- Email: [email protected]
Why Not a Patient Care Bundle? Improving Patient and Family Satisfaction by Bundling Evidence-Based Best Practices at the Bedside
Why Not a Patient Care Bundle? Improving Patient and Family Satisfaction by Bundling EvidenceBased Best Practices at the Bedside Linda McClarigan, BSN, MHA, RN, David Mader, BSN, RN, Shawn E. Larabie, MSN, MBA, RN, Laura Gokey, RN, and Marilyn Leitsch, RN-C
I
n today’s dynamic, fast-paced healthcare
the drivers behind each new practice and initiative,
environment, new initiatives, methods, and
implementing the “change” into daily practice is
practices are constantly being presented to frontline
often stressful and sometimes destabilizing to staff,
staff. Frequently, these initiatives are presented as
who may not be fully aware of or support the reason
“the latest and the greatest.” Sometimes, they are
behind the change. An additional obstacle to early
implemented based on the most recent dictum from
adaptation and hardwiring of the change may be a
one of the several regulatory agencies governing the
belief it is merely the latest fad, trend de jour, or fla-
healthcare environment. Occasionally, they may
vor of the day as staff wait to see if not implement-
even be rolled out as a “pet project.” Regardless of
ing the change has consequences.
www.nurseleader.com
Nurse Leader
45
A
t Adirondack Health, the nursing leadership team was working to bring multiple initiatives to the forefront and have them hardwired within the staff. Many of these initiatives have been worked on at the staff level for several years. The objectives of the bundle were to align all nursing units within the organization to the philosophy of patient- and family-centered care delivery model; to implement each initiative of the patient/family care bundle throughout the organization through education and training; and to improve patient quality outcomes and the patient/family experience within the organization by increasing the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) score for value-based purchasing.1 The nursing leadership team at Adirondack Health employed several leadership principles during this project. These principles include servant leadership, proactive leadership, evidence-based best practices, alignment of initiatives, and buy-in/staff engagement. The remainder of this article will discuss these principles and how the leadership team applied these to the project.
LEADERSHIP PRINCIPLES Servant Leadership Many organizations have adopted servant leadership as their management philosophy. “The serving leader revolves around a state of being and traits consistent with the notion of holistic care or treating the whole person including the mind, body, and spirit rather than simply the body or disease.”2 According to Greenleaf,3 the 10 principles of servant leadership are listening, empathy, healing, awareness, persuasion, conceptualization, foresight, stewardship, commitment to the growth of people, and building community. The nursing leadership team at Adirondack Health used several of these principles in the initiation of the patient/family-centered care bundle. Many of the initiatives brought into the bundle were born out of the hospital’s long-standing nurse practice committee, driven by frontline staff. Inspiring and supporting innovation and creativity among frontline is key. Providing staff with the proper tools and environment to perform well at their job is the responsibility of the servant leader. If some of those tools are missing, the nurse can go off track and not pay full attention to what the needs of the patients are. This leadership team understands its obligation to help solve problems, provide guidance, and foster clinical growth among the staff. With the tools provided in the bundle, the nursing staff is able to focus on the goal of meeting individual patient needs by taking the time to maximize the patient/family experience. Proactive leadership Instead of problem solving in a reactionary fashion, the nursing leadership team at Adirondack Health decided to pursue a proactive leadership position. This was done through thinking strategically and outlining a vision of what excellent, patient-centered care should look like at Adirondack Health. “A compelling vision for what a company stands for and
46
Nurse Leader
does can provide considerable motivation for staff…the right vision can infuse workers with a sense of purpose they apply to otherwise menial tasks.”4 The leadership team decided not to roll out random individual initiatives. The team wanted to frame the initiatives within a larger context (patient-centered care) to create a unified vision. Engaging in proactive leadership begins with the leadership team. If a team does not work well together, or is unable to bring their issues to the table without fear of reprisal, how can the leadership team expect their staff to work together and succeed on a project? Fostering a leadership team that promotes diversity, encourages creativity, and respects differences is crucial to obtaining the best outcome. Proactive leaders lead by example. This will allow staff to emulate the behaviors modeled by the leadership team, collaborate together, and work through differences in opinion, all while pursuing the same shared vision. Evidence-Based Best Practice and Bundling To provide excellent patient care every day, nurse executives and leaders of today must realign priorities and systems, maximizing evidence-based practices, and focus on specific quality initiatives that have predictable outcomes to enable the organization’s success. The evidence-based best practices included in the bundle at Adirondack Health have been written about in many professional journals. Based on our research abstract, we used the following: bedside shift-toshift report using situation, background, assessment, and recommendations (SBAR), use of white boards, rounding, the Silent Hospitals Help Healing (SHHH) program, discharge processes, individualized patient care, and nursing excellence expectations. Using bundles helps to solve problems related to: high uncertainty, low predictability, frequent interruptions, and poor outcomes. The theory behind care bundles is that when several evidence-based interventions are grouped together in a single cluster of care, it will improve patient outcomes. The process used in developing the bundle was the plan, do, check, act (PDCA) methodology. The steps performed included: 1. Identify an area for improvement (patient satisfaction scores). 2. Research the cluster of practices that show improvement. 3. Complete a literature search related to each best practice identified. 4. Prioritize each best practice according to quality outcomes. 5. Delete any practices from current repertoire that were not supported by research. 6. Develop the patient care bundle based on the researched evidence. 7. Educate all staff and hardwire education in the institution. 8. Audit and monitor HCAHPS results, share with stakeholders, and adjust as needed. Alignment of initiatives To be successful in sports, all members of the team need to be playing the same game, on the same field, using the same
December 2014
playbook, and working together to run the plays at the same time. This also applies to any project a team within a hospital is implementing. There were several places where alignment needed to occur for Adirondack Health’s nursing department to make this bundle project work. First, the nursing leadership team needed to decide which initiatives would become part of the bundle. As was said earlier, the hospital’s nurse practice committee had worked on several of these initiatives for quite some time, but struggled with full implementation of them. Because of this, those that were already started were automatically included in the bundle. Once the initiatives were selected for the bundle, the leadership team had to align themselves as the change drivers. Alignment of the organizational leadership ensured frontline staff would implement the selected initiatives consistently throughout the hospital. Without a solid leadership front, staff may not fully engage in the project and will wait for it to become old news. Lastly, nursing leadership needed to align staff with the bundle and make it part of their everyday routine. This was accomplished by teaching 100% of the nursing staff about the bundle. To ensure consistency of each class, a teaching guideline and PowerPoint presentation were developed. Leadership held practice sessions to build confidence and familiarity with the material to bring credibility to the content and alignment of the team. Staff ’s perception of leadership’s commitment is imperative to the success of any change. Leaders need to be aligned in their initiatives. Buy-In (Top-Down)/Staff Engagement With any new initiative or project, whether it is in business or healthcare, getting those on your team to support it can be a challenge. Scott Whitaker5 states, “A new initiative without staff support is like dough without yeast: work as you might, you’ll never get it to rise to success.” You’ll need the right approach to change the most adverse staff in order for the “buy-in” to take hold. How did the leadership team encourage the nurses at Adirondack Health to get on board with the patient care bundle? The leadership team came together and identified the change, the improvement goals, and strategies. The best practices were derived from evidence-based ideas already in place or suggested by our nurse practice committee. Staff input during development was crucial because it provided ownership and buy-in from the team. Our senior leadership team was challenged with “making the case for change,” because it is critical from the outset that frontline personnel know exactly why the changes are being made and what the anticipated goals, outcomes, and expectations are. The team met regularly to develop an educational presentation seeking to do just that: make the case for change. Our leadership team was committed to presenting a unified message with top-down support and commitment. The educational program was mandatory for all nursing personnel and has become an integral part of new-employee orientation across the organization. The chief nursing officer opened the presentation with an overview of the mission and the components of patient-centered care. The nursing directors each presented key topics,` such as communication, SHHH www.nurseleader.com
program, discharge processes, etc., and shared personal narratives from practice to illuminate each key principle and integrate emotion into each concept. Emotion can help drive and support the needed changes. Sustainability Sustaining a positive impact: the bundle as a whole, the innovations in improved processes, the renewed approach to patientcentered care, and the resulting change in culture have clearly made a difference in HCAHPS performance. Sustaining a positive impact on HCAHPS survey results and non-HCAHPS patient satisfaction measures depended on a top-down leadership commitment. Adirondack Health leadership teams round daily to ensure adherence to the care bundle initiatives. While speaking with patients, families and the staff, careful attention is paid to the components of the bundle, i.e., maintenance of the white boards, reducing noise levels, bedside shift-to-shift reporting, use of SBAR handoffs, and observing for patient-centered nursing interactions. Any lapse in processes is immediately reviewed and acted upon according to our process improvement model. All findings are reviewed with direct care staff. Ongoing encouragement, education, and shared vision all help to keep this initiative active and staff engaged. This is accomplished through sharing at staff meetings, round the clock meetings with the chief nursing officer, annual competency training, and posting of monthly HCAHPS results and comments. Our experience demonstrates that encouraging and rewarding positive outcomes at every level can propel an organization forward in improving patient satisfaction. Embracing innovative change positively affects the way hospitals deliver care. Empowering staff to lead innovative efforts has positively influenced patient-centered care and has reshaped the culture. This ensures that everyone, at every level of responsibility, initiates changes to meet or exceed expectations of the patient and/or family. Efforts such as these are critical as institutions situate themselves to achieve optimal reimbursement based on patient satisfaction ratings. In a time when healthcare is changing rapidly, and the future is unclear, Adirondack Health believes embracing and innovating change positively affects the way hospitals deliver care. To steer healthcare organizations toward success, they must invest in processes that support frontline staff. “Nurses will play a fundamental role in shaping the new paradigm of healthcare.”6
RESULTS As can be seen in Figure 1, Adirondack Health has been fortunate to see a statistically significant increase in the top box percentage points on our HCAHPS scores. Although the organization is not exactly at their satisfaction goals, trend lines continue to move in an upward trajectory. Further review and changes to the bundle will help keep the initiatives out in front of the staff and stay current with new evidence-based research.
CONCLUSION Patient satisfaction and improved quality outcomes should be a priority for every healthcare organization.
Nurse Leader
47
Figure 1. HCAHPS SCORES April 2013 Thru March 2014
Implementing change into practice has become a recurring theme for frontline staff as well as for leadership, and it is necessary if an organization wishes, not only to survive, but to remain vibrant and thrive. The constant waves of change can negatively impact care delivery and be demotivating to staff if not implemented correctly. The leadership team at Adirondack Health utilized several leadership principles to successfully create a shared vision of optimal patient-centered care and obtain staff buy-in and drive the desired change. In so doing, the leadership team redesigned the culture of care within the organization. As a result of this change, positive results are being realized and scores continue to rise. So, we ask, why not a patient care bundle for your organization? NL
Linda McClarigan, BSN, MHA, RN, is CNO at Adirondack Health in Saranac Lake, New York. She can be reached at [email protected]. David Mader, BSN, RN, is Patient Care coordinator; Shawn E. Larabie, MSN, MBA, RN, is Patient Care director for the Emergency Department, Intensive Care Unit, and Program Director for the Colby Senior Behavioral Health Unit; Laura Gokey, RN, is Patient Care director of the Medical/Surgical and Renal Dialysis Units; Marilyn Leitsch, RN-C, is Patient Care director for Perinatal Services at Adirondack Health in Saranac Lake, New York. 1541-4612/2014/ $ See front matter Copyright 2014 by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.mnl.2014.09.004
References 1. Resar R, Griffen FA, Haraden C. Nolan TW. Using Care Bundles to Improve Health Care Quality. IHI Innovation Series White Paper. Cambridge, MA: Institute for Healthcare Improvement; 2012. 2. Nagel C, Andenoro AC. Healing leadership: the serving leader’s impact on patient outcomes in a clinical environment. J Healthc Leadership. 2012;4:25-31. 3. Greenleaf RK. Servant Leadership: A Journey Into the Nature of Legitimate Power and Greatness. 25th Anniversary ed. Mahwah, NJ: Paulist Press; 2002. 4. Dontigney E. Describe the Characteristics of a Proactive Leader. AZ Central Web site. http://yourbusiness.azcentral.com/ describe-characteristics-proactive-leader-21160.html. Accessed June 12, 2014. 5. Whitaker S. Who's With Me? (Building Staff Buy-In). November 2008. http://www.asaecenter.org/Resources/ANowDetail.cfm?ItemNumber⫽37217. Accessed June 22, 2014. 6. Dias J. 9 Inspiring Quotes for Nurse Leaders from AONE 2014. http://epatientexperience.com/9-inspiring-quotes-for-nurse-leaders-fromaone-2014/. Accessed June 20, 2014.
48
Nurse Leader
December 2014
I
n today’s dynamic, fast-paced healthcare
the drivers behind each new practice and initiative,
environment, new initiatives, methods, and
implementing the “change” into daily practice is
practices are constantly being presented to frontline
often stressful and sometimes destabilizing to staff,
staff. Frequently, these initiatives are presented as
who may not be fully aware of or support the reason
“the latest and the greatest.” Sometimes, they are
behind the change. An additional obstacle to early
implemented based on the most recent dictum from
adaptation and hardwiring of the change may be a
one of the several regulatory agencies governing the
belief it is merely the latest fad, trend de jour, or fla-
healthcare environment. Occasionally, they may
vor of the day as staff wait to see if not implement-
even be rolled out as a “pet project.” Regardless of
ing the change has consequences.
www.nurseleader.com
Nurse Leader
45
A
t Adirondack Health, the nursing leadership team was working to bring multiple initiatives to the forefront and have them hardwired within the staff. Many of these initiatives have been worked on at the staff level for several years. The objectives of the bundle were to align all nursing units within the organization to the philosophy of patient- and family-centered care delivery model; to implement each initiative of the patient/family care bundle throughout the organization through education and training; and to improve patient quality outcomes and the patient/family experience within the organization by increasing the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) score for value-based purchasing.1 The nursing leadership team at Adirondack Health employed several leadership principles during this project. These principles include servant leadership, proactive leadership, evidence-based best practices, alignment of initiatives, and buy-in/staff engagement. The remainder of this article will discuss these principles and how the leadership team applied these to the project.
LEADERSHIP PRINCIPLES Servant Leadership Many organizations have adopted servant leadership as their management philosophy. “The serving leader revolves around a state of being and traits consistent with the notion of holistic care or treating the whole person including the mind, body, and spirit rather than simply the body or disease.”2 According to Greenleaf,3 the 10 principles of servant leadership are listening, empathy, healing, awareness, persuasion, conceptualization, foresight, stewardship, commitment to the growth of people, and building community. The nursing leadership team at Adirondack Health used several of these principles in the initiation of the patient/family-centered care bundle. Many of the initiatives brought into the bundle were born out of the hospital’s long-standing nurse practice committee, driven by frontline staff. Inspiring and supporting innovation and creativity among frontline is key. Providing staff with the proper tools and environment to perform well at their job is the responsibility of the servant leader. If some of those tools are missing, the nurse can go off track and not pay full attention to what the needs of the patients are. This leadership team understands its obligation to help solve problems, provide guidance, and foster clinical growth among the staff. With the tools provided in the bundle, the nursing staff is able to focus on the goal of meeting individual patient needs by taking the time to maximize the patient/family experience. Proactive leadership Instead of problem solving in a reactionary fashion, the nursing leadership team at Adirondack Health decided to pursue a proactive leadership position. This was done through thinking strategically and outlining a vision of what excellent, patient-centered care should look like at Adirondack Health. “A compelling vision for what a company stands for and
46
Nurse Leader
does can provide considerable motivation for staff…the right vision can infuse workers with a sense of purpose they apply to otherwise menial tasks.”4 The leadership team decided not to roll out random individual initiatives. The team wanted to frame the initiatives within a larger context (patient-centered care) to create a unified vision. Engaging in proactive leadership begins with the leadership team. If a team does not work well together, or is unable to bring their issues to the table without fear of reprisal, how can the leadership team expect their staff to work together and succeed on a project? Fostering a leadership team that promotes diversity, encourages creativity, and respects differences is crucial to obtaining the best outcome. Proactive leaders lead by example. This will allow staff to emulate the behaviors modeled by the leadership team, collaborate together, and work through differences in opinion, all while pursuing the same shared vision. Evidence-Based Best Practice and Bundling To provide excellent patient care every day, nurse executives and leaders of today must realign priorities and systems, maximizing evidence-based practices, and focus on specific quality initiatives that have predictable outcomes to enable the organization’s success. The evidence-based best practices included in the bundle at Adirondack Health have been written about in many professional journals. Based on our research abstract, we used the following: bedside shift-toshift report using situation, background, assessment, and recommendations (SBAR), use of white boards, rounding, the Silent Hospitals Help Healing (SHHH) program, discharge processes, individualized patient care, and nursing excellence expectations. Using bundles helps to solve problems related to: high uncertainty, low predictability, frequent interruptions, and poor outcomes. The theory behind care bundles is that when several evidence-based interventions are grouped together in a single cluster of care, it will improve patient outcomes. The process used in developing the bundle was the plan, do, check, act (PDCA) methodology. The steps performed included: 1. Identify an area for improvement (patient satisfaction scores). 2. Research the cluster of practices that show improvement. 3. Complete a literature search related to each best practice identified. 4. Prioritize each best practice according to quality outcomes. 5. Delete any practices from current repertoire that were not supported by research. 6. Develop the patient care bundle based on the researched evidence. 7. Educate all staff and hardwire education in the institution. 8. Audit and monitor HCAHPS results, share with stakeholders, and adjust as needed. Alignment of initiatives To be successful in sports, all members of the team need to be playing the same game, on the same field, using the same
December 2014
playbook, and working together to run the plays at the same time. This also applies to any project a team within a hospital is implementing. There were several places where alignment needed to occur for Adirondack Health’s nursing department to make this bundle project work. First, the nursing leadership team needed to decide which initiatives would become part of the bundle. As was said earlier, the hospital’s nurse practice committee had worked on several of these initiatives for quite some time, but struggled with full implementation of them. Because of this, those that were already started were automatically included in the bundle. Once the initiatives were selected for the bundle, the leadership team had to align themselves as the change drivers. Alignment of the organizational leadership ensured frontline staff would implement the selected initiatives consistently throughout the hospital. Without a solid leadership front, staff may not fully engage in the project and will wait for it to become old news. Lastly, nursing leadership needed to align staff with the bundle and make it part of their everyday routine. This was accomplished by teaching 100% of the nursing staff about the bundle. To ensure consistency of each class, a teaching guideline and PowerPoint presentation were developed. Leadership held practice sessions to build confidence and familiarity with the material to bring credibility to the content and alignment of the team. Staff ’s perception of leadership’s commitment is imperative to the success of any change. Leaders need to be aligned in their initiatives. Buy-In (Top-Down)/Staff Engagement With any new initiative or project, whether it is in business or healthcare, getting those on your team to support it can be a challenge. Scott Whitaker5 states, “A new initiative without staff support is like dough without yeast: work as you might, you’ll never get it to rise to success.” You’ll need the right approach to change the most adverse staff in order for the “buy-in” to take hold. How did the leadership team encourage the nurses at Adirondack Health to get on board with the patient care bundle? The leadership team came together and identified the change, the improvement goals, and strategies. The best practices were derived from evidence-based ideas already in place or suggested by our nurse practice committee. Staff input during development was crucial because it provided ownership and buy-in from the team. Our senior leadership team was challenged with “making the case for change,” because it is critical from the outset that frontline personnel know exactly why the changes are being made and what the anticipated goals, outcomes, and expectations are. The team met regularly to develop an educational presentation seeking to do just that: make the case for change. Our leadership team was committed to presenting a unified message with top-down support and commitment. The educational program was mandatory for all nursing personnel and has become an integral part of new-employee orientation across the organization. The chief nursing officer opened the presentation with an overview of the mission and the components of patient-centered care. The nursing directors each presented key topics,` such as communication, SHHH www.nurseleader.com
program, discharge processes, etc., and shared personal narratives from practice to illuminate each key principle and integrate emotion into each concept. Emotion can help drive and support the needed changes. Sustainability Sustaining a positive impact: the bundle as a whole, the innovations in improved processes, the renewed approach to patientcentered care, and the resulting change in culture have clearly made a difference in HCAHPS performance. Sustaining a positive impact on HCAHPS survey results and non-HCAHPS patient satisfaction measures depended on a top-down leadership commitment. Adirondack Health leadership teams round daily to ensure adherence to the care bundle initiatives. While speaking with patients, families and the staff, careful attention is paid to the components of the bundle, i.e., maintenance of the white boards, reducing noise levels, bedside shift-to-shift reporting, use of SBAR handoffs, and observing for patient-centered nursing interactions. Any lapse in processes is immediately reviewed and acted upon according to our process improvement model. All findings are reviewed with direct care staff. Ongoing encouragement, education, and shared vision all help to keep this initiative active and staff engaged. This is accomplished through sharing at staff meetings, round the clock meetings with the chief nursing officer, annual competency training, and posting of monthly HCAHPS results and comments. Our experience demonstrates that encouraging and rewarding positive outcomes at every level can propel an organization forward in improving patient satisfaction. Embracing innovative change positively affects the way hospitals deliver care. Empowering staff to lead innovative efforts has positively influenced patient-centered care and has reshaped the culture. This ensures that everyone, at every level of responsibility, initiates changes to meet or exceed expectations of the patient and/or family. Efforts such as these are critical as institutions situate themselves to achieve optimal reimbursement based on patient satisfaction ratings. In a time when healthcare is changing rapidly, and the future is unclear, Adirondack Health believes embracing and innovating change positively affects the way hospitals deliver care. To steer healthcare organizations toward success, they must invest in processes that support frontline staff. “Nurses will play a fundamental role in shaping the new paradigm of healthcare.”6
RESULTS As can be seen in Figure 1, Adirondack Health has been fortunate to see a statistically significant increase in the top box percentage points on our HCAHPS scores. Although the organization is not exactly at their satisfaction goals, trend lines continue to move in an upward trajectory. Further review and changes to the bundle will help keep the initiatives out in front of the staff and stay current with new evidence-based research.
CONCLUSION Patient satisfaction and improved quality outcomes should be a priority for every healthcare organization.
Nurse Leader
47
Figure 1. HCAHPS SCORES April 2013 Thru March 2014
Implementing change into practice has become a recurring theme for frontline staff as well as for leadership, and it is necessary if an organization wishes, not only to survive, but to remain vibrant and thrive. The constant waves of change can negatively impact care delivery and be demotivating to staff if not implemented correctly. The leadership team at Adirondack Health utilized several leadership principles to successfully create a shared vision of optimal patient-centered care and obtain staff buy-in and drive the desired change. In so doing, the leadership team redesigned the culture of care within the organization. As a result of this change, positive results are being realized and scores continue to rise. So, we ask, why not a patient care bundle for your organization? NL
Linda McClarigan, BSN, MHA, RN, is CNO at Adirondack Health in Saranac Lake, New York. She can be reached at [email protected]. David Mader, BSN, RN, is Patient Care coordinator; Shawn E. Larabie, MSN, MBA, RN, is Patient Care director for the Emergency Department, Intensive Care Unit, and Program Director for the Colby Senior Behavioral Health Unit; Laura Gokey, RN, is Patient Care director of the Medical/Surgical and Renal Dialysis Units; Marilyn Leitsch, RN-C, is Patient Care director for Perinatal Services at Adirondack Health in Saranac Lake, New York. 1541-4612/2014/ $ See front matter Copyright 2014 by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.mnl.2014.09.004
References 1. Resar R, Griffen FA, Haraden C. Nolan TW. Using Care Bundles to Improve Health Care Quality. IHI Innovation Series White Paper. Cambridge, MA: Institute for Healthcare Improvement; 2012. 2. Nagel C, Andenoro AC. Healing leadership: the serving leader’s impact on patient outcomes in a clinical environment. J Healthc Leadership. 2012;4:25-31. 3. Greenleaf RK. Servant Leadership: A Journey Into the Nature of Legitimate Power and Greatness. 25th Anniversary ed. Mahwah, NJ: Paulist Press; 2002. 4. Dontigney E. Describe the Characteristics of a Proactive Leader. AZ Central Web site. http://yourbusiness.azcentral.com/ describe-characteristics-proactive-leader-21160.html. Accessed June 12, 2014. 5. Whitaker S. Who's With Me? (Building Staff Buy-In). November 2008. http://www.asaecenter.org/Resources/ANowDetail.cfm?ItemNumber⫽37217. Accessed June 22, 2014. 6. Dias J. 9 Inspiring Quotes for Nurse Leaders from AONE 2014. http://epatientexperience.com/9-inspiring-quotes-for-nurse-leaders-fromaone-2014/. Accessed June 20, 2014.
48
Nurse Leader
December 2014