Wednesday, April 25, 2012

Research:       Involvement of Registered Nurses in Decision-Making
Jessica McGaha Bertagnolli RN, BSN and Terilyn Dove RN, BSN
Research Question
What is the actual level of decisional involvement for nurses at targeted health system in Idaho, and what is the desired level of decisional involvement for those nurses?
Decisional Involvement is the pattern of distribution of authority for decisions and activities
that govern nursing practice policy and the practice environment.*
 * Havens, D., Vasey, J.  (2003)  Measuring Staff Nurse Decisional Involvement:  The Decisional Involvement Scale.  Journal of Nursing Administration.  33(6), 331-336.
To evaluate the actual (what nurses perceive actually occurs) vs. desired (what nurses believe should occur) level of decisional involvement of nurses at targeted health system hospitals.
Havens & Vasey developed a 21-item instrument – the Decisional Involvement  Scale (DIS) –
that compares actual and desired levels of nursing decisional involvement (2003).
Demographic items collected:
Shared Governance Involvement
Shift most often worked
Number of hours currently working
"The nursing processes in place allow me to deliver safe and quality patient care."
SAMPLE- Randomized sample of direct patient care Registered Nurses, including staff nurses, managers, designated charge nurses and clinical supervisors at the health system hospitals were invited to participate in an on-line survey.
66% (1, 020) of all direct patient care nurses were contacted by letter to invite their participation in the survey.
Data collection took place during January 2009.
Of the 1,020 RNs contacted, a total of 265 responded to the Survey (26% response rate).
Over-all staff responses indicated:
Staff should have more primary decision making responsibility and administration should have less.
Decisions should be shared more equally between staff and administration  than they currently are.
Significant differences were noted in:
Hours Worked: Those who work more than 40 hours per week feel that staff should have more decisional involvement than  those who work less hours.
Shift Worked:   Those who work day and evening shift feel that staff should have more decisional involvement than those who work night shift.
No significant differences were observed between:
The perceived level of current involvement in decision-making, and hours/shifts worked or involvement in shared governance. This finding was consistent across all sites.
Subscale analysis reflects that Direct Patient Care Nurses believe they SHOULD have more decisional involvement than they DO in all categories.
Define Decisional Involvement
Why did we do this study?
Research done on the success of hospitals that have attained Magnet status has shown that decisional involvement is a common characteristic (Manojlovich, 2007). A core component of nursing shared governance is the power of staff to make decisions that effect them, their environment and how they carry out their work.
Shared governance can be implemented to involve nurses in the decision making process, but the actual success or extent of practice is more difficult to measure. Havens and Vasey developed a 21-item instrument that compares actual and desired levels of nursing decisional involvement (2003
Havens, D., Vasey, J. (2003) Measuring staff nurse decisional involvement: The decisional involvement scale. Journal of Nursing Administration, 33(6), 331-336.
Manojlovich, M. (2007). Power and empowerment in nursing: Looking backward to inform the future. On line Journal of Issues in Nursing, 12(1). Retrieved on 12-13-2007.

Practicum-Home care hospitalizations

Practicum Report          Jessica Bertagnolli                  

Unplanned Hospitalizations, Re-hospitalizations and Emergent Care Visits
Home health care is an important part in the continuum of care that a patient receives during an episode of illness and recovery. Patients are referred to home health from various referral sources, including clinics, emergent care settings, hospitals, skilled nursing facilities and assisted living facilities. Home health care is a skilled service that is paid for by Medicare and Medicaid. The Centers for Medicare & Medicaid Services (CMS) is moving to implement Pay for Performance. This is an initiative that encourages home care to utilize valid quality measures of patient improvement data (Crossen-Sills, Toomey & Doherty, 2006). Acute care hospitalization rates is a utilization outcome that is mentioned by CMS in this initiative and an outcome measure that is now being reported and monitored via the OASIS (a mandatory reporting tool required of home care agencies by CMS to receive payment for services). Hospitalizations are stressful on the patient and family and have a significant financial impact on the health care system.
Unplanned hospitalizations and re-admissions have become more of an issue, because patients are being discharged sooner from the hospital following an acute episode, therefore are sicker and more complex. This has been driven by payer practices and the need for organizations to be profitable. Home health care can help to keep these patients out of the hospital following discharge, but need to implement strategies to reduce unplanned hospitalizations in their practices. Some strategies are front loading visits within the first 2 weeks of home care services, creating a standard of care for specific populations (i.e. disease management programs) and daily monitoring via telehealth. The identification of at risk patients is key to early intervention and care planning (Crossen-Sills, Toomey & Doherty, 2006).
Crossen-Sills, Toomey & Doherty (2006), of the Norwell Visiting Nurse Association, report their outcomes from implementation of a three-step unplanned hospitalization intervention process. The three-steps involved changing the service delivery model by standardizing visit frequencies, implementing an education and training program for staff and implementing early home telemonitoring. These efforts resulted in a 2.6% decrease in hospitalization rate in a 6 month period. Evaluating current practices and outcomes can help to identify areas of opportunity to help reduce unplanned and avoidable hospitalizations in the home care patient population.
Anderson, Hanson, DeVilder and Helms (1996) identified the need to look further into hospital readmissions of patients receiving home care services. It was identified that there was much literature and focus on hospital readmissions from the medical standpoint and acute-care perspective, but minimal information available about acute-care readmissions for home care patients. They developed the Hospital Readmission Inventory (HRI), an audit tool to gather data about the characteristics of those patients on home care services that are readmitted to the acute care setting within the first 31 days of home care service delivery.
In the pilot study, Anderson, Hanson, DeVilder and Helms (1996) audited 68 medical records from 8 home care agencies in the Midwest. They specifically looked at those referred to home care at time of discharge from a facility (acute care hospital, rehabilitation or skilled care), patients 65 years or older, had at least one skilled home care service discipline and had been readmitted to the hospital during the first 31 days of home care service. It was found that those re-hospitalized were mostly elderly females, required help to care for self, referred to home care by the hospital, average length of stay on home care services was 14 days, primary diagnosis at home health admission and hospital readmission was COPD or CHF.
Following the pilot study, Anderson, Helms, Hanson and DeVilder (1999) again looked at unplanned hospital readmissions utilizing the HRI tool. During the study, they evaluated 916 medical records from 11 Midwestern home care agencies. This time the inclusion criteria was that the patient was referred to home care from a facility (same as the pilot study from 1996), at least one home care discipline ordered and was re-hopitalized within 100 days of start of home care service. Again, they found that the patients typically readmitted were elderly females and were readmitted after an average of 18 days on home care services.
            For my leadership practicum, I evaluated 20 medical records from one home care agency. The inclusion criteria was that the patient was on home care services at some time during the month to August, 2011, had at least one emergent care visit or hospitalization during the current home care episode and had an OASIS (Outcome and Assessment Information Set, CMS) completed at the start of home care services. The patients were pulled from a report made available from SHP (Strategic Healthcare Programs, LLC). This is a real time OASIS-C data scrubbing and benchmarking software (See for more information about the program). It was found that most of the patients utilizing emergent care were elderly females, being hospitalized within the first 2 weeks of home care services and failing to utilized the home care triage system prior to emergent care (See attached Data Summary document).
Change and Effective Leadership

Effective leaders must involve those whose practice and work outcomes are being evaluated early in the change process. There are various studies that have shown management style and organizational characteristics have an effect staff satisfaction, as described by Stordeur & D’Hoore (2007). Factors which can affect nurse satisfaction are compensation and recognition, shared decision making, staff empowerment and leaderships’ communication practice.
Shared decision making practices and leaderships ability to effectively listen are important factors when considering retention and staff satisfaction (Stordeur & D’Hoore, 2007). It is important that staff perceive that management listens and responds to their concerns, contributions and needs.  According to Porter-O’Grady and Malloch (2011), there are three important elements to accountability; the right, power, and competence to decide and act. This requires the leader to provide forums for shared decision making and engaging staff to “own” their practice
Nurses want to be involved in the decision making process. One way this is achieved is through shared governance practices, where nurses can discuss issues that affect their work environment and ways to address the issues at hand. This way, those who are delivering the care, who have insight and experience about the practice, are the ones who are the change agents and have accountability for the desired action.
Havelock’s theory on change describes six parts  to the change process; building a relationship, diagnosing the problem, acquiring the relevant resources, choosing the solution, gaining acceptance and stabilization and self-renewal (Roussel, 2006). It is important to involve staff at the point of care in the beginning of this process. It is much more effective for a leader to present the problem, not the solution. In order to allow for accountability at the point of care, the staff must be able to realize the problem and have ownership in identification of the solution.
After gathering the preliminary data about emergent care visits and hospitalizations for patients on home care (HC) services, I went to the home care Nursing Practice Council. It was here that I presented the problem of hospitalizations and more importantly, avoidable hospitalizations. I spoke of the health system as a whole and how home care fits in when addressing the problem of avoidable hospitalizations as a system. I then presented some of the HC data for the month of August 2011. I offered information on trends that I found and information on specific diagnoses.
After discussing the preliminary data, I asked the council members if they saw anything that is of concern that they may be able to address in their practice. Members pointed out the data on the use of home care triage prior to emergent care (EC) visits and hospitalizations. They felt that there may be a way to better educate the patients on when and how to utilize their triage prior to going to EC. Another topic that was brought up by council members was that of identification of high risk patients for hospitalization and how to address it in the plan of care. They discussed the idea of more standardized practices of the number of visits for identified patients.
In Havelock’s change theory, the meeting with the home care practice council included the steps of building a relationship and diagnosing the problem. In presenting the data and allowing the nurses to diagnose the problem allowed me to acquire relevant resources and pursue possible solutions. In collaborating with the nurse educator, manager and director of home care I was able to identify current practices and align with the goals and vision of the department. The nurses on the practice council and the management team, all felt that better identification of high risk patients and better patient education about triage throughout the plan of care would be appropriate solutions to focus on.
Based on these meetings and information, I pursued further data collection and looked at other research that was in the literature on the topic. I gathered more data and analyzed further. I then put the information in a report and noted significant trends found.
The next steps in the change process will be to gain acceptance and stabilization, then self-renewal. My plan is to meet with the nurse educator and practice council chairperson to solidify a practice proposal to the nurses in early January. This proposal will include standardizing verbiage and consistency of education at every visit about the use of HC triage and avoidable hospitalizations. It was identified that the only hospitalized patients that utilized HC triage were those who were opened to services within two weeks of EC, which may reflect the need to re-educate throughout the HC episode. The reminding and re-educating of patients at certain intervals throughout their care may help to increase the involvement that HC can have in addressing use of EC and avoidable/unplanned hospitalization with early interventions and communication with the physician.
I think that having the nurses on the practice council take the practice change forward to the rest of the staff will help to gain acceptance and stabilization of the practice. The hospitalization and EC visit data for the month following the practice change should be analyzed utilizing the same data collection tool, to assess the impact of the effort. This will allow evaluation of the change and provide positive feedback to the nurses to help stabilize the change or will help to identify a different process to address the problem, if found that no impact was made. Feedback to those at the point of care will be important in stabilizing the change that is made and recognizing them for the work they do. 

Anderson, M., Hanson, K., DeVilder, N. & Helms, L. (1996). Hospital readmissions during   home care: a pilot study. Journal of Community Health Nursing, 13(1), 1-12.
Anderson, M., Helms, L., Hanson, K. & DeVilder, N. (1999). Unplanned hospital readmissions: A home care perspective. Nursing Research, 48(6), 299-307.
Crossen-Sills, J., Toomey, I. & Doherty, M. (2006). Strategies to reduce unplanned hospitalizations of home healthcare patients: A step by step approach. Home Healthcare Nurse, 24(6), 369-376.
Porter-O’Grady, T.  & Malloch, k. (2011). Quantum Leadership: Advancing Innovation, Transforming Health Care (3rd ed.). Jones & Bartlett Learning, LLC.
Roussel, L. (2006). Management and Leadership for Nurse Administrators (4th ed.). Jones & Bartlett Publishers, Inc.
Stordeur S. & D’Hoore W. (2007). Organizational configuration of hospitals succeeding in attracting and retaining nurses. Journal of Advanced Nursing, 57(1), 45-58.


Self-Assessment         Jessica Bertagnolli     Nurs6655    

During Nursing 6655 Advanced Leadership, there were many opportunities to learn about and discuss various aspects of leadership. During the beginning of the semester we created groups to work in and had an opportunity to tell a little about ourselves. With this being an online course, I did not know any of the members of my group prior to this class.
Reflecting back on the beginning of this semester, I think that the members of my group could have gotten to know each other a little more. I did glean information about my partners as the semester progressed as we had discussion with guest speakers and I did share information about myself that was going to affect my availability to the group during certain times (when baby was due), but we could have had more in-depth knowledge about what professional strengths each of us had to share/offer.
According to Porter-O’Grady and Malloch (2011), it is important to understand how all of the pieces fit together to make the final product. We must all have an understanding and appreciation of what the others are doing in order to be efficient and to produce a quality end product. I think that by establishing communication and a relationship at the beginning of the semester, it would have allowed our group to better communicate and establish roles throughout the semester.
Part way through the semester, I read through the final paper rubric and created a rough outline of topics that I thought needed to be covered in the paper. I emailed this out, working off of the topic that another team member had proposed as a focus for our paper. There was no feedback for a few weeks and I did not pursue. About a month later, another team member offered to work on an outline and I pointed out that I had begun a rough draft and to please look at what I had started as it was taken forward. I feel that I should have pursued a response and encouraged the progression of the discussion when I first initiated it, because I felt like my work and effort was not utilized. This takes us back to the topics of communication, rework and efficiencies.
During the process of creating our final paper the issue of efficiencies continued to be on my mind. Again, I think that it might have helped if we would have created a better line of communication from the very beginning of our work relationship. It is important to set clear expectations from the beginning, not only to avoid misunderstanding, but also to have accountability. As Porter-O’Grady and Malloch describe, to be accountable one must have a sense of ownership. It is important that each team member feels that they are valued and have an important part in the final product.
I feel that our group created quality products and I also feel that our parts were not defined. We ended up working well together and had input throughout. I think we were all open to ideas and flexible, as it was a smooth process of creating papers. It stood out to me just once that because of the vaguely defined roles, one team member tended to create more work for themselves due to a lack of communication and clear expectations about topics and direction.
The group work for this course gave me an opportunity to work closely with other emerging leaders. In my professional experience, I have mostly worked with groups of experienced leaders and/or groups of emerging leaders being led by experienced leaders. In this course, we were to lead ourselves in defining roles and expectations. I think we did a good job assigning each other tasks, such as what power point slides to be responsible for and who was going to be the one to present our power point.
          In the past, I feel that I have been more outspoken as a leader than I was during this course. I think it is because I anticipated not being available 100% related to having a baby. My professional experience has allowed me to lead large groups in shared governance, being a chairperson. This experience was different in the sense that we were all co-chairs in the group.
I plan to take the experience and knowledge from this course forward by being more aware of relationships and communication. Having good communication is one of the major foundations to good leadership. Communication and relationship building takes effort and consistency. I think it would be good to have weekly huddle meetings about all that is going on during a course. This allows us to get to know each other and better understand the value each of us brings to the table. At the end of each huddle, there should be a summary of what was discussed sent to all members. This would really help to organize, set expectations and be accountable.

Porter-O’Grady T. & Malloch K. (2011). Quantum Leadership: Advancing Innovation, Transforming Health Care (3rd ed.). Jones & Bartlett Learning, LLC.

Quantum Leadership

Ten Principles of Quantum Leadership
Jessica McGaha
Nurs 6655
Idaho State University

Tim Porter-O’Grady andKathy Malloch developed the ten principles of Quantum Leadership. Quantum Leadership encompasses Complexity Theory and Chaos Theory to guide the leader in understanding relationships, behaviors and change. The ten principles are as follows:
“Principle 1: Wholes are made up of parts

 Principle 2: All health care is local

Principle 3: Adding value to a part adds value to the whole

Principle 4: Simple systems make up complex systems

Principle 5: Diversity is a necessity of life

Principle 6: Error is essential to creation

Principle 7: Systems thrive when all of their functions intersect and interact

Principle 8: Equilibrium and disequilibrium are in constant tension

Principle 9: Change is generated from the center outward

Principle 10: Revolution results from the aggregation of local changes”

(Porter-O’Grady and Malloch, 2011)
There are various personality traits, skills and leadership abilities that could make one successful in the new ways of thinking, as described in the ten principles of Quantum Leadership. Personality traits and behaviors have a large effect on how we build and maintain relationships with others, therefore self-awareness is an important trait for leaders to have.
A visionary leader has the ability to view the potential reality, as described by Porter-O’Grady and Malloch (2011). The visionary is able to think outside of the box and have innovative ideas. Having new ideas and new ways of looking at situations can allow for new ways of approach. Innovation in health care is at the forefront of moving forward and being successful.
A quantum leader needs to be empathetic. An empathetic leader can see the efforts and impact on all sides, including that at point of service and the system as a whole. This allows them to understand the struggles and needs of each perspective, which leads to effective mediation when conflict arises.
Being a team player is also important in the quantum leadership principles. The team player strives to do their share of work and holds others accountable for expected outcomes. The quantum leader also needs to be able to see the big picture on how we all affect one another. The leader needs to understand and operate the controls to fly the plane, but cannot forget to look out the windshield. All the smaller units and pieces together create the larger outcome.
The ability to analyze is an important leadership ability. Being able to analytically breakdown a system or process, to figure out where or what can be considered as an opportunity, is just as important as being able to see how each unit feeds the system. The quantum leader also views issues as opportunities, not problems.
          Finally, the quantum leader is flexible and non-controlling. It is important for the leader to be able to “read the sign posts (Porter-O’Grady and Malloch, 2011)” and adjust speed and direction accordingly.


Tim Porter-O’Grady & Kathy Malloch (2011). Quantum Leadership: Advancing Innovation, Transforming Health Care (3rd ed.). Jones & Bartlett Learning, LLC.

Change Theory

The Change Process
Jessica Bertagnolli
Nursing Leadership 652
Idaho State University

The process of change affects everyone in different ways. Some embrace change and recognize that it represents the forward momentum that an organization needs to survive in the changing market (Bruhn, 2004), and there are those who view change as a threat to there comfort zone. The leader is responsible for monitoring and fostering the process of change before, during and after the change takes place.
            There must be steps in the change process, as described in Kotter's Eight Stage Process of Creating Major Change (1996) or Spradley's Model (Rousel, 2006). Following steps allow for proper preparation, planning and implementing of the change. Using specific steps in the change process helps to guide the leader to move forward and not allow the change effort to fizzle out. Many of the processes described in change theories are necessary to allow for staff to be aware of the coming change, the need for it, the acknowledgment of the change and the action and acceptance of the change.
            Rousel describes the relationship between the "change agent" and the "change system" (2006, 64). The leader is the "agent" and the "system" is the group that is leading the change. Bruhn explains that the change leader shares a vision of change and delegates the tasks of change to others (2004). This empowers those who the change is going to affect with accountability and ownership of the change (Potter-O'Grady, 2003).
            I will incorporate change theory in my leadership approach by recognizing the difference between managing change and leading it (Bruhn, 2004). I will also search for the positive deviance for guidance (Pascale, 2005). I think that consulting the positive deviance and utilizing their expertise in the "different" way of doing things would allow for the accountability and ownership of the change, as described above. The organized, step-by-step approach in change theories will help to keep me on track, especially in the beginning stages of my leadership development.


Bruhn, J. (2004). Leaders who create change and those who manage it: How leaders limit success. Health Care Manager, 23(2), 132-140.

Kotter, J. (1996). Leading Change. Boston: Harvard Business School Press.

Pascale, R. & Sternin, J. (2005). Your company's secret change agents. Harvard Business Review, 83(5), 72-81.

Roussel, L. (2006). Management and Leadership. Boston: Jones and Bartlett.

Leadership Ethics

Ethical Accountability in Leading Change
Jessica Bertagnolli
Nursing Leadership 652
Idaho State University

            Honesty and fairness are among the top qualities that I value in a leader. Bruhn describes an ethical work climate as one that contains openness, respect and dialogue (2004). These are all necessary elements in creating trust. A leader must maintain an environment that is not threatening and expectations are known. Honesty, fairness and respect are key concepts in trusting relationships, and qualities that a great leader should have.
            According to Potter-O'Grady and Malloch (2003), the good leader is vulnerable. As they point out, I think that the word 'vulnerability' has a negative and scary meaning to most of us; although, some of the aspects of vulnerability are valuable for the leader to embrace during the change process. Absence of ego, trust in others, awareness of limitations, acknowledgement of strengths and weaknesses are needed for the leader to be open to new ideas and others view points (Potter-O'Grady and Malloch, 2003). In order for leadership to effectively lead change they must be open to diversity and be willing and ready to be wrong, or at least not right. I think that the quality of vulnerability has its essential aspects for the leader in the change process.
            One of the most important ethical accountabilities of the leader is to walk the talk. If a leader wants the staff to be open, honest and flexible the leader must model this. I had the opportunity to go to a seminar put on by Tim Potter-O'Grady and he talked about how busy nurses are. The message was that at some point one can get so busy that nothing is accomplished. I think that Walton, of WalMart, has an invaluable expectation of his employees to look the customer in the eye, greet them and ask if they needed help (Bruhn, 2004). The nurse leader must assure that they are not too busy to connect with their staff, if they expect their staff to not get too busy to connect with the patient. We in health care have an ethical responsibility to make our patients feel safe and comfortable during one of the most vulnerable times in their life.

Bruhn, J. (2005). The ethic of the organizational good: Is doing the right thing enough? Healthcare Manager, 23(1), 4-10.

Health Insurance Exchanges

Trend:  Health Insurance Exchange        Jessica Bertagnolli           N621

When the Patient Protection and Affordable Care Act were signed into law in March 2010, many changes to health insurance went into effect.  Some of the changes include the subscriber not being charged for preventative services, children with pre-existing illness cannot be denied coverage and parents can provide health insurance for their children up to the age of 26 years (Department of Insurance, 2012).  Many of the policies that are included in healthcare reform are aimed at increasing preventative access and services, as well as providing options for appropriate health insurance for as many individuals as possible. 

Health insurance exchanges are another aspect of healthcare reform that is currently being addressed in our nation.  The purpose of insurance exchanges are to provide access to health insurance for the masses, especially focused on the uninsured, under-insured and those who buy private health insurance that is non-work related.  Again, this is another part of healthcare reform that is focused on providing health insurance for as many individuals as possible.  Exchanges are also aimed at changing the health insurance market by making it more transparent to consumers (Focus on Health Reform, 2009).

A health insurance exchange is an entity that provides consumers choices in health plans, making price comparison and quality information available.  This would allow the consumer to make an educated choice with little sluth work needed to determine if the consumer has coverage when care is needed.  The exchange would also facilitate enrollment and help to determine eligibility and provide subsides (Focus on Health Reform, 2009).

Rules for health insurance providers to be more transparent could save the hospital money when considering administrative costs in working with insurance companies to get paid for services.  In my experience with utilization management, as a nurse case manager, much time can be spent in trying to contact and negotiate with insurance companies and in being the barer of bad news to the patient when services are not covered.  Time is money and transparency could help to alleviate unnecessary time spent away from discharge planning and care coordination, while in the hospital.

Uninsured and under-insured patients that require acute care may or not be able to afford to pay hospital bills.  The hospital loses money when patients are unable to pay for expensive hospitalizations and treatment.  Exchanges would help to reduce the number of uninsured and increase utilization of subsidies when appropriate.  This would also help to decrease administrative costs to the hospital by reducing the need for hospital financial representatives and social workers to determine eligibility and coordinate subsidies and other programs, such as Medicaid.

It is estimated that a total of 29 million people will be enrolled in exchange plans by 2019 (Health Policy Brief, 2011).  Insurance providers is largely how healthcare providers get paid, so it would be of interest to the hospital to be involved in and aware of policies effecting health insurance exchange plans. 

Each state has an opportunity to establish their own exchange, prior to 2014, after which the federal government will come to establish and manage one, as laid out in federal health reform legislation.  How the state sets up the exchange is flexible and the state legislation can leave policies to be worked out as time goes on (Health Policy Brief, 2011).  This flexibility will allow for progression as the program is grown and what works well is determined.  It would be in the hospitals interest to be involved in discussions about policy, as payment may be impacted.  Also, funding of the exchange program will have to come from somewhere (yet to be determined), and could fall as a tax on health care providers (Health Policy Brief, 2011).

Department of Insurance, 2012. Federal reform and health insurance in Idaho: Health

            reform. Retrieved from, on

            February 27, 2012.

Focus on Health Reform, 2009. Explaining health care reform: What are health

            insurance exchanges? The Henry J. Kaiser Family Foundation, publication 7908.

            Retieved from, on February 27, 2012.