Although self-management allows patients to be more independent, it can also lead to errors. How can we help patients avoid errors during self-management?

Patients at risk for self-management errors include those with multiple chronic problems using multiple medications, and elderly patients trying to practice self-management in their homes. You can help patients with self-management by knowing how to assist patients in using Medisets to administer their medication; how to monitor medication use by patients and caregivers; and how to teach patients and caregivers what to review when they receive their medications, such as drug name and dose. Consider how confusing multiple oral medications with complex administration schedules might be for patients, and if patients can open childproof lids and read small-print labels (e.g., arthritis, poor eyesight). How easy is it for a patient to make an error? What interventions can you use to educate patients and their families, prevent errors, and help them improve their self-management? Medication reconciliation, which is discussed later, is also highly relevant to self-management.

Disease management, which involves self-management, can help decrease complications, length of stay, and costs. Disease management involves care coordination (one of the major priority areas of care), interprofessional teamwork, and patient-centered care. Patients who can particularly benefit include those who are chronically critically ill. In Long’s controlled study (2008), patients on mechanical ventilation for 72 hours or more were included in the sample. Patients were monitored and received disease management interventions from an advanced practice nurse. This coordinated, patient-centered approach improved outcomes. Nurses in the program communicated effectively, showed commitment to good patient outcomes, and understood how to help the patient and family navigate the system.

Nurse or patient navigation is being used in some clinical settings to assist patients through their treatment trajectory to meet their health needs, as was mentioned earlier. The nurse navigator works with the patient and family to guide them through the complex healthcare system to ensure better outcomes. Clinical nurse leaders (CNLs) often serve in this role.

The goals of disease management are to improve quality of life, decrease disease progression, and reduce hospitalizations. A nurse call center typically provides services such as monitoring health status; giving patient education and advice; and sharing information from labs, physicians, and pharmacies. Chronic illnesses that are typically monitored include diabetes, heart disease and hypertension, asthma, cancer, depression, renal disease, low back pain, and obesity. Insurers typically develop disease management programs and use case management to control costs. Disease management and case management are also relevant to community health.

The Institute of Health Improvement (IHI) offers tools to support self-management at http://www.ihi.org/knowledge/Pages/Tools/ToolkitforClinicians.aspx. These tools are great resources. Examples of the tools are: Quality Compass Benchmarks, Blood Pressure Visual Aid for Patients, Self-Management Support: Patient Planning Worksheet, My Shared Plan, and Group Visit Starter Kit.

The number of persons with chronic illnesses has increased, as well as the number of people with more than one chronic illness. Some data on chronic illness includes (Centers for Disease Control and Prevention, 2011):

Why does the United States have these problems with chronic illness? One reason is that with the better treatment available today, people with chronic illnesses live longer; consequently, there are more of them. The United States must improve care provided for those with chronic illness. Many of the IOM priority areas of care, monitored annually in the National Healthcare Quality Report, are chronic illnesses.

Effective management of a chronic illness requires daily management of the illness, and also should include activities to improve health in general. To accomplish this, the person with chronic illness needs to have an understanding of the illness and interventions to achieve self-management. Self-management focuses on care of the body and management of the condition, adapting everyday activities and roles to the condition, and dealing with the emotions arising from having the condition. “Self-management support is the care and encouragement provided to people with chronic conditions to help them understand their central role in managing their illness, make informed decisions about care, and engage in healthy behaviors” (IHI, 2008e).

One approach is to use the Chronic Care Model, a patient-centered approach (Wagner, 1998; Improving Chronic Illness Care, 2003). The model emphasizes two principles:

This model is described in Figure 4-2, and at the web site of Improving Chronic Illness Care, http://www.improvingchroniccare.org. There are many links to content and application of the model to care issues, including an audiovisual presentation.

The Improving Chronic Illness Care organization is dedicated to assessing and developing strategies to improve chronic illness care in the United States, and to helping people with chronic illness to lead healthier, quality lives (Improving Chronic Illness Care, 2003). “Over 145 million people—almost half of all Americans—suffer from asthma, depression and other chronic conditions. Over eight percent of the U.S. population has been diagnosed with diabetes. Approximately one third of cases of diabetes are undiagnosed” (Improving Chronic Illness Care, 2011). According to the IOM reports, some of the major issues are:

The following are some critical patient issues to consider when applying disease management to chronic illness:

How do cultural issues affect self-management? How is the community involved? When providing care in the community, chronic illness is important, as this is where most of the prevention of chronic illness and care for chronic illness occur. Patients from different ethnic groups may respond to chronic illness and to self-management differently. Language affects patients’ abilities to understand directions, which is critical to effective self-management. Family roles vary in different cultures, which can influence how families respond and the roles they may or may not assume. Health literacy (discussed later) is a critical factor in ensuring quality care in any diversity situation.

Safety-net hospitals treat poor and underserved patients. Medicaid often reimburses for this care, but many patients may have no way to pay for their care (Reinberg, 2008). Data collected between 2004 and 2006 from 3,665 safety-net and non-safety-net hospitals revealed that the quality of care at safety-net hospitals is below the level of other hospitals (Werner, Goldman, & Dudley, 2008). The results relate directly to healthcare disparities. What do you need to know about the safety-net system and the needs of vulnerable populations?

These hospitals rely on state and federal funding from Medicaid and other sources. Most are inner-city and teaching hospitals and do not have the funds to improve the quality of care at the same rate as other hospitals. Ironically, though, these hospitals may not receive funding to improve because such funding is often performance-based.
Hospitals that receive Medicare and Medicaid Disproportionate Share Hospital (DSH) payments are the hospitals that serve a larger proportion of low-income patients, such as those on Medicaid, and uninsured patients. Though healthcare reform should help reduce this problem, provisions of the current healthcare reform legislation dealing with this issue do not go into effect until 2014.

Quality ratings at hospitals that are described as safety-net hospitals have been variable. McHugh, Kang, and Hasnain-Wynia (2009) note in their study that one has to be careful and consider the criteria used to classify a hospital as a safety-net hospital: “Public or teaching hospitals had lower performance scores on four ‘process of care’ measures than did private, nonteaching hospitals, but results were mixed for safety-net hospitals identified by the level of uncompensated care they provide.” This is a topic that you can explore and then discuss as to its impact on quality care and on nursing.

Americans are older than ever, living with multiple comorbidities and chronic health needs. The other end of the life span is also at increasing risk, with a population of children who before the age of 10 are experiencing comorbidities such as hypertension, diabetes, and obesity; furthermore, many women are delaying childbearing well into their forties, which may lead to complications during pregnancy and for the newborn. These demographics indicate that long-term health care will require a delivery system capable of handling this growing complexity. Because these are major shifts from the patient pool of the past, healthcare professionals need education that prepares them to intervene in complex health problems in a more efficient, safer way to reach quality outcomes that are also cost-effective.

At the same time, the population is becoming more diverse. Understanding cultural beliefs and values and their relationship are part of developing cultural competence. Understanding the demographics and cultural backgrounds of your patients, and addressing them in patient care plans, is an important part of providing care to diverse populations.

For example, examine the study by Li, Glance, Yin, and Mukamel (2011). This study considers the impact of racial disparities on rehospitalization among Medicare patients in skilled nursing facilities (SNFs). There was a difference in readmission rates between White patients and Black patients (rehospitalization at 30 days was 14.3% for White patients and 18.6% for Black patients; at 90 days it was 22.1% for White patients and 29.5% for Black patients). The researchers commented that the SNFs that had more Black patients tended to have fewer resources. How might their data relate to safetynet hospitals?

Emergency care is a critical concern in the United States, as noted in three IOM reports from 2007 discussed in Part 1. A common assumption is that we have this problem
because so many uninsured persons use the emergency department (ED) when they do not need urgent care. Actually, this is not correct. The uninsured do not come to the ED for a bad cold, because they have to pay for this care; in contrast, someone with insurance coverage has to pay only a copayment for this service (Carmichael, 2008). Carmichael (2008) notes that 17% of people are uninsured, but they account for only 10% to 15% of ED visits. From 2008-2009, though, there was an increase in use of emergency departments (EDs) by the uninsured. However, diversity issues are prevalent in emergency care, and the need for quick, effective communication with patients and families is critical. Accessibility of interpreters is often a barrier in the emergency care delivery system.

“Emergency departments have the only legal mandate in the U.S. healthcare system to provide health care according to the Emergency Medical Treatment and Labor Act (EMTALA). This law ensures that anyone who comes to an emergency department, regardless of their insurance status or ability to pay, must receive a medical screening exam and be stabilized. According to a 2009 American College of Emergency Physicians (ACEP) survey on the U.S. financial crisis, 66 percent of emergency physicians polled have seen an increase of uninsured patients in their emergency departments during the current financial crisis” (ACEP, 2011).

Patients with nonurgent medical conditions may wait longer for care, but once seen, they are treated quickly and released. “Dangerous overcrowding is caused when a lack of hospital resources results in acutely ill patients being ‘boarded’ in an emergency department because no hospital inpatient beds are available, and ambulances must be diverted to other hospitals. The Centers for Disease Control and Prevention (CDC) classified only 12.1 percent of hospital emergency department visits as nonurgent in 2006” (ACEP, 2011). The IOM reports on emergency services are described in Part 1.

The current design and administration of clinical trials in the United States underrepresents certain populations (Mozes, 2008). Participation in clinical studies among African Americans, Hispanics, and older Americans is disproportionately low. Mozes’s study indicates that the disparities are largely due to reliance on strict sample inclusion or exclusion criteria, the use of lengthy and complicated consent forms available only in English, and a lack of specific information on cost reimbursement for participants. These disparities can skew treatment recommendations based on studies with inequitable representation in their samples. We need to expand clinical trial participation so research results can better reflect all populations.

Evidence-based practice (EBP) includes consideration of diversity (Wessling, 2008). Because many studies do not include racially diverse participants, it is critical to consider similarities or differences in populations when reviewing evidence, to better ensure effective EBP.

Typically, care for people who live in rural areas is covered in community health content. The rural population often includes multiple ethnic groups, but the rural population as a whole also experiences disparities in health care (Healthy People 2020; South Carolina Rural Health Research Center, 2009):

Much more must be done to improve care in rural areas. The National Rural Health Association provides important current information on this topic (http://www.ruralhealthweb.org/go/left/about-rural-health/what-s-different-about-rural-health-care).

The Joint Commission published a practical guide that healthcare organizations can use to develop and improve programs and services that accommodate the needs of diverse populations (Joint Commission, 2008). The recommendations of this report include:

The report is available online, along with other Joint Commission resources on diverse patient populations, at http://www.jointcommission.org/Advancing_Effective_Communication/

National League for Nursing (NLN) data for 2005-2006 (March 3, 2008) indicate that the percentage of graduating prelicensed students who are members of racial or ethnic minority groups increased from 2008 to 2009 (NLN, 2009). There was also an increase in the percentage of men. This is good news, but much more remains to be done regarding workforce diversity. An increasing number of grant opportunities are aimed at increasing the mix of ethnic groups among nurses so they can provide more culturally sensitive, appropriate care. Data about the nursing workforce also indicate more diversity. The Health Resources and Services Administration (HRSA) reports that in 2008, 16.8% of nurses were Asian, Black/African American, American Indian/Alaska Native, and/or Hispanic, which is an increase from 12.2% in 2004 (HRSA, 2010).

As mentioned in Part 1, there is a pressing need to monitor healthcare disparities (IOM, 2002). Since 2003, the AHRQ has prepared the NHDR. The annual report analyzes racial, ethnic, socioeconomic, and geographic disparities in health care. The IOM recommendations for this annual report include (IOM, 2002, p. 7):

The 2010 report (reports are several years behind current date) focused on three questions (AHRQ, 2010a, 2010b):

Figure 4-3 describes the most current matrix for the report. The matrix has changed since the first IOM report on disparities, which was described in Part 1. The annual report matrix provides an excellent tool for students to understand the issues and to use the annual report data. The annual report is available at www.ahrq.gov/qual/qrdr10.htm.

“The process of developing cultural competence is a means of responding effectively to the huge ethnic and racial demographic shifts and changes that are confronting our country’s healthcare system. Cultural competence is a defined set of policies, behaviors, attitudes, and practices that enable individuals and organizations to work effectively in cross-cultural situations. Cultural competence is the ability of systems to provide care to patients with diverse values, beliefs, and behaviors, including the tailoring of delivery to meet patients’ social, cultural, and linguistic needs” (Salisbury & Byrd, 2006, p. 90). The American Association of Colleges of Nursing (AACN) strongly supports teaching cultural competence in baccalaureate education, as stated in The Essentials of Baccalaureate Education for Professional Nursing Practice (AACN, 2008b)—a viewpoint that clearly derives from the IOM reports on diversity and healthcare disparities. Another definition of cultural competence is the “attitudes, knowledge, and skills necessary for providing quality care to diverse populations” (California Endowment, 2003, as cited in AACN, 2008b, p. 1). The Essentials of Masters Education in Nursing also emphasizes the need for cultural competence in its Essential VIII, which “recognizes that the master’s-prepared nurse applies and integrates broad, organizational, client-centered, and culturally appropriate concepts in the planning, delivery, management, and evaluation of evidence-based clinical prevention and population care and services to individuals, families, and aggregates/identified populations” (AACN, 2011, p. 5).

Cultural competence must be integrated in the curriculum. This perspective is based on the following assumptions (AACN, 2008b, pp. 2-3; Paasche-Orlow, 2004):

A paper from AACN (2008a) describes background and content that should be considered in baccalaureate programs to facilitate cultural competence. This document complements Essentials of Baccalaureate Education for Professional Nursing Practice (AACN, 2008b).

The AACN cultural competence toolkit (www.aacn.nche.edu/education-resources/toolkit.pdf) identifies five competencies for culturally competent care, and content recommendations. The competencies are (2008a, pp. 2-3):

Consider how you currently meet these competencies.

Campinha-Bacote (2003) developed a cultural competence assessment tool in versions for students and staff. It is based on Campinha-Bacote’s volcano model of the process of cultural competence in the delivery of healthcare services, which defines cultural competence as “the process in which the healthcare professional continually strives to achieve the ability and availability to effectively work within the cultural context of a client” (Campinha-Bacote, 2008). It is a process of becoming culturally competent, not being culturally competent. Campinha-Bacote’s model of cultural competence views cultural awareness, cultural knowledge, cultural skill, cultural encounters, and cultural desire as the five constructs of cultural competence. The five constructs are:

Disparities can be a difficult topic for faculty and students. Healthcare providers view themselves as caring people who are open. “Discourse on provider bias has been silent in healthcare literature. Medicine and nursing as predominantly White professions have failed to acknowledge the White domination inherent in and perpetuated by its research, clinical, and educational practices” (Byrne, 2000; Feagin & Vera, 1995, as cited in Baldwin, 2003, p. 8). You need opportunities to discuss these issues in a safe environment—one in which your opinions will not be negatively criticized, but rather will be used to develop professional attitudes and behaviors. For example, you need to understand that many patients mistrust the healthcare system because they have experienced bias from healthcare providers in the past, which affects future encounters. Communication is a critical element, and health literacy also plays a major role in disparities. (Information about health literacy is covered in this section.) Cultural competence is also highly personal. Take some time to consider your own cultural background and how it influences you personally and might influence your practice.

Self-management will not be effective if the patient has a low level of health literacy. Why would this be so? What skills do patients need to manage their diabetes or arthritis? Consider how health literacy problems might relate to adult health, pediatrics, mental health, obstetrics, and community/public health. Nurses need to understand that health literacy issues can arise in all types of situations and can have an important impact on care and outcomes.

What does health literacy mean to you? How does your view of health literacy compare to the definition of health literacy used in the IOM report? Try to imagine the stigma that health-illiterate patients may feel.

Have you ever worked with an interpreter to facilitate communication with a patient? It can be a frustrating experience trying to communicate through a third party. This communication is different: You should speak directly to the patient, even though the natural tendency is to speak to the interpreter. What might be the advantages and disadvantages of depending on family members as interpreters? What might be the impact of a culture in which the husband makes decisions? Would the wife feel comfortable expressing herself, and would the husband try to soften difficult messages? Would it be better to use a native speaker or a language expert to interpret? There are options if no interpreter is available: finding a healthcare provider who speaks the language, working with community groups to help interpret, preparing visual materials that might aid communication, and so on.

It is important to connect health literacy with health education. Review consent forms, admission forms, and patient rights information, and assess your own ability to understand those forms and documents. What might interfere with patients’ reading and understanding what they have read? What would help them understand the documents better? You have some healthcare background, but what about patients and families who have none? During clinical experiences, how might health literacy affect your teaching of specific assigned patients? When you develop health education plans for individual patients, families, caregivers, or groups, consider assessment of health literacy issues in the assignment. Make sure this assessment is included in the plan of care.

What is done in a specific healthcare organization to address health literacy? How do health agencies used for clinical experiences respond to health literacy in their patient information and education programs? You can gather information by observation, interviewing staff, and reviewing written materials and other types of educational materials (such as videos that might be shown to patients). Are interpreters available, and are they used? Is hearing-impaired equipment accessible, and is it used? Look at signs and their effectiveness (for example, the use of color to direct patients). What could be improved, and how could the environment be changed so that all patients can be understood and can better understand healthcare providers?

You can assess health literacy levels with a population group in their community or an agency and its patients, identifying problems and interventions that might have been taken and outcomes, and consider other types of interventions that might improve health literacy. Health literacy should be part of individual patient assessments. Is health literacy included in your patient assessments? If not, how could it be included? How should this assessment be done? Is it part of a healthcare organization’s standard assessment forms? Compare assessment forms from different healthcare organizations or different services within an organization.

What is the best way to assess patient health literacy? The typical response would be to identify years of school completed or birth location. However, Rapid Estimate of Adult Literacy in Medicine (REALM), a standardized tool that takes only five minutes to administer, is a more effective method (Baker, 2007).

The topics of privacy, confidentiality, and HIPAA relate to patient-centered care. The critical issue is that the patient makes decisions about his or her health care. Healthcare providers share their expertise and recommendations, but do not make the decisions; a patient may decide to defer to the healthcare professional, but it should never be assumed that the patient will do so. You also need to clearly understand all aspects of patient information use and sharing. For example, you understand the ramifications of
electronic communication that you may be involved in, such as taking photos with cell phones while in clinical areas and then sharing them through social media networks, as well as discussing with friends on Facebook, Twitter, and the like about patients you have cared for in enough detail that the agency, patient, and/or staff could be identified. This same issue applies to electronic (and other) communication throughout the healthcare delivery system in public places.

“There is a growing appreciation of the centrality of patient involvement as a contributor to positive healthcare outcomes and as a catalyst for change in healthcare delivery” (IOM, 2007e, p. 25). It is difficult to discuss patient-centered care without considering patient advocacy. A patient advocate is “the patient navigator, both in its aim to help and guide patients to make well-informed decisions about their health for the best outcomes and in its quest to create more effective systems and policies” (Earp, French, & Gilkey, 2008, p. xv). Earlier sections discussed some of the critical characteristics of patient-centered care as described by the IOM. Gerteis, Edgman-Levitan, Daley, and Delbanco (1993) describe dimensions of patient-centered care (which correlate with the IOM perspectives) as:

The three overarching goals of patient advocacy are patient-centered care, safer medical systems, and increased patient involvement (Gilkey, Earp, & French, 2008). Safety, as highlighted in the IOM reports, is critical, and there is greater need to bring the patient into the safety process (as discussed further regarding the quality improvement core competency). All three patient advocacy goals are related, and patient involvement is necessary for success of advocacy.

Patients have not always been welcomed into the healthcare process. Patients need to be partners in their own care; they have important information to share and must be involved in the decisions. Patient-provider communication plays a key role in meeting all three goals of patient advocacy. Patient advocacy can be described as a continuum (Gilkey, Earp, & French, 2008).

The key strategies to meet the three patient advocacy goals are as follows (Earp, French, & Gilkey, 2008, pp. v-vii):

Nursing should be part of this strategy, particularly this last item. Nurses describe themselves as patient advocates, but in this major publication on patient advocacy there were no nurse authors, and nursing is mentioned only in the beginning of the book. The book is based on a large conference on patient advocacy that was held in 2003 and 2005; it is notable that nursing did not have a leadership role.

Patient etiquette may seem like a strange topic, but it is relevant to patient-centered care. Kahn (2008) discusses the need for etiquette-based medicine, but it seems to get lost in quite a few nursing education programs and experiences. Patients must be treated with respect, but we know that this does not always happen automatically or naturally. Viewing nurses as respectful of patients is also part of the nursing profession’s image. Patient etiquette includes items such as asking permission to enter the patient’s room and waiting for an answer; introducing yourself, shaking hands if appropriate, sitting down, and smiling as appropriate; briefly explaining your role on the team, or asking patients how they are feeling and how they feel about their illness and the care they have received. This would “[p]ut professionalism and patient satisfaction at the center of the clinical encounter and bring back some of the elements of ritual that have always been an important part of the healing process” (Kahn, 2008, p. 1988). Patient etiquette demonstrates respect for the patient and the patient’s values and preferences (patientcentered care).

Patient education is a complex process and should be included in all nursing curricula. If a patient does not have enough information, this can affect care. Some areas that require patient education are identified in the IOM reports, such as tobacco, alcohol, high-fat foods, and firearm injuries. Nurses in community settings typically include such topics in community education, but patients in other settings also need similar counseling. Patient education must be culturally sensitive because the meanings of health, illness, and death are not the same everywhere. For example, some Muslim families believe that this plane of life is just one level of existence, and thus resuscitating the patient is not as important as honoring the predestination of life events. The saving of locks of hair or pictures of Indian babies who are dying is not culturally accepted in all families; some believe that these mementos bind the child to this earthly world and do not allow the child to reach the next.

Keeping the patient in the center of care means that we need to consider what the patient feels is important and listen to the patient. Patient, family, or community health education should also address safety issues such as prevention of medication errors, and its relationship to self-management of care. Health literacy must be considered when patient education is planned, implemented, and evaluated.

Patient advocacy and patient-centered care are directly related to family-centered care. “Family-centered care is a partnership approach to the planning, delivery, and evaluation of health care and is grounded in a belief that each participant in a clinical encounter brings valuable experience to the table” (Seyda, Shelton, & DiVenere, 2008, p. 64). One cannot assume that all patients want their families involved, nor can one take for granted what level of involvement there will be and what information may be shared with the family. Patients must be asked about this before steps are taken to communicate with and include the family. The core principles of family-centered care are dignity and respect, information sharing, participation, and collaboration. As with patient-centered care, the overall goal is better outcomes. Family-centered care is “increasingly linked to improved health outcomes, lower healthcare costs, more effective allocation of resources, reduced medical errors and litigation, greater patient, family, and professional satisfaction, increased patient/family self-efficacy/advocacy, and improved medical/health education” (Seyda, Shelton, & DiVenere, 2008, p. 66).

Family-centered care is most likely thought of as relevant only to children’s health, but it applies to all patients. The family will naturally be involved in the support of a dying patient, such as hospice care; and in caring for older family members, a growing responsibility in the United States. Families can be very important in preventing errors; they have valuable information for healthcare providers and may observe as care is provided—asking questions, noting differences, and so on. This can lead to fewer errors and improved communication that reduces the likelihood of litigation.

The American Academy of Pediatrics (2007) describes the medical home as a model of delivering primary care that is accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective. This same model can be applied to adults. The Association of American Medical Colleges (AAMC) also describes the medical home. “Every person should have access to a medical home—a person who serves as a trusted advisor and provider supported by a coordinated team—with whom they have a continuous relationship. The medical home promotes prevention; provides care for most problems and serves as the point of first-contact for that care; coordinates care with other providers and community resources when necessary; integrates care across the health system; and provides care and health education in a culturally competent manner in the context of family and community” (AAMC, 2008).

The medical home model is based on patient-centered care. Individualized care is preventive and manages chronic illness. Same-day appointments and expanded appointment hours are more available; tools like secure e-mail enhance communication; prescriptions are transmitted electronically; and electronic health records (EHRs) are used. You can explore and learn more about this concept at http://www.medicalhomeinfo.org. What would be the nurse’s role, both ANPs and non-ANPs, in this model? Research information about medical homes and consider how this new model might affect nursing roles and responsibilities.

Patient- and family-centered rounds lead to greater patient-centered care (Siserhen, Blaszak, Woods, & Smith, 2007). This should be an interprofessional approach. If, however, nursing staff do not attend these rounds—which they should—then nursing can change nursing rounds only. Rounds should also include the patient’s family if the patient does not object. Engaging the family is important when the family is a significant part of the patient’s life, but in some cases patients may not want family members to hear the information. Students should participate in these important learning opportunities. Rounds demonstrate the impact of care that includes the family, interprofessional teams, communication, coordination, and collaboration. Reflect on the experience and identify examples from the rounds where these activities were evident. Preparation for rounds—communication methods, general process of rounds, when to ask questions, and so on—is important.

Team communication is a critical element in meeting patient needs, providing quality care, and reaching effective patient outcomes. It is intertwined with healthcare professional roles, ability to work with others, recognition that the team is the best method for reaching required goals, and willingness to compromise, collaborate, and coordinate together. It also has a major impact on errors.

The team should be an important element of any discussion about communication, but teams do not just communicate orally. It is easy for students to view documentation as something done to communicate nurse to nurse; however, there is much more to written communication. It helps the entire healthcare team to communicate the plan of care, what has been done, and outcomes. Not only is documentation important to all the healthcare providers, but it also provides data for quality improvement and is essential to reimbursement. Documentation and written communication have important legal
implications, particularly when there are care problems. A source for further discussion and examples of current documentation issues can be found at http://www.medscape.com/viewarticle/754374?src=ptalk

Communication skills are always important and should be developed throughout the curriculum. A growing concern for nurses is verbal abuse from other staff, physicians, and family members. In fact, verbal abuse is cited as one of the reasons that nursing is such a stressful profession. Students need guidance in how to respond and examples of the strategies that some HCOs are using to prevent verbal abuse. What is your school’s policy about tolerance of verbal abuse from students, faculty, administrators, or staff?

In 2011, the IOM published a brief report on patient-clinician communication, noting its importance to healthcare delivery, particularly quality care (Paget et al., 2011). Seven basic principles should be integrated into this communication.

The IOM report discusses each of these principles, all of which are important to nurses.

The Joint Commission notes that “ineffective communication is the most cited category of root causes of sentinel events” (2007, p. 2). Communication is closely connected to healthcare literacy, diversity, and patient education. How do we teach patients and families? Effective patient education has become more and more difficult because of the nursing shortage, patients who may not be able to concentrate, higher acuteness of patient conditions, short lengths of stay, and the highly stressful healthcare environment that does not allow much time for staff even to talk with patients and families.

Our old methods of patient teaching most likely need revision. Are we considering the communication principles noted earlier in this part? Are we taking full advantage of technology today? Patients are much more involved in all types of technology that could be used for patient education; for example, patients can download patient discharge information into a handheld computer and take the information with them, or access this information on a web site or through e-mail. The Joint Commission strongly supports effective communications, which is critical to protect the safety of patients across the continuum of care (Joint Commission, 2007).

Improving care is possible only if the problems of recruitment and retention are solved. Staff shortages have an impact on how care is provided and how well it meets standards. Successful job searches require knowledge of interviewing, identifying a positive work environment, developing résumés and query letters, and matching a job to your competencies, professional goals, and personal needs. Important retention issues that may arise during the first year of employment are the need for stress management, assertiveness, and problem-solving ability.

It is clear that we must consider the needs of students and new graduates from different perspectives. As part of this shift, nurse externships and residencies have resurfaced. These programs help new graduates transition to practice and offer a host of opportunities to expand their competencies. Some healthcare organizations use nurse externships and residencies to increase recruitment and retention of new graduates, decrease costs related to orientation and turnover, and increase quality of care. Nurse externship programs typically are developed by hospitals and other healthcare organizations for nursing students and are offered during the summer between the junior and senior years. Sometimes a school of nursing is involved. Students are employed and get some additional educational opportunities during their externship. The student role varies from state to state based on state board of nursing guidelines for employment of student nurses. Nurse externships should reflect IOM recommendations such as the core competencies and the need for greater emphasis on quality improvement.

This is also true of nurse residencies, which take place after graduation and can vary from several months to one year in length. The longer programs provide more time for the new graduate to transition to practice. Nurse residencies may be organized by
a healthcare organization (HCO) or in collaboration with a school of nursing. Effective residencies should offer graduated patient care responsibilities, additional educational experiences and competency development, professional socialization, and support for the critical transition during the first post-graduation year. These programs, too, should incorporate the recommendations and core competencies from the IOM.

In 2002, the AACN partnered with some HCOs to pilot standardized post-baccalaureate residency programs (IOM, 2004b). This ongoing AACN program is only for BSN graduates, but given the current large number of associate-degree (AD) graduates, we should also consider their transition to practice. If only BSN graduates can take advantage of residencies, this may imply that AD graduates do not need a residency, which is not the case. Nurse residencies that are not AACN residencies tend to accept all types of graduates if they meet the program’s specific admission and employment requirements.

The National Council of State Boards of Nursing (NCSBN) has examined the transition-to-practice problem. A model addressing transition to practice is found in Figure 4-4. This NCSBN model for nurse residency programs integrates the IOM core competencies.