Exploration of the problem identified in Code Green:
In order to empower nursing and employ change, it is necessary to have a grounded and complete understanding of issues that need to be tackled and essentially how to deal and solve such issues.
In Rosswurm and Larrabee’s paper titled “A Model for Change to Evidence-Based Practice [(EBP)],” EBM (Rosswurm & Larrabee, 1999[S1] ) they established six systematic steps to approach change in practice by employing EBP to their model for change.
The six steps are outlined below:
1. Assess need for change in practice.
2. Link problem interventions and outcomes.
3. Synthesize best evidence.
4. Design practice change.
5. Implement and evaluate change in practice.
6. Integrate and maintain change in practice.
For the first step, it is necessary for practitioners to point-out problems that need to be addressed. Rosswurm and Larrabbee have provided guides to assess if there is a requirement for adjustments or changes in current practices. One or more of the following may prompt this: “awareness of patient preferences and dissatisfaction, quality improvement data, practitioner queries, evaluation data, or new research data.
For the Code Green scenario, the issue may be approached using R&L’s proposed model for change and start by assessing the problem.
Sociologist Dana Beth Weinberg conducted a study using two Boston hospitals to show how market pressures affect the quality of nursing and the well-being of patients in an attempt to cut costs (Santora, 2005). The examination of nursing quality is in managed care. The focus of the report is on the helpless feeling of dedicated professionals in health care as short-staffing and restructuring increase burnout rates and undermines the quality of care that is able to be provided to patients. Many of the dedicated professionals showed extreme distress and their feelings of helplessness reduced some to tears (Weinberg, 2003).
The foundation for Weinberg’s Code Green report is a story of reduced patient care resulting in cost cutting measures which are common in the United States. In the 1990’s, many hospitals ran in the red and a necessary trend was set to run hospitals as a profitable business rather than a humanitarian aid station. The power of private insurance companies grew as managed care grew and reimbursement rates began to reduce. In 1997, the Balanced Budget Act restricted Medicare reimbursement. What this did was give hospitals the opportunity to make deals with the private sector to cut costs, consolidate financial burdens, restructure the running of the hospital and apply pressure to staff to generate profit before providing care (Weinberg, 2003).
These “opportunities” reduced nurse placement and exceeded the recommended patient/nurse ratio. Many of the tasks of a RN were not being fulfilled or performed by personnel with inappropriate training. The irony of these “opportunities” for hospitals was that patients were not receiving adequate care, becoming even sicker and were being discharged from hospitals before they were fully recovered because of the reimbursement cutbacks. Weinberg named this scenario Code Green . Green represented the drive for profit (money) making Code Green the signal for urgent facility failure (Weinberg, 2003).
Weinberg chose two Boston hospitals that attempted to fight off Code Green by merging. Beth Israel Hospital merged with New England Deaconess. The merge resulted in one common name for both hospitals—Beth Israel Deaconess Medical Center (BIDMC). The forming of BIDMS was an attempt to survive in a very competitive Massachusetts health care system. increasing healthcare cost, reimbursement rates, and the bargaining of private insurance with managed care. Beth Israel (BI) was a national model for nurse strength and professionalism. New England Deaconess nurses were less educated than those at BI and worked in a standardized model. The pride of Deaconess nurses was in their ability to provide quality care in the most cost-effective way (Weinberg, 2003).
How the problem came to be:
The problem that arose from the merger was a direct result in the different styles of nursing. BI nurses did not respect the Deaconess model. The BI nurses believed that standardized care offered less care than patient’s needed from nurses. At the same time Deaconess nurses felt that the BI model was wasteful and a way of nursing that the hospital could not afford. The reality of the merger was two different styles of nursing were forced to coexist under one roof (Groff, Lien, & Su, 2007). The question that arose was “What is a nurse?” There were only two possible answers and only one could be deemed correct. Was a nurse a skilled technician or a professional caregiver (Weinberg, 2003)?
The problem at BIDMC was whether the hospital was going to support nurses as advocates for patients. Obviously, from the clash of nursing styles the merger between BI and Deaconess was not an ideal match (Weinberg, 2003).
The first restructuring policy was called flex staffing. Flex staffing immediately increased the patient/nurse ratio. Along with increased patient responsibility, nurses also were required to take on more tasks to pick up the slack of resource and staff cut backs throughout the hospital. The powerful force of BI nurses was split up and nurses were separated from nursing administrators. Concern for patient safety by BI nurses was ignored and claims that the BI nurses were being resistant to the restructuring policy. Units at BIDMC became the center for turf wars amongst the nurses and surgeons resulting in a significant decrease in nurse-physician collaboration (Weinberg, 2003).
After the problems are carefully assessed, the next step proposed in the R&L model is to link the problem or “define the problem using the language of standardized classifications and link the problem with classification of interventions and outcomes.” This is necessary to stimulate understanding. Following their model, the factors that led to and characterized the problem are explored.
At the ground level, the nursing shortage created by restructuring became the example used to characterize the problem in Code Green. Weinberg explained that nurses were trying desperately to provide the most basic of care in spite of the restructuring policies. The patient’s long-term interests were often overlooked to meet the needs of all patients—the balance of patient well-being and cost-effectiveness became a daily struggle (Weinberg, 2003). The administrative priority was to weaken Beth-Israel’s nursing power, since this was identified as a necessity in the change and integration of the nursing models. One way this was accomplished was by developing a new set of rules for patient care hence changing the reporting structure of the nurses. The nurses reported to the nursing department, and in the new structure, other departments also reported to the nursing department. Power struggles occurred between physicians from both hospitals and resistance to change from the cardiologist and cardiac surgeons. The impacts of these on the nursing staff was evidenced by orders that deviated from the standard of practice, an increase in the visibility of resident and not of primary physicians in the unit, and the failure to take care of each others’ patient if a nurse required a question to be answered. The direct impact on patient care is not necessarily always negative but a delay in treatment can occur or a non-hospital protocol could be followed just to provide care by a nurse who reverts to a more familiar protocol due to lack of consistency.
Another problem identified was the lack of communication between stakeholders, physicians, nurses and patients both in decisions and plans for coordinating the merger of systems and nursing, the miscommunication between front line nurses and nursing administration. The administration believed that resistance is a self-serving action by nurses, rather than a patient advocate. Nursing concerns were viewed as obstructions to the welfare of the hospital. Nurse perception of autonomy and control over resources limited decision making of the nurses and also added to a delay in patient care.
The result of the merger was “dismantling of nursing” (Code Green) where the administration minimized the importance of nursing. The increased role of nursing assistants who had different levels of training limited the nurse’s connection on an emotional level with the patients. Part of assessing a patient is the face to face conversations that occur, getting to know the patient, and earning their trust. Primary nursing was no longer the model used but no new model was ever really implemented or enforced. Allegations made by nurses that patient care was suffering were never investigated. In-house arguments continued and decision making was viewed as a sign of power which added to conflict and resistance. Inefficient strategies and research prior to and even after the merger eventually led to a failure of the merged hospital in financial recovery.
Weinberg describes nurses as feeling powerless without a voice to fight the changes that were being forced onto them. Out of frustration nurses began to sacrifice their own well-being and to blame themselves for the decrease in quality of care. It is important to note that hospital administrators held a different view than the nurses. Although administrators denied a reduction in the quality of care patients received the reality of Code Green was that there was evidence that quality care had been affected. Evidence to support Weinberg’s claims came from survey data and patient outcome tracking. Complaints poured in to the central nursing office at BIDMC. When trying to measure the functional role of a nurse it is at times difficult because many key nursing duties take place in the mind of a nurse (Idel, Melamed, Merlob, Yahav, Hendel, & Kaplan, et al, 2003).
Administrators, family members, patients and financial consultants easily overlook the absence of actual physical evidence of what a nurse does—many of her duties are done in her head. The reality that hit the health care system with brute force was that declining care was becoming an acceptable industry practice. The crux of cost-cutting restructuring is that the main goal of restoring financial viability to the hospital often times does not happen even after the pain of restructuring and decline of patient care becomes evident. The failure of hospitals to become financially viable through restructuring created an even greater nursing shortage (Weinberg, 2003).
Code Green has compounded the premier evidences (such as problems, potential interventions, etc.) for this research work and as a result has exposed the failure of the health care system to provide adequate patient care while the priority is to make a profit. Other issues that were exposed involved nurses and the sacrifices they have made for hospitals. Nursing was and remains underpowered, underfunded and underappreciated (Mallon, 2003).
The design for change in practice including suggested possible solution(s) to improve the situation of BIDMC are found at the end of the book .
Health care executives looking for the next solution to finance management may have to accept that bigger is not always better. The oversight of the patient has been a crucial mistake by hospital executives since it has become obvious that the patient isn’t overlooking them. The failure of hospital executives to develop cost-effective health care facilities have replaced health care with what is commonly called sick-care by professionals in the field (Kjekshus, and Hagen, 2007)
Another solution to Code Green could be hiring a management company like Streamline Health. Streamline Health is the leading supplier of management tools for workflow, documents, services and operational efficiencies. Streamline Health isn’t a replacement for hospital management—it is a system of integrated tools that are taught to management. Integrated tools include automating documentation through the use of e-forms and document workflow. Technology is also incorporated in the form of optical character recognition, interoperability and portal connectivity( streamline health).
The advantage of utilizing the services of Streamline Health would be seen in the revenue cycle. Solutions would be implemented to enhance chart coding, physician order processing, pre-admission registration, signature capturing, verification of patient insurance, secondary billing, benefits processing and information processing. Streamline Health has integrated tools that will also address the needs of workflow within Human Resource and Supply Management.
Streamline Health is a possible solution for BIDMC because of its immediate access for clinicians to patient information, its process for improving acute care facilities and its ability to use technology to better serve patients and their families. Centralized documentation of current and past patient health information along with technical support will give clinicians quicker access and improve the standard of providing health care services to patients.
Another area that should be looked at is, identify the impact on stake holders, physicians, nurses and patients. Identify the reaction upon announcement of the merger, e.g. the changes in pattern of behavior, denial, dissociation, depression or acceptance (Idel, Melamed, Merlob, Yahav, Hendel, & Kaplan, 2003). Be prepared for various reactions and educate the staff on ways to deal with these emotions in order to accept the inevitable change. Teach the staff to be objective by encouraging the staff to keep a journal that records objective data and proposals for reorganization; encourage staff to record their personal thoughts and feelings; encourage staff to take care of themselves. Identify those with an increased commitment to the organization will have increased stress hence encourage self reward; set-up a support system for staff needing support during the transition phase, and in some cases beyond the transition phase. Administration should find a common ground on which staff from both hospitals can meet or agree on; and last but not the least, encourage staff to form committees for them to feel that they too play an important part in the change being made (Katz & Clemons, 1995).
Code Green brings to light the challenge of reducing high vacancy and high turnover rates at hospitals who struggle in the areas of recruitment and retention of nurses. Novice nurses begin their career with an expectation of advanced technology being readily available. Students are looking for flexibility in the nursing and believe that nursing is a way to generate it. For hospitals to attract nurses’ executives need to provide choice, flexibility and fairness. There is no greater attraction then satisfied employees.
The simplest solution to resolve the issues presented in Code Green is to allow nurses to move freely among units. Obtaining their work schedule further in advance is a simple solution(Groff, 2007). This will increase job satisfaction and work productivity. The results of these simple solutions to Code Green include removing the barriers between units. Temporary staffing issues would be handled easier, vacancy rates would decrease, Staffing agencies would help fill the need for staffing of new units at the hospital and the career of nurses would be fostered instead of impeded (Manthey, 2004).
If you were the VP for Nursing at BIDMC, what strategies would you implement to have a positive impact on the organizational environment as it affects nursing practice?
The most important strategy for increasing the quality of patient care is implementing more stringent safety solutions. The purpose of safety solutions is to redesign the care process of patients. The inevitability of human error in the area of patient care is staggering. The definition of Patient Safety Solutions is
Any system design or intervention that has demonstrated the ability to prevent or mitigate patient harm stemming from the processes of health care There are nine Patient Safety Solutions approved for dissemination by the World Alliance for Patient Safety (“Patient Safety Solutions”, 2007).
The first safety solution understands that the most common error in the dispensing of medicine is in the form of sound-alike names. A significant amount of errors occur because of the confusion of brand or generic name recognition. Similar packaging is the cause of many errors in patient safety (“Patient Safety Solutions”, 2007).
Patient identification is a continuing failure that is widespread throughout health care. Correctly identifying patients can prevent the wrong medicine being dispensed, testing errors from occurring, the wrong type of blood from being transfused, wrong procedures from occurring and babies being released to the wrong families. These first patient safety solutions are founded in communication. Communication is the third patient safety solution. Gaps in hand-over communication is critical to assuring the correct care gets to the correct patient. Communication between nurses in patient care units and amongst care teams must never breakdown if patient safety is to be ensured. Continuity in care and treatment hinges on appropriate communication between nurses (“Patient Safety Solutions”, 2007).
Cases that involve wrong procedures or site surgery are founded in lack of communication or miscommunication. The lack of preoperative standardized processes is the cause of many procedural errors. The concentration of electrolyte solutions used for injections can be dangerous to patient safety if nurses are not aware of the dangers. Part of medication accuracy is to assure that transitions of medications are error free (“Patient Safety Solutions”, 2007).
Catheters, syringes and tubing are currently designed in such a way that it is quite easy to make an error in connecting them. The error that occurs from connecting tubing, catheters and syringes is in the delivery of medication or fluids—such deliveries often cause the death of the patient (“Patient Safety Solutions”, 2007).
Strategic initiatives in the key area of patient safety are the focus of the Disclosure Guidelines created by nursing organizations. The work of nursing organizations to provide leadership and support in the form of a framework for all areas of healthcare workers is a working strategy. Patient safety is the highest priority in nursing. What is needed is to make patient safety a higher priority than money.
In other words, given the results of the merger, what could be done to write the next chapter in the history of the organization?
Nursing administrators face many challenges. The main challenge in the 21st Century is the impact of culture on medicine. The cultural impact in combination with hands-on nursing as is called for by Evidence Based Medicine (EBM) is burdening nursing leaders and makes it a challenge to practice medicine. Nursing administration is becoming nearly impossible with the combined impact of culture, education and emphasis of EBM (Rosswurm & Larrabee, 1999[S2] ).
Nurse administrators are tied down by their tactical role. There is no time for vision and futuristic thinking in nursing today. Leadership in nursing is in danger( kerfoot, 1997). It is imperative that nursing administrators shift their focus to strategic thinking that focuses on the larger picture instead of the day-to-day functions of nursing. It is necessary to have direct reports be able to carry on with the tactical while envisioning the future of their profession(Kerfoot, 1997). The relationship between nurse administrators and nurse managers needs to become interdependent. Both sides must work together to deliver efficient health care while making sure the future of nursing changes with the times. For a nurse administrator to be recognized as a leader in the medical profession, the old way of operational thinking must transition into strategic or reflective thought. The combination of action and thought is a deadly force. Action and thought will position nurse administrators to carve a better future for the nursing profession within medicine.
To regain strength in nursing administration what exactly are nurse managers doing on the job needs to be examined. How much time a nurse spends in crises management is the first question that needs answering. Nurse Managers who spend more than 15% of their time in crisis management mode needs to change the way she functions. If a nurse manager is working in crisis management mode then she is not leading.
The next question to be asked is are all the crisis the nurse administrator managing nursing related or is time spent cleaning up other departments messes. The nurse administrator works at an interdependent level with other departments in the hospital–because of this reality there is often a gray area for nurse administrators. It is easy to be caught up in a crisis situation that is not your responsibility to fix. Lack of self-discipline is the downfall of many nurse administrators.
The interdependent relationship between a nurse administrator and other departments in a hospital is interdependent as mentioned above. The nurse administrator is recognized as an intricate part of a variety of subgroups within a hospital. The nurse administrator has an effect on the subgroup just like the subgroup effects the nurse administrator. It is important to realize that a nurse administrator is not an independent state—a nurse administrator needs to function within subgroups to perform at the highest level of care giving. It is because of this interdependent relation that many nursing administration initiatives fail. For a revamping in the nursing system to occur there needs to be cooperation from all the subgroups the nurse administrator works with. Even though many nursing initiatives fail, it is still the nursing profession who is looked to as the leader in change for the health care system.
The nature of nursing itself makes it difficult for the administrators to be strategic instead of operational. There is always a patient in pain, meds to be given, vital signs to be taken and the list goes on and on. It is at the detriment of the profession, however, that nurse administrators fall short of having the self-discipline to not get caught up in the daily operational tasks. ??Years of clinical experience may make a good nurse, but it doesn’t always make for a good nurse administrator. Compounding the problem of operational thinking by nurse administrators and managers is the reality that a nurse’s function is to respond immediately to urgent situations and issues. Administrators who come up in ranks do what they know best—they manage the crisis.
The cultural impact of an organization forces the nurse administrator to manage in crisis mode. Short-term emergencies take over the leadership efforts of the nurse administrator. This is of course at the expense of the profession as a whole. Long-term direction is more important than short-term emergencies. Getting the health care system to believe this theory is the challenge of nurse administrator.
At the management level you will find many nurse administrators who have decades of clinical experience. These nurse administrators go to work and do what they do best—they handle the day-to-day operations. Instead of leading their nurse managers, the nurse administrator steps back into the role of a tactician. She becomes who she is suppose to manage. The lack of strategic focus of the nurse administrator not only hurts her subordinates it creates stress in her workload. She finds herself fulfilling all her administrative responsibilities as well as performing tactician in the daily operations of running the floor. Not every situation of the floor is a crisis that needs the managerial attention of the nurse administrator. The nurse administrator needs to stop reacting out of habit and take a very important step back and let her subordinates do their job while she watches and thinks reflectively at the situation and responds accordingly. To ensure the well-being of patients it is necessary that a crisis be handled immediately, but at the same time, the nurse administrator has a responsibility to create and adopt varying approaches to daily operations (Allen, Nelson, Netting and Cox, 2007).
Time for assessment is key to being a successful nurse administrator. The core competencies of the nursing staff need to be assessed and reassessed on a regular basis. As a nurse administrator you need to know if your staff can handle a crisis, communicate effectively and represent you when necessary. The checklist approach to assessment is not going to be an effective way to measure your bench depth (Scanlon, 2005).
The assessment of your staff will serve as a building block for your strategies and initiatives. Remember you will be using your staff as role models for the rest of the hospital. The development and measurement of competencies does not end when the crisis ends. Debriefing your staff is crucial to skill building and generating bench depth.
The current trend in nursing administration is reductionism rather than expansionism. Expansionism takes a situation and learns the factors that created the issue and opens these factors up so that a wide range of resolutions can be developed and enacted. Reductionism takes the problem and breaks it into smaller units and fixes the parts in hopes that the whole will eventually be fixed (Simons, 2006).
In nursing administration sometimes addressing a nursing issue is a lesson in futility because of the interdependent relationships with other departments in the hospital. Many times an issue appears to be a nursing issue when in actuality it is not. This is where the gray area of nursing lies. Nurse administrators need to be self-disciplined enough to not accept what is left at their door—if the issue belongs to nurses then fine fix the problem, but if the problem is really that of another department then it must be given back for that department to manage. Understanding the factors that make a problem cannot be successful if the nurse administrator is in operational thinking mode. Deciphering between nursing issues and departmental issues involves strategic thinking (Allen, Nelson, Netting and Cox, 2007).
A good nurse administrator will embrace a system approach because it makes her less likely to assume the burden of issues within the hospital that are not hers. Her ability to be disciplined in her work benefits the patient and her subordinates. A self-conscious approach to time management is a nurse administrator’s best friend. If the nurse administrator is spending more time strategizing than doing then she is managing her position correctly.
A nurse administrator creates her own work environment. What she does with the events of her day is up to her. She makes the choice daily to be an operational thinker or a strategic one. A good nurse administrator will go through her day attending to some events while ignoring others—she will talk to people about what they are doing or should be doing and make suggestions along the way. The way the nurse administrator conducts her day shapes the environment of the whole hospital.
Nurse administrators who are operational create organizational environments that are in a crisis all the time. Nurse administrators who are strategic thinkers create a reality of communication, learning and futuristic thinking.
What changes would you make?
Competent persistent action is the only way for nurses to make a real change. Above I addressed hospital management solutions, but in this section I would like to focus on how nurses can change their own careers. I believe there are five basic principles in nurse education. The responsibility of all nurses is to teach these five basic principles to the novice nurse.
Principle one is to find people to mentor you. Every nurse needs a mentor. It is not uncommon to have more than one mentor. In fact, it is rare to find just one person who has all the qualities to help you grow into your own moral clarity (Kerfoot, 1997).
The second principle is about sponsorship. Find sponsors who will help you find your way into the advanced positions you want in your career. A sponsor is different than a mentor. A sponsor has the ability to open doors for you within the nursing profession. Your sponsor will believe in you, your convictions and your ability to work in the realm of moral certainty. A sponsor will market your skills and abilities to key people in your health care organization and other organizations. Balance is important in sponsorship. You want a broad base of sponsorship within your organization and without. If you do not have this balance then you need to figure out why and rectify the situation immediately (Kerfoot, 1997).
The third principle is reciprocity. Mentoring and sponsor is not only about you—they both are a two-way street. Balance in this relationship is often a challenge. There is no entitlement in mentoring or sponsorship. Exploitive relationships are unhealthy. Reciprocity is about interdependence–it is a relationship between people that is genuine, honest and equal. What you can do for others is a question you have to answer for yourself. It is important that you figure out what you can do for your mentors, your sponsors and your health care organization (Kerfoot, 1997).
Principle four is about self-conception. Have an established mission and know just how much you are willing to invest in the plan for the future. you must always be aware of just what it is You have to offer. Determining your value is key to marketing yourself. If unsuccessful at reaching goals then you need to figure out why? This is where a mentor can help. To turn a business around and make it successful find the opportunities available to do just that. The goal is to become valuable to your heallth institution (Kerfoot, 1997).
The final principle is about caring. You genuinely need to be able to care for other people. A nurse cannot be taught compassion and caring. This may sound simple, but not everyone has the ability to genuinely care for people. These people can be found in nursing very easily—they are the ones complaining and with the negative attitude—they come to work late and are always trying to leave early—they are poison to the nursing profession. I feel the role as a successful nurse is to shine brighter than those who lack compassion and caring (Kerfoot, 1997).
An interview with the clinical director of Holisticare Hospice a Company I work for undergoing an acquisition, although not a hospital but a hospice company, has followed some of the same errors that have caused the unsuccessful merger of BIDHMC. The company which was privately owned was sold on 5 September 2008 for 7.4 million dollars to a corporate organization. The company went from a company of 125 employees to 33,000 employees. We have anticipated the corporate office coming in and taking over, which oddly has not occurred. The reactions by the staff present at the announcement on September 4, 2008 the feelings of loss are definitely something you go through. Since I belong to the middle management, I had no direct contact with the corporate office, and could not tell the staff about the way I felt, hence the lack of support, for me, was very evident. I have kept one major focus throughout this transition and this is to complete my BSN. As I think about it, I realize that there is one person that supports me as I support her, and that is my sister-in-law, who is our office manager. We tend to get together and talk after office hours, and majority of our discussion include statements like “only trust us” and “we have to stick together”. The original owner that is no longer with the company has been a major loss to the functioning of the company since he covered multiple tasks, e.g. billing, payroll and human resources. We had lax rules and the team had control of patient care and the resources needed. Notice my use of the word “team” as this is how we function regardless of our position and the roles we play. Now the changes are gradually being felt as supplies and materials are being replaced with those of less cost. Oddly there were no directions for the nursing staff on how to complete patient care and the proper forms to use. We have new federal regulated Conditions of Participation that need to be in place by January and still nothing is being done. No one from the corporate office has given us any communication, in fact no one has bothered to visit and see how we function, except for payroll for two days. (G. Zimmerman, Personal communication November 10, 2008).
This book is definitely an eye opener that if an acquisition is done improperly or is solely-based on the theory of cost and increased productivity, and patient care needs are not taken into consideration, the company will definitely not survive the stronger counterparts. After reading this book, I requested a meeting with the administrator/previous owner and expressed my concerns of all the systems and accountability not in place. I also expressed my goals in my own professional growth. I would like to put a proposal in place for this new company and present it to them as an educational opportunity. Reality wise, they have 6 other hospices spread throughout the USA, none were due to an acquisition and all are much smaller than us. I believe that the new company thought we would be better prepared to demonstrate to them how to merge the multiple systems and operations this is unfortunately not the case and may lead to a failed merger.
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[S1]R & L need to be applied to your solution model
[S2]R & L need to be applied to your solution model
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