Theoretical and Scientific Foundations of Nursing

App ication of Theory in N ursing Administration and Management Melinda Granger Oberleitner

Greto Mortin is a family nurse practitioner who hos been employed for several years os port of a multiphysicion practice. Most of her practice hos beern focused on managing the core of adults with chronic illnesses, such as heart failure, arthritis, and diabetes.

Although she enjoys her work very much, Greto hos always been inlerested in exploring one of the entrepreneurial opportunities that o coreer in nursing hos to offer. Recently, she hos focused on combining her interests in computers and tech- nology with her expertise as on advanced practice nurse IAPN]. Along wi,th several investors, she is in the process of creating on Internet-based disease mo1nogement company. As envisioned, the company will focus on the needs of seniors and wi l1I engage APNs and other registered nurses (RNs) to provide clinical services and lo serve as case managers far pion members diagnosed with chronic illnesses.

As she began the planning process for the project, Greto found that she hod much to learn in regard to applying management and administration principles. In particular, she needed to learn more about organizational design. As the company is established, she must examine issues such as chain of commond, control, author- ity, and responsibility. The group must determine how the company will be structured and who will be responsible for day-to-day operations.

The group is also looking at case management models to sel.ect or modify one that is appropriate for use with its anticipated clientele and the method of delivery. Finally, Greto realized that she should learn about her leadership style and develop her leadership abilities to direct the new company. Recognizi1ng her deficiencies in administration and management, Greto sought information from o number of sources to learn about administration theories and how ta apply them i,n her new enterprise.

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476 Unit IV Application of Theory in Nur~ing

1':ursing pral·tkc indudin~ JJ,·.mccd nursing prJcticl', occur~ within .1 larga con· tor th;r is slup~d by tr.i..litio11.1I J.nd prl'niling theorks, mo .. kb, .1.nJ fr.11;1'-''' orks of .1dmi11i~tr.1tion .1.nd manJ.gemtnt. En.·n if only one nur,..: is employed hy .m org.1- nization, rhat nurse\ pr:Kticl· i~ intlu<.'IKL'll by models .md prindpks of leadership, m.m,1gcmenr .. md .1dministr.1tion used by th,: k·.1d..:r, of the org,Jni1.Jtion. To he most dkcri,·,:, .1ll nur,e, ,hould b,: .1hk co recognize .md .1d.1pt to th..: specific dur.Kt..:risti.:~ that ddine the organiz,1tion in which ~I,,: or lw pr.1ctice~.

This ch.1pt..:r expJnds on .:1111tcpts .md principln presented in ChJ.pta 17. It explores .1pplil'Jtion of .1dministrJti11n .ind mJ.nag.enient theories, models, ,rnd fr.1mework~ in nur~ing and he.11th c.1.r..:. These concepts include mgani1..1tionJ.I design; sh,m:d goYernance; tr.msforn1.1tion,1I le.1d..:rship; p.nient c.U'e ddin·ry models; case m.rnagemenr; dise.1se/chronic illn .. ·ss m.m.1gement; quality m.m.1gement (QM)/ perform.mce impron:ment processes, tools, .md t..:dmiqm:s; .rnd ..:,·id..:nce-ba~ed pr.1ctice ( EB!' J.

Organizational Design Th,: ~tructurl' of ,lll org.mization prm·ides ,l formal fr,um:,,-ork in \\'hich m,lll.lg.em..:nt proce~~c~ otcllr. This li,rmal fr.1me\\ ork historicall~· ~e1Te, m.rny pL1rpml.·~. including pro\'i~ion of a d1Jin of .1dministr.1ti,-c commJnd or authority th.a ~hould be ,:,·ident to .111 employc.:n, .1 ti,rm.1I ~\'~tem of (ommunic.uion bet,wen 111.1nagerncnt .rnd ~t.1ft~ .md .1 llll' rhod to .Kcor11pli~h th .. · work of thi.: organintion cfti:eti\'dy .rnd effici'-·ntly. The right ,tru<.'tur..: en.1blc, the orgJnization to reJdl its organiz.uion,tl goah.

Six clement~ of ,rruc.:run: that \\"ere formul.tted by m.rn,1g.eml·nt theorist~ in th,: 19()(),, ,rill pru\'ide a guide to the design of org.111i;:.1tion~ in the 2 ht ccntltr\·. The~c six clements .ue list\.·d in Bo, 2 I -L, .rnd eJch is discussed briefly in thl· following ~ections l R.obbim & Judge, 20 H· }.

Work Specialization \Vor/1 .1prcin/i::,ntio11 is h,wing e,1d1 ,rep of the.: \\ork process performed hy .1 ditli:rent indi,·idu.11 r.nha th.rn the whole proces~ being done hy one pcr~on. Proponents of wo rk spcciJliz,\ti<>n ,1rguc th.tr ir nl.lke\ the mo,t ctlicicnt u,;c of worker skills, .1ttri· hutes •. ind ch.1r.1<.'t..:risti<.'s. i\kdication .1dministr,1tion c,111 b,: used to illustr.ne the .;-unc.:epr of work specializJ.tion. Physici.rns determine the necJ for ,l 1m·dication order and lkciJc;: on the composition of th.tt order; hmpit.11 pharnucist~ thc:n rc\'icw rhc order .md fill rh..: pre~c.:,iption .1, directed by the physici.111. The nur,,: on the unit .1dmini~tl·1-s rhc: mcdic,ltion ordered by the phy~ician .md prq,arc:d by the pharma .. ·i~t. In the lr,1ditio11,1l hospit.11 ~tru\.""tllrc, pharm.Ki,t~ work in ,\I\ i,ol.ued group to prq1,1rl· .1111m·dicatiom to bi.: d,:li,·en:d b~· nur~e~ to patienrs in the faciliry.

Box 21 -1 Elements of Organizational Structure

1. Work speciolizotion 2. Chain of command 3. Spon of control 4. Authority ond respoMibility 5. Centralization versus decentralization 6. Deporlmentolizotion

Chapter 21 Application of Theory in Nursing Administration and Management 477

The usual configuratinn of :\P'.'\'!t i~ an cxcdknt repn:!,ent.1tion of work !,pecial- ization. For example, .1 certified n:gistered nur~e .rnesthetist ( CR1"-!A) would not be considered inrer..:h.111ge.1bk \\"ith .1 ..:ertificd 1rnr-;e midwit~ (Cl'\M) bei.:ausi.: oflhc ob- \"iom dcgrce of work spccialization in thc rn·o rolcs. Both lhe CRJSA and thc C~,\ \ .1n: edu..:ationally prcpJ.rcd .1~ cxperts in a ~pc..:ific spccialty ,1rc.1 .rnd .m: not ..:onsiden:d gl·ncrJli~t~.

In recent years, recognition th.n work -;pecializJ.tion .:an ..:ontribute to boredom, low productivity, .md poor 1..Ju,1liry has led tu .1 1Tcx.1111ination nfthe concept. In 111,rny c;1ses, this lus re~llltl·d in .u,signing employees .1 ,·aricty of acrh·itie~ w .1ecompli~h .rnd encouraging cmplo~•ee!, lo work in te,1111!,. In some hospital~, ., dinic;1[ ph.1rm.tcist is part of a tl·,1m of he.11th c.u·1.: worker!, .,s~igned to .10.:ompli~h the work of the unit .rnd fl'Side~, along with the tr.1Liitirn1.1l m1r~ing ~tJ.ft: on the dinic.11 unit. S1>mc unit-b,1~ed dinical pharrna..:ists eng,.1ge in ta!iks, ~u..:h .1~ ml'di..:.nion administration, \\ hid, w.,~ 011..:c ..:onsidcred rhc cxclusin· domain nf nursing.

Chain of Command rJyol ( 1949), Webcr ( 1970), .rnd Taylor ( 191 I) (\ee Cluptt•r 17) .1drnc.1tl·d th.u .m cmplo~"l'c ,hould bc admini~tratin:ly rcsponsibk to, or report to, only om· supcr\"isor. This ,1rr.mgement is tcrmcd t/Jf dmin 1f command. Chain of commJllli n:ti:r, to for- nul line!> of ..:ommuni..:ation .md ,rnthority .md ..:Jn usu.1lly be dctcr111i1Kd by looking. .lt .m organization.1I ..:hart. Howen.·r, .1~ or~ani1..uions h.n·c becomc increasingly ..:0111-

plcx, indi,·iduals in orgJniz.uiom n1.1y tind them~cln:~ .1dmi11isrr.1ti\·ely respomible to mon: than 1111c inJiYidual (_~l.m..:ini, 2015)_

,-\!though thc nurse working un the 7 pm to 7 .1m shifr in thc intensi,·e ore unit (ICU) is ultim.ncly administr.ni,-ch· re~ponsiblc to thc !Cl._1 dirrctor, then: is usuall~- .1 ditfrrent cl1ain of command on the night shift; this m.1y include the night ..:h.1rge nur~e and the night house supen·isor.

Simil.uly, APN~ in tod.1~-'s h1.:.1hh c.uc org.mizatiom ma\· be adminisrrati\"cly responsibk to ,\ ,·ariery of indi\·id11;1b, some of whom n1.1y lllJt be m1r~e,, su..:h .,, produ..:t or scr\"i..:e line 111an,1ger~. Some :\PNs m.1v ,ilso ,,s~ume managerial rolc~, as in the ..:.1se of .1 CR.NA who i, ,1dministratin.·h· in ch.irge of,\ group of nurse anesthetists.

Span of Control Thc third clement of management, ,pan of control, c.m abo lK dctcrmincd from thc organizational ..:hart. Span of .:ontrol refers to thc numbcr of cmployres di - re..:red b~- ,l 111.111:1.ger ( Mancini, 20 I :i }. Thc d,15sii.:.1I 111an.1gc111cnt rhcori,t~ recom- mended 11.1rn_1,, span~ of 1..·ontrol ti,r \\ orkcr~ performing complex jobs. There is no ..:omt'n~u~ rrg.arding the optin1.1I numbn ofcrnployecs tine nunagrr ,hould h.n·e in his or her ~pJn of control-~uggc.:~tcd r.mges are from 3 to :i0 employees. Sc,·cr.11 contingencies play a role in rhe ,·ari.1bility of the range of numhen of employees in i.p.rn of ..:nntrol. These contingen..:ies indulk the qualit\" ;1nd cxperien..:e of the m.1nagcr. the .1bilitil·s and marurin· of thc employees, thc complexity of the task, and, in somc .:ase~, the ~cographi..: lo..:ation of the work sctting. Research re~ult~ indicatc ..1 ~ignific.int kn:) of improYemcnt in nurse eng:.1g.ement "·hen the 111.rna~cr is respomiblc for :iO or kwer dir1..·ct reponl> l Cathc.1rt ct aL, 2004 J. \\'idcr ~prns of ..:ontrol in he.11th .:,,re organizarions lun· been ~hown to produ.:r neg.1ti\"e cffects on ctk..:ti,·e k ,Kkrship styles .rnd .,re detriml.'.nt.11 to stJ.ff and paticnt ,:1.ti~L1.:tion ( l\kver et al., 20 l J )_

478 Unit IV Application of Theory in Nursing

Rcccnt J1:aeasc in rcimbursement levels frir hcalth care services has resulted 111 restructuring and downsizing in hcalth care institutions. In some organizations, this has kd to th1: dimination or deaeJsc in nurse man.1ger positiom and inae.1sed span of control for rct.1incd man~1gcn, t \Vong ct al., 2015 ). The exp.rndcd nur~c.: man.1gcr rok in .1cute c.1rc facilities inch1ck~ signilic.:ant linancial, operational, and human re- sourcc.:s responsibilities for profr~~ional, multidisc.:iplin.1.r~·, :md unliccnsc.:d employees in one or morc ser\'ice lines.

Rcscarch on cffccts of increasing spans of control for nurse ma11.1gers include scriou~ ncgati,·c cnnscquem:cs ()11 nurse turnover r,rn.:s, ~r.1ff empowerment, and time for professional de\'clopmcnt of st.1ft: which in rurn c.111 han: dcleteriow, impacts on p.uient care and patient satisfaction. i-:or example, H.waei, Dahintcn, .111d MacPhn: ( 2015 l ex;1111inni the influcnct· of pen:ei\·ed organizational support, which was de- fined a~ cmployecs' perccptiom of how much tht:y arc \·alu,:d by the organization, ~p.111 ofc.:ontrol, and leadership r.rnk on the org.mizational commitment of nurse kad- cr~ \\·ho were consider..:d tu be novic,:s. Th,:~· dct,:rmincd th,u organizational support is linked tu nurse satisfaction .rnd loyJ!ty to th,: org.mizJtion; the higher thc pac,:i\·t:d support from t.h,: organization by the nurse, csp,:cially in time~ of downsi1:ing or r,:- structuring, the higher the satisfaction with and loyalty tu the\\ ork institution lw the nurs1:. In addition, organization,11 ~upport al~o positively influenced organiz.1tional commitment.

factors which should be considered \\·hen contemplating alrcring marugeri.11 sp.m of rnntrol on nursing units indude skill mix .rnd ,:xpcrti~e of the unit ~taft~ duties offirst-lc\'cl managers (i.e., ch.1rgc nurses ) whcn the middle-k,·cl ma1ugcr is not pr,:~cnt, potcntial ~avings in s.il.iry expense~, .rnd impact on nur,c mrnovcr .md on nursc and paticnt satisfaction ( Havaci ct JI., 201 fi; Jones, 1\lcLa11ghlin, Gcbbcns, & Terhorst, 2015 ). Link to Practice 21-1 prcsc.:nts how one h,:alth care org,mization de\'\:loped .1 tool to mt·asurc .1spccts of span of control and its dfrcts .

Link to Practice 21- l Measuring Scope and Span of Control Nurse administrators affiliated with the University af Pittsburgh Medical Center, an integrated health system composed of 22 hospitals, developed o measurement tool to determine the varying scope and span of control of nurse managers in their system. Implementation of the tool hos enabled collection of quantifiable doto in five oreos central to the nurse manager role: heod count, deportment workload, hours of opera- tion, number of cost centers, ond controlloble expenses exclusive of salaries. Outcomes associated with implementation included o significant decrease in nurse monoger sep- aration rotes and transfer of nurse managers out of leadership roles by the end of the first year of implementation, recognition that the nurse manager role should be compensated comparably to others on the leadership poy structure in the organization, ond the recognition that "scope creep" occurs as odditionol responsibilities ore odded to the nurse manager roles.

Jones. D .. Mcloughlin, M., Gebbens, C., & Terhorst. L. (20151. Utilizing o scope ond spon of control tool to meosure workload and derermine supporting resource, for nurse monogers. The Jovrnol of Nursing Admini•• Ira/ion, 45(5), 243-249.

Chapter 21 Applicotion of Theory in Nursing Administration ond Monogemenl 479

Authority and Responsibility Li11c a11t/J01·ity .rnd sta.fj'am/Jm·ity .m: two di~tim:tion~ that dc:~o.:ribl· fornul rd.niun- ships in an org,mizJtion. When looking at .111 organizatirnul chart, line J.uthority rd\.'rS to cluin of .:umnund, sup..-rior-subordinatl·, and kadcr-follo\\'cr relationships. for cxJ.mpk, the chief nursing offil·er I c::-.:o) dekg.1te~ Juthority to the unit m,rnager. ,,·ho then dekgatl·~ to a subordinate, the ,:barge nursl·. The i.:omm.md rd.ltionship is .1 dirl'Ct "line" benn·l·n ~upen·isor and :,ubordirute.

In larger org.rniz.ltiom, m.magc:r~ .:.m be: dc:,ignated a~ top-kn:), milkik-k,·l·I, 1>r fir~t-kwl m.111.1gcr~. Top-k,·l·I m.magcrs include rhc: organizJtion·~ chicfl·wcutiw offi- cer (CEO_) and thl· hig.hl'St nursing .1dmi11i~tr.1tor. /\ fiddk -lc\·d managers, as the: name implies, .:oordin.ltl' m.u1.1gc:mc:nt .tc.:ti,·itici, bet\\'cen thc: top management k,·d .md first- kYd man:1gen,. i\Iiddk-lc:, cl m.m,1gc:r~ arc usu.tlly inn>h·c:d in long-range: pl.urning and in policy dl·t:isiuns that atfrct 1,ne unit or multiple units. This m.111.1gcr is usu.1lly re.spon- ~iblc for d,1y-to-c.i.ly a.:ti\'itil·s of the unit.s. Titk~ in nursing tl\Jt rcprl·:,c:nt middk-lc,·l•I m,magc:rs include mirsl· 111an.1gcrs, unit m.m.1gc:rs, unit dirl'Ctors, and unit supen·isors. First-lC\·d m.uugers .u-c as~igncd to one: unit .md .m: cnncc:rn~·d with th,lt specifi.: unit's work. hrst-k,·d 111.magtrs, such as i.::hargc: 11LJrSL'S, tl·.un kadc:rs, .md primary .:,ll'C: nurses, arc .:rui.::ial to tl1t· ~uci.:c:s~ of thc: unit\ \\urk .. -\PNs .1r.: most oltl'll administr.nivcly rc:- sponsiblc to eithc:r top-lcn:l or middlc:-k, d m.magers. APNs \\·ho .1ssumc .1dministra- tiw Tl'Sponsibiliti.:s in the org.mizJtion nuy be top-lc,·d or middk-k\'d m,lllJgas.

In som.: organiz.nions, :\l'Ns ,lrl' in .rra/f positions .ts opposc:d to lint' pmitiom. StalLmthorin· supports the \\'ork of th.: line m.mager \\'ithout h:l.\'ing am· line: authority or rc:spomibility. Employc:l'S in suff positions support, Jssist, .ind .1ddsc: tho~e in line authrnity positions. In a st.1ff position, thc: .-\PN is not respomiblc frir the: hiring, firing, d.irl·o.:ting, nr disi.::iplining of othc:r emplorl·es. This l.tck of authority could bl· a dis.Ki- \'ant.1gc to thl· APN in :i.:l·omplishing the: t.1sks of tlu: role: heo.:.rnsc: the Al'!\: oti:en mu\t work through othas to ac.:omplish goJls. E,·c:n wl1t·n the: .-\.PN is in J ~taff position, thl· .-\P1' is n:sponsibk to .1 line: m.1n.1gl·r. who is l'ithl·r .1 top-lc,·cl ur middk-k,·cl man.1ger.

Centralization Versus Decentralization Cmtra/i::,ario11 and dao1tm/i::,mio11 ,1rc degree~ of how deo.:i,ion n1.1king is dispersed or diffuscd throughout the organiz.nion. [n organizations with centralized dc.:ision m.1k.ing, decisions ,ll'l' m.1dc by tine: indi,·idu.1I or .1 snull group of indi\'idu.1b .lt thl· top of the: organilation.11 structure:. Dc.:cnrraliz.1tio11 refrrs to dcci~ion m.1king that oc.:uri. ,lt the lo\\'eSt lc,·ds frasihk. J\lost of todJ.y's org.mizatiom :1rc really ncithc:r tot.uh· centralized nor dccc:ntr.1li1.cd but .m: .1 comhin.1tion of the two. \\lith the ad- n·nt of perfnrm;1JKC impro\'Cmc:nr initi.1ti,·es owr the: past 30 m -Hl ye.1rs, the trend in .-\merii.::an organizJtiom has bec:n tern .1rd decc:ntr.1liz.1tion in an effort to in\'O)\'e employc:es dirc.:tly respon~iblc for the ,nirk produl·t in the decision-making proi.::ess. In nursing, organizational designs, su.:h a, sh.ll'cd gowrna1Kc:, h~1,·e gained popu!J.rity a~ ,1 method to empowc:r and l't1g.1g,c: st,1ffin the decision-making pro.:e~s.

Departmentalization The priman· purpose of d,:p11rt11101ta/i::,ati1111 is to subdividl· the: \\urk nf thc: organi- z.nion so that spl·cializ.Hion of thc work can be: Jl-n>mplished. Dl·partment.tlizarion l'lllphasizes ~pl·cialization of skill~. Hospitals haYe historic1lly implcml'ntcd depart- mentalization with traditiOJul department~, sud, ai. l·cmr.11 supply, pai.toral .:arc, and patient i.::.uc dc:p.utmcnts, among nthc:r~ .• -\ typi.:al nunufacruring p!Jnt, ,llthough

480 Unit IV Application of Theory in Nursing

ditkrrnr frnm .1 hospital, i_., pmb.1bly org;Jnizcd in mud1 tlw s.1m1.: ,ny .1s thr ho_-.pit,\l. For C'Xampk, both probably h.1n: 111.ukcting, .1ccounting, Jnd bum.m r1.:_.,ourcl'.S dep.1rt- m1:m,. (.;rouping .icti\'ities in thi~ m:mnn i~ known ,l\ tiinctional ,kp.utmenr.1liz.1tio11.

( )ther type", of d1:p:.u-tment.1lintion include product, customer, geographic, ,md pro- c1:,., d,:p.1rtnwnt.1liz.1tion. TodJy, hospit.1b ;md orhcr org,111iz.1tiom u~1.: crm~-disciplinarv tl',1111-" to J,xomplish tlw org.mizJ.tion \ perform.11Kl' initiari,·e~ that rr:mscend traditional do:partmentJI bound.1ric:s tu bertn focus nn rnstonwr 111.:rds I Robbins & Judge, 2014 ).

Shared Governance Slmrt'dlf1JPLT111111c,· is ".1 ,tructur~1l mud,:) through which mirs ... ·~ r.m o:xpre,_., .md n1.111- .1ge their own practi.:e with .1 highn lc\'o:I of profr_.,sirnul .rntonom(' ( Port,·r-O'Gr.1dy, 200J. p. 251 ). Nursing shared go, ern.11,.:e, .111 organintion.11 ~tru.:ture .rnd pro.:,:~~. \\ a~ imrodur..:d in thl' l,m: I 97Ch .1_-. .111 .1ltern.1ti,·1: to tr,Hiition,11 or ind11~tri.1l bu- re.u1.:r.1tic orgJnizational de,ign { L.1~.:hinger & fineg,111, 20():, ). In thi~ design, pro- tcssio11.1l nur~es m.: ~df-dir,·..:h:d "ork r,·.1ms at the unit ln·d to m.1kc proti:ssion,11 pra.:tict: de.:i~iom J.nd to a.:.:onlplish the \\'ork of the unit.

Portcr-O'lirady, H,1wkim, .md P.1rkc:r ( 1997) d.:s..:ribed the m.1jor component~ ohh,m:d gowrnan..:1: .1~ th1: cre.1tion ofp.1rmcrships, equity, a..:count.1bilin·, and own- ership. Much of the effort dir1:.:red .u rcstru.:rnring thl' nursing org.1ni1..1tion to im- pkm1:nt sh:1rni go, ern,HKe w.1~ done to ,·mp<l\\ er nur~<:!> to join \\'ith ca.:h other .md with other ho:.1lth c.1re Je.:ision m.1kLT~ to better confront i~~ues .1tfrcting tlw practice of protcs~ion.1I nur_-.ing. In thl' ~lured g:un:rn.11Kl' modd, st.1th, not m.m.1gcrs, .1rr empowered to mak,: p,Hient c.1r1: deL-i~ions .lt thl' ~t.1ff Ind I Mandni, 20 IS).

Implement.1tion Df~harnl gm·ern.11Kl' is usu.llly acco111p,111ied by the simultanem1~ impkmcntation of participation .mJ dc.:,·11tr.11iz.1ti1111. P.uticipation Jnd 1.kL-entraliz.1- tion ,lrl' not ,uh~titutl'~ for _.,h.u,·d g:o,·crna11ec .111d ~hould not be med synom·mously with the t.:rm sl111rcd _rr1111t'n1n11Ct'. Parti.:ipJti\'e moLkls .:.111 for employ1:1:s to b,: in- ,·olved in th.: de..:i,iom tlut inniln.· them. Ho,,·e,·cr, 111.rn.1gl'm<:nt ~till 1.ktnmin.:~ th,· br1:.1dth .md depth of r:mploy,:e parti.:ip.1tio11. lk.:cntr.1liz.1tion .11lo\\, employ1:n .lt lower k\'cb of the.: hier.urhic.11 suurtlll'l' to h,1n: gr~·.1ter in\'C>h·1.:ment in de..:i~ion nuking Jnd to ha, e ~<llll.: authority to impl1:ment till' '-k.:isiorn,, but 111.1n.1g:1:m1:nt w,ually rc:t.1im the: re,11 .1uthority and power in term~ of which dc:..:i~ion~ an· to Ix· impkmc:nt<:d. I 11 short, both p.1rticip,1tion .md de..:emr.1liL.1tion rel~· on m.rnag.,·mc:nr di.,cretion to detcrmine thc: amount of employc:L' imol\'c:mc:nr in dc.:ision m.1king., wherc.1s \h.1red g;o\'ern.llKC' does not (Marqui, & Huston, 1012 ).

Nursing ~lured gowrnam·e mndds 11.1n: alw,1ys lil.:mni 011 nun,c, .:ontrolling their profr~sion,11 practice. To h,: abk to control practice:, nurs1:s must haw control o, c:r re,ource, th.u impact profrssion.11 pr.1cri..:,· .111d they must ,ll~o haw influ1:n.:c: owr thc:1md,·1:, ·" .1 proti:~~ion,11 group ( Bi..:ber & Jo.1d1im, 2016; M,mcini, 2015 l.

Portc:r-O'Gr.1d~· 11012) J,h".mred th1: ide.1 th.it in or ... kr for rruL· interprofrssionJl t1:.1m-ba~eJ rnodd~ of ,Kcoumabiliry to thri,·e in health scn·icc:s orgmiF.atiorn,, fin· principle~ gon:rn the prJcticc: and rd.uionship~ of the t,·.1111, ,md .m: n1:eded to sustJin shared gm·ern.u11.:e:

Prnks!.iom .ire dri,·,:n b~· practice .md pra.:tition,:rs-thc locu_-. of .:ontrol for derision nuking in term~ ofwh.lt constitute, proks~ional pr,1cticc:, qu,1lity, competence. and knowkdge gencr.uion mu,t be ret.1im:J by the: practitioner. Th1: farther .nny thl' dc.:i~ion nuking i, from the knowlcdg;e worka I thl' proti:ssion,11 ), the lower the decision qu.11it'I' ,rnJ th1: higher the cost of the decision.

Chapter 21 Application of Theory in Nursing Administration and Monogement 481

Stn1cturc i~ key-there must be direct .1lignmcnr benn:cn orgJnization.il ,tructurc .rnd intended bch.1viors .111d outcome~. Org.iniz.:itional '1ructun.:s th.1t .1re ineffcctin: in producing the most efti:ctiYc outcomes for knowledge workers such .1~ RNs include tr.1ditio11.1l bure.mcratic ~trucrurcs Sllch ,ls n:rtical, hicr.uchical stru..:rurcs in whiL·h nunagemcnt h.1s ultimate control of Lk..:i~ion and policy making. .-\ccountabilit\' is centr.il to proti:ssiona.l practice-true J.ccountJhility hy proti:~sirn1Jls c.111 only thrin: in cm·ironmcnt.s in which the org-.111iz.uionJl ,tructun: i~ such that .1..:cmmt.1hility i.~ within the control of the pr.1ctitioner .1t the point of practi\:C. Control of Jccount.1bility mmt be purpusdi.illy dcsignc.:d into the ,h.1rcd gon:rm.111:c ~tructun:-,harcd govan.111.:c 1:i..:ilit.1t1.:~ distributive dccision making, In .1 true sh.ucd g<wcrn.1ncc modcl, practitioncrs n:tJin control o,·cr profc~sional practice-not man.1gemcn t. LeJc.krship by management i~ crucial to the- cftcctiwness of ~hared gon:rn.1111:c-the competcncie~ of m.11ug.:rs and lc.1dcr~ in shared org.:inization .u-c difti:rent th.111 in tr.1ditio11.1l org.1nizatinns. These eornpl'ten..:il·~ incluc.k distributive dc..:ision m.1k.ing, ctkcriw scrnnt kalkrship, and assisting pr.ictice peer~ to ne.1te work cm·ironments in which knowledge worker~ -:.m prai.:tice to the fullest extent ( Poncr-O'Gr.1dy, 2012).

Three gc-ncral mnJcls of sh.ued go,·ern.mi.:e arc:

1. Councilor model-the 1110,;t common model; utilize~ .1 ..:oon.iin,lting coun- cil to integratc de..:ision~ nude hy ~raff .md 111an.1gen, in ~uhcommittces th,H reporr to the coordin.iting -:ouncil

2. .-\dminisrrarive modd-thc organizarirnul chart i, ~plit to rl·semblc rwo tr.1eks-J 111.111ag;ement tr,1ck .md ,1 dinic1l track; membership in both tra..:b indudc~ n1.1n.1gcr~ and ~t.1ff

3. CDngrcssional modcl-usL'S ,1 democr,uic prcxess tu cmpm\·cr nurses m nice nn issues

Structun: of the mmkls is not import:1nt; wh.u is important is l·omrnl on:r practice rlut le.ids to impron-d patient, nur,c •. md organiz.1tion.1I outconll.'.1> (Anthony, 200-L Bi.:bcr & Joachim, 2016 ).

Rc~l·,1rch-based :m1die~ l1.1n.· .lttcmptc-d to c,·.1lu.1te the outcomc-s of~h:ircd gm·er- nance from the pcrspl·ctin:~ of the org.1nization, the nursl', .md the patil.'nt. From an organiz.1tion,1l perspccti\'C, in generJI, research ~upport~ the finding of ,111 improved n11.1nci.1l posturt for the orgJniz.uion ati:c-r impkmentation of ~h.1rc-d g:m·ern,111cc. The improved niunec~ ~tem from l'ither co~t sJ,·ing~ or ..:ost n:Juctions. Reported ex;1mpk3 of cost savings .rnd rl·ductions range from .l decrl·,1sc- in on;rall meeting time for staff to multimillion doll.tr reductiom in the: u.,c of temporary or ,1gnKy nurses once shared gm-crn.11Kc l1.1s bcc.:n full~· implemented. Research studies indicate i111plt: - mcnt.1tion of sh.ucd governance hJ~ resulted in improving the work e1wironment of m1rscs, which lc.1ds to increasL"J nur~e ~.uisfaction .rnd ultim.1tdy to improv.:d nur,L' retention (Jmcph & Bogue, 2016).

In one recent exJmpk, Kutney-1.ec and teJm (2016) examined the rdJtionships between sh.1n:d gon:rn.mcc, speciti..:.1llv nurse engagement, .md impact on nurse Jnd patient outcoml·, in -t-25 nontt:derJl JCute cJre hospitals in the LTnited St.Hes. They den:-rmincd tlut hospiuls which prm·ide nurses ,,·ith the .1bilitv to be the most JC-

tiwly invoh-c-d in insrin1tiu11.1l decision making .1rc morL· likely to be imtirutiom in which lllirSl'., culti,·atc bcttcr pJticnt experiences resulting in supc-rior lcvcb of care .md

482 Unit IV Application of Theory in Nursing

iticn:ascd p.uicnt .md m1r~c s~ui~facrion kn:k Indeed, incn:a~cd n,1,ir.,c cngJgemcm in institution.11 dt'cision 111.1king i~ aitical in .m er.1 focused on ,·alue-ba~ed purdu~ing .mJ cost containment. It ;1lso ha~ ,trong imp.Kt un the hc.1lth carc in~tinnion ·~ financi:11 picture in tams ofsignitic.mt loss.:s, fin:rnci.11 .rnd other, .:issoci.ucd \\'ith 11ursi: rurnm·cr.

Derr,1ctors of thc ~lured go, ernanct' model point ro thl· i:xpense of introducing .md m.1int.1ining; thc model. the longer time it take~ to arri,·e .n decisions u~ing the model, ,mJ the fact rh.n not .1II nurses \\'ant ro lun: .1 role in deci~ion making or \\',lilt accounrabilin· for decisions.

Transformational Leadership in Nursing and in Health Care

Historic.1lly, nursing .rnd health c,ll'l" organitation~ \\'en: built on old par.1digm bdid~ ot' hierard1i..:al ~tnictures with an emplu~is on rationality and logic.11 decision nuking. The old paradigm i~ e\'ol\'ing to a ne\\ par.1digm that ,·aluc~ mutualin·, affiliation, co- op~·ration, net\\·orking:, and .111 emphasis 011 human n:brions. In nursing;, the ~hifi- h.1~ led to dccentr;11iz.1tin11, particip.1tiv<.: 111.m.1gcmcnt .rnd dcci~ion m,1king, .rnd ~hared g< )\'ertl,UKC.

In transform,nional lc.:ader~hip. the lc.1da and thc follo\\'cr h.1,·l· the ~.1111e pur- pmc. Barkn ( 1994) proposed th.1t it is e.1sier to study the.: l't'm!ts of tr.111sfor111.1tional kadcrship Llun the:: prnCl'ss. Tramfornutiu11.1l k ,1lkr~hip i~ mor.11 .md philosophic.11 lcadcr~hip rather th.111 tcdrnical leadership. Benni~ and Nanu~ ( l 98S l (OtKcptua'1izcd four strategics for t r.msformational kadcrship: t l) (reating; a Yision, ( 2) building J so- (ial Jrchitccture th.It pro\'ilks the frJmcwork for g<-"nnaring; commirmcnr to rhe ,·ision .111d for c~tablishing; ,lll organizational identity, ( 31 de\'c.:loping .111d ~ustaining org.1- nit,ltion,11 trmt. and (-! I .lttcnding to the.: ~elt'-c::stccm of other~ in the organiz:1tiun. Cottingham ( 1988) propmcd six stratc::g;ie~ for a tr.1mfor111atio11.1I lc.1da ( Box 21 -2).

Portcr-O'GraJy ( 1992 I suggc~tcd that transformational nursing lc;1dcr~ shn u,ld fon1s on rd.1tionships .rnd dcn:lop pcrscm,11 skill~ ~u(h .1~ p.1radigm .1sstssmcnr, procc::ss ,1mbiguity, staffdc(i~ion nuking, .rnd sh.ired gm·crnancc. Transti.1rmatin11.1I lcadcrshi11 i~ not k.1ding and controlling; r.1thc::r, it i~ (oordinating, inrcg;r.lting, .md t:1cilit,lt· ing. Tr.111sformation.1l lc.1dcrs should strin: to build coalirium .md networb .1111011g

Box 21 -2 Strategies for a Transformational Leader

Know the people you work with: Find out obout their interests outside of the work environment; be visible ond accessible.

Help people to leom ond develop: Expose them to new ideas and methods; encourage ottendonce of seminors to help team members leorn as much as possible obout their roles.

Provide frequent feedbock obout performonce: Give feedbock quickly rnther than waiting far a formal evaluation meeting . Feedback should be specific enough to enoble the person to correct deficiencies; criticism should be positive rother lhon negative.

Award responsibility ond stotus to coworkers: Give them the opportunity to porticipote in work projects that will ollow for growth ond increased responsibility. Recognize the potential in others and give them the opportunity to reolize thot potentiol.

Reword coworkers for o ;ob well done: Monetory rewords should be os high os possible within the fromework of the orgonizolion.

Make informotion ovoiloble to o/1 involved: Involve coworkers in decision moking and problem solving and support their efforts.

Chapter 21 Application of Theory in Nursing Administration and Management 483

discipline!> and dcp.1rtmcnts by bringing din-rs~· group~ together rm,·Jrd a slurcd \'ision or g:o.tl while .tt the sami: time managing thi: ..:omplcxity of the org.mizJtion.

One esscnti.11 dcmenr of the l\\Jgncr recognition model is cYidcncc of tr.tn!>- ti.,rmJtin1ul kadcrship in the orga11iz,1tion. Cla\'cllc, Drcnbrd, Tullai-M..:Cuinness, Jnd Fit7.p:mi..:k ( 2012) explored lc..1dcr,hip prJ..:ti..:cs of CNOs in ,\-l.1gnct fa..:ilitic~. The results ofthi~ srudy ren:.1kd incn:J~ed cdu..:arion and c-xpericnn: of the c:--:O w.1s positin:l~· .:orrcl.m:d with tr.1mfor111.1tiunal le.idcrship ..:har:i..:teristii:,. Older cr--:o~ ,rnd those- with dot.:roral dcgn:es s<.:(lred signifi.:amly higher in the tr.111sfor111.1tion,1I k:iJ- crship pr,1..:tit.:cs uf impiring .1 slurcd ,·isinn .md d1Jlknging the prn.:ess. Key pr.1t.:tii:c:, identified by the !>tudy were c1ubling others ro ,1..:t .111d modding the w.1y for others.

In ,t re..:cntly published ,,-ork, Fis..:hcr { 2016 l an.llyzcd the .:on..:cpt uf transforma- tional leadership ,md prm·idcd tkfining ,H-rriburcs spc-..:ifo.: to the nursing context. She identilll:d .1 set of i:ompetencie~ .1s~o..:i.1ted with it. Th.::,c ..:ompctcni:ics Jrc .:motio11.1l intclligcn..:c • ..:ommunit.:.1tion, ..:olbborJtion, coaching, .md mentoring. Applic.ition of ..:ompctencic:, pro\'idc:, J found,uion for developing tr.msti,rm.ttion.11 lc.idcr~ for pr.1..:tit.:c .rnd in ,Kadcmi..: c1n-ironmcnts.

Patient Care Delivery Models Nursing c.:Jrc in the .1cutc Glrc ,ctting is dcli,·crcJ most often utilizing J group practi..:c: model. The group pra..:ti..:c model prm·idcs the stru..:turc .md ..:ontcH for the: dclin:ry of <.:Jn:. Pra..:ti..:c models r.1ngc from tho~e tlut .ire b.1~c-J on pJtient ,1\signmcnts (su.:h .1~ tc.1m nursing) •• 1..:..:ount.1bili~· wstc:m:, (primary nur:,ing), and m.111.1gcJ ..:.1n: ( case 111.111:i.gemcnt J to model, rh.H ,1re designed to in..:orporatc proti:ssion.11 pra..:ti~·c ..:on..:ept~ of Jutonomy, dcci:,ion nuking, p.irtit.:ip,uion .. md proti:~,iorul ,·,tlucs l \har.:d g0Ycrn.111cc model) ( Anthony, 200--l; ,\l.1rquis & Hus ton, 2012 J •

.,\:,\ignmcnt :,y\tcms for nursing. stJff or p.1ticnt ..:arc dcli\'cry model~ dung~· in n:spomc to ..:hanging needs. for .:x.1mplc, in the 1920:,, thc CIT.ft' 111cthorl ,md p1·ipatf rlllt_)' 1111rri11._rr models of tot,11 p.tticnt .:.1rc w.:rc the system:, most often implcmemed. By the I 950s,_ti111cticmnl 1111rsi11,11 wa:, 111trodu..:cd a, J re,pomc to ,t shorr.1~c of mm,cs. Ti:aw or 111orl11/ar 1111ni11._11 w.1~ .tl~o introdui.:cd in the 1950s to ,·.1pitaliz.: on th.: cxper- tb.: of protessional nurses ,llld to me nonprot~ssional team members in the prm·ision ofnur~ing ..:.m:. J>rimnry 1111rsi11.__11, .1 ,hi~ b.1t.:k to ..:.1rc ofindi,·idu,11 patient!> by pruti:s- siun.1I mmc:,, w.1s commonly med in th.: ( l)60s .111J J 970s. The method th.tt ha.~ most rc.:rntly ,1ppc.1rcd in the literature is pntirnt·fornurl <'nn- ( PFC 1.

E.1..:h of tlw dcliwry method~ h.1s inherent ad,·.unages .u1d dbadYJnt.iges. Thc~c pJticnt i.:.uc dcli\'cry methods .trc used primarily in ho~pitals, but they c.1n be ad.1ptcd for use in other setting:,. f.Ktor, ro ..:omidcr prior to impkmentJtion of ,l particul.tr method or system include t~-pc .md a..:uiry of patient~. t.:omplcxiry of the tasks to be performed, a\'ail.tbiliry or supply of R.Ns, skill .md t·xpcrri~c of the st.1tl~ and the ci.:onomi, rc~nuri.:e~ of the org.mization.

Total Patient Core !Functional Nursing) Tot.11 p.1tient <.:Jre, the oldest tkliYery method, w,1s a..:compli~h..-d hy nur~c~ in the home ,tnd ho~pital setting~ . .\lost of the p,Hicnts were .t~~ig.neJ to nur:,i.:s Js ..:.1:,es; one nur~c .1ttentkd to .111 of the p.tticnt's needs during the ..:our!>C oftlw nunc\ shiti:. The nujor ~fo.idnntagc of this method is cost, parri..:ul.irly in times of nursing ,hort.1gcs.

En,h·ing ,l\ ,t result of the mrrsing ,hortagc th.lt n..:currcd during World \V,1r II, the f1.11Ktional method of pnl\"iding p.1ti1:nt care- w.1., Jcriwd from the prin..:iplcs of

484 Unit IV Application of Theory in Nursing

~cientilic m.111.1gement. that i~, emph,lsi~ < >11 efficiency, diYi~ion of l.lbor, ;rnd rigid controls ( !l.1arriner-Tomey, 20091. In thi~ method, the p.lticnt\ pln·sicJI needs .ire at- tended to primaril~· by unlicemed worker, ( i.e., m1r~ing aides), \\'ith lli'!s responsibk primarily for m.magcrial fonctiom. The focm of this method w.1~ on the completion of certain tasks, ~uch JS admini~tcring medication t>r perfrJrming treatments. rather than on meeting .1ll of the need, nf the p.1ticnt by one nurse, .1\ \\·.1s accomplished in total p.ttient c.11-c methods ( Sportsm.m, 2015 ).

Although patient care .1ppc.1rs t<, be dcli\'ercd c-flicientl~· .rnd there would appear to be- littk conti.ision rc.:g.irding n.:spomibilitks for t,1sks .111d .1ssignmc.:11ts \\'ith this method, ti.inction,11 nur ing lus sc.:n:ral di~ad\'atltage~. These disad,·anrage~ indude tht· need for g.re.1ter ..:nordinarinn of care-, fr.1gnu:ntation of ..:ar~-, the nujori~· of c::m: being pnn·ided by nonprufr:ssional .1nd unlicensed worker~, de-cmplusi~ on the psy- chologi..:al nc.:e1.h of the patient, .rnd the repc.:titi\'e 1umn.: of the \\'ork. In times of nursing ~hortagc.:s, he.11th c.u~· administrators often return to .1 ln-brid of functio11.1I nursing, induding the u~e of 1111lin:1N:d he.11th c.1re worker~ or unlicensed .1~sisti,·e pc.:r~onncl (LTAP) ( /1.Llrquis & Huston, 2012; Sport~m.111, 2015).

Team Nursing Team nursing was dC\-doped .lti:er \Vorld \V.1r II in .111 c.:tfort to .11lni.1tc.: the.: fr.1gmcmc.:d care.: ,1ssoeiatcd with ti.mcrion.11 c.1re. In the tc.1m nursing ,1pproach, ,\ professional or tcdmic.:al nurse i~ the n:.1m lc.::1dcr of ,1 group of other he.11th can: \\'orker~ th.it lllJY include other protl'.s~ion.11 .111d technic.11 nur~e~ .1nd unli..:enscd per~onnd such a~ nur~ing ,1ssist.111t~. The re.1111 i~ respon~iblc.: for rhe pro,·ision of t:.1re to ,\ group of patients on .1 nursing unit.

The team leader i\ the ..:oordinator of the group .rnd is responsible for .1~signing t..:.1m member~ to \pc.:cific p,1tient .1ssignment~. The te.1111 lc.:.1der m.1y or may not ha\'e a p,ltil·nt .1ssignmen1. The- te,1111 leadc-r i~ responsible for kno\\'ing Jbuut the t:onditiom .md need~ of .111 of the.: patients assigned to the te.1111 .rnd for communicating with physi..:iam. Dutie\ th.it ..:annot b..: performed by other te,\Jn members bc.:c,rns..: of lack of ~kill, expati~e, or lieem,urc.: .1rc performed by the te,1111 kadc.:r. Te.1111 member\ report to the team leader, who in turn reports to the unit 111.1n.1ger.

Ad,·.1ntages of team nursing .,re the.: demoaati,· 11,1rurc.: of rhc.: method, thl.' focus on the- c.:mire p.nic.:nt r.nher th.111 on sp1;.•citic t.,~ks tt1 be .1ecomplished, thl' ,\utonom,· provided to the te.1111 to .1cco111plish the work, .md in..:reascd satisfa.:tion with the method lw workers .md patient~. Dis.1dv:mt.1gcs of tc.:.1m nursing indude the high degrc-c- of coordin.nion Jnd pl.uming required and the dc.:pendcn..:e on the unique ~kill~ of the tl.'am leader to make.: the con.:ept \\'ork efli..:iently and effreti\'c.:ly. Team nursing h,1s rJrdy been implcmentt:d in its pure,r form. lmtead, a combination of team .rnd ti.111ctio11.1l m,r~ing h.1~ 1110~1 frequc.:ntl\' been implemented I 1\1.lrqui~ & Huston, 2012}.

Primary Nursing Prim,u~· nur~ing \\',l' initi.1tcd in the late 1960s .md early l 97(h in response to pro- fcssion.11 nur~es \\'ho decried the.: lack of personal conta.:t \\'ith p.1tients and \\'ho wc1\: unhJpp~· with the pro\'ision of frJgmented c.1re. Primary nursing uses ,ome of the ..:on..:ept!> on \,·hi..:h tot.ii p,Hient care \\'a, b.1scd (i.e., during \\'Ork hours, the primary nurse, .rn RN, \\'ould be responsible for plannin~ C.lfe .ind prm·iding tot.ii p.lticnt c.1re to J group of patients). \\/hen the.: priniar\' nur~c \\'J.!, not on du~·, .rn .1s\oci.1te nurse ( another RN) \\·otdd pro\'id~· care to the patients ba~ed on a cJre pl.m developed by

Chapter 21 Application of Theory in Nursing Administration and Management 485

the- primary nurse-. Howc-n:r, the- prim::iry nur<,c- rc-tainc-d n:sponsibilitY l<lr the as~igrn:d patknt lo .1d 24 hour~,\ ,fay "·hik the patient ,,·.1s hospit.1.liz..:d ( Sportsman, 2015 ).

Job satisfaction is high in prinury nur~ing bc-c.wsc of the high dc-gree ofautonomy .111d rc~ponsibilit\· .1ffordcd m the prim.1ry nurse. Continuity of c.m: i~ gre.nly facil- it.ucd b~· the p1in1.1ry nursing model. Di~ad\'ant.1g.c~ ro prinury nursing. indude the number of R .... '1~ required w implement prim.try nursing and the high degree of coor- din.nion .md protc!->sional nursing cxpcrti!->c requin.-d for thc role. Primary nur~ei, who .1rc inadcqu.1teh· tr.1incd or incompet..:m H, implement the role m.1y be incapable of fulfilling thl'.' prim.1r,· nur~c role.

Patient-Focused Care/Patient-Centered Care The ri-:c modd \\"as dc,·doped in an effi.,rr to dccre.1sc the cost ofpro\'iding he.11th c.1re \\"hilc impro\'ing the qu.1lity of the sen·icc .md \\",b focu~ed 011 thc inp.uienr care expc- ricm:c ( J\lycrs, 1998 J. The principle~ of PFC .m: de1i,·ed from tot.11 Qi\ljcontinuou~ qu.1lity impro\'emcnt I QI l in th,ll PfC brings p.,ticnt ~·.m: need~ .1., do~e ,lb pm:.ibk ro the bcd~idc. :\ go.11 of PfC i~ to decre.1~e the number of health care ,,orker~ needed while i,imult.rncuusly in..:rL'J~ing the time nursL·~ would h.nc to ~pend with patient~. Theoretically, the co~t of c.1re ,hould dccrc,1se " ·hilc qualit\· of care incre.i~c~.

i\bng ( 1995) described prim:iplc~ of impkmcntation of PfC. Tlll:sc principle~ .u-c ~umrnarizcd in Bo\ 21-~ .md .ire Lfocussed bricth- in the following text. Pntirnt rofr:ploymmt in\'oh-c~ pladng patient\ \\ ith ~imil.u- need~ .md di.1gnme~ in the ~.1mc geographic location. The optinul number of p.1tient~ with ,imilar needs .md di.1g110-

on .1 unit ~hould be het\, cen 50 .md 100 to ere.He .111 c..:0110111,· of ~..:.ile ,md to cmun: pn:dict,1bk cen~u:, and worklo.1d. Dccmtmli::.ati011 1!{ support scrJ>icn refrr~ to relocation of ancillary sen·icc~ ( i.e. , pharma1..-y, r.1diology, .1dmissions, and labor,ltor~·) closer to the patiL·nt to .1llow fr>r nwrL' efficient use of pcr~onnd.

Crc:,uion of 11111/tislcillcd worlttn, or cross-trained \\'orkcr~, i~ ,KL·omplished b~- combining .1ppropri.1tc t\pes of tasb. for example, the mulriskillcd worker would be responsible for housekecping, food ~cr\'icc, .111d nther umkilled u~b for a group of pa- tients. The go.11 ofrre,Hing. the multi~killed worker i~ co decrease the number of worker~ thi: typical patient com..:~ in .:ontact \\ith b~· up to 73'Y., ((:lourcn & Weber, 1994).

Now a key indicawr of hig.h-qu.1lity <:.ue .1s defined by the I mtiture of i\kdicine 1 IOM 1, p.uicm-focuscd, patient-centered ore e\'<il\'cd into .1 model in whkh p.iticnts ,111d familic~ arc .1<:ti,·e participJllt!-> in deci~ion making. ,1bout c.1re. four concept~ .ue .1:..sociatcd with contemporary patient- .md family -<:entered c.1rc modeb: dignity .ind respect, information ~h.iring, particip.ltion, .md <:oll.lboration I Johnson ct al., 2008 ). 1111..ked, in thi., modd, patient!> mu~t be ,,·cll informed .111d induded in .111 decision nuking rcl.ited to thc plan of c.m: . In ,1Jditio11, tnsk si111pl~/irnrio11 would be .1.pplic:d to c, en' aspect of th<: patient\ can· to allm,· for greater ctfo:icncy and time sa,·ing~. \\"hich results in c.1rlicr disch.1rgc ti ir the plticnt.

Box 21 -3 Principles of Patient-Focused Care

Patient redeployment Support services decentralization Worker cross-training Creation of multidisciplinary teoms Patient involvement Task simplification

486 Unit IV Application of Theory in Nursing

The goals of PFC art' ro ( 1) tr,msform the health ..:.ue organiz,1tion into .1 ..:ustumer-focused org.rniz:nion; ( 2) improve continuity ofcare for patients; ( 3) impro\·e protcssion,11 rehniunships among doctor~, nurses, and othcr caregiH·r~; (_-!) minimize the mon:ment of patients throughout hospit.lls; ( 5) increase the proportion of direct care activities .1s compared to other acti\·ities in the org;J11iz,1tion; ( 6 J reconfigure the clinical em·ironment to truly meet the need~ of the patient~; ,llld (7) empowcr direct caregi\·ers to pLm and implt'mt'.nt \\·ork i_n "·ays that Jre most rcsponsivc to thc nt't'd~ of p:i.tients ( Zaru bi, Reiley, & i\h:C1rter, 2008). The re~ults of studies e\·alu.ning the PFC model in1fa:ate that patient and staff ~atisfaction improvc ath:r implementation of PFC, .1~ docs physician satisfaction in rcbtionship \\·ith nursing staff In terms of sa\·ing;s, some institutions reported J decrease in time of the admission process, a decrease in im·entorY, and an impro\'ement in costs. Qu.11ity indic.nors, su..:h as direct p,niem care time, patirnt satisfaction, continuity of care, ,rnd no~ocomi.11 inti:ction rates, rcn~aled positiYe trends ,11ter implementation of PFC.

Some health carc organizatiom haw extended the patient- .md family-centered care modcl by engaging formcr paticnt~ .rnd family members in ,m advisorv capacity to assist the org:i.nization \\'ith p.Hient satisfaction, 9u.1lity, and safrty ..:onccrns ( Cunninglum & \Val ton, 2016; \Varren, 2012 ). These ,llh·isors relate their expe• riences from p.1st care encm111ter~ in the organization or facility with the goal of imprm·ing the care experien..:e~ of other patient~ .md families in the ti.1turc. Paticnt and family ,llh·isors ha,·e assisted hcalth ..:are fa..:ilitie~ \\·ith making ch.mges to poli..:ies, the physical i:1l\'iro11ment, and aspects of clinical care deli\·ery as \\'di as 1\-irh staff education and dc\'clopment.

There is ..:onsider,1blc interest in patient- .md family-centered ..:an: modcls .1s ,1 rcsult ofpro\'isions of the P.nienr Protcction ,md Alford,1blc Care Act (ACA). These models focu~ on patient sati~faction and which ha,·e the potential to signific.111tly i111- p,1ct reimbursenll'nt tc>1· ..::1re provided in hcalth .:arc org:111iz.1tions. For example, The Hospital Consumer As~e~sment of Healthcare Pro\·iders and Systems ( HCAHPS) ini- ri.niw prclYide~ ,1 mei.:hanism for health ..:an: facilities to benchmark patient satisfac- tion trends in thcir facilities \,·ith expected national outcomes; outcome$ .1re tied tu financial inccntivcs for health care insritutions (Cropley, 2012). l111plcment,1tion of patient- and family-centered care models 111.1y lead to impro\·ed raticnt/famil\' expc- riences, which results in increased sarisfaction ~..:ore~ and nn,rncial incenti,·e,., for thi: institution pro\'iding the care.

Also induded in pro\'isions ofrhe 2010 ACA, the PJtient-Cent1:Tcd Out.:omes Rcse:1rch Institute ( PCORI) \\'as established to fund research dforrs focused nn n .Hn· paring p.1tient-ccntered clinical dkcti,·eness resc.1rch. A ..:entral tenet of POOR.I is that induding the patie111 perspecti,·e in health rese,u..:h i~ valu,1ble .md should rcsult in the a..:..:elcr:i.tion of the integration of re~e,1rch finding~ into dini..:.11 practicc to tht ultimate beni:fit of patients ( frank, Basch, & Selby, 2014 ).

Use of Patient Care Delivery Models Today Rarely do pure forms nf .111~· of the paticm c.ue deli\·ery merhods dc.scribcd earlier exist in practi..:e today. Typically. components of se\'eral of rhc methods, o r .1 combi- nation of rhe metlmds, .m: used to aci.:omplish patient care. Delivery methods usu.1lly diftcr between inp.nient and outpaticnt areas .rnd from unit to unit, depending on the nature of thc patient cart' unit :md the ~kill mix of the licensed and unli..:ensed staff assigned to the unit.

The Nursing Work lndcx-Rnised (Aiken & P.:urician, 2000) has bei;:n mcd to measure Jttributes of the work environment of professional nur.!.es that support

Chapter 21 Application of Theory in Nursing Administration and Management 487

profi:ssion.11 dinic.,I practic..-. Th..-~e .1ttrihm..-~ indud..- organization.1) support for nursing prJctic.:, speciti-:ally, Jlkquacy of rc~ources to support the pr.Ktin: of proti:s- sion,,1 nursing, induding :1dequatl' R.1'1 st.1fti11g, ,1utonomy for nurses, nursc control of nursing prKtice, and collegial nursc-physici.rn n:IJtion'.'-hip~. Whl·n these attribute~ .1rc present ro .1 sufticicnt degree, mir,c job ,,1ti~factio11 is higher ,md burnout r.1tl', and phpic.:al dis,1bilit~· rat..:, .uc lower. Imprm·ed patienr-reLm:d outcome, such as de- creased adn-r..c c,·em~. lower mortality, .md higher kn:b of packm satisfac.:tion with c,ue .11-..: noted.

Aiken, Cl.uke, Sloane, Sochalski, .md Silbt:r I 2002) wen: sotm: of the c.1rlicM rc- '.'-earc.:hers to n:plicatl' the c,·idmc.:c linking nur.,l' st.ltfu1g ro patient outc.:ornes. In a srudy b.N:d on .111 an.1lysi, of oureomt:s of m.my thou~.mth of patic-nts in 168 Pt"tmsylv:mia hospit.11'> m·er .1 20-mumh pniod, ri.~k of dc-.uh following c.:0111mo11 surgical proecdun:s inc.:rca!>ed by 7% for each patil·nt aJdul to th..: nurse's workln.ld on:r J nursl· · to· pati..:nt r.ttio of l :4. The result i!, th.it nur~l'S emplo\'c-d by hospitals which rnforCl' l.1rgc patient lo.tlh .m: signiti..:amly k!>s likcl~· ro saw the lifr of .1 patient who de,·l·lops a ~riom c.:omplic.:ation. In addition, inc.:n:.lscd nc:edlcstic.:k injuries for nurse~. inerc-.1~cd patient .md family rnt11pl.1ints, fall, with injuric-s, mc:dicJtion errors, .111d hospital- acquirt:d inti:ctiom .1re more likd\' to occur when the nursc-to-patil·nt ratio is hight:r (..\ikl'll, Clarke, & Sin.me, 2002: Cho, Kcretian, Barkau~bs, & Smith, 2003 l.

Higher patient· to-nurst' ratios ,1re ,llso .1~soci.1ted with incre.1sed c-111otirn1.1I exhaustion, turnO\ n intention, and job dissatisfac.:tion ( G.1bricl, Eric.:k.son, ,".1orJn, Didi:ndorff, & Bromley, 2013 ). Rc-c.:ently, Cimiotti, Aiken, Sloane •• md Wu l 2012) doc.:ume11ted a signilic.:ant .t~soc.:iation bet\n."en paticnt-to-nur\c ratio .md inc.:idenc.:e of urinary tr.Kt .md surgic.:al site: inti:c.:tions. \Vhcn using a ~t.itistic.:.11 mndd tlut c.:nntrolll'd for patient se,·c-1ity .111d m1r,c .md hmpital durac.:teristic~. only IL'l burnout w.1s sig- nificantly .1ssod.1tl·d with urinary tr Jl"t .111d ~urgi..:.11 sitl· intcctions. These tinding~ bc-- ~·oml' even more: sig;niticant when naminc:d in light of pro\'isions .1ssoci.1ted "·ith tht: P.1ticnt Pmtl·ction .111d Accountabk Care Ac.:t, whic.:h indudcJ lms of n:imbursement to he.11th c.:arc- nrganizatiom for fa..:ilitY-ac.:quirt'd conditiom ~uch as urin.1ry tra.:t .md ~urgi..:.11 ,itl' inti.:criom ( Amici, [).widow, Hollander, & Murt·no, 20 l 2 }.

In l 999, Californi.l bcc.:.1me cht: tir,t st.Uc in the Unircd St.rn:s to p.1~~ kgislation ro cnfrm:i: minimum nun,c ,tatting k\'ds in ho~pitals to impro,·e the ~ualiry uf care for parients. Spi:tz { 2008 J condueti:d .1 ~tudy to namin~· whl·ther nurse~ who \\'ork in hospit.lb in C.1lifornia \\ t:rc- more- ,.ui,ti..:d with ~t.1fting kn·b .md other job anribut,:~ !>inc,: minimum ~tafling level, ,n:rl· en.1etl·d. The results indic.ncd that nur~t' satisfac- tion did inerea~t: bi:t\\'ci:n 20().+ .rnd 2006.

Oth.:r l,tudi,:s faikd to sub~t.tnti,lfl" a relationship berwc-i:n incn:as..-d m1N: staffing kYcls .rnd imprm·cJ patient outC<>llll'\ ( Burnc11 Bolton t't al., 2007; Donakhon ct al., 200:i; Hickey, Gau\'rcau, Jenkin~, ril\\"l'.c-tr, & Ha~·m.m, 20 I I). Howc\'cr, .1 study c.:onducted by .-\.ikcn .111d colleagui:s 1 20 IO) (ondudcd tlut m.md.nory statling Ie,·cl~ in CJlih,rni.1 were .ts~oc.:i.ncd with }o\\'cr patient mort.1liry .111d with improwJ nur~t' rl'tl·ntion. Furthcrn1orl', Tellez ,rnd Seago ( 2013) nplorcd thl' effrct of CJ!iforni.1 \ minimum ~raffing legisl.1tion on c.:h,rnges to thl· C.1lifornia R.;"ll workforce, partil'.ularly the dircc.:t care nurSl' in the .,cur,: c.tre \Ctting., .md c.:nnduded there \\'3~ impro,·ement in m1r~l· ,atisfaction .

In a tin.ii nampk, Aiken .111d .:ulleague~ (2011) JttcmptcJ to determine the con- ditions under whic.:h th,: impact of rhn·t' \'Jriabk!,-mJTsc-paticnt statllng r.1tim, nur,e cduc.:acirnul le,'l'l, J.nd work c1wironmcnt- a.re .1ssoc.:i.1t~·d with p,ltient outcomes, ~uch ,1, inp.1tic-11t nwrrality r.Hl' .111d failurc- -to-rcsntl' r.ttl's.

The rc!>ult~ ofthi~ s.rudy rewakJ that lowering. tlu· paticnt-to-nur~ ratio by one p,lticnt per 11ur~c: in ho\pit.11~ " ·irh good \\'ork i:11\'ironnK·nrs ~ignific.:.rntly improwd

488 Unit IV Application of Theory in Nursing

patient outcome~, slightly impro\'ed nurcnmes in ho~piuls with ,JYerag.e pr,1ctice erwironments, but lud no dkcr in hospit.1ls with poor e,wironrnents. Inl.Te,1sing by I 0% the numbers of nurscs with thc bachelor of ~...:icrn:e in nursing; l BSN J dcgn:e kd to a-!% dc...:n;,1se in patient death, whid1 ...:onlirm~ pre,·ious findings by Aikcn, Clarke, Cheung;, Slu.1ne, .md Silber ( 2003 \.

A...:..:ording to the Amcri...:an Nurses As~u...:iatiun ( 2015 ), as of December 2015, I 4 states ( California, Conneccieut, Illinois, Maryl.rnd, Minnesota, Nevad.1, New Jersey, Ne\\· York, Ohio, Oregon, Rhode Isl.111d, Texas, Vermont, ,111d \Vashington) han: cn.Kted kgi~l.uion specili...: to nurse staffing kn:ls .. -\ttc-mpt~ to e11.1a legislation .lt the kder.11 lcvd to require ~tafling pLlm, basc-d on unit needs .111d R.i'i-to-paticnt ~r.1fling ratios ha,·e been umul."<..:essful to d.1tc.

American Nurses Credentialing Center Magnet Recognition Program The Magner Rel."ognirion Program originated .1~ .1 re~ult of ,1 I 983 landmark policy study (McClure-, Poulin, Sovie, & \V,rndclt, 1983 ) wnducted br the- ,-\mcric,111 Acad- emy of Nur~ing ro identi~· i:h.ir.Kteristic~ common to ho~pitals wirh erwironment~ of nurse reauitment .111d retention. At thar time, during .1 n.uional nursing shortage, 41 hospitab became the focus of in tensin: n.:~ear,.:h efforts. The clura...:teristic~ idcn - ti ficd were rdcrrcd to as the "forces of !'.lagnetism" (\Volt~ Triolo, & Ponte-, 2008 ).

The M.1gner Recognition Program \\·a~ dewloped by the Americ.111 :-.:ur~c-~ Cred.:nti,1ling Cenrc-r (.\NCC) in the ea riv I 99(h to rel."ognize he.11th ...:.1r.: organi- z.nions th.it pnwidc- nemplary m,r~ing ,::in: and th.it uphold the tradiriom within nursing of proti:~sional nursing practice. The program .1lso sen·1:·~ .1~ a metlH>d or means tu tfaseminate !>Uccessful best practii:e~ .ind ~tr.uegie~ in nursing among in- stitutions. Magnet hospitals ha,·e in...:orporat.:d proven ~olutions to addre~~ nurse rc-cruitment and retention and to foster nursing lcadc-rship ( (:laH:lk, Portc-r ()'Grady, & Drenkard, 2013).

After undergoing SDlllC research-based moditii:.uiuns to the progr.1111 in 2005 (Triolo, Scherer, & Floyd, 2006; \Volf et .ii., 2008 ), the modd for ,\fag.net \\,l~

adopted in 2008. The new mudd l.°tmsolidared the 1-t forces of Magneti~m into h\·e components which lead to empirically derived, quality outi:umes. Overarching the fiy,: componc-nts is the- i:oneept of global issues in nursing and hea.lth c.m:. The li,·e ,:omponents .1r,.: presented in Box 21-4 (ANCC, 2008 l.

The Magnet Rc..:ognirion Program is bJsed on quality indii:aturs .rnd sr.1ndard~ of nursing practin: .1~ originally defined in the Americ;m Nurses A~sociation's !2004) Scop,: n11d St11nd11rdJ .filr Nttl'St' Admi11iJtrntors. The ,\bg:net designation pro,~·s~ indudes the .1pprai~a1 of both qualitati\'C .rnd quantitative factor~ in nursing:. A, of mid 2017, a total of 469 health .:an: orgJnizations in the United States, as well as 3 org.mizations in Australi.1, I in Canada, 1 in Lebanon, .111d 2 in Saudi Ar,1bi.1, h.1,·e .Khie,·ed i\lagner de~ign.nion {.'\.1'\/CC, 2017 J.

Box 21 -4 Components of the Magnet Model

Transformational leadership Structural empowerment Exemplary professional nursing practice New knowledge, innovations, and improvements Empirical quality results

Chapter 21 Application of Theory in Nursing Administration ond Monogement 489

Comidt-r,1bk n:~c.in:h h.is b1:e11 done on tht: cfti:ct of the 1.ignct desig11Jtion. Intked, \\'hen compared to non-~ lJg:nct hospit.1b, ~fagnt:t hmpit.ils h.in::

lktt.:r patient outcome~ .ind lmn::r mortality rat1.:, \ kHugh t:t al., 2013) Reduced incidt:ncc of hospital-a.::quired pn:~sure ukers ( Ma & P.1rk, 20 L 5) Lowt:r i.:entral linc-,1~so.::i,1ted bloodstre,1111 intl.·.::tion 1-.ltes / B.irne~, Rearden, & ~kHugh, 20l6) Lo\\'cr nur~c turnti,·cr rar~·s ( P.1rk, Gas~. & Boyk, 2016) lktter o\'cr~1l1 working c1wironment ( Cl.1n:llc et al., 2013 l

lore inn1h-e111rnt in decision m,1king by ~t.1ff nur~o ( Houston er al., 2012 l

Llstly, Stimptel, Slo.ine, ~kHugh, ;utJ :\iken 12016) e.umined the relationship between nur~ing cxcdlence, \\'ith ~bgnet recognition .1~ ,lll indicator of ,::,.cclkrKe, .md p,Hi..:nt:-.' experiem:e!. .1~ reported in the HCAHPS. The re~ult::. ofthi~ study indi- .::ated tlut p.lticnt~ ,1dmitted to 1\1.lgnet hospitab r.m:d their owrall experiences higher, l1.1d mon: fa\'orahk perceptiom of their .::ommunications \\ ith nurse c.in:gi\'(:rs, .ind \\'ere more likeh· to rc.::ommcnd the hospital to others. These lindings .1r~· importJnt bc:cJusc patient experience r.1ting!> .ire intq~r.il ,llld signitic.int in determining tin.inci.11 inccnti\'c~ .rnd reimbur~emcnt~ to hc.1lth c.trL' t:1.::ilities undcr, .1luc-b.1scd purchasing; initi.1ri\'cs cndot-sL·d by the Cent,:rs for ~kdic.1rc & ~kdic.1id Scn-iccs (C\lSJ .ind support .1 bmines:-. .:as,: for ~fagner recognition ( JJ\'awardh.in.i, \Vdton, & LinJrooth, 20]4).

Case Management

The C.1sc ~1Jn.1gcmcnt Society of :\merica ( C:MSA J dctinc, rnsi- 111111rn_rrrmmt ,1s "'a .::oll.1bor.1ti,·e proccss that JS!.c~~e,, pl.ins, impkmenb, i.:oordinatcs, monitors, .ind ,:valuates options and s,:n·ice~ to 111cct ,Ill indi,·idual's he.11th needs through com- munic.nion .rnd .n·ail.lhle resource., to promote quality cost-ctfrcti,·,: outcomes" (Y.imamoto &. Lu.::ey, 2005 l. C:.1~e 111,lll.1g,:ment is J role de\'dopcd in the l.tte l lJ8(h and early I <)9()s in response to thc prmpccti,·e p.n·mcnt ~~·stem and diagnosi~·rdated groups ( DRGs). An cxp.msion of the total paticnt C.ll'c system, L·,1sc m.lll,lgcmcnt origin.11L·d in outp.nic:nr sc:ttings. For cxJmple, community .ind public he.11th nur~.:, .::arry J .::.1sclo.1d of patients for\\ hich they pl.in, coordin.ite, .md e\'alu.ite c.1r,:. R.ircly do thcse nur~es impkmenr th~· .:.ire pcrson.illy; hm,·c\'er, tht:y rcrain responsibility t«>r patient outi.:omcs.

As .1 rc~ult of the prolikrJtion of managL·d c.uc in hospit.ib, .::3sL' m.magcmcnt wa~ also .1doptcd in inp.1tienr facilities, which is ,ometimcs reti:rn.:d to .\lo "\\"ithin thc walls" ca,e m.in.1gcml·nt ( Yamamoto & Lucey. 2005 ). ,\1mt inpJtient case man.igc- mcnt ~y~terns ,11-c b.iscd on one of rwo models: thc l'-:e\,. Engl.ind i\kdic.11 Center i\lodd, which focuscs prim.uilv 011 m.uug.ing. patient .:arc to .:onrrol resource~. or the Sr. ~bry's (or Carond,.:lct) i\Iodcl, in whi(h the role ofth,: ..:,he 111.m.igcr i~ to control or lo\\"er costs asso.::i.ucd \\'ith p,ltient ~t.iy~ \\'bile sirmtlmm:ously reducing the length of stay and produ..:ing. optim.il p.Hicnt outcnmo.:s ( Sportsm.rn. 2015 ).

The minimal rccommendcd ed11t.:.11ion.1I r~·quircmcnt for m1r~e .::Jsc manago:r rolcs is the b.i.::.::,11.iure,lte degree in nur~ing.. Ho\\'e\'er, .ilthough not .ill o.:.isc m.m.1g.er, may need to perform c.1se 111.m.1gem,:nt Juries at the .1J,·;111.::cd k\'cl, m.inr org.miz.itiom prcter .1dnn.::L·d educ,1tion.1I pn:p.ir Jtion .ind specialilation for nur~t:, in the rok of ~·.1se m.m.1g.er. :\d\'JntJgt:s of the AP:-J .1s opposed to tht: BS:\ in the .::J~l.' m.in.igemcnr rok indude rccognition of the Al'N .,~ cxpcrt pra.:titioncr, change agent, rcse.ircht:r, man.ig.a. re.Kher, .md con~ultant.

490 Unit IV Application of Theory in Nursing

Although c.1~e m.rn.1gcment imple111ent.1tion ,·;:iries from institution to imrirution .111d location tn loc1tinn, one ,-.1ri;1tion is to .1ssig11 .1 c.i.-,e manager to a group ufhigh- risk patient~" ithin .1 specific population. for example, one hospital, health care nrga- nizarion, or insurati.:..: ..:ompan~· 111.1y h,l\'..: cas..: 111an.1gcrs in pedi.Hri..:s, neuroscience, oncology, c.u-dim·ascubr, orthopniics, .md other specialty .ucas. The case m.111.1ger docs not cnordinarc the care of ,111 the p.itknts in ,1 speci.1h:y. lnstc.td, coordin.ltion of ..::ire by .1 ..:.1,e m.rnag;er occurs only for those pJticnts ,,·ho h,l\'c been designated .ts "'high risk" bc..:.rnsc of Jgc, comorbiditics, ,Uld t>ther facrori. that would pl.ice tlut p,Hicnr .lt risk for grc.ttcr consumption of rcsoun:c, or prolonged length of stay.

ldc.1l1y, the c,1,c nunag;er coordin.nes the c.1re of the p;1tient from pre,1dmis,ion to tlK timc of disch.ugc Jnd pcrhap, beyond ,focharge. This coordin.nion of can: requires inrerdi,ciplinJry collJborat ion and cooper.1tion. The c.1i,c 111,m.1ger's role in thi, model tr;1mccndi. gcographi..: or unit bound.tries. The ncuros(icncc ca:.c m.rn.1gcr, for example, 111,1y fir,t mect the p.nienr in the ncurosurgl.' r\" dini( or at thc neurosur- geon's office .md would pl.ly .1 role in coordin.ning preadmission testing,. following surgery, the c.1,c m.rn.1g,cr would track the progress of the patient from the ICU, to an inttTmniiatc ..:.trL· unit, to the neurology floor, ,md then to a rel1.1hilit.11ion unit if required. Thc (:ls..: m,rnJger would thcn be innll\'cd in establishing postdisdurgc home c.ire ifncccss.1ry (Sportsm.111, 2015).

C.1sc 111.111.1ger, .ue cmploved not only by hospitals but .1lso by he.11th maintcn.mcc org;rni1.ations ( Hl\ 10, l, other 111JJ1.1ged c.1rc organizations ( l\1COs), insur.rncc com- panies, and disc.1sc 111.rnag,emcnt cnmpanies. C.1~e 111.rnag,crs sen·e .1s the li.1ison hr· nn:cn patirnts .111d families, he.11th plam, c.1rc prm·idcrs, .rnd purchasers to determine thc extent of co\'er,1ge .md prob.1blc (osr, .md to coordin.nc trcatment ,lt .1 lower ..:ost and outside of inp.1ric11t c.11-c if pnssibk.

As .111 example of the inrcgral rok th.It c.1,c m.111.1gcrs pl.l~· in coordi11.1ting. c.ll"c outside ofi11p.1tie11t facilities, .1 joinr ,·enturc bctWL'ell Hanner He.11th .md Blue Cross Blue Shirk! of .-\ri1011.1 .-\dv.111tagc pro\'ide\ .lt k,1\t one home Yisit b\· .1 c.1,c m.rn.1gcr fr,r members who qu.1lit\ ti>r c:tse m.rnag;ement ~ervices. P.nients who qu.1lil}· for thc , ·isits .ire typic.1lly no longer eli~dblc for home he.11th ,111d ,uc recon:ring .lt home from 111.tjor conditions or ..:hronic illnesses such .1, strokc, hc.ut arr.ick, hc.ut failure, ;111d/or chronic ubstructi,·e pulmomry disease ( COPD L T he prog;r.1m .1bo t.1rg;cts individu.1b who were .1dmittcd following fr.1ctures .rnd rebtrd health problem~ re- sulting. from .1 fall. The home , ·isit is focused on condu(ting .1 home Jssc~~llll'IH to dccre.1sc the client', risk for subsequent falls. The p1im.uy goal of the home visit ini- ti.ni,·e is to reduce re.1dmi~sion ratc-s into acute c.1rc fa.:ilities . SinCl: the prog;r.1111 was established, re.1d111is~ion rJtcs for .1II ag;c group~ have dropped by I J'¾, (AHC 1\kdia, 2013 l. .'\!though RNs .:onstitute the l.1rg;cst prnfr~sirnul group in case 111.1n.1gcment, the rolc is becoming in..:reJ~ingly multidi,ciplin.1n-. with social ,n>rkcrs, rcspir.uon· ther.1pists, phy,icJ I therapists, and other he.11th ..:arc prufrssionals joining; org;aniz.1- tion~ .1~ c.isc man.1gcrs. Howt:\'e r, m :uw recognize the unique (Jp;:ibilitie~ of the ll::--;' in optimi,ing the role of (.1~e 111.m.1g;cr.

Disease/Chronic Illness Management Thc 011::.ct .111d c, -cntu.1I progression of mam· chronic illnesse~ is considcrcd by 111.my to be pre,-cnt,1bk. J)i.1cnsc 111n11nJ1c111mt lus been defined in thl'.' lite rJture .1., a patient c.u-c .1ppro.1ch th.u cmphJ~ize~ comprchensi\'e, coordinated care along .1 disc.1sc con- tinuum .rnd ,1cros~ health care ddi,·cry sysrems ( Ellrodt et al., 1997 ). Dis..:a~e managc- mem i~ th,· redirection of p.1tient c.1rc ~en·kes from inp.1ticnt to outparient settings

Chapter 21 Application of Theory in Nursing Administration and Management ,4'91

Box 21 -5 Criteria for Evaluating Need for Disease Management Services

A high percentage of complications associated with the disease ore preventable. The effect of o disease monogement program would be evident within 1-3 years o~er implementation. The conditions that ore manifested con be managed in a nonsurgical, outpatient setting. There is o high rote of noncompliance with treatment protocols; however, the noncompliance is amenable to change. Practice guidelines ore available (or there is potential to develop such guidelines) that outline optimal treotments of the diseose.

J.nd i5 vic.:m:d a~ a proactiw r.nh1:r than .1 rcactin: .1ppro.11:h to prm·iding hc.1lth c.lrl' sc1Ticcs. In csscncc, disease 111.mag1:111c.:nt progr.,m~ use medic.ii, pn:\cription drug, .rnd other hc.:alth-rcl.nnl d.1t.1 to identit\ indi\'idu.11!, \\'ith chronic illncss..:s who ,ll'e ,lt high risk for experiencing 5erious health probkms .md to prm·idc carh- intc.:rn·ntion to a\'oid or minimize.: thO-"l' problems ( Marquis & Hu~ton, 2012 I.

People diJgno~ed \\"ith chronic illncsw, (e.g., .1sthm.1, di.1b<:tcs mdlitus, congl.',- ti,·I.' h..-an failure.: [ CHf], AIDS, lowcr back pain, .md ccrt.1in forms ofcanceri Mc po- tential candidatc5 for disl·asc m;111.1g;cment intcn·entions. 1'.ongstYedt ( 20 I 3 I oft~rc.:d a ~l't of criteria by\\ hil.:h to c,·aluatl' \\'hat ~-pl.'s of chronk illnl.'S5C5 .irc .1ppropriJtc for disease 111.magcmcnt ( Box 21-5 ).

The potential of disea~c 111a11.1gement tn reduce hc:ilth car..: cmts .,~~o(i.nni \\'ith co111111011 chronic illnc~sc.:., seem~ ~ignificant. With the Jging of the large "'haby boo111cr" cuhurt of thc population, a precipitous rise in th\.' incidence of chronic illncs~l'~. :;uch as diabetes .md Cl-IF, 5<'l'l11S to be a forcg.onc cunclu~ion. :\c cur- rcnt r.ltcs, the cconomic burdcn rc.:IJted to the trc.ltmcnt of ju5t hYe of the lllthr cost!~· .rnd prc\'ent.1bk chronic conditiom (he.ut di~easc, c.111cer, COPD/J.5thmJ, di.ihctes, .md hypcrtrnsion) in the l·nited Sures is 5taggering Jt mer 53'4-7 hi Ilion doll.tr, or .1hnut 30% oftot.11 he.11th care sp<:nJing in 20 IO (:\mcric,111 l'11hlic Hl·,1lrh As~oci.1tion, 2017).

Disease Management Models

Historical!~'. lfo<.:,1sc m.111.1gcm<:nt programs \\'Crc dc\'doped by pharmacy bcndir, m.111.1gcment ( PBi\ 11 organizations, \\'hich were mainly O\\'llcd by ph.1rmJceutic.1l comp.mies th.u had .1 fi11,111ci:.1l st,1ke in m.111agl·mcnt of disc.1scs. Th1: theory w.1, rh.1t if di~e.1se man.1gcmcnt progr.1ms wen.: ,ucccssful, th<: drug 111.rnufacturing l.·omp.my sponsoring the progr.1111 would ,ell mmc drugs to the indi\'idu.11. :\s inten:~t in disc.hi.'. 111.magemcnt h.1s grown, PBi\l,, .1s disease m.magcmcnt progr.1111 sponsor~. rcprest:nt only a small \t:g1111:nt of rhc business. Other 111ore rcccnt sponsors and Jlh·ocJtcs of disease 111.111.1g.emcnt prow,1ms include man~1ged c.1rc cnmp.mie~. imfo idual ,t.ltc ,\kdic.1id .1gencics, pro\'idcr organizatiom, and imkpendent \·cndors. lndcpcnde11t disca:,,e man.1gcnwnt \·cndor~ .1rc the most rapidly gro\\'ing sqi;1rn:11t in the di\ca,I.' m.rnagemt:nc .1rc11a bc..:;rn~c of th<: potential for pmfitahilit~·. /I.I.my ofrhe indcp<:ndcnt \'cndor!> arc \\'C'b·bJ.scd prm·id<:r5 of diseast: man.1gcmcnt \l'r\'ices.

i\l.111Jgcd c.ul.'. and 1\lC Os l.'H>h-1:d in .m ,ltt<.:mpt to control co~t~ ,1s~oci.1ted with traditional kl.'-for-scn·icc insurJnce reimbur:,,1:1111.'nt prJcricc!.. /\!CO:, arc held clinically ,md fii1J.nci.1lly r~·sponsibk for h1:.1lth outco11w5 of their enrolled mcmbn, 011

492 Unit IV Application of Theory in Nursing

.1 c.1pitatcd tcc basis. Many MCOs h.wc impkmcmed disease mJnagl.'mt:nt and "·dl- nc~s progr.1ms th.1t urilizc .1 c.1,c 111.rnagcmcnt .1ppro.u:h tu impro\'e dinic.11 uut(omc.~. The method ofdisc,lSl.' rn.rn.1gcmcnt impkrncntation in Mcdil'..1id .111d other st.1tc pro- gr.1ms ,·aric~ by st.nc .111d i~ becoming more widcly used, with ,tatcs reporting dbcasc management prug1-;1ms to C<>\'CI" ,1sthnu, di.1.bctcs, CHf, .md other chronic illnc\sc,.

Clinical outcomes h.wc been tr .. u:kcd using disease managcml.'nr indil."ator~ ~i1Kc th1.: inception of the program. Ex.1mplc, of tfocasc 111.J.nagcmcnr indicators rd.ncd to p.uicnts \\'ith C:HF, for cx.1mple, indudc rr.11:king thc pcn:cntagc of patients wirh .1ppropri.1tc u,c of drugs, such .1, .rngiotcnsin-com·erring cnzy1m: (t\CE) inhibitors .md bc:r.1-blockcrs, i11,1ppropri:ite use of c.1kium d1.11111cl blockcrs and nonstcroidal J.nti-intbmmamry drugs ( NS:\I D~ I, hospitJ.I ,llimi~~ion ratcs, use of cmcrgcnc,· de· partmcnts, .md rcgubr primary carc or cardiology ,·isits .is well ,ls otha indic.1tors.

Among the most 11nt.1blc outcnnws uf this discJ.se mJ.nJ.gemcnt program .1rc in- crc;\ses in the pcrccnt.1ge\ of p.1ticnts \\"ith impro\'cd g:lycatcd hemoglobin ( Hb . .\ ll'. l k,·cls .rnd impro,·l.·d low·dL·nsiry lipoprotcin ( LDL) lcycls .rnd thl' innc.1sed w,c of ,1spirin in th\.' di.1betic population. Clinic.11 impro\'Cmcnts wcrc also obscrvni in the CHf populariun, in patient~ with a~rhm.1, .rnd in patients wirh HIV. C.mcer-rcl.itcd ~l.·reening prJ.crices :il~o improYcd including increasl.·d u~c of mammograph~·, P.1pa- nicobou ( PAP), and pro~rare-specific ,111tigt'n ( PSA) tl.'~ting r Horswcll ct J.I., 2008 ).

Incn:asingl~-, i\P::S:s ~uch .1~ nur~c practitioner~ ( ~Ps) .m: .l~suming greater rolc~ .rnd rcsponsibilirics in di,casc managl.'rncnt progrJ.nH in recognition of the l.'qual ur superior qualir:y outcomes of NP c.uc ,lt Cl>Srs which .ire often !own rl1.1n physician· pm,·idl.'d c,l!"c for ~imil.ir ''-'n·ice~. A rcccnrl~· conduc.:rl.'d ,1nalysis of i\ kdic.::u-e cl.lirn~ dat.1 from 2012 sought to dctcrmine whl.·thn priman· care r:ypc 2 diaberes m.111.1gc- 111rnt fiir a !>Ub\ct of lvkLlic.uc bl.'nelll:iark~ diffrn.:d in outcome~ by prm·ider typc- ph~·sician or NP. The .1nal~·sis rcn:alcd patient~ in the NP-only group lud signinc.mtly improwd ourcomes in rcrm, of hcalth c.1rc ,ervic.: utiliL.1tion and in mo~t dinic.11 ourcuml.'~ .ir lower co~t~ when cornpa.red to c.1rc rccci\'cd by p.1ticnts from primary c.m: ph~·siciam ( Lutfiyya ct .1.I., 201 7 ).

Population Health Accountable Care Organizations and Medical Home Models of Care

Newer iniri.ni,·cs in hc.1lth c.1rc include the form,uion ot.Kcoum.1blc cJ.1-c organizations { ACO~) .1.nd pJ.til.'nt-ccntcrcJ mcdic.:.11 homc~ ( PCMHs) model~ of car.: coordin.uion. Popul.1tion hcalth, \\'hich is \"il.'wcd .1~ .111 extension of public hcalrh, arose a~ p,1rr of the Institute for Healthcare ImproYcment\ str.n.:gy to rransfonn the :\meric.rn hl'.,llth c.1rl.' sy~tl.'m !Fox & l;rogan, 2017 ). This strat.:g~·. rderrcd to,,~ Tripfr Aim, is focused on impro\'ing; c.1rc ro indi\·idu.1ls .111d impro,·ing the he.11th of popul.uiom whill.' rcducing. hc.1lth c.1rl.' cmrs. Idrnti~·ing; and directing. resource~ to comlur the three nujor known c.rn~c!> of mo~r chronic ilh1l.'~se~- poor nutrition, l.ick of ph~·sicJ.I excrci~c, and substJ.ncc ,1bmc-is the major focus ofTriplc Aim.

Tripk Aim became .1 priority oftlw C~IS during. the Ob.1111.1 .1dministrario11. Or- ganizations ~<:eking dc~ignation~ .is ACO~ from CJ\1S were n:quircd to integrate the three aims into thc:ir prngr.1ms. Other popularion he.11th initiari,·e~ wac incorporJted into a~pcct~ of the AC\. for cx.m1plc, till.' AC\ m.mJatcd tJ.X·cxcmpt hospitals to pcrfrirm a .:ommuniry he.11th needs ,1sscssmcnr .It lc,\st t:\·ery 3 year~. The .1sscssmcnt\ s.:n·e .1~ .1 b.1si~ for th.: Jc,·elopment of strategies whid1 fixm on the he.11th cue nrl.'ds oflowcr income, medical!~· under~en·ed, or minoriry populatiom. i\loncr,ir~· penalties and loss oft:ix-cxcmpt st.nu~ c,111 r-c·sult ifhospir.1I~ fail to comply with the reguhitions . . -\s ,\ result, there h.1~ been exp,msh·r growth of:\( 'Os .111d orher similar organizarion\

Chapter 21 Application of Theory in Nursing Administration ond Monogement 493

fo!,tcring implcmentarion of Triple Aim initi.ni,·c~ in many .1re,h uf the country ( Fox & tirogan, 2017).

According to thc C.\1S ( 2017 ). ":\CO~ .ue groups of doctors, hospit.1b, Jnd othlT he.11th c.m.: pro\'ider~. who ,:omc together \'olunr.uily to gi\'e coordinated hi~h l}UJlity CJ re to thc i\lcdicare p.itients they serve" ( pJrJ. 1 ). The goJI of ,\COs is well-coordin.tted c.ire for defined population group~ whi.:h i~ accomplished ,1crm~ c.ire ~etting!> and "hich facilitJte, partnership~ between prm idcrs, paycr~ • • md paticms/fomilks. ,-\t rhc ti.:der.11 kYcl, fituncial inccntin:s h ,l\ c hccn esr.1blishcd through rhc l\lcdic,1rc Sl1.1rcd Sa\'ings Progr.1m ro rew.ud .-\CO, which arc .1bk to meet qu.iliry performance ,tandard!> .md metrics while ~imultJncously decreJsing cu~t~ of can: pro,·ision.

The hr..t ,-\CO in the l'nitcd St.1tes \\,l!> formc:d in Ne" Hampshire in 2012 by NP., in collahoration \\ ith .-\nthcm Blue Cros.,/Blue Shield. In this ,-\CO, patient~ .m.: ma11,1ged in :-.:P-owncd .md NP-opcr.itcd dinic,. In .1 n:ccnt .111.11\'~is, p.nient~ 111an,1ged by the NP:, mer or excct·dcd all quality \tJntfards, including ~mtaining ~ume of the lowcsr hospitaliz.uion r.nc~ in the ~t.Hc while Jchieving cost~ sa\'ings compared \\ith physician-m,1nJged c.irc ( Wright, 2017 ).

Some .:h.1llcnges a~sociated with implcmentJtion ofACO~ indude enhancing the cnllJbor,ltion, cormnunication, and teamwork ,kills of physiciJns .rnd other pro,·iders . .-\!though m.my medic.11, nursing, .ind other health sciences curricul.1 nm, indudc content, such JS the situ.ltion, b.ickground, .1ss\:'s~ment, rccommcnd.uion ( SB..\R I communicJtion technique. older phy!>icians Jnd nur~e!> may nor ha,·c bt·cn c-xpmcd ro these techniqu\:'~ .md skill, .rnd will rc:quire protession.11 dn·clopmem in these .11-e.1s ( Press, .Michdow, & ~l.lcPh.1il, 2012 ).

The: goals of PC1\IH, include impro\'ing health c.m: br promoting cJrc coordinarion while reducing co,t\ .l',soci.uc-d with care. PCi\lH, emphasize prc\'enti\'c c.m.: .md primary <.:Jre .rnd ,n-rc first introduced in the cJrc- of pcdi.itric pJtic-nts in the 1960s. The PC:l\1H approach is focused on increased coordina.tion of cJrc, which TC!>Ults in c-nh.mccd pJticnr outcome,, .1s opposed to the more common \'olume-bJ.,cd model~ of can: in which pro\'idcrs .ire rcimbursc:d h,1scd on the number~ of p.1ricnrs seen .md the numbers of procedures for which they .ire .1hk to bill. PC,\ IH~ \eem to hold promi~c in pro\'iding dlccri,·c chronic disc.1st· m.m.1gcmenr .u lo\\'er cmt, ( De Vries ct JI., 2012 ).

The growing need to m.uugc chronic ill111:~se~ i!> crc.iting .111 unprecedented opportunity for nurse,, p,1rricul.lrlv ,-\PNs, who by ,·irtuc of their educ.1tional credcntiJb .md clinicJI expeni,c, .1rc uni4udy positioned to become lc;idcr~ in di~CJ\e nun.1gcment. Role~ for APN~ indudc coordin.nion of cJre ti,r pcr~om \\·ith chronic illnc,scs in for-profit .md not-t<,r-profit health care orgJnizJtions in which .-\P:-..;\ prm·idt· .111 .1rray of din:ct scn·icn to p!Jn members. AP~~ u,c publi,hcd practice guidelines to m.rn.1gc- .md coordin.1re c.1re of indi,·idu.1b with chronic illncs~cs JCTO\~ he.11th c.1re ~cttings.

Quality Management

In 1001, the IOi\1 rc:ka~ed the publication, 7,, Err Is H111111111. The rclc-asc of thi~ document, \\'hich .1ssertcd rl1.1t mcdi.:.1] errors were n:spon\ihk ti,r between 4--LOOO .md 98,000 de.1th~ annually in the United St.Uc~. spurred dcmJnds t<ir grc.iter ,Kcounr.1bility and qu.1lity in the U.S. health care ,ystc:111 ( Kohn, CorrigJn, & Don.1ld~on, 2000 J. Since thJt time, many QI or (J,\l initi.iti\'c~ h.m: been underr.1k.cn in he.11th .:.1re ~y,tcms .rnd organizations thJt directly imp.1cr the discipline of nursing.

494 Unit IV Application of Theory in Nursing

:\I though there is ~om<: ,·ariation in the empha!>i, pbced on ,pecitic a!,pect!> of Q,\I betwcen organizations, sn-cn key principles or d.:mcnts arc , ·icwed a~ integral .:0111-

poncnts of all QM progr;1ms. Tht·sc demenrs includc focus on the customer, pr< Kt·~, impro,·crncnr, ,·;uiJncc analysi!>, leadt·rship, cmploycc involn:mcm, scit·ntitic method, .111d bcnchm,1rking l B.1ker & Gelmon, 1996 ).

In thc QM environment, quality is detim·d in tcnm of what i!> acceptable to thc cusmmer; th.lt is, thc rnstomn dctcrminc, expccuriom uf quality. Comprehcmi,·c knowlcdgt· of thc cusromcr's needs and expectations i'.> imcg;ral ro prcwid.ing tht· bt''.>t in qw1.lit~· Cll!>tl>mcr sen·ict·. There .1re two types of cusrumcrs: Cll!>tomcr!> who .l!"e cxtern,1I m thc org.mization .md customn~ who ,1re internal. In IKahh care, for ex- ample, cxrcnul cmtomcrs ,1rc patients, familic!>, physici,111s not employed by the or- g.1.nization, paycrs, and communitio. Internal cu!>tomcrs arc staffmcmbcrs employed by thc org • .mizJtion tn prm·ide a sen·ice to external cmtomers. for example, the st.1ff on .1. nursing unit is a cust<nner of ph:1rmacy scn·iccs. The nun,ing staff rdie!> 011 thc.: plurmacy ~tJff to provide ,Kcur,ltt' medic.1tions in .1 rimcly fa~hion to thc.: nur~ing unit to c.:11.1ble the c.:uernal cmromcr, the pJtii.:m, to n:cci,·c nH:di.:.uion:-. appropriJtclr and on timc ( folsc, 20 IS: i\brqui~ & Huston, 2012 ).

Proci-ss improl't'II/Olt imuhc!> ~crnpuluusly n.amining work prncc.:s~c, in\'f>h·c.:d in achic,·ing a work produa. For cx.1111plc, in J. hospit.11 ~c.:tting;, th.: prrn:c~s oftr.msti:rring .1 pari~·nt from .rn orthopcdic unir ro ,1 rchahilitation unir may h:i,·c 20 or more ~rep~ .111d may invoh·c ti,·c.: or six ditfrrcnt dc.:pJrtments. The more steps t Jnd people) im-olvcd, the grc,ltc.:r the likelihood th.n the transfrr will ht· dc.:la,-cd or that an error will be 111.1.dc during thc.: transtcr, which lc.:.1d~ to inat·,1scd costs. Prncc$s improvc.:mcm dict;1tcs that t·n:ry ,1spcct of paricnr transkr mw,t be cxamincd to dctc.:rmine whc.:th.:r c.:ad1 srcp in the procc.:!>s i~ really nec:dcd to .1Ccomplish the transfrr. i\·kmbc.:r~ ofc.:.1d1 dcpartmt·nt or unit imuked in the transfi:r arc includ..:d on J procc!>s impron·mc.:nt tc.1111 ro ex,U11ine the pnKL'SS t<.>r rcdund.111.cic:s and lapses in scn·icc and to ~rrcamline the pruees!>.

Monitoring .111.d JJ1,1ly,b of v;iria.tion in proccs,cs i!> crucial_ p.uticul.1rly in he.11th care org.1niz.1tiom. Thcre .1re two types of \'ari.uion: common Gmsc nriJrion, "·hich occurs 1111 111.Htcr how \\·di .1 systcm opn.1tes •. md special c.utse ,·,uiation. Special c.rnsc nriarion i~ ,·ariJtiun that occurs outside of what is to bc expccrcd .md can bt.: c.rnst:d by employn· crror and equipment or !>y~rem~ failure. The scicntitic method med to distinguish between common c,tusc and speciJI c.n,sc , ·ari~1.tion is st.1tistic.1I control ( VJrkc.:y, Rclkr, & Resar, 2007 J.

Lc.11..kr!,hip in a Q~I cnYironmcnt l1.1s two comroncnts: comprd1ensi,·e knmd- edge .111d .m understanding of concepts .md redrniques of QI and pl.·rsonal innil\'e- mcnr. l.eJders must be familiar with the terminology. thi.: corKeprs, and the stari~tical techniques uscd in QM. Essential role!> and rc~ponsibilities of lcadcrs in QM include being pcrsonallv committed to the philosophy, pro,·iding resources that include.: train- ing others in the philosophy, rc.:vicwing progn:s~ on .1. rcgul,u b.1~is, giving recognition, :rnd man.1ging. resistance while empowering other\.

To iniriarc .rnd sust.1i11 a succe!>sli.il, mc.rningti.il QI progr.1111, all member~ of the organit.Jtion ~hould 11.1.w educ.1tion and tr.1ining rc l.11ed to Qlvl. Employccs ~hould come away from the tr.1.ining " ·ith .1 dear u11der~t.111ding of their indi,·idu.11 roks .md. responsibilities rei.ltcd to QI. A bro.1.d range of employees ~hould be encour,1ged to particip.1tc on QI te.11115 to design .1.nd improYe work procc.:ssn. Organizations th.H haw been successful in impkmenting Q,\I h.ffe cmpowercd employee!> .lt ,111 lc,·cb to search for hcttcr \\'Jys to redcsign \\'Ork prnccsscs to achien: cmtumcr ~arisfactiun .

True QI actiYitie~ ,\re h,lscd on scic.:ntitic and \tJtistical mcthod~ r.1thcr th,rn on trial-.md-error .1pproachc.:~ tu problem idenriti..:.1tion .111d problem solving. The sci- entific method is J prccisc, systematic, orderly, planned, and organized method of

Chapter 21 Application of Theory in Nursing Administration and Monogement 495

problem sol\'ing tl1.1t can be n:plic.:atcd .md understood by cmployt.·cs of the orgJni- z.1tiun. Sc,·cral pmblcm-soh-ing methods c,111 be t1.~cd by health cue organization~, including rhc me >\t commonly used appro.lch fiir rapid imprm·enK'llt in hcJlth c.1rc, the plan-do-stay-act I PDS,-\ l cyck ( \'arkey ct al., 2007 ). Other Ql methods utilized in contemporary he.11th c,in:: organizations ~,re Six Sigma ,111d kan ~tr,ltcgics. Probh:m .rn,1lysi~ tool~ ( .ilso called st~lti~ti.:al process control tools) used in the probkm-M1h·ing proccs~ indudc: tlo,, c.:lurts, cousc-~tnd-cffrct di,1grams, .rnd run c.:lurts.

Benchmarking, a process originally implcmrntcd by the Xerox Crn11nr,1tion in l 979 ( C1111p & T\\'cet, 199-! ), i~ the identification, ad.1pt.1tion. and dissemin.1tion of best pr,K- tkes .1111011g competitors .rnd noncompetirors that lc.1d to their supc1ior perti>rmancc In other \\'ords, quality can be impron:d in .111 organization b~- ,111Jlyzing .rnd tht.·n copying the method~ of k.1der~ in J tit:'ld such ,1s he.11th care. Effi:cri,·c benchnurking inn>h·cs identi~·ing ~recitk key indic.1tors of .1 pruccss (i.e., kngth of cndotrachc.1I intubarion in postopcrati,·e patients), comp.1ring this process with other org:JnizJtiom, determining the bc~t process, .rnd rhen u~ing knowkdgc of thc hcst proces!, inkrnally to dcsign 1w\\· processc!, or impro\'e exi!>ting one:,, ( B,1kcr & Gclmun, 1996 ) .

. -\s describcd pn:,·iou!,ly, there h.1~ bccn intcrn,c effort .1111011g gm crnmcnt ( C}.IS ) .ind other paycr, in ek\'.1ting l]UJ.li~· nutr<>mc!> in the Amcri.:.111 ht:alrh c,1re !>cctor, in- duding, but not limited to, .1pplication of financial incenti,-c~ .md pcn,1ltics. Since p.1s- \agc of the ACA, there h.1~ hl·en .1 decidcd ~hiti: in lul.mcing the value (cost) of he.11th c.1re in ,1ddition to mcJ\uring qu.1lity of .:.1re in .m ctfort to rein in c\'Cr-csc.1l.1ting na- tional he.11th .:,11"l" costs ( Shin:r & CJnticllo, 20 l 6 ). }.!J.n~· gm·crnmenrat public, .md pri,·Jte groups ,m: working to n1.1ki.: hc.1lth care ranking~ .md intimn,1tio11 .n·ailablc to cnnsumcr,. ror example, ming thc \\'eb~ite\ HcalthCtre.gm· .md }.kdicJ.rc.go,, ,\kdi- c.1rc l'nrollcc~ .111d otht:r l·on!,umcr~ .:Jn !>c,m.:h for .md n1mpare the quality of ph~·sici.111s, hmpit,1b, nllrsing homes, home he;1lth agencies, .md dialysis facilitics. CompJrisons of ho!>pitab indulk patient ~ati!>faction Sur\'C~· rc.sults, timclv and cffi:ctin: c.1re results, re- admi!,sion, crnnplicJtions and de.1th r.1tes, .md number of Medic.1re p.uknr~ by diagno- sis ~-pc trc.ltcd in the facilit~·- horn the\c sites, a prospccti,·e pJtient c.111 dctcrminc area\ of the hospit.11\ pcrform,mcc th.1t need impro\"Cment and .:an comp,m~ r.hc ho~pital's pcrform,rnce in !>0me c.1tcgories with :.tare .md nJtio11.1l n .. ·\ult~ r benchmarking data I.

As a result of tht'5t' Internet-based rating mcchani~ms. hcalth ..:arc consumer~ ,U"c bccoming incrca~ingly sa,·,~· .1bout dKcking qu.1lit~· "report c.1rds" of hc,1lth c.uc facilities and prm·iders. Institutions tlut ,ire implementing best pr.1cticcs .md conti11- u.1lly stri,·ing to impro,·c perfr,rm,mce while decreasing co~t, \\ ill be thc biggest win- ncr~ in thc eompctiti,·e health .:.m: cm·ironmcnt of the future. Link to Practice 1 I-2 present~ ho\\ 0lll' health care facility u~nl .1 QI to ensurc greatcr s.1ti::~--

Evidence-Based Practice

He.11th care ..:onsumcrs npect q11,11ity c.1re, and most health c.1re practitioner~ \\J.nt to prm·ide quJli~· c.1re. Prcssurc fi.,r co~t co11tainme11t compel~ pro\'idcrs to dcmonstratc th.lt int1..·n·cntiom produce n>st-eftecti,·t' outcomes th.a do not sacrifice the qu.11i~-of health c.1rt'. furthnmure, 5c:lected imcn·enriom must bc not only effrcti,·c bur .1lso justified and congrucnt \\'ith acct'pCJbk ~tand.1rds.

EBP is a problem-solving .1ppro,1eh that enables diniciam to prm·idc thc highe~t quality of c.1re to p.1tient, ,md their famili1:·~ bv inrcgr.1ting the following appro.iches:

Critical appraisal and critique of the mmt n:..:cnt .111d rdcv.mt rc~e.1rch ( e\idencc) Considering the dinici,111\ rnrn clinical expcnisc Considering prekrcnccs .mJ , alues of the pJtient r i\ klnyk & hneout-O,·crholt, 201::i )

496 Unit IV Application of Theory in Nursing

Link to Practice 21-2 Quality Improvement to Promote Safety

Occurrence of o major adverse event in a patient care setting often serves as the impetus for change in terms of quality improvement. After a patient safety issue was identified at a children's hospital related ta the use of "smart pumps" in the administra- tion of intravenous medications, a performance improvement team wa:s assembled to increase use of medication safety software by nurses. The quality ,improvement teem utilized the Deming Cycle performance improvement method to increase adhere.nc,e and compliance with intravenous medication delivery software. Strategies implemented by the team to improve compliance included improved communication with nurses who were direct caregivers, staff education related to safety software specifics, acquisition of additional technology, and implementation of the medication safety champion role. Adherence monitoring was also incorporated. Following implementation of the perfor- mance improvement strategies, nurse adherence improved dromotico'lly from 28% al baseline lo greater than 85%, an adherence rote that exceeded notionolly accepted benchmark adherence rotes.

Govriloff, C. [2012). A performance improvement pion to increase nurse adherence to use of medication safety software. Journal of Pediatric Nursing, 27(4), 375-382.

for EBP to t.1kc: root .rnd flourish in ,lll organization, thc:1-c must be in~titut ional support .rnd .:ommitmc:11t from administrator1>. This ~upport stems from ,the mission, goab, and cul run: of the: organization. \Vithout this suppo rt, lk'c1c·ssary ri:s(Htrcc~ and infra~tnu:turc: components, sud, a~ ,lCCl'.!>~ to d;1ub.1sc:s, dc:dic.ncd pc:r~onnel, ,rnd computc:r support, which an: integral to a succl·~~ful EBP program, m'Jy not bc: alloc.lted or lll,llk fully ,waibbk and accessible (J\klnyk & hnc:out-On.'.'rholt, 20 I 5).

Al'Ns must m.1kc dinic,11 dccisiom on thc: bc:sr c:,·idencc aYailabk. They mus,t .1lso sdect interventions tlut are linkc:d to cn~t-dfrcti\'c outcomes. This intc:gr.nc:d approach allows thc: APN to use critical thinking ~kills to dc:tcrminc: whethc:r scien- tific c:,·idcnce .md dinical practice guidclinc:s arc: rc:kvant and consistent \\'ith the .1pplicabk health carc: ~iruarinn .1nd with thc: patient's value~, prdi:rencc~, ,.1nd life: context.

In une example, an inpatic:nr asthm.1 education QI progr.1m at Children's Hospit.11 in Boston utilize~ l'\'idcnce-bascd guiddim:i. .md .1 tc:am approad1 of .Ill i11p;1ticnt J.l>thma nurse practitiorn:r (L'\NP ), other APNl>, and unit-based R.Ns to pro\'idc patient .md family c:duc.uion using indi,·idL1.1lizcd asthm.1 action pl.ms. The edu.:,1- tion is b.1~<.:d on 2007 National H<.:art, Lung, and Blnod Institute/National r\sthm~, Educ.1t io11 .rnd Prc:\'c:ntion Program guiddinc:s, " ·hich rc:commc:nd that rn1-... provider~ teach .md n:inforci: .1sthma self-management techniques during e,·c:ry care encounter. Acute care encounters .\IT espcci,1lly , ·alu.1bk .1~ parents and other caregiYers \HT likdy to want to participate in acti,·ities that pre,-cnt ti.1rther emergency room \'isi ts .rnd inpati<.:nt stays ( J\kCmy & R.ogc:rs, 2012 ).

Chapter 12 contains additional information about EBI'. Sec also Link to Practice 21-3 for a 11<>\'cl approach to encouraging EBP.

Chapter 21 Applicotion of Theory in Nursing Administrotion ond Monogement 497

Link to Practice 21-3 Promoting Evidence-Based Practice Nursing administrators in a hospital district in Houston hosted o Sacred Cow Contest as o strotegy to promote a culture that values clinical inquiry and to stimulate nurse interest in EBP. As part of the contest, nurses were encouroged to challenge the routines inherent in clinicol practice, such as changing bed linens daily, performing "routine" vital signs, and the necessity for oll nurses to listen to shift report on all patients on a given unit. Nurses were asked lo consciously think of octivilies and procedures they performed daily and to question why the octivity or procedure was necessary. When a practice wos questionoble, the nurses were osked to consider if it moy be a sacred cow and were asked to submit entries chollenging the proctice. Somple entry categories for the contest were cosh cow, mad cow, holy cow, ond put the cow out la posture, omong others. More than 100 Sacred Cow Contest entries were received from inpolient and outpatient settings ond from individual nurses as well os teoms of nurses. After winning entries were named, a message communicating contest follow-up actions was sent to the nursing staff. Nurses were osked lo adopt a sacred cow and were offered support and resources lo establish EBP workgroups on the nursing units to address the sacred cow issue identified.

Mick, J. 12011 J. Promoting clinical inquiry and evidence-based practice· The sacred cow contest The Journal of N,m,ng Administro1io11. 41(6), 280-28.d

Summary Thi!. d1.1ptcr tu~ provideJ e.xampks of the lpplkJtion of spec.:ifil: theories, models, .rnd fr.1me,,·orks in nursing administr.1tion .md managcrrn:nt. The model~, which were dc~cribcd along with rcbtl·d historical ,md contcmpor.try applicJtions, ~hould pro\'ide rhc .-\l'N "·ith .1 foundation for !l,l\'ig.lting the complex, e\·cr-chJnging em·ironment of health care.: organizatiom tod.1y .rnd in the' ti.iturc.

Ht.·.1lth ~·Jrc org.mizJtiom of the foturc hold great promise for .-\P~!,, such J5 lirct.1 from thc opening c.1.,c s.rudy, who J.rl· willing to .1~sumc cntrc:prcneurial Jilli

intraprcncuri,,1 mks in pro\"iJing cost-dk..-:ti\'c quality hc,1lth care. A more t.kt.1ilcd undcrstanding of ~omc of thc .. c models \\'ill bc.: neces~.1ry in certain circumstances (e.g., .1 .. in the ..-:Jsc stuJy), but it is hoped thar this chapter h.1s prm·ided J basis for tiinhc.:r investigation for those who nccJ more detailed information.

Key Points Org.miz.1tion.1l strucrnre and Jes.ign .1rc kc:y clements in Jctcrmining ctlkicncy and cftecti\'l:nes., of work proccss.c~ .md quJlity of outcomes in health care organizatitms. Slurcd go\'crnancc ii. imper;1tin: to m1r\C., controlling. protei.~ional pr.icti..-:e. Tr.rn5form.1tion:.1l lc.1Jcri. bring a compcriti,·c .1d,·ant.1gc tn ,lll organization .ind pl.ly Jn important role in cu]ti\',lting he.11th~· protessio11.1I work c.:m·ironmcnts. Nursing c.ire in the ai:ute ..-:arc setting ii. most oti:en ddi\·aed using J group prJ..-: - ticc model. Attribures of the work c1wironmc.:nr Slh.:h .ls nur~c.: stafnng r;uio~ ,md

498 Unit IV Application of Theory in Nursing

m1N.: cduc.1tional kn:l h.1,·c signific.mt and direct imp.Kt 011 p.niem outcomn such as infrction, failure-to-rcsn1e, and mortality r.uc~. lmplc1m:nr.1tion of com:ept~ ,1S\ociatcd with patient- .rnd famil~·-centered can.: models, including dignity .rnd respect, infornution sharing, participation, .111d coll.1hor.1tion, kad to impron:d patient ,llld staff s,ltisfaction. Cast: man,1gement, diseJse management, .ind population he.11th initi.iti\l.'.\ play cruci.11 mks in .Kutc care facilities and in other models of coordin,1ted ,111d intc- gr.ucd health c.1rc models such .1s H~lOs, i\lCOs, .\Clh, .111d PC.\11-b. QI .md EB!' .m.: concl"pts that .ire incxtric1bly linked in rod.1y's highest perform- ing he.11th c.1rc organizations.

Learnin Activities

1. Interview a middle-level monogEH in a hospital to determine recent changes in span of control. Hos the span of control For the manager decreased or increased in the past 2 to 3 years? What impact has the manager noticed related to de- creased or increased span of control? What is the manager's preference in terms of numbers of employees in his or her span of administrative control?

2. Hove health care organizations in your area participated in mergers and acqui- sitions in recent years as part of ,,ewly configured i ntegroted systems? If so, what APN roles, if any, hove been crElated as a result?

3. What are the roles of APNs employed by health care organizations in QI ac- tivities in your community? Are )\PNs the leaders of QI teams? What significant contributions have occurred as c1 result of APN involvement an QI teams?

4. Talk with APNs who are employed in hospitals in your area. Determine the following: o. Are the APNs unit-based? If so, what is the method of patient care delivery

on the unit, that is, primary nursing, team nursing, PFC? W hat are the ad- vantages and disadvantages to the APN role related ta each of the different delivery methods?

b. Do the APNs hove staff or line authority? What are the advantages and dis- advantages to the role of each type of authority?

c. Administratively, do the APNs report ta a senior or middle-level manager? d. Do any of the APNs work in a shored governance environment?

5. What roles do nurses, especial ly APNs, play in integrated health systems such as HMOs, MCOs, ACOs, and PCMHs in your area? Are these nurses in case management roles? Do they work independently or are they part of an interdis- ciplinary team of case managers?

6. Whot EBP activities hove APNs in your area spearheaded? Have health care consumers benefited?

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Chapter 21 Application of Theory in Nursing Administration ond Management 499

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500 Unit IV Application of Theory in Nursing

,\1.t, C.. & Park,'>. H. <20151. Hn,pital ,\l,1i;nct ,urn,. Ulllt work cnvfronmcnt •. md prc;,,c;un: ukcn. Jm,r11nl ,~( ,;\·11rnn ... ff .\dn1'nr· .rlnp. -.17 6 ,. 565-573.

M.111..:-ln.i. ~l. E. i 2015 1. l'nt..kr.itJndin~ .m..t 1.tc,1ttning org,Jni1:Jti1 ,rul ,trncturc,. l11 P. S. \'o,ln-Wssc I EJ. ,. /,,n1li,,n nird mnwrqi11" ;,, lllll'S111.fl I 6th c,I., l'r• 1.'16-l ;;2 I, \\. lA>UI', ,,·10: El<c\'ler'. •

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Portcr-O'Gr.,dy, T (2003 ). R.ncJ.n.:hlng ,h.ucd ~oH·rn.111(.:: . ..\ fiuilit~ ot'tc>1.:us. 'f11t· J;,unu,/ ,fXurs"tlJ .·l,imwl.11mtwu, 33l-l I, 1;; 1- 1~2

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Shi\'er, J .• & C.mr,dlo, I. 12016 i. .\fa11n1111111 wunmttd hell/th I:,.rrtms. Rurling:tnn. ~t\. rime~ &· l\.,nkit l~earnin~~.

"rcrl. r. 1 ]00S t ~llr\C ,.1ti~tJ...::ti, •n .rnJ the imrlc..·mcnt.1rion of minimum nur"-C ,t.itling rc[!Ul.uion,. Pt1/ir_., , Polirfrs C:'"" .\"un 11ta Prncria. 1 1. 15-21.

~ports.man. S. (10151. Lare: ddivcry Mr.1t..:!!ics. In P. S. Yoder \Vi",(' ( Ed. t, l.cndi11,1 ,111d m•rnt1nim1 itJ 1wrJ11ur ( 61h c;d .• pp. 1.:12-254 t "l. lt;UH,, ~10: El,1.:\ iL'~ ..

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Taylor, I'. W. I I'll I ) n, .. prmcrplo o/'mmt(/i< 111n,rn,11m1mt. :-IC\\ Ynrk, :-,;y HJJ'l'cr

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Weber, M. 119701. Jlurc.uu:rac,· In W. '>cxton I bl.I. ()r11nr11catwr, t/Jto1·1t·s 1pp. 3<J-H, Col111111'us. OH · l'h,ulcs E. ~le;rill

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Y.1mamoto. I. , & l.u..:c\\ C . 1 2005 I. l .1.,..: mJ11.1~tmcnt ··,\ uhrn the w.ilh"": A g:.limpsc into the future. C:rttrurl Cart .\"111·sm.1r f,.fJlnrurf,v, 2,,U1. ln1-J7J!.

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