Explain How does the nurse leader contribute to positive changes in nursing?

Explain How does the nurse leader contribute to positive changes in nursing?

Reengineering Health Care Management

By June Helbig

Essential Questions

How does the nurse leader contribute to positive changes in nursing?

How does continuous quality improvement contribute to the professionalism of nursing and improve patient outcomes?

How does nursing impact organizational processes?

How does nursing impact organizational structure?


Nursing & Conceptual Frameworks

An organization can be defined as a group of people working together to accomplish common goals. In order to be able to work together, there must be structure, rules, and regulations that govern those within the organization. Every organization must also have a leader—someone who will guide those within the organization to meet the goals of the organization. To be a successful organization, all of the organization’s members must know their roles and be responsible not only to themselves, but to the organization as a whole. There are several theories associated with the way organizations are managed and the different structures that exist within the organization. This chapter will discuss organizational theories, health care management, and the nurse leader’s role in reengineering health care. This chapter will explore change management and how it is applied to health care organizations. Strategies used to resolve practice issues, as well as the process of continuous quality improvement and the role of the nurse leader, will also be reviewed.

Organizational Theories

Classical Theory

Nursing & Conceptual Frameworks

Leadership & Advocacy

Classical organizational theory takes the scientific approach to management, which was developed by Frederick Taylor in the early 1900s. It is based on the concept of “planning of work to achieve efficiency, standardization, specialization, and simplification” (Ferdous, 2016, p.2). An example of the extended classical form of organization is visualized in Figure 5.1.

Figure 5.1

Classic Organizational Chart

The figure presents a diagram of a classic organizational chart with four tiers, as discussed in this chapter.

There are four basic principles to Taylor’s scientific method for managing an organization:

Find the best way to do something.

Find the right worker for the right task.

Proper supervision with rewards for good work and punishment for poor work.

Management’s priority is to properly plan and control (Aluan, 2014).

Classical theory is made up of management principles that were popular during the early 1990s. Taylor believed if workers were trained to use their special abilities to perform the job well, then they would be more productive. Taylor believed if the good worker was rewarded with incentives, the worker might be even more productive. Workers who performed poorly would be penalized by not being asked back to work (Ferdous, 2016).

Henri Fayol was another theorist of classical management. Fayol developed 14 principles of management that outline ways that management must work with employees of the organization in order to be successful (see Table 5.1).

Table 5.1

Fayol’s’ 14 Principles of Management

Division of Work (Labor)

Having a qualified workforce will promote productivity.

Authority and Responsibility

Management can have control over the workforce. With authority comes responsibility.


Workforce must comply with orders and responsibilities, core values associated with mission, and vision.

Unity of Command

Workers should have only one manager telling them what to do.

Unity of Direction

Everyone in the organization is working toward a common goal.

Subordination of Individual Interests to General Interests

One person’s interest should not take priority over the interest of the organization.


Rate of pay depends on success of work.


Decision making and power should be at the top of the organization’s hierarchy.

Scalar Chain (Chain of Command)

The organization should have a clear chain of command. Each person should report to one other person.


Employees should have the right supplies to be productive.


Employees should be treated fairly by employers, according to the organization’s core values.

Stability of Tenure of Personnel

Have the right staff to manage and keep employee turnover at a minimum.


Employees should be allowed to voice their opinions and be encouraged to present new ideas.

Esprit de Corps

Managers are responsible for the satisfaction of the staff.

Note. Adapted from “14 Principles of Management (Fayol),” by V. van Vliet, located on the Tools Hero website at https://www.toolshero.com/management/14-principles-of-management/

Several of Fayol’s principles are still practiced today by many organizations and are expressed in, and even defined by, the core values of these organizations as well as their missions and visions. Numerous organizations are defined by their core values, which are expressed in their missions.

Bureaucratic Organizations

A bureaucratic organization is a form of management that has a pyramidal command structure. The bureaucratic organizational theory was founded by Max Weber around 1900. Max Weber was a sociologist and political economist who viewed an organization as a “type of social relationship that has regulations enforced” (Mtengezo, n.d., slide 5). Weber believed that those at the top of the organization made the decisions, and those at the bottom of the organization were the ones who completed the work. “In Weber’s idealized organizational structure, responsibilities for workers are clearly defined and behavior is tightly controlled by rules, policies, and procedures” (“Organizational Theory,” n.d., para. 3).

Organizational charts are common, and decisions are made through an organized process. The command structure is strict, and control is ever present. Bureaucratic goals are to be fair and orderly. In bureaucracies, there are layers of management from senior executives down to workers on the frontline (see Figure 5.2). Authority is always on top where rules and regulations are written and subsequently conveyed down the line to the worker.

Figure 5.2

Bureaucratic Organizational Chart

This diagram shows an example of a bureaucratic organizational chart, with three tiers. At the top is the Chief Nursing Officer. Nurse Managers make up the second tier, and on the lowest level are Staff positions.

Systems Theory

Nursing & Conceptual Frameworks

Leadership & Advocacy

Systems theory is a management theory that views the organization as either an open system or a closed system. A system is composed of distinct parts, each fulfilling a different need. As a closed system, the organization is not affected by the environment, whereas an open system is affected by the environment. The environment of an open system is defined as consisting of inputs, throughputs, and outputs. Each system is composed of different “parts that interact to form a complex whole. An organization is also a system with parts such as employees, assets, products, resources, and information that form a complex system” (Grimsley, n.d.c, para. 3).

Open System

An open system is one in which the organization is affected by its environment. “Open system theory was developed after World War II in reaction to earlier theories such as the administrative theories of Henri Fayol. Virtually all modern theories of organization utilize the open systems perspective” (Bastedo, 2004, p. 1). In the open system theory, resources are considered inputs. The environment in an open system can be affected by other organizations, such as those that are of a political, economic, or social nature. An organization’s survival is dependent upon its relationship with the environment. An open system consists of three elements:

Inputs are resources, such as equipment, natural resources, labor, information, and energy.

Throughputs are inputs that are in the process of being transformed.

Outputs are what throughputs yield, such as products and services.

As a result, outputs are released into the environment (Grimsley, n.d.c, para. 5). Environments are defined as the “suppliers, distributors, government agencies, and competitors with which a business enterprise interacts. The general environment encompasses several influences that emanate from the geographic area in which the organization operates” (“Organizational Theory,” n.d., para. 14). The cultural values of the areas in which the business operates affects the business environment. The status of the economy and the political environment also affect the success of a business as well as the educational system. A good education system must be in place, so there are enough educated workers to fill available positions.

Closed System

A closed system organization is one that has limited or no interaction with the outside environment. Everything that is produced stays within the organization, such as information or a production line item. A production line is a good example of a closed system. The workers who work on a production line are not involved with the day-to-day operations of the organization, but are only concerned with completing the task at hand.

Feedback Loops

Feedback loops are concepts that exist in system theory within an organization’s environment. The feedback loop can be positive or negative. “An organization that is an open system takes resources from the environment, known as inputs, transforms them through a process known as throughputs, and sends the transformed resources back into the environment as outputs” (Grimsley, n.d.b, para. 4). Feedback is essentially connecting the outputs to the inputs, which provides the system with important information.

A negative loop means there is a problem and alerts the responsible person. Having the knowledge of a negative feedback loop, the organization becomes aware of the problem and can correct it. The problem can be corrected internally or externally, depending on what is needed to correct the problem. Being alerted to problems allows the system to adapt and make changes so the desired outcome is reached.

The feedback loop within the organization is paramount in making the organization run efficiently. When there is a positive loop, it means that everything is working properly and there are no problems. Feedback, whether positive or negative, is important to the success of the organization. Without the feedback loop, an organization might never know if the organization is successful or failing.

An example of a feedback loop that directly affects nursing and health care organizations is customer satisfaction. The customer is the patient who received services from the health care organization. An independent company is hired by the health care organization to send surveys to patients who have had a recent hospital stay. Questions are asked regarding care, communication, food, quiet, and cleanliness. The survey results are computed and sent to the health care organization. The health care organization reports the results to administrators and managers so that changes can be made to improve areas where the scores were low. Even when information that is gathered is positive, there are always areas where improvement can be made.

As a result of feedback loops, health care organization administrators gather leaders and managers to discuss results to find areas of opportunity. Improvements and changes are implemented to affect a positive change. If subsequent survey results show improvement, the change is viewed as successful and other opportunities for improvement will be the next quality improvement project (see Figure 5.3). Adaption is critical to the success of an organization. Organizations must respond to feedback and make adjustments, whether internally or externally, to be successful and for continued success.

Figure 5.3

Customer Satisfaction Feedback Loop

The figure shows a cyclic flow diagram of a customer satisfaction feedback loop, beginning with a patient (hospital stay) and then moving through survey sent to patient, patient responds, results analyzed, administration and managers meet to discuss results, and finally to changes made for improvement.

Service Line Organization

An example of a new, modern organizational structure is the service line organization. Traditional organizational structures have more of a central authority at the top of the organizational chart versus a more horizontal line of authority. The organization with service lines has many smaller departments, which makes it easier to manage. “The service line approach tends to focus more on the requirements of customers, which often results in noticeable increases in the customer satisfaction rate” (Davoren, n.d., para. 5). Service lines within an organization can use evidence-based medicine to improve the quality of care, enhance the patient experience, and lessen the cost of care. Service lines may have better quality metrics and are usually patient-centered (Aston, 2015).

For service line management to be successful, the service line must be supported by the organization and have annual strategic planning in place. It is important for service lines to have “leaders who exhibit competencies across people, quality, service, and collaborative leadership” (Monitor, 2009, p. 9). In health care, the service line must be a collaborative effort between administrators and physicians to provide patient-centered care. The success of the service line is dependent on the leadership and staff who work together to meet strategic goals. “Successful service lines have a clearly defined scope of operation. From a clinical perspective, the clearly defined scope would define the patient types treated along the care continuum—which in turn determines the various specialties who would logically participate” (MedAxion, 2012, para. 1).

Organizational Structure

Nursing & Conceptual Frameworks

Leadership & Advocacy

All organizations must have some sort of structure to be operational. “Organizational structure determines how the roles, power, and responsibilities are assigned, controlled, and coordinated, and how information flows between the different levels of management. A structure depends on the organization’s objectives and strategy” (“Organizational Structure,” n.d., para. 1). The following discuss several different types of organizational structures and where the decision-making power lies in each.

Vertical structure: “A vertical organization structure is one that relies on managers to command and control their employees’ work. A business owner is typically at the top of a vertical chain of command” (Bianca, n.d., para. 1). The person at the top has all the power.

Horizontal structure: In a horizontal structure, there is not a well-defined chain of command. Employees work in teams and each team has a say in decision making. Those who work in teams also have a team leader who reports to someone else. There is not one single leader.

Centralized structure: An organization that has only one person in authority is said to be centralized. With a centralized structure, the top layer of management makes the most decisions and has the decision-making power over the lower layers of the organization.

Decentralized structure: In a decentralized organization, the authority lies with middle to lower management to make the majority of decisions. The decision-making power is shared among the departments or divisions of the organization. An organizational chart shows who has the power and who is involved in decisions made.

Matrix organization: A company structure in which reporting relationships are set up as a grid, or matrix, rather than in the traditional hierarchy. In other words, employees have dual reporting relationships—generally to two managers (Woods, n.d., para. 2).

Departmentalization: “Departmentalization involves dividing an organization into different departments, which perform tasks according to the departments’ specializations in the organization” (Grimsley, n.d.a, para. 1).

Functional departmentalization: The organization has different departments that each perform a necessary function.

Geographical departmentalization: The organization is divided into geographical departments. Each geographical area handles its own business.

Product departmentalization: Each product being produced has a different department.

Process departmentalization: Each process within the organization has its own department.

Customer departmentalization: Departments are organized based on customer needs or problems.

Chain of management departmentalization: Departments are organized based on the need for managerial divisions.

Market departmentalization: Departments are determined by the needs of each market they are serving.

Authority and responsibilities in these organizational structures may be assigned using the following methods.

Line authority: Those in line authority positions are able to make decisions and give orders to those who are subordinate.

Staff authority: Staff authority includes employees who advise those who are in the position of line authority. Staff authority helps line authority to improve in their position.

Span of control: Span of control is the number of employees for whom a manager is responsible. Span of control is the number of direct reports a leader can manage efficiently. If the number of direct reports is small, leaders or managers may feel they are not being used effectively, but if the number of direct reports is too large, leaders or managers may feel they cannot effectively manage such a large group.

Organizational Process

Nursing & Conceptual Frameworks

Leadership & Advocacy

An organizational process is when the organization works harmoniously together to meet the goals of the organization. Each part of the organization plans the work and determines what is needed by each member to complete tasks toward the goal of the organization. Each member of the team has an individual responsibility to work toward achieving the goals of the organization. There are generally five steps to an organizational process.

Review plans and objectives.

Determine the work activities necessary to accomplish objectives.

Classify and group the necessary work activities into manageable units.

Assign activities and delegate authority.

Design a hierarchy of relationships. (Plunkett, Allen, & Attner, 2012, p. 227)

If any of these steps are not followed to completion, the organization may fail.


A vision statement for any organization is a clear declaration of the organization’s goals. Most organizations have a vision statement, which puts into words their strategic goals for its future. A vision statement tells people what the organization wants to accomplish and how the organization can make things different through its purpose and activities. It provides the outside world with insight about the organization’s goals. Vision statements are typically aspirational and inspirational in nature. They encourage stakeholders, employees, and customers to think in terms of what is currently happening, and where the organization is heading. Vision statements can be complex or very simple (Hendricks, n.d.).


The mission statement communicates to the customer the organization’s purpose. Included in the mission statement is what the organization stands for and why it exists. The mission statement must capture the organization’s beliefs and values. It is a statement that conveys the organization’s philosophy and goals. It can contain cultural information and the products and services offered by the organization. The mission statement is a sort of declaration that symbolizes the organization’s persona (Hartzell, n.d.).

Integration of Mission and Vision

The integration of mission and vision is the organization’s statement of its goals and a somewhat strategic guide on the decisions that affect the organization. Mission and vision statements are often visible to the public and usually headline agendas. These statements must have a continual focus on the organization’s strategies, objectives, action plans, opportunities, and obligations (Walker Company, n.d.).

The way an organization operates should align with the mission and vision of that organization. Health care organizations work with their staff to ensure that delivery of care coincides with the organization’s mission. Some organizations employ online surveys, printed surveys, focus groups, and needs assessments that help organizations acquire knowledge. By acquiring knowledge, organizations can improve organizational intelligence and build upon the knowledge acquired to measure progress toward achieving their mission and vision.

Decision Making

Nursing & Conceptual Frameworks

Leadership & Advocacy

Safety & Quality

Decision making can vary depending on who is making the decision and why a decision has to be made. There can be formal methods used to reach a decision or an analysis that must be done before a decision is made. Decision making for anyone in a position of authority can be difficult, but skills can be acquired to help managers in this task. For nurses, decision making may also have an ethical dilemma attached to it.

To make a decision one must first figure out what choices are available. This may include a choice between a number of actions to take or picking the best solution for the problem. There are those who use intuition or past experiences to make decisions and others who use facts and figures to find the solution. “More complicated decisions tend to require a more formal, structured approach, usually involving both intuition and reasoning. It is important to be wary of impulsive reactions to a situation” (“Decision Making,” n.d.). There are different techniques one can use to make a decision, and it is the complexity of the problem that determines the technique to be used. Clinical decision making is “a contextual, continuous, and evolving process, where data are gathered, interpreted, and evaluated in order to select an evidence-based choice of action” (Tiffen, Corbridge, & Slimmer, 2014, p. 401).


Delegation can be defined as the act of appointing someone to carry out a task. In 2015, the National Council of State Boards of Nursing (NCSBN) “convened two panels of experts representing education, research, and practice. The goal was to develop national guidelines based on current research and literature to facilitate and standardize the nursing delegation process” (NCSBN, 2016, p. 5). The NCSBN panels developed a delegation model (see Figure 5.4) that represents where delegation begins and how delegation responsibilities are shared. The object of the panels was to understand evidence-based standards for delegation, recognize the difference between delegation and assignment, and define the responsibilities of each level of nursing. The five rights of delegation were also included (see Figure 5.5).

Figure 5.4

Delegation Model

The figure depicts the delegation model.

Note. Adapted from “National Guidelines for Nursing Delegation,” by the National Council of State Boards of Nursing, 2016, Journal of Nursing Regulation, 7(1), 5-14.

Figure 5.5

The Five Rights of Delegation

The figure depicts the five rights of delegation as described in this chapter: right task, right circumstance, right person, right direction and communication, and right supervision and evaluation.

Note. Adapted from “National Guidelines for Nursing Delegation,” by the National Council of State Boards of Nursing, 2016, Journal of Nursing Regulation, 7(1), 5-14.


Nursing & Conceptual Frameworks

Leadership & Advocacy

Safety & Quality

Coordination can mean many different things when discussing its connotations within an organization. Coordination can be planning and coordinating services between departments. It can mean coordinating scheduling of employees so that each department has the right people working in the right positions. For nursing, it can mean coordination of patient care to ensure patients receive quality care.

Coordination is defined as:

synchronization of activities, responsibilities, and command and control structures to ensure the resources of an organization are used most efficiently in pursuit of the specified objectives. Along with organizing, monitoring, and controlling, coordination is one of the key functions of management. (“Coordination,” n.d.)

For an organization to run smoothly, all departments of that organization must work together toward a common goal through the coordination of resources. An organization’s biggest resource it its employees.


Photograph shows a survey bubble form and a pen in close-up.

“An organizational assessment is a systematic process for obtaining valid information about the performance of an organization and the factors that affect performance” (Rojas & Laidlaw, n.d., para 1). Many organizations perform assessments to evaluate how the organization is performing. It is important for organizations to understand the evaluation, so changes can be made to improve performance and identify areas for improvement. Analysis of an organization is important, especially after improvements have been initiated to evaluate the effectiveness of improvements or changes made.

Areas of Nursing Impact on the Organization

Nursing & Conceptual Frameworks

Leadership & Advocacy

Safety & Quality

The Future of Nursing

Nurses are “professionals with the capacity and responsibility to influence current and future healthcare delivery systems” (Burke, 2016, para. 2). It is through policy that nurses influence the quality of care delivered. Nurses impact health care organizations through patient outcomes and patient satisfaction. By influencing policy, nursing can shape how health care is provided in the future. Nurses play “a unique role in formulating policy. The Institute of Medicine’s 2011 report The Future of Nursing: Leading Change, Advancing Health, recognized the importance of this role and called for nurses to take leadership in improving the quality of healthcare” (Burke, 2016, para. 4).

Workflow is another way in which nursing can impact health care organizations. Workflow is the process an organization uses to complete tasks to accomplish a given goal. Most of a health care organizations’ workflow is dependent on nursing. Good workflow can define the efficiency of the organization and determine how its goals are obtained. Workflow processes “direct the care team how to accomplish a goal. A good workflow will help accomplish those goals in a timely manner, leading to care that is delivered more consistently, reliably, safely, and in compliance with standards of practice.” (Cain & Haque, 2008, para. 10).

Corporate Culture

It has been said that “the heart of a successful healthcare organization is its culture” (Rozen, 2017, para 12). Culture is important because health care workers are known to have a lot of stress. “In a nationwide survey by CareerBuilder, health care workers, such as physicians and nurses, were found to experience the most stress in their jobs compared to all other industries—more than salespeople, police officers, and countless other careers (Ricker, 2014, para. 1). Culture plays a part in how nurses feel supported and heard by the health care organization.

A culture that is supportive of nurses and other health care workers is often a characteristic of successful organizations. When looking for an organization to join, nurses want to know if the organization is supportive of staff. Nurses want to know what the organization has to offer and what the organization will do to keep nurses feeling empowered and engaged. When health care organizations show appreciation to staff, nurses tend to be loyal and supportive in return. Recognition for a job well done and having a forum for nurses to communicate without retaliation are other ways an organization can show support for its nursing staff. Nurses are key to a health care organization’s success. The culture impacts the way staff communicate, work as teams, and feel rewarded and recognized. In return for supporting and recognizing the importance of nursing, organizations will reap the benefits in Centers for Medicare and Medicaid Services (CMS) reimbursements and improved patient satisfaction scores.

Organizational Structure

The way a health care organization is structured can affect communication, teamwork, and organizational processes. The decision on the type of structure an organization has typically relies on the wants of top management. The size of an organization also will determine the type of structure of an organization. When a functional organizational structure exists, the employees of the organization are grouped together by specialization and skill. A performance management system allows for “promotion, development, and visibility of individual skills within their functional area. The specialization that functional structures hone helps to bring about in-depth knowledge and skill development among the employees” (Davoren, 2018, para. 2).

Decision-Making Patterns

In health care, decision making occurs on many levels. There are decisions made by top administrators, physicians, department heads, nurse leaders/managers, and patients. Decisions can be about finances, equipment, departments, leadership, management, staffing, and many other issues. Decisions made in health care may be simple, complex, or life threatening. Each decision made may feel complicated and at times difficult, but usually with staff and patient satisfaction as priorities.

Shared Governance

Nursing & Conceptual Frameworks

Leadership & Advocacy

Safety & Quality

The Future of Nursing

Shared governance is a “professional practice model, founded on the cornerstone principles of partnership, equity, accountability, and ownership that form a culturally sensitive and empowering framework, enabling sustainable and accountability-based decisions to support an interdisciplinary design for excellent patient care” (Vanderbilt University Medical Center, n.d., para. 1). Shared governance puts some of the decision-making power into the hands of those who will feel the impact of the decision. Nurses, through shared governance, can now make decisions that affect nursing. Decisions are made through four principles: accountability, equity, partnership, and ownership.

Accountability: The mutual commitment to positive patient care outcomes.

Equity: Valuing every role in the organization.

Partnership: Nurses’ relationships with one another, patients, or other disciplines.

Ownership: Membership in the nursing profession, clinical practice, and the work that nurses as individuals. (Porter-O’Grady, 2006)

This photograph shows doctors and nurses sitting around a table examining documents.

Shared governance may have different names in different organizations. Some organizations call it “shared leadership, shared decision-making, decentralization, decisional involvement, collaborative governance, professional governance” (Vanderbilt University Medical Center, n.d., para. 6.). Unit-based shared governance may have monthly meetings to discuss unit-based problems, where the organization’s shared governance may discuss problems occurring within the organization.

Empowering Staff

One way staff may feel empowered is through shared governance or similar unit-based committees that have authority to make unit-based decisions. Nurses can feel empowered by participating in the decisions that are made concerning their work environment. “Empowered nurses foster better health outcomes for patients” (Laschinger, Gilbert, Smith, & Leslie, 2010, para. 6). Nurses who have high self-esteem and are engaged in work often feel empowered. Environments in which effective communication occurs along with good management help the staff on that unit to feel empowered. Empowering staff provides control over the decisions and the environment in which staff members work.

Level of Accountability

Nursing & Conceptual Frameworks

Leadership & Advocacy

Safety & Quality

Accountability can mean different things to different people depending on one’s level of accountability. Accountability (n.d.) is the obligation of an individual or organization to account for activities, accept responsibility for them, and disclose the results in a transparent manner. It can include the responsibility for money or other entrusted property. Accountability within an organization is multilayered, with each individual having some form of accountability. Accountability is determined by the organizational structure and the position an individual may hold. Health care organizations must be accountable to the patient.

Accountability in health care can be complicated. The health care organization is accountable to patients, physicians are accountable to patients, and nurses are accountable to patients. Patients can also be held accountable for following orders, by being compliant with medications, and paying for expenses incurred while hospitalized. Accountability is very important in health care, not only because it is multifaceted, but because lives are at stake.

A lack of accountability, including not following policies and procedures, can result in patient death. It is important for health care organizations to have a clear vision, a well-defined mission, and to operate ethically with clear and open lines of communication. Health care organizations work toward creating a culture of accountability, and one way to do this is by holding employees accountable. “When healthcare organizations hold themselves and their employees accountable, they can learn from mistakes and continuously improve operations. A culture of accountability in healthcare improves doctor-patient trust, reduces the misuse of resources, and helps organizations provide better quality care” (Gasior, 2018, para. 7).

Accountability starts with the organization. The organization is accountable to all employees by providing the necessary resources to meet the goals of the organization, which is providing safe quality care. Organizations are held accountable by the CMS, which puts into place “a payment policy tied to public reporting of quality and safety metrics, accreditation standards and goals for quality and patient-safety performance, and clinical licensure that requires accountability for evidence-based care” (Goeschel, 2011, p. 28). Regulatory bodies hold physicians, nurse leaders, nurses, and all other ancillary departments accountable “in part by licensing caregivers who have the knowledge and skills to understand their role and perform it competently” (Goeschel, 2011, p. 29).


Nursing & Conceptual Frameworks

Leadership & Advocacy

Safety & Quality

Health Promotion & Education

Communication can be defined as the passage of information from one individual to another or, in an organization, a commitment for effective interaction between managers and employees. It is so important that many organizations provide managers with important skills learned through coaching and training. When managers are held accountable for effective communication, the result can make a huge difference between success and failure. “Managers and leaders who are effective communicators should be recognized and rewarded; those who are not should receive the appropriate feedback and asked to make improvements” (Richards, n.d., para 2).

Communication comes in many forms and can be imparted in many different ways. Misunderstandings and conflict can occur as a result of ineffective communication or lack of communication. Nurses must know how to transfer information effectively, considering the patient’s customs, religions, and culture. Communication training in large organizations focuses on diversity and learning effective communication skills. Effective communication decreases adversity in the workplace and fosters an environment of trust and teamwork. If situations arise, it is best if the individuals meet face-to-face to resolve differences and misunderstandings. Good communication promotes a healthy work environment that can lead to increased productivity.

The photograph shows a health care worker taking orders over the phone.

Communication is also the exchange of information or ideas. Communication in health care can take place in many different ways. It can occur verbally and nonverbally, through written instruction, e-mails, texts, and phone calls. Effective communication with patients fosters quality patient care and increased patient satisfaction. Communication is responsible for patients learning about illness, so hospital admissions could be averted through patient knowledge, which leads to wellness and prevention. In health care, communication is seen as one of the most important skills a health care worker could possess. Organizations are taking responsibility and teaching “communication principles and guidelines that empower healthcare workers to initiate a meaningful connection with the patients they serve” (HHS, 2016, para. 8). Communication between nurses and physicians is very important because miscommunication can lead to sentinel events. One way to ensure good communication is through the use of “read back verify” of physician orders. If the physician is giving the nurse a telephone order, the nurse writes the order down while on the phone with the physician, and then reads back the order to the physician to verify that the correct order was transcribed.

Nursing & Conceptual Frameworks

Safety & Quality

Health Promotion & Education

Communication is much more than words. Therapeutic communication is defined as “the face-to-face process of interacting that focuses on advancing the physical and emotional well-being of a patient. Nurses use therapeutic communication techniques to provide support and information to patients” (Laffan, 2011). Nurses and other health care workers must keep open a clear line of communication with the patient to be able to develop therapeutic relationships, which are fundamental to building trust between the nurse and the patient. A good therapeutic relationship will contribute toward the patients’ well-being.


Nursing & Conceptual Frameworks

Leadership & Advocacy

Safety & Quality

Health Promotion & Education

The photograph shows a nurse typing on a keyboard on a mobile computer station, adding information to a patient’s electronic medical record. The doctor can be seen talking to the patient in the hospital room behind the nurse.

Advances in technology have influenced health care and made communication easier between disciplines. “Information and communication technologies (ICTs) embody all digital technologies that support the electronic capture, storage, processing, and exchange of information in order to promote health, prevent illness, treat disease, and manage chronic illness” (Rouleau, Gagnon, & Cote, 2015, para. 4). ICTs are responsible for services such as telehealth, interdisciplinary clinical support, and the transfer of knowledge from one discipline to the other. ICTs can be used for patient teaching, online discussion forums, and telemedicine, which is a growing field in health care.

Telemedicine is becoming more and more common in health care. Many health insurance companies offer 24-hour medical care available via computer conferencing. These companies can provide on-demand medical care. There are circumstances when specialists cannot be in the hospital 24 hours a day, 7 days a week. Using teleconferencing equipment makes consultation with a physician specialist possible. Patients can see the physician, and the physician can see the patient with the use of cameras and computers. Physicians can now speak to patients miles away. New communication technologies promote patient-centered care, improve the quality of care, and can educate those who are part of the health care team.

The electronic medical record (EMR) has also been responsible for improved communication between the multidisciplinary team. The EMR is one way to share information among health care workers that is generally assessable by all members of the health care team. Other technologies available include management systems, communication systems, computerized decision support systems, and information systems.

Management systems: “computer-based systems for acquiring, storing, transmitting, and displaying patient administrative or health information” (Rouleau et al., 2015, para. 15).

Communication systems: telecommunication systems that involve the sharing of information for diagnostic, management, counseling, educational, or support purposes. Communication can take place between health care workers and between health care workers and patients (Rouleau et al., 2015).

Computerized decision support systems: pertains to an automated computer-based system to support health professionals to practice within guidelines and care pathways to provide the best evidenced-based care (Rouleau et al., 2015).

Information systems: use “internet technology to attain access to different information resources, such as health and lifestyle information. Web-based resources and e-health portals for retrieving information are applications of information systems” (Rouleau et al., 2015, para. 15).

Incorporation of Quality and Safety

Nursing & Conceptual Frameworks

Leadership & Advocacy

Safety & Quality

Health Promotion & Education

There are many organizations and governmental agencies that work on ensuring patient safety by promoting the importance of quality. Quality can be defined as a “balance between possibilities realized and a framework of norms and values” (Mitchell, 2008, para. 2). The Institute of Medicine (IOM) defines quality as the “degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” (Agency for Healthcare Research and Quality [AHRQ], 2017, para. 2). The IOM defined Six Domains for Health Care Quality within the health care system.

Safe: Avoiding harm to patients from the care that is intended to help them.

Effective: Providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (avoiding underuse and misuse, respectively).

Patient-centered: Providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions.

Timely: Reducing waits and sometimes harmful delays for both those who receive and those who give care.

Efficient: Avoiding waste, including waste of equipment, supplies, ideas, and energy.

Equitable: Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status. (AHRQ, 2016, para. 2)

There are several government agencies and educational organizations that work together to promote patient safety by improving quality:

Agency for Healthcare Research and Quality (AHRQ)

ANCC Magnet Recognition Program


Hospital Compare

Hospital Quality Alliance

Institute for Healthcare Improvement

National Coordinating Council for Medication Error Reporting and Prevention

National Quality Forum

Nursing Alliance for Quality Care

Physician Consortium for Performance Improvement

The Joint Commission (TJC)

Nursing & Conceptual Frameworks

Leadership & Advocacy

Safety & Quality

Health Promotion & Education

According to the IOM (as cited in Mitchell, 2008), patient safety is:

the prevention of harm to patients. Emphasis is placed on the system of care delivery that (1) prevents errors; (2) learns from the errors that do occur; and (3) is built on a culture of safety that involves health care professionals, organizations, and patients. (para. 6)

The AHRQ adds to the definition by defining the prevention of harm as “freedom from accidental or preventable injuries produced by medical care” (Mitchell, 2008, para. 6). TJC has been a champion for patient safety for more than 60 years by helping “health care organizations improve the quality and safety of the care they provide with patient safety-focused initiatives that encourage and support organizations in their efforts to make patient safety a continuous priority” (The Joint Commission [TJC], 2018).

Role of Quality Improvement

Nursing & Conceptual Frameworks

Leadership & Advocacy

Safety & Quality

Health Promotion & Education

To incorporate quality and safety, improvement must be measurable. By measuring improvement, one is tracking the progress the organization is making in reaching its goals for quality and safety. This can be accomplished by the use of benchmarks. Benchmarks in health care are defined as “the continual and collaborative discipline of measuring and comparing the results of key work processes with those of the best performers in evaluating organizational performance” (Hughes, 2008, para. 6). There are internal benchmarks and external benchmarks. Internal benchmarks can identify and compare best practices. External benchmarks compare data between organizations using “comparative data to judge performance and identify improvements that have proven to be successful in other organizations” (Hughes, 2008, para. 6).

Quality of health care can be measured either by observing the structure, its processes, or its outcomes. To measure the quality of health care through structure, one looks at “the accessibility, availability, and quality of resources, such as health insurance, bed capacity of a hospital, and number of nurses with advanced training” (Hughes, 2008, para. 7). Measuring through processes looks at the delivery of health care, and outcomes are measured by patient satisfaction and mortality.

Continuous quality improvement (CQI) is very similar to TQM. CQI is used to develop clinical practice and is based on the notion that there is always opportunity for improvement. Improvements can be made in processes and issues that are discovered by regulatory and accreditation agencies. Identified issues are subsequently brought to a committee where quality improvements are developed. Clinical practice improvements (CPI) are led by hospital committee members and clinicians. Quality improvement teams are organized when data need to be collected and analyzed to find new and innovative ways to make improvements. The findings or quality improvement strategies are then translated into practice changes. It is important that management meets with staff and empowers staff to implement changes. Quality improvement strategies are developed by quality improvement teams for continuous practice improvement.

Quality and Safety Objectives

Quality and safety objectives are important because they help the organization remain focused on the strategies that will help the organization to meet their goals. Objectives are put into place to keep the focus on the organization’s goal. Goals should be measurable and realistic, and reflect the vision the organization projects to the consumer. Strong leadership support and the resources necessary to accomplish organizational change are mandatory for success.

Barriers may exist that hinder organizational improvement, such as poor communication and ineffective relationships between departments. The organization must embrace the need for change to actively pursue institutionalizing a culture of safety and quality improvement (Hughes, 2008). Quality improvement is defined as “systematic, data-guided activities designed to bring about immediate improvement in health care delivery” (Hughes, 2008, para. 11). A quality improvement strategy aims to promote health and health care centered on the needs of patients, families, and communities, and incorporate evidence-based results in clinical medicine, public health, and health care delivery using collaboration to improve care

Organizational Outcomes

“The World Health Organization defines an outcome measure as a ‘change in the health of an individual or group of people that is attributable to one or more interventions.’ Outcome measures (mortality, readmission, patient experience, etc.) are the quality and cost targets healthcare organizations are trying to improve” (Tinker, n.d., para. 3). The triple aim of health care (see Figure 5.6) was developed by the Institute for Healthcare Improvement (IHI). It describes a way to optimize health system performance. It includes improving the patient experience of care, improving the health of populations, and reduces the cost of health care. It is believed that if an organization can attain those outcomes, populations will be healthier. The United States is facing an aging population with chronic health problems—a population that has the potential for a long life, putting increased pressure on medical and social services. The IHI believes there are five components that will help health care organizations achieve the triple aim (Institute for Healthcare Improvement, n.d.a).

Figure 5.6

Triple Aim of Health Care

The diagram depicts the triple aim of health care and how improving the patient experience helps to reduce health care costs, which in turn helps improve the health of populations, as discussed in the chapter.

Note. Adapted from “Initiatives: IHI Triple Aim Initiative,” by Institute for Healthcare Improvement, located on the institute’s website at http://www.ihi.org/Engage/Initiatives/TripleAim/Pages/default.aspx

Organizational Indicators

Organizational quality indicators can fall into several different categories. There are prevention quality indicators, inpatient quality indicators, patient safety indicators, and pediatric quality indicators. “Quality indicators are standardized, evidence-based measures of health care quality that can be used with readily available hospital inpatient administrative data to measure and track clinical performance and outcomes” (AHRQ, n.d., para. 1). Quality indicators can highlight potential areas for improvement and can also be used to track results from any changes that were implemented. The AHRQ has multiple tools for health care organizations to identify areas for potential improvements.

American Nurses Association Principles for Nurse Staffing

Nursing & Conceptual Frameworks

Leadership & Advocacy

Safety & Quality

Health Promotion & Education

The Future of Nursing

An association exists between nurse staffing and patient outcomes. The American Nurses Association (ANA) identified elements needed to achieve optimal staffing, which enhances the delivery of safe, quality care. Appropriate staffing matches the expertise of the nurse with the needs of the patient. The ANA found that appropriate staffing is critical to the delivery of cost-effective health care. Nurses should be partners and collaborate with other disciplines. Registered nurses must also have a say in staffing decisions and the environment in which they practice. The ANA also felt that cost effectiveness was important in the delivery of safe, quality care (American Nurses Association, 2012). The National Database for Nursing Quality Indicators (NDNQI) “is the only national nursing database that provides quarterly and annual reporting of structure, process, and outcome indicators to evaluate nursing care at the unit level” (Montalvo, 2007, para. 1).

Information Management

Hospital information management is in essence knowledge management along with data management systems. Hospital information management enables users to share information that meets technical, social, managerial, and economical requirements (Wadwa, Saxena, & Wadhwa, 2007). Information management began in the 1960s when Medicare and Medicaid essentially drove the health care system. At this time, computers were huge, and many times hospitals shared a mainframe to manage hospital accounting systems. In the 1970s, it became evident that computers were the future. Computers were smaller, which made it possible for each department within the hospital to have a computer. Specific departments, such as the lab and radiology, could have their own computers on which to keep information.

The 1980s brought about diagnosis-related groups, which defined a classification system that identified services the patient received directly related to reimbursement. “For the first time, hospitals needed to pull significant information from both clinical and financial systems in order to be reimbursed. At the same time, personal computers, widespread, non-traditional software applications, and networking solutions entered the market” (Grandia, n.d., para. 9). As a result, applications were created to enable financial and clinical systems to talk to each other.

By the 1990s, health care was driven by completion and consolidation. Hospitals had access to broad, distributed computing systems and robust networks, and data and reporting became integrated. The 2000s brought about the beginnings of outcome-based reimbursement. Technological advancements allowed for the installation of bedside clinical applications. As the years passed, everything became more complicated and the amount of data collected was enormous, so that information management is currently driven by accountable care organizations and value-based purchasing initiatives.

“Knowledge gained from analyzing an organization’s data in search of performance improvement insights will complete the operational systems cycle by refining the rules essential for successful clinical decision support” (Grandia, n.d., para. 15). There is a need for quality control systems. Hospitals must now be actively engaged in strategies that result in the capture and analysis of comprehensive data. This data will enable health care organizations to become organizations that are continuously improving and learning.

Organizational Responsiveness to Change

Organizational responsiveness is a measurement of how well the health care organization is meeting “the legitimate expectations of the population for the non-health enhancing aspects of the health system. It includes seven elements: dignity, confidentiality, autonomy, prompt attention, social support, basic amenities, and choice of provider” (Darby, Valentine, Murray, & deSilva, n.d., p. 1). When change occurs in an organization, health care professionals must use their expertise to manage change. Managing change is a process that begins with evaluation, asking the question: Why is the change needed? The next step in managing change is planning the process of change. After the planning is completed, management must find competent people to undertake the tasks necessary for success. When change is needed, management can either “support it, be indifferent to it, be passive about it or participate in it. Managing change is about handling the complexity of the process. Managing change is a complex, dynamic, and challenging process” (Al-Abri, 2007, para. 2).

With change comes resistance. Health care organizations employ large numbers of professionals who may not perform as well or adapt as well to change. Employees will want to know why the change is happening and how the change will affect them. “Bringing about change requires the manager to challenge the precedent and requires perseverance against the habits and norms of established behaviors. Bringing about change takes time and requires the commitment of time on the part of the manager (Al-Abri, 2007, para. 6).

Managers can use proactive strategies in recognizing resistance to change. Anticipating resistance is important in any change management plan, as well as identification and removal of barriers. Staff need to feel competent in their ability to work with and accept change. Change does not always follow a pattern and is never predictable. Major changes can take many years to transpire. Clinical staff may view their work as a vocation as much as a profession and may be distrusting of upper management. The need for change may be obvious for organizational performance improvement, but staff can view that premise as fundamentally flawed. For change to be successful, employees must feel included on the journey.

Health care systems may require ongoing quality improvement efforts to adopt evidence-based practices that will improve health care delivery. Implementation must take place at several different levels in health care:



Organization, and

Health care system.

Collaboration across these levels must occur for successful change.

Organizational Readiness for the Multicultural World

Nursing & Conceptual Frameworks

Leadership & Advocacy

Safety & Quality

Health Promotion & Education

The Future of Nursing

Are health care organizations ready to provide equitable care in a multicultural world? Health equity is has been established when everyone has access to health care regardless of social, economic, or environmental position. In the United States, the burdens of disease and poor health and the benefits of well-being and good health are inequitably distributed (“Summary,” 2017, p. 1). Changes in the health care delivery system are required to reduce health disparities through recognition and the necessity of addressing the health care needs of a diverse population. Health disparities are variations that exist among specific population groups. Disparities can be measured by incidence, prevalence, and mortality. Disparities can also exist across many other dimensions as well, such as gender, sexual orientation, age, disability status, socioeconomic status, and geographic location. Populations that have the least access to health care suffer the greatest impact of disparities (“The State of Health Disparities in the United States,” 2017).

Health care organizations can contribute to the elimination of health disparities, both racial and ethnic, through education. An approach used to achieve cultural competence is aimed at programs that “teach about the attitudes, values, and beliefs of a specific cultural group. This approach to training proposes that cultural competence can be taught through reflective awareness, empathy, active listening techniques, and the cognitive mechanisms” (AHRQ, 2014, para. 3). Changes must occur simultaneously at the provider and organizational level.

Cultural Competency of Staff

Nursing & Conceptual Frameworks

Leadership & Advocacy

Health Promotion & Education

The Future of Nursing

The photograph exemplifies cultural diversity in the workplace, showing several health care practitioners of different ethnic heritage.

Cultural competence is integral to how health care organizations provide health care. The AHRQ (2014) defines culturally competent care as “care that respects diversity in the patient population and cultural factors that can affect health and health care, such as language, communication styles, beliefs, attitudes, and behaviors” (para. 1). Staff must be able to relate to a multicultural patient population with cultural and social needs in addition to their need for equitable health care. The nurse leader must seek opportunities to improve the diversity among health care workers and act upon those opportunities to develop diversity among the staff, as well as develop cultural competency among the staff. The nurse leader can take the opportunity to encourage a diverse culture that is knowledgeable about providing health care to an equally diverse population. Greater diversity among health care workers may improve cultural competence through the utilization of training provided by health care organizations. Nurse leaders now ensure that training is provided to improve cultural competence in the health care organization.

It is important that health care workers are informed about their role in providing culturally competent care and it is the responsibility of organizations to provide the tools and education needed by workers to meet the challenges of a diverse patient population.

When patients feel heard and understood by their healthcare providers, they are more likely to participate in preventive healthcare and less likely to miss health appointments. This can reduce medical errors and related legal costs for healthcare facilities, and it can improve health outcomes for patients. Ultimately, a culturally competent organization can help reduce health disparities among patient populations. (Medcom Trainex, 2018, para. 10)

Research has found that the “cultural competence of the healthcare staff was associated with the cultural competence of the leaders” (Dauvrin & Lorant, 2015, p. 200).

Future Organizational Challenges and Opportunities

Quality health care is one of the most important factors in how individuals perceive their quality of life. In some countries, health care is a major political issue, along with the economy. Globally, all health economies are facing similar challenges (CGI, 2014). Because advances in technology are helping people to live longer and health care costs have been rising steadily, there has been an increasing demand for changes to health care delivery in the United States. Organizations face many challenges while learning to adapt to a rapidly changing health care environment.

Health care organizations are employing technologies, such as electronic medical records and databases, to support the collection of voluminous health information. Value-based purchasing requires health care providers to understand the importance of discharge planning and care transition. Leadership must work closely with, and confront the challenges of, population health management, data analytics, and acquiring and implementing the right technologies. Organizations confront challenges posed by a more consumer-driven system in which they “demand greater transparency, better communication, and more information about value” (Appold, 2016).

A culturally competent health care system is one that can acknowledge the importance of culture as it reflects on the dynamics of the organization. This can be demonstrated by the cultural knowledge of the staff. The organization and its leaders must recognize the importance of being culturally diverse in the services and care provided. The organization must also acknowledge that a culturally competent system is “built on an awareness of the integration and interaction of health beliefs and behaviors, disease prevalence and incidence, and treatment outcomes for different patient populations” (Betancourt, Green, Carrillo, & Ananeh-Firempong, 2003, p. 294).

Health care organizations are facing an uncertain future. The journey that began in 2010 with The Patient Protection and Affordable Care Act (ACA) to a value-based health care system will continue. People are now responsible for a larger portion of health care costs and organizations must find new ways to operate. Organizations were used to collecting money from insurance companies and the government, namely Medicare and Medicaid services. With consumers now paying part of the bill, health care is becoming more patient-centered and consumers of health care have higher expectations from providers (Ellis, n.d.). Patients have become more responsible for their own health outcomes.


The Future of Nursing

As health care evolves, so must the providers of health care. The Mayo Clinic in Rochester, Minnesota, has been a revolutionary trendsetter. In 2008, the organization created The Mayo Clinic Center for Innovation, the first innovation center for health care in the United States, which employs teams that are responsible for ensuring “the needs of the patient come first” (Beck, 2000, para. 1). This new innovative health care delivery system employs teams of clinicians, staff members, information technology specialists, and patients that turn innovative ideas into practical solutions. Changes include provider video visits, e-consults, and even a new type of clinical examination room. Mayo Clinic is developing in-home monitoring, patient-driven appointments and online communities (Bhatti, del Castillo, Olson, & Darzi, 2018, para. 6).

Many health care organizations acknowledge the importance of providing culturally competent care to diverse populations across the United States.

Research has shown that when nurses understand the culture and history of a patient’s community, communication and trust are improved. Patients feel more confident in the care they are receiving when their caregiver can relate to them culturally or ethnically. (Hancock, 2017, para. 1)

Leadership & Advocacy

This graphic representation of a multidisciplinary team shows a group of silhouettes around a conference table, each with a different colored jigsaw puzzle piece on the table, implying that each member of the team provides a different, yet essential, facet of the solution.

In its report on the future of nursing, the IOM (2011) stressed the need for a diverse workforce to achieve health care equality. Nurse leaders can encourage the development of a more culturally diverse and culturally competent staff. “Organizations with an inclusive culture that encourages collaboration, flexibility and fairness as well as equal participation are more successful in employee engagement and retention” (Hancock, 2017, para. 9). Organizations that offer diversity training and seek opportunities to engage underrepresented groups improve organizational performance and culture.

Massachusetts General Hospital Center in 2012 began the Consortium for Affordable Medical Technologies (CAMTech). This innovative design brought together a multidisciplinary team consisting of health care professionals and nonhealth care professions to “co-design novel solutions to US and global health challenges through hackathons, awards programs, and business acceleration activities. CAMTech is an open innovation platform now involving a network of over 4,300 engineers, clinicians, entrepreneurs, and designers from over 700 organizations” (Bhatti et al., 2018, para. 8). A hackathon involves hundreds of specialists working together over a 48-hour period to tackle one problem. In 2016, the hackathon revolved around the “opioid crisis, which resulted in 18 innovation proposals. One hackathon led to the development of the Augmented Infant Resuscitator, an inexpensive add-on to ubiquitous bag valve masks, that dramatically improves how birth attendants provide newborn ventilation” (Bhatti et al., 2018, para. 9). It is innovations such as these that will transform health care.

Role of the Nurse Leader (Synergy Model)

Nursing & Conceptual Frameworks

Leadership & Advocacy

Safety & Quality

As organizations evolve, health care leaders must evolve as well. The synergy model for patient care is one that takes the patient’s needs and matches them with the competencies of the nurse. Most patients have similar needs, but at times, specialized nursing care is needed.

The dimensions of a nurse’s practice are driven by the needs of a patient and family. This requires nurses to be proficient in the multiple dimensions of the nursing continuums. When nurse competencies stem from patient needs and the characteristics of the nurse and patient synergize, optimal patient outcomes can result. (American Association of Critical Care Nurses, n.d., p. 1)

There are various assumptions that guide the synergy model. Assumptions are made that nurses care for the whole patient—body, mind, and soul. Each patient has a number of characteristics or “interrelated dimensions,” as does the nurse. The goal of the nurse is to care for the patient; as the patient wishes, either back to a state of wellness or to a peaceful death. Each patient, nurse, provider, or health care organization is unique and brings with it characteristics that span the health care continuum. There are eight characteristics that make up the synergy model (see Table 5.2).

Table 5.2

Synergy Model Characteristics


The capacity to return to a restorative level of functioning using compensatory/coping mechanisms; the ability to bounce back quickly after an insult.


Susceptibility to actual or potential stressors that may adversely affect patient outcomes.


The ability to maintain steady-state equilibrium.


The intricate entanglement of two or more systems (e.g., body, family, therapies).

Resource Availability

Extent of resources (e.g., technical, fiscal, personal, psychological, and social) the patient/family/community brings to the situation.

Participation in Care

Extent to which patient/family engages in aspects of care.

Participation in Decision Making

Extent to which patient/family engages in decision making.


A characteristic that allows one to expect a certain course of events or course of illness.

Note. Adapted from “The AACN Synergy Model for Patient Care,” by the American Association of Critical Care Nurses, p. 1.

Nurses are an integral part of the health care system and possess the skills, knowledge, and attitudes to provide patient-centered care in any setting, whether it be an acute care hospital or the patient’s home. A nurse’s characteristics in the synergy model (see Figure 5.7) are based off of the patient’s needs and the nurse’s expertise, which can range from novice to expert. Under the synergy model, there are five levels of competency from competent to expert in eight different categories.

Figure 5.7

Synergy Model

Diagram demonstrating the nurse synergy model and the relationships among eight different categories, including caring practices, clinical inquiry, advocacy and moral agency, facilitation of learning, clinical judgement, systems thinking, response to diversity, and collaboration.

Note. Adapted from “The AACN Synergy Model for Patient Care,” by the American Association of Critical Care Nurses, pp. 2-3.

Nurse Leader: The Risk Taker

Nursing & Conceptual Frameworks

Leadership & Advocacy

Safety & Quality

There are many challenges facing nurse leaders in the current health care environment. To be responsible to the health care organization, nurse leaders must focus on staff providing quality care while meeting productivity and quality indicators. Leaders and managers have always focused on care delivery, but now they must focus on the outcomes of delivery provided. Nurse leaders must recognize the importance of implementing evidence-based practices and evaluating their effectiveness as it relates to patient outcomes and safety. The health care environment has been emphasizing safety and evidence-based decision making, which discourages innovation and risk taking. Having the courage in leadership to take risks can be difficult, but it plays a role in effective management (Sherman, 2014).

There are several key leadership behaviors that foster risk taking and innovation in health care. Leaders should be able to call out bad behavior and have difficult conversations. Staff who are best for the position should be in the position based on competency, not personality. Nurse leaders should do what is right and not what is easy. The organization’s mission and vision should be considered when difficult decisions must be made. Patients should always come before profits, which is difficult in this value-based reimbursement environment.

Fear plays a big role in why leaders are often unwilling to take risks. Risk taking is a learned skill, and stepping out of one’s comfort zone is taking the risk (Sherman, 2014). Innovation in nursing fosters the creation of new knowledge, which begins to elevate nursing practice.

Nursing Leadership

Nursing & Conceptual Frameworks

Leadership & Advocacy

Safety & Quality

Transforming the current health care system to meet the demands for safe, quality, and patient-centered care has demanded a shift in the role of nurse leaders. Historically, “nurses could not participate fully due to a variety of cultural, regulatory, and policy barriers that limited the nurse’s ability to effectively contribute to broad, meaningful change are now being called to lead” (Petersen, n.d., p. 40). Presently, the health care system is fragmented and inefficient, pointing to the fact that America spends more on health care than any other country in the world. There exists a lack of insurance, inconsistency in quality, and excessive administrative waste. With the advent of the IOM (2011) report, The Future of Nursing: Leading Change, Advancing Health, nurses’ roles and responsibilities have been redefined to meet the needs of an evolving health care system (Petersen, n.d., p. 45).

Nursing leadership emphasizes nursing practice and improvement of health outcomes while ensuring patient safety. The nurse leader as a systems thinker must look beyond the “name, blame, shame” approach to patient safety and toward focusing on human factors of how care is delivered within a less-threatening environment. Systems thinking looks at large numbers of interactions to gain understanding to help leaders target innovation efforts more effectively (Petersen, n.d., p. 60). Nurse leaders are stepping up and using knowledge and expertise to contribute new innovative strategies to engage in health care reform.

Nurse Leader: Clinical Inquiry

Clinical inquiry is the practice of asking questions about nursing practice. Clinical inquiry can be used for quality improvement, research, and formulating evidence-based practices. Nurse leaders may investigate issues that lead to improved delivery of care or nursing practice. There are many reasons why questions are asked and why answers are needed. “Quality improvement (QI) is a systematic, formal approach to the analysis of practice performance and efforts to improve performance” (American Academy of Family Physicians, n.d., para. 1). Whereas research is a systematic investigation performed to answer a question or investigate a hypothesis, evidence-based practice is the integration of clinical expertise and scientific evidence (results of research) that is implemented into practice to provide medications, treatments, or procedures to care for patients. Clinical inquiry is the combination of quality improvement, research, and evidence-based practices, which nurse leaders use to ensure that patients are receiving quality patient-centered care. Clinical inquiry is not exclusive of nursing but involves interdisciplinary collaboration.

Quality Improvement History

To Err Is Human: Building a Safer Health System

Nursing & Conceptual Frameworks

Leadership & Advocacy

Health Promotion & Education

The Future of Nursing

In 1999, the IOM published a report To Err Is Human: Building a Safer Health System. The report found that health care in the United States was not safe. The report stated that as many as “98,000 people die in hospitals each year as a result of medical errors that could have been prevented, according to estimates from two major studies” (IOM, 1999, p. 1). The report also stated that errors that occurred were the result of a failure to safely complete a task, such as “adverse drug events, improper transfusions, surgical injuries and wrong-site surgery, suicides, restraint-related death, falls, burns, pressure ulcers, and mistaken patient identities” (IOM, 1999, p. 1).

Errors were costly to the organization and left patients feeling unsafe. Patients would see multiple providers, have hospitals stays and surgical procedures, but there was no form of communication between providers or between providers and health care organizations. Contributing to the occurrence of errors was the fact that no one had complete information. Taking everything into account, the IOM came up with four strategies it believed would build a healthier health care system:

Establishing a national focus to create leadership, research, tools, and protocols to enhance the knowledge base about safety.

Identifying and learning from errors by developing a nationwide public mandatory reporting system and by encouraging health care organizations and practitioners to develop and participate in voluntary reporting systems.

Raising performance standards and expectations for improvements in safety through the actions of oversight organizations, professional groups, and group purchasers of health care.

Implementing safety systems in health care organizations to ensure safe practices at the delivery level. (IOM, 1999, pp. 3-4)

So began the quest for continuous quality improvement. President Bill Clinton’s administration issued executive orders instructing government agencies to conduct or oversee health care programs to implement proven techniques for reducing medical errors and creating a task force to find new strategies for reducing errors. Congress soon launched a series of hearings on patient safety and, in December 2000, it appropriated $50 million to the AHRQ to support a variety of efforts targeted at reducing medical errors (IOM, 1999).

Crossing the Quality Chasm: A New Health System for the 21st Century

Nursing & Conceptual Frameworks

Leadership & Advocacy

Safety & Quality

Health Promotion & Education

The Future of Nursing

In 2001, the IOM published Crossing the Quality Chasm: A New Health System for the 21st Century, which discussed “how the health system can be re-invented to foster innovation and improve the delivery of care. Toward this goal, the committee presented a comprehensive strategy and action plan for the coming decade” (IOM, 2001, p. 2). The IOM’s vision included six aims for improvement that defined how health care organizations could change:

Safe: avoiding injuries to patients from the care that is intended to help them.

Effective: providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit.

Patient-centered: providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions.

Timely: reducing waits and sometimes harmful delays for both those who receive and those who give care.

Efficient: avoiding waste, including waste of equipment, supplies, ideas, and energy.

Equitable: providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status. (IOM, 2001, p. 3)

In order to be able to achieve these aims, the IOM put together a set of 10 rules to use in order to redesign the health care system:

Care is based on continuous healing relationships. Patients should receive care whenever they need it and in many forms, not just face-to-face visits. This implies that the health care system must be responsive at all times, and access to care should be provided over the Internet, by telephone, and by other means in addition to in-person visits.

Care is customized according to patient needs and values. The system should be designed to meet the most common types of needs, but should have the capability to respond to individual patient choices and preferences.

The patient is the source of control. Patients should be given the necessary information and opportunity to exercise the degree of control they choose over health care decisions that affect them. The system should be able to accommodate differences in patient preferences and encourage shared decision making.

Knowledge is shared and information flows freely. Patients should have unfettered access to their own medical information and to clinical knowledge. Clinicians and patients should communicate effectively and share information.

Decision making is evidence-based. Patients should receive care based on the best available scientific knowledge. Care should not vary illogically from clinician to clinician or from place to place.

Safety is a system property. Patients should be safe from injury caused by the care system. Reducing risk and ensuring safety require greater attention to systems that help prevent and mitigate errors.

Transparency is necessary. The system should make available to patients and their families information that enables them to make informed decisions when selecting a health plan, hospital, or clinical practice, or when choosing among alternative treatments. This should include information describing the system’s performance on safety, evidence-based practice, and patient satisfaction.

Needs are anticipated. The system should anticipate patient needs, rather than simply react to events.

Waste is continuously decreased. The system should not waste resources or patient time.

Cooperation among clinicians is a priority. Clinicians and institutions should actively collaborate and communicate to ensure an appropriate exchange of information and coordination of care. (IOM, 2001, pp. 3-4)

The IOM has been instrumental in reinventing and redesigning the health care system. Much of what is done today was foreseen in the IOM’s papers from 1999 and 2001. The information found in To Err Is Human and Crossing the Quality Chasm is still being followed today to fix a broken health care system. Nurse leaders are tasked with the important role of reengineering health care, as well as implementing change and innovation.

Deming’s Total Quality Management

After World War II, William Edwards Deming, an engineer, statistician, and professor, developed 14 key principles for management called total quality management (TQM). TQM is an “organizational approach involving organizational management, teamwork, defined processes, systems thinking, and change to create an environment for improvement. This approach incorporated the view that the entire organization must be committed to quality and improvement to achieve the best results” (Hughes, 2008, para. 8). “Dr. Deming offered 14 key principles for management to follow to significantly improve the effectiveness of a business or organization. Many of the principles are philosophical. Others are more pragmatic. All are transformative in nature” (“Dr. Deming’s 14 Points for Management,” n.d., para. 1). Deming’s 14 principles are as follows:

Create constancy of purpose toward improvement of product and service, with the aim to become competitive and to stay in business, and to provide jobs.

Adopt the new philosophy. We are in a new economic age. Western management must awaken to the challenge, must learn their responsibilities, and take on leadership for change.

Cease dependence on inspection to achieve quality. Eliminate the need for inspection on a mass basis by building quality into the product in the first place.

End the practice of awarding business on the basis of price tag. Instead, minimize total cost. Move toward a single supplier for any one item, on a long-term relationship of loyalty and trust.

Improve constantly and forever the system of production and service, to improve quality and productivity, and thus constantly decrease costs.

Institute training on the job.

Institute leadership. The aim of supervision should be to help people, machines, and gadgets to do a better job. Supervision of management is in need of overhaul, as well as supervision of production workers.

Drive out fear, so that everyone may work effectively for the company.

Break down barriers between departments. People in research, design, sales, and production must work as a team, to foresee problems of production and in use that may be encountered with the product or service.

Eliminate slogans, exhortations, and targets (silos) for the work force asking for zero defects and new levels of productivity. Such exhortations only create adversarial relationships, as the bulk of the causes of low quality and low productivity belong to the system and thus lie beyond the power of the work force.

Eliminate work standards (quotas) on the factory floor. Substitute leadership.

Eliminate management by objective. Eliminate management by numbers, numerical goals. Substitute leadership.

Remove barriers that rob the hourly worker of his right to pride of workmanship. The responsibility of supervisors must be changed from sheer numbers to quality.

Remove barriers that rob people in management and in engineering of their right to pride of workmanship. This means, inter alia, abolishment of the annual or merit rating and of management by objective.

Institute a vigorous program of education and self-improvement.

Put everybody in the company to work to accomplish the transformation. The transformation is everybody’s job. (“Dr. Deming’s 14 Points for Management,” n.d., paras. 5-18)

Deming’s principles can be followed by nurse leaders to understand what is needed to transform health care delivery and to provide quality care by competent nurses. Quality improvement is the key to change and innovation. Health care is currently taking data and transforming the results into opportunities for improvement. Deming believed in education, and nurses are currently returning to school to obtain baccalaureate, master’s, and doctoral degrees. Nurse leaders must engage and empower nurses in quality care delivery. Improvement is a process over time. Deming believed if the workers were engaged in the process, they would then be able to effect change.

Quality Improvement

Nursing & Conceptual Frameworks

Leadership & Advocacy

Safety & Quality

Health Promotion & Education

The Future of Nursing

Quality improvement is a way for health care organizations to “ensure the most current, clinically proven techniques and practices are being put into place to deliver the safest and highest quality care” (American Health Quality Association, 2017, para. 2). This is accomplished through the collaborative efforts of health care providers and health care organizations. Quality improvement occurs as a result of the collection and analysis of quality indicators, patient health records, and patient satisfaction surveys, so areas for improvement can be identified. One necessary practice for health care organizations is to ensure a culture of quality by developing multidisciplinary teams that meet regularly to discuss the results of data that have been collected and analyzed.

“Developing meaningful measures of overall health system quality, and how it is changing, requires a combination of indicators that can reliably show how the system—which includes providers, payers, and public health—is influencing the health of the population” (Claxton, Cox, Gonzales, Kamal, & Levitt, 2015, para. 7). It is important that health care organizations provide quality care because it is a vital service to people. Most people do not understand all of the complexities of health care, so people put their lives into the hands of health care professionals and health care organizations. Nurse leaders have the responsibility of leading and managing their teams to provide safe, quality, patient-centered health care and continuous quality improvement. The quality improvement process involves several basic concepts (see Figure 5.8).

Figure 5.8

Quality Improvement Process

The diagram shows the quality improvement process for safe, quality, patient-centered care by establishing the cyclic flow from collecting and analyzing data, to setting measurable goals, to communicating results, to continuous evaluation of quality indicators and clinical outcomes, to identifying areas for improvement.

Note. Adapted from “Basics of Quality Improvement,” by the American Academy of Family Physicians, located on the academy’s website.

Model for Improvement

Nurse leaders understand the importance of continuous quality improvement to increase efficiency and improve patient outcomes. Quality improvement begins with the establishment of a culture based in transparency and continuous evaluation of nurse-sensitive quality indicators and clinical outcomes. The model for improvement was developed by Associates in Process Improvement (API). It is a simple, yet powerful tool for accelerating improvement (IHI, n.d.b). The IHI combined the total quality management tool and the plan-do-study-act cycle (PDSA) into the model for improvement.

The first step is to select the right people to establish teams. “A process improvement team is critical to a successful improvement effort. Teams vary in size and composition” (IHI, n.d.b, para. 3). Health care organizations build teams based on the process that needs improvement. After the teams are formed, goals are set, and the team determines what it is trying to accomplish and what process needs to be improved. The goal should be measurable and time-specific. Teams use quantitative measures to determine whether a specific change led to improvement. A change must be made that will result in improvement. The change is implemented on a small scale for evaluation using the PDSA cycle.

The change will be planned, tried, and observed, and actions will be taken depending on what was learned. This is action-oriented learning (IHI, n.d.b). After testing the change to see if it was successful, it can be brought to the entire organization and improvements can be made. By analyzing the data and finding areas for improvement, teams can use the model for improvement to find processes that can be implemented for quality improvement.

Reflective Summary

The nurse leader has a major role in reengineering health care. They act as change agents by developing strategies for quality improvement. The nurse leader strives to contribute positive changes to the profession of nursing to improve patient outcomes. The nurse leader is an important part of the health care organization. This chapter has examined the different types of organization and the different strategies used to meet the goals of nursing leadership within a health care organization to be able to provide a safe environment for patients. Quality improvement is especially important to health care organizations because the communities they serve expect the very best that health care has to offer. In this age of information, people are aware of the quality of care provided by the health care organizations in their community. The expectation is one of safe, patient-centered care for themselves and their families. Nurses and their leaders must continue to impact health care delivery and work within health care organizations to be major contributors to quality improvement.

Key Terms

Accountability: Being morally responsible for actions and professional conduct and accepting ownership of those actions.

Bureaucratic Organization: A form of management that has a pyramidal command structure.

Classical Organizational Theory: Scientific approach to management developed by Frederick Taylor.

Clinical Decision Making: A contextual, continuous, and evolving process, in which data are gathered, interpreted, and evaluated in order to select an evidence-based choice of action.

Closed System Organization: An organization that has limited or no interaction with the outside environment. Everything that is produced stays within the organization, such as information or a production-line item.

Communication: Interpersonal sharing of information and/or feelings are exchanged in verbal and nonverbal methods.

Continuous Quality Improvement: The ongoing efforts of organizations, including groups and individuals, working in and with the organizations to improve services or products to meet the needs of customers.

Coordination: Ensuring the overall design of the team efficiently produces increased productivity and positive patient outcomes.

Culturally Competent Care: Care that respects diversity in the patient population and cultural factors that can affect health and health care, such as language, communication styles, beliefs, attitudes, and behaviors.

Delegation: The use of personnel to accomplish a desired task by allocation of responsibility and authority under the guidelines set forth by regulating health care boards at the state and national level.

Evaluation: The assessment or reassessment of a particular person or group, task, or performance that determines the efficiency or inefficiency of a particular process.

Mission Statement: Stated organizational purpose that is recognized and integrated into professional practice.

Open System Theory: Good internal and external environment exchange of information and feedback in order to promote positive change and meet the needs of stakeholders locally, regionally, nationally, or even globally.

Organization: A group of people working together to accomplish common goals.

Organizational Processes: Processes, including planning, decision making, delegation, coordination, communication, and evaluation, that have a direct effect on employee engagement and organizational culture.

Patient Safety: The prevention of harm to patients.

Quality Improvement: A systematic and formal approach to collecting, analyzing, and disseminating data in order to improve services or products that a business renders.

Quality Indicators: Standardized, evidence-based measures of health care quality that can be used with readily available hospital inpatient administrative data to measure and track clinical performance and outcomes.

Shared Governance: A partnership between bedside nurses and nursing managers and leaders that involves decision making and empowers nurses by giving them a voice.

Systems Theory: A management theory that views the organization as either an open system or a closed system.

Therapeutic Communication: Use of communication skills that convey a sense of trust and respect in order to understand the patient’s needs

Vision Statement: A clear declaration of the organization’s goals.

Workflow: The process an organization uses to complete tasks to accomplish a given goal.


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