DNP- Chamberlain College of Nursing Coursework
Final GPA 4.0
NUR 700 Scientific Underpinnings (Sept 2013 Final grade= 99.2)
*The Theory of Bureaucratic Caring by Marilyn Anne Ray discusses the economic as well a caring cultures within nursing in large macrosystems like hospitals and other health care organizations that employ a large number of nurses. Healthcare today is complex, with emphasis on cost containment resulting in high patient to nurse staffing ratios. Ray’s theory consists of two parts: (a) relationship as a function of the intentionality and of the actions of nurses, patients and administrators; and (b) the value of these interactions within the economic framework of the organization (Turkel & Ray 2000). In majority of healthcare organizations, nursing comprises the largest number of employees. Turkel & Ray (2000) state that nurses need to have economic knowledge to take their rightful place at the negotiating table and proclaim what is unique to nursing, and patients and administrators need to understand and value the economic rewards of human caring. The Nurse practitioner role within a large healthcare organization takes from this theory that caring (and spiritual-ethical caring) is at the core of patient provider interaction. The other dimensions inter-related within this sphere of caring has been incorporated in daily patient assessment and subsequent goal setting by our orthopedic department. A theory that carries economic implications will be viewed both qualitatively but mostly quantitatively as healthcare dollar allocations are divided. Valentine (1989) states that her quantitative study on the theory of bureaucratic caring presents a data-supported representation of caring which emphasizes its integral affective, cognitive, and interactional element.
Turkel, M., & Ray, M. (2000). Relational complexity: A theory of the nurse-patient relationship with an economic context. Nursing Science Quarterly, 13(4), 308.
Valentine, K. (1989). Caring is more than kindness: Modeling its complexities. Journal of Nursing Administration, 19(11), 33.
*Nursing theory and conceptual analysis provide a foundation for nursing scholarship. Fawcett (2005) developed a framework for both the analysis and evaluation of nursing theories. Analysis involves objective and nonjudgmental descriptions of theories, whereas evaluation involves judgments about the extent to which nursing theories meet certain criteria. Fawcett’s criteria include significance, internal consistency, parsimony, testability, empirical adequacy, and pragmatic adequacy (Fawcett 2005). It is important that nursing theories are used in nursing practice. Barrett (2002) discussed Fawcett’s analysis of 116 articles published in 1999 by Nursing Research. Only 4% were grounded in an existing conceptual model of nursing, 24% tested an existing nursing theory and no studies were designed to generate new nursing theory based on a conceptual nursing model. 39% were grounded in non- nursing theories, and 33% were not based on any theory or conceptual model. It is important that these nursing theories are used in advance practice nursing to further nursing as a science. In applying Kolcaba’s theory of comfort to my practice, it can be used in the peri operative area to evaluate patients comfort level after surgery. A study on peri-anesthesia nursing’s use of the theory of comfort as a nursing framework concluded that this theory is holistic, easy to understand and implement, is congruent with standards of care for perianesthesia nursing, and entails institutional outcomes (Kolcaba & Wilson 2002). Nursing theories like this are formalized through use of Fawcett’s criteria or other similar criteria for use by advance practice nursing providers/ nurse scientists in future research studies. Nursing frameworks and theories as the basis of definition of nursing science are essential ingredients in the survival of the discipline (Barrett 2002).
Barrett, E. (2002). What is nursing science? Nursing Science Quarterly, 15(1), 57.
Fawcett, J. (2005). Scholarly dialogue: criteria for evaluation of theory. Nursing Science Quarterly, 182, 131-133.
Kolcaba, K., & Wilson, L. (2002). The framework of comfort care for perianesthesia nursing. Journal of Perianesthesia Nursing, 172, 110.
NUR 708 Health Policy (Nov 2013- Final grade= 98)
*Healthcare finance is a complex matrix of government subsidies and programs, employer/employee contributions, private pay, capitation and reimbursement. To control the rising costs of healthcare, various programs are utilized including utilization management and supply limits. Utilization management seeks to influence physician behavior; the mechanism of influencing physician decisions is simple and direct; denial of payment for services deemed unnecessary (Bodenheimer&Grumbach 2012). The stakeholders are Nurse practitioners who are responsible for quality patient care. How many of us have been pressured into releasing a patient from an inpatient bed a day earlier secondary to length of stay protocols, or to transfer a patient from ICU to a lower level of care bed? Another program to control costs is supply limits. In majority of healthcare organizations, nursing comprises the largest number of employees. When nursing staff supply is limited, higher patient to nursing staffing ratios ensue. Turkel and Ray (2000) state that nurses need to have economic knowledge to take their rightful place at the negotiating table and proclaim what is unique to nursing, and patients and administrators need to understand the value and economic rewards of human caring. Nurses must know their value in an organization to be an integral part of the healthcare team and to eliminate being considered a cost containment measure. Although most US healthcare reform efforts have focused on coverage, the far bigger long term driver of success will come from restructuring the delivery system; that is where most of the value is created and most of the costs are incurred (Porter 2009).
Bodenheimer, T., & Grumbach, K. (2012). Understanding health policy: A clinical approach (6th ed.). San Francisco, CA: McGraw-Hill Professional Publishing.
Porter, M.E. (2009). A strategy for health care reform- toward a value-based system. New England Journal of Medicine, 361, 110.
Turkel, M., & Ray, M. (2000). Relational complexity: A theory of the nurse-patient relationship with an economic context. Nursing Science Quarterly,
13(4), 308.
*Nursing as a profession has traditionally focused on patient care and outcomes. Registered nurses represent the single largest health profession in the United States (Bodenheimer & Grumbach, 2012). The political or legislative arena has not been a major concern for nursing which is unfortunate. According to the 2004 National Sample Survey of RNs, there are 2.9 million RNs who are dispersed in every voting district in the nation; this reality continues to offer the nursing profession a formidable power base that is largely untapped in the day-to-day world of politics and legislation (Abood, 2007). To be an active participant in the legislative process is to understand how this impacts our profession. Despite the quality of care we provide, nursing has been and continues to be a profession of employees, through physician offices, nursing homes and hospitals. This distances nurses from the actual business aspect of healthcare delivery. Physicians and hospitals on the other hand, need to be politically involved since they are the business suppliers directly impacted by legislation through reimbursement, changes in the law, etc. As advance practice nurses move into higher administrative or entrepreneurial roles, the shift to a more political and legislative focus may become evident as we seek to open our own practices, get legislation passed for equal reimbursement rates, pass independent practice in all States, and become a significant voice in politics. We need dedicated, impassioned DNPs to lead the largest health profession in making ourselves heard and to get our profession to advance. The time is now for nurses to not only be trusted but also to be heard so they indeed may exert the strategic influence and presence needed to facilitate meaningful change (Shirey, 2013).
Abood, S. (2007). Influencing health care in the legislative arena. Online Journal of Issues in Nursing, 12(1), 1.
Bodenheimer, T., & Grumbach, K. (2012). Understanding health policy: A clinical approach (6th ed.). San Francisco, CA: McGraw-Hill Professional Publishing.
Shirey, M.R. (2013). Executive presence for strategic influence. The Journal of Nursing Administration, 43(7), 376.
NUR 701- Analytical Methods in Research (Jan 2014, Final grade =97.4)
*Evidence based practice can be traced back to a British epidemiologist, Archie Cochrane. Cochrane published an influential book in the 1970’s that drew attention to the dearth of solid evidence about the effects of healthcare; He called for efforts to make research summaries of clinical trials available to healthcare providers, this eventually led to the development of the Cochrane Center in Oxford in 1993, and an international partnership called the Cochrane Collaboration (Polit & Beck, 2012). During the same timeframe as the Cochrane collaboration, McMaster University became the base for Dr. Sackett and colleagues, who used an ‘evidence-based medicine’ approach to learning (Brady & Lewin, 2007). Examples of nursing centers using evidence based medicine were Sarah Cole Hirsh Institute for Best Nursing Practices at Case Western Reserve University in 1998, Joanna Briggs Institute in Australia, and the University of Rochester Center for Research and Evidence-Based Practice (Brady & Lewin, 2007). It is beneficial to use evidence based practice in my current work environment. As the lead NP, I am asked many questions and posed multiple problems regarding patient care, cost containment, use of resources, etc. Beneficial outcomes of the implementation and use of evidence- based practice by staff nurses include increased ability to offer safe, cost-effective, and patient-specific interventions (Reavy & Tavernier, 2008). There is a need to get staff involved and interested in EBP, it is important to provide education on how EBP can be used in everyday nursing practice. Advance practice nurses found that strong organizational commitment towards evidence-based practice led to structures being put in place and resources being allocated to support EBP (Bellman, et al, 2011).
Bellman, L., Webster, J., Jeanes, A. (2011). Knowledge transfer and the integration of research, policy and practice for patient benefit. Journal of research in Nursing, 16(3), 259.
Brady, N., & Lewin, L. (2007). Evidence-based practice in nursing: Bridging the gap between research and practice. Journal of Pediatric Health Care, 21(1), 54.
Polit, D.F., & Beck, C.T. (2012). Nursing research: Generating and assessing evidence for nursing practice. (9th ed.). Philadelphia, PA: Wolters Kluwer, Lippincott Williams & Wilkins Publishers.
Reavy, K., & Tavernier, S. (2008). Nurses reclaiming ownership of their practice: Implementation of an evidence-based practice model and process. Journal of Continuing Education in Nursing, 39(4), 166.
*Quantitative research has many parameters needed in order to achieve quality results. Reliability and validity are parameters used in measuring instruments used in the research study and are a major criterion in determining the quality of a study's results. An instrument’s reliability is the consistency with which it measures the target attribute (Polit & Beck, 2012). The reliability of a study is based on questions such as the following: Does the instrument or test measure what it is supposed to measure? Does it do this consistently? Do the items on the instrument consistently measure the same characteristic? (Zaccagnini & White, 2014). Validity is the degree to which an instrument measures what it is supposed to measure; content validity concerns the degree to which an instrument has an appropriate sample of items for the construct being measured and adequately covers the construct domain (Polit & Beck, 2012). It is important that there is use of an appropriate instrument to answer the research question. This is where consulting with experts in the field of your research study (within your micro or macro setting) may be an effective way in becoming knowledgeable about specific instruments that are currently being used in either research or practice. No matter which methods the project leader selects for evaluation data collection, they should be reliable and valid (Zaccagnini and White, 2014). It is crucial to have both reliability and validity in a study. A study can be reliable but not valid. The high reliability of an instrument provides no evidence of its validity; low reliability is evidence of low validity (Polit & Beck, 2012). In order to follow guidelines based on EBP research, we, as users of this research, have to be cognizant of the fact that a study must have both reliability and validity so we can properly choose study results that can benefit our patients. We can become a resource for our nursing colleagues in interpreting research studies. If a nurse practices from a belief system of cause and effect, what is needed are rigorous quantitative designs that incorporate random selection and random assignment along with valid and reliable instruments and powerful statistical analyses; conducting such studies indeed would require more time and resources, but the nurses practicing within a system that values cause and effect would have more confidence in the recommended interventions (Florczak, 2011).
Florczak, K.L. (2011). Rigor: Lost in the quest for evidence-based practice. Nursing Science Quarterly, 24(3), p. 204-205.
Polit, D.F., & Beck, C.T. (2012). Nursing research: Generating and assessing evidence for nursing practice. (9th ed.). Philadelphia, PA: Wolters Kluwer, Lippincott Williams & Wilkins Publishers.
Zaccagnini, M. E., & White, K. W. (2014). The Doctor of Nursing Practice essentials: A new model for advanced practice nursing (2nd ed.). Sudbury, MA: Jones & Bartlett Publishers.
NUR 702- Practice and Practicum 1 (March 2014, Final Grade= 97.3)
*Clinical microsystems are where APNs and DNPs provide safe and comprehensive patient care. APNs are valuable members of the healthcare environment and are important drivers of clinical microsystems. APNs provide both medical and nursing knowledge in our role within clinical teams, providing leadership and collaboration. Clinical reflects the essential priorities of health and care giving; micro reflects the smallest replicable unit of healthcare delivery and system reflects that this frontline unit has an aim and is composed of people, processes, technologies and patterns of information that interact and dynamically transform one another (Nelson, et al., 2011). There are challenges and barriers within clinical microsystems that affect how APNs appropriately provide competent patient care and engage caregivers. The challenge of time constraint during the patient encounter limiting proper patient and caregiver education is a barrier to the microsystems healthcare approach. The strengths of nursing are apparent in the holistic view we take of the patient and his/her environment, and the approach we take in educating our patients. It is imperative that as DNPs we continue to expand our knowledge in order to provide leadership, effectively educate patients within the current system constraints, and become exemplary models for our nursing colleagues. It is nursing science that can and should distinguish the DNP from other midlevel healthcare providers and from physicians, and it is nursing knowledge and care that can and should foster health and wholeness in our patients (Zaccagnini & White, 2014). Delivery of healthcare is changing and as DNPs, we can provide a vision and direction for nursing as a profession through our effective management of clinical microsystems. This may in turn, affect contributions to larger meso and macro systems. Providing patient education and continued learning are important elements for successful DNPs and clinical microsystems. Inter-professional education, practice and collaboration allow nurses to present a solid definition of nursing’s role, expand their scope and knowledge base, and establish a persisting presence in the future of healthcare ( Clarke & Hassmiller, 2013).
Clarke, P.N., & Hassmiller, S. (2013). Nursing leadership: Interprofessional education and practice. Nursing Science Quarterly, 26(4), 335.
Nelson, E.C., Batalden, P.B., Godfrey, M.M., Lazar, J.S. (2011). Value by design: Developing clinical microsystems to achieve organizational excellence. San Francisco, CA: Jossey-Bass.
Zaccagnini, M. E., & White, K. W. (2014). The Doctor of Nursing Practice essentials: A new model for advanced practice nursing (2nd ed.). Sudbury, MA: Jones & Bartlett Publishers.
*APN’s provide care and competent services to the public through health care systems. Within these systems, different missions and values of organizational leadership are used to guide practice and performance. The practice issue to be discussed will be the need for preventative care and services from APNs and DNPs instead of the delivery of care within a crisis or urgent situation. Approximately half the deaths in our country each year are due to preventable causes, and far more than half of our nation’s healthcare dollars are spent too late to manage injuries and chronic illnesses that earlier, anticipatory care could have prevented or mitigated (Nelson, et al., 2011). DNP’s are essential healthcare providers equipped with the knowledge and experience to mitigate healthcare crisis and start advocating for preventive health care services to our patients. The institute of Medicine (2011) released its Future of Nursing recommendations where the need for care versus cure was addressed. As some voices in the current reform debates acknowledge, our emphasis for far too long has been on curing illness, rather than promoting health (Safriet, 2011). It would be a tremendous opportunity for DNPs to become leaders in healthcare reform toward promoting preventive health in homes, hospitals, communities and long-term facilities, where traditionally nursing services are already performed. Our collective nursing background and EBP knowledge make us important contributors to policy and system changes. This begins with nursing as a profession exerting influence on policy makers and organizational leaders to emphasize the importance of preventive care in the current healthcare system. Although most US healthcare reform efforts have focused on coverage, the far bigger long-term driver of success will come from restructuring the delivery system (Porter, 2009). We all can play a role in healthcare system change toward more preventive care and truly show how DNPs can be a solution to a long term public health problem. We can do this by advocating for our patients and emphasizing nursing strengths, that of preventive, holistic care.
Nelson, E.C., Batalden, P.B., Godfrey, M.M., Lazar, J.S. (2011). Value by design: Developing clinical microsystems to achieve organizational excellence. San Francisco, CA: Jossey-Bass.
Porter, M.E. (2009). A strategy for health care reform- toward a value-based system. The New England Journal of Medicine, 3612, p. 110.
Safriet, B.J. (2011). Federal options for maximizing the value of advanced practice nurses in providing quality, cost-effective health care. The Future of Nursing, Leading Change, Advancing Health, Appendix H, 446.
NUR 703- Organizational Leadership (May 2014, Final Grade 100)
There are roughly 2.9 million nurses in the United States, making nursing the largest healthcare workforce. Nurses practice in a wide variety of settings including hospitals, nursing homes, private offices, retail clinics; in ambulatory, specialty, surgical and palliative care. This advanced practice leadership paper will discuss high turnover within the nursing profession secondary to mobbing. Ozturk, Sokmen, Yilmaz, & Cilingir, 2008 define mobbing as an emotional attack leading to unethical approaches and systematic oppression of people in order to decrease performance, coping skills and force them to resign.
It is true that healthcare environments are high stress environments. This is secondary to the shortage of nursing personnel, increasing of nursing tasks and responsibilities, few continuing educational opportunities, lack of management support, and unfortunately, mobbing among nurses in the workforce. Respect and reverence for others historically has been a hallmark of nursing, yet patterns of incivility now disrupt the landscape with the incidence of horizontal and vertical violence on the rise (Parse, 2010, p. 193). Further compounding this increase in mobbing or horizontal/lateral violence is the disparity in age among nurses. According to Kirby, 2009, there are less young recruits entering the nursing field and over half of the current work force is due for retirement in the next few years. Despite this, there continues to be a steady decline in the number of nurses choosing to stay in the nursing profession.
This paper will explore the leadership dynamic of a nurse practitioner (NP) with 10 years of advanced practice experience in ambulatory care and the relationship with the nurse executive (Exec) in a large hospital setting. The NP has recently applied for an increase in full time NP positions secondary to a new service to be initiated which is diabetic foot care. The NP has data supporting for the need for more NPs to provide education and foot examinations secondary to patient complaints and an increase in foot infections. The NP presents this to the Exec. The Exec is aware of the new program that was approved by the Ambulatory Care Director but the Exec does not support the need for the program to employ more NP’s. The Exec believes that patient education is already part of the current NP task and that the NP needs to incorporate foot examinations into the current work load. The Exec justifies this with the argument of resource scarcity and the need to allocate resources to numerous other departments. The Exec has other priorities that are more aligned with her vision for the use of NPs. The NP is informed that she will absorb all the diabetic foot patients without any additional staff. The patients are scheduled and the NP is not given any additional time to see the new diabetic foot patients. This results in the NP not having time during the visit to perform an adequate diabetic foot exam or give appropriate education. A patient develops a serious foot infection that leads to a prolonged hospitalization and ultimately to a below the leg amputation. The patient sues the NP. The NP is frustrated, angry and feels unappreciated. She subsequently leaves the organization.
Description of Ethic of Care versus Ethic of Justice perspectives
Ethics is defined as the rightness or wrongness of acts, based on one’s role, commitment and outcomes of one’s actions on the lives and well-being of others (Sorbello & Lynn, 2008, p. 44). The advanced practice leadership dynamic presented between the NP and the Exec is a form of mobbing and will be discussed within the context of the Ethic of Justice and the Ethic of Care.
The Ethic of Justice is described by Morrow, 2012 as fairness and the receipt of mutual agreement by persons under fair conditions. Morrow discusses specific areas of nursing conflict and ethical issues including perceived arrogance, lack of commitment and bullying. The Exec understandably has to allocate resources and the Ethic of Justice concept of fairness may be used to justify this resource allocation issue. Botes, 2000 discusses the Ethic of Justice as impartial, verifiable, fair and equitable treatment of all people. The NP in this advanced practice dynamic was not provided the resources needed to adequately perform additional responsibilities resulting in harm to a patient. Perceived arrogance from the Exec and a lack of commitment to the new initiative are key elements in this dynamic. The Exec is not the NP providing direct care and therefore is only indirectly related to the situation. However, according to Sorbello & Lynn, 2008, the Ethic of Justice subscribes to giving fair, equitable and appropriate treatment in light of what is due or owed to persons. What is due or owed to the patient was a NP with the time to adequately perform a foot exam and educate the patient on foot care that most likely would have prevented this devastating consequence of limb loss. Morrow, 2012 discusses how fostering integrity, being honest and providing transparency are suggested ways for nurse leaders to incorporate the Ethic of Justice in their practice.
According to Sorbello & Lynn, 2008, the Ethic of Care develops and nurtures harmonious relationships from a need-centered and holistic point of view while being concerned and sensitive to the needs of others. The provision of holistic care has normally been associated with the nursing profession. In order to adequately perceive our patient’s needs, there is a need for caring and sensitivity while seeing the patient as a whole person. There is also a need to provide caring to nursing personnel and to view them as a whole person. The provision of care brings to mind a diversified range of actions that are beyond the biological and individual scope (Semiramis, Lima, & Peduzzi, p. 52). Milton, 2009 gives examples of lateral and horizontal violence such as demeaning acts from one nurse to another, the use of aggressive and destructive behaviors, downgrading others through words and actions, undermining confidence in tasks, and diminishing self-esteem. The NP who was not given the support she needed experienced mobbing and lateral violence. This author believes that mobbing should not be tolerated within nursing and should not be perpetuated from one nursing leader to another. As nurses are nurtured, they embrace qualities of their mentor and embody them in their work. This vicious cycle of mobbing within nursing has to stop and it is within nursing leadership that this must first take place. Leaders training new leaders with compassion, caring and holistic treatment of patients and staff can contribute to a more stable nursing work force and stop the exodus of nurses leaving the profession. This will then establish a culture based on Ethic of Care.
Reflection on the application from an Ethic of Care perspective
Milton, 2009 and Ozturk, et al., 2008 discuss mobbing within nursing in the current healthcare environment as demeaning acts from one nurse to another, the use of aggressive and destructive behaviors, downgrading others through words and actions, undermining confidence in tasks, and diminishing self-esteem. Other mobbing tactics are blocking information, with-holding promotion and isolating another nurse out of group activities. The Ethics of Care will be discussed as it applies to the current healthcare environment using these above mentioned mobbing behaviors.
Demeaning acts from nursing are belittling and criticizing another nurse in front of others. Verbal disrespect toward another nursing colleague is a common form of mobbing. This can be seen in interactions of experienced nurses with new graduates who are entering the work force for the first time. These new graduate RNs need support and guidance but instead are subjected to criticism and belittling for other nurses to witness. A nurse who disagrees with this behavior but does nothing to stop it is also committing a demeaning act. The constant endeavor of the person who subscribes to the ethic of care is to fulfill the needs of the people in the ethical situation and to maintain harmonious relations (Botes, 2000, p. 1072). The Exec belittled the needs of the NP which resulted in patient harm and the loss of an experienced NP provider.
Aggressive and destructive behaviors are not only physical acts of violence but also emotional bullying. Gossiping is a common mobbing tactic contributing to emotional distress in nurses. Nurses who would like to propose change or are willing to look outside the box are most often recipients of aggressive behavior. Turkel, 2014 discussed the use of negative words as draining energy and radiating negativity to others while positive energy expressed through words uplifts us with peaceful, calm and soothing energy.
Other mobbing tactics are undermining confidence in tasks and diminishing self-esteem in other nurses. Nursing and healthcare has had an increase in technology in the last decade contributing to electronic medical records, medication bar code scanning, nursing reporting forms for falls, patient incidents and sentinel events. This technology has been added to an already full nursing plan for the day. Nurse to patient ratio is also used to mob nurses by assigning a disproportionate amount of patients per nurse or more complex patients to the current workload. The Exec undermined the importance of diabetic foot exam and education and in doing so created a work environment for the NP that undermined confidence in the Exec and diminished self-esteem. Polifroni, 2010 discussed PEACE powers by Chinn as collectivity of nurturing, of distribution, of diversity and of responsibility.
Blocking information and isolating another nurse out of group activities contribute to a mobbing environment. It is essential for all nurses to be informed of expected tasks, duties and requirements and it is grossly unfair to leave one nurse out of this communication. It jeopardizes patient safety, makes a nurse stay longer than expected (i.e.- not informed an admission is arriving), and contributes to the potential for an increase in medication errors secondary to fatigue or distress. It is an essential nursing leadership responsibility to determine if blocking information is happening and to adhere to strict guidelines preventing this type of mobbing. The shared decision-making process is most often associated with magnet designation. Morrow, 2009 states that shared decision-making is a process where nursing staff giving direct patient care can make decisions to enhance their work especially within the confines of patient safety and care. The Exec would have had a better understanding of the diabetic foot care initiative if shared decision-making was incorporated in her leadership structure.
With-holding a promotion is a mobbing tactic that is rampant is nursing leadership. Leaders who hire based on personal friendships versus nursing experience and ability provide a disservice to their organizations. Leaders who exclusively hire nurses who conform and agree with their vision and plans eliminate the diversity that nursing professionals bring. Leaders who do not provide a platform for growth and development are voiding themselves or a strong work force in which to harvest future leaders. Leaders who are seen as status quo promoters risk losing the respect and loyalty of the nursing staff that can lead to high turn-over rates. To keep pace with the need for nurses, practitioners must be acknowledged and rewarded (Kirby, 2009, p. 2730).
A review of literature shows multiple articles using Parse’s (2007) Humanbecoming school of thought as a theoretical framework nursing leaders should use when discussing the Theory of Care within the current healthcare environment. Nursing leaders should consider how developing Parse’s Humanbecoming leadership skills of commitment to a vision, willingness to risk, and reverence for others can help establish a more ethical nursing work environment.
Conclusion
Mobbing is an unfortunate reality within the nursing profession. It is an emotional attack that is unethical and can lead to nursing performance, coping and retention issues. Nursing leadership and nursing staff must be aware of the Theory of Justice and the Theory of Care in order to recognize and eliminate mobbing in the workforce. Nursing leaders must not perpetuate a culture of mobbing, instead they must develop strong, ethical nursing personnel. Mobbing tactics discussed include demeaning acts, aggressive and destructive behaviors, undermining confidence, diminishing self-esteem, blocking information and with-holding a promotion. Nursing leaders should consider how developing Parse’s Humanbecoming leadership skills of commitment to a vision, willingness to risk, and reverence for others can help establish a more ethical nursing work environment and prevent the exodus of nursing personnel from the nursing profession. The DNP prepared nurse leader must use the Ethic of Care as a foundation for ethics related issues in the work place that not only deal with patients, but also with nursing personnel. The DNP leader must assure that there is education provided on ethics to all nursing personnel on a regular basis so that new graduates, floating and registry nurses, and experienced nurses have the ability to recognize mobbing and change the culture of nursing towards an equitable, supportive, holistic environment.
eferences
Parse, R. R. (2010). Respect! Nursing Science Quarterly, 23(3), 193.
NUR 705 – Practice & Practicum II (July 2014, Final Grade= 95.2)
*Clinical microsystems are inherent in healthcare settings for provision of care, coordination and patient centered outcomes. The clinical microsystem for my scholarly project will be the orthopedic spine clinic at the Phoenix VA Healthcare system in Phoenix, AZ, a large macrosystem. A healthcare clinical microsystem is the small group of people (including health professionals and care-receiving patients and their families) who work together in a defined setting on a regular basis to create care for discrete subpopulation of patients (Nelson, Batalden, Godfrey, & Lazar, 2011). There are many challenges in coordinating care within a microsystem. In the orthopedic spine clinic, there are providers, nurses, OR staff, schedulers, etc. who make up this microsystem. In order to obtain optimal patient outcomes, seamless coordination is imperative. From front line staff who receive phone calls, to triage nurses, to providers deciding on care, the goal must be patient centered care. A common mission and vision that is shared by all the staff involved can lead to a patient centric approach. The new patient centered approach emphasizes patient preferences, comfort, emotional support, and access to care in the healthcare experience (Clarke & Hassmiller, 2013). This scholarly project involves the addition of a written education brochure to the existing standard of care which is verbal education, both to be given pre-operatively. The desired outcome is decreased pain in post-operative lumbar laminectomy patients through the use of education. This project will need the support of the clinical microsystem (staff, patients and their families) to promote a coordinated effort in providing additional education that impacts post- operative pain. The success of this project depends on coordination, cooperation and a genuine desire to provide patient education. As a DNP leader, I will provide leadership, communicate the vision, and participate with the clinical microsystem staff in implementing this project. I will also pursue a permanent change to the pre-operative education protocol. Staff members need to be developed, directed and empowered to find the best way to accomplish organizational goals and desired outcomes (Poe & White, 2010).
Clarke, P.N., & Hassmiller, S. (2013). Nursing leadership: Interprofessional education and practice. Nursing Science Quarterly, 26(4), 333.
Nelson, E.C., Batalden, P.B., Godfrey, M.M., & Lazar, J.S. (2011). Value by design: Developing clinical microsystems to achieve organizational excellence. San Francisco, CA: Jossey-Bass.
Poe, S.S., & White, K.M. (2010). Johns Hopkins nursing evidence based practice: Implementation and translation (2nd ed). Indianapolis, IN: STTI.
*The adequate review of literature can be a daunting task and requires understanding and applying multiple steps and concepts. This discussion will compare and contrast leveling of evidence versus grading of quality. Leveling of evidence is most associated with evidence hierarchies. These hierarchies rank types of evidence sources according to the strength of evidence they provide (Polit & Beck, 2012). These hierarchies provide a schematic for deciding which research studies should be considered for practice issues and are presented in a pyramidal form. At the bottom of the pyramid (Level VII) is expert opinion, next up the ladder are qualitative or descriptive studies and systematic reviews of qualitative studies that are leveled at six and five respectively; Level IV includes case control, correlational and cohort studies, level III quasi-experimental with RCT holding the position of level II, Finally at the peak of the pyramid is the systematic review (Florczak, 2011). To assess the quality of a study, grading of quality is usually performed with 2 important criteria- reliability and validity. Reliability refers to the accuracy and consistency of information obtained in a study while validity concerns the soundness of the study- whether findings are unbiased and well grounded (Polit & Beck, 2012). It is important for the DNP to be knowledgeable in adequately critiquing literature to assure that best practice guidelines can be extracted from reliable and valid studies that follow the evidence hierarchy. Before the researcher can be reasonably confident of discovery, there is a need for consistency, both within the investigation itself and with the wider body of research in the same area (Pryjmachuk & Richards, 2007).
Florczak, K.L. (2011). Rigor: Lost in the quest for evidence-based practice. Nursing Science Quarterly, 24(3), 204.
Polit, D.F., & Beck, C.T. (2012). Nursing research: Generating and assessing evidence for nursing practice. (9th ed.). Philadelphia, PA: Wolters Kluwer, Lippincott Williams & Wilkins Publishers.
Pryjmachuk, S. ,& Richards, D.A. (2007). Look before you leap and don’t put all your eggs in one basket: The need for caution and prudence in quantitative data analysis. Journal of Research in Nursing, 12(1), p. 44.
NR 704- Concepts in Population Health (September 2014, Final grade= 99.9)
*Fairness is most commonly associated with justice. The definition of the word justice is to treat fairly or adequately and the quality of being just, impartial or fair (Morrow, 2012). Social justice can be translated into how distribution of services to the population is done in a fair and adequate manner. Social justice describes how all people should have the same rights, benefits and opportunities (Chism, 2013). The question of who uses more healthcare dollars in the US point to the elderly and those with chronic conditions. Should these subsets then get more of the healthcare budget and if so, is that fair to the other subsets? Health promotion emphasizes movement away from illness towards health seeking behaviors and activities like exercise, weight loss, smoking and drug cessation, etc. These health promotion behaviors should be geared toward the population as a whole, and not to select subsets within a population if we are to maintain fairness and social justice. The ability to obtain these health promotion services becomes more disparate when emphasis is accorded to one subset of the population over another. Leddy (2006) states that a global perspective is needed when considering quality of life and justice issues towards poverty, racism and sexism within the broader social justice issue of promoting well-being.
As a DNP leader, we can show social justice in how we provide healthcare services. I work in a federal VA facility which is associated more with socialized medicine. All eligible veterans receive the same care, have access to the same PCP’s and specialists, have the ability to get MRI, Pet scans and other expensive diagnostic tests, without regard to their income , race, age or gender. There is a copay for veterans who make more than the threshold set by the government, and even in this more socialized medicine system, some disparity can be seen.
Chism, L.A. (2013). The Doctor of nursing practice: A guidebook for role development and professional issues (2nd ed.). Sudbury, MA: Jones & Bartlett Publishers.
Leddy, S.K. (2006). Integrative health promotion: Conceptual bases for nursing practice (2nd ed.). Sudbury, MA: Jones & Bartlett.
Morrow, M.R. (2012). Fairness and justice in leading-following: Opportunities to foster integrity in the first 100 days. Nursing Science Quarterly, 252, 188.
*Healthcare is affected by multiple entities: government policies, insurance companies, hospitals, physician and surgeon fees, etc. Government has a role in ensuring that healthcare policies are enacted to benefit the majority of its constituents. The US was one of the few industrialized countries that did not have universal healthcare coverage until the Affordable Care Act of 2010. For 100 years, reformers in the US have argued for the passage of national health insurance, a government guarantee that every person is insured for basic health care (Bodenheimer & Grumbach, 2012). Healthcare policies are meant to provide resources and information to individuals, families and communities that promote healthy living and disease prevention. Today in the US, the link between healthcare policy and access to healthcare has never been clearer and nurses can play a pivotal leadership role (Wakefield, 2013). Policies on vaccination, health screening for vision and hearing are healthcare policies that receive government support and funding. Other policies include smoking cessation and obesity prevention that may have both federal and State funding. Policies on lead screening for older homes and airbags in cars are government policies that can indirectly affect healthcare. The DNP can help shape healthcare through advocacy and participation in policies being considered for enactment. There is an arena for the DNP to demonstrate leadership through initiation of policy proposals, exerting influence through organized groups on policy makers, and being an active participant in political efforts. Any nurse who has an interest in influencing policy, can find a way to become a confident advocate; there are multiple ways to get actively involved ranging from simply writing a letter, making a phone call about an issue, or getting elected to public office (Abood, 2007). We can all make a difference in how government shapes healthcare.
Abood, S. (2007). Influencing health care in the legislative arena. Online Journal of Issues in Nursing, 12(3), 3.
Bodenheimer, T., & Grumbach, K. (2012). Understanding health policy: A clinical approach (6th ed.). San Francisco, CA: McGraw-Hill Professional Publishing.
Wakefield, M. (2013). Nurses and the affordable care act: A call to lead. Reflections of Nursing Leadership, 39(3), 2.
NR 707 Practice and Practicum III (November 2014, Final Grade= 98)
*My scholarly project involves a systems change to the pre-operative provision of care in the orthopedic-spine department at the Phoenix VA. The clinical problem identified is increased post-operative pain after lumbar laminectomy surgery. These pain control issues stem from chronic pain prior to surgery, long term use of narcotic pain medications, decreased ambulation and disability from work or activities. The success rate of spinal surgery for low back pain is controversial with up to 40% of patients continuing to experience pain and disability following spinal surgery (Louw, Louw, & Crous, 2009). This project will require an additional 10 minutes to the current 20 minute standard of care verbal pre-operative education session. The additional 10 minutes will be used to exclusively discuss pain, pain management and introduce the written pain brochure. This brochure was designed for home use for both patients and caregivers to reinforce learning and address expectations. The evidence from literature has shown that the most effective combination in pre-operative teaching is the use of both verbal and written methods. A study by Papanastassiou, Anderson, Barber, Conover, & Castellvi (2011) state patients who attended the pre-care spine class reported better satisfaction with pain control (96% vs 83) versus those who did not attend. There have been challenges with enactment of a systems change to an established clinic. Additional time is always a consideration with a busy clinic along with needing printed materials. These were overcome however with education to staff and administrators, with use of evidence-based practice recommendations and with DNP leadership in establishing positive change. According to Zaccagnini & White (2014) one of the most important skills the DNP prepared administrator needs is that of collaboration; working well in teams to achieve goals can lead to improved patient safety and staff satisfaction.
Louw, A., Louw, Q., & Crous, L. (2009). Preoperative education for lumbar spine surgery for radiculopathy. South African Journal of Physiotherapy, 652, 1.
Papanastassiou, I., Anderson, R., Barber, N., Conover, C., Castellvi, A. ( 2011). Effects of preoperative education on spinal surgery patients. International Society for the Advancement of Spine Surgery, 5, 120.
Zaccagnini, M. E., & White, K. W. (2014). The Doctor of Nursing Practice essentials: A new model for advanced practice nursing (2nd ed.). Sudbury, MA: Jones & Bartlett Publishers.
*There was some confusion on my end when I first started my DNP program and project. The inclination was to perform original research since this is what the orthopedic department normally uses for EBP guidelines. The actual use of EBP as the basis of a project was a harder concept to understand at first. Federal guidelines define research as a systematic investigation, including research development, testing and evaluation, designed to develop or contribute to generalizable knowledge (Chism, 2013). The EBP scholarly project on the other hand, does not develop or contribute to generalizable knowledge. Its purpose is to use EBP knowledge and recommendations already available and incorporate these into a microsystem change project. The DNP degree focuses on the clinical scholarship of integration and application. It addresses a complex practice, process or systems problem within the student’s field of expertise, proposes an evidence based intervention to address that problem for a significant population, and uses doctoral-level leadership skills to evaluate the intervention and outcomes within the clinical practice setting (Zaccagnini & White, 2014).he similarities involve looking at pertinent issues or problems in a clinical setting and enacting a change to address these. The major difference is generalizability of findings, research does this, the EBP project does not. Research is the domain of our PhD colleagues, while DNPs use EBP since our degree is rooted in clinical practice. Knowledge of and respect for the unique roles that the PhD and the DNP nurses bring to the process must be clearly understood so as to demonstrate the strengths of each (Florczak, Poradzisz, Kostovich, 2014).
Chism, L.A. (2013). The Doctor of nursing practice: A guidebook for role development and professional issues (2nd ed.). Sudbury, MA: Jones & Bartlett Publishers.
Florczak, K.L., Poradzisz, M., Kostovich, C. (2014). Traditional or translational research for nursing: More PhDs please. Nursing Science Quarterly, 27(3), 195.
Zaccagnini, M. E., & White, K. W. (2014). The Doctor of Nursing Practice essentials: A new model for advanced practice nursing (2nd ed.). Sudbury, MA: Jones & Bartlett Publishers.
NR 706- Healthcare Informatics and Information Systems (Jan 2015, Final grade 96.2)
*Translational Science is used to refer to bridging of the gap between research and practice, in essence the translation of research into use in healthcare practice today. Translational research is the effective translation of the new knowledge, mechanisms, and techniques generated by advances in science research into new approaches for the prevention, diagnosis, and treatment of disease (Florczak, Poradzisz, Kostovich, 2014). As a practicing NP, translational science means the use of research guidelines in my current practice. The Agency for Healthcare Research and Quality (AHRQ) is used in the VA system. AHRQ began a program in 1999 called TRIP ( translating research into practice) with a wide array of strategies for implementing research including provider reminder systems, new computer decision support systems, financial incentives and use of local opinion leaders ( White & Dudley-Brown, 2012). AHRQ is a vast resource network for practice guidelines routed in research science. The VA system also has an extensive library system with access to all databases that is easily accessible to providers like myself. Informatics is one component of the curriculum to obtain a DNP degree, and with this, the use of translational science. Both nursing experience and use of EBP through translational science is a powerful combination in evaluating and implementing EBP changes in practice gathered from research. The DNP role can only further the nursing profession through more educated, evidence based prepared practitioners. In increasing numbers, DNP graduates are moving into leadership positions in almost all healthcare systems and working collaboratively with nurse researchers to implement new nursing science and practice innovations (Bednash, Breslin, Kirschling, Rosseter, 2014). In order for the nursing profession to thrive and get the respect it deserves, both PhD and DNP graduates must compliment versus criticize each other .
Bednash, G., Breslin, E.T., Kirschling, J.M., Rosseter, R.J. ( 2014). PhD or dnp: Planning for doctoral nursing education. Nursing Science Quarterly, 27(4), 299.
Florczak, K.L., Poradzisz, M., Kostovich, C. ( 2014). Traditional or translational research for nursing: More Phds please. Nursing Science Quarterly, 27(3), 198.
White, K.M., Dudley-Brown, S. (2012). Translation of Evidence Into Nursing And Healthcare Practice. New York, NY: Springer Publishing Company.
*Information systems have had major effects on industry, the economy, and in healthcare. As a practicing NP for the last 15 years, I have seen how the use of electronic medical information has helped my practice. From looking at patient histories, to consultations, to viewing xrays, all these have been an integral and effective part of my practice through the correct healthcare adaptation of information technology. The majority of the coding for billing purposes for my practice is medical in nature, there is very little in nursing diagnoses and coding. This is where the disconnect between being a Nurse practitioner and being a nurse becomes noticeable, and for billing purposes, shows the more medical nature of our advanced practice. Use of a standardized, coded nursing terminology emphasizes nursing tasks, but does not account for diagnosis and treatment. This is where the nursing profession can start with DNPs looking at how to account for nursing receiving coding and billing benefits with what we contribute to our practices. Nurses need to design systems so that information about the current encounter is captured is such a manner as to be able to be aggregated and used to inform future encounters (Androwich, 2013). Information systems have also contributed to how we as providers can access research for use in practice. Being able to go to CINAHL or MEDLINE as search engines to filter out what we need is invaluable. Access to articles and EBP is no longer as difficult as it once was. The days of physically being in the library using card catalogues is no longer effective, and accessibility brought on by information systems has changed the landscape of how we can practice. According to Palmer and Kramlich ( 2011), nurses engage in mentoring colleagues in using EBP using extensive literature searches with CINAHL, Pubmed, OVID and other information databases. The federal government has also contributed much to information systems in healthcare. According to Murphy (2010), the American Recovery and Reinvestment Act (ARRA) that started in 2011 provided $19 billion to promote healthcare reform through the use of health information technology. These incentives should help in proliferating electronic healthcare records for continuity of care and better communication among providers.
Androwich, I.M. (2013). Nursing as a learning discipline: A call to action. Nursing Science Quarterly, 26(1),37.
Murphy, J. (2010). The journey to meaningful use of electronic health records. Nursing Economics, 28(4), 283.
Palmer, D., & Kramlich, D. ( 2011). An introduction to the multisystem model of knowledge integration and translation. Advances in Nursing Science, 34(1). 32.
NR 709- Project & Practicum IV- (March 2015)
*The scholarly project for this DNP degree has a requirement for data analysis presentation in both a narrative and graphic format. Displaying findings in a graphic format gives a visualization of the data analysis and is commonly used to present results. It is important to remember that presentation of data can be an influential aspect of the results section in showing the intervention has merit. The graphics that were used in my project were histograms and bar graphs. These were chosen since my project has interval level data. Graphs for displaying interval and ratio level data include histograms and frequency poly-grams (Polit & Beck, 2012). These graphs were designed so that the reader can visualize the pre-operative pain score, the post-operative pain score, and the change between the patients who did not get the brochure and those who did. I will also present data using tables to show a decrease in pain levels post-operatively for the brochure patients.The use of color and labels also affect the completeness of a graph. It is not enough to just present a graph, it must convey the necessary elements of the data analysis in a clear, succinct manner. According to Hegge (2011), Florence Nightingale translated data into colorful graphs called coxcombs that displayed evidence so readers can see at a glance what was happening. Vertical versus horizontal presentations were also considered, as well as what is the most appropriate bar graph- smaller bars, longer bars, bars on the top and bottom, etc. A study by Hagen, Awosaga, Kellett, & Damgaard (2013) about a mandatory course in applied statistics for undergraduate nursing students explained how these students’ ability to understand graphs, tables, and statistical information presented in nursing research articles increased after taking the course. The DNP can be a premier role model for the nursing profession in understanding and applying research.
Hagen, B., Awosaga, O.A., Kellett, P., Damgaard, M. ( 2013). Fear and loathing: Undergraduate nursing students’ experiences of a mandatory course in applied statistics. International Journal of Nursing Education Scholarship, 10(1), 3.
Hegge, M.J. (2011). The Lingering presence of the nightingale legacy. Nursing Science Quarterly, 242, 156.
Polit, D.F., & Beck, C.T. (2012). Nursing research: Generating and assessing evidence for nursing practice. (9th ed.). Philadelphia, PA: Wolters Kluwer, Lippincott Williams & Wilkins Publishers.
*The implementation stage of my DNP project is completed and my final data has been collected. Now that data analysis has been performed, implications for future studies must now be addressed. The theoretical framework that I used and felt was the most appropriate for this scholarly project is Barrett’s Power as Knowing Participation in Change Theory (2009) which was derived from Martha Roger’s Science of Unitary Human beings. According to Barrett ‘we can participate knowingly in changing any situation in our lives; that does not mean we can control situations, since there is no control in an acausal view of power, but we can do what we choose to do in an ongoing mutual process with ourselves, with other people, with our immediate world and with all of the universe’ (Barrett, 2010). Barrett’s Power as Knowing Participation in Change Theory was used in a systematic review of 37 articles from 2009-2011 by Hartley, Neubrander & Repede (2012) on pre-operative education for post-operative spine patients. This study’s findings show that patient preparation in the pre-operative timeframe helps patients in their recovery process. Barrett’s Power as Knowing Participation in Change theory states power is the capacity to participate knowingly in change, and that knowing participation is the key. This theory can help in understanding perception of pain and how pre-operative verbal and written pain information can be used to decrease post-operative pain. Nursing has always been associated with caring, and returning the compassion and care to a patient who is in pain and is emotionally labile can be a difficult task. Barrett’s power in knowing theory can be used as evidence-based practice theory by the DNP in discussions with nursing staff on how to effectively handle post-operative pain issues. Barrett’s power theory and its dimensions show the freedom to participate knowingly in the alive universe and its potentials, especially compassion where all people are equal (Phillips, 2010).
Barrett, E. A. (2010). Power as knowing participation in change: What’s new and what’s next. Nursing Science Quarterly, 23(1), 47.
*The use of statistical analysis can be intimidating and daunting. Mathematical equations, tests, variance, etc. can be confusing and difficult to understand. The best technique that has worked for me in alleviating fear of statistics is to learn more about it through literature and book searches. This research did not make the mathematical equations easier to understand, but it did provide a more concrete way to look at how to properly analyze data. Reavy & Tavernier (2008) discuss barriers to the use of EBP and statistics by nurses to include lack of interest in research and other scholarly writings, reading habits, heavy workloads, lack of time and confusing terminology. This is true of statistical tests that are confusing and need additional user education and time. This is particularly disheartening for the nursing profession since there are so many important changes to care that can be explored if nursing were made more interested in using and or conducting research. The DNP can be a role model for the nursing profession in showing that change can be accomplished through the correct use of EBP literature in guiding clinical practice.The help of a statistician will be used in my project secondary to multiple unsuccessful attempts to be proficient in excel and SPSS. When my project data is completed, I have decided to have it analyzed by a statistician. My skills as a provider are excellent, however, I am aware of my mathematical limitations and know when to seek assistance. The DNP prepared nurse must use their unique set of skills in order to conduct quality research and implement the findings from that research in service to humankind (Florczak, Poradzisz, Kostovich, 2014).
Florczak, K.L., Poradzisz, M., Kostovich, C. (2014). Traditional or translational research for nursing: More PhDs please. Nursing Science Quarterly, 27(3), 200.
Reavy, K., & Tavernier, S. (2008). Nurses reclaiming ownership of their practice: Implementation of an evidence-based practice model and process. Journal of Continuing Education in Nursing, 99(4), 166.
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