Volume 2, Issue 4 July/August 2009 - Emerging Nurse Leader€¦ · Charge nurses need to become familiar with the practice acts in their own states. In addition to specific guidance

Volume 2, Issue 4 July/August 2009

www. c e n t e r f o r ame r i c a n n u r s e s . o r g

> Taking Charge: What Every Charge Nurse Needs to Know

> Conflict Training Programs: Considerations for Selection

> Career Coaching Corner

> National Experts on Conflict and Healthcare Design Highlight LEAD Summit 2009

> Seven NC Facilities Receive Award for Nursing Workplace Excellence

> Work Site Design Fact Sheet

> Supporting Family Caregivers in Providing Care

Volume 2, Issue 4 July/August 2009 2

Table of Contents

Message From the President . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Center for American Nurses Mission, Vision, Purpose, and Values . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Taking Charge: What Every Charge Nurse Needs to KnowRose O. Sherman, EdD, RN, NEA-BC, CNL and Terry Eggenberger, RN, MSN, PhD (c) . . . . . . . . . . . . . . . . . . . . . . . 6

Conflict Training Programs: Considerations for SelectionDiane Scott, RN, MSN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Career Coaching CornerMarlanda English, Ph.D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

National Experts on Conflict and Healthcare Design Highlight LEAD Summit 2009Diane Scott, RN, MSN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

LEAD Summit Highlights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Seven NC Facilities Receive Award for Nursing Workplace ExcellenceAshley Trantham . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Nursing that Works™: Work Site Design Fact SheetDiane Scott, RN, MSN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Get It Together! Financial and Health Care Paperwork You Need Right NowWISERWoman . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Supporting Family Caregivers in Providing CareSusan C. Reinhard, Barbara Given, Nirvana Huhtala Petlick, Ann Bemis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Center for American Nurses Board of DirectorsPresident: Dennis Sherrod, EdD, RN

President-Elect: Donna Warzynski, MSHSA, RN, C, CNA , BC

Treasurer: Teresa M. Haller, MSN, MBA, CNAA-BC

Directors: Rebecca Bowers-Lanier, RN, MSN, MPH, EdD

Denise Moore, MS, APRN, BC

Maureen Nalle, PhD, RN

Jackie Pfeifer, RN, MSN, CCRN-CSC, CCNS (Direct Patient Care)

Executive Director: Wylecia Wiggs Harris, MBA, CAE

Editorial Office8515 Georgia Avenue, Suite 401Silver Spring, MD 20910-3492(301) [email protected]

NURSES FIRST is published bimonthly by Gannett Healthcare Group for the Center for American Nurses, 8515 GeorgiaAvenue, Suite 401, Silver Spring, MD 20910-3492. Members of the Center receive a subscription as part of the member-ship dues. Nonmember subscriptions rates: Individual $30 per year, Institution $100 per year. All rights reserved.Reproduction in whole or in part without permission of the publisher is prohibited.

Advertising Information: Advertising inquiries should be directed to Terri Gaffney, Gannett Healthcare Group, 6400Arlington Blvd., Suite 1000, Falls Church, VA 22042; email address [email protected]; phone 301-628-5243.

Photocopying: Permission to photocopy articles for commercial and non-commercial use may be obtained from theCenter for American Nurses (301-628-5243 or [email protected]).

Notice: The statements and opinions in NURSES FIRST are solely those of the individual authors and contributors and notof the Center for American Nurses or the Gannett Healthcare Group. The presence of advertisements in NURSES FIRSTdoes not constitute a warranty, endorsement, or approval of the products or the claims made by the advertiser.

©2009 Center for American Nurses


Message From the President

Colleagues:

Nurses from around the country gathered in Orlando, Florida recently to participate in the Center for American Nurses’

Annual Education event. LEAD Summit 2009 was thought provoking, stimulating, and great fun! If you were unable to join

us, this issue of NURSES FIRST will give you a taste of what you missed. In addition, this issue is filled with articles and

tips that will help you strengthen your relationships with professional colleagues and tackle the challenges you face each

and every day. As always, at the Center we are focused on our collective mission of providing excellent patient care and

creating healthy work environments. On behalf of the Center for American Nurses Board of Directors, we hope you find the

information included in this issue helpful.

Sincerely,

Dennis Sherrod, EdD, RNPresident Center for American Nurses


Center for American Nurses Mission, Vision, Purpose, and Values

Mission

To create healthy work environments through advocacy, education, and research

Vision

The leader in workforce advocacy for professional nurses

Purpose

To articulate, advocate, and provide workforce advocacy solutions to equip nurses in shaping their work environment

Values

Leadership: Resolve professional workforce issues; act as professional resource; provide role models for the balancebetween personal and professional life

Personal and Professional Development: Encourage individual nurse initiative in creating a healthy work environmentand advocating for change in a positive persistent manner

Partnership: Build collaborative organizational and individual relationships beneficial to The Center and its professionalwork

Stewardship: Manage and develop The Center’s human and financial resources

Call for Manuscripts

NURSES FIRST invites authors to send your query letter or manuscript for publication [email protected]. For further information and to review the guidelines go towww.CenterforAmericanNurses.org



“I am just not sure that I am ready to take charge. I knowI have leadership skills but I am a relatively new nurse.Am I really ready to assume all this responsibility? Mynurse manager thinks I have excellent leadership potentialand is encouraging me to take the plunge. But what if thestaff does not respect me in the role and what if I fail?”

In today’s turbulenthealth care environ-ment, it is notunusual for nurses to

feel the type of anxiety thatthe nurse quoted aboverecently conveyed to one ofthe authors about assumingcharge nurse responsibili-ties. Charge nurses areexpected to lead staff whilemanaging the work systemsand processes on their unitsto insure that the needs ofpatients are met. It is askillful balancing act and notall organizations provide thetype of leadership trainingthat the charge nurse may need (Hansten, 2008; Hudson,2008; Sherman, 2005). Yet despite the challenges, embrac-ing the role of charge nurse can provide enormous profes-sional satisfaction and a tremendous leadership growthexperience. Important keys to success in becoming aneffective charge nurse include understanding the roleresponsibilities and developing the skills needed to enhancecommunication, reduce conflict and build team synergy.

Taking Charge Defining the role of the charge nurse is not easy in

today’s healthcare delivery systems due to the inconsisten-cies in definition and scope across facilities. The title ofcharge nurse has been around since the early 1980’s. Onedefinition for a charge nurse that has been given is “nursesassigned to a particular unit designated by the head nurse tocoordinate nursing activities on a particular shift” (Connelly,Nabarrete, & Smith, 2003, p. 204). Sometimes, a title otherthan charge nurse may be used such as unit coordinator orshift coordinator. The role may include expanded responsi-bilities such as conducting performance evaluations, sched-

uling, payroll, and chairing committees. The charge nurserole may be formal or informal. In some facilities, the rolerotates between the various senior level nurses on a shift. Inother organizations, the role is more formalized as a desig-nated support position primarily held by one individual, witha relief person on the weekends. Some charge nurses are

designated to be a resourcefor the rest of the team butmaintain responsibility fortheir own patient assign-ment. If a facility is union-ized, the union contractsmay prohibit the use of aformal charge nurse role.

Charge nurses haveaccountability to the organ-ization, staff and patientsfor the care that is deliv-ered. Organizations dependon charge nurses to be thegate keepers for safe andefficient care, which meetsregulatory requirementsand ensures an economic

return. Charge nurses conduct real time assessments of unitproductivity during various points throughout the shift. Theyoften determine how staff resources will be distributed ontheir shift, or the upcoming shift in response to changinginstitutional and patient needs. Charge nurses must also befamiliar with the institutions policies and procedures in orderto navigate through what is often a very complex system.

Charge nurses set expectations for staff and providesupport so that staff can carry out those expectations. Theyare expected to hold staff accountable for performance oftheir professional patient care duties, adherence to regula-tory requirements, and documentation of this essential infor-mation. The charge nurse serves as the conduit forinformation provided from staff to management and frommanagement to staff. Charge nurses assist with the orienta-tion, training and professional development of staff. Theyplay a key role in the competency assessment process.

Charge nurses are often clinical experts in their areas ofassignment. Their expertise allows them to engage with thestaff nurses in clinical decision making and problem solving.During their shift of responsibility, charge nurses manage

Taking Charge: What Every Charge Nurse Needs to KnowBy Rose O. Sherman, EdD, RN, NEA-BC, CNL and Terry Eggenberger, RN, MSN, PhD (c)


people, patient flow, use of equipment, and unit communi-cation to ensure that the patients and staff get the supportthat they need. In order to manage all of these responsibili-ties, charge nurses must be able to effectively delegate andsupervise care.

Delegating and Supervising Nursing CareMany charge nurses find it difficult to delegate tasks to

other members of their health care team. When done well,delegation can be a very effective management tool. It freesprofessional nurses to attend to more complex client needs,develop the skills of nursing assistive personnel and pro-mote cost containment for the organization (NCSBN, 2005).Ineffective delegation or a lack of follow-up supervision fortasks delegated can result in errors or omissions of care(Hansten, 2008). Dr. Linda Mahimeister, an attorney andnurse expert in the area of charge nurse accountability,recently noted in an interview that from a legal standpoint,charge nurses are expected to make decisions about allo-cating care based on staffing and patient needs. They willalso be held accountable to provide surveillance and super-vision of the care they delegate (Federwisch, 2008).

Most states provide specific guidance about the delega-tion of nursing care in their professional practice acts andnursing administrative rules/regulations. The National Councilof State Boards of Nursing (NCSBN, 2005) describes delega-tion as the transfer of authority by a qualified nurse to a com-petent individual for the purpose of completing selected tasksor activities. The assignment should be based on the assess-ment of the patient’s needs and the scope of practice/skills ofthe individual to whom care is delegated. The delegation canbe to another RN, a licensed practical nurse or unlicensedassistive personnel. Follow-up guidance and supervision ofcare delegated is expected. In most states, activities thatinclude the use of the nursing process or judgment/skills ofthe professional nurse (nursing assessment, diagnosis, plan ofcare, reassessment and evaluation of patient outcomes) canonly be delegated to a registered nurse.

Charge nurses need to become familiar with the practiceacts in their own states. In addition to specific guidanceabout supervision and responsibilities, nurse practice actsoutline the scope of practice of nursing team members. Priorto delegating care in a healthcare agency, key agency poli-cies such as the assignment of nursing care and administra-tion of medications should be reviewed. Healthcareagencies also have position descriptions for each role thatprovide guidance for charge nurses about the expectedcompetencies and role responsibilities of team members.Charge nurses are then ready to begin the delegation andsupervision process which should include the followingsteps and reflective questions (NCSBN, 2005):

Step One – Assessment and Planning Goal – the Right Task, Under the Right Circumstances to

the Right Person

• What are the needs and condition of the patient?• What level of clinical decision making and assess-

ment is needed?• What is the predictability of the patient’s response

to care?• What is the potential for adverse outcomes associated

with the performance of tasks and functions?• What are the cognitive and technical abilities needed

to perform the activity/function/task?• Which team member has the scope of practice, skills,

competencies and experience to perform the tasksneeded?

• What is the context of the situation and the environ-ment — was the patient just admitted or did theyhave recent surgery, is it a high acuity environmentsuch as an intensive care unit or ER?

• What level of interaction/communication is needed inthe care of the patient and with whom?

Step Two – CommunicationGoal – the Right Direction

• How is the task to be accomplished?• When and what information is to be reported?• What is the process for seeking clarification about del-

egated care?• What are the communication expectations in emer-

gency situations?

Step Three – Supervision and SurveillanceGoal – the Right Supervision

• What level of supervision and observation does thecharge nurse need to provide?

• What will be the frequency of monitoring and observ-ing care?

• How will the completion of care be verified and documented?

• How will unexpected changes in a patient’s conditionbe managed?

Step Four – Observation and FeedbackGoal – Assessment of the Effectiveness of Delegation

• Was the delegation successful?• Is there a better way to meet the needs of the patient?• Is there a need to adjust the plan of care?• Were there learning moments for staff or charge

nurse?


• Was appropriate feedback and follow-up provided bythe charge nurse?

• Was positive feedback given when appropriate by thecharge nurse?

In their discussion of the qualities of an effective chargenurse, Leary and Allen (2006) have noted that there is bothan art and science to delegation. The science of delegationinvolves understanding licensure responsibilities from alegal standpoint and the policies of agencies where nurseswork.The art of delegation involves effective communicationwith members of the health care team.

Communicating Effectively Charge nurses engage in both horizontal and vertical

communication at the unit level. They are seen as the piv-otal point person, or ‘go to’ person. They must master the artof assertive and persuasive communication, as well asdevelop negotiation and listening skills. Conversations maybe initiated by staff, patients, families, physicians, hospitalleadership, or by the charge nurses themselves. Informationis gathered and processed. Communication outcomes oftenresult in changes in patient treatments plans, transfers toother levels of care, or in facilitating interdisciplinary com-munication with physicians or other departments. The suc-cess of the charge nurse’s communication efforts is oftenreflected in staff, patient, and physician satisfaction scores.They are frequently the first stop for any complaint. Chargenurses must also be familiar with the unique communicationissues, styles, and preferences related to gender, generation,and cultural dynamics. Additionally, charge nurses mustovercome the many distractions which create barriers tocommunication that prevent them from advocating effec-tively on behalf of the patients and staff.

Effective communication is essential for the reduction ofmedical errors and promotion of safety practices. Structuredtechniques which permit assertive clarification of team com-munication and avoidance of errors can be promoted androle modeled by the charge nurse. Strategies and Tools toEnhance Performance and Patient Safety (TeamSTEPPS) isan evidence-based communication model that has beendeveloped for use in clinical practice with funding from theAgency for Healthcare Research and Quality. Tools in themodel include the Two-Challenge Rule, Call-Outs, andCheck-Backs (AHRQ).

• The Two-Challenge Rule requires the communicatorto voice their concern at least twice to receiveacknowledgment by the receiver. This rule may beinvoked when a member of the healthcare team sug-gests or performs an intervention that deviates fromthe standard of care. The charge nurse would

assertively voice their concern at least two times andif the team member who is being challenged does notacknowledge this concern, the charge nurse wouldthen take a stronger action or utilize the hospital chainof command as needed.

• Call-Outs are a strategy that the charge nurse canuse to inform all team members of crucial informationduring emergencies to assist team members in antic-ipating what comes next. For instance, during a strokealert, the results of the patient’s NIH scale and theneed to transport the patient as rapidly as possible fora CT scan may be communicated out loud to the restof the team.

• Check-Back’s require the sender of the communica-tion to verify the information that is being received bythe other team member, or to use closed-loop com-munication. For example, the charge nurse is oftenresponsible for verifying that telephone order readbacks are performed according to policy.

Some communication takes place during times of esca-lating stress, such as in a rapid response event. Here effec-tive and efficient communication is crucial for successfulpatient outcomes. Charge nurses can model and demon-strate evidenced based practice by utilizing recognizedcommunication tools such as SBAR (Situation-Background-Assessment-Recommendation) (Institute of HealthcareImprovement). Communication handoffs that promote ashared mental model regarding the patient’s unique condi-tion are essential (Haig, Sutton, & Whittington, 2006). Ashared mental model is the understanding about the currentpatient situation that is shared among the team (AHRQ). Ifthe team is communicating well, then responses to patientneeds will be quicker and deaths due to ‘failure to rescue’will be avoided. Staff nurses must be able to trust in thecharge nurses ability to assist them to respond to a suddenchange in a patient’s condition. Skilled communication atthe unit level is viewed as one measure to balance a cultureof safety with the workforce challenges that exist in the cur-rent healthcare environment (Hinshaw, 2008). When thereare communication difficulties at the unit level, it can lead tothe development of conflict between one or more teammembers.

Managing Conflict Casey Stengel, the beloved manager of many major

league baseball teams, once noted that “Finding goodplayers is easy. Getting them to play as a team is anotherstory” (Stengel). The same could be said of teams inhealthcare settings. Communication breakdowns and con-flict are inevitable on teams. The results of recent researchindicate that few members of healthcare teams are com-


fortable having the type of crucial conversations thatteams need to have when there is conflict or poor perform-ance (Vital Signs, 2005).

Guiding team members past their day to day problems,conflicts and communication issues to work together as ateam can be challenging for charge nurses. If conflict is man-aged effectively, it can be viewed as an opportunity for teamgrowth. The necessity of effectively managing team conflictshould be framed in terms of a patient safety issue. Rootcause analysis studies done by the Joint Commission onAccreditation of Healthcare Organizations since 1995 indi-cate that a breakdown in communication among caregiversis the top contributor to sentinel events (JCAHO, 2008).

Conflict between team members usually evolves fromdifferences in experiences, attitudes, behaviors, and workvalues. Left unresolved, conflict can cause a loss of produc-tive work time, medical errors, decreased patient satisfac-tion, and staff turnover (Manion, 2005). Open discussionwith staff about differences in attitudes and values is animportant first step. Staff may not be willing to considerother viewpoints as legitimate unless they are required toparticipate in conflict resolution.

The following steps in the conflict resolution process canbe used to help staff discuss and mediate conflict thatinvolves differences (Moss, 2005):

1. Agree to ground rules for discussion that are accept-able to all parties.

2. Allow each person to tell their story from their perspective.

3. Highlight an overall goal that all team members value— example — providing the best care possible toour patients.

4. Develop interventions collaboratively and agree todisagree on points of contention.

5. Keep the lines of communication open and respectdifferences in attitudes, values and behaviors.

The charge nurse’s overall goal in the mediation of con-flict should be to help team members work more effectivelytogether to meet the needs of patients.

Building Team Synergy Charge nurses play a crucial role in the retention and

turnover of registered nurses. As team leaders, they set thetone for unit performance by creating a culture which pro-motes staff effectiveness and productivity, with the goal ofcoordinating all components of patient care. The chargenurse is at the core of everything happening on the unit.With increasing patient acuity and shortened lengths of stay,charge nurses are the essential drivers of positive patientoutcomes. In environments where staff work 12-hour shifts,

they are often the only stable force as the other team mem-bers are fluid and always changing. Whereas the staff nurseis cued in to their individual patient assignment and isolatedtasks, the charge nurse must maintain a more global sys-tems perspective. Charge nurses anticipate the need for cri-sis intervention, respond to unique individual circumstances,maintain quality standards, and coordinate patient care.Charge nurses can encourage team collaboration and pro-mote the use of interdisciplinary patient rounds. More effec-tive teamwork and coordinated patient handoffs are criticalto the promotion of a safe patient care environment(Edwards, 2008; Schmalenberg & Kramer, 2009; Shortell &Singer, 2008).

The TeamSTEPPS (AHRQ) model for high functioningteams includes principles from the Crew ResourceManagement Model (CRM) which originated in the aviationindustry (Kosnik, Brown &Maund, 2007). The CRM model isdesigned to promote effective team management with agoal of addressing errors in ‘dynamic environments’ thatcould be caused by ineffective communication in interde-pendent processes. The charge nurse role is uniquely posi-tioned to guide the team in the use of these strategies. Inhealthcare, the entire team is responsible for the patient.Charge nurses are at the front lines of patient care, andremain accessible to the staff while facilitating and oversee-ing the multitude of human interactions which take place ina typical patient care day. As a result, they can providestrong team leadership. This is essential to inspire a clear,shared vision, and to build the necessary trust and confi-dence necessary to optimize patient and productivity out-comes. Team members who clearly understand their rolesand responsibilities can then be proactive, rather than reac-tive. Effective charge nurses actually create the climate thatallows teamwork to happen.

The TeamSTEPPS model emphasizes that the chargenurse, as the team leader, must remain both situationallyaware and cognizant of the current conditions which may beimpacting the work of the team (AHRQ). Briefings areencouraged at the beginning of the shift to plan for patientcare, huddles can occur on an as needed basis to problemsolve, and timely conflict resolution is recommended. Teammembers can then assist each other with tasks and provideeffective feedback. The charge nurse can then lead debriefings in order to provide crucial feedback afterintense patient events, or at the end of the shift. This processpromotes performance improvement and encourages allmembers of the team to learn and grow.

Staff members need to feel valued and essential to unitfunction. Many times nurses go without needed breaks. Ifnurses are not supported in caring for self, this leads to low


staff morale. The charge nurses can assist with seeing thatthese breaks are taken and heavy workloads are redistrib-uted. An additional stressor is when staff nurses precept ori-entees or novice nurses. When making assignments, theorientation for new staff must be adjusted for and supported.Although this type of knowledge may not have been formallydiscussed in their education or training, charge nurses mustensure that the orientation period is adjusted to meet theunique needs of each individual nurse. Leadership attributesof charge nurses should include motivating and inspiringcollaboration among team members. Every effort must bemade to ensure that adequate resources of staff, supplies,information, and feedback are present. Charge nurses alsomodel promoting the mission and vision of the organizationfor the team members. Effective leadership by chargenurses at the unit level can then create working conditionswhich empower the nurses and foster their commitment tothe organization (Spence Laschinger, Finegan, & Wilk, 2009).

Summary Charge nurses play a key role in providing leadership at

the point of care on their units. Developing the skills to effec-tively supervise and delegate, communicate, resolve conflictand build strong team synergy are important success fac-tors. The charge nurse role can be compared to air trafficcontrollers in the aviation industry. On today’s busy and oftenchaotic patient care units, patients, staff and interdiscipli-nary team members rely heavily on charge nurses for theirguidance and direction. Rising to meet this leadership chal-lenge can provide enormous professional satisfaction and atremendous leadership growth experience.

ReferencesAgency for Healthcare Research and Quality. (b). TeamSTEPPS.Retrieved July 1, 2009 from http://teamstepss.ahrq.gov

Connelly, L.M., Nabarrete, S.R., & Smith, K.K. (2003). A chargenurse workshop based on research. Journal for Nurses in StaffDevelopment, 19(4), p. 203-208.

Edwards, C. (2008). Using interdisciplinary shared governanceand patient rounds to increase patient safety. MEDSURGNursing, 17(4), 255-257.

Federwisch, A. (June 12th, 2008). Who’s in charge? RetrievedJuly 6th, 2009 from http://news.nurse.com/apps/pbcs.dll/arti-cle?AID=2008106160049

Haig, K. M., Sutton, S., & Whittington, J. (2006). National patientsafety goals. SBAR: A shared mental model for improving com-munication between clinicians. Joint Commission Journal onQuality and Patient Safety, 32(3), 167-175.

Hansten, R.I. (2008). Why nurses still must learn to delegate.Nurse Leader, 6(5), 19-25.

Hinshaw, A.D. (2008). Navigating the perfect storm: Balancing aculture of safety with workforce challenges. Nursing Research,57(1S), S4-10.Hudson, T. (2008). Delegation: Building a foundation for ourfuture nurse leaders. MEDSURG Nursing, 17(6), 396-399, 412.Institute for Healthcare Improvement. SBAR technique for com-munication: A situational briefing model. Retrieved July 1,2009 from http://www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/Tools/SBARTechniqueforCommunicationASituationalBriefingModel.htm

Joint Commission on Accreditation of Health Care Organizations(JCAHO). Root causes of sentinel events. Retrieved June 18th,2009 from http://www.jointcommission.org/SentinelEvents/Statistics/

Leary, C. & Allen, S.J. (2006). Navigating the path of leadership:12 qualities of an effective charge nurse. Nurse Leader, 4(6),22-23.Manion, J. (2005). Create a positive health care environment.Chicago: Health Forum Inc.

Moss, M.T. (2005). The emotionally intelligent nursing leader.San Francisco: Josey-Bass.

National Council State Boards of Nursing (NCSBN, 2005).Working with others: Delegation and other health care inter-faces. Retrieved June 10th from https://www.ncsbn.org/1625.htm

Schmalenberg, C. & Kramer, M. (2009). Nurse-physician rela-tionships in hospitals: 20 000 nurses tell their story. CriticalCare Nurse, 29(1), 74-83.Sherman, R.O. (2005). Don’t forget our charge nurses. NursingEconomics, (3), 125-130, 143.Shortell, S.M. & Singer, S.J. (2008). Improving patient safety bytaking systems seriously. JAMA, 299(4), 445447.Spence, Laschinger, H.K., Finegan, J., & Wild, P. (2009). Contextmatters: The impact of unit leadership and empowerment onnurses’ organizational commitment. JONA, 39(5), 228-235.Stengel, C. Brainy quotes. Retrieved June 15th, 2009 fromhttp://www.brainyquote.com/quotes/quotes/c/caseysteng384822.html

Vital SmartsTM (2005). Silence Kills: The Seven CrucialConversations® for Healthcare. Retrieved July 1, 2009 fromhttp://www.silencekills.com/Download.aspx

About the AuthorsRose Sherman is the Director of the Nursing LeadershipInstitute and an Associate Professor of Nursing on the fac-ulty of the Christine E. Lynn College of Nursing at FloridaAtlantic University.

Terry Eggenberger is an Instructor on the faculty of theChristine E. Lynn College of Nursing at Florida AtlanticUniversity where she is also completing her doctoral studieswith a research emphasis on the charge nurse role.


Healthcare organizations and providersthroughout the country are seeking to imple-ment an effective and financially efficientprocess to address conflict within the work-

place. The desire to provide staff with conflict education hasgained momentum as the connections between patientsafety and the healthy work environments are increasinglymore apparent. Adding tothe impetus are the addi-tion of the 2009 JointCommission new leader-ship standards andSentinel Event Alert #40which outlined the require-ments for such processesand education (Scott,2009). The purpose of thisarticle is to present poten-tial considerations whenselecting and evaluatingconflict training programsfor healthcare organiza-tions and providers.

Program ContentLearning to handle

conflict is a skill thatrequires knowledge andpractice to allow for max-imum integration withinthe daily communicationstyles of the participants.It is similar to learning anew clinical skill. Forexample, when nursingstudents first learn theskills of IV catheter inser-tion, they learn theanatomy and physiologyof the procedure and theparts of the equipment.Later, the students practice in a simulation lab to facili-tate the transfer of new knowledge to a more realisticsetting. With practice, the student develops proficiency.

Developing the skills of managing conflict follows asimilar process. First, one should gain the knowledge, thenpractice the new skills by integrating them in simulatedreal-life settings with skills-based training and coaching.Any course considered for conflict education shouldencompass both the content and the practice needed toembed these new skills.

The most effectiveprograms will utilize case-based scenarios whendescribing the content so that staff may be able to more easily applycontent within to theirown settings. Further, theuse of reflective exercisesas part of the training component willallow participants to practice the communica-tion skills such as listening, acknowledging,empathizing and clarify-ing. Participants shouldbe able to learn to usereflective practice skillsand scenarios that areintended to increase theirability to respond to oth-ers as well as increasetheir own self-awarenessof their own behaviors(McGuire, Inflow, 2005).

Trainers and facultyTrainers and faculty

optimally should have thenecessary knowledge ofconflict and be able toclearly identify with cur-

rent healthcare culture. Perhaps more importantly, the bestconflict programs should have trainers who are able tofacilitate and coach interactive skills-based exercises andbe able to provide meaningful feedback to the participants

Conflict Training Programs: Considerations for SelectionBy Diane E. Scott, RN, MSN


(Hoffman, Bowling, 2000). These coaches should havebeen specifically trained at role-playing, reflective practiceand other situational learning methods.

Customized approachOptimal training programs recognize the diversity of

experience of the participants as well as the context bywhich training is to be delivered (Schoenhaus, 2001).Programs should be adaptable with simulations that arestudent centered while recognizing the unique situationsand climates inherent to every organization. When assess-ing this area of a conflict program, it is important that thecurriculum demonstrate clear adaptability while maintain-ing evidence-based theories grounded in best practiceswithin the field of conflict.

Financial considerationsFor many organizations, the current economic down-

turn and future uncertain effects of healthcare reformhave presented formidable challenges for the selectionand implementation of substantive training programs.While many programs in the past would provide teambuilding and inspirational messages to providers, leadersare now more selective and are choosing training pro-grams that affect the system, not just the individual, togarnish the greatest results (Ulrich and Smallwood, 2009).In short, if the training provides measurable results at asystem level, there will be a greater return on investmentand the increase in the likelihood of financial approvalfrom senior administrators.

Logistical outreachFor long-term culture change and maximum impact,

conflict education needs to reach as many members ofan organization as possible. However, the logistics oftraining healthcare providers can be formidable. Ashealthcare organizations operate on a 24/7 basis conven-ing basic staff meetings is difficult and system-wide edu-cation can be a monumental task. In addition, theexpense of training facilities and the provision of patientcare while staff are attending programs can be cost pro-hibitive and difficult logistically.

However, when all employees hear the same messageand learn similar skills, they have a template for futureaccountabilities. Everyone will know the parameters ofacceptable behaviors, and more importantly, improvedresponses when witnessing conflict. Thus, when selectinga program for conflict management, consider programsoffered though a variety of methods to accommodate allstaff, regardless of the shift or hours in which they work.

Alternative solutions, including online education orwebinars accessible through the Internet, can presentinformation while laying the groundwork for future devel-opment or training.

Any program under consideration also should containcontinuing education credit as a value added incentive.Even if continuing education is not mandated for therenewal of a state licensure, many licensed staff requirecredits for certification and specialty degrees.

ConclusionLearning the skills of conflict engagement can provide

great short and long term benefits to the enhancement ofhealthy work environments. For programs to have signifi-cant impact they must contain specific content and evi-dence-based training practice for healthcare providers toenhance their new skills. Faculty should be trained inreflective practice and dispute resolution and be clearlyaware of the current types of experiences present withinthe specific organization. System-level conflict coursescan provide the template for safer, more effective patientcare and improve work environments for the people whocare for them.

About the AuthorDiane E. Scott, RN, MSN is a Program Director for theCenter for American Nurses. She can be reached [email protected]

ReferencesHoffman, D. and Bowling, D. (2000). Bringing peace into theroom: The personal qualities of the mediator and their impacton the mediation. Negotiation Journal, 16(1), 5-12.McGuire, A and Inflow, L. (2005). Interactive reflections as acreative teaching strategy. Conflict Resolution Quarterly, 22(3),365- 367.Schoenhaus, R. (2001). Pieceworks No. 36. ConflictManagement Training: Advancing Best Practices, United StatesInstitute for Peace.Scott, D. (2009). Addressing the 2009 Joint CommissionLeadership Standards. Nurses First, 2(1), 2-3.Ulrich, D. and Smallwood, N. (2009). Leadership developmentthat delivers results. Chief Learning Officer, 8(3), 32-35.


Dear Confused,

It can be disheartening when the career you’ve wantedfor as long as you can remember turns out to be lessthan satisfying. The good news is that there are many dif-ferent career choices for nurses, and with a little reflec-tion and effort on your part, the chances are high that youcan re-energize your nursing career.

First, take time to reflect on these questions:

• What have you felt most engaged in during your workas a nurse?

• What are your particular strengths?

Your responses to these questions will give you your firstclues about potential career options for you.

Next, think about other things that are important to youas you consider a career transition. Think about salaryand benefits, location, autonomy, work setting, schedule,and anything else that will impact your job satisfaction.

Armed with all of this information, you can researchpotential careers and then conduct informational inter-views with people who have positions that are interestingto you. Not only will you learn about what the job is reallylike, you’ll learn about the educational and experiencerequirements for each position.

Once you’ve completed your research, it’s time to craft atransition plan. Do you need to go back to school for anadvanced degree or specialized training? Do you need toreach out to your network to help with your search? Howwill you approach your job search?

Here are some resources that may make your transitioneasier:

• www.centerforamericannursescoaching.org/Articles_and_Resources.html

• www.nurse.com

• www.nurseconnect.com

• www.discovernursing.com

The ULTIMATE Career Guide For Nurses: PracticalStrategies for Thriving at Every State of Your Career, byDonna Cardillo, RN, M.A.

It’s not easy to make a career change, but it is possible.Good luck!

The Center for American Nurses Career Coaching Team

Dear Career Coach,

I currently work as a med-surg nurse for a large regional hospital. It’s a great place to work, but over the past fewyears, I’ve enjoyed my job less and less. Although the only career I’ve ever even considered is nursing, I’m beginningto question whether I should stay in the profession.

Confused

The path to careersatisfaction is personal.

The Center for American Nurses is proud to bring you a

coaching program designed to connect registered

nurses with professional coaches specializing in the

diverse aspects of a nursing career.

A professional coach can help you:

• Evaluate your career choices through the lens of

your strengths, values, and long-term personal and

professional goals.

• Look at the way your current choices impact your work-life balance and identify the

changes that will have the biggest impact on your personal and professional satisfaction.

• Develop more confidence, create strategies to improve your visibility and promote-ability

and give you a safe place to practice critical conversations.

• Objectively assess your leadership, communication, or conflict skills and provide you

with tools you can use immediately to increase your emotional intelligence and become more

effective both personally and professionally.

• Identify strategies to deal with a difficult situation at work.

Career and Work-Life BalanceTele-Seminars

Tele-seminars, led by members

of the Center’s coaching team,

are available. Topics range from

How to Deal with Layoffs to

Strategies for Managing

Fatigue. Program materials are

provided for each tele-seminar.

To register go to

www.CenterforAmerican

NursesCoaching.org


The Center for American Nurses’ third Annual Leadership,Education, Advocacy and Development (LEAD) Summit2009, was held June 11 through June 13 at Disney’sContemporary Resort in Orlando, Florida.

The title of the Summit, The Magic ofEngagement, initiated the theme of conflict res-olution strategies as healthcare providers weregiven the means to address and minimize con-

flict within healthcare. “The topicspresented around conflict engage-ment provided me with practical andrelevant tools that I can use in mywork”, said Carol Stevens, MS, RN,Associate Director, Academy forContinuing Education at ArizonaState University.

As a primary contributor for theCenter for American Nurses ConflictEngagement portfolio, DebraGerardi, RN, MPH, JD presented sev-eral sessions, including a pre-con-ference titled, “Skills forConflict-Competent Nurses: Movingfrom Avoidance to Engagement.”Within her sessions, she spoke ofthe nurse’s role in conflict as well asdescribing successful strategies toengage in the conversations that arecritical for healthy work environments.

Ms. Gerardi also is the primary contributor for the JointCommission Sentinel Event Alert Issue 40, Behaviors thatUndermine a Culture of Safety. During the Summit, she pre-sented the implications for healthcare providers and leadersfor this alert as well as the new leadership standards effec-tive January 2009. Specific to her content was the descrip-tion of required training for healthcare leaders needed toobtain competency in identifying and resolving conflict.

Dr. Phyllis Beck Kritek opened the plenary session withan address titled, “The Magic of Creative ConflictEngagement.” Dr. Kritek is nationally recognized for hertraining in conflict engagement skills and is a KelloggNational Leadership Fellow. In her informative session, she

discussed the contrast of relationship-based conflictengagement to existing patterns of conflict that are detri-mental to the profession of nursing.

As one of the primary national nursing organizations toaddress healthcare design and nursing, the Center forAmerican Nurses brought to this year’s LEAD Summit someof the nation’s top nursing design experts. Dr. Jan Stickler,RN, FAAN, Associate Professor of Nursing at San Diego

State University and co-editor ofHealth Environments Research andDesign (HERD), articulated ways thatnurses can participate in healthcaredesign and construction to improvetheir work environment. Her co-pre-senter, Deborah Gregory, RN, BSN,co-founder of the Nursing Institutefor Healthcare Design, discussed theinfluence of nursing on healthcaredesign as a means for healthier workenvironments for patients and thenurses who care for them.

“The LEAD Summit was the per-fect forum for nurse leaders to gaina valuable edge. If we are going totruly improve healthcare, we mustbegin with an understanding of howto improve the planning, design, andconstruction of our hospitals,” saidMary Ann Derr, RN, MBA, speaker

and national leader in the field of healthcare design andnursing. “The LEAD Summit provides insight and wisdomfrom experts who have provided patient care and designedthose environments with astute attention to detail.” Ms.Derr presented an informative session describing thenurse’s role in construction including environmental con-cerns as well as cost containments.

Others speakers at the LEAD Summit included Dr. BethUlrich, RN, EdD, FACHE, FAAN, Senior Vice President ofBusiness Analytics and Research for Versant. In heraddress, she spoke of the initiative for nurses to controland create their own positive work environments. This ini-tiative allows nurses to become engaged in ensuring safeenvironments for each other and their patients.

National Experts on Conflict and Healthcare Design Highlight LEAD Summit 2009By Diane E. Scott, RN, MSN

20092009

“The LEAD Summit was

the perfect forum for

nurse leaders to gain a

valuable edge. If we are

going to truly improve

healthcare, we must

begin with an under-

standing of how to

improve the planning,

design, and construc-

tion of our hospitals.”


During the entire LEAD Summit, attendees remarked atthe caliber of the presentations. “Given the quality and repu-tation of the speakers at previous LEAD Summits, I ampleased that we did not disappoint our attendees as ourspeakers once again provided rich and detailed informativesessions in the areas of Conflict and Healthcare Design,” saidDennis Sherrod, President of the Center for American Nurses.

Ed Suddath, Executive Director for the Maryland NursesAssociation said, “I felt that the LEAD Summit provided theattendees with valuable tools and techniques that theycould apply to their work environments.”

About the AuthorDiane E. Scott, RN, MSN, is the Program Director for theCenter for American Nurses, Conflict Engagement Programwhich offers an unprecedented approach at helping organ-izations and individuals learn the skills of successful con-flict engagement. She can be reached [email protected].

Missed the LEAD Summit or want to learn more about theCenter’s information on Conflict Engagement and otherprograms? Please visit the Center’s website at www.centerforamericannurses.org.


Debra Gerardi (left) and Phyllis Beck Kritek (right, joined by Dennis Sherrod)shared creative strategies for addressing conflict in the workplace.

20092009

The Magic of Engagement

Walt Disney World’s Magic Kingdom offered the perfect setting as nurses from across the country gathered in Orlando, Floridafor LEAD Summit 2009, The Magic of Engagement.

Leadership • Education • Advocacy • Development

“Our speakers once

again provided rich

and detailed informa-

tive sessions,” said

Dennis Sherrod,

President, Center for

American Nurses


Exploring the Magic of Creative Conflict Engagement.


Patti Digh, author of Life is a Verb helped workshop participantsto seek the magic with themselves.

American Nurses

“The topics around conflict engagement provided me

with practical and relevant tools that I can use in my

work,” said Carol Stevens, MS, RN, Associate Director

for Continuing Education Arizona State University.


Beth Ulrich, challenged participants to create healthywork environments during her session, CreatingMagic: Engaging and Being Engaged.

“I felt that the LEAD Summit provided

the attendees with valuable tools and

techniques that they could apply to

their work environments,” said Ed

Suddath, Executive Director for the

Maryland Nurses Association.

Rebecca Patton, ANA President joins Dennis Sherrodand LEAD Summit participants.


The North Carolina Nurses Association (NCNA)recently named seven nursing workplaces asHallmarks of Healthy Workplaces recipients:Randolph Hospital, Carolinas Medical Center’s

Infusion Center, Carolinas Medical Center — University’sIntensive Care/Progressive Care Unit (ICU/PCU), andCarolinas Medical Center — Mercy’s Kidney Dialysis Unit(KDU) and Surgical Intensive Care Unit (SICU). These excep-tional workplaces were recognized for creating positivework environments for registered nurses. Duke RaleighHospital and the James E. Davis Ambulatory SurgicalCenter successfully renewed their Hallmarks status. Theawards will be presented at an August 7 ceremony.

“The NCNA Hallmarks of Healthy Workplaces awardmeans a lot to our staff,” said Tremonteo Crawford,Randolph Hospital’s Chief Nurse Officer. “This award isdriven by our staff and is about our outstanding staff. It isan indication of the positive work environment that theycreate. I feel very privileged to lead nurses that take own-ership and accountability for creating a caring environmentthat extends to our patients, families, and our colleagues.I am proud of the nurses at Randolph Hospital.”

The Hallmarks of Healthy Workplaces program recog-nizes and promotes positive workplaces for nurses withinNorth Carolina and aids healthcare providers in creatingworkplaces in which communication flows freely andnurses contribute actively to facility governance. The pro-gram was created by NCNA in an effort to address thestate’s nursing shortage through recognition. Hallmarksoperates with the understanding that nurses who providecare in exceptional environments promote the highestquality of care to their consumers.

“We are delighted that Duke Raleigh Hospital has beenre-designated as a North Carolina Hallmarks of a HealthyWorkplaces Hospital,” said Rosemary Brown, DukeRaleigh’s Chief Nurse Officer. “Since our initial award in2006 we have continued to strive for a work environmentthat supports our nursing staff with the resources neces-sary so that they can provide extraordinary care. Our2009 application and on site survey confirmed that ournursing staff report high satisfaction with the organizationssupport in the areas of leadership, professional develop-ment, empowerment, safety and quality.”

The recognition program grew from a four year processthat included a literature review, focus groups on issues

related to the nursing shortage, and comparison ofHallmarks criteria with recognition criteria from otherassociations. Any workplace in which three or more regis-tered nurses are employed or volunteer is eligible to apply.This includes hospitals, units within hospitals, schools ofnursing, outpatient clinics, private practices, home healthsettings, prisons, hospices, and more.

Initial funding for the program was provided by theCenter for American Nurses, the North CarolinaFoundation for Nursing, the North Carolina Organizationof Nursing Leaders, the Nursing Spectrum-GannettFoundation, High Point Regional Health System and agrant from The Duke Endowment. The Hallmarks pro-gram is endorsed by several organizations, including theNorth Carolina Hospital Association, North CarolinaMedical Society, AARP of North Carolina, North CarolinaOrganization of Nurse Leaders, and the Association forHome & Hospice Care of North Carolina.

Hallmarks Recognition is based on three basic crite-ria: support of nursing professional development, systemsupport for nurses to provide quality service, and integra-tion of nursing into operations and governance.Applicants complete an anonymous online nurse satis-faction survey, written application, and an on-site survey.A team of three trained reviewers is assigned to eachapplicant. The team reviews orientation policies, precep-tor training manuals, meeting minutes, policies and addi-tional supporting documentation.

Previous recipients include Carolinas Medical Center’sCardiac Catheterization Lab, Carolinas Medical Center -University’s Endoscopy/Special Procedures Unit, MaternityCenter, and Surgical/Pediatrics Unit, and Duke UniversityMedical Center’s Cardiac Intensive Care Unit, DurhamRegional Hospital’s Post Anesthesia Care Unit (PACU) andEndoscopy Services Unit, FirstHealth School NurseProgram, Halifax Regional Medical Center, and theHighsmith Rainey Intensive Care Unit.

For more information, please visitwww.hallmarks.ncnurses.org or contact Ashley Tranthamat 800-626-2153 or [email protected].

About the AuthorAshley Trantham is the Director of HallmarksAdministration & Development at the North CarolinaNurses Association.

Seven NC Facilities Receive Award for Nursing Workplace ExcellenceBy Ashley Trantham

22

10 Ways of Implementing Current DesignConcepts in Your Workplace

Healthcare environments have significant effects onthe health and safety of patients and staff, efficiency ofcare, and staff effectiveness and morale (Robert WoodJohnson Foundation, 2004).

Evidence shows that a well-planned facility design canimprove the quality of care for patients, promote recruitingand retention of staff, and enhance operational efficiencyand productivity (The Center for Health Design, 2007).Improved workplaces can lead to healthier environments;this promotes the well-being and safety of healthcareworkers and patients.

Listed below are 10 ways of implementing currentdesign concepts in your workplace.

1. Become a knowledgeable change agent.• Educate yourself on current trends in design and

sustainability.• Offer open forums at which staff members and lead-

ers can voice their ideas.• Identify champions among hospital staff who are

knowledgeable and interested in design and envi-ronmental advocacy; invite them to serve on com-mittees and task forces.

2. Assemble a design steering committee.• Ensure that this committee consists of formal and

informal leaders.• Include infection control nurse specialists, physi-

cians, and representatives from all shifts.• Develop ground rules to encourage collaboration

and active participation.• Present a vision and a mission to the committee to

ensure that efforts are geared toward considerationof quality and safety.

3. Promote effective communication within thecommittee.• Focus on finding and achieving desirable outcomes.• Seek to advance collaborative relationships among

leaders and nursing colleagues.• Invite and hear all relevant perspectives.• Call upon good will and mutual respect to build a

consensus and arrive at a common understanding.

4. Develop and implement a process by whichyou and other nurses can learn about evi-dence-based design and sustainability.• Disseminate information about healthcare design

obtained from current literature and related websites.• Attend relevant conferences and semi-

nars regarding healthcare design andenvironmental sustainability.

• From the outset, include staff from otherdisciplines in the process.

• Include facilities department staff andinfection control specialists.

• Invite nurse specialists and architectsfrom architecture firms to provide edu-cational programs.

• Prior to project execution, review phasesof design and construction with anexpert in the design process. Addressoccupancy planning and move-in logis-tics, as these are often forgotten.

Nursing that Works™: Work Site Design Fact SheetBy Diane E. Scott, MSN, RN


5. Assess the workflow process.• Walk through existing operations, and create a map that

will serve as a guide to desired changes in operations.• Ensure that the processes drive the design, not

vice versa.• Address both clinical and operational processes.

6. Conduct an assessment of how planneddesign concepts are being implementedwithin your healthcare organization.• Identify priorities for change and improvement.• Develop an action plan that will allow analysis of results.• Before deciding on a design process, identify evalua-

tion criteria that can be used to assess variablesbefore and after implementation; these will provide ameans of demonstrating the success of the project.

7. Conduct site visits to healthcare organiza-tions and set up interviews with staff mem-bers who have successfully implementedsimilar design concepts.• Prior to planning a site visit, invest in learning about

best practices and evidence-based design.• Site visitation teams should include staff nurses, nursing

leaders, physicians, auxiliary staff members, adminis-trative leaders, and at least one design professional.

• Ideally, site teams should be interdisciplinary; con-sider including a patient or a family member whohas experience with the hospital.

• Include staff from all shifts.• Ask permission (ahead of time) to take pictures.• Develop a list of questions that will guide your site

visit. Include questions on process and design. Notesignage that guides a visitor’s way, visual appeal ofthe unit, noise levels, lighting, and spaces for staffand families. Assess rooms for appropriateness oflocation; note adjacencies and amount of spacedevoted to layout and function.

8. Ensure ongoing feedback and reflection.• Allow interdisciplinary team members who attended

site visits to make presentations to staff and leaderswho did not participate and to reflect on findings.

• Offer opportunities for staff and leaders to sharetheir own personal and professional stories abouthealthcare design experiences.

• Create “mock-up” rooms, in which a proposeddesign is laid out in an empty space. Lay out tape formarking walls; set up beds, gurneys, and real equip-ment; and give staff a chance to test-drive the pro-posed setup.

• Plan for realistic space and program needs—notjust for the maximum number of beds required forfuture growth. Ask finance department staff to pro-vide bed number projections.

• Develop an action plan that incorporates agreed uponconcepts and tactics, and assign responsibilities.

• Select an architect and an interior designer who areknowledgeable about evidence-based design andenvironmental sustainability.

• Candidates should be experienced with similar proj-ects, must exhibit a willingness to listen and torespond to needs, and should respect differing per-spectives; they must be able to process informationand translate it into design concepts. Candidatesshould also be knowledgeable about evidence-based design and environmental sustainability andmust work well with nurse specialists who will serveas advisors.

• Look into other healthcare organizations that haveworked on similar projects, and obtain candidatereferences from their senior leadership.

10. Communicate your findings and plans withappropriate leaders to obtain buy-in anddirection.

• Develop a one-page briefing/executive summarythat highlights what you are trying to achieve.

• Send the briefing to hospital leaders in advance, to allowample time for review before the meeting date arrives.

• Plan and coordinate a meeting with key leaders.

ReferencesWhite Papers. Designing the 21st century hospital: Environmental lead-ership, healthier patients, facilities, and communities. RetrievedSeptember 2006 from http://www.healthdesign.org/research/reports.Issue Paper #1. The impact of the environment on infections in health-care facilities. Retrieved July 2006 fromwww.healthdesign.org/research/reports.Issue Paper #2. The impact of light on outcomes in healthcare settings.Retrieved August 2006 from www.healthdesign.org/research/reports.Research Summary. The role of the physical environment in the hospi-tal of the 21st century:A once-in-a-lifetime opportunity. Retrieved June2004 from www.healthdesign.org/research/reports.Research Report. A guide to conducting healthcare facility visits.Retrieved 1994 from www.healthdesign.org/research/reports.Institute for Healthcare Improvement. (2004). Transforming care at thebedside. Cambridge, MA: Institute for Healthcare Improvement.Institute of Medicine. (2004).Work and workspace design to prevent andmitigate errors. In Keeping patients safe: Transforming the work environ-ment of nurses (Ed.A, pp. 226–285).Washington, DC: NationalAcademies Press.Also see www:rwjf.org/files/publications/other/wisdomat work.pdf.


So here’s a plan—while it’s still tax season, whynot take some time and get organized one stepfurther? Instead of just gathering up your impor-tant paperwork, make sure that you actually

have all the documents you need. The easy stuff first: find-ing your Social Security card, birth and marriage certifi-cates or divorce settlement papers. Then there are thetitles to the car and the house.

More importantly, many of us have no idea where ourHealth Care Power of Attorney is—if we even have one.

That’s because mostpeople avoid theissues that are hard-est to think about.Resolve to organizeyour important paper-work in one place.

Don’t be over-whelmed, just getstarted, and thenenjoy the peace ofmind that comes withknowing you havetaken action.

As a first step, find one place to keep your importantdocuments and make sure your family knows where it is.In a time of crisis, will your children know what insuranceyou have or what your health care wishes are? What if youwere in an automobile accident and were unable to com-municate? Have you identified the person you would liketo have making your financial or health care decisions? Orwhat if you actually died as a result of your injuries? Wouldyour family members know that you had a 401(k) withyour former employer?

Advanced planning for life’s important decisions is asnecessary as living your life. You need to make yourwishes known to the people who can carry them out if youare unable to do so. And this requires a little planning. Wealso strongly suggest that you review everything with alawyer or other expert in financial and estate planning.

Here are three basic financial documents that everyoneneeds:

• Durable Power of Attorney for Finances• Living Trust, and• Last Will and Testament

It is also important that you have health care documentscalled Advance Directives. These are:

• Health Care Proxy (also called a Durable MedicalPower of Attorney)

• Living Will

Financial Documents:1) Durable Power of Attorney for Finances is a legal

document in which you appoint another person toact on your behalf. This keeps your finances in thehands of a person you trust. If you become incapac-itated, that person has the authority to make finan-cial decisions for you. The Durable Power ofAttorney may be used immediately and is effectiveuntil you die or until you decide to revoke it. Thisperson must act in your best interests, keep accu-rate records, keep your property separate from hisor hers and avoid conflicts of interest.

2) Living Trust (not a living will) is a legal documentthat allows you, or a person you name as trustee, totransfer ownership or title to your assets into atrust, but still have control of those assets through-out your lifetime. It names those who are to receivethe assets from your trust when you die. A livingtrust allows your heirs to avoid probate.

3) Last Will and Testament is a legal document thatgives directions about where and to whom yourassets should go after you die. You name an “execu-tor” to carry out your directions as stated in the will.Consider someone in whom you have completeconfidence, who is well organized, someone whoknows you, but does not have a conflict of interest.What is considered a valid will varies from state tostate; therefore we strongly recommend that youask an attorney who specializes in estate law to atleast review your will.

Get It Together! Financial and Health Care Paperwork You Need Right NowWISERWoman

Don’t be

overwhelmed,

just get started,

and then enjoy

the peace of

mind that comes

with knowing

you have taken

action.

So how do you choose the trustee for your living

trust and the executor for your will?

Trustee. Some people name themselves as trusteeso they can manage their trust unless they becomeincapacitated or die. Or they appoint a successortrustee if they become unable or unwilling to act. Orthey appoint co-trustees. Others name an institution astrustee. If you name a trustee, remember that this per-son will have control of your assets, so choose care-fully—someone responsible and reliable. You mightdecide on a family member, a child, a business associ-ate or a financial advisor.

Executor. Your executor is the person (or institution)

you name in your will to manage your estate andcarry out your wishes after your death. An executor,unlike a trustee, is “under the supervision of the court,”and must obey the state laws.

Being named executor may or may not be consid-ered a compliment and it can be considered a burden.Consider someone in whom you have complete confi-dence, who is well organized, someone who knows you,but does not have a conflict of interest — someone whohas the personal maturity to do what has to be done. Asis the case with trustees, you can appoint co-executors.You may make a provision to pay yourexecutor.

Your executor and your trustee canbe the same person or institution.

NOTE: There are lots of people who

want to sell you their services. Be

wary of “free” estate planning semi-

nars whose business purpose is to

sell legal and financial services.

Health Care Documents —Advance Directives:

You will need two documents: a

Health Care Proxy and a Living Will.

It is advisable to have both docu-ments. The person with your Health

Care Proxy or Power of Attorney isdesignated to make decisions, based onyour instructions, if and when you are

unable to speak for yourself. While a Living Will specif-ically outlines your decisions about health care treat-ment, it does not provide a spokesperson. Together, ahealth care proxy and a living will can work to make yourhealth care wishes clear and guarantee those wishes arecarried out.

1) A Health Care Proxy, also called a Health Care

Power of Attorney or Durable Medical Power

of Attorney, is a person you appoint to makehealth care decisions for you if you are unable tomake those decisions for yourself. A health careproxy can make sure that health care providersfollow your wishes and can decide how yourwishes apply as your medical condition changes.Hospitals, doctors and other health care providersmust follow this person’s decisions as if theywere your own.

You may give this person as little or as much author-ity as you want, i.e. you may allow your proxy to make allyour health care decisions or only certain ones. Whoeverit is, be sure it is someone you trust to carry out yourwishes. You should also consider naming a proxy wholives close to you. If you are terminally ill and unable tomake decisions, your proxy might have to spend a greatdeal of time nearby to see that your wishes are followed.



2) A Living Will serves as a written declaration ofyour health care wishes when you cannot com-municate them personally. It explains your healthcare preferences and instructs your doctor aboutyour end-of-life decisions. You may say some-thing as simple as, “I prefer that all care bedirected at comfort and that life-supportive treat-ments not be used.” Or, you may want to be moreprecise and describe the medical situations inwhich you would accept or refuse medical treat-ment. For example, a do not resuscitate order(DNR) makes clear that you do not wish to havecardiopulmonary resuscitation (CPR) to restartyour heart and lungs.

(NOTE: A Living Will is not used to name a proxy. Youmust name your proxy in a separate document — seeHealth Care Proxy above.)

Writing a Living Will:

Make sure:

• The statement of your personal health care wishesis clear.

• Your name is clearly defined as the person creat-ing the Living Will.

• You have signed and dated the document.• Two witnesses sign and date the document.• The witnesses make short statements that you

signed the document willingly.• You have the Living Will notarized as a safeguard.

After preparing and signing the documents:• Make copies of the completed documents.• Keep the originals in a safe place.• Give copies to your proxy, your attorney or other

advisor, close family members, your doctor andanyone else involved in your health care.

Remember both the Health Care Proxy andLiving Will:

• Help to insure that your health care wishes are fol-lowed if you are unable to speak for yourself;

• Can be cancelled by you at any time;• Should be discussed with close friends or family

members. You may also wish to consult with a pro-fessional for assistance

Resources:

There are numerous sites online with easy to fill informs and advice. Some require payment and othersare free. You will find some examples at the following:

www.legalzoom.com

www.TheTrustguide.com

www.caringinfo.org

Volume 2, Issue 4 July/August 2009

The Agency for Healthcare Research and Quality(AHRQ)recently published a new book, Patient Safety andQuality: An Evidence-Based Handbook for Nurses. (AHRQPublication No. 08-0043). This comprehensive 1400 pagehandbook for nurses provides valuable information fornurses on patient safety and quality, evidence-based prac-tice, patient centered care, working conditions, and workenvironment for nurses. The following article is an excerptfrom Chapter 14 of this handbook. The complete book isavailable online at www.ahrq.gov/qual/nurseshdbk.

Background Most patients have families that are providing some

level of care and support. In the case of older adults andpeople with chronic disabilities of all ages, this “informalcare” can be substantial in scope, intensity, and dura-tion. Family caregiving raises safety issues in twoways that should concern nurses in all settings. First,caregivers are sometimes referred to as “secondarypatients,” who need and deserve protection and guid-ance. Research supporting this caregiver-as-clientperspective focuses on ways to protect family care-givers’ health and safety, because their caregivingdemands place them at high risk for injury andadverse events. Second, family caregivers are unpaidproviders who often need help to learn how tobecome competent, safe volunteer workers who canbetter protect their family members (i.e., the carerecipients) from harm.

This chapter summarizes patient safety and qual-ity evidence from both of these perspectives. Thefocus is on the adult caregiver who provides care andsupport primarily for adults with chronic illnesses andchronic health problems. The focus is not on thosewith developmental disabilities. In the first section, wediscuss the evidence for protecting the caregiver fromharm. The second section addresses research aimedat protecting the care recipient from an ill-preparedfamily caregiver.

Caregivers as Clients For centuries, family members have provided care

and support to each other during times of illness.What makes a family member a “family caregiver”?

Who are these family caregivers, what do they do, andwhat harm do they face? What does the research tell usabout ways to assess the needs of these hidden patientsand evidence-based interventions to prevent or reducepotential injury and harm? This section answers thesequestions and highlights the need for nurses to proactivelyapproach family caregivers as clients who need their sup-port in their own right.

Description of Caregiver Population The terms family caregiver and informal caregiver refer

to an unpaid family member, friend, or neighbor who pro-vides care to an individual who has an acute or chroniccondition and needs assistance to manage a variety oftasks, from bathing, dressing, and taking medications to

Supporting Family Caregivers in Providing Care By Susan C. Reinhard, Barbara Given, Nirvana Huhtala Petlick, Ann Bemis


tube feeding and ventilator care. Recent surveys estimatethere are 44 million caregivers over the age of 18 years(approximately one in every five adults).1 The economicvalue of their unpaid work has been estimated at $257 bil-lion in 2000 dollars.2 Most caregivers are women who han-dle time-consuming and difficult tasks like personal care.3

But at least 40 percent of caregivers are men,3 a growingtrend demonstrated by a 50 percent increase in male care-givers between 1984 and 1994.4 These male caregiversare becoming more involved in complex tasks like manag-ing finances and arranging care, as well as direct assis-tance with more personal care.5 Nurses are likely to seemany of these caregivers, although many of them will notidentify themselves as a caregiver.

Those caring for someone 50 years or older are 47years old—on average—and working at least part-time.1

If they are providing care to an elder who is 65 years orolder, they are, on average, 63 years old themselves andcaring for a spouse; one-third of these caregivers are infair to poor health themselves.6 In many cases, they arealone in this work. About two out of three older care recip-ients get help from only one unpaid caregiver.7 In the lastdecade, the proportion of older persons with disabilitieswho rely solely on family care has increased dramati-cally—nearly two-thirds of older adults who need help getno help from formal sources.4

Hazards of Caregiving Health professionals’ lack of explicit attention to care-

givers is a serious gap in health care in light of the morethan two decades of research that documents the potentialhazards of family caregiving. Caregivers are hiddenpatients themselves, with serious adverse physical andmental health consequences from their physically andemotionally demanding work as caregivers and reducedattention to their own health and health care.

Declines in physical health and premature deathamong caregivers in general have been reported.21, 25 Givenand colleagues18, 19 and Kurtz and colleagues26 found thatfamily caregivers experience significant negative physicalconsequences as the patient’s illness progresses. Elderlyspouses who experience stressful caregiving demandshave a 63 percent higher mortality rate than their noncar-egiver age-peers.21 Most recently, research documentsthat elderly husbands and wives caring for spouses whohave been hospitalized for serious illnesses face anincreased risk of dying prematurely themselves.27

Declines in caregiver health have been particularlyassociated with caregivers who perceive themselves as

burdened.21 Caregiver burden and strain have been relatedto the caregiver’s own poor health status, increasedhealth-risk behaviors (such as smoking), and higher use ofprescription drugs.28 Researchers have reported that care-givers are at risk for fatigue and sleep disturbances,29 lowerimmune functioning,30, 31 altered response to influenzashots,32 slower wound healing,33 increased insulin levelsand blood pressure,34, 35 altered lipid profiles,36 and higherrisks for cardiovascular disease.37

Caregiver burden and depressive symptoms are themost common negative outcomes of providing care for theelderly and chronically ill.20, 55, 56 Caregiver burden is definedas the negative reaction to the impact of providing care onthe caregiver’s social, occupational, and personal roles57

and appears to be a precursor to depressive symptoms.58

Whether the caregiver develops negative outcomes seemsto be directly related to the care recipient’s inability to per-form ADLs, either due to physical limitations or cognitivestatus.51 If the care recipient wanders (associated withAlzheimer’s disease) or displays unsafe behavior, the care-giver has to be alert and on call for supervision 24 hoursper day. The constant concern for managing disruptivebehaviors (such as turning on stoves, walking into thestreet, taking too many pills, yelling, screaming, or cursing)also affects the caregivers negatively.

Research Evidence: Interventions forCaregivers as Clients

The literature provides substantial evidence that care-givers are hidden patients in need of protection from phys-ical and emotional harm. Interventions directed to thefamily caregiver should serve two purposes (see EvidenceTable). First, interventions can support the caregiver asclient, directly reducing caregiver distress and the overallimpact on their health and well-being. In this interventionapproach, the caregiver is the recipient of the direct bene-fit and the patient benefits only secondarily. Second, inter-ventions can be aimed to help make the caregiver becomemore competent and confident, providing safe and effec-tive care to the patient, which can indirectly reduce care-giver distress by reducing their load or increasing theirsense of certainty and control. In this section, we focus onthe research evidence supporting caregivers as clients.

Despite the importance of information and support tohelp family caregivers, studies on interventions to increasesupport for family caregivers have lagged far behind thoseprovided for patients. A focus on the family as a part of thepatient’s therapeutic plan of care is largely absent frominterventional research and from general clinical practice


as well. Few randomized clinical trials of educational inter-ventions directed toward family caregivers have been con-ducted or published, and there is limited research to informus about skills training for caregivers to prevent backinjuries, infection, and other potential risks inherent in thecaregiver situation.

Evidence-Based Practice Implications A review of the literature found that society depends on

family caregivers to continue providing care for their lovedones, but does little to teach them how to do it and supportthem in this stressful work. At a minimum, nurses can rec-ognize and respect their efforts, assess their needs, pro-vide concrete instructions on the specific care they aregiving (e.g., medication administration, dressing changes,and similar tasks), and refer them to potential sources ofongoing help. Nursing interventions in these areas can helpreduce harm to caregivers and the patients they serve.

Respecting the Patient–Family–ProfessionalTriad

The most important practice implication of this reviewof caregiving research evidence is that nurses can mean-ingfully change the course of caregiving for both the care-giver and care recipient by respecting the role that eachhas in managing ongoing care beyond the classic bound-aries of professional patient care. For example, it is oftennot easy for the elderly patient in the hospital who is goingto need postacute care to accept the need for family help,because they view themselves as independent. Nurses canhelp shift their views of classic independence as freedomfrom functional limitations to a context of family care inwhich giving and receiving assistance does not need tostrip away autonomy.123 It is also important to understandthat burdened caregivers can successfully support theirfamily member, but these caregivers may need help to bol-ster their sense of self-esteem.124 They want to be part ofthe decisionmaking team.125

Nurses in all practice settings need to partner withpatients and their families to move from the traditionalnursing context of doing for clients in the “expert model ofservice delivery” to more mutuality in nurse-client relation-ships.126 Nurses may need to “enact more empoweringpartnering approaches” and “reframe their professionalimage, role, and values”126 to accomplish this. Listeningskills and the ability to interpret body language and verbalcommunication are essential competencies in all encoun-ters with patients and their family members.127

This model is consistent with Dalton’s theory of collab-orative decisionmaking in nursing practice triads, where

the triad comprises the client, the nurse, and the care-giver.128 In this vision of the caregiving environment, thenurse interacts with and assists not only consumers, butthe informal caregiver as well. This kind of collaborationcan increase feelings of control over health, the sense ofwell-being, and compliance with prescribed treatments.

Providing Information Nurses need to communicate effectively with clients

and caregivers to develop cost-effective plans of careand achieve positive client outcomes.129 Communicationis crucial across settings. The emergency room and hos-pital discharge planning processes, assisted living facilityadmission process, skilled nursing facility dischargeprocess, and the home health care admission and dis-charge process are all critical points of interaction wherehealth care professionals, patients, and family caregiverscan benefit from respectful, high-quality communica-tion.130 In the managed care environment, providing con-crete care information along with emotional support canhelp spouses of frail older adults better manage theircaregiving situation.118

At all points in the patient’s disease trajectory, care-givers need information to deal with the patient’s care andtreatment demands. Nurses and other health care providersshould not expect caregivers to be responsible for sortingout relevant information and applying it to the care require-ments for their family members. Research documents thatcaregivers have difficulty obtaining information from healthcare professionals, particularly physicians and nurses.131-133

Professionals should be more responsive to patients’ andfamily members’ information needs.

It is important to provide information in a clear, under-standable way through verbal, written, and electronicmethods. Caregivers want concrete information aboutmedications, tests, treatments, and resources. They alsowant time to have their questions answered. Nurses canprovide anticipatory guidance for what the caregiver canexpect.134 This kind of information can relieve caregivers’distress arising from uncertainties about their ill familymembers’ disease and treatment status and the care theymay need.135, 136 For example, teaching caregivers how tomanage pain and other symptoms benefits both the patientand the caregiver. Caregivers who report more confidencein managing symptoms report less depression, anxiety,and fatigue.137

Caregiver Assessment Given caregivers’ essential role in caring for their fam-

ily members and the hazards they face in doing so, their


needs and capacities to provide care should be carefullyassessed.138 This assessment should focus on the care-giver as both client and provider before health profession-als can assume caregivers are able to provide competentcare without harming themselves or their family member.

Assessing the home and family care situation is impor-tant in identifying risk factors for elder abuse and neglect.Heath and colleagues87 found that in-home geriatricassessments are needed to determine the risk for andoccurrence of elder care recipient mistreatment. Fulmer’sresearch86 documents the need for interdisciplinaryteams in emergency rooms to screen for elder neglect,with attention to risk factors associated with caregiver andelder vulnerability, such as the elder’s cognitive and func-tional status and depression. Health care professionalswho conduct detailed assessments of the caregiving situ-ation through separate conversations with the patient andthe caregiver are better prepared to provide guidance andcollaborate with the family to prevent abuse and neglect.

Assessing the needs of older people living in the com-munity is a prerequisite for helping caregivers findresources and adhere to a comprehensive plan of care.Outpatient geriatric evaluation and management canreduce caregiver burden, particularly for those who areless experienced caregivers.139

Linking Caregivers to Resources Caregivers need adequate resources to assure mini-

mization of risk to the patient.140 To reduce the rough cross-ing that family caregivers experience as they navigate thedischarge from hospital to home, there is a clear need todevelop referral criteria and guidelines, accurate docu-mentation, and prompt referral to continuing care profes-sionals.24 More case management programs may be usefulto help ease this transition, promote safe and effectivehospital discharges, and support caregivers in their ongo-ing, posthospital care. Nurses, preferably those trained ingerontological nursing, have a key role in case manage-ment for frail older people.141

Linking caregivers to resources throughout the diseasetrajectory is important because caregivers are oftenunaware that there are support services available to helpthem. A recent study of caregivers of people withAlzheimer’s disease found that 75 percent had unmetneeds, yet only 9 percent had used respite services andonly 11 percent had participated in support groups.142

Extending nursing care beyond the hospital boundary,nurses can help caregivers mobilize supportive resourcesin their natural network as well as formal services.143

Conclusion Family caregivers are critical partners in the plan of

care for patients with chronic illnesses. Nurses should beconcerned with several issues that affect patient safetyand quality of care as the reliance on family caregivinggrows. Improvement can be obtained through communica-tion and caregiver support to strengthen caregiver compe-tency and teach caregivers new skills that will enhancepatient safety. Previous interventions and studies haveshown improved caregiver outcomes when nurses areinvolved, but more research is needed. There is more to belearned about the effect of family caregivers on patientoutcomes and areas of concern for patient safety. Nursescontinue to play an important role in helping family care-givers become more confident and competent providers asthey engage in the health care process.

Author Affiliations Susan C. Reinhard, Ph.D., M.S.N., F.A.A.N. Professor andCo-Director, Center for State Health Policy, Rutgers, TheState University of New Jersey. E-mail: [email protected].

Barbara Given, Ph.D., R.N., F.A.A.N. Professor, MichiganState University College of Nursing. E-mail:[email protected].

Nirvana Huhtala Petlick. Research Project Assistant, Centerfor State Health Policy, Rutgers, The State University ofNew Jersey. E-mail: [email protected].

Ann Bemis, M.L.S. Research Analyst, Center for StateHealth Policy, Rutgers, The State University of New Jersey.E-mail: [email protected].

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