CHAPTER 1 CARE COORDINATION CLINICAL REASONING: CONTEMPORARY COMPETENCY EXPECTATIONS The contributions of nurses are vital in meeting 21st-century health care challenges (Institute of Medicine [IOM], 2010). In spite of advancements in disease prevention and health promotion, a need exists to educate people about healthy lifestyles and provide care for and counsel people if and when they do become ill, disabled, or unable to care for themselves. As health care systems become more complex, the economic, technical, and social forces that shape the nature of health care experiences shape the nurses’ role. Nurses have to collaborate on care coordination with other members of the health care team across systems and contexts of care. Clinical reasoning challenges multiply as the advanced practice clinician thinks about patient-centered care issues from the perspective of a health care provider, and then considers those issues in terms of the dynamics and competing values of health care teams. Add the complexity of working between and among specialty clinics and services across continuums of care and it becomes quickly evident that new models and strategies for clinical reasoning and interprofessionality (D’Amour & Oandasan, 2005) are needed to maximize care coordination that yields safe, high-quality, cost-effective health care (Lamb, 2013). LEARNING OUTCOMES After completing this chapter, the reader should be able to: 1. Define and explain why care coordination clinical reasoning is an essential nursing skill needed to support 21st-century health care demands 2. Describe contemporary policies and competency expectations for advanced practice nurses 3. Define the term “interprofessionality” 4. Explain the core competencies nurses are expected to have to support interprofessional practice, teamwork, and care coordination 5. Describe selected characteristics that support and enhance a clinical reasoning mind-set This book contributes a new model of care coordination clinical reasoning that builds on previous research and development of the Outcome-Present State-Test (OPT) model of reflective clinical reasoning (Pesut, 2001, 2002, 2004, 2006, 2008; Pesut & Herman, 1992, 1998, 1999). There is an art and a science to clinical reasoning. Nurses develop clinical reasoning skills based on analysis and understanding of individual patient stories. Each patient encounter presents opportunities to reason. Every time nurses reason about a patient story, they add to their repertoire of understanding and resources so that they can reason more effectively. Patient-centered clinical reasoning in the context of care coordination is only one aspect of the care coordination process. Reasoning about specific patients in the context of 1:1 care is quickly being superseded by the challenges of reasoning with teams and considering large numbers of patients and populations of care. Clinical reasoning in the context of teamwork that involves negotiation of competing values in multiple systems and contexts of care is especially challenging. The complexities and challenges of teamwork and multiple contexts of services require the provider to reason from different perspectives simultaneously (D’Amour & Oandasan, 2005). Each discipline has a particular filter through which it frames and then focuses on patient-care goals. Each member of the health care team views and processes information differently. This results in a team that approaches information from multiple perspectives, which challenges traditional methods and techniques of reasoning. Clinical reasoning on a case-by-case basis is the foundation of diagnostic thinking. Nonetheless, it is evident that an interprofessional health care team’s work and reasoning with regard to multiple competing patient-care issues require the development of team- and systems-centered thinking skills and concurrent consideration of different levels of filtering, framing, and focus. Thus, new models of care coordination clinical reasoning are needed to support the education, training, and professional development of contemporary health care providers and clinicians. Patients who present multiple issues require the application and use of several types of thinking skills: critical, creative, reflective, systems, and complex thinking. The OPT model of clinical reasoning (Pesut & Herman, 1998, 1999), developed in the late 1990s, provides tools and resources to help clinicians think about their thinking and gain insight into how multiple problems combine and relate. Attending to the complexity of the interrelationships of problems and taking a systems-thinking perspective often reveal a keystone issue that represents the core of the system dynamic and provides a leverage point for intervention that shifts the patient system from a present problem-oriented state to a specified desired-outcome state. There is evidence that the OPT model and its associated teaching–learning strategies positively influence the development of clinical reasoning skills in nursing students. Using an OPT model worksheet analysis and synthesis tool helps students master the clinical reasoning associated with complex patient-care scenarios. The worksheets were tested and evaluated by researchers using the clinical and simulation experiences of nursing students, and with personal assistant devices (Kuiper, 2008; Kuiper, Heinrich, Matthias, Graham, & Bell-Kotwall, 2008; Kuiper, Pesut, & Kautz, 2009). The OPT model worksheets provide structure, strategies, and scaffolding for the analysis, synthesis, and organization of data; for use of standardized nursing language; and care planning and reflection on outcomes. Evidence suggests that students who used the OPT model and methods strengthened their thinking skills, and realized differences in how they thought about patient-centered problems (Kuiper et al., 2009). The structure and process of OPT guarantee that nursing care outcomes are well defined, and promote new ways to think about the role of interventions in achieving and making judgments about outcomes in complex patient-care situations. In addition, clinical reasoning self-efficacy is strengthened as the advanced practice clinician focuses on associations and cause-and-effect relationships concerning patient-care needs, issues, and challenges. Given the shift to care coordination, the authors built on previous research and have developed a model of clinical reasoning for care coordination that extends from the foundation of the OPT model’s strategies and methods, and evolves the application of the model to interprofessional team dynamics and service/organizational considerations. The need to articulate and expand clinical reasoning expectations at the care coordination level is influenced by traditional policies, disciplinary perspectives, and current competencies and role expectations. CONTEMPORARY POLICIES AND COMPETENCY EXPECTATIONS A profession is distinguished from other occupations by several criteria. A profession has an orientation toward service within the context of a code of ethics. A profession uses a developed knowledge base. A profession systematically uses theory to guide actions. In a profession, there are standards of practice. A profession provides for the education and socialization of its members. A profession is autonomous and self-regulating. Professional self-regulation is the process by which nursing ensures that its members act in the public interest by providing the unique service with which society has entrusted them (American Nurses Association [ANA], 1995, 2010, 2015). The social context of nursing is discussed in the ANA document Nursing’s Social Policy Statement (ANA, 1980, 1995, 2010, 2015). Nursing’s Social Policy Statement is used by nurses as a framework for understanding nursing’s social contract and relationship with society and nursing’s obligations to those who receive nursing care (ANA, 2015). Nursing’s Social Policy Statement provides a definition of nursing; explains the knowledge base for nursing practice; explains the differences between basic and advanced nursing practice; and discusses the professional, legal, and self-regulated governance of nursing practice for the benefit of society. The statement provides clues about the importance of thinking and reasoning for professional nursing practice. In 1980, the statement defined nursing as “the diagnosis and treatment of human responses to actual or potential health problems” (ANA, 1980, p. 6). This definition capitalized on advances nurses made in practice, research, and knowledge development. This definition clarified that nurses deal with the human response to health care issues and underscored the importance of nursing diagnostic reasoning. In 1995, the statement was revised. Of particular interest are descriptions of nursing through time, which was included in the revised document. The document begins describing how Florence Nightingale (1859/1946) defined nursing as those things nurses do “to put the patient in the best condition for nature to act upon him” (p. 75). About a hundred years later, Virginia Henderson (1961) stated that the purpose of nursing is To assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to a peaceful death) that he would perform unaided if he had the necessary strength, will, or knowledge and to do this in such a way as to help him gain independence as rapidly as possible. (p. 5) Both of these definitions focused on nursing actions and what nurses do to promote health and healing. In recent times, the definition of nursing and especially the definition of advanced practice nursing, continues to evolve and change. In fact, scope of practice for advanced practice nursing may be different in each state and or country. Readers are advised to know the definition of nursing in their state and what the scope of practice definitions are with regard to state laws and regulations and be familiar with the Advanced Practice Registered Nurse (APRN) Consensus model for regulation that is currently sponsored by the National Council of State Boards of Nursing (2008, 2012). NURSING ART AND SCIENCE Nursing science involves the use of logic to understand and solve patient problems. Research and the scientific method are the ways people use logic to generate knowledge that nurses use in patient care. The scientific method is a problem-solving approach in which a problem is identified, possible solutions to the problem are hypothesized, and experiments are designed to test a solution to the problem. Based on the evidence from the experiment, potential solutions are identified. This is a step-by-step process that follows specific rules. The step-by-step process is guided by logic and reasoning. There are three kinds of nursing science: basic nursing science, applied nursing science, and practical science. Basic nursing science refers to knowledge that is developed purely for the sake of knowing. This knowledge adds to our sense of understanding about people. It is generally understood that the knowledge may be useful one day. Applied nursing science is knowledge that is used to care directly for patients. Both basic and applied nursing science serves as the foundation for clinical reasoning. Johnson (1991) argues for a third type of science, which she calls practical science. Practical nursing science combines the science and art of nursing. In nursing, more attention is often paid to the topic of science rather than art. However, “science alone will not solve all the problems of nursing” (Johnson, 1994, p. 1). Johnson (1994) theorized that art in nursing means (a) the ability to grasp meaning in patient encounters, (b) the ability to establish a meaningful connection with patients, (c) the ability to skillfully perform nursing activities, (d) the ability to rationally determine an appropriate course of action, and (e) the ability to morally conduct nursing practice. The art of nursing is based on caring and respect of human dignity and a compassionate approach to patient care that embraces spirituality, healing, empathy, mutual respect, and partnership (ANA, 2015). A challenge for future nurses is to figure out how to combine the science and art of nursing into a practical science. Although the science of nursing is important, the art of nursing is equally significant. The art and science of nursing are nurtured and developed in education programs that provide essential knowledge, skills, and abilities to achieve the goals and ideals of the profession. Contemporary policies and competency expectations provide the context for the professional practice of nursing. ESSENTIAL EDUCATION REQUIREMENTS The American Association of Colleges of Nursing (AACN) is the national voice for university and 4-year college education programs in nursing. This organization has published a series of documents that outlines fundamental education requirements for those wishing to pursue a career in nursing. For example, the “Essentials of Master’s Education in Nursing” (AACN, 2011) identifies the necessary curricular elements and frameworks required of master’s programs. The document delineates the core knowledge and skills that all master’s-prepared graduates, regardless of focus, major, or intended practice setting, should acquire in nine foundational areas: 1. Sciences and humanities 2. Organizational and systems leadership 3. Quality improvement and safety 4. Translating and integrating scholarship into practice 5. Informatics and health care technologies 6. Health policy and advocacy 7. Interprofessional collaboration for improving outcomes 8. Clinical prevention and population health 9. Master’s-level nursing practice Consistent and aligned with the educational foundations for practice, the National Organization of Nurse Practitioner Faculty (NONPF, 2015) has outlined the core competencies expected of nurse practitioners. These competencies are related to several of the AACN essentials in regard to scientific foundations for practice, leadership, knowledge, and skills related to quality assurance, practice, systems understanding, health information and technology, ethics, as well as skills related to independent practice and policy. Another advanced practice role that aligns practice competencies with the AACN essentials is that of clinical nurse leader (CNL). Although the practice setting for the CNL may vary, the core of responsibility is accountability for patient-care outcomes while applying evidence to design, implement, and evaluate patient-care processes and models of care delivery (National Transitions of Care Coalition [NTOCC], 2008). This care coordination role occurs across health care systems. The NONPF and CNL competencies can be reviewed in Table 1.1. To what degree have you mastered these core competencies? Try this exercise. Using a scale from 1 to 10 (1 = “I have yet to master this competency” and 10 = “I have totally mastered this competency”) review and rate yourself on each of the competencies listed in Table 1.1. Consider your ratings. What competency areas are strengths for you? What areas need attention? How specifically will you create a professional development plan to master the skill set you need based on these national standards and expectations? If you are currently in an educational program, how specifically is your curriculum preparing you to master the knowledge, skills, competencies, and abilities you will need in reference to the national AACN and NONPF or CNL standards and expectations? If you are not getting the experiences or knowledge you need what will you do to activate your learning in order to master the competencies? The profession of nursing has unique contributions to make to the diagnosis, treatment, and care of individuals, families, groups, and communities. However, nurses are part of a larger team of health care providers, all of whom have contributions to make in regard to health and healing. Care is influenced and achieved through the interprofessionality of a cohesive health care team. INTERPROFESSIONALITY Nurses have a professional responsibility to advance the science and practice of the discipline; however, the care of patients, families, and communities requires cooperative partnerships with other members of the health care team. There is a movement underway to understand more about the nature of interprofessional health care education and practice. The National Center for Interprofessional Practice and Education was recently created at the University of Minnesota in the United States to coordinate research and scholarship on the topic of interprofessional health profession work in health care. The center has established a resource exchange (https://nexusipe.org/resource-exchange) and creates forums for people to come together to communicate with and learn from each other about the complexities and challenges of interprofessionality. The future success of care coordination depends on interprofessionality. Danielle D’Amour and Ivey Oandasan (2005) define interprofessionality as “the development of a cohesive practice between professionals from different disciplines. It is the process by which professionals reflect on and develop ways of practicing that provide an integrated and cohesive answer to the needs of the patient/family/population” (p. 9). They further note that interprofessionality is a preoccupation among professionals used to reconcile differences and opposing views in service of continuous interaction and knowledge sharing that invites and optimizes partnership with patients. Interprofessionality is possible when professionals commit to sharing goals and visions as they embrace the complex task of addressing patient-care challenges in organizations and governance structures that are committed to high-quality clinical outcomes for both patients and providers. TABLE 1.1 Comparison Table of Clinical Nurse Leader (CNL) and Nurse Practitioner Competencies AACN ESSENTIALSa CNL COMPETENCIESb NONPF COMPETENCIESc ESSENTIAL 1: BACKGROUND FOR PRACTICE FROM SCIENCES AND HUMANITIES 1. Integrate nursing and related sciences into the delivery of advanced nursing care to diverse populations. 2. Incorporate current and emerging genetic/genomic evidence in providing advanced nursing care to individuals, families, and communities while accounting for patient values and clinical judgment. 3. Design nursing care for a clinical or community-focused population based on biopsychosocial, public health, nursing, and organizational sciences. 4. Apply ethical analysis and clinical reasoning to assess, intervene, and evaluate advanced nursing care delivery. 5. Synthesize evidence for practice to determine appropriate application of interventions across diverse populations. 6. Use quality processes and improvement science to evaluate care and ensure patient safety for individuals and communities. 7. Integrate organizational science and informatics to make changes in the care environment to improve health outcomes. 8. Analyze nursing history to expand thinking and provide a sense of professional heritage and identity. 1. Interpret patterns and trends in quantitative and qualitative data to evaluate outcomes of care within a microsystem and compare to other recognized benchmarks or outcomes, e.g., national, regional, state, or institutional data. 2. Articulate delivery process, outcomes, and care trends using a variety of media and other communication methods to the health care team and others. 3. Incorporate values of social justice to address health care disparities and bridge cultural and linguistic barriers to improve quality outcomes. 4. Integrate knowledge about social, political, economic, environmental, and historical issues into the analysis of and potential solutions to professional and health care issues. 5. Apply concepts of improvement science and systems theory. 1. Critically analyze data and evidence to improve advanced nursing practice. 2. Integrate knowledge from the humanities and sciences within the context of nursing science. 3. Translate research and other forms of knowledge into practice to improve practice processes and outcomes. 4. Develop new practice approaches based on the integration of research, theory, and practice knowledge. ESSENTIAL 2: ORGANIZATIONAL AND SYSTEMS LEADERSHIP 1. Apply leadership skills and decision making in the provision of culturally responsive, high-quality nursing care, health care team coordination, and the oversight and accountability for care delivery and outcomes. 2. Assume a leadership role in effectively implementing patient safety and quality-improvement initiatives within the context of the interprofessional team using effective communication (scholarly writing, speaking, and group interaction) skills. 3. Develop an understanding of how health care delivery systems are organized and financed (and how this affects patient care) and identify the economic, legal, and political factors that influence health care. 4. Demonstrate the ability to use complexity science and systems theory in the design, delivery, and evaluation of health care. 5. Apply business and economic principles and practices, including budgeting, cost–benefit analysis, and marketing, to develop a business plan. 6. Design and implement systems change strategies that improve the care environment. 7. Participate in the design and implementation of new models of care delivery and coordination. 1. Demonstrate working knowledge of the health care system and its component parts, including sites of care; delivery models; payment models; and the roles of health care professionals, patients, caregivers, and unlicensed professionals. 2. Assume a leadership role for an interprofessional health care team with a focus on the delivery of patient-centered care and the evaluation of quality and cost-effectiveness across the health care continuum. 3. Use systems theory in the assessment, design, delivery, and evaluation of health care within complex organizations. 4. Demonstrate business and economic principles and practices, including cost–benefit analysis, budgeting, strategic planning, human and other resource management, marketing, and value-based purchasing. 5. Contribute to budget development at the microsystem level. 6. Evaluate the efficacy and utility of evidence-based care delivery approaches and their outcomes at the microsystem level. 7. Collaborate with health care professionals, including physicians, advanced practice nurses, nurse managers, and others, to plan, implement, and evaluate an improvement opportunity. 8. Participate in a shared leadership team to make recommendations for improvement at the micro-, meso-, or macro-system levels. 1. Assume complex and advanced leadership roles to initiate and guide change. 2. Provide leadership to foster collaboration with multiple stakeholders (e.g., patients, community, integrated health care teams, and policy makers) to improve health care. 3. Demonstrate leadership that uses critical and reflective thinking. 4. Advocate for improved access, quality, and cost-effective health care. 5. Advance practice through the development and implementation of innovations incorporating principles of change. 6. Communicate practice knowledge effectively both orally and in writing. 7. Participate in professional organizations and activities that influence advanced practice nursing and/or health outcomes with a population focus. ESSENTIAL 3: QUALITY IMPROVEMENT AND SAFETY 1. Analyze information about quality initiatives recognizing the contributions of individuals and interprofessional health care teams to improve health outcomes across the continuum of care. 2. Implement evidence-based plans based on trend analysis and quantify the impact on quality and safety. 3. Analyze information and design systems to sustain improvements and promote transparency using high reliability and just-culture principles. 4. Compare and contrast several appropriate quality-improvement models. 5. Promote a professional environment that includes accountability and high-level communication skills when involved in peer review, advocacy for patients and families, reporting of errors, and professional writing. 6. Contribute to the integration of health care services within systems to affect safety and quality of care to improve patient outcomes and reduce fragmentation of care. 7. Direct quality-improvement methods to promote culturally responsive, safe, timely, effective, efficient, equitable, and patient-centered care. 8. Lead quality-improvement initiatives that integrate sociocultural factors affecting the delivery of nursing and health care services. 1. Use performance measures to assess and improve the delivery of evidence-based practices and promote outcomes that demonstrate delivery of higher value care. 2. Perform a comprehensive microsystem assessment to provide the context for problem identification and action. 3. Use evidence to design and direct system improvements that address trends in safety and quality. 4. Implement quality-improvement strategies based on current evidence, analytics, and risk anticipation. 5. Promote a culture of continuous quality improvement within a system. 6. Apply just-culture principles and the use of safety tools, such as failure mode effects analysis (FMEA) and root cause analysis (RCA), to anticipate, intervene, and decrease risk. 7. Demonstrate professional and effective communication skills, including verbal, nonverbal, written, and virtual abilities. 8. Evaluate patient handoffs and transitions of care to improve outcomes. 9. Evaluate medication reconciliation and administration processes, to enhance the safe use of medications across the continuum of care. 10. Demonstrate the ability to develop and present a business plan, including a budget, for the implementation of a quality-improvement project/initiative. 11. Use a variety of data sets, such as Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), nurse-sensitive indicators, National Data Nursing Quality Improvement (NDNQI), and population registries, appropriate for the patient population, setting, and organization, to assess individual and population risks and care outcomes. 1. Use best available evidence to continuously improve quality of clinical practice. 2. Evaluate the relationships among access, cost, quality, and safety and their influence on health care. 3. Evaluate how organizational structure, care processes, financing, marketing, and policy decisions impact the quality of health care. 4. Apply skills in peer review to promote a culture of excellence. 5. Anticipate variations in practice that are proactive in implementing interventions to ensure quality. ESSENTIAL 4: TRANSLATING AND INTEGRATING SCHOLARSHIP INTO PRACTICE 1. Integrate theory, evidence, clinical judgment, research, and interprofessional perspectives using translational processes to improve practice and associated health outcomes for patient aggregates. 2. Advocate for ethical conduct in research and translational scholarship (with particular attention to the protection of the patient as a research participant). 3. Articulate to a variety of audiences the evidence base for practice decisions, including the credibility of sources of information and the relevance to the practice problem confronted. 4. Participate, leading when appropriate, in collaborative teams to improve care outcomes and support policy changes through knowledge generation, knowledge dissemination, and planning and evaluating knowledge implementation. 5. Apply practice guidelines to improve practice and the care environment. 6. Perform a rigorous critique of evidence derived from databases to generate meaningful evidence for nursing practice. 1. Facilitate practice change based on best available evidence that results in quality, safety, and fiscally responsible outcomes. 2. Ensure the inclusion of an ethical decision-making framework for quality improvement. 3. Implement strategies for encouraging a culture of inquiry within the health care delivery team. 4. Facilitate the process of retrieval, appraisal, and synthesis of evidence in collaboration with health care team members, including patients, to improve care outcomes. 5. Communicate with the interprofessional health care team, patients, and caregivers about current quality and safety guidelines and nurse-sensitive indicators, including the endorsement and validation processes. 6. Apply improvement science theory and methods in performance measurement and quality-improvement processes. 7. Lead change initiatives to decrease or eliminate discrepancies between actual practices and identified standards of care. 8. Disseminate changes in practice and improvements in care outcomes to internal and external audiences. 9. Design care based on outcome analysis and evidence to promote safe, timely, effective, efficient, equitable, and patient-centered care. 1. Provide leadership in the translation of new knowledge into practice. 2. Generate knowledge from clinical practice to improve practice and patient outcomes. 3. Apply clinical investigative skills to improve health outcomes. 4. Lead practice inquiry, individually or in partnership with others. 5. Disseminate evidence from inquiry to diverse audiences using multiple modalities. 6. Analyze clinical guidelines for individualized application into practice. ESSENTIAL 5: INFORMATICS AND HEALTH CARE TECHNOLOGIES 1. Analyze current and emerging technologies to support safe practice environments and to optimize patient safety, cost-effectiveness, and health outcomes. 2. Evaluate outcome data using current communication technologies, information systems, and statistical principles to develop strategies to reduce risks and improve health outcomes. 3. Promote policies that incorporate ethical principles and standards for the use of health and information technologies. 4. Provide oversight and guidance in the integration of technologies to document patient care and improve patient outcomes. 5. Use information and communication technologies, resources, and principles of learning to teach patients and others. 6. Use current and emerging technologies in the care environment to support lifelong learning for self and others. 1. Use information technology, analytics, and evaluation methods to: a. Collect or access appropriate and accurate data to generate evidence for nursing practice b. Provide input in the design of databases that generate meaningful evidence for practice c. Collaborate to analyze data from practice and system performance d. Design evidence-based interventions in collaboration with the health professional team e. Examine patterns of behavior and outcomes f. Identify gaps in evidence for practice 2. Implement the use of technologies to coordinate and laterally integrate patient care within/across care settings and among health care providers. 3. Analyze current and proposed use of patient-care technologies, including their cost-effectiveness and appropriateness, in the design and delivery of care in diverse care settings. 4. Use technologies and information systems to facilitate the collection, analysis, and dissemination of data, including clinical, financial, and operational outcomes. 5. Use information and communication technologies to document patient care, advance patient education, and enhance accessibility of care. 6. Participate in ongoing evaluation, implementation, and integration of health care technologies, including the electronic health record (EHR). 7. Use a variety of technology modalities and media to disseminate health care information and communicate effectively with diverse audiences. 1. Integrate appropriate technologies for knowledge management to improve health care. 2. Translate technical and scientific health information appropriate for various users’ needs. a. Assess the patient’s and caregiver’s educational needs to provide effective, personalized health care. b. Coach the patient and caregiver for positive behavioral change. 3. Demonstrate information-literacy skills in complex decision making. 4. Contribute to the design of clinical information systems that promote safe, quality, and cost-effective care. 5. Use technology systems that capture data on variables for the evaluation of nursing care. ESSENTIAL 6: HEALTH POLICY AND ADVOCACY 1. Analyze how policies influence the structure and financing of health care, practice, and health outcomes. 2. Participate in the development and implementation of institutional, local, and state and federal policy. 3. Examine the effect of legal and regulatory processes on nursing practice, health care delivery, and outcomes. 4. Interpret research, bringing the nursing perspective, for policy makers and stakeholders. 5. Advocate for policies that improve the health of the public and the profession of nursing. 1. Describe the interaction between regulatory agency requirements (such as The Joint Commission [TJC], Centers for Medicare & Medicaid Services [CMS], or Healthcare Facilities Accreditation Program [HFAP]), and quality, fiscal, and value-based indicators. 2. Articulate the contributions and synergies of the CNL with other nursing and interprofessional team member roles to policy makers, employers, health care providers, consumers, and other health care stakeholders. 3. Advocate for policies that leverage social change, promote wellness, improve care outcomes, and reduce costs. 4. Advocate for the integration of the CNL within care delivery systems, including new and evolving models of care. 1. Demonstrate an understanding of the interdependence of policy and practice. 2. Advocate for ethical policies that promote access, equity, quality, and cost. 3. Analyze ethical, legal, and social factors influencing policy development. 4. Contribute in the development of health policy. 5. Analyze the implications of health policy across disciplines. 6. Evaluate the impact of globalization on health care policy development. ESSENTIAL 7: INTERPROFESSIONAL COLLABORATION FOR IMPROVING PATIENT AND POPULATION HEALTH OUTCOMES 1. Advocate for the value and role of the professional nurse as member and leader of interprofessional health care teams. 2. Understand other health professions’ scopes of practice to maximize contributions within the health care team. 3. Employ collaborative strategies in the design, coordination, and evaluation of patient-centered care. 4. Use effective communication strategies to develop, participate, and lead interprofessional teams and partnerships. 5. Mentor and coach new and experienced nurses and other members of the health care team. 6. Function as an effective group leader or member based on an in-depth understanding of team dynamics and group processes. 1. Create an understanding and appreciation among health care team members of similarities and differences in role characteristics and contributions of nursing and other team members. 2. Advocate for the value and role of the clinical nurse leader as a leader and member of interprofessional health care teams. 3. Facilitate collaborative, interprofessional approaches and strategies in the design, coordination, and evaluation of patient-centered care. 4. Facilitate the lateral integration of health care services across the continuum of care with the overall objective of influencing, achieving, and sustaining high-quality care. 5. Demonstrate a leadership role in enhancing group dynamics and managing group conflicts. 6. Facilitate team decision making using decision tools and convergent and divergent group-process skills, such as SWOT (strengths, weaknesses, opportunities, threats) analysis, Pareto analysis, and brainstorming. 7. Assume a leadership role, in collaboration with other interprofessional team members, to facilitate transitions across care settings to support patients and families and reduce avoidable recidivism to improve care outcomes. 1. Apply knowledge of organizational practices and complex systems to improve health care delivery. 2. Effect health care change using broad-based skills, including negotiating, consensus building, and partnering. 3. Minimize risk to patients and providers at the individual and systems levels. 4. Facilitate the development of health care systems that address the needs of culturally diverse populations, providers, and other stakeholders. 5. Evaluate the impact of health care delivery on patients, providers, other stakeholders, and the environment. 6. Analyze organizational structure, functions, and resources to improve the delivery of care. 7. Collaborate in planning for transitions across the continuum of care. ESSENTIAL 8: CLINICAL PREVENTION AND POPULATION HEALTH FOR IMPROVING HEALTH 1. Synthesize broad ecological, global, and social determinants of health; principles of genetics and genomics; and epidemiologic data to design and deliver evidence-based, culturally relevant clinical prevention interventions and strategies. 2. Evaluate the effectiveness of clinical prevention interventions that affect individual- and population-based health outcomes using health information technology and data sources. 3. Design patient-centered and culturally responsive strategies in the delivery of clinical prevention and health-promotion interventions and/or services to individuals, families, communities, and aggregates/clinical populations. 4. Advance equitable and efficient prevention services, and promote effective population-based health policy through the application of nursing science and other scientific concepts. 5. Integrate clinical prevention and population health concepts in the development of culturally relevant and linguistically appropriate health education, communication strategies, and interventions. 1. Demonstrate the ability to engage the community and social service delivery systems that recognize new models of care and health services delivery. 2. Participate in the design, delivery, and evaluation of clinical prevention and health-promotion services that are patient-centered and culturally appropriate. 3. Monitor the outcomes of comprehensive plans of care that address the health-promotion and disease-prevention needs of patient populations. 4. Apply public health concepts to advance equitable and efficient preventive services and policies that promote population health. 5. Engage in partnerships at multiple levels of the health system to ensure effective coordination, delivery, and evaluation of clinical prevention and health-promotion interventions and services across care environments. 6. Use epidemiological, social, ecological, and environmental data from local, state, regional, and national sources to draw inferences regarding the health risks and status of populations, to promote and preserve health and healthy lifestyles. 7. Use evidence in developing and implementing teaching and coaching strategies to promote and preserve health and healthy lifestyles in patient populations. 8. Provide leadership to the health care team to promote health, facilitate self-care management, optimize patient engagement, and prevent future decline, including progression to higher levels of care and readmissions. 9. Assess organization-wide emergency preparedness plans and coordination with the local, regional, and National Incident Management System (NIMS). 1. Integrate ethical principles in decision making. 2. Evaluate the ethical consequences of decisions. 3. Apply ethically sound solutions to complex issues related to individuals, populations, and systems of care. ESSENTIAL 9: MASTER’S-LEVEL NURSING PRACTICE 1. Conduct a comprehensive and systematic assessment as a foundation for decision making. 2. Apply the best available evidence from nursing and other sciences as the foundation for practice. 3. Advocate for patients, families, caregivers, communities, and members of the health care team. 4. Use information and communication technologies to advance patient education, enhance accessibility of care, analyze practice patterns, and improve health care outcomes, including nurse-sensitive outcomes. 5. Use leadership skills to teach, coach, and mentor other members of the health care team. 6. Use epidemiological, social, and environmental data in drawing inferences regarding the health status of patient populations and interventions to promote and preserve health and healthy lifestyles. 7. Use knowledge of illness and disease management to provide evidence-based care to populations, perform risk assessments, and design plans or programs of care. 8. Incorporate core scientific and ethical principles in identifying potential and actual ethical issues arising from practice, including the use of technologies, and in assisting patients and other health care providers to address such issues. 9. Apply advanced knowledge of the effects of global environmental, individual, and population characteristics to the design, implementation, and evaluation of care. 10. Employ knowledge and skills in economics, business principles, and systems in the design, delivery, and evaluation of care. 11. Apply theories and evidence-based knowledge in leading, as appropriate, the health care team to design, coordinate, and evaluate the delivery of care. 12. Apply learning and teaching principles to the design, implementation, and evaluation of health education programs for individuals or groups in a variety of settings. 13. Establish therapeutic relationships to negotiate patient-centered, culturally appropriate, evidence-based goals and modalities of care. 14. Design strategies that promote lifelong learning of self and peers and that incorporate professional nursing standards and accountability for practice. 15. Integrate an evolving personal philosophy of nursing and health care into nursing practice. 1. Conduct a holistic assessment and comprehensive physical examination of individuals across the life span. 2. Assess actual and anticipated health risks to individuals and populations. 3. Demonstrate effective communication, collaboration, and interpersonal relationships with members of the care delivery team across the continuum of care. 4. Facilitate modification of nursing interventions based on risk anticipation and other evidence to improve health care outcomes. 5. Demonstrate the ability to coach, delegate, and supervise health care team members in the performance of nursing procedures and processes with a focus on safety and competence. 6. Demonstrate stewardship, including an awareness of global environmental, health, political, and geo-economic factors, in the design of patient care. 7. Facilitate the lateral integration of evidence-based care across settings and among care providers to promote quality, safe, and coordinated care. 8. Facilitate transitions of care and safe handoffs among health care settings, providers, and levels of care. 9. Evaluate the effectiveness of health teaching by self and others. 10. Facilitate the implementation of evidence-based and innovative interventions and care strategies for diverse populations. 11. Design appropriate interventions using surveillance data and infection-control principles to limit health care–acquired infections (HAI) at all points of care. 12. Advocate for patients within the health care delivery system to affect quality, safe, and value-based outcomes. 13. Collaborate in the development of community partnerships to establish health-promotion goals and implement strategies to address those needs. 14. Evaluate the care of at-risk populations across the life span by identifying and implementing programs that address specialized needs. 15. Engage individuals and families to make quality-of-life decisions, including palliative and end-of-life decisions. 16. Assess an individual’s and group’s readiness and ability to make decisions, as well as to develop, comprehend, and follow a plan of care. 17. Assess the level of cultural awareness and sensitivity of health care providers as a component of the evaluation of care delivery. 18. Demonstrate coaching skills, including self-reflection, to support new and experienced interprofessional team members in exploring opportunities for improving care processes and outcomes. 19. Use coaching techniques to assist individuals in developing insights and skills to improve their current health status and function. 1. Function as a licensed independent practitioner. 2. Demonstrate the highest level of accountability for professional practice. 3. Practice independently, managing previously diagnosed and undiagnosed patients. a. Provide the full spectrum of health care services to include health promotion, disease prevention, health protection, anticipatory guidance, counseling, disease management, and palliative and end-of-life care. b. Use advanced health assessment skills to differentiate among normal, variations of normal, and abnormal findings. c. Employ screening and diagnostic strategies in the development of diagnoses. d. Prescribe medications within scope of practice. e. Manage the health/illness status of patients and families over time. 4. Provide for patient-centered care recognizing cultural diversity and the patient or designee as a full partner in decision making. a. Work to establish a relationship with the patient characterized by mutual respect, empathy, and collaboration. b. Create a climate of patient-centered care to include confidentiality, privacy, comfort, emotional support, mutual trust, and respect. c. Incorporate the patient’s cultural and spiritual preferences, values, and beliefs. d. Preserve the patient’s control over decision making by negotiating a mutually acceptable plan of care.
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