The Impact of Enhanced Orientation Programs on Nurses’ Retention Rate:

Certified Home Health Agency’s Strategy for Decreasing the Cost of Visiting Nurses’ Turnover

According to National Healthcare Retention and RN  Staffing Report (“NSI Nursing Solution, Inc,” 2016), the cost of nurse turnover can cost a hospital as much as $8.1 M annually (p. 4). Among  the US five geographic regions, North East has marked the third top for a high nurses’ turnover – 20.3 percent, after South  East and South Central that marked a nurse turnover at 26.8 percent (“NSI Nursing Solution, Inc,” 2016, p. 2) .  The trend of a high turnover rate for registered nurses continues to rise state and nationwide. At Northwell Health at Home, a Certified Home Health Agency (CHHA), which  is a division of Northwell Health Network, the percentage of newly hired nurses leaving the organization within the first year of the employment reached out an alarming point of  59 percent.

Educators and clinical facilitators at Northwell CHHA) have recognized that nurses joining the technologically and increasingly complex health care environment need a minimum of one year to grasp the specifics of home health care.  It takes time to train a nurse who is  fully confident in providing safe and effective care. It takes time and resources to make an efficient home health nurse who is able to weather the climate of a continued change in  health care industry. Home health providers must adhere to the specific standards and recognize the unique needs of the patients they served. The organizations must secure a  steady workforce of highly competent nurses to ensure that the clients’ comprehensive healthcare demands are met.

Problem Statement

Poor retention of nursing forces has been creating the need for a continued search for new nurses. This has not only been time consuming for  the managers and  talent acquisition specialists but also proved to be costly for the organization On average, for every RN that turns over,  it costs the organization 1.5 times that RN’s salary. For that reason alone “RN  turnover is a statistic that should be on everyone’s radar”  (Boston-Fleischhauer, 2016). Orientation, in-services, mentorship and preceptor program must allow for increased productivity of each nurse, in order to prevent a financial loss of revenue for  the organization (Boston-Fleischhauer, 2016).. Northwell Health system’s goal is to be an the Employer of Choice which means that people want to work for the company and the most talented workers stay with the organization throughout their careers. In return, the organization values the employees by providing many incentives, including awards, benefits, and motivational programs.

Northwell Health at Home educators and managers collaborate closely with the Human Resources (HR) Department during the process of planning and hiring. Reports from HR collected at the exit interviews indicated “feel overwhelmed” as the main reason nurses have been leaving the organization. Nurses felt inundated by the amount of daily visits, extensive documentation of the visits- a requirement  imposed by Centers for Medicare & Medicaid Services (CMS), and Information Technology advances that for many nurses was hard to grasp within only 2-4 days of training at a computer lab during presently offered  2 weeks long orientation program.. The previous attempts to reduce the nurses’ turnover by decreasing the number of daily visits not only did not bring any positive results in nursing retention but negatively affected the organization’s financial goals.  Educators had to look at the variables that the organization can change in order to increase the nurse retention and give the employees the opportunity  to stay with the organization for a long time. It was decided to focus further on nurses’ education during the orientation programs.

Clinical Practice Problem

Northwell Health at Home strategic plan that addressed the issue of nurses’ turnover led to generating the preceptor program  based on  Neal Theory Model of Home Health Nursing Practice (Neal, 1999) that  provides  a conceptual framework recognizing home care nursing as a specialty.  The research-based model lines up a three-stage process for the  new hired home health nurses: Dependence, Moderate Dependence, and Autonomy (See Appendix).  It argues that when nurses receive the appropriate training and support, they are more likely to be engaged at an organization and remain there for longer periods of time. The proposed strategic plan is to implement the preceptor program that provides educational support to the new hires with the result being increased retention. The goal of the preceptor program is to create a successful and autonomous in their practice nurse convinced that the company is her/his Employer of Choice.  The  improved and  better outlined nursing orientation program supports individualized and fluid-allowing adjustment based on the nurse’s education progress. The new program should enhance the nurse’s ability to adapt in home care throughout the awareness of clinical change and the willingness to accommodate to change (Neal, 1999).

Leaders must demonstrate their understanding of the key issues that impact turnover in the organizations. The development of new ideas to improve education and retention are of critical importance to achieve higher quality performance for nurses. The goal of the enhanced preceptor program is to  ensure that they have the tools available to acquire knowledge, and access to resources on a continuous basis. The clinical leaders must provide knowledge and input regarding training and education for nurses, along with recognizing the importance of leadership in executing this effort (Porter-O’Grady & Malloch, 2016).

The performance improvement project was designed to decrease the cost of visiting nurses’ turnover rates, to increase the retention rate, and improve the job satisfaction at Northwell Health at Home CHHA. The enhanced orientation program will make it easier to identify training and competency gaps, empower nurses into controlling assignments based on their competencies, eliminate chaotic job atmosphere, and correct imbalanced job-work life (Cuddy, 2015). Futhermore, “beyond the financial costs of increased turnover, the disruptions to productivity, team dynamics, and care quality from turnover have been recognized and solidly documented” (Boston-Fleischer, 2016, para. 3). T

The additional goal of the redesigned orientation program is to prevent the domino effect that the dissatisfied and overwhelmed nurses have on their co-workers. These nurses share their “negativity” resulting in more nurses resigning which increases the workflow of the remaining nurses. A preceptor program will support new employees by providing educational training that  would make a confident in their job professionals. The program will also present a  positive approach which would hopefully trump the negativity.

Context and Climate of the Practice Environment

Northwell Health at Home CHHA  serves over 30,000 patients annually. Hospitals, primary care physicians (PCP) and sub-acute rehabilitation centers may refer patients for home health care services (Ellenbecker, Samia, Cushman, & Alster, 2008, Chapter 13).  The clients come from all age groups including maternal – child and pediatrics. Home health care is a system of care provided by skilled practitioners, such as nurses, physical therapist, speech-language therapy,  medical supplies, equipment, and durable medical equipment to patients in their homes under the direction of a physician.. Northwell Helath at Home also provides infusion, hospice at home, and home health aide (HHA)  services. The goals of home health care are to help individuals to improve function and live with greater independence, to promote the client’s optimal level of well-being, CHHA nurses work closely with the physicians, physical therapists and  social workers to assist the patient to remain at home and  avoid hospitalization or admission to long-term care institutions.

Following the nationwide trend to gain a larger share of the consumer health market, many acute care facilities within New York’s five boroughs, Long Island, Westchester and Putnam counties have merged with Northwell Health organization to become a part of a clinically integrated network. Provider consolidations make it easier to share electronic records systems and to enhance a seamless flow of information between hospitals, providers, and insurers. This, in turn, helps coordinate the care of patients eliminate redundant costs as the network expands; furthermore, the affiliated post-acute providers must also grow to support cross-continuum care. It is known that “organizations recognize that nursing is core to the strategic achievement of outcomes, including clinical, financial, and growth/market share. Retaining top nursing talent is a strategic priority, not just for the nursing enterprise, but for the entire health care system” (Boston-Fleischer, 2016 para. 4). According to the author, the investment in nurse retention is critical, beginning with employment and commencing forward to increase retention.

SWOT Analysis

The Strength of Northwell Health at Home lies in the fact that we are the leaders in timely initiation of care with 98.8 percent  as compared to the NY state – 95 percent and nationwide 93.2 percent,  and we have the lowest hospital re-admission rate of 15.8 percent with 17.1 percent, and 16.5 percent respectively We  offer specialty clinical programs for patients discharged from the acute facilities post Heart Failure,  joint replacement, CABG, and  COPD exacerbations. Between June 1, 2016  and May 31, 2017 we were recognized for the lowest Diagnostic Related Group (DRG) penalty for hospital re-admissions related to the above diagnosis (Northwell Health and Home, 2018, pp.6-7).

The great Weakness of Northwell Health at Home organization is the nursing staff turnover.

The Opportunities are related to the growing aging population in the catchment area..

The Threats to the organization are the increased government regulations and decreased insurance/government reimbursement.

Interdisciplinary Communications and Collaboration

At Northwell Health the  educators and department managers collaborate closely with the Human Resources department during the process of planning and hiring. Within the CHHA organization, the nurses work together  with the physical therapists and social workers TO create plans of care for each patient. The performance improvement project was designed to decrease the cost of visiting nurses’ turnover, increase their retention, and improve job satisfaction at Northwell at Home CHHA. The enhanced orientation program will make it easier to identify training and competency gaps, empower nurses into accepting assignments based on their competencies, eliminate the chaotic job atmosphere, and correct an imbalanced job -work life (Cuddy, 2015). It is believed that “beyond the financial costs of increased turnover, the disruptions to productivity, team dynamics, and care quality from turnover have been recognized and solidly documented” (Boston-Fleischhauer, 2016, para. 3).

For a Certified Home Health Agency such as Northwell Health at Home, the identification of a strategic plan is essential to ensure that the organization can meet its goals and objectives in providing excellence in patient care at all levels and stay in compliance with the organization  Mission, Vision and Values (MVV) statements (Northwell Health, 2017-2018, p. 7).  Centers for Medicare & Medicaid Services (CMS) outlines the rules for the Medicare and Medicaid Condition of Participation (CoPs) to which the organization must strictly follow. One rule is related to the use of Outcome and Assessment Information Set (OASIS) data collection instrument to standardize patient assessment and transmits the data to CMS, which supports reimbursement for skilled services (Department of Health and Human Services, 2017). The enhanced orientation program for nurses allows a greater emphasis of the extended OASIS hands-on training program.

Achieving optimal quality of care throughout the home health division is essential and requires effective leadership to continuously monitor progress to improve direct care to patients in their homes and in the different stages of transition (Joshi, Ranson, Nash, & Ransom, 2014). It is essential that organizational employees rely upon the expert knowledge of leadership to implement a strategic plan which is flexible and can take on new opportunities as they emerge (Joshi et al., 2014). It is also imperative for the organization to establish a comprehensive workforce strategy to ensure that changes in the healthcare landscape are supported by experts who can manage these needs effectively, particularly as patients transition from one phase of care to the next (Datz, Hallberg, Harris, Harrison, & Samples, 2012).

The Stage of the Organization’s Strategic Plan

Northwell Health at Home, the strategic plan, which is currently under development, requires significant feedback from nurses and therapists. The guidance from a variety of leaders from different divisions ensures that the organization has the educational tools available to keep the best nurses who will serve the patients in an ethically responsible manner while meeting or exceeding financial gain in revenue. Operational assessments can offer feedback regarding any bottlenecks in the process or staffing issues which could have a significant impact on performance outcomes (Jarousse, 2012). From the nursing leadership perspective, the development of a strategic plan requires extensive input from staff nurses regarding their needs and the development of new directives. This is  to ensure that the organization has the staffing and resources available to provide home care for patients in a timely manner (Drenkard, 2012). There must be a greater emphasis on understanding the dynamics of the nursing profession and the overall development of new ideas to facilitate collaboration and to strengthen quality of care for all patients (Drenkard, 2012).

Literature Review

Understanding the dynamics of the home health care system requires an extensive review of existing research to determine the nature of current strategies, areas where successful outcomes have been achieved, and areas where improvements are required. This process is necessary to understand how to best move forward with a strategy at the home health level which is timely, appropriate, and practical for the needs of an organization going forward. Existing literature will offer a means of understanding how home health organizations respond to the needs of nurses to not only improve satisfaction rates but to also improve retention rates in the future, using methods and strategies which may be successful in aiming to promote nurse satisfaction and timely care and treatment for all patients.

One of the most critical aspects of nurse turnover is the type of leadership that exists at the employing organization. One of the key factors to consider is the rate of job satisfaction among caregivers, and if there are limitations in this regard, it can be difficult for organizations to retain nurses and keep them engaged over time (Donoghue & Castle, 2009). The authors indicate that leaders may be one of four types: the consensus manager, who engages the group for feedback and uses this to make decisions; the consultative autocrat, who may obtain feedback but makes all of the decisions independently; the autocrat, who does not seek feedback and makes all decisions; and the shareholder manager, who does not share information with staff members which is important to their roles and makes all decisions without feedback (Donoghue & Castle, 2009). These factors play a significant role in how employees perceive their leaders and their effectiveness and may also play a role in determining if they want to remain with the organization for a longer period (Donoghue & Castle, 2009).

Steinmetz, de Vries, & Tijdens (2014) address the significance of turnover in the healthcare system and how it may be impacted not only by the organization and its climate, but also the wages that are earned. From this perspective, it is also known that “working part-time hours, overtime and a long commuting time decrease the intention to stay with the same employer…job dissatisfaction is a strong predictor for the intention to leave” (Steinmetz et al., 2014). In this context, job retention rates are affected by a variety of different characteristics and require management teams to examine the tools that are available to better support employees so that they are more likely to stay with their employers than to leave after a brief tenure. It is also necessary for organizations to obtain feedback from employees and to acknowledge that they have different needs which must be addressed to improve their likelihood of remaining with the organization longer.

Castle, Degenholtz, & Rosen (2006) examined the significance of job satisfaction in the nursing home environment, obtaining the feedback of 251 caregivers over 2.5 years and every six months. The study results indicate that there are lower levels of satisfaction associated with compensation, the opportunity to obtain a promotion, and management; therefore, it is important to evaluate the different options that are available to improve these areas and to determine how employees can remain in these roles to reduce turnover (Castle et al., 2006). Most importantly, organizations in home health face similar challenges because they require their employees to be active performers and contributors to the organization. However, this cannot be effectively accomplished if they do not have a strong infrastructure in place which will provide home health workers with a variety of options to expand their careers, to increase their wages, and to work under managers who support their cause.

Al-Hussami (2008) addressed the significance of job satisfaction for nurses relative to organizational commitment, education, and type of leadership style in the nursing home environment. It is known that “retention and recruitment of nurses have shown that low wages and poor job satisfaction are the primary reasons why nurses leave their positions. Their dissatisfaction is often attributed to heavy workloads, leadership styles, motivation, inadequate training, and lack of respect” (Al-Hussami, 2008, p. 287). In this context, it is important for nurses to have the tools available to them to be proactive and to acknowledge the importance of meeting expectations, while also aligning with the organization through its support for nurses (Al-Hussami, 2008). In a study of nurses in four nursing homes in the Miami, FL area, it was determined that nurses who possess strong loyalty to their organizations and overall higher job satisfaction are likely to remain with their organizations for longer periods of time; therefore, nurse leadership has a responsibility to pay greater attention to the needs of nurses who work in these organizations and to acknowledge that their level of loyalty to the organization is associated with their level of job satisfaction within their current roles (Al-Hussami et al., 2008). These factors are critical in supporting expanded training and dedication to nurses to ensure that they not only perform effectively in their roles, but also have the resources available to them to be productive and satisfied over the long term (Al-Hussami et al., 2008).

Russell, Rosati, Rosenfeld, & Marren (2011) address the significance of continuity within the home health care industry and how this may contribute to greater outcomes for patients and improved overall health. The development of strategies to address retention rates are critical because they offer employees a reason to remain within their roles and to focus their efforts on patient care that will have a positive impact on patient health (Russell et al., 2011). For home health nurses, getting to know patients and establishing relationships with them is critical for the patient and for the nurse because it offers a means of satisfaction that the patient has continuous care from the same nurse and the nurse can provide care that is consistent and appropriate (Russell et al., 2011). Therefore, it is necessary for organizations to focus their efforts on creating continuity, which will allow nurses to be better engaged and make them more likely to remain in their roles (Russell et al., 2011).

Sims-Gould, Byrne, Craven, Martin-Matthews, & Keefe (2010) address the importance of home health care workers and the factors which contribute to their desire to enter the field and remain with their employers. It is believed that many home health workers are satisfied with these roles and find it rewarding to aid patients in this setting, but the motivation behind entering this workforce is not as well known (Sims-Gould et al., 2010). The development of new opportunities for growth within the home health sector is of critical importance to current employees, and the potential for a career path is also likely to impact new employees in the field; therefore, motivations may include skill development, autonomy, making a difference in the lives of patients, job security, and workplace regulations (Sims-Gould et al., 2010). Home health workers can be further motivated by their efforts to contribute at a high level, but they require comprehensive training and knowledge to accomplish these goals within the profession to support a greater likelihood of remaining with their organizations over the long term (Sims-Gould et al., 2010).

Action Plan for Change – Overview

The development of an enhanced orientation program for Northwell Health at Home is an important step towards improving retention rates and reducing staff turnover. It  provides employees with a greater understanding of their roles and responsibilities at the organization. The enhanced, adjusted to the  individual’s needs training should help to recognize how  the employees can contribute to the organization at a high level This will also determine if the employees are a good fit for the organization in achieving the company’s goals and objectives.

The  expansion of the currently offered orientation program for nurses is an essential factor in improving their retention rates. The primary aim of this initiative is to provide nurses with a comprehensive educational program which includes extensive training to conduct routine home health visits, along with the development of other tools which will be effective in employee engagement from the beginning of their employment. The issue driving the development was to design a strategic plan that would address increased government regulations and decreased insurance/government reimbursement. Without addressing this issue, the role of the home care nurse becomes increasingly difficult additionally resulting in poor retention.

The new nurse has difficulty with problem solving and critical thinking because she/he is  preoccupied and overwhelmed with juggling all the aspects of home care at once. At the beginning, the nurse is uncertain of her role that there is little time or energy to take the broader view or to think in an objective, critical way to assist in problem solving. The new nurse spends a lot of time concentrating on remembering and following the rules and have difficulty prioritizing.

Action Plan for Change – Milestones

The proposed enhanced orientation program will run for 6 weeks which triples its current time span. The first two tweeks that consists of the Classroom IT Integrated Orientation will be spent with the educator who introduces  new to home care nurses to the theory, government  regulations, and objectives of  home care. Educator will lead orientee through the learning process to acquire knowledge regarding logistics in order to feel certain what to tell and recommend to the patient. Nurses will learn about Joint Commission Standards, NYS Department of Health and  Federal regulations, incident and complaint reporting, as well as how to locate all Network policies, and procedures. They will become familiar with recognizing the types of home care agencies, who pays for home care services, and the Prospective Payment System (Centers for Medicare and Medicaid Services (CMS), 2017). They will learn how to differentiate the Primary MD who will sign the home care orders for the specific patient’s needs of the home care episodes, how to construct a home care patient plan of care including all orders and CMS- 485 (Department of Health and Human Services Centers for Medicare and Medicaid Services, 2002), and agency rules for conducting medication reconciliation process. The first orientation’s milestone addresses stage one of  Neil Theory – Dependence.

The practical application of Moderate Dependence – stage 2 of Neil Theory will take place during the following  three to four weeks when each orientee  will spend time with the preceptor in the field to gradually put the learned in the classroom skills into practice. After the first two days when the nurse shadows the preceptor,  the rest of the in-field orientation period will be dedicating to improve the hands-on clinical skills under the preceptor’s guidance to  gain the confidence which gradually will led to increasing from 1 to 3  the Start of Care (SOC) per week visits and daily revisits from 3 to 6.  After at least of 2 weeks into field visits, the orientees will gain the experience in utilizing the OASIS assessments (Department of Health and Human Services Centers for Medicare and Medicaid Services, 2017), illustrate competency in infection control, wound care, , multidisciplinary communication, and coordination of care throughout the implementation of TeamSTEPPS (Agency for Healthcare Research and Quality (AHRQ), n.d.). Furthermore, the nurses will demonstrate the correct usage of laptop and its applications with a virtual  back- up of the IT technicians, adherence to HIPAA guidelines and agency policy, and  practice in the home health attendant (HHA) training and supervision. The preceptor will observe the nurse’s progress by documenting the indications of movement from stage 1 to stage 2 which are demonstrated by the nurse being able   to:

• Do a procedure she/he didn’t think they go do before
• Be less fearful
• Get to know geographical areas
• Develop confidence in assessing patients/meeting needs
• Improve time management skills
• Become more confident in decision making and more assertive
• Pick up things previously missed
• Adapt and learn to prioritize
• Define their role and begin understanding of other’s role
• Learn to self-evaluate and become calmer

The progress will also be measured by a descriptive self-report survey to elicit data from the nurse orientee for the preceptor to decide whether the role of a nurse was truly adopted from dependence/moderate dependence to stage 3 – Autonomy.  According to Neil Theory the role and process may temporarily change by moving the autonomous nurse back to dependence/moderate dependence stage to fully complete the process of adaptation by allowing and promoting fluid-allowing adjustment that suits each nurse at her/his paste of learning and adaptation.

An organization must recognize that the employees need the reasons to find the company attractive. This increases their likehood of remaining with the organization for longer periods of time. It is anticipated that a detailed orientation effort will allow employees to better understand how they fit with the organization and will recognize that they can play a role in improving patient health. These efforts will demonstrate the importance of engaging employees at the onset of their employment and enabling them to provide feedback as necessary during orientation and beyond so that they are taken seriously and can be effective in their roles.

Conclusion

The need for change is required because retention rates within the home health industry are difficult to maintain due to the demands of nurses who fill these positions and how they respond in their roles. Most importantly, it is necessary to retain employees who perform well and  make a valuable contribution to an organization at a high level. This is the essential component of the home health care industry and requires employees who are satisfied with their roles and who can commit to the organization over the long term.  However, accomplishing this task without providing employees with a positive work environment is very difficult and makes a significant difference in how employees perform. The culture of the organization is significant in this process and must demonstrate that employees are valued and have support  to meet their needs effectively. The development of a comprehensive orientation program is necessary because the organization should provide nurses with the resources required to perform their roles efficiently to achieve satisfaction within these roles. It is anticipated that when the organization supports a positive and meaningful approach to training and education for home health nurses, they will feel valued and will likely be more engaged in their roles.

The development of an orientation program for nurses at Northwell Health at Home requires an extensive understanding of Neal Theory and how it aligns with current organizational needs to promote greater effectiveness within the home health sector. Most importantly, this theory supports the training of home health nurses and provides them with a comprehensive set of tools and resources that will have a positive and lasting impact on their performance as they move forward in their careers. Nurses are likely to effectively respond to their organizations and take their roles seriously when they have the framework in place and a direction for which the organization is headed in the future. The availability of different tools and resources to support nurses is instrumental to support nurses’ alignment with the goals and objectives of the organization; furthermore, it provides them with an opportunity to function effectively in their roles and to be productive in this capacity (Neal, 1999).

Neal Theory (1999) supports the need for home health nurses to identify with their roles through a stage of dependence, whereby they begin to acclimate to these roles and to acknowledge their place in the organization. This requires a high degree of adaptation to the home health setting, which is very different from the traditional hospital or clinic environment and requires adjustments regarding how to administer procedures and tests, along with managing paperwork and other needs. During moderate dependence, nurses have acclimated to their roles more effectively and have the resources available to be productive in the home health environment; furthermore, they can support their patients because they are more comfortable with the home health environment and understand how to move forward in an effective manner Finally, nurses develop autonomy and can contribute at a higher level to the organization, taking the lessons that they have learned and adapting them to their roles. This process supports their growth as home health nurses and demonstrates their level of comfort, their assertiveness in this capacity, and their ability to utilize critical thinking skills to meet the needs of their patients (Neal, 1999).

References

The American Organization of Nurse Executives (2015). Nurse executive competencies:

Post-acute care.

Boston-Fleischhauer, C. (2016, July 27). How nursing leaders are changing the C-suite: A Q&A

with Advisory Board’s new CNO. Advisory Board.

Castle, N. G., Degenholtz, H., & Rosen, J. (2006). Determinants of staff job satisfaction of caregivers in two nursing homes in Pennsylvania. BMC Health Services Research, 6(1), 60.

Cuddy, J. B. (2015). Development of an evidence-based nursing orientation Program for a

community health system. Walden University. Walden Dissertation and Doctoral Studies, 1-80.

Donoghue, C., & Castle, N. G. (2009). Leadership styles of nursing home administrators and their association with staff turnover. The Gerontologist, 49(2), 166-174.

Ellenbecker, C. H., Samia, L., Cushman, M. J., & Alster, K. (2008). Patient safety and quality:

An evidence-based handbook for nurses. Patient safety and quality in home health care. Bethesda, MD: National Center for Biotechnology Information, U.S. National Library of Medicine.

Joshi, M.S., Ranson, E.R., Nash, D.B., and Ransom, S.B. (2014).  Healthcare quality book.

Top of FormHealth Administration Press. Chicago, IL.

Mahmoud, A. H. (2008). A study of nurses’ job satisfaction: the relationship to organizational commitment, perceived organizational support, transactional leadership, transformational leadership, and level of education. European journal of scientific research, 22(2), 286-295.

Medicare and Medicaid program: Conditions of participation for home health. (2017). Retrieved

from https://s3.amazonaws.com/public-inspection.federalregister.gov/2017-00283.pdf

Medicare program integrity manual. Transmittal 23. (2002).

Neal, L. J. (1999, March). The Neal theory: implications for practice and administration. Home

Health Nurse, 17(3)(3), 181-187.

Porter-O’Grady, T., and Malloch, K. (2016).  Leadership in nursing practice; Changing the

landscape of healthcare (2nd ed). Jones & Bartlett Learning.Top of Form

Prospective payment systems – General information . (2017).

Romagnoli, K. M., Handler, S. M., & Hochheiser, H. (2013). Home care: more than just a

visiting nurse. BMJ Quality and Safety, 22(12), 972-974.

Bottom of ForTop of FRundio, A., Wilson, V., Meloy, F. (2016). Nurse executive review & resource manual.              American Nurses Credentialing Center. Silver Spring, MD.

Russell, D., Rosati, R. J., Rosenfeld, P., & Marren, J. M. (2011). Continuity in home health care:

is consistency in nursing personnel associated with better patient outcomes? Journal for healthcare quality, 33(6), 33-39.

Sims-Gould, J., Byrne, K., Craven, C., Martin-Matthews, A., & Keefe, J. (2010). Why I became

a home support worker: recruitment in the home health sector. Home Health Care Services Quarterly, 29(4), 171-194.

Steinmetz, S., de Vries, D. H., & Tijdens, K. G. (2014). Should I stay or should I go? The impact

of working time and wages on retention in the health workforce. Human resources for health, 12(1), 23.

Team STEPPS. (n.d.). Retrieved from https://www.ahrq.gov/teamstepps/index.html