practice nurses with the ability to speak more than one language may be an asset to the organization or practice (Shapiro & Rosenberg, 2002). As another example, advanced practice nurses who do not require a license to practice may want to seek certification in their field to enhance their qualifications before beginning their job search. Likewise, deficiencies should be noted to provide a realistic description of the individual’s performance (Shapiro & Rosenberg, 2002). If job applicants do not have the expertise that will help them stand apart, then they need to consider ways to make improvements to enhance their marketability (Hosking, 2010). In addition, advanced practice nurses need to give some thought to their short- and long-term goals (Selph,

1998). Determining these goals will assist in making appropriate decisions about their future employment (Mize, 2011a) and may help to make a decision if more than one job offer is made. In addition to determining strengths, weaknesses, and goals, the applicant should give thought to personal financial and benefit needs (Selph, 1998). Assessing salary and benefit requirements helps to determine what the bottom line will be in negotiations. Setting acceptable salary ranges prior to negotiations can help advanced practice nurses balance or adjust certain elements to design the best possible benefits package. There are many factors to consider. Does the organization/practice include malpractice insurance in the benefits package? If this is not the case, advanced practice nurses may wish to negotiate for an increased salary to cover this expense. Sometimes there are other benefits besides salary to consider, such as work hours (on-call, off shifts, required weekends), flexible scheduling, potential for growth, and vacation time (Selph, 1998). Last, the personal assessment should include an evaluation of the work location and setting as well as the professional environment requirements. Advanced practice nurses need to consider constraints regarding the location. Are they willing to relocate? Do they want to stay in the same location? If they want to stay locally, then do they have limits on the distance they are willing to commute? In addition, in which specialty and setting do they wish to work? With which populations are they qualified to work and enjoy working? Once the location and setting have been determined, job seekers need to assess the time commitments required by the position, the professional development requirements, and the anticipated work environment. Advanced practice nurses must decide how many hours are needed for the role and identify any personal constraints such as the necessity to leave the site at a particular time. The professional development assessment includes an evaluation of the needs for mentoring and orientation, the amount of autonomy preferred, and continuing education required to maintain licensure, certification, and credentialing. Continuing education time and expenses as well as costs of journals, professional organization membership fees, and licensure and certification should all be assessed. Having this knowledge may assist advanced practice nurses when it comes time to

negotiate the benefits package for the position. With regard to the work environment, advanced practice nurses need to assess the specific environment such as office space, support staff, pagers, cell phones, and computer (Selph, 1998). Once advanced practice nurses have completed the personal assessment, they need to prioritize these elements to determine which are essential versus which are more flexible. Often advanced practice nurses may need to make adjustments based on information obtained from the current marketplace and organizational assessments (Selph, 1998).

Marketplace Assessment After completing the personal assessment, it is time to begin a marketplace assessment. This assessment comprises an evaluation of the regional and national marketplace and political atmosphere. When evaluating the regional and national marketplace, advanced practice nurses need to take into account the state rules and regulations that guide advanced practice, the need for the roles, the number of qualified nurses, typical financial packages/salary, scope of practice, and chief surrounding competitors (Hupcey, 1993; Selph, 1998).

Organizational Assessment Once the preceding information is obtained, advanced practice nurses need to assess potential employers to determine specific healthcare organizations they would like to consider. It is important for nurses to find a practice or an organization that they admire and wish to work for. Advanced practice nurses should pursue organizations and practices, not job openings (Vilorio, 2011). Assessing the qualities of a particular practice or organization requires advanced practice nurses to complete additional research. Some experts maintain that it is inexcusable for applicants not to know the fundamentals of an organization. Thus advanced practice nurses need to know which services their potential employer provides and how the organization compares to its competitors. This information can be found through advanced practice nurses’ network contacts if possible;

otherwise, nurses can seek it out through newspaper articles, healthcare publications, employer websites, employee blogs, and online discussions (Vilorio, 2011). If possible, advanced practice nurses will want to find out as many details as possible by looking for answers to the following questions (Brox, 2010; Selph, 1998; Shapiro & Rosenberg, 2002; Vilorio, 2011): Which population does the organization service? What are common diagnoses? What are the strengths and weaknesses of the organization/practice? What is the average daily census? What is the number of patient visits per day? How many outpatient and inpatient facilities does the organization have? Where are they located? Is the organization a teaching institution with medical teaching staff? What is the relationship between advanced practice nurses and the medical teaching staff—that is, how is the work shared? Is there clear role delineation? What are the reporting mechanisms? Do advanced practice nurses report to the nursing department? If so, are they expected to fulfill other obligations, such as participating in annual educational in-service programs? Who will be completing the performance evaluation? How many advanced practice nurses work in the institution/practice? How have they structured their practices and services? Are there specialty practices? Is the practice based primarily on consultation? Are there primary care providers? What is the reimbursement scheme and payer mix? Can revenue be generated from the services that the advanced practice nurses can offer? What is the organizational structure? What is the organizational culture? Is the organization accepting of advanced practice nurses? Are nurses empowered in the organization? What is the reputation of the organization in the community and among other professionals? The preceding information helps advanced practice nurses evaluate

specific organizations’ and practices’ characteristics. This information, paired with the results of the personal assessment, helps advanced practice nurses determine their fit with an organization (Selph, 1998). Advanced practice nurses who provide direct care should also gather data about the organization’s privileging and scope of practice policies, recent political concerns, and the exposure the healthcare team has had to advanced practice roles (Selph, 1998). In addition, they should assess whether there are any competitors for the position or role they are seeking to fill. If they face competition, advanced practice nurses need to develop a strategy to advocate for their specific skills, expertise, and contributions (Selph, 1998).

Advanced Practice Nurse–Organizational Fit Assessment At this point, it is time to see whether the personal assessment fits with the organizational assessment. This initial evaluation is intended to decide whether a good relationship between the advanced practice nurse and the particular organization is viable. However, advanced practice nurses cannot fully complete the fit assessment until they have had a chance to interview for the position and interact with the particular healthcare environment. In fact, advanced practice nurses will not know for sure whether the fit is a good one until they are employed for some period of time. Organizational fit is essential for a good long-term relationship, as research studies have linked congruence between individual and organizational values (fit) with positive affect (Chatman, 1989; Mount & Muchinsky, 1978; Spokane, 1985) and a greater likelihood of staying with the organization, commitment, satisfaction, and performance (Chatman, 1989; Meir & Hasson, 1982). Causal mapping and storytelling are two strategies that, when combined, may be helpful in determining advanced practice nurses’ organizational fit. Causal mapping in this context entails reflecting on factors that have an effect on advanced practice nurses’ fit in an organization. Advanced practice nurses should contemplate which factors determine their fit in an organization. Given that they begin this evaluation before they are actually working at the institution, nurses will want to draw upon their past experiences and determine which factors

were most important to them. Through the reflections, advanced practice nurses can begin to learn the particular individual factors that influence their sense of fit in an organization (Billsberry, Ambrosini, Moss-Jones, & March, 2005). Causal mapping involves creating a graphic depiction of what affects the sense of fit. Advanced practice nurses add to the picture by reflecting on what influences their sense of fit and then what happens to cause that effect. They continue to develop this map by reflecting on additional questions that help them get more specific about what causes the feelings. Advanced practice nurses should continue to reflect until they are unable to come up with additional information. At that point, they should try to recall an individual work experience that influenced fit and tell a story about it. Some advanced practice nurses may have difficulty determining what has influenced their fit in an organization and, therefore, will have trouble creating a map. In such instances, it is useful to utilize the storytelling technique in which advanced practice nurses recount stories from their work that illustrate how they felt about their employer. These two techniques help advanced practice nurses to reflect on the underlying factors and provide an initial exploration of the sense of fit.

Portfolio Development Advanced practice nurses entering the job market need to be able to promote their positive personal and professional qualities to potential employers. Some organizations may not be familiar with the scope of practice and competencies of advanced practice nurses. As a consequence, advanced practice nurses will need to educate prospective employers as they concurrently negotiate for a position (Selph, 1998). For instance the hiring manager for a clinical nurse leader, a relatively new role in nursing and not yet employed in many settings, will need an understanding of the role and evidence of its potential impact on patient outcomes and cost savings. One strategy advanced practice nurses can utilize to educate key individuals in an organization as well as to develop a strong base for negotiation is a well-prepared career portfolio. A good portfolio must be paired with an attitude of confidence and competence to ensure success. Advanced practice nurses will want all observers to see their positive attitude, which arises from their education, clinical knowledge and skills, adaptability, effective communication skills, and strong conviction in the capability of the advanced practice nurse to contribute to positive patient and financial outcomes. Successful negotiations begin with advanced practice nurses’ passionate belief in the worth and benefits of this advanced nursing practice role. If they lack the conviction that advanced practice nurses offer a valuable service, candidates will run the risk of making compromises that undermine their professional and personal goals. It is helpful to have data to support the notion that advanced practice nurses can have a positive impact on practice (Selph, 1998). Such data can be found in the literature, proving evidence is an important strategy in today’s healthcare environment. Professional portfolios can serve two purposes. First, they display evidence of the individual’s professional knowledge, skills, expertise, work experiences, clinical experience, professional accomplishments, and scholarly work as well as highlight the contributions the individual can make to the organization. Second, they can be effective means for conveying the significant worth of advanced practice nursing by

educating potential employers who are unacquainted with the role and scope of practice (Selph, 1998). In the following discussion, the suggestions for the content of some sections of the portfolio assume that the potential employer is unfamiliar with the role. This obviously needs to be modified depending on the organization and the advanced practice role. The portfolio may contain the following components: curriculum vitae, professional development and continuing education activities, references, clinical experiences, legal regulations, standards and scope of practice, collaborative practice agreements, reimbursement guidelines, procedures, hospital privileging, job descriptions, scholarly work, protocols, advanced practice documentation, and professional expenses (Shapiro & Rosenberg, 2002). The most positive impact occurs when advanced practice nurses present and organize this information in a professional manner while maintaining attention to detail to ensure a polished project.

Curriculum Vitae Some experts recommend that advanced practice nurses include a curriculum vitae as opposed to a résumé. Although the two documents are similar, there are some significant differences. A résumé is typically a one- or two-page document that gives an overview of education, employment history, and achievements (Hinck, 1997). The curriculum vitae, by comparison, is typically longer and more detailed. Such profiles are typically used in academia, although medical and nursing professionals often use them as well. The curriculum vitae is a practical tool that can highlight advanced practice nurses’ abilities, skills, and accomplishments and promote their careers (Hinck, 1997). It is a wonderful opportunity for advanced practice nurses to make a positive impression. Of course, this document can quickly make a negative impression if it is poorly constructed or contains errors. Advanced practice nurses should carefully proofread the curriculum vitae, as misspellings, typographical errors, and grammatical errors will likely give the impression that nurses lack attention to detail and professionalism. In one study, more than 75% of organization leaders interviewed indicated that only one or two typographical errors in the curriculum vitae would eliminate the candidate from consideration for

a position (Hosking, 2010). The curriculum vitae should be printed on high-quality paper, on only one side. Some experts suggest using 10- to 14-point Times New Roman font as it is easy to read. All information in the curriculum vitae must be honest and accurate. Providing false information or embellishing one’s accomplishments is not just unethical but also can cause advanced practice nurses great trouble when the information is verified (Hinck, 1997). Advanced practice nurses should modify their curriculum vitae at frequent intervals to ensure inclusion of all accomplishments (Hinck, 1997; Hosking, 2010; Selph, 1998). When applying for a job, advanced practice nurses should include a cover letter explaining how they could benefit the employer. In addition, the content of the cover letter should express that they are familiar with the organization and explain how they can make an immediate contribution to its success (Hinck, 1997; Hosking, 2010). Cover letters are vitally important as they make the first impression and can offer insight into one’s uniqueness and passion that is not conveyed in a curriculum vitae. The curriculum vitae can be organized in different ways depending on preferences. There are no strict rules that have to be applied (Hinck, 1997). Typically, this document contains the general categories shown in FIGURE 31-1 (Critchley, 2003; Hinck, 1997; Selph, 1998).

FIGURE 31-1 Curriculum vitae template.

Description Description

Professional Development and Continuing Education Activities Advanced practice nurses may wish to include information in the portfolio about their professional development or continuing education activities. Doing so highlights their dedication to lifelong learning. In this section, advanced practice nurses should outline any ongoing specialty training that was received (Hinck, 1997). The information can be displayed in a simple table that notes the date and title of the program as well as the organization that provided the education.

References If advanced practice nurses have letters of support or recommendation available, these can be included in this section of the portfolio. If such letters are not available, advanced practice nurses can either note that references will be available upon request or list people who are willing to serve as references (Hinck, 1997). Advanced practice nurses can ask current or former managers and colleagues if they would be willing to serve as references for them as they enter the job market in the new role of an advanced practice nurse (Hosking, 2010). Nurses should not list people as references before obtaining their permission to do so, as that can increase the risk of the reference not being prepared for the call or giving a negative response to the caller (Hinck, 1997; Hosking, 2010). When listing references, advanced practice nurses should include each reference’s name, title, work address, and telephone number (Hinck, 1997).

Experience Advanced practice nurses in direct care roles should include a section in the career portfolio that underscores their experience. To demonstrate their proficiency, a summary of the types of patients managed, age ranges, diagnoses, procedures performed, preceptorships, and practice settings and locations should be provided (Burgess & Misener, 1997; Selph, 1998). When possible, advanced practice nurses should try to obtain letters of reference to strengthen this section (Selph, 1998). For

those in indirect care roles, a discussion of their experiences and accomplishments are included here. Written well, this is an opportunity for the potential employer to learn more about applicants’ uniqueness.

Legal Regulations If the organization has little or no experience with the advanced practice nurse’s role in direct care, then nurses will want to be sure to include a section on legal regulations in the portfolio. Advanced practice nurses should begin by including a copy of the state’s nurse practice act as well as regulations regarding advanced practice nursing. In addition, documentation should be provided that verifies advanced practice nurses’ prescriptive authority if appropriate. If the advanced practice nurse does not yet have prescriptive authority, then the nurse can describe the process of how it is obtained (Selph, 1998). This information indicates that advanced practice nurses are concerned with the legal aspects of their clinical practice while simultaneously educating the employer (Burgess & Misener, 1997; Hravnak & Magdic, 1997; Selph, 1998).

Standards and Scopes of Practice The portfolio ought to include any professional standards on the scope of practice for the role (Selph, 1998). In addition, this document serves as the basis for performance evaluation and a quality review program (Burgess & Misener, 1997; Selph, 1998).

Collaborative Practice Agreements For direct care providers, sample collaborative practice agreements included in the portfolio can be useful for potential employers who are not familiar with this information and would like to review a copy. Collaborative practice agreements are printed contracts among physicians and advanced practice nurses that outline the scope of the collaborative practice. The agreement should note how the two healthcare professional groups will organize and manage care and the breadth or constraints of the advanced practice nursing (APN) practice (Shapiro & Rosenberg, 2002).

Reimbursement Guidelines As appropriate, including reimbursement guidelines in the portfolio helps educate employers regarding the types of payments that are available for nurses in advanced practice roles (Burgess & Misener, 1997; Selph, 1998); nurses can include current information regarding the guidelines or statutes on reimbursement, as these criteria change frequently. To do so, advanced practice nurses should ascertain the practice payer mix and directly communicate with the payers to determine which APN services they reimburse for. Advanced practice nurses can utilize the resources that are available such as the billing department or practice manager to help determine what is typically billed and how often (what percentage) it uses each provider (Selph, 1998).

Scope of Practice: Procedures For those in direct care practices, a list of procedures typically performed by advanced practice nurses in that state should be provided in the portfolio. The procedures that advanced practice nurses can perform within their scope of practice are typically noted in the state’s nurse practice act. In this section of the portfolio, advanced practice nurses should list which procedures they have performed with supervision and which procedures they are prepared to learn. Advanced practice nurses should highlight any special training received, the number of completed procedures, and outcomes. When possible, they should provide information regarding reimbursement for the procedure, which will help in the negotiation process (Selph, 1998).

Hospital Privileging If advanced practice nurses are hoping to gain employment in a hospital, they need to be privileged based on the medical staff bylaws and policies for advanced practice nurses. Specific procedures must be followed and documentation must be submitted, which a committee will review and use as the basis for making a recommendation. If the institution has not utilized advanced practice nurses in the past, procedures may not have been established to allow privileging of advanced practice nurses. In this case, advanced practice nurses will want to research best practices for

privileging and provide this information in the portfolio. This effort helps prepare advanced practice nurses to assist in developing a plan to implement a procedure (Selph, 1998).

Job Description Depending on the individual advanced practice nurse’s situation, a job description may or may not be included in the portfolio. If advanced practice nurses are well established in the potential employer’s institution, then providing job descriptions may not be necessary. However, a sample job description can be a good tool for delineating particular instances in which advanced practice nurses can use knowledge and skills to influence patient care. As such, advanced practice nurses may wish to provide a sample job description that highlights how their skills can positively influence the healthcare environment. The job description should be individualized for the setting in which the advanced practice nurse will be working and include specific roles and responsibilities (Selph, 1998).

Scholarly Work In this part of the portfolio, advanced practice nurses can demonstrate their writing skills and showcase professional expertise by supplying copies of publications, papers, or abstracts they have written that are germane to the practice setting. These examples illustrate their capability for additional scholarly activities and lay the groundwork for negotiating time for such work and attendance at professional meetings (Selph, 1998).

Protocols In many states, advanced practice nurses utilize protocols and guidelines to inform their practice. In turn, they may wish to provide in their portfolio a sample protocol for the management of a clinical situation particular to the specialty of interest. Such protocols and guidelines are useful tools to demonstrate the responsibilities advanced practice nurses have in regard to diagnostic reasoning, treatments, and outcomes (Selph, 1998).

Advanced Practice Documentation In this section of the portfolio, advanced practice nurses can provide affirmation of advanced practice documentation ability by presenting examples of admission notes, history and physicals, orders, progress notes, and discharge summaries. They should remember to remove all identifying patient information from these samples. If possible, the documents should be related to the population with whom the advanced practice nurse intends to work. These examples can serve as powerful testaments of the advanced practice nurses’ clinical expertise and can show the distinct abilities that advanced practice nurses can provide within the practice, particularly in healthcare settings where the advanced practice nurse is a new role (Selph, 1998). Similarly, advanced practice nurses in indirect care roles can present syllabi, performance evaluations from their supervisors, student evaluations, and so forth.

Professional Expenses This section of the portfolio includes a detailed inventory of advanced practice nurses’ expected professional expenses. Advanced practice nurses may choose to hold this information aside until it is time for negotiating a benefits package; nevertheless, it is important to be cognizant of the professional costs. When developing the record of expenses, advanced practice nurses should think about all of their expenses, including one-time costs such as the initial application for a certification or for prescriptive authority, as well as annual costs such as malpractice insurance and fees for license renewal. Other expenses that can be included are the cost of continuing specialty certifications, continuing education expenses, professional organization memberships, journals, and books. The more detailed the list, the more prepared the advanced practice nurse is to articulate his or her needs and expectations (Selph, 1998).

Applying for the Job Once advanced practice nurses have completed their personal, marketplace, organizational, and advanced practice nurse–organizational fit assessments, they can present themselves to the employer, feeling empowered with the information provided in the career portfolio (Shapiro & Rosenberg, 2002). The next step in entering the job market is to place an application; this step is followed by the job interview.

Applications An increasing number of employers are moving to an online application process. Of course, although an online process might be used, there is still a human being at the receiving end who does the hiring. Advanced practice nurses can increase their chances of being hired if they contact the hiring individual instead of relying solely on computer contact. Online processes have increased the number of applications organizations receive. As a result, many organizations utilize software that can somewhat automate the selection process by rejecting candidates based on minimum qualifications or keywords. For this reason, advanced practice nurses are advised to customize the cover letter, curriculum vitae, and application for each position that they apply to. To avoid being removed by the automatic culling software, they should be sure to include the words in the job posting and to emphasize the connection between their education and skills and the duties necessary for the desired position (Vilorio, 2011). Experts recommend that advanced practice nurses use extreme caution when posting identifying personal data online, particularly on social media websites such as LinkedIn and Facebook. Many organizations conduct online information checks to evaluate potential hires. Many social media programs have loose privacy settings, which make it easy for members of the public to access users’ personal information. One way to manage this access is to search one’s own name online to see what information is available to the general public as well as to adjust privacy settings to protect personal information and

photos, control what others share about the user, and reduce information that can compromise being hired. All personal data should be kept private; however, advanced practice nurses can certainly share professional accomplishments such as publications or awards or other information that presents a professional image (Hosking, 2010; Vilorio, 2011). When possible, it is helpful for advanced practice nurses to talk with the hiring manager, as this individual is responsible for choosing candidates and has a vested interest in finding a qualified candidate who can meet the job responsibilities and fulfill the mission of the organization. If advanced practice nurses have existing contacts within the organization, perhaps those individuals might be able to arrange an informational meeting with the hiring manager. Such a meeting can help candidates learn more about the job responsibilities and the institution while also giving them a chance to impress the individual responsible for hiring. During this meeting, advanced practice nurses should be sure to demonstrate initiative while remaining polite and being mindful of the hiring channels (Vilorio, 2011). After submitting an application and curriculum vitae, advanced practice nurses should follow up with the hiring manager within 2 weeks of sending the application. Experts recommend sending a brief email or calling the organization or practice after submitting the information to confirm one’s interest in the post and to offer to respond to any questions the employer might have about the application. This sort of professional attention to detail can set advanced practice nurses apart in this process (Hosking, 2010). Once advanced practice nurses have submitted an application, they should be prepared to respond when the organization calls. The first impression begins with that call. Sometimes organizations use this initial phone conversation as a screening tool. As a result, advanced practice nurses may wish to let the call go to voicemail so that they have time to adequately prepare and make a polished first impression (Brox, 2010).

Interviewing Being brought in for an interview indicates that an organization is interested in the applicant’s background (Brox, 2010). The interview is a

critical time when advanced practice nurses have the opportunity to dazzle the employer and secure a position (Vilorio, 2011). According to experts, the main reason why people are not successful in interviews is a lack of preparation. Role-playing mock interviews with an individual who is knowledgeable about the process can help advanced practice nurses develop and hone their interviewing skills. It may also help advanced practice nurses to correct some potentially damaging behaviors. For example, many people are unaware that they use words and phrases such as “you know,” “like,” and “um” while speaking. Eliminating this habit can help advanced practice nurses obtain a job. During the interview, advanced practice nurses will want to attempt to work into the conversation all their career highlights. They should practice both delivering this information in a charming and natural fashion and telling engaging stories that help make what is listed on their curriculum vitae memorable (Brox, 2010). It might sound simple, but first impressions really do make a difference. The hiring individual wants to know that the candidate will be a good representative on behalf of the organization or practice (Mize, 2011b). As such, advanced practice nurses should show common sense and professionalism in all dealings with the possible new employer (Vilorio, 2011). At the very least, they should be on time, professionally dressed, and polite to all staff regardless of their position (Mize, 2011b; Vilorio, 2011). With any job, advanced practice nurses need to bring a positive can-do and will-do attitude. In particular, they should be prepared to respond to questions that require them to give examples of previous problem-solving and time-management scenarios (Mize, 2011b). Advanced practice nurses should prepare for the interview by developing answers to questions that the employer might potentially ask (Brox, 2010). The employer will certainly ask questions to determine the applicant’s knowledge, skills, and interests (Vilorio, 2011). Advanced practice nurses should not be vague when responding to questions but rather should provide the employer with specific details of how they solved problems and brought situations to a positive resolution. Behavioral interviews are currently in vogue in many larger organizations. In these interviews, applicants are asked about how they behaved previously in given situations. For instance, the hiring manager may ask: “Tell me about a time when you worked effectively with a team

to implement a practice change?” (as opposed to questions such as “Are you a good team player?”). The internet is the best source for sample interview questions and there is information on how to pose behavioral interview questions and how to answer them. Once again, the job posting can provide some hints on what might be asked in the interview. Having one or two stories prepared—just in case—about successes and issues in dealing with patients, team members, bosses, and so forth, is helpful. In other situations or in addition to behavioral questions, interviewers may ask generic questions, such as the following (Brox, 2010; Vilorio, 2011): What do you see yourself doing in 5 years? What are your strengths and weaknesses? Why would you like to be employed here? How do you handle conflict with peers? What do you consider to be your greatest accomplishment? What can you tell me about your reasons for leaving your last job? What was the most challenging issue you have encountered and how did you deal with it? In addition, advanced practice nurses should have a list of questions to ask the hiring manager (Vilorio, 2011). If they have not obtained details about the position and its associated responsibilities, then the interview is the time to ascertain this information. Advanced practice nurses should find out details about specific responsibilities. These details will differ based on the role. The main purpose of the interview is to help the advanced practice nurse and the employer determine whether the candidate is a good fit for the organization (Vilorio, 2011). Advanced practice nurses should be positive and truthful about everything they say but especially when discussing previous managers and colleagues (Brox, 2010; Vilorio, 2011). Advanced practice nurses’ interactions should be assertive and courteous while avoiding presumptions and aggression. For example, if advanced practice nurses have information in their employment history that potentially might be perceived as negative, such as gaps in employment or frequent job changes, then they should succinctly acknowledge the situation and then redirect the discussion toward something positive, such as what has been learned from the experience

and constructive actions that have been taken to prepare for the new position (Vilorio, 2011). Advanced practice nurses’ need to sell themselves and be clear about what they can bring to the organization (Mize, 2011b). Finding the right fit is a two-way venture. If the advanced practice nurse is not excited about the organization, foresees issues that might cause problems that are not resolvable, and did not “click” with the manager and the team, then the advanced practice nurse should continue the search for the right employment opportunity. It is better to delay employment than to accept a job in which one is unhappy and leaves after a short period of time. At the conclusion of the interview the nurse can ask what the next step or steps are and how long the decision-making process may take. Advanced practice nurses should thank the interviewer in person as well as in writing with a thank-you letter. According to experts, it is most effective to handwrite the note, but an email thank-you letter is also considered acceptable. The thank-you note gives advanced practice nurses one more opportunity to emphasize their positive qualifications and skills as well as confirm their interest in the position. The length of the hiring process can vary greatly between organizations. As such, advanced practice nurses may wish to follow up with a phone call or email to reassert their interest in the position (Vilorio, 2011).

Salary Negotiation Many organizations’ human resources departments have guidelines and structures in place to help determine what the starting pay level will be. As a result, negotiations may not yield the results nurses wish for (Mize, 2011b). However, there is generally a salary range for a particular position, and some managers may start nearer the bottom of the range, leaving room to negotiate. Beginning salary dictates the salary for the rest of the time the nurse is employed—except if he or she is promoted. When assessing compensation, however, advanced practice nurses need to consider the entire benefits package, which includes such items as life insurance, health insurance, dental and vision care, vacation, and retirement/pension plans. In addition, advanced practice nurses should

consider whether the organization will provide compensation for professional memberships, continuing education opportunities, and travel expenses. It is important to consider these factors in conjunction with the salary (Mize, 2011b).

Fostering Development Once advanced practice nurses are in their new roles, they need to continue their education and foster their growth and development. Advanced practice nurses begin their first advanced practice positions as novices and need to put structures and strategies in place to support their growth and development so that they can become experts (Ackerman, Norsen, Martin, Wiedrich, & Kitzman, 1996; Doerksen, 2010). Continuing education and ongoing training are obvious ways to promote development. A few additional strategies are discussed in this section as well.

Formal and Informal Mentorship Formal and informal mentorship has been noted in the literature as a method to address the professional development needs of advanced practice nurses. Formal mentorship (also referred to a preceptorship) is often offered by an institution/practice with some prescribed components. Each organization goes about the process differently. Ideally, a needs assessment is completed to develop an individualized program that meets the specific needs of new advanced practice nurses. In addition, novice advanced practice nurses may be paired with ones who have agreed to serve in the mentor role. Once an agreement has been reached between the two parties, they can discuss the process to be used as well as goals and expectations. Ground rules and a contract should be established to facilitate a positive experience (see Chapter 28). Some organizations provide a welcoming package including a directory of potential mentors, which lists the areas of interest and strengths of the individuals (Doerksen, 2010). This tool can be very useful for beginning advanced practice nurses who would like to identify a colleague who can help them develop their professional interests. Informal mentoring, a mentorship that emerges from an attraction of two people versus assignment of a formal mentor, can also be a useful tool for fostering the development of novice advanced practice nurses (see Chapter 29). Informal mentoring in this context refers to an ongoing

relationship with another professional who can offer assistance, provide encouragement, and stimulate growth. Being open and willing to learn and grow is the first step in developing informal mentoring relationships. Informal mentoring is less structured, with advanced practice nurses scheduling their own time with the mentor, perhaps meeting in the office or casually over coffee (Doerksen, 2010). The ongoing professional development needs of advanced practice nurses will most likely be met through multiple mentors, and these needs will likely change over time. Initially, advanced practice nurses need to learn about the daily ins and outs of their role. New advanced practice nurses may need assistance with specific activities as well as policies and procedures. With time, they will become more comfortable and confident with the daily functions, with their attention for mentoring focusing on additional growth in the role. The need for mentoring regarding research has been identified as a need that will increase for advanced practice nurses over time. On-site mentors for research can be a useful way to meet that need if the facility is lacking in such expertise. Visiting advanced practice nurses from other institutions and practices can help both with conducting research and determining how this role can be implemented in a variety of ways (Doerksen, 2010). Physicians may be able to help nurse practitioners identify gaps in clinical knowledge and help by serving as mentors for research. However, advanced practice nurses need to be cognizant of the professional obligation to further not just medical and healthcare research but nursing research as well.

Experiential Learning and Reflective Narratives Advanced practice nurses can foster their growth and development via experiential learning embedded in narratives. In this context, experiential learning involves advanced practice nurses actively reflecting on their work experiences with the assistance of written journal entries. Advanced practice nurses’ work environments can provide opportunities to acquire new skills and develop new knowledge if they are open to these events, have self-initiative, and are willing to self-evaluate. Making meaning from work experiences requires attention to pertinent occurrences, active reflection on the situation by using analytical skills, consideration of

alternative ways to handle the encounter, and development of new ideas from the experience (Cathcart, Greenspan, & Quin, 2010). Written reflections can help advanced practice nurses recognize the skilled knowledge and accomplishments they have achieved (Cathcart et al., 2010). Without contemplation, advanced practice nurses’ achievements or difficulties may be seen as merely isolated occurrences, possibly not remembered until the next time a similar event happens (Benner, 1984; Benner, Sutphen, Leonard, & Day, 2010; Benner, Tanner, & Chesla, 2009; Cathcart et al., 2010). Writing about experiences at work gives advanced practice nurses an opportunity to remember the event and start to understand the importance and implication of the incidents. It also helps them appreciate why the specific incident was important and how their judgment and actions influenced the situation. Written narratives reinforce the notion that advanced practice nurses’ professional development is a lifelong process based on constant exposure to a variety of experiences (Cathcart et al., 2010).

Online Listservs Online listservs are another practical strategy for fostering professional growth and development; they provide advanced practice nurses with a network of support and informal knowledge sharing. In this context, listservs comprise an electronic mailing list management system that lets advanced practice nurses subscribe to a mailing list of other advanced practice nurses or healthcare professionals. Listservs can help advanced practice nurses stay current with the latest changes in their area of expertise, which in turn may assist them in making informed decisions about clinical practice. Listservs provide advanced practice nurses with a professional network to which they can pose questions or ideas regarding their practice, no matter what their role. Advanced practice nurses often gladly share their knowledge, as they feel a sense of obligation if they have been given assistance previously from others or if they hope to receive help in the future. Advanced practice nurses tend to provide information to the listserv because they want to improve patient outcomes and assist their peers by imparting the needed information (Hew & Hara, 2008). There are some downsides to listservs. Notably, advanced practice

nurses should be certain to verify the information obtained via a listserv prior to using it in practice. In addition, although listservs can provide some pearls of wisdom, often advanced practice nurses receive redundant messages that can overload their email inboxes.

Grand Rounds Grand rounds are a useful venue to promote and demonstrate nursing practice as well as foster growth and development. If grand rounds are not available in the institution in which the advanced practice nurse is practicing, then Benner’s theoretical framework of skill acquisition can guide this process. Grand rounds are often held quarterly and are expected to connect evidence-based practice literature to practice. In this learning activity, healthcare professionals who provide direct care gather to hear about a clinical issue or particular patient case. For advanced practice nurses, grand rounds serve as a means to improve nursing care by focusing on the educational needs of their clinical practice. In addition, they offer a way to be recognized for clinical knowledge and skills, foster networking among advanced practice nurses and other healthcare professionals, and provide recognition of the value of nursing’s contribution to practice (Furlong, D’Luna-O’Grady, Macari-Hinson, O’Connel, & Pierson, 2007). Traditionally, grand rounds have been limited to hospitals, notably academic medical centers. However, the concept of interprofessionals gathering to learn together can happen in any setting, including universities.

Recognition Programs Recognition programs have been noted in the literature as a way to foster advanced practice nurses’ growth and development as well as that of other members of the interprofessional team. Organizations develop and implement recognition programs as a way to publicly acknowledge contributions to meeting the goals and objectives of the institution. Typically, the goals and objectives in health care involve obtaining positive patient, staff, institutional, and community outcomes. If the advanced practice nurse’s institution has not developed a recognition program, he or she might propose developing one to recognize the

numerous contributions of the healthcare professionals in that institution, including advanced practice nurses. Such a program can be utilized to acknowledge advanced practice nurses’ competency in the role, achievement of goals above and beyond their job expectations, and promotion of nursing practice (Sullivan, Arlington, Madsen, & Guidry, 2006).

Lifelong Learning As you begin your career as an advanced practice nurse consider making lifelong learning a priority. Lifelong learning involves ongoing selfmotivated learning aimed at improving knowledge, skills and attitudes. Why is lifelong learning important to advanced practice nurses? Part of the answer lies in the fact that our world is rapidly changing and we need to positively adjust to these changes. By continuing to learn, you will become less risk adverse and adapt when change occurs. Lifelong learning offers many benefits such as (Laal & Salamati, 2012): Assist you in establishing valuable relationships Keep you actively involved as a contributor to society Help you find meaning in your life Help enrich your life Improve the world Open your mind Develop your abilities Help you stay aware of changes Provide you with options Prevent boredom Make you a valuable employee Boost your confidence and self-esteem Challenge your ideas and beliefs Although lifelong learning can be accomplished in the classroom, it can also take many different forms. The following are samples of some lifelong learning activities: Reading books/journals (choose a wide variety and read often) Learn a foreign language Take continuing education classes Keep a “to learn” list Join a journal club Teach/mentor/precept others Keep a journal

Summary Advanced practice nurses’ educational programs are limited in their ability to fully assist students with the transformation that is necessary as they move from pupil to novice and eventually to expert. This transition has been described in the recent literature as a process that involves three stages: identity loss, transitional role, and incorporation. Advanced practice nurses’ educational programs attempt to facilitate this transition by providing students with a framework that emphasizes evidence-based practice, research, collaboration, and consultation as a way to inform nursing practice (Spoelstra & Robbins, 2010). Although these educational programs may assist students with this process, other strategies to facilitate a positive transition can be implemented as well. The transition from student to expert cannot be fully achieved until graduating students have secured their first position. As graduating students prepare for the job marketplace, they need to locate job openings and conduct the following assessments: personal, marketplace, organization, and advanced practice nurse–organization fit. In addition, a professional portfolio is helpful to demonstrate the benefits that advanced practice nurses can offer to an employer. Finally, advanced practice nurses need to present themselves favorably in the application and interview processes. Once advanced practice nurses have begun a new position, it is essential that they develop a lifelong learning plan that includes measures to foster their growth and development. Some suggested methods to promote development are formal and informal mentorships, experiential learning and reflective narratives, online listservs, grand rounds, and recognition programs.

Discussion Questions 1. As you lay the foundation for professional advanced nursing practice, conduct a personal analysis. What are your strengths and your needs for further development? 2. Which strategies can the novice advanced practice nurse employ to have a successful transition to the professional role? 3. Following a self-, marketplace, and organizational assessment, which factors are most important for you to consider when selecting an advanced practice position?

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Index Boxes, exhibits, figures, and tables are indicated by b, exh, f, and t following the page number

A AACN. See American Association of Colleges of Nursing; American Association of Critical-Care Nurses AACN Essential III, 102 AACN Essentials of Doctoral Education, 122 AACN Task Force on the Practice Doctorate in Nursing, 51 AAN. See American Academy of Nursing AANA. See American Association of Nurse Anesthetists AANP. See American Association of Nurse Practitioners absolute risk (AR) statistical tool, 626 absolute risk reduction (ARR), 582 calculations, 626 ACA. See Affordable Care Act acceptance techniques, stress management, 899 access in healthcare delivery, 186–187 accountability, 397–398 cost-quality dilemma in, 397–398 accountable care organizations (ACOs), 272–273, 453–454, 454f accounting disciplines, relationship of, 305, 305f Achieving Competence Today (ACT), 165 ACNM. See American College of Nurse-Midwives ACO. See accountable care organization ACP. See advanced care planning; American College of Physicians ACT. See Achieving Competence Today activities of daily living (ADL) scale, 689, 769

acupressure, 118 acupuncture, 118 acute conditions, 674 and subacute, chronic conditions, 674–676 ADA. See Americans with Disabilities Act of 1990 adapting techniques, stress management, 899 ADL scale. See activities of daily living scale administrative costs, 190 administrative practices, changing of, 396–397 administrative procedures act (APA), state level, 212, 217, 220 administrative process, 442 advance nursing education, 14 advanced care planning (ACP), 799 minority and cultural issues, 800–801 Advanced Holistic Nurse Board Certification (AHN-BC), 115 advanced practice nurses (APN) DNP in, 829–830 enhancement, 830–831 goals of nursing, 828–829 IOM in, 830 leadership, 830–831 barriers of, 834 cognitive processes, 835 expectations, 831–832 levels of, 834 models of, 832–834 advanced practice nursing (APN), 7, 62, 77, 103, 110, 122 characteristics of, 784–788 definition of, 782 experience, 914 faculty, notion of, 78 focus, 31 idea of, 14 job description, 915 leadership model for, 137–141 organizational fit, 909–910, 916 overview, 1–3 recognition programs, 922 regulations for, 914 roles and nursing curriculum, 782 clinical nurse leaders (CNLs), 7–8 clinical nurse specialists (CNSs), 8 nurse anesthetists, 18–19 nurse educator supply and demand, 10–15 nurse educators, 8–10 nurse-midwives, 17–18 nurse practitioners, 15–17 scholarly work, 915 social media, 808 transformational leadership, 136

advanced practice PHNs, roles of, 96–97 Advanced Practice Registered Nurses (APRNs), 329, 5, 6, 144, 843 big data in, 469–472 delegation of medication administration in, 232–233 history of, 214–215 implications for, 469 legislative process, 241 professional organizations, 245b regulation of, 218–219 reimbursements for, 230, 253 advanced practice roles, 2 Advanced Practice Task Force, 218 adverse events monitoring, 492 Advisory Committee for Women’s Services, 758 advocacy in health care, 61 advocacy skills, 713 Affordable Care Act (ACA), 108, 183, 329, 374, 678, 740, 753 regulatory framework in, 229–230 African Americans, 742, 744f, 748 age-cohort regression-based model, 24 Agency for Health Care Policy and Research (AHCPR), 511, 545–546 Agency for Healthcare Research and Quality (AHRQ), 546, 549 data sets, 631 evidence-based outcomes, 622 evidence evaluation, 612–613 information technology, 444 outcomes research, 634 psychological safety and communication, 157 AGREE model for EBP, 613 Agriculture Department, 756 AHCPR. See Agency for Health Care Policy and Research AHIMA. See American Health Information Management Association AHIP. See America’s Health Insurance Plans AHN-BC. See Advanced Holistic Nurse Board Certification AHNA. See American Holistic Nurses Association AHRQ. See Agency for Healthcare Research and Quality Alaska Native, 742, 742f, 743t, 744f, 752 Alexander technique, 118 altering techniques, stress management, 897 alternative payment models, 271–272, 272b Alzheimer’s disease, 758 AMCB. See American Midwifery Certification Board American Academy of Nurse Practitioners, 626 American Academy of Nursing (AAN), 109 American Association of Colleges of Nursing (AACN), 2, 5, 7, 10, 14, 15, 25, 26, 30, 77, 238, 574, 713 clinical scholarship, 596–597 Commission on Collegiate Nursing Education (CCNE), 55 DNP and PhD/DNS/DNSc programs, comparison between, 51, 51t–52t evidence-leveling system, 574t

job market, 905 research-focused doctoral programs, 50–52 American Association of Critical-Care Nurses (AACN), 288, 574, 872 American Association of Nurse Anesthetists (AANA), 18, 19, 64 American Association of Nurse Practitioners (AANP), 23 American Civil War, 18 American College of Nurse-Midwives (ACNM), 17 American College of Physicians (ACP), 145, 146 American health care, developments in, 123 American Health Information Management Association (AHIMA), 125 American Holistic Nurses Association (AHNA), 115 American Holistic Nurses’ Credentialing Corporation, 115 American Indians, 742, 742f, 743t, 744f, 752 American Medical Association (AMA), 334, 334b, 632 evidence-based outcomes, 522 American Medical Association-Physician Consortium for Performance Improvement (AMA-PCPI), 622 American Midwifery Certification Board (AMCB), 17 American Nurses Association (ANA), 8 interprofessional collaboration, 145 National Center for Nursing Quality, 633 research and evidence for practice, 633 American Nurses Credentialing Center (ANCC), 20, 483 American Organization of Nurse Executives (AONE), 2, 19, 305 guiding principles, 8 American Psychological Association, 894 American Public Health Association, 93 American Recovery and Reinvestment Act of 2009 (ARRA), 327, 412, 418, 438, 439, 452, 487, 554, 676 AMMA therapy, 118 analysis of quantitative research, 607–608 analytic studies, 543 analytical methods for evidence-based practice, 60 ANCC. See American Nurses Credentialing Center anthro-cultural beliefs and values equitable distribution of health care, 695 market justice, 695–697 social justice, 697–698 Antitrust Division of Department of Justice, 229 AONE. See American Organization of Nurse Executives APA. See administrative procedures act APN. See advanced practice nursing applied kinesiology, 118 APRN. See Advanced Practice Registered Nurse APRN Advisory Committee, 6 APRN Consensus Model, 8 APRN Consensus Work Group, 6 APRN Consensus Work Group and the National Council of State Boards of Nursing APRN Advisory Committee (2008), 25 APRN Regulatory Model, 6f

AR statistical tool. See absolute risk statistical tool aromatherapy, 118 ARR. See absolute risk reduction ARRA. See American Recovery and Reinvestment Act art therapy, 119 Asian Americans, 751–752 ASPR. See Assistant Secretary for Preparedness and Response assessment, public health nursing practice, 92 assessments and assessing advanced practice nurse-organizational fit, 909–910 EHRs systems, 451 marketplace, 908 organizational, 908–909 personal, 907–908 plan, 626 stress management tools, 896–897, 898t time management tools, 889–892, 890t–891t Assistant Secretary for Preparedness and Response (ASPR), 683 Association of Colleges of Nursing, 596 Association of Community Health Nursing Educators (ACHNE), 93, 96 assurance, public health nursing practice, 92–93 Australia, healthcare system, 196–197 authentic listening, 39–40 authoritarian leadership styles, 86 authorship negotiation, 653–654 automated dispensing of medications, 492 avoidance techniques, stress management, 899

B Bachelor of Science in Nursing (BSN), 93 bad apple theory, 548 balance billing, 190 balanced scorecards (BSC), 402–403 bar coding and automated medication dispensing, 399, 492 Barker–Sullivan model of mentorship, 880–883, 880f basic science research, 542 behavior patterns, and outcomes, 630–632 behavioral risk factors, 674, 675t, 685 beliefs and values anthro-cultural, 670, 693–694 concepts of health and health care, 671–673 cultural, 693–694 equitable distribution of health care, 696t–697t health and health care concepts, 671–673 health determinants, 684–686 health promotion and disease prevention, 677–678

managers and policy makers, 671 measurement, health, 686–693 overview, 669–670 quality of life, 673 risk factors and disease, 673–676 benchmarking, 400, 621–622 pros and cons of, 401t Benedictine values, 167 Bersin’s model of training measurement, 86 bias in research, 608 big data background, 462–463 case study, 470–472 data sources, 471 EBP, 466 EIP vs., 466 groundwork for, 466–469 healthcare delivery and policy, 463 issues in, 465–466, 467t–468t legislation and initiatives, 467t–468t magnet status and, 472 overview of, 460–462 research evidence vs., 470–471 sources of, 463–465, 465exh biochemical responses, stress management, 899 biofeedback, 120 biological variations, 715 Biomedical and Behavioral Research, 796–797 bioterrorism, 682, 683 Black Americans, 742, 742f, 743t, 744f Block Grant program, 764 BLS. See Bureau of Labor Statistics Blueprint for a Healthy Community, 96 Blum’s model of health determinants, 684 board meetings, 219–220 board rulemaking processes, 221–222 boards of health, 621 boards of nursing (BONs), 214, 219, 221 BONs. See boards of nursing Boston University, 53, 518 bottom-line approach, 276, 276b, 396–398 Boyer’s model of scholarship, 597 break-even analysis, 320 Breema bodywork, 118 BSN. See Bachelor of Science in Nursing budget process advanced nurses in, 274 capital budget product evaluation, 287–291 functions of, 274b

nursing expenses, 277–286 product and device purchasing evaluation checkpoints, 294–295 more-is-better of, 293b tools, 296–299 what-if syndrome of, 291b–292b types of, 275–277 value-based environment in, 287 ZBB vs. historical budget, 274–275, 275t business and practice management, nurse, entrepreneur, 103–104 business competency, leadership, 140

C CAAN. See Coalition of African American Nurses Canada, healthcare system, 197–198 cancer mortality, 678, 678t capital budget, 277 considerations and, 288–289 device competencies and, 288–289 GPO in, 289 product evaluation and, 287–289 request, 278f–279f safety concerns, 290–291 space renovation form, 280f staff engagement, opportunities for, 289 theft concerns, 290 trade shows, 288 value analysis, 289 CARE. See Ryan White Comprehensive AIDS Resources Emergency Caritas Processes™, 35, 36t carve-out in HMOs, 767 Case Western Reserve University, 54 causal mappings, 910 CCNBNA. See Chicago Chapter of the National Black Nurses Association CCNE. See Commission on Collegiate Nursing Education CDC. See Centers for Disease Control and Prevention CDSS. See clinical decision support system Centers for Disease Control and Prevention (CDC) chronic illnesses, 674–676 data sets, 631 health inequities, 686 pandemics, 680, 683 Centers for Medicare & Medicaid Services (CMS) data collection on outcomes, 621 electronic healthcare records, 439 federal regulations, 224, 229

hospital-acquired conditions of, 383, 384b Office of Personnel Management, 229 Centers for Medicare and Medicaid Services (CMS) mission, vision, and strategic goals in, 270b central agency in healthcare delivery, 186 CERN. See Clinical Ethics Residency for Nurses certificates and certification, 125, 874–875 APRN in, 875 for EHR vendors, 439 in informatics nursing, 483 Institute of Medicine (IOM), 230 programs, 125 regulatory framework for, 217 Certification Commission for Healthcare Information Technology, 439 certified midwives (CMs), 17 percentage of births attended by, 18f site of births attended by, 18f certified nurse-midwives (CNMs), 17, 26 percentage of births attended by, 18f site of births attended by, 18f certified registered nurse anesthetists (CRNAs), 19, 26 reimbursement, 253 Certified Speaking Professional (CSP), 109 CFR. See Code of Federal Regulations change management plans change management plans, 451 change theory, 84–86 chaos theory, 404–405, 405b Chi kung healing touch, 121 Chief of Public Health Practice, 94 children developmental vulnerability of, 756 health care issues, 754–756, 755t, 770–771 special population groups, 754–756, 755t U.S. health care system, 756 Children’s Health Insurance Program (CHIP), 180, 183 China, healthcare system, 198–200 chiropractic medicine, 118 chronic conditions children, 756 description, 674–676, 768–769 homeless mentally ill veterans, 764 special population groups, 768–769 women, 756 cigarette smoking, 750f CINAHL. See Cumulative Index to Nursing and Allied Health Literature CIS. See clinical information system (CIS) CITE. See Collaborative Interprofessional Team Education CLIA. See Clinical Laboratory Improvement Amendments of 1988 clinical care classification system, 481 clinical data repository, 480

clinical decision support system (CDSS), 480, 493 clinical education, 713–714 Clinical Ethics Residency for Nurses (CERN), 787 clinical information system (CIS) EHRs as, 445b–447b as staff development tool, 447b clinical information systems, 318, 480 clinical instructor program (CIP), 81 clinical nurse leaders (CNLs), 7 role competencies for, 9t clinical nurse specialists (CNS), 8, 26, 64, 790, 843 role of, 5, 9t clinical prevention and population health, 62 Clinical prevention and population health for improving the nation’s health, 116–117 clinical provider order-entry system (CPOES), 493 clinical research, 542–543 clinical scholarship and evidence-based practice, 595–640 collaborative research, 633–635 conceptual frameworks for evidence and practice change, 613–617, 616f data analysis, 626 data collection, 626 database design, 622–625, 623t–625t description of, 596–599 designing and implementing processes, 617, 618t DNP degree essential, 60 DNP role in, 599–600 evaluation of practice, 597, 621 evidence-based practice findings, 537 guidelines to improve practice, 620–621 information technology and research method, 625 overview, 595–596 quality improvement and patient-centered care, 613 research evidence, types of, 601–613 qualitative, 601–606 quantitative, 606–612, 606f, 609t, 610f, 612t research into practice, 599 results of the study, 611–612, 612t clinical statistical measures, 612t clinical terminology, 490 clinical trials, 543, 626 cloud-based EHRs systems, 453b C/MHCs. See Community and Migrant Health Centers CMS. See Centers for Medicare & Medicaid Services CMS program, 123 CNL Certification Examination, 7 CNLs. See clinical nurse leaders CNMs. See certified nurse-midwives CNS. See clinical nurse specialists coalition building, 244–250, 247b Coalition of African American Nurses (CAAN), 111

Cochrane Collaboration, 562 Cochrane Collaboration Review, 622 Cochrane Library, 569 Code of Ethics for Nurses with Interpretive Statements, 792 Code of Federal Regulations (CFR), 227 coding systems, 481 cognitive processes, 835 COIs. See conflicts of interest collaboration, 88–89 Collaborative Interprofessional Team Education (CITE), 165 collaborative practice agreements, 914–915 collaborative research, 633–635 collective cognitive responsibility, 157 College of American Pathologists (CAP), 425 color therapy, 119 Columbia University, 53, 55 Commerce Clause of U. S. Constitution, 225 Commission on Collegiate Nursing Education (CCNE), 2, 55 communication, 85, 714 defensiveness in, 160 effectiveness of, 159–161, 161b electronic, 442 managing, 896 of research findings, 536–537 communication model, 730f Community and Migrant Health Centers (C/MHCs), 760, 762 community-based programs, 756 community health assessment, 700 community health nursing, 90–91 community partnerships, 733–734 comparative effectiveness research, 554 comparative effectiveness reviews, 631 comparative ethics. See descriptive ethics competencies monitoring, 220 specialty-focused, 62–63 competition, 305–307 complementary therapies, 122 complex adaptive systems, 131 complexity issues, 381 complexity science change model informed by, 131–136, 131t evaluations outcomes, 135–136 forces of change, 134 implementation plan, 135 refreezing, 136 team vision, develop, 132–133 unfreezing, 132 for organizational change, 130–131 computer-based reminder systems, 495

computer literacy, 481 computerized decision support system (CDSS), 421 implementation, 422 computerized monitoring of adverse events, 492 concept development, conceptual problems and, 528–529 concepts of health and health care behavioral risk factors, 675t overview, 671–673 conceptual problems, and concept development, 528–529 conduct and utilization of research in nursing (CURN) model, 613 confidentiality, 500–501, 802–806, 803–805 conflict resolution, 161–162 conflicts of interest (COIs), 795–796 in research, 456–457 confounding variables, 510–511, 610f Consensus Conference on the Essentials of Public Health Nursing Practice and Education, 96 Consensus Model for APRN Regulation, 6, 25, 143 Consensus Statement on Emerging Nursing Knowledge, 536 considerations, 288–289 contemporary models of health determinants, 686 continuing education and training, 914 continuum of services, 191, 191t contraceptives, 759, 759f core competencies, nurse practitioner, 26–27 core practice competencies, 64 correlation statistics, 629 correlational prediction, 629 cost accounting and nursing, 304–305 cost-effectiveness, 373 cost of HIV/AIDS, 773–774, 774f cost-quality trade-offs, 311 cost sharing, 183 cost-to-benefit analysis, 320 costs to society, 316 Council of Australian Governments (COAG), 196 counseling/psychotherapy, 119 covered entity, HIPAA, 804 CQI. See continuous quality improvement cranial osteopathy, 118–119 craniosacral therapy, 119 credentialing, 216 educational preparation and, 96 critical social theory, 601–602 CRNA. See certified registered nurse anesthetist cross-cultural clinical skills, 713 cross-cultural communication, 729 cross sectional research design, 607 cross sectional samples, 507 Crossing the Quality Chasm (IOM), 325 CSP. See Certified Speaking Professional

cultural approach, 717 cultural awareness, 726 of biological variations, 715 of communication, 714 of environmental control, 715 of Hofstede’s cultural dimensions theory, 715 of social organization, 714 of space, 714 of time, 714–715 cultural awareness and sensitivity (CAS), 718 cultural competence, 717–726 eight elements of, 717b of intercultural competence, 724f methodological models of, 722t–723t in primary health care, 725b pyramid model, 725f theoretical models of, 719t–721t Cultural Competence Assessment (CCA), 718 cultural competence behaviors (CCB), 718 cultural competency beliefs and values, 693–694 puzzle, 727–729 cultural humility, 715–717, 716 cultural immersion experiences, 726–727 cultural issues, 381–382 cultural sensitivity/global health clinical education, 713–714 community partnerships, 733–734 cultural awareness, 714–715 cultural competence, 713–714, 717–726 cultural competence puzzle, 727–729 cultural humility, 715–717 cultural immersion experiences, 726–727 culturally sensitive manner, 734 evaluation, 735 global diversity, 712–713 language and communication, 729–733 LIAASE, 734b overview, 711–712 cultural variations, 717 culturally sensitive manner, 734 culture of quality, 329 of work, 156–157 culture, basic knowledge of, 713 Cumulative Index to Nursing and Allied Health Literature (CINAHL), 598, 620 database, 569 CURN model. See conduct and utilization of research in nursing model current procedural terminology, 490 curriculum standards for DNP degree, 58–65

collaborative work and, 164–166 core practice competencies, 64 entry-level competencies, 63 essentials of, 58–62 pathways to, 65, 66f curriculum vitae (CV), 911–913, 912f–913f discussion boards and forums, 873 disseminating, 868–869 LISTSERV, 872–873 organizations, 871–872 padding, 862, 863b professional associations, work of, 870–871, 871b references, 869–870 structuring, 863–865 technology skills, 873–874

D Da Vinci surgical system, 499 dance therapy, 119 dashboard, 481 data analysis, 481, 626 collection, 507–508, 626 defined, 481 data banks, 481 data mining, 481 data security, 481 data sets, 481, 489 data to wisdom concept, 482, 482f databases, 481, 523t–525t, 525, 598, 622 Davies Award (HIMSS), 444 death, causes of, 681t death rate, 746t–747t decision making, 157, 727–728 decision-making capacity, 796–801 advance directives, 799 case study, 797 determinations of, 796 legal aspects, 798–799 proxy decision making, 798 decision support, 442 Defense Department, U.S., 773 defensive medicine, 191 defensiveness in communication, 160 delegation, 894–895 demand for healthcare, 189

demand-side rationing, 696 Deming’s management method, 613 democratic leaders, 86 dependency, 755–756 Depression Improvement Across Minnesota, Offering a New Direction (DIAMOND) project, 156 descriptive ethics, 787 descriptive studies, 543 Developing a Population-Focused Student Health Service project, 167 developmental vulnerability, 755–756 device competencies, 288–289 DHHS. See Health and Human Services Department (DHHS) DHS. See Homeland Security Department diagnosis-related group (DRG), 306 diagnosis‒procedure combinations (DPCs), 202–203 Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), 673 DIAMOND project. See Depression Improvement Across Minnesota, Offering a New Direction project diet, 846–847 diet and physical activity challenges, 846–847 direct care processes, 103 disabled population group, 769 Disaster Medical Assistance Teams (DMATs), 684 disaster planning and preparedness, 404 discipline components, 419 delineating, 519–520 nursing as, 517 professional, 520–522 discrimination and HIV/AIDS, 773 disease and management conditions of, 674–676 prevention of, 677–678 risk factors, 673–675 disparities issues, 382–383, 382b disruptive behavior, 151 distribution of health care, 695, 696t–697t District of Columbia, 15 diverse society, 735 DMATs. See Disaster Medical Assistance Teams DNP. See Doctor of Nursing Practice DNP as integrative practitioner, 121–122 DNP degree, relationship of entrepreneurship and, 102–103 DNP-educated entrepreneur, 106 DNP educational program, 84 DNP, emerging roles for, 69–72 biosketches of successful DNP entrepreneurs, 109–113 DNP as integrative practitioner, 121–122 integrative practitioner, 114 biologically based practices, 120–121 energy medicine, 121

integrative healing modalities, types of, 117–121 manipulative modalities, 118–119 mind–body medicine, 119–120 nurses as integrative practitioners, 114–117 whole medical systems, 117–118 nurse administrator, 84 change theory, 84–86 collaboration, 88–89 evidence-based management practices, 88 leadership style, 86–88 nurse educator, 77–79 faculty development, 79–80 in GTA, 80 new nurse educator mentoring programs, 80–81 nursing education practicum, 80 online learning of, 81–82 peer review, critical aspects of, 82 nurse entrepreneur business and practice management, 103–104 current and future trends, 108–109 definitions, 100–101 entrepreneurship and DNP degree, relationship of, 102–103 healthcare policy and legislative issues, 107 organizational systems leadership and collaboration, 105–106 practice start-up, closure and credentialing, 104–105 relevance and opportunities of, 107–108 DNP entrepreneurs, biosketches of successful, 109–113 DNP-prepared APN, 114 DNP-prepared informaticist, future of, 127 DNP-prepared nurse educator, 14 DNP-prepared PHNs, emergence of, 94 Doctor of Nursing Practice (DNP), 2, 14, 15, 25, 29–31, 77, 521, 649, 829–830 clinical scholarship role for, 599–600 definition of, 50 evolution of, 53–55 impact of, 514–515 overview, 2, 49–50 doctoral education in nursing, evolution of, 53–55 practice-focused doctorate, 50–52 research-focused doctorate, 50–52 programs, 7 public health nurse as leader, 98–99 recipe for curriculum standards, 58 AACN essentials of doctoral education for ANP, 58–62 CRNAs, 64–65 NACNS core practice doctorate clinical nurse specialist competencies, 64 NONPF practice doctorate nurse practitioner entry-level competencies, 63 pathways to the DNP degree, 65, 66f specialty-focused competencies, 62–63 role transition, 65–72

website, 110–111 doctoral education, 58–62, 93, 103, 105 advocacy in health care, 61 history of, 49 information systems and technology, 60 in nursing, 53–55 overview, 2 scientific underpinnings of practice, 59 doctoral-level education, 102 documentation advanced practice affirmation, 916 in clinical, 485–487 medical records, 485, 486 Domiciliary Care for Homeless Veterans Program, 764–765 DRG. See diagnosis-related group drivers of interprofessional collaboration, 152–157 Drummond Group, 439 dynamic healthcare system, 206 dynamic practice, 38

E E-Intensive care unit (eICU), 501–502 E-mail, 896 e-referrals, 484 Early Periodic Screening, Diagnosis, and Treatment (EPSDT), 756 EBM. See evidence-based medicine EBP. See evidence-based practice Economic Studies, 712 economics, categories of, 304t education continuing education and training, 914 doctoral education, 49–73 informatics use in, 484–485 nurses, 517–519 and policy making, 259–261 Education Department, 756 educational preparation and credentialing, 96 EEOC. See Equal Employment Opportunity Commission egg sharing in fertility treatment, 604 EHRs. See electronic health records EI. See emotional intelligence electronic access for healthcare services, 231 electronic communication and connectivity, 442 electronic health record (EHR), 812–816 analysis of, 815

recommendations, 815–816 use by healthcare organizations, 813 patients, 812 providers, 813 uses and general benefits of, 812 electronic health records (EHRs), 124, 258, 363–364, 492–493 ACOs and, 453–454, 454f adoption progress in U.S., 429–431, 430f–431f advantages of, 444–447, 485 certification criteria, 440b–441b as clinical information system, 445b–447b components, 439–444, 440b–441b end-user adoption of, 451 evidence-based practice, 446 flexibility and expandability, 452–453 functions and communication capabilities, 443 future, 455 health information technology, 412, 413, 421f implementation, 445, 445b, 450, 451 overview, 437–438 ownership of, 450–452 resources healthcare professionals, 460 services of, 462t types of, 461t standardized terminology and, 448–449, 449b tracking clinical outcomes, 445b–446b electronic medical record (EMR), 320, 477, 492 cost for, 318–319 in hospitals, 318 electronic medical records, 806–816 electronic portfolio, 860–861 electronic Preventive Services Selector (ePSS), 848 Elsu’s communication style, 718 email, 481 Embase database, 569 embeddedness, 131 EMDR. See eye movement desensitization and reprocessing Emergency Health Personnel Act, 760 emergency regulations, 225 emerging roles integrative practitioner, 114–117 nurse administrator, 84 nurse entrepreneur, 100–109 nurse informaticist, 123–124 overview, 2–3 emotional intelligence (EI), 162–163 empirical quality standards, 549 employee issues

chaos theory, 404–405 disaster planning and preparedness, 404 healthy workplace, 403–404 OSHA, 403 encryption, 481 energy medicine, 121 energy work, 121 enrollees (member) in managed care, 185 entrepreneurship and DNP degree, relationship of, 102–103 entry-level competencies, 63 environment as determinant of health, 685 Environment of Health Model, 684 environmental control, 715 environmental health, 680, 681t epidemiological research, 543–544 epidemiology triangle, 673, 674f episodic treatment groups (ETGs), 156 EPSDT. See Early Periodic Screening, Diagnosis, and Treatment Essentials of Doctoral Education for Advanced Nursing Practice (AACN), 2, 30, 50, 79 ETGs. See episodic treatment groups ethical issues, potential, 813–815 ethical leadership. See also leadership APN in, 828–830 barriers of, 834 characteristics of, 827–828 dual loyalties, 837–838 historical and contemporary nursing leaders, 835–837 overview of, 826–827 ethics, 711–736 characteristics of good APNs, 784–788, 786t competencies, 28 ethical situations, 782, 785, 791 overview, 782–784 and policy making, 256 in research, 556–557 ETHNIC mnemonic, 731b ethnographic research, 602 eudaimonia, 785 evaluation, 735 of evidence for practice, 597, 621 of policies, 194 of practice, 597, 621 of qualitative research evidence, 606–607 of quantitative research evidence, 608–611, 609t, 610f ever-changing society, 735 evidence-based anesthesia, 19 evidence-based management practices, 88 evidence-based medicine (EBM), 550–553, 561, 562 Evidence-Based Medicine Working Group, 562 evidence-based population health programs, 98

evidence-based practice (EBP), 333f, 395, 511, 561–592 AGREE II Instrument, 583, 583t barriers to, 590–591 in big data, 466 clinical pathways and protocols, 395–396 critical appraisal clinical practice guidelines, 583 of evidence, 577, 582, 583, 585 of single intervention study, 582 tools, 577t–579t, 579f, 583 EHRs, 446 evidence synthesis, 580t–581t evidence synthesis/recommendations, 579 goal of, 563 implementation strategies, 613 key assumptions of, 563 models, 466t–467t, 566, 613, 626 nurse practitioner use, 564 nursing and, 562–564 overview, 561–562 PICOT definition and questions, 568f–569f, 569 in population-based public health nursing, 98 principles of, 598–599, 599t process, 511, 563, 568 outcomes of, 587 searching databases for best current evidence, 568–569 searching for evidence, 568–573 sources of evidence, 570t–572t, 573 UpToDate grading system, 586t–587t Evidence-Based Practice Council, 635 evidence-informed health policy (EIHP), 221, 222t evidence-informed practice (EIP), 466 expandability of EHRs systems, 452–453 expense budget nonsalary, 276 salary, 276 experiential learning, 920–921 experimental epidemiology, 544 explicit quality standards, 548 external influences in healthcare delivery, 185, 185f External Reaction Panel, 54 eye movement desensitization and reprocessing (EMDR), 119–120

F Factors and implications in health determinants, 693–694 Faculty development programs, 79–80

faculty vacancy, 10f failure mode and effects analysis (FMEA), 359–360 Falun Dafa. See Falun Gong family advisory councils, 388–389 Family Nurse Partnership program, 98 family nurse practitioner (FNP), 734, 801 family support services, 756 FDA. See Food and Drug Administration Federal Advisory Committee Act, 418 Federal Coordinating Council, 554 federal health informatics reports, 477–479 federal health IT strategic plan, 478f–479f Federal Register, 225, 227, 243 federal regulatory process, 224–225, 226b emergency regulations of, 225 federal rulemaking, 225, 226f healthcare delivery system in, 228–229 information sources of, 225–227 public comment for, 227 strengths and weaknesses of, 227–228 Federal Trade Commission (FTC), 230 fee-for-service, 268–270 Feldenkrais method, 119 feminism, 530 feminist ideology, 532 financing healthcare, overview, 181 findings from evidence-based practice, 536–537 fine-gauged needles, use of, 118 Fitzgerald Health Education Associates, Inc., 109–110 “5 As,” smoking cessation, 37 flexibility of EHRs systems, 452–453 FNP. See family nurse practitioner FNS. See Frontier Nursing Service FOCUS, 350–352, 351f Food and Drug Administration (FDA), 500, 556, 759 for-profit, 310 force field analysis, 134, 134t Force Field and Well-Being Paradigms of Health, 684 formal mentorship relationships, 883, 920 formal preceptorship programs, 883 foundation, for leadership, 137–138 Framingham epidemiological study, 544 free market in healthcare delivery, 187–189, 187f Frontier Nursing Service (FNS), 17 FTC. See Federal Trade Commission full-time equivalent (FTE), 277, 281b Future of Nursing (IOM), 15, 257, 258 The Future of Nursing, Leading Change and Advancing Health (IOM), 326

G Gantt chart, 125 gender bias, 608–609, 609t gender differences in communication, 161 genetics and genomics, 499–500, 685 Germany, healthcare system, 200 global budgets, 186 Global Disease Detection (GDD) Regional Centers, 703 global diversity, 712–713 global health, 703 in health measurements, 692–693 global pandemics, 680–682 goal setting and planning, 892–893 Golden Rule, 711, 712 graduate teaching assistant (GTA), 80 grand rounds, 921–922 grand theories, 510 Grant programs Block Grant program, 764 research, 635 grassroots lobbying, 244–250 grounded theory research, 602–603 group purchasing organization (GPO), 289 guided imagery, 120

H HAART. See highly active antiretroviral therapy HAI. See hospital-acquired infection HAN. See Health Alert Network Hard science, 523 Harvard School of Public Health, 145 hazard ratios, 626 HCFA. See Health Care Financing Administration HCH program. See Health Care for the Homeless program HCOs. See healthcare organizations healing relationship, 388 healing touch, 121 Health Alert Network (HAN), 683 Health and Human Services Department (DHHS) bioterrorism and disaster preparedness, 682 electronic healthcare records, 439, 455 Medicare and Medicaid programs, 224 nurse-managed health centers, 224

Office of Rural Health Policy, 760 Office on Women’s Health, 609 health belief model, 631 health care, challenges in, 372–373, 372b Health Care Financing Administration (HCFA), 224 Health Care for the Homeless (HCH) program, 764 Health Care Research and Quality Act of 1999, 546 health challenges and reform, 204–205 health, defined, 671–673 health delivery system competencies, 28 health determinants Blum’s model, 684 contemporary models, 686 environment, 685 heredity, 685 lifestyle, 685 medical care access, 686 health informatics technology (HIT), 476, 477 health information and data in electronic health records, 442 Veterans Administration, 429 health information exchanges (HIE), 423–429, 426f, 439 federated model, 425, 426f monolithic model, 426f Health Information Management System Society (HIMSS), 125 health information technology (HIT) EHRs, 412, 413, 421f future challenges, 431–432 health care delivery quality, 420–423, 421f health information exchanges, 423–429, 426f historical overview, 411–412 implementation, 412–416 implementation of, 415 federal government’s response, 416–420, 417t–418t, 419f historical challenges, 412–416, 414f issues, 413 Health Information Technology for Economic and Clinical Health (HITECH) Act, 809 Health Information Technology for Economic and Clinical Health Act of 2009 (HITECH), 327, 412, 414, 418, 438–439, 453b health insurance private, 270 public, 270–271 Health Insurance Portability and Accountability Act (HIPAA), 423, 804 confidentiality, 500 privacy rules, 453 health-integrated organizations, 97 Health IT Policy Committee, 418 health literacy, 389 health maintenance organizations (HMOs), 180, 184, 767 Health Manpower Shortage Areas, 760

health measurements, 686–687 birth rate, 690 demographic change of, 690 disability of, 688–689 of global health, 692–693 longevity of, 687–688 of mental health, 690–691 migration of, 690 morbidity of, 688 mortality of, 689–690 of physical health, 687 population in, 687 of social health, 691 of spiritual health, 691 utilization of, 691–692 crude measurement, 692 institutions, 692 specific targeted population, 692 health plan, defined, 185 Health Plan Employer Data and Information Set (HEDIS), 338, 339t health policy, 116, 547 health policy agenda, 240–241 coalition building, 244–250 considerations for, 240b grassroots lobbying, 244–250 healthcare reform, 250–251 legislative process, 241–242 professional organizations, 244–250 regulation, process of, 242–244 Health Professional Shortage Areas (HPSAs), 760–761 Health Professions Education Committee, 56 Health Professions Educational Assistance Act of 1976, 760 health protection and environmental health, 680 during global pandemics, 680–682 and preparedness in United States, 682–684 health-related support services, 756 Health Resources and Services Administration (HRSA), 10 health risk appraisal, 671, 677 health services research, 544–545 health services, utilization of, 691–692 Health Services Utilization Study, 547 healthcare, 672 legislation, 122 managers, 193–194 outcomes, websites for, 623t policy. See healthcare policy research and quality, 545–546 healthcare-associated (nosocomial) infections, 378 healthcare business, 267

budget process essentials. See budget process U.S. healthcare system in, 268–274 healthcare delivery, 671 Australia in, 196–197 Canada in, 197–198 China in, 198–200 in developing countries, 204 in federal regulatory process, 228–229 Germany in, 200 Israel in, 201–202 Japan in, 202–203 regulation in transforming, 228–229 Singapore in, 203–204 United Kingdom in, 200–201 in United States central agency, 186 characteristics of, 185–192 complying with regulations, 194–195 components of, 181–183, 182f continuum of services, 191, 191t description of system, 178, 180–181 external influences, 185, 185f free market, 187–189, 187f high technology, 191 imperfect market, 187–189 litigation risks, 190–191 multiple payers, 189–190 overview, 178–180 partial access, 186–187 power balancing, 190 quality, quest for, 192 scope and size of system, 178–180, 179t system foundations, 205 system outcomes, 206 system outlook, 206 system resources, 205–206 systems framework, 205–206 third-party insurers and payers, 189 trends and directions, 192–193, 192f Healthcare Information and Management Systems Society (HIMSS), 439, 444, 445, 476 healthcare information exchange and interoperability (HIEI), 455 healthcare organizations (HCOs), 477, 478 healthcare outcomes, measurement, management and quality improvement, 341t healthcare policy, 312–313 and education, 259–261 and ethics, 255–256 involvement of, 261–262 NPA, 254–255 nursing and policy making, history of, 239–240 nursing workforce development, 251–253

overview of, 237–239 policy agenda, 240–241 coalition building, 244–250 considerations for, 240b grassroots lobbying, 244–250 healthcare reform, 250–251 legislative process, 241–242 professional organizations, 244–250 regulation, process of, 242–244 and practice, 259–261 reimbursement, 253–254 and research, 257–259 scope of practice, 254–255 healthcare reform, 88, 144, 250–251, 271 ACO in, 272–273 alternative payment models, 271–272 defined, 183 insurance and, 183–184 population health, 273 value-based care, 271–272 VBP in, 273–274 HealthGrades, 306 Healthy People 2020, 92f, 95, 95f, 683, 701f, 701t achievement of, 703–704 measurement of, 205 healthy people initiatives, 700–701 healthy workplace, 403–404 Henry Street Settlement, 91 herbal therapy, 120–121 heredity as determinant of health, 685 hermeneutic study, 604–605 HIE. See health information exchanges HIEI. See healthcare information exchange and interoperability high-level functioning teams, 156 high-risk patient, 732 high technology in healthcare delivery, 191 high-touch vs. high-tech care, 501–502 highly active antiretroviral therapy (HAART), 774 HIMSS. See Healthcare Information and Management Systems Society HIPAA. See Health Insurance Portability and Accountability Act Hispanic Americans, 742f, 743t, 744f, 745–751, 745f historical budget, 274 ZBB vs., 275t historical research, 603–604 historicism, 529 HIT. See health informatics technology HITECH. See Health Information Technology for Economic and Clinical Health Act HIV/AIDS, 769–775 in children, 770–771 cost of, 773–774, 774f

discrimination and, 773 overview, 769–770, 770f, 771t provider training and, 773 public health concerns, 772–773 research and, 772 in rural communities, 770 U.S. health care system and, 774–775 in women, 772 HIV/AIDS services, 733 HMOs. See health maintenance organizations HN-BC. See Holistic Nurse Board Certification Hofstede’s cultural dimensions theory, 715 holism, 699 holistic health. See integrative health Holistic Nurse Board Certification (HN-BC), 115 holistic nursing caring model, 44 home health, 384 Homeland Security Act of 2002, 682 Homeland Security Department (DHS), 682 Homeless Block Grant, Mental Health Services for, 764 Homeless Chronically Mentally Ill Veterans Program, 764 homeless populations, 762–765 barriers to health care, 764–765 homeopathy, 117 homophobia, 772 hospital within community context, 317–318 costs for, 318–319 EMR system in, 318 operations and closure, 313–314 and patients, benefits, 319–320 privileging, 915 Hospital Consumer Assessment of Healthcare Providers and Systems Survey (HCAHPS), 555 Hospitals CMS in, 383–384, 384b Hospitals and Care Systems of the Future (AHA), 374 HPSAs. See Health Professional Shortage Areas HRSA. See Health Resources and Services Administration human resources, 205 hybrid health records, 126 hydrotherapy, 121 hypnosis, 120 hypnotherapy, 120

I IADLs. See instrumental activities of daily living

iatrogenic illnesses, 677 ICSI. See Institute for Clinical Systems Integration IDEA. See Individuals with Disabilities Education Act of 1975 identity, basic knowledge of, 713 identity loss phase of role transition, 902 IDS. See integrated delivery system IHS. See Indian Health Service immunizations, 756 implicit consent, 788–789 implicit quality standards, 548 INA. See Illinois Nurses Association incident reports, 157 incorporation phase of role transition, 903 independent practice competencies, 28–29 Index of Medical Underservice, 761 Indian Health Care Improvement Act of 1976, 752 Indian Health Service (IHS), 753 Indian talking stick, 155 indirect processes of care, 106 Individuals with Disabilities Education Act of 1975 (IDEA), 756 informal mentorship relationships, 920 informatics, 475–505 certification, 483 core competency, 476–477 definitions and descriptions, 480–482 documentation, 485–487 education and research, 484–485 health IT, 502 high-touch vs. high-tech care, 501–502 HIPAA concerns, 500 impact on care, 483–484 Internet, 496 medical technology, 498–500 nursing leadership in, 502 nursing standards, 482 overview, 475, 476f technology standardization, 488–489 telehealth, 498–499 types and methods, 491–498 Information Age bar coding, 399 online clinical documentation systems, 398–399 portable electronic devices, 399 information literacy, 481 information literacy competencies, 27–28 information systems, 481 information technology (IT) CMS rules, 487 cost-benefit analysis of, 444 in doctoral education, 60

HITECH Act, 438–439 research methods and, 525 informed consent, 788–796 conscience and personal integrity, 791–793 culturally based communication issues, 794–795 difficult patients, 795 ethical problems of, 790–791 types, 788–790 informing process, influences on, 795–796 inpatient services, 206 inspiration, leadership, 139–140 Institute for Clinical Systems Integration (ICSI), 156 Institute of Medicine (IOM), 15, 23, 30, 729, 730 ARRA, 554 core competency, 476–477 health outcomes improvement, 147 healthcare policy in, 237 licensing and certification, 231 negative quality/patient safety, 380b public health, 679 quality of healthcare, 547 report, 56–57 role of nursing, 901 transformational leadership, 136, 158 Institute of Medicine’s (IOM), report, 830 instituting state regulations, 220–221 institutional review board (IRB), 543 instrumental activities of daily living (IADLs) scale, 689, 769 insurance, 181–182 and healthcare reform, 183–184 insurance companies, 97 integrated delivery system (IDS), 188 integrated information systems, development of, 375 integrative healing modalities, types of, 117–121 integrative health, and medicine, 672, 672f, 673, 700f integrative health care, 117 websites for, 117t integrative practitioner, 114 biologically based practices, 120–121 energy medicine, 121 integrative healing modalities, types of, 117–121 manipulative modalities, 118–119 mind–body medicine, 119–120 nurses as integrative practitioners, 114–117 whole medical systems, 117 interactive imagery, 120 intercultural communication, 713 interdisciplinary collaboration, 166–168, 168t interface terminologies, 489–490 International Classification for Nursing Practice, 481

International Council of Nurses (ICN), 35, 782 Internet, 496 interoperability of EHRs systems, 452 interpersonal relationships, leadership, 140 interpretation of quantitative research, 608 interpretive approaches, 531 interprofessional collaboration advantages of, 149 barriers to, 150–152 care improvement efforts in, 147–148 communication, 159–161, 161b conflict resolution, 161–162 description of, 148 drivers of, 152–157 emotional intelligence, 162–163 health outcomes, 147 leadership, 158 models, 164–168 necessity for, 163–164 of nurse practitioners, physician assistants and doctors of medicine, 149–150 overview, 143–147 team development, 148–150 Interprofessional collaboration for improving patient and population health outcomes, 116 interprofessional education (IPE), 329 interprofessional team members, 168t patient and family as, 164 interruptions, 379, 893–894 interstate mobility, 231 interventions evidence-based designs, 627t–629t outcomes and, 618t for risk factors, 677 interviewing, 917–919 intravenous (IV) pumps, 124 IOM. See Institute of Medicine Iowa model of evidence-based practice, 613, 615f Israel, healthcare system, 201–202 IV pumps. See intravenous pumps

J Japan, healthcare system, 202–203 jargon, use of, 152, 160 Jin shin jyutsu, 119 Joanna Briggs Institute, 632 Johari window, 155 Johns Hopkins Nursing EBP Model, 566, 613

The Joint Commission (TJC) data collections on outcomes, 621 interprofessional collaborations, 146 medical records documentation, 487 regulatory role, 195 research/outcome analysis, 634 journal club, 639–640, 639t journal publications, 636 journaling and narratives, 904, 920–921 journals reviews and rewriting, 662 strategies of, 652–653 website and guidelines, 652 justice market, 695–697, 696t–697t social, 696t–697t, 697–698 in U.S. Health Delivery System, 698 Justice Department, 229

K Kaiser Family Foundation, 144 kaizen, 355 Keeping Patients Safe: Transforming the Work Environment of Nurses (IOM), 87 Kitson model (research utilization), 613 knowledge, in nursing, 515–517 Kotter’s theory of change, 86

L Laboratory Response Network (LRN), 683 language standardization, 152, 363–364 language/communication of listening, 730–731 of trust, 731–733 law of similars, 117 leadership, 451 APN in barriers of, 834 cognitive processes, 835 expectations, 831–832 goals of nursing, 828–829 levels of, 834 macro/health-policy level, 835–836

meso level, 836 micro level, 836–837 models of, 832–834 characteristics of, 827–828 competencies, 27 complexity, 158 definition of, 826–827 dual loyalties, 837–838 case, 837–838 emancipatory, 832–834 empowerment, 832 model for APN, 137–141, 137f models, exploring, 86 pillars of, 139–140 skills, 139b strong, 157–158 style, 86–88 theories, evolution of, 136–137 transactional, 827 transformational, 158, 827 vs. management, 158 leading health indicators (LHI), 703–704 Lean Six Sigma (LSS), 355 LEAN thinking flowcharts and diagrams, 361–363, 362f FMEA in, 359–360 overview of, 355 PD in, 356–359 RCA in, 360–361 RCIM in, 355–356 Leapfrog Group, 399 learning management system (LMS), 81 legal risks, 190–191 legislation bill movement, 241f health policy agenda, process of, 241–242 process of, 241–242 regulations vs., 212–213 Legislative issues, 107 Leininger’s theory, 712–713 length of stay (LOS), 275–276, 276b LEPs. See local emphasis programs Lewin’s change theory, 126 Lewin’s force field analysis model, 163 LIAASE, 734f Library of Congress, 603 licensing, 213–214, 216–217 lifelong learning, 922 lifestyle as determinant of health, 685 LISTSERV, 872–873

litigation risks, 190–191 Logical Observation Identifiers Names and Codes, 490 Logical Observations Indexes Names and Codes (LOINC), 424, 425, 427 logical positivism, 520, 522–529, 528, 531 LOINC. See Logical Observations Indexes Names and Codes long-term care, 384 longitudinal research design, 607 Loversidge’s evidence-informed health policy model, 222, 222t LRN. See Laboratory Response Network LSC. See Legislative Services Commission lymphatic therapy, 119

M Macroeconomics, 304t and nursing, 228–230 Magnet Recognition Program, 399–400, 621 magnetic therapy, 121 malpractice lawsuits, 190 managed care, 307–309 managed care organizations (MCOs), 268–270 described, 181–183 mental health and, 767 managed care systems, 767 defined, 184 role, 184–185 managements and managers, leadership vs., 157 outcomes of and leaders and partners, 336–342, 337f, 339t, 340f, 341t QI in, 348 resources, advantage of, 342 managing personal resources overview, 887–888 reflective practice, 899–900 resilience, 899–900 stress management, 896–897, 898t time management, 888–896. See also time management manipulative modalities, 118–119 manuscripts citing sources, 659–661 grammar and punctuation, 659, 660t–661t organization of, 654–655 proofreading and obtaining feedback, 661 section, paragraph and sentence structure, 655–657, 656t–657t style and language, 657–659, 658b market

expansion of, 194 free market system, 187–189, 187f market justice, 695–697, 696t–697t limitations of, 698–699 marketplace assessments, 908 markup, 242 massage therapy, 119 Master of Science in Nursing (MSN) degree, 107 master’s entry option program, 25 MAT. See Microsystem Assessment Tool maternal mortality rates, 748f, 749t McKinney Homeless Assistance Act of 1987, 764 MDGs. See Millennium Development Goals meaningful use criteria, 124 measurement instruments in research studies, 607 measurements, outcomes, 336 flowcharts and diagrams, 361–363, 362f key players and driving forces, 333–336 and leaders and partners, 336–342, 337f, 339t, 340f, 341t nursing-sensitive quality loop, 336f project of interest, 342–348 resources, advantage of, 342 media communications, 639 Medicaid, 545 and Medicare defined, 183 EPSDT program, 756 waiver program, 774 in public health insurance, 270 Medicaid reimbursement for midwifery care, 13 medical care, access to, 686 medical devices, 500 medical model, 671, 673 Medical Outcomes Study, 547 medical records, 56, 485–487, 492–493 medical-related errors, 56 medical sociologists, 671 Medically Underserved Areas (MUAs), 760, 761 Medicare, 545 and Medicaid, adoption incentive programs, 417f–418f Part B fee schedule, 17 Medicare Access and CHIP Reauthorization Act (MACRA), 557 medication errors, 377–378, 549–550 meditation, 120 MEDLINE database, 569, 621 Mental Capacity Act (2005), 788 mental health, 690–691 barriers to, 766 insured and, 766–767 managed care and, 767

measurement of, 690–691 organizations, 766t services, 765–768, 766t uninsured and, 766 Mental Health Services Centers, 631 Mental Health Services for the Homeless Block Grant program, 764 mentor, 879 mentor–mentee relationship, 879–883 mentorship and professional development, 879–885 career development, 920 coaching vs., 884–885 models of, 880, 880f networking vs., 884 overview, 879–880 preceptorship vs., 883–884 professional development plan, 914 stages of, 880–883, 882t as support system, 883–885 metaparadigm, 527 metatheory, 510 methicillin-resistant Staphylococcus aureus (MRSA), 378, 422, 445 microeconomic theory, 307 microeconomics, 304t middle-range (midrange) theories, 510 midwifery care, Medicaid reimbursement for, 17 midwifery practice, 17 migrant workers, 761–762 Millennium Development Goals (MDGs), 95 Millennium Project, 95 mind–body medicine, 119–120 Minnesota Health Information Exchange, 453 missed care, 379 monitoring adverse events, 491 competencies, 220 remote telemetry, 498–499 state regulations, 220–221, 223exh moral distress, 792 moral hazard, defined, 189 movement therapy, 119 MQSA. See Mammography Quality Standards Act of 1987 and 1992 MSD. See musculoskeletal disorders MSN degree. See Master of Science in Nursing degree MUAs. See Medically Underserved Areas multiple payers in healthcare delivery, 189–190 multiprofessional terminologies, 490 multistate regulation, 231 multitasking, 894 music therapy, 120 mutual recognition model of nursing regulation, 231

N NACNS. See National Association of Clinical Nurse Specialists NAFTA. See North American Free Trade Agreement of 1993 NANDHA. See North American Nursing Diagnosis Association nanotechnology, 498 NAPBC. See National Action Plan on Breast Cancer National Academy of Sciences, 58 National Action Plan on Breast Cancer (NAPBC), 758 National Association of Clinical Nurse Specialists (NACNS), 8 National Biosurveillance Strategy for Human Health, 683 National Cancer Institute, 37 National Center for Complementary and Alternative Medicine (NCCAM), 117 National Center for Health Services Research and Health Care Technology, 545 National Center for Health Statistics (NCHS), 687, 688t, 751 National Center on Minority Health and Health Disparities, 635 National Council of State Boards of Nursing (NCSBN), 6, 215, 216, 218, 219, 245, 858 regulation of APRN, 215 National Database of Nursing Quality Indicators (NDNQI®), 286, 333–334, 400 National Database of Nursing Quality Indicators, 633 National Diabetes Prevention Program, 678 National Disaster Medical System (NDMS), 684 National Guideline Clearinghouse, 569 national health insurance (NHI) model, 195 National Health Security Strategy (NHSS), 683 National Health Service Corps, 760 national health system (NHS) model, 195 National Institute for Child Health and Development (NICHD), 631 National Institute of Nursing Research (NINR), 511 National Institute of Standards and Technology (NIST), 439, 442 National Institutes of Health (NIH), 545 biomedical aspects of disease management, 634 data sets, 631 scientific publications, 557 women’s health issues, 759 National League for Nursing (NLN), 8, 10, 77, 215 role of nurse educator, 77–78 National Library of Medicine (NLM), 424 National Mental Health Act, 8 National Organization of Nurse Practitioner Faculties (NONPF), 14, 26, 632 practice doctorate entry-level competencies, 63 Practice Doctorate Task Force, 58 research and evidence for practice, 632 scholarship and, 597 national organizational framework, 93–94

National Practitioner Data Bank (NPDB), 340, 340f National Public Health Performance Standards Program, 94 National Research Council of the National Academies, 102 National Safety Council, 897 National Scorecard on U.S. Health System Performance, 373 Native American, 718 NCCAM. See National Center for Complementary and Alternative Medicine NCHS. See National Center for Health Statistics NCSBN. See National Council of State Boards of Nursing NDMS. See National Disaster Medical System need, defined for healthcare, 189 NEP. See national emphasis programs net present value (NPV) net present value (NPV), 319 networking, 884, 906–907 neurolinguistic programming, 120 neuromuscular therapy, 119 New faculty programs (NFPs), 80 new nurse educator mentoring programs, 80–81 New York University, 53 NFP. See not-for-profit NHI model. See national health insurance model NHS model. See national health system model NHSS. See National Health Security Strategy NIC. See Nursing Intervention Classification NICE. See National Institute for Clinical Excellence NICHD. See National Institute for Child Health and Development NINR. See National Institute of Nursing Research NIST. See National Institute of Standards and Technology NLC model. See nurse licensure compact model NLN. See National League for Nursing NNT. See number needed to treat NOC. See Nursing Outcome Classification nomenclature, defined, 481 nonexperimental research design, 607 NONPF. See National Organization of Nurse Practitioner Faculties NONPF Lifetime Achievement Award, 109 nonrandom samples, 607 nonsalary expenses, 276 normative ethics, 787 North American Nursing Diagnosis Association (NANDA), 489 nosocomial infection. See hospital-acquired infection (HAI) not-for-profit (NFP), 310 NPA. See nurse practice acts NPACE. See Nurse Practitioner Associates for Continuing Education NPs. See nurse practitioners NPSF. See National Patient Safety Foundation NQF. See National Quality Forum NSPOs. See Nurse-sensitive patient outcomes number needed to treat (NNT), 582 statistical tool, 626

nurse administrator, 84 change theory, 84–86 collaboration, 88–89 educational requirements for, 19t evidence-based management practices, 88 leadership style, 86–88 nurse administrators, 19–20 nurse anesthetists (NAs), 18–19, 335 nurse call systems, 496 nurse educator, 2, 8–10, 77–79 faculty development, 79–80 in GTA, 80 new nurse educator mentoring programs, 80–81 nursing education practicum, 80 online learning of, 81–82 peer review, critical aspects of, 82 supply and demand, 10–15 nurse entrepreneur business and practice management, 103–104 current and future trends, 108–109 definitions, 100–101 entrepreneurship and DNP degree, relationship of, 102–103 healthcare policy and legislative issues, 107 organizational systems leadership and collaboration, 105–106 practice start-up, closure and credentialing, 104–105 relevance and opportunities of, 107–108 nurse informaticist, 123–124 certification, 125 curriculum/preparation, 125 DNP-prepared informaticist, future of, 127 hybrid health records, 126 project management, 125–126 theoretical supports for nursing informatics, 126 nurse licensure compact (NLC) model, 231 nurse-midwifery programs, 17 nurse-midwifery school, 17 nurse-midwives, 17–18 nurse practice acts (NPA), 212, 215, 219, 254–255 Nurse Practitioner Associates for Continuing Education (NPACE), 633 Nurse Practitioner Certification Examination and Practice Preparation (Fitzgerald), 109 nurse practitionering concept, 38 nurse practitioners (NPs), 15–17, 34, 782 AACN endorsement of, 30 approach to patient care, 32–37 authentic listening in, 39–40 case study, 32–34 core competencies, 26–27 DNP program, 30 education and title clarification, 25–26 empathy, 40

negotiating, 40–41 nursing theories for, 35–37 practice, model of, 43, 43f program, 115 roles, 24–26, 37–39, 564 use EBP, 564 nurse-sensitive patient outcomes (NSPOs), 619 nurses education, 517–519 shortage of, 760 supply, demand of, 11t–14t training, 517 nursing as discipline, 517 language standardization, 363–364 theory movement in, 523–524 nursing baccalaureate programs, 19 nursing budget benefit time, determination of, 281, 282b close observation, demand for, 284–285, 285b FTE calculation in, 277, 281b, 281t incentives and differentials of, 283 justification, staffing patterns, 285–286 predictive analytics, 284 skill mix, 282–283 staffing patterns and ratios of, 281–282, 282b supplemental staff of, 283–284 value-based environment in, 287 variance reporting, 286–287 Nursing Care Report Card for Acute Care, The (ANA), 334, 336 nursing curriculum advanced practice nursing roles and. See advanced practice nursing (APN) nursing education careers in, 14 environment, 96 process, 101 nursing education practicum, 80 nursing faculty shortage, 14, 107 nursing hours per patient day (NHPPD), 281, 281t nursing informatics (NI), 482 theoretical supports for, 126 Nursing Intervention Classification (NIC), 489 nursing knowledge, 521 development, future, 537–538 nursing leadership, in informatics, 502 Nursing Management Minimum Data Set, 489 nursing minimum data set, 489 Nursing Outcome Classification (NOC), 489 nursing paradigm, search for, 527–528 nursing-related doctoral program, 53

nursing science definition, 622 development activities, 523 epistemologies in, 422b historicism to, 528 emergence of, 422–423 emerging trends in, 534–537 nursing-sensitive quality indicators for acute care, 335b nursing shortage, feasibility and the sporadic, 314–315 nursing theories, 35–37, 510 nursing workforce, 10 nursing workforce development, 251–253 nutritional counseling, 121 nutritional deficiencies, 846

O OBRA. See Omnibus Budget Reconciliation Act of 1987 and 1990 Observational studies, 543, 544 Occupational Safety and Health Administration (OSHA), 403 occupational stress, 897, 898t OCEBM. See Oxford Centre for Evidence-Based Medicine odds ratio (OR), 612t Office of Minority Health (OMH), 730 Office of Rural Health Policy, 760 Office of Statewide Health Planning and Development (OSHPD), 311 Office of the National Coordinator for Health Information Technology (ONC), 127, 439, 477, 478, 487 Office on Women’s Health (OWH), 609, 758 Omaha System (standardized taxonomy), 489–490 Omnibus Budget Reconciliation Act of 1987 and 1990 (OBRA 87 and 90), 788 on-site mentors, 920 ONC. See Office of the National Coordinator for Health Information Technology ONC organizational structure, 418 Oncology Nursing Society, 625 online clinical documentation systems, 398–399 online learning of, nurse educator, 81–82 online support groups for patients and families, 497 operating budget, 275 opportunistic infections, 772 Optimal Use of Individualized Asthma, Action Plans in an Electronic Health Record project, 166 optimization of EHRs systems, 450, 451 Optimizing Stewardship: A Grounded Theory of Nurses as Moral Leader in the Intensive Care Unit (Breakey), 787 oral history, 603–604

order entry management, 442 order entry systems, 493 organizational assessments, 908–909 organizational change complexity science, 130–131 theories of, 130 organizational systems communication obstacles, 161 leadership and collaboration, 105–106 mission of, 195 position of, 194 OSACH. See Ontario Safety Association for Community and Healthcare OSHA. See Occupational Safety and Health Act of 1970; Occupational Safety and Health Administration OSHPD. See Office of Statewide Health Planning and Development osteopathic medicine, 118 outcomes analyzing, 629–630 behavior patterns and, 630–632 data collections on, 621–622 evidence-based, 619t evidence-based practice, 333f health improving, 147 interventions and, 518t and leaders and partners, 336–342, 337f, 339t, 340f, 341t management, 336 measurements, 336 key players and driving forces, 333–336 and leaders and partners, 336–342, 337f, 339t, 340f, 341t project of interest, 342–348 medical study, 547 overview of, 332–333 predicting, 629–630 QI in, 348 outcomes research, 553–554, 634 outpatient care, 206 OWH. See Office on Women’s Health Oxford Centre for Evidence-Based Medicine (OCEBM) levels of evidence, 575t

P Package pricing of healthcare, 189 pain care services, 19 Pandemic and All-Hazards Preparedness Act of 2006 (PAHPA), 683 pandemics health concerns, 680–682 paradigm, 527 PARIHS model for EBP, 613–614, 616f

partial access to healthcare delivery, 186–187 pathways to DNP degree, 65, 66f patient advice system, 496 compliance, 389–390 and family advisory councils, 388–389 noncompliance, 389–390 privacy, 453 satisfaction, 400–402, 553, 555–556 value, performance measurement, 402 and values, 386–388 patient care, 309–310 complexity of, 124 patient-centered care, 102, 478 Patient-Centered Outcomes and Research Institute (PCORI), 546, 553–554 patient-centered outcomes research institute, 554–555 Patient Protection and Affordable Care Act (PPACA), 15, 24, 144, 812 provisions related to nursing, 224 regulatory policy, 224 patient safety issues of, 375–377 falls, 378–379 healthcare-associated (nosocomial) infections, 378 interruptions, 379 medication errors, 377–378 missed care, 379 Patient Safety and Quality Improvement Act (PSQIA) 2005, 549 Patient Safety Network (PSNet), 549 patient safety organizations (PSOs), 549 Patient Satisfaction Questionnaire, 555 Patient Self-Determination Act (PSDA), 788, 799–800 patient support, 442 patient–physician relationship, 729 payment models, 271–272, 272b payment system for healthcare function of, 183 multiple payers, 189–190 single-payer, 189 third-party insurers and payers, 189 payor, type of, 269t PCORI. See Patient-Centered Outcomes and Research Institute PDSA. See Plan, Do, Study, Act PEBC. See Program for Evidence-Based Care peer review, critical aspects of, nurse educator, 82 peer-reviewed journals, 636 peer reviews, 547 perfectionism, 895–896 performance improvement categories of nursing errors, 394, 394b Lean and Six Sigma, 392, 392b

PDSA cycle, 391, 392b SBAR communication, 393, 393b performance improvement (PI), 622 performance measurement benchmarking, 400 BSC in, 402–403 overview of, 400 patient satisfaction, 400–402 and patient value, 402 utilization management, 403 Perioperative Nursing Data Set, 481, 490 personal assessments, 907–908 personal health improvement plan, 847t personal health management tools (PHMT), 432 personal health record (PHRs), 432, 492 personal medical and preventive health services, 756 Pert chart, 126 Pew Health Professions Commission, 228 Pew Memorial Trust, 764 Pew Task Force on Health Care Workforce Regulation, 228 PHAB. See Public Health Accreditation Board phantom providers, 189 PHE. See public health emergency phenomenological research, 604–605 philosophical congruency/coherence, 535 philosophical ideology, evaluating, 524–527 philosophical inquiry, 605 PHMT. See personal health management tools PHNs. See public health nurses PHR. See personal health record phronesis, 784 physical activity challenges, 846–847 physical health, measurement of, 687 physical therapy, 119 physician’s curing model, 44 PI. See performance improvement Picker Institute of Boston, 555 PICOT method, 568, 568f–569f Plan-Do-Check Act (PDCA) cycle, 350f FOCUS, 350–353, 351f process of, 349t quality tools and templates, 350b planning policies, 194 PMP. See Project Management Professional POES. See professional order entry system point-of-care access, 495–496 point of service plans (POS), 270 policy competencies, 28 policy-making process

and education, 259–261 and ethics, 255–256 and nursing, history of, 239–240 and practice, 259–261 and research, 257–259 political opportunity costs for nursing, 315–316 poor-quality health care, 547 population, 687 population-based community health services, 756 population-based health programs, 97, 99 population-based nursing, 91 population-based public health nursing interventions, 91 population health, 273, 442–444 integration of individual and, 699–704 outcomes, 61–62 programs, 99 population of research study, 607 population research, 543–544 portable electronic devices, 399 portfolios contextualizing, 859 development of, 910–916 electronic portfolio, 860–861 organizing, 859–860 potential risks of, 861–862 printed portfolio, 860 and profiles, 857–860 web-based portfolio, 861 positive deviance (PD), 356–359 postacute care, 384–385 poster presentations, 638 postmodern turn, 529–533 postmodernism, 530–531, 533 power balancing in healthcare delivery, 190 PPACA. See Patient Protection and Affordable Care Act PPO. See preferred provider organization PPS. See prospective payment system practice acts, 213 practice, and policy making, 259–261 Practice Doctorate Task Force, 58 practice-focused doctorate, 50–52 practice inquiry competencies, 27 practice theory, 510 Practicing Clinicians Exchange, 633 practitioners trends in delivery systems, 193 pragmatism/neopragmatism, 533–534 preceptors, 904 preceptorship. See formal mentorship relationships predictive analytics, 284 preferred provider organization (PPO), 184

premiums for insurance, cost sharing, 183 President’s Commission for the Study of Ethical Problems in Medicine, 796 preventable adverse events, 56 Prevention and Public Health Fund (PPHF), 678 preventive ethics, 791 prewriting, 650, 651b primary care, defined, 187 primary care needs, 848–852, 849b–852b primary care physicians, shortage of, 15 primary prevention, 677 A Primer in Theory Construction (Reynolds), 523 print resources for job opportunities, 906 printed portfolio, 860 privacy, 802–806 concept, 803–804 issues, 453 Right to Privacy, 803 Privacy Rule, 804 in U.S., 804–806 private health insurance, 270 private time, 894 process administrative, 442 improvement activities, 125 registration, 217 regulatory, 219–224, 223b procrastination, 895–896 product evaluation, 287–289 professional and personal development certification, 874 curriculum vitae and résumé, 862–874 portfolios of, 857–862 reflection and self-appraisal, 844–852 reflective practice, 852–857 professional discipline, 520–522 professional efficacy, 38 professional expenses, 916 professional memberships, 906 professional organizations, 244–250, 245b professional portfolios, 910 contextualizing, 859 electronic portfolio, 860–861 organizing, 859–860 potential risks of, 861–862 printed portfolio, 860 and profiles, 857–860 web-based portfolio, 861 professional self-regulation, 218 professionalism, leadership, 139 professionals in mental health, 766t, 767–768

profit motive, 309–310 The Profit Motive and Patient Care (Gray), 309 program evaluation methods, 85 project management, 125–126 Project Management Professional (PMP), 125 project of interest, 342 actual vs. desired state of practice, 342–343 crafting, outcomes project, 345–347, 346t evidence-based outcomes, 344b, 344f measure improvement of, 347–348 unit-based projects, 343b promotion of health, 677–678 prospective payment system (PPS), 303, 306 prospective research design, 607 protocols, 916 provider-induced demand, 189 providers of healthcare, 182, 773 proxy decision making, 798 types, 798 PSDA. See Patient Self-Determination Act PSOs. See patient safety organizations PSQIA. See Patient Safety and Quality Improvement Act PSROs. See Professional Standards Review Organizations psychiatrists, 768 psychological safety and communication, 157 psychologists, 768 public comment on regulations, 277 public health, 679–680 AIDS concerns, 772–773 environmental health, 680 health protection, 680 during global pandemics, 680–682 interprofessional collaboration, 148 Public Health Accreditation Board (PHAB), 94 public health emergency (PHE), 683 public health insurance, 270 CMS in, 270 expenditures in, 271 Medicaid, 271 public health nurse doctor of nursing practice- prepared public health nurse as leader, 98–99 educational preparation and credentialing, 96 evidenced-based practice in population-based public health nursing, 98 foundational principles of, 92–93 national organizational framework, 93–94 national public health performance standards program, 94 practice sites, 97 roles of advanced practice PHNs, 96–97 theoretical framework for nursing practice in, 94–96 public health nurses (PHNs)

definition, 89–90 doctor of nursing practice- prepared public health nurse as leader, 98–99 educational preparation and credentialing, 96 evidenced-based practice in population based public health nursing, 98 foundational principles of, 92–93 history of, 91–92 national organizational framework, 93–94 national public health performance standards program, 94 practice sites, 97 roles of advanced practice PHNs, 96–97 theoretical framework for nursing practice in, 94–96 public health nursing ethical principle of, 90 practice, 93 specializing in, 96 Public Health Nursing: Scope and Standards of Practice (ANA), 96 public health nursing workforce, 97 Public Health Security and Bioterrorism Response Act of 2002, 682 Public Health Service (PHS) clinical guidelines development, 545 women’s health, 758 Public Health Services Act of PPACA, 145

Q QI. See quality improvement QICs. See quality improvement collaboratives QIOs. See Quality Improvement Organizations QOL. See quality of life Quad Council Competencies, 93 Quad Council of Public Health Nursing Associations, 98 quad-function model of healthcare delivery, 181 qualitative research, 601–606 quality accountability, 397–398 administrative practices, changing of, 396–397 clinical pathways and protocols, 395–396 employee issues, 403–405 evidence-based practice, 395 Information Age, 398–399 overview of, 390–391 performance improvement, 391–395, 392b–394b performance measurement, 400–403, 401t recognition of value, 399–400 quality assurance model, 311–312 quality competencies, 27 quality improvement (QI)

Institute of Medicine and, 547–549 LEAN thinking, 355–363 measurements of, 348, 349t patient-centered care and, 613, 617–620, 619t PDSA/PDCA, 349–353, 349t, 350f Six Sigma, 353–355 quality of healthcare. See also quality improvement (QI) healthcare delivery, 192, 192f quality of life (QOL), 673, 798 quality patient care, 311–312 quality reporting system, 385, 385b quantitative research evidence, 606–612, 606f, 609t, 610f, 612t

R Race and race relations ethnic minorities and, 742–753, 743t American Indians and Alaska Natives, 752 Asian Americans, 751–752 Black Americans, 742f, 743t, 744–745, 744f Hispanic Americans, 43t, 742f, 744f, 745–751, 745f overview, 742–744 RAND Health Insurance Experiment, 547 random samples, 607 randomized controlled trials (RCTs), 564 rapid cycle change (RCC), 355 rapid cycle improvement model (RCIM), 355–356 rapid cycle tests (RCTs), 355 rationing, 698 RCTs. See randomized controlled trials recognition, 217 recognition programs, advanced practice nurses, 922 references, employment, 914 reflective journaling and narratives, 904, 920–921 reflective learning, 163–164 reflective practice, 162, 899–900 benefits of, 854 nurturing mindfulness, 855t–856t tools, 852 typology of, 853t Regional Health Information Organizations (RHIOs), 423–424, 427 registered nurses (RNs), 115, 156, 218–219 big data in, 469–472 implications for, 469 registration process, 217 regulation and managed care, 307–309

multistate, 231 process of, 242–244 regulatory framework APNs and, 915 APRNs and, 216 case study, 232–234 credentialing, 216 current issues in, 229–231 definitions and purpose of, 213–214 emergency, 225 federal process for, 224–229, 226b, 226f history of, 214–215 information sources of, 225–227 legislation vs., 212–213 locating information, 225–227 overview, 211–212 public comments on, 227 reimbursements, 230 scope of practice, 230 self-awareness, 162 self-regulation, 218 state process, 219–224 strengths and weaknesses of, 227–228 regulatory response home health, 384 hospitals, 383–384, 384b long-term care, 384 postacute care, 384–385 quality reporting system, 385, 385b restricting/eliminating reimbursement, 383 Reiki, 121 reimbursements APRN, 230, 253–254 guidelines, 915 relative risk (RR) statistical tool, 626 relative risk ratio (RR), 612t relative risk reduction (RRR) calculations, 626 reliability of studies, 610–611 reminder systems, computer-based, 495 remote telemetry monitoring, 498–499 reporting and population health management, 442–444 REPs. See regional emphasis programs research, 541–558 Agency for Health Care Policy and Research (AHCPR), 545–546 clinical, 542–543 conflicts of interest in, 556–557 epidemiology, 543–544 ethics in, 556 evidence-based medicine, 550–553

future challenges, 557–558 grant programs, 635 health policy, 547 on health services, 544–545 on HIV/AIDS, 772 informatics usage in, 484–485 medical errors, 549–550 mentorships and, 920 on outcomes, 553–554, 634 overview, 541–542 on patient satisfaction, 553, 555 and policy making, 257–259 presentations, 637, 637t quality improvement, 547–549 translating into practice, 600–601 types, 542, 542f research-focused doctorate, 50–52 resilience, 899–900 resources in health services, 205–206 responsibility and decision making, 157 results management of electronic records, 442 résumé designing, 865–868, 867t disseminating, 868–869 résumés, 911–913, 912f–913f retrospective analysis, 360 retrospective research design, 607 return on investment (ROI) analysis, 320 revenue budget, 275–276 RHCA. See Rural Health Clinics Act RHIOs. See Regional Health Information Organizations Right to Privacy, limitations on, 803 risk-adjustment process, 311–312 Risk and Responsibility in Providing Nursing Care (ANA), 793 risk factors acute, subacute, and chronic conditions, 674–676 assessments, 626 behavioral, 674, 675t, 685 behavioral risk factors, 184 disease management, 673–675 interventions for, 677 Robert Wood Johnson Foundation (RWJF), 15, 57 community health centers, 764 educational programs, 165 future of nursing report, 228 robotics, 499 ROI. See return on investment role transition for DNPs, 65–72 job market entrance, 905, 916–919

overview, 902–903 phases of, 902–903 professional development, 914, 920 strategies for, 902–903 root cause analysis (RCA), 360–361 Rosswurm and Larrabee model (research utilization), 613 RR statistical tool. See relative risk statistical tool RRR calculations. See relative risk reduction calculations rulemaking, 225, 226f evidence vs stakeholder interests in, 234 rural health care, 759–761, 770 Rural Health Clinics Act (RHCA), 760, 762 Rush University, 54 RWJF. See Robert Wood Johnson Foundation Ryan White Comprehensive AIDS Resources Emergency (CARE) Act, 774

S Safety National Safety Council, 897 psychological, 157 Safety and Quality Initiative (ANA), 334 safety concerns, 290–291 safety-net hospitals, 316–317 salary and income levels, correlation study of, 533t, 629, 630t, 631f salary expenses, 276 salary negotiations, 919 Salvation Army, 765 SAMHSA. See Substance Abuse and Mental Health Services Administration sample in research studies, 607 SARS. See severe acute respiratory syndrome SBTPE. See State Board Test Pool Examination scheduling systems, 893 scholarly work, 916 science and knowledge, 515–517 science and technology innovations in, 191 U.S. healthcare characteristic, 191, 693 scientific foundation competencies, 27 Scientific underpinnings for practice, 59, 115 scope of practice, 230, 254–255, 915 SDLC. See system development life cycle secondary prevention, 677 security protections, 481 selecting mentors, 880–882, 882t selection bias, 608 self-appraisal

nurture connections, 852 overview of, 844–845 self-care practices, 845–852 self-awareness, 713 self-awareness and regulation, 162 self-care needs, 847–848 self-care practices diet and physical activity challenges, 846–847 primary care needs, 848–852, 849b–852b self-care needs, 847–848 stress management, 846 tobacco cessation, 845–846 self-presentation, 160 self-regulation, 218 sensitivity and specificity measures, 626 severe acute respiratory syndrome (SARS), 680, 699 shared decision making (SDM), 587 shared decision making, 157 shared purpose and team development, 153–154 SHI model. See socialized health insurance model Shiatsu, 119 shortages of nurses, 760 SHS. See student health services sickness funds, 195 Sigma Theta Tau International, 596, 633 Singapore, healthcare system, 203–204 single-payer systems, 189 SIPP. See Survey of Income and Program Participation situational leadership, 158 Six Sigma Belt designation in, 354t methodology of, 353 smartphones, 495 smoking, cigarette, 750f SNL. See standardized nursing language SNOMED. See Systematic Nomenclature of Medicine SNOMED Clinical Terms (SNOMEDCT), 425 SNOMEDCT. See SNOMED Clinical Terms social determinants of health, 686, 687f social health, measurement of, 691 social justice, 696t–697t, 697–698 concept of, 90 social media, 783, 806–816, 917 clinic/organization use, 808 definition of, 807 electronic health records, 812–816 ethical issues, 808–811 health care, use of, 807 patient uses for, 807 provider uses of, 808

social networking, 807 social organization, 714 Social Security Act, 756 social theory, 601–602 social well-being, 672 socialization. See enculturation socialized health insurance (SHI) model, 195 Society for Academic Emergency Medicine, 671 socioeconomic status (SES), 685 South Carolina University, 54 Southern Illinois University School of Medicine, 555 space, personal, 714 special population groups, 739–775 children, 754–756, 755t, 770–771 chronically ill and disabled, 769 ethnic minorities, 742–753. See also race and race relations framework to study, 740–742, 741exh HIV/AIDS, 769–770, 770f, 771t, 774f homeless, 762–765 mental health, 765–768, 766t overview, 739–740 rural health, 759–761 uninsured, 753–754, 766 women, 756–759, 757f, 759f specialty-focused competencies, 62–63 spiritual dimension of health, 672–673 spiritual health measurement of, 691 staff engagement, opportunities for, 289 staffing ratios debate, 312–313 Stage 7 Award (HIMSS), 444 Stakeholders, in healthcare outcomes, 337f standardized language, 152 standardized nursing language (SNL), 37 standardized terminology, EHRs in, 448–449, 449b State Board Test Pool Examination (SBTPE), 215 state boards of health, 621 state boards of nursing, 214, 215, 218, 220 state regulatory process, 219–224 statistical tools, 626 Stetler/Marram model (research utilization), 613 Stewart Model of Nurse Practitionering, 1, 43, 44f storytelling technique, 910 stratified samples, 607 stress management, 120, 846, 897–899, 898t student health services (SHS), 167 subacute conditions, 674–676 subjective experience, 391 submission process, 661 Substance Abuse and Mental Health Services Administration (SAMHSA), 758

Supplemental Food Program for Women, Infants, and Children (WIC), 756 Supplemental Security Income, 775 supplier-induced demand, 189 Supremacy Clause, 225 surge capacity, 683 Survey of Income and Program Participation (SIPP), 769 survival curves, 626 system development life cycle (SDLC), 125 system outcomes, 206 Systematic Nomenclature of Medicine (SNOMED), 425 systematic review, 546 Systematized Nomenclature of Medicine-Clinical Terms, 481, 490 systems framework, 205–206 systems thinking, 59

T Tablets, 495 Tai chi (chuan), 120 talking stick, 155 task assessment, 893, 893f Task Force on Doctoral Preparation of Nurse Anesthetists, 64–65 tasks, 893, 893f Teachers College, Columbia University, 53 team charter, 133b team development, 148–150 high level functioning, 156 interprofessional, 145, 146 members and reciprocal trust, 154–155 overview, 148–149 recognition and value of members, 155–156 responsibility and decision making, 157 roles and responsibilities, 156 shared purpose, 153–154 successful, 152–153 work culture, 156–157 technical excellence, 391 technology competencies, 27–28 Technology Informatics Guiding Education Reform (TIGER), 455 technology, U.S. healthcare characteristic, 191, 695 telehealth/telemedicine, 225 telephone advice, 496 terminology standards, 488, 489 tertiary prevention, 677 theft concerns, 290, 290b theoretical framework for nursing practice in public health nurse, 94–96 theories of reasoned action, 631

therapeutic interventions, 677 therapeutic touch, 121 third-party insurers and payers, 189 third-party payors, 268, 270t MCOs in, 268–270 private health insurance in, 270 public health insurance in, 270–271 “3 Ps”, 26 TIGER. See Technology Informatics Guiding Education Reform time, 714–715 time management assessment tools, 889–892, 890t–891t benefits of, 888–889 communications management, 896 consequence of poor management, 889 managing, 896 phone calls, 896 strategies, 892, 893f Title V, Social Security Act, 756 TJC. See The Joint Commission To Err Is Human (IOM), 124, 312–313, 326, 364 tobacco cessation, 845–846 TQM. See total quality management trade-offs, cost-quality, 311 trade shows, 288 explore devices and products in, 288 training, nurses, 517 transactional leadership, 827 transactional leadership style, developing, 86 transformational leaders, 137–138 transformational leadership, 136, 158, 827 foundation, 137–138 transformational leadership style, developing, 86 transitional role evolution phase, 902–903 translational modes, 632 transparency, 801–802 TRIAD. See Translating Research Into Action for Diabetes study trigger point therapy, 119 trust, foundation for leadership, 138 truth, evaluating theory, 525

U UAP. See unlicensed assistive personnel UMLS. See Unified Medical Language System Unearthing the Evidence contest, 344f Unified Medical Language System (UMLS), 425

uninsured Americans healthcare delivery system and, 184 special populations and, 754–755, 766 unit-based projects, 343b United Kingdom, healthcare system, 200–201 United States Preventative Services Task Force (USPSTF) grading system, 584, 585, 585t universal access, 187 universal coverage, 187, 201 University of Colorado, 54, 604, 635 University of Kentucky, 55 University of Minnesota, 122 unlicensed assistive personnel (UAP), 230–231 UpToDate grading system, for clinical practice, 586t–587t U.S. Bureau of Labor Statistics, 19 U.S. Department of Health and Human Services (USDHHS), 477, 478, 669, 676, 683 U.S. Department of Health and Human Services Division of Nursing, 96 U.S. Health Delivery System, justice in, 698 U.S. healthcare system healthcare reform in, 271–274 third-party payors in, 268–271, 270t U.S. life expectancy, birth, 688t USPSTF grading system. See United States Preventative Services Task Force grading system utilization management, 403 utilization of health measurements, 691–692 crude measurement, 692 institutions, 692 specific targeted population, 692 utilization of health services, 184

V vaccinations, 755t validity of studies, 610 value added, defined, 150 value analysis, 289 value-based care, 271–272 value-based purchasing (VBP), 273–274 value, recognition of, 399–400 variance reporting, 286–287 vendor selection of EHRs systems, 450 veracity, 801–802 verbal consent, 789–790 Veterans Administration (VA), 224 health information system, 429 Veterans Affairs Department, 764 Violence Against Women Act of 1994, 758 Virginia Henderson’s Need Theory, components of, 35, 36t

virtual appointments, 497 virtual teams, 154 virtues, 783 of nursing, 786–787 vision for team purpose, 153 Visiting Nurse Service, 91 visual tools flowcharts and diagrams, 361–363, 362f voice mail and texting, 496 voice of agency, 159 vulnerability framework, 740–742, 741exh

W Wearable computing, 498 web-based portfolio, 861 web resources job searches, 906, 917 listservs, 921 support groups, 497 Wennberg studies, 547 WHO. See World Health Organization whole medical systems WIC. See Women, Infants, and Children (WIC) wisdom, defined, 482 women communication differences, 161 gender bias in research, 608–609, 609t health care issues, 756–759, 757f, 759f, 772 and U.S. health care system, 758–759 Women, Infants, and Children (WIC), 756 Women’s Health Initiative, 758 workforce management issues, 379–381, 381b World Health Organization (WHO), 671, 672, 686, 687f, 693 writing for publication authorship negotiation, 653–654 journal selection, 651–653 manuscripts, 654–661 prewriting, 650 submission, 661–662 topic selection, 650–651 written consent, 790

Y

Yoga therapy, 120

Z Zero-based budgeting (ZBB), 274 historical budget vs., 275t

The antecedents are nurse practitioners and patients. The consequences listed are benefits to patients such as caring provider and trusting relationship; NPs such as autonomy, and healthcare system that includes more healthcare providers. Attributes listed are caring, humanistic approach, educating, coaching, provider of health and medical care, and professionally engaged. Empirical referents mentioned for the attribute humanistic approach is quantitative data such as measurements of nursing and medical tasks. Empirical referents mentioned for the attribute provider of health and medical care is qualitative data such as focused interviews with NPs on interactions with patients and with patients regarding receiving care from their NPs. Back to Figure The horizontal axis shows years ranging from 2005 to 2014 in equal intervals of 1 year; the vertical axis shows percentage of number of births ranging from 0 to 14 in equal intervals of 2 percent. Data from the graph in the format, year, percentage of US births, percentage of vaginal births are as follows: 2005, 7.5, 10.9; 2006, 7.5, 11; 2007, 7.5, 11; 2008, 7.7, 11.2; 2009, 7.8, 11.6; 2010, 7.9, 11.8; 2011, 7.9, 11.9; 2012, 8, 8.9; 2013, 8.1, 12.1; 2014, 8.5, 12.3. Back to Figure The antecedents are nurse practitioners and patients. The consequences listed are benefits to patients such as caring provider and trusting relationship; NPs such as autonomy, and

healthcare system that includes more healthcare providers. Attributes listed are caring, humanistic approach, educating, coaching, provider of health and medical care, and professionally engaged. Empirical referents mentioned for the attribute humanistic approach is quantitative data such as measurements of nursing and medical tasks. Empirical referents mentioned for the attribute provider of health and medical care is qualitative data such as focused interviews with NPs on interactions with patients and with patients regarding receiving care from their NPs. Back to Figure The three pathways are as follows: Pathway 1: Master’s degree with nursing specialization, Nurse practitioner, Nurse–midwife, Clinical nurse specialist, Nurse anesthetist, Public health and nursing administration to DNP degree; Pathway 2: Master’s degree as CNL to Additional specialization component to DNP degree; Pathway 3: BSN degree to Additional specialization component to DNP degree. Back to Figure The labels are as follows from circle 1 to 5: circle 1: innate, individual traits: age, sex, race, and biological holders; circle 2: individual behavior across life course; circle 3: social, family, and community networks; circle 4: living and working conditions; circle 5: broad social, economic, cultural, health, and environmental conditions and policies at the global, national, state, and local levels. The illustration also lists the interventions and outcomes of the determinants of health. The

interventions are policies, programs, and information. The outcomes are behavioral outcomes, specific risk factors, diseases, and conditions, injuries, well-being and health-related quality of life, and health equity. Outcomes lead to the interventions through assessment, monitoring, evaluation, and dissemination. Back to Figure The statements are as follows: Vision: A society in which all people live long, healthy lives; Mission: To improve health through strengthening policy and practice, Healthy people will: Identify nationwide health improvement priorities; Increase public awareness and understanding of the determinants of health, disease, and disability and the opportunities for progress; Provide measurable objectives and goals that can be used at the national, state, and local levels; Engage multiple sectors to take actions that are driven by the best available evidence and knowledge; Identify critical research and data collection needs. Back to Figure The results are timely, patient-centered, effective, efficient, equitable, and safe. Back to Figure The components involved are as follows: financing: employers, government–medicare, medicaid, and individual self-funding; insurance: insurance companies, Blue Cross or Blue Shield,

and self-insurance; delivery or providers: physicians, hospitals, nursing homes, diagnostic centers, medical equipment vendors, and community health centers; payment: insurance companies, Blue Cross or Blue Shield, and third-party claims processors. The illustration shows the integration of functions through managed care such as HMOs and PPOs through dotted lines that connect the four functions as follows: financing leads to insurance; financing also leads to payment through risk underwriting and capitation or discounts and to delivery through risk underwriting, capitation or discounts, and utilization controls. Among the four functions, delivery leads to insurance through financing, and insurance directly leads to delivery through access and through payment. Back to Figure Components for each external force are listed as follows: social values and culture: ethnic diversity, cultural diversity, and social cohesion technology; global influences: immigration, trade and travel, terrorism, and epidemics; population characteristics: demographic trends and issues, health needs, social morbidity (AIDS, drugs, homicides, injuries, auto accidents, and behaviorrelated diseases); physical environment: toxic waste, air pollutants, chemicals, sanitation, and ecological balance and global warming; technology development: biotechnology and information systems; economic conditions: general economy and competition; political climate: president and congress, interest groups, and laws and regulations. Back to Figure

The x-axis shows quantity, and the y-axis shows price. With increase in price and quantity, demand decreases and supply increases. The point of contact between the demand and supply curves where the price and quantity meet is labeled, emarket-determined equilibrium. Back to Figure The changes occurred in the directions of the trends are as follows: illness to wellness, acute care to primary care, inpatient to outpatient, individual health to community well-being, fragmented care to managed care, independent institutions to integrated systems, and service duplication to continuum services. Back to Figure The steps are as follows: Initiating event, Congress passes statute, Requiring issuance of rule, Authorizing issuance of rule, Agency develops draft proposal rule, Review or approval of draft proposal rule within agency or department, OMB or OIRA review draft of proposed rule raise to asterisk, Publication of notice of proposed rulemaking, Public comments, Publication of notice of proposed rulemaking, Review or approval of draft final rule within agency or department, OMB or OIRA review of draft final rule raise to asterisk, Publication of final rule, Rule takes effect or Legal challenge and Court determines legality of rule or Congressional review and Congress votes on disapproval resolution or Congressional review and Rule takes effect that leads to Legal challenge and Court determines legality of rule.

Back to Figure The steps involved at each stage are listed as follows: congress: drafting of legislation, bill introduction (first reading), referral to appropriate committee, and floor vote; executive: bill sent to governor or president, veto process, or bill becomes law; agency: law is sent to appropriate regulatory agency and interpretation of law into rules and regulations. Back to Figure Data from the form are as follows: header reads as follows: company XYZ capital expenditure request. The fields and the entries are as followed: Company: XYZ; Department: 1000Admin; Description: Patient ceiling lift; Request owner: John Doe; Project ID: 123; Funding owner: Nursing; Project in service month: July; Project in service owner: 2020; Project function: Medical selected from the options: Medical and Nonmedical; Status: New selected from the options: New and Replacement; Capital expenditure summary: Install new patient ceiling lift to increase staff and patient safety; Additional considerations that impact this capital request: Facility personnel will need to assist with inspection and support; Vendor: Lifts, Inc.; Attach quote: no data; Importance to department: option 1-High priority selected. Back to Figure Header reads, Company XYZ capital expenditure request. The form is divided into two parts. Part 1 shows capital budget for over 5k dollars each item. A table shows quantity, amount, and

2020 budget for each item as follows: movable equipment: no data, no data, no data; fixed equipment: 2, 2,000.00 dollars, 10,000.00 dollars; buildings: no data, no data, no data; land: no data, no data, no data; software: no data, no data, no data; improvements: no data, no data, no data; freight: 2, 250.00 dollars, 500.00 dollars; subtotal: no data, no data, 10,500 dollars; tax (if taxable): no data, no data, 588.00 dollars; total capital requested: no data, no data, 11,088.00 dollars; Part 2 shows expense budget for under 5k dollars each item. A table shows 2020 budget for each item as follows: minor equipment: 2,000.00 dollars; installation: no data; storage: no data; training: no data; other: no data; subtotal: 2,000.00 dollars; tax, if taxable: 112.00 dollars; total expense requested related to capital project: 2,112.00 dollars. Back to Figure Header of the form reads the following details: Company XYZ, Capital Request Form, Space, Building, and Renovation Request, and a field for Capital Project number. The form is divided into three parts. Part 1 is to be completed by department head. This part shows the following requirements with empty fields to be filled: Department number, Project date requested, Department name, Phone number, Campus location, Building, Floor, 1. Request for: Renovation of area, Relocation of Department or Equipment, Additional space, Reconfiguration of area, Installation of new equipment, and Other; 2. Description of work; 3. Justification for work; Signature of department head, Date; Signature of vice president, date. Part 2 is to be completed by director facilities management.

This part shows the following requirements with empty fields to be filled: 4. Cost estimate breakdown, Projected length of project, A. Project can be accomplished: with in-house labor and materials, through outside contracting, through a combination of in-house effort and contracting, and DOH approval or notification required; B. Costs: material costs in dollars, contractor costs in dollars, in-house labor costs, I. S. costs for cabling or terminations in dollars, other costs in dollars; Total project estimate in dollars; Comments; Signature of vice president facilities, date. Part 3 is for administrative use only. The following requirements with empty fields are to be filled: Ranking, Approved, Denied, Deferred, Administrator Signature, Date. An endnote reads, Please attach documentation for each request to this form! Date reads, March 24, 2018. Back to Figure Two circles separated by a distance are labeled, financial accounting and managerial accounting. An oval labeled, cost accounting, surrounds the managerial accounting circle and overlaps the financial accounting circle partially. A large oval labeled, accounting, encloses the other three shapes. Back to Figure The ad provides explanations for the following questions: What is the NPDB? How the NPDB works? What’s in the NPDB? Ad copy at the bottom reads, “Last year, the NPDB provided 7.8 million+ query responses and received 78,000+ reports.”

Back to Figure The ad copy reads, The Unearthing the Evidence Contest. Identify a nursing or medical practice that is used on a fairly regular basis BUT that should be changed based upon published evidence. Example: Saline lavage with suctioning is not supported in the literature for adult patients requiring airway suctioning. The evidence is clear. NO SALINE! And yet . . . the practice continues in some institutions on some units or by some nurses . . . . Submit a description of the current practice and offer a recommendation for change. Include copies of references. Entries will be judged on: 1. Commonness of the nursing or medical practice. Think about the things that we do every day in practice . . . are they really grounded in evidence? Are there alternative strategies we should be using? How do nurses accomplish these interventions in other countries? 2. Relevance to direct patient care. 3. Quality of literature support. 4. Realism of practice change suggestion (including fiscal reality). Prize: 100 dollars American Express Gift Certificate; Recognition in upcoming E to the power 3 Newsletter; Admiration of nursing colleagues. Accompanying illustration shows a worker wearing a helmet and working with a shovel. Back to Figure There are two column headers: symbols and meanings. Row entries are as follows: Row 1: rectangle, process; Row 2: rectangle with soft edges, alternate process; Row 3: hexagon, preparation; Row 4: diamond, decision; Row 5: square with two parallel lines drawn from top to the bottom nearby two opposite

sides at equal distance inside the square, predefined process. Back to Figure The labels are as follows: the main text is high nurse turnover. Two side arrows pointing the center arrow from the top are labeled as poor work context and high workload. Another side arrow pointing the center from the bottom is labeled, poor compensation package. Arrows pointing the side arrows are labeled as follows: poor work context: no clinical ladder, no conference education support, and poorly educated frontline managers; high workload: many vacancies, low number of BSN-prepared nurses; poor compensation package: lowest area starting salary, no bonus structure, and high parking fees. Back to Figure The offices are as follows: office of the chief privacy officer, office of the chief operating officer, office of the chief scientist, office of standards and technology, office of care transformation, office of clinical quality and safety, office of policy, office of programs, office of planning evaluation and analysis, and office of public affairs and communications. Back to Figure The five components are: department of health, community hospital, reference laboratory, university medical center, and private physician group. All data from the five components are together in one large HIE database at the center.

Back to Figure The components are department of health, community hospital, reference hospital, university medical center, and private physician group. Back to Figure The horizontal axis shows years ranging from 2001 to 2013 in equal intervals of 1 and the vertical axis shows percentage from 0 to 80 in equal intervals of 20. Data from the graph in the format, year: basic system, any EHR system, are as follows: 2001: no data, 18.2; 2002, no data, 17.3; 2003: no data, 17.3; 2004: no data, 20.8; 2005: no data, 23.9; 2006: 10.5, 29.2; 2007: 11.8, 34.8; 2008: 16.9, 42.0; 2009: 21.8, 48.3; 2010: 27.9, 51.0; 2011: 33.9, 57.0; 2012: 39.6, 71.8; 2013: 48.1, 78.4. Back to Figure The horizontal axis shows years ranging from 2008 to 2014 in equal intervals of 1 and the vertical axis shows percentage from 0 to 100 in equal intervals of 10. Data from the graph in the format, year: basic EHR system, certified EHR system, are as follows: 2008: 9.4, no data; 2009: 12.2, no data; 2010: 15.6, no data; 2011: 27.6, 71.9; 2012: 44.4, 85.2; 2013: 59.4, 94.0; 2014: 75.5, 96.9. Back to Figure The horizontal axis shows years ranging from December 2006 to April 2014 in equal intervals of 4 months and the vertical axis

shows percentage from 0 to 100 in equal intervals of 10. Data from the graph in the format, month and year, percentage are as follows: Dec-06, 0; Dec-07, 3; Dec-08, 7; Dec-09, 15; Dec10, 24; Dec-11, 43; Dec-12, 56; Dec-13, 68; Apr-14, 71. The graph also shows Medicare Improvements for Patient and Providers Act of 2008 (MIPPA) marked on June 2008 and Medicare and Medicaid EHR Incentive Programs begin marked on January 2011. Back to Figure The illustration shows five concentric circles. The innermost circle is labeled, Core Hospital EHR System. The second circle is divided into four quarters and labeled as follows (clockwise from top left): patient registration, CPOE, clinical decision support, and clinical documentation. The third circle is labeled as follows: department and ancillary systems, emergency room, pharmacy, radiology, and laboratary. The fourth circle is labeled as follows: information exchange with other providers, research and development, information exchange with other hospitals, and sharing information with the patient. The fifth circle is labeled as follows: reporting performance measures, reporting public health information, and national health information exchange. Back to Figure The surrounding components labeled are as follows (clockwise from the top): Stores data electronically for exchange and reporting, EHRs put accountability into nursing care, Standardizes care through use of shared protocols, Improves

ease of care coordination, Provides decision support to encourage evidence-based practices, Automates clinical processes, Measures clinical risks, Provides decision support, Enhances evidence-based practice, Improves practice workflows, Retains patient data and information building a more complete picture of the patient for all care providers to access, Reduce errors, and Is leveraged for clinical analysis. Back to Figure The key elements of the core competency, utilize informatics, are as follows: Regulations: HIPAA, High-tech use high touch, Biomedical and patient care equipment, Telehealth, Informatics and communication, Informatics description standards, and Documentation. Back to Figure Vision: High-quality care, lower costs, healthy population, and engaged people; Mission: Improve the health and well-being of individuals and communities through the use of technology and health information that is accessible when and where it matters most; Goals: Goal 1: Advance person-centered and selfmanaged health; Goal 2: Transform healthcare delivery and community health; Goal 3: Foster research, scientific knowledge, and innovation; Goal 4: Enhance nation’s health IT infrastructure. Back to Figure The descriptions are as follows: High-quality care: Individuals’

care is patient centered, accessible, and safe, and interventions address behavioral, social, and environmental determinants of health (National Quality Strategy) and Individuals benefit from improvement and innovation, and new knowledge is captured as part of care experience (Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine); Lower costs: Individuals, families, employers, and governments benefit from more affordable quality care through new delivery models (National Quality Strategy); Healthier population: Individuals, families, clinicians, and communities focus on prevention and wellness (National Prevention Strategy); Engaged individuals: Individuals are active in managing their health and partnering in their health care (ONC Person at the Center). Back to Figure With the focus of clinical research on patients at the center, the focus of other researches varies as follows: the two immediate research types next to clinical are biomedical focussing on organisms and health services focussing on system. The following two are disciplinary research focussing on theory placed next to biomedical and public health focussing on community next to health services. Back to Figure The text reads as follows: The definition of PICOT is as follows: P: Population/disease (age, gender, ethnicity, with a certain disorder), I: Intervention or variable of interest (therapy, exposure to a disease, risk behavior, prognostic factor), C:

Comparison (alternate therapy, placebo or usual practice, absence of risk factor), O: Outcome (risk of disease, accuracy of a diagnosis, rate of occurrence of adverse outcome), T: Time: The time it takes to demonstrate an outcome (time it takes for the intervention to achieve an outcome or time populations are observed for outcome). The templates for PICOT questions based on the type of clinical problem are as follows: Intervention/therapy query: In blank (P), how does blank (I) compare to blank (C) affect blank (O) within blank (T)? Prevention query: For blank (P), does the use of blank (I) reduce the future risk of blank (O) compared with blank (C)? Prognosis/prediction query: In blank (P), how does blank (I) compare to blank (C) influence/predict blank (O) over (T)? Diagnosis or diagnostic test query: In blank (P), are/is blank (I) compared with blank (C) more accurate in diagnosing (O)? Etiology query: Are blank (P) who have blank (I), compared with those without blank (C), at blank risk for/of blank (O) over (T)? Meaning query: How do blank (P) with blank (I) perceive blank (O) during (T)? Back to Figure The text reads as follows: PICOT Question Using Intervention Template: Clinical scenario: You are an extremely busy NP in the primary care division of a Veterans Administration Health System. It has been challenging to meet the complex care needs of veterans with diabetes in the traditional 20-minute clinic visit. You wonder what other care delivery models (e.g., shared medical appointment) may lead to improved clinical outcomes, patient satisfaction, and provider efficiency.

Population: Veterans with diabetes, Intervention: Shared medical appointments, Comparison: Routine clinic visit, Outcome: Improved clinical outcomes, and Time: 1-year period. In veterans with diabetes, how does shared medical appointment compared to standard care (routine clinic visit) improve clinical outcomes over 1 year? PICOT Question Using Prognosis/Prediction Template: Clinical scenario: A 65-year-old male comes to the cardiology clinic for his regularly scheduled physical examination. He shares that he has seen advertisements for anticoagulant medicine that does not require frequent laboratory testing. He is apprehensive about switching to one of these newer anticoagulant medicines (for example, dabigatran etexilate) because he has also seen news reports for increased complications related to these newer medicines. The PICOT question would be: Are adult patients who have dabigatran etexilate prescribed compared to warfarin at increased risk for complications? In this scenario you do not need “T.” Back to Figure The text box reads as follows: Credibility: Authors’ credentials, Credibility of publication, and No evidence of conflict of interest; Validity: Research question has PICO elements (below), Clear design matches the question, Extraneous variables controlled, Instrument reliability and validity (greater than 0.7), Sampling procedure (key: randomness), Sample size/power (greater than 80%), Results reported clearly, Evidence of significance (P less than .05); Generalizability: Sample represents similar patients, Setting is similar; Elements of research question: P: Population,

I: Intervention or trait of interest, C: Comparison group or time, O: Outcome of interest; Evaluating a research opportunity: F: Feasible, I: Interesting, N: Novel, E: Ethical, R: Relevant; Linking evidence to practice: Level I: Required, Level II: Recommended, Level III: Recommended, Level IV: Optional; Level I evidence: Multiple studies reported as meta-analysis, systematic review, or integrative review, or an evidence-based practice guideline, Well-designed studies with large sample sizes or large effect sizes; Level II evidence: Evidence from at least one well-designed randomized trial, Single randomized trials with small samples, Single studies with small to moderate effect sizes; Level III evidence: IIIA: Evidence from welldesigned trials without randomization, IIIB: Evidence from studies of intact groups, Ex post facto and causal-comparative studies, Case/control or cohort studies, IIIC: Evidence obtained from time series with and without an intervention, Single experimental or quasi-experimental studies with dramatic effect sizes; Level IV evidence: Evidence from expert panels, Systematic reviews of descriptive studies, Case series and uncontrolled studies. Back to Figure The steps are as follows: Determine general problem/purpose for research, Conduct literature review: a. Preliminary, b. Exhaustive, Decide study framework, Select specific problem, research question, or hypothesis, Define variables, Explain assumptions, Decide design and methodology, Identify population and sample, Select measurement tools/methods, Collect data according to research plan, Analyze and present

data: a. Statistical tables, b. Integrative diagrams, Interpret findings, State conclusion/generalization about problem, Propose implications for further study, and Disseminate findings. Back to Figure Independent variable such as smoking leads to dependent variable such as lung cancer. Cofounding variable such as employment status, working with asbestos, leads to both independent and dependent variables. Back to Figure The steps are as follows: Identify triggering issues or opportunities such as clinical or patient-identified issue, organization, state, or national initiative, data or new evidence, accrediting organization requirements or regulations, philosophy of care. State the question or purpose: Is this topic a priority? If No, consider another trigger. When considering another trigger, identify triggering issues or opportunities as stated earlier and consider alternatives. If the topic is a priority, form a team. Assemble, appraise, and synthesize body of evidence: conduct systematic search, weigh quality, quantity, consistency, and risk. Is there sufficient evidence? If No, conduct research. When conducting research, assemble, appraise, and synthesize body of evidence as stated or reassemble and assemble, appraise, and synthesize body of evidence. When reassembling, also consider alternatives. If there is sufficient evidence, design and pilot the practice change as follows: engage patients and verify preferences,

consider resources, constraints, and approval, develop localized protocol, create an evaluation plan, collect baseline data, develop an implementation plan, prepare clinicians and materials, promote adoption, and collect and report post-pilot data. After designing and piloting the practice change, redesign. If change is appropriate for adoption in practice, integrate and sustain the practice change as follows: identify and engage key personnel, hardwire change into system, monitor key indicators through quality improvement, and reinfuse as needed. Finally, disseminate results and Identify triggering issues or opportunities. When considering alternatives, if the answer is no, check if change is appropriate for adoption in practice. Redesigning is another option. Back to Figure The framework shows uptake of the following evidences at point of care: Sources of evidence: evidence-based practice guidelines or research synthesis at point of care; Patient preferences; Context: real-time outcomes and feedback; Facilitation: training and coaching by advanced practice nurses. Uptake undergoes nursing interventions, which leads to patient outcomes such as functional health symptom, therapeutic selfcare. Feedback from patient outcomes leads to facilitation that consists of training and coaching by advanced practice nurses. Back to Figure The horizontal axis shows income ranging from 20,000 to 140,000 in equal intervals of 40,000; the vertical axis shows years of education from 10 to 22 in equal intervals of 2.

Approximate data from the graph in the format, income range, year, are as follows: 20,000 to 30,000, 12; 35,000, 14; 35,000 to 55,000, 16; 60,000, 17; 45,000, 18; 100,000, 20; 130,000, 19. Overall trend is increase in years of education from 14 to 22 with increase in income from 20,000 to 140,000. Back to Figure The horizontal axis shows GPA ranging from 1.5 to 4.0 in equal intervals of 0.5; the vertical axis shows hours per week of TV from 0 to 30 in equal intervals of 5. Approximate data from the graph in the format, GPA, hours per week of TV, are as follows: 2.0, 20; 2.2, 25; 2.4, 10; 2.8, 16; 3.1, 15; 3.2, 14; 3.4, 9; 3.5, 23; 3.7, 4; 3.8, 8. Overall trend is decrease in hours per week of TV from 24 to 8 with increase in GPA from 1.5 to 4.0. Back to Figure Timeline measured in months and tasks are as follows: 1 month, identify indicators; 2 months, baseline data; 3 months, review literature: develop path, protocols, orders, data collection tool; 1 month, choose processes: educate and implement; monthly over 3 months, review initial data monthly: adjust and reevaluate plan; as scheduled, review data quarterly: adjust and reevaluate plan. Back to Figure The framework shows that factors such as socioeconomics and political context, governance, policy such as macroeconomic, social, health, and cultural and societal norms and values affect

the social position, education, occupation, income, gender, and ethnicity or race and vice versa. Social position, education, occupation, income, gender, and ethnicity or race affect factors such as material circumstances, social cohesion, psychosocial factors, behaviors, and biological factors, which in turn affect the health care system and vice versa. Health care system affects the distribution of health and well-being, which in turn affects the social position and socioeconomics and political context. Back to Figure The illustration shows holistic health labeled on a circle at the center. The circle is within another circle labeled with physical, social, spiritual, and mental health. This circle is within a diamond shape with its four sides labeled with the following: preventive services, social policy, health promotion, and medical care. Medical care and preventive services are categorized as individual health, and health promotion and social policy are categorized as community health. Back to Figure The labels are as follows from circle 1 to 5: circle 1: locate individual traits: age, sex, race, and biological factors; circle 2: individual behavior across life course; circle 3: social, family, and community networks; circle 4: living and working conditions; circle 5: broad social, economic, cultural, health, and environmental conditions and policies of the global, national, state, and local levels. The illustration also lists the interventions and outcomes of the determinants of health. The

interventions are policies, programs, and information. The outcomes are behavioral outcomes, specific risk factors, diseases, and conditions, injuries, well-being and health-related quality of life, and health equity. Outcomes lead to the interventions through assessment, monitoring, evaluation, and dissemination. Back to Figure The requisites are listed at each level from bottom to the top with bottom as level 1: Level 1: Requisite attitudes: Respect (valuing other cultures, cultural diversity), Openness (to intercultural learning and to people from other cultures, withholding judgment), Curiosity and discovery (tolerating ambiguity and uncertainty); Level 2: Knowledge and comprehension: Cultural self-awareness; Deep understanding and knowledge of culture (including contexts, role, and impact of culture and others’ world views); Culture-specific information; Sociolinguistic awareness; Skills: To listen, observe, and interpret; To analyze, evaluate, and relate; Level 3: Desired Internal Outcome: Informed frame of reference/filter shift: Adaptability (to different communication styles and behaviors; adjustment to new cultural environments); Flexibility (selecting and using appropriate communication styles and behaviors; cognitive flexibility); Ethnorelative view; Empathy; Level 4: Desired External Outcome: Behaving and communicating effectively and appropriately (based on one’s intercultural knowledge, skills, and attitudes) to achieve one’s goals to some degree.

Back to Figure Stage 1 lists authentic listening, curiosity, empathy, respect, and humility. Stage 1 leads to stage 2 that consists of effective cultural communication. Stage 2 leads to stage 3 that consists of patient satisfaction, adherence, and positive patient outcomes. Back to Figure The horizontal axis shows different races, and the vertical axis shows percentage of live births. Data from the graph in the format, race: year, percentage, are as follows: all races: 1990, 6.97, 2000, 7.57, 2010, 8.15, 2014, 8.00; white: 1990, 5.70, 2000, 6.55, 2010, 7.08, 2014, 6.98; black: 1990, 13.25, 2000, 12.99, 2010, 13.21, 2014, 12.83; American Indian or Alaska native: 1990, 6.11, 2000, 6.76, 2010, 7.61, 2014, 7.65; Asian or Pacific Islander: 1990, 6.45, 2000, 7.31, 2010, 8.49, 2014, 8.05; Hispanic origin: 1990, 6.06, 2000, 6.41, 2010, 6.97, 2014, 7.05. Back to Figure The horizontal axis shows different races, and the vertical axis shows percentage of mothers who smoked. Data from the graph in the format, race: year, percentage, are as follows: all races: 1990, 18.4, 2000, 12.2, 2008, 10.0, 2008, 10.2, 2014, 8.4; white: 1990, 19.4, 2000, 13.2, 2008, 11.0, 2008, 10.8, 2014, 12.2; black: 1990, 15.9, 2000, 9.1, 2008, 7.6, 2008, 9.7, 2014, 6.8; American Indian or Alaska native: 1990, 22.4, 2000, 20.0, 2008, 16.5, 2008, 19.6, 2014, 18.0; Asian or Pacific Islander: 1990, 5.5, 2000, 2.8, 2008, 2.1, 2008, 1.6, 2014, 0.7;

Hispanic origin: 1990, 6.7, 2000, 3.5, 2008, 2.6, 2008, 2.0, 2014, 2.0. Back to Figure The horizontal axis shows different races, and the vertical axis shows percentage of mothers who smoked. Data from the graph in the format, race: year, percentage, are as follows: all races: 1990, 18.4, 2000, 12.2, 2008, 10.0, 2008, 10.2, 2014, 8.4; white: 1990, 19.4, 2000, 13.2, 2008, 11.0, 2008, 10.8, 2014, 12.2; black: 1990, 15.9, 2000, 9.1, 2008, 7.6, 2008, 9.7, 2014, 6.8; American Indian or Alaska native: 1990, 22.4, 2000, 20.0, 2008, 16.5, 2008, 19.6, 2014, 18.0; Asian or Pacific Islander: 1990, 5.5, 2000, 2.8, 2008, 2.1, 2008, 1.6, 2014, 0.7; Hispanic origin: 1990, 6.7, 2000, 3.5, 2008, 2.6, 2008, 2.0, 2014, 2.0. Back to Figure The horizontal axis shows the races, and the vertical axis shows percentage of women having a mammogram within the past 2 years. Data from the graph in the format, race, percentage, are as follows: white, non-Hispanic, 67.6; black, non-Hispanic, 67.2; Hispanic, 61.4. Back to Figure The horizontal axis shows the categories of people, and the vertical axis shows remaining life expectancy measured in years. Data from the graph in the format, people category: year, years, are as follows: white male: 1970, 68.0, 1980, 70.7, 1990,

72.7, 2000, 74.9, 2010, 76.5, 2014, 76.7; white female: 1970, 75.6, 1980, 78.1, 1990, 79.4, 2000, 80.1, 2010, 81.3, 2014, 72.5; black male: 1970, 60.0, 1980, 63.8, 1990, 64.5, 2000, 68.3, 2010, 71.8, 2014, 72.5; black female: 1970, 68.3, 1980, 72.5, 1990, 73.6, 2000, 75.2, 2010, 78.0, 2014, 78.4. Back to Figure The horizontal axis shows years ranging from 1970 to 2011; the vertical axis shows deaths per 100,000 live births ranging from 0 to 70 in equal intervals of 10. Data from the graph in the format, year: race, number of deaths, are as follow: 1970: all races, 21.5, white, 14.4, black, 65.5; 1980: all races, 9.4, white, 6.7, black, 24.9; 1990: all races, 7.6, white, 5.1, black, 21.7; 2000: all races, 8.2, white, 6.2, black, 20.1; 2006: all races, 11.2, white, 8.1, black, 28.7; 2007: all races, 10.2, white, 7.7, black, 23.8; 2011: all races, 14.0, white, 11.8, black, 41.4. Back to Figure The horizontal axis shows years 1990, 2000, 2011, and 2014; the vertical axis shows percentage with fair or poor health from 0 to 18 in equal intervals of 2. Data from the graph in the format, year: race, percentage, are as follows: 1990: white, 8.1, black, 15.1; 2000: white, 8.2, black, 14.6; 2011: white, 9.0, black, 15.0; 2014: white, 8.3, black, 13.6. Back to Figure The horizontal axis shows categories of persons; the vertical axis shows percentage of smokers. Data from the graph in the

format, categories of persons, percentage of smokers, are as follows: all persons, 17.0, all males, 19.0, white males, 18.8, black males, 21.7, all females, 15.1, white females, 16.0, black females, 13.4. Back to Figure The horizontal axis shows health occupations; the vertical axis shows percentage of students. Data from the graph in the format, occupation, percentage of students, are as follows: allopathic medicine, 47.2; dentistry, 49.6; osteopathic medicine, 46.0; podiatry, 41.0, optometry, 67.1, registered nurses, 88.3. Back to Figure Data from the pie chart in the format, method, percentage, are as follows: birth control pills, 26.7; female sterilization, 25.1; condom, 22.8; withdrawal, 12.6; intrauterine device, 10.7; male sterilization, 9.0; injectable, 4.6; implant, 3.9; periodic abstinence-calendar rhythm, 2.9. Back to Figure The horizontal axis shows years from 1987 to 2014 in equal intervals of 1; the vertical axis shows number of reported cases ranging from 20,000 to 120,000 in equal intervals of 20,000. Data from the graph in the format, year, number of reported cases, are as follows: 1987, 20,000; 1988, 26,000; 1990, 40,000; 1992, 50,000; 1993, 104,000; 1995, 65,000; 1996, 70,000; 1998, 46,000; 2000, 44,000; 2004, 50,000; 2008, 46,000; 2014, 30,000.

Back to Figure Data from the pie chart in the format, category, percentage, are as follows: care and treatment, 61; global superscript 2, 19; cash assistant, 9; research, 8; prevention, 3. Back to Figure The model shows two concentric circles with the space inbetween labeled as nursing leadership. The center of the circles is labeled, nursing leadership knowing. The rest of the space inside the inner circle is divided into six parts and labeled as follows: Sociopolitical L.K. Strategy, culture; Empiric L.K. Outcome-based EMB, EBL; Aesthetic L.K. Art, vision; Personal L.K. Relationship; Unknowing L.K. Openness; Ethical L.K. Justice, ethics. Outside the circles is a box labeled, Emancipatory L.K. Transforming workplace. Opposite the box on the other side of the circles is a sphere in equilibrium with the main circles and labeled, Nursing staff. Back to Figure The illustration shows a mentor and a mentee. The following requirements are labeled between them: open, honest, discreet communications and mutual attraction based on similarity of values characterized by trust and respect. Individual characteristics required for them are listed as follows: mentor: expertise in role competencies, transformational leader, and skills as a mentor; mentee: learning needs for developing role competencies and leadership skills, which energize the mentee for self-reflection, learning, and action.

Back to Figure Data from the matrix are as follows: quadrant 1: high importance and high urgency; quadrant 2: high importance and low urgency; quadrant 3: low importance and high urgency; quadrant 4: low importance and low urgency. Back to Figure Entries to be made for the following in the template: Name, credentials; Home Address; Work Address: (if desired); Phone; Email Address; Education: (list highest degree first); Degree, Graduation date, University, University’s address; Professional Employment: (list most recent nursing position first); Dates of employment, Employer, Position title: brief description of responsibilities and achievements; Licensure and Certifications: List licenses, License number, State(s) where qualified to practice, List certifications, Certification number, Credentialing body, Dates certification is valid; Professional Honors and Recognition: (list most recent first): Professional and community awards, scholarships, honorary degrees, fellowships, and or prizes, Name of the award, Presenting organization, Date, Reason for the award; Research or Grant History: Research fellowships, Master’s theses, Doctoral dissertations, Grants (do not list a project if funding was denied); Lectures, Courses, and Presentations: (may include presentations given to colleagues, healthcare professionals, or the community), List of names of course or lecture or presentations, and Dates given. Back to Figure

Entries to be made for the following in the template: Professional Service: Peer review groups or grant study sections, Journal service: (served as a reviewer for a journal): Dates of service, Journal name; Professional organizations: Names of organizations in which current membership is held, Dates of membership, Offices held, Committees served in each organization; Consultative service: Names of organizations where salaried consulting work was provided, Address of the organization, Type of consulting work, Dates; Organizational service: Dates, Committees and task forces, Role on the committee (i.e., member or chairperson), If appropriate, note any major accomplishment of the committee, Hospital boards and committees; Public or Community Service: Community agency where volunteer work was completed, Type of service (e.g., parish nursing, fundraising, educational sessions to nonnursing groups), Population served, Date; Bibliography: (Use the American Psychological Association format for listing publications; list the publications in chronological order by year. Group types of publications separately, such as by the following groupings.), Peer-reviewed manuscripts, Case reports, technical notes, letters; Reviews, chapters, books, Papers in press, and Peer reviews of presentations (Note in the footer the date on which the curriculum vitae was last revised.). Back to Figure The cartoon shows a behemoth labeled US healthcare system being chased by an employer holding a hand net labeled, quality, a government representative holding a noose labeled, cost control, a provider, a consumer holding a spear labeled,

access, and a representative of insurance. Back to Figure Cartoon The cartoon shows a building representing US healthcare. A helicopter lands on its terrace. People are using a common pathway to enter building; the entrance shows a signboard reading, “Must pay to enter.” A person with injured leg is directed by an official to use an alternative pathway leading to an adjacent building labeled, Charity. Back to Figure The predisposing characteristic is in equilibrium with enabling characteristic, which in turn is in equilibrium with need characteristic. Similarly, physical care is in equilibrium with mental care, which in turn is in equilibrium with social care. Back to Figure There are two column headers: clinical nurse specialist and clinical nurse leader. Row entries are as follows: Row 1: Conducts a comprehensive health assessment in diverse care settings, including psychosocial, functional, physical, and environmental factors and Conducts a holistic assessment and comprehensive physical examination of individuals across the life span; Row 2: Leads and participates in the process of selecting, integrating, managing, and evaluating technology and products to promote safety, quality, efficiency, and optimal health outcomes and Uses information technology, analytics, and evaluation methods; Row 3: Leads and facilitates

coordinated care and transitions in collaboration with the patient and interprofessional team and Facilitates collaborative, interprofessional approaches and strategies in the design, coordination, and evaluation of patient-centered care; Row 4: Provides education and coaching to patients with complex learning needs and atypical responses and Demonstrates coaching skills, including self-reflection, to support new and experienced interdisciplinary team members in exploring opportunities for improving care processes and outcomes; Row 5: Consults with healthcare team members to integrate the needs, preferences, and strengths of a population into the healthcare plan to optimize health outcomes and patient experience within a healthcare system and Engages in partnerships at multiple levels of the health system to ensure effective coordination, delivery, and evaluation of clinical prevention and health promotion interventions and services across care environments; Row 6: Implements customized evidence-based advanced nursing interventions, including the provision of direct care and Uses evidence to design and direct system improvements that address trends in safety and quality; Row 7: Analyzes the ethical impact of scientific advances, cost, clinical effectiveness on patient and family values, and preferences and Advocates for policies that leverage social change, promote wellness, improve care outcomes, and reduce costs. Back to Table The following table lists the data for northeast states. There are six column headers: region and state, supply and demand raise

to a in 2014, supply in 2030, demand in 2030, difference raise to b in 2030, and adequacy raise to c in 2030. Row entries are as follows: Row 1: Connecticut, 34,000, 43,500, 40,000, 3,500, and 8.8%; Row 2: Maine, 14,600, 21,200, 16,500, 4,700, and 28.5%; Row 3: Massachusetts, 73,200, 91,300, 89,300, 2,000, and 2.2%; Row 4: New Hampshire, 15,500, 21,300, 20,200, 1,100, and 5.4%; Row 5: New Jersey, 81,700, 90,800, 102,200, (11,400), and (11.2%); Row 6: New York, 174,100, 213,400, 195,200, 18,200, and 9.3%; Row 7: Pennsylvania, 133,200, 168,500, 160,300, 8,200, and 5.1%; Row 8: Rhode Island, 11,000, 15,000, 12,500, 2,500, and 20.0%; Row 9: Vermont, 6,000, 9,300, 6,800, 2,500, and 36.8%. Back to Table The following table lists the data for midwest and south states. There are six column headers: region and state, supply and demand raise to a in 2014, supply in 2030, demand in 2030, difference raise to b in 2030, and adequacy raise to c in 2030. Row entries for midwest states are as follows: Row 1: Illinois, 116,300, 143,000, 139,400, 3,600, and 2.6%; Row 2: Indiana, 62,900, 89,300, 75,300, 14,000, and 18.6%; Row 3: Iowa, 32,500, 45,400, 35,300, 10,100, and 28.6%; Row 4: Kansas, 29,500, 47,500, 34,900, 12,600, and 36.1%; Row 5: Michigan, 91,600, 110,500, 104,400, 6,100, and 5.8%; Row 6: Minnesota, 56,200, 71,800, 68,700, 3,100, and 4.5%; Row 7: Missouri, 59,600, 89,900, 73,200, 16,700, and 22.8%; Row 8: Nebraska, 20,300, 24,700, 21,200, 3,500, and 16.5%; Row 9: North Dakota, 7,600, 9,900, 9,200, 700, and 7.6%; Row 10: Ohio, 122,800, 181,900, 132,800, 49,100, and 37.0%; Row 11: South

Dakota, 10,300, 11,700, 13,600, (1,900), and (14.0%); Row 12: Wisconsin, 58,100, 78,200, 72,000, 6,200, and 8.6%. Row entries for south states are as follows: Row 13: Alabama, 68,000, 85,100, 79,800, 5,300, and 6.6%; Row 14: Arkansas, 28,400, 42,100, 32,300, 9,800, and 30.3%; Row 15: Delaware, 9,600, 14,000, 12,800, 1,200, and 9.4%; Row 16: District of Columbia raise to d, 1,800, 8,800, 2,300, 6,500, and 282.6%; Row 17: Florida, 170,600, 293,700, 240,000, 53,700, and 22.4%. Back to Table There are four column headers: population raise to asterisk, percentage of NPs, top practice setting, and top clinical foci. Row entries are as follows: Row 1: Acute Care, 6.4, Hospital Inpatient (33.0%), and Surgical (16.1%); Row 2: Adult raise to caret, 15.7, Hospital Outpatient Clinic (15.2%), and Primary Care (32.4%); Row 3: Adult-Gerontology Acute Care, 2.0, Hospital Inpatient (43.3%), and Surgical (13.3%); Row 4: AdultGerontology Primary Care raise to caret, 4.4, Hospital Outpatient Clinic (18.7%), and Primary Care (46.6%); Row 5: Family raise to caret, 60.6, Private Group Practice (12.7%), and Primary Care (46.2%); Row 6: Gerontology raise to caret, 2.2, Long-Term Care Facility (16.6%), and Primary Care (46.2%); Row 7: Neonatal, 1.3, Hospital Inpatient Clinic (69.1%), and Neonatal (57.8%); Row 8: Pediatric-Primary Care raise to caret, 4.6, Hospital Outpatient Clinic (18.7%), and Primary Care (55.6%); Row 9: Psychiatric/Mental Health-Adult, 1.7, Psych/Mental Health Facility (23.0%), and Psychiatric (93.6%); Row 10: Psychiatric/Mental Health-Family, 2.1, Psych/Mental

Health Facility (25.8%), and Psychiatric (91.6%); Row 11: Women’s Health raise to caret, 3.4, Hospital Outpatient Clinic (15.7%), and OB/GYN (64.1%). Back to Table There are two column headers: American Nurses Credentialing Center and American Organization of Nurse Executives. Row entries from the table are as follows: Row 1: basic certification, hold a bachelor’s or higher degree in nursing, associate degree diploma bachelor’s degree; Row 2: advanced certification, hold a master’s or higher degree in nursing or hold a bachelor’s degree in nursing and a master’s in another field, master’s degree or higher. Back to Table There are three column headers: percentage of time, nursing activities, and medical activities. Row entries are as follows: Row 1: 0 to 25%, 36.7% (n equals 33) raise to asterisk in bold, and 13.3% (n equals 12); Row 2: 26 to 50%, 30.0% (n equals 27), and 34.4% (n equals 31) raise to asterisk in bold; Row 3: 51 to 75%, 25.6% (n equals 23), and 32.2% (n equals 29); Row 4: 75 to 100%, 7.8% (n equals 7), and 20.0% (n equals 18). Back to Table The table shows two column headers: DNP and PhD, DNS, and DNSc. Row entries are as follows: Row 1: Program of study, Objectives: Prepare nurse specialists at the highest level of advanced practice, Competencies: Based on Essentials of

Doctoral Education for Advanced Nursing Practice (AACN, 2006b) raise to asterisk; Objectives: Prepare nurse researchers, Content: Based on Indicators of Quality in Research-Focused Doctoral Programs in Nursing (AACN, 2001) raise to dagger. Back to Table Row entries are as follows: Row 1: Students, Commitment to a practice career, Oriented toward improving outcomes of care; Commitment to a research career, Oriented toward developing new knowledge; Row 2: Program faculty, Practice doctorate and/or experience in area in which teaching, Leadership experience in area of specialty practice, High level of expertise in specialty practice congruent with focus of academic program; Research doctorate in nursing or related field, Leadership experience in area of sustained research funding, High level of expertise in research congruent with focus of academic program; Row 3: Resources, Mentors and/or preceptors in leadership positions across a variety of practice settings, Access to diverse practice settings with appropriate resources for areas of practice, Access to financial aid, Access to information and patient-care technology resources congruent with areas of study; Mentors/preceptor in research settings, Access to research settings with appropriate resources, Access to dissertation support dollars, Access to information and research technology resources congruent with program of research; Row 4: Program assessment and evaluation, Program outcome: Healthcare improvements and contributions via practice, policy change, and practice scholarship, Oversight

by the institution’s authorized bodies (i.e., graduate school) and regional accreditors, Receives accreditation by specialized nursing accreditor, Graduates are eligible for national certification exam; Program outcome: Contributes to healthcare improvements via the development of new knowledge and other scholarly projects that provide the foundation for the advancement of nursing science, Oversight by the institution’s authorized bodies (i.e., graduate school) and regional accreditor. Back to Table Row entries are as follows: Row 1: American Holistic Nurses Credentialing Corporation or AHNCC, www.ahncc.org; Row 2: Center for Spirituality and Healing at the University of Minnesota, www.csh.umn.edu; Row 3: Life Sciences Foundation, http://lifesciencesfoundation.org; Row 4: National Center for Complementary and Integrative Health, https://nccih.nih.gov/health/integrative-health; Row 5: Academy of Integrative Health and Medicine or AIHM, www.aihm.org. Back to Table Row entries are as follows: Row 1: Step 1, Making Sense or Unfreezing; Row 2: Step 2, Leading or Serving on an Interprofessional Change Team; Row 3: Step 3, Developing a Team Vision and Charge; Row 4: Step 4, Identifying and Analyzing Forces of Change; Row 5: Step 5, Developing a Work Plan for Change Implementation; Row 6: Step 6, Implementing Change; Row 7: Step 7, Evaluating Outcomes and Refining as Needed; Row 8: Step 8, Incorporating Changes

Into the Culture or Refreezing. Back to Table There are two column headers: driving forces and restraining forces. The purpose of the team is stated in a column at the center of these forces as follows: Driving forces: faculty content experts, current courses, no costs except time, and past experience; The purpose of the team is to review the current specialization track in nursing administration to ensure that appropriate content is presented, that there is no duplication of content or assignments among the courses, and that the content is consistent with professional standards; Restraining forces: members are located at different sites, complex implementation, and time commitments of team. Back to Table There are two column headers: Initial Task Force and Final Multi-Interprofessional Team. The row entries are as follows: Row 1: DNP Student, DNP Student; Row 2: MSW mentor, MSW mentor; Row 3: RN from SHS, RN from SHS; Row 4: Student, Student, Director of Institutional Research and Assessment, VP for Enrollment Management, Registrar, Manager, Wellness Center, International student advisor, Department chair, and Physical Therapy. Back to Table There are six column headers with the following respective entries: Education or Research: Medical schools, Dental

schools, Nursing programs, Physician assistant programs, Nurse practitioner programs; Physical therapy, occupational therapy, speech therapy programs; Research organizations, Private foundations; U.S. Public Health Service (Agency for Healthcare Research and Quality, Agency for Toxic Substances and Disease Registry, Centers for Disease Control and Prevention, Food and Drug Administration, Health Resources and Services Administration, Indian Health Service, National Institutes of Health, Substance Abuse and Mental Health Services Administration), Professional associations, and Trade associations; Suppliers: Pharmaceutical companies, Multipurpose suppliers, and Biotechnology companies; Insurers: Managed care plans, Blue Cross/Blue Shield plans, Commercial insurers, Self-insured employers, Medicare, Medicaid, Veterans Affairs, and Tricare; Providers: Preventive Care: Health departments; Primary Care: Physician offices, Community health centers, Dentists, and Nonphysician providers; Subacute Care: Subacute care facilities and Ambulatory surgery centers; Acute Care: Hospitals; Auxiliary Services: Pharmacists, Diagnostic clinics, X-ray units, and Suppliers of medical equipment; Rehabilitative Services: Home health agencies, Rehabilitation centers, and Skilled nursing facilities; Continuing Care: Nursing homes; End-of-Life Care: Hospices; Integrated: Managed care organizations and Integrated networks; Payers: Blue Cross or Blue Shield plans, Commercial insurers, Employers, Third-party administrators, and State agencies; Government: Public insurance financing, Health regulations, Health policy, Research funding, and Public health.

Back to Table There are two column headers: types of health services and delivery settings. Row entries are as follows: Row 1: preventive care: public health programs, community programs, personal lifestyles, and primary care settings; Row 2: primary care: physician’s office or clinic, community health centers, self-care, and alternative medicine; Row 3: specialized care: specialist provider clinics; Row 4: chronic care: primary care settings, specialist provider clinics, home health, long-term care facilities, self-care, and alternative medicine; Row 5: long-term care: long-term care facilities and home health; Row 6: subacute care: special subacute units (hospitals, long-term care facilities), home health, and outpatient surgical centers; Row 7: acute care: hospitals; Row 8: rehabilitative care: rehabilitation departments (hospitals, long-term care facilities), home health, and outpatient rehabilitation centers; Row 8: end-of-life care: hospice services provided in a variety of settings. Back to Table There are two column headers with the following lists: Components of EIHP: External evidence: Includes best research evidence, evidence-informed relevant theories, and best evidence from opinion leaders, expert panels, and other relevant sources; Issue expertise: Includes data from such sources as professional and healthcare associations or organizations and government agencies; also includes professions’ understanding or experience with the issue; may include other data resources; Stakeholder values and ethics:

Considers the values and ethics of healthcare providers, policy shapers, healthcare consumers, and others; Steps of EIHP: Step 0: Cultivate a spirit of inquiry in the policy culture or environment; Step 1: Identify the policy problem; ask a policy question in the form of a PICOT question; Step 2: Search for or collect relevant or best evidence; Step 3: Perform critical appraisal of the evidence; Step 4: Integrate best evidence with issue expertise and stakeholder values and ethics; the result will be the desired health policy decision/change; Step 5: Contribute to the health policy development or implementation process; Step 6: Frame the policy change for dissemination; Step 7: Evaluate the effectiveness of the policy change and disseminate findings. Back to Table There are three column headers: payor type, percentage, and impact. The row entries are as follows: Row 1: payor type and percentage: private, commercial: fee-for-service, 39 percent; managed care, 14 percent; subtotal, 53 percent; impact: Private or commercial payors are the largest category of payor with a high percentage of fee-for-service. The incentive is to increase volume to increase revenue—more tests and procedures; Row 2: government: Medicare, 30 percent; Medicaid, 8 percent; subtotal, 38 percent; impact: Typically, these programs pay a lower percentage of charges than private payors, with Medicaid reimbursement usually lower than Medicare. As the age of the population increases, Medicare percentage will rise. This example is a relatively low government payor mix, minimizing the impact of political decisions that affect reimbursement; Row

3: miscellaneous: self-pay, 5 percent; other, 4 percent; subtotal, 9 percent; impact: “Other” may include bad debt, charity care, and workers’ compensation and does not pose a significant financial risk in this example; Row 4: total: 100 percent. Back to Table There are four column headers: budget type, description, advantages, and disadvantages. Row entries are as follows: Row 1: Zero-based budget; Start at zero. Justify each expense and revenue source; 1. Tight control over resources and 2. Dollars allocated based on need rather than on history; 1. Time consuming and 2. Justifying routine, required expenses; Row 2: Historical budget; Begin with previous budget. Build on past performances; 1. Works well in predictable situations, 2. Saves time, and 3. Less likely to omit key events or trends; 1. May budget for irrelevant items and 2. May not scrutinize expenses as thoroughly. Back to Table Row entries from the table are as follows: Row 1: Projected patients days equals 7,300 patient days (equates to an average daily census (ADC) of 20 patients). 7,300 patient days divided 364 days per year equals 20 patients per day; Row 2: NHPPD standards equals 10.0; Row 3: Patient days times NHPPD standard equals Total number of direct care hours required; Row 4: 7,300 patient days times 10.0 NHPPD equals 73,000 direct care hours; Row 5: 73,000 direct care hours per 2,080 (1 FTE) equals 35.09 required FTEs.

Back to Table There are two column headers: product or device consideration and suggestions. Row entries are as follows: Row 1: 1. Review and verify manufacturer claims for accuracy; Advanced nurses should make certain that manufacturer claims are accurate. Products may not perform as promised during clinical use. Review the fine print of claims and make certain that these attestations are accurate when products are actually put to the test in clinical situations. Row 2: 2. Compare available products or devices; Advanced nurses should compare products during clinical use. Select a few competing products or devices and compare them. Row 3: 3. Consider ease of use and maintenance; Consider how easy the product or device is to use. This consideration includes ease of cleaning and storing. Row 4: 4. Pay attention to ergonomics and product size and weight; Advanced nurses should pay attention to the influence the product has on body mechanics. If a product requires repetitive movements, muscle straining, or periods of prolonged standing, solicit input from staff and other healthcare professionals as to the potential for injury, particularly given the aging nursing workforce. Row 5: 5. Evaluate the complexity and readability of the manufacturer’s product instructions; Review the written instructions for clarity, readability, and accuracy. Advanced nurses should explore whether troubleshooting information is available in print and/or Web forms. It may be reasonable to ascertain whether a 24-hour contact is accessible for troubleshooting, particularly if a product or device is new to the setting. Row 6: 6. Consider safety features and prioritize features that are absolutely essential. Advanced nurses should

encourage staff to think about what could go wrong and ways in which the device might be misused. It is important to make certain that critical safety features cannot be turned off. Some devices may have delay switches that reset after a period of time to avoid the need to deliberately reset safety features once discontinued. Back to Table There are two column headers: product or device consideration and suggestions. Row entries are as follows: Row 1: 7. Estimate anticipated training costs; Advanced nurses should calculate the training costs associated with assuring competent use of new devices and equipment. Some products are quite sophisticated and may require hours of training. Others may warrant competency assessments. Explore whether vendorpackaged training materials, including computer or Web-based instruction, are available. Row 2: 8. Determine ease of repair; Many devices and products are sophisticated by design and require experts for repairs or maintenance activities. If the institution cannot afford the cost of backup equipment or cannot justify the expense of developing in-house repair expertise, it may be difficult for staff to work without equipment when it malfunctions. Consider expenses associated with repair, replacement, and/or extended warranties. Row 3: 9. Consider security needs; Consider if this product or device requires protections from theft. Is this a product or device that is likely to be appealing to would-be thieves? Can the product be used outside of the healthcare facility? Is there a secondary market or home use for this item? If thievery is a concern, consider

strategies for securing the product, restricting its access, or monitoring its use. Row 4: 10. Evaluate the environmental impact; Advanced nurses should investigate the costs associated with cleaning or disposing of the product. Environmental impacts are important not only in terms of the chemicals or processes necessary for cleaning but also the biodegradability and bulk of items when no longer useful. Are parts recyclable? Row 5: 11. Consult device safety reports; Review MAUDE databases for information about reported safety concerns that may be relevant to the devices that are under consideration. Back to Table There are four column headers: Characteristic; Evaluation: 1 equals unacceptable, 2 equals poor, 3 equals adequate, 4 equals good, 5 equals highly beneficial; Rank importance of this characteristic to the purchase decision 1 to 20; Comments: Follow-up needs (with assigned responsibility). Row entries under the column characteristic are as follows: Row 1: 1. Simplicity of use: Size of print on buttons, Manipulability of equipment, Weight, Height (Does it fit in the patient room?), Portability, and Amount of space required for storage; Row 2: 2. Instructions: Readability of written instructions, Availability of additional instructional materials (e.g., DVD, laminated information cards, signs, computer-based instruction), Vendorprovided education programs, and Step-by-step guidelines for competency development; Row 3: 3. Safety features: Alarm featured, Battery life and indicators, Default settings, Most common errors and failures with related safeguards, Reset

buttons, Expiration dates (on products), Associated allergens, and Risk to staff. Back to Table Row entries under the column characteristic are as follows: Row 4: 4. Amount of time needed to initially learn how to use the equipment, Preliminary inservice time, Predicted frequency of use and impact on nurse competence, and List of users and associated education needs; Row 5: 5. Repair services: Inhouse repair versus contracted repair, Guaranteed turnaround time for repairs, Replacement policy, Weekend or after business hours or holiday support, Repair expense, and Availability of replacement parts; Row 6: 6. Shared dependency on other departments: Components stored and managed off nursing unit? Materials management training, and Consistent coding and identification of parts between nursing and other departments: Distribution and clear designation of who does what and when, Off-hours responsibilities for each department; Row 7: 7. Ergonomics: Repetitive motions, Impact on standing or sitting, and Potential for staff injury; Row 8: 8. Required dexterity for safe use. Back to Table There are four column headers: Characteristic; Evaluation: 1 equals unacceptable, 2 equals poor, 3 equals adequate, 4 equals good, 5 equals highly beneficial; Rank importance of this characteristic to the purchase decision 1 to 20; Comments: Follow-up needs (with assigned responsibility). Row entries under the column characteristic are as follows: Row 9: 9.

Environmental impact: Discard versus clean, sterilize, Recyclable, if discard, Product ingredients, Efficiency of product packaging and impact on trash volume, Ozone discharge, air quality effects, scents, chemical usage, and Is product manufactured in eco-friendly industry/packaging center?; Row 10: 10. Expense: Purchase cost, Maintenance cost, and Miscellaneous cost; Row 11: 11. Security: Theft prevention, Tracking location, and Physical security options (e.g., locks, mounting); Row 12: 12. Potential impact on patient care outcomes of concern. Back to Table Row entries under the column characteristic are as follows: Row 13: 13. Patient perspective: Alarm noise, Transportability for mobile patients, and Patient safety; Row 14: 14. Impact of misuse: Worst-case scenario when equipment fails and Opportunities for incorrect use; Row 15: 15. What patient care problems does this product fix? Row 16: 16. Product capabilities that are useful in this clinical setting as compared with capabilities not useful or required; Row 17: 17. Gaps in processes, within and/or between departments, that this product may create; Row 18: 18. Gaps in processes, within and/or between departments, that this product may solve; Row 19: 19. Clinical and nonclinical stakeholders: Who is potentially affected by this purchase decision? Row 20: 20. Time required from securing the product (start) to finishing with the product (end). (Nursing time utilized by this product per usage.); Row 21: 21. Technology: Possibility of interference with existing systems in use? Wireless connectivity? Automatic updates?

and Integration with electronic health record or other computerized systems/software platforms? Row 22: 22. References or commentary from nonbiased users. Back to Table The table shows categories such as considers and gives us for macroeconomics and microeconomics. Row entries for macroeconomics are as follows: Row 1: Considers: The aggregate performance of all markets, including the outcomes or performance of all companies or firms in all industries; Row 2: Gives us: Indices, or measures (indicators), of a nation’s economy, such as stock prices, interest rates, jobless claims, and housing statistics; Row entries for microeconomics are as follows: Row 3: Considers: The choices made by smaller economic units, such as consumers or individual (hospital) firms; Row 4: Gives us: Such concepts as profit, profit maximization, price strategy, and nonprice competition to consider. Back to Table There is one column header: HEDIS measure of care. Row entries are as follows: Row 1: 1. Overuse and Appropriateness: a. Avoidance of antibiotic treatment in adults with acute bronchitis, b. Use of imaging studies for low back pain, c. Nonrecommended PSA (prostate-specific antigen) screening in older men; Row 2: 2. Screening, Prevention, and Wellness: a. Adult BMI (body mass index) screening, b. Colorectal cancer screening, c. Flu vaccinations, d. Diabetes and cardiovascular disease screening and monitoring for people with schizophrenia

and bipolar disorder; Row 3: 3. Chronic Condition Management: a. Use of spirometry testing in the assessment and diagnosis of COPD, b. Controlling high blood pressure, c. Statin therapy for patients with cardiovascular disease and diabetes, d. Antidepressant medication management, e. Annual monitoring for patients on persistent medications; Row 4: 4. Measures Targeted Toward Children and Adolescents: a. Lead screening in children, b. Appropriate treatment for children with upper respiratory infection, c. Metabolic monitoring for children and adolescents on antipsychotics; Row 5: 5. Measures Targeted Toward Older Adults: a. Fall risk management, b. Osteoporosis testing and management in older women, c. Medication management in the elderly; Row 6: 6. Measures of Value and Utilization: a. Emergency department utilization; Row 7: 7. Consumer and Patient Engagement and Experience: a. About CAHPS, b. Rating of health plan, c. Rating of health care, d. How well doctors communicate, e. Rating of specialist, f. Customer service. Back to Table There are three column headers: Partner, Website, and Description. Row entries are as follows: Row 1: National Quality Forum, http://www.qualityforum.org/Home.aspx, Not-for-profit, nonpartisan, membership-based organization working to catalyze healthcare improvements (NQF, 2017a). Excellent resource for uniform, evidence-based measures necessary for healthcare quality measurement. NQF does not create measures. It uses an endorsement process that involves diverse public and private sector stakeholders to support quality

improvement. A Consensus Standards Approval Committee (CSAC) considers all measures recommended for NQF endorsement (NQF, 2017b); Row 2: National Patient Safety Foundation (NPSF), www.npsf.org/http://www.ihi.org/Topics/PatientSafety/Pages/default.aspx, NPSF partnered with the Institute for Healthcare Improvement (IHI) in May 2017 to form a new entity focused on patient safety and improved outcomes (IHI, 2017a); Row 3: Institute for Healthcare Improvement (IHI), http://www.ihi.org/resources/Pages/default.aspx, Provides extensive resources for quality improvement. Website offers white papers, multimedia content, instructional materials, and popular tools that provide measurement guidance (IHI, 2017b); Row 4: Patient-Centered Outcomes Research (PCOR) at Agency for Healthcare Research and Quality (AHRQ), https://www.ahrq.gov/pcor/index.html, AHRQ invests in disseminating and supporting implementation of PCOR findings into practice using the PCOR Cycle that involves: delivering health care, identifying evidence gaps, researching answers, and disseminating evidence (AHRQ, 2016). AHRQ contributes to this work by creating evidence syntheses from PCOR findings and designing tools and education that understandable. AHRQ distributes this evidence and supports those entities and professionals that use the evidence for practice improvement (AHRQ, 2016); Row 5: American Society for Quality (ASQ), https://asq.org/, ASQ works to support a global knowledge network that works to improve quality improvement. It offers 18 certifications and provides many quality-related learning tools and products. ASQ has individual and organizational members (ASQ, 2017).

Back to Table There are two column headers: 2008 HAC categories and 2017 HAC categories. Row entries are as follows: Row 1: 1. Foreign object retained after surgery and 1. Foreign object retained after surgery; Row 2: 2. Air embolism and 2. Air embolism; Row 3: 3. Blood incompatibility and 3. Blood incompatibility; Row 4: 4. Stage III and IV pressure ulcers and 4. Stage III and IV pressure ulcers; Row 5: 5. Falls and trauma and 5. Falls and trauma; Row 6: 6. Manifestations of poor glycemic control and 6. Catheter-associated urinary tract infection; Row 7: 7. Catheter-associated urinary tract infection and 7. Vascular catheter-associated infection; Row 8: 8. Vascular catheterassociated infection and 8. Surgical site infection—mediastinitis after coronary artery bypass graft procedures; Row 9: 9. Surgical site infection following coronary artery bypass graft, bariatric surgery, orthopedic procedures (spine, neck, shoulder, elbow) and 9. Manifestations of poor glycemic control; Row 10: 10. Deep vein thrombosis (DVT)/pulmonary embolism (PE) following total knee replacement; hip replacement and 10. Deep vein thrombosis/pulmonary embolism with total knee or hip replacement procedures; Row 11: no data and 11. Surgical site infection—bariatric surgery procedures; Row 12: no data and 12. Surgical site infection—certain orthopedic procures of spine, shoulder, and elbow procedures; Row 13: no data and 13. Surgical site infection following cardiac implantable electronic device procedures; Row 14: no data and 14. Iatrogenic pneumothorax with venous catheterization procedures.

Back to Table There are two column headers: Measurement for Research, and Measurement for Learning and Process Improvement. Row entries are as follows: Row 1: Purpose, To discover new knowledge, and To bring new knowledge into daily practice; Row 2: Tests, One large “blind” test, and Many sequential, observable tests; Row 3: Biases, Control for as many biases as possible, and Stabilize the biases from test to test; Row 4: Data, Gather as much data as possible, “just in case,” and Gather “just enough” data to learn and complete another cycle; Row 5: Duration, Can take long periods of time to obtain results, and “Small tests of significant changes” accelerates the rate of improvement. Back to Table There is one column header: Steps. Row entries are as follows: Row 1: Plan: Diagnose an opportunity. Consider a change idea. Plan the change. Determine metrics of success. Design data collection plan. Determine necessary sampling plan and numbers of subjects. Row 2: Do: Test the change. Conduct a small-scale study. Track the results, measures, challenges, and unintended consequence. Row 3: Study or Check: Review the methods. Analyze results. Identify findings and compare to predictions. Summarize and reflect. Row 4: Act: Take action based on what was learned in the study step. Depending on findings, planned change should be adopted, adapted or abandoned. Back to Table

There are two column headers: Belt Color and Selected, Designated Responsibilities. Row entries are as follows: Row 1: Master Black Belt and Trains and coaches Black and Green Belts; Row 2: Black Belt and Project leader. Trains and coaches project teams; Row 3: Green Belt and Assists with data collection and analysis efforts. Leads Green Belt projects or teams; Row 4: Yellow Belt and Team participant; Row 5: White Belt and Aware of basic Six Sigma concepts. May work on local teams that support projects. May not be a Six Sigma project team member. Back to Table There are three column headers: Types of Benchmarking, Pros, and Cons. Row entries are as follows: Row 1: Literature, Broad range of access to benchmarking data and metrics, and Relevant to populations or to clinical practice? What is the standard error of the benchmark? Row 2: Internal, Ease of access, and Invalid assessment of performance when compared with other institutions; Row 3: System, Avoids pitfalls of literature and internal sources, and Requires coordinated database resources and sophisticated statistical analyses. Back to Table There are two column headers: Medicare program and Medicaid program. Row entries are as follows: Row 1: Eligible Professionals; Medicare program: Administered by CMS, 44,000 dollars maximum per physician (over 5-year period), 90 percent or more of practice must be outpatient based, Cannot

participate in Medicaid program if enrolled in Medicare program, Must apply for Stage 1 Meaningful Use by 2012 to obtain the maximum incentive, and Medicare imposes payment penalty on those failing to demonstrate meaningful use beginning 2015; Medicaid Program: Administered by state Medicaid agency, 63,750 dollars maximum per physician (over 5 years), Must have less than or equal to 30 percent Medicaid patient volume or less than or equal to 20 percent, Medicaid patient volume and be a pediatrician or practice predominantly in a Federally Qualified Health Center or Rural Health Clinic and have less than or equal to 30 percent patient volume attributable to needy individuals, less than or equal to 90 percent of practice must be outpatient based, Cannot participate in Medicare program if enrolled in Medicaid program, Can begin to certify for Meaningful Use by 2016 and still receive full incentive, and Nonparticipants exempt from Medicaid payment reductions. Row 2: Hospitals (Including Critical Access Hospitals); Medicare program: Administered by CMS, Can begin receiving incentive FY 2011 to FY 2015, but payments will decrease for hospitals that start receiving payments in FY 2014 and later, and Medicare and Medicaid program eligible; Medicaid Program: Administered by state Medicaid agency and Acute care hospitals (including critical access and cancer hospitals) with at least 10 percent Medicaid patient volume are eligible. Back to Table There are two column headers: Medicare program and Medicaid program. Row entries are as follows: Row 2:

Medicare Program: Must apply for Stage 1 Meaningful Use by FY 2013 to receive maximum incentive, Hospitals that do not successfully demonstrate meaningful use will be subject to Medicare payment penalties beginning in FY 2015, and Incentive payments are based on several factors, beginning with a 2-million-dollar base payment; Medicaid program: Children’s hospitals are eligible regardless of their Medicaid volume, Can apply for both Medicare and Medicaid programs, and Incentive payments are based on a number of factors, beginning with a 2-million-dollar base payment. Back to Table There are two column headers: Types and Exemplar. Row entries are as follows: Row 1: Websites: Professional organizations, American Nurses Association, American Association of Nurse Practitioners, American Medical Association, American Association of Medical Colleges, and American Association of Colleges of Nursing; Row 2: Social media: Social networking: Facebook, Google+, LinkedIn, Photo sharing: Pinterest, Snapchat, Flickr, Instagram, Video sharing: YouTube, Vimeo, Yahoo video, Shutterfly video, Microblogging: Twitter, tumblr, Blogging: WordPress, Blogger, Crowdsourcing: Ushahidi, CrowdFunding, and Live streaming: Facebook Live, Blab, Periscope, YouTube Live; Row 3: Search engines (in order of volume of users): Google, Bing, Yahoo, Baidu, Ask, AOL Search, Wolfram Alpha (for computational searches), DuckDuckGo (does not retain your search histories), DogPile (uses other search engines to compile results), and Others; Row 4: Electronic databases: Literature, PubMed/Medline,

CINAHL, Ovid, Specialty databases, ClinicalTrials.gov, TOXNET, National Cancer Database, U.S. National Library of Medicine: electronic databases and directories, by alphabetical listing; Information systems: Electronic health records (vendors): Epic, Cerner, Allscripts, NextGen, Athena Health, Clinical support systems, and Administrative systems. Back to Table There are two columns. Row entries are as follows: Row 1: Information Professional: Political/policy, Opinions, Consumer health advice, and Comparing providers, facilities; Row 2: Networking/communication: Job searches, Webinars/conferencing, Document sharing, Real-time patient communication (Twitter, texting), and Language translation; Row 3: Education: Online degrees, Continuing education, Libraries, and Personalized learning assessments; Row 4: Provision of services: Manage appointments and schedules, Professional license application, renewal, and verification, Patient registration and history, Reminders to patients, and Communicate with healthcare providers; Row 5: Marketing: Branding, Advertising, and Price comparisons; Row 6: Maintain or view records: Access patient portal: ask questions, renew medications. Back to Table There are three column headers: Public Laws, Executive Orders, and Initiatives, Year Enacted, Major Content Related to Data. Row entries are as follows: Row 1: Health Insurance Portability and Accountability Act: 1996, Affects healthcare data

availability, Assures a bridge for health insurance coverage for persons who have a change in employment, Requires national electronic standards for claim submission, and Provisions protect the privacy of personal health information; Row 2: Medicare Improvements for Patients and Providers Act: 2008, Provides financial incentives for electronic prescribing (eprescribing), which creates digital data for analysis; Row 3: American Recovery and Reinvestment Act: 2009, Economic stimulus package, Allocated funds to create jobs, boost economic growth, and increase accountability and transparency in government spending, Funded comparative effectiveness research, Created a nationwide health information network, Provided financial incentives for hospitals and physicians who adopted and began using EHRs, Strengthened Health Insurance Portability and Accountability Act privacy and security requirements, and Included Title VIII Health Information Technology for Economic and Clinical Health Act. Back to Table There are three column headers: Public Laws, Executive Orders, and Initiatives, Year Enacted, Major Content Related to Data. Row entries are as follows: Row 4: Health Information Technology for Economic and Clinical Health Act: 2009, Offers financial incentives to providers participating in Medicare and Medicaid for adoption of certified EHRs; ushered in widespread adoption of EHRs in the United States, Goals included improvements in care and reduced disparities, and Increased digital data for big data purposes; Row 5: Patient Protection and Affordable Care Act: 2010, With its amendment, the Health

Care and Education Reconciliation Act is known as Obamacare, Provides incentives for reporting provider performance; established public reporting of quality and cost metrics, Increases hospital data collection and analysis, and Increases the ability to share data across settings; Row 6: Genetic Information Nondiscrimination Act: 2008, Protects individuals from discrimination by insurers and employers based on the results of genetic information and test results, encouraging data collection and use; Row 7: Medicare Access and CHIP Reauthorization Act of 2015: 2015, Reforms Medicare payments to physicians, other providers, and suppliers to reflect a value-based payment model, effective 2019, and Monitors program effectiveness and reports on Medicare-eligible provider performance; Row 8: Executive order 13642: Making Open and Machine Readable the New Default for Government Information: 2013, Federal government requirement to make information easy to find, access, and use, and Adds to the amount of digital data available for exploration and to support decision making; Row 9: Precision Medicine Initiative, 2015, Research initiative that considers individual differences in genetic makeup, environments, and lifestyles and Seeks to improve treatments for cancer, expand research, create new public–private partnerships, and infrastructure needed to expand cancer genomics. Back to Table There are three column headers: Model, Description, and Processes. Row entries are as follows: Row 1: ACE Star (Stevens, 2004), EBP framework for systematically putting EBP

processes into operation, 1. Knowledge discovery, 2. Evidence summary, 3. Translation into practice, recommendations, 4. Integration into practice, and 5. Evaluation; Row 2: Advancing Research and Clinical Practice through Close Collaboration Model (ARCC model) (Melnyk & Fineout-Overholt, 2014), Provides healthcare systems with a guide for implementation and sustainability of EBP to achieve quality outcomes, 1. Assessment of organizational culture and readiness for EBP, 2. Identification of strengths and major barriers, 3. Development and use of EBP mentors, and 4. EBP implementation; Row 3: Johns Hopkins Nursing Evidence-Based Practice Model (Dearholt & Dang, 2012), Assists nurses at the bedside in translating evidence to clinical, administrative, and educational practice, 1. Practice question, 2. Evidence, and 3. Translation. Back to Table There are three column headers: Model, Description, and Processes. Row entries are as follows: Row 4: Iowa Model of Evidence-Based Practice to Promote Quality Care (Titler et al., 2001), A guide for nurses and clinicians in making decisions about day-to-day practices that affect patient outcomes, 1. Identify type of organizational trigger: problem or knowledge focused, 2. Form a team, 3. Gather and critically appraise evidence, 4. Assess if sufficient evidence, 5. Pilot practice change or conduct research, 6. Evaluate pilot practice change, and 7. Institute practice change; Row 5: Promoting Action on Research Implementation in Health Services Framework (PARIHS framework) (Kitson, Harvey, & McCormack, 1998), Provides healthcare systems with a framework for how

research findings can be successfully implemented into practice with equal recognition of level of evidence, the context into which the evidence is being implemented, and the method of facilitating the change, 1. Critical appraisal of evidence, 2. Gain understanding of practice area where change will happen, 3. Create a strategic plan for practice change, and 4. Successful implementation is a function of evidence, context, and facilitation; Row 6: Model for EBP Change (Rosswurm & Larabee, 1999), Model for translating EBP into the healthcare organization, 1. Assess the need for change in practice, 2. Locate the best evidence, 3. Critically analyze the evidence, 4. Design practice change, 5. Implement and evaluate change in practice, and 6. Integrate and maintain change in practice; Row 7: Transdisciplinary Model of EBP (Newhouse & Spring, 2010), Interdisciplinary EBP model to accelerate the translation of EBP across disciplines, 1. Primary researcher, 2. Systematic reviewer, and 3. Practitioner; Row 8: Trinity Evidence-Based Practice Model (Vratney & Shriver, 2007), A conceptual model for EBP that addresses how to overcome barriers to implementation; a guide for growing EBP in your organization while weeding out barriers, 1. Breaking ground, 2. Planting seeds, 3. Sprouting up, 4. Showering of education, 5. Heating things up, 6. Branching out, and 7. Bearing fruit. Back to Table There are four column headers: Name of Source, Type of Evidence, Access, and Fee. Row entries are as follows: Row 1: ACP PIER (American College of Physicians—Physicians Information & Education Resource), Includes guidelines and

recommendations based on all levels of medical evidence, including RCTs, cohort and observational studies, case reports, and expert opinions; https://www.acponline.org/clinicalinformation, and ACP member/fee; Row 2: Agency for Healthcare Research and Quality (AHRQ), Clinical Information Effectiveness: Evidence-based practice, Outcomes and effectiveness, Technology assessments, Guidelines: Preventive services, Clinical practice guidelines, National Guideline Clearinghouse; http://www.ahrq.gov, and Free; Row 3: Campbell Collaboration, Systematic reviews and other evidence synthesis for evidence-based social policy and practice, Emphasis on reviews of research evidence on the effectiveness of social and behavioral interventions; https://www.campbellcollaboration.org, and Free; Row 4: Centre for Evidence-Based Medicine (Oxford), Conferences, workshops, and EBM tools for how to access, appraise, and use evidence; http://www.cebm.net, and Some free, some fee to access; Row 5: Clinical Evidence, Database of best available evidence on common clinical interventions, http://clinicalevidence.bmj.com, and Subscription; Row 6: CINAHL Complete, Comprehensive nursing and allied health research database, providing full text for more than 770 journals, Evidence-based care sheets; https://www.ebsco.com/products/research-databases/cinahlcomplete, Subscription. Back to Table There are four column headers: Name of Source, Type of Evidence, Access, and Fee. Row entries are as follows: Row 7:

Cochrane Collaboration, Cochrane Reviews, http://www.cochrane.org, Free abstract, and Subscription for full text; Row 8: DARE: Database of Abstract Reviews of Effects, Contains 15,000 abstracts of systematic reviews, http://site.ovid.com/products/ovidguide/daredb.htm, and Subscription; Row 9: EBN Online, Evidence-Based Nursing; Electronic journal providing EBN, http://ebn.bmj.com, and Subscription; Row 10: Joanna Briggs Institute, Reliable evidence for health professionals to use to inform their clinical decision making; tools for how to access, appraise, and use evidence, http://joannabriggs.org, and Subscription; Row 11: National Guideline Clearinghouse, A comprehensive free database of evidence-based clinical practice guidelines and related documents, an initiative of the Agency for Healthcare Research and Quality; browse the database by condition or treatment/intervention, http://www.guideline.gov, and Free; Row 12: NICE: National Institute for Health and Care Excellence, NICE develops evidence-based clinical guidelines on the most effective ways to diagnose, treat, and prevent disease and ill health; also have patient-friendly versions of guidelines to help educate and empower patients, caregivers, and the public to take an active role in managing their conditions, http://www.nice.org.uk, and Free; Row 13: Prospero, Protocol details for systematic reviews relevant to health and social care, welfare, public health, education, crime, justice, and international development, where there is a health-related outcome, https://www.crd.york.ac.uk/PROSPERO, and Free. Back to Table

There are four column headers: Name of Source, Type of Evidence, Access, and Fee. Row entries are as follows: Row 14: PubMed/MEDLINE/NLM, Provides free access to Medline and the National Library of Medicine (NLM) database of indexed citations and original abstracts in medicine, nursing, and health care; search tutorials; evidence-based medical reviews (EBMR), http://www.ncbi.nlm.nih.gov/pubmed, and Free abstracts, Some free articles, and Subscription for full text; Row 15: RePort, Access to reports, data, and analyses of NIH research activities and the results of NIH-supported research; http://report.nih.gov, and Free; Row 15: Turning Research into Practice Database (TRIP) Database: For Evidence Based Medicine, Metasearch engine for evidence-based healthcare topics; searches hundreds of EBM and EBN websites that contain synopses, clinical answers, textbook information, clinical calculators, systematic reviews, and guidelines; http://www.tripdatabase.com, and Free; Row 16: UpToDate, Clinical decision support system that combines the most recent evidence with the experience of expert clinicians, http://www.uptodate.com, and Subscription. Back to Table There are two column headers: Level and Evidence Type. Row entries are as follows: Row 1: A: Meta-analysis of multiple controlled studies or metasynthesis of qualitative studies with results that consistently support specific action, intervention, or treatment; Row 2: B: Well-designed controlled studies, both randomized and nonrandomized, with results that consistently support a specific action, intervention, or treatment; Row 3: C:

Qualitative studies, descriptive or correlational studies, integrative reviews, systematic reviews, or randomized controlled trials with inconsistent results; Row 4: D: Peerreviewed professional organizational standards, with clinical studies to support recommendations; Row 5: E: Theory-based evidence from expert opinion or multiple case reports; Row 6: M: Manufacturers’ recommendations only. Back to Table There are two column headers: Type of question and Level of Evidence. Row entries are as follows: Row 1: Diagnostic or diagnostic test: 1. Systematic review/meta-analysis of RCTs, 2. RCTs, 3. Nonrandomized controlled trials, 4. Cohort study or case-control studies, 5. Metasynthesis of qualitative or descriptive studies, 6. Qualitative or descriptive single studies, and 7. Expert opinion; Row 2: Prognosis/prediction or etiology: 1. Synthesis of cohort study or case-control studies, 2. Single cohort study or case-control studies, 3. Metasynthesis of qualitative or descriptive studies, 4. Single qualitative or descriptive studies, and 5. Expert opinion; Row 3: Meaning: 1. Metasynthesis of qualitative or descriptive studies, 2. Single qualitative studies, 3. Synthesis of descriptive studies, and 4. Expert opinion. Back to Table There are three column headers: Evidence Type, Type of PICOT Question Answered, and Level. Row entries are as follows: Row 1: Systematic review with or without meta-analysis of single randomized controlled trials, Intervention, Diagnostic;

1; Row 2: Single randomized controlled trial, Intervention, Diagnostic; 2; Row 3: Systematic review with or without metaanalysis of mixed experimental study designs (RCT or quasiexperimental), Intervention, Diagnostic, 3; Row 4: Nonrandomized controlled trial or systematic review of mixed experimental and nonexperimental study designs, Intervention, Diagnostic, Prognosis/Prediction, Etiology, 4; Row 5: Observational studies (cohort, case-control), Intervention, Diagnostic, Prognosis/Prediction, Etiology, 5; Row 6: Metasynthesis or single qualitative or descriptive studies, Prognosis/Prediction, Etiology, Meaning; 6; Row 7: Peerreviewed professional and organizational standards with clinical studies to support recommendations, Intervention, Diagnostic, Prognosis/Prediction, Etiology; 7; Row 8: Expert opinion or literature review or peer-reviewed professional and organizational standards without clinical studies to support recommendations, Meaning, 8; Row 9: Manufacturer recommendations, Meaning, 9. Back to Table There are four column headers: Author, Tools, Research Method, and Access. Row entries are as follows: Critical Appraisal Tools by Research Method: Row 1: Johns Hopkins Nursing Evidence-Based Practice Research Evidence Appraisal, Research appraisal questions organized by research design, RCTs, Meta-analysis of RCTs, Quasi-experimental, Nonexperimental, Qualitative, Metasynthesis of qualitative studies; Dearholt, S., & Dang, D. (2012). Johns Hopkins Nursing evidence-based practice: Models and guidelines.

Indianapolis, IN: Sigma Theta Tau; Row 2: Melnyk & FineoutOverholt, Rapid Critical Appraisal (RCA) Checklist; method specific, Case-control, Cohort, RCTs, Systematic reviews, Qualitative; Melnyk, B. M., & Fineout-Overholt, E. (2014). Evidence-based practice in nursing and health care: A guide to best practice (3rd ed.). Philadelphia, PA: Lippincott Williams & Wilkins; Row 3: Centre for Evidence-Based Medicine, Critical Appraisal Sheets, Systematic, Prognostic, Diagnostic, RCT, Educational Prescription; http://www.cebm.net/critical-appraisal. Back to Table There are four column headers: Author, Tools, Research Method, and Access. Row entries are as follows: Critical Appraisal Tools by Research Method: Row 4: Craig Hospital, Englewood, CO; Appraisal support tool in the form of a bookmark, All types of research methods, no data; Critical Appraisal Tools for Clinical Guidelines: Row 5: The Agree Collaboration, AGREE II Instrument and My AGREE Plus Software, Clinical practice guideline, and http://www.agreetrust.org; Row 6: Melnyk & Fineout-Overholt, RCA for Evidence-Based Guidelines, Clinical practice guideline, and Melnyk, B. M., & Fineout-Overholt, E. (2014). Evidencebased practice in nursing and health care: A guide to best practice (3rd ed.). Philadelphia, PA: Lippincott, Williams & Wilkins. Back to Table The column headers have the following lead-in: Clinical Question in PICOT Format. There are seven column headers

with single row entry as follows: Citation: Author, year, first few words of title; Evidence Type: Type of evidence being critically appraised (for example, systematic review with meta-analysis, RCT, QI study, metasynthesis clinical practice guideline, expert opinion); Sample, Sample Size, Setting: If applicable (for example, single study), describe the sample, sample size, setting; Findings That Help to Answer Clinical Question: Describe findings that answer clinical question, Limitations: Describe limitations that should be considered when assessing the quality of evidence and worth to practice; Evidence Rating: Level: Identify the level of evidence and with the first entry, state the evidence hierarchy used; Evidence Rating: Quality: Identify the quality rating of evidence and with the first entry, state the quality rating system used. Row 2 to 6: no data. Back to Table The column headers have the following lead-in: Clinical Question in PICOT Format. There are eight column headers with single row entry as follows: Citation: Authors and title; Funding Source: Funding agency, note any conflicts; Level of Evidence: Use level of evidence table from this chapter; Purpose/Research Design: Trial’s purpose/number of subjects invited to participate, attrition rate, trial length; Intervention/Comparison Group: Describe intervention group and comparison group; Results: Include results that answer clinical question; Strengths/Weaknesses: Critically appraise study using appropriate critical appraisal tool; Worth to Practice: Clinical significance; Row 2: Study 1; Column 2 to Column 8: no data; Row 3: Study 2, etc.; Column 2 to Column 8: no data.

Back to Table There are four column headers: Level of Evidence (LOE), Total Number of Evidence Sources for LOE, Overall Summary of Evidence Source Results, and Overall Rating for Quality of Evidence Sources. There are four rows with no data except for the first column with the following entries: Level 1, Level 2, Level 3, and etc. Back to Table There are three column headers: Grade, Grade Definitions, and Suggestions for Practice. Row entries are as follows: Row 1: A: The USPSTF recommends the service. There is high certainty that the net benefit is substantial, Offer or provide this service; Row 2: B: The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial, Offer or provide this service; Row 3: C: The USPSTF recommends selectively offering or providing this service to individual patients based on professional judgment and patient preferences. There is at least moderate certainty that the net benefit is small, Offer or provide this service only if other considerations support offering or providing the service in an individual patient; Row 4: D: The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits, Discourage the use of this service; Row 5: I Statement, The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service.

Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined, Read the clinical considerations section of USPSTF Recommendation Statement. If the service is offered, patients should understand the uncertainty about the balance of benefits and harms. Back to Table There are four column headers: Grade of Recommendation, Clarity of Risk/Benefit, Quality of Supporting Evidence, Implications. Row 1: 1A: Strong recommendation, high-quality evidence, Benefits clearly outweigh risks and burdens, or vice versa, Consistent evidence from well-performed randomized controlled trials or overwhelming evidence of some other form. Further research is unlikely to change our confidence in the estimate of benefit and risk, Strong recommendation, can apply to most patients in most circumstances without reservation. Clinicians should follow a strong recommendation unless a clear and compelling rationale for an alternative approach is present; Row 2: 1B: Strong recommendation, moderate-quality evidence, Benefits clearly outweigh risks and burdens, or vice versa, Evidence from randomized controlled trials with important limitations (inconsistent results, methodologic flaws, indirect or imprecise), or very strong evidence of some other research design. Further research (if performed) is likely to have an impact on our confidence in the estimate of benefit and risk and may change the estimate, Strong recommendation and applies to most patients. Clinicians should follow a strong recommendation unless a clear and compelling rationale for an alternative approach is present; Row 3: 1C: Strong

recommendation, low-quality evidence, Benefits appear to outweigh risks and burdens, or vice versa, Evidence from observational studies, unsystematic clinical experience, or from randomized controlled trials with serious flaws. Any estimate of effect is uncertain, Strong recommendation, and applies to most patients. Some of the evidence base supporting the recommendation is, however, of low quality; Row 4: 2A: Weak recommendation, high-quality evidence, Benefits closely balanced with risks and burdens, Consistent evidence from well-performed randomized controlled trials or overwhelming evidence of some other form. Further research is unlikely to change our confidence in the estimate of benefit and risk, Weak recommendation, best action may differ depending on circumstances or patients or societal values. Back to Table There are four column headers: Grade of Recommendation, Clarity of Risk/Benefit, Quality of Supporting Evidence, Implications. Row 5: 2B: Weak recommendation, moderatequality evidence, Benefits closely balanced with risks and burdens, some uncertainty in the estimates of benefits, risks, and burdens, Evidence from randomized controlled trials with important limitations (inconsistent results, methodologic flaws, indirect or imprecise), or very strong evidence of some other research design. Further research (if performed) is likely to have an impact on our confidence in the estimate of benefit and risk and may change the estimate, Weak recommendation, alternative approaches likely to be better for some patients under some circumstances; Row 6: 2C: Weak recommendation,

low-quality evidence, Uncertainty in the estimates of benefits, risks, and burdens; benefits may be closely balanced with risks and burdens, Evidence from observational studies, unsystematic clinical experience, or from randomized controlled trials with serious flaws. Any estimate of effect is uncertain, Very weak recommendation; other alternatives may be equally reasonable. Back to Table There are five columns and four column headers with the first column without header: Research, EBP, QI, and Program Evaluation. Row entries are as follows: Row 1: Definition: Prescribed, methodical, meticulous technique of investigation, A problem-solving process that integrates existing evidence (research, QI), nursing expertise, and patient preferences to guide care decisions, Appraise the efficiency of clinical interventions and provide guidance for achieving quality outcomes, productivity, and cost containment, Evaluate a specific program using a well-defined conceptual framework to judge success or failure; Row 2: Prompted by: Gap in knowledge, New evidence from research, Process breakdown or system failure, Ineffectiveness, inefficiency, new guidelines; Row 3: Purpose: Generate new knowledge, Integrate best evidence, clinician’s expertise, and patient values and preferences to improve health outcomes, Improve system and process of healthcare delivery; real-life experience and data on application of best practices, Provide timely information/data for decision making for particular programs; Row 4: The Questions: What is the best thing to do? Are we doing the best thing? Are

we doing the best thing right, all the time? Is the thing we are doing successful? Row 5: Institutional review board approval: Yes, unless analysis of public data, No, but health systems may require a review to protect their data, No, but health systems may require a review to protect their data, No, but health systems may require a review to protect their data; Row 6: Sample: Subset of population, Patient population, Unit, service line, institution wide or health system, Specific programs. Back to Table Row entries are as follows: Row 7: Method: Quantitative or qualitative, Level of evidence matches question asked; assess strength and quality of evidence; make recommendations based on evidence; translate evidence into practice using translation strategies, Plan-Do-Study-Act (PDSA), Lean Thinking, Six Sigma, Structure, process, outcome; Quantitative or qualitative. Row 8: Rigor/Control: Maximum rigor/control, More rigor than QI but not as rigorous as research, Least rigorous, Can be as rigorous as research; Row 9: Data collection: Follow specific procedures and don’t deviate, Research and nonresearch evidence sources and critically appraise evidence, Predata and evaluation, data can come from patient record or surveys, Formative and summative evaluation; Row 10: Results: Generalizable to population, Recommendation for practice change, clinical research study, or no change, Applicable to the patients studied, Direct, persuasive, or conceptual utilization; Row 11: Dissemination: Presentation or publish, Presentation or publish, Presentation or publish, Presentation or publication; Row 12: Example:

Emergency department weekend presentation and mortality in patients with acute myocardial infarction (de Cordova, Johansen, Martinez, & Cimiotti, 2017), Alternate light sources in sexual assault examinations: An evidence-based practice project (Eldredge, Huggins, & Pugh, 2012), Large-scale implementation of the I-PASS handover system at an academic medical center (Shahian, McEachern, Rossi, Chisari, & Mort, 2017), Using the program logic model to evaluate ¡cuídate!: A sexual health program for Latino adolescents in a school-based health center (Serowoky, George, & Yarandi, 2015). Back to Table There are two columns with headers. Row entries are as follows: Row 1: Level 1 (strongest): Systematic reviews/metaanalysis of all randomized controlled trials (RCTs); clinical practice guidelines based on RCT data; Row 2: Level 2: Evidence from one or more RCTs; Row 3: Level 3: Evidence from a controlled trial; no randomization; Row 4: Level 4: Case control or cohort studies; Row 5: Level 5: Systematic reviews of descriptive/qualitative studies; Row 6: Level 6: Single descriptive or qualitative study; Row 7: Level 7: Level 7 (weakest): Opinions of authorities/experts. Back to Table There are two column headers: Author and Title. Row entries are as follows: Row 1: van Anders et al. (2017): Discusses the Science of Biology and Relevance to Policy Areas: Parenting, Sports, and Public Space; Row 2: Edward, Hii, Giandinoto, Hennessy, and Thompson (2016): Personal Descriptions of Life

Before and After Bariatric Surgery from Overweight or Obese Men; Row 3: Galbany-Estragués and Comas d’Argemir (2017): Care, Autonomy, and Gender in Nursing Practice: A Historical Study of Nurses’ Experiences; Row 4: Kellet and Fitton (2017): Supporting Transvisibility and Gender Diversity in Nursing Practice and Education: Embracing Cultural Safety; Row 5: Lauffenburger, Robinson, Oramasionwu, and Fang (2014): Racial/Ethnic and Gender Gaps in the Ease of and Adherence to Evidence-Based Preventive Therapies Among Elderly Medicare Part D Beneficiaries After Acute Myocardial Infarction; Row 6: Pederson, Greaves, and Poole (2015): GenderTransformative Health Promotion for Women: A Framework for Action; Row 7: Skop, Lorentz, Jassi, Vesprini, and Einstein (2018): “Guys Don’t Have Breasts”: The Lived Experience of Men Who Have BRCA Gene Mutations and Are at Risk for Male Breast Cancer; Row 8: Wander et al. (2014): The Impact of Patients’ Gender, Race, and Age on Health Professionals’ Pain Management Decisions: An Online Survey Using Virtual Human Technology; Row 9: Yuh-Min, Yueh-Ping, and Min-Ling (2015): Gender Differences in the Predictors of Physical Activity Among Assisted Living Residents. Back to Table There are two column headers: Clinical Statistic and Description. Row entries are as follows: Row 1: Odds ratio (OR): The odds of risk for a person in the experimental group having an adverse outcome compared with a person in the control group. An odds ratio of 1 means the event is equally likely in both groups. An odds ratio greater than 1 means the

event is more likely in the intervention group than the control group. An odds ratio less than 1 means the event is less likely in the intervention group than the control group. Used most in case control and retrospective studies; Row 2: Relative risk ratio (RR): The risk of an outcome in the intervention/treatment group (Y) compared with the control group (X). RR = Y over X. A relative risk of 1 means there is no difference between the two groups. A relative risk of less than 1 means a smaller potential for the effect to occur in the intervention group than in the control group. Used most in randomized controlled trials and cohort studies; Row 3: Relative risk reduction (RRR): The percentage of reduction in the treatment group (Y) compared with the control group (X). RRR equals 1 minus Y over X? 100 percent; Row 4: Absolute risk reduction (ARR): The difference in risk between the control group (X) and the intervention group (Y). ARR = X minus Y; Row 5: Number needed to treat (NNT): The number of patients that must be treated over a given period of time to prevent one adverse outcome. NNT equals 1 over (X minus Y). Back to Table There are five column headers: Author and Year, Design, Sample, Setting; Framework or Intervention or Measures; Goal or Aim; Outcomes or Findings. Row entries are as follows: Row 1: Bundy and Murphy (2014), QI; retrospective audit; outpatient clinic; n equals 42 medical records; In-service based on literature review and retrospective chart audit for use of systembased asthma action plan (AAP); Improve use and completion of AAP post–in-service; Statistically significant proportional

outcomes following in-service, use of AAP and procedure change; Row 2: Hande (2013) EBP; QA; retrospective audit of 90 charts (30 randomly selected for each of 3 providers); Total Quality Management (TQM/CQI); Plan, Do, Study, Act (PDSA); EBP measures modified colorectal prevention data collection form and TQE Benchmark; Assess adherence to colorectal cancer prevention (CRC-P) benchmarking; improve CRC-P; close gaps in detection; report improvement; Identified practice changes; analyzed root causes; actions for improvement. Redesign of CRC-P practices; Row 3: Koman (2018) Utilized video education program to decrease HCV transmission rates in a public health STD clinic; n equals 26; Pre- or post-test design of educational video intervention. Measures included the Brief Hepatitis C Knowledge Scale (Balfour et al., 2009); Increase in HCV knowledge; knowledge retention; decrease in HCV transmission; Increase in post-test knowledge scores by 9% at 3-week follow-up; brief intervention was effective in increasing HCV knowledge; Row 4: Patton, Lim, Ramlow, and White (2015); QI; institution of a collaborative multidisciplinary approach to increase efficiency of evaluating patients presenting with chronic cough; retrospective sample of 165 medical records divided into two groups: current practice and intervention group; Institute for Healthcare Improvement Collaborative Model with focus on Lean/Six Sigma and Awareness, Desire, Knowledge, Ability, Reinforcement (ADKAR) change management; interventions included education of referring providers, software changes, collaborative interdepartmental scheduling, inter-clinic communication, and decision support dashboard; Quality; decrease utilization and unnecessary referrals; decrease length

of time to complete evaluation; Multidisciplinary collaboration; communication associated with decreased costs and utilization of resources. Reduced number of referrals per patient from M equals 3.33 to 1.22; reduced length of itinerary from M equals 126. 93 to 12.9 days; Row 5: Wright (2017); EBP; examined the effect of an intervention to improve staff’s management of hemodialysis vascular access and patient outcomes; convenience sample of RNs, LPNs, and techs; chronic adult outpatient hemodialysis unit; Theory of Reasoned Action or Planned Behavior (TRA or PB); questionnaires based on TRA or PB to determine staff knowledge, beliefs, self-confidence, and intent to manage dialysis vascular access according to EBP guidelines; QI tracking tool; Pre-post education knowledge assessment; determine impact of education on QI measures of dialysis adequacy and vascular access Complication; Findings confirmed results of previous studies that TRA or PB was effective in determining intent to practice according to guidelines; post-education knowledge increased from pre-post education, but not significantly. Simulation offered as an adjunct practice session had few participants. There was a clinically significant decrease in vascular access complications. Back to Table There are two column headers: Outcomes Examples and Indicators. Row entries are as follows: Row 1: Patient satisfaction: Ambulatory care: Survey; Row 2: Risk: Morbidity and mortality: Summary, Patient falls: Reports, Medication errors: Medication administration records (MARs); comprehensiveness of exams; Row 3: Knowledge: Blood

pressure medication: Blood pressure control; Row 4: Conditionspecific: Postoperative pain: Pain management scale, Diabetes management: Blood glucose levels; Row 5: Infection control: Surgical procedures: Hand washing; nosocomial infection rates; Row 6: Compliance: Fluid restriction: Daily weights, Prenatal and postpartum visits. Back to Table There are two column headers: Organization and Website. Row entries are as follows: Row 1: Academy Health: www.academyhealth.org; Row 2: Agency for Healthcare Research and Quality: www.ahrq.gov; Row 3: Centers for Medicare and Medicaid Services: www.cms.gov; Row 4: Institute for Healthcare Improvement: www.ihi.org; Row 5: International Society for Pharmacoeconomics and Outcomes Research: www.ispor.org; Row 6: Johns Hopkins Center for Health Services and Outcomes Research: www.jhsph.edu/research/centers-and-institutes/health-servicesoutcomes-research/; Row 7: The Joint Commission: www.jointcommission.org; Row 8: National Cancer Institute: www.cancer.gov/; Row 9: National Committee for Quality Assurance: www.ncqa.org; Row 10: National Quality Forum: www.qualityforum.org/Home.aspx; Row 11: University of Iowa College of Nursing: www.nursing.uiowa.edu/excellence/evidence-based-practiceguidelines; Row 12: University of Arizona Health Outcomes and Pharmacoeconomics Research (HOPE): www.pharmacy.arizona.edu/centers/health-outcomes-andpharmacoeconomic-center.

Back to Table There are two column headers: Source and Content. Row entries are as follows: Row 1: American College of Physicians (ACP) Journal Club: Articles reporting original studies and systematic reviews; Row 2: ACP JournalWise: Personalized journal alerting service sends messages to a smartphone or email inbox according to subscriber interest and specialties; Row 3: AHRQ: Guidelines and technology assessments on selected topics from 12 evidence-based practice centers. Back to Table There are two column headers: Source and Content. Row entries are as follows: Row 4: AHRQ (SHARE): A five-step process for shared decision making that includes exploring and comparing the benefits, harms, and risks of each option through meaningful dialogue about what matters most to the patient; Row 5: AIDSLINE: Indexes the published literature on HIV and AIDS. The index includes journal articles; monographs; meeting abstracts; and papers, newsletters, and government reports (Fain, 2009); Row 6: CDC Sexually Transmitted Disease Treatment Guidelines: Includes web-browsable sources with cross links; Row 7: Cochrane Database of Systematic Reviews “Reviews individual clinical trials and summarizes systematic reviews from over 100 medical journals” (Fain, 2009, p. 277); Row 8: DynaMed: Point-of-care resource to support clinical decision making; Row 9: EPPI Centre Evidence for Policy and Practice Information and Coordinating Centre, Institute of Education, University of London; Row 10: Essential Evidence

Plus (formerly InfoPOEMs): Includes reviews and commentary of recently published articles by the Journal of Family Practice; Row 11: Evidence-Based Practice at the University of Iowa: Includes an evidence-based practice toolkit, information about recent evidence-based practice projects, and an evidencebased practice model and resources; Row 12: HSTAT Health Services Technology Assessment Text, full-text guidelines; Row 13: Johns Hopkins Evidence-Based Practice Center: Includes systematic reviews of evidence; Row 14: MEDLINE A compilation of information from Index Medicus, Index to Dental Literature, and the International Nursing Index. It includes published research in allied health, biological sciences, information sciences, physical sciences, and the humanities; Row 15: MedPage Today: Includes daily research updates, news by specialty, policy news, continuing medical education (CME), and surveys. Includes an excellent tool, MedPage Tools Guide to Biostatistics, that can be used as a reference guide when reading research articles. Back to Table There are two column headers: Source and Content. Row entries are as follows: Row 16: National Cancer Institute: Includes cancer literature from research, journal articles, government reports, technical reports, meeting abstracts, and papers and monographs; Row 17: Prescriber’s Letter: Includes evidence-based information on new drug developments, with links to articles and continuing education offerings; Row 18: PubMed: Provides source for queries and evidence-based filters for Medline; Row 19: School of Health and Related

Research (ScHarr): Comprehensive up-to-date evidence on the web; Row 20: The Joanna Briggs Institute: International institute that provides resources for evidence-based practice for healthcare professionals in nursing, medicine, midwifery, and allied health; Row 21: The National Quality Forum (NQF): Improving Care through Nursing Provides information on quality and nurse-sensitive outcomes from the American Nurses Association database of nursing quality measures or indicators. Back to Table There are three column headers: Strategy, Relevant Constructs, and Key Illustrative Examples: Phase 1. Row entries are as follows: Row 1: Concrete and specific recommendations; Knowledge, executability, decidability; Concrete and specific recommendations were more likely to be adopted by general practitioners (GPs) than vague, nonspecific recommendations. Observational study (Grol et al., 1998); Row 2: Identify priorities, Set targets for implementation; Goal setting, action planning; Of 228 primary care patients with cardiovascular disease risk factors who made an action plan to identify behavioral change goals, 53 percent also reported making behavioral change related to their action plan. Descriptive study (Handley et al., 2006). Back to Table There are three column headers: Strategy, Relevant Constructs, and Key Illustrative Examples: Phase 1. Row entries are as follows: Row 3: Present a rationale; Beliefs, attitudes, perceived relative advantage; Recommendations

compatible with current values were more likely to be adopted by GPs than those perceived as controversial or incompatible with values. Observational study (Grol et al., 1998); Row 4: Highlight clinical norms; Normative beliefs, attitudes, modeling/verbal persuasion; An intervention to improve myocardial infarction care that involved using local medical opinion leaders to influence peers through small-group discussions, informal consultation, and revisions of clinical protocols was compared with performance feedback alone. Hospitals in both groups improved from baseline to follow-up on indicators of quality; however, the improvement was greatest for those allocated to the peer intervention. Randomized controlled trial (Soumerai et al., 1998); Row 5: Orient to the need of the end user; Complexity; Among the guideline characteristics most commonly endorsed to promote use by GPs was “clarity, simplicity and availability of a short format.” Descriptive study of 391 GPs (Watkins, Harvey, Langley, Gray, & Faulkner, 1999); Row 6: Skills training; Skills, knowledge, self-efficacy; Continuing medical education (CME) improves knowledge, skills, attitudes, and patient outcomes. CME that is interactive, uses multimedia, uses live media, and involves multiple exposures is more effective than other types. Systematic review (Marinopoulos et al., 2007); Row 7: Social influences; Normative beliefs, attitudes, modeling, verbal persuasion; The use of local opinion leaders in hospital settings can be effective in promoting evidence-based practice. Systematic review of 12 studies (Doumitt, Gattelliari, Grimshaw, & O’Brien, 2007); Row 8: Environmental influences; Cues to action, environmental triggers; Guideline adherence improved due to the implementation of a computerized clinical decision aid that gave

clinicians real-time recommendations for venous thromboembolism prophylaxis. Time series study (Durieux, Nizard, Ravaud, Mounier, & Lepage, 2000); Row 9: Patient mediated; Knowledge, skills, and attitudes of patients; Patient request for a new drug and patient acceptability were cited as contributing to decisions to prescribe a new drug in approximately 20 percent of cases. Descriptive study (Prosser, Almond, & Walley, 2003). Back to Table There are three column headers: Strategy, Relevant Constructs, and Key Illustrative Examples: Phase 1. Row entries are as follows: Row 10: Feedback; Positive/negative reinforcement, goal setting, skill development; Audit and feedback are effective strategies for improving care, particularly when baseline adherence to the recommended practice is low. Systematic review of 118 studies (Jamtvedt, Young, Kristofferson, O’Brien, & Oxman, 2006); Row 11: Incentives; Positive/negative reinforcement; Five of six studies examining physician-level incentives and seven of nine studies examining provider-group-level incentives demonstrated partial or positive effects on quality indicators. Systematic review (Peterson, Woodward, Urech, Daw, & Sookanan, 2006); Row 12: Pilot testing with iterative refinement of implementation strategies; Perceived advantages, beliefs, trialability; Breakthrough collaborative model intervention that involved a series of iterative plan-do-study-act cycles was found to be effective in improving care for chronic heart failure. Quasi-experimental, controlled study (Asch et al., 2005).

Back to Table There are three column headers: Participant, Income, and Years of Education. Row entries are as follows: Row 1: 1, 125,000, 19; Row 2: 2, 100,000, 20; Row 3: 3, 40,000, 16; Row 4: 4, 35,000, 16; Row 5: 5, 41,000, 18; Row 6: 6, 29,000, 12; Row 7: 7, 35,000, 14; Row 8: 8, 24,000, 12; Row 9: 9, 50,000, 16; Row 10: 10, 60,000, 17. Back to Table There are three column headers: Participant, GPA, and TV Use measured in hours per week. Row entries are as follows: Row 1: 1, 3.1, 14; Row 2: 2, 2.4, 10; Row 3: 3, 2.0, 20; Row 4: 4, 3.8, 7; Row 5: 5, 2.2, 25; Row 6: 6, 3.4, 9; Row 7: 7, 2.9, 15; Row 8: 8, 3.2, 13; Row 9: 9, 3.7, 4; Row 10: 10, 3.5, 21. Back to Table The outline is as follows: 1. Introduction, 2. Purpose of the study, 3. Theoretical framework, 4. Hypothesis, 5. Design: A. What kind of study, B. Intervention, C. Sample: 1. Population, 2. Inclusion/exclusion criteria, D. Instruments; 6. Analysis: A. Method, B. Types of statistical tests used, 7. Findings, 8. Discussion, 9. Implications: A. Research, B. Clinical practice. Back to Table Row entries are as follows: Row 1: PosterPresentations.com (Scientific Template), www.posterpresentations.com; Row 2: Indiana University-Purdue University, Indianapolis, Center for

Teaching and Learning, http://ctl.iupui.edu/Resources/Documenting-YourTeaching/Resources-for-Poster-Presentations; Row 3: Posters 4 Research.com, https://posters4research.com/freetemplates/a01-36x48ppt.php; Row 4: University of North Carolina, Academic Poster Presentations, http://gradschool.unc.edu/academics/resources/postertips.html; Row 5: Vanderbilt University Poster Presentations, https://ww2.mc.vanderbilt.edu/evidencebasedpractice/50289. Back to Table There are three columns with headers: Strategy, Wordy Examples, and Concise Examples. Row entries are as follows: Row 1: Edit common phrases that are wordy: in order to, for the purpose of, in the event that, which is, who are; to, to, if, [likely can be omitted], [likely can be omitted]; Row 2: Eliminate redundant pairs; keep the one word that best reflects your intent: first and foremost, whole entire, hopes and dreams; first, entire, dreams; Row 3: Cut repetitive words from phrases: period of time, personal opinion, free gift, short in length: time, opinion, gift, short; Row 4: Reduce prepositional phrases: of particular interest, in an effort to decrease; of interest, to decrease (or decreasing); Row 5: Remove unneeded qualifiers or modifiers: actually, really, basically, probably, very, definitely, somewhat, kind of, extremely, practically; To write an excellent manuscript, you have to relearn how to write. Back to Table There are three columns with headers: Strategy, Wordy

Examples, and Concise Examples. Row entries are as follows: Row 6: Eliminate nominalization (i.e., transform a noun into a verb), The DNP students jointly gave a presentation at the conference, The DNP students presented jointly at the conference; Row 7: Eliminate grand phrases that add no meaning to a sentence: as a matter of fact, by virtue of the fact, for the most part, in a very real sense, in the process of, it seems that In the process of learning how to write, the DNP students—for the most part—did extremely superbly; While learning to write, most of the DNP students did superbly. Back to Table There are three column headers: Error, Illustration: Incorrect, and Illustration: Correct. Row entries are as follows: Row 1: Failing to hyphenate a compound adjective that could be misread when it precedes the term it modifies; Evidence based (without hyphen) practice, Middle class (without hyphen) community; Evidence-based (with hyphen) practice, Middleclass (with hyphen) community; Row 2: Using a colon instead of a semicolon to separate clauses in a sentence: Use a colon if it follows what could stand as a complete sentence. (Capitalize the first word that follows the colon). Use a colon if it follows a phrase that introduces a series. Use a semicolon to separate two independent clauses that are not linked by a conjunction (e.g., however, if, and, or, but); This sentence is complete, (comma) another (lower case a) sentence would complement it. The following punctuation marks are used. (period) Commas, periods, quotation marks, colons, and semicolons. This sentence could end with a period, (comma) however, it is short

and connects well with this thought; This sentence is complete: (comma replaced by colon) Another (letter A capitalized) sentence complements it. The following punctuation marks are used: (period replaced by colon) commas, periods, quotation marks, colons, and semicolons. This sentence could end with a period; (comma replaced by semicolon) however, it is short and connects well with this thought; Row 3: Using the wrong punctuation in a series (i.e., items in a list). If the list is introduced by a clause (punctuated by a colon), then use commas. If, however, any phrase in the series has punctuation within it, then use semicolons; This series of items is punctuated incorrectly: colons, which are symbolized by two vertically oriented dots, commas, (comma) and periods symbolized with one dot; This series of items is punctuated correctly: colons, which are symbolized by two vertically oriented dots; commas; (comma replaced by semicolon) and periods, symbolized with one dot; Row 4: Anthropomorphizing, or attributing human characteristics to inanimate objects or abstractions; The study found that . . . The QI project showed . . .; The researchers found that . . . The project leaders showed . . .; Row 5: Overuse of pronouns, leaving uncertainty about to whom or to what the pronoun refers; It was helpful to read its origins. (What is the antecedent for the possessive pronoun its?); Lee found it helpful to read about the origins of nursing; Row 6: Disagreement of the subject and verb; both should be either singular or plural; The data is missing. (Datum is singular.) The data are missing. The word data is plural. (Word is singular, so verb is singular.) Back to Table

There are three column headers: Error, Illustration: Incorrect, and Illustration: Correct. Row entries are as follows: Row 7: Misplaced or dangling modifiers, or failing to link the describing word or phrase with the word it modifies; Being uncertain about how to write, journal guidelines were followed. Sammy was uncertain about how to write, so he followed the journal guidelines; Row 8: Lack of parallel construction, or writing a list where each item is written using a different grammatical structure; instead, make each item parallel (e.g., all starting with an active verb phrase or with an adjective plus noun); The DNP students include men and women, compassionate clinicians, and those who are eagerly anticipating a doctorate; The DNP students include men and women, clinicians and academicians, and experienced and inexperienced writers. Back to Table There are three column headers: Behavioral Risks, Percentage of Population, and Year. Row 1: Alcohol (12 years and older): 52.7, 2014; Row 2: Marijuana (12 years and older): 8.4, 2014; Row 3: Cocaine use (12th graders): 1.0, 2014; Row 4: Cocaine use (10th graders), 0.6, 2014; Row 5: Cocaine use (8th graders), 0.5, 2014; Row 6: Cigarette smoking (18 years and older): 16.8, 2014; Row 7: Hypertension (20 years and older), 30.4, 2011 to 2014; Overweight and obese (20 years and older): 69.5, 2011 to 2014; Serum cholesterol (20 years and older): 12.1, 2011 to 2014. Back to Table There are six column headers: Type of Cancer, 1991 to 1995,

1994 to 2003, 1998 to 2007, 2001 to 2010, and 2009 to 2013. Row entries are as follows: Row 1: All cancers: 3.0, 1.1, 1.4, 1.5, 1.5; Row 2: Breast cancer: 6.3, 2.5, 2.2, 2.2, 1.9; Row 3: Cervical cancer: 9.7, 3.6, 2.6, 1.5, 0.8; Row 4: Ovarian cancer: 4.8, 0.5, 0.8, 2.0, 2.1; Row 5: Prostate cancer: 6.3, 3.5, 3.1, 2.7, 3.6. Back to Table There are three column headers: Cause of Death, Deaths, and Percentage of All Deaths. Row entries are as follows: Row 1: All causes: 2,626,418, 100.0; Row 2: Diseases of the heart: 614,348, 23.4; Row 3: Malignant neoplasms, 591,699, 22.5; Row 4: Chronic lower respiratory diseases: 147,101, 5.6; Row 5: Unintentional injuries: 136,053, 5.2; Row 6: Cerebrovascular diseases: 133,103, 5.1; Row 7: Alzheimer’s disease: 93,541, 3.6; Row 8: Diabetes mellitus: 76,488, 2.9; Row 9: Influenza and pneumonia: 55,227, 2.1; Row 10: Nephritis, nephrotic syndrome, and nephrosis: 48,146, 1.8; Row 11: Suicide: 42,773, 1.6. Back to Table There are four column headers: Year, Total, Male, and Female. Row entries are as follows: Row 1: 2002: 77.0, 74.4, 79.6; Row 2: White: 77.5, 74.9, 80.1; Row 3: Black: 72.2, 68.7, 75.4; Row 4: 2007: 78.1, 75.5, 80.6; Row 5: White: 78.5, 76.0, 80.9; Row 6: Black: 73.8, 70.3, 77.0; Row 7: 2014: 78.8, 76.4, 81.2; Row 8: White: 79.0, 76.7, 81.4; Row 9: Black: 75.6, 72.5, 78.4. Back to Table

There are two column headers: Market Justice and Social Justice. Row entries are as follows: Row 1: Views health care as an economic good, Views health care as a social resource; Row 2: Assumes free-market conditions for health services delivery, Requires active government involvement in health services delivery; Row 3: Assumes that markets are more efficient in allocating health resources equitably, Assumes that the government is more efficient in allocating health resources equitably; Row 4: Production and distribution of health care determined by market-based demand, Medical resource allocation determined by central planning; Row 5: Medical care distribution based on people’s ability to pay, Ability to pay is inconsequential for receiving medical care; Row 6: Access to medical care viewed as an economic reward of personal effort and achievement, Equal access to medical services viewed as a basic right. Back to Table Row entries for implications are as follows: Row 7: Individual responsibility for health, Collective responsibility for health; Row 8: Benefits based on individual purchasing power, Everyone is entitled to a basic package of benefits; Row 9: Limited obligation to the collective good, Strong obligation to the collective good; Row 10: Emphasis on individual well-being, Community well-being supersedes that of the individual; Row 11: Private solutions to social problems, Public solutions to social problems; Row 12: Rationing based on ability to pay, Planned rationing of health care.

Back to Table The list is as follows: 1. Access to health services, 2. Adolescent health (new topic area), 3. Arthritis, osteoporosis, and chronic back conditions, 4. Blood disorders and blood safety (new topic area), 5. Cancer. 6. Chronic kidney disease, 7. Dementias, including Alzheimer’s disease (new topic area), 8. Diabetes, 9. Disability and health, 10. Early and middle childhood (new topic area), 11. Educational and communitybased programs, 12. Environmental health, 13. Family planning, 14. Food safety, 15. Genomics (new topic area), 16. Global health (new topic area), 17. Health communication and health information technology, 18. Healthcare-associated infections (new topic area), 19. Health-related quality of life and well-being (new topic area), 20. Hearing and other sensory or communication disorders, 21. Heart disease and stroke, 22. HIV, 23. Immunization and infectious diseases, 24. Injury and violence prevention, 25. Lesbian, gay, bisexual, and transgender health (new topic area), 26. Maternal, infant, and child health, 27. Medical product safety, 28. Mental health and mental disorders, 29. Nutrition and weight status, 30. Occupational safety and health, 31. Older adults (new topic area), 32. Oral health, 33. Physical activity, 34. Preparedness (new topic area), 35. Public health infrastructure, 36. Respiratory diseases, 37. Sexually transmitted diseases, 38. Sleep health (new topic area), 39. Social determinants of health (new topic area), 40. Substance abuse, 41. Tobacco use, and 42. Vision. Back to Table

There are six column headers: Authors/Year, Model Name, Components of Constructs or Domains, Sources, Assessment Instrument Linkage, and Validation. Row entries are as follows: Row 1: Campinha-Bacote, 2002, Culturally competent model of care, Five constructs within the cultural content of individual, family, and community (cultural awareness, knowledge, skill, encounters, and desire [cultural desire added in 1998]), Leininger’s (1991) transcultural nursing theory; Pedersen’s (1998) multicultural development theory (as cited in CampinhaBacote, 2002b), Inventory for assessing the process of cultural competence among healthcare professionals, revised (IAPCCR), Yes; Row 2: Papadopoulos et al., 1998, Model for the development of culturally competent health practitioners, Four components (cultural awareness, cultural knowledge, cultural sensitivity, cultural competence), no data, Cultural competence assessment tool (CCA Tool), 2003, (40 items) based on Papadopoulos et al.’s 1998 model (Schim, Doorenbo, Miller, & Benkert (2003), Yes; Row 3: Kim-Godwin et al, 2001, Culturally competent community care model, Three constructs (cultural competence, healthcare system, and health outcomes) with four dimensions (caring, cultural sensitivity, cultural knowledge, and cultural skills), Concept analysis, Cultural competence scale to test the three dimensions of cultural sensitivity, knowledge, and skills, Yes. Back to Table There are six column headers: Authors/Year, Model Name, Components of Constructs or Domains, Sources, Assessment Instrument Linkage, and Validation. Row entries are as follows:

Row 4: Jeffreys, 2010a, Cultural competence and confidence model, Transcultural nursing skills in cognitive, practical, and affective dimensions, transcultural self-efficacy, and culturally congruent care, Leininger’s transcultural nursing theory; Bandura’s (1986) self-efficacy theory in psychology, Transcultural self-efficacy tool (TEST), Yes; Row 5: Schim & Doorenbos, 2010, 3D model of culturally congruent care, Three-dimensional model displaying provider level, client level, and outcomes level when provider and patient elements make for a culturally sensitive fit, Leininger’s transcultural nursing theory, Cultural competence assessment (CCA), Yes; Row 6: Campinha-Bacote, 2005, Biblically based cultural competence model, Fifteen intellectual and moral virtues (love, caring, humility, love of truth, teachableness, intellectual honesty, inquisitiveness, wisdom, discernment, judgment, prudence, attentiveness, studiousness, practical, and compassion) integrated into five constructs (cultural awareness, cultural knowledge, cultural desire, cultural skill, and cultural encounters), no data, Inventory for assessing a biblical worldview of cultural competence (IABWCC) among healthcare professionals, no data; Row 7: Papadopoulos & Lees, 2008, Model for the development of culturally competent researchers, Four components (cultural awareness, cultural knowledge, cultural sensitivity, cultural competence) with culture-generic and culture-specific competence as the two layers of cultural competence, no data, no data, no data. Back to Table There are six column headers: Authors/Year, Model Name,

Components of Constructs or Domains, Sources, Assessment Instrument Linkage, and Validation. Row entries are as follows: Row 8: Wills, 1999, Framework for cultural competence, Sevenstep progression (knowledge of one’s own culture, knowledge of other’s culture, cultural interaction, cultural tolerance, cultural induction, cultural appreciation, acceptance, cultural competence), no data, no data, no data; Row 9: Wells, 2000, Cultural development model (for individual and institutional cultural competence development), A continuum of six elements occurring over two phases (cultural incompetence, cultural knowledge, and cultural awareness as the cognitive phase; cultural sensitivity, cultural competences, and cultural proficiency as the affective phase), Cross et al., 1989; Orinda, 1992, no data, no data; Row 10: Burchum, 2002, Model for cultural competence, Six attributes (cultural awareness, knowledge, understanding, sensitivity, interaction, and skill); a nonlinear, expansive process of becoming culturally competent, Concept analysis, no data, no data; Row 11: Pacquiao, 2001, Culturally competent model of ethical decisions, Framework based on culturally competent ethical decision making and human rights. Key elements include the fundamental right of individuals, families, groups, and populations to healthcare that is meaningful, supportive, and beneficial. Recognizing values and assumptions of clients will provide better patient outcomes., Leininger’s transcultural nursing theory and principles of culturally congruent health care as a basic human right, no data, no data; Row 12: Suh, 2004, Model of cultural competence, Four domains as antecedents: cognitive (cultural awareness, knowledge), affective (sensitivity), behavior (skills), and environmental (encounters); three attributes of cultural

competence (ability, openness, flexibility); and three variables (receiver-based, provider-based, and health outcomes), Concept analysis, no data, no data. Back to Table There are six column headers: Authors, Model Name, Components or Constructs or Domains, Sources, Assessment Instrument Linkage, and Validation. Row entries are as follows: Row 1: Giger & Davidhizar, 2004, 2008, Transcultural assessment model, Six cultural phenomena (communication, space, social organization, time, environment control, and biological variations), Leininger (1991); Spector (1996); Orque, Bloch, & Monrroy (1983); as cited in Giger & Davidhizar (2004, 2008), Tested Smith (1998b) with three scales: CAS by Bonaparte (1997, 1979); CSES by Bernal & Froman (1987, 1993); and Rooda’s (1990, 1992) knowledge-based questions on cultural competence); also as cited in Giger & Davidhizar, 2002, Yes; Row 2: Spector, 2004, 2009, Health traditions model, Five aspects of heritage consistency (culture, ethnicity, religion, [acculturation, and socialization, 2009]) interrelated with six cultural phenomena (communication, space, social organization, time, environmental control, and biological variation) to maintain, process, and restore the health of the body, mind, and spirit, Giger & Davidhizar’s (1999, 2002, 2004, 2008) model; Ester & Ziow’s theory (as cited in Spector, 2013), Heritage assessment tool with 29 questions, Spector (2004b), no data; Row 3: Orque, 1983, Ethnic cultural system framework, Eight components applicable to nurses and clients (diet, family life processes, healing beliefs and practices,

language and communication process, social groups’ interactive patterns, value orientations, religion, art land history) along with two models (intercultural communication model and model of biological, sociological, and psychological systems), Nursing, sociology, Bloch’s (1983) assessment guide for ethnocultural variations. Back to Table Row entries are as follows: Row 4: Leininger, 1991, Sunrise model, Seven domains (culture values and lifeways; religion, philosophical, and spiritual beliefs; economic factors; educational factors; technological factors; kinship and social ties; and political and legal factors) and three modalities (cultural care preservation and maintenance; cultural care accommodation and negotiation; and cultural care repatterning and restructuring), Nursing, anthropology, no data, no data, no data; Row 5: Purnell, 2002, 2005, Purnell model for cultural competence, Twelve cultural domains (overview, inhabited localities, and topography; communication; family roles and organization; workforce; bicultural ecology; high-risk health behaviors; nutrition; pregnancy and childbearing practices; death rituals; spiritually; healthcare practices; and healthcare practitioners), Organizational, administrative, communication, and family development theories, no data, no data, no data; Row 6: Andrews & Boyle, 2008, Transactional nursing assessment guide for individuals and families, Twelve categories of cultural knowledge (biocultural variations; cultural affiliations; communication; cultural sanctions and restrictions; developmental considerations; economics; educational

background; health-related beliefs and practices; kinships and social networks; nutrition; religion and spirituality; values, Leininger’s transcendental nursing theory. Back to Table There are seven column headers: Item, 1970, 1980, 1990, 2000, 2010, and 2014. Row entries for prenatal care began during first trimester are as follows: Row 1: All mothers: 68.0, 76.3, 75.8, 83.2, 83.2, 84.8; Row 2: White: 72.3, 79.2,79.2, 85.0, 84.7, 86.6; Row 3: Black: 44.2, 62.4, 60.6, 74.3, 76.0, 80.8; Row 4: American Indian or Alaskan Native: 38.2, 55.8, 57.9, 69.3, 69.5, 76.7; Row 5: Asian or Pacific Islander: no data, 73.7, 75.1, 84.0, 84.8, 86.4; Row 6: Hispanic origin: no data, 60.2, 60.2, 74.4, 77.3, 83.3. Row entries for education of mother 16 years or more are as follows: Row 7: All mothers: 8.6, 14.0, 17.5, 24.7, 26.6 (data from 2008), 20.2; Row 8: White: 9.6, 15.5, 19.3, 26.3, 27.9 (data from 2008), 25.0; Row 9: Black: 2.8, 6.2, 7.2, 11.7, 13.4 (data from 2008), 12.5; Row 10: American Indian or Alaska Native: 2.7, 3.5, 4.4, 7.8, 8.5 (data from 2008), 12.2; Row 11: Asian or Pacific Islander: no data, 30.8, 31.0, 42.8, 47.1 (data from 2008), 35.1; Row 12: Hispanic origin: no data, 4.2, 5.1, 7.6, 8.7 (data from 2008), 8.4; Item: 1970, 1980, 1990, 2000, 2010, 2014. Row entries for low birth weight (less than 2,500 grams) are as follows: Row 13: All mothers: 7.93, 6.84, 6.97, 7.57, 8.15, 8.00; Row 14: White: 6.85, 5.72, 5.70, 6.55, 7.08, 6.98; Row 15: Black: 13.90, 12.69, 13.25, 12.99, 13.21, 12.83; Row 16: American Indian or Alaska Native: 7.97, 6.44, 6.11, 6.76, 7.61, 7.65; Row 17: Asian or Pacific Islander: no data, 6.68, 6.45, 7.31, 8.49, 8.05; Row 18:

Hispanic origin (selected states): no data, 6.12, 6.06, 6.41, 6.97, 7.05. Back to Table There are seven column headers: race and cause of death, 1970, 1980, 1990, 2000, 2010, and 2014. Row entries for all persons: deaths per 100,000 standard population are as follows: Row 1: All causes: 1,222.6, 1,039.1, 938.7, 869.0, 747.0, 724.6; Row 2: Diseases of the heart: 492.7, 412.1, 321.8, 257.6, 179.1, 167.0; Row 3: Ischemic heart disease: no data, 345.2, 249.6, 186.8, 113.6, 98.8; Row 4: Cerebrovascular diseases: 147.7, 96.2, 65.3, 60.9, 39.1, 36.5; Row 5: Malignant neoplasms: 198.6, 207.9, 216.0, 199.6, 172.8, 161.2; Row 6: Chronic lower respiratory diseases: 21.3, 28.3, 37.2, 44.2, 42.2 40.5; Row 7: Influenza and pneumonia: 41.7, 31.4, 36.8, 23.7, 15.1, 15.1; Row 8: Chronic liver disease and cirrhosis: 17.8, 15.1, 11.1, 9.5, 9.4, 10.4; Row 9: Diabetes mellitus: 24.3, 18.1, 20.7, 25.0, 20.8, 20.9; Row 10: Human immunodeficiency virus (HIV) disease: no data, no data, 10.2, 5.2, 2.6, 2.0; Row 11: Unintentional injuries: 60.1, 46.4, 36.3, 34.9, 38.0, 40.5; Row 12: Motor vehicle-related injuries: 27.6, 22.3, 18.5,15.4,11.3, 10.8; Row 13: Suicide: 13.1, 12.2, 12.5, 10.4, 12.1, 13.0; Row 14: Homicide: 8.8,10.4, 9.4, 5.9, 5.3, 5.1. Row entries for white are as follows: Row 15: All causes: 1,193.3, 1,012.7, 909.8, 849.8, 741.8, 725.4; Row 16: Diseases of the heart: 492.2, 409.4, 317.0, 253.4, 176.9, 165.9; Row 17: Ischemic heart disease: no data, 347.6, 249.7, 185.6, 113.5, 99.3; Row 18: Cerebrovascular diseases: 143.5, 93.2, 62.8, 58.8, 37.7, 35.2; Row 19: Malignant neoplasms: 196.7, 204.2, 211.6, 197.2,

172.4, 161.9; Row 20: Chronic lower respiratory diseases: 21.8, 29.3, 38.3, 46.0, 44.6, 43.1; Row 21: Influenza and pneumonia: 39.8, 30.9, 36.4, 23.5, 14.9, 15.1. Back to Table Row entries for white are as follows: Row 22: Chronic liver disease and cirrhosis: 16.6, 13.9, 10.5, 9.6, 9.9, 11.2; Row 23: Diabetes mellitus: 22.9, 16.7, 18.8, 22.8, 19.0, 19.3; Row 23: Human immunodeficiency virus (HIV) disease: no data, no data, 8.3, 2.8, 1.4, 1.1; Row 24: Unintentional injuries: 57.8, 45.3, 35.5, 35.1, 40.3, 43.1; Row 25: Motor vehicle-related injuries: 27.1, 22.6, 18.5, 15.6, 11.7, 11.1; Row 26: Suicide: 13.8, 13.0, 13.4, 11.3, 13.6, 14.7; Row 27: Homicide: 4.7, 6.7, 5.5, 3.6, 3.3, 3.0. Row entries for black are as follows: Row 28: All causes: 1,518.1, 1,314.8, 1,250.3, 1,121.4, 898.2, 849.3; Row 29: Race and Cause of Death: 1970, 1980, 1990, 2000, 2010, 2014; Row 30: Diseases of the heart: 512.0, 455.3, 391.5, 324.8, 224.9, 206.3; Row 31: Ischemic heart disease: no data, 334.5, 267.0, 218.3, 131.2, 112.8; Row 32: Cerebrovascular diseases: 197.1, 129.1, 91.6, 81.9, 53.0, 49.7; Row 33: Malignant neoplasms: 225.3, 256.4, 279.5, 248.5, 203.8, 185.6; Row 34: Chronic lower respiratory diseases: 16.2, 19.2, 28.1, 31.6, 29.0, 28.4; Row 35: Influenza and pneumonia: 57.2, 34.4, 39.4, 25.6, 16.8, 16.1; Row 36: Chronic liver disease and cirrhosis: 28.1, 25.0, 16.5, 9.4, 6.7, 7.2; Row 37: Diabetes mellitus: 38.8, 32.7, 40.5, 49.5, 38.7, 37.3; Row 38: Human immunodeficiency virus (HIV) disease: no data, no data, 26.7, 23.3, 11.6, 8.3; Row 39: Unintentional injuries: 78.3, 57.6, 43.8, 37.7, 31.3, 33.8; Row 40: Motor vehicle-related injuries: 31.1,

20.2, 18.8, 15.7, 10.9, 11.1; Row 41: Suicide: 6.2, 6.5, 7.1, 5.5, 5.2, 5.5; Row 42: Homicide: 44.0, 39.0, 36.3, 20.5, 17.7, 17.2. Back to Table There are three column headers: Infant Deaths, Neonatal Deaths, and Postneonatal Deaths. Row entries are as follows: Row 1: Race of Mother: 1983, 1990, 2000, 2008, 2013, 1983, 1990, 2000, 2008, 2013, 1983, 1990, 2000, 2008, 2013; Row 2: All mothers: 10.9, 8.9, 6.9, 6.6, 6.0, 7.1, 5.7, 4.6, 4.3, 4.0, 3.8, 3.2, 2.3, 2.3, 1.9; Row 3: White: 9.3, 7.3, 5.7, 5.6, 5.1, 6.1, 4.6, 3.8, 3.6, 3.4, 3.2, 2.7, 1.9, 2.0, 1.6; Row 4: Black: 19.2, 16.9, 13.5, 12.4, 10.8, 12.5, 11.1, 9.1, 8.1, 7.3, 6.7, 5.9, 4.3, 4.3, 3.5; Row 5: American Indian or Alaska Native: 15.2, 13.1, 8.3, 8.4, 7.6, 7.5, 6.1, 4.4, 4.2, 4.1, 7.7, 7.0, 3.9, 4.2, 3.5; Row 6: Asian or Pacific Islander: 8.3, 6.6, 4.9, 4.5, 4.1, 5.2, 3.9, 3.4, 3.1, 3.0, 3.1, 2.7, 1.4, 1.4, 1.1; Row 7: Hispanic origin (selected states): 9.5, 7.5, 5.6, 5.6, 5.0, 6.2, 4.8, 3.8, 3.9, 3.6, 3.3, 2.9, 1.8, 1.8, 1.5. Back to Table There are four column headers: sex and race (20 to 74 years, age adjusted), percentage with hypertension, percentage with cholesterol, level greater than 240 milligrams per deciliter, percentage that is overweight. Row entries are as follows: Row 1: Both sexes: 30.4, 27.8, and 69.5. Row entries for white are as follows: Row 2: Male: 30.2, 29.4, and 73.7; Row 3: Female: 28.0, 28.0, and 63.5. Row entries for black are as follows: Row 4: Male: 42.4, 24.5, and 69.6; Row 5: Female, 44.0, 25.7, and 82.0.

Back to Table There are eight column headers: Vaccination, Race (Total), Race (White), Race (Black), Poverty Status (Below Poverty), Poverty Status (At or Above Poverty), Inside MSA (Inner City), and Inside MSA (Remaining Areas). Row entries are as follows: Row 1: DTP superscript 1: 84, 86, 80, 79, 87, 84, 85; Row 2: Polio superscript 2: 93, 93, 92, 92, 95, 93, 94; Row 3: Measlescontaining vaccines or measles or mumps or rubella superscript 3: 92, 91, 90, 90, 93, 92, 91; Row 4: Hib superscript 4: 82, 84, 75, 83, 76, 81, 83; Row 5: Combined series superscript 5: 72, 73, 65, 66, 75, 71, 73. Back to Table There are two column headers: service and organization and number of mental health organizations. Row entries are as follows. Row 1: all organizations, 10,374; Row 2: psychiatric hospitals, 648; Row 3: general hospitals, 1,170; Row 4: outpatient clinics, 6,305; Row 5: residential treatment centers for emotionally disturbed children, 781; Row 6: all other, 1,470. Back to Table There are two column headers: staff discipline, number, and year. Row entries are as follows. Row 1: psychiatrists: 33,727, 2011; Row 2: child and adolescent psychiatrists: 6,398, 2009; Row 3: psychologists: 95,545, 2011; Row 4: clinical social workers: 193,038, 2008; Row 5: psychiatric nurses: 13,701, 2011; Row 6: substance abuse counselors: 48,080, 2011; Row

7: counselors: 144,567, 2011; Row 8: marriage and family therapists: 62,316, 2011. Back to Table There are five column headers: Characteristic, 2010 to 2014 Cumulative (Number), 2010 To 2014 Cumulative (Percentage), 2014 (Number), and 2014 (Percentage). Row entries are as follows: Row 1: Total: 1,201,185, 100.0, 44,073, and 100.0. Row entries for Sex are as follows: Row 2: Male (13 years and older): 947,580, 78.9, 35,571, 80.7; Row 3: Female (13 years and older): 244,044, 20.3, 8,328, 18.9; Row 4: Children younger than 13 years: 9,561, 0.8, 174, 0.4. Row entries for Race or Ethnic group are as follows: Row 5: White: 436,952, 38.1, 12,025, 27.3; Row 6: Black: 499,734, 41.9, 19,540, 44.3; Row 7: Hispanic: 217,650, 17.5, 10,201, 23.1; Row 8: Asian: 9,689, 0.8, 1,046, 2.4; Row 9: Native Hawaiian or other Pacific Islander: 842, 0.1, 58, 0.1; Row 10: American Indian/Alaska Native: 3,498, 0.3, 222, 0.5. Back to Table There are two column headers: locus and factors. Row entries are as follows: Row 1: Agent related: Level of moral development, Capacity to recognize ethical content; Chambliss (1996) discusses the phenomenon of “routinization of disaster,” Openness to reflection, Personal or emotional issues, Energy levels, Creativity, Locus of control (powerfulness or powerlessness), Inability to connect with patient, Fear of disapproval (peer or other), Disapproval of patient’s choice, Time of day—complexity of preceding workload or decisions,

Level of knowledge related to the issue, and Subconscious cognitive processes—effects of unexamined “universal” cognitive biases—overreliance on intuitions (Doris et al., 2010; Kahnemann, 2011); Row 2: Environmental: Pressures from peers—supervisors, Competing demands (peers or patients or relatives or institution), Social sanction, Economic and institutional conditions, Time or resource constraints, Conflicts of interest, Job insecurity, and Catastrophic conditions. Back to Table There are two columns with psychological or social queries on the first column and physical health queries on the second column. Data from the table are as follows: Psychological or social queries: Do I have quiet, reflective time for rejuvenating? Is there an opportunity for me to lead efforts to improve the practice environment so that a healthy milieu is created and maintained? How might I increase my opportunity for calm and solace? Is there an opportunity for incorporating meditation in my daily work routine? How do I increase my mindfulness? Alcohol intake inventory. Does my intake suggest a pattern of misuse? Depression screening, Relationship health check. What is the status of my relationships? How do I want them to change and what do I need to do to achieve these goals? Am I safe from interpersonal violence? Physical health queries: Physical screenings. What is my current status?: Blood pressure, Blood glucose, Colonoscopy, Mammography, Lipid panel, Dental examination and cleaning, Vision examination, Sex-specific screenings: gynecologic or prostate, Hepatitis C virus testing, Bone health evaluation, including osteoporosis

assessment if needed, Peripheral vascular health; Sexual health, if sexually active: Gonorrhea and chlamydia screening, Human immunodeficiency virus status, Am I a candidate for Preexposure prophylaxis, or PrEP? Body mass index: What is my height or weight or body mass? How has my weight and body composition changed? Is this pattern cause for concern? Nutritional intake: Meal patterns, Diet composition; Tobaccorelated behaviors, Sleep patterns, and Exercise and physical activity routines. Back to Table There are four columns without headers. Row entries are as follows: Row 1: Reflection-on-experience, The practitioner reflects on a particular situation after its event in order to learn from it to inform future practice, Doing reflection, Technical or Rational; Row 2: Reflection-in-action, The practitioner stands back and reframes the practice situation in order to proceed towards desired outcome, no data, no data; Row 3: The internal supervisor, The practitioner dialogues with self while in conversation with another as a process of making sense and response (Casement 1985), no data, no data; Row 4: Being mindful, Seeing things for what they really are without distortion, Being reflective, Professional artistry. Back to Table There are three columns headers: Type of resource, Web address or contact information, and Descriptions or notes. Row entries for Professional Associations or Organizations are as follows: Row 1: American Mindfulness Research Association:

https://goamra.org/, Scientific database of references available for download. Links to mindfulness centers and programs; Row 2: Mindfulness Association: http://www.mindfulnessassociation.net, Offers courses and resources with an emphasis on long-term, systematic training; Row 3: Center for Mindfulness in Medicine: Health Care, and Society, https://umassmed.edu/cfm/training/, The Oasis Institute is housed in the center and provides professional education and training. The center’s website provides a rich repository of evidence-based recommendations, class options (online and onsite), and video resources as well as other learning supports and opportunities. Back to Table There are three columns headers: Type of resource, Web address or contact information, and Descriptions or notes. Row entries for Professional Associations or Organizations are as follows: Row 4: Mindfulness Everyday: http://www.mindfulnesseveryday.org/, Charitable organization that provides programs on mindfulness and mindfulness-based stress reduction for people of all ages; Row 5: Mindful: https://www.mindful.org/free-mindfulness-apps-worthy-of-yourattention/, A mission-driven nonprofit that publishes a bimonthly magazine, Mindful and offers workshops, conferences, and networking opportunities to support mindfulness. Row entries for Applications for electronic devices (refer to Web address or app stores for details) are as follows: Row 6: Insight Timer (Newman, 2017): https://insighttimer.com/; Row 7: Aura (Newman, 2017): https://www.aurahealth.io/; Row 8: Omvana

(Newman, 2017): http://www.omvana.com/; Row 9: Stop, Breathe, & Think (Newman, 2017): https://www.stopbreathethink.com/; Row 10: Calm (Newman, 2017): https://www.calm.com/; Row 11: The Mindfulness App (Fischer, 2018): App store; Row 12: Headspace (Abate, 2017): App store; Row 13: MINDBODY (Abate, 2017): App store; Row 14: Buddhify (Abate, 2017): App store; Row 15: Insight Timer (Abate, 2017): App store; Row 16: Smiling Mind (Abate, 2017): App store; Row 17: Meditation Timer Pro (Abate, 2017): App store. Back to Table There are two columns headers: Résumé and Curriculum Vitae. Row entries for are as follows: Row 1: Overview Extensive description; Row 2: One page in length—never more than two, Several pages in length. May be dozens of pages, depending on career length and productivity; Row 3: Job application, Multiple uses including professional office, job application, awards, grants, presentations; Row 4: Employment origins, Academic origins. Back to Table There are three columns headers: Incorrect credentials, Corrected credentials, and Explanation. Row entries for are as follows: Row 1: Micah Ivers, M.S.N, B.S.N, NP, CCRN, Micah Ivers, MSN, RN, CRNP, ANP-BC, CCRN, Avoid periods. Use commas between credentials. Use the correct acronym of the earned certification credential. If CRNP is the license issued by the state and held by the candidate, it should be included; Row

2: Maria Rodriguez, DNP, MHA, BSN, RN, CRNA, FAAN, Maria Rodriguez, DNP, MHA, RN, CRNA, FAAN, The DNP degree requires the MSN or BSN so there is no need to include the BSN. The MHA (master’s of health administration) is a nonnursing degree and may be included; Row 3: Frank Bruce, PhD, MSN, FNP-BC, CRNP, Frank Bruce, PhD, RN, CRNP, FNP-BC, Because an MSN is required for the FNP-BC certification, even if the PhD degree is in a nonnursing area (e.g., organizational behavior), it is common practice to avoid listing the MSN degree so as to avoid an overwhelming list of letters. If the state provides a required nurse practitioner credential designated as “Certified Registered Nurse Practitioner”, the license should be included. Back to Table There are three column headers: Yes, No, and Don’t Know. Row entries are as follows: Row 1: 1. Does the person have the expert knowledge and skills in the competencies that you need to develop? no data, no data, no data; Row 2: 2. Is the person a leader by action and by example? no data, no data, no data; Row 3: 3. Does this person have the ability to guide, coach, and teach you? no data, no data, no data; Row 4: 4. Is the person respected in the organization? no data, no data, no data; Row 5: 5. Does the person have access to important organizational information and can he or she help you to direct attention on important issues? no data, no data, no data. Back to Table There are three column headers: Yes, No, and Don’t Know.

Row entries are as follows: Row 6: Does the person have a network of influential people and is he or she willing to assist you to be visible, credible, and accepted by others in the organization? no data, no data, no data; Row 7: 7. Is the person willing to work collaboratively with you? no data, no data, no data; Row 8: 8. Is the person willing to spend the time and energy required for the development of this relationship? no data, no data, no data; Row 9: 9. Are you comfortable with this person and do you trust this person to hold confidentiality? no data, no data, no data; Row 10: 10. Is the person able to provide you with negative as well as positive feedback? no data, no data, no data; Row 11: 11. Can the person help you identify what you need to learn and provide the structure for learning activities? no data, no data, no data. Back to Table The table shows scoring system at the top: Use the following scoring system for each answer below: 1 equals Never, 2 equals Rarely, 3 equals Occasionally, 4 equals Usually, 5 equals Always; Place an X in the appropriate column. There are six columns with unchecked box from second to sixth columns from second row. Row entries are as follows: Row 1: 1. I feel calm and in control of my time: 1, 2, 3, 4, and 5; Row 2: 2. I am aware of fluctuations in my energy level and perform my most challenging tasks when my energy level is at its highest; Row 3: 3. I spend the majority of my time in meaningful work that contributes to positive work in the workplace; Row 4: 4. I spend the majority of my time in activities that I find satisfying; Row 5: 5. I complete my paperwork and projects on time; Row 6: 6. I

follow through on promises I make to colleagues; Row 7: 7. I have written daily goals; Row 8: 8. I delegate tasks to others in my clinical unit; Row 9: 9. I assess tasks for their importance and their urgency; Row 10: 10. I keep a to-do list and schedule time to complete the tasks on the list; Row 11: 11. I set aside time each week to complete paperwork and other tasks; Row 12: 12. I am able to control interruptions; Row 13: 13. I embrace the philosophy “do today instead of putting off until tomorrow”; Row 14: 14. I set aside time each day for planning; Row 15: 15. I have written long-term goals. Back to Table There are six column headers, Times, Activity or People, Purpose, Energy Level, Interruptions, and Effectiveness of the Time Spent, followed by five empty rows. Back to Table The table shows scoring system at the top: Use the following scoring system for each answer below: 1 equals Never, 2 equals Rarely, 3 equals Occasionally, 4 equals Usually, 5 equals Always; Place an X in the appropriate column. There are six columns with unchecked box from second to sixth columns from second row. Row entries are as follows: Row 1: 1. I have too much responsibility with little or no authority: 1, 2, 3, 4, and 5; Row 2: 2. The organization sets unrealistic expectations and deadlines that I am unable to meet; Row 3: 3. I do not feel adequately trained for my position; Row 4: 4. I do not feel appreciated; Row 5: 5. I am not able to voice concerns; Row 6: 6. I have too much to do with too few resources; Row 7: 7. I

lack a clear understanding of what is expected of me; Row 8: 8. I have a difficult time keeping pace with technology; Row 9: 9. The physical environment in which I work has poor lighting, a lot of noise, and poor ventilation; Row 10: 10. There is the possibility of workplace violence; Row 11: 11. People in the organization have experienced sexual harassment and racial discrimination; Row 12: 12. The organization has recently downsized or restructured; Row 13: 13. Creativity and autonomy are not valued. Back to Table Row entries from the table are as follows: Row 1: 815.01, Closed Fracture of the Base of the Thumb (First) Metacarpal; Row 2: 815.11, Open Fracture of Base of Thumb (First) Metacarpal. Back to Table Unnumbered Table 2 Row entries from the table are as follows: Row 1: S62.511B, Displaced fracture of proximal phalanx of right thumb, initial encounter for open fracture; Row 2: S62.511D, Displaced fracture of proximal phalanx of right thumb, subsequent encounter for fracture with routine healing; Row 3: S62.511G, Displaced fracture of proximal phalanx of right thumb, subsequent encounter for fracture with delayed healing; Row 4: S62.511K, Displaced fracture of proximal phalanx of right thumb, subsequent encounter for fracture with non-union; Row 5: S62.511P, Displaced fracture of proximal phalanx of right thumb, subsequent encounter for fracture with malunion; Row 6: S62.511S, Displaced fracture of proximal

phalanx of right thumb, sequel. Back to Table