Textbooks:
Sullivan (2017). Read Chapters:13, 24
Overview
Workplace violence against nurses is a major challenge for healthcare leaders. Common types of violence such as physical harm, sexual abuse, aggression, mobbing and bullying can occur from patients, family and co-workers.
For this discussion, you will use information from your assigned readings, the self-paced tutorial and the literature to discuss the following in a discussion board post.
· What impact does workplace violence have on nurses, other clinical staff and the organization as a whole? Be specific and provide rationale.
· How is workplace violence addressed in your organization, i.e. policies, protocols, training. Be specific. Is it sufficient? What else could be done?
· What are the legal and ethical implications for the nurse leader if workplace violence occurs on their unit(s)?
References:
· Initial Post: Minimum of two (2) total references: one (1) from required course materials and one (1) from peer-reviewed references.
1.5 pages
Effective Leadership and Management in Nursing Ninth Edition
Eleanor J. Sullivan PhD, RN, FAAN
330 Hudson Street, New York, NY 10013
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Library of Congress Cataloging-in-Publication Data
Names: Sullivan, Eleanor J., 1938- author. Title: Effective leadership and management in nursing / Eleanor J. Sullivan, PhD, RN, FAAN. Description: Ninth edition. | Boston : Pearson, [2017] | Includes index. Identifiers: LCCN 2016021687 | ISBN 9780134153117 | ISBN 0134153111 Subjects: LCSH: Nursing services—Administration. | Leadership. Classification: LCC RT89 .S85 2017 | DDC 362.17/3068—dc23 LC record available at https://lccn.loc.gov/2016021687
1 17
ISBN-10: 0-13-415311-1 ISBN-13: 978-0-13-415311-7
About the Author
E leanor J. Sullivan, PhD, RN, FAAN, is the former dean of the University of Kansas School of Nursing, past president of
Sigma Theta Tau International, and previous edi- tor of the Journal of Professional Nursing. She has served on the board of directors of the American Association of Colleges of Nursing, testified before the U.S. Senate, served on a National Insti- tutes of Health council, presented papers to international audiences, been quoted in the Chi- cago Tribune, St. Louis Post-Dispatch, and Rolling Stone Magazine, and named to the “Who’s Who in Health Care” by the Kansas City Business Journal. She earned nursing degrees from St. Louis Community College, St. Louis University, and Southern Illinois University and holds a PhD from St. Louis University.
Dr. Sullivan is known for her publications in nursing, including this award- winning textbook, Effective Leadership & Management in Nursing, and Becoming Influential: A Guide for Nurses, from Pearson Education. In addition, Dr. Sullivan has authored numerous professional articles, book chapters, and books, including Creating Nursing’s Future: Issues, Opportunities and Challenges, among others.
Today, Dr. Sullivan is also active in the mystery writing field. She served on the national board of Sisters in Crime, chaired an award committee for the Mystery Writ- ers of America, and is published in Mystery Scene Magazine and Ellery Queen Mystery Magazine.
She has published five mystery novels. Her first three mysteries (Twice Dead, Deadly Diversion, and Assumed Dead) feature nurse sleuth Monika Everhardt. The latter two were bought by Harlequin, reissued in paperback, and are still available as e-books (Deadly Diversion, Assumed Dead).
Her latest series, the Singular Village Mysteries, features 19th century midwife Ade- laide Bechtmann and her cabinetmaker husband, Benjamin. Two books in the series (Cover Her Body and Graven Images) are available in print, e-book, and audio formats. The third book, Tree of Heaven, will be released in the fall of 2017. The series is set in the Ohio village of Dr. Sullivan’s ancestors. Dr. Sullivan’s blog, found on her website, reveals the history behind her historical fiction.
Connect with her at EleanorSullivan.com, Facebook, and LinkedIn.
This book is dedicated to my family for their continuing love and support.
—Eleanor J. Sullivan
iii
Thank You
O ur heartfelt thanks go out to our colleagues from schools of nursing across the country who gave generously of their time, expertise, and knowledge to help us create this exciting new edition of our text. We have reaped the benefit of
your collective experience as nurses and teachers, and this edition is vastly enriched due to your efforts.
Contributors Michael Bleich, PhD, RN, FAAN President, Maxine Clark and Bob Fox Dean and Professor Goldfarb School of Nursing Barnes Jewish College Chapter 2: Designing Organizations
Debra J. Ford, PhD. Program Director, Leadership, and Research Assistant Professor The University of Kansas Medical Center Chapter 10: Communicating Effectively Chapter 13: Handling Conf lict
Rachel A. Pepper, RN, DNP, NEA-BC Senior Director of Nursing The University of Kansas Hospital Chapter 15: Budgeting and Managing Fiscal Resources Chapter 17: Staffing and Scheduling
Pamela Klauer Triolo, PhD, RN, FAAN Former Chief Nursing Officer (Corporate) and Associate Dean University of Pittsburgh Medical Center Chapter 19: Evaluating Staff Performance Chapter 20: Coaching, Disciplining, and Terminating Staff
Reviewers Wendy Bailes, PhD, RN Associate Director, Undergraduate Programs University of Louisiana at Monroe Monroe, Louisiana
Diane Daddario, MSN, ANP-C, ACNS-BC, RN-BC, CMSRN Adjunct Faulty, College of Nursing Pennsylvania State University University Park, Pennsylvania
iv
Teresa Fisher, MSN, RN, PBT (ASCP) Assistant Professor of Nursing Arkansas State University Jonesboro, Arkansas
Ruth Gladen, MS, RN Associate Professor RN Faculty & Director North Dakota College of Science Wahpeton, North Dakota
Lisa Harding, RN, MSN, CEN Professor Bakersfield College Bakersfield, California
Mary Alice Hodge, PhD, CNL-C, RN Director, Graduate Program The University of South Carolina Upstate Spartanburg, South Carolina
Mona P. Klose, MS, RN, CNE, CPHQ Director of Quality Management Assistant Professor of Nursing University of Jamestown Jamestown, North Dakota
Tara O’Brien, PhD, RN, CNE Assistant Professor The University of North Carolina Charlotte, North Carolina
Jennifer O’Connor, RN, MS, CFCN, CNE Instructor Northeastern State University Tahlequah, Oklahoma
Rose M. Powell, PhD, RN Associate Professor Stephen F. Austin State University Nacogdoches, Texas
Joyce A. Shanty, PhD, RN Associate Professor Indiana University of Pennsylvania Indiana, Pennsylvania
Deborah Smitherman, MSN, RN, CCM Assistant Professor of Nursing Belhaven University Jackson, Mississippi
Thank You v
Preface
N ever have nurses been more important to healthcare organizations than they are today. Passage of the Affordable Care Act (ACA) in 2010 reversed decades of focus on providing quantities of care to emphasize quality of care. Prevent-
ing illness and coordinating care are the cornerstones of the ACA, and nurses are key to its success.
In addition, leading and managing are essential skills for all nurses in this radically changed healthcare environment. New graduates find themselves managing unlicensed assistive personnel, and experienced nurses are managing groups of healthcare providers from a variety of disciplines and educational levels. All need to know how to manage.
This text is designed to provide new graduates or novice managers with the infor- mation they need to become effective managers and leaders in healthcare. In addition, a sidebar in each chapter illustrates how nurses can lead at the bedside. More than ever before, today’s rapidly changing healthcare environment demands highly devel- oped management skills and superb leadership.
Features of the Ninth Edition Effective Leadership and Management in Nursing has made a significant and lasting con- tribution to the education of nurses and nurse managers in its eight previous editions. Used worldwide and translated into numerous languages, this award-winning text is now offered in an updated and revised edition to reflect today’s healthcare arena and in response to suggestions from the text’s users. The ninth edition builds upon the work of previous contributors to provide the most up-to-date and comprehensive learning package for today’s busy students and professionals.
Features of the ninth edition include the following:
• Implementation of the Affordable Care Act
• Evolving models of healthcare organizational structures and relationships
• Expanded content on cultural and gender diversity
• Emphasis on quality management
• Addition of emotional leadership concepts
• Use of social media in management
• Harassing, bullying, and lack of civility in healthcare
• Emergency preparedness for terrorism, disasters, and mass shootings
• Prevention of workplace violence
Two new chapters have been added to this award-winning text. Chapter 7, Under- standing Legal and Ethical Issues, encompasses the myriad of issues confronting nurses and managers today. Chapter 28, Imagining the Future, helps readers contemplate the possibilities inherent in a fast-evolving environment.
Most notably, this text is available for the first time with a suite of digital resources to enhance your learning. This digital program includes the MyLab Nursing program
vi
that lets you review the chapter materials, decision-making cases that allow you to apply your learning, and the E-Text 2.0 digital text that is easy to navigate and gives you tools for highlighting, note taking, and more.
Student-friendly Learning Tools Designed with the adult learner in mind, the text focuses on the application of the con- tent presented and offers specific guidelines on how to implement the skills included. To further illustrate and emphasize key points, each chapter in this edition includes these features:
• A chapter outline and preview
• A complete audio version of each chapter
• Key terms in pop-up boxes linked to their first appearance and defined in the glossary at the end of the text
• Flashcards to self-test knowledge of new vocabulary
• What You Know Now summaries at the end of each chapter
• A Tool Box with a list of tools, or key behaviors, for using the skills presented in the chapter
• Questions to Challenge You in an interactive journal format to help students relate concepts to their experiences
• Up-to-date references
• Case Studies to demonstrate application of content, with discussion board questions
Organization The text is organized into five sections that address the essential information and key skills that nurses must learn to succeed in today’s volatile healthcare environment and to prepare for the future.
Part 1. Understanding Nursing Management and Organizations Part 1 introduces the context for nursing management, with an emphasis on chang- ing organizational structures, ways that nursing care is delivered, the concepts of leading and managing, how to initiate and manage change, providing quality care, and how to use power and politics—all necessary for nurses to succeed and prosper in today’s chaotic healthcare world. A new chapter addresses how to weigh legal and ethical issues,
Part 2. Learning Key Skills in Nursing Management Part 2 delves into the essential skills for today’s managers, including thinking critically, making decisions, solving problems, communicating with a variety of individuals and groups, delegating, working in teams, resolving conflicts, and managing time.
Preface vii
Part 3. Managing Resources Knowing how to manage resources is vital for today’s nurses. They must be adept at budgeting fiscal resources; recruiting and selecting staff; handling staffing and sched- uling; motivating and developing staff; evaluating staff performance; coaching, disci- plining, and terminating staff; managing absenteeism, reducing turnover, and retaining staff; and handling disruptive staff behaviors, especially harassing and bul- lying behaviors. In addition, collective bargaining, preparing for emergencies and pre- venting workplace violence are included in Part 3.
Part 4. Taking Care of Yourself Nurses are their own most valuable resource. Part 4 shows how to manage stress and to advance in a career.
Part 5. Looking Toward the Future New to this edition, this chapter provides ways to consider the future, societal predic- tions about the future, the future of healthcare, and the future of nursing.
Instructor Resources The assignable and gradable assessments in MyLab Nursing provide educators with insight into students’ preparation for class, students’ understanding of the material, and clarity around areas in which additional instruction may be needed.
Additional Instructor Resources can be accessed by registering and logging in at www.pearsonhighered.com/nursing and include the following:
• TestGen Test Bank
• Lecture Note PowerPoints
• Instructor’s Resource Manual
viii Preface
Part 1 Understanding Nursing Management and Organizations
1 Introducing Nursing Management 1
2 Designing Organizations 13
3 Delivering Nursing Care 33
4 Leading, Managing, Following 43
5 Initiating and Managing Change 60
6 Managing and Improving Quality 75
7 Understanding Legal and Ethical Issues 94
8 Understanding Power and Politics 110
Part 2 Learning Key Skills in Nursing Management
9 Thinking Critically, Making Decisions, Solving Problems 125
10 Communicating Effectively 145
11 Delegating Successfully 163
12 Building and Managing Teams 178
13 Handling Conflict 198 14 Managing Time 211
Part 3 Managing Resources
15 Budgeting and Managing Fiscal Resources 224
16 Recruiting and Selecting Staff 241
17 Staffing and Scheduling 260
18 Motivating and Developing Staff 271
19 Evaluating Staff Performance 283
20 Feedback and Coaching, Disciplining, and Terminating Staff 296
21 Managing Absenteeism, Reducing Turnover, Retaining Staff 307
22 Dealing with Disruptive Staff Problems 323
23 Preparing for Emergencies 332
24 Preventing Workplace Violence 340
25 Handling Collective Bargaining Issues 349
Part 4 Taking Care of Yourself
26 Managing Stress 356
27 Advancing Your Career 366
Part 5 Looking to the Future
28 Imagining the Future 382
Brief Contents
ix
Acknowledgments
T he success of previous editions of this text has been due to the expertise of many contributors. Nursing administrators, management professors, and faculty in schools of nursing all made significant contributions to earlier editions. I am
enormously grateful to them for sharing their knowledge and experience to help nurses learn leadership and management skills.
I am especially grateful to the contributors to this edition. They revised and updated content in the following chapters: Chapter 2: Michael Bleich, Chapters 10 and 12: Debbie Ford, Chapters 15 and 17: Rachel Pepper, and Chapters 19 and 20: Pamela Triolo. All are excellent writers, and this edition would not exist without their contributions. In addition, Michael Bleich lent his expertise to a review of the eighth edition, and Rachel Pepper reviewed the previous edition and added specific examples to demonstrate content for this edition as well.
At Pearson Education, I am grateful to continue to work with Executive Editor Pamela Fuller, who has supported this text through many editions. For this edition, Program Manager Erin Rafferty facilitated all aspects of the text’s progress, and Devel- opment Editor Pamela Lappies’s expertise and fine attention to detail ensure that the text will continue to be the first choice of faculty and students worldwide.
To everyone who has contributed to this fine text over the years, I thank you.
Eleanor J. Sullivan, PhD, RN, FAAN www.EleanorSullivan.com
x
Contents
About the Author iii Thank You iv Preface vi
Part 1 Understanding Nursing Management and Organizations
1 Introducing Nursing Management 1
Introduction 2
Changes in Healthcare 2 Paying for Healthcare 2
Changes in Society 7 Cultural, Gender, and Generational Differences 7 Violence, Pandemics, and Disasters 8
Changes in Nursing’s Future 8 Current Status of Nursing 8 Institute of Medicine’s Recommendations for Nursing 9 Adapting to Constant Change 9 What You Know Now 9
Questions to Challenge You 10
References 10
2 Designing Organizations 13 Introduction 14
Reductive and Adaptive Organizational Theories 15 Reductive Theory 15 Humanistic Theory as a Bridge 17 Adaptive Theories 18
Organizational Structures and Shared Governance 19 Functional Structure 19 Service-line Structure 20 Matrix Structure 21 Parallel Structure 21 Shared Governance 22
Healthcare Settings 22 Primary Care 23 Acute Care Hospitals 23 Home Healthcare 23 Long-term Care 23
Ownership and Complex Healthcare Arrangements 24 Ownership of Healthcare Organizations 24 Healthcare Networks 24 Interorganizational Relationships 26 Diversification 26 Managed Healthcare Organizations 27 Accountable Care Organizations 27
Redesigning Healthcare 28 Organizational Environment and Culture 29 What You Know Now 30
Questions to Challenge You 30
References 31
3 Delivering Nursing Care 33 Introduction 34
Traditional Models of Care 34 Total Patient Care 35 Functional Nursing 35 Team Nursing 35 Primary Nursing 35
Integrated Models of Care 36 Practice Partnerships 36 Case Management 36 Critical Pathways 37
Evolving Models of Care 38 Patient-centered Care 38 Synergy Model of Care 39 Patient-centered Medical Home 39 What You Know Now 41
Questions to Challenge You 41
References 41
4 Leading, Managing, Following 43 Introduction 44
Leaders and Managers 44 Leadership 45
Leadership Theories 45 Traditional Leadership Theories 45 Contemporary Leadership Theories 46
Followership: An Essential Component of Leadership 49
xi
xii Contents
Traditional Management Functions 50 Planning 50 Organizing 51 Directing 51 Controlling 51
Nurse Managers in Practice 52 Nurse Manager Competencies 52 Staff Nurse 52 First-level Management 54 Charge Nurse 54 Clinical Nurse Leader 56 What You Know Now 57
Tools for Leading, Managing, and Following 57
Questions to Challenge You 58
References 58
5 Initiating and Managing Change 60
Introduction 61
The Nurse as Change Agent 62
Change Theories 62
The Change Process 64 Step 1: Identify the Problem or Opportunity 64 Step 2: Collect Necessary Data and Information 65 Step 3: Select and Analyze Data 65 Step 4: Develop a Plan for Change, Including Time Frame and Resource 65 Step 5: Identify Supporters and Opposers 66 Step 6: Implement Interventions to Achieve Desired Change 66 Step 7: Evaluate Effectiveness of the Change and, if Successful, Stabilize the Change 66
Change Strategies 67 Power–Coercive Strategies 67 Empirical–Rational Model Strategies 67 Normative–Reeducative Strategies 67
Resistance to Change 68
The Nurse’s Role 69 Initiating Change 69 Implementing Change 71 Unplanned Change 71 Handling Constant Change 72 What You Know Now 73
Tools for Initiating and Managing Change 73
Questions to Challenge You 73
References 74
6 Managing and Improving Quality 75
Introduction 76
Quality Management 76 Total Quality Management 76 Continuous Quality Improvement 77 Components of Quality Management 77 Six Sigma 78 Lean Six Sigma 79 DMAIC Method 79
Improving the Quality of Care 80 National Initiatives 81 Evidence-based Practice 82 Electronic Health Records 82 Dashboards 82 Rounding 82 Reducing Medication Errors 83
Risk Management 83 Nursing’s Role in Risk Management 84 Incident Reports 84 Examples of Risk 85 Root-cause Analysis 87 Peer Review 87 Role of the Nurse Manager 87 Creating a Blame-free Environment 90 What You Know Now 90
Tools for Managing and Improving Quality 91
Questions to Challenge You 91
References 92
7 Understanding Legal and Ethical Issues 94
Introduction 95
Law and Ethics 95
Ethical Decision Making 96 Autonomy 96 Beneficence and Nonmaleficence 97 Distributive Justice 97
The Legal System 97 Sources of Law 97 Types of Law 98 Liability 99
Legal Issues in Nursing 100 Nursing Licensure 100 Patient Care Rights 100 Management Issues 105
Employment Issues 107 What You Know Now 108
Questions to Challenge You 109
References 109
8 Understanding Power and Politics 110
Introduction 111
Power and Leadership 111 Power: How Managers and Leaders Get Things Done 111
Using Power 114 Image as Power 114 Using Power Appropriately 116
Shared Visioning as a Power Tool 117
Power, Politics, and Policy 118 Nursing’s Political History 118 Using Political Skills to Influence Policies 119 Influencing Public Policies 121
How Nurses Can Influence the Future 123 What You Know Now 123
Tools for Using Power and Politics 124
Questions to Challenge You 124
References 124
Part 2 Learning Key Skills in Nursing Management
9 Thinking Critically, Making Decisions, Solving Problems 125
Introduction 126
Critical Thinking 126 Critical Thinking in Nursing 127 Using Critical Thinking 127 Creativity 128
Decision Making 130 Types of Decisions 130 Decision-making Conditions 131 The Decision-making Process 132 Decision-making Techniques 133 Group Decision Making 135
Problem Solving 135 Problem-solving Methods 135 The Problem-solving Process 137 Group Problem Solving 140
Stumbling Blocks 141 Personality 141 Rigidity 141 Preconceived Ideas 141
Innovation 142 What You Know Now 142
Tools for Making Decisions and Solving Problems 143
Questions to Challenge You 143
References 143
10 Communicating Effectively 145 Introduction 146
Communication 146 Transactional Model of Communication 147 Channels of Communication 148 Nonverbal Messages 149 Directions of Communication 150 Effective Listening 150
Effects of Differences in Communication 151 Gender Differences in Communication 151 Generational and Cultural Differences in Communication 152 Differences in Organizational Culture 152
The Role of Communication in Leadership 153 Employees 153 Administrators 154 Coworkers 156 Medical Staff 156 Other Healthcare Personnel 156 Patients and Families 157
Collaborative Communication 157
Enhancing Your Communication Skills 158 What You Know Now 160
Tools for Communicating Effectively 160
Questions to Challenge You 161
References 161
11 Delegating Successfully 163 Introduction 164
Delegation 164
Benefits of Delegation 165 Benefits to the Nurse 166 Benefits to the Delegate 166 Benefits to the Manager 166 Benefits to the Organization 166
The Five Rights of Delegation 166
Contents xiii
The Delegation Process 167 Steps in the Delegation Process 168 Key Behaviors for Successful Delegation 170 Accepting Delegation 171
Ineffective Delegation 172 Organizational Culture 172 Lack of Resources 172 An Insecure Delegator 172 An Unwilling Delegate 174 Underdelegation 174 Reverse Delegation 175 Overdelegation 175 What You Know Now 176
Tools for Delegating Successfully 176
Questions to Challenge You 176
References 177
12 Building and Managing Teams 178
Introduction 179
Groups and Teams 179 Group Interaction 182 Group Leadership 182
Group and Team Processes: Homans Framework 182
Norms 184 Roles 185
Building Teams 186 Assessment 186 Team-building Activities 187
Managing Teams 187 Task 187 Group Size and Composition 188 Productivity and Cohesiveness 188 Development and Growth 190 Shared Governance 190
The Nurse Manager as Team Leader 190 Communication 190 Evaluating Team Performance 191
Leading Committees and Task Forces 192 Guidelines for Conducting Meetings 192 Managing Task Forces 193 Patient Care Conferences 195 What You Know Now 196
Tools for Building and Managing Teams 196
Questions to Challenge You 196
References 196
13 Handling Conflict 198 Introduction 199 Conflict 199
Interprofessional Conflict 199 Conflict Process Model 200
Antecedent Conditions 200 Perceived and Felt Conflict 202 Conflict Behaviors 203 Conflict Resolved or Suppressed 203 Outcomes 203
Managing Conflict 204 Conflict Responses 206 Alternative Dispute Strategies 208 What You Know Now 209
Tools for Handling Conflict 209
Questions to Challenge You 209
Resources 209
References 210
14 Managing Time 211 Introduction 211
Time-wasters 212
Setting Goals 214 Determining Priorities 215 Daily Planning and Scheduling 216 Grouping Activities and Minimizing Routine Work 216 Personal Organization and Self-discipline 217
Controlling Interruptions 217 Phone Calls, Voice Mail, Email, and Text Messages 218 In-person Interruptions 220 Paperwork 220
Controlling Time in Meetings 221
Respecting Time 222 What You Know Now 222
Tools for Managing Time 222
Questions to Challenge You 223
References 223
Part 3 Managing Resources
15 Budgeting and Managing Fiscal Resources 224
Introduction 225
The Budgeting Process 225 Timetable for the Budgeting Process 227
xiv Contents
Approaches to Budgeting 227 Incremental Budget 228 Zero-based Budget 228 Fixed or Variable Budgets 229
The Operating Budget 229 The Revenue Budget 229 The Expense Budget 230
Determining the Salary and Nonsalary Budget 230 The Salary Budget 230 The Supply and Nonsalary Expense Budget 233
The Capital Budget 234
Monitoring and Controlling Budgetary Performance During the Year 234
Variance Analysis 235 Position Control 237
Staff Impact on Budget 237 Improving Performance 237 What You Know Now 239
Tools for Budgeting and Managing Resources 240
Questions to Challenge You 240
References 240
16 Recruiting and Selecting Staff 241
Introduction 242
The Recruitment and Selection Process 242
Recruiting Applicants 243 Where to Look 244 How to Look 245 When to Look 245 How to Promote the Organization 245 Cross-training as a Recruitment Strategy 246
Selecting Candidates 247
Interviewing Candidates 248 Principles for Effective Interviewing 248 Involving Staff in the Interview Process 252 Interview Reliability and Validity 253
Making a Hire Decision 253 Education, Experience, and Licensure 253 Integrating the Information 254 Making an Offer 255
Legality in Hiring 255 What You Know Now 258
Tools for Recruiting and Selecting Staff 259
Questions to Challenge You 259
References 259
17 Staffing and Scheduling 260 Introduction 261
Staffing 261 Patient Classification Systems 262 Determining Nursing Care Hours 263
Planning FTE Workforce 263 Determining Staffing Mix 264 Determining Distribution of Staff 264
Scheduling 266 Self-staffing and Scheduling 266 Shared Schedule 267 Open Shift Management 267 Weekend Staffing Plan 267 Automated Scheduling 268
Supplementing Staff 268 Internal Pools 268 External Pools 269 What You Know Now 269
Tools for Handling Staffing and Scheduling 269
Questions to Challenge You 270
References 270
18 Motivating and Developing Staff 271
Introduction 272
A Model of Job Performance 272 Employee Motivation 273 Motivational Theories 273
Staff Development 275 Orientation 276 On-the-job Instruction 276 Preceptors 277 Mentoring 278 Coaching 278 Nurse Residency Programs 279 Career Advancement 279 Leadership Development 280
Succession Planning 281 What You Know Now 281
Tools for Motivating and Developing Staff 281
Questions to Challenge You 282
References 282
19 Evaluating Staff Performance 283 Introduction 284
Performance Management 284
Contents xv
The Performance Evaluation Process 284 Management Responsibilities 287 Components of the Annual Performance Evaluation 287 Developing Evaluation Tools 288
Methods for Collecting Performance Data 288 Peer Review 288 Self-evaluation 289 Skill Competency 290 Manager’s Evaluation 291
Facing the Challenges of Performance Review 291 Conducting the Annual Performance Review 292
What You Know Now 294
Tools for Evaluating Staff Performance 294
Questions to Challenge You 295
References 295
20 Feedback and Coaching, Disciplining, and Terminating Staff 296
Introduction 297
Feedback 297
Coaching 297
Feedback versus Coaching 299
Confronting Behavior 299
Discipline 299
Termination 303 What You Know Now 305
Tools for Feedback and Coaching, Disciplining and Terminating Staff 305
Questions to Challenge You 305
References 306
21 Managing Absenteeism, Reducing Turnover, Retaining Staff 307
Introduction 308 Absenteeism 308
A Model of Employee Attendance 308 Managing Employee Absenteeism 311 Absenteeism Policies 312 Selecting Employees and Monitoring Absenteeism 313 Family and Medical Leave 313
Reducing Turnover 314 Cost of Nursing Turnover 314 Causes of Turnover 315 Understanding Voluntary Turnover 315
Retaining Staff 316 Job Satisfaction 316 Improving Salaries 317 Retention Strategies 318 What You Know Now 320
Tools for Reducing Turnover, Retaining Staff 320
Questions to Challenge You 321
References 321
22 Dealing with Disruptive Staff Problems 323
Introduction 323
Harassing Behaviors 324 Bullying 324 Lack of Civility 324 Horizontal Violence 325
How to Handle Problem Behaviors 326 Marginal Employees 327 Disgruntled Employees 327
The Employee with a Substance Abuse Problem 327 State Board of Nursing 329 Strategies for Intervention 329 Reentry 330 The Americans with Disabilities Act and Substance Abuse 330 What You Know Now 330
Tools for Managing Staff Problems 331
Questions to Challenge You 331
References 331
23 Preparing for Emergencies 332 Introduction 332
Types of Emergencies 333 Natural Disasters 333 Man-made Disasters 333 Levels of Disasters 334
Hospital Preparedness for Emergencies 334 All-hazards Approach 334 Emergency Operations Plan 334 Surge Capacity 335 Disaster Triage 336 Continuation of Services 336
Staff Utilization in Emergencies 336 What You Know Now 338
Tools for Preparing for Emergencies and Preventing Violence 338
Questions to Challenge You 338
References 339
xvi Contents
24 Preventing Workplace Violence 340
Introduction 340
Violence in Healthcare 341 Incidence of Workplace Violence 341 Horizontal Violence 341 Consequences of Workplace Violence 342 Factors Contributing to Violence in Healthcare 342
Preventing Violence 343 Zero-tolerance Policies 343 Reporting and Education 343 Environmental Controls 343
Dealing with Violence 344 Verbal Intervention 344 A Violent Incident 344 Other Dangerous Incidents 345 Post-incident Follow-up 345 What You Know Now 347
Tools for Preventing Violence 347
Questions to Challenge You 347
References 347
25 Handling Collective Bargaining Issues 349
Introduction 349
Laws Governing Unions 350
Process of Unionization 350
Handling Grievances 351 Unfair Labor Practices 351 The Grievance Process 352
Collective Bargaining and Nurses 352 Legal Issues of Supervision 353 The Future of Collective Bargaining for Nurses 354 What You Know Now 354
Tools for Handling Collective Bargaining Issues 355
Questions to Challenge You 355
References 355
Part 4 Taking Care of Yourself
26 Managing Stress 356 Introduction 356
The Nature of Stress 357
Causes of Stress 358
Organizational Factors 358
Interpersonal Factors 358
Individual Factors 359
Consequences of Stress 360
Managing Stress 361
Personal Methods 361
Organizational Methods 362
What You Know Now 364
Tools for Managing Stress 364
Questions to Challenge You 364
References 365
27 Advancing Your Career 366 Introduction 366
Envisioning Your Future 367
Acquiring Your First Position 367
Applying for the Position 368
The Interview 368
Accepting the Position 373
Declining the Position 373
Progressing in Your Career 373
Tracking Your Progress 375
Identifying Your Learning Needs 376
Finding and Using Mentors 378
Considering Your Next Position 379
Finding Your Next Position 379
Leaving Your Present Position 379
Adapting to Change 380
What You Know Now 380
Tools for Advancing Your Career 381
Questions to Challenge You 381
Online Resources 381
References 381
Part 5 Looking to the Future
28 Imagining the Future 382 Introduction 382
Ways to Consider the Future 383
Possible Future 383
Plausible Future 383
Probable Future 383
Preferable Future 383
Contents xvii
Societal Predictions About the Future 383
The Future of Healthcare 384 Technological Innovations 384 Healthcare Legislation 385 Demands of Consumerism 385
The Future of Nursing 386 Institute of Medicine Recommendations 386 New Careers in Nursing Project 386
What You Know Now 388
Questions to Challenge You 388
References 388
Glossary 390
Credits 398
Index 401
xviii Contents
Chapter 1
Introducing Nursing Management
Learning Outcomes
After completing this chapter, you will be able to:
1. Explain changes to healthcare over the past decade, including those resulting from implementation of the Affordable Care Act; demands to reduce errors and improve patient safety; and evolving medical and communication technology.
2. Describe how nursing management is influenced by changes in society.
3. Identify the changes and challenges that nurses face now and in the future.
Key Terms accountable care organization
(ACO)
Affordable Care Act (ACA)
benchmarking
Centers for Medicare & Medicaid Services (CMS)
electronic health records (EHRs)
evidence-based practice (EBP)
health home
Leapfrog Group
Magnet Recognition Program
Changes in Healthcare Paying for Healthcare
Changes in Society Cultural, Gender, and Generational Differences
Violence, Pandemics, and Disasters
Changes in Nursing’s Future Current Status of Nursing
Institute of Medicine’s Recommendations for Nursing
Adapting to Constant Change
1
2 Chapter 1
medical errors
medical home
Quality and Safety Education for Nurses (QSEN)
quality management
robotics
telehealth
Introduction Today, all nurses are managers. And leaders. And followers. Whether you work in an urgent care center, an ambulatory surgical center, a critical care unit in an acute care hospital, or in hospice care for a home care agency, you interact with staff, including other nurses and unlicensed assistive personnel, who work with you and for you. You must be able to collaborate with others, as a leader, a follower, and a team member. More than ever before, today’s rapidly changing healthcare environment demands highly refined management skills and superb leadership.
Leading at the Bedside: Management Skills You may think you don’t need this text. After all, you’re a staff nurse. You take care of patients in a hospital or clinic. You’re neither a designated manager nor an identified leader.
But you would be wrong. For every plan you make, every time you instruct an
assistant, every interaction with a patient or family member,
you use management skills. Don’t you manage patient safety? Solve problems? Handle conflict? And—my favorite—manage time? These are just a few of the skills you will learn in this text. Good luck!
Changes in Healthcare Healthcare continues to change at a rapid rate. Reimbursement for care, demands for safe care, and evolving technology are affecting every aspect of care. In addition, soci- etal changes, including cultural, gender, and generational differences, as well as an increase in violence, pandemics, and disasters force the healthcare system to adapt quickly. In turn, these changes challenge nursing and nurses to adapt.
Paying for Healthcare In the past, healthcare providers were paid for the amount of care they gave patients. The more care they provided, the more money they received. There was no provi- sion for the effectiveness of that care. Also, if mistakes were made, healthcare orga- nizations were reimbursed for whatever care they provided to ameliorate those mistakes. That system is being replaced by reimbursement for the quality of the care provided and not reimbursing healthcare organizations for the cost of correct- ing mistakes.
AffordAblE CArE ACt Implementation of the Affordable Care Act (ACA) in 2010 radically changed how healthcare is delivered and compensated in the
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United States. Such healthcare reform was desperately needed to fix a system that rewarded more care and discouraged preventive care. In addition, the cost of medical care continued to soar while many Americans lacked access to basic care (Centers for Medicare & Medicaid Services [CMS], 2015). Although the ACA has undergone numerous court challenges that remain unsettled, implementation is proceeding.
The ACA was designed to provide quality, affordable healthcare for all Ameri- cans (Emanuel, 2015). Its emphasis is on preventing disease and coordinating care, and it provides mechanisms for the uninsured to acquire health insurance by enrolling in state or federal exchanges of health insurance companies (Blumenthal & Collins, 2014). Through incentives and penalties, the ACA encourages health- care organizations to establish accountable care organizations (ACO), consisting of hospitals and healthcare providers who agree to provide care to a designated population.
Also changed is how primary care providers offer care via a health home (previ- ously called a medical home) (U.S. Department of Health and Human Services, 2015a). Instead of serving as gatekeepers to specialty care in order to contain costs, primary care providers facilitate access to specialty care when needed and monitor that care using electronic health records (Russell, 2014). Regular follow-ups by care providers monitor chronic health conditions and reinforce treatment regimens. Patients, too, have access to their medical records and are encouraged to participate in decisions about their care.
Whether the ACA will remain as it is, be changed by legislation, or be repealed entirely remains to be seen. What is apparent, however, is that access, cost, and quality of care will continue to concern providers, insurers, state and federal gov- ernments, and the American people.
COSt Of MEdiCAL ERRORS Another factor affecting the healthcare system is the cost of medical errors (Andel, Davidow, Hollander, & Moreno, 2012). Since the Insti- tute of Medicine (IOM) reported that 98,000 deaths occur each year from preventable medical mistakes (Institute of Medicine, 1999), both healthcare providers and insur- ers have mounted efforts to prevent such errors, including falls, wrong site surgeries, avoidable infections, pressure ulcers, and adverse drug events. In spite of numerous efforts to prevent mistakes, the cost of medical errors has continued to climb. In addi- tion to loss of life or diminished quality of life, actual dollar estimates put such costs at $17.1 billion annually (Den Bos et al., 2011).
To incentivize hospitals to reduce medical mistakes, the Centers for Medicare & Medicaid Services (CMS), the agency that oversees government payments for care, changed its reimbursement policy to no longer cover costs incurred by medical mis- takes. If medical mistakes occur, the hospital must absorb the costs. Thus, pay for per- formance became the norm, and performance is now measured by the quality of care (Milstein, 2009).
dEMANd fOR QuALity In an effort to ameliorate medical mistakes, a number of quality initiatives have emerged. These include quality management, the Leapfrog Group, benchmarking, evidence-based practice, the Magnet Recognition Program, and Quality and Safety Education for Nurses.
Quality Management. Quality management is a preventive approach designed to address problems before they become crises. Although quality management was
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originally designed for manufacturing, the healthcare industry has adopted various quality management strategies from the airline industry and other fields. Good man- agement techniques can often be transferred from one use to another.
Leapfrog Group. The Leapfrog Group is a consortium of public and private pur- chasers that uses its mammoth purchasing power by rewarding healthcare organi- zations that demonstrate quality outcome measures. Today, the Leapfrog Group compares hospitals’ performance on preventing errors, accidents, injuries, and infections. In 2014, the Leapfrog Group assessed 1,501 hospitals (Leapfrog Group, 2015).
Benchmarking. Benchmarking is a comparison of an organization’s data with simi- lar organizations. Outcome indicators are compared across disciplines or organiza- tions. Once the results are known, healthcare organizations can address areas of weakness and enhance areas of strength (Nolte, 2011).
Evidence-based Practice. Evidence-based practice (EBP) has emerged as a strat- egy to improve quality by using the best available knowledge integrated with clini- cal experience and the patient’s values and preferences to provide care (Houser & Oman, 2010).
Similar to the nursing process, the steps in EBP are as follows:
1. Identify the clinical question.
2. Acquire the evidence to answer the question.
3. Evaluate the evidence.
4. Apply the evidence.
5. Assess the outcome.
Research findings with conflicting results puzzle consumers daily, and nurses are no exception, especially when they search for practice evidence. Hader (2010) suggests that evidence falls into several categories:
• Anecdotal—derived from experience
• Testimonial—reported by an expert in the field
• Statistical—built from a scientific approach
• Case study—an in-depth analysis used to translate to other clinical situations
• Nonexperimental design research—gathering factors related to a clinical condition
• Quasi-experimental design research—a study limited to one group of subjects
• Randomized control trial—uses both experimental and control groups to deter- mine the effectiveness of an intervention
While all forms of evidence are useful for clinical decision making, randomized control design and statistical evidence are the most rigorous (Hader, 2010).
Magnet Recognition Program. More than 25 years ago, the Magnet Recognition Pro- gram was designed to recognize excellence in nursing. The purpose was to improve patient care by focusing on nurses’ qualifications, work life, and participation within the organization. The program designated 14 factors that indicated a culture of
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excellence, resulting in an environment for quality patient care. Institutions that met the stringent guidelines for nurses were credentialed by the American Nurses Creden- tialing Center (ANCC) as Magnet-certified hospitals.
In 2007, the Magnet program was redesigned to provide a framework for the future of nursing practice and education (American Nurses Credentialing Center, 2008). To focus on outcome measures, the 14 factors from the original program were reconfigured into five components:
• Transformational leadership
• Structural components
• Exemplary professional practice
• New knowledge, innovations, and improvement
• Empirical outcomes
Magnet hospitals are those organizations that are recognized for “quality patient care, nursing excellence and innovations in professional nursing practice.” (American Nurses Credentialing Center, 2016). To qualify for recognition as a Magnet hospital, the organization must demonstrate that they are achieving the following:
• Promoting quality in a setting that supports professional practice
• Identifying excellence in the delivery of nursing services to patients/residents
• Disseminating “best practices” in nursing services (ANCC, 2015)
In 2013, the US News Best Hospitals in America Honor Roll included 15 medical centers of the 18 recognized as holding Magnet certification (ANCC, 2015).
Quality and Safety Education for Nurses. Based on recommendations of the Institute of Medicine (IOM, 2003), a national advisory board of experts developed quality and safety competencies, designating targets of knowledge, skills, and attitudes (KSAs) for nursing education known as Quality and Safety Education for Nurses (QSEN; Cronenwett et al., 2007).
The six prelicensure KSAs are as follows:
• Patient-centered care
• Teamwork and collaboration
• Evidence-based practice
• Quality improvement
• Safety
• Informatics (Quality and Safety Education for Nurses Institute, 2015)
These competencies are being used as guides for nursing education, to assist nurses transitioning to practice, and for nurses continued lifelong learning (Amer, 2013).
EvOLviNG tECHNOLOGy Rapid changes in technology seem, at times, to over- whelm us. Hospital information systems (HIS); electronic health records (EHRs); com- puterized physician/provider point-of-care data entry (CPOE); barcode medication administration; dashboards to manage, report, and compare data across platforms; telehealth provided from a distance; and robotics—to name a few of the many
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evolving technologies—both fascinate and frighten us simultaneously. At the same time, communication technology—from smartphones to social media—continues to march into the future. It is no wonder that people who work in healthcare complain that they can’t keep up! The rapidity of technological change promises to continue unabated (Huston, 2013).
Electronic Health Records. Electronic health records (EHRs) reduce redundancies, improve efficiency, decrease medical errors, and lower healthcare costs. Continuity of care, discharge planning and follow-up, ambulatory care collaboration, and patient safety are just a few of the additional advantages of EHRs. Furthermore, fully inte- grated systems allow for collective data analysis across clinical conditions and between and among healthcare organizations, and they support evidence-based decision making. Federal incentives (e.g., reimbursement and grants) encourage the expanded use of EHRs, which is expected to continue (Amer, 2013).
Telehealth. telehealth has evolved as technologies to assess, intervene, and moni- tor patients remotely continue to improve. The technology to diagnose and treat patients from a distance, along with patient-accessible EHRs and mobile devices such as smartphones, enables providers to interact with patients regardless of their location.
Nurses, for example, can watch banks of video screens miles away from the hospi- tal monitoring ICU patients’ vital signs. Electronic equipment, such as a stethoscope, can be accessed by a healthcare provider in a distant location. Such systems are espe- cially useful in providing expert consultation for specialty care (Zapatochny-Rufo, 2010). This technology, too, is expected to grow (Amer, 2013).
Robotics. Another technological advance is robotics. In the hospital, supplies can be ordered electronically. Next, laser-guided robots fill orders in the pharmacy or central supply and deliver them to nursing units via dedicated elevators—and do so more efficiently, accurately, and in less time than individuals can. Robot functionality will continue to expand, limited only by resources and ingenuity.
Communication Technology. Communication technologies are evolving just as rap- idly as clinical and data technology, changing forever the ways people keep informed and interact (Sullivan, 2013). Information (accurate or inaccurate) is disseminated with lightning speed, while smartphones capture real-time events and broadcast images instantaneously.
Social media have revolutionized communication beyond the realm of possibili- ties of just a few years ago. Social media connect diverse populations and encourage collaboration by way of the exchange of images, ideas, and opinions in online forums, blogs, wikis, podcasts, RSS feeds, Instagram, Pinterest, YouTube, Twitter, Facebook, and LinkedIn, among others (Sullivan, 2013).
Like other enterprises, most healthcare organizations maintain a website as well as a presence on social media sites such as Facebook, Twitter, and blogs. Units within the organization may maintain Facebook pages as well, with staff designated to post on those sites. These opportunities for information sharing and relationship building also come with risks. Patient confidentiality, the organization’s reputa- tion, and recruiting efforts can be enhanced or put in jeopardy by posts to the site (Sullivan, 2013).
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Changes in Society Societal change is occurring as rapidly as healthcare is changing. Changes include dif- ferences in the composition of today’s population, including the nursing population, as well as demands on the healthcare system resulting from increasing violence, threats of pandemics, and challenges of potential disasters.
Cultural, Gender, and Generational Differences The population mix in the United States, the number of men entering nursing, and the average age of practicing nurses all affect nursing. All require nursing to adjust and adapt.
CuLtuRAL diffERENCES According to the U.S. Census Bureau (2013), the minority population in the United States is projected to rise to 56% of the total by 2060, compared with 38% in 2014 (U.S. Census, 2015). This includes Hispanic, Asian, and African American populations, but the fastest growing minority group in the United States are people who identify themselves as two or more races (U.S. Cen- sus, 2015). In addition, the recognition that lesbian, gay, bisexual, and transgender (LGBT) populations are part of communities across the United States challenges healthcare providers to offer appropriate care and services (Budden, Zhong, Moulton, & Cimiotti, 2013).
The nursing profession, however, does not reflect the cultural diversity seen in the general population. A 2013 survey of registered nurses found that only 17% are minor- ities (Budden et al., 2013). Efforts to increase diversity in nursing are recommended (IOM, 2010).
GENdER diffERENCES The gender mix found in nursing also differs from the gen- eral population, with men greatly outnumbered by women. While only 7% of the nursing population is male, only 5% in the profession were male in 2000 (Budden et al., 2013). Cultural and gender diversity challenge nurses to consider such differences when working with staff, colleagues, and administrators as well as mediating conflicts between individuals.
GENERAtiONAL diffERENCES Generational differences in the nursing popula- tion challenge interactions and relationships between workers and patients alike. Three generational cohorts (baby boomers, generation X, and generation Y) are cur- rently working together (Keepnews, Brewer, Kovner, & Shin, 2010) and a fourth (gen- eration Z) will soon join them (Levit, 2015).
Each generational group has different expectations in the workplace. Baby boomers value professional and personal growth and expect that their work will make a difference. Generation X members strive to balance work with family life and believe that they are not rewarded given their responsibilities. Generation Y (also called millennials) are technically savvy and expect immediate access to infor- mation electronically. Generation Z, born in the mid-1990s to early 2000s, will soon graduate and join their older coworkers. Generation Z members are curious, pas- sionate, and diverse, and willing to pursue nontraditional options in their futures (Levit, 2015).
The challenge for nurses in dealing with different generations is similar to that of dealing with cultural and gender differences: to avoid stereotyping within the
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generations, to value the unique contributions of each generation, to encourage mutual respect for differences, and to leverage these differences to enhance team work (Murray, 2013).
Violence, Pandemics, and Disasters Sadly, violence invades today’s workplaces, and healthcare is no exception. Verbal threats, physical attacks, and violent assaults can and do occur in healthcare set- tings (Papa & Venella, 2013). As those who work closely with patients, nurses are vulnerable to attack from patients, family members, coworkers, or others. To reduce the incidence and impact of workplace violence, the organization must establish clear guidelines to prevent it, and staff must be adequately trained to respond to incidents of violence.
A pandemic is a disease outbreak that spreads rapidly, usually because the infecting virus is new, and humans have little or no immunity to it. The H1N1 virus of 2009 is an example (U.S. Department of Health and Human Services, 2015b). Pan- demics are public health emergencies that require healthcare organizations to have in place the necessary protocols to respond rapidly in the event of a pandemic (Fineberg, 2014).
Both natural and human-caused disasters have increased in recent years and require healthcare organizations to prepare for the influx of mass casualties that may occur. Natural disasters, such as earthquakes, floods, and tornadoes, may damage not only communities but hospitals as well (e.g., the 2012 tornado in Joplin, Missouri). Human-caused disasters may occur accidentally (e.g., industrial accidents, bridge collapses, power outages), but intentional harm from acts of terrorism are unfortu- nately common today. All hospitals and other healthcare organizations must have emergency plans in place and have staff adequately trained to respond to these all-too- common events.
Changes in Nursing’s Future As healthcare organizations are restructuring to implement the ACA, scrambling to improve outcomes to meet safety and quality benchmarks, and struggling to adapt to constantly evolving technology, nurses ask, “What does this mean for our future?”
Current Status of Nursing Slightly more than 3 million nurses are currently licensed as registered nurses in the United States, with 2.6 million practicing in the profession (U.S. Bureau of Labor Sta- tistics, 2014). To meet both anticipated increases in population and an aging populace (U.S. Census Bureau, 2015), more than 500,000 additional nurses will be needed by 2022 (U S. Bureau of Labor Statistics, 2014). Unfortunately, as the population ages, nurses, too, are growing older (Budden et al., 2013). The average age of nurses practic- ing today is 50 years or older, up from 45 a few years ago (Health Resources and Ser- vices Administration [HRSA], 2013).
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Institute of Medicine’s Recommendations for Nursing The IOM’s report on the future of nursing makes sweeping recommendations for the profession, including that “nurses should be full partners, with physicians and other healthcare professionals, in redesigning healthcare in the United States” (IOM, 2010, p. 3). Also, the IOM posits that today’s healthcare environment necessitates better- educated nurses and recommends that 80% of nurses be prepared at the baccalaureate or higher level by 2020.
In addition, the report recommends that barriers limiting the scope of practice for advanced practice nurses be eliminated, and that racial, ethnic, and gender diversity among the nursing workforce should be increased to better care for a diverse patient population. While nurses are consistently ranked as the most trusted profession in the United States (Gallup, 2014), few nurses hold positions of leadership in healthcare, and the IOM recommends an increase in their numbers. Progress on meeting the recommen- dations of the IOM report is substantial and ongoing (Hassmiller & Reinhard, 2015).
Adapting to Constant Change What does the future hold for nursing? Change is the one constant! The challenge for nurses is how to manage in this continually fluctuating system.
Nurses are charged with monitoring and improving the safety and quality of care, managing with limited resources, participating in organizational decision making, working with teams of professionals and nonprofessionals from various generations and cultures, adapting to technological advances, and preparing for constant environ- mental changes. This is no small task. It requires that nurses be committed, involved, enthusiastic, flexible, and innovative; above all else, it requires that they have good mental and physical health. The nurse of today must be a coach, a teacher, and a facili- tator. Most of all, the nurse must be able to live with ambiguity and be flexible enough to adapt to the changes it brings.
That is a tall order, but nurses are up to the challenge. This text is designed to pre- pare you to meet that challenge.
What You Know Now • The Affordable Care Act, which may be changed
or repealed, altered how healthcare is provided and compensated.
• Reducing medical errors is a priority, and organi- zations are scrambling to achieve outcomes better than benchmarks.
• The Magnet Recognition Program certifies hospi- tals that meet rigorous standards and provide excellent nursing.
• Electronic health records, robotics, and telehealth are just a few of the many technologies continu- ing to evolve.
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