Section 1 – Preamble
These guidelines describe and contrast the authority and accountability for management and the practice of nursing within Meritus Medical Center (WCH). The management structure within the Division of Nursing is consistent with that of WCHA and is outlined in Article I, Section 7, of these guidelines.
Within the Division of Nursing, the Bylaws are the governance structure and serve as the framework for the communication between four nursing councils, which are the heart of the Division of Nursing. The responsibility, accountability and commensurate authority for establishing and maintaining standards of nursing care and practice belong to nursing. Each council has an identified role and partnership with the other councils to contribute to the whole. Healthy partnerships are sustained through consensus decision making and responsible constructive communication. The Clinical Practice, Professional Development, and Nursing Leadership Councils are devoted to professional nursing issues. The Coordinating Council maintains the constancy and coordination between council activities that determine the practice of professional nursing. The Nursing Leadership Council, as one of the member councils of the governance structure, provides the vital link in the continuous chain of partnerships between the nursing staff, nursing management, and the hospital. The structure is designed to facilitate principles of partnership in achieving the vision, mission, and philosophy of the Division of Nursing. Administrative overrule is not necessary unless these principles are violated.
Section 2 - Mission, Vision, Philosophy, and Nursing Theory of the Nursing Division
To be a dynamic force in the advancement of nursing practice and advocate for the promotion of quality healthcare for all.
To foster the development and advancement of nursing practice and to work to achieve quality healthcare for all.
We believe that…….
Excellence of care for patients and families matters most,
Superior customer service and constant innovation sustains excellence,
Quality patient care is measurable,
Evidenced based practices result in optimal patient outcomes,
Fiscal responsibility ensures the ability to provide the best possible care,
Nursing leadership must utilize strategies to attract and retain individuals in healthcare roles,
Nurses know the healthcare needs of our community and implement plans to promote wellness, and
most of all, the Nursing care we provide Matters.
The nursing staff at Meritus Medical Center ascribe to the following theories in their daily nursing practice: Orlando’s definition and vision of nursing process, collaborative practice, and Swanson’s Theory of Caring.
The first theory of nursing is based on Ida J. Orlando’s definition and vision of the nursing process. The nursing process is also the basis for the Maryland Nurse Practice Act. Dr. Orlando’s theory defines the nursing process which includes the initial assessment of patient needs, plan development, implementation of the plan, and evaluation of the outcomes. The dynamic relationships and interaction between the patient and the nurse is fundamental in implementation of a theoretical framework for the nursing process.
The second theory of Collaborative Practice is utilized by all members of the health care team at Meritus Medical Center. This model is integrated into our clinical system, which outlines the expected interdisciplinary course of events for a patient with a specific diagnosis. The guidelines are established through evidenced based practice and research.
The third theory is Kristen M. Swanson’s Theory of Caring. This nursing theory is derived of five caring processes based on the definition that caring is “a nurturing way of relating to a valued other, toward whom one feels, a personal sense of commitment and responsibility.” Caring is central to all nursing practice. The five caring processes are as follows:
Knowing: Striving to understand the event as it has meaning in the life of the other by avoiding assumptions, centering on the one cared for, assessing thoroughly, seeking cues, and engaging the self of both Being with: Being emotionally present to the other by being there, conveying ability, sharing feelings, not burdening Doing for: Doing for the other as he/she would do for the self if it were at all possible by comforting, anticipating, performing competently/skillfully, protecting, and preserving dignity Enabling: Facilitating passages through life transition and unfamiliar events by comforting, anticipating, performing competently/skillfully, protecting, and preserving dignity. The nursing staff ascribes to following theories of the nursing process, collaborative practice, and patient/family centered care for the management of nursing care for our patients and families. Maintaining belief: Sustaining faith in the other’s capacity to get through an event of transition and face a future with meaning by believing in/holding in esteem, maintaining a hope-filled attitude, offering realistic optimism, and going the distance for the other
Embracing these theories allows the nursing staff to provide appropriate care and plan for the future of nursing care
Section 3 - Definition of Nursing Practice The Nursing practice incorporates the American Nurse’s Association Code of Ethics for Nurses with Interpretive Statements and the Maryland Nurse Practice Act. Scope and standards for Nurse Administrators (ANA) are implemented throughout nursing. Nursing practice is a dynamic process which utilizes assessment, planning, implementation, and of the plan of care. Our practice is based on evidence and research.
Section 4 - Where Nursing is Practiced
The nursing process is used to provide quality patient care that includes an interdisciplinary collaborative team approach which concentrates on holistic care for the patient and family.
Nursing care is a part of the patient care services provided in the following departments:
Behavioral Health Services
Cardiac Cath Lab
John R. Marsh Cancer Center
Oncology/Male Urology/Palliative Care
Post Anesthesia Care Unit
Progressive Care Unit Radiology
Geriatric Medical Rapid Diagnostic Center Same Day Surgery Special Care Nursery Urgent Care, Pennsylvania Avenue Urgent Care at Robinwood Women and Children Wound Center
Section 5 - The Role of the Professional Registered Nurse
The professional registered nurse (RN) has the authority, responsibility and accountability for performing the nursing process in whatever patient care setting she/he is practicing. The RN role is fundamental to the patient’s continuum of care. The RN must partner with others to fulfill his/her accountability for the outcomes of patient care. Partnership begins with the patient and/or significant others and the physician to identify goals and plans of care and continues throughout the care continuum, from RN to RN and to other care providers. The RN role is defined by the ongoing integrative function that she/he fills in the care continuum versus an episode of care.
Section 6 - Participation
Participation in the WCH nursing staff is a privilege extended to all registered nurses who meet the qualifications, standards, and requirements as outlined in Nursing Policy/Procedure and Human Resources manuals. Accepting this privilege constitutes agreement on the part of the individual to practice in accordance with the standards promulgated by the nursing bylaws and outlined by nursing policy/procedure and practice guidelines, and to uphold the policies of WCH.
A. Categories of Participation
WCH professional registered nurse employees
Flexible staffing team (FST)
Adjunct Staff - credentialed for professional nursing practice within WCH and obliged to comply with the standards of care and practice/policy and procedure of the Division of Nursing. The adjunct staff participates in the work of the governance structure in an advisory capacity when input is requested.
Advanced practice nurses, nurse practitioners, CRNA’s, case managers, clinical nurse specialists, and care specialists
Associate members may include licensed practical nurse, certified nursing assistant, and unlicensed staff.
To qualify for participation on the nursing staff of Meritus Medical Center, the individual RN must demonstrate:
Valid, active licensure as a RN in the state of Maryland or associated compact state.
Credentials supporting relevant and appropriate education and experience.
Competence for the RN role within Meritus Medical Center.
Skill and knowledge to meet the criteria and requirements indicated in these guidelines and those of the position/unit for which the individual has applied for specific privileges.
C. Credential Process:
Credentials and privileges of the WCH registered nursing staff and other professional registered nurses practicing in supportive capacities within WCH are administered as follows:
The credentials review process may consist of all or part of the following:
Evidence that the applicant has the appropriate license, certificates or degrees, diplomas, or other evidence indicating required preparation.
Completion of a successful interview for a nursing staff position with a nursing manager and staff nurses. This step includes the verification of applicant’s ability to be a resource to the unit/department, as well as the applicant’s ability to uphold the Division of Nursing’s standards.
Recommendation for hiring applicant by a nursing manager and staff participation in the interview.
Nursing management, in collaboration with the clinical educator and the RN, complete the following for the credential process:
Successful validation of the nurse’s unit based skills requirements.
Satisfactory completion of orientation.
The credential review process consists of evidence that the individual has the skills and knowledge to:
Consistently achieve quality outcomes in patient care delivery;
Perform tasks and think critically about the nursing care required for the unit’s patient population; and demonstrates critical thinking and takes actions appropriate to patient need
Establishes constructive and productive relationships with patients, families, hospital staff and physicians.
This evidence is documented annually through the use of competencies, peer review and performance appraisal tools.
D. Obligations of the nursing staff
The application submitted for consideration within the credentials review process constitutes the applicant’s acknowledgment of staff obligations within the nursing division.
Appointment to the nursing staff confers upon the nurse the clinical obligation to provide nursing care to patients consistent with the standards of care and within the level of nursing practice of their demonstrated competence and participation category.
Participants are obligated to abide by these articles and rules and regulations herein outlined. This obligation further applies to the values, standards and policies of WCH.
Section 7 - Structure
The Vice President, Chief Nursing Officer coordinates the direction, planning and implementation of nursing services. She/he is responsible for shaping the Division of Nursing’s vision and ensuring its alignment with Meritus Health. All nurses who practice nursing within the health system are ultimately responsible to the Vice President, Chief Nursing Officer for nursing practice.
The Vice President, Chief Nursing Officer shares responsibility for the nursing performance in a matrix structure for the nursing services which have a direct reporting line to other non –nursing directors. These directors have administrative responsibility for nursing and other disciplines serving a unique population of patients. In the WCH structure these include the following departments/entities: Home Health, Behavioral Health Services, Total Rehabilitation Care, Health Management, and the John R. Marsh Cancer Center.
The Division of Nursing of Meritus Medical Center is comprised of units/departments that are led and managed by a nursing management team, which includes a clinical manager and administrative director. They each have responsibility for managing the delivery and evaluation of nursing services for patients/families and other customers by working collaboratively with other disciplines. Each nursing manager has a staff of licensed and unlicensed personnel to whom she/he provides leadership by mentoring, facilitating, and coaching in clinical processes and ensuring available resources to meet, care, and practice standards.
Nursing management has 24 hour accountability for their unit(s). There are also Administrative Nursing Supervisors (ANS) on the evening, night shifts, weekends and on holidays, to provide administrative responsibility for operations of the off shifts. They provide leadership to staff through coaching in clinical and resource management decision making.
Nursing Management may be nurses or possess other relevant health care background for their service. Each recognizes their obligation to ensure quality practice of the disciplines responsible to them.
The clinical educators, under general direction of the administrative director and in collaboration with the clinical manager, manage the orientation, clinical and professional development of staff.
The director of informatics provides professional and managerial assistance in the administration of the operations of both the division of nursing and the division of patient
care services. Works collaboratively with all clinical management staff within the hospital in providing administrative oversight to the human resource, financial, and information management functions; enhancing or developing systems that facilitate efficient and effective care.
Section 8 - Discipline, Appeals and Removal from the Nursing Staff
All nursing staff has the same rights, privileges, and access to employment protection policy and procedures as all employees of WCH, through the Human Resources Department, regardless of category. They are subject to the employment, disciplinary, and appeals process, as mandated through WCH’s personnel policies and procedures.
When a member of the permanent, probationary, temporary, or adjunct staff is unsuccessful in meeting the standards expected of their role in the hospital, removal from the hospital may be undertaken through initiation of the hospital’s disciplinary process, as outlined in the Human Resources Policy and Procedures Manual or through the medical staff review process as appropriate for non-employed nurses.
ARTICLE II - Division Wide Council Structure
Section 1 - Purpose, Responsibility and Authority
The purpose of the operational guidelines is to establish and maintain evidenced based standards of nursing care and practice to ensure the delivery of high quality nursing services to the population served by WCH.
The guidelines are responsible for executing the above mentioned purpose and are granted through the Board of Directors and management of WCH, the authority for same.
Section 2 – Membership
Membership is a privilege extended to the professional registered nurse credentialed to practice within the Division of Nursing and who by virtue of their employment commitment (regular full, regular part-time, or part-time) have the organizational exposure facilitating the critical thinking required to address nursing practice issues of the organization. Membership provides eligibility to participate in the work of nursing by participating in the council structure. Members are selected by the nomination process. A member may self nominate or be nominated by a peer; both of which require a management recommendation.
Section 3 - Definition
The purpose, responsibility, and authority of nursing is realized through a structure
of interdependent councils consisting of four division wide councils and unit councils. All members have access to and are responsible for knowledge of the work of the councils through minutes of meetings. Each council will select two co-chairs.
Section 4 - Rules and Regulations
A. Nomination Process
Council members, managers, directors and advisors are appointed by utilizing a nomination process. Membership on all division wide councils is voluntary and the length of service of any one member is prescribed. Membership will vary depending on either a one or two year term. Each October the opportunity for a change in membership will be opened on each nursing council. It is the expectation that council chairs (both unit and division wide) and nursing management will continuously mentor and coach new and potential members, and plan and execute an orientation for new members.
Each council will outline a member and officer orientation plan that shall include at a minimum:
Receipt and review of a copy of the WCH Nursing Bylaws
Review and discussion of role expectations
Identification and information on the council’s most pertinent and current issues
C. Code of Conduct
Be prompt and ready to work.
Avoid individual/personal conversations.
Assume your share of responsibility for maintaining order in the meeting.
Support the chair in his/her authority to control discussion time and in maintaining order.
Create conditions that make dialogue safe, honest and respectful.
Actively participate in decision making by exercising your right and responsibility to vote.
Support the council’s decisions when a majority vote/consensus is achieved.
Assume your share of responsibility in providing clear direction for task force assignment.
Respect and support the recommendations of task forces/work groups.
Be proactive: think Win/Win
D. Responsibilities for Nursing Division Wide Councils
Formulate the agenda
Convene and conduct the meeting
Assure follow-up of all council business
Represent the council at Coordinating Council
Appoint committee members to task forces
Representative to Clinical Care Congress (CPC only)
Orient co-chair responsibilities
Rotate two year term
Orient to Co-chair responsibilities
Consistently support and participate in follow-up of council business
Membership selected from nomination process. Members are expected to abide by the Council’s Code of Conduct and to participate in council business and discussions in a constructive manner.
Council Decisions/Activities/Information are to be communicated to divisional staff by the Council members in a timely fashion.
Issues involving individual members and not resolved by the council will be referred to the appropriate Clinical Manager by the co-chairs.
E. Decision Making Process
Decisions are made by majority rule. A quorum shall be attendance of greater than 50% of council membership.
Attendance at the monthly division council meetings is required. A pre-designated, consistent replacement may attend two times per year. (October - October).
Minutes of each meeting shall be recorded. The magnet department assistant, or other assistant coordinated by the advisor, will be responsible for recording minutes. Minutes are made available through Office Automation and the Intranet to all nurses in the organization.
H. Discipline and Appeal
Discipline for non-compliance with council rules will be communicated to the Coordinating Council by the co-chairs. Appeals may be made in writing to the Coordinating Council.
I. Management Advisor
The advisor functions as a facilitator to the council. The advisor ensures effective operations of the council related to its roles and responsibilities. Those that cannot vote provide input into deliberations only as needed to keep the overall achievement of the vision and mission into perspective, and to ensure a relationship between staff and management.
The role, responsibility, and authority of each of the councils are here outlined:
A. Clinical Practice Council (CPC)
Role: The Clinical Practice Council (CPC) establishes standards of care through evidenced based practice guidelines, research, and policy and procedures. Ensures the Division of Nursing’s measurement and evidence of The Joint Commission and other reviewing agencies’ standards are in compliance
Maintains systems for developing, reviewing, and revising standards of care for the division of nursing.
Implements standards into practice documents, e.g., practice guidelines, documentation tools, and policies.
Directs all interdisciplinary clinical issues to the Clinical Care Congress as identified.
Collaborates with the other nursing councils and departments to achieve goals related to practice change.
Contributes to the assessment and evaluation of new products.
Develops standards of care, policy and procedures and protocols based upon the following: Evidence Based Nursing Practice (EBNP), research, performance improvement data, patient satisfaction, medication variances, adverse events, JCAHO National Patient Safety Goals, model of care, documentation, The Joint Commission, Maryland Board of Nursing (MBON), any nationally recognized specialty organizations with standards of practice, and peer review.
13 staff RN’s from recommended nursing service lines
Women & Children
1 - Clinical educator
1 - APN or specialty care
Non voting members
1 – Clinical Manager
1 – Administrative Director (advisor)
Meetings: Monthly for 2 hours
NURSING RESEARCH COUNCIL BYLAWS
To contribute to nursing evidence in practice and support the direct care nurse’s participation in research, ultimately improving nursing procedures, patient outcomes, and care delivery. Support the mission, vision, and philosophy statements of the department of nursing.
Expand the knowledge base of the nursing staff regarding nursing research.
Establish consistent standards for the development, implementation, conduct and completion of nursing research.
Facilitate development of nursing research to support nursing practice that is evidence-based and knowledge driven.
Facilitate the professional growth and development of nurses through participation and conduct of research following Good Clinical Practice.
Facilitate the collaboration of nurse researchers with researchers/staff from other disciplines/hospital departments.
Facilitate nursing research at the bedside.
Foster the identification of areas suitable for nursing research.
Use established mechanisms for the review of proposed research studies, including protection of the rights of human subjects.
Membership is comprised of primarily direct care nurses that have graduated from an accredited school of nursing and who are identified by staff and nursing leaders based on interest, skills or other contributions and are nominated by the Director/Manager of each nursing service areas. All nurses conducting research under the guidance of the Research Consultant are also members of the Research Council. Membership is rotated every 2 years with 25% of the Nursing Research Council beginning rotation at the end of the first year. Nurses who are conducting research are not rotated off of the Nursing Research Council. Representatives from other disciplines may be a member or may be consulted as needed.
Each member must complete a human subject protection module agreed upon by the Nursing Research Council.
The chairperson for the Nursing Research Council will be the Research Consultant. A vice-chairperson will be mentored by the Research Consultant. The chairperson shall appoint Nursing Research Council members and task forces and shall conduct regular council business. For immediate operational decisions and/or emergency situations that occur between regularly scheduled meetings, the chairperson may act for the council. There may be an appointee to support the Nursing Research Council objectives and responsibilities.
The Nursing Research Council will meet, at a minimum of monthly for 90 minutes with a planned but open agenda.
Promote quality outcomes and facilitate a Good Clinical Practice nursing research environment by providing support for the following: development of all study documents, protocol, informed consent, logs table, shells, etc.; submission of all required research documents to the Institutional Review Board (IRB) of record following institutional procedures; study initiation including staff training on protocol requirements, study conduct and data collection; and study completion activities including data analysis and determination of most appropriate venue(s) for dissemination of study findings.
Facilitate nursing practice in an environment that uses continuous evaluation of procedures to improve care delivery and patient outcomes as the basis for ongoing research activities.
Promote nursing research that provides results to ensure nursing practice that is evidence-based and knowledge driven.
Promote understanding and effective use of organizational, management, and nursing theories and research.
Identify resources needed to support nursing research projects.
Facilitate the conduct and utilization of research and other scholarly activities, such as presentation and / or publication of nursing research study results.
Works with staff nurse research interns to enhance his/her research skills and knowledge.
Attend at least 80% of the Nursing Research Council meetings. Members shall contact the chairperson prior to any meeting if he/she will not be able to attend.
Develop yearly written goals and plans of action within appropriate timeframes due by December 1, to the Chief of Nursing.
A quorum shall exist when 30% of the membership is present. A quorum is mandatory if voting is required.
B.Professional Development Council (PDC)
Role: The Professional Development Council (PDC) monitors and assesses effectiveness of delivery of nursing service and patient care outcomes. Addresses professionalism, credentialing, education and image.
Responsible for the systematic monitoring and continuous improvement of processes and outcomes including data collection and analysis.
When an opportunity for improvement is identified, the four step process (Plan, Do, Study, Act) to measure the effectiveness of standards and guidelines will be implemented.
Oversees the clinical career ladder by establishing the criteria and evidence for clinical advancement (promotion) and unit based peer review.
Maintains a system for matching competency requirements and the means for their acquisition and evaluation utilizing evidenced based standards of care/practice, practice guidelines and management expectations to identify competency requirements.
Defines professional image
Participates in strategic planning
Promotes collaborative practice teams
Develops recruitment and retention activities
Publishes the “Nursing Matters” newsletter
Manages the “Terrific Team” award
Promotes professional certification
Participates in reward and recognition through the coordination and celebrations of nursing division activities (i.e. Nurses week, CNA celebrations, etc.)
Administers the Nursing Education Fund.
Review and development of the nursing department competencies.
1 - Manager
1 - Administrative Director (advisor)
1 – HRD Rep (Ad hoc)
Meetings: Monthly 2 hours
C.Nursing Leadership Council (NLC)
Role: The Nursing Leadership Council (NLC) provides leadership and management for professional practice, providing the vital link between the WCH vision and the delivery of patient care.
Responsibilities: The NLC facilitates the effective and efficient achievement of nursing outcomes and has the responsibility and accountability to:
Recruit, recognize, and retain qualified competent staff by facilitating activities to enhance the manager’s ability to retain and recognize nursing staff while promoting the professional image of nursing and provide the essential elements that support the practice of excellence to nursing management.
Identify and schedule appropriate staff, numbers and skill mix, to meet agreed upon practice and care standards.
Provide a mechanism and support for continued competence and development of staff to achieve desired outcomes.
Budget and allocate resources.
Maintain consistency in the implementation of the nursing vision and the council structure on each unit.
Support a peer review process that assures quality outcomes for our patients.
Maintain and monitor the environment of the work place.
Provide management educational activities and provide mentors and orientation plan for new managers by:
Providing ongoing education for the nursing management team and the initial orientation to the management role be it administrative director, clinical manager, or administrative nursing supervisor.
Establish, review, and revise standards of nursing administration.
Review and revise job descriptions for the division of nursing by:
Ensuring appropriate review and update of all job descriptions for the division of nursing.
Ensuring appropriate review and update of related staff competencies for job descriptions in the division of nursing.
Enhancing awareness of legal implications of the Nurse Practice Act and other regulatory agencies that impact required skills and competencies of staff in the division of nursing.
Provide nursing leadership in the integration of performance improvement principles and interdisciplinary and interdepartmental collaboration to achieve continuous patient care delivery.
Review and revise standards that fall within managerial domain.
Remain informed of legislative issues that impact nursing.
Non voting members:
1 – Magnet Coordinator
1 – Director of Informatics
Ad Hoc Members:
Director of Quality
Meetings: Monthly 2 hours
Role: The Coordinating Council’s purpose is to maintain the constancy of focus for nursing. It ensures the coordination and integration of the Councils’ activities that determine the practice of professional nursing within the organization.
Responsibilities: The Coordinating Council has the responsibility, accountability and authority to:
Review and revise the bylaws
Plan and coordinate the development and monitoring of the nursing strategic plan.
Review the plans and actions of the other councils at the time of report to ensure alignment with:
Vision, mission, and values of WCH and the Division of Nursing
Organizational strategic initiatives
Administrative, personnel and clinical policies of WCH
Role, responsibility, and authority as outlined in these bylaws
Rules and regulations appropriate to each council
Assure peer review of the nursing profession is being practiced.
Collaborate with each individual council to annually evaluate the effectiveness of each council.
Assure communication of nursing actions and achievements to the professional nursing staff and the organization as a whole.
Investigate, deliberate, and rule on disciplinary appeals related to rules and regulations of the councils.
Membership: The Coordinating Council shall be comprised of the following members: Co-chairs, of each:
Clinical Practice Council
Professional Development Council
Nursing Leadership Council
The Vice President, Chief Nursing Officer
The Director of Informatics
The Magnet Project Coordinator - Chair
Meetings: Monthly 1 hr
Article III – Unit Council Structure
A. Unit Councils
Role: Maintain and assure quality of care and patient safety standards in their respective unit through evidence based practice guidelines, research, and policy and procedures. Develops standards of care, policy and procedures and protocols based upon following: Evidence Based Nursing Practice (EBNP), research, performance improvement data, patient satisfaction, medication variances, adverse events, JCAHO National Patient Safety Goals, model of care, documentation, The Joint Commission, Maryland Board of Nursing (MBON), any nationally recognized specialty organizations with standards of practice, and peer review.
Performance Improvement monitoring
Evidence based practice
Membership / Term
All professional registered nurses will participate in unit shared governance. Each October the opportunity for a change in council membership will be opened on each nursing unit. It is the expectation that council chairs (both unit and division wide) and nursing management will continuously mentor and coach new and potential members, and plan and execute an orientation for new members.
Associate members on unit based councils may include licensed practical nurses, certified nursing assistants, and unlicensed staff of the unit or affiliated disciplines/departments. They do not hold office or participate at the division wide level. Participation in the unit based councils will be determined by the unit.
Addendum: Membership for the first year 2007-2008 will be a combination of 1 year and 2 years terms. This will allow rotation of experienced membership.