M. Response to Discussion 1. The complexity of cost is a major

M. Response to Discussion 1. The complexity of cost is a major issue driving development of healthcare system. Nurses have a major role to play in demonstrating that access to care and quality management are essential components of cost control. While Emergency departments (Eds) are used at a higher rate by patients having greater frailty, chronic care needs, and higher disease burden, they now are more frequently being used to care for frail older adults with multiple healthcare needs because of convenience, a perception of increased quality of care, and a lack of rapid access to primary care providers (Morganti et al., 2013). The number of seniors seen in my workplace has increased over the years and many seniors worried about the costs because they are on a fix income. Many patients come back for the same reason many times. Medicare cover most expenses for seniors. However, changes have created new rules and procedures that may affect patient care. Medicare had begun to address such perverse incentives with reimbursement policies that preclude reimbursement for same cause readmission if it is within one month after discharge and fining hospitals whose readmission rate is too high, to name just two examples. These payment changes have created delivery changes that nurses see regularly in practice. The shift to virtually all reimbursement being tied to value has the potential to completely redesign the U.S. health care system. Notably, these changes are exterior to the ACA and rooted in Medicare rules (Palumbo, Rambur & Hart, 2017). Studies have demonstrated that EDs with enhanced care-transition protocols, such as targeted referral and follow-up for unmet medical and social needs can reduce risk of admission or delay admission to skilled nursing facilities by up to 70 percent for 120 days following discharge from the ED (Ko, Ula Hwang, Biese, & Agha, 2019). The complex environment of health care can provoke the development of new strategies to guide professional and patients through chaos and uncertainty. It requires a clear vision, a few simple rules, and the extension of freedom to support adaptation, evolution, and emergence (Marshall, & Broome, 2017). Increasing consumer attention to disease prevention and promotion of healthful lifestyles have been helpful. Older patients have becoming active in care planning. The ED in my community does a lot of patient teaching in disease prevention which have helped many patients not coming back to the ED. The framework’s reference to business means that leaders need to understand the business of health care, their role in it, and the basic skills of management. Well-being concepts have been woven into the “Team, Change, Business” framework, making the commitment explicit (Jacobs, McGovern, Heinmiller & Drenkard, 2018). Changes in nursing roles and the settings in which nurses provide services are changing the leadership and management of knowledge that nurses need. Jacobs, B., McGovern, J., Heinmiller, J., & Drenkard, K. (2018). Engaging employees in well-being: Moving from the Triple Aim to the Quadruple Aim. Nursing Administration Quarterly, 42(3), 231–245. doi:10.1097/NAQ.0000000000000303 Ko, K., Ula Hwang, Biese, K., & Agha, Z. (2019). Emerging Priorities and Opportunities in Geriatric Emergency Care: Early analysis of the clinical and cost impacts of Geriatric Emergency Departments is promising–and the GED movement is growing. Generations, 42–46. Marshall, E., & Broome, M. (2017). Transformational leadership in nursing: From expert clinician to influential leader (2nd ed.). New York, NY: Springer. Morganti, K. G., et al. 2013. The Evolving Role of Emergency Departments in the United States. Santa Monica, CA: RAND Corporation. Palumbo, M. V., Rambur, B., & Hart, V. (2017). Is health care payment reform impacting nurses’ work settings, roles, and education preparation? Journal of Professional Nursing?: Official Journal of the American Association of Colleges of Nursing, 33(6), 400–404. https://doi-org.ezp.waldenulibrary.org/10.1016/j.profnurs.2016.11. G Response to discussion 2. Top of Form A current national healthcare issue/stressor is nursing burnout. There have been studies that have proven that nurses undergo high levels of stress at work. The stressor includes time pressure, minimal staffing support, increased workload, and high acuity patients with complicated treatment options (Portoghese et al., 2014). This amount of stress placed on the nurse can result in adverse patient outcomes and personal bias towards the healthcare organization. There are strategies to decrease nursing burnout, such as meditation, exercise, and healing touch (De Oliveira et al., 2019). Nursing stressors can be reduced in the work environment if management acknowledges and understands the staff’s stressors. By recognizing the issue, there can be interventions that develop to decrease stress. The American Association of Critical Care Nurses also has recommendations for reducing stress, such as pressure reducing classes, relaxation, hobbies, and having balancing personal life and work (AACN, 2016). In recent months, the stressors have been intense on the nurses at my healthcare organization, especially with the pandemic crisis. One of the hardest things that I had to face is the lack of resources we had during the pandemic, particularly at the beginning of the outbreak. We were overwhelmed with the lack of supplies, the lack of support from management, and the patient to nurse ratios. Thankfully, my organization took measures to improve these stressors by hiring travel nurses, creating team nursing, and resting mentally. Pastoral care is also offering stress-reducing online classes for all staff members. I am so grateful to have a supporting manager in which I feel comfortable in discussing work-related issues. It is also vital to have a good rapport with the manager because it can contribute to another stressor, if not.  References AACN Joins Effort to Prevent Burnout in the ICU. (2016). AACN Bold Voices, 8(9), 6. Retrieved from https://search-ebscohost-com.ezp.waldenulibrary.org/login.aspx?direct=true&db=rzh&AN=118099254&site=ehost-live&scope=site De Oliveira, S. M., de Alcantara Sousa, L. V., Vieira Gadelha, M., & do Nascimento, V. B. (2019). Prevention Actions of Burnout Syndrome in Nurses: An Integrating Literature Review. Clinical practice and epidemiology in mental health: CP & EMH, 15, 64–73. https://doi.org/10.2174/1745017901915010064 Portoghese, I., Galletta, M., Coppola, R. C., Finco, G., & Campagna, M. (2014). Burnout and workload among health care workers: the moderating role of job control. Safety and health at work, 5(3), 152–157. https://doi.org/10.1016/j.shaw.2014.05.004

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