Marshall, David R. JD, MSN, RN, NEA-BC
It is again a privilege, for the third consecutive year, to serve as the guest editor of the annual American Organization of Nurse Executives (AONE)/The Journal of Nursing Administration (JONA) research issue. The opportunity to serve as the guest editor is one of the most rewarding aspects of being an AONE board member. The vision of AONE is "shaping the future of healthcare through innovative nursing leadership," and one of AONE's core business functions is research, primarily through the AONE Institute for Nursing Leadership Research and Education.1 The commitment of AONE to the use of the best theory and data available at the time to make decisions, the definition of evidence-based management espoused by Stanford University professors Pfeffer and Sutton,2 is emphasized by its annual strategic plan and its continued investment in the AONE Institute for Nursing Leadership Research and Education.
The following organizational goals set out in the 2010-2012 AONE Strategic Plan, clarified by additional strategic objectives, provide the following areas of emphasis for AONE: Design of Future Patient Care Delivery Systems-nurse leaders are active and recognized leaders in the design, implementation, and evaluation of future patient care delivery systems that effectively leverage human, financial, and technological resources to produce high-quality, safe, patient/family-centered healthcare; Healthful Practice Environments-nurse leaders serve as initiators and influencers in creating positive, safe, healthful practice/work environments; Quality and Safety-nurse leaders are actively involved and viewed as leaders in the development of cultures within healthcare organizations in which quality and patient safety are paramount; Workforce Supply/Competency-nurse leaders are supported by AONE to enhance the competency and supply of nurses by serving as a convener for organizations, healthcare leaders, other associations, and educational partners to work collaboratively on these critical issues; Leadership-nurse leaders are valued members of executive and management teams in healthcare organizations, key in setting strategic direction for the development, implementation, and evaluation of evidence-based patient care delivery systems and healthful practice/work environments that produce high-quality, cost-effective, safe patient outcomes; and Strong and Engaged AONE Membership-nurse leaders value the benefit of AONE membership and are actively engaged in the growth and success of the organization.1
The 2010-2012 AONE Strategic Plan is supported by a foundation of resources developed by AONE for nurse leaders. These resources include the AONE Nurse Executive Competencies, an introductory guide to healthcare regulation, various guiding principles, toolkits, and positions on best practice.3 This issue of JONA presents 6 salient research articles that provide evidence that supports aspects of AONE's strategic direction and resources.
Labor and Nursing Leader Partnership to Improve the Work Environment
The article by Porter et al describes their examination of the impact of the implementation of a nursing labor management partnership (NLMP) model on nurse turnover and job satisfaction. The authors point out that the model could be implemented in a union or nonunion environment. Porter et al state that "the NLMP provides the forum for nursing leaders, both formal and informal, to work together toward shared goals, operational decision making, and team building." The findings by Porter et al provide evidence that supports the AONE Nurse Executive Competencies, in particular in the domain of communication and relationship building.4
AONE believes that leaders at all levels must be competent in communication and relationship building, among other things. Communication and relationship-building competencies include effective communication, relationship management, influence of behaviors, ability to work with diversity, shared decision making, community involvement, medical staff relationships, and academic relationships. The findings by Porter et al also provide evidence that supports the Nursing Organization Alliance (NOA) Principles and Elements of a Healthful Practice/Work Environment, particularly the elements collaborative practice culture, communication rich culture, and shared decision making at all levels.5
Interruptions Distract Nurses During Medication Administration Process
The article by Trbovich et al describes their findings from observations of registered nurses during the medication administration process in a Canadian teaching hospital outpatient chemotherapy setting. The reported observations identified the sources and timing of interruptions, including interruptions during safety-critical tasks. The authors' findings and recommendations for future research and specific interventions provide evidence that further supports the AONE 2010-2012 Strategic Plan quality and safety organizational goal and, more specifically, the strategic objective to provide resources and support to ensure that nurses have the tools needed to enhance quality and safety processes in their organizations,1 including tools that assist in the development of appropriate information technology systems and applied technology that are an essential part of patient safety, quality, and care delivery.
Entry-Level Considerations for Second-Degree Master's Graduates
Nurse executives who desire to or do employ second-degree master's graduates will find guidance in the article describing findings from interviews with second-degree master's program graduates by Moore et al. The authors discuss important factors identified by the participants in the choice of their first nursing position, for example, opportunities for growth and a perceived progressive, cutting-edge environment. They also discuss the practice strengths identified through the analysis of interviews with the participants, that is, the ability to establish relationships and strong critical thinking skills. The analysis of the topics of transition to practice concerns, what enhanced the transition to practice, and the participants' relationship with nurses and the team are also described.
Of particular interest to nurse leaders is the advice to nurse administrators gleaned from the participants. The authors' analysis showed that the second-degree master's graduates would urge nurse executives to explore the backgrounds, education, and experience of second-degree master's graduate employees, so their unique abilities to contribute may be leveraged to improve patient care and the nursing environment. The AONE Position Statement on Diversity acknowledges that diversity has many aspects, including talents, abilities, human capacity, viewpoints, perspectives, values, ideas, and practice experiences, among others.6 Two points of the AONE Position Statement on Diversity seem particularly applicable when considering application of the findings of Moore et al. The first is, "relationships are the true currency of organizations, and diversity, when valued, is treated as a strength, which can increase work productivity and minimize time-consuming disruptions." The second is, "the need to address educational pipeline issues is an urgent matter if we are to have an adequate workforce for the future." The AONE 2010-2012 Workforce Supply/Competency organizational goal is also supported by the evidence presented in this article.1
Excellent Nursing Care: It Is Not Just About the Numbers
Hickey et al report on their analysis of data compiled in existing databases on staffing, institutional characteristics, that is, Magnet® recognition, and outcomes for patients undergoing surgical repair of congenital defects in children's hospitals. The authors' discussion of findings is of particular interest; for example, they found that none of the nursing characteristics analyzed was "significantly associated with mortality, which is contrary to major adult studies." The authors also discuss their finding that ICU worked hours did not differ between Magnet® and non-Magnet® facilities, but ICU skill mix in Magnet®-recognized hospitals was significantly lower than in non-Magnet® hospitals. Hickey et al conclude that these findings support "the notion that excellent nursing care requires a constellation of factors beyond the actual numbers of nurses." The authors did not find a significant relationship of nurse staffing or skill mix to mortality and surmise that "the outcome variable of mortality may be insensitive to nursing characteristics in children's hospitals, as long as certain staffing thresholds have been achieved."
The NOA Principles and Elements of a Healthful Practice/Work Environment5 also support the conclusion that excellent nursing care requires a constellation of factors beyond the actual numbers of nurses, including a communication-rich culture; shared decision making at all levels; the presence of adequate numbers of qualified nurses; and the presence of expert, competent, credible, and visible leadership, among others.5
Making Care Safer: Implementing Fatigue Countermeasures
Scott et al describe findings from their analysis of interviews with nurses who participated in a fatigue countermeasures program for nurses (FCMPN) and managers of nurses participating in an FCMPN. Awareness, restfulness, and lifestyle control were identified as benefits by nurses participating in the FCMPN, and they identified work culture, physical environment, and emotional turmoil as challenges. Perceived ease of program implementation, employee/employer partnerships, and research engagement were identified as benefits by nurse managers, and they identified lack of support, nursing/organizational culture, and dissonance in staff levels and organizational policies as challenges. The interventions and findings presented by Scott et al provide evidence that supports the AONE 2010-2012 Strategic Plan quality and safety organizational goal.1
These findings also support the NOA Principles and Elements of a Healthful Practice/Work Environment, particularly the principle/element dealing with the presence of adequate numbers of qualified nurses. This principle/element is further clarified in the NOA Principles and Elements of a Healthful Practice/Work Environment by including the statements that the presence of adequate numbers of qualified nurses includes (a) the ability to provide quality care to meet the client/patient's needs and (b) work/home life balance.5
Nurses Identify, Interrupt, and Correct Medical Errors
Dykes et al surveyed a number of experienced, certified critical care nurses using the Recovered Medical Error Inventory, a tool developed by the authors, to determine the type, frequency, and severity of potential medical errors recovered by the respondents during a 1-year period. The results presented emphasize the significant role played by critical care nurses in preventing medical errors. On the basis of the survey results, the authors performed calculations of the potential impact in the United States, concluding that if each of the estimated 1.36 million hospital-based nurses in the United States "recovered one error a week, as did study participants, this [would translate] to 70,702,000 medical errors recovered per year!" The authors also concluded that, "since 70% of participants recovered at least one potentially lethal error per year, this [would translate] into 952,000 deaths prevented by nurses every year."
These findings support a strategic objective under AONE's Quality and Safety organizational goal to provide resources and support to ensure that nurses have the tools needed to enhance quality and safety processes in their organizations, including tools that assist in the development of appropriate information technology systems and applied technology that are an essential part of patient safety, quality, and care delivery.1 The results also support the value of nursing's contribution. Recognition of the value of nursing's contribution is an element of the NOA Principles and Elements of a Healthful Practice/Work Environment.5 The evidence provided by this article also supports the AONE Guiding Principles for the Role of the Nurse Executive in Patient Safety and its associated toolkit, the AONE Toolkit for the Role of the Nurse Executive in Patient Safety.
The role of the nurse executive in patient safety is to help lead best practices and establish the right culture across multiple disciplines within the organization. The nurse leader must have the competencies necessary to design, coordinate, and move forward patient safety principles and practices across the domains of governance, practice/patient care, education, and research. This can only be accomplished in collaboration with the interdisciplinary team of healthcare academia, solution providers, policy makers, and the community.7
The evidence supporting patient safety practice improvements and work environment enhancements presented in this issue's research articles supports many of the strategic resources developed by AONE for nurse leaders-nurse leaders in all capacities, including aspiring nurse leaders. These resources include the 2010-2012 AONE Strategic Plan, the Principles and Elements of a Healthful Practice/Work Environment, the Guiding Principles for the Role of the Nurse Executive in Patient Safety and its associated toolkit, the AONE Position Statement on Diversity, and the AONE Nurse Executive Competencies, among others. These resources developed by AONE for nurse leaders provide a solid foundation to allow nurse leaders to use the best theory and data available to make the decisions required in the context of today's complex healthcare system. AONE is dedicated to the development of additional resources and to the refinement of current resources to support nurse leaders, and the AONE 2010-2012 Strategic Plan focuses these efforts on the Design of Future Patient Care Delivery Systems, Healthful Practice Environments, Quality and Safety, Workforce Supply/Competency, Leadership, and a Strong and Engaged AONE Membership.
© 2010 Lippincott Williams & Wilkins, Inc.