Project Planning, Implementation, and Evaluation: A Guide For Nurses and Interprofessional Teams 4th Edition James L. Harris

Project Planning, Implementation, and
Evaluation: A Guide for Nurses and

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James L. Harris
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Library of Congress Cataloging-in-Publication Data
Names: Harris, James L. (James Leonard), 1956- editor. | Roussel, Linda, editor. |
Dearman, Catherine, editor. | Thomas, Patricia L., 1961- editor.
Title: Project planning, implementation, and evaluation : a guide for nurses and
interprofessional teams / edited by James L. Harris, Linda Roussel, Catherine
Dearman, Patricia L. Thomas.
Other titles: Project planning and management (Harris)
Description: Fourth edition. | Burlington, MA : Jones & Bartlett Learning, [2023] |
Preceded by Project planning and management : a guide for nurses and
interprofessional teams / edited by James L. Harris, Linda Roussel, Catherine
Dearman, Patricia L. Thomas . Third edition. [2020]. | Includes bibliographical
references and index.
Identifiers: LCCN 2021044277 | ISBN 9781284248340 (paperback)
Subjects: MESH: Nursing Administration Research--methods | Quality
Improvement | Program Evaluation | Program Development--methods | Planning
Techniques | Interprofessional Relations
Classification: LCC RT89 | NLM WY 105 | DDC 362.17/3068--dc23
LC record available at https://lccn.loc.gov/2021044277
Printed in the United States of America
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Contents
Preface
Acknowledgments
Contributors
CHAPTER 1 Key Foundations of Successful Quality Project Planning,

Implementation, Evaluation, and Management: An Overview
Introduction
Quality Improvement Projects, Project Plans, and Project Management: Necessary
Distinctions for Deliverable Outcomes
Differentiation of Quality Improvement Projects and Research
Importance of Legislation, Health Policy, Economic Conditions, Culture, Social and
Environmental Factors, Values, and Norms When Designing Quality
Improvement Projects
Historical Influences, Determinants, and Unintended Consequences/Risks
Associated with Quality Improvement Projects
Requisite Skills and Techniques of an Improvement Team Leader and Members for
Sustainable Projects in Healthcare Systems
Managing Projects and Teams in a Virtual Environment
Summary
Reflection Questions and Learning Activities
References
Case Exemplars
CHAPTER 2 Quality Improvement Projects and Quality Improvement

Research: Advancing Translational Science
Introduction
Quality Improvement
Quality Improvement as Systems and Processes
Focus on Patients
Focus on Being Part of the Team
Focus on the Use of Data
Ethical Considerations for Protection of Human Participants in Quality
Improvement Activities
Quality Improvement Programs and Quality Improvement Research
Quality Improvement Research
Translational Science: Quality Improvement and Research Implications
Summary
Reflection Questions
References
Case Exemplars
CHAPTER 3 Implementation Science, Team Science, and Translational

Science: The Value for Improvement Projects
Introduction
Promoting Action on Research Implementation in Health Sciences
Consolidation Framework for Implementation Research
Knowledge-to-Action (KTA) Framework
Reach, Effectiveness, Adoption, Implementation, and Maintenance
Aims, Ingredients, Mechanism, Delivery
Implementation Strategies
Value of Implementation and Team Science for Sustainable Clinical Projects
Implications for Project Planning and Management
Summary
Learning Activities
References
Case Exemplar
CHAPTER 4 Forming and Managing a Synergistic Interprofessional
Improvement Team
Introduction
Interprofessional Teams: Overview and Management
Forming, Understanding, and Managing a Synergistic Improvement Team
Stages of Team Development
Synergy and Creativity
Appreciative Inquiry
Transformational Leadership
Innovation
Common Language: A Driver for Interprofessional Project Improvement Team
Successful Outcomes
Barriers to Team Effectiveness
Coaching Interprofessional Project Teams
Leading Interprofessional Project Teams Based on Needs and Mandates
Measuring Interprofessional Project Leader Effectiveness and Value
Summary
References
Case Exemplars
CHAPTER 5 Making the Case for a Project: Organizational and Needs

Assessment
Introduction
Purpose of Needs Assessment
Population
Organization and Systems
Methods and Instruments
Instruments
Data Collection
Analysis and Use of Findings
Summary
Learning Activities
References
Case Exemplars
CHAPTER 6 Using Findings from Organizational Analysis and Clinical
Needs Assessment to Frame Improvement Projects and Implementation
Introduction
Organizational Analysis: Deep Dive to Determine Needs
Project Life Cycle: Role of the Clinical Needs Assessment
Planning for Implementation
Developing a Project Charter
Model for Improvement
Micro-, Meso-, and Macro-Collaboration
Communicate, Communicate, and Communicate
Change Management
Evidence-Based Practice: Incorporates Institute of Medicine (IOM) Aims, Models,
Levels, Guidelines, and Critical Appraisal
Quality Improvement: Measurable Outcomes and Evaluative Structures
Direct Impact on Patient Care, IOM Aims, Project Impact, Ethics, and Culture
Outcomes Evaluation, Methods, Measures, and Strategies
System Dynamics, Leadership, Change Agents, Opinion Leaders, Champions, and
Level of Change
Sustainability, Champions, Outcome Impact, and Accountability
Resistance to Change Is a Reality—Embrace It
Post-Project Monitoring and Evaluation
Project Implementation Challenges and Risks
Summary
References
Case Exemplar
CHAPTER 7 Synthesizing, Leveling, and Assessing the Fidelity of

Evidence in Support of Project Implementation and Proposed
Interventions
Introduction
Literature Synthesis and Establishing the Fidelity of Evidence
Assessing the Fidelity of Evidence
Organization of Evidence
Aligning Evidence with Project Interventions and Implementation
Establishing and Maintaining Fidelity of Implementation
Tools, Guidelines, and Techniques for Literature Synthesis and Project Alignment
Cognitive Maps
Synthesis Matrix
Synthesis Writing
Summary
References
Case Exemplars
CHAPTER 8 Building the Improvement Project Budget: Quantifying the

Cost and Quality Equation
Introduction
Key Definitions and Budgeting Principles
Context and Definitions for Projects, Project Plans, and Project Management
The Project Budget
Attributes of a Well-Constructed Project Budget
Often Overlooked Cost
Language and Definitions in the Budget Process
Types of Budgets
Cost Avoidance, Cost-Effectiveness, and Cost–Benefit
Common Pitfalls in the Establishment of Project Budgets or Expected Financial
Outcomes
Summary
References
Case Exemplar
CHAPTER 9 Information Management in Clinical Projects: Technology,

Metrics, and Measurement
Introduction
Information Technology as an Enabler for Clinical Project Success
Stakeholder and Partner Roles in Information Technology
Informatics Core Competencies and Skill Sets
The Value of Linking Projects to Information Systems
Organizational Culture and Project Management
Use of Evidence-Based Practice: An Intertwined Element
Selecting the Right Variables to Tell Your Story
Fundamental Types of Measures
Process Measures
Outcome Measures
Qualitative Measures
Selecting the Right Data
Matching Populations
Common Data Sources
Benefits of Using Established Measures
Eliminating Unnecessary Measures
Data Management Plan
Step One: Define Data Needs
Step Two: Identify Data Sources
Step Three: Identify Performance Measures
Step Four: Design the Study
Step Five: Retrieve the Data
Step Six: Analyze the Data
Summary
References
CHAPTER 10 The Institutional Review Board Process

Introduction
Historical Perspective Related to Protection of Human Subjects
The History of the Human-Subjects’ Protection System
Definition of Research
Boundaries Between Practice and Research
Applying the Ethical Principles to Both Research and Quality Improvement
Respect for Persons
Beneficence
Justice
Informed Consent
Institutional Review Board Processes and Procedures
Research Purpose
Subject or Population
Design of the Study
Privacy and Confidentiality
Inclusion/Exclusion Criteria
Risks and Benefits from Participation
Outcomes
Informed Consent Form
Levels of Institutional Review Board Reviews
Multiple Institutional Review Boards
Implementation and Evaluation of Outcomes
Summary
References
Case Exemplars
CHAPTER 11 Big Data and Information Systems: Understanding the

Value for Improvement Projects
Introduction
Big Data and Information Systems Defined and the Link to Value
Big Data and Information Systems as a Facilitator for Improvement
The Importance of Stakeholders, Partnerships, and Information Systems Using
Data Big or Small as Improvement Projects Are Developed
Keys to Positive and Sustainable Project Outcomes: The Five Vs of Big Data
Data Integrity, Accuracy, Relevance, and Use for Future Improvement Priorities
Summary
References
Case Exemplars
CHAPTER 12 Measuring the Value of Projects Within Organizations,

Healthcare Systems, and Globally
Introduction
How Value Is Defined in Health Care
Measurement
Project Evaluation
Steps in Program Evaluation
Aligning Metrics with Project Aims
Case Study Application
Principles of Project Evaluation Methods
Information Dissemination: Roles and Responsibilities for Communication
Tools of the Trade
Summary
Learning Activities
References
CHAPTER 13 Innovation, Diffusion, and Dissemination of Improvement

Project Outcomes
Introduction
Aligning Innovation, Diffusion, and Dissemination: The Value for Continuous
Improvement
Forums and Techniques: Considerations for Disseminating Improvement Project
Outcomes
Role of Appreciative Inquiry in Presentations
Value of Publications and Information Sharing
Potential Pitfalls in Dissemination
Summary
References
Case Exemplar
Index
Preface
Textbooks are references for students, faculty, interprofessional

teams, and consumers of care. As healthcare organizations are
challenged to maintain a competitive edge and relative advantage,
multiple strategies are required. What one views as a crisis situation
in one healthcare organization may provide an opportunity for
creativity and innovation in another. This situation offers
transformative, transformational, and challenging opportunities. As a
result, meaningful interprofessional quality improvement projects
add quantum value and contribute to new evidence.
The authors’ dedication as educators, administrators, clinicians,
and nurse researchers led to them updating this fourth edition of the
text in an attempt to meet the constant healthcare changes, as well
as reflect updates in the recent release of the Future of Nursing
Report 2020–2030, the revised Essentials of Nursing, and the myriad
of challenges within any organization. As healthcare environments
continue to require up-to-date information, the acknowledgment of
interpretive design, biotechnologies, computational technologies,
interprofessional project team assignments, and learning, they form
collaborative improvement teams. The collective talents and insights
of teams and their engagement are necessary if the challenges of
providing quality, safe, and efficient care are to be met. As
interprofessional teams work together, new behaviors develop and
an understanding that embraces the contributions from other
disciplines emerges.
The authors contend that the content in the Fourth Edition is not
all-inclusive, but rather a snapshot for designing, updating, and
evaluating interprofessional quality improvement projects that
transcend a global care continuum. This edition’s content provides
an introspective foundation for successful project planning and
management, interprofessional team management, appreciative
inquiry, implementation science, team synergy, use of a needs
assessment, and metrics to shape sustainable project outcomes.
Based on comments from students, faculty, external reviewers,
biomedical librarians, and institutional review boards, this text
features essential information related to influences and determinants
of projects. Based on additional comments, this edition also
incorporates information on team science, big data, literature
synthesis, evidence fidelity, and organizational alignment to projects.
The authors have provided information in the Fourth Edition that
will challenge interprofessional teams to become innovative forces
dedicated to developing projects that improve healthcare delivery,
innovation, and discovery. These skills enhance a team’s vision,
which serves as a compass to guide meaningful projects and spread
evidence, add value, and engender a culture of sustainable change.
James L. Harris
Linda Roussel
Catherine Dearman
Patricia L. Thomas
Acknowledgments
The authors acknowledge each of the contributors of this text,

mentors who have guided our visionary careers, and the review
comments from diverse individuals and disciplines represented. In an
era of constant change imposed by a pandemic and need to join
forces toward normalization, the call for action by transformational
leaders who support and encourage interprofessional quality
improvement team activities is paramount. Projects create pathways
for patient-centered care, as well as opportunities for synergy,
evidence-based knowledge creation, and directions for the future to
meet the demands of a global society facing any future healthcare
crises.
To our families, colleagues, and external reviewers who supported
this edition, we offer our gratitude for the encouragement and
guidance. To the staff at Jones & Bartlett Learning, your consistent
support and unwavering direction are equally appreciated.
James L. Harris
Linda Roussel
Catherine Dearman
Patricia L. Thomas
Contributors
Michael Bleich, PhD, RN, NEA-BC, FNAP, FAAN

President and CEO NursDynamics, LLC
Senior Professor and Director, VCUSON Langston Center for
Innovation in Quality and Safety
Ballwin, MO
Lolita Chappel-Aiken, PhD, RN
Chair of Graduate Programs
Division of Nursing
School of Health Sciences
Winston-Salem State University
Winston-Salem, NC
Clista Clanton, MSLS
Biomedical Library
University of South Alabama
Mobile, AL
Catherine Dearman, PhD, RN
Adjunct Faculty
University of West Florida
Pensacola, FL
Todd Harlan, DNP, RN
Associate Professor of Nursing
Chair, Community Mental Health Nursing
Mobile, AL
James L. Harris, PhD, MBA, APRN-BC, CNL, FAAN
Professor of Nursing
Mobile, AL
Carolyn Thomas Jones, DNP, MSPH, RN
Lead Instructor, Master of Applied Clinical and Preclinical Research
Assistant Professor of Nursing, College of Nursing
The Ohio State University
Columbus, OH
Shea Polancich, PhD, RN
Assistant Professor of Nursing
University of Alabama, Birmingham
Birmingham, AL
Bettina Riley, PhD, RN
Associate Professor Nursing
Mobile, AL
Dionne Roberts, PhD, FNP-C, CNE
Associate Professor & FNP/DNP Program Director
FNP (MSN and DNP) Director
Winston-Salem State University
Winston-Salem, NC
Linda Roussel, PhD, RN, NEA-BC, CNL, FAAN
Cizik School of Nursing
The University of Texas Health Science Center at Houston
Houston, TX
Patricia L. Thomas, PhD, RN, NEA-BC, ACNS-BC, CNL, FACHE,
FNAP, FAAN
Associate Dean Nursing Faculty Affairs and Associate Professor
Cohn College of Nursing
Wayne State University
Detroit, MI
Kathryn M. Ward-Presson, DNP, RN, NEA-BC
Jonas Scholar in Veterans Healthcare Alumni
Raleigh, NC
Lonnie K. Williams, MSN, RN
Educational Consultant
Washington, DC
Janet E. Winter, DNP, MPA, RN, FNAP
Associate Dean of Undergraduate Programs in Nursing
Cook DeVos Health Science Center
Kirkhof College of Nursing
Grand Valley State University
Grand Rapids, MI
Case Exemplar Contributors

Jennifer Anne Blalock, RN
Former Graduate Student
Mobile, AL
Amy Campbell, DNP, MSN, RN
Assistant Professor
Mobile, AL
Catherine Dearman, PhD, RN
Adjunct Faculty
University of West Florida
Pensacola, FL
Wes Garrison, DNP, RN, MBA
Associate Chief Nursing Officer
Northeast Georgia Medical Center
Gainesville, GA
Kimberly Goins, MSN, RN
Ardmore, AL
Todd Harlan, DNP, RN
Associate Professor of Nursing
Chair, Community Mental Health Nursing
Mobile, AL
James L. Harris, PhD, APRN-BC, MBA, CNL, FAAN
Mobile, AL
Carolyn Thomas Jones, DNP, MSPH, RN
Lead Instructor, Master of Applied Clinical and Preclinical Research
Assistant Professor of Nursing, College of Nursing
The Ohio State University
Columbus, OH
Theodora Ledford, MSN, RN, CNL
Clinical Nurse Leader
Charles George VA Medical Center
Asheville, NC
Jacqueline M. Lollar, DNP, RN
Assistant Professor of Nursing
Mobile, AL
K. Michele Lyons, MN, RN
Southeastern Louisiana University
Hammond, LA
Margaret Mitchell, DNP, MN, FNP
Former Graduate Student
Mobile, AL
Terri Poe, DNP, RN, NE-BC
Chief Nursing Officer
University of Alabama Hospitals
Birmingham, AL
Bettina Riley, PhD, RN
Associate Professor
Mobile, AL
Linda Roussel, PhD, RN, NEA-BC, CNL, FAAN
Cizik School of Nursing
The University of Texas Health Science Center at Houston
Houston, TX
Heather Surcouf, DNP, MSN, BSN, FNP
Methodist Health Systems Foundation
Slidell, LA
Patricia L. Thomas, PhD, RN, NEA-BC, ACNS-BC, CNL, FACHE,
FNAP, FAAN
Associate Dean Nursing Faculty Affairs and Associate Professor
Cohn College of Nursing
Wayne State University
Detroit, MI
Kathryn M. Ward-Presson, DNP, RN, NEA-BC
Jonas Scholar in Veterans Healthcare Alumni
Raleigh, NC
Lonnie K. Williams
Educational Consultant
Washington, DC
Swapna Thomas, DNP, APRN, FNP-BC
Primary Care Practice
Houston TX
CHAPTER 1
Key Foundations of
Successful Quality Project
Planning, Implementation,
Evaluation, and
Management: An Overview
James L. Harris
Bettina Riley
CHAPTER OBJECTIVES
1. Differentiate between a quality improvement project, project plan, and
project management for deliverable outcomes.
2. Discern the differences between the scope of quality improvement projects
and research.
3. Discuss the importance of legislation, health policy, and economic conditions
when designing quality improvement projects.
4. Identify historical influences, determinants, and unintended
consequences/risks related to a well-defined quality improvement project in
a culturally diverse healthcare environment.
5. Identify requisite skills and techniques of the project leader and designated
team members whether on-site or virtual when designing value-based
quality improvement projects from inception to completion, including
dissemination of outcomes.
KEY TERMS
Continuous quality improvement
Design
Diversity
Economics
Environment
Evidence-based
Health disparities
Health policy
History
Influences and determinants
Just culture
Legislation
Management
Organizational culture
Outcomes
Political environment
Project budget
Project life cycle
Project management
Project plan
Quality improvement
Regulations
Research
Social factors
Stakeholders
Sustainability
Teams
Unintended consequences
Value
Virtual environment
ROLES
Analyzer
Communicator
Designer
Educator
Leader
Manager
PROFESSIONAL VALUES
Civility
Ethics
Inclusivity
Integrity
Norms
Patient- and customer-centeredness
Quality
Values
CORE COMPETENCIES
Analysis
Appreciative inquiry
Assessment
Communication
Critical thinking
Emotional intelligence
Evidence-based practice
Health policy knowledge
Innovation
Regulatory knowledge
Risk anticipation and mitigation of unintended consequences
Systems thinking
Understanding of civility and diversity
Introduction
Vision coupled with transformational change is central to the future
success of efficient healthcare delivery in an evolving global
economy. What was once merely pondered by many in the
healthcare arena has now evolved into sustainable project plans and
value-based programs that are driven by the basic instinct of
survival. With release of the 2020–2030 Future of Nursing report
(National Academies of Sciences, Engineering, and Medicine, 2021),
new vistas of appreciative inquiry await a mindful revolution of
individuals, teams, and global leaders dedicated to seamless
integration and coordination of improvement (Stratton-Berkessel,
2016). New paths of improvement will be charted that are dedicated
to a culture of health, reduced health disparities, and improved
health and well-being of society. Appreciative inquiry will guide each
improvement, highlighting current industry trends, and act as a
catalyst for organizational change.
As individuals and teams consider the daunting task of
establishing a culture of health, reducing health disparities, and
improving the health and well-being of society, they must recognize
that having a project idea and implementing it are two different
actions. Understanding the scope of a project, the dynamics
associated with stakeholder and partnership involvement, culture,
information technology, team dynamics, economics, and the political
environment can easily result in a state of project paralysis. In the
current healthcare industry, the path to an innovative project must
include micro-, meso-, and macro-level input linked to global
considerations for substantive change and influence that evidence
ongoing opportunities.
Successful planning and implementation of any project are
supported by the notion that for an effective system to be
strengthened, it requires systems thinking and attention to how the
parts work together to create a seamless whole (Crisp, 2010). As
knowledge is gained from project outcomes, knowledge transfer
becomes an imperative. Evidence is spread and systems of care are
strengthened and sustained. This is relevant in the current
environment, where the focus of work is on obtaining the right
outcomes, as opposed to past decades, where performing the right
processes was emphasized (Porter-O’Grady & Malloch, 2015, 2017).
Likewise, the relevance is increasingly predominant in a global
market driven by value-based versus volume-based care delivery and
reimbursement (Frist, 2016; Simatupang et al., 2017).
This chapter focuses on differences between a quality
improvement project, project plan, project management, and
research related to deliverable outcomes. The importance of
legislation, health policy, and economic conditions when designing
projects will also be addressed. The importance in identifying
historical influences, determinants, and unintended consequences or
risks in culturally diverse settings is examined. In addition, the skills
and tools of an improvement team leader and identified members for
a sustainable project are described as work environments become
increasingly virtual.
Quality Improvement Projects, Project Plans,
and Project Management: Necessary
Distinctions for Deliverable Outcomes
The genesis of any quality improvement project is planning, but
ongoing management of the project is essential as well. All projects
have a beginning, duration, and an end, which collectively constitute
the project’s life cycle. Project outcomes may, for example, be
adopted in the form of evidence-based guidelines or viewed as
opportunities for conducting additional inquiry and validation studies
before incorporating them in practice. It is critical, however, not to
immediately adopt findings from a small project, as they may not be
generalizable to a broader context. According to Peters (1999),
approximately 50% of the work completed in organizations may be
considered as projects. Many staff working on projects as de facto
members or managers may not possess the critical path and earned
value analysis skills, which are key to orchestrating and managing a
project from inception to completion (Lewis, 2011).
What is a quality improvement project? Projects are temporary
endeavors that focus on producing a unique operational entity such
as a product, service, or result differing from that obtained in prior
projects (Project Management Institute, 2013). Through a
systematic process, outcomes are produced that improve system
efficiency and patient experiences. Regardless of the project, it
should be based on the idea of accomplishing a goal for systems,
stakeholders, and/or customers.
When does the project begin? A series of iterative processes,
activities, and actions precedes the initiation of a project. One
fundamental consideration is readying the project environment by
identifying and validating the need for the project, developing the
plan, and obtaining system buy-in and/or approval from
stakeholders. Identifying and engaging stakeholders early and
throughout the improvement project is pivotal to success. The value
of stakeholder involvement cannot be underestimated in any project
as new partnerships are formed, their interests are represented,
ownership is reinforced, and support becomes center stage (Ives,
2019).
A project plan encompasses several components that collectively
culminate in a realistic and well-planned sequence of actions and
processes. The project plan goes beyond a general project scope
and includes the details necessary to make a meaningful and value-
based addition that reduces or eliminates variation in a work unit or
an entire system. As the project proceeds and causative factors are
eliminated, productivity and measureable quality outcomes are
evident.
According to Tuthill (2014), the project plan includes a project
budget, a work and activity breakdown and schedule, an overall
project schedule, and any supporting documents. Haughey (2014)
identifies other related parts of the project plan, including project
goals, deliverables, schedule, and supporting documents (human
resources, communications, and risk management plans).
Additionally, other project plan considerations were outlined by
Billows (2014), whose project plan template provides for scope
definition, major deliverables, risk identification, team resource
requirements, and decomposing individual tasks. A variety of
project-planning programs are available commercially and often used
by larger, more complex projects within systems.
Thinking and rethinking what one needs or desires in relation to
the project plan are key aspects of complex ecosystem planning to
extend beyond the workplace view (Merrifield, 2009). This author
identified three important “rethinking questions” for any student or
project planning team:
1. Does the project exactly correlate with any of the organization’s
key business goals?
2. Does the project have a strong connection to the organization’s
brand or corporate identity?
3. Does the effort required for the project result in increased
organizational performance and change the value of the project
to achieve organizational effectiveness?
What is project management? The Project Management Body of
Knowledge (PMBOK) Guide defines project management as
“application of knowledge, skills, tools, and techniques to project
activities to meet project requirements. Project management is
accomplished through the application and integration of the project
management processes of initiating, planning, executing, monitoring
and controlling, and closing” (Project Management Institute, 2013,
p. 6). Of interest, the PMBOK Guide has, as its primary objective, the
explanation of how each of the processes may be accomplished in
practice.
Although consistent management of activities is essential for
project completion, project management extends beyond managing
and scheduling activities. Project management entails a combination
of tools, people, and systems (Lewis, 2011). Tools may include
computers, software applications and platforms that include
electronic management systems, and daily planners. People include
organizations and project teams who engage in processes geared
toward goal accomplishment within systems. Management of people
may present as a challenge in this endeavor, and leaders and
communicators must use multiple skills to coach and mentor
individuals toward achieving the common goal. The manager’s
emotional intelligence may be tested along the way, as will be
examined further in this chapter.
Regardless of the depth or breadth of the project, plan, and
management, the various stages of the project life cycle must not be
neglected. Tuthill (2014) identified this cycle as having four phases:
1. Initiating the project (including identifying customer-driven
factors and obtaining leadership approval and support)
2. Planning (including human and physical resources)
3. Executing (monitors, control, and cycle of efforts)
4. Project closing (training, operations, and support)
Project planning across the life cycle should additionally consider
the project’s feasibility, value, key drivers for success, skills and tools
needed, and processes whereby project teams may be managed in
virtual environments. Virtual work environments have gained
popularity in the last decade as more employees work from distant
locations, especially when operating in a contingency or crisis
situation as demonstrated during the COVID-19 pandemic. Likewise,
virtual work environments proved advantageous as organizations
remained responsive to customers and stakeholders with fewer
expenditures dedicated to office space, supplies, and indirect costs
(Bloch, 2017).
Differentiation of Quality Improvement
Projects and Research
Creating an environment receptive to change and evidence-based
practice requires a series of purposeful actions and partnerships.
Actions include various quality improvement projects that are led by
interprofessional team members that culminate in sustainable
practice change and outcomes. As project teams form, partnerships
emerge and a common goal is established. Including researchers as
equal partners on the quality improvement project team is an asset,
thus avoiding a waste of valuable resources. This creates
opportunities for the design and methodology, allowing teams to
disseminate relevant information to the larger community. This
opportunity informs decisions with reliable and evidence-based data
(Marjanovic et al., 2017).
Often, individuals use language indiscriminately. Differentiating
between quality improvement and research is essential to avoid
barriers that lead to misunderstandings by quality improvement
team members. For purposes of this chapter, the following
definitions of quality improvement and research apply.
Quality improvement focuses on systems, processes, and functions
associated with clinical quality, satisfaction, and cost outcomes.
Meaningful quality improvement projects contribute to a better
understanding of care processes through the application of
knowledge. Research involves a process of systematic inquiry,
whereby knowledge is developed, refined, and/or expanded.
Research answers questions to develop knowledge grounded in a
scientific method (Melnyk & Fineout-Overholt, 2005, 2019). Although
there are connections between quality improvement and research,
differences also exist. These differences include intent, design,
setting benefits, generalizability of findings, oversight, subject and
risk consent, ethical justification, and dissemination. Research can
focus on quality improvement initiatives, but a quality improvement
project is not always considered research (Gregory, 2015). Further
consideration of the differences is discussed in Chapter 2.
Importance of Legislation, Health Policy,
Economic Conditions, Culture, Social and
Environmental Factors, Values, and Norms
When Designing Quality Improvement
Projects
Demonstrating effectiveness in healthcare operations is required for
sustainability in today’s market. Doing more with less has resulted in
organizations charging teams to design quality improvement projects
that strengthen efficiency and accountability while achieving
sustainable outcomes. Cost, quality, safety, and access provide a
basis for innovative improvement teams. Innovation is a critical value
of alignment between the multiple forces affecting health care and
decisions that follow (Porter-O’Grady & Malloch, 2015). To appreciate
the impact of innovation in health care, sharing the project
outcomes that used identified dissemination plans must become the
lifeblood of a 21st-century organization and be linked to new
ideologies of business and a data-rich environment (Porter-O’Grady
& Malloch, 2017). The shift from volume-based to value-based care
has required innovative leaders to shift previous mental models of
care to those that ensure advancement of the health of a nation
(Centers for Medicare and Medicaid Services, 2013; U.S. Department
of Health and Human Services, 2011). Likewise, quality improvement
project design must balance innovation with value if a return on
investment is realized. Using a cost–benefit model, project teams
can create opportunities for practice change, whereby evaluation of
outcomes is based on implementation with their fidelity to the
original project design. This necessitates for project designs to
reflect all work processes and activities subject to ongoing inquiry
and reassessment (Porter-O’Grady & Malloch, 2015, 2017).
Incentives that balance innovation with value also have sizable
implications for survival in the current healthcare arena. Incentives
should be developed based on evidence-based economies, fairness,
and equitability that have an intuitive appeal that benefits patient
outcomes and system efficiency. Economics will continue to shape
the landscape of health care and the design of quality improvement
projects as reimbursement processes are reformed.
As a quality improvement team begins to design a project,
examining the impact of legislation and health policy provides insight
into the demand to demonstrate effectiveness. Legislation,
regulations, and health policy are grounded in evidence, inform
budgets and management decisions, and strengthen accountability
(Pew-MacArthur Foundation, 2015). The exponential number of
federal regulations affecting the healthcare industry increasingly
requires multiple resources to manage and meet mandates.
According to the American Hospital Association (AHA, 2017), 629
regulations are mandated by four agencies (Centers for Medicare
and Medicaid, the Office of Civil Rights, the Office of Inspector
General, and the Office of the National Coordinator of Information
Technology) that promulgate the requirements with additional
directives forthcoming.
Laws and public policies do not exist in a vacuum. Action taken in
one domain may have unintended consequences in another domain
while having synergistic, positive effects in yet another (Senterfitt et
al., 2013). If quality improvement teams dismiss this reality, a
disconnect will prevail, and the efficacy of project improvement
project design, implementation, and outcomes will be jeopardized.
There is no question that the culture of an organization, social and
environmental factors, and values and norms also affect the design,
implementation, and adoption of quality improvement project
outcomes. Universally, change in health care is driven by projects
that result from errors, inefficiency, and survival instincts. Getting to
the root cause of an issue becomes the foundation for a well-
designed and executed quality improvement project. Innovation of
key stakeholders is a key to integrating organizational culture for
sustainability of quality improvements.
Projects are advanced as leaders acknowledge the importance of
context and culture. Assessing organizational culture is pivotal to
planned change and adoption of improvements. Organizations that
value quality improvement project team activities and their outcomes
create windows of opportunity. As a result, the full potential of
employees is realized, and care access, delivery, and efficiency are
advanced. This requires moving from an organizational culture that
blames others to adoption of a just culture (Khatri et al., 2009).
A just culture is an environment where an atmosphere of trusting,
encouraging, and rewarding others for providing essential safety-
related information occurs (Reason, 2008). A just culture addresses
two areas: (1) the role of punitive sanction in the safety of the
healthcare system and (2) the effects of a punitive sanction as a
remedy for human error as a help or hindrance to safety efforts
(Marx, 2001). With adoption of a just culture based on consideration
of human limitations, numerous advances in healthcare practices
and operations have been achieved, yet advances are needed in
cultural transformation (Kennedy, 2016).
Social and environmental factors are important to consider for any
quality improvement project team. These factors are the largest
predictor of health outcomes and are influential in changing
practices (Senterfitt et al., 2013). Health and health-related problems
result from multiple factors. For example, factors such as educational
level, employment, environment where individuals live and work,
and support are primary determinants of health outcomes. As quality
improvement teams design projects, remaining aware of these
factors is essential if outcomes are realized (Mosadeghrad, 2014).
Consider the current debate surrounding requirements for
immunizing infants and preschoolers. Addressing the social and
environmental factors related to immunizations requires others to
interpret evidence, advocate for adherence, and align messages that
are supportive of universal practices. Similarly, the adoption of
quality improvement project findings can be impacted by social
group acceptance and the environment targeted for change.
Advocacy for change becomes paramount in these circumstances.
One’s values and norms in society also influence quality
improvement projects. If individuals or organizations have conflicting
values associated with a project, the likelihood of the development
or success is endangered. Societal norms also affect acceptance of a
project and its outcomes. If the norm is to only adopt changes from
one specific group, new projects and ideas are destined for
disapproval or failure. An environment of constant evaluation and
adaptation is essential.
The convergence of team efforts and consideration of the
aforementioned factors form a collective network of knowledge and
facts as improvement projects are developed, implemented, and
evaluated. Ruland (2010) concluded that reliable data increase
decision quality, diminish errors, and strengthen the adoption of
projects and outcomes. Regardless of the system, whether local,
national, or international, data guides legislation, policy formulation,
and decisions. However, this will require individuals to question if
existing policy and practices are achieving the balance between
potential risks and benefits (Heitmueller et al., 2014).
Some of the most prominent healthcare organizations arise from
the accumulation of knowledge. When a healthcare organization
improves services, others adopt what works and benefit from its
knowledge. The spread of this knowledge and its universal adoption
result in situations that influence the economic outlook,
sustainability, quality of services, and satisfied consumers.
Quality improvement project design must balance innovation with
value if a return on investment is realized. Using a cost–benefit
model, project teams can create opportunities for practice change,
whereby evaluation of outcomes is based on implementation with
their fidelity to the original project design. This calls for project
designs to reflect all work processes and activities subject to ongoing
inquiry and reassessment (Porter-O’Grady & Malloch, 2015).
Incentives that balance innovation with value also have sizable
implications for survival in the current healthcare arena.
Historical Influences, Determinants, and
Unintended Consequences/Risks Associated
with Quality Improvement Projects
The current healthcare system is driven by the need to respond to a
rapidly changing environment and delivery of quality care.
Healthcare quality is a universal marker that systems use to measure
if care and desired outcomes are achieved (Batalden & Davidoff,
2007). The status quo is no longer acceptable. Current assumptions
and processes must be challenged and replaced with robust
improvements driven by measurable quality, safety, and value-based
outcomes. Influences, determinants, and any unintended
consequences or risks must be considered if improvements are
valuable and sustainable within organizations. This requires positive
engagement and actions by the entire healthcare team if systems of
care are changed. Change must be based on clear expectations
relevant to the situation that foster relevant learning (Nelson et al.,
2007). This is not a linear process, but a series of explorations
resulting in meaningful outcomes (Moran, 2014).
History guides individual and group actions (Fairman & D’Antonio,
2013). This includes preparation and dissemination of policies,
funding allocations, system improvements, and the design of quality
improvement projects. Making sense and understanding the value of
history when designing a quality project are invaluable. Historical
data provide a lens to assess prior improvement attempts,
processes, and variations in outcomes. History offers evidence that
guides the work of quality improvement project teams and provides
direction when choices are vague and lack basis.
Gaining insight into an organization’s quality improvement project
attempts and determinants of success is made easier when one
considers three domains: process, structure, and outcomes
(Donabedian, 1985). Process provides the context necessary to
understand approaches that guide quality improvement project
development and engagement of team members. Structure includes
the specific elements that are most likely to have relevance and
attain desired outcomes. Outcomes provide pathways for
documenting the efficacy and impacts of the project. Outcomes are
further evident as project data are analyzed and communicated, and
changes are adopted across the healthcare system.
Beyond the value of history and determinants of quality
improvement project success are unintended consequences and
project risks. Anticipating and managing the unintended
consequences and potential risks can be difficult even for a skillful
leader. Unintended consequences extend beyond clinical
effectiveness and include dismissal of evidence, social factors,
financial impacts, and stakeholder partisanship. Evidence may be
dismissed in geographical regions, cultures, and groups. Evidence
may be jeopardized when controversy and differing opinions exist,
limiting the development of a meaningful quality improvement
project. Thus, environments may not be conducive to change based
on the current evidence. Evidence is desirable to ensure
interventions are optimized, negative outcomes are minimized, and
resources are used effectively. Realizing an immediate financial gain
or incurring upfront costs may be viewed as a risk and limit the full
impact of a quality improvement project or its adoption. Partisanship
among and between stakeholders may also affect buy-in of a quality
improvement project, thus preventing or curtailing the design and
initiation of projects that solidify quality, safety, and value-added
outcomes.
Addressing and remaining cognizant of unintended consequences
and potential risks require the actions of all quality improvement
team members. Advocating for the use of current evidence,
interpreting the need for an evidence-based quality improvement
project, and using available tools and resources are essential
determinants of success.
Requisite Skills and Techniques of an
Improvement Team Leader and Members for
Sustainable Projects in Healthcare Systems
In the fast-paced, ever-changing healthcare landscape, a plethora of
project leader and team member skills and techniques are needed
throughout the life cycle of a project, especially quality improvement
ones. The basic nature of individuals to learn and use new
techniques creates a positive sense of competition and often
uncertainty that can benefit project activities and outcomes (Khan,
2012). The idea that evidence-based quality improvement project
outcomes transform practice and advance quality is a strategic
differentiator tool for sustaining a competitive edge (Mosadeghrad,
2014). Achieving equilibrium between practice and quality offers a
strategic regimen that ensures all evidence is available as quality
improvement projects are envisioned, developed, and completed.
However, this does not occur in a singular process, but requires use
of various tools and techniques that support meaningful projects.
Envisioning a future state where the path forward can readily be
recognized and followed by others is a deliberate action that leads to
meaningful projects and supports their sustained management. The
ability to manage the delicate maneuvers of leading, engaging, and
inspiring others toward greatness is among the many skills needed
by a project leader. Investment in skill development and core
competencies for project planning and management is central to
shaping business outcomes in all industries, especially in health care.
Applying human factors engineering in health care allows one to
gain the knowledge needed to examine human behavior and
interaction with others or with their surroundings and apply
information for greater efficacy (Carayon & Wood, 2010; Gosbee &
Anderson, 2003; Weinger & Gaba, 2014). Human factors engineering
can further assist both the novice and expert project planner and
manager in gaining insight into processes quickly and being able to
initiate actions for course correction, as indicated. The patient’s
journey through the multifaceted and complex systems should be a
consideration of the process (Carayon et al., 2020).
The skills and techniques needed for success with a project
include an array of critical approaches. Although there is no singular
set of skills and techniques that guarantees success, some options
are mutually beneficial to teams, individuals, and organizations. The
process for instilling these skills and techniques into practice requires
first understanding each of them and then linking it to goals and
measurable, sustainable outcomes. The skills and techniques will be
examined in this text, keeping in mind no particular skill or technique
is necessarily better than—or a replacement for—another.
Throughout an improvement project, keeping activities focused on
the customer is important, especially when the organization depends
on those customers for revenue and most of its market share. When
the customer is satisfied, loyalty is preserved and repeat business
occurs. For example, if a manager requests the development of a
quality improvement project that will increase customer satisfaction,
it is important to first understand customer needs and expectations
and then to communicate those needs and expectations throughout
the organization, while measuring value and reporting results. The
understanding is gleaned through an organizational analysis and
assessment tools, which are explored in Chapters 5 and 6.
Every project requires a designated leader to establish the
project’s direction and goal. Although there may be informal leaders,
the project leader should possess the skills needed to create and
maintain the environment where others engage in meeting the
project’s goal. Creating opportunities to encourage others and
involve them in both the current project and future projects is a
mark of transformational leaders, who continually inspire and
recognize others’ contributions.
Being an effective communicator who possesses emotional
intelligence will engage others and provide the leverage necessary to
initiate and complete projects in an expeditious fashion (Galli, 2020;
Goleman, 2005). However, this outcome will not occur without the
ability, awareness, and cultural sensitivity to address cultural and
diverse differences in today’s workforce. All individuals process
information differently because of their diverse backgrounds and
cultural beliefs. Being aware and sensitive can facilitate progress on
projects (Saxena, 2014; Seibert et al., 2002; Young & Guo, 2016).
Planning and organizational skills, such that one can assimilate
information from various assessment processes and break down
information into discrete parts, can set the stage for effective
ongoing management of the project. Individual creativity may
flourish when these skills are applied to organize outcomes for
dissemination.
Managing Projects and Teams in a Virtual
Environment
One of the great rewards of technology is the opportunity to have
global project team members contribute remotely. Project managers
can leverage the strengths and talents of multiple individuals that
match the project plan, strategy, and desired outcomes. As Porter-
O’Grady and Malloch (2015) explain, teams are small systems and
often mirror the complexity in other levels of the larger system. The
effectiveness and performance of a project team, whether virtual or
not, are contingent upon a combination of attributes and skill sets.
These personal assets include, but are not limited to, individual
competence, interpersonal skills, flexibility, accommodation,
creativity, strong work ethic, and a focus on outcomes, to name a
few. If the team has no identified purpose or end point, there is no
meaning to the work to be accomplished. Projects may fail or yield
limited outcomes that are not sustainable, and future virtual teams
may be considered suspect.
As the moral compass for the virtual team, the leader should bring
diplomacy to bear in the discourse with staff, managers,
stakeholders, and/or distractors. In particular, it is the virtual team
leader’s responsibility to defend the project and virtual team by
shielding the overarching goal from distractors (Sturmberg & Martin,
2012). Adaptability becomes pivotal to success and is often more
important than anticipation in such an environment.
Managing a team, whether onsite or virtual, can be rewarding as
well as challenging. Virtual Hires (2014) identified nine guidelines
that apply when selecting and managing individuals and teams in
virtual environments, which are easily applicable to on-site teams:
1. Perform a project evaluation. Project leaders must be
knowledgeable about goals, tactics, and deliverables if they are
to communicate effectively with prospective team members.
2. Determine the skill sets needed by team members. Match the
skills of team members to the delegated tasks and mutually
reach consensus on assignments. Leveraging individual strengths
promotes measurable outcomes.
3. Identify and anticipate obstacles. Knowing what has been
attempted previously to resolve a problem or opportunity can
only benefit the present outcomes. Conversely, disregarding this
information can mean a loss for the plan, as the strategy may
actually require only a minor redesign or assignment of a team
member with matching skills and competencies.
4. Constantly engage members and encourage bidirectional
communication. Contact with virtual team members often is
employed to verify needs for supervision and encouragement.
Likewise, the team member can communicate successes and
challenges encountered that require intervention.
5. Establish a timeline and milestones. Identify expectations and the
schedule needed to move the project toward completion. Monitor
progress at designated intervals. Share accomplishments with all
virtual members and stakeholders.
6. Ensure individual team member accountability. Recognizing the
importance of each individual member’s investment in achieving
the critical priorities of a specific project and their buy-in to the
larger institutional performance is a critical success factor.
7. Be cognizant of cultural differences. Being aware and sensitive to
the diversity of virtual team members is important to avoid
conflicts and delays in completing assigned tasks.
8. Manage conflict and difficult team members. Avoiding a conflict
will only perpetuate the issue and result in inefficiency of the
individual and team function. Although crucial conversations may
be difficult on a personal level, they are valuable for resolution of
identified issues that may create project paralysis.
9. Provide education and training. Just-in-time or accelerated
learning techniques may be required to assure all team members
are on the same page with respect to the project goal and
Another random document with
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worship of the brilliant Steerforth,—in short, his general way of
looking at the world is so exactly like that of the ordinary healthy boy
under similar circumstances that these parts of the book are, in the
highest and best sense of the word, very realistic.
But as a whole the work has no such convincing power over me to-
day as it had when I first read it. Some of the characters, indeed, like
little Miss Mowcher, Barkis, and Mr. Creakle, seem more like puppets
and less like real persons than they did. Many of them seem to carry
about with them a sort of trade-mark, to certify to their genuineness,
—Heep’s “humility,” for instance, Murdstone’s “firmness,” or Littimer’s
“respectability”; or perhaps the test of identity is a formula, like
“thinking of the old ’un” of Mrs. Gummidge, or “waiting for something
to turn up” of Micawber. In many cases the picture is a caricature
rather than a real portrait, and yet it has the advantage of the
caricature, that it sets forth in bold relief the leading feature and fixes
itself forever in the memory.
There is little to say about the story, for it is known to all. Practically
three or four stories are woven into one. There is the story of David
himself, a boy who, after a comfortable childhood with his young
widowed mother and her old house servant Peggotty, falls under the
tyranny of a stepfather and his sister, and is sent to be beaten and
abused at Creakle’s school, and when his mother dies is put out to a
miserable and hopeless existence at the dismal counting-house of
Murdstone and Grinby. He runs away, and in absolute destitution
betakes himself to the home of Betsey Trotwood, an aunt whom he
has never seen, but with whom he finds a refuge. Then follows the
description (one of the best chapters in the book) of his school days
at Canterbury; his devotion to Miss Shepherd; his romantic adoration
of Miss Larkins, who marries an elderly hopgrower; his disastrous
fight with a butcher. He is then articled to Mr. Spenlow, of Doctor’s
Commons, to become a proctor, and falls in love with Dora,
Spenlow’s daughter, an affectionate, foolish little creature, whom he
marries. He wins a reputation as an author, and after the death of his
“child-wife,” and a period of travel, finally weds Agnes Wickfield, who
has always loved him, and who, ever since his school days at
Canterbury, has been the guardian spirit of his life.
Intertwined with this story is that of the family of Mr. Peggotty, the
brother of David’s old nurse, who lives in the boat on the sand at
Yarmouth, with his nephew Ham, and Em’ly, his adopted child, a
beautiful creature, who is betrayed by David’s friend Steerforth, with
whom she elopes on the eve of her marriage to Ham, and who
afterwards abandons her. An affecting picture is given of the honest
Mr. Peggotty seeking his poor child through the world; of her final
return, and of the great storm and shipwreck, in which Steerforth
goes down, and Ham loses his life in a vain attempt at rescue.
Another strand in the cord of this remarkable story is that of

Micawber and his family, with whom Copperfield becomes a lodger
during his gloomy days at Murdstone and Grinby’s,—a man who,
after various misfortunes, including poverty, jail, and a wretched life
in which he is made the tool of the hypocritical Uriah Heep, is finally
sent to Australia on the same vessel with Mr. Peggotty and Emily,
and begins a career of ultimate prosperity.
But the story is interesting not so much on account of the plot as of

the people who are in it, and the human interest which runs through
the whole.
In addition to the naturalness of Copperfield’s own feelings, there are

other characters that are very true to life. That of his eccentric aunt,
Betsey Trotwood, is perhaps a little overdrawn at first, in her
interview with the doctor on the occasion of David’s birth, but
afterwards her warmth of heart, frankness, and the strong good
sense which underlie her rude behavior and eccentricities, the
combination of strength and weakness in her nature, call to my own
mind at every step one whom I have intimately known and greatly
loved. There is something immensely refreshing, for instance, in her
outbreak at the slimy Uriah Heep:
“‘If you’re an eel, sir, conduct yourself like one. If you’re a man,
control your limbs, sir. Good God!’ said my aunt, with great
indignation, ‘I’m not going to be serpentined and corkscrewed out
of my senses!’”
Her noble conduct in concealing what she believed to be the

defalcation of her old friend Mr. Wickfield is equally characteristic:
“‘And at last he took the blame upon himself,’ added my aunt, ‘and
wrote me a mad letter, charging himself with robbery and wrong
unheard of; upon which I paid him a visit early one morning, called
for a candle, burned the letter, and told him if he ever could right
me and himself to do it, and if he could not, to keep his own
counsel for his daughter’s sake.’”
The “umble,” pious, and vindictive scoundrel, Uriah Heep, has been
a type of whining hypocrisy. The description of him as Copperfield
first saw him is remarkable:
“A red-haired person, a youth of fifteen, as I take it now, but

looking much older; whose hair was cropped as close as the
closest stubble, who had hardly any eyebrows and no eyelashes,
and eyes of a red brown, so unsheltered and unshaded that I
remember wondering how he went to sleep. He was high-
shouldered and bony, dressed in decent black, with a white wisp
of a neckcloth buttoned up to the throat, and had a long, lank,
skeleton hand, which particularly attracted my attention as he
stood at the pony’s head, rubbing his chin and looking up at us in
the chaise.”
On the whole, perhaps Heep’s character is rather a grotesque than a

reality. Everywhere he inspires us with unutterable aversion. He
worms himself into the secrets of Wickfield, his employer, takes
advantage of his weakness for drink, and finally gets possession of
much of his property. Afterwards, in the prison scene, he is equally
true to his snaky nature, and becomes an edifying and pious pattern
of the products of prison reform.
The quiet, respectful, and respectable Littimer, Steerforth’s serving-
man, who seemed to be always saying to the awestruck David, “You
are young, sir; you are very young,”—and who afterwards became
his master’s tool in the disgraceful intrigue with Em’ly, will find many
a counterpart in actual life. There are some of us who in our youth
have felt similar awe in the presence of such a domestic.
Perhaps the most charming chapters in the book are those which
describe the courting, the marriage, and the disastrous
housekeeping of David and his child-wife, Dora, in which the little
dog Jip plays such a conspicuous part. They are a pair of precious
young noodles; yet the love-making, in spite of its absurdity, is so
absolutely natural, and the foolish Dora so utterly affectionate, up to
the pathetic scene of her death, that the incidents awaken a very
strong sympathy.
Mr. Micawber, of course, is an exaggeration; but how many men

have we known who possessed some of his essential traits,—his
stilted diction, his sudden alternations of supreme joy and utter
despair, his mania for letter-writing, his visionary hopes and schemes
in the midst of his distresses? How perfect in its way is the final
newspaper account of the public dinner in Australia given in his
honor!
Mr. Peggotty’s search through the world for Little Em’ly seems to me
now greatly overstrained, though I did not think so when I first read it.
There is a very true touch in the description of the old Mrs.
Gummidge, who had always been querulous and complaining until
great sorrow fell upon the household, when she became at once
helpful, considerate, and cheerful in comforting the distress of
others. We have all seen examples of this kind of transformation.
Dickens has done mankind a service by portraying the dignity of

simple things and the delicacy and nobility of character that often lie
beneath a rough exterior, among those whom Lincoln used to call
“the plain people,” of whom Lincoln was himself perhaps the most
illustrious type. What could be nobler and in its essential character
more gentlemanly than the behavior of Mr. Peggotty and Ham after
the betrayal of Little Em’ly; what more delicate than Peggotty’s
appreciation of Em’ly’s feeling toward him?
“‘She would go to the world’s furdest end if she could once see
me again, and she would fly to the world’s furdest end to keep
from seeing me. For tho’ she ain’t no call to doubt my love—and
doen’t—and doen’t—but there’s shame steps in and keeps
betwixt us.’”
Dickens’s style is often intensely vivid—for instance, in his

description of a London fog in “Bleak House”; of the burning
Marseilles sun in “Little Dorrit”; of the storm and shipwreck in “David
Copperfield”;—all fine instances of word-painting. Yet the crudities
are many and glaring, there is very little finish, and sometimes the
diction is commonplace.
But there are occasional passages of extraordinary beauty, due

possibly not so much to the style as the sentiment and the things
described. Witness the following, where David describes his feelings
when he had taken refuge with his aunt in her cottage at Dover, after
his escape from Murdstone and Grinby’s:
“The room was a pleasant one, at the top of the house,

overlooking the sea, on which the moon was shining brilliantly.
After I had said my prayers, and my candle had burnt out, I
remember how I still sat looking at the moonlight on the water, as
if I could hope to read my fortunes in it, as in a bright book; or to
see my mother with her child, coming from Heaven along that
shining path, to look upon me as she had looked when I last saw
her sweet face. I remember how the solemn feeling with which at
length I turned my eyes away, yielded to the sensation of gratitude
and rest with which the sight of the white-curtained bed—and how
much more the lying softly down upon it, nestling in the snow-
white sheets—inspired. I remember how I thought of all the
solitary places under the night sky where I had slept, and how I
prayed that I never might be houseless any more, and never
might forget the houseless. I remember how I seemed to float,
then, down the melancholy glory of that track upon the sea, away
into the world of dreams.”
“David Copperfield” may not be the supreme work of fiction which
some of us once fancied it, but it touches the heart very closely. It
dignifies humble life and common things, makes us better friends
with the world, and awakens those human traits which work for
kindness and goodwill toward all mankind.
THE SCARLET LETTER
NATHANIEL HAWTHORNE
Most persons of culture, if asked who was the foremost American

writer of fiction would undoubtedly answer, “Nathaniel Hawthorne.”
Among his works “The Scarlet Letter” is, I think, the most generally
read and widely known. This high estimate of Hawthorne is in most
respects well deserved. His works have a fine literary and poetic
quality. The style is faultless; the dramatic situations are admirably
conceived; and the structure of the plot, while simple, is extremely
artistic. Hawthorne generally deals with the darker phases of human
life, with scenes of wickedness and crime. His description of the
emotions awakened by criminal acts is extremely powerful. And yet it
seems to me, in reading his pages, that Hawthorne had little
knowledge of what were the actual motives and feelings of the guilty,
and that his account of the development of passions and character
came rather from reflection and abstract reasoning than from acute
observation.
The book begins dramatically rather than historically—that is to say,

in the very middle of the impressive story which it relates. Hester
Prynne, the heroine, had married old Roger Chillingworth, a union
unnatural and without affection, which was followed on her part,
during her husband’s long and unexplained absence, by a guilty
passion for Arthur Dimmesdale, the eloquent clergyman of a Puritan
New England town. All the incidents connected with the growth and
development of this passion, and with the birth of the child which
followed it, are omitted from the narrative, which opens with a scene
at the door of the prison, from which Hester comes forth to suffer the
punishment prescribed for her crime,—to stand for a certain time in
the scaffold by the pillory, and to wear for the rest of her life the
scarlet letter A upon her breast. We have nothing to tell us how the
temptation began, nor how it grew, nor the terrible anxieties which
must have preceded the discovery of her wrongdoing. Possibly these
things are the more impressive because left wholly to the
imagination.
But among the multitude that gaze upon the unfortunate woman in
the hours of her public exposure is a face that she knows only too
well. Old Roger Chillingworth, who has been so long absent, and
supposed even to be dead, appears and recognizes her. He visits
her afterwards in prison, and exacts from her an oath that his identity
shall remain unknown. The terrible punishment of the scarlet letter to
a sensitive mind is powerfully portrayed; her shame at every new
face that gazes upon it, and the consciousness of another sense,
giving her a sympathetic knowledge of hidden sin in other hearts, a
strange companionship in crime, upon which Hawthorne lays much
stress in many of his works. Even little Pearl, her child, gives her no
comfort, for the child’s character is wayward, elusive, elf-like. She is
a strange creature, whose conversation brings to her mother
constant reminders of her guilt. Hester, with great constancy, refuses
to disclose the name of the child’s father, and Dimmesdale, the
honored pastor of the community, is tortured by a remorse which
constantly grows upon him. Old Chillingworth suspects him,
becomes his physician, lives with him under the same roof,
discovers a scarlet letter concealed upon his breast, and enjoys for
years the exquisite revenge of digging into the hidden places of a
sensitive human soul and gloating over the agonies thus
unconsciously revealed to a bitter enemy. An account is given of
Dimmesdale’s self-imposed penances, and of the concealed scourge
for his own chastisement. One night he resolves to go forth and
stand on the same scaffold where Hester has undergone her
punishment. The bitterness of his emotions is finely drawn; the wild
shriek which barely fails to rouse the citizens of the town; the
passing of Hester on her way from her ministrations at a death-bed;
the standing together of the three, father, mother, and child, upon the
scaffold; the letter A which appears in the sky; Pearl’s keen
questions; and the face of old Chillingworth, who has come forth to
look on them.
Hester at last resolves to disclose to Dimmesdale the identity of his

evil companion. Her character has grown stronger through openly
bearing the burden of her guilt, while the poor clergyman’s soul has
become shattered through his constant hypocrisy. She meets him in
the forest, and in a scene of great natural tenderness and beauty
tells him that Chillingworth is her husband. He reproaches her bitterly
for her long concealment, then forgives her. She urges him to flee,
as his only hope.
“‘Exchange this false life of thine for a true one. Be, if thy spirit
summon thee to such a mission, the teacher and apostle of the
red men. Or,—as is more thy nature,—be a scholar and a sage
among the wisest and the most renowned of the cultivated world.
Preach! Write! Act! Do anything, save to lie down and die! Give up
this name of Arthur Dimmesdale, and make thyself another, and a
high one, such as thou canst wear without fear or shame. Why
shouldst thou tarry so much as one other day in the torments that
have so gnawed into thy life!—that have made thee feeble to will
and to do!—that will leave thee powerless even to repent; Up, and
away!’
“‘O Hester!’ cried Arthur Dimmesdale, in whose eyes a fitful light,

kindled by her enthusiasm, flashed up and died away, ‘thou tellest
of running a race to a man whose knees are tottering beneath
him! I must die here! There is not the strength or courage left me
to venture into the wide, strange, difficult world, alone!’
“It was the last expression of the despondency of a broken spirit.

He lacked energy to grasp the better fortune that seemed within
his reach.
“He repeated the word.
“‘Alone, Hester!’
“‘Thou shalt not go alone!’ answered she, in a deep whisper.
“Then, all was spoken!”
In connection with their proposed departure to Europe, the minister

inquired of Hester the time at which the vessel would depart, and
learned that it would probably be on the fourth day thereafter. “That
is most fortunate!” the clergyman then said to himself. The reason
why he considered it fortunate revealed a very subtle phase of
human nature.
“It was because, on the third day from the present, he was to
preach the Election Sermon; and as such an occasion formed an
honorable epoch in the life of a New England clergyman, he could
not have chanced upon a more suitable mode and time of
terminating his professional career. ‘At least, they shall say of me,’
thought this exemplary man, ‘that I leave no public duty
unperformed, nor ill performed.’”
And of this strange feeling the author remarks:
“No man, for any considerable period, can wear one face to
himself, and another to the multitude, without finally getting
bewildered as to which may be the true one.”
Having resolved upon flight, however, and in the joy of his

anticipated release from a dreadful life, a curious change comes
over Mr. Dimmesdale, a revolution in his sphere of thought and
feeling.
“At every step he was incited to do some strange, wild, wicked

thing or other, with a sense that it would be at once involuntary
and intentional; in spite of himself, yet growing out of a profounder
self than that which opposed the impulse.”
When he met one of his old deacons, it was only by the most careful
self-control that he could refrain from certain blasphemous
suggestions respecting the communion supper. When he met a
pious and exemplary old dame, the eldest of his flock, whom he had
often refreshed with warm, fragrant Gospel truths, he could now
recall no text of Scripture, nor aught else, except a brief, pithy, and,
as it then appeared to him, unanswerable argument against the
immortality of the human soul. He was tempted to make certain evil
suggestions to one of the young women of his flock, and to teach
some very wicked words to a knot of little Puritan children. He had
come back from the forest another man.
But when the hour of departure approaches, and amid the

preparations for the great Election Sermon, Hester hears that Roger
Chillingworth has learned of their intended flight and taken passage
by the same ship!
The final climax is reached when Dimmesdale, after preaching his

great sermon, which arouses the people to the highest pitch of
enthusiasm, comes forth from the church, and recognizes Hester
and Pearl. At his earnest entreaty she supports him to the scaffold,
where he stands at her side, and, against the protestations of old
Chillingworth, confesses his guilt, shows the scarlet letter upon his
own breast, and expires. Chillingworth does not long survive him.
Hester goes with Pearl across the sea, but after some years returns
alone, again resumes the scarlet letter, and takes up her old life in
her little cottage near the town.
The moral of the book, from the poor minister’s miserable

experience, is put into this sentence: “Be true, be true, be true; show
freely to the world, if not your worst, yet some trait whereby the worst
may be inferred.” Hester’s strength in bearing her sorrow is
contrasted powerfully with the growing weakness and degeneracy of
Dimmesdale, and with the transformation of Chillingworth into a
devil, through constant gratification of his revenge. The strange
conduct of Pearl, who, with her child’s instinct, resents the conduct of
the minister who will recognize her mother and herself only in secret,
adds to the effect; yet it can not be said that Pearl is in the least a
natural child. She seems almost as mature when she first asks her
mother who it was that sent her into the world, and denies that she
has a Heavenly Father, as she does in the last pages of the book.
The appearance of Mistress Hibbins, the old witch, who was
afterwards executed, throws a gleam of the supernatural across the
pages.
It is a weird story, the product of a luxuriant though somewhat morbid

imagination; but the novelist, on the other hand, lacks that acute
perception, that knowledge of trifling circumstances, such as would
have appeared in the pages of Balzac or Tolstoi—those suggestive
details which unconsciously set forth men’s motives, feelings, and
character better than any philosophical reflections.
HENRY ESMOND
WILLIAM MAKEPEACE THACKERAY
The equestrian painting by Velasquez of Prince Balthasar Charles,

the original of which is in the Madrid Museum, is now well known
throughout the world by means of photographs and other
reproductions. It represents a very small boy on a very huge horse,
which is in the act of rearing. The anatomy of the animal is
impossible, and it is safe to say no boy as small as the Prince ever
assumed under like circumstances the attitude attributed to him; and
yet, in spite of its defects, this picture is a very remarkable and a
very beautiful painting. We know in an instant that it is the work of a
master. Indeed it is only the work of a master which could contain
such blemishes and still be great. Similar flaws sometimes deface
the greatest works of literature—for instance, the putting out of
Gloucester’s eyes in “Lear,” or the Walpurgis Night’s Dream in the
first part of “Faust.” And so it is with “Henry Esmond.” It is marred by
one or two dreadful deformities; and yet, in spite of them, it is
perhaps the most charming novel ever written.
The book opens with one of the most exquisite scenes in all
literature, where young Esmond, a lad twelve years of age, who is
supposed to be the illegitimate son of Thomas, Viscount
Castlewood, and who has led a rather hard life as a page of the old
viscountess, and been left alone in the great house after his father’s
death, is now found in the yellow gallery by Lady Castlewood, the
young and beautiful wife of the new viscount, when she comes with
her husband to take possession of the property. The scene is thus
described:
“She stretched out her hand—indeed, when was it that that hand
did not stretch out to do an act of kindness, or to protect grief and
ill-fortune? ‘And this is our kinsman,’ she said; ‘and what is your
name, kinsman?’
“‘My name is Henry Esmond,’ said the lad, looking up at her in a

sort of delight and wonder, for she had come upon him as a Dea
certe, and appeared the most charming object he had ever looked
on. Her golden hair was shining in the gold of the sun; her
complexion was of a dazzling bloom; her lips smiling, and her
eyes beaming with a kindness which made Harry Esmond’s heart
beat with surprise.
“‘His name is Henry Esmond, sure enough, my lady,’ said Mrs.

Worksop, the housekeeper (an old tyrant whom Henry Esmond
plagued more than he hated), and the old gentlewoman looked
significantly toward the late lord’s picture; as it now is, in the
family, noble and severe-looking, with his hand on his sword and
his order on his cloak, which he had from the Emperor during the
war on the Danube against the Turk.
“Seeing the great and undeniable likeness between this portrait

and the lad, the new viscountess, who had still hold of the boy’s
hand as she looked at the picture, blushed and dropped the hand
quickly, and walked down the gallery, followed by Mrs. Worksop.
“When the lady came back, Harry Esmond stood exactly in the
same spot and with his hand as it had fallen when he dropped it
on his black coat.
“Her heart melted, I suppose (indeed she hath since owned as

much) at the notion that she should do anything unkind to any
mortal, great or small; for when she returned, she had sent away
the housekeeper upon an errand by the door at the further end of
the gallery; and, coming back to the lad, with a look of infinite pity
and tenderness in her eyes, she took his hand again, placing her
other fair hand on his head, and saying some words to him, which
were so kind, and said in a voice so sweet, that the boy, who had
never looked upon so much beauty before, felt as if the touch of a
superior being or angel smote him down to the ground, and kissed
the fair protecting hand, as he knelt on one knee. To the very last
hour of his life, Esmond remembered the lady as she then spoke
and looked—the rings on her fair hands, the very scent of her
robe, the beam of her eyes lighting up with surprise and kindness,
her lips blooming in a smile, the sun making a golden halo round
her hair.”
The story now digresses, returning to Esmond’s early life, the vague
recollections of his childhood abroad, his coming to Castlewood, his
education by Father Holt, a Jesuit priest, the plots and intrigues of
the family on behalf of King James, the seizure of the great house by
King William’s troops, the arrest of the viscountess in her bed, and
the death of the viscount at the battle of the Boyne.
The young page was warmly welcomed by the new viscount, as well
as by Lady Castlewood, and he became the instructor of their
children. There are exquisite descriptions of their domestic life in the
earlier pages of the book.
“There seemed, as the boy thought, in every look or gesture of

this fair creature, an angelical softness and bright pity—in motion
or repose she seemed gracious alike; the tone of her voice,
though she uttered words ever so trivial, gave him a pleasure that
amounted almost to anguish. It can not be called love that a lad of
twelve years of age, little more than menial, felt for an exalted
lady, his mistress; but it was worship. To catch her glance, to
divine her errand, and run on it before she had spoken it; to
watch, follow, adore her, became the business of his life.
Meanwhile, as is the way often, his idol had idols of her own, and
never thought of or suspected the admiration of her little pigmy
adorer.
“My lady had on her side her three idols; first and foremost, Jove
and supreme ruler, was her lord, Harry’s patron, the good
Viscount of Castlewood. All wishes of his were laws with her. If he
had a headache, she was ill. If he frowned, she trembled. If he
joked, she smiled, and was charmed. If he went a-hunting, she
was always at the window to see him ride away, her little son
crowing on her arm, or on the watch till his return. She made
dishes for his dinner; spiced his wine for him; made the toast for
his tankard at breakfast; hushed the house when he slept in his
chair, and watched for a look when he woke. If my lord was not a
little proud of his beauty, my lady adored it. She clung to his arms
as he paced the terrace, her two fair little hands clasped round his
great one; her eyes were never tired of looking in his face and
wondering at his perfection.”
But it was not long until my lord began to grow weary of the bonds in
which his lady held him and at the jealousy which went hand and
hand with her affection.
“Then perhaps, the pair reached that other stage, which is not
uncommon in married life, when the woman perceives that the
god of the honeymoon is a god no more; only a mortal like the
rest of us; and so she looks into her heart, and lo! vacua sedes et
inania arcana!”
One unhappy day Esmond brings the smallpox to Castlewood from

an ale-house in the village, which he has visited, and where he has
met Nancy Sievewright, the blacksmith’s pretty daughter. Lady
Castlewood, on hearing this, breaks out into a strange fit of rage and
jealousy; but when Esmond is taken ill she nurses him tenderly,
contracting the disease herself, while the viscount with his little
daughter Beatrix flees from the contagion. He returns to find his
wife’s beauty marred a little for a time, whereupon his love for her
grows weak and she betakes herself to the affection of her children.
With a little legacy that comes into her possession, she sends
Esmond to the University, whence he returns on vacation to find a
skeleton in the household. His kind mistress is shedding tears in
secret, while her husband drinks heavily, neglects her for an actress
in a neighboring town, and brings home Lord Mohun, a notorious
rake, with whom he spends his nights at play, and squanders his
fortune. At last Mohun is suspected of designs against my lady, and
in a drive with this unscrupulous man Esmond warns him to leave
Castlewood. An accident occurs; Mohun is thrown out and injured.
The viscount tells his wife that “Harry is killed” (Harry being the name
both of Esmond and Mohun). She screams, and falls unconscious. A
duel follows, and Lord Castlewood is slain by Mohun’s sword, but
before his death confesses that he has learned from Father Holt that
Esmond is the legitimate son of his predecessor, and the lawful heir
to Castlewood. Esmond burns the confession and resolves not to
profit by a claim which will bring sorrow upon his kind mistress and
her children. He is sent to prison for participating in the duel, from
which he had endeavored to dissuade his patron and afterwards to
defend him. Here Lady Castlewood visits him. She brings no
comfort, however, but upbraids him in her wild grief:
“‘I lost him through you—I lost him, the husband of my youth, I
say. I worshiped him—you know I worshiped him—and he was
changed to me. He was no more my Francis of old—my dear,
dear soldier! He loved me before he saw you, and I loved him!
Oh, God is my witness, how I loved him! Why did he not send you
from among us? ’Twas only his kindness, that could refuse me
nothing then. And, young as you were—yes, and weak and alone
—there was evil, I knew there was evil in keeping you. I read it in
your face and eyes. I saw that they boded harm to us—and it
came, I knew it would. Why did you not die when you had the
smallpox, and I came myself and watched you, and you didn’t
know me in your delirium—and you called out for me, though I
was there at your side. All that has happened since was a just
judgment on my wicked heart—my wicked, jealous heart. Oh, I
am punished, awfully punished! My husband lies in his blood—
murdered for defending me, my kind, kind, generous lord—and
you were by, and you let him die, Henry!’”
He is crushed by her injustice, but does not waver in his devotion.

After his imprisonment is over he procures an ensign’s commission
and participates in the destruction of the French fleet in Vigo Bay. On
his return he hears that his mistress is about to marry the chaplain of
Castlewood, and he hastens to prevent the match. The rumor is
unfounded, but it furnishes the opportunity for reconciliation. They
meet in Winchester Cathedral after the service:
“She gave him her hand—her little fair hand; there was only her
marriage ring on it. The quarrel was all over. The year of grief and
estrangement was passed. They never had been separated. His
mistress had never been out of his head all that time. No, not
once. No, not in the prison, nor in the camp, nor on shore before
the enemy, nor at sea under the stars of solemn midnight, nor as
he watched the glorious rising of the dawn; not even at the table
where he sat carousing with friends, or at the theater yonder,
where he tried to fancy that other eyes were brighter than hers.
Brighter eyes there might be, and faces more beautiful, but none
so dear—no voice so sweet as that of his beloved mistress, who
had been sister, mother, goddess to him during his youth—
goddess now no more, for he knew of her weaknesses, and by
thought, by suffering, and that experience it brings, was older now
than she; but more fondly cherished as woman perhaps than ever
she had been adored as divinity. What is it? Where lies it? the
secret which makes one little hand the dearest of all? Who ever
can unriddle that mystery?”
And then when Esmond gently reproaches her that she had never
told him of her sorrow for her cruel words, and that the knowledge
would have spared him many a bitter night:
“‘I know it, I know it,’ she answered, in a tone of such sweet
humility as made Esmond repent that he should ever have dared
to reproach her. ‘I know how wicked my heart has been; and I
have suffered too, my dear. I confessed to Mr. Atterbury—I must
not tell any more. He—I said I would not write to you or go to you;
and it was better, even, that, having parted, we should part. But I
knew you would come back—I own that. That is no one’s fault.
And to-day, Henry, in the anthem, when they sang it, “When the
Lord turned the captivity of Zion, we were like them that dream,” I
thought, yes, like them that dream—them that dream. And then it
went, “They that sow in tears shall reap in joy; and he that goeth
forth and weepeth shall doubtless come home again with
rejoicing, bringing his sheaves with him;” I looked up from the
book, and saw you. I was not surprised when I saw you. I knew
you would come, my dear, and saw the gold sunshine round your
head.’”
“‘If—if ’tis so, dear lady,’ Mr. Esmond said, ‘why should I ever
leave you? If God hath given me this great boon—and near or far
from me, as I know now, the heart of my dearest mistress follows
me—let me have that blessing near me, nor ever part with it till
death separate us. Come away—leave this Europe, this place
which has so many sad recollections for you. Begin a new life in a
new world. My good lord often talked of visiting that land in
Virginia which King Charles gave us—gave his ancestor. Frank
will give that. No man there will ask if there is a blot on my name,
or inquire in the woods what my title is.’
“‘And my children—and my duty—and my good father, Henry?’

she broke out. ‘He has none but me now; for soon my sister will
leave him, and the old man will be alone. He has conformed since
the new Queen’s reign; and there in Winchester, where they love
him, they have found a church for him. When the children leave
me I will stay with him. I cannot follow them into the great world,
where their way lies—it scares me. They will come and visit me;
and you will, sometimes, Henry—yes, sometimes, as now, in the
Holy Advent season, when I have seen and blessed you once
more.’
“‘I would leave all to follow you,’ said Mr. Esmond; ‘and can you
not be as generous for me, dear Lady?’
“‘Hush, boy!’ she said, and it was with a mother’s sweet, plaintive
tone and look that she spoke. ‘The world is beginning for you. For
me, I have been so weak and sinful that I must leave it, and pray
out an expiation, dear Henry. Had we houses of religion as there
were once, and many divines of our church would have them
again, I often think I would retire to one and pass my life in
penance. But I would love you still—yes, there is no sin in such a
love as mine now; and my dear lord in heaven may see my heart;
and knows the tears that have washed my sin away—and now—
now my duty is here, by my children while they need me, and by
my poor old father, and—’
“‘And not by me?’ Henry said.
“‘Hush!’ she said again, and raised her hand to his lip. ‘I have
been your nurse. You could not see me, Henry, when you were in
the smallpox, and I came and sat by you. Ah, I prayed that I might
die, but it would have been in sin, Henry. Oh, it is horrid to look
back to that time. It is over now and past, and it has been forgiven
me. When you need me again I will come ever so far. When your
heart is wounded then come to me, my dear. Be silent! Let me say
all. You never loved me, dear Henry—no, you do not now, and I
thank Heaven for it. I used to watch you, and knew by a thousand
signs that it was so. Do you remember how glad you were to go
away to College? ’Twas I sent you. I told my papa that, and Mr.
Atterbury too, when I spoke to him in London. And they both gave
me absolution—both—and they are godly men, having authority
to bind and to loose. And they forgave me, as my dear lord
forgave me before he went to heaven.’
“‘I think the angels are not all in heaven,’ Mr. Esmond said. And as
a brother folds a sister to his heart; and as a mother cleaves to
her son’s breast—so for a few moments Esmond’s beloved
mistress came to him and blessed him.”
After this wonderful chapter there comes another of almost equal

beauty, if it stood alone, but the two together make a strange
discord. For when they reach Walcote, which is now the family
home, Beatrix, the daughter of Lady Castlewood, comes down the
stairs to greet him.
“Esmond had left a child and found a woman, grown beyond the
common height, and arrived at such a dazzling completeness of
beauty that his eyes might well show surprise and delight at
beholding her. In hers there was a brightness so lustrous and
melting that I have seen a whole assembly follow her as if by an
attraction irresistible; and that night the great Duke was at the
playhouse after Ramillies, every soul turned and looked (she
chanced to enter at the opposite side of the theater at the same
moment) at her, and not at him. She was a brown beauty—that is,
her eyes, hair, and eyebrows and eyelashes were dark; her hair
curling with rich undulations, and waving over her shoulders. But
her complexion was as dazzling white as snow in sunshine;
except her cheeks, which were a bright red, and her lips, which
were of a still deeper crimson. Her mouth and chin, they said,
were too large and full, and so they might be for a goddess in
marble, but not for a woman whose eyes were fire, whose look
was love, whose voice was the sweetest low song, whose shape
was perfect symmetry, health, decision, activity, whose foot, as it
planted itself on the ground, was firm but flexible, and whose
motion, whether rapid or slow, was always perfect grace—agile as
a nymph, lofty as a queen—now melting, now imperious, now
sarcastic—there was no single movement of hers but was

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Nursing and Health Interventions: Design, Evaluation,

Agile Change Management: A Practical Framework for

Valvular Heart Disease: A Guide for Cardiovascular

Project Planning, Scheduling and Control: The Ultimate

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CHAPTER 1 Key Foundations of Successful Quality Project Planning,

CHAPTER 2 Quality Improvement Projects and Quality Improvement

CHAPTER 3 Implementation Science, Team Science, and Translational

CHAPTER 5 Making the Case for a Project: Organizational and Needs

CHAPTER 7 Synthesizing, Leveling, and Assessing the Fidelity of

CHAPTER 8 Building the Improvement Project Budget: Quantifying the

CHAPTER 9 Information Management in Clinical Projects: Technology,

CHAPTER 10 The Institutional Review Board Process

CHAPTER 11 Big Data and Information Systems: Understanding the

CHAPTER 12 Measuring the Value of Projects Within Organizations,

CHAPTER 13 Innovation, Diffusion, and Dissemination of Improvement

Textbooks are references for students, faculty, interprofessional

The authors acknowledge each of the contributors of this text,

Michael Bleich, PhD, RN, NEA-BC, FNAP, FAAN

Case Exemplar Contributors

Another strand in the cord of this remarkable story is that of

But the story is interesting not so much on account of the plot as of

In addition to the naturalness of Copperfield’s own feelings, there are

Her noble conduct in concealing what she believed to be the

“A red-haired person, a youth of fifteen, as I take it now, but

On the whole, perhaps Heep’s character is rather a grotesque than a

Mr. Micawber, of course, is an exaggeration; but how many men

Dickens has done mankind a service by portraying the dignity of

Dickens’s style is often intensely vivid—for instance, in his

But there are occasional passages of extraordinary beauty, due

“The room was a pleasant one, at the top of the house,

Most persons of culture, if asked who was the foremost American

The book begins dramatically rather than historically—that is to say,

Hester at last resolves to disclose to Dimmesdale the identity of his

“‘O Hester!’ cried Arthur Dimmesdale, in whose eyes a fitful light,

“It was the last expression of the despondency of a broken spirit.

“He repeated the word.

“Then, all was spoken!”

In connection with their proposed departure to Europe, the minister

And of this strange feeling the author remarks:

Having resolved upon flight, however, and in the joy of his

“At every step he was incited to do some strange, wild, wicked

But when the hour of departure approaches, and amid the

The final climax is reached when Dimmesdale, after preaching his

The moral of the book, from the poor minister’s miserable

It is a weird story, the product of a luxuriant though somewhat morbid

The equestrian painting by Velasquez of Prince Balthasar Charles,

“‘My name is Henry Esmond,’ said the lad, looking up at her in a

“‘His name is Henry Esmond, sure enough, my lady,’ said Mrs.

“Seeing the great and undeniable likeness between this portrait