Nurses are committed to safe, high‐quality, patient‐centered care. Nurses demonstrate leadership and management skills in the provision of patient care, both interdependently with physicians and other members of the interprofessional team, and independently as nursing professionals. Various theories about Leadership and Management have been developed, as discussed in Chapter 1 of this book. These Leadership and Management theories are utilized by nurses in their personal life and from Day 1 of their clinical nursing practice. Millions of Americans turn to nurses for delivery of primary health care services, health care education. and health advice and counseling. The Gallup Poll (Brenan, 2018) has consistently found the nursing profession to be ranked as the Number One trusted profession in its annual polls of Americans. Suzanne Gordon is a journalist who has been writing about nursing issues since 1986. She writes,

“Nurses are regarded as honest and ethical but their breadth of skill is not known. When I was at the Beth Israel hospital, I was on the oncology clinic and followed these nurses for two years. Doctor comes in one day. Had a patient with breast cancer and the patient died. The husband gives him a trip around the world. What does he give the two nurses who cared for her? A scarf. The woman died, so it didn't work. The people who cared for her were the nurses. I happen to know the doctor, he was a, you're dying, I'm disappearing, kind of guy. The people who took care of her were her nurses. He gets the trip around the world, they get scarves. I think that says it all” (Maggi, 2001, p. 2).

Typically, professions are distinguished by certain specific characteristics. These include, but are not limited to:

Professions progress through an expected evolutionary process. This consists of:

Nursing's progression has been spotty and incomplete, largely because of the influence of external communities of interest, and the fact that nurses have resisted and personalized decisions that are necessary for future generations (Joel & Kelly, 2002). A profession must have a clear educational pathway into the practice and a constantly growing body of knowledge within institutions of higher learning (Blais & Hayes, 2011). Currently, there are many pathways for nursing education, ranging from 2‐year degree programs to Bachelor to direct‐entry Masters and Doctorate programs. For around 100 years, nurses have debated entry into practice. The result has been a myriad of programs with graduates used interchangeably in the real world. This absence of consensus within the discipline of nursing causes consumer confusion and seriously compromises our ability to serve the public (Joel & Kelly, 2002). Despite the variety of nursing programs and the range of advanced degrees they offer, all students have their basic professional nursing skills assessed by The National Council of State Boards of Nursing Licensure Exam (NCLEX). Successful completion of the NCLEX exam permits any RN to practice under the nursing practice act of an individual state, regardless of the level of education attained, though more and more health care institutions are choosing to give RNs with a Bachelor degree priority in the hiring process.

In 1999, a National Academy of Sciences, Institute of Medicine (IOM) Report, To Err Is Human: Building a Safer Health Care System (Kohn, Corrigan, & Donaldson, 1999), shocked the nation and called attention to the adverse events that occur in many acute care hospitalizations. The IOM Report stated that the annual estimated cost of medical errors was between $17 billion and $29 billion at hospitals across the country, with between 44,000 and 98,000 deaths yearly, more than die from motor vehicle accidents, breast cancer, or AIDS.

In 2004, another IOM Report, Keeping Patients Safe: Transforming the Work Environment of Nurses (Institute of Medicine, 2004), found that, “how we are cared for by nurses affects our health, and sometimes can be a matter of life and death … nurses are indispensable to our safety.” Nurses play a crucial role in protecting patient safety and providing quality health care. This finding has since been confirmed by several research studies (Aiken et al., 2017; Aiken et al., 2014; Cho, et al., 2016; Cho, Kim, Yeon, You, & Lee, 2015; Harrison et al., 2019; Kim & Bae, 2018; McHugh et al., 2016; You et al., 2013). The 2004 IOM Report concluded that education for the health professions was in need of a major overhaul.

In 2005, the Robert Wood Johnson Foundation funded a national project to educate nurses about patient safety and quality. The project developed Quality and Safety Education for Nurses (QSEN) Competencies, which identify the knowledge, skills, and attitudes needed for safety, quality, patient‐centered care, informatics, teamwork and collaboration, and evidence‐based practice to provide safe and effective quality nursing care. Today, QSEN Competencies are being integrated into nursing curricula, research, accreditation, and licensing to address the gap between nursing education and nursing practice.

In 2010, the Report, Unmet Needs: Teaching Physicians to Provide Safe Patient Care by the Lucian Leape Institute (2010) at the National Patient Safety Foundation highlighted the need for medical schools to integrate systems analysis, quality improvement, and patient‐centered care into their curricula. The Report emphasized the importance of a culture of safety in teaching hospitals, stressing that unprofessional behavior and authority gradients prevent physician trainees from reporting and learning from errors (Ranji, 2014).

In 2016, Henry reported that improving quality and safety has been a focal point in medical education for more than a decade, but improvements have not been dramatic. Some medical schools are changing their curriculum—and cultures—to make greater strides through their work with the American Medical Association's Accelerating Change in Medical Education Consortium (Henry, 2016).

Makary & Daniels (2016) found that more than 250,000 people in the United States die every year because of medical mistakes, making medical mistakes the third leading cause of death after heart disease and cancer. Makary & Daniels (2016), define a death due to medical error as a death that is caused by inadequately skilled staff, an error in judgment or care, a system defect, or a preventable adverse effect. These deaths include deaths from mix‐ups with the dose or type of medications administered to patients, surgical complications that go undiagnosed, and computer breakdowns. Makary & Daniels (2016), also noted that death certificates in the U.S., used to compile national statistics, have no way to identify medical error and that the reporting system should be revised to facilitate better understanding of deaths due to medical error. In 2019, the Institute for Healthcare Improvement (IHI) noted that health care delivery continues to be unsafe and that substantive improvements in patient safety will be difficult to achieve without major medical education reform at the medical school and residency training program levels (Gandhi et al., 2018).

The Robert Wood Johnson Foundation (RWJF) partnered with the Institute of Medicine (IOM) in 2010 and released a Report on The Future of Nursing: Leading Change, Advancing Health (National Academy of Science, 2011). This Report offered a series of recommendations to advance nursing's contributions to the health care environment, as follows:

Following this Report, the American Association of Retired Persons (AARP) and RWJF launched the Future of Nursing: Campaign for Action to shepherd the implementation of the Report's recommendations. The Future of Nursing: Campaign for Action coordinated through the Center to Champion Nursing in America (CCNA), works nationally and through state Action Coalitions to advance its goals. The Future of Nursing: Campaign for Action Dashboard 2017 yearly progress report on the 2010 IOM Recommendations on The Future of Nursing: Leading Change, Advancing Health Report notes the following progress on the goals:

(Future of Nursing: Action Dashboard, available at, https://campaignforaction.org/wp-content/uploads/2019/07/Dashboard-Indicator-Updates_7.9.19.pdf, accessed July 22, 2017.) and The Nurses on Boards Coalition, available at, (https://www.nursesonboardscoalition.org/, accessed August 31, 2019).

Following passage of the Affordable Care Act of 2010, the Center for Medicare and Medicaid Services (CMS) invested in patient safety by tying hospital reimbursement to patient and family satisfaction, patient outcomes, and quality and safety.

As mentioned earlier, Leadership and Management theories are utilized by nurses from Day 1 of their clinical practice. This text, Nursing Leadership & Management, Fourth Edition, is edited by Patricia Kelly Vana and Janice Tazbir. It explores the Leadership and Management theories and skills that beginning nurses need in order to collaborate with the interprofessional team and structure the patient care environment to meet patient needs. Nurses use informatics and apply evidence‐based, safe, high‐quality standards and develop and monitor work processes and staffing, etc., to achieve high quality, safe, patient‐centered care outcomes.

The Editors, Patricia and Janice, believe that all nurses, regardless of their role, are leaders and managers. Nursing Leadership and Management begins at a personal level when the new nurse reviews their career and life goals, such as goals for education and certification, type and quality of hospital for employment, desired type of patient care unit to work on, work benefits, financial goals, home purchase goals, etc. Nursing Leadership and Management continues with the staff nurse at the bedside. This bedside staff nurse is responsible for assuring that the evidence‐based health care structures and processes needed to achieve safe, high quality patient‐centered outcomes are available to patients. The staff nurse at the bedside demonstrates this commitment to patient care quality and safety with the utilization of evidence‐based care, development of a high quality, safe, patient care environment, safe staffing, review of quality patient care guidelines and medications, and the development of professional communication, speech, and dress that strengthens the nurse's ability to manage and collaborate with the interprofessional team and lead patients to safe, high quality, patient‐centered outcomes. In addition, the bedside staff nurse recognizes that many factors in the environment and health care system influence the development of evidence‐based, safe, high‐quality, patient‐centered outcomes. Accordingly, this bedside staff nurse recognizes the importance of developing personal, professional, and political power and joining nursing, hospital, and community committees, associations, Boards of Directors, etc., to assure the development of evidence‐based, safe, high‐quality, patient‐centered outcomes.

Nursing Leadership & Management, Fourth Edition reviews information from the Agency for Healthcare Quality and Research, The Joint Commission, the Leapfrog Group, the National Quality Forum, and the Institute for Healthcare Improvement (IHI), among others, all focused on improvement of the quality and safety of patient care.

The chapter contributors to this Fourth Edition include many different types of nurses and members of the interprofessional team including: staff, educators, administrators, faculty informaticists, historians, quality scholars, clinical nurse specialists, nurse lawyers, nurse practitioners, entrepreneurs, physicians, librarians, psychologists, and others. These contributors are from all sections of the United States, illustrating a broad view of nursing leadership and management. There are chapter contributors and interviews from California, Colorado, Florida, Illinois, Indiana, Kentucky, Maine, Maryland, Massachusetts, Michigan, Minnesota, Missouri, New Hampshire, New Orleans, New York, New Jersey, Ohio, Rhode Island, South Carolina, Texas, Vermont, Washington, and Wisconsin.

Nursing Leadership & Management, Fourth Edition, consists of 29 chapters organized in a Conceptual Framework. This Conceptual Framework highlights nursing leadership and management responsibilities to the patient, to the community, to the interprofessional health care team, to the institution, and to self. The Four Units of the Conceptual Framework provide beginning nurse leaders and managers with the knowledge needed in today's health care environment.

Unit 1 introduces Kelly Vana’s Nursing Leadership and Management. This unit discusses Nursing Leadership and Management in the Health Care Environment and reviews Nursing Leadership and Management in a Historical Context, and Nursing in a High Reliability Health Care Organization. It discusses Organization and Staffing of Patient Care at the Unit Level, as well as Health Care Economics and the Hospital, Department, and Unit Budget. Unit 2 discusses Leadership and Management of Patient‐Centered Care. This Unit reviews Patient and Health Care Education, Evidence‐Based Practice, Searching for the Evidence, Quality Improvement, and Improving Quality at the Unit Level, along with Safety for the Patient and Health Care Team. Lastly, Informatics is also discussed. Unit 3 discusses Nursing Leadership and the Interprofessional Team. This Unit reviews Interprofessional Teamwork and Collaboration and Members of the Interprofessional Team. It discusses Delegation, Assignment, and Supervision of Patient Care, Time Management and Setting Priorities, Change, Critical Thinking and Clinical Reasoning. Power and Politics, Legal Aspects of Nursing, Ethical Aspects of Nursing, and Culture, Generational Differences, and Spirituality are also discussed. Unit 4 discusses Leadership and Management of Self and the Future. This Unit discusses NCLEX‐RN Preparation, Entry into the Profession—Your First Job, Career Planning and Achieving Balance, Balancing A Healthy Personal and Professional Life, and Nursing Career Opportunities. Numerous additions and supplemental offerings have been made to the text to increase understanding and broaden your learning experience. Some of these are outlined below.

All chapters have been revised to reflect current practice.

Chapters on Nursing Leadership and Management in a Historical Context and Organization of Patient Care in High Reliability Health Care Organizations have been added.

A new website, accessed at www.wiley.com/go/kelly-Nursing-Leadership, is provided including:

Several standard chapter features are utilized throughout the text, which provide the reader with a consistent format for learning and an assortment of resources for understanding and applying the knowledge presented. Chapter features include the following:

Special elements are sprinkled throughout the chapters to enhance student learning and encourage critical thinking. These include:

QUOTE

OBJECTIVES

OPENING SCENARIO

CASE STUDIES

EVIDENCE FROM THE LITERATURE

CRITICAL THINKING EXERCISES

REAL WORLD INTERVIEWS

DISCUSSION POINTS

INFORMATICS

LEAN BACK

EXPLORING THE WEB

KEY CONCEPTS

KEY TERMS

REVIEW QUESTIONS

REVIEW ACTIVITIES

EXPLORING THE WEB

REFERENCES

SUGGESTED READING

PHOTOS, TABLES, AND FIGURES

Chapter PowerPoints are available to Faculty and students online. They are designed to assist the faculty in presenting to nursing students the essential skills and information that are needed to help them secure a position as a beginning nursing manager and leader. The IR will assist faculty in planning and developing their programs and classes for the most efficient use of time and resources. The IR includes several must‐have components:

Linda Searle‐Leach

Azusa Pacific University, Azusa, CA, USA, and Huntington Hospital, Pasadena, CA, USA

Source: Jenny Chenying, Ryan Beattie, Jason Ortiz, Brittany Bryne, and Abigail Alund.

Leadership is not about titles, positions or flowcharts. It is about one life influencing another.

(John Maxwell, 1997)

Upon completion of this chapter, the reader should be able to:

Ed Harley was admitted to the cardiac observation unit earlier in the day. He had been diagnosed previously with heart disease and had experienced episodes of ventricular arrhythmias. His cardiologist had determined the need to change his antiarrhythmic medication to reduce the side effects Mr. Harley was experiencing. That evening, while Mr. Harley was talking to his wife on the phone and as his nurse, Maria, was walking to his bedside, he suddenly stopped talking and went into ventricular fibrillation and cardiac arrest. Maria reacted instinctively and startedAdvanced Cardiac Life Support (ACLS) defibrillating him immediately. Normal sinus rhythm appeared on the monitor before anyone else could respond to the code. Mr. Harley was then transferred to theCoronary Care Unit (CCU).

Maria had been a Registered Nurse (RN) for less than one year at the time, and although she had participated in Code arrests a few times, she had never witnessed one occur right before her eyes. Her knowledgeable action saved this patient's life. In nursing, Cardiopulmonary Resuscitation (CPR) and ACLS are mandatory skills and considered part of a nurse’s ordinary work. Yet it is quite extraordinary work.

Everything had happened so quickly that evening that Maria did not have a chance to talk to the patient before he was transferred. She entered his room the next morning in CCU, as the sun was just rising. As he awoke, Maria spent that quiet time with him. While he embraced the start of a new day, his thoughts were intense. What he chose to share was this acknowledgment: “You saved my life. Thank you.” This precious moment was a celebration of both of their lives.

What leadership characteristics did Maria demonstrate in preventing a nurse‐sensitive outcome of cardiac arrest?

Why is Maria considered a leader, even though she is not in a formal leadership or management position?

For all nurses, their knowledge of nursing and ability to apply that knowledge, is the basis of their leadership. Many people think that leaders are only top corporate executives and administrators, political representatives, military generals, or those who head an organization. This is because these leaders are highly visible and hold high‐profile positions. However, leaders are needed at all levels of an organization. With the advent of the information age, many professionals, including nurses, became known as knowledge workers. Nurses' education and specialized clinical preparation develops their expertise and leadership ability. Nursing knowledge workers are leaders. This idea of nursing knowledge workers contrasts with the manufacturing age, where the manager was the most knowledgeable person and closely supervised employees to carry out routine work. Leadership however is a basic competency for all nursing professionals. Leadership development is a necessary part of the preparation of nurses.

Nurses make a critical difference every day in the lives of their patients and patients' families, yet nurses believe those accomplishments are part of their ordinary work. Nurses are leaders, and by using their expert knowledge, they coordinate patient care and lead patients and families through health care journeys. Nurses lead themselves as they develop in their career and nurses lead change to improve patient outcomes and the quality of care. Nurses are leaders and lead without being in a management position.

Leadership and management are different. Leadership influences or inspires the actions and goals of others. One does not have to be in a position of authority to demonstrate leadership. Not all leaders are managers. Leaders have been characterized as people who do the right thing whereas managers are viewed as people who do things right (Drucker, 1993). Both leadership and management are crucial but different.

This chapter lays the groundwork for the development of knowledge about nursing leadership and management. Many concepts touched on in this chapter will be developed in depth in the chapters that follow. This chapter discusses leadership and provides a framework to differentiate leadership and management and explain emotional intelligence. Leadership characteristics, styles of leadership, and leadership theories are described emphasizing transformational leadership and complexity leadership. The chapter introduces the process of management and explains management and motivation theories. The content is developed for the beginning nurse preparing to graduate from a pre‐licensure program and enter the profession in the role of registered nurse. Benner's work describing skill acquisition of nurses uses a framework called, “From Novice to Expert” and labels this new graduate nurse as an advanced beginner (Benner, Tanner, & Chesla, 2009).

Leadership is commonly defined as a process of influence in which the leader influences others toward goal achievement (Yukl, 2006). Nurses function as leaders when they lead themselves and influence others toward goal achievement. Influence is an instrumental part of leading others and leaders influence others, often by inspiring, enlivening, and engaging others to participate. Leadership can occur personally. It can occur between the leader and another individual; between the leader and a group; or between a leader and an organization, a community, or a society. Defining leadership as a process helps us understand more about leadership than the traditional view of a leader being in a position of authority, exerting command, control, and power over subordinates. There are many more leaders in organizations than those who are in positions of authority. Each person has the potential to set goals and enact leadership. What this means for nurses as professionals is that nurses set goals and are leaders.

Leadership can be formal leadership, as when a person is in a position of authority or in a sanctioned, assigned role within an organization that connotes influence, such as a nurse manager (Northouse, 2018). The traditional formal leadership roles in nursing include clinical supervisor, unit/department manager, director of nursing and the top‐level nurse executive, usually called the chief nurse executive or chief nursing officer. Other formal leader roles in nursing include the charge nurse of a patient care unit, the Chief Operating Officer, of a hospital the nurse who leads interprofessional team rounds and the nurse who represents her unit/department at an event or meeting.

An informal leader is a person who demonstrates leadership outside the scope of a formal leadership role or as a member of a group rather than as the head or leader of the group. The informal leader is considered to have emerged as a leader when she is accepted by others, is an opinion leader, and is perceived to have influence. Informal leader roles in nursing include examples such as the staff nurse who regularly sets personal, proffessional, and patient care goals, assuring the delivery of safe, evidence‐based, patient‐centered, high quality care, including responding quickly to a code.

Leaders and followers are both necessary roles. Nurses are alternately leaders and followers when they work with other health care team members to achieve patient care goals, participate in meetings, and so forth. The most valuable followers are skilled, self‐directed employees who participate actively in setting the group's direction and who invest time and energy in the work of the team or group, thinking critically and advocating for new ideas (Grossman & Valiga, 2013). Good followers communicate and work well with others, being supportive, yet thoughtful, in their approach to new ideas.

Kotter (1990a) describes the differences between leadership and management in the following way: Leadership is about creating change. He says that leaders establish direction, align people through empowerment, and motivate and inspire others toward achieving a vision and creating meaningful change; whereas managers focus on managing, defined as planning and budgeting, organizing and staffing, problem solving, and controlling complexity. Complexity has to do with interdependence; being dependent on others to carry out our work. Interdependence requires coordination and cooperation. Managers engage in controlling complexity to produce predictability, stability, and order (Kotter, 1990b).

Nurses function as leaders when they demonstrate leadership characteristics in their personal and professional roles and work with other nurses and health care staff to lead patients, families, and communities to their best health. See Table 1.1 for examples of selected nursing leadership characteristics and personal and professional role activities.

Table 1.1 Nursing Leadership Characteristics and Role Activities

Note: Adapted from Moore, J. (2004). Leadership: Lessons learned. Terre Haute, Indiana, and the author's personal observations.

One popular way of characterizing leadership is by describing it as authentic leadership. The American Association of Critical Care Nurses in their landmark work, AACN Standards for Establishing Healthy Work Environments: A Journey to Excellence, cite authentic leadership as one of the key standards necessary for establishing a healthy work environment. AACN's belief is that to establish and sustain healthy work environments for nurses, leadership that is authentic is a critical element. Authentic leadership requires skill in the core competencies of self‐knowledge, strategic vision, risk taking and creativity, interpersonal and communication effectiveness, and inspiration (American Association of Critical Care Nurses (AACN), 2004; Raso, 2019).

Leaders are also described by fundamental qualities that effective leaders have been found to share (Bennis & Nanus, 1985). The first quality is a guiding vision. Leaders focus on a professional and purposeful vision that provides direction toward a preferred future. The second quality is passion. Passion expressed by the leader involves the ability to inspire and align people toward the promises of life. Passion is an inherent quality of the nurse leader. The third quality is integrity that is based on knowledge of self, honesty, and maturity developed through experience and growth. Other leadership qualities include self‐awareness—knowing our strengths and weaknesses—that can allow us to use feedback and learn from our mistakes (McCall, 1998). Daring and curiosity are also basic ingredients of leadership that leaders draw on to take risks, learning from what works as much as from what does not work (Bennis & Nanus, 1985).

Certain characteristic traits are commonly attributed to leaders. These traits are considered desirable and seem to contribute to the perception of being a leader; intelligence, self‐confidence, determination, integrity, and sociability (Stodgill, 1948, 1974). Research among 46 hospitals designated as Magnet^® Hospitals by the American Nurses Center for Certification (ANCC) for their success in attracting and retaining registered nurses reported that nurse leaders who are visionary and enthusiastic, are supportive and knowledgeable, have high standards and expectations, value education and professional development, demonstrate power and status in the organization, are visible and responsive, communicate openly, and are active in professional associations are valued (Kramer, 1990; Kramer & Schmalenberg, 2005; McClure & Hinshaw, 2002; McClure, Poulin, Sovie, & Wandelt, 1983). Research findings from other studies on nurses revealed that caring, respectability, trustworthiness, and flexibility were the leadership characteristics most valued. In one study, nurse leaders identified managing the dream, mastering change, designing organization structure, learning, and taking initiative as leadership characteristics (Murphy & DeBack, 1991). Research by Kirkpatrick and Locke (1991) concluded that leaders are different from non‐leaders across six traits: drive, the desire to lead, honesty and integrity, self‐confidence, cognitive ability, and knowledge of the business. Although no set of traits is definitive and reliable in determining who is a leader or who is effective as a leader, many people still rely on many of these traits to describe and define leadership characteristics.

Many believe that the critical factor needed to maximize people's involvement is leadership (Bennis & Nanus, 1985). A more in‐depth understanding of leadership can be gleaned from a review of leadership theories. Leadership theories can be classified various ways. These are summarized in Table 1.2.

Table 1.2 Leadership Theories

Leadership studies from the 1930s by Kurt Lewin and colleagues at Iowa State University conveyed information about three leadership styles based on the leader's behavior that are still widely recognized today: autocratic, democratic, and laissez‐faire leadership (Lewin, 1939; Lewin & Lippitt, 1938; Lewin, Lippitt, & White, 1939). Autocratic leadership involves centralized decision making, with the leader making decisions and using power to command and control others. Democratic leadership is participatory leadership, with authority delegated to others. To be influential, the democratic leader uses expert power and the power base afforded by having close, personal relationships. The third leadership style, laissez‐faire leadership, is passive and permissive, and the leader defers decision making. Lewin (1939) contrasted these styles and concluded that autocratic leaders were associated with high‐performing groups, but that close supervision was necessary and feelings of hostility were often present in these groups. Democratic leaders engendered positive feelings in their groups and performance was strong, whether the leader was present or not. Low productivity and feelings of frustration were associated with laissez‐faire leaders.

Behavioral leadership studies from the University of Michigan and from Ohio State University led to the identification of two basic leader behaviors: job‐centered behaviors and employee‐centered behaviors. Effective leadership was described as having a focus on the human needs of subordinates and was called employee‐centered leadership (Griffin & Moorhead, 2014). Job‐centered leaders were viewed as less effective because of their focus on schedules, costs, and efficiency, resulting in a lack of attention to developing work groups and high‐performance goals (Griffin & Moorhead, 2014).

The researchers at Ohio State focused their efforts on two dimensions of leader behavior: initiating structure and consideration. Initiating structure involves an emphasis on the work to be done, a focus on the task, and production. Leaders who focus on initiating structure are concerned with how work is organized and on the achievement of goals. Leader behavior includes planning, directing others, and establishing deadlines and details of how work is to be done. For example, a nurse demonstrating the leader behavior of initiating structure could be a charge nurse who, at the beginning of a shift, makes out a patient assignment.

The dimension of consideration involves activities that focus on the employee and emphasize relating and getting along with people. Leader behavior focuses on the well‐being of others. The leader is involved in creating a relationship that fosters communication and trust as a basis for respecting other people and their potential contributions. A nurse demonstrating consideration behavior will take the time to talk with coworkers, be empathetic, and show an interest in them as people.

The leader behaviors of initiating structure and consideration define four leadership styles:

The Ohio State University studies associate the high initiating structure–high consideration leader behaviors with better performance and satisfaction outcomes than the other styles. This leadership style is considered effective, although it is not appropriate in every situation.

It is important that beginning nurses see themselves as leaders. Leadership doesn't mean you have to have an administrative title. The central task of leadership is catalyzing others to achieve shared values in a complex world that is constantly changing and requiring us to design new ways of achieving our goals. This is a description of what is required of nurses each day, every day.

Angela Barron McBride, PhD, RN, FAAN

Distinguished Professor‐Dean Emerita

Indiana University School of Nursing

Indianapolis, Indiana

Citation: Buresh, B. and Gordon, S. (2013). From silence to voice: What nurses know and must communicate to the public (The culture and politics of health care work). 3rd ed. Ithaca, NY: ILR Press.

Discussion: In this book by Suzanne Gordon and Bernice Buresh, the authors convey their journalistic perspectives and experience in writing about health care work. They provide an informative insight that nurses need to do a better job of accurately describing what nurses do and how nurses use expert knowledge acquired through scientific and technical mastery. They caution that nurses fail to articulate the value of the contribution nurses make to successful patient outcomes. Their message to nurses is that there is a reason that the public has such little understanding of nursing and the importance of our work. The reason is twofold: traditional stereotypes about nursing cloud the reality of nursing as it is currently practiced, and nurses have been patterned to describe their contribution to health care in self‐sacrificing and anonymous ways.

Implications for Practice: Nurses need to be clear about why it is important for the public to know what nurses do and how nurses use specialized knowledge based on science to deliver health care. This book is an important vehicle from which nurses can begin to examine their own words and ways of discussing what nurses do and reflect upon the historical religious and societal practices that interfere with a clear, accurate, and realistic image of modern nursing. It is important for nurses to be clear about the value of nursing—their assessments, decisions, knowledgeable actions, ability to educate, emergency responses, and therapeutic compassion. What nurses often think of as their ordinary work is really quite extraordinary. Nurses use scientific knowledge, expert judgment, and complex skills to make critical decisions that affect patient outcomes. Nurses need to be able to articulate how they do their work and the difference it makes in the lives of patients and families, their communities and to the health of the nation.

I have been a nurse for almost 60 years. I have come to realize that leadership and a happy life begins with me. As new nurses beginning your career, I suggest you assume leadership and identify your professional and personal goals. Select and add to the professional and personal goals and leadership strategies below. Identify your completion timeframe also.

Remember, leadership and a happy life begins with you. Set your goals and lead yourself to a wonderful life!

Patricia Kelly Vana

Professor Emerita

Purdue University Northwest

Hammond, Indiana

Another approach to leadership is contingency theory. Contingency theory acknowledges that factors in the environment influence outcomes as much as leadership style and that leader effectiveness is contingent upon or depends upon something other than the leader's behavior. The premise is that different leader behavior patterns will be effective in different situations.

Fielder (1967) is credited with the development of the contingency model of leadership effectiveness. Fielder's theory of leadership effectiveness views the pattern of leader behavior as dependent upon the interaction of the personality of the leader and the needs of the situation. The needs of the situation or how favorable the situation is toward the leader involves leader‐member relationships, the degree of task structure, and the leader's position of power (Fielder, 1967). Leader‐member relations are the feelings and attitudes of followers regarding acceptance, trust, and credibility of the leader. Good leader‐member relations exist when followers respect, trust, and have confidence in the leader. Poor leader‐member relations reflect distrust, a lack of confidence and respect, and dissatisfaction with the leader by the followers

Task structure refers to the degree to which work is defined, with specific procedures, explicit directions, and goals. High task structure involves routine, predictable, clearly defined work tasks. Low task structure involves work that is not routine, predictable, or clearly defined, such as creative, artistic, or qualitative research activities.

Position power is the degree of formal authority and influence associated with the leader. High position power is favorable for the leader, and low position power is unfavorable. When all dimensions—leader‐member relations, task structure, and position power—are high, the situation is favorable to the leader. When these dimensions are low, the situation is not favorable to the leader. In both circumstances, Fielder showed that a task‐directed leader, concerned with task accomplishment, was effective. When the range of favorableness is intermediate or moderate, a human relations leader, concerned about people, was most effective. These situations need a leader with interpersonal and relationship skills to foster group achievement. Fielder's contingency theory is an approach that matches the organizational situation to the most favorable leadership style for that situation.

Situational leadership theory addresses the follower characteristics in relation to effective leader behavior.

Whereas Fielder examines the situation, Hersey and Blanchard consider follower readiness as a factor in determining leadership style. Rather than using the words, initiating structure and contingency, they use the words, task behavior and relationship behavior. Task behavior is used to identify behaviors focused on tasks. The words, relationship behavior, are used to identify behaviors focused on relationships

High task behavior and low relationship behavior is called a telling leadership style. A high task, high relationship style is called a selling leadership style. A low task and high relationship style is a participating leadership style. A low task and low relationship style is a delegating leadership style.

Follower readiness, called maturity, is assessed to select one of the four leadership styles for a situation. For example, according to Hersey and Blanchard's situational leadership theory (2000), groups with low maturity, whose members are unable or unwilling to participate or are unsure, need a leader to use a telling leadership style to provide direction and close supervision. The selling leadership style is a match for groups with low to moderate maturity who are initially unable to do the task but willing and confident and need clear direction and supportive feedback to get the task done. Participating leadership style is recommended for groups with moderate to high maturity who are able but unwilling to do a task or are unsure and who need support and encouragement. The leader should use a delegating leadership style with groups of followers with high maturity who are able to do a task and ready to participate and can engage in the task without direction or support.

An additional aspect of situational leadership theory is the idea that the leader not only changes leadership style according to followers' needs but also develops followers over time to increase their level of maturity (Schindler, 2015). Use of these four leadership styles helps a nurse manager lead effectively and assign work to others.

In this leadership approach, the leader works to motivate followers and influence goal accomplishment. The seminal author on path‐goal theory is Robert House (1971). By using the appropriate style of leadership for the situation (i.e., directive, supportive, participative, or achievement oriented), the leader makes the path toward the goal easier for the follower. The directive style of leadership provides structure through direction and authority, with the leader focusing on the task and getting the job done. The supportive style of leadership is relationship oriented, with the leader providing encouragement, interest, and attention. Participative leadership means that the leader focuses on involving followers in the decision‐making process. The achievement‐oriented style provides high structure and direction as well as high support through consideration behavior. The leadership style is matched to the situational characteristics of the followers, such as the desire for authority, the extent to which the control of goal achievement is internal or external, and the ability of the follower to be involved. The leadership style is also matched to the situational factors in the environment, including the routine nature or complexity of the task, the power associated with the leader's position, and the work group relationship. This alignment of leadership style with the needs of followers is motivating and believed to enhance performance and satisfaction. The path‐goal theory is based on expectancy theory, which holds that people are motivated when they, (a) believe they are able to carry out the work, (b) think their contribution will lead to the expected outcome, and (c) believe that the rewards for their efforts are valued and meaningful (Northouse, 2018).

Substitutes for leadership are variables that may influence followers to the same extent as the leader's behavior. Kerr and Jermier (1978) investigated situational variables and identified substitutes that eliminate the need for leader behavior and other aspects that act as neutralizers and nullify the effects of the leader's behavior. Some of these variables include follower characteristics, such as the presence of structured routine tasks, the amount of feedback provided by the task, and the presence of intrinsic satisfaction in the work; and organizational characteristics, such as the presence of a cohesive group, a formal organization, a rigid adherence to rules, and low position power. For example, an individual's experience substitutes for task‐direction leader behavior (Kerr & Jermier, 1978). Nurses and other professionals with a great deal of experience already have knowledge and judgment and do not need direction and supervision to perform their work. Thus, their experience serves as a leadership substitute. Another substitute for leader behavior is intrinsic satisfac tion that emerges from just doing the work. Intrinsic satisfaction occurs frequently among nurses when they provide care to patients and families. Intrinsic satisfaction substitutes for the support and encouragement of relationship‐oriented leader behavior.

Beginning nurses show leadership by bringing their understanding of evidence‐based practices (EBP) and by implementing them at the bedside. They are part of committees and have a voice about unit and hospital policies. Every nurse, no matter if brand new or seasoned, brings leadership qualities to the bedside. In the Intensive Care Unit where I work, assessing changes in the patient's condition, communicating with physicians, and making sure something gets done to help the patient in a matter of minutes requires leadership. This is what we do to make sure patients get the best care.

Johnny Tazbir, RN, BSN

Crown Point, Indiana

Several characteristics attributed to leaders include:

Review each of these characteristics attributed to leaders. Are these the characteristics you think are important for nurse leaders? To what extent do you portray each of these leadership characteristics?

Can professional nursing standards, such as the Code of Ethics for nurses, https://www.nursingworld.org/coe-view-only, accessed January 31, 2020, serve as a substitute for leadership?

Contemporary approaches to leadership address the leadership functions necessary to develop learning organizations. Contemporary leadership approaches include charismatic theory, transformational leadership theory, knowledge workers, complexity leadership, and servant leadership.

A charismatic leader has an inspirational quality that promotes an emotional connection from followers. House (1971) developed a theory of charismatic leadership that described how charismatic leaders behave as well as distinguishing characteristics and situations in which such leaders would be effective. Charismatic leaders display self‐confidence, have strength in their convictions, and communicate high expectations and their confidence in others. They have been described as emerging during a crisis, communicating vision, and using personal power and unconventional strategies (Conger & Kanungo, 1987). One consequence of this type of leadership is a belief in the charismatic leader that is so strong that it becomes almost an obsession that takes over, and the leader is worshipped as if superhuman. Charismatic leaders can have a positive and powerful effect on people and organizations. Martin Luther King, Lee Iacocca, former chief executive officer (CEO) of Chrysler Corporation, and Herb Kelleher, former CEO of Southwest Airlines, are all described as charismatic leaders. This type of leader can contribute significantly to an organization, even though all the leaders in an organization are not charismatic leaders. There are also effective leaders who do not exhibit all the qualities associated with charismatic leadership. Charisma seems to be a special and valuable quality that some people have while others do not.

Transformational leadership is one of the most prominent contemporary leadership theories. Transformational leadership is defined as a process in which “leaders and followers raise one another to higher levels of motivation and morality” (Burns, 1978, p. 21). Transformational leadership theory is based on the idea of empowering others to engage in pursuing a collective purpose by working together to achieve a vision of a preferred future. This kind of leadership can influence0 both the leader and the follower to a higher level of conduct and achievement that transforms them both (Burns, 1978). Burns maintained that there are two types of leaders: the traditional manager concerned with day‐to‐day operations, called the transactional leader, and the leader who is committed to a vision that empowers others, called the transformational leader.

Transformational leaders motivate others by behaving in accordance with values, providing a vision that reflects mutual values, and empowering others to contribute. Bennis and Nanus (1985) describe this leader as a person who “commits people to action, who converts followers into leaders, and who converts leaders into agents of change” (p. 3). According to research by Tichy and Devanna (1986), effective transformational leaders identify themselves as change agents; are courageous; believe in people; are value driven; are lifelong learners; are able to negotiate complexity, ambiguity, and uncertainty; and are visionaries. Yet transformational leadership may be demonstrated by anyone in an organization regardless of his position (Burns, 1978). The interaction that occurs between individuals can be transformational and motivate both to a higher level of performance (Bass, 1985).

Transformational leadership at the organizational level is about innovation and change. The transformational leader uses vision based on shared values to align people and inspire growth and advancement. It is both the inspiration and the empowerment aspects of transformational leadership that lead to commitment beyond self‐interest, commitment to a vision, and commitment to action that creates change. Transformational leadership theory suggests that the relationship between the leader and the follower inspires and empowers an individual toward commitment to the organization.

A nurse is making rounds on her new postoperative laryngectomy patient. As the nurse enters the room, the patient begins to bleed from his neck incision. The nurse applies direct pressure to the patient's carotid artery with one hand and calls for assistance. Help arrives, and the patient is taken to surgery, with the nurse still maintaining pressure on the bleeding site. The patient's condition is stabilized and the patient is discharged to home a few days later.

How does nursing leadership and management on a patient care unit ensure good patient care in an emergency?

How can you develop your leadership and management skills to improve your ability to care for a group of patients?

Nurse researchers have described nurse executives according to transformational leadership theory and have used this theory to measure leadership behavior among nurse executives and nurse managers (Dunham‐Taylor, 2000; Leach, 2005; McDaniel & Wolf, 1992; Wolf, Boland, & Aukerman, 1994; Young, 1992). Additionally, transformational leadership theory has been the basis for the nursing administration curriculum and for investigation of relationships such as relationships between a nurse's commitment to an organization (Leach, 2005) and productivity in a hospital setting (McNeese‐Smith, 1997) and the ethical aspects of transformational leadership (Cassidy & Koroll, 1998). Barker (1990) also comprehensively discussed nursing in terms of transformational leadership theory. Of the contemporary theories of leadership, transformational leadership has been a popular approach in nursing and is well suited to the rapidly changing health care environment.

Most recently, the National Academy of Medicine (NAM) identified transformational leadership theory as a precursor to any change initiative and stated that transformational leadership can be a crucial approach toward achieving work environments that optimize patient safety (NAM, 2003).

Nurses are knowledge workers. Knowledge workers are those who bring specialized, expert knowledge to an organization (Drucker, 2006, 1993, 1959). They are valued for what they know. Knowledge organizations, in which the knowledge worker is at the front lines with the expertise and the information to act, have become the dominant organizational type in the information age (Drucker, 2006, 1993; Helgesen, 1995). The knowledge organization shares, provides, and grows the information necessary to work efficiently and effectively. In organizations such as these, the ideas of leadership at the top and leadership equated with the power of a position are obsolete notions. Knowledge workers with the expertise and information to act are the organization's leaders. They provide the service, interact with the customer, represent the organization, and accomplish its goals.

Knowledge workers work in the information age, where the rapid, instant access to information makes information the medium of exchange. Knowledge workers are valued for what they know. The development of new knowledge and innovation and meaningful interpretation and application becomes the source for transactions with patients and staff. Nursing's transition to the information age has occurred in the context of rapidly advancing technology and nanotechnology and been influenced by three key trends: mobility, virtuality, and user‐driven practices (Porter O'Grady, 2001).

Mobility refers to the ability to do work in convenient places using telehealth rather than working at fixed places, which may or may not be convenient. Technology has enabled mobility with the development of the small computer chip. Nurses work in a variety of settings today and use portable computers in wireless phones and computers at the bedside.

Virtuality means working through virtual means using digital networks, where the worker may be far from the patient but present in a digital reality. Telemetry monitoring and telehealth care by nurses are examples of virtuality.

User‐driven practices mean that, at a time when digital mediums have given us more access to information and therefore more choices, the individual acts more independently and is increasingly accountable for those choices and actions. Nurses use electronic devices for self and patient education and teach patients to use digital monitors for self‐care.

Nursing leadership practices are evolving to match nurses' work within this mobile, changing environment, with nurses as knowledge workers who can make decisions and take action. This is facilitated by the growth and sophistication of nursing research, the application of nursing science, and the translation of available evidence into evidence‐based nursing practice. Nurses are able to display the rich and valuable contribution that their knowledge and expertise make to the quality of patient care and to quality health care outcomes.

Good nursing leadership and management of patients includes getting to know the patients; spending time assessing normal behavior, physiological and psychological responses to illness and hospitalization; and using knowledge to recognize even subtle changes in the patients' conditions and further evaluate them. Another key aspect of using knowledge is developing the ability to anticipate patient care problems. When a nurse intervenes with a postoperative patient who is bleeding from his incision by applying pressure at the site, the nurse minimizes the amount of bleeding. Using knowledge and anticipating such complications assists a nurse to intervene correctly. Thinking in advance about what should be done if a particular complication should occur, and then monitoring the patient to assess and identify complications early or, when possible, to prevent them, is one way that nurses apply their knowledge. Another aspect of using knowledge for good leadership and management on the patient care unit is to have the right type of personnel and the right amount of personnel; in other words, having patient care unit staffing with enough registered nurses, licensed practical nurses, or nursing assistants on the unit, so that they all can fulfill their roles appropriately with enough people to adequately care for the patients.

Nurses develop their leadership and management skills with continuing education and by increasing their knowledge and expertise in caring for a group of patients by taking care of those patients regularly. The more experience a nurse gains in caring for a population of patients, the more opportunity the nurse has to learn to recognize patterns that occur with these patients. These patterns can include the type of symptoms that are common, possible complications or emergencies, and actions that can help prevent complications or negative outcomes. Planning in advance, prioritizing time and attention, determining actions needed and what can be delegated to others are ways that nurses manage a group of patients.

Knowledgeable nursing leadership and management on a nursing unit fosters good patient care by providing a supportive environment for nurses to deliver care. A supportive leadership and management environment is characterized by a clear chain of command, clear job descriptions, evidence‐based patient care standards, appropriate staffing, accessible Internet and library resources, and continuing education support. This allows the nurse to set goals, seek a mentor, and continue employment in a setting that is supportive of high quality, safe, patient‐centered care.

Margaret Wheatley, in Leadership and the New Science (1999), says, “There is a simpler way to lead organizations, one that requires less effort and produces less stress than the current practices.” She presents a new view of leadership, one encompassing connectedness and self‐organizing systems that follow a natural order of both chaos and uncertainty, which is different from a linear order in a hierarchy. The leader's function is to guide an organization using vision, to make choices based on mutual values, and to engage in the culture to provide meaning and coherence. This type of leadership fosters growth within each of us as individuals and as members of a group. A new model of leadership and understanding health care organizations and patient care units as Complex Adaptive Systems (CAS) has emerged from these ideas. CAS are complex, nonlinear, interactive and self‐organizing systems with the capacity for self‐renewal. The environment in a CAS is unpredictable and control is distributed with simple rules as the basis of operation. CAS are able to learn and adapt as a network of interacting, interdependent agents who cooperate in common goals and create new patterns of operating (Plowman & Duchon, 2008).

Complexity leadership is the new model where leadership is described as transformational, collaborative, self‐reflective, and relationship based. Complexity leaders see people in organizations as self‐organizing and self‐renewing and envision work occurring through relationships. This optimizes autonomy at all levels because the relationships among the individual and the whole are strong. For nursing, such relationships might provide the infrastructure that will foster interprofessional decision making and strengthen the connection with other health co‐workers.

In Wheatley's subsequent book, Finding Our Way: Leadership for an Uncertain Time (2005), she discusses how humans learn best when they are engaged in relationships with others and can exchange knowledge and expertise through informal, self‐organized communities. Wheatley refers to these as communities of practice and encourages us to develop new leaders using communities of practice. Her notion of a community of practice represents several elements nurses are familiar with, that is, forming informal groups, using a group process of organizing, using principles of learning, and sharing information. What is unique in her description of these communities of practice is that they form via self‐organization. They come together naturally. What makes these communities of practice different from informal groups is Wheatley's characterization of a community of practice built from relationships and participation in a way that connects nurses and allows the creation of meaning from information or the exchange of knowledge. One example of the concept of a community of practice is a group of nurses and physicians who work together to identify the best evidence to establish efficient patient flow through the emergency department to admission to the hospital. In work done for the Center of Creative Leadership, communities of practice are described as being different from the ideas or experiences we have had with groups, teams, and collective forming, because communities of practice emerge from shared activity, shared knowledge, and ways of knowing that create meaning and thus a culture of engagement, participation, and relationships (Drath & Palus, 1994). Wheatley directs nurses to name these communities of practice that bring people together, support these connections, nourish the community, and illuminate their work. These exciting notions hold great promise for health professionals as we learn how to collaborate within and across disciplines and countries to advance health care practices.

Servant Leadership is a leadership philosophy that emphasizes service to others, a holistic approach to work, and promotes a sense of community and sharing of power in decision‐making (Spears & Lawrence, 2004). Some common features of servant leadership are that the servant leader considers the needs of employees first, commits to helping employees develop expertise and improve performance, and insists that the organization make a positive contribution to society. While not losing their focus on a healthy bottom line, servant leaders make sure an organization improves its community, region, and nation.

Emotional intelligence is a component of leadership and refers to the capacity to accurately perceive and express emotion, to use feelings to inform and guide thinking, to understand the meanings of emotions and to manage emotions for personal and social growth (Goleman, 1998). Emotional intelligence consists of social and emotional skills enabling the capacity to interact with understanding and respect, resolve conflicts, withstand stress and adversity to persevere. Better performance and job success have been attributed to emotional intelligence, whereas problems with interpersonal relationships and difficulty adapting occur when emotional intelligence is low or absent. Emotional intelligence is necessary for nurses to maintain a calm and professional demeanor in emergency situations, to participate effectively in teams and groups and to navigate interpersonal issues and adversity.

Emotional intelligence includes five basic emotional and social competencies: i.e., Self‐awareness, Self‐regulation, Motivation, Empathy, and Social skills (Table 1.3).

Table 1.3 Emotional Intelligence (EI)

Transformational leadership encourages the retention of nurses through job satisfaction. Initially, it is important for a beginning nurse to have structure and supportive supervision. The nurse leader should be visible and approachable. The younger generation generally wants meaningful work, feedback, continuous learning, and flexibility for balancing activities. Transformational leadership fosters healthy staff‐focused workplaces through such techniques as shared organizational goals, learning opportunities for career development, rewards and recognition, empowerment, autonomy, employee health programs, and shared governance. That facilitates quality of care, and consequently, job satisfaction and nurse retention.

Anne Marriner‐Tomey, PhD, RN

Author, Guide to Nursing Management and Leadership

Professor Emerita

Indiana State University‐College of Nursing

Terre Haute, Indiana

The COVID‐19 Pandemic began as an active crisis in 2020, causing thousands of deaths. Now more than ever, nurses, as leaders and managers, were responding to protect patients, family, friends, the public, and members of the interprofessional health care team, including nurses. Situations not thought plausible had become reality. The American Nurses Association Response to the COVID‐19 Pandemic document highlights Nursing's response and illustrates one of the ways that nurses have always answered the call to serve their patients, their country, and communities during times of crisis.

Doctors and nurses were dying because of lack of personal protective equipment (PPE) supplies; not just in one country, but in many. Nurses were being fired for voicing truths, such as hospital PPE shortages; how could we protect transparency and patient safety? Nurses had to demonstrate leadership in safeguarding their patients and themselves.

This situation has put a magnifying glass on the errors in many world health care systems and shows that some health care systems and governments prepared and responded better than others. The Pandemic has brought a plethora of opportunities and critical needs for nursing and also underscores our need for data‐driven decisions. Nurses' voices need to be heard and this is a call for you to use yours. An incomplete list of opportunities and critical needs for nursing leaders includes: (see COVID‐19 and disaster planning p. 15)

Note. American Nurses Association. ANA Response to COVID‐19 Pandemic, available at, www.nursingworld.org/practice-policy/work-environment/health-safety/disaster-preparedness/coronavirus/ana-covid-19-statement, Accessed April 2, 2020.

Management is defined as a process of coordinating actions and allocating resources to achieve organizational goals. It is a process of planning, organizing and staffing, leading, and controlling actions to achieve goals. Planning involves setting goals and identifying ways to meet them. Organizing and staffing is the process of ensuring that the necessary human and physical resources are available to achieve the planning goals. It also involves assigning work to the right person or group and specifying who has the authority to accomplish certain tasks. Finally, controlling is comparing actual performance to a standard and revising the original plan as needed to achieve the goals. The daily activities of managers are diverse and fast paced, with regular interruptions. Priority activities are integrated among inconsequential ones. In the scope of one morning, a nurse manager may make serious decisions about a critically ill patient, a staff or patient complaint, a shortage of nurse staffing, and so forth. A nurse manager's work is driven by problems that emerge in random order and that have a range of importance and urgency. These circumstances create an image of the nurse manager as a firefighter involved in immediate and operational concerns. A significant proportion of a manager's time is spent in interaction with others, and more of the work is concerned with handling information than in making decisions (McCall, Morrison, & Hannan, 1978). Nurse managers constantly interact with other members of a health care administrative team. This administrative team can include nurses, various clinical practitioners, unit staff, and staff from other departments who share information and assure that quality patient outcomes are achieved.

One of the most frequently referenced taxonomies of managerial roles is from an in‐depth, month‐long study of five chief executives by Henry Mintzberg. A taxonomy is a system that orders principles into a grouping or classification. Mintzberg's observations led to the identification of three categories of managerial roles: (a) information‐processing role, (b) interpersonal role, and (c) decision‐making role (Mintzberg, 1973).

A role includes behaviors, expectations, and recurrent activities within a pattern that is part of the organization's structure (Katz & Kahn, 1978). Specific or distinct roles are part of each of the three categories of managerial roles. The information‐processing roles are monitor, disseminator, and spokesperson, each of which is used to manage the information needs that people have. The interpersonal roles are §head, leader, and liaison, and each of these roles is used to manage relationships with people. The decision‐making roles are the entrepreneur, disturbance handler, allocator of resources, and negotiator roles that managers use to act when making decisions.

Newly graduated nurses are concerned about their abilities to perform as nurses. They are worried about their skills and abilities and about advancing to independently manage a full patient load. New graduate nurses also deal with the emotional and physical realities of full‐time work and the transition from the role of student into professional nurse. To help support this transition, all new nurses are included in our year‐long Nurse Residency Program. This program provides them with a monthly opportunity to learn new skills and affirm their current skills and abilities through a variety of learning activities, including simulation. The new nurses also discuss their challenges and experiences when discussing tales from the bedside. They learn how to take the theory of EBP and apply it to a unit‐based issue. They create change within the Medical Center through their EBP projects! This often is the highlight of the first year of transition.

Katherine Pakieser‐Reed, PhD, RN

Director, Center for Nursing Professional Practice and Research

University of Chicago Medical Center

Chicago, Illinois

In the early 1900s, an emphasis on management as a discipline emerged with a focus on the science of management and a view that management is the art of accomplishing things through people (Follet, 1924). Henri Fayol, a manager, wrote a book in 1917 called General and Industrial Management. He described the functions of planning, organizing, coordinating, and controlling as the management process (Fayol, 1917/1949). His work has become a classic in the way that we define the process of managing. Two other individuals, Gulick and Urwick, in some part resulting from their esteemed status as informal advisers to President Franklin D. Roosevelt, defined the management process further according to seven principles (Fayol, 1917/1949). Their principles form the acronym POSDCORB, which stands for Planning, Organizing, Staffing, Directing, Coordinating, Reporting, and Budgeting (Fayol, 1917/1949; Gulick & Urwick, 1937). Their work is also considered to be a classic description of management and is still a relevant description of how the management process is carried out today.

More recently, Yukl (2013) and colleagues (Kim & Yukl, 1995; Yukl, Wall, & Lepsinger, 1990) followed this classic work by describing 13 management functions that address two broad aspects of the management process: managing the work and managing relationships. The management functions for managing the work are planning and organizing, problem solving, clarifying roles and objectives, informing, monitoring, consulting, and delegating. The management functions for managing relationships are networking, supporting, developing and mentoring, managing conflict and team building, motivating and inspiring, and recognizing and rewarding.

The amount of time managers spend on particular roles or functions varies by the level of their positions in organizations, ranging from the first‐level management positions, to the middle‐level management positions, to the executive‐level management positions. A first‐level managerial role or function in health care organizations is the nurse manager at the clinical bedside. First‐level nurse managers spend the majority of time directly managing patient care and supervising others as they deliver care. The next highest percentage of their time is spent in planning. The rest of first‐level nurse managers' functions typically take fewer than 10% or less of their time: planning and organizing, problem solving, clarifying roles and objectives, informing, monitoring, consulting, and delegating.

Select three opportunities to observe interactions by the nurse manager of the unit where you are doing your clinical rotation or where you are a new graduate nurse. These opportunities could be during a unit staff meeting, when the nurse manager makes rounds, and during conversation with others at the nurses' station. Which of the following nurse management functions do you see your unit nurse manager performing?

In contrast, middle‐level managers, usually called nursing directors, spend less time in direct supervision and more time in the other managerial roles or functions, particularly, planning and coordinating. At the highest level of the organization, usually described as the executive level, planning and being a generalist are greatly expanded role functions. Direct supervision is not a major aspect of the executive role as it is in the other two levels. Nurses in executive‐level roles in health care organizations usually have the title Chief Nurse Executive or Chief Nursing Officer or, in acute care hospitals, the title may be Vice President of Patient Care Services.

The current management practices have evolved from earlier theories. Management practices were part of the governance in ancient Samaria and Egypt as far back as 3,000 b.c. (Daft & Marcic, 2015). Most of our current understanding of management, however, is based on theories of management that were introduced during the industrial age as factories developed and manufacturing flourished. Some of these theories are discussed in Table 1.4.

Table 1.4 Management Theories

Note. Compiled with information from Burns, L. R., Bradley, E. H., & Weiner, B. J. (2020). Shortell & Kaluzny’s health care management: Organization design and behavior. 6th ed. Chapter 4: Motivating People). Boston, MA: Cengage Learning.

While practicing managers, such as Fayol, who was mentioned earlier, were describing the functions of managers, a man named Frederick Taylor was focusing his attention on the operations within an organization by exploring production at the worker level. Taylor is acknowledged as the Father of Scientific Management for his use of the scientific method and as the author of Principles of Scientific Management (1911). Productivity was the area of focus in Scientific Management. Taylor, an engineer, introduced precise procedures based on systematic investigation of specific situations. The underlying point of view of Scientific Management is that the organization is a machine to be run efficiently to increase production. Scientific Management pioneered studies of time and motion that emphasized efficiency and culminated in “one best way” of carrying out work.

Max Weber is the German theorist recognized for the management theory of Bureaucracy. Weber's beliefs were in stark contrast to the typical European organization that was based on a family‐type structure in which employees were loyal to an individual, not to the organization. Weber, however, believed efficiency is achieved through impersonal relations within a formal structure, competence should be the basis for hiring and promoting an employee, and decisions should be made in an orderly and rational way based on rules and regulations. Organizations were bureaucracies based on a hierarchy with clear superior‐subordinate communication and relations, based on positional authority, in which orders from the top were transmitted down through the organization via a clear chain of command.

Management that focused on human relations began by examining employee responses to conditions through a series of studies called the Hawthorne experiments. In contrast to the science of exact procedures, rules and regulations, and formal authority that characterized Scientific Management, theories from the Human Relations Management school of thought espoused the individual worker as the source of control, motivation, and productivity in organizations. During the 1930s, labor unions became stronger and were instrumental in advocating for the human needs of employees. During this time, experiments were conducted at the Hawthorne plant of the Western Electric Company in Chicago that led to a greater understanding of the influence of human relations in organizations.

Electricity had become the preferred power source over gas; the Hawthorne plant experiments were run to show people that more light was necessary for greater productivity. This approach was designed to increase the use of electricity. Researchers Mayo (1933) and Roethlisberger and Dickson (1939) measured the effects on production of altering the intensity of lighting. They found that, with more and brighter light, production increased as expected. However, production also increased each time they reduced the light, even when the light was extremely dim. Their research findings led to the conclusion that something else besides the light was motivating these workers.

The notion of social facilitation, or the idea that people increase their work output in the presence of others, was a result of the Hawthorne experiments. The researchers also concluded that the effect of being watched and receiving special attention could alter a person's behavior. The phenomena of being observed or studied, resulting in changes in behavior, is now called the Hawthorne Effect. Also emerging from this study was the concept that people benefit and are more productive and satisfied when they participate in decisions about their work environments.

The human relations perspective in management theory grew from the conclusion that worker output was greater when the worker was treated humanely. This spawned a human relations point of view and a focus on the individual as a source of motivation. Motivation is not explicitly demonstrated by people but rather is interpreted from their behavior. Motivation is a source of influence for personal choices. Motivation is a process that occurs internally to influence and direct our behavior in order to satisfy needs (Lussier & Achua, 2015). Motivation theories are not management theories per se; however, they are frequently considered along with management theories.

There are many theories of motivation, e.g., Maslow's Hierarchy of Needs; Aldefer's Expectancy‐Relatedness‐Growth (ERG) Theory and Model of Growth Needs, Relatedness Needs, and Existence Needs; Herzberg's Two‐Factor Theory; and McClelland's Theory and Model of Achievement, Power, and Affiliation. Table 1.5 discusses several of these Motivation Theories, including Maslow's Hierarchy of Needs, Herzberg's Two‐Factor Theory, McGregor's Theory X and Theory Y, Ouchi's Theory Z, and Vroom's Expectancy Theory.

Table 1.5 Selected Motivation Theories

One of the most well‐known theories of motivation is Maslow's Hierarchy of Needs. Maslow (1970) developed a Hierarchy of Needs that shows how an individual is motivated. Motivation, according to Maslow, begins when a need is not met. For example, when a person has a basic physiological need, such as thirst, this unmet need has to be satisfied before a person is motivated to pursue the next higher‐level needs. Certain needs have to be satisfied first, beginning with basic physiological needs, then safety needs, then social belonging needs, then self‐esteem needs, and finally self‐actualization needs. After each level of these needs is met, an individual is motivated by needs at the next level. The need for self‐actualization drives people to the pinnacle of performance and achievement.

Frederick Herzberg (1968) contributed to research on motivation and developed the Two‐Factor Theory of Motivation. He analyzed the responses of accountants and engineers and concluded that there are two sets of factors associated with motivation. One set of motivation factors must be maintained to avoid job dissatisfaction. These factors include such items as salary, working conditions, status, quality of supervision, relationships with others, and so on. These factors have been labeled Hygiene Maintenance Factors.

Other Motivation Factors, such as achievement, recognition, responsibility, advancement, and so on, also contribute to job satisfaction. These factors are intrinsic and serve to satisfy or motivate people. Herzberg proposed that, when these Motivation Factors are present, people are very motivated and satisfied with their jobs. When these Motivation Factors are absent from a work setting, people have a neutral attitude about their organizations. In contrast, when the Hygiene Maintenance Factors are absent, people are dissatisfied. Herzberg believed that, by providing the Hygiene Maintenance Factors, job dissatisfaction could be avoided, but that Hygiene Maintenance Factors alone will not motivate people.

New graduate nurses can use Herzberg's Two‐Factor Theory by evaluating the Hygiene Maintenance Factors present in health care organizations when they apply for jobs. The pay, working conditions, and the beginning relationship that has been established with a supervisor are aspects of a job that the nurse should consider. If these Hygiene Maintenance Factors are not adequate to begin with, then the nurse may become easily dissatisfied with the job. The higher‐level needs that Herzberg describes as Motivation Factors should also be evaluated by the nurse before joining an organization. Are there opportunities for the nurse to achieve professional growth, to take on new responsibilities, to advance and be recognized for the contribution he has made?

It is important to recognize that not all employees respond to the same motivation factors. For example, a manager might be surprised to learn that some personnel will not respond to opportunities for autonomy and personal growth on the job. Rather, they may view their jobs as a means of providing income and seek various forms of personal fulfillment off‐the‐job through their families and leisure activities (Burns, Bradley & Weiner, 2020).

Continuing the emphasis on factors that stimulate job satisfaction and what motivates people to be involved and contribute productively at work, McGregor capitalized on his experience as a psychologist and university president to develop Theory X and Theory Y (McGregor, 1960). Theory X and Theory Y identify two different views of how to motivate or influence others based on underlying attitudes about human nature. Each view reflects different attitudes about the nature of humans. Theory X identifies how, in bureaucratic organizations, employees prefer security, direction, and minimal responsibility. Coercion, threats, or punishment are necessary because people do not like the work to be done. These employees are not able to offer creative solutions to help the organizations advance.

The assumptions of Theory Y are that, in the context of the right conditions, people enjoy their work; can show self‐control and discipline; are able to contribute creatively; and are motivated by ties to the group, the organization, and the work itself. In essence, this view espouses the belief that people are intrinsically motivated by their work. Theory Y was a guide for managers to take advantage of the potential of each person, which McGregor thought was being only partially utilized, and to provide support and encouragement to employees to do good work (McGregor, 1960).

Theory Z was developed by William Ouchi (1981) based on his years of study of organizations in Japan. He identified that Japanese organizations had better productivity than organizations in the United States and that they were managed differently with their use of quality circles to pursue better productivity and quality. Theory Z focuses on a better way of motivating people through their involvement. The organization invests in its employees and considers both home and work issues when creating a path for career development. Democratic leaders, who are skilled in interpersonal relations, foster employee involvement (Ouchi, 1981).

Vroom's Expectancy Theory of Motivation centers around what people want and their prospect of getting it (Vroom, 1964). There are three variables in Vroom's motivation theory. They are force, valence, and expectancy. Force describes the amount of effort one will exert to reach one's goal. Valence speaks to the level of attractiveness or unattractiveness of the goal. Valence is graded between +1, an outcome that is highly attractive to the individual, and −1, a highly unattractive goal. A valence of 0 indicates the goal does not interest the individual. Expectancy is the perceived possibility that the goal will be achieved. Expectancy is evaluated between 1 and 0. A score of 1 indicates assurance that the goal will be achieved, and a score of 0 indicates that the individual sees the goal as impossible to achieve. Vroom's theory appears in the form of an equation as Force = Valence × Expectancy. Vroom proposes that this equation can help to predict the motivation of an individual to achieve a goal as negative, neutral, or positive based on the underlying notion that our expectations affect our motivation.

Motivation theories are useful because they help explain why people act the way they do and how a manager can relate to individuals as human beings and workers. When you are interested in creating change, influencing others, and managing patient care outcomes, it is helpful to understand the motivation that is reflected in a person's behavior. Motivation is a critical part of leadership because we need to understand each other to lead effectively. See Table 1.6 for common motivation problems and potential solutions.

Table 1.6 Common Employee Motivation Problems and Potential Solutions

Source: Compiled with information from Burns, L. R., Bradley, E. H., & Weiner, B. J. (2020). Shortell & Kaluzny’s health care management: Organization design and behavior. 6th ed. Chapter 4: Motivating People). Boston, MA: Cengage Learning. Bradley, E. H., & Weiner, B. J. (2020).

Write the number from 1 to 5 that you selected for each factor. Total each column for a score between 12 and 60 points. The closer to 60 your score is, the more important these factors (Motivating or Hygiene Maintenance Factors) are to you.

Source: From. Lussier, R.N, and Achua, C.F. (2015) Leadership: Theory, Application, Skill Development Cincinnati, OH: South‐Western College Publishing.)

Search the Web, checking the following sites:

Ronda G. Hughes1, and Janice Tazbir2, 3, 4, 5

¹ Center for Nursing Leadership, Executive Doctorate of Nursing Practice, University of South Carolina, Columbia, SC, USA

²University of Chicago Medicine, Chicago, IL, USA

³Anderson Continuing Education, Sacramento, CA, USA

⁴Retired, Purdue University Northwest, College of Nursing, Hammond, IN, USA

⁵Health Education Systems, Inc. (HESI), Houston, TX, USA

Nurses work together to provide high‐quality care and to seek opportunities for improvement.

Source: Tish Watts, Johnny Tazbir & Venita Chew.

Health care in the twenty‐first century will require a new kind of health professional: someone who is equipped to transcend the traditional doctor–patient relationship to reach a new level of partnership with patients; someone who can lead, manage, and work effectively in a team and organizational environment; someone who can practice safe, high‐quality care but also constantly see and create the opportunities for improvement.

(Donaldson, 2001)

Upon completion of this chapter, the reader should be able to:

Your neighbor calls, asking you to come over and advise her as to what to do with her grandchild who is sick. Finding the 3‐year‐old child with a runny nose, a slight fever, and a congested cough, you recommend that she take the child to her primary care clinician for an office visit, especially if the fever continues or rises, and if her symptoms seem worse. Your neighbor feels that there is no urgency because of the high cost of the office visit co‐pay, her difficulty in getting the child to the clinician during the limited hours that don't coincide with her work schedule, and she can't get an appointment until 2 weeks later because her grandchild is covered by Medicaid. She opts to wait until a couple of days later when she gets home from work and finds that her grandchild seems more fussy, and then takes the child to the emergency department (ED) where she will have no co‐pay and can get seen right away. By the time they arrive at the hospital, the child has a temperature of 104°F (40°C) and is subsequently hospitalized for a week in the pediatric intensive care unit.

The U.S. health care system consists of a mix of different types of health care providers from either nonprofit or for‐profit organizations in both the public government and private sectors. These providers and organizations provide more than 300 million American citizens with access to cost‐effective, quality health care. Reimbursement for health care services is paid in one or a combination of these four ways:

Public government health care programs such as Medicare and Medicaid, State Children's Health Insurance Program (SCHIP), Department of Veterans Affairs, and other programs (e.g., for the military, American Indians (AI), and federal prisoners) provide health care services primarily funded through a percentage of dollars collected through Federal taxes. National health care expenditures (NHE) grew 3.9% to 3.5 trillion in 2017 and accounted for 17.9% of the gross domestic product (GDP) (NHE, 2019). Many Americans are surprised that the Federal Government already funds almost half of health care services, yet verbalize reluctance to move toward a government run health care program for all citizens.

This chapter discusses a selected history of American health care. It discusses health care in various settings, disease management, and the influence of external forces on health care. The chapter reviews how health care is organized, funded, and accredited. It explores health care disparities and clinical variation, and reviews reports of the Institute of Medicine (IOM) Committee on Health Care. Finally, the chapter discusses issues regarding quality health care and the education of health care professionals. Patient Protection and Affordable Care Act (PPACA) of 2010 and the Health Care and Education Reconciliation Act (HCERA) of 2010. We will explore how health care is organized and financed in the United State, compare U.S. health care with that of other industrialized countries, identify major issues facing health care, and relate efforts for improving the quality, safety, and access to health care.

Most Americans are in good health, but many children, elderly, sick, and disabled are in need of better access to quality health care services at a reasonable cost. The need for accessible, high‐quality, safe, and reasonable priced care has driven various initiatives to improve health care in the past and present. Some of the key initiatives include the 1935 passage of the Social Security Act; the 1946 passage of the Hill‐Burton Act; and the 1965 passage of Medicare and Medicaid. The 2010 passage of both the PPACA and the HCERA was a recent attempt to improve health care access for the millions of Americans without health care coverage.

The U.S. spends 17.9% (an average of $10,224 per person) of its GDP on health care, more than any other wealthy country, all of whom provide health care insurance for all their citizens (Papanicolas, Woskie, & Jha, 2018). Many wealthy countries in the world spend less on health care, for example, Canada ($4.902), Germany ($5,728), Sweden ($5,511), and the United Kingdom ($4,246), yet provide Universal Health Care (UHC) to their citizens (Sawyer & Cox, 2018). In these countries, per capita spending on health care is considerably less than in the U.S., yet health care outcomes for such things as infant mortality, immunization rates, and life expectancy in the U.S. are poorer by comparison (Nolte & McKee, 2008). Perhaps Americans need to study what other countries have done in health care and modify it to fit. Throughout the history of the U.S., efforts to implement a UHC program have been resisted, with costly social and economic consequences.

To avoid the financial burden of health care costs, many Americans delay obtaining care. Their contact with the health care system is episodic and usually in acute care settings. Even after their symptoms have progressed and are well‐advanced, many Americans are likely to obtain only irregular, sporadic care. This means that they lack consistent care from a health care provider whom they see regularly, whether for health promotion, illness prevention, early detection, or health restoration.

Inability to pay for recommended treatments and medications also compromises adherence to health care recommendations, which in turn affects recovery. Medical debt is now the number one reason for personal bankruptcy in the U.S. The majority of people declaring bankruptcy because of medical debt are employed and have health insurance (Himmelstein, Warren, Thorne, & Woolhandler, 2005). A cascading effect occurs for patients with soaring costs, high incidence of medical bankruptcy, progressively worsening health outcomes, and a high incidence of medical malpractice claims.

Spending on health care services is concentrated in disproportionate ways, which also adds to health care costs. For example, 90% of health care costs are on chronic conditions (Centers for Disease Control and Prevention (CDC), 2019). In 2016, half of all health spending was on 5% of the population, The 5% of people who spend the most on health care spend an average of around $50,000 annually; people in the top 1% have average spending of over $109,750. The 50% of the population with the lowest spending accounted for only 3% of all total health spending; the average spending was $276 (Sawyer, Claxton, & Kaiser, 2016).

The fight to achieve quality health care for all continues. Schulte (2011) recommends the development of evidence‐based guidelines by the nursing and medical professional associations as one way to tackle the health care problem. Adherence to these guidelines then could be regularly monitored on electronic health records to note the outcomes, improve both patient care and evidence‐based guidelines, and decrease the incidence of medical malpractice.

In 2010, 47 million uninsured people in the United States did not have health care insurance. This led to many discussions of rights to health care, access, fairness, sustainability, safety, quality, and discussions of the amount of money spent by the government on health care. The PPACA (Public Law 111–148) (Kaiser Family Foundation, 2010) was signed into law by President Barack Obama on March 23, 2010. Along with the HCERA of 2010 (Public Law 111–152), signed March 30, the Acts are a product of the health care reform efforts of the 111th Congress and the Obama administration (Office of the Legislative Counsel. 111th Congress, 2d Session. May, 2010). PPACA and HCERA required most U.S. citizens and legal residents to have health insurance and introduced many insurance market reforms over the next few years. They prohibited insurers from establishing annual insurance coverage caps and provide funds for medical research. They created a new insurance marketplace with state‐based American Health Benefit Insurance Exchanges through which individuals can purchase insurance coverage, with premium‐ and cost‐sharing credits available to individuals and families with income between 133% and 400% of the federal poverty level (FPL) (the poverty level was $18,310 for a family of three in 2009).

PPACA and HCERA created separate state Insurance Exchanges through which small businesses can purchase insurance coverage. They subsidized insurance premiums for people making up to 400% of the FPL ($88,000 for a family of four in 2010), so their maximum out‐of‐pocket payment for annual premiums will be from 2% to 9.8% of income, providing incentives for businesses to provide health care benefits, prohibiting denial of coverage and denial of claims based on pre‐existing conditions, prohibiting insurers from establishing annual coverage caps, and giving support for medical research. The costs of these provisions are offset by a variety of taxes, fees, and cost‐saving measures, such as new Medicare taxes for those in high‐income brackets, taxes on indoor tanning, cuts to the Medicare Advantage program in favor of traditional Medicare, and fees on medical devices and pharmaceutical companies. There is also a tax penalty for those who do not obtain health insurance, unless they are exempt due to low income or other reasons. The Congressional Budget Office estimated that the net effect of both Acts will be a reduction in the federal deficit by $143 billion over the first decade.

PPACA included fundamental changes to Medicare, expansion of the Medicaid program, and reforms to Part D, closing the Medicare donut hole by 2020. It includes initiatives to prevent fraud and abuse; includes more health information technology (IT); and promotes disease prevention programs across the health care system. HCERA makes a number of health‐related financing and revenue changes to the PPACA of 2010. HCERA is divided into two titles, one addressing health care reform and the other addressing student loan reform. It was anticipated that PPACA and HCERA would impact health care significantly, and it was estimated that the net effect of both PPACA and HCERA would be a reduction in the federal deficit by $143 billion over the first decade. A fast‐forward of changes since the ACA was enacted (Collins, Bhupal, & Doty, 2019). Today, 45% of U.S. adults aged 19–64 are inadequately insured (almost the same as in 2010)

Florence Nightingale observed that noise, food, rest, light, fresh air, and cleanliness were instrumental in health and illness patterns. Thus, she maintained, the aim of nursing was to put the patient in the best condition for nature to act upon her or him (Nightingale, 1865/1970). Nightingale also discovered the link between adverse patient outcomes and a lack of cleanliness and hand washing. Yet generations after the insights of Nightingale were first set forth, sporadic adherence by health care providers to hand washing continues. Although significant progress has been made in preventing some health care‐associated infection types, there is much more work to be done. On any given day, about one in 31 hospital patients has at least one health care‐associated infection. Three percent of hospitalized patients in the 2015 survey had one or more HAIs. There were an estimated 687,000 HAIs in U.S. hospitals in 2015. About 72,000 hospital patients with HAIs died during their hospitalizations (CDC, 2018b).

One hundred years ago, illnesses such as tuberculosis or pneumonia required lengthy hospitalizations and were often catastrophic for individuals and families. Today, such illnesses are preventable and are often easily treated. Vaccination programs have been used extensively to prevent the spread of communicable diseases. Additionally, surgical interventions in hospitals (e.g., tonsillectomies, appendectomies, and reproductive procedures) have improved to treat otherwise debilitating or mortal conditions. Health care is delivered by professional nursing and medical practitioners who are science based and who use evidence‐based practice. Health care is primarily directed at preventing and treating chronic and behavioral diseases. Health care advances have extended life expectancy, with the consequence of more elderly people requiring more health care for chronic and complex health problems. The majority of clinical care is still provided in hospitals, but length of stay is much shorter, and a variety of innovative models of care are now used to provide cost‐effective care for people with acute, community, and long‐term clinical needs (Health Workforce Solutions LLC & Robert Wood Johnson Foundation, 2008).

Health care‐associated infections currently result in increased length of stay, mortality, and health care costs. In addition, a Centers for Disease Control and Prevention (CDC, 2018) report estimates that the overall annual direct medical costs of health care‐associated infections in U.S. hospitals ranges from $28.4 to $33.8 billion. These infections are most often attributed to invasive supportive measures such as endotracheal intubation and the placement of intravascular lines and urinary catheters. Several studies have noted that health care‐associated infections can be prevented through a number of multidisciplinary, evidence‐based interventions, reducing the incidence of infection by as much as 70% (Anderson et al., 2007; Harbarth, & Gastmeir, 2003; Muto et al., 2005).

Nightingale also described the importance of structuring hospitals around nursing care. The initial design of hospitals followed that advice by building large wards where nurses could easily monitor and observe their patients. Later, hospital design evolved to placing patient rooms surrounding centrally located nursing stations. Then, as today, the physical environment of hospitals can create stress for patients, their families, and clinical staff. Research is finding links between the physical environment and patient outcomes, patient safety, and patient and staff satisfaction (Hamilton, 2003). Studies show that such elements of hospital design as exposure to natural light, private rooms, and facilities that are staff friendly and have less noise contribute to improved patient outcomes (Ulrich, Quan, Zimring, Joseph, & Choudhary, 2004).

Although little is known about how to best design the hospital environment to facilitate clinical advances and care delivery, an estimated $200 billion will be expended for new hospital construction across the United States during the next 10 years (Institute of Medicine (IOM), 2004a). The Robert Wood Johnson Foundation (RWJF), the nation's largest philanthropy devoted exclusively to health and health care, has provided funding to the Center for Health Design, a nonprofit research organization, for the Designing the twenty‐first Century Hospital Project, which is the most extensive review of the evidence‐based approach to hospital design ever conducted. Launched in 2000, the Pebble Project is a joint research effort between the Center for Health Design and health care providers. The project engages health care providers that are building new health care facilities or renovating old ones using an evidence‐based design. The project uses the latest available evidence to inform design innovations and then measure the outcomes of the innovations through carefully designed research projects. The results are shared with the larger health care community to promote change. The Pebbles Project is an example of facility design to improve quality of care (The Center for Health Design, 2011).

Nightingale also astutely recognized the importance of collecting and using data to assess the quality of health care. She employed coxcomb diagrams to present visual images of the number of preventable deaths during the Crimean war (Figure 2.1) and then later in London hospitals.

FIGURE 2.1 Florence Nightingale's coxcomb diagram of the causes of mortality in the army in the East.

Source: Florence Nightingale (1820–1910). [Public domain].

Today, data is collected through patient records, surveys, and administrative systems. From these, reports are developed, such as To Err is Human (IOM, 1999); the CDC National Vital Statistics Reports (Martin, Hamilton, Sutton, & Ventura, 2006); and The National Healthcare Disparities Report (NHDR) (Agency for Healthcare Research and Quality (AHRQ), 2005). These reports provide invaluable information, and data is displayed with charts and pictures to emphasize the successes and failures of health care throughout our nation. Evidence of significant disparities and low quality continue to demonstrate the need for significant health care improvement.

Recognizing the influence of external forces on care delivery and scope of practice, Nightingale also kept informed of the activities of practitioners and government policy makers (Dossey, Selanders, & Beck, 2005). With health care being the largest sector of our economy, employers, clinicians, managers, and patients all have vested interests in proposed changes to health care financing, organization, and the responsibilities and scope of practice for clinicians. Today, nursing leaders, managers, and staff need to be aware of and involved in the ongoing processes of making health policy.

Health care systems have three main components: structure, process, and outcome. The structure component of health care includes resources or structures needed to deliver quality health care, for example, human and physical resources, such as nurses and nursing and medical practitioners, hospital buildings, medical records, and pharmaceuticals. The process component of health care includes the quality activities, procedures, tasks, and processes performed within the health care structures, such as hospital admissions, surgical operations, and nursing and medical care delivery following standards and guidelines to achieve quality outcomes. The outcome component of health care refers to the results of good care delivery achieved by using quality structures and quality processes and includes the achievement of outcomes such as patient satisfaction, good health and functional ability, and the absence of health care acquired infections and morbidity. See Table 2.1 for examples of structure, process, and outcome performance measures in clinical care, financial management, and human resources management. The American Nurses Association's (ANA) Nursing Care Report Card for Acute Care (1995) also uses the structure, process, outcome framework for its indicators of quality.

Table 2.1 Examples of Performance Measures by Category

Source: Compiled with information from Shortell, S. M., & Kaluzny, A. D. (2006). Health care management (5th ed.). Clifton Park, NY: Delmar Cengage Learning.

It would be naïve to consider health care in the United States, as it is currently being delivered, as being an effective system of care. If that were true, it would imply that health care is based on shared values and goals; is organized around the patient; utilizes all pertinent information; ensures value‐based and quality‐based care; rewards quality care; is universally standardized and simplified; is available to everyone regardless of income, race, ethnicity, or education; is affordable; and reflects effective collaboration among clinicians and with patients. The World Health Organization (WHO) has put forth primary goals for what good health care should do: improve equity in health, reduce health risks, promote healthy lifestyles and settings, and respond to the underlying determinants of health (World Health Organization (WHO), 2019).

Consistent with these goals, Healthy People 2020 has also developed overarching goals to increase quality and years of healthy life and eliminate health disparities. These goals are:

What can be said about the United States health care system is that it is not really a system, but rather a hodge‐podge of systems, some great, some not so great, with a “sometimes” desire for universal service, but with also the fierce energy of independent individuals seeking autonomy.

Ellyn Stecker, MD

Shipshewana, Indiana

Despite having the most expensive health care, the United States ranks last overall among the 11 countries on measures of health system equity, access, administrative efficiency, care delivery, and health care outcomes. While there is room for improvement in every country, the U.S. has the highest costs and lowest overall performance of the nations in the study, which included Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the United Kingdom. The U.S. spent $9,364 per person on health care in 2016, compared to $4,094 in the U.K., which ranked first on performance overall (Commonwealth Fund, 2017). An overall score of 64% was recently given to the United States for its achievement across 42 core health indicators related to long, healthy, and productive lives; quality; access; efficiency; and equity of health care (Commonwealth Fund, 2012) (see Figure 2.2).

FIGURE 2.2 U.S. scorecard on health system performance.

Source: The Commonwealth Fund. (2012, January 15). Scores Dimensions of a High Performance Health System. Retrieved from https://www.commonwealthfund.org/chart/scores‐dimensions‐high‐performance‐health‐system.

Some major findings from the U.S. Scorecard include the following (Radley, Hayes, & Collins, 2019):

The United States is one of only a few large countries in the world without a universal system of health care. The U.S. has higher prices for most health care services and prescription drugs, according to available internationally comparable data. Meanwhile, utilization of several services, including physician consultations and hospital stays, is lower than in many comparable countries. Use of some services, such as C‐sections and knee replacements, is higher in the U.S. than in similar countries (Sawyer, McDermott, & Kaiser, 2019). In the US we have fewer office visits and shorter average hospital stays, yet the U.S. overall spends twice as much per person on health care than do comparable countries (Sawyer et al., 2019).

Note that some countries, such as Britain, New Zealand, and Cuba, provide health care in government hospitals, with the government paying the bills. Others (e.g., Canada and Taiwan) rely on private‐sector providers, paid for by government‐run insurance. Many other wealthy countries (e.g., Germany, the Netherlands, Japan, and Switzerland) provide universal coverage using private doctors, private hospitals, and private insurance plans. In some ways, health care is less socialized overseas than in the United States, where almost all Americans sign up for government Medicare insurance at age 65. In Germany, Switzerland, and the Netherlands, seniors stick with private insurance plans for life. Meanwhile, the U.S. Department of Veterans Affairs is one of the world's purest examples of government‐run health care (Reid, 2009).

The number of acute care hospital beds in the United States is 6,210 and in 2016, there were about 35.7 million hospital stays with a mean length of stay of 4.6 days and a mean cost of $11,700 per stay (AHA, 2019). From 1980 to 2015, the overall mortality rate in the United States fell by 29%, compared to a 54% decline in comparable countries. Disability adjusted life years (DALYs) are a measure of disease burden and the rate per 100,000 shows the total number of years lost to disability and premature death. Though DALYs have declined in the U.S. and comparable countries since 2000, the U.S. continues to have higher age‐adjusted rates than those of comparable countries. In 2017, the DALYs rate was 31% higher in the U.S. than the comparable country average (Sawyer et al., 2019).

Think about how you could improve the delivery of health care delivery with limited funding and clinicians. Why are people in the United States not as healthy as they are in other countries? Health care that focuses on more delivery of prevention and primary care would increase health and decrease disease throughout the U.S. How can you work individually and with your community to begin to accomplish this?

As a nurse practitioner, there are many things about the American health care system that I really value. There are minimal wait times and there are lots of specialties.

I like that a patient whom I refer with a serious diagnosis can be seen by a specialist within 2 weeks. We develop and make top‐notch technology available and we have great health care standards. For all of these reasons, we keep the world on track and it follows our lead. I'm also aware every day of the shortcomings of the health care system. It's far too expensive, there are too many special interest groups, and it's all going to collapse under its own weight, a classic example of capitalism gone amuck. For example, health insurance companies have too much power, and I hate how all the insurance hoops prevent me and my colleagues from giving the best care to our patients. We need a national health policy, and if the American people make enough noise, politicians will get behind it, too. I'm in favor of a national health plan, one that will ensure that all Americans have access to care. It needs to be one that incorporates what we already do best with what's useful from other countries such as Japan and Canada. We have a lot to learn from what they do well that we don't do.

Nadine Lamoreau, RN, MSN, FNP, APRN‐C

Fort Fairfield, Maine

When you look at a group of 1,000 people, it is estimated that 800 of them will experience symptoms of some disease or condition. Of this group of 800, 265 people will be seen in a practitioner's office or hospital outpatient department or emergency department, or they will use home health care. Only eight will eventually be hospitalized. The majority of the people don't need hospitalization and would benefit from more resources available for primary health care delivery outside the hospital (Green, Gryer, Yawn, Lanier, & Dovery, 2000). This finding seems odd when considering where the research dollars are targeted and where the majority of health care dollars are devoted, that is, acute care settings in hospitals. Note that a consistent focus on illness and injury, often referred to as a downstream focus, means fewer dollars are invested in upstream efforts. A focus on upstream efforts would be directed at keeping the population well through health promotion and illness prevention strategies and would be less costly.

The majority of patient care and health care occurs in communities outside acute care settings. Primary care “which provides integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community” (IOM, 1996, p. 1), should be better understood and appreciated for the role it has in improving patient's health status and health outcomes. The key foundations of primary care (Starfield, 1998) can be applied across the health care continuum and across organizational settings, because primary care emphasizes seven important features: care that is continuous, comprehensive, coordinated, community oriented, family centered, culturally competent, and begun at first contact with the patient. According to Starfield (1998), patients and clinicians need to work together to appropriately utilize services, based on the following four foundations of primary care:

You work in an Emergency Department (ED) that sees 6,000 patients a month. Patients are charged at least $200.00 per visit plus charges for tests and medications. Thus, these 6,000 patients can generate $1,200,000 in gross revenue for the hospital. Consider that there are 15 RNs making $30.00 hr and 6 MDs, making $150.00 hr working each shift. Salaries for the RNs total $324,000. Salaries for the MDs total $648,000. The total salary for these two groups is $972,000. Of the 6,000 patients, 50% have Medicare/Medicaid, 45% are covered by managed care or insurance, and 5% have no insurance. Thus, just 95% of patients can pay their bills. The other 5% of patient's bills are written off by the hospital as bad debt.

Medicare/Medicaid/Managed Care/Insurance companies often pay only 55% of the bills for these patients. They may deny payment for 45% of the bills. Thus, for the $1,140,000 billed (95% of $1,200,000), the hospital will receive approximately $627,000 (55% of the $1,140,000 billed). Approximately $513,000 of the bill will not be paid by Medicare/Medicaid/Managed Care/Insurance. Consider the following:

What other expenses besides salary must the hospital pay out of the $627,000 that it receives? Consider hospital space, liability insurance, technology costs, and so on.

Notice the effect that increasing the volume of patients has on your budget figures. What happens to your budget if the patient volume goes to 8,000 patient ED visits per month and staffing stays the same?

Are patients receiving useful information about future illness prevention and healthy living practices in the ED?

Is this a cost‐effective way to deliver health care?

How could we better serve the health care needs of Americans?

Primary care clinicians, which primarily include both medical and nursing practitioners, can be a patient's greatest asset in negotiating the health care system and improving patient outcomes. It is through understanding the patient's past and present that future health care needs can be anticipated. Primary care interventions, such as health promotion and timely preventive care and medication administration, can reduce the need for hospitalizations, improve the health of patients, and avert adverse morbidity and mortality outcomes. Patients and their families can communicate with clinicians to understand their health care needs, how to achieve the best possible health, and how to partner with clinicians to improve decision making. This is what patient‐centered care is based on, both primary care and patient decision making. The World Health Report (2008b), Primary Health Care: Now More than Ever, underscores the need for primary health care. The report cites a disproportionate focus on specialist hospital care, fragmentation of health systems, and the proliferation of unregulated commercial care. The WHO (2010b) has also identified key elements in improving health status through primary care strategies aimed at reducing disparities through universal access, enhancing coordination and delivery of care, and increasing stakeholder participation at multiple levels.

The federal government is a major driver of health care organization and delivery. Distinct, major divisions of the U.S. Department of Health and Human Services (DHHS) include the following:

Public health services at the state and local levels include boards of health and state and local health departments. Even with the 1988 IOM Report on public health, the ability of public health departments to engage in improving the health of the public has become limited (Tilson & Berkowitz, 2006). In addition, efforts for bioterrorism and disaster preparedness have brought the nation's infrastructure desolation to light, causing increased funding for this nation's disaster preparedness efforts, with little money focused on public health care funding and infrastructure redevelopment.

The location of care delivery is continually changing to adapt to technologies and patient needs. The use of home health care services continues to grow as more and more individuals access these services in the community setting, in lieu of institutional care. According to the Centers for Medicare and Medicaid Services (CMS) (2018), home health care expenditures were 3% of national health care expenditures in 2017, of the overall spending of having reached $3.5 trillion. This increase has been primarily driven by higher growth in Medicaid spending, partly due to Medicaid's continued shifting of long‐term care from institutional to home settings. In light of an aging population, home health care services will continue to serve an integral role in health care delivery.

Inequalities in such things as gender, age, ethnicity, etc. (Figure 2.3) have been recognized as great influences on health outcomes. Socioeconomic status is the number one predictor of poor health. The 2018 NHDR found from 2000 to 2017 (AHRQ, 2019):

FIGURE 2.3 The spectrum of inequality.

Source: https://www.nationalarchives.gov.uk/doc/open‐government‐licence/version/3/ Contains Parliamentary information licensed under the Open Parliament Licence v3.0

The report also noted, even when the overall quality of care improves, health care disparities often still persist across socioeconomic groups, racial and ethnic populations, and geographical areas (AHRQ, 2019). In addition, not enough health care delivery and attention is directed toward the top underlying causes of death in the United States (Table 2.2).

Table 2.2 Top 10 Actual Causes of Death in the United States in 2000

Source: CDC. “FastStats ‐ Deaths and Mortality.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 21 June 2019, www.cdc.gov/nchs/fastats/deaths.htm.

Quality of health care improved overall from 2000 through 2016–2017, but the pace of improvement varied by priority, which are (AHRQ, 2019):

Person‐Centered Care: Almost 70% of measures were improving.

Patient Safety: More than 60% of measures were improving.

Healthy Living: Almost 60% of measures were improving.

Effective Treatment: Almost half of measures were improving.

Care Coordination: One‐third of measures were improving.

Care Affordability: No care affordability measures changed.

Overalls, as one ages, more health care services are utilized; women use health care services more frequently than men; and whites have greater health care access, and therefore higher utilization rates, than do patients of color as reported by the National Healthcare Disparities Report (NHDR), 2018; (AHRQ, 2019). Both financial and nonfinancial barriers to care delivery result in lack of attention to health care disparities and factors contributing to the underlying causes of death, which affects health outcomes. In‐depth information on national health care disparities is reported in the annual National Health Disparities Report (AHRQ, 2019).

For example, disparities in infant morbidity and mortality, cardiovascular and pulmonary disease, diabetes, communicable disease, cancer, and disease prevention (i.e., immunization and health screening) are more likely to be experienced by people disadvantaged by poverty, age, skin color, or ability to speak English. Such differences are further aggravated by miscommunication and misunderstanding, stereotyping, discrimination, and prejudice between patients and providers. Lifestyle behaviors that contribute to illness are higher among vulnerable groups. Because of their financial difficulties and other difficulties in accessing the health care system, vulnerable people often postpone health care. They are more likely to use the acute care system when their illness symptoms are advanced. Use of emergency departments and other acute care facilities for treatment is the most expensive way to obtain health care. In countries with a national health care system, health disparities also exist, but virtually everyone in those countries, regardless of socioeconomic background, is assured of equal access to quality health care. Health care is associated with 10–20% of the modifiable contributors to healthy patient outcomes (Magnan, 2017). The other 80–90% are dependent on health behaviors (e.g., tobacco use, diet/exercise, and alcohol use), social/economic factors (e.g., education, income, and employment), and the individual's physical environment (e.g., air quality, housing, and transit) (Magnan, 2017). These “social determinants” are so important when it comes to health that they have been called the “causes of causes.”

Social determinants of health (SDOH) include access to health care, culture, language, education/literacy, access to transportation, crime rates, and safe housing. Research studies indicate that SDOH do matter and can have a significant impact on a population's health (CDC, 2018).

In the United States, health insurance has been generally employment‐based, so long as it is affordable for the employer to offer this health care coverage to employees. The higher one's income in this country, the greater the likelihood of having health insurance coverage. The opposite is true for those with low incomes, especially those with poverty‐level incomes. Patients who are at poverty levels often cannot afford insurance premiums nor can they afford, in the majority of instances, out‐of‐pocket health care costs. Since the inception of private health insurance in the late 1920s following the development of hospitals as the center of health care and subsequent rising health care costs (Starr, 1983), private health insurance from third‐party payers such as insurance companies has been generally voluntarily offered as a benefit to employees and sometimes their families. Patients may make payments to providers of health care and third‐party payers. Providers of health care deliver service to patients and bill third‐party payers. Third‐party payers may make payments to providers as direct payment fees for individuals, capitated payment for services for a group of patients, or as prospective payments for future patients. Health insurance distributes health care funds from the healthy to the sick (Figure 2.4).

FIGURE 2.4 Economic relationships in the health care delivery system.

Source: Adapted from “What Can Americans Learn from Europeans?” by U. E. Reinhardt, 1989, Health Care Financing Review [Supplement], pp. 97–103.

One reason proposed for the steady incline in health care costs is that the elderly have virtually UHC coverage through Medicare. This UHC coverage indicates that the United States will likely experience very rapid growth in overall health expenditures in the coming years, as the population continues to age. Other sources of health care funding, and where it went, are shown in Figures 2.5 and 2.6.

FIGURE 2.5 The nation's health dollar, calendar year 2017 where it came from. Centers for Medicaid and Medicare (CMS), Office of the Actuary, National Health Statistics

Source: Centres for Medicaid and Medicare (CMS), Office of the Actuary, National Health Statistics Group.

FIGURE 2.6 The nation's health dollar, calendar year 2017, where it went to.

Source: Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group.

In the United States, health care insurance is one of the most significant factors in facilitating access to health care services. Recently, the number of people covered by insurance as well as the breadth and depth of health insurance coverage has decreased. According to data from the Kaiser Family Foundation‐Health Research and Educational Trust Annual Employer Survey (2018), the average yearly costs for employer‐sponsored health insurance in 2018 are $6,896 for single coverage and $19,616 for family coverage. The average single premium increased by 3% and the average family premium increased by 5% in the last year. Workers' wages increased by 2.6% and inflation increased by 2.5% over the past year. The average insurance premium for family coverage has increased by 20% since 2013 and by 55% since 2008.

In the past, American health insurance companies have routinely rejected applicants with a preexisting condition. The insurance companies often denied claims. If a customer was hit by a truck and faced big medical bills, the insurance company dug through the records looking for grounds to cancel the policy, often while the victim was still in the hospital (Reid, 2009). Foreign health insurance companies, in contrast, must accept all applicants, and they can't cancel insurance as long as premiums are paid. Everyone is mandated to buy insurance to give the plans an adequate pool of rate payers. The key difference is that foreign health insurance plans exist only to pay people's medical bills, not to make a profit. The United States is the only developed country that lets insurance companies profit from basic health coverage. In many ways, foreign health care models are not really foreign to America, because our health care system uses elements of all of them. In Britain, the government provides health care, funding it through general taxes, and patients get no bills. In Germany, premiums are split between workers and employers, and private insurance plans pay private doctors and hospitals. In Canada; everyone pays premiums for an insurance plan run by the government, and the public plan pays private doctors and hospitals according to a set fee schedule. In the world's poor nation, sick people pay out of pocket for medical care; those who can't pay, stay sick or die. Seven hundred thousand Americans are forced into bankruptcy each year because of medical bills. In France, the number of medical bankruptcies is zero; Britain, zero; Japan, zero; and Germany, zero (Reid, 2009).

I was admitted to the hospital in December for what was later diagnosed as angina. After being stabilized in the emergency room, I was admitted to the cardiac care unit. A series of tests were ordered by my cardiologist to determine enzyme levels in my blood. This would show if I had suffered a heart attack. Blood was drawn every 8 hr for 24 hr. The news was good—no heart attack—until I received the bill. My insurance company said the enzyme tests for angina were frivolous and not necessary, and they would not pay. I had my cardiologist write a letter of explanation, saying the tests he ordered were routine for determining a diagnosis. After this second appeal, the insurance company rejected my payment claim again. After several more appeals, my insurance company ultimately paid the laboratory bill for these tests but would not pay the pathologist for his interpretation of the blood tests. It has now been six months since I received my initial bill, and the hospital and pathologist's office have turned my case over to a collection agency. They did not take into consideration the fact that I was appealing the bill. They wanted me to pay upfront and then appeal. That was not going to happen.

Kathleen A. Milch

Patient

Whiting, Indiana

Canadians have their choice of health care providers. In Austria and Germany, if a doctor diagnoses a person as stressed, medical insurance pays for weekends at a health spa. Canada does make patients wait weeks or months for nonemergency care, as a way to keep costs down. But studies by the Commonwealth Fund and others report that many nations—Germany, Britain, Austria—outperform the United States on measures such as waiting times for appointments and for elective surgeries (Reid, 2009).

Many gaps have existed in insurance programs in the United States, including incomplete health care coverage, need for copayments and deductibles, lack of provider choice, need for preauthorization, and other difficulties in maneuvering through the insurance company requirements. Copayments are a fixed health care fee paid by the patient to the health care provider at the time of service; this amount is paid in addition to the money the health care provider will receive from the insurance company. Deductibles are a predetermined out‐of‐pocket fee paid by a patient for health care services before reimbursement through health insurance begins to be paid. For example, if an insurance plan has a $50 copayment and a $1,000 deductible, the patient is responsible for paying the $50 at each health care visit plus paying the first $1,000 of health care costs, after which costs will be reimbursed as allowed by the patients' health insurance plan. Preauthorization requires that approval be obtained from the insurance company before care or treatment, such as hospitalization or diagnostic testing, is initiated if such services are to be reimbursed by the patients' health insurance plan.

Because the United States does not have a national/UHC program, public health care programs are intended to help fill the gap. Beginning in 1965 under Titles XVIII (Medicare) and XIX (Medicaid) of the Social Security Act, eligibility for public insurance has been based on age (Medicare for those age 65 and older) or based on having a low income and/or having a disability (Medicaid). Medicare and Medicaid programs ensure access to many needed services for patients. Medicare is the largest federal program. Medicare Part A is an insurance plan for hospital, hospice, home health, and skilled nursing care that is paid through Social Security taxes. Nursing home care that is mainly custodial is not covered. Medicare Part B is an optional insurance that covers physician services, medical equipment, and diagnostic tests. Part B is funded through federal taxes and monthly premiums paid by the recipients. Part D is optional coverage for outpatient medications.

Medicaid, a state program financed by federal and state funds, pays for services provided to persons who are medically indigent, blind, or disabled and to children with disabilities. The federal government pays between 50% and 83% of total Medicaid costs based on the per capita income of the state. Services funded by Medicaid vary from state to state but must include services provided by hospitals, physicians, laboratories, radiology, prenatal and preventive care, and nursing home and home health care services.

Other large public insurance programs are associated with American Indian and Alaska Native heritage, and the Military Services, that is, veteran's health and insurance for active military personnel and their families. The IHS, under the U.S. DHSS, provides health services to American Indians and Alaska natives enrolled in more than 500 tribes, villages, and pueblos (U.S. Department of Health and Human Services, 2010). The Indian Self‐Determination Act of 1975 gave many tribal organizations the responsibility for the provision of health care services. IHS maintains some hospitals and clinics, yet recent legislation has severely cut funding for these sites of care.

The Department of Defense (DOD) finances and manages TRICARE, the triple option benefit care plan available for military families, formerly called the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), for enlisted military personnel and their military dependents as well as for retirees and their dependents and survivors. The Department of Veterans Affairs, established in 1921, finances and manages the Veterans Health Administration (VHA). This program is available for U.S. veterans if they need any medical, prescription, surgical, and rehabilitation care services.

You work in a large health care system. One of your patients is not following his health care regime. You wonder what thought processes this patient is using to justify continuing an activity that presents risk to his health.

How can you best assist the patient in your health care system and community? What kinds of structures, processes, and outcomes will your system want to develop to improve care to this patient and the population of patients that your system serves? How could you work in the community to enhance the population's choices for diet, exercise, or lifestyle?

Three key pieces of federal legislation set forth national standards that the individual states use to regulate health insurance. First, the Employee Retirement Income Security Act (ERISA) of 1974 provides a framework for states to regulate health insurers. Second, the Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985 ensures that employees who resigned, were laid off, were terminated, or lost their jobs due to family‐related reasons, can retain their health insurance coverage for up to 18 months and, in some cases, up to a maximum of 36 months if they are deemed qualified and pay the full premiums. A third piece of legislation, the Health Insurance Portability and Accountability Act (HIPAA) of 1996, imposed restrictions on limitations and exclusions of insurance coverage for those with preexisting conditions and restricted other attempts to exclude employees from insurance coverage. It also provides protection of insurance coverage as employees change employers, and it provides tax exclusions for medical savings accounts.

To the extent that the United States is similar economically and socio‐politically to countries such as France, Canada, and Japan, an examination of the health systems in those countries is useful. The differences in health care spending in the United States as compared to other countries as a percent of GDP are graphically displayed in Figure 2.7 (Table 2.3).

FIGURE 2.7 International health care spending per capita by source of funding. Tikkanen, 2018.

Source: Tikkanen, R. (2018). Multinational Comparisons of Health Systems Data, 2018. Retrieved October 6, 2019, from https://www.commonwealthfund.org/sites/default/files/2018‐12/Multinational Comparisons of Health Systems Data 2018_RTikkanen_final.pdf.. (Commonwealth, 2017)

Table 2.3 HIPAA Privacy Regulations

Source: Compiled with information from U.S. Department of Health & Human Services. (1996). Summary of the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule, available at www.hhs.gov/ocr/privacy

The UK is rated as number one (and spends 9.6% of its GDP on health care), followed respectively by Australia (10.3%), the Netherlands (10.1%), New Zealand (9.0%), Norway (10.4%), Sweden (10.9%), Switzerland (12.3%), Germany (11.3%), Canada (10.4%), France (11.3%), and trailing at 11th with 17.2% of the GDP spent on health care, the United States Papanicolas (2018). The U.S. ranks last overall on health care outcomes. Compared to other countries, the U.S. comes in last on infant mortality, life expectancy at age 60, and deaths that were potentially preventable with timely access to effective health care Papanicolas (2018).

France, ranked as having the tenth best health care system in the world, spends 11.3% of its GDP on health care Papanicolas, (2018). This is almost one‐half of what the United States spends on health care per person. Comprehensive health care is guaranteed for all citizens and legal residents in France. Similar to the United States, health care in France is provided through private and government insurance. Unlike Canada and Britain, there are no lengthy wait times in France. Unlike the United States, everyone is insured in France, and there are no additional patient charges for health insurance plan deductibles (Shapiro, 2008). Employed residents are covered by a national health insurance plan, referred to as Sécurité sociale, which includes spouses and children. Another plan, couverture maladie universelle (CMU), provides coverage for those people who do not qualify for the sécurité sociale program, and is free to some people whose income is below a certain level. The national health insurance plan is funded through private and public means, with employees paying up to 21% of their incomes to the national health care system and employers making similar contributions. By comparison, Americans pay fewer taxes but pay more for health care (e.g., through paying health insurance premiums and other out‐of‐pocket expenses not covered by their insurance plans). In France, costs are dependent upon the type of provider seen; for example, a general practitioner is less expensive than a specialist. Likewise, it is more expensive to seek treatment at night, on the weekend, or on public holidays. Hospital care is reimbursed through the national health plan, and a percentage of the cost of prescription drugs is also reimbursed to the patient. Essentially, the sicker a person is, the more coverage is allowed, including for expensive drugs and experimental cancer treatments. Reducing cost and improving efficiency are the challenges for this system. Waste, such as doctor shopping, whereby a patient seeks treatment from more than one health care provider for the same ailment, and overuse of prescription drugs, are partly responsible for high health care costs in France (National Coalition on Health Care (NCHC), 2008; Shapiro, 2008).

Annually, the Canadian government spends 10% of its GDP on its national health care system Papanicolas, (2018). The Canadian health care system is administered by each Canadian provincial or territorial government. Seventy percent of health spending is publicly funded through federal and provincial taxation of individuals and corporations, and the remaining 30% is paid through private and out‐of‐pocket sources for additional services such as prescription medications or dental and vision care (Canadian Institute for Health Information (CIHI), 2006). All Canadians have equal access to the same quality and quantity of health care. Under the Canada Health Act of 1984, comprehensive health care is publicly administered, portable between provinces, and accessible to all. Primary care is provided by physicians and nurse practitioners, who may work in private clinics or public institutions. These health care providers are reimbursed on a fee‐for‐service basis, which allows them to be reimbursed by each provincial or territorial health plan for each health care service rendered to a patient.

Unlike the privatized health care system in the United States, extra billing, deductibles, and copayments are not allowed. The health care provider bills the provincial or territorial health plan and is reimbursed with an agreed‐upon amount for each health service given. No additional charges or costs can be billed to or recovered from the patient. With only one insurance payer, referred to as a single‐payer system, many of the problems embedded within the American health care system are eliminated. The problem currently facing the Canadian health care system is the lengthy wait times to access family practitioners, specialists, emergency room services, diagnostic tests, and surgical procedures (NCHC, 2008). To help remedy this issue, Canada has established benchmarks for treatment and waiting times. 2018 data for the Canadian Institute for Health Information reveals that the Canadian benchmark for hip replacement is 182 days and they are currently at 75% compliance with the benchmark. In the U.S., patients cannot imagine a “standard” wait time of 6 months to have a hip replacement. With more life threatening issues such as a hip fracture, their benchmark for a hip fracture repair speeds up to 48 hr and they are at an impressive 88% compliance with the benchmark (Canadian Institute for Health Information, 2018). This illustrates that wait times in Canada are circumvented based on the gravity of a patient's condition, but this solution aggravates the waiting time for less urgent cases. In a geographically vast country with a small population compared to the United States, some Canadians in rural or isolated locales often travel long distances to obtain specialized services (Canadian Institute for Health Information, 2018).

As an example of the comprehensiveness and affordability of the Canadian health care service, a 51‐year‐old Canadian nurse working in the United States recently returned with her spouse and 15‐year‐old child to her home province of Alberta for 1 year. During that time, the family enrolled in the Alberta Health Care Insurance Plan for a cost of $88 per month (Alberta Health and Wellness, 2004). Health care for the nurse included an annual physical examination, lab tests, mammogram, bone density testing, and a routine colonoscopy. The colonoscopy required a 5‐month wait. Her husband underwent elective day surgery, which was booked 7 months in advance. Her daughter was immunized at school, and she was once treated at a community health center for a persistent respiratory infection. Beyond payment of their monthly premium, the family was issued no bills for the health care they received.

To pay for its national health care system, Japan spends 10.2% of its GDP on health care Papanicolas, (2018). This is less than France, Canada, or the United States, and Japan enjoys the longest life expectancy of all 83.98 years as of 2016 (World Bank, 2018). The government regulates close to all aspects of health care in Japan. The Universal Statutory Health Insurance System (SHIS) requires by law that the national and local governments provide efficient, quality medical care Papanicolas, (2018). Citizens are mandated to enroll in one of the SHIS plans based on age, employment status, or place of residence. Non‐citizens, immigrants, and visitors are not covered. The majority of the Japan has some form of private health insurance, only as a supplementary or complementary role.

All SHIS plans provide the same benefits package that is decided by the government. The package covers hospital, primary, specialty, and mental health care, approved prescription drugs, home care services by medical institutions, hospice care, physiotherapy, and most dental care Papanicolas, (2018). Plan participants have to pay a 30% coinsurance for services and goods received and there are zero deductibles. In 2013, out‐of‐pocket payments for cost‐sharing accounted for 13% of current health expenditures Papanicolas, (2018).

The Japanese health care system provides comprehensive care and is one of the most advanced in the world. Physicians and hospitals are predominantly run as private businesses, and costs for care are reimbursed through the national health care system. Patients' health care costs are reimbursed at a fixed amount determined by the government. Refusal of coverage by insurers is impossible, and personal medical debt is nonexistent.

Factors contributing to lower health care costs in Japan include healthier diets and lifestyles, with a lower incidence of chronic diseases. Reimbursement rates for health care services are low, but reimbursement strategies for quantity rather than quality of services erodes the advantage a healthier lifestyle might have in terms of curbing costs. Despite cost containment efforts, health care expenses are increasing, especially with the earthquakes of 2011. A shortage of physicians also means the wait time to access the health system is an issue. With an aging population and shrinking workforce, concerns as to how access, affordability, and quality will continue in the future are being voiced (National Coalition Health Care, 2008; Reid, 2009).

Health care costs are measured as part of the U.S. GDP. The GDP is an economic measure of a country's national income and output within a year and reflects the market value of goods and services produced within the country. The GDP is used as a barometer of the national economy. Health care costs in the U.S. were increased by 3.9% percentage points in 2017 (CMS, 2018). Employer‐based health care premiums have doubled since 2000, yet those who are insured incur greater financial burdens as they pay for more out‐of‐pocket expenses.

U.S. national health care expenditures were $3.5 trillion in 2017 (CMS, 2018). Health spending totaled $74.6 billion in 1970. In 2000, health expenditures had increased to about $1.4 trillion, and in 2017 the amount spent on health had more than doubled to $3.5 trillion (CMS, 2018). Health care spending continues to increase faster than the overall U.S. economy and analysts project this number to keep rising.

There are many factors contributing to the rising costs of health care. The five key factors include population growth, population aging, disease prevalence or incidence, service utilization, and service price and intensity (Dieleman, 2017). Between 1996 and 2013, inflation‐adjusted spending on inpatient, ambulatory, retail pharmaceutical, nursing facility, emergency department, and dental care increased at 3.5% annually, from $1.2 trillion to $2.1 trillion (Dieleman, 2017). The areas with the highest increases were in emergency departments (6.4%) and on medications (5.6%). Diabetes as a whole had the greatest increase in cost at an annual rate of 6.1–7.0%, translating into $57.9–$70.6 billion (Dieleman, 2017). Back and neck pain had the second‐largest increase in spending, at an annual rate of 6.5% (or $57.2 billion) between 1996 and 2013. During the same time frame, the treatment of hypertension rose to $47.6 billion, the treatment of hyperlipidemia to $41.9 billion, and depressive disorders to $30.8 billion annually (Dieleman, 2017).

More and more baby boomers are turning 65, and the average life expectancy is increasing, with the elderly are becoming the largest group in the population. The U.S. Census Bureau (2019) reports:

The CMS (2019) published a National Health Expenditures Report 2018–2027. Prescription drug spending was projected to have grown by 3.3% in 2018. This is due to an increase in new drug introductions. Prescription drug spending growth was projected to increase to 4.6% in 2019, because of faster utilization growth from both existing and new drugs, as well as a modest increase in drug price growth. For the reminder of the projection, 2020–2027, prescription drug spending is projected to grow by 6.1% per year on average, or by 1.5 percentage points more rapidly than in 2019, influenced by new drugs and efforts to encourage patients with chronic conditions to consistently treat their disease (CMS, 2019).

Although technological advances have helped with earlier diagnoses and better treatment of disease, factors such as the greater availability of new technology drive per capita expenditures higher (Boddenheimer, 2005b). Treatment for the five most expensive health conditions include septicemia, osteoarthritis, complications of device, implant or graft, newborn care, and acute myocardial infarction (AHA, 2019). These require the use of expensive medications and technologies. While use of some technologies such as electronic record keeping may reduce costs, the presumed success of sophisticated drugs and technologies shapes consumer expectations of what the health care system can deliver (Woo, Ranji, Lundy, & Chen, 2007). Health care consumers, including both patients and providers, also contribute to the cost of health care. These consumers' demands for intense services, despite the lack of definite clinical need, strains health care spending. Mikulic (2019) reports that the number of magnetic resonance imaging (MRI) machines per million population is 37.56 in the U.S., 34.49 in Germany, 29.08 in Korea, and 28.4 in Italy. Yet the United States lags behind these same countries with respect to patient care outcomes (Commonwealth Fund, 2006).

The United States is home to groundbreaking medical research, but so are other countries with much lower cost structures. Any American who has had a hip or knee replacement is standing on French innovation. Deep‐brain stimulation to treat depression is a Canadian breakthrough. Many of the wonder drugs promoted endlessly on American television, including Viagra, come from British, Swiss, or Japanese labs. Overseas, strict cost controls actually drive innovation. Under the pressure of cost controls, Japanese researchers found ways to perform the same diagnostic technique for one‐fifteenth of the American price and still make a profit (Reid, 2009).

A large proportion of health care dollars are devoted to hospital care. The Hill‐Burton Act of 1946 funded the development of the nation's infrastructure of hospitals. Today, there are 6,210 hospitals nationwide (AHA, 2019). As technology and scientific knowledge grow and patients live longer, there has been a greater severity of illness in the hospitalized population. Hospital services contribute to the rise in health care costs due to the increased utilization of expensive technologies, high labor costs, the shortage of nurses, rising malpractice premiums, and increased costs of hospitalization. Given the aging hospital infrastructure and increases in hospital reimbursements, future building of new hospital beds will also increase health care costs (Bazzoli, Gerland, & May, 2006) (Table 2.4).

Table 2.4 Cost of Selected Medications

Source: GoodRx. (2019). Prescription Prices, Coupons & Pharmacy Information. Retrieved from www.goodrx.com. October 5, 2019.

Defensive medicine and the high cost of medical malpractice insurance all add to increasing physician costs. Malpractice claims in the United States are filed 50% more often than in Great Britain and 350% more often than in Canada (Anderson, Hussey, Frogner, & Waters, 2005). Two‐thirds of claims in the United States are dropped, which results in a similar distribution of claim settlements among these countries. Regardless, the need for medical malpractice insurance to protect American physicians against such claims contributes to the cost of physician care. There are many calls for malpractice reform.

The U.S. has less fewer doctors, especially psychiatrists per capita in the U.S. than there are in most comparably wealthy countries and the U.S. has a similar number of nurses per capita (Sawyer, Sroczynski, & Kaiser, 2016). This shortage is most pronounced in certain practice specialties, for example, family practice physicians and geriatric physicians. Physician shortages are also apparent in rural areas. U.S. physicians earn more than physicians in most countries. A physician specialist who makes $300,000 in the U.S or a family physician whose income is $175,000 per year in the U.S. would, on average, earn approximately 25–50% less in Canada (Eisenberg, 2006) (Table 2.5).

Table 2.5 Health Care Compensation

Source: Salary Comparison, Salary Survey, Search Wages. (2019). Retrieved October 5, 2019, from www.payscale.com and Ramsey, L. (2019, May 16). Health care CEOs make as much as $26 million a year. Here's what the industry's top executives earned in 2018. Retrieved from www.businessinsider.com/pharma-and-healthcare-ceo-compensation-2018-2019-4.

Physicians can be extremely persuasive in health care and hospitals as they advise patients where to go for treatment. The physician represents the primary source of patients for most hospitals. A physician affiliated with two or three hospitals can steer patients toward any of those hospitals. This power over admissions is one of the most important forces in the hospital. Physician control over admissions also affects nursing home admissions, home care agency patient referrals, and referrals to other physician specialists.

The popular practice of cost shifting, whereby health care providers raise prices for the privately insured to offset the lower health care payments from both Medicare and Medicaid as well as the often nonpayment of health care premiums from the uninsured, continues to raise the cost of health care. Medicare and Medicaid payments are less than 50% of what private insurers pay. Health care providers shift charges for health care costs to the private insurance sector. Some estimates of the cost shift are being valued at $6 billion annually. Cost shifting increases the cost of all health care. The health care facility or the health care professional shifts the cost of health care to other patients with health insurance or to those patients who can afford to pay. Costs to the public for these programs continue to increase. Almost two‐thirds of all Medicaid spending for services goes to the elderly and those with disabilities. The elderly and those with disabilities made up less than one‐quarter of all Medicaid enrollees as of 2014 (Rudowitz, Orgera, & Hinton, 2019). Dual eligible beneficiaries alone account for almost 40% of all spending, mostly for long‐term care. The 5% of Medicaid beneficiaries with the highest costs drive more than half of all Medicaid spending (Rudowitz et al., 2019). The high costs are due to their needs, acute care, long‐term care, or often both. Higher costs for prescription drugs, long‐term services and supports, and behavioral health services, as well as state policy decisions to implement targeted provider rate increases, have been recently cited as factors putting upward pressure on Medicaid spending (Rudowitz et al., 2019).

According to Boddenheimer (2005a), the cost of administration of U.S. health care in 1999 was 24% of the nation's health care expenditures. In an attempt to reduce these costs, providers such as practitioners' offices, clinics, hospitals, and so on, have invested in Information Technology (IT). IT has played a role in improving quality through availability of the electronic medical record, aiding with HIPAA compliance, and streamlining insurance coding and billing services. Because of the increased demand for such systems, the administrative cost of implementation has also gone up.

It may seem to Americans that U.S.‐style free enterprise (i.e., private‐sector, for‐profit health insurance) is naturally the most cost‐effective way to pay for health care. But, in fact, many other countries' payment systems are more efficient than ours. U.S. health insurance companies have the highest administrative costs in the world. The CMS (2019) estimates project that $496 billion will be spent on administrative costs in the U.S. alone. Himmelstein (2014) reports that administrative costs account for about one‐fourth of the US hospital spending and this is more than spent in Canada (12%), England (16%), and the Netherlands (20%). Interestingly, Himmelstein found that there is no apparent link between higher administrative costs and better quality care (2014).

U.S. hospital administrative costs rose from 23.5% of total hospital costs ($97.8 billion) in 2000 to 25.3% ($215.4 billion) in 2011. During that period, the hospital administration share of national GDP rose from 0.98% to 1.43%. Canada spends 0.41% of their GDP on health care administrative costs. The rising spending on administrative costs need to be addressed at every level and corporate greed addressed.

Several years ago, I went to the hospital with excruciating pain. They admitted me to the hospital, and I had tests and X‐rays for 9 days before they found the cause. I had cancer in my left kidney, and I needed immediate surgery. I had the surgery and was discharged on my 18th hospital day. Thank heaven, I was now cancer free.

The hospital bill for this stay was $18,689.20. The radiologist and surgeon submitted additional bills. I was glad that I had Medicare and Blue Cross insurance, which paid it all. The only charge I had to pay was $25.00 per day for a private room. When I looked at the hospital bill, there were many charges for medications and treatments I never received. There were even charges for the day after I was discharged. I wonder how the hospital makes out the bill. I also wonder how people with no insurance pay these kinds of hospital bills.

Leona McGuan

Patient

Schererville, Indiana

Americans could narrow the life‐expectancy gap between the United States and other countries by adopting a healthier lifestyle. It is estimated that sticking to five low‐risk lifestyle‐related factors could prolong life expectancy at age 50 years by 14.0 and 12.2 years for female and male US adults, respectively, compared with individuals who adopted zero low‐risk lifestyle factor (Li et al., 2018). The five lifestyle related factors include diet, smoking, physical activity, alcohol consumption, and body mass index (BMI). Unhealthy lifestyles counterbalance the gain in life expectancy, particularly the increasing obesity epidemic and decreasing physical activity levels. Three‐quarters of premature CVD deaths and half of premature cancer deaths in the U.S. could be attributed to lack of adherence to a low‐risk lifestyle (Li et al., 2018). Prevention should be a top priority for national health policy, and preventive care should be an integral part of the US health care system. A healthy diet pattern, moderate alcohol consumption, nonsmoking, a normal weight, and regular physical activity are each associated with a low risk of premature mortality. Smoking is a strong independent risk factor of cancer, diabetes mellitus, CVDs, and mortality (Li et al., 2018). Physical activity and weight control significantly reduce risks of diabetes mellitus, cardiac disease, and breast cancer. Changing lifestyles is the most cost‐effective way to prevent illness and increase quality of life, yet it seems to be the most difficult for Americans. Note other factors that can both increase and decrease utilization, as listed in Table 2.6.

Table 2.6 Forces that Affect Overall Health Care Utilization

Source: Adapted from Bernstein, A. B., Hing, E., Moss, A. J., Allen, K. F., Siller, A. B., Tiggle, R. B. (2003). Health care in America: Trends in utilization. Hyattsville, MD: National Center for Health Statistics; and Shortell, S. M., & Kaluzny, A. D. (2006). Health care management (5th ed.). Clifton Park, NY: Delmar Cengage Learning. And CDC. (2018). National Center for Health Statistics. Health, United States, 2017: With special feature on mortality.. National Center for Health Statistics. Health, United States, 2017: With special feature on mortality. Retrieved from www.cdc.gov/nchs/data/hus/hus17.pdf

Research has suggested the hazards and ethical problems in the overuse of services in fee‐for‐service settings (where payment is made based on service rendered to individuals for individual services) rather than service underuse in capitated care (where payment is made based on service rendered to a group of patients) (Berwick 1994; Leape et al., 1990). Over the years, cost containment strategies have targeted the financing and reimbursement sides of health care. Financing strategies have used health services regulation and limitation by means of taxes or insurance premiums and encouraged competition such as managed competition. Reimbursement containment strategies have used regulatory and competitive price controls and utilization controls, such as capitation, patient cost sharing, and utilization management. Capitation and prospective payment have had some of the most significant impacts on cost containment.

Even though legislation creating managed care was passed in 1973 (the Health Maintenance Organization Act), managed care did not become a major player or driving force in health care until the late 1980s. In an effort to reduce the number of hospitalizations and control profit incentives for health care providers, managed care plans offered hospitals and practitioners a capitated set fee for office visits and hospitalizations for a group of patients. Capitation is the payment of a fixed dollar amount, per person, for the provision of health services to a patient population for a specified period of time, for example, 1 year. Under capitation, health care organizations benefit from using their financial resources to keep people well. Otherwise, health care providers bear the financial loss. Then in the mid‐1990s, the U.S. population had quality concerns with this system and backlashed against managed care organizations.

Reacting to rapidly increasing costs to Medicare, the Tax Equity and Fiscal Responsibility Act (TEFRA) passed in 1982 mandated the Prospective Payment System (PPS) to control health care costs. For Medicare Part A services, PPS uses Medicare's administrative data to develop and continually refine PPS payments based on diagnosis‐related groups (DRGs), that is, patients with similar diagnoses. The PPS is a method of reimbursement in which Medicare payment is made based on a predetermined, fixed amount for reimbursement to acute inpatient hospitals, home health agencies, hospices, hospital outpatient and inpatient psychiatric facilities, inpatient rehabilitation facilities, long‐term care hospitals, and skilled nursing facilities. For Medicare Part B services, the Resource‐Based Relative Value Scale (RBRVS) is used to determine reimbursement amounts for practitioner services. The major problem that the CMS has encountered with funding prospective payment is DRG creep, in which health care providers up code or over bill a patient to indicate a need for financial reimbursement for more expensive health care services to recoup what the health care provider believes is a more equitable payment.

The health care report To Err Is Human, confronted health care clinicians and managers with concerns about the poor quality of health care attributable to misuse, overuse, and underuse of resources and procedures, which was responsible for thousands of deaths (IOM, 1999). The health care report, Crossing the Quality Chasm (IOM, 2001), and several large studies (McGlynn et al., 2003; Thomas et al., 2000), have shown that the quality of health care in the United States is at an unexpected low level and needs improvement in many dimensions, given the amount of money the United States spends on health care (Table 2.7). One implication is that if a measure is described in a way that is clear and understandable, people are more likely to value the measure (AHRQ, 2011).

Table 2.7 Health Care Dimensions Needing Improvement

Source: Compiled with information from the Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press; and Berwick, D. M. (2002). A user's manual for the IOM's ‘Quality Chasm’ report. Health Affairs, 2 (3), 80–90.

Groundbreaking research beginning in the 1970s and continuing into the 1990s demonstrated that there was significant variation in utilization of specific health care services associated with geographical location, provider preferences and training, type of health insurance, and patient‐specific factors such as age and gender (Adams, Fraser, & Abrams, 1973; Greenfield et al., 1992; Leape, 1992; Safran, Rogers, Tarlov, McHorney, & Ware Jr., 1997; Wennberg & Gittelsohn, 1973). Associations between utilization rates of health care services have been found with availability of services and technologies, for example, MRIs, hospital beds, practitioners (Joines, Hertz‐Picciotto, Carey, Gesler, & Suchindran, 2003), prevalence and severity of morbidities (Dunn, Lyman, & Marx, 2005; AHRQ, 2008b), race or ethnicity (AHRQ, 2008b), patient adherence, health‐seeking behaviors of patients (Calvocoressi et al., 2004), and many other factors. Variation in the delivery and quality of health services is also associated with socio‐demographics, hospital types (e.g., urban and rural, teaching and nonteaching), and clinical areas (e.g., heart disease, diabetes, pneumonia, and clinical preventive services). Regions of the country and health care providers with more resources had higher rates of use and cost. Efforts to decrease the variation of health care practices through standardization of care with quality, evidence‐based guidelines are important to improve clinical decision making, care delivery, health outcomes, and cost efficiency.

Achieving health care transparency or truth in reporting is the ability to discover information about health care costs, medical errors, or practice preferences, preferably before receiving the service. Transparency is being encouraged by the CMS, though transparency can be hampered by the fear of litigation or reprisal against the health care provider. The Patient Safety and Quality Improvement Act of 2005 addresses such concerns by encouraging health care providers to participate in developing and implementing evidence‐based improvement initiatives. The Act also highlights the importance of recognizing and responding to the underlying hazards and risks to patient safety. Establishing national health benchmarks, such as those in Healthy People 2020 (USDHHS, 2010), is another strategy by which to achieve and measure quality improvement.

Using the example of the management of heart disease, recent research findings illustrate the need for significant improvements to standardize the process of health care delivery. Each year, heart disease contributes to thousands of deaths. When evidence‐based standards are used to guide the care of the patient with heart disease. and aspirin and beta‐blockers are given to patients who have had a myocardial infarction, it can lower health care dollars and save lives associated with heart disease (Schulte, 2011). This is true, even if it is because aspirin use is being measured to assess provider performance (Williams, Schmaltz, Morton, Koss, & Loeb, 2005). Standardization of patient care can change the list of the top ten health care conditions, both in cost and mortality, by making patient care delivery more reliable (Table 2.8).

Table 2.8 Top 10 Causes of Death—Cost and Death

Source: CDC. (2019). FastStats—Deaths and Mortality. Retrieved from www.cdc.gov/nchs/fastats/deaths.htm.

Performance and quality measurement is an essential component of health care improvement efforts. Performance and quality are measured to determine resource allocation, organize care delivery, assess clinician competency, and improve health care delivery processes. Hospitals and practitioners have been given past and present financial incentives to score well on measures of quality from both public and private health care payers. When the quality of care is measured, it improves (Brook, Kamberg, & McGlynn, 1996; Chassin & Galvin, 1998). possibly largely due to the Hawthorne effect, which has illustrated that observed activity shows improvement. Ramirez (2019) reports that more people receive evidence‐based care (EBC) for heart attack when they arrive at a hospital, hospital‐acquired conditions decreased from 2014 to 2017, that medicare 30‐day hospital readmission rates have declined, and that mortality rates within 30 days after hospital admission for heart attack, stroke, and pneumonia have decreased.

From 2003 to 2013, the mortality rate for deaths amenable to health care in the U.S. declined by about 17%. More recently, the rate has increased slightly.

Nursing leaders have also recognized the need to establish classifications that can be used to measure nursing care. Selected classifications are listed in Table 2.9.

Table 2.9 Selected Classification Systems (List compiled by R. Hughes).

Note that setting standards for appropriate care and guideline development should have a basis in validated measures of quality, using reliable performance data, and making appropriate adjustments in care delivery. Reliable methods and measures need to be developed and tested. Some practitioners have been resistant to their care delivery being measured because they have believed that it would interfere with their professionalism and autonomy. If this belief persists, the majority of health care delivery will not be measured.

Health care organizations are eligible to consider another framework for health care quality and to apply for the Malcolm Baldridge National Quality Award. The Health Care Criteria of the Malcolm Baldridge National Quality Award explores a hospitals mission and key objectives in seven critical areas: Leadership, Strategy, Customers, Measurements, Workforce, Operations, and Results. The Baldrige framework is based on core values and concepts that represent beliefs and behaviors found in high‐performing organizations. Baldrige works with public and private sector partners to address critical national needs related to long‐term success and sustainability, including cybersecurity risk management and excellence in US communities (Eastman, 2019).

Outcome measurements can be done indicating an individual's clinical state, such as the severity of illness, course of illness, and the effect of interventions on the individual's clinical state. Outcome measures involving a patient's functional status evaluate a patient's ability to perform activities of daily living (ADLs). These can include measures of physical health in terms of function, mental and social health, cost of care, health care access, and general health perceptions. The measures can distinguish the concepts of physical and mental health and identify the five indicator categories of clinical status, functioning, physical symptoms, emotional status, and patient/family evaluation, and in Canada perceptions about quality of life. Selected quality‐of‐life measures include quality‐adjusted life years (QALYs), quality‐adjusted life expectancy (QALE), and quality‐adjusted healthy life years (QUALYs) (Drummond, Stoddart, & Torrance, 1994).

The assessment of health‐related quality of life (HR‐QOL) is an essential element of health care evaluation. Many generic and specific HR‐QOL instruments have been developed and include the Medical Outcomes Study 36‐Item Short Form (SF‐36) health survey; the Nottingham Health Profile (NHP); the Sickness Impact Profile (SIP); the Dartmouth Primary Care Cooperative Information Project (COOP) Charts; the Quality of Well‐Being (QWB) Scale; the Health Utilities Index (HUI); and the EuroQol Instrument (EQ‐5D) (Coons, Rao, Keininger, & Hays, 2000). The U.S. News & World Report (2019) reports that the country with the best quality of life is Canada, followed by Sweden and Denmark. The U.S. lags in sixth place.

Public reporting of organizational performance and quality information is being driven by several forces. As more data about quality become available electronically, individuals reporting the data and those wanting to make comparisons among organizations want the data analyzed and the findings reported. This information can be used to determine where there are health care inefficiencies and poor quality of care. Performance reporting is also used to influence clinician and patient utilization behavior. It also moves health care toward a population‐based approach, as opposed to focusing on individual patient care.

The IOM, established in 1970 under the charter of the National Academy of Sciences, provides independent, objective, evidence‐based advice to policymakers, health professionals, the private sector, and the public. In 1996, the IOM launched a concerted, ongoing effort focused on assessing and improving the nation's quality of care. The Ensuring Quality Cancer Care Report (1999) documented the wide gulf that exists between ideal cancer care and the reality many Americans with cancer experience.

Other reports released by the IOM on the quality of health care include:

A complete listing of IOM Reports is available at www.iom.edu/Reports.aspx

Eight principles are integral to health care reform, as envisioned by the IOM (2008). These eight principles are:

These principles are consistent with a professional nursing agenda, which states that all persons are entitled to affordable, quality health care services (American Nurses Association (ANA), 2010). The Quality Chasm report described broader quality issues, defined six aims, and highlighted ten rules for care delivery redesign (Table 2.7) (IOM, 2001).

Several key national public quality sources of interest for health care and nursing leaders and managers for purposes of performance measurement and benchmarking or comparison are as follows:

Public reporting of quality performance has been shown to improve care. While providers and policymakers do seek out these public quality reports, the general public does not search them out, does not understand them, distrusts them, and fails to make use of them (Marshall, Hiscock, & Sibbald, 2002). In many respects, hospitals are providing quality care. Data to assess clinical performance from the Joint Commission (JC) core measures program, which uses standardized, evidence‐based measures, and data from the Medicare program, show improvements in the quality of care in hospitals (Williams et al., 2005).

According to the The Care Continiuum Alliance (2010), disease management is a system of coordinated health care interventions and communications for populations with conditions in which patient self‐care is significant. What makes caring for patients with chronic diseases problematic is that the patients usually have multiple chronic conditions (e.g., the patient with congestive heart failure who also has hypertension, diabetes, emphysema, urinary incontinence, and chronic pain). Heart disease, stroke, cancer, chronic respiratory diseases, and diabetes are the leading cause of mortality in the world (WHO, 2019). Common, modifiable risk factors underlie the major NCDs. They include tobacco, harmful use of alcohol, unhealthy diet, insufficient physical activity, overweight/obesity, raised blood pressure, raised blood sugar, and raised cholesterol (WHO, 2019).

Source: Adapted from Yong, P., Saunders, R., & Olsen, L. (2010). Healthcare Imperative: Lowering Costs and Improving Outcomes: Workshop Series Summary [National Institutes of Health]. doi: http://www.nap.edu/catalog/12750.html

Discussion: The IOM's Roundtable on Value & Science‐Driven Health Care has been convened to help transform the way evidence on clinical effectiveness is generated and used to improve health and health care. Participants have set a goal that, by the year 2020, 90% of clinical decisions will be supported by accurate, timely, and up‐to‐date clinical information, and will reflect the best available evidence.

This summary highlights the presentations and discussions from these workshops, delving into the major causes of excess spending, waste, and inefficiency in health care. The ideas and observations presented are offered in the truism that health reform, now and in the future, will benefit from identifying actionable options to lower health care costs in ways that maximize value.

Implications for Practice: This series delves into the major causes of excess spending, waste, and inefficiency in health care. By understanding where waste exists, nurses can help reduce waste and improve patient and cost outcomes.

Another type of results reporting that is used by organizations is the balanced scorecard. A balanced scorecard is a framework to implement and manage strategy. It links a vision to strategic objectives, measures, targets, and initiatives. It balances financial measures with performance measures and objectives related to all other parts of the organization. They are used to monitor customer perspective; financial perspective; internal processes and human resources; and learning and growth for strategic management and as a way to examine performance throughout the organization. This examination allows the organization to review multiple key areas of performance, selected on the basis of their importance to the organization's strategic plan for quality.

The body of evidence supporting clinical practice is steadily growing. However, even when evidence‐based quality care guidelines are available for numerous conditions, for example, diabetes, congestive heart failure, and asthma, they have not been fully implemented in actual patient care, and variation in clinical practice is abundant (IOM, 2001; McGlynn et al., 2003; Timmermans & Mauck, 2005). Health care knowledge continues to expand. This requires practice guidelines and the measures of quality on which they are based to be continually updated. It also requires attention to continuing to develop health care quality.

Health care accreditation is a mechanism used to ensure that organizations meet certain national standards. Hospitals and other organizations seek accreditation to demonstrate their abilities to meet national quality standards. The Joint Commission (JC), formerly known as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), is the preeminent regulatory body overseeing health care quality. Its review processes are extensive, and payments to a hospital by government insurers of health care (CMS) are dependent on the organization's ability to meet JC standards with a high degree of compliance (Table 2.10). In addition, other federal, state, local, and voluntary regulatory agencies oversee the quality of specific organizational components such as pharmacy, laboratory, long‐term care, rehabilitative care, dietary, behavioral health, and fire safety. Accreditation, which signifies that the organization meets the standards for practice of these oversight agencies, influences market perception about the quality of health care that the organization provides and engenders trust and confidence in the organization.

Table 2.10 Hospital Accreditation Standards Overview

Source: © Joint Commission: CAMH: 2010 Comprehensive Accreditation Manual for Hospitals. Oakbrook Terrace, IL: Joint Commission, 2011, available at www.jcrinc.com/Joint-Commission-Requirements/Hospitals

There is a need to focus on retooling the health care workforce with new knowledge and requisite skills to function in better, redesigned health care systems. To begin to realize the quality agenda set forth by the IOM (2001), a subsequent report, Health Professions Education: A Bridge to Quality (IOM, 2003c), delineates a needed overhaul of the curriculum of health professionals' education to transform current skills and knowledge (IOM, 2003c, p. 1). This curriculum includes training clinicians to develop:

The IOM's 2004 Report on Patient Safety was the first in a series of three reports published since the year 2000 to emphasize the connections among nursing, patient safety, and quality of care. Keeping Patients Safe sets forth the structures and processes that health care workers use in the delivery of care and emphasizes the need to design the nurses' environments to promote the practice of safe nursing care (IOM, 2004b). The importance of organizational management practices, strong nursing leadership, and adequate nurse staffing for providing a safe care environment is critical (Laschinger & Leiter, 2006). The IOM Report (2010) The Future of Nursing Leading Change Advancing Health suggest that nurses should practice to the full extent of their education and training, achieve higher levels of education and training through an improved education system that promotes seamless academic progression, and be full partners with physicians and other health care professionals.

In 2008, the American Association of Colleges of Nursing (AACN) and the National League for Nursing (NLN) embraced the inclusion of quality improvement systems thinking, change strategies, and patient safety, etc., into undergraduate and graduate nursing education curricula. In 2005, the RWJF funded the University of North Carolina at Chapel Hill School of Nursing on a long‐term project aimed at increasing the inclusion of quality in nursing education and the development of well‐prepared faculty to teach the quality and safety competencies recommended by the IOM to make health care safe, effective, patient centered, timely, efficient, and equitable (IOM, 2001). In 2009, the AACN lent its support to this Quality and Safety Education for Nurses (QSEN) project (www.qsen.org) (Kovner et al., 2010).

The QSEN website is now a comprehensive resource for teaching strategies, etc., for the development of quality and safety competency in nursing.

Think about the competencies needed to improve health care education:

How can you improve your education and experience in each of the competencies now and throughout your career?

In 2008, the CMS identified hospital‐acquired conditions (never conditions) for which they will not reimburse hospitals for a higher DRG payment (i.e., pressure ulcers; fractures, dislocations, intercranial injury, crushing injury, and burns; catheter‐associated urinary tract infections; vascular catheter‐associated infections, object left in patient during surgery, air embolism, blood incompatibility, and mediastinitis after coronary artery bypass graft). Medicare no longer pays hospitals for these conditions (Waxman, 2008). Clearly the nurse of the future must be educated about never events. The term “Never Event” was first introduced in 2001 by Ken Kizer, MD, former CEO of the National Quality Forum (NQF), in reference to gross medical errors like wrong‐site surgery that should never occur. Over time, the term's use has expanded to signify adverse events that are clearly identifiable and measurable, resulting in death or significant disability, and usually preventable. Since the initial never event list was developed in 2002, it has been revised multiple times, and now consists of 29 “serious reportable events” grouped into seven categories (Abimanyi‐Ochom, Jones, & Cheng, 2019). The latest list from 2016 includes:

A complete listing, including the subcategories, is available at www.qualityforum.org

Until recently, shortages of nurses have been cyclical. These nurse shortages are associated with increased demand for patient care services at a time of falling nursing school enrollment, salary compression, and nominal increases in wages. The U.S. is projected to experience a shortage of Registered Nurses (RNs) that is expected to intensify as Baby Boomers age. According to a 2018 survey conducted by the National Council of State Boards of Nursing and The Forum of State Nursing Workforce Centers, 50.9% of the RN workforce is age 50 or older. The HRSA projects that more than 1 million registered nurses will reach retirement age within the next 10–15 years. The RN workforce was expected to grow from 2.9 million in 2016 to 3.4 million in 2026, an increase of 438,100 or 15% (ANA, 2019). According to the Bureau of Labor Statistics' Employment Projections 2016–2026, it projects the need for an additional 203,700 new RNs each year through 2026 to fill newly created positions and to replace retiring nurses. The current nursing workforce has 56% of RNs prepared at the baccalaureate or graduate degree level. The AACN reported a 3.7% enrollment increase in baccalaureate programs in nursing in 2018. According to AACN's report on 2018–2019 Enrollment and Graduations in Baccalaureate and Graduate Programs in Nursing, U.S. nursing schools turned away more than 75,000 qualified applicants from baccalaureate and graduate and nursing programs in 2018. Changing demographics signal a need for more nurses to care for our aging population. Issued in May 2014, the U.S. Census Bureau report on An Aging Nation: The Older Population in the United States, found that by 2050 the number of U.S. residents aged 65 and over is projected to be 83.7 million, almost double its estimated population of 43.13 million in 2012. With larger numbers of older adults, there will be an increased need for geriatric care, including care for individuals with chronic diseases and comorbidities. With an aging nursing workforce (Norman et al., 2005), more nursing faculty is needed to train larger numbers of students.

The ANA is a full service, professional organization representing the nation's entire RN population. The ANA represents the 4 million RNs in the United States through its 54 constituent state and territorial associations. The ANA's mission is to work for the improvement of health standards and availability of health care services for all people, foster high standards for nursing, stimulate and promote the professional development of nurses, and advance their economic and general welfare (ANA, 2019).

The National Labor Relations Board (NLRB) recognizes the ANA as a collective bargaining agent. The fact that the ANA has a dual role of being a professional organization and a collective bargaining agent causes controversy. Some nurses believe that unionization is not professional and that the ANA cannot truly support nursing as a profession if it is also a collective bargaining agent. Nurse managers are excluded from union membership. The ANA lobbies Congress and regulatory agencies on health care issues affecting nurses and the general public. The ANA initiates many policies involving health care reform. It also publishes its position on issues, ranging from whistle blowing to patients' rights. The American Nurses Credentialing Center (ANCC), a subsidiary of the ANA, created the Magnet Recognition Program to recognize health care organizations that provide the very best in nursing care. Since 1994, many institutions have received this award.

In this chapter, we have explored how health care is organized and financed in the United State, compared U.S. Health care with that of other industrialized countries, identified major issues facing health care, and related efforts for improving the quality, safety, and access to health care. Staying abreast of U.S. health care and health care in other countries is part of being a registered nurse and understanding the environment in which we work.

With the ongoing debate about the cost and importance of everyone throughout the nation having access to health care, regardless of ability to pay, concern continues among the disadvantaged or low income groups about their future ability to access health care services. Unfortunately, this is a common scenario for all too many Americans. As the only industrialized nation in the world without UHC, the rising costs of health care, and the challenges of being able to access care at any time or any place, many in our nation will continue to be exposed to situations where the outcomes could have been better. As nurses, we may assume that patients will do the right thing when it comes to their health or the health of those that depend upon them. With experience and understanding of health care research, we know this is not always the case. We have tremendous opportunities to make needed changes in how health care can be accessed and payed for, as well as helping patients understand how they can best navigate the health care system.

FEDERAL GOVERNMENT:

PRIVATE FOUNDATIONS AND ORGANIZATIONS:

Brigid Lusk, PhD, RN, FAAN

Midwest Nursing History Research Center, University of Illinois at Chicago, College of Nursing, Chicago, IL, USA

Rebecca Singer, new doctoral graduate, examines historical artifacts.

Source: Midwest Nursing History Research Center, University of Illinois at Chicago College of Nursing.

Why study nursing history? The answer lies in the work we do every day with the patients, families, and communities we serve. Understanding how early twentieth‐century nursing leaders sought educational advancement in higher education, advocated health care policy reforms, supported immigrant populations, and developed innovative models of care offers much for the profession today.

Sandra Lewenson, PhD, RN, FAAN

Upon completion of this chapter, the reader should be able to:

You graduated about a year ago, as one of 10 male nurses in your class, and now work in the critical care unit of a major teaching hospital. Most of your work has been on the night shift. One evening, with a few nights off duty coming up, you go out with some friends from college. Talking with them, you realize that they don't have a clue about what you do. They joke that you must have entered nursing because of the numbers of eligible women. They have no idea of your responsibilities or your stress when at work. They don't know that a few nights back you diagnosed a probable pulmonary embolism and thus saved a young woman's life. They don't know that you calmed a hysterical man in the waiting room whose wife had just unexpectedly died. Most aggravating is their response when you tell them that you're planning to return to college for your doctorate—a PhD or a DNP, you're not sure yet—and they look amazed and exclaim “A nursing Dr.! Who knew?”

Nursing history is the story of nursing care given through antiquity to the present day. The history of nurses and nursing can be fascinating but, with a nursing curriculum that is positively bursting at the seams, is history relevant and important enough to be included in all nursing educational programs? The answer is a resounding YES! Here's why: knowledge of nursing's history: (a) positively impacts patient care, (b) generates professional identity by reflecting the profession's history as well as the profession's current status, and thus contributing to career stability, (c) demands critical thinking, and (d) supports effective writing, a skill that is essential in nursing leadership. Additionally, the sheer fascination of reading nurses' notes written long ago or touching worn student nurses' uniforms—with patients' blood and students' sweat still visible on them—may be added to these reasons for studying the history of nursing.

Let's tackle these four reasons one by one, bearing in mind that they can't really be looked at separately. First, how can knowledge of nursing history positively impact patient care? One reason is that the patients' voices we “hear” through historic documents such as nurses' notes, or case studies, or in the meeting minutes of patient care committees, remind us that our patients are the raison d'etre of our work. In today's technological world this is sometimes forgotten. Another reason is that history is the basis for nursing practice research. For example, with current outbreaks of infectious diseases such as measles, nurses want to study ways to increase the percentage of childhood immunization. Yet any research on immunization rates would be flawed if nurses ignored the history of why parents had refused immunization for their children in the past. Historical research, such as that conducted by Lusk, Keeling, and Lewenson (2016), identified the critical interconnected variables of poverty, social class, ignorance, and fear of authority that was demonstrated during the forced smallpox vaccinations at the turn of the last century. Historical research provides the foundation for current nursing investigations

Second, nursing history generates professional identity, that is the public's understanding of what a nurse does, by reflecting the profession's history as well as the profession's current status, and thus career stability. Satisfying careers, whether in the arts or the sciences, usually have a history. Think of some familiar careers. Today's chemists or biologists or mathematicians proudly follow famed predecessors and carry part of their mystique. Likewise, artists of every stripe add to the acknowledged body of art that came before them. Knowing that nurses, too, have a long and rich history provides professional identity and commitment, thus leading to career stability. However, nursing history hasn't been adequately acknowledged, either within or outside the profession. Today's nurses and members of the public are not aware of nursing's rich and important past. That needs to change for everyone's benefit—including the patients. If nurses leave nursing because work that doesn't have a history isn't worth fighting for, then the nursing shortage continues and the patients suffer.

The third claim, that nursing history demands critical thinking, is based on the complexity of nursing's past. The history of nursing is not a linear progression from simple to advanced. For example, Florence Nightingale is revered as being the founder of modern nursing, but she was vehemently against registration for nurses. Taken at face value, that is probably shocking to most nurses today. Yet closer analysis of this issue by nurse historian Carol Helmstadter suggests that Nightingale had good reasons for objecting to nurse registration. Registration, Nightingale thought, would create an elite class of nurses who had the financial means to afford the requisite nursing education. Working‐class nurses, the vast majority of nurses at the time, would be excluded. Further, Nightingale wisely understood that registration would legally place nurses under the authority of physicians, typically male, and thus limit nursing's female empowerment. Lastly, Nightingale found the state registration proposals for credentialing inadequate. She believed that registration, if attempted, should be more rigorous (Helmstadter, 2007). The registration issue, as are most issues, was nuanced, requiring critical thinking. Attempting to understand historical complexities serves as excellent preparation for understanding the intricacies of our patients and their care.

Finally, the last claim, that nursing history supports effective writing that is clear and convincing, was made because history requires reading—history is not a series of numbers or bullet points. With longer reading comes better analysis and writing skills. It is that simple. So that when you need to develop and fight for a plan, or you need to argue that person A is right for a position and person B is not, or when you are on a board promoting a health care initiative, reasoning and writing skills are imperative. Indeed, the need for effective writing is more relevant today, in this electronic age, than ever.

This chapter will give you selected highlights of the history of professional nursing in the United States. Other parts of the world have their own historical stories. Nurses who have excelled in leadership and management covering a range of workplaces will be featured as case studies. Critical thinking boxes will pose overtly nuanced scenarios chosen to illustrate that nursing practice is complex. The chapter will start with a discussion of the founding of nursing in the years before nurses received any kind of specialized training and close with a review of nursing's historic contributions and future nursing challenges. Nursing's history was affected by the role of women and women's place in society, social forces, industrialization, scientific awakening, and discrimination toward race and gender (negatively impacting minorities, women, and men). As former nursing dean Helen Grace wrote: “The struggles reflected in the development of nursing as a profession…mirror the struggles of women through the ages in defining a position of equality and worth” (Grace, 1978, p. 17).

Women and men practiced nursing whenever human beings gathered. Nurses helped people through illness, childbirth, and death. These nurses were often friends or family members or local women and men who were known for their healing and consoling skills. The past few hundred years have provided more evidence of these nurses' work as they gained in specialized knowledge. Military religious nursing orders, known as Hospitallers, were men who undertook nursing in the Crusades of the Middle Ages (Donahue, 2011). English midwives in the seventeenth century trained in unofficial midwifery apprenticeships and were licensed by the church (Evenden, 2000). Historian Nina Rattner Gelbart (1998) relays the fascinating history of Madame du Coudray who, on the orders of the King, traveled all over France educating midwives in the eighteenth century. For her teaching demonstrations, Du Coudray invented a model doll and pelvis, her “obstetrical machine,” made of wicker, fabric, leather, stuffing, and sponges. From du Coudray's time through to the start of the nineteenth century, when medicine in Europe had become increasingly based on science, more educated nurses were needed (Helmstadter & Godden, 2011).

In the United States (U.S.), Native Americans had a long history of nursing their ill with natural remedies, rituals, and prayer when the European settlers arrived in the seventeenth century (Keeling, Hehman, & Kirchgessner, 2018). Unfortunately for these settlers, they chose to fight the Native Americans rather than learn from them. As the decades progressed and thousands of settlers had died through famine and/or disease, rudimentary order began to surface. The diary of Maine midwife, Martha Ballard, written from 1785 to 1812, offers a detailed and intimate picture of her work as meticulously presented by historian Laurel Thatcher Ulrich (1991). We learn that Ballard was a highly skilled midwife who delivered 816 babies over the 27‐year period of her diary. She was also a wife, the mother of nine, and an accomplished nurse. Ulrich notes that Ballard “knew how to manufacture salves, syrups, pills, teas, and ointments, how to prepare an oil emulsion, how to poultice wounds, dress burns, treat dysentery, sore throat, frostbite, measles, colic, “Whooping Cough,” [sic] “chin cough,” “St. Vitus dance,” “flying pains,” the salt rhume,” and “the itch,” how to cut an infant's tongue, administer a “clyster” (enema), lance an abscessed breast, apply a “blister” or a “back plaster,” induce vomiting, assuage bleeding, reduce swelling, and relieve a toothache, as well as deliver babies (Ulrich, 1991, p. 11).

We have less information about most other nurses' work, but there are some things to be elicited from surviving records. For example, Susanna Emlen's letters describing her breast amputation because of a tumor in 1814, without anesthesia of course, note that a nurse came with the surgeon, as well as his sister and his daughter. Four other doctors also attended. “About one o'clock,” Emlen wrote, “Nurse Hooke came into the chamber I was in to tell me the Doctors waited my coming in my own room. She covered my head with a handkerchief, as she led me in, hoping it might save me the sight of the preparations—I however saw Dr. Dorsey with his sleeves tucked up and his cloaths [sic] covered with a large apron …. My suffering was severe beyond expression” (Garfinkel, 1990, p. 21). We may extrapolate from this that Nurse Hooke was an experienced nurse. She was brought by the lead doctor to attend Susanna Emlen, and she had the skill to try and protect her patient from the visual impact of the impending surgery.

Sadly, it was wartime, in this period we are thinking of the U.S. Civil War, lasting from 1861 to 1865, which publicized and even romanticized nurses' work. Thousands of women volunteered as nurses during the Civil War. In all, the Union Army's hospital records alone listed approximately 5,600 women as nurses. However, historian Mary Holland notes that no African American women were recorded as nurses. They were listed as “laundress” or “cook.” Of course, these women were actually nurses (Holland, 1998). Most Northern nurses worked in the Army hospitals and their work was primarily concerned with the patient's diet, his physical needs such as laundry, and his emotional and spiritual care. From these nurses came the impetus for the first U.S. Training Schools. Matilda Morris, one Union Army nurse, recalled the scene after the second battle of Bull Run. “A sadder sight one could not imagine than those loads of wounded men. That day my life as a hospital nurse began. Our hearts and hands were full, tending to so many. Some died before they reached the building. Each ward had 50 beds and two nurses…first we gave each a drink of cold water, as that was their only cry. I shall never forget one who was lying near an old building. He looked as if he were dead, but I stopped to make sure, and I thought I saw his lips move. The man who was carrying the pail cried: “Come along! He is dead, fast enough.” “No, wait a minute,” I replied, and began to wet his lips. Very soon I had him revived enough, so much that he could drink out of my cup” (Holland, 1998, p. 187).

Further, as historian Christopher Maggs has pointed out, in times of war, nurses could and did substitute for doctors (Maggs, 1996). For example, Civil War nurses, just years after the discovery of ether and chloroform anesthesia, administered anesthesia on the battlefield before surgery (Lusk, Cockerham, & Keeling, 2019). At that time, administering anesthesia was typically a physician's responsibility.

These Civil War nurses were exemplars of nursing management and leadership. Note that Matilda Morris had the charge of 50 patients, along with one other nurse, and note that she overruled the man accompanying her who wanted her to leave a dying man. Imagine having the care of 50 wounded men in need of food and dressings and sanitation. Thus, modern nursing began in the United States.

Florence Nightingale did not invent the training of nurses all by herself—it took a “village” of scientific advances in knowledge, nineteenth century social forces including rapid industrialization, women's desire for greater independence, and the work of many other strong and smart women and men. But let's start with Nightingale because she is an integral part of nursing's heritage.

Florence Nightingale first attracted international attention because of her work for the British army during the Crimean War, 1853 to 1856, when Britain allied with France and Turkey to prevent Russian expansionism. A key factor in this war was that newspaper reporters, for the first time, came out and witnessed the fighting and destruction. Among other war news, the English were horrified to read about the terrible state of their wounded men. They demanded action. Thus Nightingale, accompanied by 38 nurses, went to the large British military hospital at Scutari, a Turkish army barracks near what is now Istanbul. Conditions were ghastly. Most of the men were dying from typhus, typhoid, cholera, and dysentery rather than from their wounds. The place was filthy. “There was no clean linen; the clothes of the soldiers were swarming with bugs, lice, and fleas; the floors, walls, and ceilings were filthy; and rats were hiding under the beds” (Fee & Garofalo, 2010, p. 1591). Nightingale rose to the challenge—through sound management, political understanding, firm leadership, and good use of her society connections back in England. Mortality among the soldiers plummeted and the British public revered Nightingale as the “Lady with the Lamp.” In Nightingale's honor, the public collected the enormous sum of £45,000 (almost two million dollars U.S. today). In 1860, Nightingale used this money to set up a nurses' training school at St. Thomas's Hospital in London. In 1873, three training schools were founded in the United States, in Connecticut, Massachusetts, and New York, using Nightingale's principles. Nurse training schools were based in hospitals where students typically worked full time while hearing lectures in their off duty hours.

Nightingale believed in good nutrition, cleanliness, and fresh air. These, she was sure, would put the body in the strongest position to recover. But later nineteenth century scientific advances further necessitated specialized training for nurses. Important early discoveries included anesthesia and, later, antisepsis. Anesthesia for patients undergoing surgery had been known since the 1840s and enabled patients to tolerate complex surgeries. Under anesthesia the muscles were relaxed, the patient wasn't in danger of neurogenic shock from pain, and there was time for delicacy and skill.

Likewise, use of antiseptic techniques during and after surgery hugely increased the likelihood that patients would survive surgery. Hungarian obstetrician Ignaz Semmelweis is rightly honored for discovering that, somehow, washing hands with a chlorinated lime solution before assisting at childbirth drastically reduced the incidence of puerperal fever. But this was in the mid‐nineteenth century and the germ theory of disease had not yet gained widespread scientific support. Even Nightingale was not a believer in microorganisms until her later years. Joseph Lister was the Scottish surgeon who, apprised of Louis Pasteur's assertions that “tiny little organisms floating in the air and settling on organic matter caused its decay” (cited in Goldman, 1987, p. 8), took action. Lister instituted a process he termed “antisepsis”—that is, warding off sepsis before it started—using carbolic acid. In 1869, Lister was appointed Chair of Clinical Surgery at Edinburgh University and his methods, with the resultant drop in patient mortality, gained international acceptance (Goldman, 1987).

Additional factors that demanded trained nurses included the rapid industrialization of the nineteenth century, which caused immense social upheaval. Work environments changed and became increasingly dangerous. Many women had to work outside the home, leaving children, the elderly, and the sick to manage as best they could. Meanwhile, enhanced communication through newspapers, telegrams, and even the telephone informed society of scientific and medical advances.

Source: Adapted from Holme, A. (2015). Big ideas. Why history matters to nursing. Nurse Education Today, 35, 635–637.

Discussion: Holme cites a media and public complaint that nurses today, possibly because of a higher level of education, are not as compassionate as they were 50 years ago. Nursing history contradicts this. Just like today, in years past, some nurses were compassionate and others were not. Higher education has not made nurses less compassionate. However, without historical awareness, nurses are not prepared to rebut this perception. Holme argues that it is imperative that nurses know their history.

Implications for Practice: Policy makers might act on this incorrect assumption about level of compassion as they respond to their constituents. Nursing education may then be forced to recede, through funding cuts and other policy initiatives, to the detriment of patients.

By 1873, when the first U.S. nurse training schools were established, science was starting to exponentially expand medical understanding and treatment. Skilled and knowledgeable nursing was necessary. That said, as historian Christopher Maggs reminds us, a lot of nursing was still the work that women traditionally had done but now it was “professional.” Maggs writes: “Only by strict interpretation of discipline, the routinization of rituals and tasks and discussions in textbooks and training about ventilation and sewage disposal could cleaning be inculcated as the ‘science of hygiene’” (1996, p. 23).

In 1880, the Illinois Training School for Nurses was founded by a group of prominent Chicago women along the lines of Nightingale's school in London. The school was not part of a hospital but its students provided care to patients in some wards of the sprawling Cook County Hospital—the city's only public hospital. Cook County paid the Illinois Training School for the students' work through using money saved by dismissing the untrained nurses—“many of them men” (Brainard, 1922).

That last point, that many of the untrained nurses who were dismissed from Cook County Hospital were men, is worthy of discussion. Before the later nineteenth century, there were many men in nursing but early nursing leaders, including Nightingale, considered nursing solely as a women's profession. Nursing, like teaching, was a professional field that women could own and develop just for women. And it wasn't just nursing leaders who wanted only female nurses—a glance through the Journal of the American Medical Association in the 1880s and 1890s indicated that many doctors also only wanted women as nurses (Lusk & Robertson, 2005). For male physicians during this period, female nurses were viewed as having the qualities of good women; they were submissive, obedient, and good housekeepers.

To return to the Illinois Training School for Nurses. In 1905, the first student, Isabella Lauver, remembered her arrival: “Twenty‐five years ago trained skirts were in vogue. My dress was of that style.” The superintendent “having viewed me over she found some pins and shortened my skirt, took a ribbon bow from my hair, and I was ready to go to work… Then the third night it was thought best to take charge of the night work as well as the day, and I was chosen for the first night nurse. What a responsibility!” (Schryver, 1930, p. 23) Figure 3.1.

FIGURE 3.1 Isabella Lauver.

Source: Illinois Training School Collection, Midwest Nursing History Research Center, University of Illinois at Chicago, College of Nursing.

The Illinois Training School for Nurses at that time was responsible for just two wards in the sprawling Cook County Hospital—the female surgical and the male medical, each averaging 50 patients (Schryver, 1930). Apparently, Isabella Lauver did well—she graduated in 1882 after just over 2 years of nurse training. Her first year was spent working on the wards, her second year was spent either in the wards or being sent out as a private duty nurse in the homes of “the rich or the poor” (Schryver, 1930, p. 21). The only actual lectures were given in the evenings by the medical staff after the students had completed a 12‐hr working day. This type of nursing education was typical of nurse training schools of this era Figure 3.2.

FIGURE 3.2 Student nurses listening to a lecture after work. This photograph is from Chicago's Provident Hospital—a hospital founded in 1891 by African Americans to train African American nurses and physicians because they were not admitted to “White” hospitals.

Source: Chicago Medical Society (1922). History of medicine and surgery and physicians and surgeons in Chicago. Chicago: Biographical Publishing Corp.

Let us dissect Nurse Lauver's work in terms of management and leadership. Her superintendent described her as a woman of “calmness and common sense sufficient to make up for lack of experience” (Schryver, 1930, p. 24). She had to be! Imagine this young woman as the only nurse for a ward of 50 sick and/or post‐operative patients. And then imagine her as a young woman in 1882, nearly 40 years before women even had the right to vote, leaving her home to start training as a nurse. She was stepping out into the unknown into this new opening for women who wanted something meaningful out of their lives other than being a housewife or a teacher—the only other respected occupations open to women. For the next 47 years, Isabella Lauver worked as a nurse in private duty and in institutions (Schryver, 1930).

M. Helena McMillan, an 1894 graduate of the Illinois Training School, founded Chicago's Presbyterian Hospital School of Nursing in 1903. McMillan, who had a college degree from Montreal's McGill University, planned a curriculum that focused on education rather than service. The first class attracted women from across the U.S. for the three and a half‐year program, which included a six‐month period with no clinical duties. Students needed a high school diploma to enter and one or more years of college were preferred. The school was affiliated with Rush Medical College. In 1903, McMillan wrote: “a special feature of the school is that the pupils will not be overworked.” McMillan was active in professional organizations including being a founding member of the International Council of Nurses in 1899. In Illinois, she spearheaded the passage of the state's first Nurse Practice Act in 1907. Upon her retirement in 1938, the American Journal of Nursing editors wrote that she had been “Associated with practically every progressive movement in nursing” (Lusk, 2001, p. 575).

Compare McMillan's plan for nursing education, as Director of Chicago's Presbyterian Hospital School of Nursing, to the experience of Isabella Lauver at the Illinois Training School for Nurses 30 years earlier.

Early nurse leaders such as McMillan would have objected to physicians who wanted nurses to be submissive and obedient. McMillan wanted well‐educated nurses who were legally protected by the state's Nurse Practice Act. Can you give some reasons, from the perspective of patient safety, why nurses today should continue to follow McMillan's lead and resist policy makers or others who want nurses to be submissive and obedient?

Discuss the founding of nursing through the lenses of gender, society, science and place.

Other young nursing graduates opened up the field of public health nursing during these early years of the nursing profession as Visiting Nurses. These Visiting Nurses went to the homes of the poor to provide free nursing care and coordinate support services. Wealthier patients hired nurses to stay with them. The 1890s were years of severe economic need in the U.S.; an economic depression as severe as that of the more infamous 1930s Great Depression occurred. In addition, U.S. cities became home to thousands of immigrants who were new to the American language and customs. Some nursing organizations, staffed by a small cadre of trained nurses in the late nineteenth century, responded to the people adversely affected by these conditions. It is worthwhile noting that these nurses often connected with their patients through the use of the newly invented telephone. Patients and doctors typically called the local pharmacy and left messages for the nurse. The nurse, in turn, visited the pharmacy at a set time each day to review the messages and then plan her work Figure 3.3.

FIGURE 3.3 Chicago VNA nurse in patient's home, c. 1890s.

Source: Chicago VNA Collection, Midwest Nursing History Research Center, University of Illinois at Chicago, College of Nursing.

One of the foremost nurse leaders and activists at this time was Lillian Wald, who is regarded as the founder of U.S. public health nursing. After her nurse's training in New York, and disenchanted with her first job in a children's home, Wald entered medical school. During her first semester, in 1893, she was told of a need for a teacher to conduct a home nursing course for immigrants on the lower East Side of the city. Wald volunteered and thus changed her life and the lives of countless others. She described making her way to a student's home “… through crowded ‘evil‐smelling’ streets, past open courtyard ‘closets’, up slimy settlement steps, and finally into the sickroom” (Buhler‐Wilkerson, 2001, p. 99). That same year, 1893, Wald and her friend Mary Brewster founded New York City's Visiting Nurse Service and Wald founded the Henry Street Settlement House, a site for poor and immigrant children and families to receive social services and health care.

In 1889, 4 years before the Henry Street Settlement House, a group of society women in Chicago founded the Chicago Visiting Nurse Association (VNA). The Chicago VNA aimed to provide nursing care to the poor, many of them immigrants, in their homes. Remember, in these days before antibiotics became available in the 1940s, most invalids required long periods of nursing to recover from an illness or surgery. The Chicago VNA nurses were assigned to all parts of the city and cared for patients suffering from multiple diseases including tuberculosis, smallpox, and polio, as well as giving maternity and chronic disease care. Jane Addams, the Nobel Prize winner and founder of Chicago's Hull House Settlement, was a charter member of the Chicago VNA. One of the VNA nurses was based in Hull House. In 1892 her supervisor wrote: “No one could conceive the dirt and ignorance that the Hull House nurse has to contend with. She has often had to care for a typhoid fever patient in a small room crowded with a dozen or more chattering and gesticulating Italian men and women, not one of whom could speak a word of English. Pigeons underfoot or flying on the bed” (VNA Annual Report, 1892, pp. 14–15, cited in Lusk et al. 2016). We can reflect on the difficulties these families endured, in a strange city with a very ill loved one, enduring the dangers, the dirt, and the overcrowding. And one can admire the intrepid and hardworking nurses visiting these homes.

In addition, the Chicago VNA was an early provider of school nursing, industrial nursing, and social services. In 1893/4, the city's last major smallpox epidemic occurred. Chicago had 3,726 smallpox cases and 1,210 deaths. The city's smallpox hospital was so crowded that tents had to be set up to accommodate the overflow of disease victims. Chicago VNA nurses staffed a temporary isolation hospital and cared for 265 patients. Twenty‐six VNA nurses volunteered to work in this hospital and 4 contracted smallpox. In 1903, the VNA also formally recognized the high incidence and dreadful toll of tuberculosis and established a Tuberculosis Committee that became the Chicago Tuberculosis Institute in 1906 (Burgess, 1990).

Reflect on this. Over a hundred years ago, nurses exposed themselves to dangerous diseases such as smallpox, were active in public health such as forming a tuberculosis committee or initiating school nursing, and were responsible for skilled hospital work. Thus, nurses such as Harriett Fulmer, an early superintendent of the Chicago VNA and the founder of the Illinois State Association of Graduate Nurses, realized that trained nurses needed to organize in order to protect the name of “nurse” and thus the new profession of nursing.

Early on, nurse leaders saw the need for nurses to unite. Isabel Adams Hampton, a superintendent of the Illinois Training School for Nurses, who then founded the Johns Hopkins Training School for Nurses, attended the World's Columbian Exposition in Chicago in 1893. During the Exposition, multiple talks were presented, including talks by nurses in a nursing section chaired by Hampton. Edith Draper, superintendent of the Illinois Training School for Nurses, stated: “I know that to every thinking woman among us, the needs for a national organization are becoming more and more strongly realized, until now our success for the future depends on our unity” (Draper, 1894, p. 569). Hampton and others proposed forming an association. The 18 women present at the Chicago Exposition meeting, superintendents of nurse training schools across the country, founded the American Society of Superintendents of Training Schools for Nurses, now known as the National League for Nursing (NLN).

But these nurse leaders knew of the need for regular working nurses, not just superintendents, to have an association of their own. In 1896, 3 years after the American Society of Superintendents of Training Schools for Nurses was formed, 12 representatives from the society met with 12 members of nurse training school alumnae associations in Brooklyn, New York. There they formed the Nurses Associated Alumnae of the United States and Canada, now the American Nurses Association ANA. Isabel Adams Hampton was elected the first President (Keeling, Hehman, & Kirchgessner, 2018).

African American women during these times did not have the opportunities open to Whites. Nurses' training was rarely open to Black women in White hospitals and, likewise, the fledgling professional nursing organizations were not open to Blacks in all parts of the U.S. Thus, the leadership of such women as Martha Franklin, who graduated as a nurse in 1897, is all the more impressive. In 1907, Franklin, an African American graduate of the nurse training school of the Women's Hospital of Philadelphia, personally wrote 1,500 letters to Black nurses throughout the United States asking about forming a society. In 1908, 52 Black nurses met in New York and founded the National Association of Colored Graduate Nurses. Franklin was the first president. At the close of the first meeting, Lillian Wald invited the women to the Henry Street Settlement House for lunch and to offer support and mentorship (Keeling et al., 2018).

Lillian Wald was among those nurses who established another significant nursing organization, the National Organization of Public Health Nurses. In 1911, a committee, formed of members of the American Society of Superintendents of Training Schools for Nurses and the Nurses Associated Alumnae of the United States and Canada, met to standardize the field of public health nursing. They wrote to over a thousand organizations that employed public health nurses and, at the 1912 meetings of the two organizations held in Chicago, the public health organization was formed (Kandel, 1920). Wald, considered to be the founder of public health nursing, became the first president (Keeling, et al., 2018). It is instructive to appreciate how important public health nursing was at this time. We might think that nurses mainly worked in hospitals prior to quite recently—but they didn't. Nurses have been actively involved with public health, working to promote health and support home care, for centuries. In terms of leadership, these pioneers who founded early nursing organizations deserve our respect for their imagination and sense of purpose. Today, nursing organizations present a rich source of support for all nurses. Many nurses join a general national organization, such as the ANA, as well as one that is specific to their nursing specialty.

The following Table 3.1 lists just a few of the scores of national nursing professional organizations, beginning with the oldest, the American Society of Superintendents of Training Schools for Nurses.

Table 3.1 Professional Nursing Organizations Compiled by B. Lusk

The possibilities and the problems we confront in our daily work raise new questions that we look to documents in our archives to answer. Our generation wonders how groups of nurses influenced broader movements of social change, transforming their lives as well as those of their patients and communities, and created opportunities and aspirations that took them beyond the health care system itself.

Patricia D'Antonio, PhD, RN, FAAN

Carol E. Ware Professor in Mental Health Nursing

Director, Barbara Bates Center for the Study of the History of Nursing

University of Pennsylvania School of Nursing

Philadelphia, Pennsylvania.

Adah Belle Thoms graduated from the Lincoln Hospital School of Nursing in 1905, a New York City school only for Black students, although under White administration. During the First World War, nurses volunteering for war service joined the American Red Cross but Black nurses were rarely accepted. Only during the last month of the war, in the fall of 1918, were 24 Black nurses called up. Meanwhile, 22,000 White nurses had been accepted. Seeing the futility of trying to volunteer, Thoms set up an organization of Black nurses called the Blue Circle Nurses, which was associated with the recently founded Circle for Negro War Relief. These nurses functioned as public health nurses for needy Black families. In 1929, Thoms was appointed the first Black Assistant Superintendent of Nurses at Lincoln Hospital. That same year, Thoms' book, Pathfinders, the first account of prominent Black nurses, was published (Clark Hine, 1989).

Consider why Black patients, nurses, medical, and ancillary staff needed Black hospitals during the late nineteenth and early twentieth centuries.

Thoms was a remarkable early nurse leader, as evidenced by her organization of the Blue Circle Nurses, her administrative work, and her book, all accomplished within the context of rampant racism. Can you identify some leadership qualities she might have possessed to support her in accomplishing all this?

Nursing education was, in some respects, a victim of its own success. Nursing students were both superior to untrained women and cheaper than graduate nurses. Nursing students were highly disciplined and compliant young women who could work longer and harder than nursing employees at a fraction of the cost. Nursing students were expected to work at least 8 hr a day and then spend time preparing for classes. In most schools, students worked more than 48 hr a week on day duty and, in about 40% of schools, they worked over 70 hr a week on night duty (Committee, 1934, p. 166). Disturbingly, most of the nursing superintendents in the mid‐1920s preferred student nurses rather than graduate nurses to give patient care. Some of their reasons were: “The student nurse is less apt to be careless in technique, gives better cooperation in regard to hospital regulations, is less extravagant with hospital linen and supplies, and with the help and advice of an experienced supervisor, gives her patients care equal to that of the graduate”… “Graduates on general duty are demanding, exacting, and shifting” (Burgess, 1928, p. 412).

The nurse training period in the 1920s was typically 3 years. This time was mainly spent working within different wards of the hospital and attending lectures after work. But this was not an apprenticeship. The students were the nurses for the hospital patients. They were not practicing under the direction of graduate nurses. A national study by the Committee on the Grading of Nursing Schools in the early 1930s found that two‐thirds of the schools did not have even one graduate nurse employed for bedside nursing (Committee, 1934, p. 180). Upon graduation, the new crop of nurses were given a diploma and left the hospital, mainly to work as nurses in private homes, while the hospital nurse training school admitted a new batch of students. Hospital administrators could not ignore the advantage of an unpaid nursing workforce and the number of nurse training schools mushroomed. In 1880, there had been 15 schools. In 1920, there were 2,155 schools (Burgess, 1928, p. 35). However, many of these new nurse training schools were situated in small or specialist hospitals, entirely unsuited to general nursing education. Furthermore, as noted earlier, African Americans were rarely accepted as students or nurses at White hospitals, while men were rarely accepted at any hospital or nurse training school. A few male only and African American only nurse training schools were founded; the latter also served as training and practice sites for African American physicians and other health care workers.

Nurse leaders were concerned at the direction nursing education was taking. Some university schools of nursing were opening and the large teaching hospitals still gave a broad education and attracted well‐educated nursing students. But these nurse training schools were in the minority. The Committee on the Grading of Nursing Schools, cited earlier, publicized this issue but did not correct it. The correction came from the financial collapse of the Great Depression. In essence, people could not afford to hire nurse training school graduates as private duty nurses. Thus, the graduate nurses were desperate for work and accepted positions in hospitals for just their room and board. This being even cheaper for hospitals than operating training schools, the smaller, poorer schools rapidly began to close. From 1926 to 1936, there was a drop in the number of hospital‐based diploma nursing schools nationwide, from 2,155 schools in 1926 to 1,478 schools in 1936 (JAMA, 1937).

Anne Larson Zimmerman, born in 1914, graduated with her diploma in nursing in 1935. Later she remembered a nursing school instructor whom she had greatly admired, who told Zimmerman that she, “had been promised when she came that if her work was satisfactory after the first year, she would be given a raise in salary,” and then the superintendent said to her, “Well, we're doing so much charity and we are so poor that we really won't be able to give you a raise,” and she said, “Well, but sister, I am doing your charity, not you … and I don't think I should subsidize what you call your charity” (Fitzpatrick, 1985, p. 2). Zimmerman's nursing school instructor's words remained with her as she worked as a single mother in Montana, California, and finally in Illinois. As the Executive Director of the Illinois Nurses Association, Zimmerman encouraged nurses to stand up for their rights. At Chicago's Cook County Hospital, where the conditions for nurses and patients were awful, a colleague remembered that Zimmerman “was excellent. There on every picket line. Always there. She would never ask you to do something she had not done herself” (Stafford, 2016). As President of the ANA from 1976 to 1978, Zimmerman advocated for economic welfare for nurses, nationalized health care, and passage of the equal rights amendment. Not surprisingly, Zimmerman successfully argued that the ANA president deserved a salary.

With some insight into nursing history, what do you think about nurses unionizing today?

Zimmerman remembered a former nursing instructor who would not accept the superintendent's denial of her raise. What is your opinion of the nursing instructor's argument that she should not have to subsidize “what you call your charity”? Figure 3.4

FIGURE 3.4 Anne Zimmerman.

Source: Anne Zimmerman Collection, Midwest Nursing History Research Center, University of Illinois at Chicago, College of Nursing.

Mary Adelaide Nutting, a renowned nurse educator and activist, declared in 1908, “There is no place in its (the hospital) strenuous scheme of life for the machinery of a school. All the space, the effort, the means which the hospital can provide are needed to carry out its immediate purpose, which is the care of the sick, and any scheme of education must, of necessity, take a secondary and insignificant place” (Nutting cited in Grace, 1978, p. 20). In other words, nursing education had to get out from under hospital control. But, until the mid‐1950s, most nursing programs continued in the 3‐year diploma, hospital‐based training model.

University programs for nurses had been around since 1909, but their development was accelerated by a study, commissioned in 1948 by the National Nursing Council, to examine who should organize, administer, and finance schools of nursing. The National Nursing Council was composed of multiple constituent nursing organizations. The study's Director, Esther Lucille Brown, an anthropologist, strongly recommended that nursing education move out of hospitals and into colleges and universities (Brown, 1948). Starting in the mid‐1950s, the number of 3‐year diploma, hospital‐based nurse training schools went down and the number of baccalaureate and associate degree programs increased.

In the early 1950s, after World War II, there occurred, as has happened quite regularly over the years, a nursing shortage. Nurses leaving the profession, many of whom wanted to get married or to start a family after the war, exacerbated this shortage. Other nurses, who had served in the armed forces, didn't want to return to the constraints and rules of civilian nursing and, possibly, wanted to utilize the G.I. Bill of Rights to gain a college education. In addition, the Hill‐Burton Act of 1946 supported extensive new hospital construction, which required more nurses. Mildred Montag, a nurse who was pursuing a doctorate in education at Teachers College, Columbia University, in New York, proposed a novel educational solution. Her dissertation, titled “Education for Nursing Technicians,” proposed a 2‐year Community College program for nurses. Nursing technicians could, as conceived by Montag, perform the technical rather than the professional components of nursing (Montag, 1963). A later grant enabled Montag to put her proposal into action in seven Community Colleges in six states, New York, New Jersey, Michigan, Utah, California, and Virginia (Montag, 1959). Montag's study showed that the 2‐year nursing program, and at this time it was just 2 years, with 1 year of general studies and 1 year of nursing, attracted non‐traditional students. Furthermore, graduates of the 2‐year program compared favorably with 3‐year diploma graduates in terms of test scores and satisfaction from all parties. Montag's plan was for the 2‐year associate degree program to develop a technical nurse—not a “professional” one (Montag, 1963). She thought that associate degree and baccalaureate degree programs should not blend with each other because they were just too different (Orsolini‐Hain & Waters, 2009). Supported by the Nurse Training Act of 1964, associate degree nursing programs grew exponentially. By 1980, approximately 80% of new graduates were from associate degree programs (Orsolini‐Hain & Waters, 2009).

Meanwhile, back in 1899, Teacher's College at Columbia University in New York had established the first graduate education program for nurses in the fields of hospital economics and educational administration (Grace, 1978). However, the bulk of nursing graduate education was developed in the 1950s and 1960s, as the need for nurse educators in the college programs expanded (Gerard, Kazer, Babington, & Quell, 2014). The early nursing graduate programs focused mainly on education and administration. Later, in the 1960s, graduate degrees for clinical nursing roles came to the forefront (Gerard et al., 2014).

Early nursing research focused on the education of nurses. This was understandable because graduate degrees for nurses had been based on theories of education. But as nursing education started to shift away from hospital‐based schools to colleges and universities, a separate and independent body of nursing knowledge was needed. That is, nursing needed to clarify the scientific knowledge behind nursing practice.

Essential to an independent body of nursing knowledge was the development of independent theories of nursing. In 1959, nurse Dorothy Johnson wrote: “…the question of the existence of a body of substantive knowledge which can be called the science of nursing…is a question of considerable significance for nursing's continued development as a recognized professional discipline” (Johnson, 1959, cited in Tobbell, 2018, p. 65). Historian Dominique Tobbell (2018) has outlined three reasons why theories of nursing were developed during the 1960s and the following decades.

In 1972, the NLN required that a nursing conceptual model should frame nursing curricula. Within the 1950s, 1960s, and 1970s, many nurse theorists developed theories of nursing science based on a functional view of nursing and health (Im & Chang, 2012). Table 3.2 details several prominent nurse theorists and their work.

Table 3.2 Prominent Nurse Theorists and Their Work

Source: Compiled with information from Nursing Theory at www.nursing-theory.org. Retrieved on October 3, 2019.

With the introduction of Diagnosis Related Groups in 1983 as an attempt by the U.S Federal Government to rein in Medicare costs, the number of hospitalized patients decreased, but their acuity (level of illness) went up. Around the same time, the Human Immunodeficiency Virus (HIV), the cause of Acquired Immunodeficiency Syndrome (AIDS), emerged as a new and terrifying disease. Caring for patients infected with HIV caused nurses to examine their courage and their ethical beliefs in a way that was new in modern nursing. Modern scientific treatments, such as vaccines and antibiotics, had lulled nurses and others into a false sense of safety in their work. HIV was different because it was fatal. Barbara Fassbinder was a Wisconsin nurse who looked after a very ill patient admitted to the emergency room on a busy night in 1986. Because of that care, Fassbinder was later identified as the first nurse to contract AIDS from a patient. Fassbinder died in 1994 (Lusk, 1997).

Increased patient acuity, exacerbated by shorter hospital stays, demanded that nurses have further education in specialized fields. Of the currently accepted Advanced Practice Nursing Roles (Nurse Midwife, Nurse Anesthetist, Clinical Nurse Specialist, and Nurse Practitioner (NP)), nurse midwifery and nurse anesthetist have the longest history. In the U.S., many nurses at the start of the twentieth century frowned upon nurse midwives. Clara Noyes, a noted nurse leader, wrote in 1912: “The word ‘midwife’, in America, at least, is one to which considerable odium is attached and immediately creates a mental picture of illiteracy, carelessness and general filth” (Noyes, 1912, p. 466). At the same time, in the early twentieth century, the medical profession in the U.S. was growing in prestige and flaunted its expertise. Physicians were eager to join with early nurse leaders in disparaging midwives as ignorant and dangerous. Childbirth evolved as a medically lucrative pathology rather than a natural event. Yet many women were unable, due to geographical location or cost, to obtain medical care and relied upon the local untrained but experienced midwife. Within a few decades, during the 1930s and 1940s, nurse midwifery schools opened. The public's interest in natural childbirth during the 1970s supported further growth in nurse midwifery (Lusk, Cockerham, & Keeling, 2019).

The story for nurse anesthetists started more abruptly with the discovery in the mid‐nineteenth century of gases that induced anesthesia. Isabel Adams Hampton, in her 1893 nursing textbook, gives instructions to nurses on how to administer both ether and chloroform (Hampton, 1893). However, in these early days, nurses primarily gave anesthesia in situations where no physicians were present except for the surgeon. The first specific nurse anesthesia training was probably given by Dr. William Worrell Mayo during his surgeries in the late 1890s at St. Mary's Hospital in Rochester, Minnesota. Nurse Alice Magaw, sometimes referred to as the “mother of anesthesia,” worked for Dr. Mayo and wrote of her anesthesia “observations” of over a thousand cases in 1900 (Lusk et al., 2019).

The Clinical Nurse Specialist role had its foundation in psychiatric nursing. Indeed, the woman known as the first trained nurse in the U.S., Linda Richards, an 1870s graduate, organized a nursing school for the preparation of nurse specialists in psychiatric nursing (Richards, 1911). NPs, the fourth type of Advanced Practice Nursing role, include diagnosis and treatment in their nursing care. Forerunners of today's NPs were nurses who treated patients who were often too poor to obtain medical care. Such a nurse was Rose Hawthorne.

Teacher's College, Columbia University, instituted the first doctoral degree for nurse educators, granting the education doctorate in 1924 (Robb, 2005). By 1949, there were 24 doctoral programs open to nurses in the U.S., 75% of which were in education. Twenty years later, this number had grown to over 300 with 10% of these doctoral programs in nursing and 21% in the social sciences and the remainder in education (Grace, 1978). Over the ensuing years, doctoral nursing education acquired such titles as Doctor of Nursing Science (DNSc) and the Doctor of Science in Nursing (DSN). Today we have primarily the titles of Doctor of Philosophy (PhD), a research doctorate, and the Doctorate in Nursing Practice (DNP), a clinical doctorate. In 2016, there were just under 5,000 nursing students enrolled in research focused doctoral programs compared with over 25,000 nursing students in DNP programs (American Association of Colleges of Nursing (AACN), 2017).

Rose Hawthorne was born in 1851 and, after the death of her only child from diphtheria, she left her husband and took a short course in cancer nursing at the New York Cancer Hospital, now Memorial Sloane‐Kettering Cancer Center. Her aim was to nurse poor people with cancer. Hawthorne ran a dispensary and then a home for people dying of cancer, without attracting questions from the medical establishment about encroachment on their medical practice. Hawthorne applied different types of salves (ointments) to the open wounds of her patients, depending on her judgment of the wound's condition and the type of dressing needed. For Mary Watson, her first patient, Hawthorne cleansed the wound with either water or a weak creolin (tar) solution, or with peroxide. She then applied the type of ointment she thought appropriate. Hawthorne also gave Watson one to three tablets of morphine a day (Hawthorne, 1896). Hawthorne's patients were poor and that is probably why she was allowed to diagnose and prescribe without complaints from physicians. Hawthorne was indeed practicing as a NP back in the nineteenth century.

Has the knowledge that NPs have a long history, as demonstrated by Hawthorne, changed your perspective, as a consumer and as an undergraduate nurse, of the NP role today?

Based on your knowledge of nursing at this time, do you think you could set up a nursing practice that included diagnosis and treatment, such as Hawthorne's practice, today? Why or why not?

I'll admit, when I started my doctoral program, I had no interest in the history of nursing. Nor did I understand its value within the profession. When I took a required historical research methods course, I realized I could use history to answer my research questions instead of the more traditional methods of research I had always known. Now as a new faculty member, I continue to pursue historical scholarship, promote historical methods among the doctoral students, and host a historical book club among faculty and students to discuss important events of the past and how they inform our present profession and society.

Gwyneth Milbrath, PhD, RN

Clinical Assistant Professor

University of Illinois at Chicago College of Nursing

Chicago, Illinois

Historically, the public appears to hold nurses in higher esteem during wartime. The media's image of nurses both reflects and influences nurses' professional identity. Lusk, the author of this chapter, has conducted two studies assessing: (a) how nurses were portrayed in the general literature, 1880–1928, and (b) how nurses were portrayed in hospital management journals, 1930–1950 (Lusk, 2000, 2002). Lusk found that nurses were indeed portrayed as more knowledgeable and autonomous in these media during war years. As the First World War started, images of nurses and articles about them burgeoned in the popular press. Reporters were sent over to Europe to write about hospital work. The reporters stressed that only trained nurses, not volunteers, were needed. Nursing was portrayed as a highly patriotic occupation in which female nurses had a significant presence near the front lines. The Second World War was similarly covered. In marked contrast to the 1930s and the 1950s, when nurses were depicted as minimally skilled and subservient to physicians, nurses in advertisements during the war years of the 1940s showed nurses engaged in more complex and independent procedures, for example, adjusting nasogastric suction and setting up oxygen delivery systems. These changes may be correlated with peace time perceptions of nurses' work as lower skilled physicians' helpers as opposed to war time perceptions of nurses' work as skilled, autonomous providers of care who would help the country “win the war.” What do you think of the fact that nurses' professionally benefit from positive portrayals during times of war? There are many reasons we can speculate about why nurses were portrayed less positively after the war, during the 1950s. Some of these affect the image of nurses today. What reasons can you think of?

In 2018 the Gallup Organization found, for the 17th year in a row, that the public consider nursing to be the most ethical profession. By ethics, we mean the study of morality from a range of perspectives (American Nurses Association (ANA), 2015). In 2016 the Hastings Center produced a Report titled: Nurses at the Table: Nursing, Ethics, and Health Policy (Ulrich, Grady, Hamric, & Berlinger, 2016), sponsored by the American Academy of Nursing. The Report implied that nurses were uniformly ethical. In contrast to this, historian Lynn Dunphy (2001) wrote about nurses who cared for children with polio who were in external pressure ventilators, “iron lungs,” during the polio outbreaks of the mid‐twentieth century. These ventilators were metal tubes in which the patient's body was placed, and only the patient's head was outside the tube. Dunphy quoted a former patient: “…she [the nurse] told me to stop crying. She said she would turn my respirator off if I didn't stop crying. When she did, I passed out immediately” (p. 20). Dunphy wrote that stories like that abounded in her interviews.

Do you think that this was unusual nursing behavior?

Have you ever seen nurses behave with questionable ethics?

What would you do if you saw such behavior today?

This chapter has skimmed over some of the key events in nursing's history. It has told some stories in depth, for example, that of nursing student Isabella Lauver's early experiences at Cook County Hospital in the 1880s and Madame du Coudray's work in France in the 1700s. The point is to alert you to the complexity of history. There was no golden age of nursing when nurses were always wise and had plenty of time for hands‐on patient care. That is a product of wishful thinking on the part of today's public and public policy makers. Likewise, nursing education didn't start with Florence Nightingale, as demonstrated by Madame du Coudray and her “obstetrical machine” of the century before Nightingale. The past was both worse and better than we might imagine and it cannot be judged with today's lens. Furthermore, we cannot consider nursing's past in isolation from its contextual issues of gender, society, science, and place. Society in the nineteenth and early twentieth centuries lacked today's social safety nets, such as Medicaid, Medicare, and Social Security, but medical science was advancing rapidly. Nurses thus witnessed extraordinary patient need alongside the new realities of, for example, effective drugs and newly developed vaccines. The concept of place in nursing's past means that nurses' education and practice was affected by the geographical setting—urban or rural, southern state or northern state, general hospital or tuberculosis hospital.

The rise of public health nursing came from late nineteenth, early twentieth century concerns about great income disparities and lack of health care for immigrants and the poor. Some nurses addressed these concerns at the policy level, while thousands of public health nurses went from door to door doing the actual work of nursing. The work of these public health nurses of the past has influenced health care administration today with the current shift to outpatient care wherever possible (McDermott, Elixhauser, & Sun, 2017). Additionally, nursing has a history of giving care to the poor, who in these days are the uninsured. Witness the work of Rose Hawthorne discussed in Case Study 3.4.

The checkered story of formal education in nursing, briefly covered in this chapter, must be placed in the context of society in the nineteenth century, particularly the role of women at that time. In the nineteenth century and the early decades of the twentieth century, women's education was not a priority. Women were expected to become mothers and housewives. But the scientific advances of the nineteenth and twentieth centuries required that nurses, even though they were predominantly women, become appropriately educated. The importance of professional organizations over the decades, and their leadership, cannot be overemphasized in the history of nursing. From the NLN's early nursing curricula, starting in 1917, to the Advanced Practice Nurse organizations' recent moves in clarifying and publicizing the advanced practice roles, professional organizations have led the way forward.

Appreciation of nurses' current ethical responsibilities must be guided by awareness of nursing's complex past, as described in Dunphy's (2001) story of the iron lung nurses in the 1950s and 1960s. History has shown us that nursing is not exempt from ethical wrongdoing; to state that nurses are always ethical is naïve. Critical thinking, strengthened by historical analysis, will support nurses' understanding of complex issues and ethical questions. Table 3.3 summarizes key events in the history of nursing in order to expose you to thought‐provoking elements of your profession and pique your interest for further study.

Table 3.3 Historically Significant Events in the History of Nursing Compiled by B. Lusk

Patti Ludwig‐Beymer

Purdue University Northwest, College of Nursing, Hammond, IN, USA

A strong safety culture requires skillful leaders with exceptional communication abilities.

Source: Used with permission from the U.S.A. Government.

A strong safety culture begins with leadership; their behaviors and actions set the bar. I urge all health care leaders to make safety culture a top priority at their health care organization. Establishing and improving safety culture is just as critical as the time and resources devoted to revenue and financial stability, system integration and productivity—because a lack of safety culture can have serious consequences for patients, staff and other stakeholders.

Ana Pujols McKee, MD, Executive Vice President and Chief Medical Officer,

The Joint Commission (TJC, 27 December 2017, para. 6).

Upon completion of this chapter, the reader should be able to:

Ms. Smith's daughter Kali is a patient in the Neonatal Intensive Care Unit (ICU). Ms. Smith diligently pumps her breasts to provide nourishment to her newborn. After pumping, Ms. Smith gives the milk to the nurse, who labels it and places it in the refrigerator. The next day, the nurse prepares a feeding for Kali. After administering the feeding, the nurse notices that the milk is labeled with Ms. Brown's name.

By definition, this is a serious safety event. The organization takes immediate action: it notifies both Ms. Smith and Ms. Brown, and tests Ms. Brown for a variety of infectious diseases. In addition, the error is thoroughly investigated by a team that includes nurses, nursing assistants, physicians, and staff from infection prevention, risk management, quality, information technology, and administration. The team conducts a root cause analysis to determine the underlying cause of the breast milk mis‐administration and creates a corrective action plan. The executive leadership team and board of directors review the information and approve the corrective action plan. Everyone at the hospital expresses confidence that the processes put into place will prevent this event from happening again. Unfortunately, within a few months, the incorrect breast milk is administered to a baby in the pediatric department.

The Institute of Medicine (IOM, 1999) described the safety of U.S. health care in To Err is Human. They suggested that 44,000–98,000 people die in hospitals each year from medical errors that could have been prevented and provided a roadmap to safety. The IOM outlined strategies to prevent errors, including enhancing knowledge about safety; identifying and learning from errors; raising expectations for improving safety; and implementing safety systems in health care organizations to ensure safe practices at the patient care delivery level. Seventeen years later, Makary and Daniel (2016) estimated that medical errors cause 251,000 deaths each year. This makes medical errors the third leading cause of death in the Unites States (U.S.) after heart disease and cancer.

Safety is the responsibility of every nurse and each member of the interprofessional team. Despite the heavy focus on quality and safety, errors continue to occur. Nursing managers and leaders are in a unique position to foster a culture of high reliability. This chapter will describe the current state of quality and safety in health care organizations. After defining and evaluating the characteristics of HRO s, the chapter will analyze the impact of QSEN competencies on high reliability. Last, the chapter will describe the role of the nurse in creating a culture of safety and identify resources nurse leaders can use in a journey toward high reliability.

Health care is dangerous, and mistakes or errors can have devastating consequences for patients and staff. Nurses and other health care professionals do not come to work intending to harm patients. However, humans make mistakes. It is part of the nature of being human. Most medical errors do not result from individual recklessness. Instead, many medical errors are caused by faulty health care systems, processes, and conditions that lead people to make mistakes or fail to prevent them. This means that health systems can best prevent mistakes by creating processes that make it easier to do the right thing and harder to do the incorrect thing.

An error is defined as a deviation from generally acceptable performance standards. Performance standards may be found within a health care organization or may exist external to the organization. Internal standards include policies, procedures, protocols, and order sets.

External standards include professional practice standards and practice requirements imposed by accreditation.

An error may cause varying levels of harm to a patient. A near miss safety event occurs when the safety event doesn't reach the patient because it is caught by chance or because the process was engineered with a detection barrier. For example, Ms. Johnston and Ms. Johnsen may both be hospitalized on the same nursing unit. The nurse may accidently bring Ms. Johnston's medications to Ms. Johnsen. By properly identifying the patient using two unique identifiers, this error can be identified before causing harm to the patient. Nurses often fail to report Near Misses, rationalizing that no one was hurt. However, near miss safety events serve as an early warning system of something that could go wrong. By reporting near miss safety events, health care organizations can work on improving processes so that no one else makes the same error.

Precursor safety events occur when the health care error reaches the patient and results in no harm or minimal detectable harm. For example, the nurse may do a finger stick to check a blood sugar for Ms. Johnston when it was ordered for Ms. Johnsen. The error has reached the patient but has resulted in minimal harm, in this case a finger stick. Like near miss safety events, precursor safety events should be reported so that they can be used to improve care.

Adverse events or serious safety events occur when the error reaches the patient and results in moderate to severe harm or even death.

Sentinel events are a subcategory of adverse events. A sentinel event is a patient safety event that is not primarily related to the natural course of the patient's illness or underlying condition, reaches the patient, and results in death, permanent harm, or severe temporary harm (TJC, January 2018). For example, imagine that the nurse administered a unit of packed red blood cells intended for Ms. Johnston to Ms. Johnsen. The results could be catastrophic, and the health care team would need to take immediate action to save Ms. Johnsen's life. After the immediate crisis is handled, sentinel events must be carefully investigated. Corrective action plans must be created to reduce risk and prevent harm for future patients.

TJC is an independent, not‐for‐profit group in the United States that provides accreditation for many hospitals and other health care organizations. TJC publishes a list of the most frequently occurring sentinel events, summarized in Table 4.1. The reporting of sentinel events is voluntary and represents only a small proportion of actual sentinel events.

Table 4.1 Five Most Frequent Sentinel Events, 2014 through 2017 (TJC, January 2018)

Source: The Joint Commission (January 2018). Patient Safety Systems. Retrieved from https://www.jointcommission.org/assets/1/6/PS_chapter_HAP_2018.pdf.

Errors are often noticed at the point of care, where nurses and other clinicians interact with patients. This is considered the “sharp end” of a triangle (Cook & Woods, 1994). These errors are considered active errors because they occur at the point of interface between humans and a complex system. Clinicians often blame themselves when errors happen. However, their work with patients is influenced by many factors and decisions made before an actual error occurs. These factors and decisions are considered the “blunt end” of the triangle.

Latent errors are hidden problems within health care systems that contribute to adverse events (Agency for Healthcare Research and Quality [AHRQ], 2018a, 2018b). For example, policies and procedures within an organization may be inaccessible, difficult to understand, or inaccurate. Work processes might be confusing and patient handoffs may be rushed and inadequate. The environment may be cramped and noisy, making it difficult to concentrate. Technology may fail or be cumbersome to use. Individuals may blame others rather than taking personal responsibility. The culture of the hospital might hinder a nurse's ability to speak up about safety concerns. All of these “blunt end” factors may contribute to an error at the “sharp end,” where clinicians interact with the patient.

James Reason (1997) proposed the Swiss Cheese model, shown in Figure 4.1, to illustrate how errors occur. The model suggests that every step in a process has the potential for error. The holes in the Swiss cheese represent opportunities for a process to fail, and each slice is a defensive layer to prevent an error in the process. An error may pass through a hole in one layer but in the next layer, the hole is in a different spot and the layer catches the error before it reaches the patient. More layers of cheese and smaller holes allow more errors to be stopped or caught. When the holes in the Swiss cheese line up, an error occurs.

FIGURE 4.1 Swiss cheese model.

Source: © Used with permission granted from Patti Ludwig‐Beymer.

Building an HRO is a cultural transformation designed to ensure safe practices and reduce errors and sentinel events in health care. Health care is complex and involves the risk of significant and potentially catastrophic consequences when failures occur. HROs operate under these trying conditions and have fewer accidents. They have the ability to provide consistent health care at a high level of excellence over a long period of time. HROs in health care establish and maintain high quality and safety expectations for patient care. Quality and safety error rates are near zero in HROs (Weick & Sutcliffe, 2007).

The risk of health care error is a function of both probability and consequence. For example, consider the care needed for a dehydrated patient with renal failure. Administering fluids too slowly can result in prolonged hypotension. Administering fluids too rapidly can result in fluid retention and heart failure. An IV pump is used to assist the nurse in providing accurate amounts of fluid. The IV pump decreases the probability of error. However, if the pump is programmed incorrectly or fails completely, the consequences can be catastrophic. By decreasing the probability of an error, HROs operate to make health care systems safer.

HROs operate in complex, high‐hazard situations for extended periods without serious accidents or catastrophic failures. HROs relentlessly prioritize safety over other performance pressures. An example is a military aircraft carrier. The carrier operates under significant production pressures with aircrafts taking off and landing every 48–60 seconds; constantly changing conditions; and a hierarchical (military) organizational structure. However, personnel consistently prioritize safety and have both the authority and the responsibility to make real‐time operational adjustments to maintain safe operations as the top priority (AHRQ, 2018a, 2018b).

In the 1970s, research conducted by the National Aeronautics and Space Administration suggested that most commercial airplane crashes were caused by communication failures among pilots and crew, not by mechanical failures. In some cases, co‐pilots were aware that pilots were making unsafe decisions but did not verbalize their concerns because of authority gradient. Authority gradient refers to one's position within a group or profession. It was defined first in aviation when it was noted that pilots and copilots did not always communicate effectively in stressful situations if there was a significant difference in their perceived authority. Multiple aviation, aerospace, and industrial incidents have been attributed to authority gradients. This information was used to develop and implement the Crew Resource Management (CRM) training program. The training program focuses on interpersonal communication, leadership, and decision making in the cockpit, with the informal motto “see it, say it, fix it.” CRM is credited with the dramatic safety improvements in the airline industry (Helmreich, Merritt & Wilhelm, 1999) and has been adapted for use in health care and many other industries.

Similarly, the nuclear power industry has worked for many years to improve safety. The Institute of Nuclear Power Operations defines safety culture characteristics, some that are adaptable to the health care environment, and include: everyone is responsible for safety, leaders demonstrate commitment to safety, trust permeates the organization, decision making reflects safety first, a questioning attitude is cultivated, organizational learning is embraced and safety needs constant examination (Institute of Nuclear Power Operations, 2004). The American College of Healthcare Executives and Institute for Healthcare Improvement (IHI) published a blueprint for safety (2014) and is summarized in Table 4.2. These characteristics are essential for cultural transformation and are as applicable for all health care organizations.

Table 4.2 Safety Culture Characteristics

Source: Based on American College of Healthcare Executives and Institute for Healthcare Improvement. (2017). Leading a Culture of Safety: A Blueprint for Success. Retrieved from www.osha.gov/shpguidelines/docs/Leading_a_Culture_of_Safety-A_Blueprint_for_Success.pdf

Weick and Sutcliffe (2007) identified five key principles of HROs that are used to this day, summarized in Table 4.3. These characteristics, when present, help an organization to achieve high reliability. Each characteristic is described in detail below.

Table 4.3 HRO Characteristics

Source: Patti Ludwig‐Beymer.

In preoccupation with failure, nurses and other health care providers are aware that the risk of error is always present. An HRO recognizes that failures can occur and deploys processes to diminish harm. An HRO proactively identifies high risk activities and analyzes all the potential error points in the process. This analysis can be performed as a Failure Modes and Effect Analysis (FMEA), a rigorous process in which a team of clinicians identify and eliminate known and potential failures, errors, or problems before they occur (Hughes, 2008). Failures are prioritized according to the seriousness of the consequences, how frequently they occur, and how easily they can be detected. An FMEA example is provided in Figure 4.2.

FIGURE 4.2 FMEA.

Source: Patti Ludwig‐Beymer.

Preoccupation with failure requires that critical information be communicated across time, across the health care team, and across sites of care. For example, a patient may be seen in the Emergency Department (ED) and require admission to the acute care hospital. Prior to transferring the patient, the ED nurse provides a thorough report to the nurse on the receiving unit.

In preoccupation with failure, nurses report questionable or unsafe practices. They notice and learn from near miss safety events and precursor safety events. These events are viewed as early warnings that something is wrong. Nurses recognize when an error can or has occurred, feel confident in stopping unsafe practices, and assume the responsibility for reporting errors or near misses. The organization then uses the reports to correct unsafe processes through rigorous process improvement activities.

Reluctance to simplify motivates an organization to understand errors. Nurses in HRO health care facilities focus on drilling down to determine the true cause of error. They challenge the current situation to make health care processes and structures safer. For example, a nurse may fail to check a patient's blood sugar as ordered. Initially, the nurse may just indicate “I forgot.” However, analyzing the situation for contributing factors to this failure helps the organization to find real, root cause, and develop solutions. Multiple factors could have contributed to the failure to check a patient's blood sugar. The patient may have been off the unit for a test. The information may not have been shared at change of shift, or a reminder prompt in the electronic health record (EHR) may have been missing. The necessary supplies and equipment may not have been available. An examination of each of these factors allows an HRO to determine ways to prevent this error.

Reluctance to simplify also requires taking action to eliminate work=arounds, the use of short cuts to streamline care without realizing the potential impact on safety. For example, a national patient safety goal requires the use of hand cleaning guidelines from the Centers for Disease Control and Prevention or the World Health Organization. Nurses may save time by rinsing rather than thoroughly washing their hands. Unfortunately, this increases risk to patients and staff. Leaders in HROs identify and extinguish these types of work‐arounds.

Sensitivity to operations acknowledges the complex nature of health care. Factors such as fatigue, distractions, and workload can contribute to unsafe conditions. In HROs, nursing leaders make rounds and talk to staff to look for weaknesses in the care delivery system that allow errors to occur. When weaknesses are identified, leaders allocate resources to prevent harm. For example, the automated medication dispensing system may be in a hallway on a medical surgical unit. When making rounds, the nurse leader may see that the nurse is interrupted by physicians, patients, visitors, and other staff while obtaining medications from the dispensing system. Nurses on the unit may express concern about this process, which interferes with their ability to concentrate on preparing the medications. The nursing leader may resolve the problem by allocating funds to create a small medication room to house the automated medication dispensing system and minimize distractions.

Commitment to resilience is the ability to overcome problems, learn from mistakes, and move forward. It allows nurses and clinicians to recover when a serious safety event occurs. Because we are humans, mistakes will happen. Rather than blaming others, nurses in HROs discuss how the error occurred and what can be done to prevent such an error in the future. Transparency is essential; errors are openly discussed and used to improve health care processes. In HROs, nurses learn to perform quick situational assessments when an error occurs, work as a team to contain or manage the error, and then take steps to reduce the harm.

In HROs, clinicians are offered support when they are involved in a safety event. Nurses and other clinicians feel guilty when they make an error that harms a patient. The term “Second Victim” is used to describe the pain and anguish experienced by the clinician (Wu, 2000). Programs have been developed to assist clinicians to build resilience and recover from these safety events. The forYOU program (Scott, 2015) is an evidence‐based second victim intervention that provides immediate emotional and social support. Members of the forYOU team provide emotional support using three levels: local support from a colleague, support from specially trained peers, and support through a network of chaplains, social workers, and employee assistance programs. Resources that help build resilient nurses are also available through the Academy of Medical‐Surgical Nurses (n.d.) and the American Association of Critical Care Nurses (2014).

Simulation learning is used in HROs to practice responses to errors or safety events. Drills for environmental disasters, active threats, rapid responses, and cardiopulmonary resuscitation allow nurses and other clinicians to practice as an interprofessional team and build resilience for emergency situations (Figure 4.3).

FIGURE 4.3 Simulation exercise.

Source: Used with permission.

Deference to expertise acknowledges that collective knowledge is better than the proficiency of one individual. This allows a team to recognize and use the unique skills of everyone involved. HROs minimize the authority gradient and hierarchy so that everyone feels comfortable about speaking up. Authority gradients exist in nursing and in other health care professions. Consider the difference in perceived authority between direct care nurses, nurse managers, nurse directors, and the Chief Nursing Officer (CNO). Hierarchy also exists in health care settings and refers to the perceived level of power across groups. Consider, for example, the perceived power for a housekeeper compared to a direct care nurse, or a direct care nurse and a physician. Health care has been and remains hierarchical. Physicians have been historically viewed as the “captain of the ship,” with nurses and other clinicians viewed as less powerful.

Regardless of authority gradient, or hierarchy, deference to expertise stipulates that team members with the most expertise about the issue have the authority to make decisions. In an HRO, decisions about nursing practice are informed by and driven by practicing nurses rather than by the CNO or by physicians. Deference to expertise also requires open communication with information flowing in all directions among all team members.

When nursing staff is asked the question “what can leadership improve upon?”, the answer is often related to communication and education with respect to change. While safe staffing ratios are vitally important, adverse safety events and job dissatisfaction may come from implementing a new process, device, or expectations without properly notifying or educating staff. Providing up‐to‐date information—even laying the framework to changes or potential concerns coming in the future, can help nurses adapt to and implement changes quickly.

We love our unit newsletter because it allows us to look at where we are and where we are going while always keeping safety in the front of our minds. It is a collaborative effort between the educators, management, infection control, and various other departments (like pharmacy and the vascular team). Fun articles celebrating employee birthdays, anniversaries, and humor segments along with unit pride pieces help make the newsletter fun to read as well as educational. Creating a graph of catheter‐associated urinary tract infections (CAUTI) rates has been largely unsuccessful in convincing nurses of the importance of HAIs. Writing a short article on the number of CAUTIs the hospital has had for the month and on which units they occurred gets everybody talking about the problem. It's a different spin on the same material. The hope is that in combination with staff meetings, education sessions, huddle alerts, updated intranet splash pages, and other communication strategies, we are bombarding our staff with information to keep their patients—and themselves—SAFE. When we are consistently safe, we improve patient outcomes and nurses are more engaged in their work and their hospital.

Bonny Dieter, MS, RN, CMSRN

Clinical Leader and Creator of PMU Newsletter

Pulmonary Medicine Unit

Edward Hospital

Naperville, IL Figures and

FIGURE 4.4 PMU Newsletter. Newsletter designed to increase communication on safety issues.

Source: Bonny Dieter.

Every nurse, at every level of the organization, plays a role in an organization's journey toward high reliability. Each nurse and each member of the interprofessional health care team must be committed to high reliability. Direct Care nurses are essential in HROs. While many contributing factors lead to errors, an actual error occurs when the nurse or another clinician interacts with the patient, at the “sharp end” of care. The nurse is often the last line of defense against health care errors. As such, the nurse must be cognizant of personal behaviors to enhance safety and communication techniques that can be helpful in preventing errors and patient harm.

However, individual actions are not sufficient. Committed nurse leaders are needed to implement system changes that are essential for becoming an HRO. In collaboration with other organizational leaders, nurse leaders are accountable for the provision of effective and efficient care while protecting the safety of patients, employees, and visitors. Leadership's failure to create an effective safety culture is a contributing factor for many types of adverse events (The Joint Commission, 2018a, 2018b, 2018c). Shaping an organization into a culture of safety and reliability is essential for enhancing safety and improving the “blunt end” or care.

To prepare nursing students to function in the complex health care environment. The QSEN project was established. The QSEN Institute is a collaborative of healthcare professionals focused on education, practice, and scholarship to improve the quality and safety of health care systems. Their goal is to prepare future nurses at the baccalaureate and graduate levels with the knowledge, skills, and attitudes necessary to continuously improve the quality and safety of the health care systems within which they work. Based on earlier work completed by the Institute of Medicine (2001), QSEN identified six core competencies for new graduates, as outlined in Table 4.4 (QSEN, 2018). Each core competency is described below. The competencies are used to frame this chapter's discussion of high reliability.

Table 4.4 QSEN Competencies

Source: QSEN.org.

In this competency, nurses recognize that the patient or designee is the source of control. Patients are full partners when the nurse is providing compassionate and coordinated care. Patients identify their designees, typically family members or close friends. Nurses respect the preferences, values, and needs of their patients and the way in which patients define family.

The relationship between direct patient care and patient‐centered care is easy to understand. In addition, nurses and nurse leaders must consider patients and their designees in a broader context. Nurse leaders must create organizational cultures that assess and support patient and family preferences. They must use current evidence when designing patient care areas to promote patient‐centered care. Nurse leaders must also work within their institutions to remove barriers to the presence of families and their designees. Establishing a Patient Family Advisory Committee can be helpful in providing input for nurse leaders and other organizational leadership. Patient‐centered care is discussed in greater detail in Chapter 8.

Providing patient‐centered care is an important part of building a high reliability culture. Chris, a nurse on the Pediatric ICU, is caring for a 3‐month‐old with a history of supraventricular tachycardia, cough, and congestion. Chris reviews the patient's EHR and finds an order for Propranolol 20 mg TID. As an experienced pediatric nurse, Chris realizes this dose is high. She knows pediatric doses are weight‐based and consults a drug reference book to determine the appropriate dose. Chris also talks with the mother and learns that the infant was taking 2 mg of Propranolol three times a day at home. She then speaks to the physician, who changes the medication order and thanks Chris for her diligence.

In this scenario, Chris took two positive safety actions: she demonstrated a questioning attitude while providing patient care, and she involved the patient's mother in his investigation. Chris carefully considered the patient care situation and asked herself some key questions. Is this what I expected to see? Does this fit with what I know? Does this make sense to me? She then investigated by checking with independent, expert sources, competent people, and written materials that could help resolve the question.

In this competency, nurses function effectively within both nursing and interprofessional teams. They foster open communication, mutual respect, and shared decision‐making to achieve quality patient care. This needs to happen at every level of the organization. Direct care nurses must function within their scope of practice and integrate the contributions of others to help patients achieve health outcomes. Nurses must communicate effectively with the nursing team and with many other clinicians to enhance patient care and minimize risks associated with handoffs. Nurse leaders must lead or participate in the design and implementation of systems that support effective teamwork. They must create an organization that appreciates and values clear communication. Several strategies for enhancing communication are described below.

Improving the effectiveness of communication among caregivers is one of the National Patient Safety Goals (TJC, 2018a, 2018b, 2018c). Communication ensures that messages are heard correctly and accurately; prevents incorrect assumptions and misunderstandings that could lead to wrong decisions; and is essential within nursing and with other members of the interprofessional team.

TeamSTEPPS ^® (AHRQ, 2013a, 2013b) provides several tools for improving communication, including call‐out and closed‐loop (or three way) communication.

Call‐Out is a tool used to communicate important information. It informs all team members simultaneously during an emergency and helps team members anticipate next steps. For example, during a code, the nurse uses a call‐out to report “I've administered 1 mg Epinephrine IV.”

Closed loop communication ensures that the message received is the same as what was intended by the sender. The sender initiates communication with a receiver by providing a request, information, or clinician order. The receiver acknowledges the communication with a repeat‐back. The sender then confirms the accuracy of the acknowledgement by saying “that's correct.” If communication isn't clear, the nurse must clear up the confusion. “Let me ask a clarifying question” is a helpful and non‐threatening phrase to use when attempting to clarify communication.

Sam is a nurse on a medical‐surgical unit. When he receives a telephone order from a physician, he enters it into the EHR and reads it back to the physician. Sam waits for the physician to verify the order before concluding the conversation. Sam also uses closed‐loop communication when communicating with or delegating to a nursing assistant.

FIGURE 4.5 Registered nurse catches up on safety news by reading the PMU newsletterr.

Source: Kary Blaschak.

Communication also includes the transfer of information during transitions of care, for example across units or sites of care, during shift changes, and during hospital discharge. These communication handoffs provide an opportunity to ask questions, clarify information, and confirm understanding. The tool I PASS the BATON can be used effectively in handoffs. The I PASS the BATON acronym for remembering the key components of the handoff is presented in Figure 4.6

FIGURE 4.6 I PASS the BATON.

Source: Patti Ludwig‐Beymer.

SBAR is another helpful tool for handoffs. The acronym SBAR stands for Situation, Background, Assessment and Recommendation. Kaiser Permanente originally adapted a United States Navy tool to enhance collaboration between nurses and physicians (Institute for Health Care Improvement, 2018c). Situation refers to a concise statement of the immediate problem. Background is a brief summary of pertinent information related to the situation. Assessment refers to analysis and consideration of action options. Recommendation addresses the actions requested.

Jean uses SBAR as a nurse in labor and delivery. When caring for Mrs. Jones, she calls the obstetrician to report, “Here's the situation. I have some concerns about Mrs. Jones' baby related to the fetal heart rate. For the past two hours the baby has had a rising baseline from 135 to 170. Now, the strip has minimal variability with no elicited fetal heart rate accelerations using vibroacoustic stimulation and position change. I need you to come and visualize this strip and assess the situation. When can I expect you?”

Health care delivery requires strong and supportive health care teams, where members monitor team function, share the workload, and support each other. TeamSTEPPS (AHRQ, 2013a, 2013b) provides team strategies and tools to enhance performance and patient safety. CRM, described earlier in this chapter, was adopted into health care from aviation to promote and reinforce the team behaviors of cooperation, coordination, and sharing regardless of formal position. It's been used to improve patient care in obstetrics, the operating room, the emergency department, and other settings (Kreiser, 2012).

To enhance patient safety and quality, many hospitals have implemented rapid response teams. These interprofessional teams are activated by a staff nurse or other clinician when a patient's condition deteriorates unexpectedly. A rapid response brings clinical experts quickly to the patient's bedside and can be implemented in a cost‐effective manner (Mitchell, Schatz, & Francis, 2014). In recognition of patient‐centered care, some facilities permit a rapid response team to be activated by patients and family members (Gerdik, Vallish, Miles, Godwin, Wludyka, & Panni, 2010).

Source: Adapted from Leach, L.S. & Mayo, A.M. (2013). Rapid response teams: Qualitative analysis of their effectiveness. American Journal of Critical Care, 22(3), 198–210.

Discussion: The article describes the effectiveness of rapid response teams in a large teaching hospital using grounded theory methodology. Researchers found that effective team performance included the concepts of organizational culture, team structure, expertise, communication, and teamwork. Because of inconsistency in membership, team members had little opportunity to develop relationships or team skills.

Implications for Practice. Communication between team members and managing a crisis are critical aspects of an effective response team. Team training is needed to enhance the performance of teams that work together infrequently and experience time pressure to perform.

High team performance is facilitated when nurses and other staff members are expected to and comfortable with providing both positive and constructive feedback to team members. Positive feedback is essential for reinforcing safe behavior. Clinicians perform many safe actions every day and should be recognized for that. Constructive feedback is needed to discourage and change unsafe behaviors. People tend to avoid constructive feedback because they are uncomfortable providing it. However, a simple reminder is often all that is needed to correct behavior. Constructive feedback should always be met with a thank you, and a change in behavior.

Cross‐monitoring is a tool to assist in error reduction in teams and allows team members to monitor unusual situations or hazards, identify safety slips or lapses, and provide impromptu consultation and feedback. For example, many HROs use two‐person patient identification when administering narcotics via a patient‐controlled administration system. If the pump were set incorrectly, the patient could receive an inappropriate dose, have a respiratory arrest, and potentially die. The two‐person process is an essential safety step and reinforces teamwork when providing care.

Providing mutual support to team members is the ability to anticipate team members' needs and provide assistance as needed through accurate knowledge about their workloads and responsibilities. Team members are expected to advocate for the patient. Feedback should be timely, respectful, specific, and directed toward quality improvement.

In this competency, nurses integrate best current evidence with clinical expertise and patient/family preferences and values to deliver optimal health care. Direct care nurses develop an individualized plan of care for each patient based on the evidence, patient values, and their clinical expertise. Nurse leaders design the work environment and organizational systems to support evidence‐based practice and facilitate the integration of new evidence into standards of practice. They also translate knowledge into practice and generate new knowledge for nursing practice. Providing care based on the evidence is essential for an HRO and plays a key role in fostering both staff and patient safety. Evidence‐based practice is discussed in greater detail in Chapter 10.

In this competency, nurses use data to monitor the outcomes of care processes. They also use improvement methods to design and test changes to continuously improve the quality and safety of health care systems. As part of the nursing process, direct care nurses evaluate the care they deliver to each patient. In addition, direct care nurses work together to improve the outcomes of care for the populations served in the care setting. Clinical nurses and nurse leaders identify gaps between local outcomes and best practice outcomes. Nurse leaders lead and provide resources for quality improvement efforts, including access to quality data, quality improvement tools, and quality experts.

An HRO has a strong commitment to health care process improvement. Becoming an HRO requires that the organization systematically review the complexity of health care processes, identify the root causes of failures, implement solutions, measure and monitor outcomes, and sustain the improvement. In some cases, an entirely new process may be required to enhance safety. Increasingly, patients and their families are being engaged to assist in health care process improvements. Quality improvement is described in greater detail in Chapter 18.

Nurses who work on an Orthopedic Unit notice that their patients have a longer length of stay after hip replacement surgery than the national average. They use QI tools to understand this variation and determine that an underlying cause is inconsistent patient preparation prior to surgery. Some patients anticipate a speedy recovery and have not identified the help they will need after discharge. Other patients expect to be admitted to a rehabilitation unit to recover after surgery, which may not be indicated for the procedure. These situations result in discharge delays while the unit's nurse case manager arranges for family help, home care services, or rehabilitation services. The nurses work with other members of the interprofessional team, including physicians, physical therapists, and occupational therapists, to design a test of change. They create a patient education video that clearly outlines recovery expectations and guides patients in establishing a post‐discharge plan of care.

After implementing the intervention, they note that length of stay has decreased and there are still opportunities for improvement. The team designs another test of change. In addition to the video, each patient also receives a call from the nurse case manager to answer questions and discuss and document the plan of care. Again, the team sees a decrease in length of stay and continued opportunities. The team designs a third test of change. The day before the surgery, a nurse from the Preadmission Testing Unit (PAT) calls the patient and verifies the plan of care that the patient developed with the nurse case manager. If the plan is still in place and appropriate, the surgery is performed as scheduled. If the plan needs to be changed, the PAT nurse notifies the surgeon and nurse case manager and they work together to resolve the issues. After implementing this test of change, length of stay for patients having total hip replacement surgery is lower on the orthopedic Unit than the benchmark, and the team also sees a decrease in 30‐day readmission rates.

The purpose of the Nursing Quality Council is to review house‐wide quality data and share unit‐based quality improvement projects. As chair of the council, my role was to support staff nurses working on quality improvement projects by helping to provide data, research evidence, and other resources needed. Working with patients directly at the bedside gives staff nurses a unique insight on what positively affects quality of care. Having staff nurses involved in quality and safety improvement is vital, as it not only broadens the staff nurse's knowledge related to performance data, but also empowers them to offer their perspective on improvement projects that will directly affect patient care.

Karen Zaehler, BSN, RN, CMSRN

Staff Nurse, Surgical Care Unit, Edward Hospital

Naperville, IL

In this competency, nurses minimize risk of harm to patients and providers through both system effectiveness and individual performance. Direct care nurses incorporate human factors and other safety design principles into their care. They use effective strategies to decrease reliance on memory to reduce risk of harm to self and others. Direct care nurses identify and report concerns about safety and participate in analyzing errors and designing system improvements. They participate in root cause analyzes and use national patient safety resources in their professional development. Nurse leaders strategically plan to improve practice and reduce risk of harm to patients, staff, and others. They create HROs based on human factors research and foster a safe and reliable culture where safe design principles are developed and implemented. Nurse leaders anticipate and mitigate system failures and hazards and design and implement changes in response to identified hazards and errors.

Incorporate Human Factors. Humans function primarily in three performance modes: skill‐based, rule‐based, and knowledge‐based. Errors occur in each performance mode. By understanding the way humans function, nurses can decrease the number of errors that occur in each performance mode.

Individuals use skill‐based performance for routine, familiar tasks that can be done without thinking about them. The drive home, for example, may be so familiar that drivers arrive without knowing how they got there. Nurses often function in this mode because of the repetitive nature of some nursing tasks. Consider, for example, Jerry who is completing his documentation in the EHR. Jerry logs onto the EHR many times each day and he doesn't need to think about his user identification or his password. He's on auto‐pilot. He pulls up his assigned patients in the EHR and begins to document.

Generally, skill‐based performance is accurate, but there is still risk for error. Slips occur when, without intending to, the individual does the wrong thing. Jerry could open a patient's record and document care that was delivered to a different patient. Lapses occur when, without intending to, the individual fails to do what he meant to do. Jerry could document on the correct patient but forget to save or file his work before closing the record. Fumbles occur when, without intending to, an individual mishandles a word or action. Jerry might notice that his patient was visited by a “dear friend” and accidently document that the patient was visited by a “dead friend.”

Several strategies help nurses to stop and think before acting to prevent skill‐based errors. Nurses may use PAR (Pause‐Act‐Review). With this technique, nurses pause for 1 or 2 s to focus their attention on the task; act by concentrating and performing the task; and review their actions to check for the desired result. This self‐checking takes only a few seconds but greatly reduces the probability of making an error. Double checking one's own work also helps to prevent these errors. Nurses learn to check, re‐check, and check a third time before administering medications. Determining that the right drug in the right dose is being given by the right route, at the right time, and to the right patient involves checking the medication label against the medication order or medication administration record three times. In addition, two unique patient identifiers are verified prior to administering the medication. Health care facilities typically define which two patient identifiers are to be used, most often full name and date of birth. High risk medications, such as insulin, may require independent verification by another nurse. The independence of this double‐check helps to prevent skill‐based errors.

In rule‐based performance, the clinician applies a learned rule to an appropriate situation. The delivery of health care is largely based on rules, often called protocols. Rules may be learned in nursing school or through life experience, clinical experience, or continuing education. Errors may occur when functioning in a rule‐based performance mode. Leaders need to track data on staff compliance with rule‐based clinical performance and continually look for ways to improve practice. Errors occur in three ways: using the wrong rule; misapplying the rule; and disregarding the rule.

Sometimes, clinicians use the wrong rule. They may have been taught or somehow learned the wrong response for a situation. For example, Donna graduated many years ago and learned to treat patients for hypoglycemia if the glucose was 60 mg/dl or less. If Donna has not kept current with more recent diabetes and hypoglycemia guidelines, she will fail to treat a patient with a glucose of 70. The solution to this type of error is to educate clinicians with the right rule.

A rule‐based error also occurs if the clinician misapplies the rule. The nurse may know the right response but select another response instead. For example, Donna's patient has a blood sugar of 64 mg/dl. Donna knows it needs to be treated. Rather than rely on her memory, she quickly consults the hypoglycemia algorithm—an excellent safety practice. The algorithm indicates treatment with 15 g of glucose. Donna misreads the algorithm and gives 30 g of carbohydrates instead. This could over‐correct the low blood sugar, causing the blood sugar to spike and creating another patient safety event. This type of error may be prevented by pausing and thinking or reviewing a second time.

Rule‐based performance errors may also be caused by disregarding the rule, as when the clinician knows the rule but chooses not to follow it. For example, Donna's patient has a hypoglycemic event and she treats it appropriately. Donna knows that she should recheck her patient's glucose level 15 to 30 minutes after treating hypoglycemia. She sees that the patient is alert and oriented and looks fine. Donna tells the patient to put on her call light if she runs into any problems and does not recheck the blood sugar. Non‐compliance with rules can be prevented in several ways. First, Donna needs to understand the risks involved in not following the rules. In addition, organizations need to reduce the burden or difficulty of following the rules. Nurse leaders need to consider if there are adequate numbers of bedside glucose monitors so that a glucose recheck can be easily accomplished. They need to examine staffing to ensure it is enough to allow time for the glucose recheck. Last, Donna may need to be coached by her manager to make better decisions. If this is a repeated behavior, Donna will need to be counseled and disciplined by a nurse manager.

Donna, RN is caring for Mrs. Miller. Nursing Assistant Carly tells Donna that Mrs. Miller's routine bedside glucometer reading was 63 mg/dL. Donna appropriately treats Mrs. Miller with 15 g of glucose and asks Carly to recheck the blood sugar for the patient in room 532 in a half hour or so. Forty‐five minutes later, Carly tells Donna that she checked Mrs. Martin's blood sugar and it was 97 mg/dL. The nurse enters Mrs. Miller's room an hour later and finds her pale, diaphoretic, and confused.

Answer these questions:

In knowledge‐based performance, a clinician is solving problems in a new and unfamiliar situation. Clinicians may try to figure out how to perform based on what they already know, using trial and error, or even guessing at the solution. This is very dangerous. For example, Cindy is an experienced nurse who has been working in critical care for 15 years. When she arrives on her shift, her patient is receiving Continuous Renal Replacement Therapy. Cindy has not previously managed this therapy and is not familiar with the supplies and fluids used. Rather than proceeding independently, Cindy needs to stop and consider requesting a safer assignment. Alternatively, Cindy may work with an expert and consult a written resource such as an evidence‐based protocol while providing care.

Nurses and nurse leaders need to understand skill, rule, and knowledge‐based performance when investigating errors. Nurses who have been involved in an error should focus on how they made the decision they did. Did they develop a short cut or work‐around to save time? Did they fail to do a double check of their own work? Did they proceed even though they were not familiar with the procedure? Each type of error requires a different solution. The three performance modes are critical to keep in mind when designing error prevention strategies.

Root cause analysis (RCA) is an error analysis tool used in health care to investigate serious adverse events. TJC has mandated the use of RCAs to analyze sentinel events since 1997. RCAs identify underlying problems that increase the likelihood of errors rather than focusing on mistakes made by individuals. An RCA uses a systems approach to identify both active and latent errors. The goal of an RCA is to prevent future harm by eliminating the latent errors that often underlie adverse events.

RCAs begin with data collection and reconstruction of the event through record review and participant interviews. An interprofessional team then analyzes the sequence of events leading to the error, with two main goals: identify how the event occurred through identification of active errors; and identify why the event occurred through systematic identification and analysis of latent errors (AHRQ, 2018a, 2018b). Action plans are developed, implemented, and evaluated based on RCA findings.

Nurse leaders striving for high reliability must facilitate RCA investigations into how and why errors occur. These investigations make errors visible, encourage learning from events, and help prevent errors in the future. Direct care nurse involvement in RCAs is critical to their success. As part of the RCA investigation, nurses need to be comfortable while recounting the actions they took and the rationale for their actions. In addition, direct care nurses are crucial for the development of action plans to help mitigate future risk.

This is a critical role for the CNO and other nurse leaders within an organization. Patients are counting on health care organizations for help and do not expect to be injured as part of that care. Nurse leaders must take many actions to achieve this culture. It begins with strategic planning.

Strategic planning is a continuous, systematic process of making decisions today with the greatest possible knowledge of their effects on the future (Drucker, 1974). The final product of the strategic planning process is the creation of a strategic plan. A strategic plan has several purposes. First, it clearly defines the mission of the organization and establishes realistic goals and objectives consistent with that mission. Next, it communicates the mission, goals, and objectives to the organization and the community. Third, a strategic plan helps to ensure that the needed resources are available to carry out the initiatives that have been identified as important to the organization. Next, it provides a method to track progress and a mechanism for making changes when needed in the future. Last, a strategic plan allows nurse leaders to select among seemingly equal alternatives based on each alternatives' potential to move the organization toward the desired end goal.

Strategic planning may be conducted for an entire organization, a unit or division, or a major initiative. This chapter will focus on creating a strategic plan to embark on a journey toward high reliability.

Large strategic planning projects benefit from the formation of an advisory board selected from various constituencies what will be affected by the plan. The advisory board does not have formal authority over a program but is instrumental in reviewing the plan and making recommendations and suggestions. Because the advisory board is deliberately selected to reflect representation from various areas, the board will be able to identify potential concerns and provide sound guidance for the plan.

Various strategic planning approaches or models exist. Because they are both based on the scientific method, strategic planning steps are similar to the steps in the nursing process. In strategic planning, the organization analyzes the environment, reviews the literature, formulates goals, develops strategies and action plans, implements the plan, and evaluates the plan. Table 4.5 lists more detailed steps in the strategic planning process.

Table 4.5 Steps in the Strategic Planning Process

Source: Patti Ludwig‐Beymer.

An environmental assessment requires a broad view of the organization's current environment. Both the external and the internal environment are carefully appraised. The external environmental assessment is broad based and attempts to view trends and future issues and needs that could impact the organization. The internal assessment seeks to inventory the organization's assets and liabilities.

A SWOT analysis is frequently used to conduct environmental assessments. SWOT is an acronym for strengths, weaknesses, opportunities, and threats. A SWOT analysis identifies strengths and weaknesses in the internal environment and opportunities and threats in the external environment. The SWOT analysis is useful both for initial brainstorming and for a more formal planning document. Table 4.6 provides a hypothetical SWOT analysis focused on creating an HRO in a community hospital.

Table 4.6 SWOT Analysis for a Hypothetical Hospital

Source: Patti Ludwig‐Beymer.

Stakeholder assessment is an important part of an environmental assessment. A stakeholder is any person, group, or organization that has a vested interest in the program or project under review. A stakeholder assessment is a systematic consideration of all potential stakeholders to ensure that the needs of each of these stakeholders are incorporated in the planning phase. For an organization or program to be successful, the involvement of those who will be affected is essential. This is true whether the stakeholders are in the community or are unit staff who will be affected by a proposed strategic plan. When stakeholders are not involved in the project planning, they do not gain a sense of ownership and may not enthusiastically accept a program or strategic goal.

Other Methods of Assessment may be used to support involvement in the strategic planning process. Thoughtful planning is required to determine the method and when to use the method.

Frequently, surveys or questionnaires are used when there are many stakeholders. For example, staff might be polled to see whether they would attend continuing education on safety and high reliability and which days and times would be most desirable.

Focus groups are small group meetings composed of individuals selected because of a common characteristic. Members are invited to meet in a group and respond to questions about a topic in which they are expected to have an interest or expertise. For example, a group of patients who recently had experiences with childbirth might be asked to come together to discuss their obstetric experiences at the institution in the hope that the discussion will lead to insights or information that could be used for enhancing safety. Focus groups are usually more time consuming and expensive to conduct than questionnaires or surveys. They work best when the topic is broad and qualitative input is being sought by the organization.

Think about a health care organization with which you are familiar.

What activities of the organization are reflective of its mission?

A review of the literature should be completed early in the strategic planning process. This allows the project team to identify similar organizations or programs, their structures and processes, successes, and potential problems and challenges. It helps to make the plan evidence‐based. The literature review is an ongoing process that includes tentatively identifying programs, searching the literature for successes and issues, and then refining the program ideas. Identifying best practices or evidence‐based innovations that have been adopted with success by other organizations can facilitate strategic planning. Nurse leaders need to carefully examine the existing evidence and practices prior to beginning planning.

Determining the congruence of the project or program with the organizational mission is another step in the strategic planning process. Early in the planning process, the project or program must be considered within the context of the organizational mission to ensure that the project or program is congruent with organization's main mission. Typically, the overall mission and vision of the organization is reviewed as part of strategic planning. At times, the mission of the organization needs to be modified. For example, to become an HRO, the central theme of safety needs to be a part of the organization's mission.

Next, the Strategic Planning team next identifies goals and objectives.

Then the Strategiv Planning team designs strategies or programs to achieve their goals and objectives. After the goals, objectives, and strategies have been identified, they are prioritized according to strategic importance, resources required, and time and effort involved.

Action plans are established based on this prioritization. Action plans identify timelines, financial resources, and individuals responsible for the implementation. A realistic timeline allows an organization to evaluate each goal and objective and the degree to which each can be implemented in the specified time frame and with the available resources. Setting a timeline for completing a strategic plan is similar to the prioritization process in that the strategic importance, resources, and effort required are major considerations. Realistic timelines and individual responsibilities must be developed, specified, clarified, and communicated to all stakeholders. This will help to avoid misunderstandings and unmet expectations.

A plan for communicating the strategic plan, often called a marketing plan, is required for all strategic plans. This holds true whether the strategic planning involves new programming for external audiences or only internal redesign or restructuring. All constituents need to understand the strategic plan, goals, and objectives. This communication is essential when building a culture of high reliability. Designing, implementing, and evaluating new safety strategies will require substantive changes in work flow and in the way that nurses and other staff members carry out their day‐to‐day work processes. Clearly communicating education requirements will help to ensure proper preparation for nurses, physicians, and other staff members. Without adequate thought to communication across the organization about the project, there is less chance of success and a greater risk of poor cooperation. A marketing plan ensures that all stakeholders have the needed information.

Implementation and evaluation of the strategic plan are the final two steps in the process. The action plans must be put into place, and outcomes associated with the plan need to be evaluated. For organizations on the journey toward high reliability, it is expected that safety events will initially rise as nurses and other staff begin to feel more comfortable reporting errors. However, over time, those safety events decrease as the organization begins to practice in new and safer ways.

When implementing a strategic plan with a focus on creating an HRO, nurse leaders must make their commitment to safety clear. This may be achieved by including safety stories at each meeting. A safety story can review a tool for preventing error, provide an example of using the tool, explain why safety is important, summarize a harmful event, or thank a staff member for being committed to patient or employee safety. Many hospitals use safety stories to keep safety at the top of everyone's mind.

Nurse leaders are responsible for creating a fair and just culture to minimize blame and punishment and encourage individuals to report errors so that the system problems can be corrected. In the past, health care took a punitive approach toward errors, viewing those who made errors as “bad apples” (Institute of Medicine, 1999). This approach served as a disincentive to reporting errors and mistakes and resulted in missed opportunities to uncover and correct problems that impacted safety. The approach also over‐simplified safety by overlooking the impact of the system on safety care. More recently, the concept of a just culture has been embraced within health care.

A just culture creates an atmosphere of trust, encouraging and rewarding people for providing essential safety‐related information (Reason, 1997). It views errors as opportunities to improve the understanding of both health care system risk and individual behavioral risk. It changes staff expectations and behaviors so that everyone looks for risks in the environment, reports errors, helps to design safe health care systems, and makes safe choices. A just culture also identifies what constitutes acceptable and unacceptable behavior. The American Nurses Association (2010) has endorsed the just culture model.

Ultimately, the just culture model creates a learning culture that is open and fair; manages behavioral choices; and designs safe health care systems. An HRO cannot exist in the absence of learning. The learning organization is an organization where people continuously learn and enhance their capabilities to create (Senge, 1990). Nurse leaders in HROs view each failure as an opportunity to learn from mistakes. They readily admit weaknesses and commit to learning from its mistakes. They take a systems approach to safety and improving the culture of safety. Nurse leaders in these organizations create a supportive learning environment by putting processes in place to facilitate learning and encourage creativity among employees. Such a learning environment requires transparency related to safety, so that everyone is aware of opportunities for improvement.

Reporting errors and near miss safety events can assist in understanding a problem rather than hiding that a problem exists. As a result, nurse leaders must put tactics in place to increase error reporting. Speaking up for safety may appear to be easy. Health care providers come into health care to do the right thing, help patients, and cause no harm. However, errors happen. In an HRO, all health care providers are responsible for reporting safety events, including near misses, adverse events, and sentinel events. This type of reporting has its limitations, as it depends on both the recognition of the safety event and the completion of a safety event report. When using voluntary reporting and error tracking, only around 10 to 20 % of all errors are reported in health care organizations (Classen, et al., 2008). A study of Medicare beneficiaries found that only 14 % of patient harm events were captured in hospital incident reporting systems (Health and Human Services, 2012). Nurse leaders must encourage and reward staff who report safety events and decrease the fear inherent in error reporting.

This starts with a robust error‐reporting system which can be easily accessed and completed by direct‐care nurses and other clinicians. Next, nurse leaders need to thank staff for reporting errors, mistakes, events, and near misses. The Good Catch award, implemented in many hospitals across the country, is one way to recognize staff who report near misses or close calls. Edward Hospital in Naperville Illinois implemented the Good Catch award in 2008. Each month, Risk Managers compile a list of safety events that have been identified by staff and have not reached the patient to cause harm. Members of the senior leadership team vote on the most significant event. The person or team is recognized at a Management Team meeting and receives a certificate, a lapel pin, and a Good Catch trophy. The program recognizes those who speak up and fosters a culture of transparency and safety.

Speaking up for safety requires more than reporting actual or potential errors. It also involves clinicians stopping a care process whenever a member of the care team has a safety concern. This may be uncomfortable for clinicians who have historically viewed health care as hierarchical. As a result, nurse leaders must clearly communicate that everyone has the authority to stop for a safety concern at any time. Nurses are expected to voice their concern and “stop the line” if they sense or discover a safety issue. The acronym CUS may be used. The letters represent “I am Concerned;” “I am Uncomfortable;” and “This is a Safety Issue.” Consider this powerful and effective way of speaking up: “I am concerned with Mr. Lopez's sudden hemiparesis and am concerned with your choice of not implementing the stroke protocol. I believe this is a safety issue.”

The just culture model requires leadership competencies to manage behavioral choices. The Just Culture recognizes that many errors result from interactions between humans and the systems in which they work. Nurses and other clinicians should not be held accountable for system failings over which they have no control. Discipline should be tied to the behavior of individuals and the riskiness of their behavior, not only to the actual outcome of their actions (Marx, 2001). Nurse leaders must appropriately hold individuals accountable for their behaviors and investigate the behaviors that led to the error.

Building and reinforcing accountability is part of managing behavioral choices. Nurse leaders must set clear behavioral expectations, educate staff, and build staff skills. Everyone within the organization must be educated on these expectations. Nurse leaders must recognize that three types of accountability exist: vertical, horizontal, and intrinsic accountability.

Vertical accountability occurs when humans perform in a certain way because someone, like a manager, is watching. Horizontal accountability occurs when humans perform in a certain way because of peers, teamwork, or the desire to function as effectively as others.

Intrinsic accountability exists within the individual. Nurse leaders need to expect accountability and enhance the intrinsic motivation of the nurse to meet performance expectations. In addition, nurses need to hold their peers accountable for safety. While each type of accountability is important, the ultimate goal is for staff to practice in a safe manner even when nobody's watching.

A Performance Management Decision Guide is available to guide management decisions when human error occurs (Reason, 1997). The first step is a deliberate act test. If the individual acted with malicious intent, disciplinary action and a report to a professional group, regulatory body, and/or law enforcement is warranted. If there is confirmed ill health and the individual was unaware, a leave of absence and physician referral is appropriate. If substance abuse is suspected, testing, disciplinary action, and treatment are warranted. If the individual chose to take an unacceptable risk based on policies, procedures, and protocols commonly used within the organization, disciplinary action may be warranted. However, if the individual adhered to generally accepted performance expectations and simply made an unintended error, the individual needs to be consoled and coached. In every case, leadership is also responsible for correcting safety problems that contributed to the error.

The just culture model acknowledges that humans make mistakes. As a result, no system can be designed to produce perfect results. However, health care systems can be designed to decrease risk. Consistent with creating a Just Culture and demonstrating sensitivity toward operations, nurse leaders must identify and correct system problems.

Many system problems can be discovered at a daily safety huddle, a short meeting at the beginning of the day that includes senior and operational leaders. This meeting allows the organization to address safety issues for patients or staff quickly and efficiently. Operational leaders review actual or potential safety issues from the past 24 hours and anticipate issues that may occur over the next 24 hours. They identify how the safety issues may impact other departments. They discuss any barriers to safe care, such as inadequate staffing, supplies, medications, or technology. They describe any high‐risk or non‐routine situations, such as a planned surgery for an incarcerated individual. Appropriate experts are mobilized and empowered to solve the problem. For example, leaders from several clinical areas may report a needle stick injury to a nurse. Without a daily safety huddle, leaders may not be aware of this increase until monthly or quarterly data are tabulated. Because of the safety huddle, however, the information may be used to quickly launch a system‐wide task force to determine the causes of the injuries and develop strategies to decrease the needle stick injuries.

Frequent and regular leader rounding in clinical practice areas allows nurse leaders to see the conditions under which care is delivered and to talk with staff about safety concerns for themselves and their patients. Nurse leaders can also provide feedback and reinforcement to staff. Both positive and constructive feedback is needed to decrease human errors, and the majority should be positive. Immediate and specific feedback helps to reinforce positive behaviors. Thanking nurses for practicing safely helps to reinforce safe behaviors. If nurse leaders observe unsafe behaviors, they should immediately correct the behavior and offer a practice tip to extinguish the unsafe behavior. For example, a nurse leader may see a nurse enter a room and provide care without sanitizing her hands. The nurse leader should correct the nurse, tie hand hygiene to the core value of safety, and ask the nurse to commit to performing hand hygiene and helping others to do the same in the future.

Nurse leaders must also assess the organizational culture to determine the shared values and beliefs of individuals in a group or organization. This chapter will consider culture as it relates to safety and high reliability.

Culture is sometimes described as the way people act when no one is looking. For example, consider Beth, a patient care technician caring for a patient in isolation. Beth entered the patient's room without wearing appropriate personal protective equipment. By deviating from policy, she put herself, her family, her patients, other staff, and everyone she encountered at risk for infection. When asked about her behavior, Beth stated that she knew the patient was in isolation and that she should put on a gown and gloves. She further explained that she did not think anyone was watching. This illustrates an employee who has not yet internalized a culture of safety.

On the other hand, consider Bill, a housekeeper who informed his supervisor that he found a sharp metal edge on a door handle on the Adolescent Behavioral Health Unit. Bill and his supervisor were concerned that someone could get hurt and alerted the unit manager. The manager asked Joe from facilities to fix the handle as quickly as possible. Joe noticed that two screws were missing from the metal plate. The manager of the unit was notified, and staff members searched the unit including each patient's room. The missing screws were eventually located in a patient's tooth brush holder. Because Bill and Joe paid attention to detail and spoke up, the patient was kept safe from harming himself. This scenario exemplifies employees who are living a culture of safety.

Many organizations use a culture of safety survey tool to capture the perspectives of health care providers. Two commonly used tools are the Survey on Patient Safety Culture (AHRQ, 2017) and the Safety Attitudes Questionnaire (Sexton et al., 2006). Organizations may also choose to assess their stage of organizational maturity toward becoming an HRO using a model proposed by Chassin and Loeb (2013).

The AHRQ sponsored the development of separate patient safety culture surveys for hospitals, nursing homes, medical offices, community pharmacies, and ambulatory surgery centers. Each survey measures multiple dimensions of safety culture. For example, the hospital survey measures teamwork within units; supervisor/manager expectations and actions promoting patient safety; organizational learning; management support for patient safety; overall perceptions of patient safety; feedback and communication about error; communication openness; frequency of event reporting; teamwork across units; staffing; handoffs and transitions; nonpunitive response to errors; number of events reported; and asks the participant to assign a patient safety grade to the organization. The Patient Safety Culture surveys are available in English and Spanish and are publicly available at no cost on the AHRQ website.

AHRQ also created databases for Patient Safety Culture survey data from organizations that administer the surveys. The databases allow health care organizations to compare their patient safety culture survey results to similar sites in support of patient safety culture improvement. Survey results are used by organizations to raise staff awareness about patient safety; assess and diagnose the current status of the patient safety culture; identify strengths and areas of opportunity for patient safety culture improvement; examine trends in patient safety culture changes over time; evaluate the impact of patient safety initiatives and interventions on the culture; and conduct internal and external evaluations the culture of safety. AHRQ provides an Action Planning Tool to assist an organization in analyzing and improving their patient safety culture.

The Safety Attitudes Questionnaire was developed with funding from the Robert Wood Johnson Foundation and the AHRQ. The 36‐item survey obtain frontline staff perspectives about specific patient care areas. The key factors that are measured include teamwork climate; safety climate; perceptions of management; job satisfaction; working conditions; and stress recognition. The survey is used by health care organizations to compare themselves to other organizations; identify interventions needed to improve safety attitudes; and measure the effectiveness of the interventions.

Chassin and Loeb (2013) developed a grid to allow health care organizations to assess their stage of organizational maturity toward becoming an HRO: beginning, developing, advancing, and approaching. Chassin and Loeb identified performance based on Position (Board, CEO/Management, Physicians); Initiatives (quality strategy, quality measures, and information technology); Safety Culture (trust, accountability, identifying unsafe conditions, strengthening systems, and assessment); and Robust Process Improvement (methods, training, and spread). Their grid may be used by leaders to assess their journey toward becoming an HRO.

In this final QSEN competency, nurses use information and technology to communicate, manage knowledge, mitigate errors, and support decision making. Direct care nurses apply technology and information management tools to support safe processes of care. They effectively navigate the EHR and respond appropriately to clinical decision‐making supports and alerts. They use information management tools to monitor outcomes of care and they use high quality electronic sources of health information. Nurse leaders ensure that nurses participate in the selection, design, implementation, and evaluation of information technology. They also anticipate unintended consequences of new technology and participate in the design of clinical decision support systems.

Intravenous pumps with built‐in limits for medication doses serve as an example of technology that assists in preventing catastrophic medication errors.

Tina is caring for a patient with pulmonary emboli. She reviews the medication orders to administer 80 units of heparin per kilogram by intravenous bolus, followed by 18 units per kilogram as an hourly infusion. Tina knows her patient weighs 161 pounds, or 73 kg. She correctly calculates and administers the initial dose of 5,840 units. Tina calculates the continuous infusion rate at 1,314 units per hour. When programming the pump, however, her finger slips and she enters the numbers 11,314 into the pump. Because the programmed dose is beyond the normal range for heparin, the pump does not administer the drug, and Tina receives an error message from the pump. She quickly identifies and corrects the programming error. An independent double check from a peer for this high‐risk medication would also catch this programming error before it reaches the patient.

Answer these questions:

In this scenario, the IV pump caught the error because the dose was excessive. What other strategies could Tina use to catch a programming error before it reaches the patient?

In an HRO, health information technologies help facilitate and sustain quality improvement efforts to improve patient safety. Using health information systems to document care and gather quality and safety information is essential. Additionally, health care information systems provide a method for reporting errors and near misses. The lack of health information systems can impede progress to an HRO. Health care organizations are challenged to devote scarce resources to implement information systems that require significant capital expense and ongoing maintenance costs. In addition, hospital leaders sometimes apply technology to faulty health care processes. Technology can only help improve health care processes when applied appropriately. As part of technology implementation, safe health care processes must be designed and technology must be used to support and sustain the improvements. As seen below, telehealth technology can also be used to make resources available to patients and clinicians remotely (Figure 4.7).

FIGURE 4.7 Four senior nursing students at Purdue University Northwest demonstrate how to use a Telehealth cart.

Sources: Joshua Kocoj, Amber Mills, Jonathan Miskus and Riley Wayco.

Informatics can also help organizations to identify events that cause harm to patients in order to select and test changes to reduce harm. The Institute for Healthcare Improvement Global Trigger Tool (IHI, 2017) helps health care organizations get a clearer understanding of the safety of care by measuring risk and harm at the hospital level. The Global Trigger Tool (GTT) uses specific patient care triggers as indicators that an adverse event may have occurred. Using GGT to identify adverse events (AEs) is an effective method for measuring the overall level of harm from patient care in a health care organization. GTT provides an easy‐to‐use method for accurately identifying AEs (harm) and measuring the rate of AEs over time. Tracking AEs over time is a useful way to tell if changes being made are improving the safety of the patient care processes.

More than 50 triggers are consolidated into categories on the GTT related to the provision of surgical, ICU, perinatal, medication, and emergency department care (Institute for Healthcare Improvement, 2018). For example, transfer to a higher level of care is one of the Global Triggers. Consider a situation where a patient is transferred from a medical–surgical unit to the ICU due to a rapid drop in blood pressure and decreased level of consciousness. This event would activate a trigger. The patient's EHR would be reviewed to determine what happened to the patient, when it happened, and if it could have been avoided. In an HRO, investigation results and the GTT results are shared with health care providers and process improvement changes are put into protocols, policies, and procedures to reduce the chance of future safety problems occurring. In an HRO, a multifaceted reporting approach is needed that is comprehensive and provides accurate measurements of errors and near misses.

Increasingly, the government is mandating public reporting for healthcare safety, quality, and financial indicators. This transparency holds health care providers and organizations accountable for quality care and is designed to help the consumer make informed choices about selecting health care providers. Public awareness of medical errors, poor quality outcomes, and perceived low value are driving changes in health care. Multiple groups are now focused on safety in health care. Many resources are available to nurses in the journey toward high reliability. Resources include nursing associations, interprofessional organizations, government agencies, accreditation agencies, and consumer organizations.

Many nursing associations addresses safety, high reliability, or one or more of the five components of HROs. For example, the American Nurses Association identified the Culture of Safety as their focus for 2016. They focused on a different theme each month to explore the benefits of a collaborative commitment to safety, and how to achieve it (ANA, 2016). The American Association of periOperative Nurses (2018) uses “Safe Surgeries Together” as their tagline. Their website includes publications on many topics, including patient and worker safety, perioperative safety, medication safety, radiation safety, surgical smoke safety, sharps safety, and product and equipment safety. The Association of Women's Health, Obstetric and Neonatal Nurses' website (2018) includes a variety of educational modules designed to improve safety for obstetric and neonatal patients.

Designation by the American Nurse's Credentialing Center (ANCC) as a Magnet™ organization denotes nursing excellence and is factored into payer reimbursement and recognition (ANCC, 2017). The components of the Magnet Recognition Program^® are congruent with the HRO concepts. The Magnet components include Transformational Leadership; Structural Empowerment; Exemplary Professional Practice; New Knowledge, Innovations and Improvements; and Empirical Outcomes. The original Forces of Magnetism emphasized structure and process. The current Magnet Model recognizes that an excellent infrastructure must result in positive outcomes in order to create a culture of excellence and innovation. Safety is a main component of a culture of excellence.

The Transformational Leadership component of the Magnet Model requires strong advocacy and support for staff and patients by all nursing leaders. The CNO must be positioned to effectively influence other executive stakeholders, including the board of directors. In a Magnet‐designated hospital, the CNO is an active leader in creating an HRO by working with the hospital's executive team to establish a strategic plan for quality and safety. These strategic goals support the organization's commitment to zero major quality failures.

Source: Adapted from Jeffs, L., Baker, G. R., Taggar, R., Hubley, P., Richards, J. et al. (2018). Attributes and actions required to advance quality and safety in hospitals: Insights from nurse executives. Nursing Leadership, 31(2), 20‐31. doi:10.12927/cjnl.2018.25606

Discussion: The article describes qualitative research conducted to explore nurse executives' understanding of and engagement with patient safety and quality improvement. Three themes emerged: 1) being a strategic and system thinker while possessing emotional intelligence and influencing staff; 2) building credibility and relationships with point‐of‐care staff, board of directors, and the leadership team; and 3) creating a culture of safety and high reliability.

Implications for Practice. Study findings are helpful for nurse leaders at all levels to enhance their knowledge, attitudes, and skills in quality and safety.

The Structural Empowerment component of Magnet addresses the need to create structures and processes that allow nurses to practice safely and effectively. For example, one source of evidence related to Structural Empowerment calls for clinical nurse involvement in interprofessional decision‐making groups at the organizational level. Five of the 13 Structural Empowerment sources of evidence address nursing's role related to quality and safety. Both the Transformational Leadership and Structural Empowerment components of Magnet require the active engagement of nurses.

The Exemplary Professional Practice component of Magnet indicates that “achievement of exemplary professional practice is grounded in a culture of safety, quality monitoring, and quality improvement” (ANCC, 2017, p. 40) and that “[n]urses participate in safety initiatives that incorporate national best practices” (ANCC, 2017, p. 41). Many of the Exemplary Professional Practice sources of evidence require documentation of safe nursing practices. For example, all organizations that provide inpatient care are required to report on two nurse‐sensitive clinical indicators: patient falls with injury and hospital‐acquired pressure injury, stages 2 and above. The hospitals must report two additional measures from a list that includes: central line‐associated blood stream infection, catheter‐associated urinary tract infection, Clostridium difficile, Methicillin‐resistant Staphylococcus aureus, venous thromboembolism, peripheral intravenous infiltrations, physical and sexual assault, and device‐related hospital‐acquired pressure injury. Two ambulatory indicators must also be reported. The performance on each of the six indicators must exceed the mean or median value for the majority of units the majority of the time to meet Magnet standards. Other sources of evidence require examples of nurse partnership with patients and/or families to influence change in the organization; and improved outcomes related to the professional practice model, interprofessional collaborative plan of care, interprofessional quality improvement activity, interprofessional education, and clinical nurse involvement in the evaluation of patient safety data at the unit level. Last, nurse safety is also addressed within the Exemplary Professional Practice component. Organizations must provide an example of an improved workplace safety outcome for nurses specific to workplace violence.

The New Knowledge, Innovations and Improvements component of Magnet requires nurses to use evidence and innovation for safe, high‐quality care. Last, the Empirical Outcomes component of Magnet requires the organization to continually assess and monitor a variety of indicators for nursing leadership and clinical practice. Sustained quality performance on empirical outcomes will move an organization on the journey to becoming an HRO.

Magnet is a continuous journey that creates a culture that strives to improve outcomes centered on safety, quality, and service for patients and nurses. As nurses lead the care delivery environment, they are at the sharp point of creating a healthy environment and delivering safe quality care which are the pillars of a Magnet organization.

Wendy Tuzik Micek, PhD, RN, NEA‐BC

Director Nursing Science and Magnet Program Director

Advocate Children's Hospital

Oak Lawn, IL

Participation in interprofessional organizations can also assist nurse leaders in their quest to become HROs. Organizations include the IHI, The Institute for Safe Medication Practices (ISMP), National Patient Safety Foundation, National Quality Forum (NQF), and Patient Safety Organizations.

The work of the IHI began as part of a demonstration project to redesign health care into a system without errors, waste, delay, and unsustainable costs. IHI works with health systems, countries, and other organizations on improving quality, safety, and value in health care. They use a science of improvement approach, characterized by combining expert subject knowledge with improvement methods and tools. This interprofessional approach draws on clinical science, systems theory, psychology, statistics, and other fields. IHI's methodology is based on the work of W. Edwards Deming, who taught that organizations can increase quality and simultaneously reduce costs (Institute for Healthcare Improvement, 2018). The IHI Model for Improvement asks three questions: 1) What are we trying to accomplish; 2) How will we know that a change is an improvement; and 3) What changes can we make that will result in improvement? As seen in Figure 4.8, the model then employs Plan‐Do‐Study‐Act (PDSA) cycles for small, rapid‐cycle tests of change (Institute for Healthcare Improvement, 2018).

FIGURE 4.8 PDSA Quality Improvement Model.

Source: Institute for Healthcare Improvement, 2018.

The ISMP is a nonprofit organization devoted to medication error prevention and safe medication use. It provides impartial, timely, and accurate medication safety information. ISMP's initiatives are built on non‐punitive approaches and system‐based solutions. It focuses on knowledge, analysis, education, cooperation, and communication. ISMP reviews all medication error reports submitted by health care facilities and health care professionals. In addition, it works directly and confidentially with the pharmaceutical industry to prevent errors that stem from confusing or misleading naming, labeling, packaging, and device design (Institute for Safe Medication Practices, 2018).

ISMP publishes monthly newsletters to educate the health care community about safe medication practices (Figures 4.4 and 4.5). They suggest that nursing students have a key role to play in a culture of safety. ISMP analyzed nursing student‐associated medication incidents and created the following practice tips to enhance the culture of safety: (a) students bring a new perspective to the medication‐use system and should be encouraged to question, identify, and report errors or gaps; (b) be sure that the preceptor's workload accounts for the level of supervision each student needs to optimize her of his learning in a safe environment; and (c) review organizational challenges impacting students to identify opportunities to improve the culture of safety (Institute for Safe Medication Practices, September 2018).

The National Patient Safety Foundation (NPSF) partners with patients and families, the health care community, and key stakeholders to create a world where patients and those who care for them are free from harm. They work collaboratively to advance patient safety, promote health care workforce safety, and disseminate strategies to prevent harm. NPSF offers a portfolio of programs targeted to diverse stakeholders across the health care industry. The American Society of Professionals in Patient Safety (ASPPS) is part of NPSF. It provides education and oversees professional certification in patient safety and quality. The Institute for Healthcare Improvement and the National Patient Safety Foundation began working together as one organization in May 2017. The merged entity uses its combined knowledge and resources to focus and energize the patient safety agenda in order to build systems of safety across the continuum of care (National Patient Safety Foundation, 2018).

The National Quality (NQF) focuses on improving the quality of health care, with patient safety central to achieving the goal. About 100 of the 600 NQF endorsed quality measures are patient‐safety focused. NQF has endorsed 34 Safe Practices for Better Health Care and 28 Serious Reportable Events. There are still significant gaps in the measurement of patient safety. By convening panels and other educational forums, NQF works with quality measure developers and others in health care to help understand measurement gaps and encourage strategies to fill them. A list of 28 adverse events, also called Never Events because they should never occur in health care, are grouped into six categories; surgical, product or device related, patient protection, care management, environmental, radiologic, and potential criminal events (National Quality Forum, 2018).

A Patient Safety Organization (PSO) is a group, institution, or association that improves patient care by reducing errors. PSOs exist to allow organizations to learn from their own safety events and the safety events of others. The Patient Safety and Quality Improvement Act of 2005 was enacted in response to the publication To Err is Human (Institute of Medicine, 1999) and growing patient safety concerns in the United States. The law provides confidentiality and privilege protections, which means the information cannot be included in a law suit. A complete list of federally‐approved PSOs may be found on the AHRQ website (AHRQ, n.d.).

Government agencies also focus on safety and provide resources for organizations on a journey toward high reliability. Key agencies include the Agency for Healthcare Research and Quality; Centers for Disease Control and Prevention; and the Centers for Medicare and Medicaid.

The Agency for Healthcare Research and Quality (AHRQ)'s mission is to produce evidence to make health care safer; of higher quality; more accessible, equitable, and affordable; and to work with the U.S. Department of Health and Human Services and with other partners to make sure that research findings are understood and used. AHRQ funds a variety of research and demonstration initiatives and creates materials to teach and train health care providers and health care system professionals to put the results of research into practice. In addition to the AHRQ initiatives already discussed in this chapter, AHRQ safety innovations include:

The Centers for Disease Control and Prevention (CDC) provides tools and data to assist organizations on their journey toward high reliability. Their website includes information on diseases and conditions; healthy living; travelers' health; emergency preparedness; injury, violence and safety; environmental health; and workplace safety and health (CDC, 2019). CDC provides educational material for both consumers and health care workers. For example, the website includes a variety of tools and promotional materials available at no cost to enhance the performance of hand hygiene (Figure 4.9) (Centers for Disease Control and Prevention, 2019).

FIGURE 4.9 This Clean Hands Flyer Count Flyer from the CDC increases patients' and visitors' involvement in safe care.

Source: Clean Hands Campaign, Centers for Disease and Control (2019). Retrieved August 29, 2019. Retrieved from: from www.cdc.gov/handhygiene/campaign/index.html

As a major financial reimbursor for health care services in the United States, the Centers for Medicare and Medicaid (CMS), recognizes the escalation of health care costs, poor patient outcomes, health care errors, and waste. As such, CMS posts safety, quality, and patient experience data on the CMS website (www.medicare.gov/hospitalcompare/search.html). CMS created the Centers for Medicare and Medicaid Innovation as part of the Affordable Care Act to enhance the quality of health care and reduce costs through innovative approaches to health care delivery.

CMS ties financial incentives to reliability through pay for performance programs focused on care provided in hospitals, home care, physician practices, and skilled nursing settings (Centers for Medicare and Medicaid Services, 2018a, 2018b, 2018c, 2018d). The three hospital‐based pay for performance programs are the value‐based purchasing (VBP) program, the readmission reduction penalty program, and the hospital‐acquired conditions( HAC) reduction program. Hospitals with better than expected outcomes receive higher reimbursement for patients insured under Medicare, while those with worse than expected outcomes receive lower reimbursements.

In value‐based purchasing (VBP), hospitals earn scores based on achievement of or improvement in their safety, quality, patient experience, and financial performance (Centers for Medicare and Medicaid Services, 2018a, 2018b, 2018c, 2018d). VBP evaluates a hospital on five domains: patient and caregiver centered experience of care and care coordination; clinical care outcomes; efficiency and cost reductions; safety; and clinical care processes.

The hospital readmission reduction penalty program focuses on patients being readmitted to hospitals for six specific conditions: acute myocardial infarction, coronary artery bypass graft surgery, chronic obstructive pulmonary disease, heart failure, pneumonia, and total hip and knee arthroplasty. The hospital's actual readmission rate is compared to the expected rate of readmissions given the patient's comorbidities (Centers for Medicare and Medicaid Services, 2018a, 2018b, 2018c, 2018d). Comorbidities are two or more coexisting medical conditions or disease processes that are additional to an initial diagnosis. For example, a patient may be admitted for pneumonia. If the patient also has diabetes and heart failure, these coexisting conditions must be documented because they make patient care more complex.

The HAC reduction program examines hospitals' performance on safety indicators and hospital‐acquired infections. Safety indicators are based on physician, advanced practice registered nurse, and physician assistant documentation. The coded data are then analyzed as part of the Agency for Healthcare Research and Quality Patient Safety Indicators (PSI‐90). For hospital‐acquired infections, hospitals are required to submit their data on central line‐associated bloodstream infections, CAUTI, surgical site infections for colon and hysterectomy surgeries; methicillin‐resistant Staphylococcus aureus bacteremia, and Clostridium difficile infections to the Center for Disease Control and Prevention National Healthcare Safety Network (NHSN) databases. Each hospital's performance is compared to the mean. Poor performing hospitals receive a 1 % penalty (Centers for Medicare and Medicaid, 2018).

CMS publicly reports each hospital's performance on these measures. In addition, many states require health care organizations to report specific adverse events and safety, quality, and staffing indicators. These indicators are available to the public at state websites.

The Medical Product Safety Network (MedSun) is an adverse event reporting program within the U.S. Food and Drug Administration's Center for Devices and Radiological Health (FDA, 2018). MedSun's goal is to work collaboratively with the clinical community to identify, understand, and solve problems with the use of medical devices.

The Safe Medical Devices Act requires hospitals and other health care organizations to report medical device problems that result in serious illness, injury, or death. Once a problem is identified, MedSun clarifies the problem and shares information with the clinical community and the public, without facility and patient identification, so that other clinicians can take preventive actions. MedSun participants are also highly encouraged to voluntarily report problems with devices that resulted in actual or potential harm. By monitoring reports about problems and concerns before a more serious event occurs, the FDA, manufacturers, and clinicians can work together to prevent serious injuries and death. Sometimes, this results in a product redesign.Current Educator, Clinical Educator, Novasyte Health representing Hill‐Rom Figure 4.10

FIGURE 4.10 Nancy Withers, BSN, RN, displaying her MedSun recognition certificate.

Source: Nancy Withers.

Nancy Withers

I was providing care for a patient who had just been transferred into ICU after a rapid response. I saw what appeared to be a purple band on the patient. At my hospital, like at many hospitals across the country, a purple band designates a DNR (Do Not Resuscitate) code status. There was no indication of a DNR order for this patient, so I asked the patient about the purple band. The patient told me she was wearing it because she'd had an implantable port placed, and the band was part of the kit provided by the vendor. Staff at the surgical center suggested that the patient wear the band to remind health care providers of her port. When I looked at the band closely, I noticed it was actually a gradation of colors, purple fading to gray. I clarified the patient's code status with her and removed the band for patient safety.

I also completed an unusual occurrence, which brought the situation to the attention of our risk manager. The risk manager reported the event to the FDA through a MedSun report as a near miss. MedSun told us later that they worked with the manufacturing company to change their practices. The company was not aware of the national efforts underway to standardize arm band colors and has now stopped including the purple band in their port kits.

Nancy Withers, BSN, RN

Former Clinical Leader, ICU, Edward HospitalCurrent Educator, Clinical Educator, Novasyte Health representing Hill‐Rom.

The Baldrige Award is conveyed by the National Institute of Standards and Technology (NIST), which is part of the U.S. Department of Commerce. NIST recognizes organizations that have improved and sustained quality results. The Baldrige Award in health care is designed to challenge organizations to improve their effectiveness of care and health care outcomes to pursue excellence, which moves organizations toward becoming an HRO. The Baldrige framework is built on core values and concepts and requires measurement, analysis, and knowledge management. The framework embraces integration between leadership, strategy, customers, workforce, operations, and results (National Institute of Standards and Technology (NIST), n.d.).

The three hospital accrediting agencies address patient safety. These agencies include Det Norske Veritas Healthcare, Inc. (DNV), Healthcare Facilities Accreditation Program (HFAP), and TJC.

Det Norske Veritas Healthcare, Inc. (DNV) empowers quality and patient safety through an outcomes‐based accreditation program. They received authority from the Centers for Medicare and Medicaid (CMS) to provide accreditation to hospitals in 2008, and integrate the CMS Conditions of Participation with the ISO 9001 Quality Management Program. The ISO 9001 quality system is a structured way of delivering a better service or product, supported by detailed procedures such as work instructions, quality manuals, and written quality policies to provide all employees with detailed, understandable, and workable instructions that define expectations and actions to achieve the stated quality goals. DNV's goal is to enable a broader culture change toward high performance and continual improvement by combining the mandatory CMS evaluation with a quality management system into one seamless program (DNV, 2018).

Healthcare Facilities Accredition Program (HFAP) was originally created in 1945 to conduct an objective review of services provided by osteopathic hospitals. In 1965, HFAP received authority from the Centers for Medicare and Medicaid to provide accreditation to hospitals, ambulatory care/surgical facilities, mental health facilities, physical rehabilitation facilities, clinical laboratories, and critical access hospitals. HFAP adopted the 34 Safe Practices set forth by the National Quality Forum (NQF) in 2009 (HFAP, 2017).

The mission of TJC is to continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value (TJC, 2018a, 2018b, 2018c). Founded in 1951, TJC uses the Donabedian conceptual framework of structure, process, and outcomes to assess an organization. TJC (March 1, 2017) identified 11 leader expectations for developing a safety culture, as outlined in Table 4.7. These expectations are very appropriate for nurse leaders in every level of an organization.

Table 4.7 Joint Commission Expectations for Leaders in Developing a Safety Culture

Source: The Joint Commission. (2018b). 2019 Hospital National Patient Safety Goals. Retrieved from www.jointcommission.org/assets/1/6/2019_HAP_NPSGs_final.pdf.

The journey toward high reliability is complex and involves every aspect of an organization. The role of the governance or the board of directors is essential. Table 4.8 identifies questions board members should ask to ensure that the health care organization is focused on safety (American College of Healthcare Executive, 2017). Nurse leaders must put resources in place and create a culture so that these questions can be answered affirmatively.

Table 4.8 Questions to Confirm a Healthcare Organization's Focus on Safety

Source: Patti Ludwig‐Beymer.

Becoming an HRO involves creating a culture of safety and reliability. This type of culture improves safety, an important element for an effective, efficient health care system. Similarly, a culture of high reliability enhances quality. In addition, a culture of reliability enhances the patient experience. Afterall, what patients or family member is pleased if their care is unsafe or of poor quality? Last, a culture of safety and reliability improves the financial performance of a health care organization.

Much of the early work on safety and high reliability was done in other industries, like commercial aviation and nuclear power. These industries experienced major safety improvements because of their focus on high reliability principles. Health care organizations can apply what has been learned in other safety‐focused industries to improve patient safety.

Regardless of role and setting, nurses must apply the six QSEN competencies to enhance safety. Nursing organizations, interprofessional organizations, government agencies, and accreditation agencies serve as valuable resources when building a culture of safety and high reliability. Nurses are in a strong position to advocate for patient safety and lead interprofessional efforts to achieve high reliability.

Go to the website for the Centers for Medicare and Medicaid Hospital Compare, www.medicare.gov/hospitalcompare/search.html. Accessed August 28, 2019. Enter several hospitals located close to your zip code. Review the ratings. What are their strengths? Where do they have opportunities to improve their safety?