Engaging Frontline Staff in Performance Improvement: The American Organization of Nurse Executives Implementation of Transforming Care at the Bedside Collaborative.

BACKGROUND: Process improvement stresses the importance of engaging frontline staff in implementing new processes and methods. Yet questions remain on how to incorporate these activities into the workday of hospital staff or how to create and maintain its commitment. In a 15-month American Organization of Nurse Executives collaborative involving frontline medical/surgical staff from 67 hospitals, Transforming Care at the Bedside (TCAB) was evaluated to assess whether participating units successfully implemented recommended change processes, engaged staff, implemented innovations, and generated support from hospital leadership and staff. METHODS: In a mixed-methods analysis, multiple data sources, including leader surveys, unit staff surveys, administrative data, time study data, and collaborative documents were used. RESULTS: All units reported establishing unit-based teams, of which >90% succeeded in conducting tests of change, with unit staff selecting topics and making decisions on adoption. Fifty-five percent of unit staff reported participating in unit meetings, and 64%, in tests of change. Unit managers reported substantial increase in staff support for the initiative. An average 36 tests of change were conducted per unit, with 46% of tested innovations sustained, and 20% spread to other units. Some 95% of managers and 97% of chief nursing officers believed that the program had made unit staff more likely to initiate change. Among staff, 83% would encourage adoption of the initiative. CONCLUSIONS: Given the strong positive assessment of TCAB, evidence of substantial engagement of staff in the work, and the high volume of innovations tested, implemented, and sustained, TCAB appears to be a productive model for organizing and implementing a program of frontline-led improvement.

Healthcare Team Vitality Instrument (HTVI): developing a tool assessing healthcare team functioning.

AIM: This paper is a report of a study conducted to refine, shorten and validate the Healthcare Team Vitality Instrument. BACKGROUND: The Healthcare Team Vitality Instrument was developed to assess team vitality of nurses as well as other licensed and unlicensed personnel working as part of healthcare teams in inpatient hospital units. This instrument was necessary for two reasons. First, other commonly used instruments assess characteristics of Registered Nurses or perceptions about and characteristics of the organizations in which they work, but not these factors in combination with critical factors of interdisciplinary team functioning and collaboration. Second, a short tool for repeated, regular measurement of team vitality was needed to track the impact of changes to improve work environments. METHOD: Revisions to the Healthcare Team Vitality Instrument occurred in two phases. Phase 1 entailed collecting preliminary data and conducting cognitive interviews to refine the initial items. During Phase 2, the factor structure of the Healthcare Team Vitality Instrument was identified and a brief form developed and validated. Data were collected in 2006 and 2007. FINDINGS: Exploratory factor analyses suggested a four-factor solution with the following dimensions: (1) support structures, (2) engagement and empowerment, (3) patient care transitions and (4) team communication. CONCLUSION: The Healthcare Team Vitality Instrument can contribute both to better management practices and advancing knowledge to promote retention of nurses, and to some extent other healthcare professionals, as well as efforts to transform the acute healthcare work environment.

Value-added care: a paradigm shift in patient care delivery.

Spiraling costs in health care have placed hospitals in a constant state of transition. As a result, nursing practice is now influenced by numerous factors and has remained in a continuous state of flux. Multiple changes within the last 2 decades in nurse/patient ratio and blend of front-line nurses are examples of this transition. To reframe the nursing practice into an economic equation that captures the cost, quality, and service, a paradigm shift in thinking is needed in order to assess work redesign. Nursing productivity must be evaluated in terms of value-added care, a vision that goes beyond direct care activities and includes team collaboration, physician rounding, increased RN-to-aide communication, and patient centeredness; all of which are crucial to the nurse's role and the patient's well-being. The science of appropriating staffing depends on assessment and implementation of systematic changes best illustrated through a "systems theory" framework. A throughput transformation is required to create process changes with input elements (number of front-line nurses) in order to increase time spent in value-added care and to decrease waste activities with an improvement in efficiency, quality, and service. The purpose of this pilot study was two-fold: (a) to gain an understanding of how much time RNs spent in value-added care, and (b) whether increasing the combined level of RNs and unlicensed assistive personnel increased the amount of time spent in value-added care compared to time spent in necessary tasks and waste.

Achieving magnet redesignation: a framework for cultural change.

Magnet recognition is the highest award that the ANCC bestows on an institution and exemplifies a hospital's accomplishments in providing commitment, support, and resources for nursing excellence throughout the organization. Magnet hospitals attain their status based on structure and outcome criteria known as the 14 Forces of Magnetism. The authors discuss one hospital's journey and the outstanding models integrated in their organization that paved the way for their first award, followed by their journey toward redesignation.

The relationship between the volume and type of transforming care at the bedside innovations and changes in nurse vitality.

Through an initiative called Transforming Care at the Bedside (TCAB), the Robert Wood Johnson Foundation and the Institute for Healthcare Improvement have created an innovative bottom-up framework for redesigning the work environment on medical-surgical units. The specific purpose of this study, conducted by the University of California Los Angeles/RAND evaluation team, was to examine the number of innovations tested and the association of the volume of tests made and changes in a summary measurement of self-reported vitality at the 13 participating hospitals. The findings of this evaluation yielded several important implications for nurse leaders.

Spreading nursing unit innovation in large hospital systems.

Healthcare administrators increasingly face the challenge of how to spread innovation throughout their organizations. The authors present the results of an evaluation of the efforts of 3 major hospital systems to internally disseminate nursing unit change among medical-surgical units. The findings show that all 3 organizations carefully planned, coordinated, and implemented a spread process; none left dissemination to chance. Although clear differences were evident in the way they engineered their spread, many similarities also were found.

Assessing nursing staffing ratios: variability in workload intensity.

In 2004, California became the first state to implement specific nurse-to-patient ratios for all hospitals. These mandated enactments have caused significant controversy among health care professionals as well as nursing unions and professional organizations. Supporters of minimum nurse-to-patient ratios cite patient care quality, safety, and outcomes, whereas critics point to the lack of solid data and the use of a universally standardized acuity tool. Much more remains to be learned about staffing policies before mature links may be made regarding set staffing ratios and patient outcomes - specifically, how nurses spend their time in terms of variability in their daily work. This study examines two comparable telemetry units with a 1:3 staffing ratio within a California hospital system to determine the relative rates of variability in nursing activities. The results demonstrate significant differences in categorical nursing activities (e.g., direct care, indirect care, etc.) between the two telemetry units (chi(2) = 91.2028; p < or = .0001). No correlation was noted between workload categories with daily staffing ratios and staffing mix between the two units. Although patients were grouped in a similar telemetry classification category and care was mandated at a set ratio, patient needs were variable, creating a significant difference in registered nurse (RN) categorical activities on the two units.

Value-added care: a new way of assessing nursing staffing ratios and workload variability.

OBJECTIVE: To thoroughly understand the implications of California regulatory staffing ratios on nursing units, the present study examines the relative amounts of time allocated to workload activities among registered nurses. BACKGROUND: Nursing is a synergistic, intuitive process and may not be capable of being translated into minimum patient-to-nurse ratios that work across an entire region or state. A fundamental step in evaluating the appropriateness of prescribed ratios lies in assessing how registered nurses spend their time while caring for patients. Once workload intensity is assessed, additional factors can be identified to design mandated staffing levels for acute care settings. METHODS: Variability in workload intensity was assessed using the Robert Woods Johnson Foundation "Transforming Care at the Bedside" work flow methodology approach in evaluating value-added care and assessing the amount of time nurses spent on direct care and other categorical activities. RESULTS: The results revealed a marked variation in the medical-surgical unit compared with the 2 telemetry units regarding the amount of time spent by registered nurses on value-added, necessary, and non-value-added activities, as well as variability in the amount of time that registered nurses spent on direct care, indirect care, documentation, waste, and other activities. CONCLUSION: By evaluating patient quality of care in acute care settings, we can return to a basic aspect of how nurses spend their time caring for patients-the activities that not only involve direct care but also benefit the patient.

The magnet designation process: a qualitative approach using Donabedian's conceptual framework.

Twelve nurse leaders and 12 registered nurses from 2 hospitals were interviewed to gain an understanding on the process for preparing for magnet designation. These leaders and nurses provided insight into whether a cultural shift within the organization was occurring while striving for magnet designation and the level of staff nurses' engagement during the process. Donabedian's framework provided the conceptual context for this study. According to Donabedian, stable organizational structures will influence professional nursing processes and result in better outcomes as measured by magnet status. The authors discuss how a magnet culture is achieved when structural factors such as adequate staffing and pay are present before building the processes, as well as the ways certain ingredients such as professional governance councils need to be primed to achieve the desired magnet outcome. However, transforming the culture into a "valued-practice" magnet organization entails a paradigm shift marked by the willingness to share information and the depth and breadth of commitment toward staff engagement in fulfilling the mission of a culture that truly values nursing expertise.

What constitutes effective leadership? Perceptions of magnet and nonmagnet nurse leaders.

Magnet hospitals, so named because of their ability to attract and retain nurses, have been operating for nearly 20 years. Although research on their success, particularly related to job satisfaction and retention of nurses, is available, research on magnet nurse leader effectiveness has been limited to the pivotal role the nurse leader plays in supporting a magnet culture. To enhance the research groundwork in magnet hospitals and nursing leadership, 16 nurse leaders from magnet and nonmagnet hospitals were interviewed. They were asked to identify leadership qualities they considered valuable in today's healthcare setting. The author contrasts the opinions of magnet and nonmagnet leaders relating to their leadership traits, organizational structures they discern as being supportive of professional nursing practice, and their perceptions of how a successful organization is created.

The interrelationship of organizational characteristics of magnet hospitals, nursing leadership, and nursing job satisfaction.

This study examined whether magnet hospitals continue to provide higher levels of job satisfaction and empowerment among nurses when compared with non-magnet hospitals. Also studied at both types of hospitals was whether job satisfaction discrepancy was interlinked with leadership effectiveness and support of professional nursing practice. Nurses employed at magnet hospitals experienced higher levels of empowerment and job satisfaction due to greater access to work empowerment structures. The elements accounting for differences in empowerment and job satisfaction scores included: (1) greater accessibility of magnet nurse leaders, (2) better support of clinical nurse autonomous decision making by magnet nurse leaders, and (3) greater access to work empowerment structures such as opportunity, information, and resources at magnet hospitals.

What's the attraction to Magnet hospitals? Unlimited opportunity, resources, and autonomy draw nurses to these empowering facilities.

Here, review study results that find nurses employed at Magnet hospitals experience enhanced job satisfaction due to greater access to empowerment structures within their practice setting.

Assessing differences in job satisfaction of nurses in magnet and nonmagnet hospitals.

Is there a difference in the level of job satisfaction among clinical nurses employed at magnet versus nonmagnet hospitals, and is it linked to nurse executive leadership? To answer these questions, 305 clinical nurses employed at magnet and nonmagnet hospitals rated their perceptions of job satisfaction while 16 leaders from the same hospitals were interviewed for their perception of their role in healthcare. The author discusses that differences in job satisfaction scores were linked to greater visibility and responsiveness by magnet nurse leaders; better support of clinical nurse autonomous decision-making by magnet nurse leaders; and greater support of a professional nursing climate at magnet hospitals as evidenced by adequate staffing in the workforce.

What constitutes successful nurse leadership?: A qualitative approach utilizing Kanter's theory of organizational behavior.

What constitutes successful leadership in today's healthcare environment and what are the principal components of an organization that supports the role of the nurse leader? To answer these questions, 16 nurse leaders from four acute care hospitals were interviewed for their perception of leadership traits that are effective in the inpatient hospital setting and types of organizational infrastructures that create conditions for job effectiveness. Kanter's theory of organizational behavior provided the conceptual framework for this study. Leadership effectiveness is linked to having access to opportunity, resources, information, and formal and informal power in the work setting. Nurse leaders with access to these structures are empowered and successful, which leads to enhanced worth and overall organizational achievement. Also, strong central beliefs and business astuteness are considered vital attributes in today's economically oriented environment.