Leadership and Ethics in Advanced Nursing Practice

Ethical Dimensions of Organizational and Leadership Behavior in Advanced Nursing Practice

Ethical conduct is a major element of advanced nursing practice, and, among other things, it is pertinent to organizational and leadership behavior. From the perspective of organizational behavior, the interdisciplinary and intradisciplinary interactions of nurses are of primary importance. Some of the ethical requirements in this respect are described by the American Nurses Association (2015). They include the development of respectful relationships with colleagues (Provision 1) and collaboration with them (Provisions 2, 3, and 8) in providing high-quality care, promoting patient safety and rights, and contributing to the development of nursing.

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As for leadership, the ethical conduct of a leader is of great importance for the successful functioning of an organization due to the impact that it can have on the followers (Demirtas & Akdogan, 2014). As pointed out by Demirtas and Akdogan (2014) ethical aspects of leadership are multiple, but they are aimed at the development of ethical culture at the workplace. An ethical leader is expected to lead by example and promote ethical decision-making and conduct; in other words, ethical leadership includes ethical organizational behavior. Since advanced practice nurses often find themselves in leadership positions, ethics is important to them.

An example of an ethical dilemma that may occasionally occur at my workplace is the engagement of nurses and officers in behaviors that can be characterized by prejudice. In particular, I have noticed that the officers of my correctional institution tend to exhibit ableism, which is less common among nurses.

As a DNP-prepared nurse, I recognize the importance of promoting a safe and inclusive environment for the diverse population that we serve, which is why I believe that the only ethical decision is to address the instances of prejudice directly and immediately by discussing the issue with the person exhibiting undesired behavior and supporting the victim. Also, I find that it is important to improve the staff’s awareness of minorities by implementing regular diversity training (Alhejji, Garavan, Carbery, O’Brien, & McGuire, 2015). As a leader, I can promote this kind of intervention at my workplace.

Quality Improvement and Patient Safety Outcomes in Advanced Nursing Practice

In my setting, which is a correctional institution, there are multiple patient safety concerns. However, a matter that is predominantly nursing-related is medication errors; also, it is a well-known issue that occurs in a variety of nursing settings (Keers, Williams, Cooke, & Ashcroft, 2013). However, medication errors are a complex issue that can be caused by multiple factors, which can include ineffectively distributed workload and tiredness, mistakes in drug calculation, damaged orders, environmental distractions, miscommunication, and many others (Gorgich, Barfroshan, Ghoreishi, & Yaghoobi, 2015). As a result, the problem requires a customized multicomponent solution: it is necessary to review the specifics of a particular issue and introduce appropriate interventions.

At my workplace, nurses occasionally report medication errors, but, as pointed out by Durham, Suhayda, Normand, Jankiewicz, and Fogg (2016), insufficient awareness and certain cultural and leadership problems (like the lack of trust) make self-reporting less effective than desired. To improve the situation, it is necessary to promote the nurses’ awareness of the significance of medication errors, which Durham et al. (2016) achieve through training.

As a DNP-prepared nurse who is interested in the roles of leader and educator, I would promote this improvement initiative because it can address certain causes of medication errors (for example, that of mistakes in the calculation) while also training the nurses to provide feedback. The latter can be employed to detect other issues and ensure continued quality improvement.

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Conflict Management and Quality Improvement in Advanced Nursing Practice

A top-down quality improvement initiative (the introduction of new guidelines for emergency cases) took place at my correctional institution. The change was led by the administration, and while the care providers had a chance to offer feedback, no direct responses to them or apparent adjustments were made. As a result, the conflicts were mostly stifled: the providers mostly voiced their discontent in private discussions with other staff members.

The administration may have used the avoidance strategy (Erdenk & Altuntaş, 2017), which was effective in stifling the discontent. However, it left the providers unsatisfied, demotivated them, and made the relationships between the two parties tenser. It appears to be more beneficial to engage in discussion with the followers. Some of the effective strategies are compromise and collaboration. The former is concerned with finding a solution that is acceptable to both parties, and the latter suggests integrating multiple solutions that may have been proposed by different people to make a specific, customized way to settle the conflict (Labrague & McEnroe-Petitte, 2017). The latter strategy appears to be especially beneficial for continuous quality improvement because it promotes discussion.

Professional Practice Model Impact on Quality Improvement in Advanced Nursing Practice

The quality improvement project that I have proposed for my settings is the introduction of a training program for the nurses and correctional officers on the management of the behavioral and psychological symptoms of dementia (BPSD). A professional practice model that I could employ for the project was developed by a New York hospital. It incorporates the following elements: “Leadership; Professionalism; Excellence/safety; Caring/honoring the human spirit; Collaboration” (Slatyer, Coventry, Twigg, & Davis, 2015, p. 142).

Slatyer et al. (2015) analyze multiple models, but I chose this one because it is recent and appears to be capable of engaging both nurses and officers (the elements apply to both professions). Also, it introduces important features that support the need for change (excellence, safety, professionalism, and honoring the human spirit) and can promote it (leadership, professionalism, collaboration).

PICOT: In nurses and officers working at the correctional institution in question (P), does a customized BPSD training program (I), which will be developed and implemented within eight weeks (T), improve the ability of the staff to manage BPSD (O) as compared to their performance before the intervention (C)?

Level of evidence: the proposed intervention is a customized training intervention based on the STAR-VA intervention (Karlin et al., 2016). It is supported by a limited amount of evidence. According to the AORN model of evidence rating (Spruce, Wicklin, Hicks, Conner, & Dunn, 2014), it is supported by an II-level mixed-methods quasi-experiment (Karel, Teri, McConnell, Visnic, & Karlin, 2015), III-level mixed-method study (Karlin, Visnic, McGee, & Teri, 2014), and V-level mixed-methods report on an organizational experience (McConnell & Karel, 2016).

Also, prior research has shown that the effectiveness of staff training in improving the quality of care for patients with dementia is supported by randomized controlled trials (Level I) and mixed methods quasi-experiments (Level II) that do not focus on STAR-VA.

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Frameworks for Assessing Population High-risk Factors

One of the tools that can be applied for the epidemiological analysis of a condition is the epidemiological triangle (Stanhope & Lancaster, 2014, p. 264). For example, the primary cause of dementia with Lewy bodies (DLB) is the damage to the brain of the patient caused by the protein aggregations termed Lewy bodies (Boot, 2015), which allows viewing Lewy bodies as the agent of the condition. Regarding the host, immutable characteristics like age and gender, and genetics, matter. In particular, the populations of greater age, male sex, and with a family history of the condition (or the E4 allele of the APOE gene) are more likely to experience DLB (Boot et al., 2013).

Boot et al. (2013) state that DLB causes and risk factors are relatively understudied, but their research suggests that a history of several mental issues, including depression, and Parkinson’s disease may also be a risk factor. Finally, lifestyle factors may affect DLB development. Boot et al. (2013) find that coffee and moderate alcohol usage may reduce the risk of DLB development. These features can be applied to the environment element: the cultural and socioeconomic factors that promote a moderate use of alcohol and caffeine might affect the risks of DLB development, reducing them.

The PRECEDE-PROCEED model takes into account multi-level factors that can affect the implementation of health promotion programs. The first component determines the goal of the program, the issues that affect the process of achieving the goal, the factors that can contribute by influencing the issues, and the policies that need to be in place for the goal to be attained. The second component includes the design and implementation of the intervention, as well as its assessment from the perspectives of the process, impact, and outcomes (Perrin, 2014, p. 53).

Aghamolaei, Hosseini, Farshidi, Madani, and Ghanbarnejad (2015) successfully employ the model to develop a program for the modification of hypertension patients’ lifestyles. Banerjee, Strachan, Boyle, Anand, and Oremus (2015) use certain elements of the model to evaluate their church-based program for the promotion of heart health in the elderly population. Thus, the model provides a comprehensive framework that can guide the processes of the planning and assessment of interventions.

The purpose of care delivery models is to organize care by providing it with a structure that is based on evidence (Wiencek & Coyne, 2014). The models develop and evolve as more opportunities arise (Jortberg & Fleming, 2014). Their primary aim is the improvement of care, which can take the form of more efficient or more high-quality care.

Health Disparities and Health Equity

According to Braveman (2014), health disparities (HD) and health equity (HE) are not very well-defined in modern research, but they can receive some descriptions. The term HD refers to the health differences that can reasonably be attributed to the disparities that leave the socially disadvantaged populations with worse health outcomes when compared to the non-disadvantaged populations (Braveman, 2014). HE is the state of events in which there is no HD; in other words, in HE, all the populations should have equal opportunities and no disadvantages with respect to health and healthcare (Weinstein, Geller, Negussie, & Baciu, 2017). The two terms are apparently interconnected.

Nowadays, the concepts of HE and HD are framed by the approaches and philosophies that are connected to human rights movements (for example, the feminist perspective or that of the critical race theory). As a result, they involve the critical examination of modern-day society from the perspective of the factors that can contribute to inequality. As pointed out by Braveman (2014), these approaches are sufficiently rooted in evidence.

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HE can be increased, and HD can be decreased, for example, through the advocacy and programs aimed at the elimination of socioeconomic disparities (Weinstein et al., 2017), including the education of healthcare professionals on the topic of inequality (Beavis et al., 2015). Moreover, a healthcare organization needs to create an inclusive space, which implies that no discrimination at the workplace should be allowed. A diverse healthcare workforce can also assist in reducing HD and promoting HI by advancing related knowledge and advocating for the rights of minority patients (Phillips & Malone, 2014). Thus, the strategies that reduce HD tend to increase HI, which is understandable given the connection between the two terms.

Evidence-Based Interventions for Populations

Evidence-based interventions should employ high-quality evidence, which implies that the findings of high-quality (valid and reliable) randomized controlled trials and their meta-analyses or systematic reviews are the two primary sources to be used by them (Spruce, Wicklin, Hicks, Conner, & Dunn, 2014). Also, high-quality guidelines developed by healthcare organizations may be helpful. To shorten the time required to integrate research findings into clinical practice, a nurse can actively engage in the change led by these findings and promote it through compliance and feedback. The former will help to routinize the innovation, and the latter can assist in adjusting it to the needs of the organization.

Also, a nurse can advocate for change and, possibly, take part in gathering the funding for it (Farran, Zurawski, Inventor, Urbanic & Paun, 2017). As for a nursing leader, they can promote change by applying relevant change theories and following their advice (Spear, 2016). For instance, leaders can contribute by making the change better-aligned with the organizational mission and vision, promoting communication between stakeholders, and bringing down various barriers (for example, resistance to change).

Technology is of major interest to healthcare. Apart from improving the quality of care and patient safety, it offers new opportunities for treatment and makes healthcare more accessible. For example, telehealth can assist in managing high-risk populations with the help of communication technologies, making the care more accessible (Merriel, Andrews, & Salisbury, 2014). Similarly, the computerization of medication orders reduces the challenges of medication errors (Shahverdi & Javadzadeh, 2016), improving the safety of patients and quality of care. In summary, technology has multiple uses that can be beneficial for patients.

Evaluating Evidence-Based Interventions for Populations

The evaluation of evidence-based intervention programs is necessary to determine their outcomes, which can then be employed for the improvement of the tested model and the development of other ones. Furthermore, evaluation models can be used as planning frameworks, which helps to ensure a program’s success (Perrin, 2014, p. 53). The Centers for Disease Control and Prevention and Program Performance and Evaluation Office (2017) offer an evaluation model that seems to cover all these aspects.

The first stage consists of engaging the stakeholders of the program in the evaluation procedures. This step promotes interprofessional collaboration since the programs are likely to involve the stakeholders from different fields of healthcare and, possibly, from outside of them. For instance, my DNP project (an educational intervention for the staff of a correctional institution) would involve the administration, nurses, and correctional officers.

Having engaged the stakeholders, the evaluation team needs to describe the program and focus on its evaluation design. The latter effort can be viewed as the planning of an evaluation. Thus, the first three stages indicate that the evaluation of every program needs to be customized while taking into account its specifics. After that, the program suggests gathering evidence, analyzing, and synthesizing it, which should result in the fifth step: justified conclusions. These conclusions can be viewed as the primary outcome of the assessment.

Eventually, the model indicates that it is necessary to use and share the lessons of the evaluation process as the sixth step. As a result, the model fulfills another function: that of informing future programs and efforts. Also, the cyclical nature of the model suggests that one of the uses of the gathered information, conclusions, and lessons consists of engaging future stakeholders who can be encouraged to participate by the positive outcomes of the program. Thus, the evaluation model offers multiple positive outcomes and exemplifies the value of such models to healthcare programs.

References

Centers for Disease Control and Prevention, & Program Performance and Evaluation Office. (2017). A framework for program evaluation. Web.

Perrin, K. (2014). Essentials of planning and evaluation for public health. Burlington, MA: Jones & Bartlett Learning, LLC.

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