Appendix C Communication Strategies
Advocating for Safety with Assertive Statements
When a team member perceives a potential patient safety concern, they should assertively communicate with the decision-maker to protect patient safety. This strategy holds true for ALL team members, no matter their position within the hierarchy of the health care environment. The message should be communicated to the decision-maker in a firm and respectful manner using the following steps[1]:
- Make an opening.
- State the concern.
- State the problem (real or perceived).
- Offer a solution.
- Reach agreement on next steps.
Examples of Using Assertive Statements to Promote Patient Safety
A nurse notices that a team member did not properly wash their hands during patient care. Feedback is provided immediately in a private area after the team member left the patient room: “I noticed you didn’t wash your hands when you entered the patient’s room. Can you help me understand why that didn’t occur?” (Wait for an answer.) “Performing hand hygiene is essential for protecting our patients from infection. It is also hospital policy and we are audited for compliance to this policy. Let me know if you have any questions and I will check back with you later in the shift.” (Monitor the team member for appropriate hand hygiene for the remainder of the shift.)
Two-Challenge Rule
When an assertive statement is ignored by the decision-maker, the team member should assertively voice their concern at least two times to ensure that it has been heard by the decision-maker. This strategy is referred to as the two-challenge rule. When this rule is adopted as a policy by a health care organization, it empowers all team members to pause care if they sense or discover an essential safety breach. The decision-maker being challenged is expected to acknowledge the concern has been heard.[2]
CUS Assertive Statements
During emergent situations, when stress levels are high or when situations are charged with emotion, the decision-maker may not “hear” the message being communicated, even when the two-challenge rule is implemented. It is helpful for agencies to establish assertive statements that are well-recognized by all staff as implementation of the two-challenge rule. These assertive statements are referred to as the CUS mnemonic: “I am Concerned – I am Uncomfortable – This is a Safety issue!”[3]
Using these scripted messages may effectively catch the attention of the decision-maker. However, if the safety issue still isn’t addressed after the second statement or the use of “CUS” assertive statements, the team member should take a stronger course of action and utilize the agency’s chain of command. For the two-challenge rule and CUS assertive statements to be effective within an agency, administrators must support a culture of safety and emphasize the importance of these initiatives to promote patient safety.
Read an example of a nurse using assertive statements in the following box.
Assertive Statement Example
A nurse observes a new physician resident preparing to insert a central line at a patient’s bedside. The nurse notes the resident has inadvertently contaminated the right sterile glove prior to insertion.
Nurse: “Dr. Smith, I noticed that you contaminated your sterile gloves when preparing the sterile field for central line insertion. I will get a new set of sterile gloves for you.”
Dr. Smith: (Ignores nurse and continues procedure.)
Nurse: “Dr. Smith, please pause the procedure. I noticed that you contaminated your right sterile glove by touching outside the sterile field. I will get a new set of sterile gloves for you.”
Dr. Smith: “My gloves are fine.” (Prepares to initiate insertion.)
Nurse: “Dr. Smith – I am concerned! I am uncomfortable! This is a safety issue!”
Dr. Smith: (Stops procedure, looks up, and listens to the nurse.) “I’ll wait for that second pair of gloves.”
Learn More
View a detailed video webinar describing the TeamSTEPPS® principles.[4]
ISBARR
A common format used by health care team members to exchange client information is ISBARR, a mnemonic for the components of Introduction, Situation, Background, Assessment, Request/Recommendations, and Repeat back.[5],[6]
- Introduction: Introduce your name, role, and the agency from which you are calling.
- Situation: Provide the client’s name and location, the reason you are calling, recent vital signs, and the status of the client.
- Background: Provide pertinent background information about the client such as admitting medical diagnoses, code status, recent relevant lab or diagnostic results, and allergies.
- Assessment: Share abnormal assessment findings and your evaluation of the current client situation.
- Request/Recommendations: State what you would like the provider to do, such as reassess the client, order a lab/diagnostic test, prescribe/change medication, etc.
- Repeat back: If you are receiving new orders from a provider, repeat them to confirm accuracy. Be sure to document communication with the provider in the client’s chart.
Nursing Considerations
Before using ISBARR to call a provider regarding a changing client condition or concern, it is important for nurses to prepare and gather appropriate information. See the following box for considerations when calling the provider.
Communication Guidelines for Nurses[7]
- Have I assessed this client before I call?
- Have I reviewed the current orders?
- Are there related standing orders or protocols?
- Have I read the most recent provider and nursing progress notes?
- Have I discussed concerns with my charge nurse, if necessary?
- When ready to call, have the following information on hand:
- Admitting diagnosis and date of admission
- Code status
- Allergies
- Most recent vital signs
- Most recent lab results
- Current meds and IV fluids
- If receiving oxygen therapy, current device and L/min
- Before calling, reflect on what you expect to happen as a result of this call and if you have any recommendations or specific requests.
- Repeat back any new orders to confirm them.
- Immediately after the call, document with whom you spoke, the exact time of the call, and a summary of the information shared and received.
Read an example of an ISBARR report in the following box.
Sample ISBARR Report From a Nurse to a Health Care Provider
I: “Hello Dr. Smith, this is Jane Smith, RN from the Med-Surg unit.”
S: “I am calling to tell you about Ms. White in Room 210, who is experiencing an increase in pain, as well as redness at her incision site. Her recent vital signs were BP 160/95, heart rate 90, respiratory rate 22, O2 sat 96% on room air, and temperature 38 degrees Celsius. She is stable but her pain is worsening.”
B: “Ms. White is a 65-year-old female, admitted yesterday post hip surgical replacement. She has been rating her pain at 3 or 4 out of 10 since surgery with her scheduled medication, but now she is rating the pain as a 7, with no relief from her scheduled medication of Vicodin 5/325 mg administered an hour ago. She is scheduled for physical therapy later this morning and is stating she won’t be able to participate because of the pain this morning.”
A: “I just assessed the surgical site and her dressing was clean, dry, and intact, but there is 4 cm redness surrounding the incision, and it is warm and tender to the touch. There is moderate serosanguinous drainage. Her lungs are clear and her heart rate is regular. She has no allergies. I think she has developed a wound infection.”
R: “I am calling to request an order for a CBC and increased dose of pain medication.”
R: “I am repeating back the order to confirm that you are ordering a STAT CBC and an increase of her Vicodin to 10/325 mg.”
Handoff Reports
Handoff reports are defined by The Joint Commission as “a transfer and acceptance of patient care responsibility achieved through effective communication. It is a real-time process of passing patient specific information from one caregiver to another, or from one team of caregivers to another, for the purpose of ensuring the continuity and safety of the patient’s care.”[8] In 2017 The Joint Commission issued a sentinel alert about inadequate handoff communication that has resulted in patient harm such as wrong-site surgeries, delays in treatment, falls, and medication errors.[9]
The Joint Commission encourages the standardization of critical content to be communicated by interprofessional team members during a handoff report both verbally (preferably face to face) and in written form. Critical content to communicate to the receiver in a handoff report includes the following components[10]:
- Sender contact information
- Illness assessment, including severity
- Patient summary, including events leading up to illness or admission, hospital course, ongoing assessment, and plan of care
- To-do action list
- Contingency plans
- Allergy list
- Code status
- Medication list
- Recent laboratory tests
- Recent vital signs
Several strategies for improving handoff communication have been implemented nationally, such as the Bedside Handoff Report Checklist, closed-loop communication, and I-PASS.
Closed-Loop Communication
The closed-loop communication strategy is used to ensure that information conveyed by the sender is heard by the receiver and completed. Closed-loop communication is especially important during emergency situations when verbal orders are being provided as treatments are immediately implemented.
- The sender initiates the message.
- The receiver accepts the message and repeats back the message to confirm it (i.e., “Cross-Check”).
- The sender confirms the message.
- The receiver notified the sender the task was completed (i.e., “Check-Back”).
See an example of closed-loop communication during an emergent situation in the following box.
Closed-Loop Communication Example
Doctor: “Administer 25 mg Benadryl IV push STAT.”
Nurse: “Give 25 mg Benadryl IV push STAT?”
Doctor: “That’s correct.”
Nurse: “Benadryl 25 mg IV push given at 1125.”
I-PASS
I-PASS is a mnemonic used to provide structured communication among interprofessional team members. I-PASS stands for the following components[11]:
I: Illness severity
P: Patient summary
A: Action list
S: Situation awareness and contingency plans
S: Synthesis by receiver (i.e., closed-loop communication)
See a sample I-PASS Handoff in Table 7.5b.[12]
Table C.1Sample I-PASS Verbal Handoff[13]
|
Table C.1 Sample I-PASS Verbal Handoff |
||
|---|---|---|
| I | Illness Severity | This is our sickest patient on the unit, and he’s a full code. |
| P | Patient Summary | AJ is a 4-year-old boy admitted with hypoxia and respiratory distress secondary to left lower lobe pneumonia. He presented with cough and high fevers for two days before admission, and on the day of admission to the emergency department, he had worsening respiratory distress. In the emergency department, he was found to have a sodium level of 130 mg/dL likely due to volume depletion. He received a fluid bolus, and oxygen administration was started at 2.5 L/min per nasal cannula. He is on ceftriaxone. |
| A | Action List | Assess him at midnight to ensure his vital signs are stable. Check to determine if his blood culture is positive tonight. |
| S | Situations Awareness & Contingency Planning | If his respiratory distress worsens, get another chest radiograph to determine if he is developing an effusion. |
| S | Synthesis by Receiver | Ok, so AJ is a 4-year-old admitted with hypoxia and respiratory distress secondary to a left lower lobe pneumonia receiving ceftriaxone, oxygen, and fluids. I will assess him at midnight to ensure he is stable and check on his blood culture. If his respiratory status worsens, I will repeat a radiograph to look for an effusion. |
Documentation
Accurate, timely, concise, and thorough documentation by interprofessional team members ensures continuity of care for their clients. It is well-known by health care team members that in a court of law the rule of thumb is, “If it wasn’t documented, it wasn’t done.” Any type of documentation in the electronic health record (EHR) is considered a legal document. Abbreviations should be avoided in legal documentation and some abbreviations are prohibited.
Learn More
Read the current list of error-prone abbreviations by the Institute of Safe Medication Practices. These abbreviations should never be used when communicating medical information verbally, electronically, and/or in handwritten applications. Abbreviations included on The Joint Commission’s “Do Not Use” list are identified with a double asterisk (**) and must be included on an organization’s “Do Not Use” list.
Nursing staff access the electronic health record (EHR) to help ensure accuracy in medication administration and document the medication administration to help ensure patient safety.
The electronic health record (EHR) contains the following important information:
- History and Physical (H&P): A history and physical (H&P) is a specific type of documentation created by the health care provider when the client is admitted to the facility. An H&P includes important information about the client’s current status, medical history, and the treatment plan in a concise format that is helpful for the nurse to review. Information typically includes the reason for admission, health history, surgical history, allergies, current medications, physical examination findings, medical diagnoses, and the treatment plan.
- Provider orders: This section includes the prescriptions, or medical orders, that the nurse must legally implement or appropriately communicate according to agency policy if not implemented.
- Medication Administration Records (MARs): Medications are charted through electronic medication administration records (MARs). These records interface the medication orders from providers with pharmacists and are also the location where nurses document medications administered.
- Treatment Administration Records (TARs): In many facilities, treatments are documented on a treatment administration record.
- Laboratory results: This section includes results from blood work and other tests performed in the lab.
- Diagnostic test results: This section includes results from diagnostic tests ordered by the provider such as X-rays, ultrasounds, etc.
- Progress notes: This section contains notes created by nurses, providers, and other interprofessional team members regarding client care. It is helpful for the nurse to review daily progress notes by all team members to ensure continuity of care.
- Nursing care plans: Nursing care plans are created by registered nurses (RNs). Documentation of individualized nursing care plans is legally required in long-term care facilities by the Centers for Medicare and Medicaid Services (CMS) and in hospitals by The Joint Commission. Nursing care plans are individualized to meet the specific and unique needs of each client. They contain expected outcomes and planned interventions to be completed by nurses and other members of the interprofessional team. As part of the nursing process, nurses routinely evaluate the client’s progress toward meeting the expected outcomes and modify the nursing care plan as needed.
- AHRQ. (2020, January). Pocket guide: TeamSTEPPS. https://www.ahrq.gov/teamstepps/instructor/essentials/pocketguide.html ↵
- AHRQ. (2020, January). Pocket guide: TeamSTEPPS. https://www.ahrq.gov/teamstepps/instructor/essentials/pocketguide.html ↵
- AHRQ. (2020, January). Pocket guide: TeamSTEPPS. https://www.ahrq.gov/teamstepps/instructor/essentials/pocketguide.html ↵
- AHRQ Patient Safety. (2017, July 26). Introduction to the fundamentals of TeamSTEPPS® concepts and tools. [Video]. YouTube. Video in the Public Domain. https://youtu.be/fxlRtpzsUug ↵
- Institute for Healthcare Improvement (n.d.). ISBAR trip tick. http://www.ihi.org/resources/Pages/Tools/ISBARTripTick.aspx ↵
- Grbach, W., Vincent, L., & Struth, D. (2008). Curriculum developer for simulation education. QSEN Institute. https://qsen.org/reformulating-sbar-to-i-sbar-r/ ↵
- Studer Group. (2007). Patient safety toolkit – Practical tactics that improve both patient safety and patient perceptions of care. Studer Group. ↵
- Starmer, A. J., Spector, N. D., Srivastava, R., Allen, A. D., Landrigan, C. P., Sectish, T. C., & I-Pass Study Group. (2012). Transforming pediatric GME. Pediatrics, 129(2), 201-204. https://www.ipassinstitute.com/hubfs/I-PASS-mnemonic.pdf ↵
- The Joint Commission. (n.d.). Sentinel event alert 58: Inadequate hand-off reports. https://www.jointcommission.org/resources/patient-safety-topics/sentinel-event/sentinel-event-alert-newsletters/sentinel-event-alert-58-inadequate-hand-off-communication/ ↵
- The Joint Commission. (n.d.). Sentinel event alert 58: Inadequate hand-off reports. https://www.jointcommission.org/resources/patient-safety-topics/sentinel-event/sentinel-event-alert-newsletters/sentinel-event-alert-58-inadequate-hand-off-communication/ ↵
- The Joint Commission. (n.d.). Sentinel event alert 58: Inadequate hand-off reports. https://www.jointcommission.org/resources/patient-safety-topics/sentinel-event/sentinel-event-alert-newsletters/sentinel-event-alert-58-inadequate-hand-off-communication/ ↵
- Starmer, A. J., Spector, N. D., Srivastava, R., Allen, A. D., Landrigan, C. P., Sectish, T. C., & I-Pass Study Group. (2012). Transforming pediatric GME. Pediatrics, 129(2), 201-204. https://www.ipassinstitute.com/hubfs/I-PASS-mnemonic.pdf ↵
- Starmer, A. J., Spector, N. D., Srivastava, R., Allen, A. D., Landrigan, C. P., Sectish, T. C., & I-Pass Study Group. (2012). Transforming pediatric GME. Pediatrics, 129(2), 201-204. https://www.ipassinstitute.com/hubfs/I-PASS-mnemonic.pdf ↵
Measuring Outcomes
An important aspect of quality improvement is the use of measures, also referred to as metrics, to identify the level of change on specific elements of the project. The Institute for Healthcare Improvement(IHI) provides a white paper on Whole System Measures (Martin et al., 2007). The IHI white paper identifies a system of existing metrics that impact quality in a health system. These metrics are unique to each health system and should be considered as the leader selects measures for their specific project. Depending upon the scope of the project, multiple measures are utilized.
IHI identifies three types of measures that are used in for improvement efforts. They include outcomes measures, process, measures and balancing measures (IHI, n.d.).
For this textbook, we are focusing on Outcome and Process measures examples from the IHI. Process measures can be considered indicators that are measured at specific intervals of the project. Process measures are vital for success of a project as they can inform leaders of the need to change the direction throughout the project, as opposed to waiting until the end of a change project.
Process Measures (IHI, n.d.)
Are the parts/steps in the system performing as planned? Are we on track in our efforts to improve the system?
- For diabetes: Percentage of patients whose hemoglobin A1c level was measured twice in the past year
- For access: Average daily clinician hours available for appointments
- For critical care: Percentage of patients with intentional rounding completed on schedule
Outcome measures are those that indicate change at the end of a specified period of time.
Outcome Measures (IHI, n.d.)
How does the system impact the values of patients, their health and wellbeing? What are impacts on other stakeholders such as payers, employees, or the community?
- For diabetes: Average hemoglobin A1c level for population of patients with diabetes
- For access: Number of days to 3rd next available appointment
- For critical care: Intensive Care Unit (ICU) percent unadjusted mortality
- For medication systems: Adverse drug events per 1,000 doses
Use of existing measures is ideal so change can be tracked over a period of time. This box shares some examples of existing measures. Additional measures are described in further detail in the pages below.
Examples of Existing Measures (IHI, n.d.)
- Patient/client satisfaction surveys
- Length of stay
- Adverse events
- Staff turnover rates
- Staff-to-patient ratio
- Infection rates
- Employee satisfaction surveys
Utilization Review
Health care agencies are reimbursed from Medicare, Medicaid, and private insurance based on their quality performance measures. A utilization review is an investigation of health care services performed by doctors, nurses, and other health care team members to ensure money is not wasted covering unnecessary or inefficient expenditures for proper treatment. Utilization review also allows organizations to objectively measure how their health care services and resources are being used to best meet their patients’ needs. Information from patients’ medical records is analyzed, along with patient demographics, to evaluate resource allocation, efficiency, and quality of health promotion initiatives (Institute of Medicine, 1989). See Figure 6.1 (Dave Dugdale, n.d.) for an illustration of utilization review related to costs.
Using Informatics to Promote Quality
Utilization review relies on the collection of meaningful data from health records to determine if quality metrics are being met. Informatics refers to using information and technology to communicate, manage knowledge, mitigate error, and support decision-making (QSEN, n.d.). Informatics allows members of the health care team to share, store, and analyze health-related information. Nurses have an important role in informatics. Nursing informatics is the science and practice of integrating nursing knowledge with information and communication technologies to promote the health of people, families, and communities worldwide (AMIA, n.d.). It is a nursing specialty with certification available from the ANCC. See Figure 6.2 (mariojsantos, n.d.) for an artistic rendition of informatics.
These are several benefits of using informatics in health care (Otokiti, 2019):
- Improvement of Patient Safety: Informatics allows for up-to-date information sharing by both the patient and members of the health care team. Using informatics can help to reduce the occurrence of medication errors, as well as monitor patient side effects and overall health status. For example, barcode scanning has reduced medication errors by ensuring the correct dose is administered to the correct patient at the correct time.
- Reduction of Delays in Care: Some health care informatics systems allow for direct communication between health care team members and patients. The ability to ask and answer questions without needing to schedule an office appointment promotes the ability for care to be delivered efficiently in a cost-effective manner.
- Reduction of Waste: The use of informatics to share information between care team members reduces waste associated with duplication of tests or exams when more than one provider is on the care team. Additionally, patients can request their records be shared with health providers from other health organizations, which reduces duplication and unnecessary spending across the nation.
- Promotion of Patient-Centered Care: Many informatics systems have “patient portal” options where the patient and/or designated personnel are able to be active participants in the care planning and health promotion processes. Informatics offers an inclusive environment for patients to communicate and share directly with their care team regardless of physical location and timing.
- Support of Quality Improvement: The continuous process of quality improvement requires the ability to collect and analyze data in a systematic and reliable manner. Using informatics provides members of the health care team a secure place to store data, as well as the ability to review in a timely manner.
Quality Indicators
The National Database of Nursing Quality Indicators (NDNQI) was developed as a national nursing database used to evaluate quality in nursing care. This database was purchased by Press Ganey in 2014. In collaboration with the American Nursing Association (ANA), the original NDNQI database established nurse-sensitive quality indicators such as these (Montalvo, 2007):
- Nursing Care Hours Per Patient Day
- Hospital-Acquired Pressure Injuries
- RN Job Satisfaction
Nurses use quality indicators to support practice changes with evidence directly related to improved patient outcomes.
Learn More
Read about current quality measures promoting clinical excellence at the Press Ganey website.
Next: 6.3 Spotlight Application
Chapter References
Accreditation: A review process to determine if an agency meets the defined standards of quality determined by the accrediting body.
Acuity-based staffing: A patient assignment model that takes into account the level of patient care required based on the severity of a patient’s illness or condition.
Admission: Refers to an initial visit or contact with a client.
Advocacy: The act or process of pleading for, supporting, or recommending a cause of course of action for individuals, groups, organizations, communities, society, or policy issues.
Affordable Care Act (ACA): Legislation enacted in 2010 to increase consumers' access to health care coverage and protect them from insurance practices that restrict care or significantly increase the cost of care.
ANA Standards of Professional Practice: Authoritative statements of the actions and behaviors that all registered nurses, regardless of role, population, specialty, and setting are expected to perform competently.
Brief: A short session to share a plan, discuss team formation, assign roles and responsibilities, establish expectations and climate, and anticipate outcomes and contingencies.
Budget: An estimate of revenue and expenses over a specified period of time, usually over a year.
Capital budgets: Budgets used to plan investments and upgrades to tangible assets that lose or gain value over time. Capital is something that can be touched, such as buildings or computers.
Change: The process of altering or replacing existing knowledge, skills, attitudes, systems, policies, or procedures.[1]
Change agent: Anyone who has the skill and power to stimulate, facilitate, and coordinate the change effort.
Closed-loop communication: A communication strategy used to ensure that information conveyed by the sender is heard by the receiver and completed.
Collective bargaining: Negotiation of wages and other conditions of employment by an organized body of employees.
Continuity of care: The use of information on past events and personal circumstances to make current care appropriate for each individual.[2]
Conflict: Competitive or opposing action of incompatibles : antagonistic state or action (as of divergent ideas, interests, or persons) https://www.merriam-webster.com/dictionary/conflict
Co-pay: A flat fee the consumer pays at the time of receiving a health care service as a part of their health care plan.
Core measures: National standards of care and treatment processes for common conditions. These processes are proven to reduce complications and lead to better patient outcomes.
Cultural diversity: A term used to describe cultural differences among clients, family members, and health care team members.
Cultural humility: A humble and respectful attitude toward individuals of other cultures that pushes one to challenge their own cultural biases, realize they cannot possibly know everything about other cultures, and approach learning about other cultures as a lifelong goal and process.[3]
Culture of safety: Organizational culture that embraces error reporting by employees with the goal of identifying systemic causes of problems that can be addressed to improve patient safety. Just Culture is a component of a culture of safety.
CUS statements: Assertive statements that are well-recognized by all staff across a health care agency as implementation of the two-challenge rule. These assertive statements are “I am Concerned - I am Uncomfortable - This is a Safety issue!”[4]
Debrief: An informal information exchange session designed to improve team performance and effectiveness through reinforcement of positive behaviors and reflecting on lessons learned after a significant event occurs.
Deductible: The amount of money a consumer pays for health care before their insurance plan pays anything. These amounts generally apply per person per calendar year.
DESC: A tool used to help resolve conflict. DESC is a mnemonic that stands for Describe the specific situation or behavior and provide concrete data, Express how the situation makes you feel/what your concerns are using “I” messages, Suggest other alternatives and seek agreement, and Consequences are stated in terms of impact on established team goals while striving for consensus.
Discharge: The completion of care and services in a health care facility and the client is sent home (or to another health care facility).
Economics: The study of how society makes decisions about its limited resources.
Evidence-Based Practice (EBP): A lifelong problem-solving approach that integrates the best evidence from well-designed research studies and evidence-based theories; clinical expertise and evidence from assessment of the health care consumer’s history and condition, as well as health care resources; and patient, family, group, community, and population preferences and values.[5]
Feedback: Information is provided to a team member for the purpose of improving team performance. Feedback should be timely, respectful, specific, directed towards improvement, and considerate.[6]
Floating: An agency strategy that asks nurses to temporarily work on a different unit to help cover a short-staffed shift.
Followership: The upward influence of individuals on their leaders and their teams.
Grievance process: A process for resolving disagreements between employees and management.
Handoff reports: A transfer and acceptance of patient care responsibility achieved through effective communication. It is a real-time process of passing patient specific information from one caregiver to another, or from one team of caregivers to another, for the purpose of ensuring the continuity and safety of the patient’s care.[7]
Huddle: A brief meeting during a shift to reestablish situational awareness, reinforce plans already in place, and adjust the teamwork plan as needed.
I’M SAFE: A tool used to assess one’s own safety status, as well as that of other team members in their ability to provide safe patient care. It is a mnemonic standing for personal safety risks as a result of Illness, Medication, Stress, Alcohol and Drugs, Fatigue, and Eating and Elimination.
Informatics: Using information and technology to communicate, manage knowledge, mitigate error, and support decision-making.[8] This allows members of the health care team to share, store, and analyze health-related information.
Interdisciplinary care conferences: Meetings where interprofessional team members professionally collaborate, share their expertise, and plan collaborative interventions to meet client needs.
Interprofessional collaborative practice: Multiple health workers from different professional backgrounds working together with patients, families, caregivers, and communities to deliver the highest quality of care.
I-PASS: A mnemonic used as a structured communication tool among interprofessional team members. I-PASS stands for Illness severity, Patient summary, Action list, Situation awareness, and Synthesis by the receiver.
ISBARR: A mnemonic for the components of Introduction, Situation, Background, Assessment, Request/Recommendations, and Repeat back.[9],[10]
Just Culture: A culture where people feel safe raising questions and concerns and report safety events in an environment that emphasizes a nonpunitive response to errors and near misses. Clear lines are drawn between human error, at-risk, and reckless employee behaviors.
Leadership: The art of establishing direction and influencing and motivating others to achieve their maximum potential to accomplish tasks, objectives, or projects.[11],[12]
Magnet® Recognition Program: An organizational credential that recognizes quality patient outcomes, nursing excellence, and innovations in professional nursing practice.
Management: Roles that focus on tasks such as planning, organizing, prioritizing, budgeting, staffing, coordinating, and reporting.[13]
Mandatory overtime: A requirement by agencies for nurses to stay and care for patients beyond their scheduled shift when short staffing occurs.
Medicaid: A joint federal and state program covering groups of eligible individuals, such as low-income families, qualified pregnant women and children, and individuals receiving Supplemental Security Income (SSI). States may choose to cover additional groups, such as individuals receiving home and community-based services and children in foster care who are not otherwise eligible.
Medicare: A federal health insurance program used by people aged 65 and older, younger individuals with permanent disabilities, and people with end-stage renal disease requiring dialysis or a kidney transplant.
Meta-analysis: A type of nursing research (also referred to as a "systematic review") that compares the results of independent research studies asking similar research questions. This research often collects both quantitative and qualitative data to provide a well-rounded evaluation by providing both objective and subjective outcomes.
Mission statement: An organization’s statement that describes how the organization will fulfill its vision and establishes a common course of action for future endeavors.
Mutual support: The ability to anticipate and support team members' needs through accurate knowledge about their responsibilities and workload.
Nursing informatics: The science and practice integrating nursing, its information and knowledge, with information and communication technologies to promote the health of people, families, and communities worldwide.
Nursing research: The systematic inquiry designed to develop knowledge about issues of importance to the nursing profession.[14] The purpose of nursing research is to advance nursing practice through the discovery of new information. It is also used to provide scholarly evidence regarding improved patient outcomes resulting from nursing interventions.
Off with benefits: An agency staffing strategy when a nurse is not needed for their scheduled shift. The nurse does not typically receive an hourly wage and is not expected to report to work, but they still accrue benefits such as insurance and paid time off.
On call: An agency staffing strategy when a nurse is not immediately needed for their scheduled shift. They may have options to stay at work and complete work-related education or stay home.
Operating budgets: Budgets including personnel costs and annual facility operating costs.
Organizational culture: The implicit values and beliefs that reflect the norms and traditions of an organization. An organization’s vision, mission, and values statements are the foundation of organizational culture.
Patient-centered care: The patient is the source of control and full partner in providing compassionate and coordinated care based on respect for patient’s preferences, values, and needs.[15]
Patient safety goals: Guidelines specific to organizations accredited by The Joint Commission that focus on problems in health care safety and ways to solve them.
Pay for Performance: A reimbursement model, also known as value-based payment, that attaches financial incentives based on the performance of health care agencies and providers.
Peer-reviewed: Scholarly journal articles that have been reviewed independently by at least two other academic experts in the same field as the author(s) to ensure accuracy and quality.
Primary source: An original study or report of an experiment or clinical problem. The evidence is typically written and published by the individual(s) conducting the research and includes a literature review, description of the research design, statistical analysis of the data, and discussion regarding the implications of the results.
Resource stewardship: Using appropriate resources to plan, provide, and sustain evidence-based nursing services that are safe, effective, financially responsible, and used judiciously.
Quality: The degree to which nursing services for health care consumers, families, groups, communities, and populations increase the likelihood of desirable outcomes and are consistent with evolving nursing knowledge.
Quality improvement: Using data to monitor the outcomes of care processes and using improvement methods to design and test changes to continuously improve the quality and safety of health care systems.[16]
Quality Improvement (QI): A systematic process using measurable data to improve health care services and the overall health status of patients. The QI process includes the steps of Plan, Do, Study, and Act.
Qualitative research: A type of study that provides subjective data, often focusing on the perception or experience of the participants. Data is collected through observations and open-ended questions and often referred to as experimental data. Data is interpreted by developing themes in participants' views and observations.
Quantitative research: A type of study that provides objective data by using number values to explain outcomes. Researchers can use statistical analysis to determine strength of the findings, as well as identify correlations.
Shared governance: A shared leadership model between management and employees working together to achieve common goals.
Shared mental model: The actions of a team leader that ensure all team members have situation awareness and are "on the same page" as situations evolve on the unit.[17]
Secondary source: Evidence is written by an author who gathers existing data provided from research completed by another individual. This type of source analyzes and reports on findings from other research projects and may interpret findings or draw conclusions. In nursing research these sources are typically published as a systematic review and meta-analysis.
Situation awareness: The awareness of a team member knowing what is going on around them.[18]
Situation monitoring: The process of continually scanning and assessing the situation to gain and maintain an understanding of what is going on around you.[19]
Social Determinants of Health (SDOH): The conditions in the environments where people live, learn, work, and play that affect a wide range of health, functioning, and quality of life outcomes and risks.
Social Determinants of Health (SDOH): Conditions in the places where people live, learn, work, and play, such as unstable housing, low income areas, unsafe neighborhoods, or substandard education that affect a wide range of health risks and outcomes.
STEP tool: A situation monitoring tool used to know what is going on with you, your patients, your team, and your environment. STEP stands for Status of the patients, Team members, Environment, and Progress Toward Goal.[20]
Systems leadership: A set of skills used to catalyze, enable, and support the process of systems-level change that focuses on the individual, the community, and the system.
Systems theory: The concept that systems do not function in isolation but rather there is an interdependence that exists between their parts. Systems theory assumes that most individuals strive to do good work, but are affected by diverse influences within the system.
Team nursing: A common staffing pattern that uses a combination of Registered Nurses (RNs), Licensed Practical/Vocational Nurses (LPN/VNs), and Assistive Personnel (AP) to care for a group of patients.
TeamSTEPPS®: An evidence-based framework used to optimize team performance across the health care system. It is a mnemonic standing for Team Strategies and Tools to Enhance Performance and Patient Safety.[21]
TeamSTEPPS® (Team Strategies and Tools to Enhance Performance and Patient Safety): An evidence-based framework to improve client safety through effective communication in health care environments consisting of four core competencies: communication, leadership, situation monitoring, and mutual support.
Teamwork and collaboration: Functioning effectively within nursing and interprofessional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care.[22]
Two-challenge rule: A strategy for advocating for patient safety that includes a team member assertively voicing their concern at least two times to ensure that it has been heard by the decision-maker.
Utilization review: An investigation by insurance agencies and other health care funders on services performed by doctors, nurses, and other health care team members to ensure money is not wasted covering things that are unnecessary for proper treatment or are inefficient. This review also allows organizations to objectively measure how effectively health care services and resources are being used to best meet their patients’ needs.
Values statement: The organization’s established values that support its vision and mission and provide strategic guidelines for decision-making, both internally and externally, by members of the organization.
Vision statement: An organization’s statement that defines why the organization exists, describes how the organization is unique and different from similar organizations, and specifies what the organization is striving to be.
Whistleblower: A person who exposes any kind of information or activity that is deemed illegal, unethical, or not correct within an organization.
Systems Theory and Health Care
As nurses we know that the success of our patient-centered care interventions is dependent upon many factors. All too often, despite extensive planning and hard work, a patient care intervention fails to lead to the intended results. Factors beyond our control, and often beyond our knowledge, change the intended outcomes. This is typical of events in a complex adaptive system.
So how can we be successful leaders if we cannot predict what will happen when we attempt to guide others? Perhaps a review of the first two principles of the complex adaptive system will provide an answer to this question. The first principle, which is focused on using the lens of complexity, and the second principle, which describes good enough vision, provide us with clues on how to lead others within the complex adaptive health care system. Organizations and nurse leaders acknowledge that they cannot control change, and thus they do not try to control every aspect of organizational change. Successful health care leaders attempt to give a general sense of direction to employees, rather than focus on specific details. Next, leaders also encourage employees to develop innovative responses that best meet their individual strengths and needs and meet the healthcare system’s ultimate goal of quality patient care. Leaders cannot predict all the factors that will influence the final results of change activities, but by following these principles, they know that the final response will be what is best suited to the environment, or healthcare system, and the needs of the individual.
Learning Exercise 2.1.1
What are we talking about when we speak about systems theory in a health care organization? For a deeper understanding, watch this video titled “System Theory of Management” (7:37) by Nguyen Thanh Thi, then answer the following questions:
- What are the three basic system types? Describe each type.
- What type of system is a hospital?
- What is synergy? What is entropy?
There are three fundamental concepts that, when applied to our individual organizations, can transform the way we provide health care. For additional information, watch this video titled “Systems Thinking and Complexity in Health: A Short Introduction” (5:02), then complete the following exercises:
- Define the three fundamental concepts that can transform the way we provide health care.
- Give an example of how each concept can make a difference to health care provision.
Organizational Culture and Nursing Leadership
Organizational culture can be described as “the implicit knowledge or values and beliefs within the organization that reflect the norms and traditions of the organization" (Mancini & Wong, 2015, p. 152). Schein (cited in Ko, Murphy, & Birdman, 2015) further describes organizational culture as “the pattern of shared basic assumptions . . . as the correct way to perceive, think and feel” (p. S676). Organizational vision, mission, and values, established by leadership, provide the foundation for the establishment’s culture. Since individual organizations have their own vision, mission, and value statements, each organization has a different culture. Not surprisingly, when there are conflicts between the mission and vision of various institutions, collaboration in providing services to the patient or consumer can also lead to disagreements (Ko et al. 2015). With the increasing emphasis upon collaboration between health care organizations, it is essential to understand how to overcome the challenges of cultural differences that may impede group efforts.
Further Research
Hung, D., Chung, S., Martinez, M., & Tai-Seale, M. (2016). Effect of organizational culture on patient access, care continuity and experience of primary care. Journal of Ambulatory Care Management, 39(3), 242–252.
Purpose: To examine the relationships between organizational culture and patient-centered outcomes in a large medical practice.
Discussion: This American study was conducted in a large physician group practice setting of 357 physicians, 41 primary care departments, and nearly a million patients. Organizational culture was found to be significantly associated with “patient access to care, continuity of care, and reported experiences with care delivery” (Hung et al., 2016, pp. 245–246).
Application to Practice: When introducing change to an organization, it is essential to recognize the underlying organizational culture. Acknowledging and leveraging this aspect of collective behavior, while targeting specific patient-centered care goals, will lead to improved care.
Leaders know that employees frequently resist change and innovation in their workplace using the argument that “it has always been this way.” Leaders play a pivotal role in inspiring change. When introducing innovation or transformation, it is important to recognize that cultural change cannot be commanded, but can only be inspired. Effective leaders understand both implicit and explicitly stated cultural norms and traditions when they introduce change into the organization. One highly valued nursing leadership and innovation is the Magnet-recognized organization(Learning Exercise 2.1.2).
Research with Magnet® hospitals in the United States reinforced the need for a health care environment that is focused on the provision of quality patient care. This necessity has also been identified in the UK. When caregivers are provided with adequate resources, support, and respect, there is evidence of increased job satisfaction and reduced patient morbidity and mortality (Aiken, Clarke, Sloane, Lake, & Cheney, 2008).
Holistic leadership approaches, which include a focus on relational leadership and staff empowerment, foster a strong and robust care provider culture within the organization. When supportive care provider cultures are present, improved health is likely to be evident for both care providers and patients (Wagner, Cummings, Smith, Olson, & Warren, 2013). Research indicates that successful and effective nurse leaders have a positive impact upon the well-being of nurses, which converts into improved patient–client outcomes (Cummings, 2004).
Learning Exercise 2.1.2
Explore the Magnet® Recognition Program: https://www.nursingworld.org/organizational-programs/magnet/about-magnet/why-become-magnet/
Reflect on the following:
- What is Magnet a Magnet® Recognition Program?
- What are 3 characteristics of Magnet® Organizations?
- How does Magnet® recognition benefit stakeholders?
- Is your organization a Magnet® -recognized organization?
- If yes, what do you perceive as the primary benefit?
- If not, what would it take for your organization to pursue this recognition?
Next: Organizational Vision, Mission, and Values
Chapter References
Systems Theory and Health Care
As nurses we know that the success of our patient-centered care interventions is dependent upon many factors. All too often, despite extensive planning and hard work, a patient care intervention fails to lead to the intended results. Factors beyond our control, and often beyond our knowledge, change the intended outcomes. This is typical of events in a complex adaptive system.
So how can we be successful leaders if we cannot predict what will happen when we attempt to guide others? Perhaps a review of the first two principles of the complex adaptive system will provide an answer to this question. The first principle, which is focused on using the lens of complexity, and the second principle, which describes good enough vision, provide us with clues on how to lead others within the complex adaptive health care system. Organizations and nurse leaders acknowledge that they cannot control change, and thus they do not try to control every aspect of organizational change. Successful health care leaders attempt to give a general sense of direction to employees, rather than focus on specific details. Next, leaders also encourage employees to develop innovative responses that best meet their individual strengths and needs and meet the healthcare system’s ultimate goal of quality patient care. Leaders cannot predict all the factors that will influence the final results of change activities, but by following these principles, they know that the final response will be what is best suited to the environment, or healthcare system, and the needs of the individual.
Learning Exercise 2.1.1
What are we talking about when we speak about systems theory in a health care organization? For a deeper understanding, watch this video titled “System Theory of Management” (7:37) by Nguyen Thanh Thi, then answer the following questions:
- What are the three basic system types? Describe each type.
- What type of system is a hospital?
- What is synergy? What is entropy?
There are three fundamental concepts that, when applied to our individual organizations, can transform the way we provide health care. For additional information, watch this video titled “Systems Thinking and Complexity in Health: A Short Introduction” (5:02), then complete the following exercises:
- Define the three fundamental concepts that can transform the way we provide health care.
- Give an example of how each concept can make a difference to health care provision.
Organizational Culture and Nursing Leadership
Organizational culture can be described as “the implicit knowledge or values and beliefs within the organization that reflect the norms and traditions of the organization" (Mancini & Wong, 2015, p. 152). Schein (cited in Ko, Murphy, & Birdman, 2015) further describes organizational culture as “the pattern of shared basic assumptions . . . as the correct way to perceive, think and feel” (p. S676). Organizational vision, mission, and values, established by leadership, provide the foundation for the establishment’s culture. Since individual organizations have their own vision, mission, and value statements, each organization has a different culture. Not surprisingly, when there are conflicts between the mission and vision of various institutions, collaboration in providing services to the patient or consumer can also lead to disagreements (Ko et al. 2015). With the increasing emphasis upon collaboration between health care organizations, it is essential to understand how to overcome the challenges of cultural differences that may impede group efforts.
Further Research
Hung, D., Chung, S., Martinez, M., & Tai-Seale, M. (2016). Effect of organizational culture on patient access, care continuity and experience of primary care. Journal of Ambulatory Care Management, 39(3), 242–252.
Purpose: To examine the relationships between organizational culture and patient-centered outcomes in a large medical practice.
Discussion: This American study was conducted in a large physician group practice setting of 357 physicians, 41 primary care departments, and nearly a million patients. Organizational culture was found to be significantly associated with “patient access to care, continuity of care, and reported experiences with care delivery” (Hung et al., 2016, pp. 245–246).
Application to Practice: When introducing change to an organization, it is essential to recognize the underlying organizational culture. Acknowledging and leveraging this aspect of collective behavior, while targeting specific patient-centered care goals, will lead to improved care.
Leaders know that employees frequently resist change and innovation in their workplace using the argument that “it has always been this way.” Leaders play a pivotal role in inspiring change. When introducing innovation or transformation, it is important to recognize that cultural change cannot be commanded, but can only be inspired. Effective leaders understand both implicit and explicitly stated cultural norms and traditions when they introduce change into the organization. One highly valued nursing leadership and innovation is the Magnet-recognized organization(Learning Exercise 2.1.2).
Research with Magnet® hospitals in the United States reinforced the need for a health care environment that is focused on the provision of quality patient care. This necessity has also been identified in the UK. When caregivers are provided with adequate resources, support, and respect, there is evidence of increased job satisfaction and reduced patient morbidity and mortality (Aiken, Clarke, Sloane, Lake, & Cheney, 2008).
Holistic leadership approaches, which include a focus on relational leadership and staff empowerment, foster a strong and robust care provider culture within the organization. When supportive care provider cultures are present, improved health is likely to be evident for both care providers and patients (Wagner, Cummings, Smith, Olson, & Warren, 2013). Research indicates that successful and effective nurse leaders have a positive impact upon the well-being of nurses, which converts into improved patient–client outcomes (Cummings, 2004).
Learning Exercise 2.1.2
Explore the Magnet® Recognition Program: https://www.nursingworld.org/organizational-programs/magnet/about-magnet/why-become-magnet/
Reflect on the following:
- What is Magnet a Magnet® Recognition Program?
- What are 3 characteristics of Magnet® Organizations?
- How does Magnet® recognition benefit stakeholders?
- Is your organization a Magnet® -recognized organization?
- If yes, what do you perceive as the primary benefit?
- If not, what would it take for your organization to pursue this recognition?
