NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.
Open Resources for Nursing (Open RN); Ernstmeyer K, Christman E, editors. Nursing Management and Professional Concepts [Internet]. Eau Claire (WI): Chippewa Valley Technical College; 2022.
• Advocate for client rights and needs
• Utilize advocacy resources appropriately
• Evaluate implications of contemporary health care policy for health care consumers and nursing practice
• Explore the role of professional organizations in nursing practice
• Discuss legislative policy-making activities that influence nursing practice and health care
• Examine various positions on unions and collective bargaining
• Compare and contrast various workplace advocacy models
What do you think of when you hear the word “advocacy”? Nurses act as advocates for their clients (e.g., individuals, families, communities, or populations) by protecting their “patient rights” and voicing their needs. Nurses have a long history of acting as client advocates. Early nurses advocated for professional nurses’ value and knowledge and fought for implementation of best practices, safety measures, and other quality improvements. Florence Nightingale advocated for practice changes that improved environmental conditions in health care and reduced life-threatening infections by using data to support her recommendations. Lillian Wald worked to establish public health nursing and improve the lives of immigrant communities.
More recently, nurses led the establishment of Nurse Practice Acts in each state and pushed for multistate licensing via the Nurse Licensure Compact (NLC). The American Nurses Association (ANA) declared 2018 as the “Year of Advocacy” to highlight the importance of advocacy in the nurse’s role. Nurses continue to advocate for building healthier communities as demonstrated in the Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity report.[1]
In this chapter, we will review how every nurse is responsible for client advocacy and examine the powerful influence nurses can have on local, state, and federal health care policies that affect the nation’s health and the profession of nursing.
Read the Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity at Future of Nursing: Campaign for Action.
National Academies of Sciences, Engineering, and Medicine. (2021). The Future of nursing 2020-2030: Charting a path to achieve health equity. The National Academies Press. 10.17226/25982 ↵ 10.17226/25982. [PubMed : 34524769 ] [CrossRef] [CrossRef]
The American Nurses Association (ANA) emphasizes that advocacy is fundamental to nursing practice in every setting. See Figure 10.1[1] for an illustration of advocacy. Advocacy is defined as the act or process of pleading for, supporting, or recommending a cause or course of action. Advocacy may be for individuals, groups, organizations, communities, society, or policy issues[2]:
Individual: The nurse educates health care consumers so they can consider actions, interventions, or choices related to their own personal beliefs, attitudes, and knowledge to achieve the desired outcome. In this way, the health care consumer learns self-management and decision-making.[3]
Interpersonal: The nurse empowers health care consumers by providing emotional support, assistance in obtaining resources, and necessary help through interactions with families and significant others in their social support network.[4]
Organization and Community: The nurse supports cultural and social transformation of organizations, communities, or populations. Registered nurses understand their obligation to help improve environmental and societal conditions related to health, wellness, and care of the health care consumer.[5]
Policy: The nurse promotes inclusion of the health care consumers’ voices into policy, legislation, and regulation about issues such as health care access, reduction of health care costs and financial burden, protection of the health care consumer, and environmental health, such as safe housing and clear water.[6]
Advocacy at each of these levels will be further discussed in later sections of this chapter.
Advocacy is one of the ANA’s Standards of Professional Performance. The Standards of Professional Performance are “authoritative statements of the actions and behaviors that all registered nurses, regardless of role, population, specialty, and setting, are expected to perform competently.”[7] See the following box to read the competencies associated with the ANA’s Advocacy Standard of Professional Performance.[8]
• Champions the voice of the health care consumer.
• Recommends appropriate levels of care, timely and appropriate transitions, and allocation of resources to optimize outcomes.
• Promotes safe care of health care consumers, safe work environments, and sufficient resources.
• Participates in health care initiatives on behalf of the health care consumer and the system(s) where nursing happens.
• Demonstrates a willingness to address persistent, pervasive systemic issues.
• Informs the political arena about the role of nurses and the vital components necessary for nurses and nursing to provide optimal care delivery.
• Empowers all members of the health care team to include the health care consumer in care decisions, including limitation of treatment and end-of-life care.
• Embraces diversity, equity, inclusivity, health promotion, and health care for individuals of diverse geographic, cultural, ethnic, racial, gender, and spiritual backgrounds across the life span.
• Develops policies that improve care delivery and access for underserved and vulnerable populations.
• Promotes policies, regulations, and legislation at the local, state, and national levels to improve health care access and delivery of health care.
• Considers societal, political, economic, and cultural factors to address social determinants of health.
• Role models advocacy behavior.
• Addresses the urgent need for a diverse and inclusive workforce as a strategy to improve outcomes related to the social determinants of health and inequities in the health care system.
• Advances policies, programs, and practices within the health care environment that maintain, sustain, and restore the environment and natural world.
• Contributes to professional organizations.
1. What Advocacy competencies have you already demonstrated during your nursing education?
2. What Advocacy competencies are you most interested in performing next?
3. What questions do you have about ANA’s Advocacy competencies?
American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵.
American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵.
American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵.
American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵.
American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵.
American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵.
American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵.
American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵.
As discussed previously, the American Nurses Association (ANA) defines advocacy at the individual level as educating health care consumers so they can consider actions, interventions, or choices related to their own personal beliefs, attitudes, and knowledge to achieve the desired outcome. In this way, the health care consumer learns self-management and decision-making.[1] Advocacy at the interpersonal level is defined as empowering health care consumers by providing emotional support, assistance in obtaining resources, and necessary help through interactions with families and significant others in their social support network.[2]
What does advocacy look like in a nurse’s daily practice? The following are some examples provided by an oncology nurse[3]:
Ensure Safety. Ensure the client is safe when being treated in a health care facility and when they are discharged by communicating with case managers or social workers about the client’s need for home health or assistance after discharge so it is arranged before they go home.
Give Clients a Voice. Give clients a voice when they are vulnerable by staying in the room with them while the doctor explains their diagnosis and treatment options to help them ask questions, get answers, and translate information from medical jargon.
Educate. Educate clients on how to manage their current or chronic conditions to improve the quality of their everyday life. For example, clients undergoing chemotherapy can benefit from the nurse teaching them how to take their anti-nausea medication in a way that will be most effective for them and will allow them to feel better between treatments.
Protect Patient Rights. Know clients’ wishes for their care. Advocacy may include therapeutically communicating a client’s wishes to an upset family member who disagrees with their choices. In this manner, the client’s rights are protected and a healing environment is established.
Double-Check for Errors. Know that everyone makes mistakes. Nurses often identify, stop, and fix errors made by interprofessional team members. They flag conflicting orders from multiple providers and notice oversights. Nurses should read provider orders and carefully compare new orders to previous documentation. If an order is unclear or raises concerns, a nurse should discuss their concerns with another nurse, a charge nurse, a pharmacist, or the provider before implementing it to ensure patient safety.
Connect Clients to Resources. Help clients find resources inside and outside the hospital to support their well-being. Know resources in your agency, such as case managers or social workers who can assist with financial concerns, advance directives, health insurance, or transportation concerns. Request assistance from agency chaplains to support spiritual concerns. Promote community resources, such as patient or caregiver support networks, Meals on Wheels, or other resources to meet their needs.
American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵.
American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵.
Nurses advocate for issues in their communities and their organizations.
Advocacy is commonly perceived as acting on behalf of a client, but it can be a much broader action than affecting a single client and their family members. Nurses advocate for building healthier communities by addressing social determinants of health (SDOH). SDOH are the conditions in the environments where people live, learn, work, and play that affect a wide range of outcomes. SDOH include health care access and quality, neighborhood and environment, social and community context, economic stability, and education access and quality. Social determinants of health (SDOH) have a major impact on people’s health, well-being, and quality of life. See Figure 10.2[1] for an illustration of SDOH.[2]
Social Determinants of Health
Specific examples of addressing SDOH include the following goals:
Improving safe housing and public transportation Decreasing discrimination and violence Expanding quality education and job opportunities Increasing access to nutritious foods and physical activity opportunities Promoting clean air and clean water Enhancing language and literacy skills[3]SDOH contribute to health disparities and inequities among different socioeconomic groups. For example, individuals who don’t have access to grocery stores with healthy foods are less likely to have good nutrition, increasing their risk for health conditions like heart disease, diabetes, and obesity, and potentially lowering their life expectancy relative to people who do have access to healthy foods.[4]
One of Healthy People 2030’s goals specifically relates to advocacy regarding SDOH. The goal states, “Create social, physical, and economic environments that promote attaining the full potential for health and well-being for all.” Across the United States, people and organizations at the local, state, territorial, tribal, and national levels are working hard to improve health and reduce health disparities by addressing SDOH.[5] Read more information about these advocacy efforts in the following box.
Nurses advocate for organizational issues in the nursing profession and the workplace through participation in unions, collective bargaining, workplace advocacy models, and professional organizations.
A nursing union is a type of labor union that advocates for the interest of its nurse members. According to the Bureau of Labor Statistics, 20 percent of RNs and 10 percent of LPNs/VNs in the United States are union members.[6] Nursing union goals are typically to advocate for the improvement of benefits, wages, patient safety, and workplace conditions. Advocacy is accomplished by collective bargaining. Collective bargaining refers to the negotiation of wages and other conditions of employment by an organized body of employees. See Figure 10.3[7] for an image of a union worker.
Although there is no single union that represents all nurses across the country, there are several nursing unions such as the National Nurses United, SEIU United Healthcare, and The United Food and Commercial Workers International Union. The National Nurses United union is the largest nursing union in the United States and has joined with other unions across the country to address unsafe staffing. Read more about these unions in the following box.
Read more about nursing unions:
Nursing unions can provide several potential benefits to the nursing profession. They may improve job security, improve working conditions, negotiate for better pay and benefits, protect seniority, establish staffing ratios, address workplace violence and incivility, and provide a well-defined grievance process. Unionized nurses earn an average of $200-$400 more per week than nonunionized nurses. Unions assist with grievance processes for resolving disagreements between employees and management. Examples of grievances include the promotion of one employee over another who has more seniority, disputes over holiday pay, and problems related to employee discipline.[8]
However, there are also potential disadvantages of unions, such as the cost of dues (up to $90/month per nurse), difficulty in removal of incompetent nurses, mandatory strikes with no pay, the issue of seniority taking precedence over good performance, and creation of working environments that can be adversarial between management and nursing. Additionally, many nursing unions are not organized or led by nurses, causing the belief that some unions are more interested in collecting dues than in improving the work environment for nurses. Although there has been research to determine if unions are good for nurses and good for clients, the findings are not conclusive. Some studies have shown that unionized hospitals have lower mortality rates, but higher failure-to-rescue and pressure injury rates. Another study found that unionized hospitals had higher levels of job dissatisfaction but higher levels of nurse retention.[9],[10]
Nurses can advocate for improvements in the workplace via various mechanisms, such as shared governance and the ANCC Magnet Recognition Program, and by participation in professional organizations. Nurses can also seek legislative solutions for workplace problems by advocating for legislation such as whistleblower protection.[11] Whistleblower protection is further discussed in the “Policy Advocacy” section of this chapter.
Shared governance refers to a shared leadership model between management and employees working together to achieve common goals. Shared governance models are believed to promote nurses’ empowerment, engagement, autonomy, accountability, and collaboration while also striving to improve patient safety, quality care, and positive outcomes. This style of management encourages and empowers nurses to be part of making decisions that impact their daily work environments. When organizations utilize a shared governance model, employees feel valued and invested in the organization’s success. Nurse engagement also improves both staff and client outcomes, such as increased job satisfaction and patient satisfaction.[12] Implementation of a shared governance model has led to organizational cost savings, decrease in meeting times, fewer sick days used by employees, and a decrease in staff turnover.[13] See the following box for an example of effective shared governance.
Example of Effective Shared Governance[14]
A busy telemetry unit wants to address issues with low patient satisfaction scores and an increase in both central line and indwelling catheter days. A quality improvement project is instituted by a multidisciplinary team that works to communicate the project’s goals and objectives, respecting each team member’s expertise and input. The team initiates daily multidisciplinary rounding on the unit. Six months after the implementation of multidisciplinary rounding, patient satisfaction scores improve and a decrease in both central line and indwelling catheter days is noted. Multidisciplinary rounding provides a collaborative team approach, acknowledging the expertise and leadership role of each discipline with the same end goal of improving client outcomes.
Nurses can advocate for their excellence in the workplace by participating in activities required for Magnet Recognition. As previously discussed in this book, the Magnet Recognition Program is an organizational credential from the American Nurses Credentialing Center (ANCC) recognizing quality client outcomes, nursing excellence, and innovations in professional nursing practice. The Magnet Recognition Program requires nursing advocacy in the areas of technology, education, policies, and process development. This advocacy is accomplished by creating unit-based practice councils who meet regularly to discuss unit policies, practices, and outcomes. Additionally, an organization-wide practice council includes a representative from each unit council and reviews organizational-wide policies and practices. Read more about the Magnet Recognition Program in the following box.
Professional organizations provide easy access to nursing advocacy work being done across the nation and the world. There are over 100 local, state, and national organizations that advocate for the nursing profession. Professional nursing organizations may advocate for specific nursing issues in certain areas of practice, such as critical-care nursing (American Association of Critical-Care Nurses, AACN) or broader national nursing issues, such as the American Nurses Association (ANA). Professional organizations also provide opportunities for continuing education, advanced certification, and participation in political action committees. Membership in state and national organizations helps nurses stay up-to-date on current evidence-based practices and research findings.
“Healthy People 2030 SDOH Graphic.png” by U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion is in the Public Domain. Access for free at https://health .gov/healthypeople /objectives-and-data /social-determinants-health ↵.
Dube, A. Kaplan, E., & Thompson, O. (2016). Nurse unions and patient outcomes. ILR Review , 69(4), 803-833. ↵ 10.1177/0019793916644251. [CrossRef]
Seago, J. A., Spetz, J., Ash, M., Herrera, C., & Keane, D. (2011). Hospital RN job satisfaction and nurse unions. Journal of Nursing Administration , 41(3), 109-114. ↵ 10.1097/nna.0b013e31820c726f . [PubMed : 21336038 ] [CrossRef]
American Nurses Association. (n.d.). Five opportunities and challenges for workforce advocacy program. https://www .nursingworld .org/practice-policy/advocacy/ ↵.
Kroning, M., & Hopkins, K. (2019). Healthcare organizations thrive with shared governance. Nursing Management , 50(5), 13-15. ↵ 10.1097/01.numa.0000557781.40049.2d. [PubMed : 31045707 ] [CrossRef]
Anthony, M. (2004). Shared governance models: The theory, practice, and evidence. Online Journal of Issues in Nursing , 9(1), 7. ↵. [PubMed : 14998357 ]
Kroning, M., & Hopkins, K. (2019). Healthcare organizations thrive with shared governance. Nursing Management , 50(5), 13-15. ↵ 10.1097/01.numa.0000557781.40049.2d. [PubMed : 31045707 ] [CrossRef]
National, state, and local policies impact nurses at all levels of care, from nurse administrators to bedside nurses, making it essential for nurses to take an active role in advocating for their clients, their profession, and their community. Nurses advocate for improved access to basic health care, enhanced funding of health care services, and safe practice environments by participating in policy discussions. Nurses also participate in state and national policy discussions affecting nursing practice. For example, nurses advocate for the removal of practice barriers so nurses can practice according to the full extent of their education, certification, and licensure; address reimbursement based on the value of nursing care; and expand funding for nursing education.[1]
When advocating, nurses must view themselves as knowledgeable professionals who have the power to influence policy and decision-makers. A nurse can advocate for improved policies through a variety of pathways. Each method provides a unique opportunity for the nurse to impact the health of individuals and communities, the profession of nursing, and the overall health care provided to clients. These are few easy ways for nurses to get involved:
Becoming involved in professional nursing organizations Engaging in conversations with local, state, and federal policymakers on health care related issues Participating in shared governance committees regarding workplace policiesLegislative policies are external rules and regulations that impact health care practice and policy at the national, state, and local levels. These regulations seek to protect clients and nurses by defining safe practices, quality standards, and requirements for health care organizations and insurance companies. Nurses have been involved in the adoption of these rules and regulations and continue to advocate for new and updated legislation affecting health care.
Examples of federal legislation addressing health care include advocating for the Patient’s Bill of Rights, patient privacy and confidentiality, improved access to health care, and protections for individuals who report unethical or illegal activities in the health care environment (i.e., whistleblower legislation). Examples of legislation at the state level includes topics such as right-to-die and physician-assisted suicide, medicinal marijuana use, and nurse-to-patient staffing ratios.
Review how patient rights are defined by policies at the federal, state, and organizational levels in the following box.
Patient’s Rights Defined at Multiple Levels
In 1973 the American Hospital Association (AHA) adopted the Patient’s Bill of Rights. The bill has since been updated and adapted for use throughout the world in all health care settings, but, in general, it safeguards a patient’s right to accurate and complete information, fair treatment, and self-determination when making health care decisions. In 2010 the Affordable Care Act was passed at the federal level. It included additional patient rights and protections for health care consumers in the areas of preexisting conditions, choice of providers, and limited lifetime coverage limits imposed by insurance companies.
States further define patient rights beyond federal regulations and provide specific rights of health care consumers in their state. For example, Wisconsin’s Department of Health Services defines treatment rights, protections for records privacy and access, communication rights, personal rights, and privacy rights.
With over four million registered nurses in the United States, nursing has a powerful voice that can significantly influence health care legislation. Nurses have been recognized as a major influence on health care policies related to client safety and quality care. They can become involved in policy making at the state and federal level by joining a professional nursing organization, communicating with their state representatives, or running for political office to take an active role in policy creation.
Most professional nursing organizations have a legislative policy committee that reviews proposed federal and state legislation and makes recommendations for change, endorses the legislation, or leads opposition. For example, organizations such as the American Nurses Association (ANA), National League of Nursing (NLN), and state nursing associations inform members of current legislative initiatives, provide comprehensive reviews, and encourage members to contact their representatives about pending legislation.
Nurses are expected to follow federal, state, and agency policies and regulations, be proactive in policy development, and speak up when policies are not being followed. When regulations and policies are not being followed, nurses must advocate for public safety by reporting the problem to a higher authority. Whistleblowing refers to reporting a significant concern to your supervisor, the federal or state agency responsible for the regulation, or in the case of criminal activity, to law enforcement agencies. A whistleblower is a person who exposes any kind of information or activity that is deemed illegal, unethical, or not correct within an organization. See Figure 10.5[2] for federal instructions regarding whistleblowing.
Whistleblowing typically begins with reporting the wrongdoing to a supervisor and following the internal chain of command. This first step of reporting allows the organization to correct the issue internally. However, there may be situations where an individual may need to directly report to an external authority, such as a State Board of Nursing or other regulatory agency. For example, any person who has knowledge of conduct by a licensed nurse violating state or federal law may report the alleged violation to the State Board of Nursing where the conduct occurred.
Acting as a whistleblower can be a difficult decision because the individual may be labelled “disloyal” or potentially face retaliatory actions by the accused individual or organization. Although there are legal protections for whistleblowers, these types of actions may occur. Read important information from the ANA regarding whistleblowing in the following box.
• If you identify an illegal or unethical practice, reserve judgment until you have adequate documentation to establish wrongdoing.
• Do not expect those who are engaged in unethical or illegal conduct to welcome your questions or concerns about this practice.
• Seek the counsel of someone you trust outside of the situation to provide you with an objective perspective.
• Consult with your state nurses’ association or legal counsel if possible before taking action to determine how best to document your concerns.
• Remember, you are not protected in a whistleblower situation from retaliation by your employer until you blow the whistle.
• Blowing the whistle means that you report your concern to the national and/or state agency responsible for regulation of the organization for which you work or, in the case of criminal activity, to law enforcement agencies as well.
• Private groups, such as The Joint Commission or the National Committee for Quality Assurance, do not confer protection. You must report to a state or national regulator.
• Although it is not required by every regulatory agency, it is a good rule of thumb to put your complaint in writing.
• Document all interactions related to the whistleblowing situation and keep copies for your personal file.
• Keep documentation and interactions objective.
• Remain calm and do not lose your temper, even if those who learn of your actions attempt to provoke you.
• Remember that blowing the whistle is a very serious matter. Do not blow the whistle frivolously. Make sure you have the facts straight before taking action.
American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵.
“Whistleblowing .pdf’” by United States Office of Special Counsel is in the Public Domain ↵.To become a nursing advocate, identify causes, issues, or needs where YOU can exert influence.
Steps to becoming an advocate include the following[1]:
Identify a problem that interests you.
Research the subject and select an evidence-based intervention.
Network with experts who are, or could be, involved in making the change.
Work hard for change.
After you have identified a topic of interest, get involved. Volunteering to participate in committees that review practice policies, joining a professional nursing organization, researching best practices, or reviewing health policy agendas of elected officials are great first steps to becoming an advocate. Membership in state and national professional organizations provides access to current legislative and policy initiatives that impact the nursing profession. These organizations publish public policy agendas each year and keep members updated on ways to be involved, progress towards the shared goals, and promote legislation that impacts health care and health care delivery.
Nurses are in a powerful position to be effective advocates. As frontline care providers, nurses provide a unique and knowledgeable perspective on health care delivery, client experience, and the work environment. As the largest sector of the health care workforce, nurses have the opportunity to influence policy at every level of decision-making. There are many ways for nurses to create change when acting as advocates that can lead to improved quality of care, better outcomes for patients, and safe work environments for nurses. If every nurse was an active advocate for the profession, think of the difference we could make!
Review information about a new professional nursing association called the Nurse Advocacy Association.
The Quality and Safety Education for Nurses (QSEN) project began advocating for safe, quality patient care in 2005 by defining six competencies for nursing graduates. This initiative was created after a decade of review and investigation into the high number and high cost of medical errors in the United States. The goal of the QSEN initiative was to prepare future nurses with the knowledge, skills, and attitudes needed to improve the quality and safety of the health care system. Historically, nursing education focused on knowledge and skill acquisition, but did not address the attitudes and values of the nurse. The QSEN competencies are designed to train nursing students in prelicensure nursing programs. The six QSEN competencies, as shown in Figure 10.6,[1] are Patient-Centered Care, Teamwork and Collaboration, Evidence-Based Practice, Quality Improvement, Safety, and Informatics.[2]
The Patient-Centered Care QSEN competency advocates for the client as “the source of control and full partner in providing compassionate and coordinated care based on respect for patient’s preferences, values, and needs.”[3] This competency encourages nurses to consider clients’ cultural traditions and personal beliefs while providing compassionate care. Patient-centered care also includes the family in the care team. The goal of patient-centered care is to improve the individual’s health outcomes. Integration of this competency has led to improved patient satisfaction scores, reduced expenses, and a positive care environment.[4]
The Teamwork and Collaboration QSEN competency focuses on functioning effectively within nursing and interprofessional teams and fostering open communication, mutual respect, and shared decision-making to achieve quality patient care.[5] Effective communication has been proven to reduce errors and improve client safety.[6] The Joint Commission also includes improved communication as one of the National Patient Safety Goals, aligning with this QSEN competency. Collaboration requires information sharing across disciplines with respect for the knowledge, skills, and experience of each team member. Two examples of tools used to promote effective teamwork and collaboration are ISBARR and TeamSTEPPS®. Additionally, “principles of collaboration” have been established by the ANA.
Several communication tools have been developed to improve communication in various health care settings. ISBARR is an example of a well-established communication tool. As previously discussed in the “Collaboration Within the Interprofessional Team” chapter, ISBARR is a mnemonic for the components to include when communicating with other health care team members: Introduction, Situation, Background, Assessment, Request/Recommendations, and Repeat back.[7]
As previously discussed in the “Collaboration Within the Interprofessional Team” chapter, TeamSTEPPS® (Team Strategies and Tools to Enhance Performance and Patient Safety) is a well-established framework to improve client safety through effective communication in health care environments. It consists of four core competencies: communication, leadership, situation monitoring, and mutual support.
The American Nurses Association (ANA) and the American Organization of Nurse Executives (AONE) jointly created the “Principles of Collaboration” to guide nurses in creating, enhancing, and sustaining collaborative relationships. These principles include effective communication, authentic relationships, and a learning environment and culture. The principle of authentic relationships includes the following guidelines[8]:
Be true to yourself – be sure your actions match your words and those around you are confident that what they see is what they get.
Empower others to have ideas, to share those ideas, and to participate in projects that leverage or enact those ideas.
Recognize and leverage each other’s strengths. Be honest 100% of the time – with yourself and with others. Respect others’ personalities, needs, and wants. Ask for what you want, but stay open to negotiating the difference. Assume good intent from others’ words and actions, and assume they are doing their best.The Evidence-Based Practice QSEN competency focuses on integrating scientific evidence with clinical expertise and client/family preferences and values for delivery of optimal health care.[9] See Figure 10.7[10] for an illustration of Evidence-Based Practices (EBP). Read more about EPB in the “Quality and Evidence-Based Practice” chapter. Read examples of evidence-based improvements in the following box.
The Quality Improvement QSEN competency focuses on using data to monitor the outcomes of care processes and using improvement methods to design and test changes to continuously improve the quality and safety of health care systems.[11] The goal of this competency is to improve processes, policies, and clinical decisions to improve client outcomes and system performance. As the pool of nursing literature grows and nursing practices have been updated to reflect current evidence, health care organizations have seen improvements in quality, safety, and experienced cost savings.[12]
Read more about the quality improvement processes in the “Quality and Evidence-Based Practice” chapter.
The Safety QSEN competency focuses on minimizing “risk of harm to patients and providers through both system effectiveness and individual performance.”[13] Although safety is embedded in all of the QSEN competencies, this competency specifically advocates for preventing client harm. Despite the health care industry’s continued focus on process improvement and improving client outcomes, errors continue to occur, and nurses are often involved in these events as frontline caregivers. Safe nursing practice starts with an awareness of the potential risks for client harm in every situation.
Several initiatives have been adopted to reduce risk for client harm, such as double-checking high-risk medications and verifying a patient’s name and date of birth prior to every intervention. However, client safety is compromised when there are gaps in quality measures such as inadequate staff training, broken equipment, or an organizational culture that doesn’t support best practices.
The “Safety” competency is best addressed by organizations establishing a safety culture where every worker commits to keeping client safety at the center of decision-making. An organization that has a culture of safety encourages reporting of unusual incidents, process failures, or other issues that could cause client harm, allowing the organization to investigate the event and take action to prevent the event from occurring in the future. Improvements are made as a result of a culture that questions attitudes, actions, and decisions in client care and recognizes threats to safety. Read more about safety culture in the “Legal Implications” chapter.
The Informatics QSEN competency focuses on using information and technology to communicate, manage knowledge, mitigate error, and support decision-making.[14] Health care is filled with various technologies used to promote a safe care environment, such as electronic medical records (EMRs), bedside medication administration devices, smart IV pumps, and medication distribution systems. These technologies provide safeguards and reminders to help prevent client harm, but the nurse must be knowledgeable in using technology, as well as understand how information obtained from technologies is used to improve client patient outcomes. As information related to technology continues to evolve, it is the responsibility of every nurse to participate in continued professional development related to informatics.
Roseman, D., Osborne-Stafsnes, J., Amy, C. H., Boslaugh, S., & Slate-Miller, K. (2013). Early lessons from four 'aligning forces for quality' communities bolster the case for patient-centered care. Health Aff (Millwood) , 32(2), 232-241. ↵ 10.1377/hlthaff.2012.1085 . [PubMed : 23381515 ] [CrossRef]
QSEN. (n.d.). About. https://qsen .org/about-qsen/ ↵.Burgener, A. M. (2020). Enhancing communication to improve patient safety and to increase patient satisfaction. The Health Care Manager , 39(3), 128-132. ↵ 10.1097/hcm.0000000000000298 . [PubMed : 32701609 ] [CrossRef]
Enlow, M., Shanks, L., Guhde, J., & Perkins, M. (2010). Incorporating interprofessional communication skills (ISBARR) into an undergraduate nursing curriculum. Nurse Educator , 35(4), 176-180. ↵ 10.1097/nne.0b013e3181e339ac . [PubMed : 20548190 ] [CrossRef]
American Nurses Association & American Organization of Nurses Executives. (n.d.). ANA/AONE principles for collaborative relationships between clinical nurses and nurse managers. https://www .nursingworld .org/~4af4f2/globalassets /docs/ana/ethics /principles-of-collaborative-relationships.pdf ↵.
QSEN. (n.d.). About. https://qsen .org/about-qsen/ ↵."Evidence-Based Practice.jpg" by Kim Ernstmeyer for Chippewa Valley Technical College is licensed under CC BY 4.0 ↵.
QSEN. (n.d.). About. https://qsen .org/about-qsen/ ↵.Cullen, L., Titler, M. G., & Rempel, G. (2011). An advanced educational program promoting evidence-based practice. Western Journal of Nursing Research , 33(3), 345-364. ↵ 10.1177/0193945910379218 . [PubMed : 20705775 ] [CrossRef]
QSEN. (n.d.). About. https://qsen .org/about-qsen/ ↵. QSEN. (n.d.). About. https://qsen .org/about-qsen/ ↵.An 85-year-old woman was admitted with sudden onset of dyspnea, pleuritic chest pain, and right upper arm edema. She had a peripherally inserted central catheter (PICC) placed three weeks previously for treatment of osteomyelitis of the left hand. A caretaker had been infusing her antibiotics and managing her PICC with the oversight of a home care nurse. A chest computerized tomography scan confirmed the presence of a pulmonary embolism. She was admitted to the inpatient floor at change of shift, and orders were received for a weight-based heparin bolus and infusion. The bolus was administered, and the infusion was initiated. During handoff report to the next shift, the pump alarm sounded. In responding to the alarm, the oncoming nurse discovered that the entire bag of heparin (25,000 units) had infused in less than 30 minutes. She discovered the rate on the pump was set by the previous nurse at 600 mL/hour rather than the weight-adjusted 600 units/hour.
The oncoming nurse who discovered the heparin error immediately disconnected the infusion, assessed the client for signs of bleeding, and notified the physician of the error. Appropriate precautions were initiated and an incident report was submitted. Subsequently, an investigation was conducted by the unit supervisor and the risk manager by interviewing involved staff. They found that the client’s admitting nurse, who administered the heparin bolus and infusion, was a traveling nurse who had been in the organization for three weeks and had been floated to the telemetry unit for the first time. While the traveling nurse had been trained on an orthopedic unit, she had not initiated a heparin infusion at this facility. The facility used an infusion pump that included a drug library with medication-specific infusion limits for client safety. The nurse had been trained to use the infusion pump drug library in a brief orientation, but she had witnessed several nurses bypass this safety measure. In addition, although she had her heparin bolus and infusion calculations double-checked by another nurse, she was not aware that this double-check should include a review of pump settings. Finally, because the change of shift handoff report was hurried, it did not include a bedside report to review infusions and client status with the oncoming nurse. What appeared to be a serious individual error was, in fact, a complex series of failures in the facility’s safety culture that placed a nurse in the very difficult position of making an error that placed a client at risk of harm. Fortunately, no significant bleeding events occurred as a result of the error.[1]
1. Create a list of safety failures in this example and categorize them based on the QSEN competencies.
2. Outline communication tools and best practices that could have prevented this error from occurring.
Sherwood, G., & Nickel, B. (2017) Integrating quality and safety competencies to improve outcomes: Application in infusion therapy practice. Journal of Infusion Nursing, 40(2), 116-122. ↵10.1097/NAN.0000000000000210 [PubMed : 28248812 ] [CrossRef]
The act or process of pleading for, supporting, or recommending a cause of course of action for individuals, groups, organizations, communities, society, or policy issues.
Negotiation of wages and other conditions of employment by an organized body of employees.
Integrating scientific evidence with clinical expertise and patient/family preferences and values for delivery of optimal health care.[1]
A process for resolving disagreements between employees and management.
Using information and technology to communicate, manage knowledge, mitigate error, and support decision-making.[2]
A mnemonic for the components to include when communicating with another health care team member: Introduction, Situation, Background, Assessment, Request/Recommendations, and Repeat back.
Magnet® Recognition Program
An organizational credential that recognizes quality patient outcomes, nursing excellence, and innovations in professional nursing practice.
The patient is the source of control and full partner in providing compassionate and coordinated care based on respect for patient’s preferences, values, and needs.[3]
Using data to monitor the outcomes of care processes and using improvement methods to design and test changes to continuously improve the quality and safety of health care systems.[4]
A shared leadership model between management and employees working together to achieve common goals.
Social Determinants of Health (SDOH)
The conditions in the environments where people live, learn, work, and play that affect a wide range of health, functioning, and quality of life outcomes and risks.
TeamSTEPPS® (Team Strategies and Tools to Enhance Performance and Patient Safety)
An evidence-based framework to improve client safety through effective communication in health care environments consisting of four core competencies: communication, leadership, situation monitoring, and mutual support.
Teamwork and collaboration
Functioning effectively within nursing and interprofessional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care.[5]
A person who exposes any kind of information or activity that is deemed illegal, unethical, or not correct within an organization.
