Applying the American Nurses Association Credentialing Center Accreditation Program in the Setting of Registered Nurse Remediation

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Applying the American Nurses
Association Credentialing Center
Accreditation Program in the Setting of
Registered Nurse Remediation
Andrew D. Harding, DNP, RN, CPHQ, FACHE, FAHA, FAEN ƒ
Margie Sipe, DNP, RN, NEA-BC ƒ Kathryn C. Whalen, DNP, RN, FAHA ƒ
Nicole Almeida, MSN, RN, CNL
The objective of this project was to use and evaluate the
American Nurses Credentialing Center (ANCC) accreditation
program in the context of registered nurse practice
remediation using Just Culture. The quality improvement
project intervention was aimed at educating nursing
professional development educators about the accreditation
program for registered nurse remedial education and
implementing this program for remediation. It compared
pre- and postintervention data for nurse educators using the
nine key elements.
n 2000, the Institute of Medicine (IOM) report, To Err
Is Human: Building a Safer Health System initiated a
wave of attention from healthcare providers, legislators, insurers, academics and patients toward improving
safety in the healthcare industry (Kohn, Corrigan, &
Donaldson, 2000). This report from Kohn and colleagues
(2000) emphasized that it is not bad people that cause
harm in health care, but rather systems that need to be
made safer. In 2001, the IOM published Crossing the Quality Chasm: A New Health System for the 21st Century,
which stated, ‘‘The biggest challenge to moving toward a
safer health system is changing the culture from one of
blaming individuals for errors to one in which errors are
treated not as personal failures, but as opportunities to
improve the system and prevent harm’’ (p. 79). However,
Classen et al. (2011), along with Krause, Bell, Provost, and
Etchegaray (2017), suggest that there has not been significant progress in improving patient safety since release of
the IOM reports. They believe that when errors do occur,
the focus on improvement should be placed primarily on
systemic issues and not on individuals; this approach has
been termed a culture of safety (O’Leary, 2003; Reason,
1997). One tool used to evaluate the root cause of errors
is a Just Culture algorithm (Outcome Engenuity, 2015;
Reason, 2000).
The Just Culture algorithm aims to objectively evaluate
an individual’s actions after an error occurs. The algorithm
identifies whether the individual’s actions were system induced or were generated by recklessness or negligence.
Errors related to an individual’s negligence may require education to address the root cause of the error. When there is
a gap in proficiency in professional nursing practice and
quality resulting in an error, remedial education is often a
strategy used by nurse managers and others to improve the
nurses’ practice (Effken, Verran, Logue, & Hsu, 2010).
Professional nurses are required to complete remedial
education at most healthcare institutions to address gaps
or lapses in the knowledge, skills, or attitudes expected
in professional nursing practice. Remedial education is
defined as educational interventions designed for nurses
with identified gaps in their professional nursing practice
for the purposes of this project. Nurses will not be able to
meet performance expectations if they are unable to incorporate the education provided in their clinical
practice (Moyer & Graebe, 2018; Wolf, 2008). No national
standard exists for providing remedial education for
professional nurses. Notably, the terms remedial education and remediation are not used by leading nursing
professional associations such as the American Nurses
Andrew D. Harding, DNP, RN, CPHQ, FACHE, FAHA, FAEN, is Chief
Nursing Officer, MetroWest Medical Center in Framingham and Natick,
Margie Sipe, DNP, RN, NEA-BC, is Director of Doctor of Nursing Practice Programs, MGH Institute of Health Professions, Boston,
Kathryn C. Whalen, DNP, RN, FAHA, is Trauma Program Nurse Manager, South Shore Health System, Weymouth, Massachusetts.
Nicole Almeida, MSN, RN, CNL, is Clinical Expert Nurse, Southcoast
Hospitals Group, New Bedford, Massachusetts.
The authors have disclosed that they have no significant relationship with,
or financial interest in, any commercial companies pertaining to this article.
Farm Road, Bridgewater, MA 02324 (e<mail:
DOI: 10.1097/NND.0000000000000503
Journal for Nurses in Professional Development E1
JNPD Journal for Nurses in Professional Development & Volume 34, Number 6, E1YE7 & Copyright B 2018 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
Association (ANA), the Emergency Nurses Association,
the National Association of Clinical Nurse Specialists,
the American Association of Critical-Care Nurses, or the
Association for Nursing Professional Development. Presumably these terms are not used as they may convey
negative connotations or perceptions of weakness, risk,
or lack of skill. There are just three expert reviews, provided by this author and colleagues, that address professional
nurse remediation in the practice setting (Harding &
Batista, 2016; Harding & Connolly, 2012; Walker-Cillo &
Harding, 2013). The American Nurses Credentialing Center
(ANCC) accreditation program is one method used to close
gaps in nursing professional practice and could be used for
remedial education.
The ANCC accreditation program’s educational design
process for continuing education is evidence based and
provides components of an education plan, including nine
key elements: identified practice gap, evidence of the practice gap, description of expected outcomes, outcomes
measurements, learner engagement strategies, time frames
for completion, proof of instructor competence, conflict
of interest resolution disclosure, and summary of outcomes
(ANCC, 2016). This performance improvement project
adapted the design of the ANCC accreditation program
from the context of continuing education and applied this
design in the setting of professional registered nurse remedial education.
The overall aim of this quality improvement (QI) project
was to improve the structure, process, outcomes, and documentation of remedial education for nurses by providing
an evidence-based method of education for nurses with
identified gaps in their professional nursing practice. The
process begins with identifying a gap in nursing practice
and then follows the ANCC educational method to plan
and document remediation and demonstration of the
learner’s competency. There are no guidelines for developing an educational plan, documenting progress,
or outcomes that specifically address a nurse’s gap in
practice which requires remedial education. Remedial
education is different than orientation, inservices, and
continuing education. The difference is context, in that
remedial education occurs after an incident or near miss
at work through a Just Culture, where the reason for the
incident or near miss is related to a gap in the nurse’s
knowledge. This places emphasis on ensuring that new
knowledge is used in practice. The nurse’s employer and
nurses in professional development using a Just Culture
will want to ensure the education provided gives the
nurse the best opportunity to improve. Documenting
the remedial education will also demonstrate how the
employer supports its staff and addresses opportunities
for improvement. Furthermore, the employer can learn
if there are patterns of gaps in knowledge in individuals
or groups that could be addressed proactively. Without
evidence-based remedial education programs, gaps in
a nurse’s practice may continue. Gaps in professional
nursing practice pose a potential threat to patient safety
(Kavanagh, Cimiotti, Abusalem, & Coty, 2012). Nurses
who have gaps in their nursing knowledge or skills have
the potential to harm patients. Therefore, providing a
standardized method of remedial education could ultimately help to improve patient safety.
Improving patient safety and achieving excellent patient quality outcomes are the goals of value-based care;
if patients are harmed, hospitals and providers can incur
financial penalties (Kessell et al., 2015). Thereby, remedial education is viewed as a cost-effective method to aid
in avoiding patient harm and healthcare facility financial
penalties. For example, the Centers for Medicare & Medicaid Services (CMS) value-based purchasing program
has defined evidence-based patient safety indicators, including hospital-acquired infections such as catheter
associated urinary tract infections and central line-associated
blood stream infection rates. When patients are harmed
and the hospital’s rate of hospital-acquired infections
(e.g., CAUTI) are above the median, up to 2% of the hospital
revenue payments can be withheld from CMS.
The specific aim of this project was to standardize the
registered nurse remediation plans using the nine ANCC
elements 100% of the time following the education intervention for the nurses in professional development.
Safety Culture
A culture of safety was used as the theoretical framework
for this QI project. The four aspects of Reason’s (1997)
safety culture include reporting culture, Just Culture,
flexible culture, and learning culture. A reporting culture
includes a safe environment reliant on frontline workers
to report their errors and near misses. The framework of
Just Culture is evident when management supports
reporting by frontline workers and disciplinary processes
are used based on employee risk taking (Singer & Vogus,
2013). Flexible culture is when official authority or hierarchy is loosened to support reporting about safety
concerns and those with authority respect and listen to
frontline workers because of their expertise (Brennan,
& Keohane, 2016). Learning culture is when an organization uses the reported information to affect change
(Reason, 1997). These four cultures build upon each other
and are interrelated to provide the safety framework.
The concept of ‘‘Just Culture’’ relates to managing
organizations in an open and fair manner to hold individuals accountable and investigate actions or behaviors that
led to an error. It is used to promote a learning culture that
uses knowledge from previous errors or near misses to design safer systems and address behaviors incongruent with
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Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
safety (Frankel, Leonard, & Denham, 2006). Just Culture
should not be used solely to fix problems, but to change
the expectations of individuals to improve or redesign systems and to monitor and mitigate any risks identified
during this effort.
The ANA (2010) supports the concept and use of Just
Culture. This QI project depended upon the framework
of Just Culture for its implementation. Just Culture was
necessary to ensure the registered nurses were identified
appropriately and would feel safe participating in the remedial education. The clinical site health system has a
well-developed culture of safety, which also supported
the implementation of this project. The clinical site also
uses the ANCC accreditation model when providing
continuing education for nurses, so the nine steps are familiar to nurse educators and nurse planners within the
The IOM’s seminal report To Err Is Human: Building a
Safer Health System (Kohn et al., 2000) sparked a national
focus on patient safety, including an emphasis on nonpunitive systems review with personal accountability
when errors do occur in the healthcare industry. According
to the report, errors should be assessed to determine their
cause. When an error occurs in nursing professional practice and is related to the performer’s lack of knowledge,
skill, ability, or judgment, then the education provided
to correct this deficit is called remediation (ANA, 2008;
Harding & Connolly, 2012; NSCBN, 2005; Zhong, Kenward,
Sheets, Doherty, & Gross, 2009), the goal of which is to
help nurses perform safely and competently within their
professional role.
Educational remediation is a strategy used by many
nurse managers and executives when addressing poor
performance and errors in the work place (Effken et al.,
2010). The National Council of State Boards of Nursing
(NCSBN, 2009) has reported that remedial education for
unsafe or incompetent nursing practice is used relatively
frequently (i.e., 25%) as a probationary measure for nurses
who have been disciplined by their state’s board of nursing.
Inservice or just-in-time education is another important approach for addressing nursing practice concerns (Murthy,
2014). However, inservice education, in general, is not as
highly valued or effective as a teaching method by nurses
(Harding, 2011). Many nurses find inservice education
harried and offered at times that do not allow for everyone
to participate. Thereby, having a more specific approach
such as using the ANCC accreditation program format for
designing remediation for affected registered nurses may
be a more valued approach.
The ANA (2015a, 2015b) and the NCSBN (2005) both
affirm that registered nurses are responsible and accountable for their own competent professional nursing practice.
Competence is the ability to perform what is professionally
expected (ANA, 2008). The ANA (2009) in their Nursing
Administration: Scope and Standards of Practice states
that nurses in management positions are responsible for
ensuring the competence of the nurses they supervise.
The Joint Commission (2016) also expects the leadership
of the hospital to ensure the competence of the staff to deliver safe health care.
The NCSBN (1996) defines competence as, ‘‘the application of knowledge and the interpersonal, decisionmaking and psychomotor skills expected for the practice
role, within the context of public health’’ (p. 16). Comparatively, the ANA (2010) defines competence as ‘‘an
expected and measurable level of nursing performance
that integrates knowledge, skills, abilities, and judgment,
based on established scientific knowledge and expectations for nursing practice’’ (p. 4). Failure of the nurse to
integrate knowledge, skills, abilities, and judgment in delivering nursing practice can lead to indiscretion in
patient care, which may lead to unethical, illegal, or incompetent behaviors (Harding, Connolly, & Wilkerson,
2011). Healthcare organizations should provide routine
and on-going education to maintain staff competence
(Harding, Walker-Cillo, Duke, Campos, & Stapleton,
2013). Professional nursing competence in knowledge,
skills, and judgment is supported by leading professional
nursing organizations. When professional nurses have a
gap in competence, Just Culture directs the organization
to identify the cause and provide remedial education
when indicated. Due process is given to nurses within
an organization using Just Culture.
Use of a standardized evidence-based education program
to deliver remedial education will help nurses protect
patients and establish a culture of safety. Applying QI
methods in the work of nurses in professional development with nurses who require remediation also contributes
to this safe practice. After reviewing the records of those
nurses in need of remedial education as part of this project,
the author observed that documentation of the education
process was inconsistent. The opportunities for improvement involved identifying the learning opportunity,
describing the teaching methods, and determining expected
learning outcomes. Safety culture had been formalized
with the organization’s policies and procedures for more
than 10 years and, in 2010, included the use of the Just
Culture algorithm. These concerns were then shared with
the organization’s director of nursing professional development (NPD).
The NPD department believed that using an evidencebased method of registered nurse professional practice
remediation would develop their safety culture and ultimately
lead to better patient care. The clinical site described in
Journal for Nurses in Professional Development E3
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
this project used remediation as a strategy to address errors
or identified gaps in nursing practice. However, there were
only six documented registered nurse practice remediations. The remaining remedial education efforts were
decentralized outside the NPD department or not documented. The author and NPD director approached the
Associate Chief Nursing Officers to obtain support for this
project, advocating that the nurse managers consistently
partnered with nurse educators when creating and delivering remedial education. The Associate Chief Nursing
Officers agreed and communicated their approval to the
nurse managers to partner with the nurse educators when
remedial education was required. The intention of the
nurse manager and nurse educator partnership was to provide a high-quality remedial education experience for
registered nurses and to increase the previously reported
low rate of documented remediation.
In the first step of this QI project, the authors compared the previous six remediation documents to the
nine key elements of the ANCC accreditation program.
The results of these previously documented remedial
education data are illustrated in Figure 1. Of note, the only
category completed in 100% of the previous cases was the
identification of a practice gap. Other steps, including recording the learner engagement strategies, were not
consistently documented.
The nine key elements of the ANCC accreditation program can be applied to various scenarios. For example,
an identified practice gap is typically an error or near
miss in nursing practice, often attributable to a lack of
nursing cognitive knowledge or psychomotor skill. To
address the gap, a clear description of what occurred
and a specific expectation of outcomes are first needed.
The outcomes measurements are how the learner will
demonstrate their attainment of the knowledge or skill.
The learner engagement strategies are the teaching strategies to be used by the educator to connect with the
learner. The time frame for addressing completion reflects
when the educational activities and expected outcomes
will be completed. The proof of instructor competence
should include a description of the nurse educators’ expertise, educational background, and demonstrated
competencies. Conflict of interest resolution disclosure is
used to prevent or avoid the appearance or actual conflict
of interest between the learner and nurse educator. The
summary of outcomes should serve to quickly describe
the learners’ progress through the remedial education process, along with the actual identified outcome.
This QI project compared data elements of registered nurse
remedial education completed prior to and following an
educational intervention in one hospital to examine the use
of the ANCC format for remedial education documentation
and remedial education plans completed using a case
method approach. Registered nurse remedial education
plans from the previous 2 years were reviewed for the nine
key ANCC elements. The existing remedial education plans
were not standardized in their format or content. This previous process did not align the Just Culture framework
supported by the organization and inconsistencies made
tracking the findings of the remedial education and its
effect on organizational learning difficult. Therefore, an educational intervention was planned for the nurse educators
to share a new way to document remedial education for
registered nurses.
The clinical site for this QI project was a health system
located near Boston, Massachusetts. The system includes
three acute care community nonteaching hospitals having
over 700 beds, 3,000 infant deliveries and 190,000 annual
emergency department visits, and more than 1,000 registered nurse employees. The hospital NPD educators
provide remedial education to registered nurses, but the
documentation of this education, along with measured outcomes and other quality aspects of demonstrated competency
assessment, was found to be incomplete or missing. In the
period from 2014 to 2016, there were six registered nurses
with documented remedial education experiences, but the
health system had no clear data to help evaluate the process of administering remedial education.
The health system included 15 nurse educators who
attended a 1-hour single session educational program
in a classroom setting, led by the project team. The education included instruction about the critical components of
remedial education in general. The nurse educators were
taught how to use the ANCC format and were provided a
tool with nine key elements to use while creating,
implementing, and reviewing registered nurse remedial
education. Educational strategies used during the session
included a slide sharing presentation along with the opportunity for discussion. Handouts of the presentation were
also available to learners. An example remediation plan
and a checklist of the nine ANCC elements were supplied
to the nurse educators to further their understanding and
application of this new process. A checklist of the nine
ANCC key elements and remedial education documents
were also furnished. The remedial education documents
provided a documentation tool for the nurse educators that
would prompt them to include the key elements when
working with an individual nurse. The nurse educators were
apprised of their new expectations during the educational
intervention requiring the use of the nine ANCC key elements
when creating, implementing, and documenting registered
nurse remedial education. The Director of NPD was available
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to the nurse educators for support after this education. One
measure of success was to compare the completeness of remedial education documentation after the educational
intervention to those prior.
There were no subjects requiring remediation during
the 2-month planned time frame for this project; therefore, a case study methodology was employed with the
nurse educators. The case study discussed the situation
of a registered nurse who had a gap in professional practice related to an educational deficit. The case study was
designed to provide a scenario with poor practice, policy
violation, and near misses. The case study was reviewed
for face validity by two doctorally prepared registered nurses
who served as professors and worked full time in the acute
care hospital setting. This case study was presented to the
same 15 educators who participated in the initial educational intervention. The nurse educators reviewed the
case study and were asked to create a remediation plan
using the ANCC accreditation program. The remediation
plan created separately by the nurse educators was evaluated by the authors for the inclusion of the nine key elements
of the ANCC accreditation program. This exercise reinforced
the education and increased the likelihood that the use of
the new remediation process by the NPD educators would
continue after this QI project was completed. The nurse educators were completely successful in documenting each of
the nine ANCC key elements in their cases.
Following the educational intervention, whose goal was
to help standardize the process and structure of remedial
education documentation, there were no incidents
needing registered nurse remediation. Therefore, a QI
project was completed by the nurse educators. The six
previous records were compared to the 15 case studies
completed for the documented presence of the nine
ANCC key elements. This comparison includes the percentage of each of the individual elements identified
in the documentation of the remedial education plans.
Furthermore, a comparison of the key elements for each
registered nurse requiring remediation or case study was
A convenience sample of documented professional registered nurse remedial education plans from the past 2
years was used for the preintervention comparison. The
goal was to include any available remediation plans created in a 2-month period post the educational intervention
about the use of the new remediation documentation
format. The author and the NPD director, who served
as the on-site QI project coordinator, had secure storage
and handling of data. A letter of support for this QI project was provided from the health system. This QI project
was reviewed by the Partners Institutional Review Board
and was given an exempt status. Data collected did not
include any protected health or patient information.
Information identifying educators and recipients of remediation education was not collected, and there were
no identifying features of individuals undergoing remediation included in data collection, thus assuring
FIGURE 1 Pre- and postintervention comparison of the nine ANCC key aspects documentation.
Journal for Nurses in Professional Development E5
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Documentation of remedial education pre- and postintervention of educating the NPD staff about the nine key
elements of the ANCC educational design is provided in
Figure 1. The t-test results demonstrate variation preintervention and postintervention for each of the nine key
elements of the ANCC accreditation program. All elements
demonstrated improvement in the percentage documented
following the education session. The total score, the percentage of documentation completed for each of the nine
key elements for the participants, of the pre (n = 6, 35%)
and post (n = 15, 100%) data documentation mean was statistically significant (p G .001).
In the predata, only 35% of the nine ANCC key elements were evident for the total sample with opportunities
for documentation in aggregate, a 35% completion rate in
other words, and after the intervention, 100% of the
expected documentation was completed (see Figure 1).
These total score percentage differences were statistically
significant (p G .05). The total predata percentage of
documentation for each of the nine ANCC key elements
was as follows: 100% identification of a practice gap,
33% evidence of the practice gap, 83% description of
the expected outcomes, 67% outcomes measurements,
0% learner engagement strategies, 17% time frames for
completion, 0% proof of instructor competence, 0% conflict of interest resolution disclosure, 17% summary of
The overall aim of this QI project was to improve the structure, process, outcomes, and documentation of remedial
education for nurses by providing an evidence-based
method of education for nurses with identified gaps in
their professional nursing practice. The specific aim of
this project was to address the registered nurse remedial
education plans using the nine ANCC key elements 100%
of the time following the intervention. Although the results of the case study demonstrated that the tool could
be successfully implemented, only one case was available
and may not have reflected all the variations that might
appear in real remediation situations. It also does not reflect whether the information would be retained over a
longer period of time by the nurse educators. Notably,
the 100% identification of the nine key elements could
reflect the fact that the nine ANCC key elements format
served as a type of checklist, providing a structure and list
of important elements to include. Also, the framework is
currently used at the organization for continuing education
programs, so NPD educators have some familiarity with its
purpose and use.
As suggested by the literature, further structure is needed for registered nurse remediation, and with this tool,
there could be greater possibility of remediation plans
incorporating key educational design elements. This small
project demonstrated that using a well-designed and clearly documented education plan can help to improve the
remedial education process for professional nurses in
one setting (ANCC, 2016; Harding & Connolly, 2012). Used
consistently, a structured process based on a commonly
understood evidence-based tool has implications for improvement in professional nursing practice and thereby
may contribute to increases in patient safety.
The limitations of this QI project include that the results are not generalizable to a larger population. The
use of a case study methodology did not permit for understanding of the intervention’s impact on actual professional
nursing practice. The next steps include exploring the feasibility of the nine ANCC key elements for actual registered
nurse remedial education plans. The format for documentation includes a checklist, which may lead to fostering
completion. Other questions that require further study
include outcomes measurement of learner satisfaction
and learner application of knowledge over time. Satisfaction of NPD educators and recipients of remedial
education is an important consideration for review of progress and outcomes.
Future study of the sustainability and satisfaction for
nurse educators when using the nine ANCC key elements in remedial education should also be explored.
This remedial education method should also assess the
participant’s experiences in remediation of professional
nursing practice. Future study could examine whether
educator characteristics such as experience and certification are correlated with appropriateness and completeness
of remediation plans in actual NPD practice. The authors
would also suggest that categories of types of remediation
be examined for completeness of remediation plans.
The nine ANCC key elements were effectively included by
the nurse educators in their remedial education plans using
a case study methodology 2 months after the educational
intervention. The authors suggest that this project offers a
standardized evidence informed approach for beginning to
address educational remediation in professional nursing
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