Our Future Leaders in Nursing discussion

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. Our Future Leaders in Nursing discussion

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. Our Future Leaders in Nursing discussion

“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? Copyright of Kai Tiaki Nursing New Zealand is the property of New Zealand Nurses Organisation and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder’s express written permission. However, users may print, download, or email articles for individual use. 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) • Our Future Leaders in Nursing discussion

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 – Our Future Leaders in Nursing discussion

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) – determi …