Contemporary Issues in Nursing Administration



Contemporary Issues in Nursing AdministrationEric C. JeanFerris State UniversityAbstractHealthcare today is arguably more complex than at any time in history and thus presents many challenges to nursing leadership. As healthcare evolves nurse administrators must respond and guide healthcare organizations to success. This paper will examine two prominent challenges faced by the nursing specialty role of nurse administrator. First, nurses are struggling to adapt to the technological requirements of caring for patients. The second challenge faced by the administrator is the challenge of guiding organizational performance. Support is provided herein to identify the context and nature for each of these challenges. This paper uses relevant theory, research, and literature to first examine these issues, and then to develop strategies to address the issues. A plan of action is put forth to promote sustainable change regarding each challenge.Contemporary Issues in Nursing AdministrationHealthcare today may be more complex than at any time in history. As healthcare evolves nursing leadership must guide healthcare organizations to accommodate these changes. This paper examines two prominent challenges faced by the nursing specialty role of nurse administrator. First, nurses are struggling to adapt to the technological requirements of caring for patients today. Healthcare information technology (HIT) is advancing rapidly and recent government actions have accelerated the pace of this change (Murphy, 2010). Nurses are now required to have skills in informatics, basic computer use, and nursing (McCartney, 2011). Although HIT brings with it the promise of evidence based practice and improved patient outcomes, nurses have been slow to adopt technology (Simpson, 2006). As healthcare leaders, administrators must put forth a plan to address this growing challenge within nursing. These technologies intended to benefit the patient are having the unintended consequence of harming the nurses.The second challenge faced by the nurse administrator is the challenge of guiding organizational performance. Just as legislation meant to improve patient outcomes and decrease costs has increased the use of HIT, it has also made managing the organization more challenging. Several of these legislative acts are identified herein. The definition of organizational performance is evolving to include a diversity of success measures. Identifying these measures and leading the organization to achieve them is a significant challenge for nurse administrators. Past attempts to measure and manage organizational performance have often given poor results having focused too heavily on financial measures (Moynihan, 2008). The challenge to nurse leaders is to manage the organization at these times of change while empowering and engaging staff in the process (Suominen et al., 2011). This paper will use relevant theory, research, and literature to first examine these issues, and then to develop strategies to address the issues. A plan of action will be put forth to promote sustainable change in each case.Nurses and TechnologyContext and Nature of ChallengeThe Health Information Technology for Economic and Clinical Health (HITECH) provision of the 2009 American Recovery and Reinvestment Act has allocated over 19.2 billion dollars to stimulate health information technology adoption (McCartney, 2011). These funds are responsible in part for a significant expansion in the use of HIT by bedside nurses. In addition to these government incentives, society at large is evolving and consumers are becoming more technologically savvy. These government actions and the general technological advance of society are causing a rapid increase in technology use by nurses (Peace, 2011). Patients now have increased access to health information and at times demand that their healthcare providers be as technologically savvy as they are. These consumers now demand that the healthcare they pay for meets the technical criteria of daily life. Nurses must now be competent in both nursing and basic informatics competencies (Hart, 2008; Peace, 2011; McCartney, 2011). HIT holds the promise of point of care evidenced based information yet many of today’s nurses lack the necessary computer and information literacy skills. Nursing as a profession has been slow to progress towards HIT. Nurses face the risk of being overwhelmed if they do not adapt to these technologies (Hart, 2008). The basic informatics skills needed by nurses include computer skills, information literacy, and information management (McCartney, 2011). In addition to the need for nursing and basic informatics competencies, nurses must also be prepared to effectively address process disruptions associated with computer use (Peace, 2011). When these process disruptions are not addressed adequately, nurses often create workarounds, bypassing necessary safety protocols. These changing requirements are occurring at a time when many in the profession are nearing retirement. Those entering the work force now have never known nursing without computers while more seasoned nurses may be longing for the days of the paper chart.Despite the potential of computer use to improve patient outcomes, various authors have shown that nurses are challenged by HIT. Nurses face both internal and external barriers to using computers (Eley, Fallon, Soar, Buikstra, & Hegney, 2008). The perception of these barriers varies according to job level and age. Many nurses have shown to have less than favorable attitudes towards HIT use. According to Zuzelo, Hansell, and Thomas (2008), nurses responses to new technologies include fear, apprehension, and uneasiness. Nurses have said they do not trust the technologies and felt less like real nurses when using them. According to Lee (2008) nurses negative experiences with computer use include, changes in work flow, decreased quality of work, and poorer relationships with patients among reasons for dissatisfaction with computer use. Processes which were previously on paper must be carefully converted to electronic format.Fowler, Sohler, and Zarillo (2009) showed that computer technologies such as barcoding can provide an important safety mechanism for patients yet the use of these devices often decreases nurse satisfaction. Nurses who work in locations which have a high degree of HIT adoption have been shown to spend more time documenting (DesRoches, Miralles, Buerhaus, Hess, & Donelan, 2011). Nurses who encounter difficulty using established HIT protocols often use work arounds as a means to bypass the computer and treat the patient (Peace, 2011). The use of HIT by nurses has been shown to induce anxiety and job dissatisfaction (Nkosi, Asah, & Pillay, 2011). These reactions have been associated with a lack of education to deal with the technology in question. Poorly designed processes may also play a role.Relevance to Nurse AdministratorsThe issue of nurses struggling with technology at a time when technology is rapidly expanding presents a major challenge for nurse administrators. Nurses represent the largest workforce in healthcare (Nkosi, Asah, & Pillay, 2011) and therefore are well positioned to impact the success or failure of HIT initiatives. With billions of dollars in government incentives associated with the successful implementation of these initiatives, nurse administrators must take the necessary steps to ensure that nurses embrace technology. Nurse administrators must foster an environment where nurses are encouraged to discuss HIT concerns and engage in problem solving (Peace, 2011). Nurses use the system and therefore should participate in the design.The relevance of this issue is supported by the American Nurses Association (ANA) Nursing Administration Scope and Standards of Practice recommendation that administrators possess knowledge of information technology, data management, organizational behavior, and change management (2009). The American Organization of Nurse Executives (AONE) has put forth guiding principles for nurse executives to leverage technology to enhance patient outcomes (2009). These guidelines recognize the constraints of HIT systems and recommend an ongoing proactive approach to facilitate HIT adoption. With billions of dollars on the line and the largest body of healthcare workers directly impacted, administrators cannot afford to ignore technology.Strategy to Create Sustainable ChangeFor nurse administrators to address this problem in a sustainable manner require a systematic approach which includes knowledge of administration, informatics, and education. It may be helpful for the administrator to possess broad basic knowledge of the systems in use or on the drawing board and the skills required to use them. Thus possessing informatics knowledge will help identify and clarify the problem. Once the problem is identified and assessment of organizational readiness may benefit the sustainability of HIT implementation (Pare, Sicotte, Poba-Nzaou, & Balouzakis, 2011). This assessment may include components of the electronic system and human readiness as well. Administrators may benefit from knowledge of theory when considering HIT initiatives.To assess organizational readiness in regards to HIT adoption, knowledge of Diffusion of Innovations Theory is an appropriate theory. Diffusion of Innovations Theory recognizes five stages of technology adoption: a) knowledge, b) persuasion, c) decision, d) implementation, and e) confirmation. In addition, the theory recognizes the following technology adopter categories: a) innovators, b) early adopters, c) early majority, d) late majority, and e) laggards (Rogers, 1995). Knowledge of the adopter categories may identify early adopters to serve as organizational champions to facilitate the change process and participate in education. Administrators may empower these early adopters by involving them in the decision making process regarding the technologies and the adoption process thus enhancing the potential success of the project (Suominen, Harkonen, Rankinen, Kuokkanen, Kukkuraien, & Doran, 2011). Knowledge of the stages of adoption may give insight into the organization’s overall level of acceptance of HIT initiatives and help further hone strategy. If an organization is experiencing difficulty adopting a previous HIT initiative it may be too early to attempt the next one.Nurses must be educated properly to be able to embrace HIT, yet nurse educators often lack technological competency themselves (Fetter, 2009). For the administrator this presents the challenge of hiring technologically competent educators or facilitating training for those who are not. Once the problem this requires skillful budgeting and allocation of resources. According to Coonan (2008) educational innovation requires administrators to recognize the needs of information age students and to partner with learning institutions to enhance HIT education. Nurses who receive additional training via an informatics immersion program have demonstrated improvements in their perception of HIT and the ability to apply these tools to patient care (Bickford et al., 2005). McCain (2008) recommends a blended learning approach to teaching nurses HIT which includes both computer based training and traditional classroom time. This approach allows students to go through self-paced computer based training and to also have the support of an educator and peers in a classroom setting.It has been shown that significant financial incentives are associated with the adoption of HIT by nurses and that nurses are struggling with these technologies for varying reasons. A plan has been set forth to address this challenge for nurse administrators. The adoption of these technologies plays a significant role in organizational sustainability. The guidance of organizational performance presents yet another challenge faced by nurse anizational PerformanceContext and Nature of ChallengeThe challenge of guiding organizational performance in healthcare has never been more complex than or as difficult as it is today. Government actions meant to increase the quality of patient care and decrease healthcare costs are impacting the role of nurse administrators daily. Legislation impacting healthcare delivery includes the 1996 Health Insurance Portability and Accountability Act (HIPPA). This legislation is well known to most healthcare providers as the one that protects patient privacy and confidentiality (HHS, 2013). HIPPA has created necessary change to protect patient rights yet these changes bring challenges. Where processes and plans were in place to protect information prior to creation of the electronic medical record these must be adapted to address digitalization of records and the quick access to information it provides.The 2009 American Recovery and Reinvestment Act has greatly accelerated the adoption of HIT (McCartney, 2011). The ultimate promise of this HIT is decreased cost, improved access to information and improved outcomes, yet these benefits are not yet fully realized. The 2010 Affordable Care Act has put significant healthcare reforms in place changing the requirements of healthcare organizations and impacting reimbursement from government and insurance providers (United States Government, 2013). Although the intentions of this legislation are to increase access to healthcare and decrease costs, this requires change and therefore brings challenge to healthcare leaders. These three key pieces of legislation among others set the stage for today’s nurse administrator. Healthcare leaders must guide the organization through a myriad of technological changes to improve patient outcomes while protecting their rights, all during major healthcare reform which is closely tied to reimbursement. This context sets the stage so that the challenge of guiding organizational performance management may be more closely examined.Modern organizations exist in a complex environment where the success of an organization may be based on more than the quality of products produced or the financial performance of the business (Kaplan & Norton, 1996). The sustainability of the organization depends on a diversity of tangible and intangible assets. As demonstrated, recent government actions are changing the factors which lead to success in healthcare and the definition of success. Healthcare organizations must meet the changing criteria for public and private reimbursement but must also meet operational costs. Historical attempts at performance management have often fallen short and resulted in the gathering of information which was not timely or structured to provide the greatest benefit to the organization (Moynihan, 2008). As companies move from the industrial age to the information age they are no longer able to blindly throw money into capital investments expecting financial returns based solely on the size of the business (Kaplan & Norton, 1996). Although financial outcomes alone may not predict the long term success of the organization, they are rated as the primary concern of healthcare executives (Erwin, 2009). Given these changes in business and the increasing government regulation of healthcare, nurse administrators are challenged to design an organization with a high degree of performance based on a holistic approach. Financial outcomes are important but the organization must also meet the needs of internal and external customers.Relevance to Nurse AdministratorsSupport for the relevance of this challenge to nurse administrators is provided within The Future of Nursing: Leading Change, Advancing Health report (IOM, 2010). The Institute of Medicine makes the key message that United States nurses become full partners in redesigning healthcare (2010). To achieve this, nurse administrators must play a key role in designing the organization and guiding performance to meet the needs of customers. This is further supported by the report recommendation that nurses are prepared to lead change to advance health (IOM, 2010). AONE has established competencies for the nurse executive. These competencies include: a) leadership, b) professionalism, c) communication and relationship management, d) knowledge of the healthcare environment, and e) business skills and principles (AONE, 2005). A mastery of each of these competencies is likely to be necessary to guide organizational performance management. To address the challenge of guiding organizational performance management an administrator must possess a diversity of competencies and an understanding of performance measurement frameworks (PMF). PMFs are one means of conducting organizational performance measurement and may also provide a template for organizational self-examination. The Balanced Scorecard (BSC) and the American Nurses Credentialing Center (ANCC), Magnet Model are two PMFs that may be used in a complimentary way. The BSC allows for both detailed examination of the company and may also be used to guide business measurement and management based on diverse indicators to enhance sustainability (Kaplan & Norton, 1996). According to the ANCC, Magnet designation is the highest recognition for organizational nursing excellence (ANCC, 2008). The American Nurse Association Scope and Standards of Practice for Nurse Administrators recognizes the Magnet Recognition Program as a framework for nursing administrative practice (ANA, 2009), however, this model may also serve as an evidenced based framework to measure performance in healthcare.For an organization to achieve Magnet designation requires the organization to meet a diversity of empirical outcomes in the areas of: a) patient, b) nurse, c) organizational, and d) consumer outcomes (ANCC, 2008). In addition to these empirical outcomes the Magnet Model includes the components of: a) transformational leadership, b) structural empowerment, c) exemplary professional practice, and d) new knowledge, innovations, and improvements. Along with these components is the underlying element of the integration of evidence based practice throughout the organization (ANCC, 2008). To apply for Magnet designation requires a rigorous organizational evaluation process that results in a comprehensive view of the company.David Norton and Robert Kaplan conducted a study in 1990 which gave birth to the Balanced Scorecard (Sharma, 2009). This framework combines financial and non-financial metrics to provide a diverse approach to measuring organizational performance. According to Kaplan and Norton (1996) the Balanced Scorecard includes the following four perspectives: a) financial, b) customer, c) internal-business process, and d) learning and growth. Detailed examination of each of these perspectives leads to the development of performance indicators which provide a complete view of organizational performance. The purpose of the BSC is to provide a framework to translate the organizational vision and strategy into measurable performance metrics (Kaplan & Norton, 1996). A key component of the Balanced Scorecard is the use of both leading indicators or performance drivers and lag indicators or outcome measures (Kaplan & Norton, 1996). By balancing performance drivers and outcome measures across the four perspectives the company can measure financial performance while also predicting future business. Strategy to Create Sustainable ChangeA strategy to guide organizational performance may begin with performing an organizational self-examination based on the Magnet Model. This will allow the organization to identify areas of strength and weakness based on and supported by evidence. The Magnet Model emphasizes quality of care (ANCC, 2008) therefore if an organization meets the requirements of Magnet designation it knows the customers are receiving an excellent product. Meeting the criteria for Magnet designation alone may not guarantee the success of the organization. To measure organizational performance a BSC may be utilized. This BSC will provide a combination of leading and lagging metrics based on the four BSC perspectives. Some performance metrics may be identified and prioritized during the Magnet evaluation process. The Magnet evaluation process and BSC are complimentary processes which together may increase the potential for organizational performance more than either process would alone.To successfully guide organizational performance, the leadership style of Transformational Leadership is well suited. Transformational Leadership is a leadership style and theory which fosters open communication and a shared well defined vision of the organization (ANA, 2009). Transformational Leadership is a Magnet component (ANCC, 2008) but may also serve as a stand-alone leadership style. When employees share the vision of the organization, this enhances the potential to achieve the vision (Forrest & Kleiner, 2011). A transformational leader can empower frontline staff to engage in the Magnet designation process to help create this shared vision. This vision would then be transformed into a strategy with measurable outcomes via the creation of the BSC. Engaging staff through decision making enhances empowerment and increases confidence regarding organizational reform (Suominen et al., 2011). A transformational leader would engage employees to determine what is important to them based on these frameworks. ConclusionThe complexity of healthcare today is increasing due in part to advancing technology and recent legislation presenting a diversity of challenges to nursing leadership. As healthcare evolves nurse administrators must respond and guide healthcare organizations to success. Two prominent challenges faced by the nursing specialty role of nurse administrator include a) nurses are struggling to adapt to HIT, and b) administrators must guide organizational performance. The context and nature for each of these challenges has been provided and supported by relevant literature. A plan of action based on research and theory is provided for each of these challenges to promote sustainable change.ReferencesAmerican Nurse’s Association. (2009). Nursing administration: Scope and standards of practice. Silver Springs, MD: .American Organization of Nurse Executives. (2009). AONE Guiding principles for the nurse executive to enhance clinical outcomes by leveraging technology. Retrieved from Organization of Nurse Executives. (2005). The AONE nurse executive competencies. Retrieved from Nurses Credentialing Center. (2008). Application manual: Magnet recognition program (2008 ed.). Silver Spring, MD.Bickford, C., Smith, K., Ball, M., Frantz, G., Pannier, T., Newbold, S., . . .Cortes-Cormerer, N. (2005). Evaluation of a nursing informatics training program shows significant changes in nurses perception of their knowledge of information technology. 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