Intrroduction Communication between physicians, nurses and APNs
Communication between physicians, nurses and APNs. Historically, medicine
and nursing have taken two separate paths: medicine has been associated with
authoritative and hierarchical in structure; nursing has had a more supportive or
subservient role. This dynamic resulted in fragmentation and compartmentalization of
patient care (Jansen, 2008). Physicians had professional autonomy and control over
patients and dominance over other health care professions (Gair & Hartery, 2001).
Through advancing education and growth, nursing has emerged as an equal partner in the
health care team. In today’s complex health care system, no one profession can fulfill all
patient needs. The evidence-driven advent of patient-centered care has resulted in greater
professional flexibility in both physicians and nurses—in the context of interprofessional
dialogue that focuses on the patient (Reeves et al., 2013).
Although in recent decades the quality and effectiveness of MD–RN interaction has
improved, the potential and need for further improvement in interprofessional
collaboration are substantial. To assess this need, Weaver et al. (2014) recently examined
teamwork and collaboration between staff nurses, residents, hospitalists, and oncology
physicians in oncology units at a large urban hospital. The investigators found that
physicians rated the quality of their own collaboration “very high” with other physicians
and with nurses. Physician ranked nurses’ collaboration with physicians as ranging from
87% to 100%. In stark contrast, however, nurses rated the quality of collaboration with
physicians poorly, from 35%–65%. Weaver et al. found that hierarchies persist and can
interfere with collaboration. Nurses believed that a negative attitude toward
communication as a significant obstacle to collaboration. A nurse may be reluctant to call
a physician if the nurse perceives that their relationship is not mutually supportive and
collaborative. On the other hand, physicians, having a positive perception of
collaboration, perceive difficulty contacting other providers as the main obstacle to
collaboration. Physicians who assume they have a good collaborative relationship with
nurses may not seek additional information because they (the physicians) are unaware of
potential or actual problems (Weaver et al., 2014).
Vazirani et al. (2005) surveyed registered nurses (n = 123), physicians (n = 45),
and a combined group of resident physicians and interns (n = 111) to determine whether
introduction of an APN role to the team was followed by changes in team communication
and collaboration. Physicians reported that, when an APN was part of the team, the level
of collaboration with nurses and APNs was significantly higher. Physicians also reported
that when an APN was part of the team, the team had fewer unnecessary delays and better
general communication. In the same study, the staff nurses reported significantly better
communication with APNs than with physicians (Vazirani et al., 2005). Kilpatrick (2012)
also found that communication and decision-making improve quality of care when the
participating APN is able to act within the full scope of the APN role. Among other
positive outcomes, this study reported that APN participation was associated with
decreases in length of patient stay and costs for patients treated on the intervention unit,
without an increase of readmission rates.
Vazirani’s (2005) study employed surveys to assess the degree of communication
and collaboration over two units. Physicians were surveyed immediately after they
completed a given rotation, starting at the onset of the interventions. Nurses were
surveyed biannually. The statistical analysis took into account correlation of observations
due to repeated sampling (Vazirani et al., 2005). Limitations in this study included
physician and staff nurse confusion about the role of APNs. Prior to the study, no APNs
were employed in the hospital’s internal medicine department. Chicago Medical Center
(CMC) employs approximately 200 APNs throughout all medical and surgical services,
thus role confusion is not a problem. The second limitation of this study pertained to
sample size. Physicians and nurses were not allowed to work on both the interventional
and control units; accordingly, the pool of physicians and pool of nurses available to
participate in the study was restricted. This can present problems with sample size but
also falsely promote familiarity and foster improved communications, skewing positive
results.
Although the quantity of studies is limited, it is clear that when an APN is an
integral part of the interprofessional team, the quality of communication and collaboration
increases. This DNP project specifies inclusion of the APN and staff nurse as members of
the professional team. The patient, who is also an integral part of this team, is not a
professional but is in fact the core leader of the health care team. In the decision-making
process, the patient’s understanding and input are invaluable
Communication and collaboration between APNs and staff nurses. The
majority of studies of communication and collaboration in health care contexts focused on
the nurse–physician relationship (Baggs & Ryan, 1990; Chapman, 2009;
DechairoMarino et al., 2001; Nathanson et al., 2011; Shortal et al., 1991). There have
been minimal formal studies looking at MD-APN and improved communication with
staff and its effects on patient care (Cowan et al., 2006). In nursing intraprofessional
teams, communication has been identified as the essential component of good team
functioning (Dreaschlin et al., 1999; Jones, 2005; Richardson et al., 2010). APNs possess
diverse knowledge that can facilitate understanding of collaborative practice to optimize
patient care (Crecelius, 2011). The Agency for Healthcare Research and Quality (2014)
found that when nurse practitioners are included in daily multidisciplinary rounds, the
rounding team’s communication and collaboration improve.
The increasing use of health care teams has made nursing practice more salient, in
that nurses serve as a link between team members and patients. Effective communication
between all team members is essential for successful teamwork and high-quality patient
care (Apker et al., 2006). The advance nurse practitioner function as the central link of the
health care team integrating other health care providers and patients. Good
communication among staff and between staff and patients is the cornerstone of quality
care.
Gooden and Jackson (2004) documented one of the earliest studies examining
staff nurses’ attitudes toward APNs. The investigators found that as APNs have come to
manage an increasing number of patients, staff nurses have begun to view the APNs as
leaders. Staff RNs consistently scored APNs higher than physicians in measures of
communication, respect for staff opinion, quality of care, clinical expertise, and
willingness to teach staff, patients, and patients’ families.
Moore and Prentice (2013) reported a case study that analyzed the collaborative
process between APNs and nurse in an outpatient oncology setting in Canada. The
researchers discovered four basic themes to collaboration:
▪Time that APNs spend together outside of work translates into collaboration at
work.
▪The basic skill of clinical knowledge and experience are essential ingredients
for successful collaboration.
▪Other factors that that contribute to the success of collaboration include
sharing a similar philosophy of care and mutual trust, respect and esteem.
▪Barriers to collaboration inevitably arise. Nurses are largely unaware of how
collaboration should manifest in the practice and are not trained on principles
of effective collaboration in practice.
▪Nurses and APNs attitudes are changing toward collaboration, viewing
collaboration as a means of achieving positive results.
Moore and Prentice (2013) found that intraprofessional collaboration (a) is
complex, (b) is influenced by interpersonal and professional factors, and (c) does not
occur spontaneously. Nurse must have a solid understanding of the concept of
collaboration and how to apply it in the clinical setting.
Patient-centered care. Improvement of patient satisfaction and quality of care is
directly due to the implementation of patient-centered care. Patient-centered care, the
“new normal” in today’s healthcare system, provides a mechanism for nurses to engage
patients as active participates in their care. The Institute of Medicine (IOM, 2001, p. 6)
defines patient-centered care as “healthcare that establishes a partnership among
practitioner, patients and their families to ensure that decisions reflect patient s wants,
needs and preferences” (see also Boykins, 2014; Sepucha & Ozanne, 2010). Optimal
patient participation requires a dynamic interaction between partners (patient and staff) in
terms of interpersonal interaction, therapeutic approach, focus on resources, resources,
patient opportunities to participate in and influence health care team decision making, and
patient education (Sahlsten et al., 2007). Including the patient in bedside reports or
handoffs has been reported to improve teamwork, safety and efficiency (Wildner & Ferri,
2012). This bedside practice also entails the participation of patients as partners in their
care, with the expectation that their participation will lead to improved care, better
outcomes, improved adherence to treatment and medication regimen and greater
satisfaction with care. Barriers to implementation of patient-centered care and bedside
rounding include time and resource requirements; the potential for patients to feel
confused, upset, or dehumanized as a result of hearing clinical explanations; and the
potential for breach of patient confidentiality (McMurry et. al 2011). In addition, when
presenting sensitive or confidential information, some nurses may feel uncomfortable, or
be inhibited by a lack experience—especially in the presence of patients’ family members
or relatives are present. O’Connell, Macdonald, and Kelly (2008) found that viewed
handoffs as being too time consuming, and ineffective, or efficient. The investigators
recommended that a handoff guideline or information template should be developed to
promote and facilitate the reporting of objective relevant information.
Patient satisfaction and its effects on quality of care. As a subjective
phenomenon, “patient satisfaction” is difficult to define. The self-reported determination
of patient satisfaction is a personal evaluation of health care services and of the providers
of that care (Ware et al., 1983); patients’ attitudes and expectations regarding care greatly
affect their sense of satisfaction. Because satisfaction ratings are relative, subjective, and
not directly observable, attempting to meaningfully quantify patients’ personal evaluation
of care is highly problematic (Ware et al., 1983).
The challenges inherent in measuring patient satisfaction have ramifications for
policy and practice. For example, in 2012, the Center for Medicare and Medicaid
Services (CMS) began to implement a reimbursement system that adjusts payment rates
based on patient satisfaction scores (Lyu et al., 2013). Patient satisfaction is a key
determinant of quality of care and an important component of the pay-for-performance
metrics instituted by CMS. Beginning in 2012, CMS implemented value-based incentive
payments to acute-care hospitals based in part on results of satisfaction surveys from
patients discharged on or after October 1, 2012. The patient’s perception of quality is
significant determinant of the provider’s federal reimbursement. Patients now make
decisions based on their perceptions of the quality of and satisfaction with health care
providers (Bowers, Swan, & Koehler, 1994).
A study conducted by Fenton, Jerant, Bertakis, and Franks at the University of
California–Davis examined mortality rate in relation to patient satisfaction (N = 51,946);
the researchers’ analysis adjusted for a number of factors (i.e., demographics, health
status and chronic disease burden, Year 1 utilization and expenditures, availability of a
usual source of care, and insurance status). The investigators were surprised to find that,
in comparison with the mortality rate of patients in the lowest satisfaction quartile, the
mortality rate of patients in the highest satisfaction quartile was 26% higher (adjusted
hazard ratio, 1.26; 95% CI [1.05, 1.53]). This perhaps counterintuitive finding raises the
question of whether current satisfaction measures are in fact good indicators of health
care quality (Fenton et al., 2012). The researchers concluded that the connection between
patient satisfaction and health care outcomes is yet unclear.
Practitioners need to understand that ineffective communication can result in poor
outcomes. Improved communication not only results in better health outcomes, but also
may positivity impact patient satisfaction. For patients who want to be involved in their
care and who understand what is occurring during care, improved communication may
ultimately lead to greater patient satisfaction. The inclusion of APNs in the care team has
been reported to improve communication and the efficiency of care (McCauley, Bixby, &
Naylor, 2006).
Evidence-based practice. Evidence-based practice (EBP) is at the forefront of
change in today’s health care environment. EBP is the practice of using documented
evidence as a guide to problem solving approach to clinical decision making. To
implement EBP, one must “locate, critique, synthesize, translate, and evaluate evidence”
(Drenning, 2006, p.299). This includes the dissemination of information during the
implementation phase of practice. Although ostensibly EBP is the standard of nursing
practice, implementation of EBP is not always easy (Krom & Bautista, 2010). Barriers to
EBP implementation include (a) lack of requisite knowledge and skills on the part of
clinicians, (b) perception that EBP is time consuming, (b) perception that EBP is
burdensome, and (d) lack of management support at the organizational level (Melnyk &
Fineout-Overholt, 2012). Among clinical staff members, APNs, nurse educators, and
DNPs—who understand translational research—are uniquely qualified to fulfill their
responsibility to fulfill the mandate to implement evidence –based changes in practice.
These organizational change agents must persuasively teach the EBP process to staff
nurses and thereby transform the organizational culture—from a culture in which change
is resisted to a culture in which evidence-based improvements in practice are welcomed.
To achieve this transformation in organizational culture, APNs, nurse educators, and
DNPs must employ an interactive approach.
APNs serve as both leaders and knowledge resources for helping nursing staff to
ground care in current evidence. In a study conducted by Mahanes, Quatrara, and Shaw
(2013) at the University of Virginia, the researchers implemented APN-led nursing
rounds. Although the specific effects of the APN-led nursing rounds were impossible to
isolate, Mahanes and her colleagues were able to determine that rates of blood stream
infections, catheter-associated urinary tract infections, hospital-acquired pressure ulcers,
and ventilator-associated pneumonia and falls all declined. Similarly, in study that a
analyzed the effectiveness of an APN-managed heart failure program, Dahl and Penque
(2002) reported reduced 90-day readmission rates, fewer in-patient hospital days, lower
re-admission charges, and lower overall charges for health care services.
APNs have demonstrated implementation of EBP practices, better working
relationship with staff nurses, and improved patient-centered care with cost savings. The
development of an intraprofessional APN–staff nurse team to conduct bedside rounding
should improve patient care, increase communication and collaboration, and improve
patient satisfaction.
The daily goals reminder sheet. The need to develop clear team communication
has led to the development and institution of daily goal sheets. Studies in ICUs have
demonstrated that the use of daily goal sheets can result in nurses’ and physicians’ having
better understanding of patient care goals and in decreased ICU length of stay (Agarwal et
al., 2008; Narasimhan et al., 2006; Pronovost et al., 2003). A study conducted by
Phipps and Thomas (2007) examined the use of a daily goals sheet in the ICU at The
University of Pennsylvania’s Hershey Children’s Hospital. The researchers found that
85% of nurses felt the use of the goals sheets improved communications between
physicians and nurses and improved communication between nurses working on different
shifts. Phipps and Thomas also reported that 95% of the nursing staff felt that the extra
expenditure of time spent in completing the daily goals sheet was worthwhile. In another
study, the Beth Israel Medical Center in New York instituted use of a worksheet that was
posted at bedside after completion. Narasimham and colleagues (2006) found that pre and
post scores for understanding patient goals and communication improved significantly,
and that this improvement was sustained over a 9-month period. Furthermore, after
completion of the study, most of the practitioners requested that the use of the worksheet
be continued. In the DNP project, instituting a daily goals reminder worksheet associated
with APN–RN–patient bedside rounding enhanced communication between APNs, staff
nurses, and patients.
Needs Assessment and Description of the Project
Population identification. In this DNP project, the population identified for
selection and participation comprises APNs who have prior knowledge of and experience
with APN–RN–patient bedside rounding.
Identification of the project sponsor and key stakeholders. This DNP project
has no sponsors. Key stakeholders include the student investigator and ultimately the
APNs and RNs who will participate in the learning module.
Assessment of available resources. No monetary resources were available for
this project. As project investigator, I was responsible for the development of the learning
module. The project had no public advertisement. APNs were approached through the
hospital’s standardized email by the student researcher (Appendix B).
Team selection. The project investigator, served as the team for this project, with
consultation from the DNP project committee members.
Scope of the project. The project entailed only the development of the 1-hour
learning module. Further plans for implementation will be considered at some point in
the future. The module’s topics included (a) the requirement for close communication and
collaboration between team members to assure seamless, high-quality health care, (b) the
definition of APN–RN rounds, (c) the schedule and length of rounds, (d) the personnel
composition of rounding teams, (e) topics of discussion during the rounds, and (f) the use
of a daily goal reminder sheet to ensure the consistency of all elements of the patient's
treatment plan and goals.
As project investigator, I used the literature as a basis for creating the written
learning module. After completing the module and obtaining University of Nevada Las
Vegas Institutional Review Board approval, the learning module was sent to three APNs
in the hospital for review and feedback; all of these APNs had prior experience in
working with APN–RN rounds at other facilities. In addition, to assess the learning
module’s effectiveness, I developed an evaluation form to be completed by participating
APNs and RNs following their completion of the learning module.
All results of this project were shared with a representative of the CMC’s
administration and the Chief Nurse Executive. I hope to work with administration and
staff in implementing the APN–RN–patient rounding on a pilot unit and, on the basis of
results, further develops the model for use on other inpatient units.
Mission, Goals, and Objectives
The mission and goals of this project are to improve communication and
collaboration between the intraprofessional team of APNs and staff nurses and to improve
APN–staff nurse communication with patients.
This DNP project’s primary objective was to develop a structured learning module
pertaining to APN–RN–patient bedside rounding. The project’s long-term goals,
following completion of this project, are to implement the model and to improve
communication and collaboration between APNs, clinical nurses, and the patients cared
for by these nurses.
Chapter 3
Theoretical Underpinnings of the DNP Project
Of the several theories that have informed our understanding of holistic patient
centered care and educating adults, two theories are among the most influential: King’s
theory of goal attainment and Knowles’s theory of andragogy. In light of the theories’
relevance to developing interventions for improving health care team collaboration and
communication—the central concern of this dissertation—these two theories were
selected to serve as the theoretical underpinnings of the DNP staff education project in
support of APN–RN–patient bedside rounding. Specifically, King’s theory of goal
attainment informed the process of identifying content for the staff education module;
Knowles’s theory of andragogy informed the design of the module’s presentation to
training participants.
King’s Theory of Goal Attainment
In “Crossing the Quality Chasm: A New Health System for the 21st Century,” the
IOM (2001) describes six aims for the improvement of health care. One of the aims is to
provide patient-centered care that is respectful of and responsive to individual patients’
personal preferences, needs, and values; in patient-centered care, patients’ values play a
central role in informing clinical decision making clinical decisions. Among theoretical
frameworks that inform clinical understanding of the role of the patient in this
decisionmaking, Imogene Kings’ theory of goal attainment is seminal.
King’s theory and patient-centered health care. In King’s theory, health care
team decision-making includes a “transaction” in which the nurse and patient engage in
mutual goal setting (King, 1991, pp. 19). According to King, this transactional process of
interpersonal systems involves four steps—action, reaction, interaction, and transaction—
by which the patient and nurse (a) share information about their perceptions; (b) set goals
(through communication and interaction); and (c) explore and agree on means to achieve
these goals. To implement a true transactional process, the communication environment
must be reciprocal, and bidirectional. In this DNP project,
King’s theory—including the theory’s view of this transactional process—was applied to
inform the design of a patient-centered clinical environment. For example, to create and
maintain a patient-centered environment, APNs, clinical nurses, and patients must share
and be mutually informed about relevant considerations.
The theory of goal attainment: Assumptions and concepts. King developed her theory
of goal attainment in the 1960s. This theory describes the interpersonal dynamic
relationships between patients and their quest for goal attainment. Factors that can affect
goal attainment include roles, stressors, space, and time. In order for health care to be
optimal during the course of treatment for individual patients, both the patients and their
providers must continuously accommodate and adjust for changes in these factors.
King’s theory refers to three interacting systems: individuals (personal system),
groups (interpersonal system), and society (social system). The personal system is a
unified, complex, whole self who perceives, thinks, desires, imagines, decides, identifies
goals, and selects means to achieve them.
Assumptions. King’s framework is based on two assumptions:
▪Human beings are the focus of nursing.
▪The goals of nursing are health promotion, maintenance and restoration, care
of the sick or impaired, and care of the dying.
On the basis of these assumptions, King designed a conceptual system to explain
the organized wholes in which nurses are expected to function (see Figure 1; King, 1999).
Wholeness. King used the concept of “wholeness” to describe the broader
organization or social systems in which nurse’s function. (King, 1996, p. 61). The goal of
an interacting system is health for individuals, families, communities, and the world
(King, 1996).
Personal, interpersonal, and social systems. King’s conceptual framework is
organized into three “systems”: personal, interpersonal, and social. A personal or
individual system is essentially a single whole system. In contrast, an interpersonal
system represents the interaction of two or more individuals (i.e., small groups) in various
environments. Social systems are composed of large groups, such as educational,
governmental, or religious organizations.
Although in recent decades the quality and effectiveness of MD–RN interaction has
improved, the potential and need for further improvement in interprofessional
collaboration are substantial. To assess this need, Weaver et al. (2014) recently examined
teamwork and collaboration between staff nurses, residents, hospitalists, and oncology
physicians in oncology units at a large urban hospital. The investigators found that
physicians rated the quality of their own collaboration “very high” with other physicians
and with nurses. Physician ranked nurses’ collaboration with physicians as ranging from
87% to 100%. In stark contrast, however, nurses rated the quality of collaboration with
physicians poorly, from 35%–65%. Weaver et al. found that hierarchies persist and can
interfere with collaboration. Nurses believed that a negative attitude toward
communication as a significant obstacle to collaboration. A nurse may be reluctant to call
a physician if the nurse perceives that their relationship is not mutually supportive and
collaborative. On the other hand, physicians, having a positive perception of
collaboration, perceive difficulty contacting other providers as the main obstacle to
collaboration. Physicians who assume they have a good collaborative relationship with
nurses may not seek additional information because they (the physicians) are unaware of
potential or actual problems (Weaver et al., 2014).
Vazirani et al. (2005) surveyed registered nurses (n = 123), physicians (n = 45),
and a combined group of resident physicians and interns (n = 111) to determine whether
introduction of an APN role to the team was followed by changes in team communication
and collaboration. Physicians reported that, when an APN was part of the team, the level
of collaboration with nurses and APNs was significantly higher. Physicians also reported
that when an APN was part of the team, the team had fewer unnecessary delays and better
general communication. In the same study, the staff nurses reported significantly better
communication with APNs than with physicians (Vazirani et al., 2005). Kilpatrick (2012)
also found that communication and decision-making improve quality of care when the
participating APN is able to act within the full scope of the APN role. Among other
positive outcomes, this study reported that APN participation was associated with
decreases in length of patient stay and costs for patients treated on the intervention unit,
without an increase of readmission rates.
Vazirani’s (2005) study employed surveys to assess the degree of communication
and collaboration over two units. Physicians were surveyed immediately after they
completed a given rotation, starting at the onset of the interventions. Nurses were
surveyed biannually. The statistical analysis took into account correlation of observations
due to repeated sampling (Vazirani et al., 2005). Limitations in this study included
physician and staff nurse confusion about the role of APNs. Prior to the study, no APNs
were employed in the hospital’s internal medicine department. Chicago Medical Center
(CMC) employs approximately 200 APNs throughout all medical and surgical services,
thus role confusion is not a problem. The second limitation of this study pertained to
sample size. Physicians and nurses were not allowed to work on both the interventional
and control units; accordingly, the pool of physicians and pool of nurses available to
participate in the study was restricted. This can present problems with sample size but
also falsely promote familiarity and foster improved communications, skewing positive
results.
Although the quantity of studies is limited, it is clear that when an APN is an
integral part of the interprofessional team, the quality of communication and collaboration
increases. This DNP project specifies inclusion of the APN and staff nurse as members of
the professional team. The patient, who is also an integral part of this team, is not a
professional but is in fact the core leader of the health care team. In the decision-making
process, the patient’s understanding and input are invaluable
Communication and collaboration between APNs and staff nurses. The
majority of studies of communication and collaboration in health care contexts focused on
the nurse–physician relationship (Baggs & Ryan, 1990; Chapman, 2009;
DechairoMarino et al., 2001; Nathanson et al., 2011; Shortal et al., 1991). There have
been minimal formal studies looking at MD-APN and improved communication with
staff and its effects on patient care (Cowan et al., 2006). In nursing intraprofessional
teams, communication has been identified as the essential component of good team
functioning (Dreaschlin et al., 1999; Jones, 2005; Richardson et al., 2010). APNs possess
diverse knowledge that can facilitate understanding of collaborative practice to optimize
patient care (Crecelius, 2011). The Agency for Healthcare Research and Quality (2014)
found that when nurse practitioners are included in daily multidisciplinary rounds, the
rounding team’s communication and collaboration improve.
The increasing use of health care teams has made nursing practice more salient, in
that nurses serve as a link between team members and patients. Effective communication
between all team members is essential for successful teamwork and high-quality patient
care (Apker et al., 2006). The advance nurse practitioner function as the central link of the
health care team integrating other health care providers and patients. Good
communication among staff and between staff and patients is the cornerstone of quality
care.
Gooden and Jackson (2004) documented one of the earliest studies examining
staff nurses’ attitudes toward APNs. The investigators found that as APNs have come to
manage an increasing number of patients, staff nurses have begun to view the APNs as
leaders. Staff RNs consistently scored APNs higher than physicians in measures of
communication, respect for staff opinion, quality of care, clinical expertise, and
willingness to teach staff, patients, and patients’ families.
Moore and Prentice (2013) reported a case study that analyzed the collaborative
process between APNs and nurse in an outpatient oncology setting in Canada. The
researchers discovered four basic themes to collaboration:
▪Time that APNs spend together outside of work translates into collaboration at
work.
▪The basic skill of clinical knowledge and experience are essential ingredients
for successful collaboration.
▪Other factors that that contribute to the success of collaboration include
sharing a similar philosophy of care and mutual trust, respect and esteem.
▪Barriers to collaboration inevitably arise. Nurses are largely unaware of how
collaboration should manifest in the practice and are not trained on principles
of effective collaboration in practice.
▪Nurses and APNs attitudes are changing toward collaboration, viewing
collaboration as a means of achieving positive results.
Moore and Prentice (2013) found that intraprofessional collaboration (a) is
complex, (b) is influenced by interpersonal and professional factors, and (c) does not
occur spontaneously. Nurse must have a solid understanding of the concept of
collaboration and how to apply it in the clinical setting.
Patient-centered care. Improvement of patient satisfaction and quality of care is
directly due to the implementation of patient-centered care. Patient-centered care, the
“new normal” in today’s healthcare system, provides a mechanism for nurses to engage
patients as active participates in their care. The Institute of Medicine (IOM, 2001, p. 6)
defines patient-centered care as “healthcare that establishes a partnership among
practitioner, patients and their families to ensure that decisions reflect patient s wants,
needs and preferences” (see also Boykins, 2014; Sepucha & Ozanne, 2010). Optimal
patient participation requires a dynamic interaction between partners (patient and staff) in
terms of interpersonal interaction, therapeutic approach, focus on resources, resources,
patient opportunities to participate in and influence health care team decision making, and
patient education (Sahlsten et al., 2007). Including the patient in bedside reports or
handoffs has been reported to improve teamwork, safety and efficiency (Wildner & Ferri,
2012). This bedside practice also entails the participation of patients as partners in their
care, with the expectation that their participation will lead to improved care, better
outcomes, improved adherence to treatment and medication regimen and greater
satisfaction with care. Barriers to implementation of patient-centered care and bedside
rounding include time and resource requirements; the potential for patients to feel
confused, upset, or dehumanized as a result of hearing clinical explanations; and the
potential for breach of patient confidentiality (McMurry et. al 2011). In addition, when
presenting sensitive or confidential information, some nurses may feel uncomfortable, or
be inhibited by a lack experience—especially in the presence of patients’ family members
or relatives are present. O’Connell, Macdonald, and Kelly (2008) found that viewed
handoffs as being too time consuming, and ineffective, or efficient. The investigators
recommended that a handoff guideline or information template should be developed to
promote and facilitate the reporting of objective relevant information.
Patient satisfaction and its effects on quality of care. As a subjective
phenomenon, “patient satisfaction” is difficult to define. The self-reported determination
of patient satisfaction is a personal evaluation of health care services and of the providers
of that care (Ware et al., 1983); patients’ attitudes and expectations regarding care greatly
affect their sense of satisfaction. Because satisfaction ratings are relative, subjective, and
not directly observable, attempting to meaningfully quantify patients’ personal evaluation
of care is highly problematic (Ware et al., 1983).
The challenges inherent in measuring patient satisfaction have ramifications for
policy and practice. For example, in 2012, the Center for Medicare and Medicaid
Services (CMS) began to implement a reimbursement system that adjusts payment rates
based on patient satisfaction scores (Lyu et al., 2013). Patient satisfaction is a key
determinant of quality of care and an important component of the pay-for-performance
metrics instituted by CMS. Beginning in 2012, CMS implemented value-based incentive
payments to acute-care hospitals based in part on results of satisfaction surveys from
patients discharged on or after October 1, 2012. The patient’s perception of quality is
significant determinant of the provider’s federal reimbursement. Patients now make
decisions based on their perceptions of the quality of and satisfaction with health care
providers (Bowers, Swan, & Koehler, 1994).
A study conducted by Fenton, Jerant, Bertakis, and Franks at the University of
California–Davis examined mortality rate in relation to patient satisfaction (N = 51,946);
the researchers’ analysis adjusted for a number of factors (i.e., demographics, health
status and chronic disease burden, Year 1 utilization and expenditures, availability of a
usual source of care, and insurance status). The investigators were surprised to find that,
in comparison with the mortality rate of patients in the lowest satisfaction quartile, the
mortality rate of patients in the highest satisfaction quartile was 26% higher (adjusted
hazard ratio, 1.26; 95% CI [1.05, 1.53]). This perhaps counterintuitive finding raises the
question of whether current satisfaction measures are in fact good indicators of health
care quality (Fenton et al., 2012). The researchers concluded that the connection between
patient satisfaction and health care outcomes is yet unclear.
Practitioners need to understand that ineffective communication can result in poor
outcomes. Improved communication not only results in better health outcomes, but also
may positivity impact patient satisfaction. For patients who want to be involved in their
care and who understand what is occurring during care, improved communication may
ultimately lead to greater patient satisfaction. The inclusion of APNs in the care team has
been reported to improve communication and the efficiency of care (McCauley, Bixby, &
Naylor, 2006).
Evidence-based practice. Evidence-based practice (EBP) is at the forefront of
change in today’s health care environment. EBP is the practice of using documented
evidence as a guide to problem solving approach to clinical decision making. To
implement EBP, one must “locate, critique, synthesize, translate, and evaluate evidence”
(Drenning, 2006, p.299). This includes the dissemination of information during the
implementation phase of practice. Although ostensibly EBP is the standard of nursing
practice, implementation of EBP is not always easy (Krom & Bautista, 2010). Barriers to
EBP implementation include (a) lack of requisite knowledge and skills on the part of
clinicians, (b) perception that EBP is time consuming, (b) perception that EBP is
burdensome, and (d) lack of management support at the organizational level (Melnyk &
Fineout-Overholt, 2012). Among clinical staff members, APNs, nurse educators, and
DNPs—who understand translational research—are uniquely qualified to fulfill their
responsibility to fulfill the mandate to implement evidence –based changes in practice.
These organizational change agents must persuasively teach the EBP process to staff
nurses and thereby transform the organizational culture—from a culture in which change
is resisted to a culture in which evidence-based improvements in practice are welcomed.
To achieve this transformation in organizational culture, APNs, nurse educators, and
DNPs must employ an interactive approach.
APNs serve as both leaders and knowledge resources for helping nursing staff to
ground care in current evidence. In a study conducted by Mahanes, Quatrara, and Shaw
(2013) at the University of Virginia, the researchers implemented APN-led nursing
rounds. Although the specific effects of the APN-led nursing rounds were impossible to
isolate, Mahanes and her colleagues were able to determine that rates of blood stream
infections, catheter-associated urinary tract infections, hospital-acquired pressure ulcers,
and ventilator-associated pneumonia and falls all declined. Similarly, in study that a
analyzed the effectiveness of an APN-managed heart failure program, Dahl and Penque
(2002) reported reduced 90-day readmission rates, fewer in-patient hospital days, lower
re-admission charges, and lower overall charges for health care services.
APNs have demonstrated implementation of EBP practices, better working
relationship with staff nurses, and improved patient-centered care with cost savings. The
development of an intraprofessional APN–staff nurse team to conduct bedside rounding
should improve patient care, increase communication and collaboration, and improve
patient satisfaction.
The daily goals reminder sheet. The need to develop clear team communication
has led to the development and institution of daily goal sheets. Studies in ICUs have
demonstrated that the use of daily goal sheets can result in nurses’ and physicians’ having
better understanding of patient care goals and in decreased ICU length of stay (Agarwal et
al., 2008; Narasimhan et al., 2006; Pronovost et al., 2003). A study conducted by
Phipps and Thomas (2007) examined the use of a daily goals sheet in the ICU at The
University of Pennsylvania’s Hershey Children’s Hospital. The researchers found that
85% of nurses felt the use of the goals sheets improved communications between
physicians and nurses and improved communication between nurses working on different
shifts. Phipps and Thomas also reported that 95% of the nursing staff felt that the extra
expenditure of time spent in completing the daily goals sheet was worthwhile. In another
study, the Beth Israel Medical Center in New York instituted use of a worksheet that was
posted at bedside after completion. Narasimham and colleagues (2006) found that pre and
post scores for understanding patient goals and communication improved significantly,
and that this improvement was sustained over a 9-month period. Furthermore, after
completion of the study, most of the practitioners requested that the use of the worksheet
be continued. In the DNP project, instituting a daily goals reminder worksheet associated
with APN–RN–patient bedside rounding enhanced communication between APNs, staff
nurses, and patients.
Needs Assessment and Description of the Project
Population identification. In this DNP project, the population identified for
selection and participation comprises APNs who have prior knowledge of and experience
with APN–RN–patient bedside rounding.
Identification of the project sponsor and key stakeholders. This DNP project
has no sponsors. Key stakeholders include the student investigator and ultimately the
APNs and RNs who will participate in the learning module.
Assessment of available resources. No monetary resources were available for
this project. As project investigator, I was responsible for the development of the learning
module. The project had no public advertisement. APNs were approached through the
hospital’s standardized email by the student researcher (Appendix B).
Team selection. The project investigator, served as the team for this project, with
consultation from the DNP project committee members.
Scope of the project. The project entailed only the development of the 1-hour
learning module. Further plans for implementation will be considered at some point in
the future. The module’s topics included (a) the requirement for close communication and
collaboration between team members to assure seamless, high-quality health care, (b) the
definition of APN–RN rounds, (c) the schedule and length of rounds, (d) the personnel
composition of rounding teams, (e) topics of discussion during the rounds, and (f) the use
of a daily goal reminder sheet to ensure the consistency of all elements of the patient's
treatment plan and goals.
As project investigator, I used the literature as a basis for creating the written
learning module. After completing the module and obtaining University of Nevada Las
Vegas Institutional Review Board approval, the learning module was sent to three APNs
in the hospital for review and feedback; all of these APNs had prior experience in
working with APN–RN rounds at other facilities. In addition, to assess the learning
module’s effectiveness, I developed an evaluation form to be completed by participating
APNs and RNs following their completion of the learning module.
All results of this project were shared with a representative of the CMC’s
administration and the Chief Nurse Executive. I hope to work with administration and
staff in implementing the APN–RN–patient rounding on a pilot unit and, on the basis of
results, further develops the model for use on other inpatient units.
Mission, Goals, and Objectives
The mission and goals of this project are to improve communication and
collaboration between the intraprofessional team of APNs and staff nurses and to improve
APN–staff nurse communication with patients.
This DNP project’s primary objective was to develop a structured learning module
pertaining to APN–RN–patient bedside rounding. The project’s long-term goals,
following completion of this project, are to implement the model and to improve
communication and collaboration between APNs, clinical nurses, and the patients cared
for by these nurses.
Chapter 3
Theoretical Underpinnings of the DNP Project
Of the several theories that have informed our understanding of holistic patient
centered care and educating adults, two theories are among the most influential: King’s
theory of goal attainment and Knowles’s theory of andragogy. In light of the theories’
relevance to developing interventions for improving health care team collaboration and
communication—the central concern of this dissertation—these two theories were
selected to serve as the theoretical underpinnings of the DNP staff education project in
support of APN–RN–patient bedside rounding. Specifically, King’s theory of goal
attainment informed the process of identifying content for the staff education module;
Knowles’s theory of andragogy informed the design of the module’s presentation to
training participants.
King’s Theory of Goal Attainment
In “Crossing the Quality Chasm: A New Health System for the 21st Century,” the
IOM (2001) describes six aims for the improvement of health care. One of the aims is to
provide patient-centered care that is respectful of and responsive to individual patients’
personal preferences, needs, and values; in patient-centered care, patients’ values play a
central role in informing clinical decision making clinical decisions. Among theoretical
frameworks that inform clinical understanding of the role of the patient in this
decisionmaking, Imogene Kings’ theory of goal attainment is seminal.
King’s theory and patient-centered health care. In King’s theory, health care
team decision-making includes a “transaction” in which the nurse and patient engage in
mutual goal setting (King, 1991, pp. 19). According to King, this transactional process of
interpersonal systems involves four steps—action, reaction, interaction, and transaction—
by which the patient and nurse (a) share information about their perceptions; (b) set goals
(through communication and interaction); and (c) explore and agree on means to achieve
these goals. To implement a true transactional process, the communication environment
must be reciprocal, and bidirectional. In this DNP project,
King’s theory—including the theory’s view of this transactional process—was applied to
inform the design of a patient-centered clinical environment. For example, to create and
maintain a patient-centered environment, APNs, clinical nurses, and patients must share
and be mutually informed about relevant considerations.
The theory of goal attainment: Assumptions and concepts. King developed her theory
of goal attainment in the 1960s. This theory describes the interpersonal dynamic
relationships between patients and their quest for goal attainment. Factors that can affect
goal attainment include roles, stressors, space, and time. In order for health care to be
optimal during the course of treatment for individual patients, both the patients and their
providers must continuously accommodate and adjust for changes in these factors.
King’s theory refers to three interacting systems: individuals (personal system),
groups (interpersonal system), and society (social system). The personal system is a
unified, complex, whole self who perceives, thinks, desires, imagines, decides, identifies
goals, and selects means to achieve them.
Assumptions. King’s framework is based on two assumptions:
▪Human beings are the focus of nursing.
▪The goals of nursing are health promotion, maintenance and restoration, care
of the sick or impaired, and care of the dying.
On the basis of these assumptions, King designed a conceptual system to explain
the organized wholes in which nurses are expected to function (see Figure 1; King, 1999).
Wholeness. King used the concept of “wholeness” to describe the broader
organization or social systems in which nurse’s function. (King, 1996, p. 61). The goal of
an interacting system is health for individuals, families, communities, and the world
(King, 1996).
Personal, interpersonal, and social systems. King’s conceptual framework is
organized into three “systems”: personal, interpersonal, and social. A personal or
individual system is essentially a single whole system. In contrast, an interpersonal
system represents the interaction of two or more individuals (i.e., small groups) in various
environments. Social systems are composed of large groups, such as educational,
governmental, or religious organizations.
Although in recent decades the quality and effectiveness of MD–RN interaction has
improved, the potential and need for further improvement in interprofessional
collaboration are substantial. To assess this need, Weaver et al. (2014) recently examined
teamwork and collaboration between staff nurses, residents, hospitalists, and oncology
physicians in oncology units at a large urban hospital. The investigators found that
physicians rated the quality of their own collaboration “very high” with other physicians
and with nurses. Physician ranked nurses’ collaboration with physicians as ranging from
87% to 100%. In stark contrast, however, nurses rated the quality of collaboration with
physicians poorly, from 35%–65%. Weaver et al. found that hierarchies persist and can
interfere with collaboration. Nurses believed that a negative attitude toward
communication as a significant obstacle to collaboration. A nurse may be reluctant to call
a physician if the nurse perceives that their relationship is not mutually supportive and
collaborative. On the other hand, physicians, having a positive perception of
collaboration, perceive difficulty contacting other providers as the main obstacle to
collaboration. Physicians who assume they have a good collaborative relationship with
nurses may not seek additional information because they (the physicians) are unaware of
potential or actual problems (Weaver et al., 2014).
Vazirani et al. (2005) surveyed registered nurses (n = 123), physicians (n = 45),
and a combined group of resident physicians and interns (n = 111) to determine whether
introduction of an APN role to the team was followed by changes in team communication
and collaboration. Physicians reported that, when an APN was part of the team, the level
of collaboration with nurses and APNs was significantly higher. Physicians also reported
that when an APN was part of the team, the team had fewer unnecessary delays and better
general communication. In the same study, the staff nurses reported significantly better
communication with APNs than with physicians (Vazirani et al., 2005). Kilpatrick (2012)
also found that communication and decision-making improve quality of care when the
participating APN is able to act within the full scope of the APN role. Among other
positive outcomes, this study reported that APN participation was associated with
decreases in length of patient stay and costs for patients treated on the intervention unit,
without an increase of readmission rates.
Vazirani’s (2005) study employed surveys to assess the degree of communication
and collaboration over two units. Physicians were surveyed immediately after they
completed a given rotation, starting at the onset of the interventions. Nurses were
surveyed biannually. The statistical analysis took into account correlation of observations
due to repeated sampling (Vazirani et al., 2005). Limitations in this study included
physician and staff nurse confusion about the role of APNs. Prior to the study, no APNs
were employed in the hospital’s internal medicine department. Chicago Medical Center
(CMC) employs approximately 200 APNs throughout all medical and surgical services,
thus role confusion is not a problem. The second limitation of this study pertained to
sample size. Physicians and nurses were not allowed to work on both the interventional
and control units; accordingly, the pool of physicians and pool of nurses available to
participate in the study was restricted. This can present problems with sample size but
also falsely promote familiarity and foster improved communications, skewing positive
results.
Although the quantity of studies is limited, it is clear that when an APN is an
integral part of the interprofessional team, the quality of communication and collaboration
increases. This DNP project specifies inclusion of the APN and staff nurse as members of
the professional team. The patient, who is also an integral part of this team, is not a
professional but is in fact the core leader of the health care team. In the decision-making
process, the patient’s understanding and input are invaluable
Communication and collaboration between APNs and staff nurses. The
majority of studies of communication and collaboration in health care contexts focused on
the nurse–physician relationship (Baggs & Ryan, 1990; Chapman, 2009;
DechairoMarino et al., 2001; Nathanson et al., 2011; Shortal et al., 1991). There have
been minimal formal studies looking at MD-APN and improved communication with
staff and its effects on patient care (Cowan et al., 2006). In nursing intraprofessional
teams, communication has been identified as the essential component of good team
functioning (Dreaschlin et al., 1999; Jones, 2005; Richardson et al., 2010). APNs possess
diverse knowledge that can facilitate understanding of collaborative practice to optimize
patient care (Crecelius, 2011). The Agency for Healthcare Research and Quality (2014)
found that when nurse practitioners are included in daily multidisciplinary rounds, the
rounding team’s communication and collaboration improve.
The increasing use of health care teams has made nursing practice more salient, in
that nurses serve as a link between team members and patients. Effective communication
between all team members is essential for successful teamwork and high-quality patient
care (Apker et al., 2006). The advance nurse practitioner function as the central link of the
health care team integrating other health care providers and patients. Good
communication among staff and between staff and patients is the cornerstone of quality
care.
Gooden and Jackson (2004) documented one of the earliest studies examining
staff nurses’ attitudes toward APNs. The investigators found that as APNs have come to
manage an increasing number of patients, staff nurses have begun to view the APNs as
leaders. Staff RNs consistently scored APNs higher than physicians in measures of
communication, respect for staff opinion, quality of care, clinical expertise, and
willingness to teach staff, patients, and patients’ families.
Moore and Prentice (2013) reported a case study that analyzed the collaborative
process between APNs and nurse in an outpatient oncology setting in Canada. The
researchers discovered four basic themes to collaboration:
▪Time that APNs spend together outside of work translates into collaboration at
work.
▪The basic skill of clinical knowledge and experience are essential ingredients
for successful collaboration.
▪Other factors that that contribute to the success of collaboration include
sharing a similar philosophy of care and mutual trust, respect and esteem.
▪Barriers to collaboration inevitably arise. Nurses are largely unaware of how
collaboration should manifest in the practice and are not trained on principles
of effective collaboration in practice.
▪Nurses and APNs attitudes are changing toward collaboration, viewing
collaboration as a means of achieving positive results.
Moore and Prentice (2013) found that intraprofessional collaboration (a) is
complex, (b) is influenced by interpersonal and professional factors, and (c) does not
occur spontaneously. Nurse must have a solid understanding of the concept of
collaboration and how to apply it in the clinical setting.
Patient-centered care. Improvement of patient satisfaction and quality of care is
directly due to the implementation of patient-centered care. Patient-centered care, the
“new normal” in today’s healthcare system, provides a mechanism for nurses to engage
patients as active participates in their care. The Institute of Medicine (IOM, 2001, p. 6)
defines patient-centered care as “healthcare that establishes a partnership among
practitioner, patients and their families to ensure that decisions reflect patient s wants,
needs and preferences” (see also Boykins, 2014; Sepucha & Ozanne, 2010). Optimal
patient participation requires a dynamic interaction between partners (patient and staff) in
terms of interpersonal interaction, therapeutic approach, focus on resources, resources,
patient opportunities to participate in and influence health care team decision making, and
patient education (Sahlsten et al., 2007). Including the patient in bedside reports or
handoffs has been reported to improve teamwork, safety and efficiency (Wildner & Ferri,
2012). This bedside practice also entails the participation of patients as partners in their
care, with the expectation that their participation will lead to improved care, better
outcomes, improved adherence to treatment and medication regimen and greater
satisfaction with care. Barriers to implementation of patient-centered care and bedside
rounding include time and resource requirements; the potential for patients to feel
confused, upset, or dehumanized as a result of hearing clinical explanations; and the
potential for breach of patient confidentiality (McMurry et. al 2011). In addition, when
presenting sensitive or confidential information, some nurses may feel uncomfortable, or
be inhibited by a lack experience—especially in the presence of patients’ family members
or relatives are present. O’Connell, Macdonald, and Kelly (2008) found that viewed
handoffs as being too time consuming, and ineffective, or efficient. The investigators
recommended that a handoff guideline or information template should be developed to
promote and facilitate the reporting of objective relevant information.
Patient satisfaction and its effects on quality of care. As a subjective
phenomenon, “patient satisfaction” is difficult to define. The self-reported determination
of patient satisfaction is a personal evaluation of health care services and of the providers
of that care (Ware et al., 1983); patients’ attitudes and expectations regarding care greatly
affect their sense of satisfaction. Because satisfaction ratings are relative, subjective, and
not directly observable, attempting to meaningfully quantify patients’ personal evaluation
of care is highly problematic (Ware et al., 1983).
The challenges inherent in measuring patient satisfaction have ramifications for
policy and practice. For example, in 2012, the Center for Medicare and Medicaid
Services (CMS) began to implement a reimbursement system that adjusts payment rates
based on patient satisfaction scores (Lyu et al., 2013). Patient satisfaction is a key
determinant of quality of care and an important component of the pay-for-performance
metrics instituted by CMS. Beginning in 2012, CMS implemented value-based incentive
payments to acute-care hospitals based in part on results of satisfaction surveys from
patients discharged on or after October 1, 2012. The patient’s perception of quality is
significant determinant of the provider’s federal reimbursement. Patients now make
decisions based on their perceptions of the quality of and satisfaction with health care
providers (Bowers, Swan, & Koehler, 1994).
A study conducted by Fenton, Jerant, Bertakis, and Franks at the University of
California–Davis examined mortality rate in relation to patient satisfaction (N = 51,946);
the researchers’ analysis adjusted for a number of factors (i.e., demographics, health
status and chronic disease burden, Year 1 utilization and expenditures, availability of a
usual source of care, and insurance status). The investigators were surprised to find that,
in comparison with the mortality rate of patients in the lowest satisfaction quartile, the
mortality rate of patients in the highest satisfaction quartile was 26% higher (adjusted
hazard ratio, 1.26; 95% CI [1.05, 1.53]). This perhaps counterintuitive finding raises the
question of whether current satisfaction measures are in fact good indicators of health
care quality (Fenton et al., 2012). The researchers concluded that the connection between
patient satisfaction and health care outcomes is yet unclear.
Practitioners need to understand that ineffective communication can result in poor
outcomes. Improved communication not only results in better health outcomes, but also
may positivity impact patient satisfaction. For patients who want to be involved in their
care and who understand what is occurring during care, improved communication may
ultimately lead to greater patient satisfaction. The inclusion of APNs in the care team has
been reported to improve communication and the efficiency of care (McCauley, Bixby, &
Naylor, 2006).
Evidence-based practice. Evidence-based practice (EBP) is at the forefront of
change in today’s health care environment. EBP is the practice of using documented
evidence as a guide to problem solving approach to clinical decision making. To
implement EBP, one must “locate, critique, synthesize, translate, and evaluate evidence”
(Drenning, 2006, p.299). This includes the dissemination of information during the
implementation phase of practice. Although ostensibly EBP is the standard of nursing
practice, implementation of EBP is not always easy (Krom & Bautista, 2010). Barriers to
EBP implementation include (a) lack of requisite knowledge and skills on the part of
clinicians, (b) perception that EBP is time consuming, (b) perception that EBP is
burdensome, and (d) lack of management support at the organizational level (Melnyk &
Fineout-Overholt, 2012). Among clinical staff members, APNs, nurse educators, and
DNPs—who understand translational research—are uniquely qualified to fulfill their
responsibility to fulfill the mandate to implement evidence –based changes in practice.
These organizational change agents must persuasively teach the EBP process to staff
nurses and thereby transform the organizational culture—from a culture in which change
is resisted to a culture in which evidence-based improvements in practice are welcomed.
To achieve this transformation in organizational culture, APNs, nurse educators, and
DNPs must employ an interactive approach.
APNs serve as both leaders and knowledge resources for helping nursing staff to
ground care in current evidence. In a study conducted by Mahanes, Quatrara, and Shaw
(2013) at the University of Virginia, the researchers implemented APN-led nursing
rounds. Although the specific effects of the APN-led nursing rounds were impossible to
isolate, Mahanes and her colleagues were able to determine that rates of blood stream
infections, catheter-associated urinary tract infections, hospital-acquired pressure ulcers,
and ventilator-associated pneumonia and falls all declined. Similarly, in study that a
analyzed the effectiveness of an APN-managed heart failure program, Dahl and Penque
(2002) reported reduced 90-day readmission rates, fewer in-patient hospital days, lower
re-admission charges, and lower overall charges for health care services.
APNs have demonstrated implementation of EBP practices, better working
relationship with staff nurses, and improved patient-centered care with cost savings. The
development of an intraprofessional APN–staff nurse team to conduct bedside rounding
should improve patient care, increase communication and collaboration, and improve
patient satisfaction.
The daily goals reminder sheet. The need to develop clear team communication
has led to the development and institution of daily goal sheets. Studies in ICUs have
demonstrated that the use of daily goal sheets can result in nurses’ and physicians’ having
better understanding of patient care goals and in decreased ICU length of stay (Agarwal et
al., 2008; Narasimhan et al., 2006; Pronovost et al., 2003). A study conducted by
Phipps and Thomas (2007) examined the use of a daily goals sheet in the ICU at The
University of Pennsylvania’s Hershey Children’s Hospital. The researchers found that
85% of nurses felt the use of the goals sheets improved communications between
physicians and nurses and improved communication between nurses working on different
shifts. Phipps and Thomas also reported that 95% of the nursing staff felt that the extra
expenditure of time spent in completing the daily goals sheet was worthwhile. In another
study, the Beth Israel Medical Center in New York instituted use of a worksheet that was
posted at bedside after completion. Narasimham and colleagues (2006) found that pre and
post scores for understanding patient goals and communication improved significantly,
and that this improvement was sustained over a 9-month period. Furthermore, after
completion of the study, most of the practitioners requested that the use of the worksheet
be continued. In the DNP project, instituting a daily goals reminder worksheet associated
with APN–RN–patient bedside rounding enhanced communication between APNs, staff
nurses, and patients.
Needs Assessment and Description of the Project
Population identification. In this DNP project, the population identified for
selection and participation comprises APNs who have prior knowledge of and experience
with APN–RN–patient bedside rounding.
Identification of the project sponsor and key stakeholders. This DNP project
has no sponsors. Key stakeholders include the student investigator and ultimately the
APNs and RNs who will participate in the learning module.
Assessment of available resources. No monetary resources were available for
this project. As project investigator, I was responsible for the development of the learning
module. The project had no public advertisement. APNs were approached through the
hospital’s standardized email by the student researcher (Appendix B).
Team selection. The project investigator, served as the team for this project, with
consultation from the DNP project committee members.
Scope of the project. The project entailed only the development of the 1-hour
learning module. Further plans for implementation will be considered at some point in
the future. The module’s topics included (a) the requirement for close communication and
collaboration between team members to assure seamless, high-quality health care, (b) the
definition of APN–RN rounds, (c) the schedule and length of rounds, (d) the personnel
composition of rounding teams, (e) topics of discussion during the rounds, and (f) the use
of a daily goal reminder sheet to ensure the consistency of all elements of the patient's
treatment plan and goals.
As project investigator, I used the literature as a basis for creating the written
learning module. After completing the module and obtaining University of Nevada Las
Vegas Institutional Review Board approval, the learning module was sent to three APNs
in the hospital for review and feedback; all of these APNs had prior experience in
working with APN–RN rounds at other facilities. In addition, to assess the learning
module’s effectiveness, I developed an evaluation form to be completed by participating
APNs and RNs following their completion of the learning module.
All results of this project were shared with a representative of the CMC’s
administration and the Chief Nurse Executive. I hope to work with administration and
staff in implementing the APN–RN–patient rounding on a pilot unit and, on the basis of
results, further develops the model for use on other inpatient units.
Mission, Goals, and Objectives
The mission and goals of this project are to improve communication and
collaboration between the intraprofessional team of APNs and staff nurses and to improve
APN–staff nurse communication with patients.
This DNP project’s primary objective was to develop a structured learning module
pertaining to APN–RN–patient bedside rounding. The project’s long-term goals,
following completion of this project, are to implement the model and to improve
communication and collaboration between APNs, clinical nurses, and the patients cared
for by these nurses.
Chapter 3
Theoretical Underpinnings of the DNP Project
Of the several theories that have informed our understanding of holistic patient
centered care and educating adults, two theories are among the most influential: King’s
theory of goal attainment and Knowles’s theory of andragogy. In light of the theories’
relevance to developing interventions for improving health care team collaboration and
communication—the central concern of this dissertation—these two theories were
selected to serve as the theoretical underpinnings of the DNP staff education project in
support of APN–RN–patient bedside rounding. Specifically, King’s theory of goal
attainment informed the process of identifying content for the staff education module;
Knowles’s theory of andragogy informed the design of the module’s presentation to
training participants.
King’s Theory of Goal Attainment
In “Crossing the Quality Chasm: A New Health System for the 21st Century,” the
IOM (2001) describes six aims for the improvement of health care. One of the aims is to
provide patient-centered care that is respectful of and responsive to individual patients’
personal preferences, needs, and values; in patient-centered care, patients’ values play a
central role in informing clinical decision making clinical decisions. Among theoretical
frameworks that inform clinical understanding of the role of the patient in this
decisionmaking, Imogene Kings’ theory of goal attainment is seminal.
King’s theory and patient-centered health care. In King’s theory, health care
team decision-making includes a “transaction” in which the nurse and patient engage in
mutual goal setting (King, 1991, pp. 19). According to King, this transactional process of
interpersonal systems involves four steps—action, reaction, interaction, and transaction—
by which the patient and nurse (a) share information about their perceptions; (b) set goals
(through communication and interaction); and (c) explore and agree on means to achieve
these goals. To implement a true transactional process, the communication environment
must be reciprocal, and bidirectional. In this DNP project,
King’s theory—including the theory’s view of this transactional process—was applied to
inform the design of a patient-centered clinical environment. For example, to create and
maintain a patient-centered environment, APNs, clinical nurses, and patients must share
and be mutually informed about relevant considerations.
The theory of goal attainment: Assumptions and concepts. King developed her theory
of goal attainment in the 1960s. This theory describes the interpersonal dynamic
relationships between patients and their quest for goal attainment. Factors that can affect
goal attainment include roles, stressors, space, and time. In order for health care to be
optimal during the course of treatment for individual patients, both the patients and their
providers must continuously accommodate and adjust for changes in these factors.
King’s theory refers to three interacting systems: individuals (personal system),
groups (interpersonal system), and society (social system). The personal system is a
unified, complex, whole self who perceives, thinks, desires, imagines, decides, identifies
goals, and selects means to achieve them.
Assumptions. King’s framework is based on two assumptions:
▪Human beings are the focus of nursing.
▪The goals of nursing are health promotion, maintenance and restoration, care
of the sick or impaired, and care of the dying.
On the basis of these assumptions, King designed a conceptual system to explain
the organized wholes in which nurses are expected to function (see Figure 1; King, 1999).
Wholeness. King used the concept of “wholeness” to describe the broader
organization or social systems in which nurse’s function. (King, 1996, p. 61). The goal of
an interacting system is health for individuals, families, communities, and the world
(King, 1996).
Personal, interpersonal, and social systems. King’s conceptual framework is
organized into three “systems”: personal, interpersonal, and social. A personal or
individual system is essentially a single whole system. In contrast, an interpersonal
system represents the interaction of two or more individuals (i.e., small groups) in various
environments. Social systems are composed of large groups, such as educational,
governmental, or religious organizations.
Although in recent decades the quality and effectiveness of MD–RN interaction has
improved, the potential and need for further improvement in interprofessional
collaboration are substantial. To assess this need, Weaver et al. (2014) recently examined
teamwork and collaboration between staff nurses, residents, hospitalists, and oncology
physicians in oncology units at a large urban hospital. The investigators found that
physicians rated the quality of their own collaboration “very high” with other physicians
and with nurses. Physician ranked nurses’ collaboration with physicians as ranging from
87% to 100%. In stark contrast, however, nurses rated the quality of collaboration with
physicians poorly, from 35%–65%. Weaver et al. found that hierarchies persist and can
interfere with collaboration. Nurses believed that a negative attitude toward
communication as a significant obstacle to collaboration. A nurse may be reluctant to call
a physician if the nurse perceives that their relationship is not mutually supportive and
collaborative. On the other hand, physicians, having a positive perception of
collaboration, perceive difficulty contacting other providers as the main obstacle to
collaboration. Physicians who assume they have a good collaborative relationship with
nurses may not seek additional information because they (the physicians) are unaware of
potential or actual problems (Weaver et al., 2014).
Vazirani et al. (2005) surveyed registered nurses (n = 123), physicians (n = 45),
and a combined group of resident physicians and interns (n = 111) to determine whether
introduction of an APN role to the team was followed by changes in team communication
and collaboration. Physicians reported that, when an APN was part of the team, the level
of collaboration with nurses and APNs was significantly higher. Physicians also reported
that when an APN was part of the team, the team had fewer unnecessary delays and better
general communication. In the same study, the staff nurses reported significantly better
communication with APNs than with physicians (Vazirani et al., 2005). Kilpatrick (2012)
also found that communication and decision-making improve quality of care when the
participating APN is able to act within the full scope of the APN role. Among other
positive outcomes, this study reported that APN participation was associated with
decreases in length of patient stay and costs for patients treated on the intervention unit,
without an increase of readmission rates.
Vazirani’s (2005) study employed surveys to assess the degree of communication
and collaboration over two units. Physicians were surveyed immediately after they
completed a given rotation, starting at the onset of the interventions. Nurses were
surveyed biannually. The statistical analysis took into account correlation of observations
due to repeated sampling (Vazirani et al., 2005). Limitations in this study included
physician and staff nurse confusion about the role of APNs. Prior to the study, no APNs
were employed in the hospital’s internal medicine department. Chicago Medical Center
(CMC) employs approximately 200 APNs throughout all medical and surgical services,
thus role confusion is not a problem. The second limitation of this study pertained to
sample size. Physicians and nurses were not allowed to work on both the interventional
and control units; accordingly, the pool of physicians and pool of nurses available to
participate in the study was restricted. This can present problems with sample size but
also falsely promote familiarity and foster improved communications, skewing positive
results.
Although the quantity of studies is limited, it is clear that when an APN is an
integral part of the interprofessional team, the quality of communication and collaboration
increases. This DNP project specifies inclusion of the APN and staff nurse as members of
the professional team. The patient, who is also an integral part of this team, is not a
professional but is in fact the core leader of the health care team. In the decision-making
process, the patient’s understanding and input are invaluable
Communication and collaboration between APNs and staff nurses. The
majority of studies of communication and collaboration in health care contexts focused on
the nurse–physician relationship (Baggs & Ryan, 1990; Chapman, 2009;
DechairoMarino et al., 2001; Nathanson et al., 2011; Shortal et al., 1991). There have
been minimal formal studies looking at MD-APN and improved communication with
staff and its effects on patient care (Cowan et al., 2006). In nursing intraprofessional
teams, communication has been identified as the essential component of good team
functioning (Dreaschlin et al., 1999; Jones, 2005; Richardson et al., 2010). APNs possess
diverse knowledge that can facilitate understanding of collaborative practice to optimize
patient care (Crecelius, 2011). The Agency for Healthcare Research and Quality (2014)
found that when nurse practitioners are included in daily multidisciplinary rounds, the
rounding team’s communication and collaboration improve.
The increasing use of health care teams has made nursing practice more salient, in
that nurses serve as a link between team members and patients. Effective communication
between all team members is essential for successful teamwork and high-quality patient
care (Apker et al., 2006). The advance nurse practitioner function as the central link of the
health care team integrating other health care providers and patients. Good
communication among staff and between staff and patients is the cornerstone of quality
care.
Gooden and Jackson (2004) documented one of the earliest studies examining
staff nurses’ attitudes toward APNs. The investigators found that as APNs have come to
manage an increasing number of patients, staff nurses have begun to view the APNs as
leaders. Staff RNs consistently scored APNs higher than physicians in measures of
communication, respect for staff opinion, quality of care, clinical expertise, and
willingness to teach staff, patients, and patients’ families.
Moore and Prentice (2013) reported a case study that analyzed the collaborative
process between APNs and nurse in an outpatient oncology setting in Canada. The
researchers discovered four basic themes to collaboration:
▪Time that APNs spend together outside of work translates into collaboration at
work.
▪The basic skill of clinical knowledge and experience are essential ingredients
for successful collaboration.
▪Other factors that that contribute to the success of collaboration include
sharing a similar philosophy of care and mutual trust, respect and esteem.
▪Barriers to collaboration inevitably arise. Nurses are largely unaware of how
collaboration should manifest in the practice and are not trained on principles
of effective collaboration in practice.
▪Nurses and APNs attitudes are changing toward collaboration, viewing
collaboration as a means of achieving positive results.
Moore and Prentice (2013) found that intraprofessional collaboration (a) is
complex, (b) is influenced by interpersonal and professional factors, and (c) does not
occur spontaneously. Nurse must have a solid understanding of the concept of
collaboration and how to apply it in the clinical setting.
Patient-centered care. Improvement of patient satisfaction and quality of care is
directly due to the implementation of patient-centered care. Patient-centered care, the
“new normal” in today’s healthcare system, provides a mechanism for nurses to engage
patients as active participates in their care. The Institute of Medicine (IOM, 2001, p. 6)
defines patient-centered care as “healthcare that establishes a partnership among
practitioner, patients and their families to ensure that decisions reflect patient s wants,
needs and preferences” (see also Boykins, 2014; Sepucha & Ozanne, 2010). Optimal
patient participation requires a dynamic interaction between partners (patient and staff) in
terms of interpersonal interaction, therapeutic approach, focus on resources, resources,
patient opportunities to participate in and influence health care team decision making, and
patient education (Sahlsten et al., 2007). Including the patient in bedside reports or
handoffs has been reported to improve teamwork, safety and efficiency (Wildner & Ferri,
2012). This bedside practice also entails the participation of patients as partners in their
care, with the expectation that their participation will lead to improved care, better
outcomes, improved adherence to treatment and medication regimen and greater
satisfaction with care. Barriers to implementation of patient-centered care and bedside
rounding include time and resource requirements; the potential for patients to feel
confused, upset, or dehumanized as a result of hearing clinical explanations; and the
potential for breach of patient confidentiality (McMurry et. al 2011). In addition, when
presenting sensitive or confidential information, some nurses may feel uncomfortable, or
be inhibited by a lack experience—especially in the presence of patients’ family members
or relatives are present. O’Connell, Macdonald, and Kelly (2008) found that viewed
handoffs as being too time consuming, and ineffective, or efficient. The investigators
recommended that a handoff guideline or information template should be developed to
promote and facilitate the reporting of objective relevant information.
Patient satisfaction and its effects on quality of care. As a subjective
phenomenon, “patient satisfaction” is difficult to define. The self-reported determination
of patient satisfaction is a personal evaluation of health care services and of the providers
of that care (Ware et al., 1983); patients’ attitudes and expectations regarding care greatly
affect their sense of satisfaction. Because satisfaction ratings are relative, subjective, and
not directly observable, attempting to meaningfully quantify patients’ personal evaluation
of care is highly problematic (Ware et al., 1983).
The challenges inherent in measuring patient satisfaction have ramifications for
policy and practice. For example, in 2012, the Center for Medicare and Medicaid
Services (CMS) began to implement a reimbursement system that adjusts payment rates
based on patient satisfaction scores (Lyu et al., 2013). Patient satisfaction is a key
determinant of quality of care and an important component of the pay-for-performance
metrics instituted by CMS. Beginning in 2012, CMS implemented value-based incentive
payments to acute-care hospitals based in part on results of satisfaction surveys from
patients discharged on or after October 1, 2012. The patient’s perception of quality is
significant determinant of the provider’s federal reimbursement. Patients now make
decisions based on their perceptions of the quality of and satisfaction with health care
providers (Bowers, Swan, & Koehler, 1994).
A study conducted by Fenton, Jerant, Bertakis, and Franks at the University of
California–Davis examined mortality rate in relation to patient satisfaction (N = 51,946);
the researchers’ analysis adjusted for a number of factors (i.e., demographics, health
status and chronic disease burden, Year 1 utilization and expenditures, availability of a
usual source of care, and insurance status). The investigators were surprised to find that,
in comparison with the mortality rate of patients in the lowest satisfaction quartile, the
mortality rate of patients in the highest satisfaction quartile was 26% higher (adjusted
hazard ratio, 1.26; 95% CI [1.05, 1.53]). This perhaps counterintuitive finding raises the
question of whether current satisfaction measures are in fact good indicators of health
care quality (Fenton et al., 2012). The researchers concluded that the connection between
patient satisfaction and health care outcomes is yet unclear.
Practitioners need to understand that ineffective communication can result in poor
outcomes. Improved communication not only results in better health outcomes, but also
may positivity impact patient satisfaction. For patients who want to be involved in their
care and who understand what is occurring during care, improved communication may
ultimately lead to greater patient satisfaction. The inclusion of APNs in the care team has
been reported to improve communication and the efficiency of care (McCauley, Bixby, &
Naylor, 2006).
Evidence-based practice. Evidence-based practice (EBP) is at the forefront of
change in today’s health care environment. EBP is the practice of using documented
evidence as a guide to problem solving approach to clinical decision making. To
implement EBP, one must “locate, critique, synthesize, translate, and evaluate evidence”
(Drenning, 2006, p.299). This includes the dissemination of information during the
implementation phase of practice. Although ostensibly EBP is the standard of nursing
practice, implementation of EBP is not always easy (Krom & Bautista, 2010). Barriers to
EBP implementation include (a) lack of requisite knowledge and skills on the part of
clinicians, (b) perception that EBP is time consuming, (b) perception that EBP is
burdensome, and (d) lack of management support at the organizational level (Melnyk &
Fineout-Overholt, 2012). Among clinical staff members, APNs, nurse educators, and
DNPs—who understand translational research—are uniquely qualified to fulfill their
responsibility to fulfill the mandate to implement evidence –based changes in practice.
These organizational change agents must persuasively teach the EBP process to staff
nurses and thereby transform the organizational culture—from a culture in which change
is resisted to a culture in which evidence-based improvements in practice are welcomed.
To achieve this transformation in organizational culture, APNs, nurse educators, and
DNPs must employ an interactive approach.
APNs serve as both leaders and knowledge resources for helping nursing staff to
ground care in current evidence. In a study conducted by Mahanes, Quatrara, and Shaw
(2013) at the University of Virginia, the researchers implemented APN-led nursing
rounds. Although the specific effects of the APN-led nursing rounds were impossible to
isolate, Mahanes and her colleagues were able to determine that rates of blood stream
infections, catheter-associated urinary tract infections, hospital-acquired pressure ulcers,
and ventilator-associated pneumonia and falls all declined. Similarly, in study that a
analyzed the effectiveness of an APN-managed heart failure program, Dahl and Penque
(2002) reported reduced 90-day readmission rates, fewer in-patient hospital days, lower
re-admission charges, and lower overall charges for health care services.
APNs have demonstrated implementation of EBP practices, better working
relationship with staff nurses, and improved patient-centered care with cost savings. The
development of an intraprofessional APN–staff nurse team to conduct bedside rounding
should improve patient care, increase communication and collaboration, and improve
patient satisfaction.
The daily goals reminder sheet. The need to develop clear team communication
has led to the development and institution of daily goal sheets. Studies in ICUs have
demonstrated that the use of daily goal sheets can result in nurses’ and physicians’ having
better understanding of patient care goals and in decreased ICU length of stay (Agarwal et
al., 2008; Narasimhan et al., 2006; Pronovost et al., 2003). A study conducted by
Phipps and Thomas (2007) examined the use of a daily goals sheet in the ICU at The
University of Pennsylvania’s Hershey Children’s Hospital. The researchers found that
85% of nurses felt the use of the goals sheets improved communications between
physicians and nurses and improved communication between nurses working on different
shifts. Phipps and Thomas also reported that 95% of the nursing staff felt that the extra
expenditure of time spent in completing the daily goals sheet was worthwhile. In another
study, the Beth Israel Medical Center in New York instituted use of a worksheet that was
posted at bedside after completion. Narasimham and colleagues (2006) found that pre and
post scores for understanding patient goals and communication improved significantly,
and that this improvement was sustained over a 9-month period. Furthermore, after
completion of the study, most of the practitioners requested that the use of the worksheet
be continued. In the DNP project, instituting a daily goals reminder worksheet associated
with APN–RN–patient bedside rounding enhanced communication between APNs, staff
nurses, and patients.
Needs Assessment and Description of the Project
Population identification. In this DNP project, the population identified for
selection and participation comprises APNs who have prior knowledge of and experience
with APN–RN–patient bedside rounding.
Identification of the project sponsor and key stakeholders. This DNP project
has no sponsors. Key stakeholders include the student investigator and ultimately the
APNs and RNs who will participate in the learning module.
Assessment of available resources. No monetary resources were available for
this project. As project investigator, I was responsible for the development of the learning
module. The project had no public advertisement. APNs were approached through the
hospital’s standardized email by the student researcher (Appendix B).
Team selection. The project investigator, served as the team for this project, with
consultation from the DNP project committee members.
Scope of the project. The project entailed only the development of the 1-hour
learning module. Further plans for implementation will be considered at some point in
the future. The module’s topics included (a) the requirement for close communication and
collaboration between team members to assure seamless, high-quality health care, (b) the
definition of APN–RN rounds, (c) the schedule and length of rounds, (d) the personnel
composition of rounding teams, (e) topics of discussion during the rounds, and (f) the use
of a daily goal reminder sheet to ensure the consistency of all elements of the patient's
treatment plan and goals.
As project investigator, I used the literature as a basis for creating the written
learning module. After completing the module and obtaining University of Nevada Las
Vegas Institutional Review Board approval, the learning module was sent to three APNs
in the hospital for review and feedback; all of these APNs had prior experience in
working with APN–RN rounds at other facilities. In addition, to assess the learning
module’s effectiveness, I developed an evaluation form to be completed by participating
APNs and RNs following their completion of the learning module.
All results of this project were shared with a representative of the CMC’s
administration and the Chief Nurse Executive. I hope to work with administration and
staff in implementing the APN–RN–patient rounding on a pilot unit and, on the basis of
results, further develops the model for use on other inpatient units.
Mission, Goals, and Objectives
The mission and goals of this project are to improve communication and
collaboration between the intraprofessional team of APNs and staff nurses and to improve
APN–staff nurse communication with patients.
This DNP project’s primary objective was to develop a structured learning module
pertaining to APN–RN–patient bedside rounding. The project’s long-term goals,
following completion of this project, are to implement the model and to improve
communication and collaboration between APNs, clinical nurses, and the patients cared
for by these nurses.
Chapter 3
Theoretical Underpinnings of the DNP Project
Of the several theories that have informed our understanding of holistic patient
centered care and educating adults, two theories are among the most influential: King’s
theory of goal attainment and Knowles’s theory of andragogy. In light of the theories’
relevance to developing interventions for improving health care team collaboration and
communication—the central concern of this dissertation—these two theories were
selected to serve as the theoretical underpinnings of the DNP staff education project in
support of APN–RN–patient bedside rounding. Specifically, King’s theory of goal
attainment informed the process of identifying content for the staff education module;
Knowles’s theory of andragogy informed the design of the module’s presentation to
training participants.
King’s Theory of Goal Attainment
In “Crossing the Quality Chasm: A New Health System for the 21st Century,” the
IOM (2001) describes six aims for the improvement of health care. One of the aims is to
provide patient-centered care that is respectful of and responsive to individual patients’
personal preferences, needs, and values; in patient-centered care, patients’ values play a
central role in informing clinical decision making clinical decisions. Among theoretical
frameworks that inform clinical understanding of the role of the patient in this
decisionmaking, Imogene Kings’ theory of goal attainment is seminal.
King’s theory and patient-centered health care. In King’s theory, health care
team decision-making includes a “transaction” in which the nurse and patient engage in
mutual goal setting (King, 1991, pp. 19). According to King, this transactional process of
interpersonal systems involves four steps—action, reaction, interaction, and transaction—
by which the patient and nurse (a) share information about their perceptions; (b) set goals
(through communication and interaction); and (c) explore and agree on means to achieve
these goals. To implement a true transactional process, the communication environment
must be reciprocal, and bidirectional. In this DNP project,
King’s theory—including the theory’s view of this transactional process—was applied to
inform the design of a patient-centered clinical environment. For example, to create and
maintain a patient-centered environment, APNs, clinical nurses, and patients must share
and be mutually informed about relevant considerations.
The theory of goal attainment: Assumptions and concepts. King developed her theory
of goal attainment in the 1960s. This theory describes the interpersonal dynamic
relationships between patients and their quest for goal attainment. Factors that can affect
goal attainment include roles, stressors, space, and time. In order for health care to be
optimal during the course of treatment for individual patients, both the patients and their
providers must continuously accommodate and adjust for changes in these factors.
King’s theory refers to three interacting systems: individuals (personal system),
groups (interpersonal system), and society (social system). The personal system is a
unified, complex, whole self who perceives, thinks, desires, imagines, decides, identifies
goals, and selects means to achieve them.
Assumptions. King’s framework is based on two assumptions:
▪Human beings are the focus of nursing.
▪The goals of nursing are health promotion, maintenance and restoration, care
of the sick or impaired, and care of the dying.
On the basis of these assumptions, King designed a conceptual system to explain
the organized wholes in which nurses are expected to function (see Figure 1; King, 1999).
Wholeness. King used the concept of “wholeness” to describe the broader
organization or social systems in which nurse’s function. (King, 1996, p. 61). The goal of
an interacting system is health for individuals, families, communities, and the world
(King, 1996).
Personal, interpersonal, and social systems. King’s conceptual framework is
organized into three “systems”: personal, interpersonal, and social. A personal or
individual system is essentially a single whole system. In contrast, an interpersonal
system represents the interaction of two or more individuals (i.e., small groups) in various
environments. Social systems are composed of large groups, such as educational,
governmental, or religious organizations.
Although in recent decades the quality and effectiveness of MD–RN interaction has
improved, the potential and need for further improvement in interprofessional
collaboration are substantial. To assess this need, Weaver et al. (2014) recently examined
teamwork and collaboration between staff nurses, residents, hospitalists, and oncology
physicians in oncology units at a large urban hospital. The investigators found that
physicians rated the quality of their own collaboration “very high” with other physicians
and with nurses. Physician ranked nurses’ collaboration with physicians as ranging from
87% to 100%. In stark contrast, however, nurses rated the quality of collaboration with
physicians poorly, from 35%–65%. Weaver et al. found that hierarchies persist and can
interfere with collaboration. Nurses believed that a negative attitude toward
communication as a significant obstacle to collaboration. A nurse may be reluctant to call
a physician if the nurse perceives that their relationship is not mutually supportive and
collaborative. On the other hand, physicians, having a positive perception of
collaboration, perceive difficulty contacting other providers as the main obstacle to
collaboration. Physicians who assume they have a good collaborative relationship with
nurses may not seek additional information because they (the physicians) are unaware of
potential or actual problems (Weaver et al., 2014).
Vazirani et al. (2005) surveyed registered nurses (n = 123), physicians (n = 45),
and a combined group of resident physicians and interns (n = 111) to determine whether
introduction of an APN role to the team was followed by changes in team communication
and collaboration. Physicians reported that, when an APN was part of the team, the level
of collaboration with nurses and APNs was significantly higher. Physicians also reported
that when an APN was part of the team, the team had fewer unnecessary delays and better
general communication. In the same study, the staff nurses reported significantly better
communication with APNs than with physicians (Vazirani et al., 2005). Kilpatrick (2012)
also found that communication and decision-making improve quality of care when the
participating APN is able to act within the full scope of the APN role. Among other
positive outcomes, this study reported that APN participation was associated with
decreases in length of patient stay and costs for patients treated on the intervention unit,
without an increase of readmission rates.
Vazirani’s (2005) study employed surveys to assess the degree of communication
and collaboration over two units. Physicians were surveyed immediately after they
completed a given rotation, starting at the onset of the interventions. Nurses were
surveyed biannually. The statistical analysis took into account correlation of observations
due to repeated sampling (Vazirani et al., 2005). Limitations in this study included
physician and staff nurse confusion about the role of APNs. Prior to the study, no APNs
were employed in the hospital’s internal medicine department. Chicago Medical Center
(CMC) employs approximately 200 APNs throughout all medical and surgical services,
thus role confusion is not a problem. The second limitation of this study pertained to
sample size. Physicians and nurses were not allowed to work on both the interventional
and control units; accordingly, the pool of physicians and pool of nurses available to
participate in the study was restricted. This can present problems with sample size but
also falsely promote familiarity and foster improved communications, skewing positive
results.
Although the quantity of studies is limited, it is clear that when an APN is an
integral part of the interprofessional team, the quality of communication and collaboration
increases. This DNP project specifies inclusion of the APN and staff nurse as members of
the professional team. The patient, who is also an integral part of this team, is not a
professional but is in fact the core leader of the health care team. In the decision-making
process, the patient’s understanding and input are invaluable
Communication and collaboration between APNs and staff nurses. The
majority of studies of communication and collaboration in health care contexts focused on
the nurse–physician relationship (Baggs & Ryan, 1990; Chapman, 2009;
DechairoMarino et al., 2001; Nathanson et al., 2011; Shortal et al., 1991). There have
been minimal formal studies looking at MD-APN and improved communication with
staff and its effects on patient care (Cowan et al., 2006). In nursing intraprofessional
teams, communication has been identified as the essential component of good team
functioning (Dreaschlin et al., 1999; Jones, 2005; Richardson et al., 2010). APNs possess
diverse knowledge that can facilitate understanding of collaborative practice to optimize
patient care (Crecelius, 2011). The Agency for Healthcare Research and Quality (2014)
found that when nurse practitioners are included in daily multidisciplinary rounds, the
rounding team’s communication and collaboration improve.
The increasing use of health care teams has made nursing practice more salient, in
that nurses serve as a link between team members and patients. Effective communication
between all team members is essential for successful teamwork and high-quality patient
care (Apker et al., 2006). The advance nurse practitioner function as the central link of the
health care team integrating other health care providers and patients. Good
communication among staff and between staff and patients is the cornerstone of quality
care.
Gooden and Jackson (2004) documented one of the earliest studies examining
staff nurses’ attitudes toward APNs. The investigators found that as APNs have come to
manage an increasing number of patients, staff nurses have begun to view the APNs as
leaders. Staff RNs consistently scored APNs higher than physicians in measures of
communication, respect for staff opinion, quality of care, clinical expertise, and
willingness to teach staff, patients, and patients’ families.
Moore and Prentice (2013) reported a case study that analyzed the collaborative
process between APNs and nurse in an outpatient oncology setting in Canada. The
researchers discovered four basic themes to collaboration:
▪Time that APNs spend together outside of work translates into collaboration at
work.
▪The basic skill of clinical knowledge and experience are essential ingredients
for successful collaboration.
▪Other factors that that contribute to the success of collaboration include
sharing a similar philosophy of care and mutual trust, respect and esteem.
▪Barriers to collaboration inevitably arise. Nurses are largely unaware of how
collaboration should manifest in the practice and are not trained on principles
of effective collaboration in practice.
▪Nurses and APNs attitudes are changing toward collaboration, viewing
collaboration as a means of achieving positive results.
Moore and Prentice (2013) found that intraprofessional collaboration (a) is
complex, (b) is influenced by interpersonal and professional factors, and (c) does not
occur spontaneously. Nurse must have a solid understanding of the concept of
collaboration and how to apply it in the clinical setting.
Patient-centered care. Improvement of patient satisfaction and quality of care is
directly due to the implementation of patient-centered care. Patient-centered care, the
“new normal” in today’s healthcare system, provides a mechanism for nurses to engage
patients as active participates in their care. The Institute of Medicine (IOM, 2001, p. 6)
defines patient-centered care as “healthcare that establishes a partnership among
practitioner, patients and their families to ensure that decisions reflect patient s wants,
needs and preferences” (see also Boykins, 2014; Sepucha & Ozanne, 2010). Optimal
patient participation requires a dynamic interaction between partners (patient and staff) in
terms of interpersonal interaction, therapeutic approach, focus on resources, resources,
patient opportunities to participate in and influence health care team decision making, and
patient education (Sahlsten et al., 2007). Including the patient in bedside reports or
handoffs has been reported to improve teamwork, safety and efficiency (Wildner & Ferri,
2012). This bedside practice also entails the participation of patients as partners in their
care, with the expectation that their participation will lead to improved care, better
outcomes, improved adherence to treatment and medication regimen and greater
satisfaction with care. Barriers to implementation of patient-centered care and bedside
rounding include time and resource requirements; the potential for patients to feel
confused, upset, or dehumanized as a result of hearing clinical explanations; and the
potential for breach of patient confidentiality (McMurry et. al 2011). In addition, when
presenting sensitive or confidential information, some nurses may feel uncomfortable, or
be inhibited by a lack experience—especially in the presence of patients’ family members
or relatives are present. O’Connell, Macdonald, and Kelly (2008) found that viewed
handoffs as being too time consuming, and ineffective, or efficient. The investigators
recommended that a handoff guideline or information template should be developed to
promote and facilitate the reporting of objective relevant information.
Patient satisfaction and its effects on quality of care. As a subjective
phenomenon, “patient satisfaction” is difficult to define. The self-reported determination
of patient satisfaction is a personal evaluation of health care services and of the providers
of that care (Ware et al., 1983); patients’ attitudes and expectations regarding care greatly
affect their sense of satisfaction. Because satisfaction ratings are relative, subjective, and
not directly observable, attempting to meaningfully quantify patients’ personal evaluation
of care is highly problematic (Ware et al., 1983).
The challenges inherent in measuring patient satisfaction have ramifications for
policy and practice. For example, in 2012, the Center for Medicare and Medicaid
Services (CMS) began to implement a reimbursement system that adjusts payment rates
based on patient satisfaction scores (Lyu et al., 2013). Patient satisfaction is a key
determinant of quality of care and an important component of the pay-for-performance
metrics instituted by CMS. Beginning in 2012, CMS implemented value-based incentive
payments to acute-care hospitals based in part on results of satisfaction surveys from
patients discharged on or after October 1, 2012. The patient’s perception of quality is
significant determinant of the provider’s federal reimbursement. Patients now make
decisions based on their perceptions of the quality of and satisfaction with health care
providers (Bowers, Swan, & Koehler, 1994).
A study conducted by Fenton, Jerant, Bertakis, and Franks at the University of
California–Davis examined mortality rate in relation to patient satisfaction (N = 51,946);
the researchers’ analysis adjusted for a number of factors (i.e., demographics, health
status and chronic disease burden, Year 1 utilization and expenditures, availability of a
usual source of care, and insurance status). The investigators were surprised to find that,
in comparison with the mortality rate of patients in the lowest satisfaction quartile, the
mortality rate of patients in the highest satisfaction quartile was 26% higher (adjusted
hazard ratio, 1.26; 95% CI [1.05, 1.53]). This perhaps counterintuitive finding raises the
question of whether current satisfaction measures are in fact good indicators of health
care quality (Fenton et al., 2012). The researchers concluded that the connection between
patient satisfaction and health care outcomes is yet unclear.
Practitioners need to understand that ineffective communication can result in poor
outcomes. Improved communication not only results in better health outcomes, but also
may positivity impact patient satisfaction. For patients who want to be involved in their
care and who understand what is occurring during care, improved communication may
ultimately lead to greater patient satisfaction. The inclusion of APNs in the care team has
been reported to improve communication and the efficiency of care (McCauley, Bixby, &
Naylor, 2006).
Evidence-based practice. Evidence-based practice (EBP) is at the forefront of
change in today’s health care environment. EBP is the practice of using documented
evidence as a guide to problem solving approach to clinical decision making. To
implement EBP, one must “locate, critique, synthesize, translate, and evaluate evidence”
(Drenning, 2006, p.299). This includes the dissemination of information during the
implementation phase of practice. Although ostensibly EBP is the standard of nursing
practice, implementation of EBP is not always easy (Krom & Bautista, 2010). Barriers to
EBP implementation include (a) lack of requisite knowledge and skills on the part of
clinicians, (b) perception that EBP is time consuming, (b) perception that EBP is
burdensome, and (d) lack of management support at the organizational level (Melnyk &
Fineout-Overholt, 2012). Among clinical staff members, APNs, nurse educators, and
DNPs—who understand translational research—are uniquely qualified to fulfill their
responsibility to fulfill the mandate to implement evidence –based changes in practice.
These organizational change agents must persuasively teach the EBP process to staff
nurses and thereby transform the organizational culture—from a culture in which change
is resisted to a culture in which evidence-based improvements in practice are welcomed.
To achieve this transformation in organizational culture, APNs, nurse educators, and
DNPs must employ an interactive approach.
APNs serve as both leaders and knowledge resources for helping nursing staff to
ground care in current evidence. In a study conducted by Mahanes, Quatrara, and Shaw
(2013) at the University of Virginia, the researchers implemented APN-led nursing
rounds. Although the specific effects of the APN-led nursing rounds were impossible to
isolate, Mahanes and her colleagues were able to determine that rates of blood stream
infections, catheter-associated urinary tract infections, hospital-acquired pressure ulcers,
and ventilator-associated pneumonia and falls all declined. Similarly, in study that a
analyzed the effectiveness of an APN-managed heart failure program, Dahl and Penque
(2002) reported reduced 90-day readmission rates, fewer in-patient hospital days, lower
re-admission charges, and lower overall charges for health care services.
APNs have demonstrated implementation of EBP practices, better working
relationship with staff nurses, and improved patient-centered care with cost savings. The
development of an intraprofessional APN–staff nurse team to conduct bedside rounding
should improve patient care, increase communication and collaboration, and improve
patient satisfaction.
The daily goals reminder sheet. The need to develop clear team communication
has led to the development and institution of daily goal sheets. Studies in ICUs have
demonstrated that the use of daily goal sheets can result in nurses’ and physicians’ having
better understanding of patient care goals and in decreased ICU length of stay (Agarwal et
al., 2008; Narasimhan et al., 2006; Pronovost et al., 2003). A study conducted by
Phipps and Thomas (2007) examined the use of a daily goals sheet in the ICU at The
University of Pennsylvania’s Hershey Children’s Hospital. The researchers found that
85% of nurses felt the use of the goals sheets improved communications between
physicians and nurses and improved communication between nurses working on different
shifts. Phipps and Thomas also reported that 95% of the nursing staff felt that the extra
expenditure of time spent in completing the daily goals sheet was worthwhile. In another
study, the Beth Israel Medical Center in New York instituted use of a worksheet that was
posted at bedside after completion. Narasimham and colleagues (2006) found that pre and
post scores for understanding patient goals and communication improved significantly,
and that this improvement was sustained over a 9-month period. Furthermore, after
completion of the study, most of the practitioners requested that the use of the worksheet
be continued. In the DNP project, instituting a daily goals reminder worksheet associated
with APN–RN–patient bedside rounding enhanced communication between APNs, staff
nurses, and patients.
Needs Assessment and Description of the Project
Population identification. In this DNP project, the population identified for
selection and participation comprises APNs who have prior knowledge of and experience
with APN–RN–patient bedside rounding.
Identification of the project sponsor and key stakeholders. This DNP project
has no sponsors. Key stakeholders include the student investigator and ultimately the
APNs and RNs who will participate in the learning module.
Assessment of available resources. No monetary resources were available for
this project. As project investigator, I was responsible for the development of the learning
module. The project had no public advertisement. APNs were approached through the
hospital’s standardized email by the student researcher (Appendix B).
Team selection. The project investigator, served as the team for this project, with
consultation from the DNP project committee members.
Scope of the project. The project entailed only the development of the 1-hour
learning module. Further plans for implementation will be considered at some point in
the future. The module’s topics included (a) the requirement for close communication and
collaboration between team members to assure seamless, high-quality health care, (b) the
definition of APN–RN rounds, (c) the schedule and length of rounds, (d) the personnel
composition of rounding teams, (e) topics of discussion during the rounds, and (f) the use
of a daily goal reminder sheet to ensure the consistency of all elements of the patient's
treatment plan and goals.
As project investigator, I used the literature as a basis for creating the written
learning module. After completing the module and obtaining University of Nevada Las
Vegas Institutional Review Board approval, the learning module was sent to three APNs
in the hospital for review and feedback; all of these APNs had prior experience in
working with APN–RN rounds at other facilities. In addition, to assess the learning
module’s effectiveness, I developed an evaluation form to be completed by participating
APNs and RNs following their completion of the learning module.
All results of this project were shared with a representative of the CMC’s
administration and the Chief Nurse Executive. I hope to work with administration and
staff in implementing the APN–RN–patient rounding on a pilot unit and, on the basis of
results, further develops the model for use on other inpatient units.
Mission, Goals, and Objectives
The mission and goals of this project are to improve communication and
collaboration between the intraprofessional team of APNs and staff nurses and to improve
APN–staff nurse communication with patients.
This DNP project’s primary objective was to develop a structured learning module
pertaining to APN–RN–patient bedside rounding. The project’s long-term goals,
following completion of this project, are to implement the model and to improve
communication and collaboration between APNs, clinical nurses, and the patients cared
for by these nurses.
Chapter 3
Theoretical Underpinnings of the DNP Project
Of the several theories that have informed our understanding of holistic patient
centered care and educating adults, two theories are among the most influential: King’s
theory of goal attainment and Knowles’s theory of andragogy. In light of the theories’
relevance to developing interventions for improving health care team collaboration and
communication—the central concern of this dissertation—these two theories were
selected to serve as the theoretical underpinnings of the DNP staff education project in
support of APN–RN–patient bedside rounding. Specifically, King’s theory of goal
attainment informed the process of identifying content for the staff education module;
Knowles’s theory of andragogy informed the design of the module’s presentation to
training participants.
King’s Theory of Goal Attainment
In “Crossing the Quality Chasm: A New Health System for the 21st Century,” the
IOM (2001) describes six aims for the improvement of health care. One of the aims is to
provide patient-centered care that is respectful of and responsive to individual patients’
personal preferences, needs, and values; in patient-centered care, patients’ values play a
central role in informing clinical decision making clinical decisions. Among theoretical
frameworks that inform clinical understanding of the role of the patient in this
decisionmaking, Imogene Kings’ theory of goal attainment is seminal.
King’s theory and patient-centered health care. In King’s theory, health care
team decision-making includes a “transaction” in which the nurse and patient engage in
mutual goal setting (King, 1991, pp. 19). According to King, this transactional process of
interpersonal systems involves four steps—action, reaction, interaction, and transaction—
by which the patient and nurse (a) share information about their perceptions; (b) set goals
(through communication and interaction); and (c) explore and agree on means to achieve
these goals. To implement a true transactional process, the communication environment
must be reciprocal, and bidirectional. In this DNP project,
King’s theory—including the theory’s view of this transactional process—was applied to
inform the design of a patient-centered clinical environment. For example, to create and
maintain a patient-centered environment, APNs, clinical nurses, and patients must share
and be mutually informed about relevant considerations.
The theory of goal attainment: Assumptions and concepts. King developed her theory
of goal attainment in the 1960s. This theory describes the interpersonal dynamic
relationships between patients and their quest for goal attainment. Factors that can affect
goal attainment include roles, stressors, space, and time. In order for health care to be
optimal during the course of treatment for individual patients, both the patients and their
providers must continuously accommodate and adjust for changes in these factors.
King’s theory refers to three interacting systems: individuals (personal system),
groups (interpersonal system), and society (social system). The personal system is a
unified, complex, whole self who perceives, thinks, desires, imagines, decides, identifies
goals, and selects means to achieve them.
Assumptions. King’s framework is based on two assumptions:
▪Human beings are the focus of nursing.
▪The goals of nursing are health promotion, maintenance and restoration, care
of the sick or impaired, and care of the dying.
On the basis of these assumptions, King designed a conceptual system to explain
the organized wholes in which nurses are expected to function (see Figure 1; King, 1999).
Wholeness. King used the concept of “wholeness” to describe the broader
organization or social systems in which nurse’s function. (King, 1996, p. 61). The goal of
an interacting system is health for individuals, families, communities, and the world
(King, 1996).
Personal, interpersonal, and social systems. King’s conceptual framework is
organized into three “systems”: personal, interpersonal, and social. A personal or
individual system is essentially a single whole system. In contrast, an interpersonal
system represents the interaction of two or more individuals (i.e., small groups) in various
environments. Social systems are composed of large groups, such as educational,
governmental, or religious organizations.
Although in recent decades the quality and effectiveness of MD–RN interaction has
improved, the potential and need for further improvement in interprofessional
collaboration are substantial. To assess this need, Weaver et al. (2014) recently examined
teamwork and collaboration between staff nurses, residents, hospitalists, and oncology
physicians in oncology units at a large urban hospital. The investigators found that
physicians rated the quality of their own collaboration “very high” with other physicians
and with nurses. Physician ranked nurses’ collaboration with physicians as ranging from
87% to 100%. In stark contrast, however, nurses rated the quality of collaboration with
physicians poorly, from 35%–65%. Weaver et al. found that hierarchies persist and can
interfere with collaboration. Nurses believed that a negative attitude toward
communication as a significant obstacle to collaboration. A nurse may be reluctant to call
a physician if the nurse perceives that their relationship is not mutually supportive and
collaborative. On the other hand, physicians, having a positive perception of
collaboration, perceive difficulty contacting other providers as the main obstacle to
collaboration. Physicians who assume they have a good collaborative relationship with
nurses may not seek additional information because they (the physicians) are unaware of
potential or actual problems (Weaver et al., 2014).
Vazirani et al. (2005) surveyed registered nurses (n = 123), physicians (n = 45),
and a combined group of resident physicians and interns (n = 111) to determine whether
introduction of an APN role to the team was followed by changes in team communication
and collaboration. Physicians reported that, when an APN was part of the team, the level
of collaboration with nurses and APNs was significantly higher. Physicians also reported
that when an APN was part of the team, the team had fewer unnecessary delays and better
general communication. In the same study, the staff nurses reported significantly better
communication with APNs than with physicians (Vazirani et al., 2005). Kilpatrick (2012)
also found that communication and decision-making improve quality of care when the
participating APN is able to act within the full scope of the APN role. Among other
positive outcomes, this study reported that APN participation was associated with
decreases in length of patient stay and costs for patients treated on the intervention unit,
without an increase of readmission rates.
Vazirani’s (2005) study employed surveys to assess the degree of communication
and collaboration over two units. Physicians were surveyed immediately after they
completed a given rotation, starting at the onset of the interventions. Nurses were
surveyed biannually. The statistical analysis took into account correlation of observations
due to repeated sampling (Vazirani et al., 2005). Limitations in this study included
physician and staff nurse confusion about the role of APNs. Prior to the study, no APNs
were employed in the hospital’s internal medicine department. Chicago Medical Center
(CMC) employs approximately 200 APNs throughout all medical and surgical services,
thus role confusion is not a problem. The second limitation of this study pertained to
sample size. Physicians and nurses were not allowed to work on both the interventional
and control units; accordingly, the pool of physicians and pool of nurses available to
participate in the study was restricted. This can present problems with sample size but
also falsely promote familiarity and foster improved communications, skewing positive
results.
Although the quantity of studies is limited, it is clear that when an APN is an
integral part of the interprofessional team, the quality of communication and collaboration
increases. This DNP project specifies inclusion of the APN and staff nurse as members of
the professional team. The patient, who is also an integral part of this team, is not a
professional but is in fact the core leader of the health care team. In the decision-making
process, the patient’s understanding and input are invaluable
Communication and collaboration between APNs and staff nurses. The
majority of studies of communication and collaboration in health care contexts focused on
the nurse–physician relationship (Baggs & Ryan, 1990; Chapman, 2009;
DechairoMarino et al., 2001; Nathanson et al., 2011; Shortal et al., 1991). There have
been minimal formal studies looking at MD-APN and improved communication with
staff and its effects on patient care (Cowan et al., 2006). In nursing intraprofessional
teams, communication has been identified as the essential component of good team
functioning (Dreaschlin et al., 1999; Jones, 2005; Richardson et al., 2010). APNs possess
diverse knowledge that can facilitate understanding of collaborative practice to optimize
patient care (Crecelius, 2011). The Agency for Healthcare Research and Quality (2014)
found that when nurse practitioners are included in daily multidisciplinary rounds, the
rounding team’s communication and collaboration improve.
The increasing use of health care teams has made nursing practice more salient, in
that nurses serve as a link between team members and patients. Effective communication
between all team members is essential for successful teamwork and high-quality patient
care (Apker et al., 2006). The advance nurse practitioner function as the central link of the
health care team integrating other health care providers and patients. Good
communication among staff and between staff and patients is the cornerstone of quality
care.
Gooden and Jackson (2004) documented one of the earliest studies examining
staff nurses’ attitudes toward APNs. The investigators found that as APNs have come to
manage an increasing number of patients, staff nurses have begun to view the APNs as
leaders. Staff RNs consistently scored APNs higher than physicians in measures of
communication, respect for staff opinion, quality of care, clinical expertise, and
willingness to teach staff, patients, and patients’ families.
Moore and Prentice (2013) reported a case study that analyzed the collaborative
process between APNs and nurse in an outpatient oncology setting in Canada. The
researchers discovered four basic themes to collaboration:
▪Time that APNs spend together outside of work translates into collaboration at
work.
▪The basic skill of clinical knowledge and experience are essential ingredients
for successful collaboration.
▪Other factors that that contribute to the success of collaboration include
sharing a similar philosophy of care and mutual trust, respect and esteem.
▪Barriers to collaboration inevitably arise. Nurses are largely unaware of how
collaboration should manifest in the practice and are not trained on principles
of effective collaboration in practice.
▪Nurses and APNs attitudes are changing toward collaboration, viewing
collaboration as a means of achieving positive results.
Moore and Prentice (2013) found that intraprofessional collaboration (a) is
complex, (b) is influenced by interpersonal and professional factors, and (c) does not
occur spontaneously. Nurse must have a solid understanding of the concept of
collaboration and how to apply it in the clinical setting.
Patient-centered care. Improvement of patient satisfaction and quality of care is
directly due to the implementation of patient-centered care. Patient-centered care, the
“new normal” in today’s healthcare system, provides a mechanism for nurses to engage
patients as active participates in their care. The Institute of Medicine (IOM, 2001, p. 6)
defines patient-centered care as “healthcare that establishes a partnership among
practitioner, patients and their families to ensure that decisions reflect patient s wants,
needs and preferences” (see also Boykins, 2014; Sepucha & Ozanne, 2010). Optimal
patient participation requires a dynamic interaction between partners (patient and staff) in
terms of interpersonal interaction, therapeutic approach, focus on resources, resources,
patient opportunities to participate in and influence health care team decision making, and
patient education (Sahlsten et al., 2007). Including the patient in bedside reports or
handoffs has been reported to improve teamwork, safety and efficiency (Wildner & Ferri,
2012). This bedside practice also entails the participation of patients as partners in their
care, with the expectation that their participation will lead to improved care, better
outcomes, improved adherence to treatment and medication regimen and greater
satisfaction with care. Barriers to implementation of patient-centered care and bedside
rounding include time and resource requirements; the potential for patients to feel
confused, upset, or dehumanized as a result of hearing clinical explanations; and the
potential for breach of patient confidentiality (McMurry et. al 2011). In addition, when
presenting sensitive or confidential information, some nurses may feel uncomfortable, or
be inhibited by a lack experience—especially in the presence of patients’ family members
or relatives are present. O’Connell, Macdonald, and Kelly (2008) found that viewed
handoffs as being too time consuming, and ineffective, or efficient. The investigators
recommended that a handoff guideline or information template should be developed to
promote and facilitate the reporting of objective relevant information.
Patient satisfaction and its effects on quality of care. As a subjective
phenomenon, “patient satisfaction” is difficult to define. The self-reported determination
of patient satisfaction is a personal evaluation of health care services and of the providers
of that care (Ware et al., 1983); patients’ attitudes and expectations regarding care greatly
affect their sense of satisfaction. Because satisfaction ratings are relative, subjective, and
not directly observable, attempting to meaningfully quantify patients’ personal evaluation
of care is highly problematic (Ware et al., 1983).
The challenges inherent in measuring patient satisfaction have ramifications for
policy and practice. For example, in 2012, the Center for Medicare and Medicaid
Services (CMS) began to implement a reimbursement system that adjusts payment rates
based on patient satisfaction scores (Lyu et al., 2013). Patient satisfaction is a key
determinant of quality of care and an important component of the pay-for-performance
metrics instituted by CMS. Beginning in 2012, CMS implemented value-based incentive
payments to acute-care hospitals based in part on results of satisfaction surveys from
patients discharged on or after October 1, 2012. The patient’s perception of quality is
significant determinant of the provider’s federal reimbursement. Patients now make
decisions based on their perceptions of the quality of and satisfaction with health care
providers (Bowers, Swan, & Koehler, 1994).
A study conducted by Fenton, Jerant, Bertakis, and Franks at the University of
California–Davis examined mortality rate in relation to patient satisfaction (N = 51,946);
the researchers’ analysis adjusted for a number of factors (i.e., demographics, health
status and chronic disease burden, Year 1 utilization and expenditures, availability of a
usual source of care, and insurance status). The investigators were surprised to find that,
in comparison with the mortality rate of patients in the lowest satisfaction quartile, the
mortality rate of patients in the highest satisfaction quartile was 26% higher (adjusted
hazard ratio, 1.26; 95% CI [1.05, 1.53]). This perhaps counterintuitive finding raises the
question of whether current satisfaction measures are in fact good indicators of health
care quality (Fenton et al., 2012). The researchers concluded that the connection between
patient satisfaction and health care outcomes is yet unclear.
Practitioners need to understand that ineffective communication can result in poor
outcomes. Improved communication not only results in better health outcomes, but also
may positivity impact patient satisfaction. For patients who want to be involved in their
care and who understand what is occurring during care, improved communication may
ultimately lead to greater patient satisfaction. The inclusion of APNs in the care team has
been reported to improve communication and the efficiency of care (McCauley, Bixby, &
Naylor, 2006).
Evidence-based practice. Evidence-based practice (EBP) is at the forefront of
change in today’s health care environment. EBP is the practice of using documented
evidence as a guide to problem solving approach to clinical decision making. To
implement EBP, one must “locate, critique, synthesize, translate, and evaluate evidence”
(Drenning, 2006, p.299). This includes the dissemination of information during the
implementation phase of practice. Although ostensibly EBP is the standard of nursing
practice, implementation of EBP is not always easy (Krom & Bautista, 2010). Barriers to
EBP implementation include (a) lack of requisite knowledge and skills on the part of
clinicians, (b) perception that EBP is time consuming, (b) perception that EBP is
burdensome, and (d) lack of management support at the organizational level (Melnyk &
Fineout-Overholt, 2012). Among clinical staff members, APNs, nurse educators, and
DNPs—who understand translational research—are uniquely qualified to fulfill their
responsibility to fulfill the mandate to implement evidence –based changes in practice.
These organizational change agents must persuasively teach the EBP process to staff
nurses and thereby transform the organizational culture—from a culture in which change
is resisted to a culture in which evidence-based improvements in practice are welcomed.
To achieve this transformation in organizational culture, APNs, nurse educators, and
DNPs must employ an interactive approach.
APNs serve as both leaders and knowledge resources for helping nursing staff to
ground care in current evidence. In a study conducted by Mahanes, Quatrara, and Shaw
(2013) at the University of Virginia, the researchers implemented APN-led nursing
rounds. Although the specific effects of the APN-led nursing rounds were impossible to
isolate, Mahanes and her colleagues were able to determine that rates of blood stream
infections, catheter-associated urinary tract infections, hospital-acquired pressure ulcers,
and ventilator-associated pneumonia and falls all declined. Similarly, in study that a
analyzed the effectiveness of an APN-managed heart failure program, Dahl and Penque
(2002) reported reduced 90-day readmission rates, fewer in-patient hospital days, lower
re-admission charges, and lower overall charges for health care services.
APNs have demonstrated implementation of EBP practices, better working
relationship with staff nurses, and improved patient-centered care with cost savings. The
development of an intraprofessional APN–staff nurse team to conduct bedside rounding
should improve patient care, increase communication and collaboration, and improve
patient satisfaction.
The daily goals reminder sheet. The need to develop clear team communication
has led to the development and institution of daily goal sheets. Studies in ICUs have
demonstrated that the use of daily goal sheets can result in nurses’ and physicians’ having
better understanding of patient care goals and in decreased ICU length of stay (Agarwal et
al., 2008; Narasimhan et al., 2006; Pronovost et al., 2003). A study conducted by
Phipps and Thomas (2007) examined the use of a daily goals sheet in the ICU at The
University of Pennsylvania’s Hershey Children’s Hospital. The researchers found that
85% of nurses felt the use of the goals sheets improved communications between
physicians and nurses and improved communication between nurses working on different
shifts. Phipps and Thomas also reported that 95% of the nursing staff felt that the extra
expenditure of time spent in completing the daily goals sheet was worthwhile. In another
study, the Beth Israel Medical Center in New York instituted use of a worksheet that was
posted at bedside after completion. Narasimham and colleagues (2006) found that pre and
post scores for understanding patient goals and communication improved significantly,
and that this improvement was sustained over a 9-month period. Furthermore, after
completion of the study, most of the practitioners requested that the use of the worksheet
be continued. In the DNP project, instituting a daily goals reminder worksheet associated
with APN–RN–patient bedside rounding enhanced communication between APNs, staff
nurses, and patients.
Needs Assessment and Description of the Project
Population identification. In this DNP project, the population identified for
selection and participation comprises APNs who have prior knowledge of and experience
with APN–RN–patient bedside rounding.
Identification of the project sponsor and key stakeholders. This DNP project
has no sponsors. Key stakeholders include the student investigator and ultimately the
APNs and RNs who will participate in the learning module.
Assessment of available resources. No monetary resources were available for
this project. As project investigator, I was responsible for the development of the learning
module. The project had no public advertisement. APNs were approached through the
hospital’s standardized email by the student researcher (Appendix B).
Team selection. The project investigator, served as the team for this project, with
consultation from the DNP project committee members.
Scope of the project. The project entailed only the development of the 1-hour
learning module. Further plans for implementation will be considered at some point in
the future. The module’s topics included (a) the requirement for close communication and
collaboration between team members to assure seamless, high-quality health care, (b) the
definition of APN–RN rounds, (c) the schedule and length of rounds, (d) the personnel
composition of rounding teams, (e) topics of discussion during the rounds, and (f) the use
of a daily goal reminder sheet to ensure the consistency of all elements of the patient's
treatment plan and goals.
As project investigator, I used the literature as a basis for creating the written
learning module. After completing the module and obtaining University of Nevada Las
Vegas Institutional Review Board approval, the learning module was sent to three APNs
in the hospital for review and feedback; all of these APNs had prior experience in
working with APN–RN rounds at other facilities. In addition, to assess the learning
module’s effectiveness, I developed an evaluation form to be completed by participating
APNs and RNs following their completion of the learning module.
All results of this project were shared with a representative of the CMC’s
administration and the Chief Nurse Executive. I hope to work with administration and
staff in implementing the APN–RN–patient rounding on a pilot unit and, on the basis of
results, further develops the model for use on other inpatient units.
Mission, Goals, and Objectives
The mission and goals of this project are to improve communication and
collaboration between the intraprofessional team of APNs and staff nurses and to improve
APN–staff nurse communication with patients.
This DNP project’s primary objective was to develop a structured learning module
pertaining to APN–RN–patient bedside rounding. The project’s long-term goals,
following completion of this project, are to implement the model and to improve
communication and collaboration between APNs, clinical nurses, and the patients cared
for by these nurses.
Chapter 3
Theoretical Underpinnings of the DNP Project
Of the several theories that have informed our understanding of holistic patient
centered care and educating adults, two theories are among the most influential: King’s
theory of goal attainment and Knowles’s theory of andragogy. In light of the theories’
relevance to developing interventions for improving health care team collaboration and
communication—the central concern of this dissertation—these two theories were
selected to serve as the theoretical underpinnings of the DNP staff education project in
support of APN–RN–patient bedside rounding. Specifically, King’s theory of goal
attainment informed the process of identifying content for the staff education module;
Knowles’s theory of andragogy informed the design of the module’s presentation to
training participants.
King’s Theory of Goal Attainment
In “Crossing the Quality Chasm: A New Health System for the 21st Century,” the
IOM (2001) describes six aims for the improvement of health care. One of the aims is to
provide patient-centered care that is respectful of and responsive to individual patients’
personal preferences, needs, and values; in patient-centered care, patients’ values play a
central role in informing clinical decision making clinical decisions. Among theoretical
frameworks that inform clinical understanding of the role of the patient in this
decisionmaking, Imogene Kings’ theory of goal attainment is seminal.
King’s theory and patient-centered health care. In King’s theory, health care
team decision-making includes a “transaction” in which the nurse and patient engage in
mutual goal setting (King, 1991, pp. 19). According to King, this transactional process of
interpersonal systems involves four steps—action, reaction, interaction, and transaction—
by which the patient and nurse (a) share information about their perceptions; (b) set goals
(through communication and interaction); and (c) explore and agree on means to achieve
these goals. To implement a true transactional process, the communication environment
must be reciprocal, and bidirectional. In this DNP project,
King’s theory—including the theory’s view of this transactional process—was applied to
inform the design of a patient-centered clinical environment. For example, to create and
maintain a patient-centered environment, APNs, clinical nurses, and patients must share
and be mutually informed about relevant considerations.
The theory of goal attainment: Assumptions and concepts. King developed her theory
of goal attainment in the 1960s. This theory describes the interpersonal dynamic
relationships between patients and their quest for goal attainment. Factors that can affect
goal attainment include roles, stressors, space, and time. In order for health care to be
optimal during the course of treatment for individual patients, both the patients and their
providers must continuously accommodate and adjust for changes in these factors.
King’s theory refers to three interacting systems: individuals (personal system),
groups (interpersonal system), and society (social system). The personal system is a
unified, complex, whole self who perceives, thinks, desires, imagines, decides, identifies
goals, and selects means to achieve them.
Assumptions. King’s framework is based on two assumptions:
▪Human beings are the focus of nursing.
▪The goals of nursing are health promotion, maintenance and restoration, care
of the sick or impaired, and care of the dying.
On the basis of these assumptions, King designed a conceptual system to explain
the organized wholes in which nurses are expected to function (see Figure 1; King, 1999).
Wholeness. King used the concept of “wholeness” to describe the broader
organization or social systems in which nurse’s function. (King, 1996, p. 61). The goal of
an interacting system is health for individuals, families, communities, and the world
(King, 1996).
Personal, interpersonal, and social systems. King’s conceptual framework is
organized into three “systems”: personal, interpersonal, and social. A personal or
individual system is essentially a single whole system. In contrast, an interpersonal
system represents the interaction of two or more individuals (i.e., small groups) in various
environments. Social systems are composed of large groups, such as educational,
governmental, or religious organizations.
Although in recent decades the quality and effectiveness of MD–RN interaction has
improved, the potential and need for further improvement in interprofessional
collaboration are substantial. To assess this need, Weaver et al. (2014) recently examined
teamwork and collaboration between staff nurses, residents, hospitalists, and oncology
physicians in oncology units at a large urban hospital. The investigators found that
physicians rated the quality of their own collaboration “very high” with other physicians
and with nurses. Physician ranked nurses’ collaboration with physicians as ranging from
87% to 100%. In stark contrast, however, nurses rated the quality of collaboration with
physicians poorly, from 35%–65%. Weaver et al. found that hierarchies persist and can
interfere with collaboration. Nurses believed that a negative attitude toward
communication as a significant obstacle to collaboration. A nurse may be reluctant to call
a physician if the nurse perceives that their relationship is not mutually supportive and
collaborative. On the other hand, physicians, having a positive perception of
collaboration, perceive difficulty contacting other providers as the main obstacle to
collaboration. Physicians who assume they have a good collaborative relationship with
nurses may not seek additional information because they (the physicians) are unaware of
potential or actual problems (Weaver et al., 2014).
Vazirani et al. (2005) surveyed registered nurses (n = 123), physicians (n = 45),
and a combined group of resident physicians and interns (n = 111) to determine whether
introduction of an APN role to the team was followed by changes in team communication
and collaboration. Physicians reported that, when an APN was part of the team, the level
of collaboration with nurses and APNs was significantly higher. Physicians also reported
that when an APN was part of the team, the team had fewer unnecessary delays and better
general communication. In the same study, the staff nurses reported significantly better
communication with APNs than with physicians (Vazirani et al., 2005). Kilpatrick (2012)
also found that communication and decision-making improve quality of care when the
participating APN is able to act within the full scope of the APN role. Among other
positive outcomes, this study reported that APN participation was associated with
decreases in length of patient stay and costs for patients treated on the intervention unit,
without an increase of readmission rates.
Vazirani’s (2005) study employed surveys to assess the degree of communication
and collaboration over two units. Physicians were surveyed immediately after they
completed a given rotation, starting at the onset of the interventions. Nurses were
surveyed biannually. The statistical analysis took into account correlation of observations
due to repeated sampling (Vazirani et al., 2005). Limitations in this study included
physician and staff nurse confusion about the role of APNs. Prior to the study, no APNs
were employed in the hospital’s internal medicine department. Chicago Medical Center
(CMC) employs approximately 200 APNs throughout all medical and surgical services,
thus role confusion is not a problem. The second limitation of this study pertained to
sample size. Physicians and nurses were not allowed to work on both the interventional
and control units; accordingly, the pool of physicians and pool of nurses available to
participate in the study was restricted. This can present problems with sample size but
also falsely promote familiarity and foster improved communications, skewing positive
results.
Although the quantity of studies is limited, it is clear that when an APN is an
integral part of the interprofessional team, the quality of communication and collaboration
increases. This DNP project specifies inclusion of the APN and staff nurse as members of
the professional team. The patient, who is also an integral part of this team, is not a
professional but is in fact the core leader of the health care team. In the decision-making
process, the patient’s understanding and input are invaluable
Communication and collaboration between APNs and staff nurses. The
majority of studies of communication and collaboration in health care contexts focused on
the nurse–physician relationship (Baggs & Ryan, 1990; Chapman, 2009;
DechairoMarino et al., 2001; Nathanson et al., 2011; Shortal et al., 1991). There have
been minimal formal studies looking at MD-APN and improved communication with
staff and its effects on patient care (Cowan et al., 2006). In nursing intraprofessional
teams, communication has been identified as the essential component of good team
functioning (Dreaschlin et al., 1999; Jones, 2005; Richardson et al., 2010). APNs possess
diverse knowledge that can facilitate understanding of collaborative practice to optimize
patient care (Crecelius, 2011). The Agency for Healthcare Research and Quality (2014)
found that when nurse practitioners are included in daily multidisciplinary rounds, the
rounding team’s communication and collaboration improve.
The increasing use of health care teams has made nursing practice more salient, in
that nurses serve as a link between team members and patients. Effective communication
between all team members is essential for successful teamwork and high-quality patient
care (Apker et al., 2006). The advance nurse practitioner function as the central link of the
health care team integrating other health care providers and patients. Good
communication among staff and between staff and patients is the cornerstone of quality
care.
Gooden and Jackson (2004) documented one of the earliest studies examining
staff nurses’ attitudes toward APNs. The investigators found that as APNs have come to
manage an increasing number of patients, staff nurses have begun to view the APNs as
leaders. Staff RNs consistently scored APNs higher than physicians in measures of
communication, respect for staff opinion, quality of care, clinical expertise, and
willingness to teach staff, patients, and patients’ families.
Moore and Prentice (2013) reported a case study that analyzed the collaborative
process between APNs and nurse in an outpatient oncology setting in Canada. The
researchers discovered four basic themes to collaboration:
▪Time that APNs spend together outside of work translates into collaboration at
work.
▪The basic skill of clinical knowledge and experience are essential ingredients
for successful collaboration.
▪Other factors that that contribute to the success of collaboration include
sharing a similar philosophy of care and mutual trust, respect and esteem.
▪Barriers to collaboration inevitably arise. Nurses are largely unaware of how
collaboration should manifest in the practice and are not trained on principles
of effective collaboration in practice.
▪Nurses and APNs attitudes are changing toward collaboration, viewing
collaboration as a means of achieving positive results.
Moore and Prentice (2013) found that intraprofessional collaboration (a) is
complex, (b) is influenced by interpersonal and professional factors, and (c) does not
occur spontaneously. Nurse must have a solid understanding of the concept of
collaboration and how to apply it in the clinical setting.
Patient-centered care. Improvement of patient satisfaction and quality of care is
directly due to the implementation of patient-centered care. Patient-centered care, the
“new normal” in today’s healthcare system, provides a mechanism for nurses to engage
patients as active participates in their care. The Institute of Medicine (IOM, 2001, p. 6)
defines patient-centered care as “healthcare that establishes a partnership among
practitioner, patients and their families to ensure that decisions reflect patient s wants,
needs and preferences” (see also Boykins, 2014; Sepucha & Ozanne, 2010). Optimal
patient participation requires a dynamic interaction between partners (patient and staff) in
terms of interpersonal interaction, therapeutic approach, focus on resources, resources,
patient opportunities to participate in and influence health care team decision making, and
patient education (Sahlsten et al., 2007). Including the patient in bedside reports or
handoffs has been reported to improve teamwork, safety and efficiency (Wildner & Ferri,
2012). This bedside practice also entails the participation of patients as partners in their
care, with the expectation that their participation will lead to improved care, better
outcomes, improved adherence to treatment and medication regimen and greater
satisfaction with care. Barriers to implementation of patient-centered care and bedside
rounding include time and resource requirements; the potential for patients to feel
confused, upset, or dehumanized as a result of hearing clinical explanations; and the
potential for breach of patient confidentiality (McMurry et. al 2011). In addition, when
presenting sensitive or confidential information, some nurses may feel uncomfortable, or
be inhibited by a lack experience—especially in the presence of patients’ family members
or relatives are present. O’Connell, Macdonald, and Kelly (2008) found that viewed
handoffs as being too time consuming, and ineffective, or efficient. The investigators
recommended that a handoff guideline or information template should be developed to
promote and facilitate the reporting of objective relevant information.
Patient satisfaction and its effects on quality of care. As a subjective
phenomenon, “patient satisfaction” is difficult to define. The self-reported determination
of patient satisfaction is a personal evaluation of health care services and of the providers
of that care (Ware et al., 1983); patients’ attitudes and expectations regarding care greatly
affect their sense of satisfaction. Because satisfaction ratings are relative, subjective, and
not directly observable, attempting to meaningfully quantify patients’ personal evaluation
of care is highly problematic (Ware et al., 1983).
The challenges inherent in measuring patient satisfaction have ramifications for
policy and practice. For example, in 2012, the Center for Medicare and Medicaid
Services (CMS) began to implement a reimbursement system that adjusts payment rates
based on patient satisfaction scores (Lyu et al., 2013). Patient satisfaction is a key
determinant of quality of care and an important component of the pay-for-performance
metrics instituted by CMS. Beginning in 2012, CMS implemented value-based incentive
payments to acute-care hospitals based in part on results of satisfaction surveys from
patients discharged on or after October 1, 2012. The patient’s perception of quality is
significant determinant of the provider’s federal reimbursement. Patients now make
decisions based on their perceptions of the quality of and satisfaction with health care
providers (Bowers, Swan, & Koehler, 1994).
A study conducted by Fenton, Jerant, Bertakis, and Franks at the University of
California–Davis examined mortality rate in relation to patient satisfaction (N = 51,946);
the researchers’ analysis adjusted for a number of factors (i.e., demographics, health
status and chronic disease burden, Year 1 utilization and expenditures, availability of a
usual source of care, and insurance status). The investigators were surprised to find that,
in comparison with the mortality rate of patients in the lowest satisfaction quartile, the
mortality rate of patients in the highest satisfaction quartile was 26% higher (adjusted
hazard ratio, 1.26; 95% CI [1.05, 1.53]). This perhaps counterintuitive finding raises the
question of whether current satisfaction measures are in fact good indicators of health
care quality (Fenton et al., 2012). The researchers concluded that the connection between
patient satisfaction and health care outcomes is yet unclear.
Practitioners need to understand that ineffective communication can result in poor
outcomes. Improved communication not only results in better health outcomes, but also
may positivity impact patient satisfaction. For patients who want to be involved in their
care and who understand what is occurring during care, improved communication may
ultimately lead to greater patient satisfaction. The inclusion of APNs in the care team has
been reported to improve communication and the efficiency of care (McCauley, Bixby, &
Naylor, 2006).
Evidence-based practice. Evidence-based practice (EBP) is at the forefront of
change in today’s health care environment. EBP is the practice of using documented
evidence as a guide to problem solving approach to clinical decision making. To
implement EBP, one must “locate, critique, synthesize, translate, and evaluate evidence”
(Drenning, 2006, p.299). This includes the dissemination of information during the
implementation phase of practice. Although ostensibly EBP is the standard of nursing
practice, implementation of EBP is not always easy (Krom & Bautista, 2010). Barriers to
EBP implementation include (a) lack of requisite knowledge and skills on the part of
clinicians, (b) perception that EBP is time consuming, (b) perception that EBP is
burdensome, and (d) lack of management support at the organizational level (Melnyk &
Fineout-Overholt, 2012). Among clinical staff members, APNs, nurse educators, and
DNPs—who understand translational research—are uniquely qualified to fulfill their
responsibility to fulfill the mandate to implement evidence –based changes in practice.
These organizational change agents must persuasively teach the EBP process to staff
nurses and thereby transform the organizational culture—from a culture in which change
is resisted to a culture in which evidence-based improvements in practice are welcomed.
To achieve this transformation in organizational culture, APNs, nurse educators, and
DNPs must employ an interactive approach.
APNs serve as both leaders and knowledge resources for helping nursing staff to
ground care in current evidence. In a study conducted by Mahanes, Quatrara, and Shaw
(2013) at the University of Virginia, the researchers implemented APN-led nursing
rounds. Although the specific effects of the APN-led nursing rounds were impossible to
isolate, Mahanes and her colleagues were able to determine that rates of blood stream
infections, catheter-associated urinary tract infections, hospital-acquired pressure ulcers,
and ventilator-associated pneumonia and falls all declined. Similarly, in study that a
analyzed the effectiveness of an APN-managed heart failure program, Dahl and Penque
(2002) reported reduced 90-day readmission rates, fewer in-patient hospital days, lower
re-admission charges, and lower overall charges for health care services.
APNs have demonstrated implementation of EBP practices, better working
relationship with staff nurses, and improved patient-centered care with cost savings. The
development of an intraprofessional APN–staff nurse team to conduct bedside rounding
should improve patient care, increase communication and collaboration, and improve
patient satisfaction.
The daily goals reminder sheet. The need to develop clear team communication
has led to the development and institution of daily goal sheets. Studies in ICUs have
demonstrated that the use of daily goal sheets can result in nurses’ and physicians’ having
better understanding of patient care goals and in decreased ICU length of stay (Agarwal et
al., 2008; Narasimhan et al., 2006; Pronovost et al., 2003). A study conducted by
Phipps and Thomas (2007) examined the use of a daily goals sheet in the ICU at The
University of Pennsylvania’s Hershey Children’s Hospital. The researchers found that
85% of nurses felt the use of the goals sheets improved communications between
physicians and nurses and improved communication between nurses working on different
shifts. Phipps and Thomas also reported that 95% of the nursing staff felt that the extra
expenditure of time spent in completing the daily goals sheet was worthwhile. In another
study, the Beth Israel Medical Center in New York instituted use of a worksheet that was
posted at bedside after completion. Narasimham and colleagues (2006) found that pre and
post scores for understanding patient goals and communication improved significantly,
and that this improvement was sustained over a 9-month period. Furthermore, after
completion of the study, most of the practitioners requested that the use of the worksheet
be continued. In the DNP project, instituting a daily goals reminder worksheet associated
with APN–RN–patient bedside rounding enhanced communication between APNs, staff
nurses, and patients.
Needs Assessment and Description of the Project
Population identification. In this DNP project, the population identified for
selection and participation comprises APNs who have prior knowledge of and experience
with APN–RN–patient bedside rounding.
Identification of the project sponsor and key stakeholders. This DNP project
has no sponsors. Key stakeholders include the student investigator and ultimately the
APNs and RNs who will participate in the learning module.
Assessment of available resources. No monetary resources were available for
this project. As project investigator, I was responsible for the development of the learning
module. The project had no public advertisement. APNs were approached through the
hospital’s standardized email by the student researcher (Appendix B).
Team selection. The project investigator, served as the team for this project, with
consultation from the DNP project committee members.
Scope of the project. The project entailed only the development of the 1-hour
learning module. Further plans for implementation will be considered at some point in
the future. The module’s topics included (a) the requirement for close communication and
collaboration between team members to assure seamless, high-quality health care, (b) the
definition of APN–RN rounds, (c) the schedule and length of rounds, (d) the personnel
composition of rounding teams, (e) topics of discussion during the rounds, and (f) the use
of a daily goal reminder sheet to ensure the consistency of all elements of the patient's
treatment plan and goals.
As project investigator, I used the literature as a basis for creating the written
learning module. After completing the module and obtaining University of Nevada Las
Vegas Institutional Review Board approval, the learning module was sent to three APNs
in the hospital for review and feedback; all of these APNs had prior experience in
working with APN–RN rounds at other facilities. In addition, to assess the learning
module’s effectiveness, I developed an evaluation form to be completed by participating
APNs and RNs following their completion of the learning module.
All results of this project were shared with a representative of the CMC’s
administration and the Chief Nurse Executive. I hope to work with administration and
staff in implementing the APN–RN–patient rounding on a pilot unit and, on the basis of
results, further develops the model for use on other inpatient units.
Mission, Goals, and Objectives
The mission and goals of this project are to improve communication and
collaboration between the intraprofessional team of APNs and staff nurses and to improve
APN–staff nurse communication with patients.
This DNP project’s primary objective was to develop a structured learning module
pertaining to APN–RN–patient bedside rounding. The project’s long-term goals,
following completion of this project, are to implement the model and to improve
communication and collaboration between APNs, clinical nurses, and the patients cared
for by these nurses.
Chapter 3
Theoretical Underpinnings of the DNP Project
Of the several theories that have informed our understanding of holistic patient
centered care and educating adults, two theories are among the most influential: King’s
theory of goal attainment and Knowles’s theory of andragogy. In light of the theories’
relevance to developing interventions for improving health care team collaboration and
communication—the central concern of this dissertation—these two theories were
selected to serve as the theoretical underpinnings of the DNP staff education project in
support of APN–RN–patient bedside rounding. Specifically, King’s theory of goal
attainment informed the process of identifying content for the staff education module;
Knowles’s theory of andragogy informed the design of the module’s presentation to
training participants.
King’s Theory of Goal Attainment
In “Crossing the Quality Chasm: A New Health System for the 21st Century,” the
IOM (2001) describes six aims for the improvement of health care. One of the aims is to
provide patient-centered care that is respectful of and responsive to individual patients’
personal preferences, needs, and values; in patient-centered care, patients’ values play a
central role in informing clinical decision making clinical decisions. Among theoretical
frameworks that inform clinical understanding of the role of the patient in this
decisionmaking, Imogene Kings’ theory of goal attainment is seminal.
King’s theory and patient-centered health care. In King’s theory, health care
team decision-making includes a “transaction” in which the nurse and patient engage in
mutual goal setting (King, 1991, pp. 19). According to King, this transactional process of
interpersonal systems involves four steps—action, reaction, interaction, and transaction—
by which the patient and nurse (a) share information about their perceptions; (b) set goals
(through communication and interaction); and (c) explore and agree on means to achieve
these goals. To implement a true transactional process, the communication environment
must be reciprocal, and bidirectional. In this DNP project,
King’s theory—including the theory’s view of this transactional process—was applied to
inform the design of a patient-centered clinical environment. For example, to create and
maintain a patient-centered environment, APNs, clinical nurses, and patients must share
and be mutually informed about relevant considerations.
The theory of goal attainment: Assumptions and concepts. King developed her theory
of goal attainment in the 1960s. This theory describes the interpersonal dynamic
relationships between patients and their quest for goal attainment. Factors that can affect
goal attainment include roles, stressors, space, and time. In order for health care to be
optimal during the course of treatment for individual patients, both the patients and their
providers must continuously accommodate and adjust for changes in these factors.
King’s theory refers to three interacting systems: individuals (personal system),
groups (interpersonal system), and society (social system). The personal system is a
unified, complex, whole self who perceives, thinks, desires, imagines, decides, identifies
goals, and selects means to achieve them.
Assumptions. King’s framework is based on two assumptions:
▪Human beings are the focus of nursing.
▪The goals of nursing are health promotion, maintenance and restoration, care
of the sick or impaired, and care of the dying.
On the basis of these assumptions, King designed a conceptual system to explain
the organized wholes in which nurses are expected to function (see Figure 1; King, 1999).
Wholeness. King used the concept of “wholeness” to describe the broader
organization or social systems in which nurse’s function. (King, 1996, p. 61). The goal of
an interacting system is health for individuals, families, communities, and the world
(King, 1996).
Personal, interpersonal, and social systems. King’s conceptual framework is
organized into three “systems”: personal, interpersonal, and social. A personal or
individual system is essentially a single whole system. In contrast, an interpersonal
system represents the interaction of two or more individuals (i.e., small groups) in various
environments. Social systems are composed of large groups, such as educational,
governmental, or religious organizations.
Although in recent decades the quality and effectiveness of MD–RN interaction has
improved, the potential and need for further improvement in interprofessional
collaboration are substantial. To assess this need, Weaver et al. (2014) recently examined
teamwork and collaboration between staff nurses, residents, hospitalists, and oncology
physicians in oncology units at a large urban hospital. The investigators found that
physicians rated the quality of their own collaboration “very high” with other physicians
and with nurses. Physician ranked nurses’ collaboration with physicians as ranging from
87% to 100%. In stark contrast, however, nurses rated the quality of collaboration with
physicians poorly, from 35%–65%. Weaver et al. found that hierarchies persist and can
interfere with collaboration. Nurses believed that a negative attitude toward
communication as a significant obstacle to collaboration. A nurse may be reluctant to call
a physician if the nurse perceives that their relationship is not mutually supportive and
collaborative. On the other hand, physicians, having a positive perception of
collaboration, perceive difficulty contacting other providers as the main obstacle to
collaboration. Physicians who assume they have a good collaborative relationship with
nurses may not seek additional information because they (the physicians) are unaware of
potential or actual problems (Weaver et al., 2014).
Vazirani et al. (2005) surveyed registered nurses (n = 123), physicians (n = 45),
and a combined group of resident physicians and interns (n = 111) to determine whether
introduction of an APN role to the team was followed by changes in team communication
and collaboration. Physicians reported that, when an APN was part of the team, the level
of collaboration with nurses and APNs was significantly higher. Physicians also reported
that when an APN was part of the team, the team had fewer unnecessary delays and better
general communication. In the same study, the staff nurses reported significantly better
communication with APNs than with physicians (Vazirani et al., 2005). Kilpatrick (2012)
also found that communication and decision-making improve quality of care when the
participating APN is able to act within the full scope of the APN role. Among other
positive outcomes, this study reported that APN participation was associated with
decreases in length of patient stay and costs for patients treated on the intervention unit,
without an increase of readmission rates.
Vazirani’s (2005) study employed surveys to assess the degree of communication
and collaboration over two units. Physicians were surveyed immediately after they
completed a given rotation, starting at the onset of the interventions. Nurses were
surveyed biannually. The statistical analysis took into account correlation of observations
due to repeated sampling (Vazirani et al., 2005). Limitations in this study included
physician and staff nurse confusion about the role of APNs. Prior to the study, no APNs
were employed in the hospital’s internal medicine department. Chicago Medical Center
(CMC) employs approximately 200 APNs throughout all medical and surgical services,
thus role confusion is not a problem. The second limitation of this study pertained to
sample size. Physicians and nurses were not allowed to work on both the interventional
and control units; accordingly, the pool of physicians and pool of nurses available to
participate in the study was restricted. This can present problems with sample size but
also falsely promote familiarity and foster improved communications, skewing positive
results.
Although the quantity of studies is limited, it is clear that when an APN is an
integral part of the interprofessional team, the quality of communication and collaboration
increases. This DNP project specifies inclusion of the APN and staff nurse as members of
the professional team. The patient, who is also an integral part of this team, is not a
professional but is in fact the core leader of the health care team. In the decision-making
process, the patient’s understanding and input are invaluable
Communication and collaboration between APNs and staff nurses. The
majority of studies of communication and collaboration in health care contexts focused on
the nurse–physician relationship (Baggs & Ryan, 1990; Chapman, 2009;
DechairoMarino et al., 2001; Nathanson et al., 2011; Shortal et al., 1991). There have
been minimal formal studies looking at MD-APN and improved communication with
staff and its effects on patient care (Cowan et al., 2006). In nursing intraprofessional
teams, communication has been identified as the essential component of good team
functioning (Dreaschlin et al., 1999; Jones, 2005; Richardson et al., 2010). APNs possess
diverse knowledge that can facilitate understanding of collaborative practice to optimize
patient care (Crecelius, 2011). The Agency for Healthcare Research and Quality (2014)
found that when nurse practitioners are included in daily multidisciplinary rounds, the
rounding team’s communication and collaboration improve.
The increasing use of health care teams has made nursing practice more salient, in
that nurses serve as a link between team members and patients. Effective communication
between all team members is essential for successful teamwork and high-quality patient
care (Apker et al., 2006). The advance nurse practitioner function as the central link of the
health care team integrating other health care providers and patients. Good
communication among staff and between staff and patients is the cornerstone of quality
care.
Gooden and Jackson (2004) documented one of the earliest studies examining
staff nurses’ attitudes toward APNs. The investigators found that as APNs have come to
manage an increasing number of patients, staff nurses have begun to view the APNs as
leaders. Staff RNs consistently scored APNs higher than physicians in measures of
communication, respect for staff opinion, quality of care, clinical expertise, and
willingness to teach staff, patients, and patients’ families.
Moore and Prentice (2013) reported a case study that analyzed the collaborative
process between APNs and nurse in an outpatient oncology setting in Canada. The
researchers discovered four basic themes to collaboration:
▪Time that APNs spend together outside of work translates into collaboration at
work.
▪The basic skill of clinical knowledge and experience are essential ingredients
for successful collaboration.
▪Other factors that that contribute to the success of collaboration include
sharing a similar philosophy of care and mutual trust, respect and esteem.
▪Barriers to collaboration inevitably arise. Nurses are largely unaware of how
collaboration should manifest in the practice and are not trained on principles
of effective collaboration in practice.
▪Nurses and APNs attitudes are changing toward collaboration, viewing
collaboration as a means of achieving positive results.
Moore and Prentice (2013) found that intraprofessional collaboration (a) is
complex, (b) is influenced by interpersonal and professional factors, and (c) does not
occur spontaneously. Nurse must have a solid understanding of the concept of
collaboration and how to apply it in the clinical setting.
Patient-centered care. Improvement of patient satisfaction and quality of care is
directly due to the implementation of patient-centered care. Patient-centered care, the
“new normal” in today’s healthcare system, provides a mechanism for nurses to engage
patients as active participates in their care. The Institute of Medicine (IOM, 2001, p. 6)
defines patient-centered care as “healthcare that establishes a partnership among
practitioner, patients and their families to ensure that decisions reflect patient s wants,
needs and preferences” (see also Boykins, 2014; Sepucha & Ozanne, 2010). Optimal
patient participation requires a dynamic interaction between partners (patient and staff) in
terms of interpersonal interaction, therapeutic approach, focus on resources, resources,
patient opportunities to participate in and influence health care team decision making, and
patient education (Sahlsten et al., 2007). Including the patient in bedside reports or
handoffs has been reported to improve teamwork, safety and efficiency (Wildner & Ferri,
2012). This bedside practice also entails the participation of patients as partners in their
care, with the expectation that their participation will lead to improved care, better
outcomes, improved adherence to treatment and medication regimen and greater
satisfaction with care. Barriers to implementation of patient-centered care and bedside
rounding include time and resource requirements; the potential for patients to feel
confused, upset, or dehumanized as a result of hearing clinical explanations; and the
potential for breach of patient confidentiality (McMurry et. al 2011). In addition, when
presenting sensitive or confidential information, some nurses may feel uncomfortable, or
be inhibited by a lack experience—especially in the presence of patients’ family members
or relatives are present. O’Connell, Macdonald, and Kelly (2008) found that viewed
handoffs as being too time consuming, and ineffective, or efficient. The investigators
recommended that a handoff guideline or information template should be developed to
promote and facilitate the reporting of objective relevant information.
Patient satisfaction and its effects on quality of care. As a subjective
phenomenon, “patient satisfaction” is difficult to define. The self-reported determination
of patient satisfaction is a personal evaluation of health care services and of the providers
of that care (Ware et al., 1983); patients’ attitudes and expectations regarding care greatly
affect their sense of satisfaction. Because satisfaction ratings are relative, subjective, and
not directly observable, attempting to meaningfully quantify patients’ personal evaluation
of care is highly problematic (Ware et al., 1983).
The challenges inherent in measuring patient satisfaction have ramifications for
policy and practice. For example, in 2012, the Center for Medicare and Medicaid
Services (CMS) began to implement a reimbursement system that adjusts payment rates
based on patient satisfaction scores (Lyu et al., 2013). Patient satisfaction is a key
determinant of quality of care and an important component of the pay-for-performance
metrics instituted by CMS. Beginning in 2012, CMS implemented value-based incentive
payments to acute-care hospitals based in part on results of satisfaction surveys from
patients discharged on or after October 1, 2012. The patient’s perception of quality is
significant determinant of the provider’s federal reimbursement. Patients now make
decisions based on their perceptions of the quality of and satisfaction with health care
providers (Bowers, Swan, & Koehler, 1994).
A study conducted by Fenton, Jerant, Bertakis, and Franks at the University of
California–Davis examined mortality rate in relation to patient satisfaction (N = 51,946);
the researchers’ analysis adjusted for a number of factors (i.e., demographics, health
status and chronic disease burden, Year 1 utilization and expenditures, availability of a
usual source of care, and insurance status). The investigators were surprised to find that,
in comparison with the mortality rate of patients in the lowest satisfaction quartile, the
mortality rate of patients in the highest satisfaction quartile was 26% higher (adjusted
hazard ratio, 1.26; 95% CI [1.05, 1.53]). This perhaps counterintuitive finding raises the
question of whether current satisfaction measures are in fact good indicators of health
care quality (Fenton et al., 2012). The researchers concluded that the connection between
patient satisfaction and health care outcomes is yet unclear.
Practitioners need to understand that ineffective communication can result in poor
outcomes. Improved communication not only results in better health outcomes, but also
may positivity impact patient satisfaction. For patients who want to be involved in their
care and who understand what is occurring during care, improved communication may
ultimately lead to greater patient satisfaction. The inclusion of APNs in the care team has
been reported to improve communication and the efficiency of care (McCauley, Bixby, &
Naylor, 2006).
Evidence-based practice. Evidence-based practice (EBP) is at the forefront of
change in today’s health care environment. EBP is the practice of using documented
evidence as a guide to problem solving approach to clinical decision making. To
implement EBP, one must “locate, critique, synthesize, translate, and evaluate evidence”
(Drenning, 2006, p.299). This includes the dissemination of information during the
implementation phase of practice. Although ostensibly EBP is the standard of nursing
practice, implementation of EBP is not always easy (Krom & Bautista, 2010). Barriers to
EBP implementation include (a) lack of requisite knowledge and skills on the part of
clinicians, (b) perception that EBP is time consuming, (b) perception that EBP is
burdensome, and (d) lack of management support at the organizational level (Melnyk &
Fineout-Overholt, 2012). Among clinical staff members, APNs, nurse educators, and
DNPs—who understand translational research—are uniquely qualified to fulfill their
responsibility to fulfill the mandate to implement evidence –based changes in practice.
These organizational change agents must persuasively teach the EBP process to staff
nurses and thereby transform the organizational culture—from a culture in which change
is resisted to a culture in which evidence-based improvements in practice are welcomed.
To achieve this transformation in organizational culture, APNs, nurse educators, and
DNPs must employ an interactive approach.
APNs serve as both leaders and knowledge resources for helping nursing staff to
ground care in current evidence. In a study conducted by Mahanes, Quatrara, and Shaw
(2013) at the University of Virginia, the researchers implemented APN-led nursing
rounds. Although the specific effects of the APN-led nursing rounds were impossible to
isolate, Mahanes and her colleagues were able to determine that rates of blood stream
infections, catheter-associated urinary tract infections, hospital-acquired pressure ulcers,
and ventilator-associated pneumonia and falls all declined. Similarly, in study that a
analyzed the effectiveness of an APN-managed heart failure program, Dahl and Penque
(2002) reported reduced 90-day readmission rates, fewer in-patient hospital days, lower
re-admission charges, and lower overall charges for health care services.
APNs have demonstrated implementation of EBP practices, better working
relationship with staff nurses, and improved patient-centered care with cost savings. The
development of an intraprofessional APN–staff nurse team to conduct bedside rounding
should improve patient care, increase communication and collaboration, and improve
patient satisfaction.
The daily goals reminder sheet. The need to develop clear team communication
has led to the development and institution of daily goal sheets. Studies in ICUs have
demonstrated that the use of daily goal sheets can result in nurses’ and physicians’ having
better understanding of patient care goals and in decreased ICU length of stay (Agarwal et
al., 2008; Narasimhan et al., 2006; Pronovost et al., 2003). A study conducted by
Phipps and Thomas (2007) examined the use of a daily goals sheet in the ICU at The
University of Pennsylvania’s Hershey Children’s Hospital. The researchers found that
85% of nurses felt the use of the goals sheets improved communications between
physicians and nurses and improved communication between nurses working on different
shifts. Phipps and Thomas also reported that 95% of the nursing staff felt that the extra
expenditure of time spent in completing the daily goals sheet was worthwhile. In another
study, the Beth Israel Medical Center in New York instituted use of a worksheet that was
posted at bedside after completion. Narasimham and colleagues (2006) found that pre and
post scores for understanding patient goals and communication improved significantly,
and that this improvement was sustained over a 9-month period. Furthermore, after
completion of the study, most of the practitioners requested that the use of the worksheet
be continued. In the DNP project, instituting a daily goals reminder worksheet associated
with APN–RN–patient bedside rounding enhanced communication between APNs, staff
nurses, and patients.
Needs Assessment and Description of the Project
Population identification. In this DNP project, the population identified for
selection and participation comprises APNs who have prior knowledge of and experience
with APN–RN–patient bedside rounding.
Identification of the project sponsor and key stakeholders. This DNP project
has no sponsors. Key stakeholders include the student investigator and ultimately the
APNs and RNs who will participate in the learning module.
Assessment of available resources. No monetary resources were available for
this project. As project investigator, I was responsible for the development of the learning
module. The project had no public advertisement. APNs were approached through the
hospital’s standardized email by the student researcher (Appendix B).
Team selection. The project investigator, served as the team for this project, with
consultation from the DNP project committee members.
Scope of the project. The project entailed only the development of the 1-hour
learning module. Further plans for implementation will be considered at some point in
the future. The module’s topics included (a) the requirement for close communication and
collaboration between team members to assure seamless, high-quality health care, (b) the
definition of APN–RN rounds, (c) the schedule and length of rounds, (d) the personnel
composition of rounding teams, (e) topics of discussion during the rounds, and (f) the use
of a daily goal reminder sheet to ensure the consistency of all elements of the patient's
treatment plan and goals.
As project investigator, I used the literature as a basis for creating the written
learning module. After completing the module and obtaining University of Nevada Las
Vegas Institutional Review Board approval, the learning module was sent to three APNs
in the hospital for review and feedback; all of these APNs had prior experience in
working with APN–RN rounds at other facilities. In addition, to assess the learning
module’s effectiveness, I developed an evaluation form to be completed by participating
APNs and RNs following their completion of the learning module.
All results of this project were shared with a representative of the CMC’s
administration and the Chief Nurse Executive. I hope to work with administration and
staff in implementing the APN–RN–patient rounding on a pilot unit and, on the basis of
results, further develops the model for use on other inpatient units.
Mission, Goals, and Objectives
The mission and goals of this project are to improve communication and
collaboration between the intraprofessional team of APNs and staff nurses and to improve
APN–staff nurse communication with patients.
This DNP project’s primary objective was to develop a structured learning module
pertaining to APN–RN–patient bedside rounding. The project’s long-term goals,
following completion of this project, are to implement the model and to improve
communication and collaboration between APNs, clinical nurses, and the patients cared
for by these nurses.
Chapter 3
Theoretical Underpinnings of the DNP Project
Of the several theories that have informed our understanding of holistic patient
centered care and educating adults, two theories are among the most influential: King’s
theory of goal attainment and Knowles’s theory of andragogy. In light of the theories’
relevance to developing interventions for improving health care team collaboration and
communication—the central concern of this dissertation—these two theories were
selected to serve as the theoretical underpinnings of the DNP staff education project in
support of APN–RN–patient bedside rounding. Specifically, King’s theory of goal
attainment informed the process of identifying content for the staff education module;
Knowles’s theory of andragogy informed the design of the module’s presentation to
training participants.
King’s Theory of Goal Attainment
In “Crossing the Quality Chasm: A New Health System for the 21st Century,” the
IOM (2001) describes six aims for the improvement of health care. One of the aims is to
provide patient-centered care that is respectful of and responsive to individual patients’
personal preferences, needs, and values; in patient-centered care, patients’ values play a
central role in informing clinical decision making clinical decisions. Among theoretical
frameworks that inform clinical understanding of the role of the patient in this
decisionmaking, Imogene Kings’ theory of goal attainment is seminal.
King’s theory and patient-centered health care. In King’s theory, health care
team decision-making includes a “transaction” in which the nurse and patient engage in
mutual goal setting (King, 1991, pp. 19). According to King, this transactional process of
interpersonal systems involves four steps—action, reaction, interaction, and transaction—
by which the patient and nurse (a) share information about their perceptions; (b) set goals
(through communication and interaction); and (c) explore and agree on means to achieve
these goals. To implement a true transactional process, the communication environment
must be reciprocal, and bidirectional. In this DNP project,
King’s theory—including the theory’s view of this transactional process—was applied to
inform the design of a patient-centered clinical environment. For example, to create and
maintain a patient-centered environment, APNs, clinical nurses, and patients must share
and be mutually informed about relevant considerations.
The theory of goal attainment: Assumptions and concepts. King developed her theory
of goal attainment in the 1960s. This theory describes the interpersonal dynamic
relationships between patients and their quest for goal attainment. Factors that can affect
goal attainment include roles, stressors, space, and time. In order for health care to be
optimal during the course of treatment for individual patients, both the patients and their
providers must continuously accommodate and adjust for changes in these factors.
King’s theory refers to three interacting systems: individuals (personal system),
groups (interpersonal system), and society (social system). The personal system is a
unified, complex, whole self who perceives, thinks, desires, imagines, decides, identifies
goals, and selects means to achieve them.
Assumptions. King’s framework is based on two assumptions:
▪Human beings are the focus of nursing.
▪The goals of nursing are health promotion, maintenance and restoration, care
of the sick or impaired, and care of the dying.
On the basis of these assumptions, King designed a conceptual system to explain
the organized wholes in which nurses are expected to function (see Figure 1; King, 1999).
Wholeness. King used the concept of “wholeness” to describe the broader
organization or social systems in which nurse’s function. (King, 1996, p. 61). The goal of
an interacting system is health for individuals, families, communities, and the world
(King, 1996).
Personal, interpersonal, and social systems. King’s conceptual framework is
organized into three “systems”: personal, interpersonal, and social. A personal or
individual system is essentially a single whole system. In contrast, an interpersonal
system represents the interaction of two or more individuals (i.e., small groups) in various
environments. Social systems are composed of large groups, such as educational,
governmental, or religious organizations.
Although in recent decades the quality and effectiveness of MD–RN interaction has
improved, the potential and need for further improvement in interprofessional
collaboration are substantial. To assess this need, Weaver et al. (2014) recently examined
teamwork and collaboration between staff nurses, residents, hospitalists, and oncology
physicians in oncology units at a large urban hospital. The investigators found that
physicians rated the quality of their own collaboration “very high” with other physicians
and with nurses. Physician ranked nurses’ collaboration with physicians as ranging from
87% to 100%. In stark contrast, however, nurses rated the quality of collaboration with
physicians poorly, from 35%–65%. Weaver et al. found that hierarchies persist and can
interfere with collaboration. Nurses believed that a negative attitude toward
communication as a significant obstacle to collaboration. A nurse may be reluctant to call
a physician if the nurse perceives that their relationship is not mutually supportive and
collaborative. On the other hand, physicians, having a positive perception of
collaboration, perceive difficulty contacting other providers as the main obstacle to
collaboration. Physicians who assume they have a good collaborative relationship with
nurses may not seek additional information because they (the physicians) are unaware of
potential or actual problems (Weaver et al., 2014).
Vazirani et al. (2005) surveyed registered nurses (n = 123), physicians (n = 45),
and a combined group of resident physicians and interns (n = 111) to determine whether
introduction of an APN role to the team was followed by changes in team communication
and collaboration. Physicians reported that, when an APN was part of the team, the level
of collaboration with nurses and APNs was significantly higher. Physicians also reported
that when an APN was part of the team, the team had fewer unnecessary delays and better
general communication. In the same study, the staff nurses reported significantly better
communication with APNs than with physicians (Vazirani et al., 2005). Kilpatrick (2012)
also found that communication and decision-making improve quality of care when the
participating APN is able to act within the full scope of the APN role. Among other
positive outcomes, this study reported that APN participation was associated with
decreases in length of patient stay and costs for patients treated on the intervention unit,
without an increase of readmission rates.
Vazirani’s (2005) study employed surveys to assess the degree of communication
and collaboration over two units. Physicians were surveyed immediately after they
completed a given rotation, starting at the onset of the interventions. Nurses were
surveyed biannually. The statistical analysis took into account correlation of observations
due to repeated sampling (Vazirani et al., 2005). Limitations in this study included
physician and staff nurse confusion about the role of APNs. Prior to the study, no APNs
were employed in the hospital’s internal medicine department. Chicago Medical Center
(CMC) employs approximately 200 APNs throughout all medical and surgical services,
thus role confusion is not a problem. The second limitation of this study pertained to
sample size. Physicians and nurses were not allowed to work on both the interventional
and control units; accordingly, the pool of physicians and pool of nurses available to
participate in the study was restricted. This can present problems with sample size but
also falsely promote familiarity and foster improved communications, skewing positive
results.
Although the quantity of studies is limited, it is clear that when an APN is an
integral part of the interprofessional team, the quality of communication and collaboration
increases. This DNP project specifies inclusion of the APN and staff nurse as members of
the professional team. The patient, who is also an integral part of this team, is not a
professional but is in fact the core leader of the health care team. In the decision-making
process, the patient’s understanding and input are invaluable
Communication and collaboration between APNs and staff nurses. The
majority of studies of communication and collaboration in health care contexts focused on
the nurse–physician relationship (Baggs & Ryan, 1990; Chapman, 2009;
DechairoMarino et al., 2001; Nathanson et al., 2011; Shortal et al., 1991). There have
been minimal formal studies looking at MD-APN and improved communication with
staff and its effects on patient care (Cowan et al., 2006). In nursing intraprofessional
teams, communication has been identified as the essential component of good team
functioning (Dreaschlin et al., 1999; Jones, 2005; Richardson et al., 2010). APNs possess
diverse knowledge that can facilitate understanding of collaborative practice to optimize
patient care (Crecelius, 2011). The Agency for Healthcare Research and Quality (2014)
found that when nurse practitioners are included in daily multidisciplinary rounds, the
rounding team’s communication and collaboration improve.
The increasing use of health care teams has made nursing practice more salient, in
that nurses serve as a link between team members and patients. Effective communication
between all team members is essential for successful teamwork and high-quality patient
care (Apker et al., 2006). The advance nurse practitioner function as the central link of the
health care team integrating other health care providers and patients. Good
communication among staff and between staff and patients is the cornerstone of quality
care.
Gooden and Jackson (2004) documented one of the earliest studies examining
staff nurses’ attitudes toward APNs. The investigators found that as APNs have come to
manage an increasing number of patients, staff nurses have begun to view the APNs as
leaders. Staff RNs consistently scored APNs higher than physicians in measures of
communication, respect for staff opinion, quality of care, clinical expertise, and
willingness to teach staff, patients, and patients’ families.
Moore and Prentice (2013) reported a case study that analyzed the collaborative
process between APNs and nurse in an outpatient oncology setting in Canada. The
researchers discovered four basic themes to collaboration:
▪Time that APNs spend together outside of work translates into collaboration at
work.
▪The basic skill of clinical knowledge and experience are essential ingredients
for successful collaboration.
▪Other factors that that contribute to the success of collaboration include
sharing a similar philosophy of care and mutual trust, respect and esteem.
▪Barriers to collaboration inevitably arise. Nurses are largely unaware of how
collaboration should manifest in the practice and are not trained on principles
of effective collaboration in practice.
▪Nurses and APNs attitudes are changing toward collaboration, viewing
collaboration as a means of achieving positive results.
Moore and Prentice (2013) found that intraprofessional collaboration (a) is
complex, (b) is influenced by interpersonal and professional factors, and (c) does not
occur spontaneously. Nurse must have a solid understanding of the concept of
collaboration and how to apply it in the clinical setting.
Patient-centered care. Improvement of patient satisfaction and quality of care is
directly due to the implementation of patient-centered care. Patient-centered care, the
“new normal” in today’s healthcare system, provides a mechanism for nurses to engage
patients as active participates in their care. The Institute of Medicine (IOM, 2001, p. 6)
defines patient-centered care as “healthcare that establishes a partnership among
practitioner, patients and their families to ensure that decisions reflect patient s wants,
needs and preferences” (see also Boykins, 2014; Sepucha & Ozanne, 2010). Optimal
patient participation requires a dynamic interaction between partners (patient and staff) in
terms of interpersonal interaction, therapeutic approach, focus on resources, resources,
patient opportunities to participate in and influence health care team decision making, and
patient education (Sahlsten et al., 2007). Including the patient in bedside reports or
handoffs has been reported to improve teamwork, safety and efficiency (Wildner & Ferri,
2012). This bedside practice also entails the participation of patients as partners in their
care, with the expectation that their participation will lead to improved care, better
outcomes, improved adherence to treatment and medication regimen and greater
satisfaction with care. Barriers to implementation of patient-centered care and bedside
rounding include time and resource requirements; the potential for patients to feel
confused, upset, or dehumanized as a result of hearing clinical explanations; and the
potential for breach of patient confidentiality (McMurry et. al 2011). In addition, when
presenting sensitive or confidential information, some nurses may feel uncomfortable, or
be inhibited by a lack experience—especially in the presence of patients’ family members
or relatives are present. O’Connell, Macdonald, and Kelly (2008) found that viewed
handoffs as being too time consuming, and ineffective, or efficient. The investigators
recommended that a handoff guideline or information template should be developed to
promote and facilitate the reporting of objective relevant information.
Patient satisfaction and its effects on quality of care. As a subjective
phenomenon, “patient satisfaction” is difficult to define. The self-reported determination
of patient satisfaction is a personal evaluation of health care services and of the providers
of that care (Ware et al., 1983); patients’ attitudes and expectations regarding care greatly
affect their sense of satisfaction. Because satisfaction ratings are relative, subjective, and
not directly observable, attempting to meaningfully quantify patients’ personal evaluation
of care is highly problematic (Ware et al., 1983).
The challenges inherent in measuring patient satisfaction have ramifications for
policy and practice. For example, in 2012, the Center for Medicare and Medicaid
Services (CMS) began to implement a reimbursement system that adjusts payment rates
based on patient satisfaction scores (Lyu et al., 2013). Patient satisfaction is a key
determinant of quality of care and an important component of the pay-for-performance
metrics instituted by CMS. Beginning in 2012, CMS implemented value-based incentive
payments to acute-care hospitals based in part on results of satisfaction surveys from
patients discharged on or after October 1, 2012. The patient’s perception of quality is
significant determinant of the provider’s federal reimbursement. Patients now make
decisions based on their perceptions of the quality of and satisfaction with health care
providers (Bowers, Swan, & Koehler, 1994).
A study conducted by Fenton, Jerant, Bertakis, and Franks at the University of
California–Davis examined mortality rate in relation to patient satisfaction (N = 51,946);
the researchers’ analysis adjusted for a number of factors (i.e., demographics, health
status and chronic disease burden, Year 1 utilization and expenditures, availability of a
usual source of care, and insurance status). The investigators were surprised to find that,
in comparison with the mortality rate of patients in the lowest satisfaction quartile, the
mortality rate of patients in the highest satisfaction quartile was 26% higher (adjusted
hazard ratio, 1.26; 95% CI [1.05, 1.53]). This perhaps counterintuitive finding raises the
question of whether current satisfaction measures are in fact good indicators of health
care quality (Fenton et al., 2012). The researchers concluded that the connection between
patient satisfaction and health care outcomes is yet unclear.
Practitioners need to understand that ineffective communication can result in poor
outcomes. Improved communication not only results in better health outcomes, but also
may positivity impact patient satisfaction. For patients who want to be involved in their
care and who understand what is occurring during care, improved communication may
ultimately lead to greater patient satisfaction. The inclusion of APNs in the care team has
been reported to improve communication and the efficiency of care (McCauley, Bixby, &
Naylor, 2006).
Evidence-based practice. Evidence-based practice (EBP) is at the forefront of
change in today’s health care environment. EBP is the practice of using documented
evidence as a guide to problem solving approach to clinical decision making. To
implement EBP, one must “locate, critique, synthesize, translate, and evaluate evidence”
(Drenning, 2006, p.299). This includes the dissemination of information during the
implementation phase of practice. Although ostensibly EBP is the standard of nursing
practice, implementation of EBP is not always easy (Krom & Bautista, 2010). Barriers to
EBP implementation include (a) lack of requisite knowledge and skills on the part of
clinicians, (b) perception that EBP is time consuming, (b) perception that EBP is
burdensome, and (d) lack of management support at the organizational level (Melnyk &
Fineout-Overholt, 2012). Among clinical staff members, APNs, nurse educators, and
DNPs—who understand translational research—are uniquely qualified to fulfill their
responsibility to fulfill the mandate to implement evidence –based changes in practice.
These organizational change agents must persuasively teach the EBP process to staff
nurses and thereby transform the organizational culture—from a culture in which change
is resisted to a culture in which evidence-based improvements in practice are welcomed.
To achieve this transformation in organizational culture, APNs, nurse educators, and
DNPs must employ an interactive approach.
APNs serve as both leaders and knowledge resources for helping nursing staff to
ground care in current evidence. In a study conducted by Mahanes, Quatrara, and Shaw
(2013) at the University of Virginia, the researchers implemented APN-led nursing
rounds. Although the specific effects of the APN-led nursing rounds were impossible to
isolate, Mahanes and her colleagues were able to determine that rates of blood stream
infections, catheter-associated urinary tract infections, hospital-acquired pressure ulcers,
and ventilator-associated pneumonia and falls all declined. Similarly, in study that a
analyzed the effectiveness of an APN-managed heart failure program, Dahl and Penque
(2002) reported reduced 90-day readmission rates, fewer in-patient hospital days, lower
re-admission charges, and lower overall charges for health care services.
APNs have demonstrated implementation of EBP practices, better working
relationship with staff nurses, and improved patient-centered care with cost savings. The
development of an intraprofessional APN–staff nurse team to conduct bedside rounding
should improve patient care, increase communication and collaboration, and improve
patient satisfaction.
The daily goals reminder sheet. The need to develop clear team communication
has led to the development and institution of daily goal sheets. Studies in ICUs have
demonstrated that the use of daily goal sheets can result in nurses’ and physicians’ having
better understanding of patient care goals and in decreased ICU length of stay (Agarwal et
al., 2008; Narasimhan et al., 2006; Pronovost et al., 2003). A study conducted by
Phipps and Thomas (2007) examined the use of a daily goals sheet in the ICU at The
University of Pennsylvania’s Hershey Children’s Hospital. The researchers found that
85% of nurses felt the use of the goals sheets improved communications between
physicians and nurses and improved communication between nurses working on different
shifts. Phipps and Thomas also reported that 95% of the nursing staff felt that the extra
expenditure of time spent in completing the daily goals sheet was worthwhile. In another
study, the Beth Israel Medical Center in New York instituted use of a worksheet that was
posted at bedside after completion. Narasimham and colleagues (2006) found that pre and
post scores for understanding patient goals and communication improved significantly,
and that this improvement was sustained over a 9-month period. Furthermore, after
completion of the study, most of the practitioners requested that the use of the worksheet
be continued. In the DNP project, instituting a daily goals reminder worksheet associated
with APN–RN–patient bedside rounding enhanced communication between APNs, staff
nurses, and patients.
Needs Assessment and Description of the Project
Population identification. In this DNP project, the population identified for
selection and participation comprises APNs who have prior knowledge of and experience
with APN–RN–patient bedside rounding.
Identification of the project sponsor and key stakeholders. This DNP project
has no sponsors. Key stakeholders include the student investigator and ultimately the
APNs and RNs who will participate in the learning module.
Assessment of available resources. No monetary resources were available for
this project. As project investigator, I was responsible for the development of the learning
module. The project had no public advertisement. APNs were approached through the
hospital’s standardized email by the student researcher (Appendix B).
Team selection. The project investigator, served as the team for this project, with
consultation from the DNP project committee members.
Scope of the project. The project entailed only the development of the 1-hour
learning module. Further plans for implementation will be considered at some point in
the future. The module’s topics included (a) the requirement for close communication and
collaboration between team members to assure seamless, high-quality health care, (b) the
definition of APN–RN rounds, (c) the schedule and length of rounds, (d) the personnel
composition of rounding teams, (e) topics of discussion during the rounds, and (f) the use
of a daily goal reminder sheet to ensure the consistency of all elements of the patient's
treatment plan and goals.
As project investigator, I used the literature as a basis for creating the written
learning module. After completing the module and obtaining University of Nevada Las
Vegas Institutional Review Board approval, the learning module was sent to three APNs
in the hospital for review and feedback; all of these APNs had prior experience in
working with APN–RN rounds at other facilities. In addition, to assess the learning
module’s effectiveness, I developed an evaluation form to be completed by participating
APNs and RNs following their completion of the learning module.
All results of this project were shared with a representative of the CMC’s
administration and the Chief Nurse Executive. I hope to work with administration and
staff in implementing the APN–RN–patient rounding on a pilot unit and, on the basis of
results, further develops the model for use on other inpatient units.
Mission, Goals, and Objectives
The mission and goals of this project are to improve communication and
collaboration between the intraprofessional team of APNs and staff nurses and to improve
APN–staff nurse communication with patients.
This DNP project’s primary objective was to develop a structured learning module
pertaining to APN–RN–patient bedside rounding. The project’s long-term goals,
following completion of this project, are to implement the model and to improve
communication and collaboration between APNs, clinical nurses, and the patients cared
for by these nurses.
Chapter 3
Theoretical Underpinnings of the DNP Project
Of the several theories that have informed our understanding of holistic patient
centered care and educating adults, two theories are among the most influential: King’s
theory of goal attainment and Knowles’s theory of andragogy. In light of the theories’
relevance to developing interventions for improving health care team collaboration and
communication—the central concern of this dissertation—these two theories were
selected to serve as the theoretical underpinnings of the DNP staff education project in
support of APN–RN–patient bedside rounding. Specifically, King’s theory of goal
attainment informed the process of identifying content for the staff education module;
Knowles’s theory of andragogy informed the design of the module’s presentation to
training participants.
King’s Theory of Goal Attainment
In “Crossing the Quality Chasm: A New Health System for the 21st Century,” the
IOM (2001) describes six aims for the improvement of health care. One of the aims is to
provide patient-centered care that is respectful of and responsive to individual patients’
personal preferences, needs, and values; in patient-centered care, patients’ values play a
central role in informing clinical decision making clinical decisions. Among theoretical
frameworks that inform clinical understanding of the role of the patient in this
decisionmaking, Imogene Kings’ theory of goal attainment is seminal.
King’s theory and patient-centered health care. In King’s theory, health care
team decision-making includes a “transaction” in which the nurse and patient engage in
mutual goal setting (King, 1991, pp. 19). According to King, this transactional process of
interpersonal systems involves four steps—action, reaction, interaction, and transaction—
by which the patient and nurse (a) share information about their perceptions; (b) set goals
(through communication and interaction); and (c) explore and agree on means to achieve
these goals. To implement a true transactional process, the communication environment
must be reciprocal, and bidirectional. In this DNP project,
King’s theory—including the theory’s view of this transactional process—was applied to
inform the design of a patient-centered clinical environment. For example, to create and
maintain a patient-centered environment, APNs, clinical nurses, and patients must share
and be mutually informed about relevant considerations.
The theory of goal attainment: Assumptions and concepts. King developed her theory
of goal attainment in the 1960s. This theory describes the interpersonal dynamic
relationships between patients and their quest for goal attainment. Factors that can affect
goal attainment include roles, stressors, space, and time. In order for health care to be
optimal during the course of treatment for individual patients, both the patients and their
providers must continuously accommodate and adjust for changes in these factors.
King’s theory refers to three interacting systems: individuals (personal system),
groups (interpersonal system), and society (social system). The personal system is a
unified, complex, whole self who perceives, thinks, desires, imagines, decides, identifies
goals, and selects means to achieve them.
Assumptions. King’s framework is based on two assumptions:
▪Human beings are the focus of nursing.
▪The goals of nursing are health promotion, maintenance and restoration, care
of the sick or impaired, and care of the dying.
On the basis of these assumptions, King designed a conceptual system to explain
the organized wholes in which nurses are expected to function (see Figure 1; King, 1999).
Wholeness. King used the concept of “wholeness” to describe the broader
organization or social systems in which nurse’s function. (King, 1996, p. 61). The goal of
an interacting system is health for individuals, families, communities, and the world
(King, 1996).
Personal, interpersonal, and social systems. King’s conceptual framework is
organized into three “systems”: personal, interpersonal, and social. A personal or
individual system is essentially a single whole system. In contrast, an interpersonal
system represents the interaction of two or more individuals (i.e., small groups) in various
environments. Social systems are composed of large groups, such as educational,
governmental, or religious organizations.
Although in recent decades the quality and effectiveness of MD–RN interaction has
improved, the potential and need for further improvement in interprofessional
collaboration are substantial. To assess this need, Weaver et al. (2014) recently examined
teamwork and collaboration between staff nurses, residents, hospitalists, and oncology
physicians in oncology units at a large urban hospital. The investigators found that
physicians rated the quality of their own collaboration “very high” with other physicians
and with nurses. Physician ranked nurses’ collaboration with physicians as ranging from
87% to 100%. In stark contrast, however, nurses rated the quality of collaboration with
physicians poorly, from 35%–65%. Weaver et al. found that hierarchies persist and can
interfere with collaboration. Nurses believed that a negative attitude toward
communication as a significant obstacle to collaboration. A nurse may be reluctant to call
a physician if the nurse perceives that their relationship is not mutually supportive and
collaborative. On the other hand, physicians, having a positive perception of
collaboration, perceive difficulty contacting other providers as the main obstacle to
collaboration. Physicians who assume they have a good collaborative relationship with
nurses may not seek additional information because they (the physicians) are unaware of
potential or actual problems (Weaver et al., 2014).
Vazirani et al. (2005) surveyed registered nurses (n = 123), physicians (n = 45),
and a combined group of resident physicians and interns (n = 111) to determine whether
introduction of an APN role to the team was followed by changes in team communication
and collaboration. Physicians reported that, when an APN was part of the team, the level
of collaboration with nurses and APNs was significantly higher. Physicians also reported
that when an APN was part of the team, the team had fewer unnecessary delays and better
general communication. In the same study, the staff nurses reported significantly better
communication with APNs than with physicians (Vazirani et al., 2005). Kilpatrick (2012)
also found that communication and decision-making improve quality of care when the
participating APN is able to act within the full scope of the APN role. Among other
positive outcomes, this study reported that APN participation was associated with
decreases in length of patient stay and costs for patients treated on the intervention unit,
without an increase of readmission rates.
Vazirani’s (2005) study employed surveys to assess the degree of communication
and collaboration over two units. Physicians were surveyed immediately after they
completed a given rotation, starting at the onset of the interventions. Nurses were
surveyed biannually. The statistical analysis took into account correlation of observations
due to repeated sampling (Vazirani et al., 2005). Limitations in this study included
physician and staff nurse confusion about the role of APNs. Prior to the study, no APNs
were employed in the hospital’s internal medicine department. Chicago Medical Center
(CMC) employs approximately 200 APNs throughout all medical and surgical services,
thus role confusion is not a problem. The second limitation of this study pertained to
sample size. Physicians and nurses were not allowed to work on both the interventional
and control units; accordingly, the pool of physicians and pool of nurses available to
participate in the study was restricted. This can present problems with sample size but
also falsely promote familiarity and foster improved communications, skewing positive
results.
Although the quantity of studies is limited, it is clear that when an APN is an
integral part of the interprofessional team, the quality of communication and collaboration
increases. This DNP project specifies inclusion of the APN and staff nurse as members of
the professional team. The patient, who is also an integral part of this team, is not a
professional but is in fact the core leader of the health care team. In the decision-making
process, the patient’s understanding and input are invaluable
Communication and collaboration between APNs and staff nurses. The
majority of studies of communication and collaboration in health care contexts focused on
the nurse–physician relationship (Baggs & Ryan, 1990; Chapman, 2009;
DechairoMarino et al., 2001; Nathanson et al., 2011; Shortal et al., 1991). There have
been minimal formal studies looking at MD-APN and improved communication with
staff and its effects on patient care (Cowan et al., 2006). In nursing intraprofessional
teams, communication has been identified as the essential component of good team
functioning (Dreaschlin et al., 1999; Jones, 2005; Richardson et al., 2010). APNs possess
diverse knowledge that can facilitate understanding of collaborative practice to optimize
patient care (Crecelius, 2011). The Agency for Healthcare Research and Quality (2014)
found that when nurse practitioners are included in daily multidisciplinary rounds, the
rounding team’s communication and collaboration improve.
The increasing use of health care teams has made nursing practice more salient, in
that nurses serve as a link between team members and patients. Effective communication
between all team members is essential for successful teamwork and high-quality patient
care (Apker et al., 2006). The advance nurse practitioner function as the central link of the
health care team integrating other health care providers and patients. Good
communication among staff and between staff and patients is the cornerstone of quality
care.
Gooden and Jackson (2004) documented one of the earliest studies examining
staff nurses’ attitudes toward APNs. The investigators found that as APNs have come to
manage an increasing number of patients, staff nurses have begun to view the APNs as
leaders. Staff RNs consistently scored APNs higher than physicians in measures of
communication, respect for staff opinion, quality of care, clinical expertise, and
willingness to teach staff, patients, and patients’ families.
Moore and Prentice (2013) reported a case study that analyzed the collaborative
process between APNs and nurse in an outpatient oncology setting in Canada. The
researchers discovered four basic themes to collaboration:
▪Time that APNs spend together outside of work translates into collaboration at
work.
▪The basic skill of clinical knowledge and experience are essential ingredients
for successful collaboration.
▪Other factors that that contribute to the success of collaboration include
sharing a similar philosophy of care and mutual trust, respect and esteem.
▪Barriers to collaboration inevitably arise. Nurses are largely unaware of how
collaboration should manifest in the practice and are not trained on principles
of effective collaboration in practice.
▪Nurses and APNs attitudes are changing toward collaboration, viewing
collaboration as a means of achieving positive results.
Moore and Prentice (2013) found that intraprofessional collaboration (a) is
complex, (b) is influenced by interpersonal and professional factors, and (c) does not
occur spontaneously. Nurse must have a solid understanding of the concept of
collaboration and how to apply it in the clinical setting.
Patient-centered care. Improvement of patient satisfaction and quality of care is
directly due to the implementation of patient-centered care. Patient-centered care, the
“new normal” in today’s healthcare system, provides a mechanism for nurses to engage
patients as active participates in their care. The Institute of Medicine (IOM, 2001, p. 6)
defines patient-centered care as “healthcare that establishes a partnership among
practitioner, patients and their families to ensure that decisions reflect patient s wants,
needs and preferences” (see also Boykins, 2014; Sepucha & Ozanne, 2010). Optimal
patient participation requires a dynamic interaction between partners (patient and staff) in
terms of interpersonal interaction, therapeutic approach, focus on resources, resources,
patient opportunities to participate in and influence health care team decision making, and
patient education (Sahlsten et al., 2007). Including the patient in bedside reports or
handoffs has been reported to improve teamwork, safety and efficiency (Wildner & Ferri,
2012). This bedside practice also entails the participation of patients as partners in their
care, with the expectation that their participation will lead to improved care, better
outcomes, improved adherence to treatment and medication regimen and greater
satisfaction with care. Barriers to implementation of patient-centered care and bedside
rounding include time and resource requirements; the potential for patients to feel
confused, upset, or dehumanized as a result of hearing clinical explanations; and the
potential for breach of patient confidentiality (McMurry et. al 2011). In addition, when
presenting sensitive or confidential information, some nurses may feel uncomfortable, or
be inhibited by a lack experience—especially in the presence of patients’ family members
or relatives are present. O’Connell, Macdonald, and Kelly (2008) found that viewed
handoffs as being too time consuming, and ineffective, or efficient. The investigators
recommended that a handoff guideline or information template should be developed to
promote and facilitate the reporting of objective relevant information.
Patient satisfaction and its effects on quality of care. As a subjective
phenomenon, “patient satisfaction” is difficult to define. The self-reported determination
of patient satisfaction is a personal evaluation of health care services and of the providers
of that care (Ware et al., 1983); patients’ attitudes and expectations regarding care greatly
affect their sense of satisfaction. Because satisfaction ratings are relative, subjective, and
not directly observable, attempting to meaningfully quantify patients’ personal evaluation
of care is highly problematic (Ware et al., 1983).
The challenges inherent in measuring patient satisfaction have ramifications for
policy and practice. For example, in 2012, the Center for Medicare and Medicaid
Services (CMS) began to implement a reimbursement system that adjusts payment rates
based on patient satisfaction scores (Lyu et al., 2013). Patient satisfaction is a key
determinant of quality of care and an important component of the pay-for-performance
metrics instituted by CMS. Beginning in 2012, CMS implemented value-based incentive
payments to acute-care hospitals based in part on results of satisfaction surveys from
patients discharged on or after October 1, 2012. The patient’s perception of quality is
significant determinant of the provider’s federal reimbursement. Patients now make
decisions based on their perceptions of the quality of and satisfaction with health care
providers (Bowers, Swan, & Koehler, 1994).
A study conducted by Fenton, Jerant, Bertakis, and Franks at the University of
California–Davis examined mortality rate in relation to patient satisfaction (N = 51,946);
the researchers’ analysis adjusted for a number of factors (i.e., demographics, health
status and chronic disease burden, Year 1 utilization and expenditures, availability of a
usual source of care, and insurance status). The investigators were surprised to find that,
in comparison with the mortality rate of patients in the lowest satisfaction quartile, the
mortality rate of patients in the highest satisfaction quartile was 26% higher (adjusted
hazard ratio, 1.26; 95% CI [1.05, 1.53]). This perhaps counterintuitive finding raises the
question of whether current satisfaction measures are in fact good indicators of health
care quality (Fenton et al., 2012). The researchers concluded that the connection between
patient satisfaction and health care outcomes is yet unclear.
Practitioners need to understand that ineffective communication can result in poor
outcomes. Improved communication not only results in better health outcomes, but also
may positivity impact patient satisfaction. For patients who want to be involved in their
care and who understand what is occurring during care, improved communication may
ultimately lead to greater patient satisfaction. The inclusion of APNs in the care team has
been reported to improve communication and the efficiency of care (McCauley, Bixby, &
Naylor, 2006).
Evidence-based practice. Evidence-based practice (EBP) is at the forefront of
change in today’s health care environment. EBP is the practice of using documented
evidence as a guide to problem solving approach to clinical decision making. To
implement EBP, one must “locate, critique, synthesize, translate, and evaluate evidence”
(Drenning, 2006, p.299). This includes the dissemination of information during the
implementation phase of practice. Although ostensibly EBP is the standard of nursing
practice, implementation of EBP is not always easy (Krom & Bautista, 2010). Barriers to
EBP implementation include (a) lack of requisite knowledge and skills on the part of
clinicians, (b) perception that EBP is time consuming, (b) perception that EBP is
burdensome, and (d) lack of management support at the organizational level (Melnyk &
Fineout-Overholt, 2012). Among clinical staff members, APNs, nurse educators, and
DNPs—who understand translational research—are uniquely qualified to fulfill their
responsibility to fulfill the mandate to implement evidence –based changes in practice.
These organizational change agents must persuasively teach the EBP process to staff
nurses and thereby transform the organizational culture—from a culture in which change
is resisted to a culture in which evidence-based improvements in practice are welcomed.
To achieve this transformation in organizational culture, APNs, nurse educators, and
DNPs must employ an interactive approach.
APNs serve as both leaders and knowledge resources for helping nursing staff to
ground care in current evidence. In a study conducted by Mahanes, Quatrara, and Shaw
(2013) at the University of Virginia, the researchers implemented APN-led nursing
rounds. Although the specific effects of the APN-led nursing rounds were impossible to
isolate, Mahanes and her colleagues were able to determine that rates of blood stream
infections, catheter-associated urinary tract infections, hospital-acquired pressure ulcers,
and ventilator-associated pneumonia and falls all declined. Similarly, in study that a
analyzed the effectiveness of an APN-managed heart failure program, Dahl and Penque
(2002) reported reduced 90-day readmission rates, fewer in-patient hospital days, lower
re-admission charges, and lower overall charges for health care services.
APNs have demonstrated implementation of EBP practices, better working
relationship with staff nurses, and improved patient-centered care with cost savings. The
development of an intraprofessional APN–staff nurse team to conduct bedside rounding
should improve patient care, increase communication and collaboration, and improve
patient satisfaction.
The daily goals reminder sheet. The need to develop clear team communication
has led to the development and institution of daily goal sheets. Studies in ICUs have
demonstrated that the use of daily goal sheets can result in nurses’ and physicians’ having
better understanding of patient care goals and in decreased ICU length of stay (Agarwal et
al., 2008; Narasimhan et al., 2006; Pronovost et al., 2003). A study conducted by
Phipps and Thomas (2007) examined the use of a daily goals sheet in the ICU at The
University of Pennsylvania’s Hershey Children’s Hospital. The researchers found that
85% of nurses felt the use of the goals sheets improved communications between
physicians and nurses and improved communication between nurses working on different
shifts. Phipps and Thomas also reported that 95% of the nursing staff felt that the extra
expenditure of time spent in completing the daily goals sheet was worthwhile. In another
study, the Beth Israel Medical Center in New York instituted use of a worksheet that was
posted at bedside after completion. Narasimham and colleagues (2006) found that pre and
post scores for understanding patient goals and communication improved significantly,
and that this improvement was sustained over a 9-month period. Furthermore, after
completion of the study, most of the practitioners requested that the use of the worksheet
be continued. In the DNP project, instituting a daily goals reminder worksheet associated
with APN–RN–patient bedside rounding enhanced communication between APNs, staff
nurses, and patients.
Needs Assessment and Description of the Project
Population identification. In this DNP project, the population identified for
selection and participation comprises APNs who have prior knowledge of and experience
with APN–RN–patient bedside rounding.
Identification of the project sponsor and key stakeholders. This DNP project
has no sponsors. Key stakeholders include the student investigator and ultimately the
APNs and RNs who will participate in the learning module.
Assessment of available resources. No monetary resources were available for
this project. As project investigator, I was responsible for the development of the learning
module. The project had no public advertisement. APNs were approached through the
hospital’s standardized email by the student researcher (Appendix B).
Team selection. The project investigator, served as the team for this project, with
consultation from the DNP project committee members.
Scope of the project. The project entailed only the development of the 1-hour
learning module. Further plans for implementation will be considered at some point in
the future. The module’s topics included (a) the requirement for close communication and
collaboration between team members to assure seamless, high-quality health care, (b) the
definition of APN–RN rounds, (c) the schedule and length of rounds, (d) the personnel
composition of rounding teams, (e) topics of discussion during the rounds, and (f) the use
of a daily goal reminder sheet to ensure the consistency of all elements of the patient's
treatment plan and goals.
As project investigator, I used the literature as a basis for creating the written
learning module. After completing the module and obtaining University of Nevada Las
Vegas Institutional Review Board approval, the learning module was sent to three APNs
in the hospital for review and feedback; all of these APNs had prior experience in
working with APN–RN rounds at other facilities. In addition, to assess the learning
module’s effectiveness, I developed an evaluation form to be completed by participating
APNs and RNs following their completion of the learning module.
All results of this project were shared with a representative of the CMC’s
administration and the Chief Nurse Executive. I hope to work with administration and
staff in implementing the APN–RN–patient rounding on a pilot unit and, on the basis of
results, further develops the model for use on other inpatient units.
Mission, Goals, and Objectives
The mission and goals of this project are to improve communication and
collaboration between the intraprofessional team of APNs and staff nurses and to improve
APN–staff nurse communication with patients.
This DNP project’s primary objective was to develop a structured learning module
pertaining to APN–RN–patient bedside rounding. The project’s long-term goals,
following completion of this project, are to implement the model and to improve
communication and collaboration between APNs, clinical nurses, and the patients cared
for by these nurses.
Chapter 3
Theoretical Underpinnings of the DNP Project
Of the several theories that have informed our understanding of holistic patient
centered care and educating adults, two theories are among the most influential: King’s
theory of goal attainment and Knowles’s theory of andragogy. In light of the theories’
relevance to developing interventions for improving health care team collaboration and
communication—the central concern of this dissertation—these two theories were
selected to serve as the theoretical underpinnings of the DNP staff education project in
support of APN–RN–patient bedside rounding. Specifically, King’s theory of goal
attainment informed the process of identifying content for the staff education module;
Knowles’s theory of andragogy informed the design of the module’s presentation to
training participants.
King’s Theory of Goal Attainment
In “Crossing the Quality Chasm: A New Health System for the 21st Century,” the
IOM (2001) describes six aims for the improvement of health care. One of the aims is to
provide patient-centered care that is respectful of and responsive to individual patients’
personal preferences, needs, and values; in patient-centered care, patients’ values play a
central role in informing clinical decision making clinical decisions. Among theoretical
frameworks that inform clinical understanding of the role of the patient in this
decisionmaking, Imogene Kings’ theory of goal attainment is seminal.
King’s theory and patient-centered health care. In King’s theory, health care
team decision-making includes a “transaction” in which the nurse and patient engage in
mutual goal setting (King, 1991, pp. 19). According to King, this transactional process of
interpersonal systems involves four steps—action, reaction, interaction, and transaction—
by which the patient and nurse (a) share information about their perceptions; (b) set goals
(through communication and interaction); and (c) explore and agree on means to achieve
these goals. To implement a true transactional process, the communication environment
must be reciprocal, and bidirectional. In this DNP project,
King’s theory—including the theory’s view of this transactional process—was applied to
inform the design of a patient-centered clinical environment. For example, to create and
maintain a patient-centered environment, APNs, clinical nurses, and patients must share
and be mutually informed about relevant considerations.
The theory of goal attainment: Assumptions and concepts. King developed her theory
of goal attainment in the 1960s. This theory describes the interpersonal dynamic
relationships between patients and their quest for goal attainment. Factors that can affect
goal attainment include roles, stressors, space, and time. In order for health care to be
optimal during the course of treatment for individual patients, both the patients and their
providers must continuously accommodate and adjust for changes in these factors.
King’s theory refers to three interacting systems: individuals (personal system),
groups (interpersonal system), and society (social system). The personal system is a
unified, complex, whole self who perceives, thinks, desires, imagines, decides, identifies
goals, and selects means to achieve them.
Assumptions. King’s framework is based on two assumptions:
▪Human beings are the focus of nursing.
▪The goals of nursing are health promotion, maintenance and restoration, care
of the sick or impaired, and care of the dying.
On the basis of these assumptions, King designed a conceptual system to explain
the organized wholes in which nurses are expected to function (see Figure 1; King, 1999).
Wholeness. King used the concept of “wholeness” to describe the broader
organization or social systems in which nurse’s function. (King, 1996, p. 61). The goal of
an interacting system is health for individuals, families, communities, and the world
(King, 1996).
Personal, interpersonal, and social systems. King’s conceptual framework is
organized into three “systems”: personal, interpersonal, and social. A personal or
individual system is essentially a single whole system. In contrast, an interpersonal
system represents the interaction of two or more individuals (i.e., small groups) in various
environments. Social systems are composed of large groups, such as educational,
governmental, or religious organizations.
Although in recent decades the quality and effectiveness of MD–RN interaction has
improved, the potential and need for further improvement in interprofessional
collaboration are substantial. To assess this need, Weaver et al. (2014) recently examined
teamwork and collaboration between staff nurses, residents, hospitalists, and oncology
physicians in oncology units at a large urban hospital. The investigators found that
physicians rated the quality of their own collaboration “very high” with other physicians
and with nurses. Physician ranked nurses’ collaboration with physicians as ranging from
87% to 100%. In stark contrast, however, nurses rated the quality of collaboration with
physicians poorly, from 35%–65%. Weaver et al. found that hierarchies persist and can
interfere with collaboration. Nurses believed that a negative attitude toward
communication as a significant obstacle to collaboration. A nurse may be reluctant to call
a physician if the nurse perceives that their relationship is not mutually supportive and
collaborative. On the other hand, physicians, having a positive perception of
collaboration, perceive difficulty contacting other providers as the main obstacle to
collaboration. Physicians who assume they have a good collaborative relationship with
nurses may not seek additional information because they (the physicians) are unaware of
potential or actual problems (Weaver et al., 2014).
Vazirani et al. (2005) surveyed registered nurses (n = 123), physicians (n = 45),
and a combined group of resident physicians and interns (n = 111) to determine whether
introduction of an APN role to the team was followed by changes in team communication
and collaboration. Physicians reported that, when an APN was part of the team, the level
of collaboration with nurses and APNs was significantly higher. Physicians also reported
that when an APN was part of the team, the team had fewer unnecessary delays and better
general communication. In the same study, the staff nurses reported significantly better
communication with APNs than with physicians (Vazirani et al., 2005). Kilpatrick (2012)
also found that communication and decision-making improve quality of care when the
participating APN is able to act within the full scope of the APN role. Among other
positive outcomes, this study reported that APN participation was associated with
decreases in length of patient stay and costs for patients treated on the intervention unit,
without an increase of readmission rates.
Vazirani’s (2005) study employed surveys to assess the degree of communication
and collaboration over two units. Physicians were surveyed immediately after they
completed a given rotation, starting at the onset of the interventions. Nurses were
surveyed biannually. The statistical analysis took into account correlation of observations
due to repeated sampling (Vazirani et al., 2005). Limitations in this study included
physician and staff nurse confusion about the role of APNs. Prior to the study, no APNs
were employed in the hospital’s internal medicine department. Chicago Medical Center
(CMC) employs approximately 200 APNs throughout all medical and surgical services,
thus role confusion is not a problem. The second limitation of this study pertained to
sample size. Physicians and nurses were not allowed to work on both the interventional
and control units; accordingly, the pool of physicians and pool of nurses available to
participate in the study was restricted. This can present problems with sample size but
also falsely promote familiarity and foster improved communications, skewing positive
results.
Although the quantity of studies is limited, it is clear that when an APN is an
integral part of the interprofessional team, the quality of communication and collaboration
increases. This DNP project specifies inclusion of the APN and staff nurse as members of
the professional team. The patient, who is also an integral part of this team, is not a
professional but is in fact the core leader of the health care team. In the decision-making
process, the patient’s understanding and input are invaluable
Communication and collaboration between APNs and staff nurses. The
majority of studies of communication and collaboration in health care contexts focused on
the nurse–physician relationship (Baggs & Ryan, 1990; Chapman, 2009;
DechairoMarino et al., 2001; Nathanson et al., 2011; Shortal et al., 1991). There have
been minimal formal studies looking at MD-APN and improved communication with
staff and its effects on patient care (Cowan et al., 2006). In nursing intraprofessional
teams, communication has been identified as the essential component of good team
functioning (Dreaschlin et al., 1999; Jones, 2005; Richardson et al., 2010). APNs possess
diverse knowledge that can facilitate understanding of collaborative practice to optimize
patient care (Crecelius, 2011). The Agency for Healthcare Research and Quality (2014)
found that when nurse practitioners are included in daily multidisciplinary rounds, the
rounding team’s communication and collaboration improve.
The increasing use of health care teams has made nursing practice more salient, in
that nurses serve as a link between team members and patients. Effective communication
between all team members is essential for successful teamwork and high-quality patient
care (Apker et al., 2006). The advance nurse practitioner function as the central link of the
health care team integrating other health care providers and patients. Good
communication among staff and between staff and patients is the cornerstone of quality
care.
Gooden and Jackson (2004) documented one of the earliest studies examining
staff nurses’ attitudes toward APNs. The investigators found that as APNs have come to
manage an increasing number of patients, staff nurses have begun to view the APNs as
leaders. Staff RNs consistently scored APNs higher than physicians in measures of
communication, respect for staff opinion, quality of care, clinical expertise, and
willingness to teach staff, patients, and patients’ families.
Moore and Prentice (2013) reported a case study that analyzed the collaborative
process between APNs and nurse in an outpatient oncology setting in Canada. The
researchers discovered four basic themes to collaboration:
▪Time that APNs spend together outside of work translates into collaboration at
work.
▪The basic skill of clinical knowledge and experience are essential ingredients
for successful collaboration.
▪Other factors that that contribute to the success of collaboration include
sharing a similar philosophy of care and mutual trust, respect and esteem.
▪Barriers to collaboration inevitably arise. Nurses are largely unaware of how
collaboration should manifest in the practice and are not trained on principles
of effective collaboration in practice.
▪Nurses and APNs attitudes are changing toward collaboration, viewing
collaboration as a means of achieving positive results.
Moore and Prentice (2013) found that intraprofessional collaboration (a) is
complex, (b) is influenced by interpersonal and professional factors, and (c) does not
occur spontaneously. Nurse must have a solid understanding of the concept of
collaboration and how to apply it in the clinical setting.
Patient-centered care. Improvement of patient satisfaction and quality of care is
directly due to the implementation of patient-centered care. Patient-centered care, the
“new normal” in today’s healthcare system, provides a mechanism for nurses to engage
patients as active participates in their care. The Institute of Medicine (IOM, 2001, p. 6)
defines patient-centered care as “healthcare that establishes a partnership among
practitioner, patients and their families to ensure that decisions reflect patient s wants,
needs and preferences” (see also Boykins, 2014; Sepucha & Ozanne, 2010). Optimal
patient participation requires a dynamic interaction between partners (patient and staff) in
terms of interpersonal interaction, therapeutic approach, focus on resources, resources,
patient opportunities to participate in and influence health care team decision making, and
patient education (Sahlsten et al., 2007). Including the patient in bedside reports or
handoffs has been reported to improve teamwork, safety and efficiency (Wildner & Ferri,
2012). This bedside practice also entails the participation of patients as partners in their
care, with the expectation that their participation will lead to improved care, better
outcomes, improved adherence to treatment and medication regimen and greater
satisfaction with care. Barriers to implementation of patient-centered care and bedside
rounding include time and resource requirements; the potential for patients to feel
confused, upset, or dehumanized as a result of hearing clinical explanations; and the
potential for breach of patient confidentiality (McMurry et. al 2011). In addition, when
presenting sensitive or confidential information, some nurses may feel uncomfortable, or
be inhibited by a lack experience—especially in the presence of patients’ family members
or relatives are present. O’Connell, Macdonald, and Kelly (2008) found that viewed
handoffs as being too time consuming, and ineffective, or efficient. The investigators
recommended that a handoff guideline or information template should be developed to
promote and facilitate the reporting of objective relevant information.
Patient satisfaction and its effects on quality of care. As a subjective
phenomenon, “patient satisfaction” is difficult to define. The self-reported determination
of patient satisfaction is a personal evaluation of health care services and of the providers
of that care (Ware et al., 1983); patients’ attitudes and expectations regarding care greatly
affect their sense of satisfaction. Because satisfaction ratings are relative, subjective, and
not directly observable, attempting to meaningfully quantify patients’ personal evaluation
of care is highly problematic (Ware et al., 1983).
The challenges inherent in measuring patient satisfaction have ramifications for
policy and practice. For example, in 2012, the Center for Medicare and Medicaid
Services (CMS) began to implement a reimbursement system that adjusts payment rates
based on patient satisfaction scores (Lyu et al., 2013). Patient satisfaction is a key
determinant of quality of care and an important component of the pay-for-performance
metrics instituted by CMS. Beginning in 2012, CMS implemented value-based incentive
payments to acute-care hospitals based in part on results of satisfaction surveys from
patients discharged on or after October 1, 2012. The patient’s perception of quality is
significant determinant of the provider’s federal reimbursement. Patients now make
decisions based on their perceptions of the quality of and satisfaction with health care
providers (Bowers, Swan, & Koehler, 1994).
A study conducted by Fenton, Jerant, Bertakis, and Franks at the University of
California–Davis examined mortality rate in relation to patient satisfaction (N = 51,946);
the researchers’ analysis adjusted for a number of factors (i.e., demographics, health
status and chronic disease burden, Year 1 utilization and expenditures, availability of a
usual source of care, and insurance status). The investigators were surprised to find that,
in comparison with the mortality rate of patients in the lowest satisfaction quartile, the
mortality rate of patients in the highest satisfaction quartile was 26% higher (adjusted
hazard ratio, 1.26; 95% CI [1.05, 1.53]). This perhaps counterintuitive finding raises the
question of whether current satisfaction measures are in fact good indicators of health
care quality (Fenton et al., 2012). The researchers concluded that the connection between
patient satisfaction and health care outcomes is yet unclear.
Practitioners need to understand that ineffective communication can result in poor
outcomes. Improved communication not only results in better health outcomes, but also
may positivity impact patient satisfaction. For patients who want to be involved in their
care and who understand what is occurring during care, improved communication may
ultimately lead to greater patient satisfaction. The inclusion of APNs in the care team has
been reported to improve communication and the efficiency of care (McCauley, Bixby, &
Naylor, 2006).
Evidence-based practice. Evidence-based practice (EBP) is at the forefront of
change in today’s health care environment. EBP is the practice of using documented
evidence as a guide to problem solving approach to clinical decision making. To
implement EBP, one must “locate, critique, synthesize, translate, and evaluate evidence”
(Drenning, 2006, p.299). This includes the dissemination of information during the
implementation phase of practice. Although ostensibly EBP is the standard of nursing
practice, implementation of EBP is not always easy (Krom & Bautista, 2010). Barriers to
EBP implementation include (a) lack of requisite knowledge and skills on the part of
clinicians, (b) perception that EBP is time consuming, (b) perception that EBP is
burdensome, and (d) lack of management support at the organizational level (Melnyk &
Fineout-Overholt, 2012). Among clinical staff members, APNs, nurse educators, and
DNPs—who understand translational research—are uniquely qualified to fulfill their
responsibility to fulfill the mandate to implement evidence –based changes in practice.
These organizational change agents must persuasively teach the EBP process to staff
nurses and thereby transform the organizational culture—from a culture in which change
is resisted to a culture in which evidence-based improvements in practice are welcomed.
To achieve this transformation in organizational culture, APNs, nurse educators, and
DNPs must employ an interactive approach.
APNs serve as both leaders and knowledge resources for helping nursing staff to
ground care in current evidence. In a study conducted by Mahanes, Quatrara, and Shaw
(2013) at the University of Virginia, the researchers implemented APN-led nursing
rounds. Although the specific effects of the APN-led nursing rounds were impossible to
isolate, Mahanes and her colleagues were able to determine that rates of blood stream
infections, catheter-associated urinary tract infections, hospital-acquired pressure ulcers,
and ventilator-associated pneumonia and falls all declined. Similarly, in study that a
analyzed the effectiveness of an APN-managed heart failure program, Dahl and Penque
(2002) reported reduced 90-day readmission rates, fewer in-patient hospital days, lower
re-admission charges, and lower overall charges for health care services.
APNs have demonstrated implementation of EBP practices, better working
relationship with staff nurses, and improved patient-centered care with cost savings. The
development of an intraprofessional APN–staff nurse team to conduct bedside rounding
should improve patient care, increase communication and collaboration, and improve
patient satisfaction.
The daily goals reminder sheet. The need to develop clear team communication
has led to the development and institution of daily goal sheets. Studies in ICUs have
demonstrated that the use of daily goal sheets can result in nurses’ and physicians’ having
better understanding of patient care goals and in decreased ICU length of stay (Agarwal et
al., 2008; Narasimhan et al., 2006; Pronovost et al., 2003). A study conducted by
Phipps and Thomas (2007) examined the use of a daily goals sheet in the ICU at The
University of Pennsylvania’s Hershey Children’s Hospital. The researchers found that
85% of nurses felt the use of the goals sheets improved communications between
physicians and nurses and improved communication between nurses working on different
shifts. Phipps and Thomas also reported that 95% of the nursing staff felt that the extra
expenditure of time spent in completing the daily goals sheet was worthwhile. In another
study, the Beth Israel Medical Center in New York instituted use of a worksheet that was
posted at bedside after completion. Narasimham and colleagues (2006) found that pre and
post scores for understanding patient goals and communication improved significantly,
and that this improvement was sustained over a 9-month period. Furthermore, after
completion of the study, most of the practitioners requested that the use of the worksheet
be continued. In the DNP project, instituting a daily goals reminder worksheet associated
with APN–RN–patient bedside rounding enhanced communication between APNs, staff
nurses, and patients.
Needs Assessment and Description of the Project
Population identification. In this DNP project, the population identified for
selection and participation comprises APNs who have prior knowledge of and experience
with APN–RN–patient bedside rounding.
Identification of the project sponsor and key stakeholders. This DNP project
has no sponsors. Key stakeholders include the student investigator and ultimately the
APNs and RNs who will participate in the learning module.
Assessment of available resources. No monetary resources were available for
this project. As project investigator, I was responsible for the development of the learning
module. The project had no public advertisement. APNs were approached through the
hospital’s standardized email by the student researcher (Appendix B).
Team selection. The project investigator, served as the team for this project, with
consultation from the DNP project committee members.
Scope of the project. The project entailed only the development of the 1-hour
learning module. Further plans for implementation will be considered at some point in
the future. The module’s topics included (a) the requirement for close communication and
collaboration between team members to assure seamless, high-quality health care, (b) the
definition of APN–RN rounds, (c) the schedule and length of rounds, (d) the personnel
composition of rounding teams, (e) topics of discussion during the rounds, and (f) the use
of a daily goal reminder sheet to ensure the consistency of all elements of the patient's
treatment plan and goals.
As project investigator, I used the literature as a basis for creating the written
learning module. After completing the module and obtaining University of Nevada Las
Vegas Institutional Review Board approval, the learning module was sent to three APNs
in the hospital for review and feedback; all of these APNs had prior experience in
working with APN–RN rounds at other facilities. In addition, to assess the learning
module’s effectiveness, I developed an evaluation form to be completed by participating
APNs and RNs following their completion of the learning module.
All results of this project were shared with a representative of the CMC’s
administration and the Chief Nurse Executive. I hope to work with administration and
staff in implementing the APN–RN–patient rounding on a pilot unit and, on the basis of
results, further develops the model for use on other inpatient units.
Mission, Goals, and Objectives
The mission and goals of this project are to improve communication and
collaboration between the intraprofessional team of APNs and staff nurses and to improve
APN–staff nurse communication with patients.
This DNP project’s primary objective was to develop a structured learning module
pertaining to APN–RN–patient bedside rounding. The project’s long-term goals,
following completion of this project, are to implement the model and to improve
communication and collaboration between APNs, clinical nurses, and the patients cared
for by these nurses.
Chapter 3
Theoretical Underpinnings of the DNP Project
Of the several theories that have informed our understanding of holistic patient
centered care and educating adults, two theories are among the most influential: King’s
theory of goal attainment and Knowles’s theory of andragogy. In light of the theories’
relevance to developing interventions for improving health care team collaboration and
communication—the central concern of this dissertation—these two theories were
selected to serve as the theoretical underpinnings of the DNP staff education project in
support of APN–RN–patient bedside rounding. Specifically, King’s theory of goal
attainment informed the process of identifying content for the staff education module;
Knowles’s theory of andragogy informed the design of the module’s presentation to
training participants.
King’s Theory of Goal Attainment
In “Crossing the Quality Chasm: A New Health System for the 21st Century,” the
IOM (2001) describes six aims for the improvement of health care. One of the aims is to
provide patient-centered care that is respectful of and responsive to individual patients’
personal preferences, needs, and values; in patient-centered care, patients’ values play a
central role in informing clinical decision making clinical decisions. Among theoretical
frameworks that inform clinical understanding of the role of the patient in this
decisionmaking, Imogene Kings’ theory of goal attainment is seminal.
King’s theory and patient-centered health care. In King’s theory, health care
team decision-making includes a “transaction” in which the nurse and patient engage in
mutual goal setting (King, 1991, pp. 19). According to King, this transactional process of
interpersonal systems involves four steps—action, reaction, interaction, and transaction—
by which the patient and nurse (a) share information about their perceptions; (b) set goals
(through communication and interaction); and (c) explore and agree on means to achieve
these goals. To implement a true transactional process, the communication environment
must be reciprocal, and bidirectional. In this DNP project,
King’s theory—including the theory’s view of this transactional process—was applied to
inform the design of a patient-centered clinical environment. For example, to create and
maintain a patient-centered environment, APNs, clinical nurses, and patients must share
and be mutually informed about relevant considerations.
The theory of goal attainment: Assumptions and concepts. King developed her theory
of goal attainment in the 1960s. This theory describes the interpersonal dynamic
relationships between patients and their quest for goal attainment. Factors that can affect
goal attainment include roles, stressors, space, and time. In order for health care to be
optimal during the course of treatment for individual patients, both the patients and their
providers must continuously accommodate and adjust for changes in these factors.
King’s theory refers to three interacting systems: individuals (personal system),
groups (interpersonal system), and society (social system). The personal system is a
unified, complex, whole self who perceives, thinks, desires, imagines, decides, identifies
goals, and selects means to achieve them.
Assumptions. King’s framework is based on two assumptions:
▪Human beings are the focus of nursing.
▪The goals of nursing are health promotion, maintenance and restoration, care
of the sick or impaired, and care of the dying.
On the basis of these assumptions, King designed a conceptual system to explain
the organized wholes in which nurses are expected to function (see Figure 1; King, 1999).
Wholeness. King used the concept of “wholeness” to describe the broader
organization or social systems in which nurse’s function. (King, 1996, p. 61). The goal of
an interacting system is health for individuals, families, communities, and the world
(King, 1996).
Personal, interpersonal, and social systems. King’s conceptual framework is
organized into three “systems”: personal, interpersonal, and social. A personal or
individual system is essentially a single whole system. In contrast, an interpersonal
system represents the interaction of two or more individuals (i.e., small groups) in various
environments. Social systems are composed of large groups, such as educational,
governmental, or religious organizations.
Although in recent decades the quality and effectiveness of MD–RN interaction has
improved, the potential and need for further improvement in interprofessional
collaboration are substantial. To assess this need, Weaver et al. (2014) recently examined
teamwork and collaboration between staff nurses, residents, hospitalists, and oncology
physicians in oncology units at a large urban hospital. The investigators found that
physicians rated the quality of their own collaboration “very high” with other physicians
and with nurses. Physician ranked nurses’ collaboration with physicians as ranging from
87% to 100%. In stark contrast, however, nurses rated the quality of collaboration with
physicians poorly, from 35%–65%. Weaver et al. found that hierarchies persist and can
interfere with collaboration. Nurses believed that a negative attitude toward
communication as a significant obstacle to collaboration. A nurse may be reluctant to call
a physician if the nurse perceives that their relationship is not mutually supportive and
collaborative. On the other hand, physicians, having a positive perception of
collaboration, perceive difficulty contacting other providers as the main obstacle to
collaboration. Physicians who assume they have a good collaborative relationship with
nurses may not seek additional information because they (the physicians) are unaware of
potential or actual problems (Weaver et al., 2014).
Vazirani et al. (2005) surveyed registered nurses (n = 123), physicians (n = 45),
and a combined group of resident physicians and interns (n = 111) to determine whether
introduction of an APN role to the team was followed by changes in team communication
and collaboration. Physicians reported that, when an APN was part of the team, the level
of collaboration with nurses and APNs was significantly higher. Physicians also reported
that when an APN was part of the team, the team had fewer unnecessary delays and better
general communication. In the same study, the staff nurses reported significantly better
communication with APNs than with physicians (Vazirani et al., 2005). Kilpatrick (2012)
also found that communication and decision-making improve quality of care when the
participating APN is able to act within the full scope of the APN role. Among other
positive outcomes, this study reported that APN participation was associated with
decreases in length of patient stay and costs for patients treated on the intervention unit,
without an increase of readmission rates.
Vazirani’s (2005) study employed surveys to assess the degree of communication
and collaboration over two units. Physicians were surveyed immediately after they
completed a given rotation, starting at the onset of the interventions. Nurses were
surveyed biannually. The statistical analysis took into account correlation of observations
due to repeated sampling (Vazirani et al., 2005). Limitations in this study included
physician and staff nurse confusion about the role of APNs. Prior to the study, no APNs
were employed in the hospital’s internal medicine department. Chicago Medical Center
(CMC) employs approximately 200 APNs throughout all medical and surgical services,
thus role confusion is not a problem. The second limitation of this study pertained to
sample size. Physicians and nurses were not allowed to work on both the interventional
and control units; accordingly, the pool of physicians and pool of nurses available to
participate in the study was restricted. This can present problems with sample size but
also falsely promote familiarity and foster improved communications, skewing positive
results.
Although the quantity of studies is limited, it is clear that when an APN is an
integral part of the interprofessional team, the quality of communication and collaboration
increases. This DNP project specifies inclusion of the APN and staff nurse as members of
the professional team. The patient, who is also an integral part of this team, is not a
professional but is in fact the core leader of the health care team. In the decision-making
process, the patient’s understanding and input are invaluable
Communication and collaboration between APNs and staff nurses. The
majority of studies of communication and collaboration in health care contexts focused on
the nurse–physician relationship (Baggs & Ryan, 1990; Chapman, 2009;
DechairoMarino et al., 2001; Nathanson et al., 2011; Shortal et al., 1991). There have
been minimal formal studies looking at MD-APN and improved communication with
staff and its effects on patient care (Cowan et al., 2006). In nursing intraprofessional
teams, communication has been identified as the essential component of good team
functioning (Dreaschlin et al., 1999; Jones, 2005; Richardson et al., 2010). APNs possess
diverse knowledge that can facilitate understanding of collaborative practice to optimize
patient care (Crecelius, 2011). The Agency for Healthcare Research and Quality (2014)
found that when nurse practitioners are included in daily multidisciplinary rounds, the
rounding team’s communication and collaboration improve.
The increasing use of health care teams has made nursing practice more salient, in
that nurses serve as a link between team members and patients. Effective communication
between all team members is essential for successful teamwork and high-quality patient
care (Apker et al., 2006). The advance nurse practitioner function as the central link of the
health care team integrating other health care providers and patients. Good
communication among staff and between staff and patients is the cornerstone of quality
care.
Gooden and Jackson (2004) documented one of the earliest studies examining
staff nurses’ attitudes toward APNs. The investigators found that as APNs have come to
manage an increasing number of patients, staff nurses have begun to view the APNs as
leaders. Staff RNs consistently scored APNs higher than physicians in measures of
communication, respect for staff opinion, quality of care, clinical expertise, and
willingness to teach staff, patients, and patients’ families.
Moore and Prentice (2013) reported a case study that analyzed the collaborative
process between APNs and nurse in an outpatient oncology setting in Canada. The
researchers discovered four basic themes to collaboration:
▪Time that APNs spend together outside of work translates into collaboration at
work.
▪The basic skill of clinical knowledge and experience are essential ingredients
for successful collaboration.
▪Other factors that that contribute to the success of collaboration include
sharing a similar philosophy of care and mutual trust, respect and esteem.
▪Barriers to collaboration inevitably arise. Nurses are largely unaware of how
collaboration should manifest in the practice and are not trained on principles
of effective collaboration in practice.
▪Nurses and APNs attitudes are changing toward collaboration, viewing
collaboration as a means of achieving positive results.
Moore and Prentice (2013) found that intraprofessional collaboration (a) is
complex, (b) is influenced by interpersonal and professional factors, and (c) does not
occur spontaneously. Nurse must have a solid understanding of the concept of
collaboration and how to apply it in the clinical setting.
Patient-centered care. Improvement of patient satisfaction and quality of care is
directly due to the implementation of patient-centered care. Patient-centered care, the
“new normal” in today’s healthcare system, provides a mechanism for nurses to engage
patients as active participates in their care. The Institute of Medicine (IOM, 2001, p. 6)
defines patient-centered care as “healthcare that establishes a partnership among
practitioner, patients and their families to ensure that decisions reflect patient s wants,
needs and preferences” (see also Boykins, 2014; Sepucha & Ozanne, 2010). Optimal
patient participation requires a dynamic interaction between partners (patient and staff) in
terms of interpersonal interaction, therapeutic approach, focus on resources, resources,
patient opportunities to participate in and influence health care team decision making, and
patient education (Sahlsten et al., 2007). Including the patient in bedside reports or
handoffs has been reported to improve teamwork, safety and efficiency (Wildner & Ferri,
2012). This bedside practice also entails the participation of patients as partners in their
care, with the expectation that their participation will lead to improved care, better
outcomes, improved adherence to treatment and medication regimen and greater
satisfaction with care. Barriers to implementation of patient-centered care and bedside
rounding include time and resource requirements; the potential for patients to feel
confused, upset, or dehumanized as a result of hearing clinical explanations; and the
potential for breach of patient confidentiality (McMurry et. al 2011). In addition, when
presenting sensitive or confidential information, some nurses may feel uncomfortable, or
be inhibited by a lack experience—especially in the presence of patients’ family members
or relatives are present. O’Connell, Macdonald, and Kelly (2008) found that viewed
handoffs as being too time consuming, and ineffective, or efficient. The investigators
recommended that a handoff guideline or information template should be developed to
promote and facilitate the reporting of objective relevant information.
Patient satisfaction and its effects on quality of care. As a subjective
phenomenon, “patient satisfaction” is difficult to define. The self-reported determination
of patient satisfaction is a personal evaluation of health care services and of the providers
of that care (Ware et al., 1983); patients’ attitudes and expectations regarding care greatly
affect their sense of satisfaction. Because satisfaction ratings are relative, subjective, and
not directly observable, attempting to meaningfully quantify patients’ personal evaluation
of care is highly problematic (Ware et al., 1983).
The challenges inherent in measuring patient satisfaction have ramifications for
policy and practice. For example, in 2012, the Center for Medicare and Medicaid
Services (CMS) began to implement a reimbursement system that adjusts payment rates
based on patient satisfaction scores (Lyu et al., 2013). Patient satisfaction is a key
determinant of quality of care and an important component of the pay-for-performance
metrics instituted by CMS. Beginning in 2012, CMS implemented value-based incentive
payments to acute-care hospitals based in part on results of satisfaction surveys from
patients discharged on or after October 1, 2012. The patient’s perception of quality is
significant determinant of the provider’s federal reimbursement. Patients now make
decisions based on their perceptions of the quality of and satisfaction with health care
providers (Bowers, Swan, & Koehler, 1994).
A study conducted by Fenton, Jerant, Bertakis, and Franks at the University of
California–Davis examined mortality rate in relation to patient satisfaction (N = 51,946);
the researchers’ analysis adjusted for a number of factors (i.e., demographics, health
status and chronic disease burden, Year 1 utilization and expenditures, availability of a
usual source of care, and insurance status). The investigators were surprised to find that,
in comparison with the mortality rate of patients in the lowest satisfaction quartile, the
mortality rate of patients in the highest satisfaction quartile was 26% higher (adjusted
hazard ratio, 1.26; 95% CI [1.05, 1.53]). This perhaps counterintuitive finding raises the
question of whether current satisfaction measures are in fact good indicators of health
care quality (Fenton et al., 2012). The researchers concluded that the connection between
patient satisfaction and health care outcomes is yet unclear.
Practitioners need to understand that ineffective communication can result in poor
outcomes. Improved communication not only results in better health outcomes, but also
may positivity impact patient satisfaction. For patients who want to be involved in their
care and who understand what is occurring during care, improved communication may
ultimately lead to greater patient satisfaction. The inclusion of APNs in the care team has
been reported to improve communication and the efficiency of care (McCauley, Bixby, &
Naylor, 2006).
Evidence-based practice. Evidence-based practice (EBP) is at the forefront of
change in today’s health care environment. EBP is the practice of using documented
evidence as a guide to problem solving approach to clinical decision making. To
implement EBP, one must “locate, critique, synthesize, translate, and evaluate evidence”
(Drenning, 2006, p.299). This includes the dissemination of information during the
implementation phase of practice. Although ostensibly EBP is the standard of nursing
practice, implementation of EBP is not always easy (Krom & Bautista, 2010). Barriers to
EBP implementation include (a) lack of requisite knowledge and skills on the part of
clinicians, (b) perception that EBP is time consuming, (b) perception that EBP is
burdensome, and (d) lack of management support at the organizational level (Melnyk &
Fineout-Overholt, 2012). Among clinical staff members, APNs, nurse educators, and
DNPs—who understand translational research—are uniquely qualified to fulfill their
responsibility to fulfill the mandate to implement evidence –based changes in practice.
These organizational change agents must persuasively teach the EBP process to staff
nurses and thereby transform the organizational culture—from a culture in which change
is resisted to a culture in which evidence-based improvements in practice are welcomed.
To achieve this transformation in organizational culture, APNs, nurse educators, and
DNPs must employ an interactive approach.
APNs serve as both leaders and knowledge resources for helping nursing staff to
ground care in current evidence. In a study conducted by Mahanes, Quatrara, and Shaw
(2013) at the University of Virginia, the researchers implemented APN-led nursing
rounds. Although the specific effects of the APN-led nursing rounds were impossible to
isolate, Mahanes and her colleagues were able to determine that rates of blood stream
infections, catheter-associated urinary tract infections, hospital-acquired pressure ulcers,
and ventilator-associated pneumonia and falls all declined. Similarly, in study that a
analyzed the effectiveness of an APN-managed heart failure program, Dahl and Penque
(2002) reported reduced 90-day readmission rates, fewer in-patient hospital days, lower
re-admission charges, and lower overall charges for health care services.
APNs have demonstrated implementation of EBP practices, better working
relationship with staff nurses, and improved patient-centered care with cost savings. The
development of an intraprofessional APN–staff nurse team to conduct bedside rounding
should improve patient care, increase communication and collaboration, and improve
patient satisfaction.
The daily goals reminder sheet. The need to develop clear team communication
has led to the development and institution of daily goal sheets. Studies in ICUs have
demonstrated that the use of daily goal sheets can result in nurses’ and physicians’ having
better understanding of patient care goals and in decreased ICU length of stay (Agarwal et
al., 2008; Narasimhan et al., 2006; Pronovost et al., 2003). A study conducted by
Phipps and Thomas (2007) examined the use of a daily goals sheet in the ICU at The
University of Pennsylvania’s Hershey Children’s Hospital. The researchers found that
85% of nurses felt the use of the goals sheets improved communications between
physicians and nurses and improved communication between nurses working on different
shifts. Phipps and Thomas also reported that 95% of the nursing staff felt that the extra
expenditure of time spent in completing the daily goals sheet was worthwhile. In another
study, the Beth Israel Medical Center in New York instituted use of a worksheet that was
posted at bedside after completion. Narasimham and colleagues (2006) found that pre and
post scores for understanding patient goals and communication improved significantly,
and that this improvement was sustained over a 9-month period. Furthermore, after
completion of the study, most of the practitioners requested that the use of the worksheet
be continued. In the DNP project, instituting a daily goals reminder worksheet associated
with APN–RN–patient bedside rounding enhanced communication between APNs, staff
nurses, and patients.
Needs Assessment and Description of the Project
Population identification. In this DNP project, the population identified for
selection and participation comprises APNs who have prior knowledge of and experience
with APN–RN–patient bedside rounding.
Identification of the project sponsor and key stakeholders. This DNP project
has no sponsors. Key stakeholders include the student investigator and ultimately the
APNs and RNs who will participate in the learning module.
Assessment of available resources. No monetary resources were available for
this project. As project investigator, I was responsible for the development of the learning
module. The project had no public advertisement. APNs were approached through the
hospital’s standardized email by the student researcher (Appendix B).
Team selection. The project investigator, served as the team for this project, with
consultation from the DNP project committee members.
Scope of the project. The project entailed only the development of the 1-hour
learning module. Further plans for implementation will be considered at some point in
the future. The module’s topics included (a) the requirement for close communication and
collaboration between team members to assure seamless, high-quality health care, (b) the
definition of APN–RN rounds, (c) the schedule and length of rounds, (d) the personnel
composition of rounding teams, (e) topics of discussion during the rounds, and (f) the use
of a daily goal reminder sheet to ensure the consistency of all elements of the patient's
treatment plan and goals.
As project investigator, I used the literature as a basis for creating the written
learning module. After completing the module and obtaining University of Nevada Las
Vegas Institutional Review Board approval, the learning module was sent to three APNs
in the hospital for review and feedback; all of these APNs had prior experience in
working with APN–RN rounds at other facilities. In addition, to assess the learning
module’s effectiveness, I developed an evaluation form to be completed by participating
APNs and RNs following their completion of the learning module.
All results of this project were shared with a representative of the CMC’s
administration and the Chief Nurse Executive. I hope to work with administration and
staff in implementing the APN–RN–patient rounding on a pilot unit and, on the basis of
results, further develops the model for use on other inpatient units.
Mission, Goals, and Objectives
The mission and goals of this project are to improve communication and
collaboration between the intraprofessional team of APNs and staff nurses and to improve
APN–staff nurse communication with patients.
This DNP project’s primary objective was to develop a structured learning module
pertaining to APN–RN–patient bedside rounding. The project’s long-term goals,
following completion of this project, are to implement the model and to improve
communication and collaboration between APNs, clinical nurses, and the patients cared
for by these nurses.
Chapter 3
Theoretical Underpinnings of the DNP Project
Of the several theories that have informed our understanding of holistic patient
centered care and educating adults, two theories are among the most influential: King’s
theory of goal attainment and Knowles’s theory of andragogy. In light of the theories’
relevance to developing interventions for improving health care team collaboration and
communication—the central concern of this dissertation—these two theories were
selected to serve as the theoretical underpinnings of the DNP staff education project in
support of APN–RN–patient bedside rounding. Specifically, King’s theory of goal
attainment informed the process of identifying content for the staff education module;
Knowles’s theory of andragogy informed the design of the module’s presentation to
training participants.
King’s Theory of Goal Attainment
In “Crossing the Quality Chasm: A New Health System for the 21st Century,” the
IOM (2001) describes six aims for the improvement of health care. One of the aims is to
provide patient-centered care that is respectful of and responsive to individual patients’
personal preferences, needs, and values; in patient-centered care, patients’ values play a
central role in informing clinical decision making clinical decisions. Among theoretical
frameworks that inform clinical understanding of the role of the patient in this
decisionmaking, Imogene Kings’ theory of goal attainment is seminal.
King’s theory and patient-centered health care. In King’s theory, health care
team decision-making includes a “transaction” in which the nurse and patient engage in
mutual goal setting (King, 1991, pp. 19). According to King, this transactional process of
interpersonal systems involves four steps—action, reaction, interaction, and transaction—
by which the patient and nurse (a) share information about their perceptions; (b) set goals
(through communication and interaction); and (c) explore and agree on means to achieve
these goals. To implement a true transactional process, the communication environment
must be reciprocal, and bidirectional. In this DNP project,
King’s theory—including the theory’s view of this transactional process—was applied to
inform the design of a patient-centered clinical environment. For example, to create and
maintain a patient-centered environment, APNs, clinical nurses, and patients must share
and be mutually informed about relevant considerations.
The theory of goal attainment: Assumptions and concepts. King developed her theory
of goal attainment in the 1960s. This theory describes the interpersonal dynamic
relationships between patients and their quest for goal attainment. Factors that can affect
goal attainment include roles, stressors, space, and time. In order for health care to be
optimal during the course of treatment for individual patients, both the patients and their
providers must continuously accommodate and adjust for changes in these factors.
King’s theory refers to three interacting systems: individuals (personal system),
groups (interpersonal system), and society (social system). The personal system is a
unified, complex, whole self who perceives, thinks, desires, imagines, decides, identifies
goals, and selects means to achieve them.
Assumptions. King’s framework is based on two assumptions:
▪Human beings are the focus of nursing.
▪The goals of nursing are health promotion, maintenance and restoration, care
of the sick or impaired, and care of the dying.
On the basis of these assumptions, King designed a conceptual system to explain
the organized wholes in which nurses are expected to function (see Figure 1; King, 1999).
Wholeness. King used the concept of “wholeness” to describe the broader
organization or social systems in which nurse’s function. (King, 1996, p. 61). The goal of
an interacting system is health for individuals, families, communities, and the world
(King, 1996).
Personal, interpersonal, and social systems. King’s conceptual framework is
organized into three “systems”: personal, interpersonal, and social. A personal or
individual system is essentially a single whole system. In contrast, an interpersonal
system represents the interaction of two or more individuals (i.e., small groups) in various
environments. Social systems are composed of large groups, such as educational,
governmental, or religious organizations.
Although in recent decades the quality and effectiveness of MD–RN interaction has
improved, the potential and need for further improvement in interprofessional
collaboration are substantial. To assess this need, Weaver et al. (2014) recently examined
teamwork and collaboration between staff nurses, residents, hospitalists, and oncology
physicians in oncology units at a large urban hospital. The investigators found that
physicians rated the quality of their own collaboration “very high” with other physicians
and with nurses. Physician ranked nurses’ collaboration with physicians as ranging from
87% to 100%. In stark contrast, however, nurses rated the quality of collaboration with
physicians poorly, from 35%–65%. Weaver et al. found that hierarchies persist and can
interfere with collaboration. Nurses believed that a negative attitude toward
communication as a significant obstacle to collaboration. A nurse may be reluctant to call
a physician if the nurse perceives that their relationship is not mutually supportive and
collaborative. On the other hand, physicians, having a positive perception of
collaboration, perceive difficulty contacting other providers as the main obstacle to
collaboration. Physicians who assume they have a good collaborative relationship with
nurses may not seek additional information because they (the physicians) are unaware of
potential or actual problems (Weaver et al., 2014).
Vazirani et al. (2005) surveyed registered nurses (n = 123), physicians (n = 45),
and a combined group of resident physicians and interns (n = 111) to determine whether
introduction of an APN role to the team was followed by changes in team communication
and collaboration. Physicians reported that, when an APN was part of the team, the level
of collaboration with nurses and APNs was significantly higher. Physicians also reported
that when an APN was part of the team, the team had fewer unnecessary delays and better
general communication. In the same study, the staff nurses reported significantly better
communication with APNs than with physicians (Vazirani et al., 2005). Kilpatrick (2012)
also found that communication and decision-making improve quality of care when the
participating APN is able to act within the full scope of the APN role. Among other
positive outcomes, this study reported that APN participation was associated with
decreases in length of patient stay and costs for patients treated on the intervention unit,
without an increase of readmission rates.
Vazirani’s (2005) study employed surveys to assess the degree of communication
and collaboration over two units. Physicians were surveyed immediately after they
completed a given rotation, starting at the onset of the interventions. Nurses were
surveyed biannually. The statistical analysis took into account correlation of observations
due to repeated sampling (Vazirani et al., 2005). Limitations in this study included
physician and staff nurse confusion about the role of APNs. Prior to the study, no APNs
were employed in the hospital’s internal medicine department. Chicago Medical Center
(CMC) employs approximately 200 APNs throughout all medical and surgical services,
thus role confusion is not a problem. The second limitation of this study pertained to
sample size. Physicians and nurses were not allowed to work on both the interventional
and control units; accordingly, the pool of physicians and pool of nurses available to
participate in the study was restricted. This can present problems with sample size but
also falsely promote familiarity and foster improved communications, skewing positive
results.
Although the quantity of studies is limited, it is clear that when an APN is an
integral part of the interprofessional team, the quality of communication and collaboration
increases. This DNP project specifies inclusion of the APN and staff nurse as members of
the professional team. The patient, who is also an integral part of this team, is not a
professional but is in fact the core leader of the health care team. In the decision-making
process, the patient’s understanding and input are invaluable
Communication and collaboration between APNs and staff nurses. The
majority of studies of communication and collaboration in health care contexts focused on
the nurse–physician relationship (Baggs & Ryan, 1990; Chapman, 2009;
DechairoMarino et al., 2001; Nathanson et al., 2011; Shortal et al., 1991). There have
been minimal formal studies looking at MD-APN and improved communication with
staff and its effects on patient care (Cowan et al., 2006). In nursing intraprofessional
teams, communication has been identified as the essential component of good team
functioning (Dreaschlin et al., 1999; Jones, 2005; Richardson et al., 2010). APNs possess
diverse knowledge that can facilitate understanding of collaborative practice to optimize
patient care (Crecelius, 2011). The Agency for Healthcare Research and Quality (2014)
found that when nurse practitioners are included in daily multidisciplinary rounds, the
rounding team’s communication and collaboration improve.
The increasing use of health care teams has made nursing practice more salient, in
that nurses serve as a link between team members and patients. Effective communication
between all team members is essential for successful teamwork and high-quality patient
care (Apker et al., 2006). The advance nurse practitioner function as the central link of the
health care team integrating other health care providers and patients. Good
communication among staff and between staff and patients is the cornerstone of quality
care.
Gooden and Jackson (2004) documented one of the earliest studies examining
staff nurses’ attitudes toward APNs. The investigators found that as APNs have come to
manage an increasing number of patients, staff nurses have begun to view the APNs as
leaders. Staff RNs consistently scored APNs higher than physicians in measures of
communication, respect for staff opinion, quality of care, clinical expertise, and
willingness to teach staff, patients, and patients’ families.
Moore and Prentice (2013) reported a case study that analyzed the collaborative
process between APNs and nurse in an outpatient oncology setting in Canada. The
researchers discovered four basic themes to collaboration:
▪Time that APNs spend together outside of work translates into collaboration at
work.
▪The basic skill of clinical knowledge and experience are essential ingredients
for successful collaboration.
▪Other factors that that contribute to the success of collaboration include
sharing a similar philosophy of care and mutual trust, respect and esteem.
▪Barriers to collaboration inevitably arise. Nurses are largely unaware of how
collaboration should manifest in the practice and are not trained on principles
of effective collaboration in practice.
▪Nurses and APNs attitudes are changing toward collaboration, viewing
collaboration as a means of achieving positive results.
Moore and Prentice (2013) found that intraprofessional collaboration (a) is
complex, (b) is influenced by interpersonal and professional factors, and (c) does not
occur spontaneously. Nurse must have a solid understanding of the concept of
collaboration and how to apply it in the clinical setting.
Patient-centered care. Improvement of patient satisfaction and quality of care is
directly due to the implementation of patient-centered care. Patient-centered care, the
“new normal” in today’s healthcare system, provides a mechanism for nurses to engage
patients as active participates in their care. The Institute of Medicine (IOM, 2001, p. 6)
defines patient-centered care as “healthcare that establishes a partnership among
practitioner, patients and their families to ensure that decisions reflect patient s wants,
needs and preferences” (see also Boykins, 2014; Sepucha & Ozanne, 2010). Optimal
patient participation requires a dynamic interaction between partners (patient and staff) in
terms of interpersonal interaction, therapeutic approach, focus on resources, resources,
patient opportunities to participate in and influence health care team decision making, and
patient education (Sahlsten et al., 2007). Including the patient in bedside reports or
handoffs has been reported to improve teamwork, safety and efficiency (Wildner & Ferri,
2012). This bedside practice also entails the participation of patients as partners in their
care, with the expectation that their participation will lead to improved care, better
outcomes, improved adherence to treatment and medication regimen and greater
satisfaction with care. Barriers to implementation of patient-centered care and bedside
rounding include time and resource requirements; the potential for patients to feel
confused, upset, or dehumanized as a result of hearing clinical explanations; and the
potential for breach of patient confidentiality (McMurry et. al 2011). In addition, when
presenting sensitive or confidential information, some nurses may feel uncomfortable, or
be inhibited by a lack experience—especially in the presence of patients’ family members
or relatives are present. O’Connell, Macdonald, and Kelly (2008) found that viewed
handoffs as being too time consuming, and ineffective, or efficient. The investigators
recommended that a handoff guideline or information template should be developed to
promote and facilitate the reporting of objective relevant information.
Patient satisfaction and its effects on quality of care. As a subjective
phenomenon, “patient satisfaction” is difficult to define. The self-reported determination
of patient satisfaction is a personal evaluation of health care services and of the providers
of that care (Ware et al., 1983); patients’ attitudes and expectations regarding care greatly
affect their sense of satisfaction. Because satisfaction ratings are relative, subjective, and
not directly observable, attempting to meaningfully quantify patients’ personal evaluation
of care is highly problematic (Ware et al., 1983).
The challenges inherent in measuring patient satisfaction have ramifications for
policy and practice. For example, in 2012, the Center for Medicare and Medicaid
Services (CMS) began to implement a reimbursement system that adjusts payment rates
based on patient satisfaction scores (Lyu et al., 2013). Patient satisfaction is a key
determinant of quality of care and an important component of the pay-for-performance
metrics instituted by CMS. Beginning in 2012, CMS implemented value-based incentive
payments to acute-care hospitals based in part on results of satisfaction surveys from
patients discharged on or after October 1, 2012. The patient’s perception of quality is
significant determinant of the provider’s federal reimbursement. Patients now make
decisions based on their perceptions of the quality of and satisfaction with health care
providers (Bowers, Swan, & Koehler, 1994).
A study conducted by Fenton, Jerant, Bertakis, and Franks at the University of
California–Davis examined mortality rate in relation to patient satisfaction (N = 51,946);
the researchers’ analysis adjusted for a number of factors (i.e., demographics, health
status and chronic disease burden, Year 1 utilization and expenditures, availability of a
usual source of care, and insurance status). The investigators were surprised to find that,
in comparison with the mortality rate of patients in the lowest satisfaction quartile, the
mortality rate of patients in the highest satisfaction quartile was 26% higher (adjusted
hazard ratio, 1.26; 95% CI [1.05, 1.53]). This perhaps counterintuitive finding raises the
question of whether current satisfaction measures are in fact good indicators of health
care quality (Fenton et al., 2012). The researchers concluded that the connection between
patient satisfaction and health care outcomes is yet unclear.
Practitioners need to understand that ineffective communication can result in poor
outcomes. Improved communication not only results in better health outcomes, but also
may positivity impact patient satisfaction. For patients who want to be involved in their
care and who understand what is occurring during care, improved communication may
ultimately lead to greater patient satisfaction. The inclusion of APNs in the care team has
been reported to improve communication and the efficiency of care (McCauley, Bixby, &
Naylor, 2006).
Evidence-based practice. Evidence-based practice (EBP) is at the forefront of
change in today’s health care environment. EBP is the practice of using documented
evidence as a guide to problem solving approach to clinical decision making. To
implement EBP, one must “locate, critique, synthesize, translate, and evaluate evidence”
(Drenning, 2006, p.299). This includes the dissemination of information during the
implementation phase of practice. Although ostensibly EBP is the standard of nursing
practice, implementation of EBP is not always easy (Krom & Bautista, 2010). Barriers to
EBP implementation include (a) lack of requisite knowledge and skills on the part of
clinicians, (b) perception that EBP is time consuming, (b) perception that EBP is
burdensome, and (d) lack of management support at the organizational level (Melnyk &
Fineout-Overholt, 2012). Among clinical staff members, APNs, nurse educators, and
DNPs—who understand translational research—are uniquely qualified to fulfill their
responsibility to fulfill the mandate to implement evidence –based changes in practice.
These organizational change agents must persuasively teach the EBP process to staff
nurses and thereby transform the organizational culture—from a culture in which change
is resisted to a culture in which evidence-based improvements in practice are welcomed.
To achieve this transformation in organizational culture, APNs, nurse educators, and
DNPs must employ an interactive approach.
APNs serve as both leaders and knowledge resources for helping nursing staff to
ground care in current evidence. In a study conducted by Mahanes, Quatrara, and Shaw
(2013) at the University of Virginia, the researchers implemented APN-led nursing
rounds. Although the specific effects of the APN-led nursing rounds were impossible to
isolate, Mahanes and her colleagues were able to determine that rates of blood stream
infections, catheter-associated urinary tract infections, hospital-acquired pressure ulcers,
and ventilator-associated pneumonia and falls all declined. Similarly, in study that a
analyzed the effectiveness of an APN-managed heart failure program, Dahl and Penque
(2002) reported reduced 90-day readmission rates, fewer in-patient hospital days, lower
re-admission charges, and lower overall charges for health care services.
APNs have demonstrated implementation of EBP practices, better working
relationship with staff nurses, and improved patient-centered care with cost savings. The
development of an intraprofessional APN–staff nurse team to conduct bedside rounding
should improve patient care, increase communication and collaboration, and improve
patient satisfaction.
The daily goals reminder sheet. The need to develop clear team communication
has led to the development and institution of daily goal sheets. Studies in ICUs have
demonstrated that the use of daily goal sheets can result in nurses’ and physicians’ having
better understanding of patient care goals and in decreased ICU length of stay (Agarwal et
al., 2008; Narasimhan et al., 2006; Pronovost et al., 2003). A study conducted by
Phipps and Thomas (2007) examined the use of a daily goals sheet in the ICU at The
University of Pennsylvania’s Hershey Children’s Hospital. The researchers found that
85% of nurses felt the use of the goals sheets improved communications between
physicians and nurses and improved communication between nurses working on different
shifts. Phipps and Thomas also reported that 95% of the nursing staff felt that the extra
expenditure of time spent in completing the daily goals sheet was worthwhile. In another
study, the Beth Israel Medical Center in New York instituted use of a worksheet that was
posted at bedside after completion. Narasimham and colleagues (2006) found that pre and
post scores for understanding patient goals and communication improved significantly,
and that this improvement was sustained over a 9-month period. Furthermore, after
completion of the study, most of the practitioners requested that the use of the worksheet
be continued. In the DNP project, instituting a daily goals reminder worksheet associated
with APN–RN–patient bedside rounding enhanced communication between APNs, staff
nurses, and patients.
Needs Assessment and Description of the Project
Population identification. In this DNP project, the population identified for
selection and participation comprises APNs who have prior knowledge of and experience
with APN–RN–patient bedside rounding.
Identification of the project sponsor and key stakeholders. This DNP project
has no sponsors. Key stakeholders include the student investigator and ultimately the
APNs and RNs who will participate in the learning module.
Assessment of available resources. No monetary resources were available for
this project. As project investigator, I was responsible for the development of the learning
module. The project had no public advertisement. APNs were approached through the
hospital’s standardized email by the student researcher (Appendix B).
Team selection. The project investigator, served as the team for this project, with
consultation from the DNP project committee members.
Scope of the project. The project entailed only the development of the 1-hour
learning module. Further plans for implementation will be considered at some point in
the future. The module’s topics included (a) the requirement for close communication and
collaboration between team members to assure seamless, high-quality health care, (b) the
definition of APN–RN rounds, (c) the schedule and length of rounds, (d) the personnel
composition of rounding teams, (e) topics of discussion during the rounds, and (f) the use
of a daily goal reminder sheet to ensure the consistency of all elements of the patient's
treatment plan and goals.
As project investigator, I used the literature as a basis for creating the written
learning module. After completing the module and obtaining University of Nevada Las
Vegas Institutional Review Board approval, the learning module was sent to three APNs
in the hospital for review and feedback; all of these APNs had prior experience in
working with APN–RN rounds at other facilities. In addition, to assess the learning
module’s effectiveness, I developed an evaluation form to be completed by participating
APNs and RNs following their completion of the learning module.
All results of this project were shared with a representative of the CMC’s
administration and the Chief Nurse Executive. I hope to work with administration and
staff in implementing the APN–RN–patient rounding on a pilot unit and, on the basis of
results, further develops the model for use on other inpatient units.
Mission, Goals, and Objectives
The mission and goals of this project are to improve communication and
collaboration between the intraprofessional team of APNs and staff nurses and to improve
APN–staff nurse communication with patients.
This DNP project’s primary objective was to develop a structured learning module
pertaining to APN–RN–patient bedside rounding. The project’s long-term goals,
following completion of this project, are to implement the model and to improve
communication and collaboration between APNs, clinical nurses, and the patients cared
for by these nurses.
Chapter 3
Theoretical Underpinnings of the DNP Project
Of the several theories that have informed our understanding of holistic patient
centered care and educating adults, two theories are among the most influential: King’s
theory of goal attainment and Knowles’s theory of andragogy. In light of the theories’
relevance to developing interventions for improving health care team collaboration and
communication—the central concern of this dissertation—these two theories were
selected to serve as the theoretical underpinnings of the DNP staff education project in
support of APN–RN–patient bedside rounding. Specifically, King’s theory of goal
attainment informed the process of identifying content for the staff education module;
Knowles’s theory of andragogy informed the design of the module’s presentation to
training participants.
King’s Theory of Goal Attainment
In “Crossing the Quality Chasm: A New Health System for the 21st Century,” the
IOM (2001) describes six aims for the improvement of health care. One of the aims is to
provide patient-centered care that is respectful of and responsive to individual patients’
personal preferences, needs, and values; in patient-centered care, patients’ values play a
central role in informing clinical decision making clinical decisions. Among theoretical
frameworks that inform clinical understanding of the role of the patient in this
decisionmaking, Imogene Kings’ theory of goal attainment is seminal.
King’s theory and patient-centered health care. In King’s theory, health care
team decision-making includes a “transaction” in which the nurse and patient engage in
mutual goal setting (King, 1991, pp. 19). According to King, this transactional process of
interpersonal systems involves four steps—action, reaction, interaction, and transaction—
by which the patient and nurse (a) share information about their perceptions; (b) set goals
(through communication and interaction); and (c) explore and agree on means to achieve
these goals. To implement a true transactional process, the communication environment
must be reciprocal, and bidirectional. In this DNP project,
King’s theory—including the theory’s view of this transactional process—was applied to
inform the design of a patient-centered clinical environment. For example, to create and
maintain a patient-centered environment, APNs, clinical nurses, and patients must share
and be mutually informed about relevant considerations.
The theory of goal attainment: Assumptions and concepts. King developed her theory
of goal attainment in the 1960s. This theory describes the interpersonal dynamic
relationships between patients and their quest for goal attainment. Factors that can affect
goal attainment include roles, stressors, space, and time. In order for health care to be
optimal during the course of treatment for individual patients, both the patients and their
providers must continuously accommodate and adjust for changes in these factors.
King’s theory refers to three interacting systems: individuals (personal system),
groups (interpersonal system), and society (social system). The personal system is a
unified, complex, whole self who perceives, thinks, desires, imagines, decides, identifies
goals, and selects means to achieve them.
Assumptions. King’s framework is based on two assumptions:
▪Human beings are the focus of nursing.
▪The goals of nursing are health promotion, maintenance and restoration, care
of the sick or impaired, and care of the dying.
On the basis of these assumptions, King designed a conceptual system to explain
the organized wholes in which nurses are expected to function (see Figure 1; King, 1999).
Wholeness. King used the concept of “wholeness” to describe the broader
organization or social systems in which nurse’s function. (King, 1996, p. 61). The goal of
an interacting system is health for individuals, families, communities, and the world
(King, 1996).
Personal, interpersonal, and social systems. King’s conceptual framework is
organized into three “systems”: personal, interpersonal, and social. A personal or
individual system is essentially a single whole system. In contrast, an interpersonal
system represents the interaction of two or more individuals (i.e., small groups) in various
environments. Social systems are composed of large groups, such as educational,
governmental, or religious organizations.
Although in recent decades the quality and effectiveness of MD–RN interaction has
improved, the potential and need for further improvement in interprofessional
collaboration are substantial. To assess this need, Weaver et al. (2014) recently examined
teamwork and collaboration between staff nurses, residents, hospitalists, and oncology
physicians in oncology units at a large urban hospital. The investigators found that
physicians rated the quality of their own collaboration “very high” with other physicians
and with nurses. Physician ranked nurses’ collaboration with physicians as ranging from
87% to 100%. In stark contrast, however, nurses rated the quality of collaboration with
physicians poorly, from 35%–65%. Weaver et al. found that hierarchies persist and can
interfere with collaboration. Nurses believed that a negative attitude toward
communication as a significant obstacle to collaboration. A nurse may be reluctant to call
a physician if the nurse perceives that their relationship is not mutually supportive and
collaborative. On the other hand, physicians, having a positive perception of
collaboration, perceive difficulty contacting other providers as the main obstacle to
collaboration. Physicians who assume they have a good collaborative relationship with
nurses may not seek additional information because they (the physicians) are unaware of
potential or actual problems (Weaver et al., 2014).
Vazirani et al. (2005) surveyed registered nurses (n = 123), physicians (n = 45),
and a combined group of resident physicians and interns (n = 111) to determine whether
introduction of an APN role to the team was followed by changes in team communication
and collaboration. Physicians reported that, when an APN was part of the team, the level
of collaboration with nurses and APNs was significantly higher. Physicians also reported
that when an APN was part of the team, the team had fewer unnecessary delays and better
general communication. In the same study, the staff nurses reported significantly better
communication with APNs than with physicians (Vazirani et al., 2005). Kilpatrick (2012)
also found that communication and decision-making improve quality of care when the
participating APN is able to act within the full scope of the APN role. Among other
positive outcomes, this study reported that APN participation was associated with
decreases in length of patient stay and costs for patients treated on the intervention unit,
without an increase of readmission rates.
Vazirani’s (2005) study employed surveys to assess the degree of communication
and collaboration over two units. Physicians were surveyed immediately after they
completed a given rotation, starting at the onset of the interventions. Nurses were
surveyed biannually. The statistical analysis took into account correlation of observations
due to repeated sampling (Vazirani et al., 2005). Limitations in this study included
physician and staff nurse confusion about the role of APNs. Prior to the study, no APNs
were employed in the hospital’s internal medicine department. Chicago Medical Center
(CMC) employs approximately 200 APNs throughout all medical and surgical services,
thus role confusion is not a problem. The second limitation of this study pertained to
sample size. Physicians and nurses were not allowed to work on both the interventional
and control units; accordingly, the pool of physicians and pool of nurses available to
participate in the study was restricted. This can present problems with sample size but
also falsely promote familiarity and foster improved communications, skewing positive
results.
Although the quantity of studies is limited, it is clear that when an APN is an
integral part of the interprofessional team, the quality of communication and collaboration
increases. This DNP project specifies inclusion of the APN and staff nurse as members of
the professional team. The patient, who is also an integral part of this team, is not a
professional but is in fact the core leader of the health care team. In the decision-making
process, the patient’s understanding and input are invaluable
Communication and collaboration between APNs and staff nurses. The
majority of studies of communication and collaboration in health care contexts focused on
the nurse–physician relationship (Baggs & Ryan, 1990; Chapman, 2009;
DechairoMarino et al., 2001; Nathanson et al., 2011; Shortal et al., 1991). There have
been minimal formal studies looking at MD-APN and improved communication with
staff and its effects on patient care (Cowan et al., 2006). In nursing intraprofessional
teams, communication has been identified as the essential component of good team
functioning (Dreaschlin et al., 1999; Jones, 2005; Richardson et al., 2010). APNs possess
diverse knowledge that can facilitate understanding of collaborative practice to optimize
patient care (Crecelius, 2011). The Agency for Healthcare Research and Quality (2014)
found that when nurse practitioners are included in daily multidisciplinary rounds, the
rounding team’s communication and collaboration improve.
The increasing use of health care teams has made nursing practice more salient, in
that nurses serve as a link between team members and patients. Effective communication
between all team members is essential for successful teamwork and high-quality patient
care (Apker et al., 2006). The advance nurse practitioner function as the central link of the
health care team integrating other health care providers and patients. Good
communication among staff and between staff and patients is the cornerstone of quality
care.
Gooden and Jackson (2004) documented one of the earliest studies examining
staff nurses’ attitudes toward APNs. The investigators found that as APNs have come to
manage an increasing number of patients, staff nurses have begun to view the APNs as
leaders. Staff RNs consistently scored APNs higher than physicians in measures of
communication, respect for staff opinion, quality of care, clinical expertise, and
willingness to teach staff, patients, and patients’ families.
Moore and Prentice (2013) reported a case study that analyzed the collaborative
process between APNs and nurse in an outpatient oncology setting in Canada. The
researchers discovered four basic themes to collaboration:
▪Time that APNs spend together outside of work translates into collaboration at
work.
▪The basic skill of clinical knowledge and experience are essential ingredients
for successful collaboration.
▪Other factors that that contribute to the success of collaboration include
sharing a similar philosophy of care and mutual trust, respect and esteem.
▪Barriers to collaboration inevitably arise. Nurses are largely unaware of how
collaboration should manifest in the practice and are not trained on principles
of effective collaboration in practice.
▪Nurses and APNs attitudes are changing toward collaboration, viewing
collaboration as a means of achieving positive results.
Moore and Prentice (2013) found that intraprofessional collaboration (a) is
complex, (b) is influenced by interpersonal and professional factors, and (c) does not
occur spontaneously. Nurse must have a solid understanding of the concept of
collaboration and how to apply it in the clinical setting.
Patient-centered care. Improvement of patient satisfaction and quality of care is
directly due to the implementation of patient-centered care. Patient-centered care, the
“new normal” in today’s healthcare system, provides a mechanism for nurses to engage
patients as active participates in their care. The Institute of Medicine (IOM, 2001, p. 6)
defines patient-centered care as “healthcare that establishes a partnership among
practitioner, patients and their families to ensure that decisions reflect patient s wants,
needs and preferences” (see also Boykins, 2014; Sepucha & Ozanne, 2010). Optimal
patient participation requires a dynamic interaction between partners (patient and staff) in
terms of interpersonal interaction, therapeutic approach, focus on resources, resources,
patient opportunities to participate in and influence health care team decision making, and
patient education (Sahlsten et al., 2007). Including the patient in bedside reports or
handoffs has been reported to improve teamwork, safety and efficiency (Wildner & Ferri,
2012). This bedside practice also entails the participation of patients as partners in their
care, with the expectation that their participation will lead to improved care, better
outcomes, improved adherence to treatment and medication regimen and greater
satisfaction with care. Barriers to implementation of patient-centered care and bedside
rounding include time and resource requirements; the potential for patients to feel
confused, upset, or dehumanized as a result of hearing clinical explanations; and the
potential for breach of patient confidentiality (McMurry et. al 2011). In addition, when
presenting sensitive or confidential information, some nurses may feel uncomfortable, or
be inhibited by a lack experience—especially in the presence of patients’ family members
or relatives are present. O’Connell, Macdonald, and Kelly (2008) found that viewed
handoffs as being too time consuming, and ineffective, or efficient. The investigators
recommended that a handoff guideline or information template should be developed to
promote and facilitate the reporting of objective relevant information.
Patient satisfaction and its effects on quality of care. As a subjective
phenomenon, “patient satisfaction” is difficult to define. The self-reported determination
of patient satisfaction is a personal evaluation of health care services and of the providers
of that care (Ware et al., 1983); patients’ attitudes and expectations regarding care greatly
affect their sense of satisfaction. Because satisfaction ratings are relative, subjective, and
not directly observable, attempting to meaningfully quantify patients’ personal evaluation
of care is highly problematic (Ware et al., 1983).
The challenges inherent in measuring patient satisfaction have ramifications for
policy and practice. For example, in 2012, the Center for Medicare and Medicaid
Services (CMS) began to implement a reimbursement system that adjusts payment rates
based on patient satisfaction scores (Lyu et al., 2013). Patient satisfaction is a key
determinant of quality of care and an important component of the pay-for-performance
metrics instituted by CMS. Beginning in 2012, CMS implemented value-based incentive
payments to acute-care hospitals based in part on results of satisfaction surveys from
patients discharged on or after October 1, 2012. The patient’s perception of quality is
significant determinant of the provider’s federal reimbursement. Patients now make
decisions based on their perceptions of the quality of and satisfaction with health care
providers (Bowers, Swan, & Koehler, 1994).
A study conducted by Fenton, Jerant, Bertakis, and Franks at the University of
California–Davis examined mortality rate in relation to patient satisfaction (N = 51,946);
the researchers’ analysis adjusted for a number of factors (i.e., demographics, health
status and chronic disease burden, Year 1 utilization and expenditures, availability of a
usual source of care, and insurance status). The investigators were surprised to find that,
in comparison with the mortality rate of patients in the lowest satisfaction quartile, the
mortality rate of patients in the highest satisfaction quartile was 26% higher (adjusted
hazard ratio, 1.26; 95% CI [1.05, 1.53]). This perhaps counterintuitive finding raises the
question of whether current satisfaction measures are in fact good indicators of health
care quality (Fenton et al., 2012). The researchers concluded that the connection between
patient satisfaction and health care outcomes is yet unclear.
Practitioners need to understand that ineffective communication can result in poor
outcomes. Improved communication not only results in better health outcomes, but also
may positivity impact patient satisfaction. For patients who want to be involved in their
care and who understand what is occurring during care, improved communication may
ultimately lead to greater patient satisfaction. The inclusion of APNs in the care team has
been reported to improve communication and the efficiency of care (McCauley, Bixby, &
Naylor, 2006).
Evidence-based practice. Evidence-based practice (EBP) is at the forefront of
change in today’s health care environment. EBP is the practice of using documented
evidence as a guide to problem solving approach to clinical decision making. To
implement EBP, one must “locate, critique, synthesize, translate, and evaluate evidence”
(Drenning, 2006, p.299). This includes the dissemination of information during the
implementation phase of practice. Although ostensibly EBP is the standard of nursing
practice, implementation of EBP is not always easy (Krom & Bautista, 2010). Barriers to
EBP implementation include (a) lack of requisite knowledge and skills on the part of
clinicians, (b) perception that EBP is time consuming, (b) perception that EBP is
burdensome, and (d) lack of management support at the organizational level (Melnyk &
Fineout-Overholt, 2012). Among clinical staff members, APNs, nurse educators, and
DNPs—who understand translational research—are uniquely qualified to fulfill their
responsibility to fulfill the mandate to implement evidence –based changes in practice.
These organizational change agents must persuasively teach the EBP process to staff
nurses and thereby transform the organizational culture—from a culture in which change
is resisted to a culture in which evidence-based improvements in practice are welcomed.
To achieve this transformation in organizational culture, APNs, nurse educators, and
DNPs must employ an interactive approach.
APNs serve as both leaders and knowledge resources for helping nursing staff to
ground care in current evidence. In a study conducted by Mahanes, Quatrara, and Shaw
(2013) at the University of Virginia, the researchers implemented APN-led nursing
rounds. Although the specific effects of the APN-led nursing rounds were impossible to
isolate, Mahanes and her colleagues were able to determine that rates of blood stream
infections, catheter-associated urinary tract infections, hospital-acquired pressure ulcers,
and ventilator-associated pneumonia and falls all declined. Similarly, in study that a
analyzed the effectiveness of an APN-managed heart failure program, Dahl and Penque
(2002) reported reduced 90-day readmission rates, fewer in-patient hospital days, lower
re-admission charges, and lower overall charges for health care services.
APNs have demonstrated implementation of EBP practices, better working
relationship with staff nurses, and improved patient-centered care with cost savings. The
development of an intraprofessional APN–staff nurse team to conduct bedside rounding
should improve patient care, increase communication and collaboration, and improve
patient satisfaction.
The daily goals reminder sheet. The need to develop clear team communication
has led to the development and institution of daily goal sheets. Studies in ICUs have
demonstrated that the use of daily goal sheets can result in nurses’ and physicians’ having
better understanding of patient care goals and in decreased ICU length of stay (Agarwal et
al., 2008; Narasimhan et al., 2006; Pronovost et al., 2003). A study conducted by
Phipps and Thomas (2007) examined the use of a daily goals sheet in the ICU at The
University of Pennsylvania’s Hershey Children’s Hospital. The researchers found that
85% of nurses felt the use of the goals sheets improved communications between
physicians and nurses and improved communication between nurses working on different
shifts. Phipps and Thomas also reported that 95% of the nursing staff felt that the extra
expenditure of time spent in completing the daily goals sheet was worthwhile. In another
study, the Beth Israel Medical Center in New York instituted use of a worksheet that was
posted at bedside after completion. Narasimham and colleagues (2006) found that pre and
post scores for understanding patient goals and communication improved significantly,
and that this improvement was sustained over a 9-month period. Furthermore, after
completion of the study, most of the practitioners requested that the use of the worksheet
be continued. In the DNP project, instituting a daily goals reminder worksheet associated
with APN–RN–patient bedside rounding enhanced communication between APNs, staff
nurses, and patients.
Needs Assessment and Description of the Project
Population identification. In this DNP project, the population identified for
selection and participation comprises APNs who have prior knowledge of and experience
with APN–RN–patient bedside rounding.
Identification of the project sponsor and key stakeholders. This DNP project
has no sponsors. Key stakeholders include the student investigator and ultimately the
APNs and RNs who will participate in the learning module.
Assessment of available resources. No monetary resources were available for
this project. As project investigator, I was responsible for the development of the learning
module. The project had no public advertisement. APNs were approached through the
hospital’s standardized email by the student researcher (Appendix B).
Team selection. The project investigator, served as the team for this project, with
consultation from the DNP project committee members.
Scope of the project. The project entailed only the development of the 1-hour
learning module. Further plans for implementation will be considered at some point in
the future. The module’s topics included (a) the requirement for close communication and
collaboration between team members to assure seamless, high-quality health care, (b) the
definition of APN–RN rounds, (c) the schedule and length of rounds, (d) the personnel
composition of rounding teams, (e) topics of discussion during the rounds, and (f) the use
of a daily goal reminder sheet to ensure the consistency of all elements of the patient's
treatment plan and goals.
As project investigator, I used the literature as a basis for creating the written
learning module. After completing the module and obtaining University of Nevada Las
Vegas Institutional Review Board approval, the learning module was sent to three APNs
in the hospital for review and feedback; all of these APNs had prior experience in
working with APN–RN rounds at other facilities. In addition, to assess the learning
module’s effectiveness, I developed an evaluation form to be completed by participating
APNs and RNs following their completion of the learning module.
All results of this project were shared with a representative of the CMC’s
administration and the Chief Nurse Executive. I hope to work with administration and
staff in implementing the APN–RN–patient rounding on a pilot unit and, on the basis of
results, further develops the model for use on other inpatient units.
Mission, Goals, and Objectives
The mission and goals of this project are to improve communication and
collaboration between the intraprofessional team of APNs and staff nurses and to improve
APN–staff nurse communication with patients.
This DNP project’s primary objective was to develop a structured learning module
pertaining to APN–RN–patient bedside rounding. The project’s long-term goals,
following completion of this project, are to implement the model and to improve
communication and collaboration between APNs, clinical nurses, and the patients cared
for by these nurses.
Chapter 3
Theoretical Underpinnings of the DNP Project
Of the several theories that have informed our understanding of holistic patient
centered care and educating adults, two theories are among the most influential: King’s
theory of goal attainment and Knowles’s theory of andragogy. In light of the theories’
relevance to developing interventions for improving health care team collaboration and
communication—the central concern of this dissertation—these two theories were
selected to serve as the theoretical underpinnings of the DNP staff education project in
support of APN–RN–patient bedside rounding. Specifically, King’s theory of goal
attainment informed the process of identifying content for the staff education module;
Knowles’s theory of andragogy informed the design of the module’s presentation to
training participants.
King’s Theory of Goal Attainment
In “Crossing the Quality Chasm: A New Health System for the 21st Century,” the
IOM (2001) describes six aims for the improvement of health care. One of the aims is to
provide patient-centered care that is respectful of and responsive to individual patients’
personal preferences, needs, and values; in patient-centered care, patients’ values play a
central role in informing clinical decision making clinical decisions. Among theoretical
frameworks that inform clinical understanding of the role of the patient in this
decisionmaking, Imogene Kings’ theory of goal attainment is seminal.
King’s theory and patient-centered health care. In King’s theory, health care
team decision-making includes a “transaction” in which the nurse and patient engage in
mutual goal setting (King, 1991, pp. 19). According to King, this transactional process of
interpersonal systems involves four steps—action, reaction, interaction, and transaction—
by which the patient and nurse (a) share information about their perceptions; (b) set goals
(through communication and interaction); and (c) explore and agree on means to achieve
these goals. To implement a true transactional process, the communication environment
must be reciprocal, and bidirectional. In this DNP project,
King’s theory—including the theory’s view of this transactional process—was applied to
inform the design of a patient-centered clinical environment. For example, to create and
maintain a patient-centered environment, APNs, clinical nurses, and patients must share
and be mutually informed about relevant considerations.
The theory of goal attainment: Assumptions and concepts. King developed her theory
of goal attainment in the 1960s. This theory describes the interpersonal dynamic
relationships between patients and their quest for goal attainment. Factors that can affect
goal attainment include roles, stressors, space, and time. In order for health care to be
optimal during the course of treatment for individual patients, both the patients and their
providers must continuously accommodate and adjust for changes in these factors.
King’s theory refers to three interacting systems: individuals (personal system),
groups (interpersonal system), and society (social system). The personal system is a
unified, complex, whole self who perceives, thinks, desires, imagines, decides, identifies
goals, and selects means to achieve them.
Assumptions. King’s framework is based on two assumptions:
▪Human beings are the focus of nursing.
▪The goals of nursing are health promotion, maintenance and restoration, care
of the sick or impaired, and care of the dying.
On the basis of these assumptions, King designed a conceptual system to explain
the organized wholes in which nurses are expected to function (see Figure 1; King, 1999).
Wholeness. King used the concept of “wholeness” to describe the broader
organization or social systems in which nurse’s function. (King, 1996, p. 61). The goal of
an interacting system is health for individuals, families, communities, and the world
(King, 1996).
Personal, interpersonal, and social systems. King’s conceptual framework is
organized into three “systems”: personal, interpersonal, and social. A personal or
individual system is essentially a single whole system. In contrast, an interpersonal
system represents the interaction of two or more individuals (i.e., small groups) in various
environments. Social systems are composed of large groups, such as educational,
governmental, or religious organizations.
Although in recent decades the quality and effectiveness of MD–RN interaction has
improved, the potential and need for further improvement in interprofessional
collaboration are substantial. To assess this need, Weaver et al. (2014) recently examined
teamwork and collaboration between staff nurses, residents, hospitalists, and oncology
physicians in oncology units at a large urban hospital. The investigators found that
physicians rated the quality of their own collaboration “very high” with other physicians
and with nurses. Physician ranked nurses’ collaboration with physicians as ranging from
87% to 100%. In stark contrast, however, nurses rated the quality of collaboration with
physicians poorly, from 35%–65%. Weaver et al. found that hierarchies persist and can
interfere with collaboration. Nurses believed that a negative attitude toward
communication as a significant obstacle to collaboration. A nurse may be reluctant to call
a physician if the nurse perceives that their relationship is not mutually supportive and
collaborative. On the other hand, physicians, having a positive perception of
collaboration, perceive difficulty contacting other providers as the main obstacle to
collaboration. Physicians who assume they have a good collaborative relationship with
nurses may not seek additional information because they (the physicians) are unaware of
potential or actual problems (Weaver et al., 2014).
Vazirani et al. (2005) surveyed registered nurses (n = 123), physicians (n = 45),
and a combined group of resident physicians and interns (n = 111) to determine whether
introduction of an APN role to the team was followed by changes in team communication
and collaboration. Physicians reported that, when an APN was part of the team, the level
of collaboration with nurses and APNs was significantly higher. Physicians also reported
that when an APN was part of the team, the team had fewer unnecessary delays and better
general communication. In the same study, the staff nurses reported significantly better
communication with APNs than with physicians (Vazirani et al., 2005). Kilpatrick (2012)
also found that communication and decision-making improve quality of care when the
participating APN is able to act within the full scope of the APN role. Among other
positive outcomes, this study reported that APN participation was associated with
decreases in length of patient stay and costs for patients treated on the intervention unit,
without an increase of readmission rates.
Vazirani’s (2005) study employed surveys to assess the degree of communication
and collaboration over two units. Physicians were surveyed immediately after they
completed a given rotation, starting at the onset of the interventions. Nurses were
surveyed biannually. The statistical analysis took into account correlation of observations
due to repeated sampling (Vazirani et al., 2005). Limitations in this study included
physician and staff nurse confusion about the role of APNs. Prior to the study, no APNs
were employed in the hospital’s internal medicine department. Chicago Medical Center
(CMC) employs approximately 200 APNs throughout all medical and surgical services,
thus role confusion is not a problem. The second limitation of this study pertained to
sample size. Physicians and nurses were not allowed to work on both the interventional
and control units; accordingly, the pool of physicians and pool of nurses available to
participate in the study was restricted. This can present problems with sample size but
also falsely promote familiarity and foster improved communications, skewing positive
results.
Although the quantity of studies is limited, it is clear that when an APN is an
integral part of the interprofessional team, the quality of communication and collaboration
increases. This DNP project specifies inclusion of the APN and staff nurse as members of
the professional team. The patient, who is also an integral part of this team, is not a
professional but is in fact the core leader of the health care team. In the decision-making
process, the patient’s understanding and input are invaluable
Communication and collaboration between APNs and staff nurses. The
majority of studies of communication and collaboration in health care contexts focused on
the nurse–physician relationship (Baggs & Ryan, 1990; Chapman, 2009;
DechairoMarino et al., 2001; Nathanson et al., 2011; Shortal et al., 1991). There have
been minimal formal studies looking at MD-APN and improved communication with
staff and its effects on patient care (Cowan et al., 2006). In nursing intraprofessional
teams, communication has been identified as the essential component of good team
functioning (Dreaschlin et al., 1999; Jones, 2005; Richardson et al., 2010). APNs possess
diverse knowledge that can facilitate understanding of collaborative practice to optimize
patient care (Crecelius, 2011). The Agency for Healthcare Research and Quality (2014)
found that when nurse practitioners are included in daily multidisciplinary rounds, the
rounding team’s communication and collaboration improve.
The increasing use of health care teams has made nursing practice more salient, in
that nurses serve as a link between team members and patients. Effective communication
between all team members is essential for successful teamwork and high-quality patient
care (Apker et al., 2006). The advance nurse practitioner function as the central link of the
health care team integrating other health care providers and patients. Good
communication among staff and between staff and patients is the cornerstone of quality
care.
Gooden and Jackson (2004) documented one of the earliest studies examining
staff nurses’ attitudes toward APNs. The investigators found that as APNs have come to
manage an increasing number of patients, staff nurses have begun to view the APNs as
leaders. Staff RNs consistently scored APNs higher than physicians in measures of
communication, respect for staff opinion, quality of care, clinical expertise, and
willingness to teach staff, patients, and patients’ families.
Moore and Prentice (2013) reported a case study that analyzed the collaborative
process between APNs and nurse in an outpatient oncology setting in Canada. The
researchers discovered four basic themes to collaboration:
▪Time that APNs spend together outside of work translates into collaboration at
work.
▪The basic skill of clinical knowledge and experience are essential ingredients
for successful collaboration.
▪Other factors that that contribute to the success of collaboration include
sharing a similar philosophy of care and mutual trust, respect and esteem.
▪Barriers to collaboration inevitably arise. Nurses are largely unaware of how
collaboration should manifest in the practice and are not trained on principles
of effective collaboration in practice.
▪Nurses and APNs attitudes are changing toward collaboration, viewing
collaboration as a means of achieving positive results.
Moore and Prentice (2013) found that intraprofessional collaboration (a) is
complex, (b) is influenced by interpersonal and professional factors, and (c) does not
occur spontaneously. Nurse must have a solid understanding of the concept of
collaboration and how to apply it in the clinical setting.
Patient-centered care. Improvement of patient satisfaction and quality of care is
directly due to the implementation of patient-centered care. Patient-centered care, the
“new normal” in today’s healthcare system, provides a mechanism for nurses to engage
patients as active participates in their care. The Institute of Medicine (IOM, 2001, p. 6)
defines patient-centered care as “healthcare that establishes a partnership among
practitioner, patients and their families to ensure that decisions reflect patient s wants,
needs and preferences” (see also Boykins, 2014; Sepucha & Ozanne, 2010). Optimal
patient participation requires a dynamic interaction between partners (patient and staff) in
terms of interpersonal interaction, therapeutic approach, focus on resources, resources,
patient opportunities to participate in and influence health care team decision making, and
patient education (Sahlsten et al., 2007). Including the patient in bedside reports or
handoffs has been reported to improve teamwork, safety and efficiency (Wildner & Ferri,
2012). This bedside practice also entails the participation of patients as partners in their
care, with the expectation that their participation will lead to improved care, better
outcomes, improved adherence to treatment and medication regimen and greater
satisfaction with care. Barriers to implementation of patient-centered care and bedside
rounding include time and resource requirements; the potential for patients to feel
confused, upset, or dehumanized as a result of hearing clinical explanations; and the
potential for breach of patient confidentiality (McMurry et. al 2011). In addition, when
presenting sensitive or confidential information, some nurses may feel uncomfortable, or
be inhibited by a lack experience—especially in the presence of patients’ family members
or relatives are present. O’Connell, Macdonald, and Kelly (2008) found that viewed
handoffs as being too time consuming, and ineffective, or efficient. The investigators
recommended that a handoff guideline or information template should be developed to
promote and facilitate the reporting of objective relevant information.
Patient satisfaction and its effects on quality of care. As a subjective
phenomenon, “patient satisfaction” is difficult to define. The self-reported determination
of patient satisfaction is a personal evaluation of health care services and of the providers
of that care (Ware et al., 1983); patients’ attitudes and expectations regarding care greatly
affect their sense of satisfaction. Because satisfaction ratings are relative, subjective, and
not directly observable, attempting to meaningfully quantify patients’ personal evaluation
of care is highly problematic (Ware et al., 1983).
The challenges inherent in measuring patient satisfaction have ramifications for
policy and practice. For example, in 2012, the Center for Medicare and Medicaid
Services (CMS) began to implement a reimbursement system that adjusts payment rates
based on patient satisfaction scores (Lyu et al., 2013). Patient satisfaction is a key
determinant of quality of care and an important component of the pay-for-performance
metrics instituted by CMS. Beginning in 2012, CMS implemented value-based incentive
payments to acute-care hospitals based in part on results of satisfaction surveys from
patients discharged on or after October 1, 2012. The patient’s perception of quality is
significant determinant of the provider’s federal reimbursement. Patients now make
decisions based on their perceptions of the quality of and satisfaction with health care
providers (Bowers, Swan, & Koehler, 1994).
A study conducted by Fenton, Jerant, Bertakis, and Franks at the University of
California–Davis examined mortality rate in relation to patient satisfaction (N = 51,946);
the researchers’ analysis adjusted for a number of factors (i.e., demographics, health
status and chronic disease burden, Year 1 utilization and expenditures, availability of a
usual source of care, and insurance status). The investigators were surprised to find that,
in comparison with the mortality rate of patients in the lowest satisfaction quartile, the
mortality rate of patients in the highest satisfaction quartile was 26% higher (adjusted
hazard ratio, 1.26; 95% CI [1.05, 1.53]). This perhaps counterintuitive finding raises the
question of whether current satisfaction measures are in fact good indicators of health
care quality (Fenton et al., 2012). The researchers concluded that the connection between
patient satisfaction and health care outcomes is yet unclear.
Practitioners need to understand that ineffective communication can result in poor
outcomes. Improved communication not only results in better health outcomes, but also
may positivity impact patient satisfaction. For patients who want to be involved in their
care and who understand what is occurring during care, improved communication may
ultimately lead to greater patient satisfaction. The inclusion of APNs in the care team has
been reported to improve communication and the efficiency of care (McCauley, Bixby, &
Naylor, 2006).
Evidence-based practice. Evidence-based practice (EBP) is at the forefront of
change in today’s health care environment. EBP is the practice of using documented
evidence as a guide to problem solving approach to clinical decision making. To
implement EBP, one must “locate, critique, synthesize, translate, and evaluate evidence”
(Drenning, 2006, p.299). This includes the dissemination of information during the
implementation phase of practice. Although ostensibly EBP is the standard of nursing
practice, implementation of EBP is not always easy (Krom & Bautista, 2010). Barriers to
EBP implementation include (a) lack of requisite knowledge and skills on the part of
clinicians, (b) perception that EBP is time consuming, (b) perception that EBP is
burdensome, and (d) lack of management support at the organizational level (Melnyk &
Fineout-Overholt, 2012). Among clinical staff members, APNs, nurse educators, and
DNPs—who understand translational research—are uniquely qualified to fulfill their
responsibility to fulfill the mandate to implement evidence –based changes in practice.
These organizational change agents must persuasively teach the EBP process to staff
nurses and thereby transform the organizational culture—from a culture in which change
is resisted to a culture in which evidence-based improvements in practice are welcomed.
To achieve this transformation in organizational culture, APNs, nurse educators, and
DNPs must employ an interactive approach.
APNs serve as both leaders and knowledge resources for helping nursing staff to
ground care in current evidence. In a study conducted by Mahanes, Quatrara, and Shaw
(2013) at the University of Virginia, the researchers implemented APN-led nursing
rounds. Although the specific effects of the APN-led nursing rounds were impossible to
isolate, Mahanes and her colleagues were able to determine that rates of blood stream
infections, catheter-associated urinary tract infections, hospital-acquired pressure ulcers,
and ventilator-associated pneumonia and falls all declined. Similarly, in study that a
analyzed the effectiveness of an APN-managed heart failure program, Dahl and Penque
(2002) reported reduced 90-day readmission rates, fewer in-patient hospital days, lower
re-admission charges, and lower overall charges for health care services.
APNs have demonstrated implementation of EBP practices, better working
relationship with staff nurses, and improved patient-centered care with cost savings. The
development of an intraprofessional APN–staff nurse team to conduct bedside rounding
should improve patient care, increase communication and collaboration, and improve
patient satisfaction.
The daily goals reminder sheet. The need to develop clear team communication
has led to the development and institution of daily goal sheets. Studies in ICUs have
demonstrated that the use of daily goal sheets can result in nurses’ and physicians’ having
better understanding of patient care goals and in decreased ICU length of stay (Agarwal et
al., 2008; Narasimhan et al., 2006; Pronovost et al., 2003). A study conducted by
Phipps and Thomas (2007) examined the use of a daily goals sheet in the ICU at The
University of Pennsylvania’s Hershey Children’s Hospital. The researchers found that
85% of nurses felt the use of the goals sheets improved communications between
physicians and nurses and improved communication between nurses working on different
shifts. Phipps and Thomas also reported that 95% of the nursing staff felt that the extra
expenditure of time spent in completing the daily goals sheet was worthwhile. In another
study, the Beth Israel Medical Center in New York instituted use of a worksheet that was
posted at bedside after completion. Narasimham and colleagues (2006) found that pre and
post scores for understanding patient goals and communication improved significantly,
and that this improvement was sustained over a 9-month period. Furthermore, after
completion of the study, most of the practitioners requested that the use of the worksheet
be continued. In the DNP project, instituting a daily goals reminder worksheet associated
with APN–RN–patient bedside rounding enhanced communication between APNs, staff
nurses, and patients.
Needs Assessment and Description of the Project
Population identification. In this DNP project, the population identified for
selection and participation comprises APNs who have prior knowledge of and experience
with APN–RN–patient bedside rounding.
Identification of the project sponsor and key stakeholders. This DNP project
has no sponsors. Key stakeholders include the student investigator and ultimately the
APNs and RNs who will participate in the learning module.
Assessment of available resources. No monetary resources were available for
this project. As project investigator, I was responsible for the development of the learning
module. The project had no public advertisement. APNs were approached through the
hospital’s standardized email by the student researcher (Appendix B).
Team selection. The project investigator, served as the team for this project, with
consultation from the DNP project committee members.
Scope of the project. The project entailed only the development of the 1-hour
learning module. Further plans for implementation will be considered at some point in
the future. The module’s topics included (a) the requirement for close communication and
collaboration between team members to assure seamless, high-quality health care, (b) the
definition of APN–RN rounds, (c) the schedule and length of rounds, (d) the personnel
composition of rounding teams, (e) topics of discussion during the rounds, and (f) the use
of a daily goal reminder sheet to ensure the consistency of all elements of the patient's
treatment plan and goals.
As project investigator, I used the literature as a basis for creating the written
learning module. After completing the module and obtaining University of Nevada Las
Vegas Institutional Review Board approval, the learning module was sent to three APNs
in the hospital for review and feedback; all of these APNs had prior experience in
working with APN–RN rounds at other facilities. In addition, to assess the learning
module’s effectiveness, I developed an evaluation form to be completed by participating
APNs and RNs following their completion of the learning module.
All results of this project were shared with a representative of the CMC’s
administration and the Chief Nurse Executive. I hope to work with administration and
staff in implementing the APN–RN–patient rounding on a pilot unit and, on the basis of
results, further develops the model for use on other inpatient units.
Mission, Goals, and Objectives
The mission and goals of this project are to improve communication and
collaboration between the intraprofessional team of APNs and staff nurses and to improve
APN–staff nurse communication with patients.
This DNP project’s primary objective was to develop a structured learning module
pertaining to APN–RN–patient bedside rounding. The project’s long-term goals,
following completion of this project, are to implement the model and to improve
communication and collaboration between APNs, clinical nurses, and the patients cared
for by these nurses.
Chapter 3
Theoretical Underpinnings of the DNP Project
Of the several theories that have informed our understanding of holistic patient
centered care and educating adults, two theories are among the most influential: King’s
theory of goal attainment and Knowles’s theory of andragogy. In light of the theories’
relevance to developing interventions for improving health care team collaboration and
communication—the central concern of this dissertation—these two theories were
selected to serve as the theoretical underpinnings of the DNP staff education project in
support of APN–RN–patient bedside rounding. Specifically, King’s theory of goal
attainment informed the process of identifying content for the staff education module;
Knowles’s theory of andragogy informed the design of the module’s presentation to
training participants.
King’s Theory of Goal Attainment
In “Crossing the Quality Chasm: A New Health System for the 21st Century,” the
IOM (2001) describes six aims for the improvement of health care. One of the aims is to
provide patient-centered care that is respectful of and responsive to individual patients’
personal preferences, needs, and values; in patient-centered care, patients’ values play a
central role in informing clinical decision making clinical decisions. Among theoretical
frameworks that inform clinical understanding of the role of the patient in this
decisionmaking, Imogene Kings’ theory of goal attainment is seminal.
King’s theory and patient-centered health care. In King’s theory, health care
team decision-making includes a “transaction” in which the nurse and patient engage in
mutual goal setting (King, 1991, pp. 19). According to King, this transactional process of
interpersonal systems involves four steps—action, reaction, interaction, and transaction—
by which the patient and nurse (a) share information about their perceptions; (b) set goals
(through communication and interaction); and (c) explore and agree on means to achieve
these goals. To implement a true transactional process, the communication environment
must be reciprocal, and bidirectional. In this DNP project,
King’s theory—including the theory’s view of this transactional process—was applied to
inform the design of a patient-centered clinical environment. For example, to create and
maintain a patient-centered environment, APNs, clinical nurses, and patients must share
and be mutually informed about relevant considerations.
The theory of goal attainment: Assumptions and concepts. King developed her theory
of goal attainment in the 1960s. This theory describes the interpersonal dynamic
relationships between patients and their quest for goal attainment. Factors that can affect
goal attainment include roles, stressors, space, and time. In order for health care to be
optimal during the course of treatment for individual patients, both the patients and their
providers must continuously accommodate and adjust for changes in these factors.
King’s theory refers to three interacting systems: individuals (personal system),
groups (interpersonal system), and society (social system). The personal system is a
unified, complex, whole self who perceives, thinks, desires, imagines, decides, identifies
goals, and selects means to achieve them.
Assumptions. King’s framework is based on two assumptions:
▪Human beings are the focus of nursing.
▪The goals of nursing are health promotion, maintenance and restoration, care
of the sick or impaired, and care of the dying.
On the basis of these assumptions, King designed a conceptual system to explain
the organized wholes in which nurses are expected to function (see Figure 1; King, 1999).
Wholeness. King used the concept of “wholeness” to describe the broader
organization or social systems in which nurse’s function. (King, 1996, p. 61). The goal of
an interacting system is health for individuals, families, communities, and the world
(King, 1996).
Personal, interpersonal, and social systems. King’s conceptual framework is
organized into three “systems”: personal, interpersonal, and social. A personal or
individual system is essentially a single whole system. In contrast, an interpersonal
system represents the interaction of two or more individuals (i.e., small groups) in various
environments. Social systems are composed of large groups, such as educational,
governmental, or religious organizations.
