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Wakefield, M. Putting patients first: Improving patient safety through collaborative education. Washington DC: Author. William M. Mercer Inc. Attracting and retaining registered nurses - survey results. Woodtli, A. Senior internship: A strategy for recruitment, retention and collaboration. Nursing Connections , 1 3 , Decentralization as a determinant of autonomy job satisfaction, and organizational commitment among nurse managers. Nursing Research, 46 1 , Adams, A.

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A causal model of voluntary turnover among nursing personnel in long-term psychiatric settings. Research in Nursing and Health, 21, Amid nursing shortages, schools employ strategies to boost enrollment. Position Statement: The baccalaureate degree in nursing as minimal preparation for professional practice. American Association of Colleges of Nursing.

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Essential clinical resources for nursing's academic mission. Joint position statement on education for nurses in administrative roles. Nurse staffing in California hospitals Sacramento, CA: Author. Survey on nurses' working environment. A role delineation survey of baccalaureate, diploma, and associate degree nurses. Strategies to reverse the new nursing shortage: Tri-Council policy statement, January Nurse recruitment and retention study.

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Nursing Spectrum, 10A 2 , NJ4. Gothberg, S. Retention of nurses: an organizational priority. Nursing Economics, 19 6 , Health Resources and Services Administration National survey cites slowdown in number of registered nurses entering profession, , Washington, DC: Author. Collaborative education to ensure patient safety. Hendrickson, M. Nursing intern program eases new graduates into career. Nursingmatters , 10 2 , 1, 9. Hinshaw, A. Nursing staff turnover, stress, and satisfaction: Models, measures, and management. Annual Review of Nursing Research, 1 , Institute of Medicine Crossing the quality chasm, a new health system for the 21st century.

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Journal of Advanced Nursing, 30 1 , Healthy People , second edition. Vance, C. Annual Review of Nursing Research, 9, Ventura, M. Staffing issues-ethics on the job: A survey, part 4. RN, 62 2 , Appendix A. Does the organization have a written philosophy and mission statement that reflect an emphasis on quality, safety, interdisciplinary collaboration, continuity of care, and professional nursing accountability?

Does the organization have committees with nursing representation that provide input into policy development and operational management of issues related to quality of care, safety, continuity of care, patient-staff ratios, and clinical outcomes? Does the organization have a formal mechanism for quality assurance that includes criteria to assess whether nursing practice is based on the most current research evidence?

What is the nurse-to-patient ratio? What support staff are available on the unit to assist nurses? Request a copy of the job description s of the registered nurse. How does the organization hold professional nurses accountable for high quality practice? Does the annual performance evaluation have explicit criteria related to level of practice expertise? Are there differentiated practice levels or roles for nursing congruent with differences in educational preparation, certification, and other advanced preparation in nursing i.

Does the organization have differentiated pay scales that recognize role distinctions and educational preparation among staff nurses? Does the organization recognize professional role distinctions among all disciplines by title on nametags, etc? Promote executive level nursing leadership. Request a copy of the job description. Request a copy of the organizational chart of the governing body and hospital structure to determine: Where is the top nursing voice in the organizational chart?

Where are nurses represented in key committees and activities of governance? What resources and functions fall under the domain of the nurse executive? What professional development, educational, and research functions are included in nursing services? Do nurses control decisions directly related to nursing practice and delivery of nursing care, such as staffing, nursing quality improvement, and peer review? Do nurses have input into the systems, equipment, and environment of care? How is nurse staffing addressed in the hospital plan of care? Request a copy of the hospital plan of care.

What issues are evident in the performance improvement plans for this department? What role is defined for nursing staff in the unit plan? How does this system influence daily staffing? Request a copy of the hospital performance improvement plan to determine: Is the role of nursing evident? What are the key issues reflected in this overall hospital plan? Are bachelor's prepared graduates distinguished from other nursing personnel in terms of: Employment responsibilities?

Opportunities for advancement and promotion? Initial pay schedule or salary? If yes, what are the differences? What rewards based on educational preparation are available? How are clinical competencies and professional contributions evaluated? How does this evaluation relate to the promotion process? Does the evaluation of clinical advancement, competencies, and professional contributions include consideration of: Patient satisfaction?

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Self-initiated education? Dissemination of clinical information, e. Improvement of clinical outcomes and efficiency? Evidence-based practice? Ability to delegate to and guide non-bachelor's prepared nursing staff? Serving as mentor, consultant, or preceptor to students and recent graduates? Demonstrated ability to work in an interdisciplinary context? Leadership role in institutional self-governance and practice committees? How are nurses recognized for meeting the professional practice criteria listed above, e. How do peers, patients, and supervisors provide input into the review process?

Request a copy of procedures or information regarding the performance evaluation process and any clinical advancement system: Is peer review included in this process? What are salary increases based on? Demonstrate professional development support for nurses. What resources are committed to the ongoing professional development of nurses, i. Practitioners must disclose to patients any pertinent actual or potential conflict of interest that is involved in a consultation relationship, including financial incentives or penalties or restrictive guidelines truth-telling.

Definitions: Levels of Consultation Consultation is the act of seeking assistance from another physician s or health care professional s for diagnostic studies, therapeutic interventions, or other services that may benefit the patient. Their descriptions are as follows: A single-visit consultation involves examination of the patient or the patient's medical record and performance of diagnostic tests or therapeutic procedures.

The findings, procedures, and recommendations of the consultant are recorded in the patient's medical record or provided to the practitioner with the primary clinical responsibility for the patient in a written report or letter, and a fee may be charged. The subsequent care of the patient continues to be provided by the referring practitioner.

Examples of such consultations are confirming the findings of a pelvic examination, performing a specific urodynamic procedure on a patient with urinary stress incontinence, and interpreting an electronic fetal monitoring tracing or imaging studies. In the latter two cases, the tracing or other output can be transmitted electronically, allowing for the performance of a single-visit consultation without personal contact between the patient and consultant. Continuing collaborative care describes a relationship in which the consultant provides ongoing care in conjunction with the referring practitioner.

Thus, the consultant assumes at least partial responsibility for the patient's care. An example is a high-risk obstetric patient with a medical complication of pregnancy who is periodically assessed by the consultant, whereas the referring practitioner is responsible for the day-to-day management of the patient. Transfer of primary clinical responsibility to the consultant may be appropriate for the management of problems outside the scope of the referring practitioner's education, training, and experience or in cases in which the patient must be transferred to another facility.

Examples are the transfer of care of a patient in preterm labor from a birth center to a consultant in a perinatal center or referral of a patient with ovarian cancer to a gynecologic oncologist. In many of these situations, patients will eventually return to the care of the referring practitioner when the problem for which the consultation was sought is resolved. Responsibilities Associated with Consultation Seeking Consultation and Requesting Referral Consultations usually are sought when practitioners with primary clinical responsibility recognize conditions or situations that are beyond their level of expertise or available resources.

Giving Consultation and Accepting Referral Physicians generally provide consultations or accept referred patients in the interest of providing excellent care for patients and promoting good relationships among colleagues. Practical Recommendations Providing optimal care demands a good working relationship with a number of other physicians and health care professionals.

Responsibilities of the Referring Practitioner The responsibilities of the referring practitioner can be outlined as follows: The referring practitioner should request consultation in a timely manner, whenever possible before an emergency arises. A good working relationship between the referring practitioner and the consultant requires shared concern for the patient's needs and a commitment to timely and clear-cut communication.

The referring practitioner is responsible for preparing the patient with an explanation of the reasons for consultation, the steps involved, and the names of qualified consultants. The referring practitioner should provide a summary of the history, results of the physical examination, laboratory findings, and any other information that may facilitate the consultant's evaluation and recommendations Whenever possible, the referring practitioner should document in the medical record the indications for the consultation and specific issues to be addressed by the consultant.

The referring practitioner should discuss the consultant's report with the patient and give his or her own recommendation based on all available data in order to serve the best interest of the patient. A complex clinical situation may call for multiple consultations. Unless authority has been transferred elsewhere, the responsibility for the patient's care should rest with the referring practitioner 3. This practitioner should remain in charge of communication with the patient and coordinate the overall care on the basis of information derived from the consultants.

This will ensure a coordinated effort that remains in the patient's best interest. Responsibilities of the Consultant The responsibilities of the consultant can be outlined as follows: Consultants should recognize their individual boundaries of expertise and provide only those medically accepted services and technical procedures for which they are qualified by education, training, and experience. When asked to provide consultation, the consultant should do so in a timely manner and without regard to the specialty designation or qualifications of the referring practitioner.

The consultant should effectively communicate findings, procedures performed, and recommendations to the referring practitioner at the earliest opportunity A summary of the consultation should be included in the medical record or sent in writing to the referring practitioner. The extent to which the consultant will be involved in the ongoing care of the patient should be clearly established by mutual agreement of the consultant, the referring practitioner, and the patient.

At times it may be appropriate for the consultant to assume primary clinical responsibility for the patient. Even if this is only a temporary circumstance, the consultant should obtain the referring practitioner's cooperation and assent, whenever possible. When the consultant does not have primary clinical responsibility for the patient, he or she should try to obtain concurrence for major procedures or additional consultants from the referring practitioner.

In all that is done, the consultant must respect the relationship between the patient and the referring practitioner, being careful not to diminish inappropriately the patient's confidence in her other caregivers 3. The consultant should be cognizant of the referring practitioner's abilities, and the consultant and referring practitioner should discuss who can best provide the agreed-upon care.

Job Descriptions and Contracts in Critical Care eBook

Reliance on the referring practitioner's abilities may increase convenience to the patient, limit transportation needs, and ultimately result in more cost-effective care. In other cases, however, it may not be possible for the consultant's recommendations to be addressed adequately by the referring practitioner. If the consultant believes that the referring practitioner is not qualified to provide an appropriate level of continuing care, the consultant should recommend to the referring practitioner and, if necessary, to the patient that the referring practitioner transfer care of the patient.

References American Medical Association. Referral of patients. In: Code of medical ethics of the American Medical Association: current opinions with annotations. Code of professional ethics of the American College of Obstetricians and Gynecologists. Available at: acog. Ethics manual: fifth edition. Ann Intern Med ;— Physicians working with physicians. In: The assistant: information for improved risk management.