conference coverage
WHAT SKILLS WILL THE N
Carol Huston – a brave new nursing world
K
eynote speaker at the conference, American
nursing professor and former president of
the international honour society of nursing, Sigma Theta Tau, Carol Huston, painted a
picture of a brave new nursing world in 2020,
in her opening presentation, Preparing nurse
leaders for 2020.
She outlined eight leadership competencies
every nurse leader would need in the 2020. The
first was a global perspective. “Every health care
issue has to be looked at from a global perspective. We used to think pandemics were confined
to developing countries. We now know they are
just one short flight away.”
There was a more urgent need for international standards for basic nursing education.
The nursing shortage was one of the most
serious threats to global health, she said, and
it would get significantly worse before it got
better. Nurse migration was a global problem.
(See news p7.)
The second leadership competency was better
use of technology to connect people. Technology
had driven so many changes already in health
care but knowledge and information acquisition
and distribution was going to multiply exponentially. “Forty percent of what we know today will
be obsolete in three years,” Huston said.
She listed a range of technological developments that would have a major impact on health
care in the next 20 years. By 2030 diagnostic
body scans, which could identify underlying
pathology, would become part of showering.
Improvements in body scanning technology
would mean there would be no need for invasive
surgery or tests. “Nano bots” circulating in the
blood stream would identify disease processes
and begin to repair them. Gene therapy would
mean what was now untreatable would be treatable and could see cancer abolished completely
14
within two decades. Stem cell therapy would
eliminate the need for organ transplants “as we
will grow new organs. It is predicted we will be
able to grow heart, kidneys and livers by 2020.
There are already clinical trials underway growing new teeth – instead of dentures you would
grow you own new teeth.”
Merging of the human and the machine would
advance significantly and by 2020 there would
be pancreatic pacemakers for diabetics and the
technology to enable blind people to see and
deaf people to hear.
Robotics would continue to develop, with
physical service robots which could wash patients and help feed and carry patients. There
was the potential for the use of robots in
therapeutic roles. Paro, a robotic seal developed
in Japan, responded to patting by closing its
eyes and moving its flippers and was already
being used as a therapeutic device for those
with autism and Alzheimers. Kansei (emotion)
robots are being developed and are programmed
so key words trigger facial expressions.
Robotic simulation for nursing education
provided a safer environment for students and
mannequins could now cry, sweat, and become
cyanotic. “The challenge for nurse leaders in
2020 will be how much simulation is too much?
How important is human contact to learning the
art of professional nursing?” Huston said.
Other areas of development would be digital
records of health care history, the continued
development of biometrics, with confidentiality
protected by biometric signatures, the increasing use of “smart” objects, including a bed that
could call a nurse if the patient was attempting
to get out of bed, or a coverlet which could take
a patient’s vital signs as they lay in the bed.
“Nursing leaders will have to balance technology and the human element. I’m not worried
about the science of nursing but I am a little
worried about the art of nursing. Technology
can supplement but not replace nursing care,”
Huston said.
The third leadership competency was expert
decision-making skills rooted in both empirical
science and intuition. She referred to “wicked”
problems, ie those with no right answers. Clinical
decision support software packages will, with
provider input of data, come up with a list of
differential diagnoses and best practice.
There would be increasing numbers of tools
to help decision makers, including the opportunity to buy information and advice from expert
networks of thinkers. Nurse leaders with both
right brain and left brain skills were needed and
Huston suggested that nurse leaders should surround themselves with people with a different
brain dominance from their own.
The fourth leadership competency was the
development of organisational cultures which
emphasised quality patient care and worker and
patient safety. “There has been an inordinate
amount of money spent on medical errors but
we haven’t seen that greater reduction in error
rates. Part of the reason is how health care
systems are created.”
If as much energy was focused on fixing the
underlying processes which caused errors as was
focused on blame, much more would be learnt.
“I’m not absolving individual health providers.
We must find a balance between creating safer
health care systems and individuals’ responsibility for the care they provide.”
Being politically smart was the fifth leadership competency. “Nurses are the largest group
of health care professionals but they are not
always an integral part of health care decision
making. This has something to do with how
women are socialised to view power and with
how they have been controlled by outside forces,
notably medical and administrative. Politics can
be defined as the art of using power effectively.
In 2020 nursing input will be needed more than
ever. Nurses must use their political skills to
solve problems such as workforce shortages,
turnover rates, reforming broken health care systems and bringing nursing education entry levels
up to that of other professions,” Huston said.
Team building skills
Nurse leaders of 2020 must also have highly
developed collaboration and team building
skills. The key to leadership success in 2020
would be the ability to integrate the priorities
of industrial age leadership, with its emphasis
on productivity, and relationship age leadership.
“Health in 2020 will be characterised by highly
educated, multidisciplinary experts and this will
complicate, not ease teamwork. The key will be
to create teams of experts, not expert teams. The
nurse leader will have to be a team builder.”
The nurse leader of 2020 must be visionary
and proactive in response to an environment
which will be increasingly characterised by
chaos and change. “Health care organisations
in the 21st century will be in a state of constant, dramatic change and will be more fluid,
more flexible and more mobile. Nurse leaders in
2020 will be experts in addressing resistance
KAI TIAKI NURSING NEW ZEALAND > JULY 2010 > VOL 16 NO 6
to change and helping followers work through
that change.”
The final leadership competency was ensuring
leadership succession, given the average age of
a nurse in the United States is 47. “We must do
a better job of mentoring the newest members
of our profession.”
She explained the “Queen Bee Syndrome”, a
characteristic of female occupations – “the nurse
leader who has had to struggle to get to the top
and is so embittered by the struggle she thinks
every nurse should have to go through that to
get to the top.”
Huston said mentoring and nurturing was
the key to advancement in traditionally male
occupations.
She referred to “demographic invisibles”, ie
those people not even considered for leadership roles because of their ethnicity, gender,
age or nationality, and “stylistic invisibles”, ie
those who didn’t fit the stereotype of a leader.
“Nursing education programmes must be much
more open about where the next generation of
leaders is going to come from. Education and
management development programmes must
ensure nurse leaders have the skill set and
competencies to be successful.”
Huston said the ability to achieve a balance
between old and new skills, technology and
the human element, national and international
perspectives, empirical science and intuition,
productivity and relationship, and using power
wisely for the benefit of self and others, would
be critical for future nurse leaders.
“We must be proactive in identifying, preparing and supporting our nursing leaders to
address the realities in 2020.”
• Huston’s second presentation on the last day
of the conference, was a light-hearted look
at her own nursing leadership journey and
examined her mistakes and what she learnt
from them. •
PRISON NURSES WORK IN UNIQUE PRIMARY HEALTH CARE ENVIRONMENT
P
rison nurses provide primary health care
nursing services to around 8680 prisoners
in the unique and challenging environment
of the country’s 20 prisons, the Department of
Correction’s clinical director Debbie Gell told the
conference. Prisoners, on the whole, were not a
healthy group, with a high prevalence of mental
illness, communicable and chronic diseases and
up to 70 percent of prisoners were alcohol and
drug dependent, she said.
“The prison environment is not very conducive
to supporting health needs and this is compounded by isolation and worries about home
and family,” Gell said.
The average length of stay was nine months,
with some remand prisoners staying just a few
days, so nurses had to get positive health messages across within short timeframes. Nursing
practice was also affected by security con-
cerns, with prisoners having to be escorted to
health clinics or to hospital by custodial staff,
sometimes up to three. Nurses on medication
administration rounds had to be accompanied
by custodial staff and a round always involved
myriad locked gates.
There are 280 prison nurses and last year
they were involved in 200,000 nursing consultations.
Gell outlined a “typical” day in the life of a
prison nurse, with the aid of videos of nurses
talking about their work. Nursing clinics were
held in prison health centres and included immunisation, sexual health clinics, dental health
and chronic care management. In large prisons,
doctors visited daily but care was led by nurses
with the support of doctors. “Prison nurses see
a wide variety of presentations from serious
traumatic injuries to minor injuries, alcohol and
drug withdrawal, sexually transmitted infections
to sport injuries. They can encounter very complex self-harm behaviours. They need excellent
assessment skills, for example they must assess
whether a prisoner’s severe abdominal pain is
genuine or a way of securing a drug drop at the
emergency department.”
Each prisoner underwent a “reception health
triage” when first arriving in prison and then
a full health assessment within 24 hours to
seven days of arrival. “The full assessment is a
great opportunity to engage prisoners to look
at their own health. Nurses are dealing with a
high-needs population who are usually in prison
for a relatively short period of time. Nurses
must use that time effectively to help improve
the prisoner’s health and hopefully the health
of the prisoner’s family and wider community,”
Gell concluded. •
ASTHMA ASSESSMENT TOOL PROVING ITS WORTH
The three-day conference programme featured
a plethora of speakers, including five plenary
speakers. As well as Carol Huston, Michal Boyd
and Debbie Gell, the other two plenary speakers
were MidCentral District Health board clinical
nurse specialist community, Denise White, and
respiratory programme manager at Harbour
Health Primary Health Organisation in Auckland,
Wendy McNaughton.
McNaughton spoke about the web-based
asthma assessment and decision support tool,
GASP (giving support to asthma patients) she
was instrumental in developing and which
enables health professionals to follow the New
Zealand Guidelines on asthma.
She introduced her presentation with a
rundown of international and national asthma
statistics, including that there are 300 million
sufferers worldwide, New Zealand is second only
to the United Kingdom for asthma prevalence,
asthma is the most common chronic condition
among children, that in 2007 asthma was one
of the top three avoidable hospital admissions
in the Waitemata DHB region and that there are
huge disparities between Mâori and non-Mâori
asthma rates.
She said more than 300 GASP nurses had
completed a two-day, New Zealand Qualifications Authority-accredited course based on the
Asthma Foundation’s course but with sections on
critical thinking and how to establish nurse-led
clinics added. Two GASP audits of 205 patients
ranging in age from five to 64, had revealed a
76 percent decrease in hospital admissions, a
58 percent decrease in exacerbations and a 46
percent decrease in use the of oral steroids. McNaughton “implored” the government to fund
nurse-led respiratory clinics.
KAI TIAKI NURSING NEW ZEALAND > JULY 2010 > VOL 16 NO 6
continued on p16
15
conference coverage
HE NURSE LEADERS OF 2020 NEED?
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EVIDENCEBASED CARE
SHEET
Budgeting Principles
What We Know
› A budget is a financial forecast that estimates expenses and revenue for a specified period
of time, typically 1 year. A budget is developed based on a set of assumptions regarding
what can and cannot be achieved with a specific set of resources in a defined period of
time; the more accurate a projected budget is, the better the healthcare organization can
efficiently utilize its resources(3,5)
• Expenses include all monies paid out by the healthcare organization.(5)The two main
types of expenses are
– employment costs (e.g., salaries, wages, overtime costs, benefits)(5)
- The greatest expenses in a healthcare organization are related to personnel because
health care is very labor intensive(3)
– non-salary expenses (e.g., supplies, equipment, equipment repairs, travel costs)(5)
• Revenue is the income the organization receives for services provided(5)
–For healthcare organizations, revenue is provided by payments made by private
insurers, Medicare, Medicaid, and patients
• Each nursing unit is a cost center and has an operating budget. Nursing budgets are
developed and managed by nurse managers and typically account for a large share of the
expenses of a healthcare organization(3,5)
› The three most common types of budgets are the
• personnel budget, in which personnel needs are managed to prevent under- or
overstaffing(3)
• operating budget, in which the costs of supplies are managed(3)
• capital budget, in which the long-term costs of the organization are managed(3)
– Physicians play a dominant role in the capital budgeting process(4)
Authors
Hillary Ittner, RN, MSN
Cinahl Information Systems, Glendale, CA
Tanja Schub, BS
Cinahl Information Systems, Glendale, CA
Reviewers
Alysia Gilreath-Osoff, RN, BSN, CEN,
SANE
Cinahl Information Systems, Glendale, CA
Nursing Executive Practice Council
Glendale Adventist Medical Center,
Glendale, CA
Editor
Diane Pravikoff, RN, PhD, FAAN
Cinahl Information Systems, Glendale, CA
› The four most common budgeting methods are
• incremental budgeting, which is performed by multiplying current expenses by a certain
figure (e.g., the consumer price index) to project the budget for the following year(3)
• zero-based budgeting, in which the manager examines and justifies all current activities
and expenses to prioritize spending for the following year(3)
• flexible budgeting, in which the budget adjusts up and down based on the needs of
the organization. This type of budgeting is useful in healthcare organizations because
it can fluctuate based on changes in patient census and staffing needs.(3) (For more
information, see Evidence-Based Care Sheet: Flexible Budgeting )
• performance budgeting, in which the outcomes of services are used as the basis for
budgeting (3)
› Nurse managers who are in charge of budgeting must
• balance the competing priorities of containing costs and ensuring quality of care(3)
–After a budget is created, it must be continuously assessed to verify that costs
are remaining within the budgeted limits. Variances are created when there is a
discrepancy between expected budget expenditures and actual expenditures; nurse
April 20, 2018
Published by Cinahl Information Systems, a division of EBSCO Information Services. Copyright©2018, Cinahl Information Systems. All rights
reserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by
any information storage and retrieval system, without permission in writing from the publisher. Cinahl Information Systems accepts no liability for advice
or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare
professional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206
managers must work to eliminate any variances and remain on budget. Variances can
be created when nursing hours exceed the number required by the patient census(3)
- The following factors influence variance analysis:(3,5)
- Differences in the mix of staff and staff salaries. For example, payroll for registered nurses will cost more than payroll
for medical assistants (for more information, see Evidence-Based Care Sheet: Nursing Skill Mix )
- Ranges in staff salaries
- Differences in the levels of staff needed to provide care on night and weekend shifts
- Incongruity between the number of staff members working on a unit and the number actually needed (e.g., there might
be too many nurses working during a period of low patient census)
- Changes in work practices and workload; workload is the volume of work in a specific department (for more
information, see Evidence-Based Care Sheet: Nursing Workload Measurement )
- Lack of control regarding ordering goods and services and irregular purchasing patterns (e.g., fluctuating levels of
stock and supplies)
• have a thorough understanding of fiscal planning/financial analysis(3)
–Fiscal planning in health care requires nurse managers to
- identify of long- and short-term unit needs and document and communicate these to administrators(3)
- verify that unit goals are congruent with organizational goals(3)
- have knowledge of factors that influence healthcare reimbursement(3)
- be flexible in financial goal-setting(3)
- be creative and have the ability to motivate others(3)
- provide opportunities for staff members to participate in budgeting activities(3)
- recognize and effectively report to administrators if cost containment activities prevent the achievement of
organizational goals(3)
- ensure that cost containment does not impact patient safety(3)
- role-model leadership(3)
- ensure that patient care documentation is clear and complete to facilitate reimbursement(3)
- effectively plan personnel needs(3)
–Many nurses report that financial planning is difficult, most often because they lack formal education in budget planning
and forecasting(2,3)
- Researchers in Korea developed a financial-analysiseducation plan for nurses based on the following six key
components: “Understanding the need for financial analysis, introduction to financial analysis, reading and
implementing balance sheets, reading and implementing income statements, understanding the concepts of financial
ratios, and interpretation and practice of financial ratio analysis” (Lim et al., 2015). Learning objectives and course
content topics were developed based on these components(2)
• demonstrate knowledge of budgeting methods(3)
–Budgeting requires
- assessment of budgetary needs(3)
- determining long- and short-term goals(3)
- developing the budget(3)
- monitoring and analyzing expenditures(3)
- evaluating the budget throughout the fiscal year(3)
–Programme Budgeting and Marginal Analysis (PBMA) is a toolkit used in the U.K., Australia, New Zealand, and Canada
to assist managers with decision-making regarding the most effective use of resources and with the setting of priorities in
health care(1,7)
- Senior and middle managers who took part in PBMA at a children and women’s tertiary care facility in Canada reported
that PBMA implementation was a good experience and an improvement over previous practice(6)
What We Can Do
› Become knowledgeable about budgeting principles so you can accurately assess your organization’s fiscal goals and
participate in developing a fiscally responsible budget; share this information with your colleagues
› Adhere to the principles of the accounting method used in your facility and collaborate with others to successfully meet
facility budgeting responsibilities
› Learn about budgeting conflicts in your facility so you can participate in successful resolution
› Communicate details regarding the budget to your colleagues and promote commitment in meeting your healthcare
organization’s fiscal goals. Be prepared to
• defend your budget
• negotiate details of your budget
• resolve budget challenges and conflicts
• perform a variance analysis for your budget
Coding Matrix
References are rated using the following codes, listed in order of strength:
M Published meta-analysis
SR Published systematic or integrative literature review
RCT Published research (randomized controlled trial)
R Published research (not randomized controlled trial)
RV Published review of the literature
RU Published research utilization report
QI Published quality improvement report
L Legislation
C Case histories, case studies
PGR Published government report
G Published guidelines
PFR Published funded report
PP Policies, procedures, protocols
X Practice exemplars, stories, opinions
GI General or background information/texts/reports
U Unpublished research, reviews, poster presentations or
other such materials
CP Conference proceedings, abstracts, presentation
References
1. Edwards, R. T., Charles, J. M., Thomas, S., Bishop, J., Cohen, D., Groves, S., ... Bradley, P. (2014). A national Programme Budgeting and Marginal Analysis (PBMA) of health
improvement spending across Wales: Disinvestment and reinvestment across the life course. BMC Public Health, 14, 837. doi:10.1186/1471-2458-14-837 (R)
2. Lim, J. Y., & Noh, W. (2015). Key components of financial-analysis education for clinical nurses. Nursing and Health Sciences, 17(3), 293-298. doi:10.1111/nhs.12186 (R)
3. Marquis, B. L., & Huston, C. J. (2015). Fiscal planning. In Leadership roles and management functions in nursing: Theory and application (8th ed., pp. 204-234). Philadelphia,
PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. (GI)
4. Mukherjee, T., Al Rahahleh, N., Lane, W., & Dunn, J. (2016). The capital budgeting process of healthcare organizations: A review of surveys. Journal of Healthcare
Management, 61(1), 58-77. (RV)
5. Sherman, R., & Bishop, M. (2012). The business of caring: What every nurse should know about cutting costs. American Nurse Today, 7(11), 32-34. (GI)
6. Smith, N., Mitton, C., Hiltz, M. A., Campbell, M., Dowling, L., Magee, J. F., & Gujar, S. A. (2016). A qualitative evaluation of program budgeting and marginal analysis in a
Canadian pediatric tertiary care institution. Applied Health Economics and Health Policy, 14(5), 559-568. doi:10.1007/s40258-016-0250-5 (R)
7. Tsourapas, A., & Frew, E. (2011). Evaluating ‘success’ in programme budgeting and marginal analysis: A literature review. Journal of Health Services Research & Policy, 16(3),
177-183. doi:10.1258/jhsrp.2010.009053 (RV)
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