NURSING LEADERSHIP AND MANAGEMENT FOR PATIENT SAFETY AND QUALITY CARE

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NURSING LEADERSHIP AND MANAGEMENT FOR PATIENT SAFETY AND QUALITY CARE

Elizabeth Murray, PhD, RN, CNE Program Director, MSN Nurse Educator

Assistant Professor Florida Gulf Coast University

School of Nursing Fort Myers, Florida

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F. A. Davis Company 1915 Arch Street Philadelphia, PA 19103 www.fadavis.com

Copyright © 2017 by F. A. Davis Company

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Library of Congress Cataloging-in-Publication Data

Names: Murray, Elizabeth J., author. Title: Nursing leadership and management for patient safety and quality care

/ Elizabeth J. Murray. Description: Philadelphia : F.A. Davis Company, [2017] | Includes

bibliographical references and index. Identifiers: LCCN 2016052944 | ISBN 9780803630215 (alk. paper) Subjects: | MESH: Nursing Care—standards | Nursing Care—organization &

administration | Patient Safety—standards | Quality Assurance, Health Care—methods | Leadership | Nurse’s Role

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Dedication

This book is dedicated to my husband, Don, and my daughter, Angel, whose patience and encouragement are unending. Thank you for always supporting me in my professional endeavors and for understanding when I locked myself in “my cave.”

This book is also dedicated to Marydelle Polk, my mentor and friend, who shared so much with me and who had a great influence on my development as a faculty member and whom I miss dearly.

Finally, this book is dedicated to the hundreds of nurses and nursing students I have taught over the years for inspiring me to actualize my passion for nursing, quality, and patient safety through writing this book.

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Epigraph

“It may seem a strange principle to enunciate as the very first requirement in a Hospital that it should do the sick no harm. It is quite necessary nevertheless to lay down such a principle.”

Florence Nightingale, 1863 Notes on Hospitals

“The world, more specifically the Hospital world, is in such a hurry, is moving so fast, that it is too easy to slide into bad habits before we are aware.”

Florence Nightingale, 1914 Florence Nightingale to Her Nurses

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Preface

In 2000, the Institute of Medicine shocked the health-care community when they reported, in their landmark report, To Err is Human, that approximately 98,000 Americans die each year as a result of preventable adverse events. In response, many patient safety and quality initiatives were launched to make health care safer in the United States and globally. More recently, James (2013) identified evidence suggesting that a more accurate estimate of deaths from preventable errors is 200,000 to 400,000 per year. There is no question that the health-care delivery system is undergoing major changes related to safety and quality. Nurses at all levels and in all settings have been identified as key to transforming health care to a safer, higher-quality, and more effective system. Front-line nurses are being charged with taking leadership and management roles in transforming care at the bedside. Nurse educators must prepare a new generation of nurses to step into these roles as well as manage safe and effective patient care. To that end, this book was written to provide a comprehensive approach to preparing nurses in the critical knowledge, skills, and attitudes in leadership and management needed for the current and future health-care environment.

This book is built on the premise that all nurses are leaders and managers re- gardless of their position or setting in which they work. First-level or front-line nursing leaders and managers are those leading and managing care of a patient or groups of patients at the bedside and clients or groups in the community. This level may also include charge nurses, patient care managers, and supervisors. Second-level nursing leaders and managers are those holding a formal position in the system such as unit manager. Their responsibilities include leading and managing material, economic, and human resources necessary for the care of a group of patients, as well as clients or groups in the community. The third-level nursing leaders and managers are those holding a formal position in the organi- zation such as a director over several units and whose responsibilities are similar to those of the second level manager but encompass a broader scope. The fourth level or executive level includes nursing leaders and managers in positions such as chief nursing officer (CNO) or Vice President of Nursing Services. Their re- sponsibilities include administering nursing units within the mission and goals of the organization. Finally, many nurse leaders and managers hold positions outside direct care delivery such as nurses in academic settings, labor unions, political action groups, health-care coalitions, and consumer advocacy groups. This book provides an evidence-based approach to attaining the necessary knowl- edge, skills, and attitudes for nursing practice in today’s dynamic health-care environment. It will be beneficial to prelicensure nursing students, RNs returning

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to school, new nurse leaders and managers, and nurses in any type of leadership and management position that impacts health care and health-care recipients.

The underpinnings of this book are evidence-based practice, safety, quality, and effective nursing care. The book will assist students to understand a current per- spective of nursing leadership and management theories, concepts, and principles. Evidence-based content is presented on topics relevant in today’s ever-changing health-care environment, such as contemporary leadership and management theories, managing ethical and legal issues, leading and managing effectively in a culture of safety, improving and managing quality care, building and managing a sustainable workforce, leading change and managing conflict, creating and sustaining a healthy work environment, and managing resources.

The safety and quality of care depend greatly on our future nurses. I believe this book will help future nurses to attain leadership and management knowledge, skills, and attitudes critically needed to lead, manage, and provide safe, high-quality, and effective nursing care.

ELIZABETH J. MURRAY

Fort Myers, Florida

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Contributors

Brett L. Andreasen, MS, RN-BC Clinical Applications Analyst Informatics Nurse Specialist University of Washington Medicine IT Seattle, Washington

Rebecca Coey, MSN, RN, FNP Family Nurse Practitioner Fort Myers, Florida

Paula M. Davis-Huffman, DNP, ANP-BC, PPCNP-BC, Emeritus CCRN Assistant Professor Florida Gulf Coast University School of Nursing Fort Myers, Florida

Sara Jo Foley, RN, MSN, FNP Family Nurse Practitioner Fort Myers, Florida

Linda K. Hays-Gallego, MN, RN Lead Clinical Informatics Analyst, ORCA Clinical Informatics and Support University of Washington Medicine IT Seattle, Washington

Judith Walters, DNP, RN, PMHCNS-BC Assistant Professor Florida Gulf Coast University School of Nursing Fort Myers, Florida

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Reviewers

Suzanne Barsness, MSN, RN, CCRC Associate Professor Northwest University School of Nursing Kirkland, Washington

Jennifer D. M. Cook, PhD, MBA, RN, CNS Professor Emeritus Adjunct Professor University of the Incarnate Word San Antonio, Texas

Laura Crouch, EdD, RN, CPAN, CNE Associate Clinical Professor Northern Arizona University Flagstaff, Arizona

Cheryl A. Crowe, MS, RN Instructor Saint Francis College of Nursing Peoria, Illinois

Holly J. Diesel, PhD, RN Associate Professor Goldfarb School of Nursing at Barnes-Jewish College St. Louis, Missouri

Laura Dulski, RNC, CNE, MSN Assistant Professor Resurrection University Chicago, Illinois

Karen M. Estridge, DNP, RN Assistant Professor College of Nursing and Health Sciences Ashland University Mansfield, Ohio

Michelle Ficca, PhD, RN Chair and Professor Bloomsburg University of Pennsylvania Bloomsburg, Pennsylvania

Debbie Fischer, MS, RN Assistant Teaching Professor Montana State University Billings, Montana

Eileen P. Geraci, MA, PhD, ANP-C Professor Western Connecticut State University Danbury, Connecticut

Pamela G. Harrison, EdD, RN, CNE Professor Pre-Licensure Nursing Indiana Wesleyan University Marion, Indiana

Mary B. Killeen, RN, PhD, NEA-BC Associate Professor, Adjunct University of Michigan-Flint Flint, Michigan

Anita H. King, DNP, MA, FNP-BC, CDE, FAADE Professor College of Nursing University of South Alabama Mobile, Alabama

Mary Kovarna, EdD, RN Department Chair and Professor Morningside College Sioux City, Iowa

Rebecca Krepper, PhD, MBA, RN Professor Texas Woman’s University Houston, Texas

Susan Lynch, MSN, RN, CNE RN-BSN Coordinator University of North Carolina Charlotte Charlotte, North Carolina

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David Martin, MN, RN Program Director RN-BSN Program Clinical Associate Professor University of Kansas School of Nursing Kansas City, Kansas

Carrie A. McCoy, PhD, MSPH, RN, CEN, CNE Professor of Nursing Northern Kentucky University Highland Heights, Kentucky

Tammie McCoy, RN, PhD Professor and Chair BSN Program Mississippi University for Women Columbus, Mississippi

Kerry A. Milner, DNSc, RN Assistant Professor of Nursing Sacred Heart University Fairfield, Connecticut

Beatriz C. Nieto, PhD, RN Associate Professor The University of Texas–Pan American Edinburg, Texas

Elinor Nugent, PhD, APN-BC Professor Emeritus Curry College Milton, Massachusetts

Lauren E. O’Hare, EdD, RN Associate Professor of Nursing The Evelyn Spiro School of Nursing

at Wagner College Wagner College Staten Island, New York

Mary Ovitt, RN, MSN Assistant Professor Idaho State University Pocatello, Idaho

Aroha Page, PhD, RN Associate Professor Nipissing University North Bay, Ontario, Canada

Verna C. Pangman, RN, MEd, MN Senior Instructor College of Nursing University of Manitoba Winnipeg, Manitoba, Canada

Maria Rosen, PhD, APRN-BC Assistant Dean Associate Professor Massachusetts College of Pharmacy and Health

Sciences University Worcester, Massachusetts

Kevin Dean Tipton, PhD, MN, BSN, RN Associate Professor Southern Utah University Cedar City, Utah

Paulina Van, PhD, RN, CNE Associate Professor School of Nursing Samuel Merritt University Oakland, California

Laura Pruitt Walker, DHEd, MSN, RN, COI Assistant Professor of Nursing Certified Online Instructor College of Nursing Jacksonville State University Jacksonville, Alabama

Janet R. Webber, RN, BSN, MSN, EdD Professor of Nursing Director of RN-BSN Online Program Southeast Missouri State University Cape Girardeau, Missouri

Danielle White, MSN, RN Associate Professor Austin Peay State University Clarksville, Tennessee

xiv Reviewers

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Acknowledgments

I would like to thank Joanne DaCunha for helping me see that my ideas for this book could be a reality. I would also like to thank Echo Gerhart and Amy Reeve for their assistance with the editing and publishing of this project and for their encouragement throughout the entire process.

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Contents in Brief

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P a r t I Foundations and Background

C h a p t e r 1 Core Competencies for Safe and Quality Nursing Care 2

C h a p t e r 2 Health-Care Environment and Policy 27

C h a p t e r 3 Theories and Principles of Nursing Leadership and Management 45

C h a p t e r 4 Ethical and Legal Aspects 61

C h a p t e r 5 Critical Thinking and Decision Making 102

C h a p t e r 6 Effective Communication 118

P a r t I I Promotion of Patient Safety and Quality Care

C h a p t e r 7 Improving and Managing Safe and Quality Care 142

C h a p t e r 8 Health-Care Organizations 174

C h a p t e r 9 Information Technology for Safe and Quality Patient Care 195

P a r t I I I Leadership and Management Functions

C h a p t e r 10 Creating and Managing a Sustainable Workforce 212

C h a p t e r 11 Organizing Patient Care 229

C h a p t e r 12 Delegating Effectively 254

C h a p t e r 13 Creating and Sustaining a Healthy Work Environment 271

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C h a p t e r 14 Leading Change and Managing Conflict 294

C h a p t e r 15 Building and Managing Teams 313

C h a p t e r 16 Budgeting Concepts 327

P a r t I V Managing Your Future in Nursing

C h a p t e r 17 Transitioning From Student to Professional Nurse 346

Index 367

xviii Contents in Brief

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Contents

P a r t I Foundations and Background

C h a p t e r 1 Core Competencies for Safe and Quality Nursing Care 2 INSTITUTE OF MEDICINE REPORTS 3 QUALITY AND SAFETY EDUCATION FOR NURSES CORE COMPETENCIES 7

Patient-Centered Care 7 Advocacy 8 Empowerment 8 Self-Management 8 Health Literacy 9 Cultural Competence 9

OPTIMAL HEALING ENVIRONMENT 10 Teamwork and Collaboration 10

Care Coordination 12 Communication 13

Evidence-Based Practice 13 Nursing Research 15 Relationship With Quality Improvement 16 Clinical Practice Guidelines 16 Evidence-Based Management 16

Quality Improvement 17 Structure or Care Environment 18 Care Process 18 Outcomes of Care 18

Informatics 19 Information Management 19 Documentation 20

Safety 20 Human Errors and Factors 21 Standardized Protocols and Practice 22 Safety Culture 22 High-Reliability Organizations 23

CURRENT STATE OF SAFETY AND QUALITY 23

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C h a p t e r 2 Health-Care Environment and Policy 27 SYSTEMS WITHIN THE HEALTH-CARE ENVIRONMENT 28 CURRENT STATUS OF HEALTH CARE IN THE UNITED STATES 30

Access to Health Care 30 The Cost of Health Care 31 Quality of Care 33 Lack of Providers and Services 35 Lack of Health Insurance and Insurance With Limited Income 36

THE PATIENT PROTECTION AND AFFORDABLE CARE ACT 37 MEDICARE AND MEDICAID 38 HEALTH POLICY 40

C h a p t e r 3 Theories and Principles of Nursing Leadership and Management 45 HISTORICAL DEVELOPMENT OF LEADERSHIP 46

Trait Theories 46 Leadership Styles 47 Situational and Contingency Leadership Theories 47

CONTEMPORARY THEORIES OF LEADERSHIP 47 Relational Leadership Theories 48

Quantum Leadership 48 Transactional Leadership 48 Transformational Leadership 49 Connective Leadership 49

Attribution Leadership Theories 50 EMERGING LEADERSHIP THEORIES 50 PROFESSIONAL COMPETENCE IN NURSING LEADERSHIP 51 LEADERSHIP CHARACTERISTICS 51 FOLLOWERSHIP 54 MENTORSHIP 57

C h a p t e r 4 Ethical and Legal Aspects 61 ETHICAL ASPECTS OF NURSING PRACTICE 62

Morals 63 Moral Integrity 63 Moral Obligation 63

Values 64 Values Clarification 64 Core Professional Values for Nurses 64

Principles 65 Autonomy 65 Beneficence 66 Nonmaleficence 66 Justice 67 Fidelity 68 Veracity 68 Privacy 68 Confidentiality 68

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Theories 69 Utilitarianism 69 Deontology 70 Principlism 70

Codes of Ethics 70 International Council of Nurses Code of Ethics for Nurses 71 Canadian Nurses Association Code of Ethics for Registered Nurses 72 American Nurses Association Code of Ethics for Nurses With Interpretive Statements 72

Ethical Dilemmas 73 Ethical Decision Making 76 Ethics Committees 76

LEGAL ASPECTS OF NURSING PRACTICE 77 Standards for Clinical Practice 78

Nursing’s Social Policy Statement: The Essence of the Profession 78 Nursing: Scope and Standards of Practice 79

Licensure and Regulation of Nursing Practice 79 Licensure 79 Regulation 80

STATE NURSE PRACTICE ACTS 80 NATIONAL COUNCIL OF STATE BOARDS OF NURSING 80 STATE BOARDS OF NURSING 81

Federal and/or State Legislation 81 Health Insurance Portability and Accountability Act 81 Patient Self-Determination Act 82 Safe Medical Devices Act 83 Good Samaritan Laws 83 Disclosure Statutes 83 Employment Laws 84

Classifications of Law That Relate to Nursing Practice 85 Negligence and Malpractice 85

Elements of Malpractice 86 DUTY OWED THE PATIENT 87 BREACH OF THE DUTY OWED THE PATIENT 87 FORESEEABILITY OF HARM 87 CAUSATION 87 INJURY OR HARM 87

Major Categories of Malpractice 88 FAILURE TO ASSESS AND MONITOR 88 FAILURE TO FOLLOW STANDARDS OF CARE 88 FAILURE TO COMMUNICATE 89 FAILURE TO DOCUMENT 90 FAILURE TO ACT AS A PATIENT ADVOCATE 90 FAILURE TO USE EQUIPMENT IN A RESPONSIBLE MANNER 90

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Expert Witnesses 90 Liability 90

Professional Liability Insurance 93 ETHICAL AND LEGAL ISSUES 93

Advance Directives 93 Living Will 94 Do Not Resuscitate 94 Durable Power of Attorney for Health Care 95

Confidentiality and Information Security 96 Informed Consent 97 Disruptive Behavior, Incivility, and Bullying 97 Unsafe or Questionable Practice 98

C h a p t e r 5 Critical Thinking and Decision Making 102 CRITICAL THINKING 103

Elements of and Cognitive Skills for Critical Thinking 103 Reactive, Reflective, and Intuitive Thinking 105 Modeling Critical Thinking 107

DECISION MAKING 107 Decision Making and the Nursing Process 108 Tools for Decision Making 109

DECIDE Model 110 Decision-Making Grid Analysis 110 SWOT Analysis 111

Shared Decision Making 112 Appreciative Inquiry 112

C h a p t e r 6 Effective Communication 118 WHY EFFECTIVE COMMUNICATION IS CRITICAL 119 BASICS OF COMMUNICATION 120

The Communication Process 120 Verbal and Nonverbal Communication 121

Verbal Communication 121 Nonverbal Communication 122

Active Listening 123 FACTORS THAT IMPACT COMMUNICATION 124

Gender 124 Generation 124 Culture 124 Values and Perceptions 124 Personal Space 125 Environment 125 Roles and Relationships 125

FORMAL AND INFORMAL COMMUNICATION 126 TYPES OF COMMUNICATION IN A HEALTH-CARE ENVIRONMENT 127

Organizational Communication 127 Interprofessional Communication 128

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Interprofessional Team Rounding 129 TeamSTEPPS 130 SBAR 130

Intraprofessional Communication 133 Nurse-to-Nurse Transitions in Care 134

P a r t I I Promotion of Patient Safety and Quality Care

C h a p t e r 7 Improving and Managing Safe and Quality Care 142 MEDICAL ERRORS 144 CREATING A CULTURE OF SAFETY 148 PATIENT SAFETY INITIATIVES 150

Agency for Healthcare Research and Quality 150 American Nurses Association 151 National Quality Forum 151 Institute for Healthcare Improvement 152 The Joint Commission 154 World Health Organization 155

PRINCIPLES OF QUALITY IMPROVEMENT 155 MODELS FOR QUALITY IMPROVEMENT 159

Donabedian Model 159 Lean Model 160 Six Sigma Model 161 Institute for Healthcare Improvement Model of Improvement 161 Failure Modes and Effects Analysis 161 Root Cause Analysis 162

QUALITY IMPROVEMENT TOOLS 164 Run Chart 164 Bar Chart 165 Histogram 165 Fishbone Diagram 165 Flow Chart 167 Pareto Chart 167

C h a p t e r 8 Health-Care Organizations 174 BASIC ELEMENTS OF A HEALTH-CARE ORGANIZATION 175

For-Profit Versus Not-for-Profit Organizations 175 Types of Health-Care Organizations 176 Levels of Service 176

ORGANIZATIONAL STRUCTURE AND CULTURE, AND STRATEGIC PLANNING 177

Organizational Structure 177 Organizational Culture 179 Strategic Planning 179

Contents xxiii

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REGULATION AND ACCREDITATION 182 Regulation 182 Accreditation 182

The Joint Commission 183 DNV GL 183 Magnet Recognition Program 183

ORGANIZATIONAL THEORIES 188 Classical Organization Theories 189 Contemporary Organizational Theories 190

General Systems Theory 190 Complexity Theory 191 Learning Organization Theory 192

C h a p t e r 9 Information Technology for Safe and Quality Patient Care 195 UNDERSTANDING NURSING INFORMATICS 196

Basic Elements of Informatics 196 Technical Aspects of Informatics 198

Network 199 Data 199 Database 199 Data Mining 199 Interfaces 199 Decision Support Systems 200 Rules and Alerts 200 Standardized Languages 200

HOW INFORMATICS CONTRIBUTES TO PATIENT SAFETY 201 LEGISLATIVE AND REGULATORY IMPACTS ON INFORMATICS 202

Health Insurance Portability and Accountability Act 203 American Recovery and Reinvestment Act of 2009 203 Regulatory Requirements 203

INFORMATICS DEPARTMENTS 204 USE OF DATA IN INFORMATICS 204

Data Set 204 Coding 204 Data Security 205

INFORMATION SYSTEMS USED IN HEALTH CARE 205 Electronic Medication Administration Record 206 Computerized Provider Order Entry 206 Barcode Medication Administration 206 Patient Portals 206 Telehealth 206 Online Health Information 207

IMPLEMENTATION OF AN INFORMATICS PROJECT 207 Conversion Strategy and Conversion Planning 207 Implementation Support Model 208 Maintenance 208 System Downtime 208

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P a r t I I I Leadership and Management Functions

C h a p t e r 10 Creating and Managing a Sustainable Workforce 212 CREATING A SUSTAINABLE WORKFORCE 213

Recruiting 213 Interviewing 214 Orienting 216 Retaining 217

MANAGING THE WORKFORCE 218 Managing Generational Differences 218 Coaching Staff Members 220 Appraising Performance 221 Using Corrective Action 223

C h a p t e r 11 Organizing Patient Care 229 CARE DELIVERY MODELS 230

Traditional Models 231 Total Patient Care 231 Functional Nursing 231 Team Nursing 232 Primary Nursing 232 Nursing Case Management 232

Nontraditional Models 233 Patient-Focused Care 233 Partnership Models 233 Nonclinical Models 234 Integrated Models 234

Contemporary Models 234 Professional Nursing Practice Model 234 Differentiated Nursing Practice Model 235 Clinical Nurse Leader Model 235 Synergy Model for Patient Care 236 Transforming Care at the Bedside 236 Patient- and Family-Centered Care Model 238

STAFFING FOR PATIENT SAFETY 239 Shortage of Nurses 240 Core Concepts of Staffing 241

Full-Time Equivalent 241 Productive Time 242 Average Daily Census 242 Staffing Mix 242 Workload and Units of Service 242 Unit Intensity 243 Patient Acuity 243 Skill Mix 243

RN SCOPE OF PRACTICE 243

Contents xxv

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LPN/LVN SCOPE OF PRACTICE 245 UAP SCOPE OF PRACTICE 245

Staffing Approaches 245 Patient Classification Systems 246 American Association of Nurses Principles for Safe Staffing 246 Agency for Healthcare Research and Quality Nurse Staffing Model 247 National Database of Nursing Quality Indicators Staffing Benchmarks 247

Developing and Implementing a Staffing Plan 249 Monitoring Productivity 250 Evaluating Staffing Effectiveness 251

C h a p t e r 12 Delegating Effectively 254 KEY PRINCIPLES OF DELEGATION 255

What Can and Cannot Be Delegated 257 Who Can and Cannot Delegate 258

THE FIVE RIGHTS OF DELEGATION 259 Right Task 259 Right Circumstances 260 Right Person 260 Right Direction or Communication 260 Right Supervision or Evaluation 261

THE DELEGATION PROCESS 261 BARRIERS TO EFFECIVE DELEGATION 265

Delegator-Related Barriers 266 Delegatee-Related Barriers 267 Leadership- and Management-Related Barriers 267 Breaking Down Barriers 269

C h a p t e r 13 Creating and Sustaining a Healthy Work Environment 271 GUIDELINES FOR BUILDING A HEALTHY WORK ENVIRONMENT 272 SAFETY ISSUES IN A HEALTH-CARE ENVIRONMENT 275

Safe Patient Handli

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