are mutually agreed upon, people must always be given the authority necessary to be successful.
Several times in this book, a better understanding of R+A+A is identified as a key solution to management issues uncovered in studies on nurse job satisfaction.
Clarity of Self, Role, and System
In many of the case studies you will read in this book, clinicians wishing to improve practice look at the latent variable of “clarity.” In various chapters, “clarity of self, role, and/or system” are shown to predict desirable outcomes. In order to facilitate greater understanding of those case studies, here is the “clarity of self, role and system” section of the “5Cs for Leading Lasting Change” (Felgen & Koloroutis, 2007).
Felgen and Koloroutis posit that any time courageous leaders in any roles at any level successfully challenge the status quo, five critical conditions—clarity, competence, confidence, collaboration, and commitment—are in place. What follows is a brief description of the condition and mindset of clarity:1
Clarity of Self
I am clear that I am an instrument of healing—that what I do or don't do matters. Either way, there is an impact. I am clear that I am responsible for my own growth and contribution to the team.
Clarity of Role
I know the broadest boundaries of my role and the roles of others, so I/we can optimize our individual and collective efforts for the team and the patients and families we serve.
Clarity of System
I embrace the mission, vision, and values of the organization. The operating functions behind the scenes can make or break our organization's ability to deliver the best care. Therefore, we must involve and empower first‐line staff members to shape our systems to be reliable and effective for patients, families, and teams.
It is gratifying to see, in nearly every case study in this book, how many people in organizations across the world have resonated with this idea that we have long known to be so important.
Primary Nursing
Primary Nursing is the care delivery system embedded in the Relationship‐Based Care model. In 1980, a little more than a decade after Primary Nursing's creation, Marie Manthey, one of its originators, wrote, “Primary Nursing is a delivery system for nursing at the [unit] level that facilitates professional nursing practice despite the bureaucratic nature of hospitals” (Manthey, 1980, p. 1). It was founded in the late 1960s by a group of highly committed nurses who were unsatisfied with the task‐focus of team nursing and functional nursing. Neither of those systems of care delivery gave these nurses enough time to really know their patients, and they agreed that care was lacking when the patient was seen as the “reason for the tasks” rather than a person with wants, needs, thoughts, and concerns (Wessel & Manthey, 2015). In Primary Nursing, one professional nurse oversees the care of the patient from admission to discharge in inpatient settings (Person, 2004) and is assigned to the patient upon subsequent visits in outpatient settings (Wessel & Manthey, 2015).
Past measurement of Primary Nursing has included (a) assignment of the primary patient relationship at or soon after admission, (b) assessment of the continuity of care, (c) collaboration of the nurse with interprofessional colleagues involved with the patient's care, (d) care planning with the care team, (e) patient and family satisfaction, and (f) the relationship between patient and nurse (Nelson, 2001). The importance of Primary Nursing to nurse job satisfaction has been confirmed using factor analysis of the Healthcare Environment Survey (HES) in the United States (Nelson, Persky, et al. 2015), Scotland (Nelson & Cavanagh, 2017), and Turkey (Gozum, Nelson, Yildirim, & Kavla, 2021).
Several American studies in this book show that Primary Nursing is a chief satisfier of nurses. In studies around the world, it is often the case that while the term Primary Nursing is either not well known or has a negative association for nurses, the tenets of Primary Nursing (once the barrier of the term is removed) are consistently shown to contribute to nurse job satisfaction.
Summary
While caring is a traditionally embraced construct in nursing, it will require greater evidence to advance it as a pivotal part of a new paradigm in healthcare. Frameworks of care delivery are necessary to operationalize the paradigm that caring contributes to healing, and the frameworks of care that are explained in this chapter and studied in this book hold caring for self and others as central to effective practice.
If you think of clinical competence as being the combination of relational competence and technical competence—which implies that there is no clinical competence without relational competence (Koloroutis & Trout, 2012)—you will understand more fully how important it is to measure the effect that caring, clarity, and relationships have on healthcare outcomes. As you learn about the ways in which predictive analytics are being used to improve outcomes in healthcare, notice the vital role that the context of care plays every time. It is not just the technical aspects of care that are being measured now, because it is not just the technical aspects of care that matter. Caring, clarity, and relationships matter, so we are measuring them.
There is no clinical competence without relational competence.
Note
1 1 Felgen & Koloroutis, 2007.
3 Cultivating a Better Data Process for More Relevant Operational Insight
Mary Ann Hozak
An organization's performance improvement plan has traditionally been based on data that measures a compilation of (a) demographic information, (b) prevalence of outcomes such as use of restraints or pressure injuries, and (c) percentage of policy compliance such as: How many falls? How many appointments were canceled? Were patients happy or unhappy? What percentage of the form was completed? Although helpful as a starting point for identifying and quantifying quality indicators, the only thing these scores really show us is an abundance of data points moving up or down each month. They indicate whether a specific task is being performed well or poorly, but they do little to help us understand the big picture. Since “task performance” is an inadequate measure of professional practice, we need to rethink what we are measuring and how we are measuring it.
Since “task performance” is an inadequate measure of professional practice, we need to rethink what we are measuring and how we are measuring it.
Data collection itself is challenging. How do you decide what to collect or where to collect it, and how can you be sure it is collected the same way for every audit or that every auditor is auditing the same way? Then, once it is collected, what is the best way to present the data to help communicate with others what new realities you have come to understand?
Most often, data is collected manually, with some information technology assistance, which is a very arduous process. Once collected, however, the data is not always analyzed to find and correct any collection errors and outlier information before it is distributed to people
