The Nursing Bylaws for Shared Governance

HAHV Nursing Bylaws Page 1 The Nursing Bylaws for Shared Governance Approved by the Coordinating Council on 3/28/2012 Edited and approved by the Coordinating Council on 8/22/2012 SHARED GOVERNANCE Coordinating Leadership Quality & Safety Practice & Professional Development NURSING COUNCILS

HAHV Nursing Bylaws Page 2 Table of Contents Article I: Preamble Section 1: Purpose and Objectives Section 2: Definitions Article II: Roles Section 1: Role of the Professional Nurse (RN) Section 2: Expectations and Accountability Article III: Nursing Services Section 1: PCS Division of Nursing- Role Section 2: Shared Governance s Integration Article IV: Nursing Governance Structure Section 1: Councils Section 2: The Coordinating Council Section 3: The Patient Care Leadership Council Section 4: The Practice and Professional Development Council Section 5: The Quality and Safety Council Section 6: The Unit/ Department Council Article V: Amendments Appendices: Appendix A- New York State Article 139; ANA Code of Ethics; Mission, Vision, Values of HAHV Appendix B- References Appendix C- The Synergy Model for Patient Care

HAHV Nursing Bylaws Page 3 ARTICLE I: PREAMBLE In accordance with the Mission, Vision, and Value statements of the HealthAlliance of the Hudson Valley (HAHV), Shared Governance shall foster team harmony within the organization with respect to the art and science of nursing, advancement of nursing practice, and the delivery of service to the community across the health care continuum. We recognize the Synergy Model as the conceptual framework to guide our practice, and support a paradigm shift that fosters a culture of excellence based on the principles of partnership, accountability, equity, and ownership. SECTION 1: Purpose and Objectives of the Bylaws Define the structure of Shared Governance for the Division of Nursing and Patient Care Services by: 1. Describing a structure for professional accountability, empowerment, standards-of-practice, development and advancement based on the Synergy Model of Patient Care. 2. Providing a framework for participation, communication, and practice decisions within the nursing division. 3. Promoting a work environment that ensures quality of patient care, encourages professional growth and personal satisfaction for nursing; thereby, enhancing recruitment and retention of nurses. SECTION 2: Definitions Shared Governance: Shared Governance is an organizational management model that is structured for shared decision making and shared leadership where the majority of the organization s decision making occurs at the point of care (i.e. bedside & unit level). Shared governance structure ensures that staff nurses can control their practice and are accountable for quality patient outcomes. Sharing power over decision-making processes related to nursing practice, results in behaviors necessary to achieve improved outcomes for patients and organizational goals. (1).

HAHV Nursing Bylaws Page 4 Synergy Model: Synergy develops when the needs of a patient, clinical-unit, or system are matched with a nurse s competencies and optimal outcomes occur. (2). Patient, Clinical-Unit, or System Characteristics Resiliency Vulnerability Stability Complexity Resource Availability Participation in Care Participation in Decision Making Predictability See Appendix C for more information. Nurse Competencies Clinical Judgment Clinical Inquiry Caring Practices Response to Diversity Advocacy/Moral Agency Facilitation of Learning Collaboration Systems Thinking Nurse Definitions: Staff Nurse/ Direct Care Nurse: A nurse that provides nursing services at the point of care (including licensed practical nurses- LPN s). Professional Nurse: A registered nurse (RN); including, nurses with an Associates, Bachelors, Masters or PhD degree. Mentor/Advisor Nurse: A professional nurse who is an expert nurse or a masters/phd prepared nurse who serves as a facilitator, guide, and leader to the novice / beginner nurses. ARTICLE II: ROLES SECTION 1: Role of the Professional Nurse (RN) Consistent with New York State Education Department (NYSED) laws, rules and regulations that govern the practice of nursing, the registered professional nurse assumes accountability for the delivery of nursing care within the HealthAlliance organization. As outlined in Article 139 6902 of NYSED, the practice of the profession of nursing as a registered professional nurse in the state of New York is defined as diagnosing and treating human responses to actual or potential health problems through such services as casefinding, health teaching, health counseling, and provision of care supportive to or restorative of life and well-being, and executing medical regimens prescribed by a licensed

HAHV Nursing Bylaws Page 5 physician, dentist or other licensed health care provider legally authorized under this title and in accordance with the commissioner's regulations. The professional nurse at the HealthAlliance is accountable to the patient and the organization for the care rendered. The RN defines and manages the organized delivery of patient care nursing services through contributions to shared governance councils, hospital committees, and unit activities. The RN will remain focused on the goal of facilitating optimum patient outcomes. SECTION 2: Expectations and Accountability All nurses hired within the HealthAlliance shall: 1. Adhere to and promote the American Nursing Association s Code of Ethics (see Appendices). 2. Promote the Values and Standards of Excellence adopted by the HealthAlliance (see Appendices). 3. Demonstrate the Synergy Model Nurse Competencies as evidenced by yearly evaluations and peer-review. 4. Demonstrate commitment to clinical and professional advancement. 5. Actively participate in unit based councils and committees. Nurses actively participating in Shared Governance shall include: 1. Staff nurses; selected by their peers and supported by their management. 2. Nurse executives, directors, managers, and clinical coordinators who provide the support, encouragement, resources, training, and boundaries necessary for success. (3) 3. Nurse advisors/mentors (defined above). ARTICLE III: HEALTHALLIANCE NURSING SERVICES SECTION 1: Patient Care Services Division of Nursing- Role The Patient Care Services Division of Nursing collaborates with the other disciplines throughout the HealthAlliance to coordinate the plan of care for patients and families within the community. The Division of Nursing is integrated with the medical staff and other disciplines that participate in patient care through participation in mutual unit/ department planning, councils, committees, policy decisions and institutional planning.

HAHV Nursing Bylaws Page 6 SECTION 2: Shared Governance s Integration Shared Governance shall be integrated into the Division of Nursing within the HealthAlliances three hospital campuses including, Margaretville Hospital, Kingston Hospital and Benedictine Hospital. NISTEL nursing employees may participate. Shared Governance may also be integrated into Mountianside Residential Care Center, and all of the outpatient services; including, but not limited to, Kingston Hospital s Dialysis Center, The Pain Center, The Breast Center, and Cardiology Rehabilitation. Involvement in Shared Governance is open to all Nurses within the HealthAlliance. ARTICLE IV: NURSING GOVERNANCE STRUCTURE SECTION 1: Councils There are four governing councils that assume the accountability and authority for managing the operation and integration of the nursing division for the HealthAlliance. They are responsible for the process and outcomes of all issues and decisions related to nursing practice, education, quality assurance, research and management. The councils include the following: The Coordinating Council The Patient Care Leadership Council The Practice & Professional Development Council The Quality & Safety Council (Removed the icon until new one approved) The Unit/Department Councils- Each specialty, department, and unit within the HealthAlliance will also have Unit/Department Councils that reflect the four governing councils on a smaller scale. Unit Councils will drive the services at the point of care and reflect their own culture and concerns within the organization. SECTION 2: The Coordinating Council A. Role. The initial purpose of this council is to provide guidance during the implementation of shared governance throughout the system. It provides oversight and assists staff and leaders with transition and communication during the implementation process. The long term purpose is to coordinate and promote communication between councils and the organization. B. Accountabilities. The Coordinating Council: 1. Coordinates all shared governance activities. 2. Defines, describes, and identifies roles within shared governance. 3. Writes, maintains and recommends revision of the bylaws.

HAHV Nursing Bylaws Page 7 4. Evaluates the progress of shared governance within the system and directs or redirects as necessary. 5. Creates subcommittees and task forces as the need arises. 6. Assists in resolution of issues that overlap two or more councils. 7. Establishes a communication process throughout the organization. C. Membership. 1. Members of the Coordinating Council are nursing representatives from each of the patient care departments and units within the Health Alliance. 2. A member may represent more than one specialty, department or unit. 3. The Chairperson, Co-Chair and Secretary are elected from among the representatives and shall be rotated and/or reviewed on a biennial basis. 4. The Chairpersons from the other councils are members. 5. A senior nursing advisor/mentor serves as a resource to the council and has a vote. 6. A representative from Nursing Administration will serve as advisor(s) to the council and will attend meetings. 8. Guests or Ad hoc members may be invited on an as needed basis. 9. Staff Representatives should serve at least two years at which time representation will be rotated or reviewed. 10. Members shall disseminate information from the council to their respective specialties, departments or units via unit-based councils, staff meetings or verbal/written communication. It is the responsibility of the council member to obtain information from a missed meeting and disseminate it to their unit(s). D. Leadership roles. 1. The Chairperson shall: Call the meetings Develop and prioritize the agenda items Facilitate decision making Speak for the Council between regularly scheduled meetings Serve for two years 2. The Co-Chairperson shall: Assist the Chairperson Take the place of the Chairperson when he/she cannot attend

HAHV Nursing Bylaws Page 8 Take over the position of Chairperson if he/she is unable to fulfill duties 3. The Secretary shall: Take the minutes for the meetings Take the place of the Chairperson or Co-Chairperson if they cannot attend meetings. E. Voting & Elections. Each member will have one vote. The nature of the decision dictates whether a vote will be taken. In most cases, a simple majority of those present will determine the outcome. Elections for leadership will be conducted biennially in November on the even years. Leaders will assume their positions in January of the odd year. F. Meetings. Meetings will be held monthly, with a minimum of ten meetings in a year. Sub committees will convene as needed and will report back to the committee monthly until their goals are accomplished. G. Quorum. Attendance of 7 members is required to meet quorum. Quorum is not necessary for meeting, but voting (i.e. approval of minutes, policy changes, etc.), does require quorum and at least 50% of quorum must consist of staff nurses. A chair or designee must be present. H. Attendance. Members are accountable for 70% attendance at meetings held. Inability to attend should be communicated to the Chair or Co-Chair. Members may send an alternate who will be responsible for communication and representation. Consistent failure to attend and/or send an alternate may result in dismissal. SECTION 3: The Patient Care Leadership Council A. Role. The purpose and responsibility of the Leadership Council is to organize and provide resource allocation, support, mentoring, advice, and protection for nursing staff at the point of care. It responds to the needs expressed by the four other governing councils and the unit-based councils. It provides system and organizational links between the Executive Members of the Health Alliance, Medical staff, and the nursing division. B. Accountabilities. The Patient Care Leadership Council: 1. Controls and allocates human, fiscal and material resources. 2. Provides accountability and mentorship for point of care nurses and facilitates their autonomy and professionalism 3. Assures compliance with regulatory requirements.

HAHV Nursing Bylaws Page 9 4. Promotes organizational, macrosystem and mesosystem interdependence. 5. Facilitates strategic planning. 6. Creates subcommittees and task forces as the need arises. 7. Members shall disseminate information from the council to their respective specialties, departments or units via unit-based councils, staff meetings or verbal/written communication. C. Membership. Members of the Leadership Council are nursing representatives from Kingston, Benedictine and Margaretville hospitals and include: - The Chief Nursing Officer - Director of Nursing - Administrative Directors - Infection Control Coordinator - Director of Quality and Performance Improvement - Director of Education - The Directors, Managers and or Clinical Coordinators of Nursing - The Chairs of the other Councils, who are point of care nurses Guests or Ad hoc members may be invited on an as needed basis. D. Voting. Each member will have one vote. The nature of the decision dictates whether a vote will be taken. A motion is passed by majority. With most issues, consensus decision-making will be employed. E. Meetings. Meetings will be held monthly, for at least one hour. There will be a minimum of ten meetings in a year. F. Attendance. Members are accountable for 70% attendance at held meetings. Inability to attend must be clearly communicated to the CNO or Director of Nursing. Failure to attend may result in dismissal. Only members or guests approved by the Chair may attend meetings. SECTION 4: The Practice and Professional Development Council A. Role. The purpose and responsibility of the Practice and Professional Development Council is to solicit or identify patient care and/or nursing practice issues and assist in the resolution of those issues. It promotes the education and professional development of the HAHV nursing personnel and also supports the philosophy that each employee has the obligation, accountability, and responsibility to be competent in his or her practice.

HAHV Nursing Bylaws Page 10 B. Accountabilities. The Practice & Professional Development Council shall: 1. Review current practice standards and evaluate the need for revisions based on evidence based research and regulatory standards. 2. Assist in nursing policy review, revision, and implementation. 3. Identify the need to evaluate and/or make recommendations regarding products, equipment, and technology that impact patient care. 4. Identify educational needs related to practice changes; assist with plan to implement the necessary education and evaluate the outcome(s). 5. Support and maintain a culture of professional development i.e. Clinical Advancement Program (CAP) participation, ongoing education and national certification(s), nursing research and evidence-based practice. 6. Create subcommittees and task forces as the need arises. 7. Members shall disseminate information from the council to their respective specialties, departments or units via unit-based councils, staff meetings or verbal/written communication. It is the responsibility of the council member to obtain information from a missed meeting and disseminate it to their unit(s). C. Membership. 1. Members of the Practice & Research Council are nursing representatives from each of the patient care departments and units within the HealthAlliance. 2. A member may represent more than one specialty, department or unit and should be selected by their unit peers. 3. The Chairperson, Co-Chair and Secretary are elected from among the representatives and shall be rotated and/or reviewed on a biennial basis. 4. A representative from Nursing Administration will serve as advisor(s) to the council and will attend meetings. 5. Unit Directors, Managers, and/or Clinical Coordinators (They may request of the Council Chair that one more of their areas be combined for the purposes of representation on the Council.)

HAHV Nursing Bylaws Page 11 6. Guests or Ad hoc members may be invited on an as needed basis. 7. Staff Representatives should serve at least two years at which time representation will be rotated or reviewed. D. Leadership roles. 1. The Chairperson shall: Call the meetings Develop and prioritize the agenda items Facilitate decision making Speak for the Council between regularly scheduled meetings Serve for two years 2. The Co-Chairperson shall: Assist the Chairperson Take the place of the Chairperson when he/she cannot attend Take over the position of Chairperson if he/she is unable to fulfill duties 3. The Secretary shall: Take the minutes for the meetings Take the place of the Chairperson or Co-Chairperson if they cannot attend meetings. E. Voting & Elections. Each member will have one vote. The nature of the decision dictates whether a vote will be taken. In most cases, a simple majority of those present will determine the outcome. Elections for leadership will be conducted biennially in November on the odd years. Leaders will assume their positions in January of the even year. F. Meetings. Meetings will be held monthly, with a minimum of ten meetings in a year. Sub committees will convene as needed and will report back to the committee monthly until their goals are accomplished. G. Quorum. Attendance of 7 members is required to meet quorum. Quorum is not necessary for meeting, but voting (i.e. approval of minutes, policy changes, etc.), does require quorum and at least 50% of quorum must consist of staff nurses. A chair or designee must be present. H. Attendance. Members are accountable for 70% attendance at meetings held. Inability to attend should be communicated to the Chair or Co-Chair. Members may send an alternate who will be responsible for communication and representation. Consistent failure to attend and/or send an alternate may result in dismissal.

HAHV Nursing Bylaws Page 12 SECTION 5: The Quality & Safety Council A. Role. The purpose of the Quality & Safety Council is to develop consistent vision and direction for continuous quality improvement processes in the Patient Care Services division (PCS). This council is accountable for the hospital and unit-specific quality improvement projects and reporting to the leadership. B. Accountabilities. The Quality & Safety Council: 1.Enhances nursing practice by establishing an ongoing quality review of incidents, standards of care and an improvement process in order to assist in the creation of excellent patient outcomes. 2.Directs outcomes by measurements that establish direct, consistent, reliable, cost-effective, and integrated quality care. 3.Incorporates nursing research findings, evidence based practice and regulatory standards into quality improvement projects. 4. Ensures appropriate process of peer review. 5. Creates subcommittees and task forces as the need arises. 6. Members shall disseminate information from the council to their respective specialties, departments or units via unit-based councils, staff meetings or verbal/written communication. It is the responsibility of the council member to obtain information from a missed meeting and disseminate it to their unit(s). C. Membership. 1. Members of the Quality & Safety Council are nursing representatives from each of the patient care departments and units within the Health Alliance. 2. A member may represent more then one specialty, department or unit and should be selected by their unit peers. 3. The Chairperson, Co-Chair and Secretary are elected from among the representatives and shall be rotated and/or reviewed on a biennial basis. 4. A representative from Nursing Administration will serve as advisor(s) to the council and will attend meetings. 5.Unit Directors, Managers, and/or Clinical Coordinators (They may request of the Council Chair that one more of their areas be combined for the purposes of representation on the Council.) 6.Guests or Ad hoc members may be invited on an as needed basis.

HAHV Nursing Bylaws Page 13 7.Staff Representatives should serve at least two years at which time representation will be rotated or reviewed. D. Leadership roles. 1. The Chairperson shall: Call the meetings Develop and prioritize the agenda items Facilitate decision making Speak for the Council between regularly scheduled meetings Serve for two years 2. The Co-Chairperson shall: Assist the Chairperson Take the place of the Chairperson when he/she cannot attend Take over the position of Chairperson if he/she is unable to fulfill duties. 3. The Secretary shall: Take the minutes for the meetings Take the place of the Chairperson or Co-Chairperson if they cannot attend meetings. E. Voting & Elections. Each member will have one vote. The nature of the decision dictates whether a vote will be taken. In most cases, a simple majority of those present will determine the outcome. Elections for leadership will be conducted biennially in November on the odd years. Leaders will assume their positions in January of the even year. F. Meetings. Meetings will be held monthly, with a minimum of ten meetings in a year. Sub committees will convene as needed and will report back to the committee monthly until their goals are accomplished. G. Quorum. Attendance of 7 members is required to meet quorum. Quorum is not necessary for meeting, but voting (i.e. approval of minutes, policy changes, etc.), does require quorum and at least 50% of quorum must consist of staff nurses. A chair or designee must be present. H. Attendance. Members are accountable for 70% attendance at meetings held. Inability to attend should be communicated to the Chair or Co-Chair. Members may send an alternate who will be responsible for communication and representation. Consistent failure to attend and/or send an alternate may result in dismissal. SECTION 6: The Unit/Department Council

HAHV Nursing Bylaws Page 14 A. Role. The purpose of the unit/department council is to facilitate communication, collaboration and decision making at the unit/department level among those involved at the point of care. B. Accountabilities. The Unit/Department Council: 1. Fosters change and problem solving within the unit related to nursing practice, quality and competency. 2. Facilitates interdisciplinary collaboration to address issues specific to the unit. 3. Supports unit based evidence-based practice and initiatives. Assures compliance to regulatory requirements in concert with unit leadership. 4. Creates unit based councils/teams (Quality & Safety, Practice & Professional Development), or subcommittees/task forces to accomplish unit based goals. * Units/departments may combine personnel to accomplish common goals. 5. Ensures that the unit s annual Quality Performance Plan is developed, implemented and maintained. 6. Addresses the unit s professional development needs and education initiatives, including orientation, ongoing education, and unit specific skills training. An annual unit based Education Plan will be developed. 7. Supports informational forums for new clinical products, equipment and procedures. 8. Provides for unit specific development or revision of policies, procedures and standards of care. 9. Creates a forum for unit based peer review. 10. Participates in the hiring of new staff. 11. Evaluates the progress of unit based shared governance activities and sends quarterly reports to the Health Alliance Coordinating Council. 12. Maintains a continuous flow of information between the Hospital-wide Shared Governance Councils and the Unit/Department Council. C. Membership. Unit representatives from each of the HA Nursing Councils

HAHV Nursing Bylaws Page 15 Chairperson- a staff nurse selected by the unit/dept. staff Co-Chair- a staff nurse selected by the unit/dept. staff Secretary- selected by the staff Unit/dept s nursing staff Advisor/Mentor- (nonvoting) Unlicensed Assistive Personnel -(nonvoting) Guest or Ad hoc members may be invited on an as needed basis. D. Leadership roles. 1. Chairperson shall: Call the meetings Develop and prioritize the agenda items Facilitate decision making Speak for the Council between regularly scheduled meetings Serve for two years 2. The Co-Chairperson shall: Assist the Chairperson Take the place of the Chairperson when he/she cannot attend Take over the position of Chairperson if he/she is unable to fulfill duties. 3. The Secretary shall: Take the minutes for the meetings E. Voting. In the majority of issues, consensus decision-making will be employed. A motion will be considered approved when passed by a minimum of 2/3 majority vote of those members present. Active members may vote only on issues that pertain to work within their scope of practice. F. Meetings. Meetings are scheduled with a minimum of 10 per year. These meetings belong to the staff and are not manager driven. Additional meetings may be warranted for specific unit/dept projects. G. Quorum. Each unit/department shall determine their quorum. H. Attendance. Members are accountable for 70% attendance at meetings held. Inability to attend should be communicated to the Chair or Co-Chair. ARTICLE V: AMENDMENTS These bylaws may be altered, amended, or replaced as needed by a quorum vote of active membership of the Coordinating Council. Any member of the hospital wide or unit/department councils may suggest changes in the bylaws. Any proposed changes may be submitted in writing to the Coordinating Council and/or Chair/ Co-Chairperson. Once the proposal has been reviewed by the Coordinating Council and an opportunity provided for the member to verbally

HAHV Nursing Bylaws Page 16 present their proposed changes, a vote will be made by the Coordinating Council. APPENDICES: Appendix A New York State Article 139, Nursing: (Effective June 18, 2010) 6901. Definitions. As used in section sixty-nine hundred two: 1. "Diagnosing" in the context of nursing practice means that identification of and discrimination between physical and psychosocial signs and symptoms essential to effective execution and management of the nursing regimen. Such diagnostic privilege is distinct from a medical diagnosis. 2. "Treating" means selection and performance of those therapeutic measures essential to the effective execution and management of the nursing regimen, and execution of any prescribed medical regimen. 3. "Human Responses" means those signs, symptoms and processes which denote the individual's interaction with an actual or potential health problem. 6902. Definition of practice of nursing. 1. The practice of the profession of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential health problems through such services as casefinding, health teaching, health counseling, and provision of care supportive to or restorative of life and well-being, and executing medical regimens prescribed by a licensed physician, dentist or other licensed health care provider legally authorized under this title and in accordance with the commissioner's regulations. A nursing regimen shall be consistent with and shall not vary any existing medical regimen. 2. The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of casefinding, health teaching, health counseling, and provision of supportive and restorative care under the direction of a registered professional nurse or

HAHV Nursing Bylaws Page 17 licensed physician, dentist or other licensed health care provider legally authorized under this title and in accordance with the commissioner's regulations. ANA Code of Ethics: See online version for viewing at http://nursingworld.org/codeofethics Mission, Vision, Values of the HealthAlliance: Mission: HealthAlliance of the Hudson Valley s purpose is to provide the highest quality health care services to all people in our communities through the distinct missions of its affiliated members. Vision: To be the destination of choice for the regional healthcare services, centering on patient care and community health, while integrating HealthAlliance s guiding principles of Quality, People, Stewardship, and Growth. Values: Our core values serve as a base and guide for all operational and strategic decisions that are made: Respect for the individual Integrity in all we do Compassionate culture of caring Excellence in services delivered Appendix B References: 1. Aizer, et al. Evidence-Based Practice Councils- Potential Path to Staff Nurse Empowerment and Leadership Growth. JONA, 2012; 28. 2. Kerfoot, et al. Conceptual Models and the Nursing Organization- Implementing the AACN Synergy Model for Patient Care. Nurse Leader, 2006; 21. 3. Swihart. Shared Governance- A Practical Approach to Transform Professional Nursing Practice 2 nd edition. 2011;18. Note: A majority of the inspiration and formatting for these bylaws were obtained by the Sample Bylaws Appendix F from Tim Porter O Grady s Shared Governance Implementation Manual, p149-163. Appendix C HealthAlliance of the Hudson Valley s Nursing Practice Model- The Synergy Model for Patient Care: The core premise of the model is that the needs of the patients and families drive the competencies of the nurse. The model was initially developed

HAHV Nursing Bylaws Page 18 to guide the Critical Care Registered Nurse certification program; however, the model is well suited to guide nursing care across every dimension of complex health care organizations. (1) Patient, Unit/Department, System Characteristics: According to the Synergy Model, each patient brings a unique set of characteristics to the health care situation. Among the many characteristics that are present, 8 are consistently seen in patients who experience critical events. These 8 characteristics are consistently assessed by nurses in variable levels given each patient situation. These Patient Characteristics, as well as other patterns that are unique to each patient s circumstances, should be assessed in every patient. Resiliency is the patient s capacity to return to a restorative level of functioning using a compensatory coping mechanism. The level of resiliency assessed in a patient is often dependent upon their ability to rebound after an insult. This ability can be influenced by many factors including age, comorbidities and compensatory mechanisms that are intact. Vulnerability is the level of susceptibility to or actual or potential stressors that may adversely affect patient outcomes. Vulnerability can be impacted by the patient s physiological make-up or health behaviors exhibited by the patient. Stability refers to the patient s ability to maintain a steady state of equilibrium. Response to therapies and nursing interventions can impact the stability of the patient. Complexity is the intricate entanglement of two or more systems. Systems refer to either physiological or emotional states of the body, family dynamics, or environmental interactions with the patient. The more systems involved, the more complex are the patterns displayed by the patient. Resource availability is the extent of resources brought to the situation by the patient, family, and community. The resources can present as technical, fiscal, personal, psychological, social, or supportive in nature. The more resources that a person brings to the health care situation, the greater the potential for a positive outcome. Participation in care is the participation by a patient and family in being engaged in the delivery of care. Patient and family participation can be influenced by educational background, resource availability, and cultural background. Participation in decision making is the level of engagement of the patient and family in comprehending the information provided by health care providers and acting on this information to execute informed decisions. Patient and family engagement in clinical decisions can be impacted by the knowledge level of the

HAHV Nursing Bylaws Page 19 patient, his capacity to make decisions given the insult, the cultural background (eg beliefs and values), and the level of inner strength during a crisis. Predictability allows one to expect a certain course of events or course of illness. (1) *The patient characteristics can also be applied to our units, departments and the organization as a whole. The definitions of these characteristics and the nursing competencies help to shape our goals. For example: Is my unit vulnerable? Does my organization have the resources to operate? Now, what can I do, as a nurse to meet my patient, unit, or organization s needs? Nurse Competencies: The Nurse Competencies can be considered as those that are essential for providing care to the critically ill. All 8 competencies reflect an integration of knowledge, skills and experience of the nurse. Clinical judgement is the clinical reasoning utilized by a health care provider in the delivery of care. It consists of critical thinking and nursing skills that are acquired through the process of integrating education, experiential knowledge, and evidenced-based guide lines. The integration of knowledge brings about the clinical decisions made during the course of care provided to the patient. Clinical inquiry is the ongoing process of questioning and evaluating practice, providing informed practice, and innovating through research and experiential learning. Clinical inquiry evolves as the nurse moves from novice to expert. Caring Practices are the constellation of nursing interventions that create a compassionate, supportive, and therapeutic environment for patients and staff, with the aim of promoting comfort and healing and preventing unnecessary suffering. Caring behaviors include compassion, vigilance, engagement, and responsiveness to the patient and family. Response to diversity is the sensitivity to recognize, appreciate, and incorporate differences into the provision of care. Nurses recognize the individuality of each patient while observing for patterns that respond to nursing interventions. Individuality can be observed in someone s spiritual beliefs, ethnicity, family configuration, lifestyle values, and use of alternative and complementary therapies. Advocacy and moral agency is working on another s behalf when the other is not capable of advocating for him/herself. The nurse serves as a moral agent in identifying and helping to resolve ethical and clinical concerns within the clinical setting.

HAHV Nursing Bylaws Page 20 Facilitation of learning means that the nurse formally and informally facilitates learning for patients, staff, and the organization. Collaboration is the nurse working with others to promote and encourage each person s contributions to achieve optimal and realistic outcomes. System s thinking comprises the tolls and knowledge that the nurse uses to recognize the holistic interrelationships that exist within and across the health care systems. (1) References: 1. Kerfoot, et al. Conceptual Models and the Nursing Organization- Implementing the AACN Synergy Model for Patient Care. Nurse Leader, 2006; 21-23.