The ACA will bring new opportunities to overcome some of the barriers discussed above and use nurses in new and expanded capacities. All four initiatives have shown enough promise that they were selected to receive additional financial support under the ACA. Depending on their outcomes, these exemplars may lead the way to broader changes in the health care system.
They can also terminate or modify programs that are not working well. These types of decisions had previously been allowed only after congressional action. However, it wishes to emphasize to the Center for Medicare and Medicaid Innovation that each of these four initiatives depends on high-functioning, interprofessional teams in which the competencies and skills of all nurses, including APRNs, can be more fully utilized.
New models of care, still to be developed, may deliver care that is better and more efficient than that provided by these four initiatives. Nursing, in collaboration with other professions, should be a part of the design of these initiatives by shaping and leading solutions. Innovative solutions are most likely to emerge if researchers from the nursing field work in partnership with other professionals in medicine, business, technology, and law to create them.
The ACO is a legally defined entity consisting of a group of primary care providers, a hospital, and perhaps some specialists who share in the risk as well as the rewards of providing quality care at a fixed reimbursement rate Fisher et al. Payment for this set of services, as provided for in the ACA, will move beyond the traditional fee-for-service system and may include shared savings payments or capitated payments for all services.
The goal of this payment structure is to encourage the ACO to improve the quality of the care it provides and increase care coordination while containing growth. ACOs that use APRNs and other nurses to the full extent of their education and training in such roles as health coaching, chronic disease management, transitional care, prevention activities, and quality improvement will most likely benefit from providing high-value and more accessible care that patients will find to be in their best interest.
The concept of a medical home was first developed by pediatricians in the late s AAP, Medical homes play a prominent role in the ACA, but the law is not consistent in its terminology for them. The latest phase of the broader nursing strategy at the VA, for example, consists of the implementation of a medical home model with expanded roles for RNs. Previously, primary care providers physicians and NPs at the VA felt that they were not receiving enough professional support to do their jobs effectively. The new strategy calls for including staff nurses on the primary care teams.
The case study in Box illustrates how the medical home concept is being applied in the VA health system. The Patient-Centered Medical Home. CHCs have a long track records of providing high-value, quality primary and preventive care in poor and underserved parts of the United States. Many also offer dental, mental health, and substance abuse and pharmacy services as well.
CHCs generally are very team oriented and depend on nurses to deliver services. Nurses provide primary care, preventive services, and home visits, and many serve in administrative and leadership positions. CHC patients are less likely to have unmet medical needs, visit the emergency department for nonurgent care, or need hospitalization relative to the general population.
As the name implies, they are run by nurses—although many employ physicians, social workers, health educators, and outreach workers as members of a collaborative health team. The majority of NMHCs are affiliated with a nursing school and about half with a community-based nonprofit organization King and Hansen-Turton, NMHCs report that their clients make 15 percent fewer emergency department visits than the general population, have 35—40 percent fewer nonmaternity hospital days, and spend 25 percent less on prescriptions NNCC, The case study presented in Box shows how an NMHC worked with community leaders to reduce health disparities in an underserved poor neighborhood in Philadelphia.
A Nurse-Managed Health Center Reduces Health Disparities in Philadelphia L isa Scardigli, age 44, has suffered periodically from spasticity, a symptom of the multiple sclerosis she has more There is perhaps no greater opportunity to transform practice than through technology. Information technology has long been used to support billing and payments but has become increasingly important in the provision of care as an aid to documentation and decision making. Diagnostic and monitoring machines have proven invaluable in the treatment of cancer, heart disease, and many other ailments.
Since that report was published, the expanded use of online communication has resulted in so-called telehealth services that are not limited to diagnosis or treatment but also include health promotion, follow-up, and coordination of care. Delivery of telehealth services has, however, like that of APRN services, been complicated by variability in state regulations, particularly whenever online communications cross state lines. ARRA strengthened standards for maintaining the privacy and security of health information.
ARRA provided grants to help state and local governments as well as health care providers in their efforts to adopt and use HIT. The meaningful use objectives will likely continue to be refined but outline core requirements that should be included in every EHR. By adopting these recommendations, users will be eligible for federal incentive payments and will be able to report information on the clinical quality of care. States can add or modify additional objectives to this definition for their Medicaid programs CMS, A recent article in the New England Journal of Medicine summarizes the meaningful use criterion as follows: Given the nature of patient data collection, nurses will be integral to proper collection of meaningful use data.
As EHRs become more refined and integrated, nurses will have the opportunity to help define additional meaningful use objectives. Care supported by interoperable digital networks will shift in the importance of time and place. Remote patient monitoring is expanding exponentially. An ever-growing array of biometric devices e. Some of these devices can also provide direct digitally mediated care; the automated insulin pump and implantable defibrillators are two examples. The implications of these developments for nursing will be considerable and as yet are not fully understood Abbott and Coenen, It is not clear how much of nursing care might be independent of physical location when HIT is fully implemented, but it will likely be a significant subset of care, possibly in the range of 15—35 percent of what nurses do toda.
That is, for this proportion of care, nurses need not be in the same locale or even the same nation as their patients. As new technologies impact the hospital and other settings for nursing services, this phenomenon may increase. HIT will fundamentally change the ways in which RNs plan, deliver, document, and review clinical care. The process of obtaining and reviewing diagnostic information, making clinical decisions, communicating with patients and families, and carrying out clinical interventions will depart radically from the way these activities occur today. Moreover, the relative proportion of time RNs spend on various tasks is likely to change appreciably over the coming decades.
While HIT arguably will have its greatest influence on how RNs plan and document their care, all facets of care will be mediated increasingly by digital workflow, computerized knowledge management, and decision support. In the future, virtually every facet of nursing practice in each setting where it is rendered will have a significant digital dimension around a core EHR.
Biometric data collection will increasingly be automated, and diagnostic tests, medications, and some therapies will be computer generated and managed and delivered with computer support. Patient histories and examination data will increasingly be collected by devices that interface directly with the patient and automatically stream into the EHR.
Examples include automated blood pressure cuffs, personal digital assistant PDA —based functional status, and patient history surveys.
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In HIT-supported organizations, a broader array and higher proportion of services of all types will be provided within the context of computer templates and workflows. There will likely be greater opportunities for such interventions as counseling, behavior change, and social and emotional support—interventions that lie squarely within the province of nursing practice. Adoption of HIT is expected to increase the efficiency and effectiveness of clinician interactions with each patient and the target population. HIT will lead to greater efficiency if it takes less time for a clinician to provide the same unit of service or if a lowercost clinician practicing with extensive HIT support can deliver the same type of care as a higher-cost non-HIT-supported provider.
Controlled time and motion studies that have compared clinicians performing the same task with and without HIT support have produced mixed findings on time efficiencies gained across clinicians and settings. One area with emerging evidence is hospital nursing time spent in documentation, with studies showing a 23—24 percent reduction Poissant et al. On the other hand, these efficiency gains may be partially offset by the information demands of quality improvement initiatives and similar programs undertaken by a growing number of institutions DesRoches et al. According to a review of the literature conducted for the committee, although research on the impact of HIT on the quality of nursing care is limited, documentation quality and accessibility generally improve after the implementation of HIT.
Medication errors almost always decrease after the implementation of bar code medication administration Waneka and Spetz, No differences were found in time spent on patient care activities for nurses in hospitals with and without minimally functioning systems. Technology is also used to measure patient outcomes, with varying results. While measuring outcomes is critical to the provision of 21st-century health care, complications have developed in ensuring that outcome measures from different institutions and organizations are, in fact, comparable. Even ensuring that outcome measures from different parts of the same organization are comparable can be problematic.
They found that variations in the way information was entered in the EHRs accounted for significant variations within the institution and could be responsible for as much as a fold difference in outcome measures among hospitals Kahn and Ranade, A longitudinal study of hospitals found that those that had implemented more advanced EHR systems over the time period had higher costs and increased nurse staffing levels Furukawa et al.
Patient complications increased in these hospitals, while mortality for some conditions declined. It should be noted, however, that these results may be difficult to interpret because of the implementation of minimum nurse staffing regulations at the same time that the implementation of EHRs ramped up.
During that time, nurse staffing rose, and thus costs per patient rose, and if there is any correlation between implementation of EHRs and increased nurse staffing due to the ratios, the results may confound the two. In addition, the study did not control for hospital ownership e. Finally, a systematic review of the literature fewer than 25 articles showed that the time spent on documentation of care may increase or decrease with EHRs Thompson et al.
Furthermore, interoperable EHRs linked with personal health records and shared support systems will influence how these teams work and share clinical activities.
1 638,31 RUB
It will increasingly be possible for providers to work on digitally linked teams that will collaborate with patients and their families no longer limited by real-time contact. Similarly, many types of care previously provided by physicians and other highly trained personnel can be provided effectively by APRNs and other specialty trained RNs.
Increasingly, technology is allowing nurses and other health care providers to offer their services in a wider range of settings.
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For example, the ability of the Visiting Nurse Service of New York to tap into mobile technology, as described in Chapter 2 , allowed that organization to provide ever more complex care in the home setting IOM, a. As the largest segment of the health care workforce with some of the closest, most sustained interactions with patients, nurses are often the greatest users of technology.
In many instances, they may know what will work best with regard to technological solutions, but they are asked for their opinions infrequently. Studies show that involving nurses in the design, planning, and implementation of technology systems leads to fewer problems during implementation Hunt et al. Nurses have also invented new technology to help them care for their patients. For instance, Barbara Medoff Cooper, professor in pediatric nursing and director of the Center for Biobehavioral Research at the University of Pennsylvania School of Nursing, developed a microchip device that is situated between the nipple and the rest of the baby bottle.
The information thus gathered has helped guide parents and providers in better planning for the care of high-risk neonates at home Bakewell-Sachs et al.
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Another effort, called TelEmergency, brings a certified emergency room physician to 12 rural hospitals in Mississippi from the University of Mississippi via a T-1 line, but only when needed. The system is managed by a group of 35 APRNs who provide care in these rural communities, including management of the technology as a referral system.
The case study in Box shows how nurses at one institution are working to ensure that they spend their time in patient care and not on the technology associated with delivering modern health care. Technology at Cedars-Sinai Medical Center. The nursing profession has evolved more rapidly than the public policies that affect it.
Evidence does not support the conclusion that APRNs are less able than physicians to provide safe, effective, and efficient care Brown and Grimes, ; Fairman, ; Groth et al. The roles of APRNs—and the roles of all nurses—are undergoing changes that will help make the transformative practice models outlined at the beginning of this chapter a more common reality. Such changes must be supported by a number of policy decisions, including efforts to remove the existing regulatory barriers to nursing practice.
If the current conflicts between what nurses can do based on their education and training and what they may do according to state and federal policies and regulations are not addressed, patients will continue to experience limited access to high-quality care. While medicine and a number of other professions enjoy practice regulations that are comparable across states, this goal has been elusive for nurses, particularly those working in advanced practice. With the availability now of a consensus document that offers agreed-upon standards for APRN education, training, and regulation, states that have been reluctant in the past may move toward broader scopes of practice.
Such a move, however, considered by the committee to be a critical one, is not guaranteed. And while the committee defers to the rights of states to continue their regulation of health professionals, it also wishes to note why and how the federal government can play an important role in this arena.
The primary reason the federal government has a compelling interest in state regulation of health professionals is the responsibility to patients covered by federal programs such as Medicare and Medicaid. If access to care is hindered, if costs are unduly high, or if quality of care could be improved for these millions of patients through evidence-based changes to the ways in which professionals may practice, the federal government has a right to explore the options and encourage change. Certain federal entities may both defer to the states in adopting their own practice regulations and encourage the adoption of regulations that are consistent with current clinical evidence and comparable across the country.
Congress, CMS, OPM, and the FTC each have specific authority or responsibility for decisions that either must be made at the federal level to be consistent with state efforts to remove scope-of-practice barriers or could be made to encourage and support those efforts. While no single actor or agency can independently make a sweeping change to eliminate current barriers, the various state and federal entities can each make relevant decisions that together can lead to much-needed improvements. Moreover, an important priority in national health care reform is achieving better value for the expenditures made on health care services.
Since health care is labor intensive, getting more value from the health care system will depend in large part on enhancing the productivity and effectiveness of the workforce. Nurses therefore represent a large and unexploited opportunity to achieve greater value in health care. The committee believes that any proposed changes in the responsibilities of the nursing workforce should be evaluated against their ability to support the provision of seamless, affordable, quality care that is accessible to all.
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In particular, the committee argues that now is the time to finally eliminate the outdated regulations and organizational and cultural barriers that limit the ability of nurses, including APRNs, to practice to the full extent of their education, training, and competence. The committee also believes that nurses must be allowed to lead improvement and redesign efforts see Chapter 5. Specifically, in order that all Americans may have access to high-quality, safe health care, federal and state actions are required to update and standardize scope-of-practice regulations to take advantage of the full capacity and education of nurses.
Cultural and organizational barriers should also be eliminated. States and insurance companies must follow through with specific regulatory, policy, and financial changes that uphold patient-centered care as the organizing principle for a reformed health care system. The education and training of nurses support their ability to offer a wider range of services safely and effectively—as documented by numerous studies. And nurses must respond to the challenge, reinventing themselves as needed in a rapidly evolving health care system.
Nursing is, of course, not the only profession to confront the need to transform itself in response to new realities; similarly disruptive challenges have been faced in other fields, such as medicine, health care, publishing, education, business, manufacturing, and the military. To facilitate the most effective transition to team practice, as well as practice that encompasses the full extent of their scope, all providers will require continual teaching and learning to facilitate the highest level of team functioning see Chapter 4.
Going forward under the ACA and whatever reforms may follow, the health care system is likely to change so rapidly that building the adaptive capacity of the nursing workforce to work across settings and in different types of roles in new models of care will require intentional development, expanded resources, and policy and regulatory changes. Therefore, the committee concludes that nurse residency programs should be instituted to provide nurses with an appropriate transition to practice and develop a more competent nursing workforce.
View in own window. When the committee refers to NPs, the term denotes only NPs. To get a sense of the size and proportion of the NP workforce across the country, Stange and Sampson computed the ratio of the total number of licensed NPs to the total number of primary care MDs, physician assistants, and NPs in a given area. The physician assistant share was computed similarly. These computations are for proportion and growth analysis purposes only; they are not to suggest that all NPs or physician assistants are providing primary care. Personal communication, Mary Naylor, Marian S.
Quality-of-care indicators included those in preventive care mammography, influenza vaccination, pneumococcal vaccination, colorectal cancer screening, cervical cancer screening , outpatient care care for diabetes [e. Personal communication, Bruce H. This section is based on a September 10, , personal communication with Barbara J. See for example, AMA. For this study, respondents were randomly recruited to participate in the IOM survey activity via e-mail; others were allowed to join the survey by volunteering when they visited the site.
The majority of respondents have specialties in cardiology 6 percent , family medicine 35 percent , internal medicine 26 percent , and oncology 4 percent. The remaining physicians surveyed are distributed across a wide range of specialties. This section draws on a September 8, , personal communication with Kay T. Turn recording back on. National Center for Biotechnology Information , U.
Among the many innovations that a versatile, adaptive, and well-educated nursing profession have helped make possible are the evolution of the high-technology hospital;. Nurses and Access to Primary Care Given current concerns about a shortage of primary care health professionals, the committee paid particular attention to the role of nurses, especially APRNs, 2 in this area. Nurses and Quality of Care Beyond the issue of pure numbers of practitioners, a promising field of evidence links nursing care to a higher quality of care for patients, including protecting their safety.
Examples of Redesigned Roles for Nurses Many examples exist in which organizations have been redesigned to better utilize nurses, but their scale is small. Department of Veterans Affairs 5 In , Congress greatly expanded the number of veterans eligible to receive VA services, which created a need for the system to operate more efficiently and effectively VHA, Geisinger Health System 7 The Geisinger Health System employs physicians; 1, nurses; and more than 1, NPs, physician assistants, and pharmacists.
Kaiser Permanente 10 , 11 As one of the largest not-for-profit health plans, Kaiser Permanente provides health care services for more than 8. Summary The VA, Geisinger, and Kaiser Permanente are large integrated care systems that may be better positioned than others to invest in the coordination, education, and assessment provided by their nurses, but their results speak for themselves.
Regulatory Barriers As the committee considered how the additional 32 million people covered by health insurance under the ACA would receive care in the coming years, it identified as a serious barrier overly restrictive scope-of-practice regulations for APRNs that vary by state. History of the Regulation of the Health Professions A paper commissioned by the committee 13 points out that the United States was one of the first countries to regulate health care providers and that this regulation occurred at the state—not the federal—level.
Variation in Nurse Practitioner Scope-of-Practice Regulations Regulations that define scope-of-practice limitations vary widely by state. The Federal Government and Regulatory Reform 16 Precisely because many of the problems described in this report are the result of a patchwork of state regulatory regimes, the federal government is especially well situated to promote effective reforms by collecting and disseminating best practices from across the country and incentivizing their adoption.
Expanding Scopes of Practice for Nurses For several decades, the trend in the United States has been toward expansion of scope-of-practice regulations for APRNs, but this shift has been incremental and variable. The stated goals of the APRN consensus process are to: BOX Case Study: Professional Resistance Increasing access to care by expanding state scope-of-practice regulations so they accord with the education and competency of APRNs is a critical and controversial topic. Physician Challenges to Expanded Scope of Practice The AMA has consistently issued resolutions, petitions, and position papers supporting opposition to state efforts to expand the scope of practice for professional groups other than physicians.
Effect of Fragmentation on Realizing the Value of Nurses Within this system, the contributions of nursing are doubly hidden. High Turnover Rates As the health care system undergoes transformation, it will be imperative that patients have highly competent nurses who are adept at caring for them across all settings. Difficulties of Transition to Practice High turnover rates among newly graduated nurses highlight the need for a greater focus on managing the transition from school to practice Kovner et al. Residencies Outside of Acute Care Residency programs are supported predominantly in hospitals and larger health systems, with a focus on acute care.
Evidence in Support of Residencies Much of the evidence supporting the success of residencies has been produced through self-evaluations by the residency programs themselves. Demographic Challenges As discussed in Chapter 2 , the population of the United States is growing older and is becoming increasingly diverse in terms of race, ethnicity, and language. An Aging Workforce Like the U. Gender Diversity Throughout much of the 20th century, the nursing profession was composed mainly of women. Racial and Ethnic Diversity To better meet the current and future health needs of the public and to provide more culturally relevant care, the current nursing workforce will need to grow more diverse.
Nursing careers and educational pathways are now formally included in job-related programs implemented by the Presbyterian Community Center PCC. For example, over the past 2 years, PCC has selected 50 community residents into the Changemaker program, which targets to year-olds to engage them in self-discovery, goal setting, and progress toward career goals, with the condition of giving back to the community.
Each year about four to six Changemakers examine health careers in depth. HNC included nursing and health careers in the proposal that funded this pathway and provides supervised clinical experiences, mentoring, part-time job opportunities where possible, and education about nursing. Community health students and faculty now provide education at the community middle school regarding careers in nursing. Last year no African American student was accepted. Dialogue with faculty led to an examination of policies that resulted in the omission of minority students. Literally hundreds of undergraduate and graduate nursing students from several academic institutions have supervised learning experiences in the community.
These include at least 10 undergraduate community health nursing students each semester, a class of 30 graduate nursing students enrolled in a health promotion class each year, and 2 or more NP students based in the clinic each semester. About 5 NP and 10 undergraduate students participate in a Back to School event each fall where Harambee offers school physicals and immunizations for underserved middle school students.
Demographic Challenges The nurse workforce is slowly becoming more diverse, and the proportion of racially and ethnically diverse nursing graduates has increased by 10 percent in the last two decades, growing from Accountable Care Organizations The ACO is a legally defined entity consisting of a group of primary care providers, a hospital, and perhaps some specialists who share in the risk as well as the rewards of providing quality care at a fixed reimbursement rate Fisher et al.
Community Health Centers CHCs have a long track records of providing high-value, quality primary and preventive care in poor and underserved parts of the United States. Opportunities Through Technology There is perhaps no greater opportunity to transform practice than through technology.
Implications for Time and Place of Care Care supported by interoperable digital networks will shift in the importance of time and place. Implications for Nursing Practice HIT will fundamentally change the ways in which RNs plan, deliver, document, and review clinical care. Impact of Technology on Quality, Efficiency, and Outcomes Adoption of HIT is expected to increase the efficiency and effectiveness of clinician interactions with each patient and the target population. Involving Nurses in Technology Design and Implementation As the largest segment of the health care workforce with some of the closest, most sustained interactions with patients, nurses are often the greatest users of technology.
White paper on the education and role of the clinical nurse leader. The essentials of baccalaureate education for professional nursing practice. Enhancing diversity in the nursing workforce. Nursing faculty shortage fact sheet. The aging of full-time U. Post-baccalaureate nurse resi dency.
Successful Professional Portfolios for Nursing Students (Transforming Nursing Practice Series)
Distance emergency care using nurse practi tioners. The Harambee Nursing Center: Community-based, nurse-led health care. AARP policy supplement: Scope of practice for advanced practice registered nurses. Physician-nurse practitioner restrictive col laboration requirements by state map. Globalization and advances in information and communication technologies: The impact on nursing and health.
Nursing Outlook 56 5: A health insurer pays more to save. New York Times , June Impact of clinical alarms on patient safety. Nurse workforce challenges in the United States: Implica tions for policy. Education policy initiatives to address the nurse shortage in the United States.
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Health Affairs 28 4: PMC ] [ PubMed: The AMA scope of practice data series: The scope of practice of nurse anesthetists. Comparison of quality of care for patients in the Veterans Health Administration and patients in a national sample. Annals of Internal Medicine The timing of physiologic maturation of premature infants. Outcomes of a one-year pilot program.
Journal of Nursing Administration 31 Bridging the gap between school and workplace: Developing a new graduate nurse curriculum. Journal of Nursing Ad ministration 34 A call for radical transfor mation. New England Journal of Medicine 6: Current problems and proposed solutions. Health Affairs 29 5: The business case for TCAB: Estimates of cost savings with sustained improvement.
American Journal of Nursing Smart technology, enduring solutions: Technology solutions can make nursing care safer and more efficient. Journal of Healthcare Information Management 22 4: The Permanente Journal 12 1: A meta-analysis of nurse practitioners and nurse midwives in primary care.
Nursing Research 44 6: The future of the nursing workforce in the United States: Data, trends, and implications. The recent surge in nurse employment: Reports of Board of Trustees. California Department of Public Health. Statement of deficiencies and plan of correction. Advanced practice nursing roles in neonatal care. Paediatric Child Health 5 3: Organizational fragmentation and care quality in the U. Journal of Economic Perspectives 22 4: Payment regulations for advanced practice nurses: Implications for primary care.
Chart overview of nurse practitioner scopes of practice in the United States. Medicare and Medicaid programs; electronic health record incentive program. Federal Register 75 Current and projected workforce of nonphysician clinicians. New directions for nurse practitioners and physician assistants in the era of physician shortages.
Academic Medicine 82 9: Massachusetts nurse practitioners step up as one solution to the primary care access problem. Physician task force confronts scope-of-practice legislation. American Medical News , September Tapping the potential of the health care workforce: Scope of practice and payment policies for advanced practice nurses and physician assistants background paper no.
National Health Policy Forum. Medicare nurse pay too broad. American Medical News , July The economic value of professional nursing. Medical Care 47 1: Psychiatrists, allies defeat psychology-prescribing bills. Psychiatric News 42 Geisinger chief Glenn Steele: Health Affairs 29 6: Registered nurses use of electronic health records: Findings from a national survey. Medscape Journal of Medicine 10 7. Overlap of registered nurse and physician practice: No harm found when nurse anesthetists work without supervision by physicians.
Campbell Biology by Peter V. Urry and Steven A. Wasserman , Hardcover 8. Fundamentals of Pathology by Husain A. Sattar , Paperback Fundamentals of Pathology - Pathoma: Step 1 Review By Dr. Mar 14, Jane rated it it was amazing. I was asked to review this book by the Nursing Times Journal Description: This text book is such a user friendly and easy guide for a nursing student to construct their portfolio.
This works in conjunction with the NMC to ensure that students evidence their competencies. I have been lucky to have not only been taught by the author, but also was part of an independent hospital professional development group and gained so much knowledge from the author that it is a pleasure to be review I was asked to review this book by the Nursing Times Journal Description: I have been lucky to have not only been taught by the author, but also was part of an independent hospital professional development group and gained so much knowledge from the author that it is a pleasure to be reviewing one of her publications.
The book acts as a tool and is easy to use because the author has spent a great deal of tome working with students and her style of writing is good. For the nursing student there are good examples from other student portfolios so the student can gauge what is a good example. The fact this is linked to the NMC makes this ideal and for the student there is no confusion working with differing tools.
The strengths are that this is well written and sets out the journey well for the student throughout the seven chapters. It is up to date covers the 6Cs, evidence based practice, the use of reflection and critical thinking. The further reading at the end of each chapter is relevant and up to date and that the Francis report is mentioned in this text book as there is still lessons to be learnt.