Improving Depression Screening in Adults with Type 2 Diabetes: A Nursing Literature
Tiffany Amaya
St. Thomas University
NUR-611-AP2.25/SU2
Dr. Janet M. Huxley DNP, ARNP, FNP-C ( Do not put my credentials)
July 20, 2025
Improving Depression Screening in Adults with Type 2 Diabetes: A Nursing Literature Review
The common comorbidity in type 2 diabetes is depression, which is very serious yet largely unrecognized. The probability of being depressed is nearly two times that of the normal population when an individual has diabetes (De Groot, 2023). Depression, in turn, leads to poor glycemic control and a lack of compliance, high healthcare expenses, and overall as well as worse outcomes when not diagnosed and managed accordingly. Primary care nurse practitioners (NPs) can easily identify and treat this comorbidity since they are well-positioned to provide routine screening , as they are well-positioned to provide routine screening that aligns with evidence-based guidelines. Nevertheless, such screening protocols have been inconsistently followed( What literature do you have to support this statement? , failing to make the diagnosis and provide care that is less than ideal. This literature review examines existing studies on the screening of depression among diabetic patients in primary care facilities and the role of nurse practitioners in this process. It outlines a methodology for improving the screening.
Literature Review
Andrews et al. (2025)
The study by Andrews, Convoy, Anderson, and WaldropS (2025) is a quantitative randomized clinical trial aimed at determining whether a standardized depression screening tool among diabetic patients in a primary care facility was an effective practice. Nurse practitioners assessed one hundred and twenty 120 patients with Type 2 diabetes type 2 diabetes patients using the PHQ-9 screening tool. It was observed that practitioners who followed a more dramatic screening guideline were 40 percent more likely to spot depression symptoms than those who followed the regular ones. The authors inferred, based on this argument, that screening depression with evidence-based tools and their regular use results in greater detection and thus justification of incorporating depression screening in the process of diabetes care. The methodological rigorquality of this study was high, and this study scored high quality (A). Comment by Janet Huxley [2]: Andrews et al., (2025) Comment by Janet Huxley [3]: Why dramatic? That is not a concise term. Strict screening guidelines.
De Groot (2023)
In an interventional study, De Groot (2023) examined the tactics of managing depression and diabetes comorbidity in primary health services. A total of 15 randomized controlled trials were reviewed to test the effects of routine screening interventions, the collaborative care models, and the NP training programs. The data supported the fact that systematic depression screening, along with follow-up care, led to improved mental health as well as the self-management of diabetes. The point of critical observation made was that the installation of screening tools in the workflow and electronic health records (EHRs) enhanced their compliance (Groot, 2023). Although the review was thorough, the study's inhomogeneity in terms of setting and interventions justifies assigning it a moderate quality rating (B). Still, the results also highlight the significance of operational aid and training as a factor in screening uniformity enhancement.
Hermanns et al. (2013)You should not be using this reference.
The study, performed presented inby Hermanns et al. (2013), was is a quantitative one, which focused on the assessment of the extentdegree to which NPs were using the recommendations of depression screening of diabetic patients. The researchers analyzed more than 300 participants and established that cases of underdiagnosing depression were prevalent, with the research noting that they were present in approximately 60 percent of the patients. The identified barriers to adherence were: lack of time, guidance, and mental health resources. Even though the study is more than five years old, it can still be applied to modern practice in terms of revealing the operations and systemic issues that have remained unchanged over these years. Because of its contribution to this knowledge base of investigation on foundation barriers, it has been ranked as of moderate quality (B).
Richardson et al. (2014) You can not use this.
A mixed-methods research design was applied in an evaluation of NP management of type 2 diabetes with depression screening behaviors conducted by Richardson, Derouin, Vorderstrasse, Hipkens, and Thompson (2014). Literature findings demonstrated inconsistent application of evidence-based screening practices across different NP-led clinic practices, as revealed by the conduct of surveys and a review of medical records. A few of the barriers were insufficient training on mental health care and the absence of EHR prompts. Even though the study only covered a subsection of screening for depression, real-life lessons can be useful in implementing the study. This study is regarded as having poor quality (C), following the fact that it has a narrower focus and a small sample size. However, it helps in gaining insight into various contextual factors that can influence NP behavior.
Findings Synthesis
The four articles to read portray a number of similar trends. To start with, depression is rarely diagnosed in people with diabetes with type 2, yet it is clear that early diagnosis is the key to recovery in terms of both psychiatric and diabetic health. Second, standardized instruments, such as PHQ-9, have a vast improvement in the detection process when used by nurse practitioners (Andrews et al., 2025). Third, the lack of adherence to the guidelines is caused by some systemic factors, including the shortage of time, training, and integration of tools into EHR systems (Hermanns et al., 2013; Richardson et al., 2014). Fourth, integrated screening processes in workflow systems and collaborative care models remarkably increase screening rates and quality of follow-ups (De Groot, 2023).
One important gap found in the U.S. based literature is the paucity of research examining the effects of structural interventions, U.N.P. focused, that directly assess specific processes on adherence to depression screening-related guidelines. A majority of the literature is aimed at general healthcare systems or general primary care providers, other than the actions of nurse practitioners. The reduction of this gap is essential since NPs are taking a more active role in giving front-line care to diabetic populations.
Proposed Methodology
To address this gap, a quantitative approach is proposed for a randomized controlled trial. The trial will estimate the impact of a bundle of interventions, that is, the NP training and implementation of PHQ-9 prompting into EHRs, on adherence to depression checks and the rate of detection in patients with diabetes. ( This seems like your population should be the nurses being trained on the PHQ-9 and watching their consistency with doing the screening, not the patients. You might want to start there.) Comment by Janet Huxley:
Design and Setting
· Research design: Randomized controlled trial (RCT)
· Setting: Three primary care clinics in the U.S. with an NP as the leader ( Start small and then expand. Look at the one you would be working at or have precepted at.)
· Sample size: 150 adult patients with type 2 diabetes (consisting of 50 patients in each of the clinics)
· Producers: 10 NPs will be selected randomly for an intervention or control group
Intervention
Members of the intervention group will take part in a 2-hour training session on PHQ-9 as a depression screening tool, and automated EHR reminders will be enabled. In the control group, the usual care will be provided, and no further training or change of EHRs will be provided.
Measures
· Primary outcomes: Percentage of depression screenings performed, percentage of depression diagnoses, and the number of follow-up referrals
· Data Collection: Excavation of EHR data and review of charts in three months
· Test: Chi-square for categorical variables and t-test for continuous results
In this research, the researcher seeks to give compelling evidence on how the changes in the system can enhance the rate of NP compliance with the guidelines on depression screening and treat diabetic patients effectively. ( This statement proves my earlier assertion that your sample size does not come from the patients. This is directed towards the NPs. They are your population.
Conclusion
Depression is a health condition that is poorly dealt with in diabetic patients, and nurse practitioners have a big role in overcoming this situation by carrying out regular screening on hypertensive patients. It emerges in the literature that when there is systematic application of evidence-based tools, diagnostics will be improved; however, there are still major obstacles. The study being proposed will pursue these objections by evaluating the impact of the training and integrating the EHR on NP adherence. The results may be used to guide the future NP training curriculum and policies that influence the betterment of the diabetic population's mental health care.
You utilized outdated resources- which is a major issue. Also you did not preparing a document that compared and contrasts the information in the articles you found. That was part of the instructions. You were also missing the gaps in knowledge
References
Andrews, W. R., Convoy, S., Anderson, B., & Waldrop, J. B. (2025). Detection of depression in patients with type 2 diabetes. The Journal for Nurse Practitioners, 21(2), 105299. https://doi.org/10.1016/j.nurpra.2024.105299
De Groot, M. (2023). Diabetes and depression: Strategies to address a common comorbidity within the primary care context. American Journal of Medicine Open, 9, 100039. https://doi.org/10.1016/j.ajmo.2023.100039
Hermanns, N., Caputo, S., Dzida, G., Khunti, K., Meneghini, L. F., & Snoek, F. (2013). Screening, evaluation, and management of depression in people with diabetes in primary care. Primary Care Diabetes, 7(1), 1–10. https://doi.org/10.1016/j.pcd.2012.11.002
Richardson, G. C., Derouin, A. L., Vorderstrasse, A. A., Hipkens, J., & Thompson, J. A. (2014). Nurse practitioner management of type 2 diabetes. The Permanente Journal, 18(2), e134–e140. https://doi.org/10.7812/TPP/13-108
Please respond to the following prompts in a clear and concise manner. Use examples from your experience or relevant literature when applicable. Your responses should demonstrate critical thinking and application of ethical principles in the context of evidence-based practice.
Enhancement of Ethical Considerations
In your own words, explain how evidence-based practice can enhance ethical considerations in patient care. Provide at least two specific ways in which EBP contributes to ethical nursing practice.
Challenges Posed by Evidence-Based Practice
Discuss how evidence-based practice can also pose challenges to ethical considerations in patient care. Describe at least one potential ethical dilemma that may arise when implementing EBP in clinical settings.
Affirmed Writing is formal in language, avoiding colloquialisms, slang, and overly informal expressions.
Not Affirmed Writing includes colloquialisms, slang, and overly informal expressions.
Affirmed Minor spelling, grammar, and/or punctuation errors present, and/or sentence structure lacks minor elements of professional writing, and/or paragraphs are consistently developed. (1-2 errors)
Not Affirmed Multiple spelling grammar and/or punctuation errors present and/or sentence structure does not meet professional writing standards, and/or paragraphs are minimally developed. (more than 2 errors)
Affirmed Writing demonstrates a strong connection between ideas, ensuring that the reader can follow the logical progression of the arguments.
Not Affirmed Writing lacks a connection between ideas, and there is no logical progression of the arguments.
Affirmed Writing addresses multiple relevant aspects of the topic with sufficient detail and analysis, providing a thorough understanding.
Not Affirmed Writing fails to address relevant aspects of the topic with insufficient detail or analysis.
Affirmed Citations and references follow the APA style guide, with less than 2 errors.
Not Affirmed Citations and references are not included when appropriate or do not follow the appropriate APA style guide. There are more than 2 errors.
You will select one research report with a qualitative design and one with quantitative design and answer the following questions regarding the following categories:
Discuss what is meant by the term Qualitative Research
Briefly, describe the characteristics of qualitative research and identify nursing issues/phenomena that lend themselves to a qualitative research approach.
Compare and contrast three different qualitative research methodologies.
Briefly, discuss the strengths and weaknesses of qualitative research evidence for informing nursing practice.
Communicate how this research design used in research.
The study, sampling, data collection, analysis, rigor, findings and limitations
Identify the purpose of the study.
Briefly, describe the design of the study and explain why you think it is either appropriate or inappropriate to meet the purpose.
Identify ethical issues related to the study and how they were/were not addressed.
Identify the sampling method and recruitment strategy that was used.
Discuss whether sampling and recruitment were appropriate to the aims of the research.
Identify the data collection method(s) and discuss whether the method(s) is/are appropriate to the aims of the study.
Identify how the data was analyzed and discuss whether the method(s) of analysis is/are appropriate to the aims of the study.
Identify four (4) criteria by which the rigor of a qualitative project can be judged.
Discuss the rigor of this study using the four criteria.
Briefly, describe the findings of the study and identify any limitations.
Use the information that you have gained from your critique of the study to discuss the trustworthiness and applicability of the study. Include in your discussion any implications for the discipline of nursing.
Discuss what you understand by the term Quantitative Research – Use the following dot points to guide your discussion (give reasons for your argument and support with references):
Describe the characteristics of quantitative research.
Identify nursing issues/phenomena that lend themselves to a quantitative research approach
Differentiate between observational and interventional research designs and also between experimental and quasi-experimental designs.
Briefly, outline the difference between inferential and descriptive statistics and their relationship to levels of measurement.
Communicate how this research design used in research.
Critique the Quantitative Research Report – Use the following headings to guide your critique (in all discussions and explanations give reasons for your argument and support with references):
The study
Identify the purpose and design of the study.
Explain what is meant by ‘blinding’ and ‘randomization’ and discuss how these were addressed in the design of the study.
Identify ethical issues related to the study and how they were/were not addressed.
Sampling
Explain the sampling method and recruitment strategy that was used.
Discuss how the sample size was determined – include in your discussion an explanation of terms used.
Data collection
Briefly, outline how the data was collected and identify any data collection instrument(s).
Define the terms validity and reliability and discuss how the validity & reliability of the instruments were/were not addressed in this study and why this is important.
Data analysis
Outline how the data were analyzed.
Identify the statistics used and the level of measurement of the data described by each statistical test – include in your discussion an explanation of terms used.
Findings and limitations
Briefly, outline the findings and identify any limitations of the study
Use the information that you have gained from your critique of the study to briefly discuss the trustworthiness and applicability of the study. Include in your discussion an explanation of the term statistical significance and name the tests of statistical significance used in this study.
Select a disease process that is of interest to you.
Pathophysiology of the disease state.
Review of the pharmacological agents used for treatment and important information related to advanced practice nurse.
Each student will clearly write a title for this topic: For examples, “Pharmacological Effects of Anti-Hypertensive Medications in the Management of Hypertension”.
CONPH NSG6020 Subjective, Objective, Assessment, Plan (SOAP) Notes
Student Name:
Course:
Patient Name: B.N.
Date:
Time:
Ethnicity: Caucasian
Age: 41
Sex: Male
SUBJECTIVE (must complete this section)
CC: “I have a heartburn and acid reflux that keeps waking me up at night”
HPI: B.N. is a 45-year-old male patient with a history of gradually worsening gastroesophageal reflux symptoms. He presents with frequent typical episodes of heartburn following spicy or fatty meals and periodic regurgitation of sour-smelling fluid into his mouth. Onset was 3 months ago and have gradually worsened. Located in the epigastric region, with occasional radiation to the throat with a duration typically last 1–2 hours after meals or when lying down at night, with a character: A burning pain or pressure in the chest and upper abdomen. The aggravating factors have been consuming spicy, fatty, or acidic foods, as well as when bending over or lying flat and the relieving factors the use of over-the-counter antacids. Timing have been intermittently throughout the day but are most frequent post-meals and during nighttime, with a Severity of 6/10 on average, with occasional exacerbations to 8/10 during severe episodes.
· Previous Medical History: Hypertension (diagnosed 4 years ago) and GERD.
Allergies: Penicillin , with dizziness and flushing sensation.
Medication Intolerances: None reported
Chronic Illnesses/Major traumas: Hypertension
Hospitalizations/Surgeries: None reported
FAMILY HISTORY
· M: Alive and healthy
· MGM: Late, asthma
· MGF: Alive, GERD
· F: Alive, obesity
· PGM: died of road accident
· PGF: Alive, healthy
Social History: B.N. is an office employee with a 14-year history of reported cigarette smoking. He smokes a half pack per day and sporadic alcohol use, having two or more beers per week. He denies all illicit drug use. His food intake is fast food and coffee drinking, frequent enough to explain his gastrointestinal complaints. His habits of smoking and eating are addressed as possible aggravating factors in his illness.
REVIEW OF SYSTEMS
General: B.N is weight loss due to acid reflux during meals.
Cardiovascular: No chest pain, palpitations, or edema
Skin: No rashes, lesions, or itching
Respiratory: No cough, shortness of breath, or wheezing
Eyes: No reported vision changes, denies eye pain.
Gastrointestinal: Heartburn, regurgitation, denies vomiting, diarrhea, or constipation
Ears: No hearing loss, tinnitus, or ear pain
Genitourinary/Gynecological:
No urinary symptoms
Nose/Mouth/Throat: No nasal congestion, or dental issues, sore throat due to acid reflux.
Musculoskeletal: No joint pain, no falls.
Breast: Denies any change.
Neurological: No headaches, dizziness, or numbness
Heme/Lymph/Endo: Denies anemia or any endocrine disorder.
Psychiatric: Denies anxiety, or mood changes.
OBJECTIVE (Document PERTINENT systems only. Minimum 3)
Weight: 180lbs
Height: 5’9”
BMI: 25.9
BP:138/88mmHg
Temp: 99.2°F
Pulse: 78bpm
Resp:16/min
General Appearance: Well-nourished, alert, and oriented x3. Appears comfortable.
Skin: Smooth with no rashes, moles, red spots
HEENT: Normocephalic, PERRLA, oral mucosa pink and moist, no pharyngeal erythema or tonsillar enlargement.
Cardiovascular: Regular rhythm and rate. S1 and S2 present, no gallops or rubs were heard.
Respiratory: Lung clear to auscultation bilaterally, no wheezes, crackles or rhonchi sounds
Gastrointestinal: Bowel sound presents is 4 quadrants, Abdomen soft upon palpation.
Breast: No lumps or tenderness noted.
Genitourinary: No tenderness, no CVA pain.
Musculoskeletal: Full range of motion in all extremities, no deformities were noted.
Neurological: Alert and oriented X 4 , speech appropriated .
Psychiatric: Patient calm and answers question appropriately , no anxiety or mood change were noted
Peptic Ulcer Disease is a disease in which ulcers or open sores occur in the stomach or duodenal lining, usually due to Helicobacter pylori infection or long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs) (Srivastav, et al., 2023). The symptoms on presentation are epigastric burning pain, nausea, and vomiting at times. ICD-10 code K27.9 is for an unspecified peptic ulcer with hemorrhage or perforation not specified. Although patient symptoms are characteristic of GERD, PUD is not excluded since both can produce upper GI distress and have some of the same symptoms such as epigastric pain. Since there are no alarm symptoms (e.g., weight loss, hematemesis), PUD is unlikely now.
Esophagitis is inflammation of the esophagus, usually caused by acid reflux, infection, or drug-induced inflammation (Tageldin, et al.,2021). Symptoms can be chest pain, dysphagia, and heartburn. Code K20 is the ICD-10 code that is specifically used to indicate this condition. Esophagitis is listed as a differential because chronic acid reflux (such as in GERD) will cause inflammation of the esophagus. GERD, if left untreated, can lead to esophagitis and therefore is still a consideration.
GERD happens when stomach acid chronically flows back into the esophagus, irritating and producing symptoms of heartburn, regurgitation, and epigastric pain. GERD is usually associated with lifestyle issues such as diet, smoking, and obesity. The ICD-10 code K21.9 is for GERD without esophagitis. The diagnosis fits the patient's presenting complaint of heartburn, regurgitation, and relief with antacids, and it is the highest presumptive diagnosis (Rogers & Eastland, 2021). The presumptive diagnosis is the most likely diagnosis given the patient's history, physical exam, and preliminary findings.
Plan/Therapeutics:
1. Lifestyle Modifications:
· stop consuming those meals that cause this problem such as spicy food.
· Avoid sleeping after consuming a full meal. Eat a minimum of three hours prior to sleeping in order to allow the stomach time to digest (Jallepalli, et al., 2022)
· Refraining from taking large meals. Eating several small meals will assist the patient.
· Avoid consuming alcohol or limit the amount and smoking (Jallepalli, et al., 2022).
Medications
· The patient should Continue taking Omeprazole 20 mg daily before breakfast (Rogers, & Eastland, 2021).
· If the symptoms persists, do an upper endoscopy.
Education:
· Discussed the significance of lifestyle modifications in managing GERD.
· Discussed long-term risks of untreated GERD, including Barrett’s esophagus and esophageal cancer.
· Provided smoking cessation resources and encouraged follow-through.
References
Jallepalli, V. R., Thalla, S., Gavini, S. B., Tella, J. D., Kanneganti, S., & Yemineni, G. (2022). Impact of patient education on quality of life in gastroesophageal reflux disease. Int J Pharm Phytopharmacol Res, 12(1), 25-8.
Rogers, J., & Eastland, T. (2021). Understanding the most commonly billed diagnoses in primary care: Gastroesophageal reflux disease. The Nurse Practitioner, 46(4), 50-55.
Srivastav, Y., Kumar, V., Srivastava, Y., & Kumar, M. (2023). Peptic ulcer disease (PUD), diagnosis, and current medication-based management options: schematic overview. Journal of Advances in Medical and Pharmaceutical Sciences, 25(11), 14-27.
Tageldin, O., Shah, V., Kalakota, N., Lee, H., Tadros, M., & Litynski, J. (2021). Esophagus. In Management of Occult GI Bleeding: A Clinical Guide (pp. 65-86). Cham: Springer International Publishing.
image1.png
,
CONPH NSG6020 Subjective, Objective, Assessment, Plan (SOAP) Notes
Thank you again for leading the Leadership workgroup for Directors! Attached you will find the “raw data” for subdomains Respect in the Workplace, Decision Making, and Transformation and Innovation, from the July 11th LDIon tab 5B. Your team is also tasked with creating new measurable actions for the missing subdomains: Systems/Adaptative Thinking and Change Management. The final draft of the ANM Leadership competency to reference is attached.
Team Lead will collaborate with their team members (identified at the post LDI debrief) to review the feedback and work to streamline into comprehensive SMART competencies. Please feel free to include Directors (or Nurse Managers for the NM groups) who did not attend the LDI or who did not sign up for the work group.
attached is the final draft of the ANM AONL Competencies. This resource is designed to support you in developing the Director-level measurable indicators.
When drafting your competencies, be sure to:
Include how you will equip the NMs with the tools, time, and guidance needed to meet their measurable indicators
Include measurable indicators specific to your Director role and scope using the AONL Nurse Executive Competency guide (attached)
American Organization for Nursing Leadership (AONL)
Competencies and Skills
AONL Leadership Domain
Example of Core Leadership Competency
Knowledge of the Health Care Environment & Clinical Principles
Ensures the use of patient safety & improvement sciences
Sub Domains
Example of Functional Leadership Director Competency
Nursing Practice & Application
► Ensure competencies & education/training ongoing ► Track & Trend assessment incident reports & develop plan of correction to address & improve patient safety. ► Quality & safety standards ►Review/Develop procedural directive for 100% participation in annual comp.
Economics & Policy Regulations
Ensuring adherence to standards (e.g. Joint commission, Magnet recognition, State boards, State legislation). Influencing healthcare policies & championing health equity & access.
Evidence-Based Practice
►Keep up w/literature to implement best practice. ►Use evidenced-based practice to improve standards of practice & development of P&P. ►Membership to national nursing organization. ►Conferences/presentations/poster abstract submission ►Research/publications ►Increase certifications in each unit by 10%
1B
American Organization for Nursing Leadership (AONL)
Competencies and Skills
AONL Leadership Domain
Example of Core Leadership Competency
Sub Domains
Example of Functional Leadership Director Competency
Patient Safety & Quality
Review & analyze quality & safety metrics for span of practice control ►Ensure those metrics are transparent and understood by staff – what they do drives these metrics. ►Data monitoring ►Sharing metrics ►Use current EBP to implement new pt safety protocols. ►Decrease falls by 15%
2
American Organization for Nursing Leadership (AONL)
Competencies and Skills
AONL Leadership Domain
Example of Core Leadership Competency
Communication and relationship Building
►Influences and persuades others, builds consensus, and gains cooperation from others to share information and accomplish goals. ►85% or > in leader communication on employee engagement survey
Sub Domains
Example of Functional Leadership Director Competency
Effective Communication
►Communicate the "Why"/validate understanding ► transparency ►meeting minutes ►Use "being" & "doing" communication style ►Openess in communication styles ►Ask for feedback/circle back on communication ►How does this look operationally ►Monthly mgrs meeting ►Montly staff meeting ►1:1 feedback/planning sessions with direct reports ►Perform quarterly 1:1 feedback sessions with direct reports ►Perform monthly staff meeting with agenda/minutes ►Establishes/maintains 3T interdisciplinary partnership annually
Relationship Management
►Be available/visible curious ►Check the pulse on how team and management is feeling ►Team building activities ►Leadership rally/strategic planning/vision casting at the division level ►Leadership rounding ►Rewards/recognition ►Stay interviews ►5 minutes with staff ►peer interviews ►Accountable for leadership rounding monthly (infection prevention – risk-EOC) & contractors ►Stoplight – reports/feedback provided quarterly
Influencing Behaviors
►Lead by example ►Get them by-in | meaningful feedback ►Engage staff in the process ►Engage in conversations about solutions not just problems ►Being & doing ►Mentorship ►Coaching ►Invested Leadership: ▪Know goals of staff ▪Provide shadowing opportunities ►Influencing staff to report as evidence by feeling that they have psychological safety ►ackowledgement of staff weekly – Care Badges ►ackowledgement of accomplishments – birthdays, anniversaries, other accolades ►Attain 80% or > in employee engagement survey in leader communication.
3A
American Organization for Nursing Leadership (AONL)
Competencies and Skills
AONL Leadership Domain
Example of Core Leadership Competency
Professionalism
Implements and maintains optimal, culturally competent healthcare across the lifespan, in all settings, addressing social determinants of health and health equity
Sub Domains
Example of Functional Leadership Director Competency
Professional Accountability
►Meet Regulatory compliance standards (TJC, AHCA) ►Develop and implement competency standards of practice ►Policy review ►Competencies ►Evaluation/Feedback sessions ►Certifications/Licenses ►Attending conferences ►Multidisciplinary meetings for pt. P.O.S. ►Maintain professional certification ►Maintain membership in prof. organizations (ex. AONL) 80% of nurse leaders members of AONL/prof. org.
Organizational Accountability
►Meet/Exceed metrics ►Quality improvement ►HCAHPS ►Track mortality rates ►Achieve 100% compliance (zero findings) fore regulatory standards. ►Develop and implement competency standards and standards of practice through: a) Annual policy review (100%) b) 100% compliance with licensure and certification renewals. c) Achieve 100% evaluation/feedback of staff. d) Attend a minimum of 1 (one) professional development conference per year. e) Maintain active membership in a minimum of 1 (one) professional organization. ►Meet & exceed metrics: a) Quality initiatives (set goals) b) PX c) Finance (set goals based on individual scorecards)
3B
American Organization for Nursing Leadership (AONL)
Competencies and Skills
AONL Leadership Domain
Example of Core Leadership Competency
Advocacy
►Ensure delivery of safe, compassionate care for all persons served (patients, staff, and customers) ►SpeakUp ►Addressing barriers/equipments ►RCA – finding? To effect process changes/staff satisfaction
Health Equity and Social Determinants of Health
►Education & policy review, training, competency leaders (NM, ANM, staff) ►Monitoring compliance/outcomes ►Community involvement ►Partner with FQHC's especially with pt. care information. ►Population Health usage and interventions.
Governance
►Participation in Councils ►Reporting compliance and making decisions ►Multidisciplinary Health Team P.O.C. Council ►Participate in systemwide decision making forums as evidence through departmental involvement in systemwide councils. ►Daily leadership rounding on 5-10 patients to ensure delivery of safe, compassionate care and positive PX. ►SpeakUp: conduct a minimum of 5 skip-level rounding to encourage speak up and staff feedback. ►Track and trend safety reports and RCA findings, and develop CAP to improve PX and employee engagement ►Participate in a minimum of 1 (one) community outreach per year. ►Create awareness of the use of Population Health to improve pt. outcomes. ► Participation in a minimum of 1 (one) hospital-specific, and 1(one) systemwide committee ►Establish/promote Shared Governance through UBC.
4A
American Organization for Nursing Leadership (AONL)
Competencies and Skills
AONL Leadership Domain
Example of Core Leadership Competency
Leader Within
Ensures that employees are appropriately recruited, selected, onboarded, educated, evaluated, and recognized.
Sub Domains
Example of Functional Leadership Director Competency
Reflective Practice
►Establish criteria to select candidates whose educational work experience aligns with JHS vision/mission. ►Trial multidisciplinary approach as evidenced by an inclusion interview panel approach. ►Involvement in surveys/think tank ►Ensure that leaders oversee completion of employee onboarding (NEO, weekly progress) ►30/60/90 Day touchpoint/eval 100% of the time for new employees
Foundational Thinking
►Critical thinker ►Building staff foundation at the point of interview
Career Development
►Provide mentorship& development opportunities as evidence by 90% participation in LDI ►Establish talent management strategies & succession planning ►Succession planning & mentorship – minimum 1 (one) person ►Clinical Ladder Development for employees by 2026 ►Ensure 30/60/90 retention meetings with new hires are completed by 95% ►Ensure 1 (one) mentee is enrolled in JHS Mentorship program per unit/dept.
4B
American Organization for Nursing Leadership (AONL)
Competencies and Skills
AONL Leadership Domain
Example of Core Leadership Competency
Sub Domains
Example of Functional Leadership Director Competency
Personal & Professional Accountability
►Increase certification through study groups or other venues by 2% yearly ►Hold leadership certification ►Become nationally certified in your specialty/certified as a requirement for hire within the first year to two years. ►Bring in course for your team to take prior to taking National certification in specialty. 25% of RN's will be nationally certified. ►Increase specialty certification among registered nurses across units/departments by 2% each year ►Increase enrollment in professional organizations for registered nurses across units/departments by 2% each year
5B
American Organization for Nursing Leadership (AONL)
Competencies and Skills
AONL Leadership Domain
Example of Core Leadership Competency
Sub Domains
Example of Functional Leadership Director Competency
Respect in the workplace
►Rounding → I-Round ►Shadow other depts. ►skip level rounds ►Loop closure ►1:1 with team members regulary week ►EMBA walks ►Speak Up-implement ►HR Rounding – per month ►Evals & feedback sessions ►no overdue ►The director will demonstrate inclusive collaboration and value teams contribution as evidenced by obtaining top 15th percentile of NDNQI survey results per FY
Decision Making
►Shared governance ►Policy review – council meetings ►involve frontline staff in decision making ►enduser involvement ►Role model use of data to drive decisions ►The director will make the decision making process using "group think" process of which group will include informal leaders of the frontline staff as evidenced by "group think" council meeting minutes for quarterly meetings.
Transformation and Innovation
►Staff meeting and minutes ►Councils ►Conferences ►Education/Higher learning ►HRO – GEMBA walks – developing at Culture of safety as evidence by safety incident reporting including near-misses ►using latest EBP to enhance pt. care ►DYADs ►Mentorship ►Fellowship programs ►The director will collaborate with educators, dept. leaders and informal leaders to generate and implement new ideas using EBP. This will be demonstrated by one project launch, completed to end, per FY, reviewed per quarter.
6
American Organization for Nursing Leadership (AONL)
Competencies and Skills
AONL Leadership Domain
Example of Core Leadership Competency
Business Skills and Principles
►Aligns and creates nursing/clinical objectives, goals, and tactics required to achieve the organization's strategic outcomes.
Sub Domains
Example of Functional Leadership Director Competency
Financial Management
►LOS for admissions – Review POC of shift for completion = D/C ►Review and maintain appropriate staffing levels – productivity – premium pay ►Flex and float staff as needed ► Utilization of staffing level ►Overseeing & meeting operational budget → quarterly ► Conscientious use of resources ►Reduce LOS for admissions GOAL: ↓ LOS by goals of divisions within 12months; Measure Track averasge LOS monthly & identify areas of opportunity ►Maintain within budgetary goals meet or exceed productivity levels ▪Goal: 98% – 100% productivity ▪Goal: Premium pay w/in targeted goal ►Conduct quarterly financial reviews w/departmental leaders. ▪Goal: Cost reduction by x amount
Strategic Management
► Cross-train nurses who wish to be dual specialty trained ►Shared governance and multiple departments participating ►Development of departmental goals aligned with JHS strategic goals ►Allocate resources to identified needs (ex. Staff) ►Biannual strategic plan review ►Meet with team to create a strategic plan yearly and meet or exceed action plan goals ►Plan and develop specialty specific goals to align w/JHS strategic goals (ex. DCF compliance, HAI, HCAPS, LOS, budget maintenance) ▪Goal: Successful implementation and meeting or exceeding 1 or above goals, biannually. ►Optimize staff utilization ▪Goals: Crosstrain at least 20% nurses to be dual specialty trained. ▪Goals: Diversity FTE mix
Human Resources Management
►Partner for proper staffing and reduce OT usage and agency use ►Reduce turnover/track retention data monthly → less than 9% at or less than organizaton goal ►Provide a healthy work environment ►Timely onboarding – less than 60days ►Continous onboarding of PRM to ↓ OT ►Increase staff engagement as evidence on staff engagement survey and Magnet RN NDNQI Survey ►Staff retention (develop/implement strategies) ►Collaborate w/HR partner monthly – monthly meeting to address openings/positions/HR issues ►Enhanced Staff retention ▪Goals: develop & implement retention strategies to reduce turnover by x % over the next year. ▪Measure: Review or maintain the turnover rate quarterly. ▪Measure: Review vacancy rate monthly.
,
Leader Within
Reflective Practice
Competency: Demonstrates strong leadership by improving team performance and engagement through regular evaluations, active participation in unit initiatives, effective communication, and timely responses to operational challenges.
Measurable Indicators:
· Increase leadership confidence by ≥5% through peer/self-assessment tools.
· Attend ≥90% of leadership meetings and ensure 95% closure on unit initiatives via documented follow-through.
· Conduct quarterly 1:1 evaluations with direct reports, resulting in ≥5% improvement in team performance metrics.
· Lead daily huddles with ≥90% staff participation, using them for feedback and post-incident debriefs.
· Document and deliver feedback at least quarterly to staff and leadership on performance and process improvements.
Career Development
Competency: Champions professional development and inclusive mentorship by guiding future leaders, fostering mentee growth, participating in continuous education, and promoting access to advancement opportunities, resulting in measurable staff engagement and leadership readiness.
Measurable Indicators:
· Mentor one or more staff yearly with ≥80% mentee-reported growth.
· Identify and train one future leader annually with tracked leadership progress.
· Support diverse, inclusive mentor/preceptor pool via annual review and adjustment.
· Attends at least one leadership conference or professional development seminar annually, implementing at least one new learned strategy on the unit. (i.e. LDI)
· Facilitates an easier process for staff to obtain tuition reimbursement for continuous learning, resulting in a 10% increase in staff pursuing higher education.
Foundational Thinking
Competency: Demonstrates foundational thinking through critical problem-solving, performance alignment, data-driven decision-making, empowerment, innovation, and continuous learning to enhance operational efficiency and staff engagement
Measurable Indicators:
· Effectively addresses ≥90% of unit-level challenges through independent decision-making or staff empowerment,
· Implement at least one new protocol annually to improve efficiency or safety—validated through audit and performance metrics.
· Achieves ≥95% staff understanding of unit expectations through regular workflow audits (e.g., daily intake, OVR reviews), proactive identification of improvement opportunities, and strategic recognition of positive practices—targeting a ≥5% quarterly increase in staff recognition submissions and consistent audit outcomes showing low ambiguity.
Personal and Professional Accountability
Competency: Demonstrate leadership through introspection, emotional intelligence, and flexible response.
Measurable Indicators:
· Complete annual self-assessments with action plans for improvement.
· Receive “role model” ratings in 85% of peer/direct report evaluations.
· Obtain or maintain a national certification.
· Maintain 100% compliance with all required licenses, certification (i.e. RN, ACLS, BLS, CHEMO), and continuing education units (CEUs) as evident by annual verification.
· Participates in leadership shadowing experiences at least twice per year to enhance organizational understanding.
· Implement two Individual Development Plans (IDPs) annually, with 80% goal completion.
· Participate in a Jackson Leadership Development Program (i.e. Leading at Jackson)
· Participate in at least one Shared Governance Council
Professionalism
Profession Accountability
Competency Statement: Ensures adherence to all professional standards, maintaining licensure compliance and ethical decision-making while demonstrating integrity in leadership.
Measurable Indicators:
· Ensures 100% of direct reports maintain active licensure and certifications.
· Demonstrates integrity in decision-making, with zero documented complaints of unethical behavior.
Health Equity and Social Determinants of Health
Competency: Promote respect in the workplace and moral courage in leadership and care.
Measurable Indicators:
· Lead or participate in one advocacy initiative or community engagement activity annually to support staff or patient rights.
· Serves as an effective ANM representative in relevant meetings, ensuring staff perspectives are heard and addressed.
· Ensures patient and family advocacy concerns are addressed in 100% of observed instances during rounding and direct interactions
Competency Statement: Ensures equitable healthcare practices by implementing policies that address social determinants of health and promote culturally competent care.
· Ensures 90% of eligible patients receive proper screenings for social determinants of health through regular audits.
· Completes at least one cultural sensitivity training annually, applying principles to improve patient-centered care.
· Demonstrates social awareness, contributing to a 5% improvement in patient satisfaction scores related to cultural sensitivity.
Organizational Accountability
Competency Statement: Takes ownership of unit-level challenges, proactively leading resolutions and ensuring service recovery through professional accountability.
