2.13 Community and Organization Advocacy
Ernstmeyer & Christman - Open Resources for Nursing (Open RN)
Nurses advocate for issues in their communities and their organizations.
Addressing Social Determinants of Health
Advocacy is commonly perceived as acting on behalf of a client, but it can be a much broader action than affecting a single client and their family members. Nurses advocate for building healthier communities by addressing social determinants of health (SDOH). SDOH are the conditions in the environments where people live, learn, work, and play that affect a wide range of outcomes. SDOH include health care access and quality, neighborhood and environment, social and community context, economic stability, and education access and quality. Social determinants of health (SDOH) have a major impact on people’s health, well-being, and quality of life. See Figure 10.2[1] for an illustration of SDOH.[2]
Specific examples of addressing SDOH include the following goals:
- Improving safe housing and public transportation
- Decreasing discrimination and violence
- Expanding quality education and job opportunities
- Increasing access to nutritious foods and physical activity opportunities
- Promoting clean air and clean water
- Enhancing language and literacy skills[3]
SDOH contribute to health disparities and inequities among different socioeconomic groups. For example, individuals who don’t have access to grocery stores with healthy foods are less likely to have good nutrition, increasing their risk for health conditions like heart disease, diabetes, and obesity, and potentially lowering their life expectancy relative to people who do have access to healthy foods.[4]
One of Healthy People 2030’s goals specifically relates to advocacy regarding SDOH. The goal states, “Create social, physical, and economic environments that promote attaining the full potential for health and well-being for all.” Across the United States, people and organizations at the local, state, territorial, tribal, and national levels are working hard to improve health and reduce health disparities by addressing SDOH.[5] Read more information about these advocacy efforts in the following box.
Read more about efforts addressing SDOH at Healthy People 2030.
Understanding and addressing SDOH is crucial for effective health care advocacy, as it provides a comprehensive view of the various elements that impact clients’ well-being. These determinants include economic stability, education, social and community context, health and health care access, and the neighborhood and built environment.
Organization Advocacy
Nurses advocate for organizational issues in the nursing profession and the workplace through participation in unions, collective bargaining, workplace advocacy models, and professional organizations.
Unions and Collective Bargaining
A nursing union is a type of labor union that advocates for the interest of its nurse members. According to the Bureau of Labor Statistics, 20 percent of RNs and 10 percent of LPNs/VNs in the United States are union members.[7] Nursing union goals are typically to advocate for the improvement of benefits, wages, client safety, and workplace conditions. Advocacy is accomplished by collective bargaining. Collective bargaining refers to the negotiation of wages and other conditions of employment by an organized body of employees. See Figure 10.3[8] for an image of a union worker.
Although there is no single union that represents all nurses across the country, there are several nursing unions such as the National Nurses United, SEIU United Healthcare, and The United Food and Commercial Workers International Union. The National Nurses United union is the largest nursing union in the United States and has joined with other unions across the country to address unsafe staffing. Read more about these unions in the following box.
Read more about nursing unions:
Nursing unions can provide several potential benefits to the nursing profession. They may improve job security, improve working conditions, negotiate for better pay and benefits, protect seniority, establish staffing ratios, address workplace violence and incivility, and provide a well-defined grievance process. Unionized nurses earn an average of $200-$400 more per week than nonunionized nurses. Unions assist with grievance processes for resolving disagreements between employees and management. Examples of grievances include the promotion of one employee over another who has more seniority, disputes over holiday pay, and problems related to employee discipline.[9]
However, there are also potential disadvantages of unions, such as the cost of dues (up to $90/month per nurse), difficulty in removal of incompetent nurses, mandatory strikes with no pay, the issue of seniority taking precedence over good performance, and creation of working environments that can be adversarial between management and nursing. Additionally, many nursing unions are not organized or led by nurses, causing the belief that some unions are more interested in collecting dues than in improving the work environment for nurses. Although there has been research to determine if unions are good for nurses and good for clients, the findings are not conclusive. Some studies have shown that unionized hospitals have lower mortality rates, but higher failure-to-rescue and pressure injury rates. Another study found that unionized hospitals had higher levels of job dissatisfaction but higher levels of nurse retention.[10],[11]
Workplace Advocacy Models
Nurses can advocate for improvements in the workplace via various mechanisms, such as shared governance and the ANCC Magnet Recognition Program, and by participation in professional organizations. Nurses can also seek legislative solutions for workplace problems by advocating for legislation such as whistleblower protection.[12] Whistleblower protection is further discussed in the “Policy Advocacy” section of this chapter.
Shared Governance
Shared governance refers to a shared leadership model between management and employees working together to achieve common goals. Shared governance models are believed to promote nurses’ empowerment, engagement, autonomy, accountability, and collaboration while also striving to improve client safety, quality care, and positive outcomes. This style of management encourages and empowers nurses to be part of making decisions that impact their daily work environments. When organizations utilize a shared governance model, employees feel valued and invested in the organization’s success. Nurse engagement also improves both staff and client outcomes, such as increased job satisfaction and client satisfaction.[13] Implementation of a shared governance model has led to organizational cost savings, decrease in meeting times, fewer sick days used by employees, and a decrease in staff turnover.[14] See the following box for an example of effective shared governance.
Example of Effective Shared Governance [15]
A busy telemetry unit wants to address issues with low client satisfaction scores and an increase in both central line and indwelling catheter days. A quality improvement project is instituted by a multidisciplinary team that works to communicate the project’s goals and objectives, respecting each team member’s expertise and input. The team initiates daily multidisciplinary rounding on the unit. Six months after the implementation of multidisciplinary rounding, client satisfaction scores improve, and a decrease in both central line and indwelling catheter days is noted. Multidisciplinary rounding provides a collaborative team approach, acknowledging the expertise and leadership role of each discipline with the same end goal of improving client outcomes.
Magnet Recognition Program
Nurses can advocate for their excellence in the workplace by participating in activities required for Magnet Recognition. As previously discussed in this book, the Magnet Recognition Program is an organizational credential from the American Nurses Credentialing Center (ANCC) recognizing quality client outcomes, nursing excellence, and innovations in professional nursing practice. The Magnet Recognition Program requires nursing advocacy in the areas of technology, education, policies, and process development. This advocacy is accomplished by creating unit-based practice councils who meet regularly to discuss unit policies, practices, and outcomes. Additionally, an organization-wide practice council includes a representative from each unit council and reviews organizational-wide policies and practices. Read more about the Magnet Recognition Program in the following box.
Read more about the Magnet Recognition Program.
Professional Nursing Organizations
Professional organizations provide easy access to nursing advocacy work being done across the nation and the world. There are over 100 local, state, and national organizations that advocate for the nursing profession. Professional nursing organizations may advocate for specific nursing issues in certain areas of practice, such as critical-care nursing (American Association of Critical-Care Nurses, AACN) or broader national nursing issues, such as the American Nurses Association (ANA). Professional organizations also provide opportunities for continuing education, advanced certification, and participation in political action committees. Membership in state and national organizations helps nurses stay up-to-date on current evidence-based practices and research findings.
Next: 2.14 Policy Advocacy
Media Attributions
- Healthy People 2030 SDOH Graphic Domain Labels
- Debbie_Stabenow_marches_on_Labor_Day_2017_21318919_10155403813215528_8762450224354658172_o
- “Healthy People 2030 SDOH Graphic.png” by U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion is in the Public Domain. Access for free at Health.gov Healthy people Objectives and Data/social Determinants Health ↵
- Healthy People 2030. (n.d.). Social determinants of health. U.S. Department of Health and Human Services. Health.gov Healthy People Objectives and Data/social Determinants Health ↵
- Healthy People 2030. (n.d.). Social determinants of health. U.S. Department of Health and Human Services. ↵
- Healthy People 2030. (n.d.). Social determinants of health. U.S. Department of Health and Human Services. ↵
- Healthy People 2030. (n.d.). Social determinants of health. U.S. Department of Health and Human Services. ↵
- Healthy People 2030. (n.d.). Social determinants of health. U.S. Department of Health and Human Services. ↵
- Rowland, T. (2020). The pros and cons of nursing unions [Blog]. Soliant. ↵
- “Debbie Stabenow Marches on Labor Day 2017” by Office of Debbie Stabenow is in the Public Domain ↵
- Rowland, T. (2020). The pros and cons of nursing unions [Blog]. Soliant. ↵
- Dube, A. Kaplan, E., & Thompson, O. (2016). Nurse unions and patient outcomes. ILR Review, 69(4), 803-833. ↵
- Seago, J. A., Spetz, J., Ash, M., Herrera, C., & Keane, D. (2011). Hospital RN job satisfaction and nurse unions. Journal of Nursing Administration, 41(3), 109-114. ↵
- American Nurses Association. (n.d.). Five opportunities and challenges for workforce advocacy program. Nursing World.org Practice policy advocacy ↵
- Kroning, M., & Hopkins, K. (2019). Healthcare organizations thrive with shared governance. Nursing Management, 50(5), 13-15. ↵
- Anthony, M. (2004). Shared governance models: The theory, practice, and evidence. Online Journal of Issues in Nursing, 9(1), 7. ↵
- Kroning, M., & Hopkins, K. (2019). Healthcare organizations thrive with shared governance. Nursing Management, 50(5), 13-15. ↵
Learning Objectives
- Identify roles of various health care professionals
- Explore interprofessional communication strategies
- Review team attributes that impact system outcomes
All health care providers must be prepared to work together in clinical practice with a common goal of building a safer, more effective, patient-centered health care system. The World Health Organization (WHO) defines interprofessional collaborative practice as multiple health workers from different professional backgrounds working together with patients, families, caregivers, and communities to deliver the highest quality of care (World Health Organization, 2010).
Effective teamwork and communication have been proven to reduce medical errors, promote a safety culture, and improve patient outcomes (AHRQ, 2015). The importance of effective interprofessional collaboration has become even more important as nurses advocate to reduce health disparities related to social determinants of health (SDOH). In these efforts, nurses work with people from a variety of professions, such as physicians, social workers, educators, policy makers, attorneys, faith leaders, government employees, community advocates, and community members. Nurses must be prepared to effectively collaborate interprofessionally in a variety of health care settings (National Academies of Sciences, Engineering, and Medicine, 2021).
The Interprofessional Education Collaborative (IPEC) has identified four core competencies for effective interprofessional collaborative practice. This chapter will review content related to these four core competencies and provide examples of effective teamwork in health systems.
The Interprofessional Education Collaborative (IPEC) established standard core competencies for effective interprofessional collaborative practice. The competencies guide the education and practice of health professionals with the necessary knowledge, skills, values, and attitudes to collaboratively work together in providing client care. See Table 3.2 for a description of the four IPEC core competencies (Interprofessional Education Collaborative, n.d.). Each of these competencies will be further discussed in the following sections of this chapter.
Table 3.1 IPEC Core Competencies
| Competency 1: Values/Ethics for Interprofessional Practice
Work with individuals of other professions to maintain a climate of mutual respect and shared values. |
|---|
| Competency 2: Roles/Responsibilities
Use the knowledge of one’s own role and those of other professions to appropriately assess and address the health care needs of patients and to promote and advance the health of populations. |
| Competency 3: Interprofessional Communication
Communicate with patients, families, communities, and professionals in health and other fields in a responsive and responsible manner that supports a team approach to the promotion and maintenance of health and the prevention and treatment of disease. |
| Competency 4: Teams and Teamwork
Apply relationship-building values and the principles of team dynamics to perform effectively in different team roles to plan, deliver, and evaluate patient/population-centered care and population health programs and policies that are safe, timely, efficient, effective, and equitable. |
(Interprofessional Education Collaborative, n.d.)
Next: 3.1 Roles and Responsibilities of Health Care Professionals
Measuring Outcomes
An important aspect of quality improvement is the use of measures, also referred to as metrics, to identify the level of change on specific elements of the project. The Institute for Healthcare Improvement(IHI) provides a white paper on Whole System Measures (Martin et al., 2007). The IHI white paper identifies a system of existing metrics that impact quality in a health system. These metrics are unique to each health system and should be considered as the leader selects measures for their specific project. Depending upon the scope of the project, multiple measures are utilized.
IHI identifies three types of measures that are used in for improvement efforts. They include outcomes measures, process, measures and balancing measures (IHI, n.d.).
For this textbook, we are focusing on Outcome and Process measures examples from the IHI. Process measures can be considered indicators that are measured at specific intervals of the project. Process measures are vital for success of a project as they can inform leaders of the need to change the direction throughout the project, as opposed to waiting until the end of a change project.
Process Measures (IHI, 2019)
Are the parts/steps in the system performing as planned? Are we on track in our efforts to improve the system?
- For diabetes: Percentage of patients whose hemoglobin A1c level was measured twice in the past year
- For access: Average daily clinician hours available for appointments
- For critical care: Percentage of patients with intentional rounding completed on schedule
Outcome measures are those that indicate change at the end of a specified period of time.
Outcome Measures (IHI, 2019)
How does the system impact the values of patients, their health and wellbeing? What are impacts on other stakeholders such as payers, employees, or the community?
- For diabetes: Average hemoglobin A1c level for population of patients with diabetes
- For access: Number of days to 3rd next available appointment
- For critical care: Intensive Care Unit (ICU) percent unadjusted mortality
- For medication systems: Adverse drug events per 1,000 doses
Use of existing measures is ideal so change can be tracked over a period of time. This box shares some examples of existing measures. Additional measures are described in further detail in the pages below.
Examples of Existing Measures (IHI, 2019)
- Patient/client satisfaction surveys
- Length of stay
- Adverse events
- Staff turnover rates
- Staff-to-patient ratio
- Infection rates
- Employee satisfaction surveys
Utilization Review
Health care agencies are reimbursed from Medicare, Medicaid, and private insurance based on their quality performance measures. A utilization review is an investigation of health care services performed by doctors, nurses, and other health care team members to ensure money is not wasted covering unnecessary or inefficient expenditures for proper treatment. Utilization review also allows organizations to objectively measure how their health care services and resources are being used to best meet their patients’ needs. Information from patients’ medical records is analyzed, along with patient demographics, to evaluate resource allocation, efficiency, and quality of health promotion initiatives (Institute of Medicine, 1989).
Using Informatics to Promote Quality
Utilization review relies on the collection of meaningful data from health records to determine if quality metrics are being met. Informatics refers to using information and technology to communicate, manage knowledge, mitigate error, and support decision-making (QSEN, n.d.). Informatics allows members of the health care team to share, store, and analyze health-related information. Nurses have an important role in informatics. Nursing informatics is the science and practice of integrating nursing knowledge with information and communication technologies to promote the health of people, families, and communities worldwide (AMIA, n.d.). It is a nursing specialty with certification available from the ANCC.
These are several benefits of using informatics in health care (Otokiti, 2019):
- Improvement of Patient Safety: Informatics allows for up-to-date information sharing by both the patient and members of the health care team. Using informatics can help to reduce the occurrence of medication errors, as well as monitor patient side effects and overall health status. For example, barcode scanning has reduced medication errors by ensuring the correct dose is administered to the correct patient at the correct time.
- Reduction of Delays in Care: Some health care informatics systems allow for direct communication between health care team members and patients. The ability to ask and answer questions without needing to schedule an office appointment promotes the ability for care to be delivered efficiently in a cost-effective manner.
- Reduction of Waste: The use of informatics to share information between care team members reduces waste associated with duplication of tests or exams when more than one provider is on the care team. Additionally, patients can request their records be shared with health providers from other health organizations, which reduces duplication and unnecessary spending across the nation.
- Promotion of Patient-Centered Care: Many informatics systems have “patient portal” options where the patient and/or designated personnel are able to be active participants in the care planning and health promotion processes. Informatics offers an inclusive environment for patients to communicate and share directly with their care team regardless of physical location and timing.
- Support of Quality Improvement: The continuous process of quality improvement requires the ability to collect and analyze data in a systematic and reliable manner. Using informatics provides members of the health care team a secure place to store data, as well as the ability to review in a timely manner.
Quality Indicators
The National Database of Nursing Quality Indicators (NDNQI) was developed as a national nursing database used to evaluate quality in nursing care. This database was purchased by Press Ganey in 2014. In collaboration with the American Nursing Association (ANA), the original NDNQI database established nurse-sensitive quality indicators such as these (Montalvo, 2007):
- Nursing Care Hours Per Patient Day
- Hospital-Acquired Pressure Injuries
- RN Job Satisfaction
Nurses use quality indicators to support practice changes with evidence directly related to improved patient outcomes.
Learn More
Read about current quality measures promoting clinical excellence at the Press Ganey website.
Next: 4.13 Spotlight Application
References
Agency for Healthcare Research and Quality. (2013, May). Module 4. Approaches to quality improvement. Practice facilitation handbook. https://www.ahrq.gov/ncepcr/tools/pf-handbook/mod4.html
AMIA. (n.d.). Informatics: Research and practice. https://amia.org/about-amia/why-informatics/informatics-research-and-practice
“Analyzing_FinancialData(5099605109).jpg” by Dave Dugdale is licensed under CC BY-SA 2.0
“Comparison_QI Process_Nursing Process.jpg” by Amy Tyznik, MPTC for Open RN is licensed under CC BY 4.0
Institute for Healthcare Improvement (2019) How to Improve. Retrieved March 1, 2023 from https://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementEstablishingMeasures.aspx
“informatics-1322241_1920.jpg” by mariojsantos at Pixabay.com is licensed under CC0
Institute of Medicine (US) Committee on Utilization Management by Third Parties, Gray, B. H., & Field, M. J., (Eds.). (1989). Controlling costs and changing patient care? The role of utilization management. National Academies Press. https://www.ncbi.nlm.nih.gov/books/NBK235000
Otokiti, A. (2019). Using informatics to improve healthcare quality. International Journal of Health Care Qual Assurance, 32(2), 425-430. https://doi.org/10.1108/ijhcqa-03-2018-0062
QSEN Institute. (n.d.). QSEN competencies: Quality improvement (QI). https://qsen.org/competencies/pre-licensure-ksas/#quality_improvement
Martin LA, Nelson EC, Lloyd RC, Nolan TW. Whole System Measures. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2007.
“Model_for_Improvement.jpg” by Cliffnorman is licensed under CC BY-SA 4.0 https://commons.wikimedia.org/wiki/File:Model_for_Improvement.jpg
Montalvo, I. (2007). The National Database of Nursing Quality Indicators (NDNQI). The Online Journal of Issues in Nursing, 12(3). https://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Volume122007/No3Sept07/NursingQualityIndicators.aspx
Verhagen, Merel J. MD∗; de Vos, Marit S. MD, PhD†; Smaggus, Andrew MD‡; Hamming, Jaap F. MD, PhD∗. Measuring What Matters at Morbidity and Mortality Conferences: A Scoping Review of Effectiveness Measures. Journal of Patient Safety 18(4):p e760-e768, June 2022. DOI: 10.1097/PTS.0000000000000936
Attribution
Materials in this chapter are attributed to the following sources:
"Leadership and Influencing Change in Nursing" by Joan Wagner Select content adapted for clarity and flow for RN-BSN students is licensed under CC BY 4.0
"Nursing Management and Processional Concepts" by Chippewa Valley Technical College, Modifications: Select content adapted for clarity and flow for RN-BSN students is licensed under CC BY 4.0
Next: 4.20 Quality and Evidence-Based Practice Introduction
TeamSTEPPS®
TeamSTEPPS® is an evidence-based framework used to optimize team performance across the health care system. It is a mnemonic standing for Team Strategies and Tools to Enhance Performance and Patient Safety. The Agency for Healthcare Research and Quality (AHRQ) and the Department of Defense (DoD) developed the TeamSTEPPS® framework as a national initiative to improve patient safety by improving teamwork skills and communication.[1]
Learn More
View this video about the TeamSTEPPS® framework[2]:
TeamSTEPPS® is based on establishing team structure and four teamwork skills: communication, leadership, situation monitoring, and mutual support. The components of this model are described in the following sections.
Team Structure
A nursing leader establishes team structure by assigning or identifying team members' roles and responsibilities, holding team members accountable, and including clients and families as part of the team.
Communication
Communication is the first skill of the TeamSTEPPS® framework. As previously discussed, it is defined as a “structured process by which information is clearly and accurately exchanged among team members.” All team members should use these skills to ensure accurate interprofessional communication:
- Provide brief, clear, specific, and timely information to other team members.
- Seek information from all available sources.
- Use ISBARR and handoff techniques to communicate effectively with team members.
- Use closed-loop communication to verify information is communicated, understood, and completed.
- Document appropriately to facilitate continuity of care across interprofessional team members.
Leadership
Leadership is the second skill of the TeamSTEPPS® framework. As previously discussed, it is defined as the “ability to maximize the activities of team members by ensuring that team actions are understood, changes in information are shared, and team members have the necessary resources.” An example of a nursing team leader in an inpatient setting is the charge nurse.
Effective team leaders demonstrate the following responsibilities[3]:
- Organize the team.
- Identify and articulate clear goals (i.e., share the plan).
- Assign tasks and responsibilities.
- Monitor and modify the plan and communicate changes.
- Review the team's performance and provide feedback when needed.
- Manage and allocate resources.
- Facilitate information sharing.
- Encourage team members to assist one another.
- Facilitate conflict resolution in a learning environment.
- Model effective teamwork.
Three major leadership tasks include sharing a plan, monitoring and modifying the plan according to situations that occur, and reviewing team performance. Tools to perform these tasks are discussed in the following subsections.
Sharing the Plan
Nursing team leaders identify and articulate clear goals to the team at the start of the shift during inpatient care using a “brief.” The brief is a short session to share a plan, discuss team formation, assign roles and responsibilities, establish expectations and climate, and anticipate outcomes and contingencies. See a Brief Checklist in the following box with questions based on TeamSTEPPS®.[4]
Brief Checklist
During the brief, the team should address the following questions:[5]
- Who is on the team?
- Do all members understand and agree upon goals?
- Are roles and responsibilities understood?
- What is our plan of care?
- What are staff and provider's availability throughout the shift?
- How is workload shared among team members?
- Who are the sickest clients on the unit?
- Which clients have a high fall risk or require 1:1?
- Do any clients have behavioral issues requiring consistent approaches by the team?
- What resources are available?
Monitoring and Modifying the Plan
Throughout the shift, it is often necessary for the nurse leader to modify the initial plan as patient situations change on the unit. A huddle is a brief meeting before and/or during a shift to establish situational awareness, reinforce plans already in place, and adjust the teamwork plan as needed. Read more about situational awareness in the “Situation Monitoring” subsection below.
Reviewing the Team's Performance
When a significant or emergent event occurs during a shift, such as a “code,” it is important to later review the team’s performance and reflect on lessons learned by holding a “debrief” session. A debrief is an informal information exchange session designed to improve team performance and effectiveness through reinforcement of positive behaviors and reflection on lessons learned.[6] See the following box for a Debrief Checklist.
Debrief Checklist[7]
The team should address the following questions during a debrief:
- Was communication clear?
- Were roles and responsibilities understood?
- Was situation awareness maintained?
- Was workload distribution equitable?
- Was task assistance requested or offered?
- Were errors made or avoided?
- Were resources available?
- What went well?
- What should be improved?
Situation Monitoring
Situation monitoring is the third skill of the TeamSTEPPS® framework and is defined as the “process of actively scanning and assessing situational elements to gain information or understanding, or to maintain awareness to support team functioning.” Situation monitoring refers to the process of continually scanning and assessing the situation to gain and maintain an understanding of what is going on around you. Situation awareness refers to a team member knowing what is going on around them. The team leader creates a shared mental model to ensure all team members have situation awareness and know what is going on as situations evolve. The STEP tool is used by team leaders to assist with situation monitoring.[8]
STEP
The STEP tool is a situation monitoring tool used to know what is going on with you, your patients, your team, and your environment. STEP stands for Status of the patients, Team members, Environment, and Progress toward goal. See an illustration of STEP in Figure 7.7.[9] The components of the STEP tool are described in the following box.[10]
